company dislocations are pair, inflammation, and fweiling. Thefe ufually abate foon after the reduction. If any degree of inflamination remain, the ufe of leeches is the best remedy.

738. When diflocated bones are accompanied with fracture near the point, the fracture must be allowed to heal before reduction be attempted. This, however, is not always necellary in very fmall bones, as thofe of the fingers. When the fracture is at a distance from the joint, the difiocation may generally be reduced immediately. Compound luxations are to be treated nearly as compound fractures. After the bone is replaced, leeches should be applied to abate the inflamination; after which the fore thould be dreffed with Goulard's cerate, or any other mild ointment, and the pain moderated by opiates and a low legimen: care ought alfo to be tak n that no matter lodge about the joint. When luxations are produced by tumors or collections of matter in the neighbourhood of the joints, they may be confider-d as incurable: when they proceed from too great a relaxation of the nigaments and tendons of the joint, the bone can hardly be preventet from being now and then displaced; but the inconvenience may be fomewhat obviated by fupporting the limb with a proper bandage, by the ufe of the cold bath, and by electricity.

740. When the head or neck is luxated, the head commonly falls forward on the breast, the patient is inftantly deprived of fenfe and motion, and foon dies if the luxation be not quickly redu ced. In reducing the luxation, the patient should be placed on the ground, and fupported by an affiftant: the furgeon ftanding behind fhould gra dually pull up the head, while the shoulders are preffed down by the affiftant till the bones are brought into their place, which is known by a fud. den crack or noife: if the patient be not dead, he immediately recovers his faculties, at least in fome meature. He should then be put to bed with his head elevated and retained in one pofture. He should lofe a quantity of blood, and live for fome time on a low diet.

SECT. III. OF LUXATIONS of the SPINE, Os COCCYGIS, CLAVICLE, and RIBS.

741. THE VERTEBRÆ are sometimes partially, but hardly ever completely, diflocated without fracture. When they occur high up, they are attended with the fame fymptoms as diflocation of the head: when farther down, befides distortion of the pine, paralyfis enfues of every part of the body fituated under the luxated bone; there is commonly alfo either a totai fuppreffion of urine, or it is discharged involuntarily together with the fæces. A luxations of this kind are generally

HEAD and NECK.

739. IF the bones of the cranium be feparated by external injury, all that can well be done is, to fusport the parts by a bandage, to prevent inflammation, to keep the patient quiet, and in a proper posture during the cure. The bones of the note are feldom luxated without fracture: when they are, the injury is easily discovered by the touch. When one of the bones is driven in wards, it may be raised and reduced by pushing a tube of a proper fize, and covered with foft int, 14:0 the noftril; which may be afterwards retain ed till there is no danger of the bone being agun difplaced. If the bone be luxated outwards, it may be reduced by the fingers, and retained by a double-headed roiler. The lower jaw is luxated. moft frequently when the mouth is opened widely; it can only take place forwards and down wards, which are leaft furrounded by the neighbouring parts; both fides are generally luxated at once; and in that cafe the mouth is opened wide, the chin thrown forwards and towards the breaft. When only one fide is difiocated, the mouth is distorted, and wideft on the found fide of the jaw, which is drawn a little towards the contrary fide. The patient thould be feated, and his head fupported. The furgeon fhould push his thumbs, protected by a covering of trong leather, as far as polible between the jaws, and then with bis fingers, applied on the outfige of the angle of the jaw, endeavour to bring it forward till it move a little from its fituation. He fhould then prefs it forcibly down, and the condyles will im mediately flip into their place. The thumbs ought to be inftantly withdrawn, as the patient is apt to bite them involuntarily. The patient should for fome time avoid much speaking or opening his mouth wide.

