Part 58

To the last method I would, from some experience, give the preference. It is the least severe, both immediately and consecutively; it is the most readily accomplished, and the most likely to be followed by a successful result. The exact site of the ends of the bones must in the first place be ascertained; the position of the bloodvessels and nerves must be looked to, that they may be avoided; a bistoury is then passed through the skin and down into the substance interposed between the ends of the bones. A strong and sharp needle, fixed in a handle, and with its eye near the point, is passed, in the track of the knife, fairly betwixt the bones, and pushed through the soft parts on the opposite side of the limb. A cord is then passed through the eye, and by withdrawal of the needle the seton is properly lodged. The effects must be attentively watched, and when sufficient action is supposed to have been excited, perhaps at the end of the first week, the cord is withdrawn, and the limb placed immoveable in a proper position. If action is slow in supervening, the chord may be smeared with irritating substances, as the unguentum oxydi hydrargyri rubri, or the unguentum cantharidis, &c. In this manner I have treated false joint in several situations successfully, but I have also been sometimes foiled in effecting my purpose. The seton must not be long retained, the object being to excite action, not to perpetuate discharge, by the profusion of which the end will be effectually frustrated. Much will depend on the period at which the practice is adopted.

Dislocations.—Some joints are so contrived—their composing bones are so notched into one another, and connected by such powerful apparatus—and they are crossed by tendons, and tied together by ligaments in such a manner,—that dislodgement can scarcely be effected but by the most violent means. Nothing short of immense force is sufficient, and the displacement is uniformly attended with fracture of portions of the bones, or of their processes. Other bones are loosely joined, permitting free and unrestrained motion in all or in many directions, and but little force, applied in particular directions, suffices to separate and luxate them. In every joint the processes are liable to be broken, and the attachments of the ligaments to be torn off; ligamentous tissue withstands a greater degree of sudden violence than the osseous. The synovial membrane, and the fibrous tissue exterior to it, are almost always torn in complete luxation; but the extent of laceration varies in different joints, according to the direction of luxation and the degree of displacement. The rent may be small, closely embracing the neck of the bone; or there may be an extensive gap on the side opposite to that on which the luxation has taken place. In an articulation surrounded by muscular substance, there is also laceration of this to a greater or less extent. In some individuals, dislocation is very apt to occur, perhaps from peculiar laxity of fibre; and if in any person luxation of a joint has once been produced, the accident is apt to occur again and again from but slight causes.

In general, the mobility of the luxated joint is much diminished; the limb is either shortened or lengthened; its contour is changed; the injury is attended with violent pain; the patient is sick and pale; the system receives a shock, from which it gradually recovers after some time. Then swelling, from effused blood, takes place; and this is followed, after some hours, by excited action of the vessels and farther effusion, giving rise to greater stiffness and pain on attempts at motion. If no means are taken to replace the bone, and painful feelings subside along with the swelling, the limb remains long useless, and is the seat of occasional lancinating pains, but at last motion and utility are to a certain extent restored by the formation of a new joint—the head of the bone, and the parts on which it rests, mutually accommodating themselves to each other, by degrees, and permitting a limited extent of motion. Post mortem examination, years after the occurrence of the injury, shows change in the form of the bones—the head is flattened, and in the bone on which it lies there is a corresponding depression, formed partly by the deposition of new matter, partly by absorption of the old; in dislocation on the dorsum of the ilium, for example, there is excavation by absorption opposite to the centre of the head of the femur, and round this new osseous matter is deposited so as to form the cavity into a cup resembling the acetabulum. New processes are formed for the attachment of the muscles, and the old are absorbed to a remarkable extent. There are also new ligaments; and a sort of capsule is formed by condensation of the surrounding cellular tissue. The new articulating surface becomes quite smooth internally, and is covered, if not by cartilage, by a smooth substance which answers the purpose tolerably well; the old is gradually filled up and obliterated, the prominences being absorbed, and the cavity occupied by new deposit. These changes do not take place so rapidly as is generally supposed; the cartilage and synovial surface are not much altered for months after the occurrence of luxation; and if replacement be effected, the functions of the parts are soon performed as before the injury.

