A SYSTEM OF SURGERY. BY BENJAMIN BELL, MEMBER OF THE ROYAL COLLEGES OF SURGEONS OF IRELAND AND EDINBURGH, ONE OF THE SURGEONS TO THE ROYAL INFIRMARY, AND FELLOW OF THE ROYAL SOCIETY OF EDINBURGH. ILLUSTRATED WITH ONE HUNDRED COPPERPLATES. VOLUME IV. THE FIRST AMERICAN EDITION, CORRECTED. PRINTED AT BOSTON, BY ISAIAH THOMAS AND EBENEZER T. ANDREWS, FAUST's STATUE, No. 45, NEWBURY STRRET. Sold by them in Boston, and by said THOMAS in Worcester. MDCCXCI.  CONTENTS. CHAPTER XXXVIII. Of TUMORS, 9 Sect. I. Of Tumors in general, 9 Sect. II. Of Acute or Inflammatory Tumors, 13 § I. Of Erysipelas, 13 § 2. Of Inflammation of the Ear, 16 § 3. Of Angina, 17 § 4. Inflammation and Abscess of the Liver, 18 § 5. Of Inflammation and Abscesses in the Breasts of Women, 23 § 6. Of Inflammation of the Testes, 26 § 7. Of Venereal Buboes, 27 § 8. Of Lumbar Abscesses, 34 § 9. Of the Paronychia or Whitlow, 40 § 10. Of Chilblains, 44 § 11. Of Sprains and Contusions, 46 Sect. III. Of Chronic or Indolent Tumors, 51 § 1. Of Encysted Tumors, 52 § 2. Of Ganglions, 61 § 3. Of Swellings of the Bursœ Mucosœ, 62 § 4. Of Collections within the Capsular Ligaments of Joints, 65 § 5. Of Concretions and preternatural Excrescences within the Capsu— lar Ligaments of Joints, 68 § 6. Of Anasarca or Oedema, 71 § 7. Of IV CONTENTS. § 7. Of the Spina Bifida, 73 § 8. Of Scrophulous Tumors, 75 § 9. Of the Bronchocele, 79 § 10. Of the Nœvi Materni,86 § 11. Of Warts, 87 § 12. Of Fleshy Excrescences, 90 § 13. Of Corns, 90 § 14. Of a simple Exostosis, Venereal Nodes, and Spina Ventosa, 91 CHAPTER XXXIX. Of FRACTURES, 103 Sect. I. General Observations on Fractures, 103 Sect. II. Of Fractures of the Nose, 122 Sect. III. Of Fractures of the Bones of the Face, 123 Sect. IV. Of Fractures of the inferior Max— illary Bones, 125 Sect. V. Of Fractures of the Clavicles and Ribs, 127 Sect. VI. Of Fractures of the Sternum, 131 Sect. VII. Of Fractures of the Vertebrœ, Os Sacrum, Coccyx, and Ossa Innominata, 133 Sect. VIII. Of Fractures of the Scapula, 135 Sect. IX. Of Fractures of the Humerus, 137 Sect. X. Of Fractures of the Bones of the Fore Arm, 139 Sect. XI. Of Fractures of the Bones of the Wrist, Hands and Fingers, 143 Sect. XII. Of Fractures of the Femur and Thigh Bone, 145 Sect. XIII. Of Fractures of the Patella, 152 Sect. XIV. Of Fractures of the Bones of the Leg, 157 Sect. v CONTENTS. Sect. XV. Of Fractures of the Bones of the Foot and Toes, 162 Sect. XVI. Of Compound Fractures, 163 CHAPTER XL. Of LUXATIONS, 176 Sect. I. General Remarks on Luxations, 176 Sect. II. Of Luxations of the Bones of the Cranium, 188 Sect. III. Of Luxations of the Bones of the Nose, 189 Sect. IV. Of Luxations of the Lower Jaw, 190 Sect. V. Of Luxations of the Head, 193 Sect. VI. Of Luxations of the Spine, Os Sa— crum, and Os Coccyx, 195 Sect. VII. Of Luxations of the Clavicles, 199 Sect. VIII. Of Luxations of the Ribs, 201 Sect. IX. Of Dislocations of the Humerus at the Joint of the Shoulder, 202 Sect. X. Of Luxations of the Fore Arm at the Joint of the Elbow, 216 Sect. XI. Of Luxations of the Bones of the Wrist, 219 Sect. XII. Of Luxations of the Bones of the Metacarpus and Fingers, 221 Sect. XIII. Of Luxations of the Femur at the Hip Joint, 222 Sect. XIV. Of Luxations of the Patella, 230 Sect. XV. Of Luxations of the Tibia and Fibula at the Joint of the Knee, 231 Sect. XVI. Of Luxations of the Foot at the Joint of the Ankle, 233 Sect. XVII. Of Luxations of the Os Calcis, and other Bones of the Foot, 235 CHAPTER vi CONTENTS. CHAPTER XLI. Of DISTORTED LIMBS, 237 CHAPTER XLII. OF DISTORTIONS of the SPINE, 244 CHAPTER XLIII. Of AMPUTATION, 248 Sect. I. General Remarks on the Operation of Amputation, 248 Sect. II. Of the Causes that may render Am— putation necessary, 249 Sect. III. General Remarks on the Method of Amputating Limbs, 261 Sect. IV. Of Amputating the Thigh, 266 Sect. V. Of Amputating the Leg, 283 Sect. VI. Of Amputating with a Flap, 288 Sect. VII. Of Amputating the Thigh at the Hip Joint, 290 Sect. VIII. Of the Flap Operation immedi— ately above the Knee, 295 Sect. IX. Of the Flap Operation below the Knee, 299 Sect. X. Of Amputating the Foot, Toes, and Fingers, 301 Sect. XI. Of Amputating the Arm at the Joint of the Shoulder, 304 Sect. XII. Of Amputating the Arm, 308 CHAPTER XLIV. Of Removing the Ends of BONES in Dis— eases of the