artery may be torn. The olechranon forms a considerable projection, on the back of the upper-arm, whereby the lower part of the m. triceps is twisted, and above the projection of the olechranon the upper-arm seems to be somewhat hollowed. On the front of the joint is felt a large hard swelling, beneath the tendon of the m. biceps; the fore-arm is fixed in a half-bent position, except when there is considerable tearing of the liga

ments.

1047. If the cubit alone, be thrown backwards, without simultaneous dislocation of the spoke-bone, behind the upper-arm-bone, the deformity of the joint is considerable, the fore-arm and hand being twisted inwards, the olechranon projecting, whilst the head of the spoke-bone retains its natural position; on the outside of the elbow-joint a remarkable projection, and on the inner a pit; the fore-arm cannot be straightened except by violence, which will reduce the dislocation, neither can it be bent farther than to a right angle (A. COOPER); the arm has been, however, observed motionless in extension, and every attempt at bending was painful and unsuccessful; pronation and supination could, however, be freely performed, the latter somewhat less than the former. If the fore-arm be but little bent, the annular ligament of the spoke-bone remains uninjured; but on greater bending, this ligament, the upper part of the interosseous ligament, and several muscular fibres are torn, and the head of the spokebone rests against the upper-arm. The distinguishing marks are, projection of the olechranon, and the twisting of the fore-arm inwards (a).

1048. The lateral dislocation may be either complete or incomplete; that outwards is more frequent than that inwards. In the former, the internal joint-surface of the upper arm-bone projects more or less, and the joint-surface of the cubit is thrust outwards; the point of the olecranon rests on the back of the upper-arm, in consequence of which the fore-arm is fixed in a slightly bent position. In the latter, a part of the sigmoid cavity projects, more or less, on the inner, and the joint-surface of the upper-arm-bone on the outer side; the fore-arm is permanently bent. These dislocations cannot happen without tearing of the ligaments of the elbow-joint; even the muscles of the fore-arm may be torn at their origin; hence also frequently, the fore-arm is not so fixed in its position, as in dislocation backwards. In complete lateral dislocation, the projection of the ends of the fore- and upper-arm are much more decided than in the incomplete, and on account of the great tearing of the soft parts the fore-arm is movable in every direction.

As in dislocations of the fore-arm, the joint-surfaces are mostly still in contact, so there may be crackling on moving the joint.

1049. Dislocation backwards of the fore-arm, is mostly produced by a fall upon the outstretched hand, whilst the fore-arm is bent and the upper fixed. If the fore-arm be violently forced to one or other side, lateral dislocation may be produced.

1050. Dislocations of the elbow-joint always produce severe inflammatory symptoms, and may lead to gangrene and nervous symptoms; generally, however, they are not dangerous. If left alone, they in a short time become irreducible; the dislocation backwards has, however, been reduced after existing two or three months. If in dislocation backwards, the joint

(a) COOPER, ASTLEY, above cited, p. 472.Révue Médicale, 1830.-SEDILLOT; in Gazette Médicale, 1839, No. 24.-FRORIEP'S N. Notizen,

July, 1839, No. 228.-MICHAELIS in VON GRAËFE and WALTHER's Journal, vol. xxix, p. 296.

surfaces of the upper-arm-bone project through the skin, the case is always very serious, though experience proves that a cure may take place without any particular symptoms. If with this dislocation, there be tearing of the m. biceps, of the brachial artery or of the median nerve, the case is exceedingly dangerous. The complete lateral dislocations are more severe than those backwards. The incomplete dislocations are neither great nor difficult to reduce; even if they be mistaken the consequences are less important, if only early motion be used.

(1) ASTLEY and BRANSBY COOPER (a) effected reduction after three months. MALGAIGNE and LISFRANC reduced a dislocation of the elbow backwards, of fourteen weeks' standing in a boy ten years old.

