excluding the ulna from the force applied, the radius sustains the whole extension." It is also right in making the extension that the hand be rendered supine, as this position draws the head of the radius from the upper part of the coronoid process of the ulna, upon which it is otherwise directed, and then to draw the fore arm by pulling the hand, and by fixing the os humeri.

The dislocation of the radius backwards our author has never seen in the living subject. One instance of the kind was brought into the dissecting room in the year 1821, from which a drawing is given by Sir Astley.

Fractures of the Elbow Joint. The condyles of the os humeri are sometimes obliquely broken off just above the joint, and the appearance produced is so similar to the dislocation of the radius and ulna backwards, that the two accidents are very liable to be confounded together. The mode of distinguishing the two injuries is, by all the marks of dislocation being removed by extension, and by their return so soon as the extension is withheld. In these accidents too, a crepitus can generally be felt when rolling the fore-arm upon the humerus. It is of much more frequent occurrence in children than in grown persons, though it happens at all periods of life.

"Its treatment consists in bending the arm, and drawing it forwards to effect replacement, and then a roller should be applied whilst it is in the bent position. The best splint for it is one formed at right angles, the upper portion of which, is to be placed behind the upper arm, and the lower portion under the fore arm; a splint must also be placed upon the fore part of the upper arm, and straps to confine both; evaporating lotions should be used; and the arm kept in a bent position by a sling. In a fortnight, if the patient be young, passive motion may be gently begun, to prevent the occurrence of anchylosis; and in the adult, at the end of three weeks, a similar treatment is to be pursued." 482.

There is sometimes considerable loss of motion, notwithstanding the most judicious means have been employed.

Fracture of the internal Condyle of the Humerus. This portion of bone is frequently broken off, in which case the ulna projects backwards, having lost its support. If the forearm be extended, the hand becomes twisted inwards towards the side; but, upon flexion, these appearances are removed. The above circumstances, and a crepitus on bending or extending the arm, will distinguish this accident from others. The treatment is the same as that for oblique fractures above the condyles of the humerus.

Fracture of the Olecranon. This process is not unfrequently broken off, and the symptoms are so evident that they can scarcely be mistaken. There is pain, and a soft swelling at the back of the elbow, through which the surgeon's finger readily sinks into the joint-the olecranon can be felt in a detached piece-elevated, and moveable from side to side, but with great difficulty drawn downwards-bending of the arm renders the separation greater-the power of extension is nearly lost-there is a proneness to semi-flexion-swelling and ecchymosis continue for some days after the accident-rotation of the radius upon the ulna is still preserved-no crepitus.

When the fracture takes place, the triceps muscle draws up the detached piece of bone from half an inch to two inches from the ulna, the extent of the separation depending on the degree of laceration in the capsular ligament, and the ligamentous band stretching from the side of the coronoid process to the olecranon. Sir Astley has made some interesting experiments on animals, in order to elucidate the nature of this injury, and the means of reparation, for which we must refer to the volume itself.*

"The treatment of this accident is as follows, but it is to be regu lated by the degree of injury. If there be much swelling and contusion, it is right to apply for two or three days evaporating lotions and leeches; and after the inflammation is reduced, a bandage should be applied; but in those cases where but little violence is done to the limb, it should be at once secured by bandage. The principle of the treatment is, to preserve the power of the limb, by making the separation of the bones as slight as possible, and consequently to shorten their ligamentous union; and secondly, to restore the natural motions of joint. If the swelling and inflammation do not prevent it, the surgeon is to place the arm in a straight position, and to press down the upper portion of the fractured olecranon, until he brings it in contact with the ulna; a piece of linen is then laid longitudinally on each side of the joint, a wetted roller is applied above the elbow, and another below it, the extremities of the linen are then to be doubled down over the rollers, and tightly tied, so as to approximate them, thus the bones are brought and held together; a splint well

We may, however, introduce a short extract shewing the results of Sir Astley's experiments.

"Therefore, this bone, like the extremity of the os calcis when it is broken off, is detached by the action of muscles, and ligamentous union takes place from want of adaptation; but a different cause exists, where bony union is deficient in fractured bones within joints, in the neck of the thigh-bone; in the coronoid process of the ulna; and in the extremity of the external condyle of the os humeri; in which injuries, the want of union depends upon the diminished support the fractured parts receive, and that little being through the medium of blood vessels intended for the nourishment of ligament." 488.

padded is to be applied upon the fore part of the arm, to preserve it in a straight position, and is to be confined to it by a circular bandage; the whole is to be frequently wetted with spirits of wine and water." 490.

In a month the splint is to be removed and passive motion begun, with great caution at first. In compound fractures of this bone, the edges of the skin must be brought into exact apposition-lint imbued in blood is to be applied on the wound with adhesive plaster-and union by adhesion effected if possible. In other respects, the treatment is the same as in simple fracture.

Fracture of the external Condyle of the Humerus is not uncommon among children; but rarely occurs in the adult, or in old age. It is recognized by swelling on the external condyle, and pain on pressure, as well as on extension or flexion of the elbow joint; "but the principal diagnostic sign is the crepitus produced by the rotatory motion of the hand and radius." In two preparations at St. Thomas's Hospital the union is by ligament.

"It is obvious therefore," says our author, "that this principle of ligamentous union, extends to all detached portions of bone within a capsular ligament; its vitality being supported merely by the ligament within the joint." 492.

Treatment. A roller is to be applied around the elbow, and above and below the joint-an angular splint is then to be applied, which should admit the elbow, and extend behind the upper arm, and receive the fore arm so as to support ita roller should next be bound over the whole to keep it firmly fixed. The splint should be worn for three weeks, when passive motion is to be begun, with great gentleness at first, and to be very gradually increased.