JOINTS, 309 CHAPTER VII CONTENTS. CHAPTER XLV. Of Preventing or Diminishing PAIN in CHIRURGICAL OPERATIONS, 314 CHAPTER XLVI. Of MIDWIFERY, 317 Sect. I. General Observations on Midwifery, 317 Sect. II. Of the Cæsarean Operation, 319 Sect. III. Of the Division of the Symphysis Pubis, 322 CHAPTER XLVII. Of Opening DEAD BODIES, 326 CHAPTER XLVIII. Of EMBALMING, 329 CHAPTER XLIX. Of BANDAGES, 331 Explanation of the Plates, 337 A TREATISE  A TREATISE ON THE THEORY AND PRACTICE OF SURGERY. CHAPTER XXXVIII. Of Tumors. SECTION I. Of Tumors in general. EVERY preternatural enlargement, in whatever part of the body it is seated, may be termed a Tumor. Tumors daily occur in one form or another: They are often followed with important consequences; they frequently give much embarrassment both to pa— tients and surgeons: for these reasons they merit par— ticular attention. Much variety occurs in the general appearances of tumors, as well as in the method of treatment best suited for their removal: But such varieties only should be mentioned in a work of this kind as require some peculiarity in the method of cure. B Tumors 10 Of Tumors in general. Chap. XXXVIII. Tumors may with propriety be divided into two general classes: Into such as are of an acute or in— flammatory nature; and such as are chronic, or indo— lent. Authors have for the most part distinguished them into such as are said to be of a warm nature; and those which they suppose to be cold; from their being destitute of pain and redness, symptoms which we commonly observe to accompany heat. But the terms we have mentioned of Acute or Inflammatory, and Chronic or Indolent, are more scientific; at the same time that they are more expressive of the real na— ture of the different affections: for it will be found to hold perhaps universally, that tumors are acute or indolent, that is, that they are rapid or slow in their progress, nearly in proportion to the degree or inflam— mation with which they are attended. I mean there— fore to rank in the first class of tumors, all such as from their commencement are accompanied with inflamma— tion; and in the second, all those which are not evi— dently accompanied with this symptom. It will unavoidably happen, however, that some tu— mors will be mentioned under one class, which, during some part of their progress, may appear to belong to the other: Thus, a tumor beginning from some in— flammatory affection, may terminate in a state of per— fect, indolence; while others, which at first were evi— dently chronic or indolent, may at last become highly inflammatory. We shall endeavour, however, to cha— racterize them by those symptoms which appear most obviously at their commencement: A mode of dis— tinction which appears to be the most accurate; for it is not what a tumor may eventually become, but what it actually is on its first appearance, that can admit of any description. CLASS I. Acute or Inflammatory Tumors. Phlegmon, with its consequences, abscess and mortifi— cation. Erysipelas. Ophthalmia. Inflammation 11 Sect. I. Of Tumors in general. Inflammation of the ear. Angina, or inflammation of the throat. Inflammation and abscess of the liver. of the breasts of women. of the testes. of the anus and perinæum. Venereal buboes. Lumbar abscesses. Paronychia or whitloe. Chilblains. Sprains and contusions. CLASS II. Chronic or Indolent Tumors. Encysted tumors, usually so termed. Ganglions. Swellings of the bursæ mucosæ. Concretions and preternatural excrescences within the capsular ligaments of joints. Aneurisms. The true, the false, and varicose aneurisms. Varicose veins. Hemorrhoidal swellings. Hydropic swellings. anasarca or oedema. hydrocephalus. hydrops pectoris and hydrops pericardii. ascites. dropsy of the ovaria. hydrocele. spina bifida. Swellings in the sublingual glands. Tumors containing air. General emphysema produced by air escaping from the lungs into the cellular substance, as sometimes happens from the spiculæ of fractured ribs pene— trating the substance of the lungs. Local emphysematous tumors produced by putre— faction in a particular part. This is a rare occur— B2 rence; 12 Of Tumors in general. Chap. XXXVIII. rence; but cases of it are recorded by different au— thors. Tympanitis. Tumors formed by the displacement of particular parts. Herniæ. of the brain. inguinal and