1051. The reduction of dislocations of the elbow is not difficult, if undertaken sufficiently early. Extension and counter-extension are performed by two assistants, one of whom grasps the fore-arm above the wrist with one hand, and its upper inner part with the other; the second assistant places one hand on the shoulder, and with the other draws back the lower part of the upper-arm. The Surgeon, in the dislocation backwards, grasps the elbow with both hands in such way, that the four fingers of the one are upon the front, and the thumb upon the back of the upperarm, with which when the extension is sufficiently made, he can press the olechranon downwards and forwards. ASTLEY COOPER puts the patient on a stool, places his knee on the inside of the elbow, grasps the wrist and bends the arm; at the same time he thrusts his knee against the spokebone and cubit, to free them from the upper-arm-bone, and whilst he keeps up the pressure with his knee, he strongly but slowly bends the arm. The arm may also be violently bent around a bed-post. After complete reduction, the elbow-joint is to be surrounded with moistened compresses, a bandage applied and the arm to be put in a sling. The supervening inflammatory symptoms must be removed by a proper antiphlogistic treatment, and the continual employment of cold applications. The bandages should be removed every two days, so that gentle movements of pronation and supination may be made, in order to ascertain the actuality of the reduction. The dislocation of the cubit alone, is always easily reduced by one of the prescribed methods; but if, as in the cases mentioned by SEDILLOT, the fore-arm be extended, extension must be made, and then the arm bent.

If the coronary ligament of the spoke-bone be not torn, that bone retains its proper position on the cubit; but if it be torn, the spoke-bone must be pressed especially into its place, and the recurrence of its displacement prevented by a splint placed along its back. If in dislocation backward, the lower ends of the upper-arm-bone be driven through the skin, the reduction is not thereby rendered difficult; it must be performed as soon as possible, and the wound closed. If severe inflammation exist, sawing off the projecting ends may alone be sufficient to lessen the symptoms. In tearing of the brachial artery and median nerve, the former must be tied before the reduction; how. ever, the probable danger of gangrene in this case may render amputation necessary.

1052. The reduction of the lateral dislocation must be effected in the way mentioned, only the joint-ends of the bones must be pressed, with both hands, in the opposite direction to that in which they are dislocated. In these dislocations also ASTLEY COOPER makes extension upon the knee, as already stated. Violent extension of the arm is also often sufficient. The inflammatory symptoms in lateral dislocation, are always more severe than in that behind; therefore also is a more strict antiphlogistic treatment required.

(a) Above cited, p. 441.

1053. Though dislocations of the elbow-joint have great disposition to become irreducible, yet if severe inflammation have come on, reduction must not be undertaken till that has been removed. Before attempting the reduction of an old dislocation, repeated motions of the fore-arm are to be made for several days previously. If repeated attempts do not succeed, violent extension must be abstained from, because otherwise severe inflammation is to be feared.

In dislocation of the elbow-joint forwards, which can only occur with fracture of the olechranon, the same treatment must be adopted as in that fracture, with simultaneous antiphlogistic remedies.

1054. The dislocation backwards of the spoke-bone is the most common, but occurs more rarely in adults, than in young persons, in whom it does not take place at once; but by the habit of pulling the child by the hand a considerable relaxation of the articular connexions of the spoke-bone is produced, which is often manifested by great projection of its end, and painful swelling of its joint, and if the violence be persisted in, dislocation of the radius backwards is produced. At the moment when the dislocation occurs the patient feels severe pain, the arm is bent, and the hand prone; supination is impossible and increases the pain; the hand and fingers are moderately bent; the upper end of the bone forms a distinct projection.

1055. The dislocation forwards of the upper end of the spoke-bone, is the consequence of violent supination. The fore-arm is slightly bent, but cannot be brought to a right angle with the upper arm; if the fore-arm be suddenly bent, the head of the bone strikes against the front of the upper-arm-bone, by which the flexion is suddenly stopped. The hand is prone, but can be brought again perfectly into pronation and supination, although pronation is nearly complete. The head of the spoke-bone can be felt, especially in rotation, which together with the continued flexion of the fore-arm are the most decided characters.

