Cooper's method of placing the knee against the lower and inner side of the humerus and drawing on the forearm, held at right angles to the arm. The characteristic snap was produced, and the symmetry of the arm was at once restored. He had no doubt, and I certainly have none, that the reduction of the dislocation was accomplished. The patient, however, injured in other ways, was forced to take the recumbent posture, and the limb was placed on a pillow with no special restraint. The surgeon intended to place the arm in its resting place with the forearm at right angles to it, and did undoubtedly do so; but the balance of power between the triceps and biceps was not established at the right angle, that being one of a hundred and thirty-five degrees. The least motion being apt to result in some alteration of the position of the arm, would produce a constant tendency to widen the angle.

At the trial there were presented two cases where the elbow was believed by the surgeons to have been reduced and luxation recurred. One of these resembled the case described above, which after reduction was placed on a pillow. The next morning the surgeon recognized the fact that the luxation had recurred; he again reduced it and dressed the limb with an angular splint, which retained the parts in apposition by keeping the forearm at right angles with the arm. The second case was that of a man who was intoxicated, and after reduction refused any retention apparatus whatever.

I made a direct experiment in one case after reduction, and before the patient had recovered from his narcosis. I shall relate it. The forearm, after reduction, was carried up at an acute angle with the arm so that the hand reached the neck. This was done by way of assurance to myself that there could be no mistake about the reduction. The arm being held up, free from contact with the bed, the forearm was gradually carried down till it reached an angle of one hundred and thirtyfive degrees, when it at once became dislocated, the olecranon swinging back into its prominent position. It was again restored, and remained in place when the forearm was held at right angles with the arm.

A case is reported by Hamilton, of a boy eleven years of age, where his attempt at reduction of the dislocation was supposed by himself at the time to be entirely successful. The patient received the necessary attention within two hours after the accident, and the occurring snap was obvious, but he utterly refused any dressing-in fact, ran away. Dr. Hamilton, however, saw the little fellow for several days in succession, but did not, until the tenth day, discover the fact of a recurring luxation. That this was the case he proved by placing the boy under chloroform and replacing the bones, which remained in place, making a slow recovery. This surgeon, believing that he had not reduced the luxation, since he had omitted the rule with reference to the carrying the hand up, as the proper test of reduction, expresses a sense of mortification at having failed to reduce the bones to their proper relations. Now I can not believe, and I think the profession will readily join in my skepticism, that Dr. Hamilton was mistaken in his first opinion. The too obvious signs, and the exceptionally special experience of so high an authority, forbid our acceptance of such an explanation. Gravity as an agent in carrying the arm downward, and thus inviting the recurrence of the luxation, is a much more probable solution of the problem. But there is another case in justification of my explanation of the one related by Dr. Hamilton, which is reported by Dr. J. N. Arnold, of Clyde, N. Y.

This was also that of a boy, three years the senior of the last, whose elbow was dislocated backward. The rectangular dressing was used; but the boy preferred to carry his hand in his pocket (this, without the Doctor's knowledge), and it was again luxated. These cases, collected from not a wide territory, not only confirm the propriety of the practice of rectangular dressing, so universally recommended by teachers and writers, but also illustrate the great danger of its omission.

As regards the other luxations at the elbow, I can not say much of the bones singly, but I have been in the habit of dressing all injuries, fractures as well as luxations involving the joint, at right angles for the first week or ten days, except fracture of the olecranon.

To pursue the subject further, I do not believe that in luxation of the wrist any special care is necessary, but of this I am not prepared to speak of my own experience. There are dislocations of the ulna, both backward and forward, which are seldom seen, but when restored should be retained by compress and bandage.

There is, however, a luxation of the ulna in connection with the fracture of the radius near the joint, which I believe to be very common, perhaps the most common one in the human body, not even excepting that of the humerus in the axilla. I know very well that this opinion is not accepted by the profession, but to my own mind it is so clear that I urge the great necessity of a complete rectification of deformity in these cases, at the cost of pain and strong effort, and then the careful and constant pressure of the ulna upward. My belief is very decided that gravity is the best means of retaining the head of the ulna in place, by bringing the weight of the hand and arm to bear on a compress under it, but the plan is not absolutely necessary. Still, my views on this subject I do not intend to press at the present time.