In some articulations, on account of the formation of the opposed surfaces, attempts at reduction prove ineffectual after the lapse of two or three weeks; in others, of more simple construction, it may be accomplished after some months. The simple mode of reduction is to put the patient off his guard, so that the muscles may be in a state of relaxation, and then to move the limb artfully in the proper direction, without much force. Occasionally, the bone is pulled into its place by the action of the muscles, during the patient’s efforts to place the limb in a comfortable position. Considerable force, however, is sometimes required in even recent luxations of large joints, and means must also be taken to weaken the muscular power. The patient, if young and robust, may be bled to syncope, or placed in the warm bath till a sense of fainting supervenes; or an enema of tobacco infusion may be administered, and smoking of tobacco may have the same effect when the patient has not been addicted to the noxious habit; or antimonial solution may be given in nauseating doses. Several or all of these methods may be necessary in some cases, particularly if the dislocation be of long standing. When thus general exhaustion has been procured, counter extension and extension are to be had recourse to. The former consists in having the patient, and the bone next to the trunk, fixed immoveably by fitting lacques and belts; and the latter is made by one or more assistants, or, if need be, with the help of pulleys. During extension, advantage is in many cases gained by lateral force and by rotation of the limb, the bone being thereby moved from its position, and brought within the sphere of muscular action, by which it is drawn suddenly into its proper place. In some cases, there is no doubt but considerable laceration is occasioned by the efforts at reduction, and perhaps this is in some degree necessary to a successful issue—as when the capsule has been slightly lacerated by the accident, and in consequence interposes an obstacle to the head of the bone slipping into its socket. After reduction, inflammatory action in the articulation and its neighbourhood is to be expected, to a greater or less degree, particularly when much force has been employed, and means must be taken to avert this; local remedies are generally sufficient, along with perfect rest.

In luxation of the lower jaw, both articulating ends are most frequently dislodged. They can escape in but one direction, forwards into the temporal fossæ; when both are dislodged, the mouth is widely open, and fixedly so, the chin is drawn downwards and backwards. When one is displaced, the jaws are partially opened, the chin is twisted to a side, and immoveable. Great pain is experienced from the pressure of the condyles of the bone on the temporal muscles, from stretching of the fibres of the pterygoids, and from interruption to the functions, by pressure, of the contiguous blood-vessels and nerves. Mastication is impossible, the speech is altered, and indeed articulation may be said to be impracticable.

It is supposed by the vulgar that the accident is particularly apt to happen to infants and young persons. Nurses are in consequence careful, when a child yawns, to support the chin, and pronounce an accompanying blessing. The articulating cavity is then shallow, yet luxation must be rare in young subjects. In my own experience no instance of dislocated jaw has occurred but in adults; and then, either from over-opening of the jaws, or from powerful muscular action during depression of the inferior maxilla.

The nature of the injury is at once known; and the displacement is easily remedied. But I have met with instances where, through ineffectual attempts at reduction, the unnatural position has been allowed to continue for many hours, to the great distress of the individual. The object in view is to depress the ramus—one or both, as may be—and to raise the chin. This is effected by pressure with the thumbs on or in the situation of the molar teeth, whilst with the fingers the jaw is moved upwards and backwards. The thumbs need not be protected by a glove, as is generally recommended; on the bone resuming its place, they are easily slipped into the space betwixt the jaw and the cheek. There is no necessity for bandaging, as retentive apparatus; the patient is not likely to yawn for some time after.

Luxation of the clavicle, at either end, is produced by force applied to the point of the shoulder. It is seldom that the sternal extremity is separated from its connexions. When this accident does happen, it is easily recognised; the end of the bone is prominent and loose, and is distinctly felt riding over the top of the sternum. Replacement is effected by bringing back the shoulder; but the bone is with difficulty retained in the proper position, and is long in becoming fixed; a certain degree of deformity is ever after present.

Displacement of the scapular extremity is by no means rare, and occurs to a greater or less extent, according to the laceration of the ligaments. If those only are torn which connect the end of the bone to the acromion, there is mere rising of the end. But if—as is often the case when the violence has been great, as in a fall either from a height or with great velocity—the conoid and trapezoid ligaments connecting the tuberosity of the bone with the coracoid process, have given way, then the end of the bone projects, pushes out the deltoid, and gives rise to considerable flattening of the shoulder. The arm falls forwards, and cannot be moved but with pain; nor is the patient able to raise it by its own muscular power. If the surgeon grasps the middle of the bone, he finds the end moveable; and the evident and deforming projection puts an end to any doubt regarding the nature of the case. The bone is readily reduced by raising the arm, and carrying the scapula backwards. The limb must be retained in the proper position for many weeks, if a cure without interruption, and with as little deformity as possible, is desired; but after the utmost care and patience, there still remains, in almost every case, some projection more than before the accident. The ligaments are slow in uniting, and the union is imperfect and weak. The requisite apparatus is the same as for fractured clavicle, but must be retained for a longer time. The patient experiences great relief from the limb being put up in this manner and maintained so; and inflammatory action, with much of the swelling, is averted.

