be, however, an apparent cavity will be noticed where the fullness of the
joint should be, and a corresponding projection observed in an opposite direc
tion, unless the head of the bone has been
pressed into the arm-pit, or behind, under
the shoulder-blade. The annexed cut
shows an outward dislocation of the head
of the shoulder.

The raost painful of these four forms
is the downward dislocation, for then the
bone presses on the whole congeries of
nerves and arteries, on their way to sup-
ply the arm with sensation and vitality.
In the majority of cases, the extension, as
the process of pulling the bone into its
place is called, should be made in a direc-
tion nearly opposite to the position of the
head of the bone.

There are several methods adopted for the reduction of this accident, but the two following will almost a ways he found successful. The patient is to be placed on his back on a mattress, or the squab of a sofa, laid on the floor, his head supported by a pillow in the manner shown in the following cut. A damp towel is then to be folded smoothly around the arm above the elbow. Upon this the operator ties a strong handkerchief, or making a hitch knot with a jack towel over it, throws the remainder over his shoulders, and having removed his right boot, takes his seat on the mattress, and placing the heel of his foot in the patient's arm-pit, either grasps the handkerchief and with both hands pulls with a

APPEARANCE OF A DISLOCATED
SHOULDER.

causes the

slow, steady strain upon the arm be has previously bent in the manner shown, or, if the jack towel is used, he makes the extension or stretch by means of his shoulders, while he holds the arm in his hands, the heel in both cases making the counterpoise. Hav ing, by a steady extension, gradually drawn out the head of the bone, and brought it in front of the cavity in the shoulder-blade, the slightest bend of his shoulders, or relaxation of the handkerchief, stretched muscles suddenly to coutract and draw the bone into the socket with an audible crack In fe male cases, and younger persons, or those of delicate constitutions, the following plan will generally be found sufficient: The patient being seated in a high-backed chair, an assistant standing on the uninjured side, places his left hand under and across the arm-pit, while with his right hand spread on the top of the shoulder, he grasps and keeps firmly in its place the shoulder-blade, and in this manner makes the counterpoise or exten sion. The operator then grasps the bent arm above the elbow, and steadily pulls the limb till he disengages little inward or outward, according as the dislocation has been in an outward the head, when, either moving it a o inward direction, and at the same time slightly relaxing his extension, the head, as in the other case, will glide with a crack into its place. Much in this operation depends on the firmness with which the assistant keeps the shoulder-blade in its place, for if that is not done the operator will, of neces sity, pull both arm and shoulder, and be no nearer the end for wh ch he minipulates.

As soon as the arm is reduced, a sling must be made with a handkerchief, and the folded arm carried in it for not less than a fortnight, to allow the muscles and tendons to recover their tone.

If the reduction has been attended with much pain, and there is any wwelling or tenderness of the joint, it will be well to foment the shoulder with warm bran poultices.

Ball and Socket Joints.-Under this head we shall embrace the shoulder-bone, fingers, hip, toes, the lower jaw, and collar-bone.

The treatment in all cases of dislocation is so nearly alike, that it may safely be generalized, except in a few instances, which will be specified in their proper place.

The first general rule to be remembered is, that all dislocations should be reduced as quickly as possible after they occur, as what with the internal laceration of ligaments, capsules, and tendons, and the pressure established on the vessels by the displaced head of the bone, severe swelling almost immediately takes place, which every hour augmenting, not only adds greatly to the suffering of the patient, but materially increases the difficulty of the reduction when it is performed.

In long-standing cases, or where some time has passed since the dislocation, the muscles become so resistant that even the power of the pulley fails to overcome their opposition. In such cases, it is found necessary to bleed the patient in an upright position, and by a large opening, so as to produce sudden sickness or fainting, and so relax the muscular tension, and enable the reduction to be effected. When bleeding is inadmissible, a nauseating dose of tartar emetic or ipecacuanha must be given to produce the same relaxing effect; or where these means cannot be carried out, an injection of tobacco must be employed instead, and immediate advantage taken of the consequent languor to reduce the dislocation.

Dislocation of the Wrist and Fingers.-The wrist is either dislocated upward or downward. The mode of reducing such an accident is for one person to grasp the arm with both hands, while the surgeon, making extension with the hand, uses either his thumbs or fingers to depress or elevate the wrist at the proper moment. A bandage is then to be passed partly over the hand and wrist, to support the joint, which will require some time to recover its usual strength.