Touching the displacements of the bones of the carpus, and the carpal articulation of the metacarpal bones with them, I may remark that, after their rectification, a constant tendency to recurrence must be restrained by compress and bandage. The phalanges, however, when their luxations are reduced, require no retention apparatus.

The deep socket of the acetabulum does undoubtedly afford by its shape the best assurance of retention that can be offered in the human body by mere passive resistance to the recurrence of a luxation. But even the hip-joint is subject to this accident if the precautions of quiet are not observed; the lax ligamentous continuity resulting from the separation of the torn surfaces easily invites a repetition of the displacement.

Of this class Dr. Bigelow reports three cases, one of which

was my own.

J. B. P., Co. H., 148th N. Y. Volunteer Infantry, U. S. A., when on the march from Bermuda Hundred to Drury's Bluff, May 13,

1864, while skirmishing up a hill sprang back to avoid the gun of a comrade in advance. His left foot became entangled in the root of a bush and was held firmly while he fell over. The weight of the body and the twist of the fall dislocated his hip. The fight was going on actively, but in his disablement, recognizing that something was out of place, he called upon his comrades to pull at his foot, with the belief that it would give him relief. In this he was not mistaken. The complete restoration of function, and the peculiar surroundings, caused him to feel that it was not a matter of much moment. He immediately resumed his skirmishing and marched seven miles, from 10 A. M. till 6 P. M. He lay down at night, and was ordered out the next day as a sharpshooter. This duty called for every variety of position, such as crawling on the ground, and being on the knees and on the feet alternately. He continued this service for five days, and returned to camp to be put on the intrenchments, and worked there for two days and nights. He afterward went "on picket," and entered the hospital May 28, having thus been actively employed for fifteen days. That the ligament should be lax under such constant motion, is not a matter of surprise. But the interference with nature's plan of repair resulted in a chronic inflammation, marked by much tenderness in the act of walking, along with an easy recurrence of luxation. This last he could produce at will. Fixing the foot firmly on the ground, he bent the knees a little and twisted the pelvis backward on the affected side, when the head would suddenly leave the socket for the dorsum ilii, and then he would restore the bone by reversing the movement. To this may add still another case in one of our own profession, who was also capable of producing this luxation and reducing it at will.

I

Of the knee and ankle it may be said that the laceration of ligaments and even concomitant fractures are so considerable as to demand the use of splints.

It only remains for me to say that the bones of the tarsus and metatarsus must be retained by compress and bandage, with complete rest.

THE SIGNIFICANCE OF CERTAIN SYMPTOMS IN HERNIAL STRANGULATIONS, AND

RULES FOR TREATMENT.

By FREDERICK HYDE, M. D., of Cortland County.

Read November 18, 1885.

THE symptoms of bowel obstruction are in the main identical, whatever the cause. When, therefore, an inguinal swelling, free from pain, direct or indirect, shows itself, and the tolerance of pressure is also true of the adjacent structures, we have come to believe that the signs of distress do not point to the groin tumor as the cause. The very mildness of the disturbance is misleading. The absence of general peritonitis is altogether too comforting, and thus day after day, for a week and a half or longer, creeps along, until the lurking evil betrays its true character, only after all hope has been abandoned. A strangulated hernia has done its work, alas! too well, for what means have we to restore to life several inches of dead intestine? Of what avail is herniotomy now? Stercoraceous vomiting, with its delusive recurrences at longer intervals, the non-tympanitic abdomen, and the bare fact that death does not invariably occur in all cases where the first-mentioned symptom is manifest, have robbed us of valuable time. Herniotomy, let me repeat, may give the intestine liberty, it can not give it life. Again, that other snare of the absence of pain in the tumor, or its reference to the epigastrium, leads up to an unfavorable prognosis, since the delay has only rendered questionable the minor operation of reduction by taxis, or the major one of surgically liberating the gut.