The inferior angle of the Scapula occasionally escapes from under the border of the latissimus dorsi, usually with some laceration of the muscular fibres. The displacement is occasioned by raising the arm above the head to an unusual extent. The angle of the bone projects considerably, and the muscle is felt playing beneath it distinctly during motion of the parts; the movements of the limb are limited and painful. The parts may be brought into their original position by pressing the angle of the scapula towards the ribs, whilst the arm is much raised; and the bone is afterwards confined in its proper place by a broad bandage passed pretty tightly round the chest. The retentive apparatus must be continued for a considerable time, and in some cases a cure may be so effected; but in general the bone soon regains its former unnatural position, and continues to do so, however often and however easily it may be replaced. The parts gradually become accustomed to the change in relative position, and little inconvenience is experienced.

Luxation of the Shoulder-joint is prevented, by the arrangement and structure of the parts, from taking place in any direction excepting towards the axilla—downwards into the hollow of the armpit, downwards and forwards under the lower border of the pectoral muscle. Occasionally, though very rarely indeed, displacement occurs backwards. On the anterior and inferior aspects, the articulation is not supported, as at its other sides, either by muscular substance or by processes of bone. The accident is occasioned sometimes, though rarely, by direct violence, as by a blow on the back part of the shoulder; and of such I have seen a few examples. But, in almost every instance, the displacement is caused by force applied to the distal extremity of the humerus; either immediately, as by falling on the elbow, or through the forearm, as when a person endeavours to break a fall by stretching out the arm, and alights with the whole weight of the body on the palm. The accident may also result from forcible abduction of the extremity, particularly when the power is applied near the extremity of the limb. There is laceration, to a greater or less extent, of the capsule, and of the muscles immediately investing the fibrous tissue round the articulating cavity. Without disruption, complete luxation cannot exist—the articulating surfaces cannot be separated, nor can the head of the humerus be altered in position; subluxation, or, in other words, a sprain, may occur in such circumstances, but true luxation cannot.

Bruises of the shoulder, with or without fracture, either of the scapula or of the upper part of the humerus, must not be mistaken for dislocation, for the consequences of such a blunder are fearful. In both descriptions of accident, the appearances of the limb are somewhat similar, and hence the examination requires to be particularly accurate and careful. In both there is flattening of the shoulder, but in fracture there is crepitus, motion to an unnatural extent, though painful, and greater suffering during manipulation; in dislocation no crepitus at all resembling that in fracture can be perceived, the motions of the limb are very limited, and the displaced head of the bone can almost always be felt. The direction of the force, too, as already observed, when on the subject of fracture, is an important assistant in diagnosis; from falls or blows upon the shoulder we may expect fracture, from falls on the elbow or palm, luxation. In dislocation an indistinct feeling, sometimes amounting to obscure crepitation, is occasionally perceived during rotation of the limb; and this arises from one or more of the tendinous attachments of the muscles having, during their disruption, torn away a portion of their osseous attachment.

