LUXATION. 



ftate of inflammation, with matter in the lower region of 

 the abdomen. 



Were a fimilar accident to prefent itfelf to the prafiitioner, 

 he ought to have recourfe to antiphlogiftic means ; for the 

 danger chiefly depends on the pelvic vifcera becoming in- 

 flamed. Copious and repeated bleedings, the warm-bath, 

 fomentations, and low diet, would be particularly indi- 

 cated. 



Luxations of the Ribs. — The ancient writers on furgery 

 have furniflied us with no obfervations concerning difloca- 

 tions of the ribs, and obfervers, who have publifhed numerous 

 fatts relative to other cafes, make no mention of thefe ac- 

 cidents. Even J. L. Petit and Duverney, authors of more 

 recent date, are filent on the fubjeft ; and as Pare, long 

 before them, had diftinftly treated of luxations of the ribs, 

 we muit afcribe their lilence to their difbelief in the pofli- 

 bility of fucli cafes. 



Whether the ribs are fufoeptible of diflocation or not, 

 is yet an unfettled queftion. 



Ambrofe Pare, Barbette, Junker, Plainer, and Heifter, 

 defcribe the accident as poffible. Plainer has obferved : 

 " Coftx longe frequentius frangunUir, quam a fua fede 

 movenlur. Non poifunt in exleriorem partem excidere, 

 cum oppofiti proceffus tranfverfi vertebrarum fummam ilia- 

 rum partem contineant, nee facile furfum vel deorfum verfus 

 promoveri poffunt. Igilur fi moventur is inleriorem partem 

 propellunlur.." Inftit. Chir. § 1149. Plainer aftually 

 enters into a detail of the fymptoms to be apprehended 

 in fuch cafe : " ciim pleura prematur, gravis inflammatio 

 et fpirandi difficullas fequitur." In a memoir inferted 

 amongft thofe of the Royal Academy of Surgery in France, 

 M. Biittet is yet more pofitive than Plainer, in only admit- 

 ting the luxation forwards ; but he does not conceive that the 

 accident can happen to all the ribs with equal facility. The 

 upper ones are protefted by the fcapula, and the lower, 

 which are unfixed and very moveable, can only be luxated 

 with great difficulty. He thinks that diflocalions can 

 hardly occur to any of thefe bones, except the four or five 

 lower true ribs, and two or three of the upper falfe ones, 

 which lall are more fufceptible of difplacement, in confe- 

 quence of not being fupported by the fternum. On the 

 other hand, Boyer, a late writer on diflocalions, is very 

 pofitive thai the ribs are exempt from thefe accidents. He 

 tells us, that he fliould have obferved the fame filence on the 

 fubjeft as J. L. Petit, did not a cafe, pubhfhed in the Me- 

 moirs of the Academy of Surgery, after the death of that 

 celebrated praftitioner, feem to eftablifh the poflibility of 

 fuch cafes. But Boyer contends, that, in reading this ex- 

 ample, it is obvious the furgeon has miftaken a frafture of 

 the pofterior end of the ribs for a diflocation. If, fays 

 Boyer, we attend to the number and force of the Ugamenls, 

 which attach the ribs to the verlebrse and fternum, and alfo 

 to the manner in which the intercoftal mufcles confine them, 

 we (hall not eafily conceive how external violence, whether 

 it ads on their middle or extremities, can luxate them. 

 They are fo firmly attached to the furrounding parts, that 

 it is very difficult to feparate them from the body in the 

 dead fubjeft ; and, in preparing Ikeletons, we often break 

 thofe bones, if we are not careful to cut all their bonds of 

 union, before we attempt to detach them from the parts with 

 which they are articulated. All the fymptoms accompany- 

 ing M. Bullet's cafe indicate a frafture of the neck, or pof- 

 terior extremity of the rib, as the pain, crepitation, and 

 motion of the bone. No conclufion could be drawn from 

 the motion, in proof of a luxation, fince the frafture (if it 

 were fuch) was fituated very near the back end of the rib. 



and, of courfe, the whole length of the bone would feem t« 

 move at once. 



Boyer excludes from confideration cafes, called by Lieu- 

 taud and others diflocalions of the ribs, which, in faft, are 

 only feparations of the ribs and dorfal vertebra: from each 

 other, in confequence of the deftruftion of their ligaments, 

 &c. by difeafe. 



Luxations of the Clavicle, or Collar-Bone. — Luxations of 

 the clavicle are much lefs frequent than fraftures ; and it 

 was ellimated by Default that the latter accidents are to the 

 former as fix to one. As far as our own experience enable* 

 us to judge, diflocalions are even more uncommon than thi« 

 calculation reprefents. 



The clavicle, however, may be luxated either from the 

 fternum, or the acromion. 



Luxations of the Jlernal Erfd. — The ftcrnal end of the 

 clavicle may be diflocaled forwards, backwards, or up- 

 wards, but never downwards, in which laft direftion a 

 luxation is prevented by the cartilage of the firft rib. The 

 diflocation forwards is by far the moft frequent, and may 

 be caufeJ by exctffive motion of the fcapulary end of the 

 clavicle backwards. Luxations upwards and backwards are 

 very rare. The former can only be occafioned by the 

 fhoulder being puflied violently forwards and downwards, 

 which fometimes happens in falls. The diflocation back- 

 wards is the moft unufual cafe of all. 



If the ftioulder is pufhed violently backwards, the fternal 

 end of the clavicle is propelled forwards, tearing the cap- 

 fule of the articulation, the anterior ligament, and the 

 tendon of the fterno-cleido-maftoideus mufcle. Quitting 

 the furface with which it is articulated, it flips in front of 

 the upper part of the fternum, and produces under the fliin 

 in this fituation, a hard prominence, vihich follows the mo- 

 tion of the flioulder. 



When the flioulder is fuddenly depreffed, the fternal end 

 of the clavicle is eafily luxated upwards, as there is nothing 

 to limit its motion in this direftion, except the inter-clavicu- 

 lar ligament, which, being relaxed by the greater conli. 

 guity of the two bones, is not capable of making effcftual 

 refiftance. 



In the luxation backwards, the extremity of the clavicle ii 

 carried behind the fuperiorpart of the fternum. 



The fuperficial fituation of the clavicle renders eafy the 

 diagnofis of all luxations of its fternal end. When the dif- 

 location happens forwards, a hard projeftion is felt, or even 

 feen on the anterior and fuperior part of the fternum. Such 

 projeftion may be made to difappear by carrying the ftioul- 

 der forwards and outwards. In the place which the head 

 of the clavicle ought to occupy, an empty fpace is per- 

 ceptible. 



In the luxation upwards, the diftance between the fternal 

 ends of the two clavicles is leflened. 



If the luxation is backwards, the head of the bone formj 

 a tumour at the interior and inferior part of the neck, and a 

 depreffion may be felt in the place which it ought to oc- 

 cupy. The head of the bone thus difplaced, may, ai 

 Monfieur .7. L. Petit has obferved, comprefs the trachea, 

 oefophagus, jugular vein, carotid artery, par ■I'^gum, i^c. 

 fo as to caufe dangerous fymptoms. It is alfo to be noticed, 

 that, in diflocalions of the fternal and of the clavicle back- 

 wards, the head is inchned towards the affefted ftioulder. 



Luxations of the fternal extremity of the clavicle may 

 be reduced by making a lever of the arm, by means of 

 which the ftioulder is firft to be brought outwards, and then 

 puftied forwards, fuppoling the diflocation to have happened 

 in that direftion. But if the luxation is backwards, the 

 4 Q 2 (houldcr. 



