SURGERY. 755 
that its outer condyle in dislocations inwards and its inner 
condyle in dislocation outwards are turned backwards as 
well as sideways. These accidents are all to be reduced by 
a very obvious process—namely, extension and pressure in 
that direction that will replace the bones. There are 
partial or subluxations in this situation which are 
troublesome to recognize or reduce. The limb can 
be bent or straightened by the surgeon without cre¬ 
ating much pain, but the patient has not himself a perfect 
command of it. It should be bent and extended, and then 
sometimes turned inwards, sometimes outwards, and, by a 
little management of this kind, may often, but not always, be 
reduced. The fibula is rarely dislocated from the top of 
the tibia by violence, but sometimes from relaxation. It is 
in either case easily replaced, but requires a long continued 
support to retain it in its situation. 
Accidents about the ankle joint.—The lower end of the 
tibia may be displaced backwards, forwards, or to either 
side. The dislocation of this bone inwards, is the com¬ 
monest. Here the inner malleolus violently stretches, and 
often bursts the skin; the ligaments connecting it with the 
astragalus are torn, and the fibula necessarily broken, a frac¬ 
ture which takes place about two or three inches from its 
lower articulation. The foot is everted and turned upwards. 
The reduction is effected by bending the leg on the thigh, 
which relaxes the muscles producing distortion; by extension 
in a slight degree; and by lateral pressure. The retention 
of the bone in its situation, is effected by splints and by a 
foot-board, to which the foot should be laced.—In disloca¬ 
tion outwards, the inner malleolus is necessarily broken 
from the tibia, either directly or by a fracture which involves 
the centre of the bone and passes into the midst of its articu¬ 
lation with the astragalus. Even the astragalus, may be 
broken; and unless the fibula itself be broken, the external 
lateral ligament must be torn Here again reduction must 
be effected by relaxing the muscles of the calf, by bending 
the leg on the thigh, and gently extending the leg. Then if 
we press the tibia inwards, the bone may be restored to its 
place, and a splint with a foot-board attached, will secure 
it in its proper station. The. foot-board should be raised 
at the part next the toes, in order to prevent the leg-bones 
slipping from their articulation.—The complete dislocations 
of the tibia forwards, cannot occur until the outer and inner 
malleoli are broken; then the tibia is thrown forwards in the 
navicular and internal cruciform bones, and the heel, aban¬ 
doned to the action of thegastrocnemii, is accordingly drawn 
behind the bones of the leg, and the toes necessarily turned 
downwards. The reduction is here very difficult, and the 
retention of the displaced bones, in situ still more so. Exten¬ 
sion and the bending the toes upwards, are the obvious means 
to be employed for reduction, and our apparatus must be 
so arranged as to keep the heel supported forwards, the leg 
retained in its due place backwards, and their apposition 
secured by properly raising the metatarsus.—There is also a 
partial dislocation of the tibia forwards, that has been oc¬ 
casionally met with. In this the tibia rests in part of the 
navicular bone, whilst its other half remains attached to the 
astragalus; the fibula is of course broken, the leg altogether 
seems a little shortened, and the toes are turned downwards, 
and are stiff. This accident, easily rectified in its early 
stages, produces so perfect a change in the state of the joint 
and the muscles, that, when long established, no efforts for 
its relief can be effectual. The appearance of a dislocation 
of the tibia backwards and its treatment, are obvious, but it 
•is the rarest of these rare accidents—so much so, that Sir A. 
Cooper has never seen a case of the kind.—The astragalus 
is sometimes dislocated ; and so difficult is this bone of re¬ 
placement, that surgeons have been usually content either 
to advise its entire removal, or to allow it to remain unre¬ 
duced. It has, however, been reduced thus:—In a dislocation 
inwards, the knee was fixed ; the foot straightened to a line 
with the leg, the toes forcibly bent outwards, and the astra¬ 
galus pressed inwards: an entirely opposite case was similarly 
successful, simply by bending the toes in the opposite direction. 