Great pain attends on dislocated humerus, from the head of the bone compressing and stretching the axillary plexus; and the interruption to the flow of the blood produces tingling at the points of the fingers, numbness of the whole limb, and after a time swelling of the hand and forearm. Flattening of the shoulder, and depression under the acromion, are the most prominent marks of displacement having occurred, and are at once apparent. They are more distinctly perceived on comparing the two shoulders; then the acromion on the affected side stands remarkably outwards. The projection is not so apparent when the immediate swelling from effused blood has been fully formed, but the hollow under the acromion can be felt through any quantity of extravasated blood. The arm admits of very little motion, is lengthened and abducted. The elbow cannot be brought close to the side, and attempts to do so are productive of great suffering. The patient has little or no muscular command over the upper arm. Rotation and elevation of the limb require considerable force, and are practicable only to a very limited extent; during attempts at the former, as already mentioned, obscure crepitus is sometimes perceived. The abduction is most remarkable in the dislocation directly downwards; and in this form of the accident, the fingers easily detect the head of the bone lying in the axilla, deep, yet distinct, particularly during attempted rotation. When the head of the bone lies forward by the coracoid process, and under the pectoralis major, it can be felt, and the prominence occasioned by it can be clearly seen in thin people, before swelling has occurred, and after its subsidence. The bone sometimes lodges in an intermediate situation, and then the signs peculiar to each form of displacement are mixed. When reduction is not accomplished, the bloody swelling first occurs to obscure the signs; this may in part subside, but then the inflammatory supervenes; both after a time disappear, the muscles waste, and then all the signs are very apparent. After some weeks, the motions of the limb become more extensive, not in consequence of the head of the humerus having changed its position, or returned into the glenoid cavity, but from the scapula moving on the ribs more freely, and to a greater extent than usual. At last, but not till after a long period, considerable motion betwixt the bones can be effected; the scapula, where the head of the humerus rests, having furnished an adventitious cavity, to which the latter has adapted itself. But free motion can never be regained, for the movements that are effected are chiefly produced by the action of the muscles of the scapula.

Replacement, even in very recent cases, sometimes is accomplished with difficulty in those whose muscles are fully developed. But in general a successful result will follow simple measures, particularly if the patient is taken unawares—as by rotating the arm with one hand whilst the fingers of the other are placed in the axilla, then suddenly lifting the head of the bone outwards, and at the same time performing abduction—the patient being all along assured that he will not be put to pain, and that there is no intention of attempting reduction. In this manner reduction may often be accomplished by the surgeon and one assistant; the trunk and scapula being fixed by the assistant, either grasping the patient in his arms, or holding a sheet or towel passed round the body, close to the axilla, whilst the surgeon extends and rotates the extremity, and at the same time lifts the head of the bone from its situation. The rotation is made by using the forearm, bent to a right angle, as a lever; thus considerable power can be exerted on the head of the bone, and the long head of the biceps muscle—the stretching of which, no doubt, affords an obstacle to reduction—is at the same time relaxed. In luxation downwards, there is no more successful method than that by counter-extension with the heel in the axilla, and extension by the surgeon grasping the wrist. The patient is placed recumbent, on a couch or on the floor, and the surgeon, sitting by his side, lodges his heel in the axilla, and with both hands extends the arm; after a short continuance of extension, he performs a sudden and powerful combination of both movements, and so jerks the bone into its natural position. In some recent, and in all old cases, it is necessary to apply considerable force, steadily, and for a long time, so as to tire out the muscles, and dislodge the head of the bone. An assistant effects this by means of pulleys. These are fixed to a laque, applied above the elbow with a clove-hitch, and to a ring fastened either in the wall or to a post; two small iron rings which can be screwed into a beam are useful in private practice, and should always accompany the pulleys. When all is prepared, the assistant pulls the end of the rope steadily, and with considerable power, whilst the surgeon rotates the limb, and endeavours to lift the head of the bone, at the same time regulating the degree of extension. The directing of the degree and continuance of the force is not the least difficult part of the procedure, for, when excessive, there is a risk of the axillary nerves and artery giving way; such accidents have happened, and been accompanied with serious and even fatal consequences; and from laceration of other tissues, the muscular, fibrous, or cellular, fatal inflammation and abscess have resulted. The surgeon is therefore called upon to exercise judgment and discretion—not to continue extension to a pernicious extent, and not to abandon attempts at reduction too soon, leaving his patient disabled for life. For making counter-extension to the extension by pulleys, a broad strong belt is useful, perforated near the middle for transmission of the injured arm; it is passed round the body so as to fix the trunk and scapula, coming under the axilla of the sound side, and being then fastened by means of a hook to a ring in the wall.

