passed through the loop attached to the arm and around a fixed point established in an appropriate position. The traction should be about twenty or twenty-five pounds, and needs to be continued for from fifteen to thirty minutes; under its influence the muscles become relaxed and the patient experiences the sensation of great fatigue, the head of the bone gradually approaches the glenoid cavity, and either enters it spontaneously or is replaced by the pressure of the surgeon's fingers, or by a sudden pull upon the arm. Instead of the rubber, a weight and pulley may be conveniently used, and the direction of the traction changed when necessary by shifting the position of the pulley. Evidence of the success of the effort to reduce is furnished by the sound commonly heard on the reëntrance of the head of the bone into the cavity of the joint, and by the restoration of the normal form of the region. When the dislocation is no longer recent-that is, when a sufficient period has elapsed for subsidence of the inflammation, and for union of the lacerated tissues in their new relations, but while there is reason to think that reduction is still possible-manipulation alone will not suffice, but resort must be had to other measures, such as more forcible traction and rotation, to break up the adhesions, and thus restore to the displaced bone the mobility which it possessed when the injury was recent. It is always a very difficult question, and one that cannot fail to cause the surgeon much anxiety, whether the attempt to reduce should be made, and how much force may properly be used in it. The length of time that has elapsed is not of itself sufficient to determine the answer to this question, for experience has shown the widest differences in this respect, some dislocations proving irreducible after two or three weeks, while others have been quite readily reduced after the lapse of several months. Some help may be got from consideration of the amount of inflammatory reaction immediately following the injury, from the position. and mobility of the head of the bone, and possibly by recognition of the condition of the articular cavity; but, after all, a positive answer can only be obtained by making the attempt. It is hardly necessary to add that the attempt should be made with the utmost caution, and with constant attention to the dangers with which experience has shown it is surrounded, especially rupture of large adjoining vessels and nerves, and fracture of the bone. As has been already said, the difficulty lies not only in the adhesions which fix the bones in their new relations, but also in the possible closing of the rent in the capsule, and in the shutting off of the articular cavity by the formation of adhesions between its margin and the overlying capsule. When these conditions exist, reduction without a cutting operation is practically impossible. The danger is by no means to be measured by the force employed in the attempt, for it is dependent also upon the changes undergone by the tissues in consequence of the dislocation, and upon their inability to accommodate themselves to the changing positions of the limb during manipulation. As dislocations of the shoulders are more common than all other dislocations taken together, and as rupture of the axillary vessels is not only the most dangerous, but also the most frequent accident during attempts at reduction; and as, moreover, a dislocated arm may still be a very useful member, it is not surprising that surgeons, speaking under the sense of their responsibility as teachers, have often uttered strenuous warnings, like this of Hutchinson's,' who, after calling attention to the chance of accident in elderly patients, adds: "Let me beg of you not to allow any impulse of selfish vanity or the desire to vaunt an unusual success mislead your judgment into attempting that which is not really for your patient's advantage. Let him go elsewhere if he likes, and let another possibly obtain the credit of success; you will still be able to reply, with the celebrated general, that, despite the fact of victory, you still hold to your former judgment that the battle ought not to have been fought." The same keen sense of the risk involved was shown by the late Professor Gross, when he said, "I have never had charge of an old or neglected dislocation without a strong secret wish that it had fallen into other hands, such have, usually, been my disappointment and the anxiety attendant upon my efforts at reduction. When it is sought to reduce a dislocation that is no longer recent, the first effort should be to liberate the displaced head by rotation of the shaft, with the view of thus breaking up the new adhesions, and then traction should be made with pulleys, or with a machine such as Jarvis's adjuster (Fig. 8), which consists essentially of two metal rods movable upon each other by a rack and pinion, one of which is made fast to the distal segment of the limb for extension, while the other makes counterextension above. These instruments, as now made, are furnished with a 1 Hutchinson: Med. Times and Gazette, 1866, i. p. 304. dynamometer, which indicates the amount of force that is being exerted, and the same indicator may also be used with the pulleys. The machine has the advantage over the pulleys of allowing the position of the limb to be changed at will, and the disadvantage that the traction cannot be suddenly released. When pulleys are used, this sudden release is effected by interposing between them and the limb a specially devised catch, constructed like a pair of forceps, by pressure upon the handles of which the end is liberated. Traction by the hands of several assistants is dangerous, because of the difficulty of regulating the force exerted by them, which, by a sudden, well combined effort, may become excessive. It seems probable that we shall see much less in the future than in the past of these repeated, prolonged, forcible efforts to reduce old fractures, and that surgeons will resort instead to arthrotomy to effect reduction, or to excision or fracture to improve the position of the limb. All three methods have yielded some good results already, at the shoulder, elbow, and hip. The antiseptic method has earned the complete and well-founded confidence of the profession, and it has been abundantly proved that under its protection even the largest joints can be opened with but little risk; the disasters that have followed incisions in cases of articular fractures and dislocations have been usually due, in my opinion, to the selection of an unfit time for the operation, one when the injury was still fresh and the parts bruised and infiltrated with blood. Against a dangerous reaction under such circumstances antiseptics do not afford an adequate security, and the surgeon who proposes to open a dislocated joint should, I think, wait, if possible, until the reaction following the original traumatism has ceased. The different operations will be described in connection with the special dislocations. After-treatment.