BOYER doubts the possibility of dislocation forwards without fracture at the same time; in which case the supination necessary to produce this dislocation is prevented by the lesser head of the upper-arm-bone, which thrusts violently against the head of the spoke-bone. This opinion, however, is contradicted by foreign and by my own experience. A. COOPER (a) has seen the dislocation of the spoke-bone forwards six times; I have seen it twice, and once as an old dislocation in a corpse. The spoke-bone separates from the cubit, at its connexion with the coronoid process, and its head is drawn back into the hollow above the outer condyle of the upper-arm-bone, and upon the coronoid process of the cubit. Examination shows the head of the spoke-bone drawn up into the cavity above the outer condyle of the upper-arm-bone, the cubit in its natural place; the coronary ligament of the spoke-bone, the chorda transversalis, the front of the capsular ligament and the interosseous membrane are partially torn, and in consequence of the tearing of the latter the separation of both bones is produced.

ROUYER (6), VILLAUME (c), and GERDY (d) have also seen dislocation of the upper ends of the spoke-bone forwards; B. COOPER (e) noticed it once with fracture of the inner condyle of the upper arm, and once with a fracture of the spoke-bone an inch and a-half from its head.

Simultaneous dislocation of the spoke-bone forwards and of the cubit backwards, have been noticed by BULLEY (ƒ) and by VIGNOLO (g).

A longitudinal dislocation of the spoke-bone, in which the head was displaced laterally and above, over the outer condyle of the upper-arm-bone, was seen by ADAMS (h).

(a) Above cited, p. 474.

(b) Journal Général de Médecine, April, 1818. (c) FRORIEP's Notizen, March, 1828, No. 429. (d) Archives Générales de Médecine, March, 1834.

(e) Above cited,

p. 457.

(f) Prov. Med. and Surg. Journal, 1841.
(9) Révue Médicale, 1841.

(h) Dublin Journal of Medical Science, 1840, vol. xvii. p. 504.

1056. The reduction of this dislocation of the spoke-bone is easy. The fore-arm is extended with one hand, whilst with the other, the head of the spoke-bone is pressed into its place, and the fore-arm brought into supination, in the dislocation backwards, and into pronation, in that forwards, and should be kept in place after the joint has been surrounded with compresses and circular bandages, by a splint placed on its front or back part. In from twenty to twenty-five days, this apparatus may be entirely removed and careful motion of the arm permitted.

According to ASTLEY COOPER, the reduction of the dislocation forwards of the spoke bone, requires much force, and he enumerates cases, in which it was impossible; from experiments on the dead body, however, the extension of the hand, in which the spokebone alone was acted on, was the most preferable; in this way I have also easily effected the reduction.

If the appearances mentioned (par. 1054) indicate the relaxation of the articular connexions of the spoke-bone, all dragging and movement of the hand must be avoided, the fore-arm must be fixed in a half-bent position, and the relaxation of the ligaments removed by suitable applications and rubbings in.

VIII. OF DISLOCATIONS OF THE WRIST.

(Luxatio Carpi, Lat.; Verrenkung des Handgelenkes, Germ.; Luxation du Poignet, Fr.) 1057. Three kinds of dislocation may take place at the wrist-joint :1, the dislocation of both bones of the fore-arm; 2, the dislocation of the spoke-bone; and, 3, the dislocation of the cubit.

1058. Dislocation of the hand from its connexion with both bones of the fore-arm, may be forwards, backwards, or to one or other side; the two latter kinds can only be incomplete, the former two more or less perfect. In the dislocation forwards, the hand is bent much backwards, and there is a great projection upon the inside of the wrist; the fingers are bent as well as the fore-arm. In the dislocation backwards, the very contrary symptoms occur; fracture of the spoke-bone mostly accompanies it (A. COOPER.) In dislocation on one or other side, there is always distortion of the hand, adduction or abduction, and a projection on the radial or ulnar side.