Luxations of the shoulder-joint may be, and have been, reduced after the lapse of two or three months; but the difficulty increases, and the chance of success diminishes, in proportion to the time which has elapsed since the date of the accident. And in deciding upon making the attempt, many circumstances are to be weighed and considered—the patient’s period of life and his occupations, the state of the parts, the degree of motion that has been acquired, and the treatment, if any, which has been previously followed. Perhaps the most important consideration is regarding the state of the parts, as indicated by the degree of motion. If the movements be to such an extent as to favour the supposition of the head of the bone having been furnished with a new recipient cavity, to which it has in a great measure accommodated itself, and that the glenoid cavity has, from disuse, become altered, the surgeon can scarcely hope for advantage to his patient from attempts to break up the new articulating apparatus, and reëstablish the old. The patient will, most probably, be put to a great deal of pain and some danger, without experiencing improvement to the limb; indeed the motions and power may prove less than before. In old men, too, force sufficient for reduction cannot be employed without great risk of laceration of nerves, bloodvessels, and muscles. But if the patient be young, the motions still limited, and the articulation apparently not changed by solid effusion, reduction may be attempted with a fair prospect of success, and without injury. In all such cases, however, the surgeon must watch every step of the proceedings, and have sufficient experience to stop short of inflicting irreparable mischief. No standard can be fixed for the degree of force that is necessary and safe; he may be foiled, even after the most powerful efforts, in a dislocation of two or three weeks’ duration; whilst, by the use of but slight force, he may succeed in one of as many months. Much assistance is obtained by the means formerly adverted to, as auxiliary, by weakening the muscular energy. Of these, nauseating doses of antimony are most generally employed, and being the most safe, may be recommended to be tried first; and if these fail to produce the desired effect, the patient may be bled freely, if he be young and robust, more especially since this will assist to avert the inflammatory action likely to follow the violent reduction. Tobacco produces the most complete prostration of muscular power, and may consequently be resorted to in extreme cases; but it ought, if possible, to be avoided, as its use is far from being void of danger. The warm bath cannot always be procured; when at hand, it merits adoption, being both safe and effectual, particularly if combined with antimony or bleeding. The extension should not be commenced till these means have begun to take effect, but everything should be prepared, so that it may be applied at a moment’s warning. After all attempts at reduction, whether successful or not, it is necessary to moderate the inflammation that ensues, by local bleeding and fomentation, combined, if necessary, with nauseating laxatives: general depletion is seldom required.

Luxation of the Elbow-joint is an extremely common accident, particularly in young persons, before the bony processes have been fully formed. It is produced by wrenches, or by force applied to the farther end of the forearm, the bones neither breaking nor bending. Sometimes, though very rarely, it is caused by direct violence, as in a fall, and then may be combined with fracture of one or both bones of the forearm; but in other circumstances, fracture and luxation can scarcely coexist. In general, both bones of the forearm are displaced backwards, sometimes a little to the ulnar side. The coronoid process occupies the cavity for the reception of the olecranon, and the head of the radius lodges behind the external condyle; the extremity is shortened, and looks twisted; it is slightly flexed, and in the middle state between pronation and supination. Unnatural lateral motion can be produced, but flexion is impracticable, the limb cannot be brought quite into the extended state, and rotation is difficult and painful. Swelling soon takes place, and consequently the hollows are filled up, and the processes of the bones obscured. Yet the olecranon and inner condyle can always be recognised and felt, and their relative position ascertained; the form of the end of the humerus, its hollows, and its prominences, can be distinctly discerned, both before and after the swelling, the soft parts being stretched over the bone; and by rotating the limb with one hand, whilst the other is placed over the outer and back part of the joint, the situation of the head of the radius is detected. Thus the relations of the bones to one another are discovered; and this must be done at once, whatever pain may be produced by the examination, for it is a saving of suffering in the end. Yet the nature of this injury would seem difficult of detection—a fact scarcely intelligible by any one who is careful in his manipulations, and who possesses common observation, and a sound knowledge of anatomy. Many cases of unreduced luxation are met with; I have seen it in both elbows of the same person; and I have had a dozen of cases, in as many months, of unreduced elbows shown too late for attempts at reduction. The frequent occurrence of such blunders is the more lamentable, as it is almost impossible to replace the bones after three or four weeks; indeed, I have been foiled at the end of two weeks. The parts soon accommodate themselves to their new position, the olecranon process shortens, motion rapidly increases, and the bones get more and more secure in their new relations,—osseous matter being deposited laterally, forming cavities for their lodgement, and new ligamentous matter confining them thereto. After a time, flexion can be made to a right angle; and the limb becomes tolerably useful. By unsuccessful attempts to restore the natural position, inflammation is excited; and thus the salutary processes, commenced by nature for reparation of the displacement, are interrupted and delayed; in young persons such disease of the joint may be produced as might lead to loss of the extremity.

