_Of Dislocations_
There are many accidents by which a limb may become dislocated; the
reduction of which is a material point in surgery. But if a surgeon is
not at hand, a man ought nevertheless, not to remain in that painful and
deplorable state, that endangers not only the limb of becoming useless,
but even the loss of life itself.
I shall proceed therefore in my directions as plain as possible,
avoiding every expression that may render this operation prolix.
It must first of all be remembered what was said of joints,
articulations, and ligaments in the first lecture under that head. We
must thence observe, that a dislocation of the upper arm with the
shoulder is the most common that happens, because of the great variety
of motion, and the flatness of the head of the arm-bone, and the cavity
of the shoulder blade. Next to this is the thigh bone, with the hip. But
this is done by much greater force, and therefore more troublesome in
reducing. All other joints that are angular are seldom really
dislocated, being stronger secured, and cannot be separated from their
articulation, without first tearing the ligamentous capsula that
surround them; yet nevertheless, some are subjected to be partly
dislocated; and this is what is commonly called sprains.
Dislocations may be from two causes; first from violence, secondly from
weakness of the ligament. In the latter case the reduction is the
easiest, but the limb is apt to slip out again by the least
accident.[11]
Footnote 11:
I remember a man who frequently had his shoulder dislocated, and was
his own operator in reducing it again. The first time the accident
happened in the ship I was surgeon of, I was naturally called to his
assistance: “Stop Doctor,” (said Tom) “I have got a tackle in my
chest, and I will soon bouse it in again;” and sure enough, he had a
pully, with which he immediately reduced it.
I shall briefly consider each kind of dislocation, that an accident
makes a man liable to.
_Dislocation of the Arm with the Shoulder._
The dislocation of that, may be two ways; (viz) downwards, and forwards;
but it cannot be backwards nor upwards; except some part of the
shoulder-blade be broke.——The best method to examine the patient what
kind of dislocation it is, (especially to one unacquainted with these
branches of surgery) is strictly to compare both shoulders, and the
difference will be very plain, both to sight and touch.
If the dislocation is downwards that is, the head of the arm-bone, slipt
in the arm-pit, there will be a cavity on the top of the shoulder,
different from the sound arm, and the elbow will be drawn upwards,
without being able to be moved either towards the body; or so, as the
patient to put his hand out without the greatest pain.
When this is found to be the case, then, in order to reduce it, set the
patient low, on a steady seat. Take a napkin or towel, of which make a
girt; put one part over your neck, and the other part under the arm-pit.
Let an assistant hold the patient steady, another take hold of the
patient’s arm, with the elbow bent, and extend it gradually; then with
both your hands take the arm, and whilst you lift up the arm by help of
the napkin resting on your neck, you press gently down the arm with your
hands like a lever; in the mean time the assistant extends, and thus you
reduce it; which you will hear by its snapping: upon which the patient
will be able to move his arm in all kind of direction, without much
pain.
If the head of the arm-bone is dislocated forwards, there will be a
cavity backwards on the shoulder, and the elbow will stick backwards,
and remain motionless, with great pain. In this case, as before, let the
patient sit low, and with the help of the napkin, and assistances, first
extend the arm forwards; then like a lever bring the head of the bone in
its cavity; which, like the former, will be perceived by a snapping, and
the voluntary motion of the patient’s arm.
When the shoulder is reduced, secure the whole with a long double-headed
bandage, cross-wide over the shoulders, and round the body. Foment it
night and morning with _spirits of wine and camphor_ (A). Keep the arm
close to the body, with the elbow bent, and wear it in a sling, that it
may be free from motion till it is well.
_Dislocation of the Elbow, or the Knee._
The elbow, as I said before, is very seldom dislocated, unless
fractured, and the ligament tore at the same time; and when so, the case
is terrible. But very often those joints receive a wrench, which, though
nothing out of its place, is often very painful, on account of the many
tendons that surround the parts. The only thing in such wrenching, is to
foment it with _spirit of wine and camphor_ (A), or else the
_saponaceous linament_ (B). The same method should be observed with the
knee, securing it well with a bandage, in order to give it rest to
recover: For rest is a principal remedy.
_Of spraining the Wrist, or Ancle._
The wrist and ancle are complicated joints, and thence capable of a
great number of motions, and subject to a variety of sprainings, but not
a perfect dislocation; nevertheless, they are very painful, and
sometimes tedious in getting well. Whatever be the matter, the sick part
should be compared with the sound, and the difference is soon seen.
If it so happens, that there appears a perceivable difference, the parts
should be gently extended, and reduced; and all that is to be done, is
the securing it well with a bandage, and fomenting it with _Spirits of
Wine and Camphor_, (A) or, what is yet better, _Linament of Soap_. (B)
The thumb, however, is liable to be dislocated, which is easily
perceived; which should be immediately reduced, and secured with a
bandage, and treated as already directed.
_Dislocation of the Thigh Bone._
The articulation of the thigh bone with the hip is similar to the
shoulder, with regard to the head of the bone, and the pan in which it
moves, except that it is much deeper. It must be a great force that
drives it out of its articulation, and consequently very difficult to be
reduced. It may either be dislocated inwards, or backwards.
If the dislocation is inwards, which is the most common, the toes will
be turned outwards, and the whole leg and thigh will be somewhat shorter
than the other; so likewise, if it is dislocated backwards, the leg and
thigh will appear shorter, but the toes will be bent inwards. The best
way of determining, as I have said before, is to make a just comparison
of the sick and sound leg.
The reduction is somewhat difficult, and will sometimes baffle the most
experienced surgeon, because the acting muscles are very strong; and
when they have first begun to contract the parts, they will not easily
suffer themselves to be relaxed. Nevertheless, lay the patient upon his
back or on the sick side, upon a steady table; let an assistant hold him
fast, another extend the thigh, so as to have the knee bent; the
operator having a napkin resting on his neck, and under the thigh of the
patient, similar to the method directed before by the shoulder; and then
with both hands bend the thigh, as with a lever, into its socket again;
when it will give a loud snap, coming into its proper place.
It very frequently happens in this heavy dislocation, that either the
articulation is not reduced, or that it immediately slips out again when
reduced; so that the patient will never recover the former use of that
limb more. In this case nature is very kind, and the part where the bone
slips into will become callous, and form as it were a new acetabulum; by
which the patient in time comes to walk, though (as it may be supposed)
but lamely. In the course of my practice I have met with but two perfect
dislocations of the thigh, both of them perfectly recovered; but it must
be remembered, they had youth on their side, and the greatest care
joined to favourable circumstances.
At best however, it is an ugly accident, for it is not only that the
ligaments that surround the joint are generally torn, but very often the
thigh bone is fractured at the same time. It requires more skill than
one would suppose, to determine which is the case, whether a fracture,
dislocation, or both; and am apt to believe they are often confounded
with each other.
When the dislocation is reduced it should be well secured with a long
double-headed bandage; the patient kept still, the part well fomented,
and if requisite, some blood taken away: a fever generally attends,
which should be duely taken care of.
On the whole, dislocations when they proceed from violence, are
sometimes attended with severe symptoms, the parts being very sensible,
and it will require sometime for the patient to recover his strength
again.—Care therefore should be taken to keep the parts warm, and give
them as much rest as possible.
A strengthening plaister spread upon leather, and put for a constancy
round the parts after the inflammation is gone of, will also prove of
singular service.
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