is downwards and inwards, or into the axilla. The second is: forwards under the pectoral muscle, when the head of the bone is placed below the middle of the clavicle, and on the sternal side of the coracoid process. The third is backwards, when the head of the bone can be both felt and distinctly seen, forming a protuberance on the back and outer part of the inferior costa of the scapula, and is situated upon its dorsum. The fourth is only partial, when the anterior portion of the capsular ligament. is torn through, and the head of the bone is found resting against the coracoid process of the scapula, on its outer side.

Sir Astley has never seen the os humeri dislocated upwards:. it can only happen in conjunction with fracture of the acromion. On the comparative frequency of these accidents, our author says that he has seen a multitude of instances of the dislocation into the axilla; of the forward one, several; and of the dislocation backwards, only two, in a practice of thirty-eight years. He does not believe that, after dislocation, any change takes place, the muscles having once contracted; so that, excepting from circumstances of great violence, the nature and directioir of the dislocation are not subsequently altered.

The usual signs of the dislocation into the axilla are too well known to need repetition here; but Sir Astley observes, that the head of the bone cannot be felt in the axilla unless the arm be removed from the side; and, from a neglect of which precaution, he has seen surgeons deceived, and give a wrong opinion as to the nature of the accident. It must be recollected that, though certain motions of the limb are lost in consequence of this dislocation, much difference in the degree of that motion will arise in the age of the patient; for, in old people, the relaxed state of the muscles will sometimes permit the arm to be carried to the upper part of the head. Crepitus sometimes is slightly felt on first moving the limb, but by a continuance of the motion it ceases. This accident is therefore principally detected by the fall of the shoulder, the presence of the head of the bone in the axilla, and the loss of the natural motions of the joint; but, as these circumstances become obscured after a few hours, by extravasation of blood and the great swelling that ensues, and which after a lapse of some time becomes absorbed. If, says our author," we at this period detect a dislocation which has been overlooked, it is our duty, in candour, to state to the patient, that the difficulty in the detection of the nature of the accident is exceedingly diminished by the cessation of inflammation and the absence of tumefaction." (p. 419.) This is liberal and candid! Would to heaven that we met with it as often in practice as in precept.

An account of the dissection of two cases of dislocated shoulder is subjoined, which afford the following important

considerations. After having exposed and described the lesions of the muscles and the condition of the joint, our author next endeavoured to reduce the bone, but found the resistance suchas he could not overcome, and he therefore proceeded, by dividing one muscle after the other, to ascertain from whence the resistance proceeded: he found the supra spinatus muscle to be the great opponent; but, when this was relaxed by raising the arm directly upwards, the head of the bone glided into the glenoid cavity. This leads to the practical conclusion, that, in this dislocation, the arm should be raised horizontally, rather than brought obliquely downwards, and the biceps is to be relaxed by slightly bending the arm. In an old dislocation, which had been long unreduced, the following circumstances were observed:"The head of the bone is altered in form, the surface towards the scapula being flattened, and a complete capsular ligament: covers the head of the os humeri. The glenoid cavity is com pletely filled by ligamentous matter; small portions of bone are suspended in this ligamentous matter, which appear to be of new formation, as no portion of the scapula or humerus is broken. A new cavity is formed for the head of the os bumeri, on the inferior costa of the scapula; but this is glenoid, as that from which the os humeri had escaped." The shoulder, when once dislocated, is known to be frequently very liable to a recurrence of the acident, the slightest motion of the arm some. times causing the displacement of the bone,-of which two or three instances are mentioned: but this may be prevented by fixing the arm to the side for two or three weeks, during which time the ruptured tendons and ligament will become united, an event which the motion of the arm either impedes or wholly prevents.

Of the Reduction of the Dislocation in the Axilla.-Many me thods of replacing this dislocation have been recommended; that which Sir Astley usually adopts in his private practice is performed as follows:-The patient is placed in the recumbent position; the surgeon then binds a wetted roller round the arm just above the elbow, upon which he ties a handkerchief; then, with one foot resting upon the floor, he separates the patient's elbow from his side, and places the heel of his other foot in the axilla, receiving the head of the os humeri upon it; he then draws the arm, by means of the handkerchief, steadily for three or four minutes, and, under common circumstances, the head of the bone is easily replaced. If more force should be required, a long towel may be substituted for the handkerchief, by which several persons may pull. The fore-arm should be bent at right angles with the arm. Extension may be made from the wrist, but it requires more force, although it has this advantage-the bandage is not liable to slip. Should the above plan fail, NO. 289.

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(which, if the person be very muscular, or the accident has happened some time, it frequently will,) then more force is required. We need not describe the minute steps of a process so universally known, but we cannot too often repeat the very important rule, that to fix the scapula is the principal object before extension of the arm be employed. The bandage used at Guy's Hospital for this purpose is a girt buckled on the top of the acromion, so as to raise the bandage nigh in the axilla. The extension is to be made slowly and steadily, the arm being either at right angles with the body, or rather above it. Sometimes a gentle rotatory motion of the arm during the extension diminishes the opposition of the muscles.