-After a dislocation has been reduced, there is needed, in most cases, only a simple retention bandage to confine the limb in an easy position. After a dislocation of the shoulder or elbow, the arm is bound to the side, with the forearm flexed and resting across the chest; after a dislocation of the hip nothing is needed but quiet rest in bed. In some other cases, dislocation of either end of the clavicle, of the head of the radius, or of the shoulder backward under the spine of the scapula (Busch and Krönlein), the tendency to recurrence is so great that special dressings are required. The joint should be kept quiet, certainly any movement that causes pain should be avoided, and if the inflammatory reaction threatens to be severe it must be opposed by the application of cold, or uniform gentle pressure if it can be borne. After the lapse of a week or two, passive motion within painless limits may be made, and the use of the limb gradually resumed. In making this passive motion or this use of the limb, those positions must be avoided in which the head of the bone would press upon the torn part of the capsule, or in which the sides of the rent would be again separated from each other. If, as sometimes happens, the joint remains stiff, weak, and sensitive, but is cold rather than warm, and aches, and perhaps becomes puffy after use, it needs massage and rubbing, and to be actively moved, either by the patient or by the physician. Its sensitiveness and immobility under such circumstances are due to the prolonged disuse, to retraction and loss of pliability in the periarticular tissues, and possibly to the presence of adhesions within the cavity itself. Sir James Paget' has written very wisely about cases of this class, and has pointed out that the temperature of the part may be taken as a safe guide in treatment. He says, "If the part be always overwarm, keep it quiet; if it be generally cold or cool, it needs, and will bear, exercise and freedom from the restraint of bandages, with friction and passive movements and other similar treatment of the reviving kind." In some cases it may be well forcibly to liberate the joint by free motion under anaesthesia. Habitual Dislocation.-A marked tendency to recurrence may be combated by prolonged immobilization of the joint if the injury is comparatively recent, or by special treatment designed to thicken and shorten the capsular and periarticular tissues. Genzmer has successfully employed in two cases of recurrent dislocation of the shoulder repeated injections into the joint of the pure tincture of iodine. The needle was introduced a finger-breadth below the coracoid process, and from seven to ten minims were injected. The arm was then immobilized, and the injections repeated from five to seven times at intervals of three or four days. He recommends the same treatment for habitual dislocation of the lower jaw. Gerster obtained a satisfactory result by arthrotomy with removal of a portion of the capsule. The patient was a girl, twenty years old, who had suffered a subcoracoid dislocation seven weeks previously. Reduction was very easy, but the weight of the limb was sufficient to cause immediate recurrence. Finding the tendency to recurrence unchanged after he had kept the limb in place for five weeks by a plaster-of-Paris dressing, Dr. Gerster opened the joint by an anterior incision and removed from the relaxed inner side of the capsule a piece one inch long by half an inch wide. A counter incision was made in the posterior part of the capsule for catgut drainage, and the anterior wound closed. High fever, six hours later, rendered it necessary to open the wound and substitute a rubber drainage tube for the catgut; the wound was then treated open, and the tube removed at the end of the second week. The wound healed in eight weeks. The mobility of the joint was fair, and there was no tendency to recurrence. 'Paget: Clinical Lectures and Essays, p. 84. * Genzmer: Centralblatt für Chirurgie, 1883, p. 563. Gerster: N. Y. Surgical Soc., in N. Y. Medical Journal, April 5, 1884, p. 390. CHAPTER VIII. ACCIDENTS THAT MAY BE CAUSED BY ATTEMPTS TO REDUCE A DISLOCATION. THE complications or accidents that may be caused by the attempt to reduce a dislocation may appear during the attempt, as the immediate consequence of the manoeuvres employed, or subsequently as a more or less remote consequence of the changed conditions, the local injuries, or the inflammation produced by those manoeuvres; and they may be localized at or near the dislocated joint, or may be the result of a local distant change or of a more diffused impression upon the organism. They may, therefore, be grouped as: 1st, primary local accidents; 2d, consecutive local accidents; 3d, cases of hemiplegia, syncope, and sudden death. The first group comprises injuries of the skin, cellular tissue, muscles, vessels, nerves, and bones; the second group includes suppuration in or about the joint, and oedema, gangrene, and paralysis consequent to injury to vessels or nerves. The third group includes those cases of shock or exhaustion, sometimes proving fatal, which have become exceedingly rare since the introduction of anæsthetics, and those others, that have come in their place, of death due to the anesthetic itself. Instances of these accidents and references to them in the writings of the older surgeons-that is, previous to the beginning of this century, are not very numerous, and they indicate that while the accidents themselves were not infrequent they were commonly attributed to the dislocation rather than to the effort to reduce. The most recent and complete work upon the subject is a Thèse de concours, by Dr. A. H. Marchand, Des accidents qui peuvent compliquer la réduction des Luxations traumatiques, published in Paris in 1875. Special articles upon the different kinds of injuries will be mentioned in the appropriate places. It is noticeable, on comparison of the cases that have occurred at different periods, that while some varieties of the lesions are common to all times, with their varying methods of treatment, others are in a manner dependent upon the means by which the reduction has been attempted. Thus, violent traction is the sole cause of some; manoeuvres, such as abduction and rotation of the arm, the principal cause of others; violent pressure at or near the head of the bone, prolongation of the effort, and anæsthetics, each of its own peculiar varieties. Notwithstanding these differences, certain points may be recognized as common to the greater number, such as the age of the patient and the length of time during which the dislocation has remained unreduced. Injuries of the vessels have been most frequent in the old and in dislocations of long standing, and all the other accidents have, in recent times at least, been rarely seen except in connection with dislocations that have long remained unreduced |