VOL. XXI. PART II.

tebra is driven either forwards or to one fide; it is therefore very difficult to reduce it. The best, as well as the fimpleft method, is to lay the patient on his face over a cylindrical body, as a large cafk, and at the same time to attempt to replace the bone with the fingers. If the bone be very much difplaced, there is very little reafon to hope for fuccefs. The os coccygis is more liable to dislocation than any other part of the ipine. It is fometimes forced outwards in laborious births. This is discovered by the great pain which is feit at the connection of the os coccygis with the facrum, and by the bone appearing to be displaced when examined. It may generally be easily reduced by preffure with the fingers. The beft fupport afterwards is a comprefs, with the T bandage. When the coccyx is luxated inwardly, the patient complains of fevere pain, tenefmus, and a fense of rulness in the rectum; the fæces are paffed with difficulty, and in fome cafes a fuppreffion of urine takes place. The injury is cafily difco. vered by introducing the finger into the anus. In this cafe the bone should be preffed outwards, by introducing the fore and middle fingers of one hand dipped in oil into the rectum, aud fupporting the parts which correfpond with it externaly till the reduction is accomplished. Diflocations of thefe bones are apt to excite inflammation, which often terminates in dangerous abfcelles: it ought therefore to be guarded against by every means in our power.

742. The CLAVICLE is most frequently luxated at its junction with the fternum; because the viclence which produces the injury is generally ap plied to the fhoulder. The luxation is difcovered by pain in the part, by the projection of the bone, and by the immobility of the shoulder. It is ca fily reduced by pulling the bone into its place U น น น

pain, fwelling, and tenfion in the contiguous parts. A grating noife when the part is handled, diftortion, and a certain degree of lofs of power in the injured part, accompany almost every fracture, except when it runs longitudinally, and the divided parts are not compietely feparated from each other. When there is only a fingie bone in a limb, a fracture is eafily detected; but where only one of two bones of a limb has fuffered, it is often difficult to judge with certainty, especially if the contiguous foft parts be tenfe and paintul before the practitioner is called. In that cafe, the opinion must be regulated, not only by the attendant symptoms, but, ift, By the age and habit of the patient; for bones are more eafily fractured in old than in yourg perfons. Different difcafes, too, induce britteness of the bones, as the ques venerea and fea-fcurvy. 2d, By the fituation of the part; for bones are more apt to be fractured in the folid parts of their bodies than towards their extremities, where they are more foft and pliant. 3d, By the pofture of the limb; for a weight may fracture a bone iying on an unequal Turface, which it would have fuftained without injury if equally fupported. Fractures are foretimes attended with a great degree of echymolis, pccafioned by the ends of the fractured bones wounding fome of the contiguous blood-veffels.

758. In giving a prognofis of fracture, various circumstances are to be attended to. Small frac tured bones are more eafily healed than large ones, and that the fracture of the middle of a bone is not near fo dangerous as near the extremity. A cure is effected much more readily in youth than in old age, and in good conftitutions than in bad. We ought alfo to attend to the concomitant symptoms, and the injury which the neighbouring parts may have sustained. The more moderate the fymptoms, the more favourable our prognolis may be. The treatment of fractures confifts of three particulars; replacement, retention, and obviating bad fymptoms.

759. I. When bones are fractured directly acrofs the parts, they are often very little moved from their natural situation; but when the fracture is oblique, they are apt to pafs over each other, and to produce much unc&finefs and defor. nity; the contiguous mufcles are feverely injured, and the pain is aggravated by the flight eft motion. The furgeon fhould put the limb into the best posture for relaxing all the mufcles connected with it, according to the practice first introduced by Mr Pott. If it be properly attended to, the ends of the bones will in general be eafily replaced. When any difficuity occurs, a final degree of extension may be made, taking caie to keep the mufcles as relaxed as poffible. Much at tention should be paid to.replacing the bones properly, otherwife the limb will remain for ever after distorted.

760. II. After the bones are replaced, the limb 1hould be laid in the easiest posture, and the bones afterwards retained in their fituation by proper compreffes and bandages, not applied too tightly, fill the cure be completed. The time neceffary for this purpose depends on the fize of the bone, the age and habit of the patient, the fteadiness with which the limb has been retained in its

place, and the violence of the attending symp toms, In middle-aged perfons, and under favcutable circumstances, a fracture of the thigh bone, or of the bones of the leg, may be cured in two months; of the arm bone, or bones of the forearm, in fix weeks; of the ribs, clavicles, and bones of the hand, in three weeks. In infancy the cure will take a shorter, and in old age a longer, time than this.

