718 
SURGERY. 
tion and fracture, the dislocation is to be reduced at once 5 
for if it is not done at first, it cannot afterwards without dis¬ 
placing the fracture. It is proper to secure the fracture, 
however, first with splints. The same rule is good when 
one bone is broken and another dislocated. 
Compound dislocations are accompanied by great injury 
of the muscles, often by rupture of blood-vessels, by the 
escape of synovia from the joint and the passage of blood 
into it. When a joint is opened, inflammation succeeding, 
suppuration in a few hours comes on, and granulations spring 
from the secreting membrane, which being of the mucous 
kind is more disposed to the suppurative than to the adhesive 
inflammation. At the extremity of the bone the cartilage 
after some time becomes absorbed, in consequence of an 
ulceration often beginning on its synovial surface, but more 
commonly arising from the end of the bone itself. The 
cartilage being destroyed, granulations spring from the 
denuded bones, and fill up the joint: generally, becoming 
ossified, they cause anchylosis; sometimes remaining soft 
a degree of motion is in time regained. During this 
process constitutional irritation rises to a great height; 
hence in weak patients we must sometimes amputate the 
limb to preserve life. The joints most subject to dislocation 
are such as have much motion, hence the frequency of luxa¬ 
tions of the humerus. Partial dislocations occur commonly 
to the knee. This joint is rarely dislocated in any other 
way. It happens also to the shoulder joint, as when the 
os humeri rests on the edge of the glenoid cavity ; the ancle 
joint even has been found subject to it. Then the end of the 
tibia rests on part of the astragalus, but a larger portion is 
seated on the os naviculare. Partial dislocations also affect 
the elbow both in respect to the radius and the ulna. 
Dislocations are caused by violence when the bone is in 
an oblique direction; it is necessary, however, that the 
muscles be unprepared, for otherwise tremendous force 
would be required to overcome their contraction. Of 
this we have examples in the cases of Damien and 
Ravillac, when repeated efforts of strong horses were in¬ 
sufficient to dislocate any of the limbs while the muscles 
were engaged in resisting them. Dislocations are uncommon 
in old persons, because their bones are more liable to break 
from injuries, and in children the same effect takes place, 
because the epiphyses are not firmly united. 
The reduction of dislocations is little impeded by the 
form of the joint. The projecting lip, indeed, of the aceta¬ 
bulum requires the head of the former to be lifted over it in 
dislocation; and in displacement of the radius, the head of 
this bone being larger than its cervix, reduction is difficult; 
but still the form of the bone is to be slightly considered. 
The weak and inelastic structure of the capsular ligaments, 
and the extensive lacerations they suffer from injuries, shews 
that they cannot impede reduction. The chief impediment 
to reduction exists in the muscles. These, independent of 
their common contraction, which always require rest after 
a short exertion, have another kind of contraction which is 
permanent, and which is in an inverse proportion to the 
resistance that is made to it. Thus if the biceps be cut, the 
triceps keeps the arm always extended. Thus when a bone 
is dislocated, the muscles draw it from the joint as far as 
possible, and there fix it. In old cases, adhesions to the 
surrounding parts also impede reduction. 
The means of reduction are constitutional and mechanical: 
the constitutional are, bleeding from a large orifice, warm 
bath at 101 or 110 , till faintness comes on, and nauseating 
doses of antimony to keep up the effect, produce relaxation 
of the muscles, and thus reduction of the limb. The 
mechanical means are to relax the stronger muscles, apply 
gradual tension to the dislocated bone by means of pul- 
lies or manual assistance, and to be careful to fix the 
opposite bone. Natural form and unimpeded motion, 
mark reduction. The shoulder is apt to slip out of its 
cavity after reduction, if not secured by bandages; espe¬ 
cially if the force of pullies has been required. Rest is all 
that is requisite for the union of. the broken ligaments, and 
the strength of the muscles and ligaments may be greatly 
promoted by pouring cold water upon the limb, and by the 
subsequent employment of friction. 
Severe injury of the muscles and nerves attends attempts 
at reduction in old dislocations. Hence, though they have 
been reduced at later period, it may be given as a general 
rule not to attempt reduction of the hip after eight weeks, 
nor of the shoulder after three months’ dislocation, except 
in aged or extremely relaxed persons.— Sir A. Cooper on 
Dislocations. 
Having thus passed in a sketching and imperfect manner 
through the varieties of acute inflammation, and of the acci¬ 
dents and other causes that produce it, we may now enter 
into some account of chronic inflammation, and of those 
tardy and inexplicable changes in the actions of blood or 
secreting vessels by which the original structures of the body 
are destroyed, and morbid structures or degenerations sub¬ 
stituted in their place. 
It is very difficult to define the characters of chronic in- 
flammation. On the surface of the body, where it is how¬ 
ever rarely observed, except as accompanying ulceration or 
desquamation, it exhibits the redness, and, in a slight degree, 
the tumour of active inflammation. But the pain and throb¬ 
bing is absent as well as the increased heat. 
The fever which attends chronic inflammation is that so 
well known by the term hectic. It is characterized by irre¬ 
gularity, rather than excess or diminution in the actions of 
the body. The heat is not permanently increased, but 
flushes come on in the evening or after meals, tinging the 
cheeks with a deep and circumscribed redness; the pulse is 
not hard but very frequent, fluttering and small; there is 
heartburn and flatulence, alternating with good appetite; 
diarrhoea comes on irregularly, and night sweats. The ner¬ 
vous system is usually in a state of unnatural excitement; 
there is want of sleep and considerable restlessness, though 
these alternate also; for sometimes we observe great alacrity, 
mildness, and quietude, The treatment of hectic fever has 
been laid down, but this is absurd. Its only cure is to re¬ 
move its cause; where this is impossible, the amelioration of 
that cause is to be had in view, but we have no power to re¬ 
move a necessary symptom. 
The commonest way in which we meet with chronic in¬ 
flammation, is producing fistulous abscesses or chronic ulcers. 
Fistulous abscesses require simply free openings, which con¬ 
vert them into ulcers or open sores. Chronic ulcers are of 
various kinds. In some, the secretion of pus is nearly 
stopped, and frequent accessions of pain and heat come on 
attended with an ichorous discharge, with inversion or ever¬ 
sion of the edges, and much constitutional disorder: these 
are called irritable ulcers. In others, the secretion of pus is 
changed in quite an opposite way; it is mixed with coagu- 
lable lymph, is very tenacious, and shews no granulations. 
The edges are smooth and hard: this they call an indolent 
ulcer. To the first kind, soothing applications are of course 
applicable; and when they get better, and we are desirous 
of bringing their sides closer together for the purpose of 
uniting the skin, care must be taken not to bandage them 
too tightly at first. The second kind of ulcer requires, in 
various constitutions, various stimuli; generally weak caus¬ 
tics; and when one does not succeed, another may be tried. 
The red precipitate ointment, under proper constitutional 
treatment, is as effectual as any thing. Ulcers are, in old 
people, rendered very troublesome and even dangerous, by 
varicose veins running into them. We need not say that 
the treatment of these sort of ulcers is to cure varicose veins. 
Of chronic inflammation in internal parts, we know very 
little. It has been the fashion to attribute tubercle, ascites, 
ossifications, and other depositions in the arteries and on the 
inner surface of the heart, tumors of all kinds, and even can« 
cers, to chronic inflammation: and while it has seemed to 
some to account for these tremendous changes, others have 
made it subservient to the explanation of the slight irritations 
that are of hourly occurrence in the digestive tube. We 
shall not adopt as proved, any theories that rest on so little 
visible 