scrotal. congenital. crural. umbilical. ventral. at the foramen ovale. in the perinæum. of the alimentary canal and mesentery. of the omentum. of the liver, spleen, and other abdominal viscera. of the bladder. of the intestines in the vagina. Protrusion of the eyeball. Prolapsus uteri. Prolapsus ani. Tumors formed by the displacement of bones in cases of dislocation. Scrophulous tumors. Bronchocele. Sarcomatous tumors. Sarcocele. Scirrhus. Cancer. Polypous excrescences in the nose and throat. Polypi in the ear. in the uterus. Condylomatous tumors in the anus. Excrescences in the urethra. Nævi materni. Warts. Corns. Tumors 13 Sect II. Of Inflammatory Tumors. Tumors from affections of the bones. Simple exostoses. Venereal nodes. Spina ventosa. We shall now proceed to consider such of these tu— mors as have not yet been described, or that will not more properly fall to be mentioned in some other chapter. Of these last, indeed, all that occur are such as are produced by the heads of bones when displaced, which will be considered when we come to the Chap— ter on Dislocations. SECTION II. Of Acute or Inflammatory Tumors. THE general theory and management of inflam— mation and its consequences, have already been fully treated of;* We must therefore refer for this part of our subject to what was then said upon it: and in considering those varieties of tumors in which in— flammation takes place, such circumstances only will be taken notice of as from peculiarity of situation, or some other cause, require a particular treatment. In the Treatise on Ulcers, erysipelas was mentioned and described as a variety of inflammation: but as phlegmon, with its consequences, was the only subject which we then meant to discuss, the treatment of ery— sipelas was not considered; we shall now therefore of— fer a few observations upon it. § 1. Of Erysipelas. In phlegmon, the inflammation is circumscribed. In general, it is deeply seated in the cellular substance; and any effusion which takes place is for the most part converted into purulent matter: But in erysipelas, the tumor * Vide a Treatise on Ulcers, &c. Part I. B3 14 Of Acute or Chap. XXXVIII. tumor is diffused, and not much elevated; it seldom proceeds deeper than the skin; and any effusion with which it is attended is commonly thin and acrid, and is not convertible into pus. By experience we know, that sores proceeding from erysipelas are in general difficult to cure: It should therefore be our first object to endeavour to prevent that effusion of which these sores are the consequences. By some it is alleged, that this practice must be at— tended with risk, as erysipelas in general appears to proceed from a constitutional affection; and hence we are advised rather to encourage the discharge of that matter which nature seems inclined to deposite. This observation, however, does not appear to be well founded; for it is found that the discussion of erysipe— latous affections may be attempted with the same free— dom and safety as inflammation of any other kind. There is a common prejudice against the use of unc— tuous applications, and whatever contains moisture, in every case of erysipelas; and fine flour, starch, or hair powder, are almost the only remedies employed exter— nally. These are used with a view to absorb the acrid matter, which affections of this kind often throw out in the form of pustules, and which unctuous and moist applications are rather supposed to encourage. But to me it appears that they prove more useful in pre— venting the effusion or formation of that matter, than in absorbing it afterwards. By soothing or allaying that uneasy sensation which usually accompanies ery— sipelas, and which they often do very effectually, they necessarily tend to lessen that preternatural exertion of the affected vessels, which in every case of inflam— mation we consider as the cause of the subsequent ef— fusion; and as they usually prove more pleasant in every respect than moist applications, they should therefore in the first stages of the disorder be preferred. It happens indeed, in some cases, that they have little or perhaps no effect in procuring relief. In such in— stances, I have sometimes found, that by keeping the inflamed 15 Sect II. Inflammatory Tumors. inflamed part exposed to the air, and wetting it every now and