761. III. In fimple fractures the inflammatory fymptoms generally fut fide in a few days. When they become wofe, which is fometimes the cale, aftringent applications thould be empicyet. If thefe fail, blood ought to be drawn from the parts affected. This is of fo much advantage, that it ought never to be omitted where the fur rounding faft parts are much injured. Friction with emollient oils, warm bathing, the use of Bath and other fimilar waters, are alfo of much fervice. The limb fometimes puts on a clumly appearance from an overgrowth of callus. When this tendency appears, ardent spirits and other aftringents are confidered as ufetui; sometimes preflure on the part by a thin piate of lead fixed by a bandage may be advantageous. Many intances occur, however, where no remedies prove fuccefful: The patient ought therefore to be acquainted beforehand with the probable event, to prevent unpleasant reflections afterwards.

762. Sometimes the ends of the bone remain loofe long after they might have been reunited. This may be owing to fome conftitutional difcate, to the benes not being kept fleadity in contaßt, to fome of the foft parts getting in between them, or to the bone being broken in different places, and the intermediate fractures being too small to adhere. Pregnancy has also been mentioned as a caufe. By removing these obftructions, a perfect union may in recent cafes be accomplished. Bat where the cafe is of long ftanding, callus of the bones becomes fo hard and imooth as to move with the ease of a joint, so that no advantage can be derived from laying them together. In that cafe, an incifion fhould be made through the fuft parts, and a small portion of the ends of the bore removed with a faw. If this be properly performed, nature will fupply the deficiency. When fnall pieces of bone remain long looft, they fhould be extracted by making an opening. Tre intervention of muscles or other soft parts is known by the very fevere pain and tension, and by particular motions of the limb cauting great pain and twitching of the muscles which move. The umb should be put into all the variety of ftuation; and if this does not fucceed, an opeumg must be made, and the foft parts removed. Sne times in fractures blood-veffels are ruptured by the fharp fpicule of the bone: this happens moit commonly in compound fractures. When the etfufion of blood is great, the part fwelle fo much that it is neceffary to lay it open, and to fecure the divided velfels by a ligature. When the fwelling is not great, the abforption of the blood is trufted to nature. When the blood remains lorz in contact with the fractured bone, it fometimes prevents the formation of cailus; the periofteurs feparates from a conâderable portion of the bone, and a thin fetid fanics is difcharged at the wound

When

When this happens, no cure can be expected till the parts of the bone deprived of periofteum have exfoliated, or have been separated by a faw.

SECT. II. Of FRACTURES of the BONES of the FACE.

763. FRACTURES of the nofe may impede refpiration, affect the fpeech and fenfe of imeiling, give rife to polypi and tedious ulcers, and may belides be dangerous from their vicinity to the brain. When any part of the bones of the nofe has been raised above t'e reft, it is to be prefled into its place with the fingers; if it has been pushed into the noftril, it is to be raised with the end of a patula or other fimilar inftrument. If any portion be almost entirely feparated from the reft, it thould be removed; but if it adheres with confiderable firmnefs, it is to be replaced. If the bones, after being replaced, do not remain in their proper fituation, they are to be retained either by Tubs introduced into the noftrik, or by a doubleheaded roller, with proper comprefies as the cafe may require. Inflammation should be prevented by the proper remedies.

764. Much care is neceffary in replacing the fractured bones of the face, and in dreffing them, in order to prevent deformity. The dreffings may be retained by adlcfive plaiters. Inflammation, by which the eyes, nofe, or antrum maxillare is apt to be injured, should be prevented. When matter collects in the antrum, it is to be removed by the methods formerly defcribed.