Luxation of the Radius alone, backwards on the outer condyle, is sometimes met with; but this bone is seldom singly displaced far from its original site. A hollow is felt below the end of the humerus, on the outer and fore part, and there is a corresponding prominence behind; the head of the bone is found unnaturally moveable on rotation, and this motion is difficult and painful; the arm is extended, presenting a twisted appearance, and flexion is very limited. Extension is to be made, along with pronation.

Sometimes the radius is displaced forwards. The coronoid process of the ulna is occasionally broken off; there is no deformity during flexion of the elbow, but when the limb is extended, the olecranon is drawn upwards.

In luxation of both bones, reduction is much facilitated by position of the arm. The arm and forearm are extended, and the limb is brought well behind the trunk, so as to relax the triceps; then the surgeon performs extension and counter-extension, pulling the forearm with one hand, whilst he pushes with the other placed on the scapula. If the force thus employed prove insufficient, as it seldom will in recent cases, the patient may be placed on his face, on a couch, and on the limb being brought into the favourable position already noticed, counter-extension may be made by the heel planted against the inferior costa of the scapula, whilst the wrist is pulled with both hands. It is seldom necessary to employ pulleys, excepting in cases of old standing; if so, the only peculiarity in their application to this joint is the direction of the force, backwards. And this I consider to be a very material part of the manipulations, for, by attention to it, I have succeeded after previous failures,—after great force had been applied, causing excoriation and swelling of almost the whole limb. In luxation of the radius, backwards, flexion and pronation, combined, if necessary, with extension, will generally effect replacement.

Dislocation at the Wrist is very unfrequent. The articulation is naturally strong, admitting of little motion, the bones being accurately fitted to each other, whilst the retaining ligamentous apparatus is both copious and unyielding; on this account greater force is required to effect displacement here than at either the elbow or shoulder-joints, and violence applied to the hands usually causes fracture of one or both bones of the forearm, not luxation of their extremities. Luxation, however, sometimes occurs, either from violent twisting, or from falling on the palm of the hand; and the displacement may be either of both bones or of one. In the latter case, it is almost uniformly the radius that suffers; in the former, the luxation is forwards.

Dislocation of the distal extremity of the radius is generally produced by a sudden wrench or twist. The bone is felt loose and prominent, sometimes riding over the upper part of the carpus. The position of the hand is towards pronation, supination cannot be performed, and, on attempting it, great pain is occasioned. Reduction is readily accomplished, by pulling the palm with one hand, whilst with the other the head of the bone is pressed backwards into its situation.

Displacement of both bones is more frequently the result of a fall on the palm, with the hand bent much backwards. In this case there are two projections, so distinct as at once to mark the true nature of the accident, one anteriorly, formed by the ends of the radius and ulna, the other posteriorly by the carpus; above the posterior prominence there is a considerable depression. Here also reduction is easy; it is sufficient to perform simple extension with one hand, whilst with the other the wrist is moulded into its proper form. The after treatment, however, requires attention, for extensive laceration of tendinous and ligamentous tissue, perhaps combined with fracture of the bony processes to a greater or less extent, must have taken place to admit of displacement; in consequence violent inflammation is to be expected, and means must be taken to avert it. On account of this laceration, also, mere reduction is not sufficient, retentive apparatus must be applied; as soon as the limb has been made straight, a pasteboard splint is to be applied on each side, as in fracture of the forearm, and retained with a roller, a wooden splint being placed exteriorly until the pasteboard hardens. This precautionary measure is also necessary to avert redisplacement in dislocation of the radius singly; in both accidents the apparatus should be retained for at least a fortnight. Afterwards, passive motion, gradually increased and combined with friction, is requisite to prevent stiffness of the joint.

In mere sprain of the wrist, large swelling soon forms anteriorly, from extravasated blood, resembling somewhat projection of the bones, and so leading towards fallacy in diagnosis; indeed it is not unreasonable to suppose that dislocation here does not occur so frequently as is imagined. Fracture also near or through the distal extremity of the radius, an accident formerly mentioned as exceedingly common from falls on the hand, is very apt to be mistaken for luxation. On this account, and because in every injury of the wrist the parts are soon obscured by bloody swelling, there is a strong necessity for early and accurate examination.