The third method, of reduction by pulleys, is resorted to when both the above methods fail, and is applicable principally to those dislocations which have remained a considerable time unreduced. Sir Astley observes, that the pulleys are not employed simply in order to obtain a greater degree of power, but on account of the gradual and equal manner in which the force can be employed. There is no difference in the position of the patient, nor in the bandages employed in this latter case; but the surgeon should first draw the pulley himself, and, when pain is complained of, he should cease to draw, keeping up the degree of extension, and conversing with the patient, to direct his mind to other objects. After a pause of two or three minutes, the extension may be renewed until pain is again complained of; thus alternating for a quarter of an hour, at intervals rotating the arm. The bone, in this instance, generally passes into the socket without the snap which is heard when other means are employed. Sir Astley, in his hospital practice, employs bleeding, the warm bath, and nauseating doses of tartarized antimony, previously to employing mechanical means; and these very much lessen the necessity of employing very considerable force. Mr. H. Cline was in the habit of directing his patients to support a weight for some time before extension was begun, in order to fatigue the muscles. A small cushion in the axilla, and the stellate bandage, together with a sling to support the arm, should be worn for some time after. The simple method of placing the knee in the axilla, first separating the arm from the side, and then pulling the arm downwards with one hand, whilst the other rests upon the acromion scapulæ, has frequently succeeded, says our author, even with muscular persons, when in a state of intoxication. The plan recommended by Mr. Kirby, of Dublin, is then described, and spoken of with approbation.

The Dislocation forwards, or behind the pectoral muscle, is more distinctly marked than that just described; as the hollow below the acromion is much more considerable, and the head of the bone can be distinctly felt, and in thin persons even seen,

and which rotation of the arm makes more evident. The arm is also somewhat shortened, and the elbow is thrown more from the side than in the former case. We shall omit noticing the dissection of this accident, because it does not lead to any practical inference, and proceed at once to the mode of reduction; and upon this point we have merely to observe, that the bone must be drawn downwards and a little backwards; and, if the foot is placed in the axilla, it is requisite to bring it more forward. In those cases where it is necessary to use pulleys, the extension must be kept up longer than in the former dislocation, as the resistance is greater.

Dislocation of the Os Humeri on the Dorsum Scapula.-Only two cases of this accident have occurred at Guy's Hospital in thirty-eight years. It cannot be mistaken, as the head of the bone forms a protuberance upon the scapula, which, when the elbow is rotated, moves also; the dislocated bone may also be easily grasped between the fingers, and distinctly felt resting below the spine of the scapula. The first case which occurred was reduced in a few minutes by the same means as those employed in the dislocation in the axilla; and the second case was treated, with equal success, in a similar manner. Three other cases of this kind are recorded; one by Mr. TOULMIN, and two by Mr. COLEY, of Bridgnorth.

The partial dislocation of the os humeri is not a very uncommon accident, and the following are its usual marks:-There is a depression opposite the back of the shoulder-joint, and the posterior half of the glenoid cavity is perceptible, from the advance of the head of the bone; the axis of the arm is thrown inwards and forwards; the elevation of the arm is prevented by the head of the humerus striking against the carocoid process; and there is an evident protuberance formed by the head of the bone in its new situation, which is felt readily to roll when the arm is rotated; in this accident the anterior part of the capsular ligament is torn. The mode of reduction is the same as that employed in the dislocation forwards; but it is necessary to draw the shoulders backwards, to bring the head of the bone to the glenoid cavity; and, as soon as the reduction is effected, the shoulders should be bound back by a clavicle bandage, or the bone will immediately slip forwards again. Our author observes that, where dislocation is complicated with fracture of the head of the os humeri, reduction is much easier than in simple dislocation, as the insertion of the principal opponent muscles, the supra and infra spinati, is removed; but it renders it more difficult to retain the bone within the glenoid cavity, when it is replaced.

A case of compound dislocation of the shoulder-joint forwards, which occurred in the practice of Messrs. Saumarez

and DIXON, of Newington, is narrated. The patient, aged fifty-five, was intoxicated at the time the accident happened. There was no difficulty in returning the os humeri into its situ ation; but, of course, great constitutional disturbance ensued, and the wound suppurated copiously; abscesses formed in va rious parts round the joints, and sinuses resulted from some of them. Nevertheless, at the end of fourteen months, the man recovered with an anchylosed joint, but with free motion of the fore-arm, which enabled him to handle his pen for all the purposes of business.

It has occurred to the writer of this article to see the head of the os humeri shattered by shot and splinters of shells upon several occasions. Two of these cases, in which amputation had not been performed in the first instance, terminated favourably, -the whole head of the bone being discharged from the wound, in three or four successive portions. Abscesses, of course, were formed in the neighbourhood of the joint, and the constitution sympathised with the local injury, but not, at any moment, to such an extent as to make the ultimate recovery of the patient at all doubtful. The joint was anchylosed, but the lower arm was capable of performing its usual offices.

From this digression we return to notice a few accidents which are liable to be confounded with dislocation of the shoulderjoint. The first is fracture of the acromion. On this occasion the roundness of the shoulder is lost, part of the attachment of the deltoid muscle being broken off; the arm sinks towards the axilla as far as the capsular ligament will permit; but, upon raising the arm, the form of the shoulder is at once restored; and, on tracing the acromion from the spine of the scapula to the clavicle, a depression is felt at their junction. The best way, therefore, to detect this accident is to raise the elbow, and then rotate the arm, when a crepitus will be felt at the point of the shoulder. The patient, directly after the accident has happened, feels as if the arm was dropping off, with a great sense of weight, and but little power to raise it. Bony union will take place in this fracture if the parts can be kept in contact. The best method to ensure this is to raise the elbow, and to fix the arm; and, if it be kept steadily in that position, it will support the broken process, and keep it in its place: a cushion should be placed in the axilla, to relax the deltoid muscle; the arm should then be bound to the chest by a roller, and kept in that situation for three weeks.

Fracture of the neck of the scapula is illustrated by the case of a young lady who was thrown from a gig, and who was told by the surgeon who was first sent for that her shoulder was dislocated: by extension, all appearance of dislocation was removed, and the arm was bound up; but the next day the arm reassumed