then with a feather soaked in a weak solution of Saccharum Saturni, immediate ease has been pro— cured, and no disadvantage has afterwards occurred from it. In general, however, the dry farinacious powders answer better. Almost an universal prejudice has prevailed against blood letting and other evacuations in erysipelas. And as it is commonly supposed to be attended with some degree of putrescency, instead of evacuations, bark, wine, and warm stimulating cordials, have been recommended. It appears, however, that the ideas of practitioners upon this point have not been founded on observation: for it is now known, that in every case of erysipelas, blood may to a certain extent be e— vacuated with safety; and by doing so, and adhering in every respect to an antiphlogistic regimen, we will in general be almost certain of preventing the disease from terminating in those effusions which we have mentioned, and which at all times we should endeav— our to prevent. It is proper, however, to remark, that local blood letting, which in other varieties of inflammation proves highly useful, is not here admissible: for the orifices by which it must be drawn off are very apt to degen— erate into those troublesome ulcers which erysipelas when it terminates in effusion is very apt to produce. By one or more general blood lettings, according to the strength of the patient; by the use of gentle laxa— tives, mild sudorifics, and a cooling diet; and by fre— quently dusting the part affected with one or other of the powders we have mentioned, almost every erysipe— latous tumor may be discussed: But when effusion is found to have occurred in any considerable quantity, it should be discharged immediately by a small open— ing in the most depending part of it. In this state of the disease, emollient cataplasms are commonly appli— ed with a view to bring the contents of the swelling to suppuration. This, however, proves always pernic— B4 ious: 16 Of Acute or Chap. XXXVIII. ious: for the effusion being of a nature which cannot be converted into pus, poultices can never be of the same use as in cases of phlegmon; and as it is com— monly sharp and acrid, it is apt to do mischief, by cor— roding the skin and other contiguous parts, when it is allowed to remain. The best application in this state of the disease, is any of the saturnine ointments, such as Goulard's cerate, or the common wax ointment, with a small proportion of Saccharum Saturni. § 2. Of Inflammation of the Ear. The passage as well as the bottom of the ear, are en— tirely membranous; consequently the inflammation which attacks them proves very painful: for we know that inflammation of membranous parts gives more pain than that of parts of a looser texture; as the blood vessels in the former do not yield so readily as those of the latter, to the distention which always ac— companies inflammation. The remedies to be employed in cases of this kind should be regulated by the stage of the disease. When the inflammation has subsisted so long as to give rea— son to suspect that it will terminate in suppuration, which it is apt to do very quickly, emollient applica— tions prove most useful: the ear should be frequently fomented with warm emollient steams; and it often proves serviceable to cover the affected side of the head with large emollient poultices. But in the com— mencement of the affection, we should in general at— tempt to prevent suppuration: for it is often difficult to obviate the effects of it when matter is once formed in the ear; and a long continued discharge is fre— quently productive of deafness. With this view noth— ing proves in general so effectual as the application of a small blister behind the ear: and by pouring a few drops of laudanum into the passage, or of compound spirit of lavendar mixed with a small proportion of oil, we very commonly have it in our power to remove or abate the pain; and the irritation being in this man— ner 17 Sect. II. Inflammatory Tumors. ner removed, the risk of suppuration ensuing is there— by much lessened. Our endeavours, however, for this purpose, will of— ten prove abortive: In which event, and when it is evident that matter is formed, we should endeavour to bring it off as freely as possible, by bathing the ear in warm water, and even by injecting a little warm water into it. By