765. For replacing fractures of the lower jaw, the patient fould be feated in a proper light, with his head firmly fecured. The furgeon fhould prefs with one hand on the infide of the bone, while with the other he guards against inequalities on the outfide. If a tooth come in the way, it thould be extracted; when any of the others are forced out of their fockets, they fhould be replaced, and tied to the neighbouring teeth till they become firm. The fractured parts being kept firm by an affiftant, a thick comprefs of liDen or cotton thould be laid over the chin, and made to extend from ear to ear over it; a fourHeaded rolier thouid be applied firm enough to keep the fractured parts in contact. The patient fhould be kept quiet during the cure, and fed upon fpoon-meat. The dreffings fhould be removed as feldom as poffible. When the fracture is accompanied with an external wound, the parts fhould be supported by an affiftant during the dreffing of it.

SECT. III. Of FRACTURES of the CLAVICLE,

RIBS, STERNUM, and SPINE.

766. A FRACTURE of the CLAVICLE is eafily difcovered by the grating noife in the fractured bone upon moving the arm freely, by the ends of the bone yielding to preffure, and by the motion of the humerus being impeded. Ali that can be done is to raise the arm, and fupport it at a proper height, either by a fling, or, which is better, by the leather cafe recommended in cafe of luxation of this bore. By this the fractured parts will be brought together, fo far at leaft as to preyent deformity, and render the bone fufficiently strong

767. Fractures of the RIBS are difcovered by preffures with the fingers. The fymptoms are commonly moderate, and the patient foon gets well. In fome cafes, however, the pain is fevere, the breathing becomes difficult, attended with cough, and perhaps with fpitting of blood, and the pulfe is quick, fuil, and fometimes oppreffed. Thefe fymptoms arife from the ribs being beat in on the lungs.

768. In the treatment, it is proper in every cafe to ditcharge fome blood. If ore end of the rib rife, it ought to be repreffed by moderate pref fure; and to prevent its rifing again, a broad leather belt should be applied pretty tight, and con. tinued for fome weeks. When a portion of the rib is forced inwards, an opening fhould be made over it with a scapel, and then it thould be elevated with the fingers or a forceps. When diftreffing symptoms proceed from air or blood collected in the cavity of the cheft, the fe fluids ought to be difcharged by an operation.

769. The fymptoms of a fractured STERNUM are nearly the fame with thofe of the ribs. It requires great attention from the vicinity of the heart and large blood-veffcis. The patient ought to iofe a quantity of blood, and be kept on an antiphlogiftic regimen. If the pain, cough, and opprefied breathing, do not yield to these remedies, an incifion fhould be made on the injured part, and the depreffed piece raifed with a levator. 'Should this be infufficient, it may be affected by means of the trepan; tins indeed requires the greatest caution, but it may certainly be attended with advantage when the patient's life is in danger.

770. Fractures of the vertebre generally end fatally. We judge of the exiftence of the fracture there by examining the parts, by the feverity of the pain, and by palfy occurring in the parts fituated below the injured part. When any parts of the vertebræ near the integuments are loofe, they may be replaced with the fingers, and retained by proper bandages. When this is impoffible, fome of the latest authors think it advisable to make an incifion, and raise any portions of the bone which may be depreffed.

SECT. IV. OF FRACTURES of the BONES of the SUPERIOR EXTREMITIES.

771. THE fcapula is feidom fractured; when it is, the fracture is cafiiy difcovered by the pain, the immobility of the arm, and by the touch. The parts may be replaced with greater ease if They are retained with difficulty. A long roller the mufcles connected with them be relaxed. fhould be employed for this purpose, with which the head and fhoulders are alfo to be fupported. The arm thouid aifo be fufpended to relax the mufcles as much as poffible, and inflammation particularly guarded against by local blocdings.

772. Fractures of the humerus are easily difcovered by the pain, the immobility of the arm, and a grating noife on handling the parts. In reducing the fracture, the mufcles fhould be completely relaxed by bending the arm and raising it to a ho rizontal pofture. Extenfion, if neceflary, may be made by one affiftant grafping the arm between the fracture and the fhoulder, and another be

tween