Compound Fracture and Dislocation of the Elbow Joint. These generally happen through the internal condyles of the humerus, the fracture taking place in an oblique direction into the joint. If judiciously treated, the constitution will generally be able to support even the most severe accidents of this kind, some very interesting cases of which are detailed by our author, for which we must refer to the original.

"In all cases of this accident, the arm should be kept in the bent position, for as anchylosis in a greater or lesser degree, is sure to be the consequence, it is attended with much less inconvenience in this position, than in any other. If the bones be much comminuted, and the wound large, all the detached portions of bone should be removed; but in old people, when much injury is done, there is often not sufficient strength to support the adhesive process, and amputation should

be recommended. The edges of the wound should be kept together by placing a piece of lint dipped in blood over them, supported by adhesive plaster, and a bandage lightly applied, wetted with spirits of wine and water." 498.

We perceive, from our limits, that we must leave some portions of the work unnoticed, and we shall, therefore, pass over the sections on dislocations and fractures of the wrist, carpal and metacarpal bones, fingers, &c. in order to concentrate our attention more on certain injuries about the trunk of the body.

On dislocation of the ribs, our author says but little, apparently from a conviction that such an accident is extremely rare. A person may, he thinks, by falling on his back upon some pointed body, receive such a blow on the ribs, as may drive them from their articulations. This injury would produce the same symptoms as fracture of the costæ:-their motions would be painful, and respiration difficult. The treatment would be the same as for fractured ribs, viz. blood-letting, and the application of a circular bandage.

INJURIES OF THE SPINE.

Dislocations of the spinal column are represented by some authors as of frequent occurrence-but Sir Astley suspects that they are extremely rare, as he has never seen an instance of the kind unaccompanied by fracture of the bodies or processes of the vertebræ. He does not, however, deny the possibility of dislocation, especially of the cervical vertebræ, the articulating processes of which are placed more obliquely than those of the other vertebræ.*

We shall here introduce some cases in illustration of this point, which were lately transmitted to us by Mr. Fielding, of Hull.

"On Partial Luxation of the Vertebræ.

"Though I presume it is almost certain, that complete luxation of the vertebræ cannot take place independent of fracture, yet, from some cases which have fallen under my own observation, it seems to me to be equally certain, that partial luxation may take place without it. I have seen four cases in which, from falls, the ligamentum nucha was injured, and the last vertebra of the neck was thrown partially forward upon the uppermost dorsal. These cases came too late under my notice to be remedied -but the effect of the injury was quite apparent ;-the spinous process of the first vertebra dorsi was much too prominent-the head, permanently bent down towards the sternum, could not be raised to the erect position. The two following cases illustrate more clearly the nature of the sort of accident I mean.

“ J. M——————, æt. 14, a delicate youth, gave me the following account: Yesterday evening, walking at a quick pace home, he set his foot upon some soft substance on the flags and slipped; apprehensive of falling, he made a sudden effort to recover himself, and succeeded; but, on the in

1823]

Sir Astley Cooper on Dislocations.

853

The effects resulting from violence done to the spinal chord are very similar to those which are produced by injuries to the brain, viz. concussion, extravasation, fracture, fracture with depression, suppuration, and ulceration.

Concussion. The effect of this, if in a severe degree, is generally paralysis of the parts beneath; the person often recovering, in a gradual manner, the motion and sensation of the parts. A case is related, where cupping, purging, and instituting a drain from the back, restored a severe injury of this kind.

Extravasation. A very severe blow upon the vertebræ will sometimes produce extravasation upon the spinal chord, but more frequently upon the sheath in which it is contained. Of late years, since it has been the custom, in examining dead bodies, to saw off the spinous processes of the vertebræ, in cases of severe injury, blood has been, several times, found on the outer side of the spinal sheath, and, in one instance, upon the spinal marrow, just above the cauda equina. We shall give the following case entire.

stant, felt violent pain in the neck, and could not bring his head into the erect position. On arriving at home, he was rubbed for supposed sprain and went to bed He passed a sleepless night, being obliged to lie always upon his back. Next morning he still could not raise his head, and on attempting to pursue his avocation in the office, found his head become dizzy and that his vision was indistinct. On his return home this morning, Sept. 10, 1822, I saw him, and found that his head was immoveably inclined to the left side, so as to be almost in contact with the shoulder, which was elevated to meet it-complained of head-ache and dizziness. On examining the spine, I at once discovered, that the spinous process of the last vertebra of the neck was distorted towards the right side, I felt (or supposed I felt) that the inferior oblique process was, also, too prominent on the same side. Without giving any notice whatever to the patient, I placed the point of the thumb of my left hand, as accurately as I could, firmly upon the oblique process, and seizing the head with the other hand, drew it quickly, but not violently, towards the right shoulder, pressing firmly upon the vertebra with my thumb at the same time; the bone was immediately replaced, the young man jumped up suddenly from his chair, and cried out "sir I am well," and immediately, at my desire, moved his head and neck in every direction with little inconvenience. He was perfectly well and returned to his employment the next day."

"Case 2. A poor girl, æt. 14, was brought to my house, Sept. 16, 1822-her mother said that she was thrown down in the street yesterday evening, by some person running suddenly against her she has never since been able to raise the head to the erect position. With the exception that the head inclines to the right side-the appearances are nearly the same as described in the former case—a similar method of reduction

was employed, and the patient was cured at once."-Private Correspondence.

Vol. III. No. 12.

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