these means we may often put a stop to the discharge: but when it still continues to flow, as— tringent injections, of lime water, or of mild saturnine solutions, should be employed; which seldom fail when the disease is solely confined to the soft parts of the ear. When the bones of the ear are affected, which in general may be known by the matter having a very offensive smell, and being of a black or dark brown colour, all that art can do, is to keep the pas— sage clear by the use of injections. The cure in these cases must be left to the operation of nature. § 3. Of Angina. Every inflammatory affection of the throat is term— ed Angina, or Squinzy. As abscesses in these parts prove always trouble— some, and in some cases dangerous, we should endeav— our to cure every inflammation with which they are attacked, by resolution. With this view, one or more general blood lettings should be prescribed, according to the strength of the patient. Smart purgatives prove particularly useful; and some advantage is often derived from diapho— retics. None of these remedies, however, can be depended on with such certainty as the local discharge of blood from the part affected, and the application of a blister to that part of the neck which lies most contiguous to it. In Plate LIII. figs. 1. and 3. instruments are de— lineated for the purpose of drawing blood from the throat by means of scarifications; and when they are employed with freedom on the first appearance of in— flammation, 18 Of Acute or Chap. XXXVIII. flammation, it will seldom terminate in suppuration. Fomenting the throat with steams of warm vinegar proves sometimes useful; and considerable advantage has been derived in different instances from astringent gargles, of infusions of oak bark, of red rose leaves, with a proportion of alum or of the vitriolic acid, and of Saccharum Saturni dissolved in water. A general prejudice prevails against the use of any of the satur— nine applications in the form of gargles, from their be— ing supposed to be of a poisonous nature. But al— though I have often used them, I never knew an in— stance of any harm occurring from them; and they have frequently proved highly serviceable. In small quantities I believe they might be swallowed with safety; but we all know that gargles may be employ— ed without any part of the liquor being allowed to go over. It will often happen, however, that these and all other remedies will fail, either from the application of them being too long delayed, or from the violence of the inflammation. When suppuration is evidently to take place, it ought to be promoted by the external application of warm poultices to the throat, and by the patient being made to inspire the warm steams of milk or of any emollient decoction by means of the machine delineated in Plate LIII, fig. 2. When matter is fully formed, it should be discharged by an opening made into it with one of the instruments men— tioned above for scarifying the throat. § 4. Inflammation and Abscess of the Liver. The substance of the liver being soft and yielding, we would not à priori imagine that it would be liable to inflame. We find, however, that in warm climates, particularly in the East Indies, this viscus becomes more frequently inflamed than perhaps any other part of the body; probably from the bile in these climates being apt to become so acrid as to excite irritation in the parts to which it is applied. In some cases too, inflammation 19 Sect. II. Inflammatory Tumors. inflammation occurs in the liver from external vio— lence. Inflammation of this part is attended with a dull uneasy sensation over all the region of the liver, with cholic pains and sickness at stomach; the patient is li— able to frequent cold and hot fits: and for the most part, the colour of his skin, as well as his urine, is ting— ed yellow. When suppuration takes place, and especially when the abscess is large, the patient complains of pain ex— tending up the right side to the top of the shoulder. In some cases this symptom occurs even in the inflam— matory state of the disorder; but it happens more fre— quently after the formation of matter, probably from the weight of the abscess acting upon the diaphragm and pleura, with which the liver is connected. The region of the liver becomes daily more tense; and if the convex part