The fingers and thumbs are, in general, easily reduced by a little extension. When, however, the muscles are strong, it may be necessary to take a piece of firm tape, on which a clove hitch having been made, is drawn tight on the next joint, and while one person holds the hand, the other makes extension by the tape, till the reduction is effected.

Dislocation of the Hip Joint, or Thigh.-Of all the dislocations to which the body is liable, this is unquestionably the most serious in its conse quences, and at the same time the most difficult to reduce. The ligaments placed by nature around it for a protection are so numerous, the muscles of the hip so short and strong, that, all combined, the difficulty experienced in overcoming the natural resistance of so many powerful levers makes the reduction of this accident a task of extreme difficulty.

Fortunately, the strong guards place i around this articulation protect it, in a great measure, from accidents; still, the cases of such a dislocation are by no means rare, and inay occur at all ages and among either sex, though those who most frequently suffer from such a misfortune are the young and the old. Among children and infants, unfortunately, it is more frequent than is generally supposed. Rough or careless nursemaids not unfrequently drop the children entrusted to them, or allow them to fall, and, not seeing any immediate Injury, keep the fact from the mother, who, perhaps, only weeks after, discovers something amiss in lier child by its crying when washed, or by its incapacity to walk, but, ignorant of the cause, trusts to rest or time to effect a cure, till, too late, she discovers her child to be a cripple, and permanently deformed by a shortened leg.

The falling over a piece of timber, or a very trifling obstruction, is sufficient to lead, either in childhood or age, to this misfortune. Old people are liable to this accident from the relaxed state of the tendons and muscles only it is very often complicated, in their case, with fracture of the neck of the thigh bone, making, in many instances, a hopeless accident. The symptoms, as already stated, are a shortening of the limb, with the knee standing forward, turned outward, or resting on SHORTENING OF THE the opposite thigh, and the toes either touching the ground, or pressing on the instep of the other foot.

LEG IN DISLOCA-
TED HIP.

Being a ball and socket joint, the first idea would be that this dislocation might be reduced as easily as that of the shoulder, by making a fulcrum of the heel. But, setting aside sex, the extreme delicacy

of the parts renders, except in the case of youths, such a mode seldom admis sible. In such cases as have been mentioned, however, the method often succeeds. The mode of procedure is as follows: The patient being placed on his back upon a mattress, a sheet passed in a broad fold between the legs and carried obliquely below and above the body, is fastened near the head, either to the foot of a large bed, a staple, or some other firm purchase. A towel is then passed around the thigh above the knee, over which a jack-towel is then passed with a clove hitch. This the surgeon extends by throwing the other end over his shoulders, first placing his heel in the groin, and grasping the limb, guides it with his hand as he makes extension, till it springs into the socket. In strong and adult persons, however, this plan seldom succeeds, and the pulley must be resorted to. When this is the case, it is customary to pass another folded sheet from the opposite side across the body, and make its ends secure like the former, so as to keep the patient perfectly fixed. To the jack-towel attached to the knee, the line from a double block pulley 18 then fastened, the pulley being made fast to some resisting object, or a staple, on a line with the floor. The surgeon now takes his place by his patient, and grasps the thigh to guide it, as an assistant, or two if necessary, with slow and steady pulling extend the limb, till the surgeon, having brought the head to its natural position, gives the word for a trifling yield, when, if rightly placed, the bone with a loud report sinks into its socket. It is in the reduc tion of such dislocations as these, occurring in strong muscular men, when no amount of straining can overcome the resistance of the muscles, that the bleeding, tartar emetic, and such relaxing means, already mentioned, must be adopted before the patient is unbound or left.

After so severe an accident, it will be necessary to enjoin some days' total rest before exerting the limb by the slightest exercise.

Dislocation of the Ankle and Toes.-The accident to the foot, like that to the hand, is either backward or forward. As in that case, the leg must be firmly held by one, while another extends the foot in a line with the leg till the proper moment arrives, when the foot is to be pushed up or back to meet the bones of the leg. A bandage, as in the case of the wrist, must be placed around to support this injury. It not unfrequently occurs with dislo cation of the foot. that there is a fracture of the upper portion of the fibula, or small bone of the leg. In such a case, the fracture must be attended to after the reduction of the joint. The displacement of the toes must be treated in the same manner as that of the fingers.