Dislocation of the wrist-joint, mentioned from the earliest time, has been doubted by DUPUYTREN, as he denied its existence, and almost its possibility, and proved the presumed cases of such dislocations were fractures of the lower end of the spoke-bone. This opinion is almost generally received, and by a strict criticism of the previous observations of such dislocations supported, against the opinions of PETIT, DESAULT, BOYER and others. But few observations have excited doubts against the statements of DUPUYTREN. VOILLEMIER has however shown the existence of such dislocations, by the most careful examination of a complete displacement of the wrist backwards and of the bones of the fore-arm forwards, and has given, as distinguishing marks between this dislocation and fracture of the lower end of the spoke-bone, that in the latter there is a bending in on the outside of the fore-arm near the joint, which is wanting in the former; the hand is abducted, but in dislocation, the whole hand is twisted towards the outside of the fore-arm; there is swelling at the fore and under part of the fore-arm, which is wanting in dislocation; but little decided projection of the ends of the fracture forwards and backwards, whilst in dislocation a projection of seven or eight lines backwards is formed by the wrist-joint, and forwards by the bones of the fore-arm; great breadth of the bones on the carpo-metacarpal surfaces, but in the dislocation only the natural breadth; the spoke-bone is shorter, but in dislocation of equal length as in the sound arm; the styloid process of the spoke-bone has its natural place at the wrist, but in dislocation it is situated on the inside of the wrist, to the inner side of the scaphoid bone; the styloid process of the cubit projects upon the back of the fore-arm, but in dislocation on the front; it projects as far or farther down than that of the spoke

bone, whilst in dislocation the styloid processes retain their reciprocal position; the position of the hand, usually though not always, is bent backwards, in dislocation commonly bent.

Compare par. 653, where is given the literature of fracture of the lower end of the spoke-bone; VOILLEMIER, in Archives Générales de Médecine, 1842, March; Prinz, G., Ueber den Bruch am unteren Ende des Radius. Erlangen, 1842.

1059. The cause of this dislocation is always, a very violent bending of the hand in this or that direction; hence the ligaments are always much torn, and the tendons on the side of the dislocation very severely torn and stretched. Rarely are other of the soft parts besides the ligaments ruptured.

1060. The reduction of dislocation of the hand is not difficult. Extension of the hand and pressure upon the carpal bones in the contrary direction to which they are dislocated, is sufficient. After reduction, the wrist is to be wrapped up in moistened linen, and fastened with a circular roller. If there be a disposition to re-dislocation, which in the dislocation forwards and backwards is generally the case, a splint must be placed on the palmar and dorsal surfaces of the hand, and confined with a circular bandage. Severe inflammatory symptoms always arise, which require suitable treatment and cold applications. Subsequently, aromatic applications, spirituous rubbings, and so on must be used to disperse the often long-continued swelling of the wrist-joint.

1061. In dislocation of the spoke-bone alone, which is rare, it is displaced on the front of the carpus, resting upon the navicular and great multangular bones. The outside of the hand is twisted backwards, and the inside, forwards; the end of the spoke-bone forms a projection on the front of the carpus, and its styloid process is no longer opposite the great multangular bone. The cause of this dislocation is a fall on the hand whilst turned backwards. The treatment is the same as that for both bones.

1062. In dislocation of the cubit, which is more rare, and in which the sacciform membrane is torn, the bone usually projects backwards, forming a protuberance on the back of the wrist, and although it can be easily pressed into its natural place, the deformity recurs when the pressure is withdrawn. The diagnostic sign is the projection of the cubit over the cuneiform bone and the dislocation of the styloid process from the line of the metacarpal bone of the little finger. Pressure restores the bones to their place, in which they are to be retained by splints on both surfaces of the arm and compress on the end of the cubit.

IX.-OF DISLOCATION OF SINGLE BONES OF THE HAND. 1063. The great bone (1) alone, can be displaced from its connexion with the scaphoid and semilunar bones, backwards, in consequence of violent bending of the hand; by which a circumscribed swelling is produced. on the situation of the great bone, in the direction of the middle finger, which disappears on pressure, but recurs when the pressure is withdrawn. The reduction is easily effected by pressure upon the projecting head of the bone, or if this be insufficient, by simultaneous pulling at the fore and middle finger. The hand is to be kept extended, until it be laid upon a flat board, pressure made upon the projection with a compress, a splint applied, and the whole fixed with a roller. If it remain, in a slight degree, it is not accompanied with any inconvenience.