of it be chiefly affected, a softness, and even a fluctuation of matter, is often discovered through the teguments of the abdomen. In the commencement of this affection, the same remedies which are useful in other cases of local in— flammation prove most successful. Blood letting should be immediately prescribed; the quantity to be determined by the strength of the patient: but in— stead of taking it from a vein, it should be drawn off by cupping and scarifying the part affected. When the scarifications are made of a sufficient depth, al— most any quantity of blood may be got in this man— ner; and no remedy with, which we are acquainted proves so effectual in removing the inflammation. Blistering the pained part is also frequently of service; the bowels should be kept moderately open with mild laxatives; and a gentle perspiration should be encour— aged over the whole surface of the body. In general, this treatment will prove successful when it has been employed early in the disease; but when the symptoms do not soon yield, mercurials should be advised without any farther delay: for in the remov— al 20 Of Acute or Chap. XXXVIII. al of inflammatory affections of the liver, nothing has hitherto proved so effectual as mercury in one form or another. The common mercurial pill of the Edin— burgh Dispensatory answers as well as any other; and it seems to act with more certainty when conjoined with small doses of opium. Frictions with mercurial ointment upon the part affected, are sometimes em— ployed with advantage: But whatever form of the medicine be used, it should be quickly carried so far as to affect the mouth, which should be kept mode— rately sore for several weeks, unless the disease subsides immediately; in which case a shorter course will an— swer the purpose. As it is of much importance in every case of this kind to give a free discharge to the bile, if the patient does not otherwise get regular and easy passage of his bowels, he should, during the mercurial course, have a gentle saline purgative every third or fourth day, by which the discussion of the inflammation is often much promoted. Suppuration, however, will often take place not— withstanding all that can be done to prevent it; and when it is known, or even suspected to have happen— ed, an incision should be made into the abscess to dis— charge the matter. When the abscess is seated on the convex or prominent part of the liver, and when the quantity of matter contained in it is considerable, we will readily discover it by the touch; and in this case there is no room to hesitate. But even where we have not this circumstance for our direction, a little attention will often enable us to discover almost with certainty whether suppuration has occurred or not. If along with the pain in the right shoulder and neck, which we have mentioned, it is observed that the re— gion of the liver is more bulky than it was before, and that the teguments which cover it are become soft and oedematous; and especially if the patient complains of frequent shivering fits, a symptom which very con— stantly 21 Sect. II. Inflammatory Tumors. stantly accompanies internal suppuration; we may conclude with much certainty that matter is formed. In every situation, matter should be discharged, perhaps as soon as it is known that complete matura— tion has taken place. But abscesses seated in any of the larger cavities, especially where they lie so deep as the liver or any other of the viscera, should be opened even before there is reason to suppose that all the ef— fused fluids are so completely converted into pus as we might otherwise wish to be the case: Indeed this should be considered as an established maxim in prac— tice; for the chance of these collections bursting in— wardly is much greater than of their bursting out— wardly, where the teguments which cover them are thick and strong, when compared with the peritonæ- um, the only membrane which lies between them and the intestines. Abscesses of the liver have been known to burst through the diaphragm, so as to be emptied into the thorax: In a few cases the matter has been carried into the duodenum by the common passage of the bile; and sometimes, by the great arch of the co— lon adhering to the liver, a communication has been formed between them; by which the matter of