Other dislocations of the tarsus produce no very serious 
deformities, and those of the phalanges are easy of reduc¬ 
tion. 
The arteries of the lower extremity require to be tied for 
aneurism or injury, in various situations. The tying of the 
internal iliac is thus described by Mr. Steevens, the first who 
performed it:—■ 
“ An incision about five inches in length, was made on 
the left side, in the lower and lateral part of the abdomen, 
parallel with the epigastric artery; and nearly half an inch 
on the outer side of it. The skin, the superficial fascia, and 
the three thin abdominal muscles were successively divided; 
the peritoneum was separated from its loose connection with 
the iliacus internus and psoas magnus, it was then turned 
almost directly inwards, in a direction from the anterior 
superior spinous process of the ilium, to the division of the 
common iliac artery. In the cavity which I had now made 
I felt for the internal iliac, insinuated the point of my fore¬ 
finger behind it, and then pressed the artery between my 
finger and thumb. I then passed a ligature behind the ves¬ 
sel, and tied it about half an inch from its origin. I found 
no difficulty in avoiding the ureter: when I turned the peri¬ 
toneum inwards, the ureter followed it. Had it remained 
over the artery, I could easily have turned it aside with my 
finger. The woman did not complain of much pain, and I 
am certain she did not lose one ounce of blood.” 
The external iliac.—The hairs being previously shaved 
from the part, begin the incision about an inch within, and 
rather below the anterior and superior spinous process of the 
ilium; continue it, in a semilunar form, in the direction of 
Poupart’s ligament, for a little more than three inches, so as 
to make it terminate just above the external abdominal ring: 
this exposes the tendon of the external oblique muscle, which 
being divided to the same extent, and turned aside, lays bare 
the internal oblique, where it arises with the transversalis 
from the outer half of Poupart’s ligament. With your finger, 
or the handle of the scalpel, turn up the borders of these 
muscles, and the spermatic cord becomes exposed; pass your 
finger behind it, push the peritoneum upwards, and you feel 
the artery with the vein on its inner side; they are closely 
connected by cellular membrane, and must be carefully sepa- • 
rated with the handle of the scalpel, or a blunt probe. After 
having cut through the tendon of the external oblique, be 
careful to use the knife as little as possible, lest you wound 
the epigastric artery, which is generally situated near the 
inner extremity of your incision, crossing behind the sper¬ 
matic cord. 
The femoral artery in the groin.—The patient being placed 
on his back, separate the thigh to be operated on from the 
other, and let the leg hang over the edge of the table; this 
renders the artery more superficial, by putting the integu¬ 
ments and sartorius muscle on the stretch. Begin the in¬ 
cision half inch below the middle of Poupart’s ligament; 
continue it downwards for three inches, inclining it slightly 
to the inner side of the thigh, taking care to avoid the 
saphena vein, which is rather superficially seated, and nearly 
over the artery. Having cut through the integuments, fat, 
aponeurosis, and fascia lata, you come to the sheath of the 
vessels. This being cautiously opened, as in the last oper¬ 
ation, exposes the artery, which has the vein on its inner 
side, but separated from it by a process of the sheath : the 
anterior crural nerve not included in the sheath, is a little to 
its outer side. 
The femoral artery in the thigh.—Put the sartorius in 
action by placing the leg in the tailor’s position; then make 
an incision, three inches in length, rather above the middle 
of the thigh, in the oblique direction of the muscle, and on 
its inner edge: continue it through the integuments and fat, 
till the border of the muscle is exposed. Observe the direc¬ 
tion of the fibres to ascertain that you have not come upon 
the vastus; then elevate the sartorius, drawing it a little out¬ 
wards, which brings the femoral sheath into view; open this 
with care by a small incision, and then dilate it by cutting 
from within outwards; this exposes the artery, which has 
the vein rather behind and to its outer side. 
The posterior tibial.—A little below the middle of the leg, 
begin 