Subluxation not unfrequently occurs; in other words, the attachments of the bones of the forearm to each other are broken up, and their extremities separated to an unnatural distance. The accident is distinctly marked by the deformity, the absence of hard projection, and by the unusual space between the radius and ulna occupied by a soft and yielding swelling. Replacement is accomplished much in the same manner as in complete luxation, the bones being compressed towards each other with one hand, whilst extension is made with the other; afterwards splints must be applied and retained.

Compound luxations of the wrist are occasionally met with, and, like compound fractures in this situation, are always troublesome, and often terminate unfavourably. The soft parts are sparing, possessed of little vitality, and much injured by the accident; consequently reparation proceeds very slowly, and is generally superseded by unhealthy and profuse suppuration, perhaps accompanied with more or less sloughing of tendons and integument. If the ends of the bones protrude bare, shattered, and split, they should be removed by means of either the saw or the cutting pliers, previously to attempts at reduction; the wound should then be approximated, and the cure conducted on ordinary principles.

Sometimes a single bone of the Carpus is displaced, usually backwards. It is quite loose and moveable, and is easily replaced, but in almost every case redisplacement occurs, the bone at one time occupying its proper situation, at others forming an inconvenient and unseemly prominence on the back of the wrist, diminished by extension, and increased by flexion of the joint. The accident, however, is rare. I have never seen simple dislocation of any of the metacarpal bones.

Dislocation of the Fingers is produced by force applied to the extremities of the phalanges; the displacement is always backwards, excepting at the middle joint, where the bone of the middle phalanx is sometimes, but very rarely, luxated forwards. The remarkable projection on the back part of the finger marks the nature of the accident, even to the most careless observer. Reduction is accomplished by extension combined with flexion. In the case of the distal phalanges, it may sometimes be necessary to fasten a cord to the tip of the finger, in order to obtain sufficient extending power. After replacement, the application of temporary splints and bandage is prudent. Compound luxations, however carefully treated, almost uniformly come to amputation.

Luxation of the first joint of the thumb is rather an uncommon accident, and is not easily managed. The base of the first phalanx is displaced backwards upon the distal extremity of the metacarpal bone, causing a remarkable prominence on the dorsal aspect, and a corresponding depression on the palmar. The thumb is shortened, deformed, and almost immoveable; the swelling and pain are severe. This displacement is generally produced by the application of force to the point of the thumb, as in falling on it, or in coming against a resisting body with the thumb straight. The deformity is such as at once to apprise even the most inattentive or inexperienced of the true nature of the injury; but the treatment is very difficult and puzzling even in the hands of the best informed surgeons. The base of the bone seems to slip through the lateral ligaments, and remain firmly locked in their embrace; and these being very strong, and in a state of complete tension, defy all usual attempts at reduction. The end of a silk handkerchief, or thick soft cord, is to be attached to the distal extremity of the displaced phalanx, by means of the clove-hitch; and with this extension is made, either by the surgeon alone, or by one or more assistants,—frequently several are required. Counter-extension is made by the surgeon or assistant grasping the forearm, or another handkerchief may be passed betwixt the thumb and forefinger for an assistant to hold on by. The extending force should be made in a direction towards the palm, and almost uniformly requires to be great and long continued, even in recent cases. The bone may occasionally be jerked into its place by a sudden attempt at flexion of the joint, during steady pulling that has been continued for some time. But cases have occurred in which all attempts have proved ineffectual, and it has been found necessary to divide one of the lateral ligaments. From what has been already stated, the reason why this proceeding should facilitate reduction is sufficiently obvious. I had recourse to it in one instance,—one in which difficulty of reduction was not to have been expected. The accident was very recent, not an hour had elapsed; the patient was an old man, and very drunk; no resistance to the reductive measures could have been offered by muscular energy; yet very powerful force was applied and persevered in without avail. At last the external lateral ligament was divided by the point of a very narrow and fine bistoury, and then replacement was immediate and easy. Some inflammation followed, but was kept within bounds, and the man regained the use of the articulation. In other cases, again, the bone is replaced by the use of but very slight force, provided it be applied, as already stated, in a direction towards the palm of the hand. The last phalanx is equally liable to luxation in the thumb as in the fingers, and has no peculiarity of treatment.