Dislocation of the Jaw.-This is a very alarming accident to see, but by no means difficult to cure; for as the person finds himself in a moment with an immovable jaw, and incapable of speech, with a mouth wide open, he can only by motions indicate what has happened. This accident is most

frequently caused by a fit of gaping, though a blow on the side of the face when the mouth is open, or a fall, have caused it. The treatment consists in seating the individual in a chair, when the surgeon. having enveloped both his thumbs in strips of lint, places a thumb on the back of the lower jaw, one on each side, and while his fingers grasp the chin, he presses firmly downward on the teeth as he brings the jaw a little for ward and upward with his fingers, till the heads spring into their sockets. So rapidly and so forcibly does the jaw close, that unless he has well protected his thumbs, the operator may expect a very severe bite.

The collar-bone, and also the ribs, are sometimes dislocated, but as both are much more frequently fractured, and nearly the same treatment is adopted in both cases, we shall defer a description of such accidents till we come to "Fractures."

The Dislocation of Hinge-like Joints.-Foremost among this order of articulations is the elbow foint, and next in importance that of the knee; and though these are sometimes by a violent force dislocated, fortunately they are so powerfully bound around and protected by ligaments, that such accidents are very rare, and only from a very high fall on the feet, by a railway collision,

or a restive horse dashing its rider against a wall, or some other extremely forcible injury, can a dislocation of such firmly-locked articulations be

effected.

The previous advice given in respect of the treatment of dislocations generally should be borne in mind in the accidents we are about to refer to with even more than ordinary attention. When once satisfied of the nature of the injury, not an unnecessary moment should be lost before proceeding to the reduction of the mischief, as every minute's delay not only adds greatly to the suffering of the patient, but by the rapid swelling that succeeds complicates the treatment.

Dislocation of the Elbow.-As three bones enter into the formation of this joint, it admits of several varieties of luxation, both backward and forward-that is, the joint of the forearm may be forced behind the bone of the arm, or it may be driven up in front of it; again, the two bones of the forearm may be dislocated from each other in several ways. The two most general forms, however, are the backward and forward dislocation.

There are three modes of effecting the reduction of such accidents, which we give in their proper order.

Ist. The following treatment will generally succeed with youths and children: The patient is to be placed in a chair, and while one assistant grasps the arm, and by counter-extension keeps the limb stationary, another, taking the forearm by the wrist, gradually extends the limb, as the surgeon, seated by the patient, grasps the member above or below the elbow, and by means of a steady pressure of either his thumbs or fingers backward or forward, as the nature of the accident may demand, forces the bones into their proper place When the muscular power resists such force, a sheet must be passed across the patient's chest and made fast to the wall; a towel is then to be wrapped around the wrist, and the line of a pulley attached to the hitch on the towel, and while the assistant at the arm and the surgeon at the elbow, as in the former case, repeat their efforts, the other assistant, by means of the longer lever of the pulley, makes a gradual and steady extension.

2d. The patient and surgeon being seated on separate chairs, the latter takes the limb in his hands, and, steadying his knee on the style of his chair, places the hollow of the arm, or the side of it, against the point of his knee, and, bending round the arm, endeavors to force the bones back to their nat ural position, the knee-cap of the operator acting as a fulcrum, and often effecting what a direct strain on the muscles could not perform-a reduction. 3d. This method is only a modification of the second, and consists in seating the patient on the foot of a bed, and, making a fulcrum of the bedpost, bending the dislocated limb upon it; the surgeon using his hands, as an assistant bends the arm, to aid the action by the pressure of his fingers.

Some surgeons have succeeded in reducing the injury by using the round arm of an easy-chair instead of the knee or bed-post.

Great care must be taken after the reduction, not only in keeping the arm in a sling for some weeks, but in applying warm fomentations around the joint, or lotions of sugar of lead and vinegar, made warm, to reduce the inflammatory action which is sure to supervene.

Dislocation of the Knee Joint and. Knee Cap.-Like the elbow, the knee may also be displaced backward and forward, and also inwardly and outwardly, as well as having the bones of the leg themselves separated from each other, Considerable force is often necessary to reduce a luxation of the knee joint, and overcome the muscular resistance; but in consequence of the large articulating surfaces of this joint, the bones, when once brought down, glide easily into their places.

