The same rule applies to the elbow-joint, and with regard to the bones of the fore-arm and arm. For when these bones protrude through a wound which they have made in the skin, all cases in which they are reduced prove fatal; but if not reduced, there is a chance of recovery; but to those that survive there is certain impediment. And if in any instance the bones of the upper articulations ( shoulder-joint? ), should be dislocated, and project through a wound which they have made in the skin, these, if reduced, are followed by more speedy death; and if not reduced, they are more dangerous than the others. But the mode of treatment which appears to me most suitable has been already described. When the joints of the toes or hands are dislocated, and the bones protrude through a wound which they have made, and when there is no fracture of the bone, but merely displacement of the joint, in these cases, if the reduction be made and allowed to remain, there is some danger of spasms ( tetanus? ) if not properly treated, and yet it may be worth while to reduce them, having warned the patient beforehand that much caution and care will be required. The easiest, the most efficient method, and the one most conformable to art, is that by the lever, as formerly described when treating of bones which have been fractured and protruded; then the patient must be as quiet as possible, lie in a recumbent position, and observe a restricted regimen. And it will be better also that he should get some gentle emetics. The sore is to be treated with dressings for fresh wounds, which permit of allusions, or with the leaves of camomile, or with the applications for fractured bones of the head, but nothing very cold must be applied. The first ( most distant? ) joints are least dangerous, but those still higher, are more so. Reduction should be made the same day, or the next, but by no means on the third or fourth, for it is on the fourth day that exacerbations especially attack. In those cases, then, where immediate reduction cannot be accomplished, we must wait until after the aforesaid days; for whatever you reduce within ten days, may be expected to induce spasm. But if the spasm supervene on its being reduced, the joint should be quickly displaced, and bathed frequently with warm water, and the whole body should be kept in a warm, soft, and easy condition, and more especially about the joints, for the whole body should rather be in a bent than in an extended state. Moreover, it is to be expected, that the articular extremities of the bones of the fingers will for this generally happens, if even the least degree of inflammation take place, so that if it were not that the physician would be exposed to censure, owing to the ignorance of the common people, no reduction should be made at all. The reduction of the bones of joints which have protruded through the skin, is attended with the dangers which have been described. When the articular bones of the fingers are fairly chopped off, these cases are mostly unattended with danger, unless deliquium come on in consequence of the injury, and ordinary treatment will be sufficient to such sores. But when resection is made, not at the articulations, but at some other point in the bones, these cases also are free from danger, and are still more easily cured than the others; and the fractured bones of the fingers which protrude otherwise than at the joint admit of reduction without danger. Complete resections of bones at the joints, whether the foot, the hand, the leg, the ankle, the forearm, the wrist, for the most part, are not unattended with danger, unless one be cut off at once by deliquium animi, or if continual fever supervene on the fourth day. With regard to the sphacelus of fleshy parts, it takes place in wounds where there are large blood-vessels, which have been strongly compressed, and in fractures of bones which have been bound too tight, and in other cases of immoderate constriction, when the parts which have been strangulated generally drop off; and the most of such patients recover, even when a portion of the thigh comes away, or of the arm, both bones and flesh, but less so in this case; and when the fore-arm and leg drop off, the patients readily recover. In cases then, of fracture of the bones, when strangulation and blackening of the parts take place at first, the separation of the dead and living parts quickly occurs, and the parts speedily drop off, as the bones have already given way; but when the blackening ( mortification ) takes place while the bones are entire, the fleshy parts, in this case, also quickly die, but the bones are slow in separating at the boundary of the blackening, and where the bones are laid bare. Those parts of the body which are below the boundaries of the blackening are to be removed at the joint, as soon as they are fairly dead and have lost their sensibility; care being taken not to wound any living part; for if the part which is cut off give pain, and if it prove not to be quite dead, there is great danger lest the patient may swoon away from the pain, and such swoonings often are immediately fatal. I have known the thigh-bones, when denuded in this manner, drop off on the eightieth day; but in the case of this patient, the parts below were separated at the knee on the twentieth day, and, as I thought, too early, for it appeared to me that this should be done more guardedly. In a case which I had of such blackening in the leg, the bones of the leg, as far as they were denuded, separated at its middle on the sixtieth day. But the separation of denuded bones is quicker or slower, according to the mode of treatment; something, too, depends upon whether the compression be stronger or weaker, and whether the nerves, flesh, arteries, and veins are quicker or slower in becoming blackened and in dying; since, when the parts are not strongly compressed, the separation is more superficial, and does not go the length of laying the bones bare, and in some cases it is still more superficial, so as not even to expose the nerves. For the reasons now stated, it is impossible to define accurately the time at which each of these cases will terminate. The treatment of such cases, however, is to be readily undertaken, for they are more formidable to look at than to treat; and a mild treatment is sufficient in all such cases, for they come to a crisis of themselves; only the diet must be attended to, so that it may be as little calculated to create fever as possible, and the body is to be placed in the proper positions: these are, neither raised very high up, nor inclined much downward, but rather upward, until the separation be completed; for at that time there is most danger of hemorrhage; on this account, wounds should not be laid in a declining position, but the contrary. But after a while, and when the sores have become clean, the same positions will no longer be appropriate; but a straight position, and one inclining downward, may be proper; and in the course of time, in some of these cases, abscesses form, and require bandages. One may also expect that such patients will be attacked with dysentery; for dysentery usually supervenes in cases of mortification and of hemorrhage from wounds; it comes on generally when the blackening and hemorrhage have arrived at a crisis, and is profuse and intense, but does not last many days; neither is it of a fatal nature, for such patients do not usually lose their appetite, nor is it proper to put them on a restricted diet. Dislocation inward at the hip-joint is to be reduced in the following manner: (it is a good, proper, and natural mode of reduction, and has something of display in it, if any one takes delight in such ostentatious modes of procedure). The patient is to be suspended by the feet from a cross-beam with a strong, soft, and broad cord; the feet are to be about four inches or less from one another; and a broad and soft leather collar connected with the cross-beam is to be put on above the knees; and the affected leg should be so extended as to moved be two inches longer than the other; the head should be about two cubits from the ground, or a little more or less; and the arms should be stretched along the sides, and bound with something soft; all these preparations should be made while he is lying on his back, so that he may be suspended for as short a time as possible. But when the patient is suspended, a person properly instructed and not weak, having introduced his arm between his thighs, is to place his fore-arm between the perineum and the dislocated head of the os femoris; and then, having joined the other hand to the one thus passed through the thighs, he is to stand by the side of the suspended patient, and suddenly suspend and swing himself in the air as perpendicularly as possible. This method comprises all the conditions which are natural; for the body being suspended by its weight, produces extension, and the person suspended from him, along with the extension, forces the head of the thigh-bone to rise up above the acetabulum; and at the same time he uses the bone of the fore-arm as a lever, and forces the os femoris to slip into its old seat. The cords should be properly prepared, and care should be taken that the person suspended along with the patient have a sufficiently strong hold.