The mode of treatment is much the same as that already described. A firm counter-extension, by means of a sheet, must be made by the thigh, and extension then established from the leg, which must be kept partially bent during the operation; a towel, secured in the ordinary manner by a clove hitch knot, is in the first instance to be adopted for making the extension; the surgeon keeping his place by the knee, to assist, with hands and fingers, the operation. When greater power is required, the towel must be joined to the pulley, and extension again made till the reduction is effected.

The KNE.. CAP, or PATELLA, is very liable to be displaced, either outward, inward, or upward. When this little flat bone is forcibly driven from its place, it is generally pushed over the protuberances of the bones, when it lies as it were in a hollow, from which it requires some art to extricate it. This is generally effected by pressing suddenly on the edge of the bone farthest from the joint, by which means the other end is canted up over the bony enlargement, when the contractile power of the muscles at once draws it into its place over the joint. When this cannot be effected, the leg of the patient, who has been placed on his back, is to be raised and bent as far as possible toward his face. It is then to be suddenly flexed or bent back on the thigh till the heel touches the hip. The surgeon, as he does so, with one hand

presses, as before explained, to its proper sit home, and quickly opening the

the into situation,

The after treatment in both of these dislocations requires rest, warm applications to soothe the joint, if necessary, and evaporating lotions if there much inflammation or heat in the part, and a bandage or elastic knee-cap support to the limb, which should be worn for some months.

EMERGENCIES-Recovery of Persons apparently Drowned, or Avoid all rough usage. Never hold the body Dead.-Lose no time. up by the feet. Nor roll the body on casks. Nor rub the body with salt and spirits. Nor inject tobacco smoke, or infusion of tobacco. Restorative Means, if apparently Drowned.-Send quickly for medical assistance; but do not delay the following means:

Convey the body CAREFULLY, with the head and shoulders supported in a raised condition to the nearest house.

Strip the body and rub it dry; then wrap it in hot blankets, and place it in a warm bed in a warm chamber.

Wipe and clean the mouth and nostrils.

In order to restore the natural warmth of the body:

Move a heated covered warming pan over the back and spine. Put bladders, or bottles of hot water, or heated bricks, to the pit of the stomach, the armpits, between the thighs, and to the soles of the feet. Foment the body with hot flannels; but, if possible, immerse the body in a warm bath as hot as the hand can bear without pain. Rub the body briskly with the hand; but do not suspend the use of the other means at the same time.

To restore breathing, introduce the pipe of a common bellows, into one nostril, carefully closing the other and the mouth; at the same time drawing downwards, and pushing gently backwards, the upper part of the wind-pipe, to allow the free admission of air; blow the bellows gently, in order to inflate the lungs, till the breast be a little raised: the mouth and nostrils should then be set free, and a Repeat this moderate pressure made with the hand upon the chest. process till life appears.

Electricity to be employed early by a medical assistant. Inject into the stomach, by means of an elastic tube and syringe, half a pint of warm brandy, or wine and water.

Apply sal-volatile to the nostrils.

If apparently Dead from Intense Cold.-Rub the body with ice, Restore warmth by slow degrees; and, after snow, or cold water. some time, if necessary, employ the means recommended for the apparently drowned. It is highly dangerous to apply heat too early.

If apparently Dead from Hanging. In addition to the means recommended for the apparently drowned, bleeding should early be employed by a medical assistant.

If apparently Dead from Noxious Vapors, Lightning, etc.Remove the body into a cold fresh air. Dash cold water on the neck, face, and breast frequently. If the body be cold, apply warmth, as recommended for the apparently drowned. Use the means for inflating the lungs as directed above. Let electricity (particularly in accidents from lightning) be early employed by a medical assistant.

If apparently Dead from Intoxication.-Lay the body on a bed, with the lead raised; remove the neckcloth and loosen the clothes. Obtain instantly medical assistance, in the meantime apply cloths soaked in cold water to the head, and bottles of hot water, or hot bricks, to the calves of the legs and to the feet.

General Observations.-On restoration to life, a tea-spoon of warm water should be given; and then, if the power of swallowing be returned, small quantities of weak brandy and water, warm; the