ab— scesses in this situation has been very completely evac— uated: but for the most part, when it is not discharg— ed by an external opening, the abscess bursts into the cavity of the abdomen. With a view to prevent such a fatal occurrence, the assistance of surgery should be immediately called in as soon as the appearances and symptoms we have mentioned give cause to suspect that matter is colle— ed: An incision of a sufficient length should be made with a scalpel through the external teguments in the most depending part of the tumor; and on reaching the abscess, it may either be opened with the point of the scalpel or with a lancet; but piercing it with a tro— car is preferable, as in this manner we have it in our power to evacuate the matter slowly and gradually, which in large collections is a point of importance, and 22 Of Acute or Chap. XXXVIII. and therefore requires attention. Even this opening into the abscess, however, should be afterwards enlarg— ed, otherwise there would be some risk of its closing before the cyst containing the matter collapses suffic— iently for the prevention of farther collections. This being done, a pledgit of soft lint covered with any e— mollient ointment, or merely dipped in oil, should be gently insinuated to a sufficient depth between the lips of the wound, to prevent them from uniting till the abscess collapses and fills up from the bottom: a pro— cess that will be much hastened by a proper applica— tion of pressure upon the tumefied parts by means of a flannel roller passed two or three times round the body. When the vacuity produced by the discharge of matter does not soon fill up, it will be proper to in— troduce a canula to preserve a free passage for any matter that may afterwards form; But this precau— tion is seldom necessary; for abscesses in the liver heal sooner; and with fewer inconveniencies, than similar affections in perhaps any other part of the body. In— deed this is so well ascertained, that I would advise an opening to be made into the abscess in every instance where there is the least cause to suspect that matter has formed in the liver. Many practitioners indeed assert, that no attempt of this kind is admissible unless the ab— scess be seated in the convex part of the liver. It must be allowed, that abscesses in this situation are much more accessible than such as are seated in the concave part of it. But wherever they are situated, a proper vent should be procured for the matter; for if it be not evacuated by an external opening, we may conclude almost with certainty, that it will be emptied into the abdomen, by which the patient will inevitably die. In all affections of the liver that occur in warm cli— mates, the bark is commonly employed on the first ap— pearance of any of the symptoms: The putrescent tendency of the bile is the ostensible reason of this. But I believe it will be found that no dependence should 23 Sect. II. Inflammatory Tumors. should be placed upon the bark during the first or in— flammatory stage of this disease. In this period of the disorder it may even do mischief: but when sup— puration has taken place, and when the matter is dis— charged from the abscess, bark will prove equally use— ful as it is found to do in similar affections of other parts of the body. When, by too long delay, it unfortunately happens that an abscess either bursts into the cavity of the chest or into the abdomen, the matter should be drawn off immediately: in the one case, by the operation of the empyema, described in Chapter XXII. and in the oth— er, by the common operation of the paracentesis Chapter XXI. § 5. Of Inflammation and Abscesses in the Breasts of Women. The breasts of women are liable to be acted upon by every cause which excites inflammation in other parts of the body: But affections of this kind occur most frequently in nurses by the gorging or stoppage of the milk, which almost constantly takes place from sudden or imprudent exposure to cold: The breast becomes stiff, swelled, and painful; the milk runs off in small quantities, but not so as to afford any effectu— al relief; and the patient grows hot and restless, while much thirst prevails, along with a full quick pulse. Practitioners are divided with respect to the method of treating cases of this kind: By some it is said, that discussion of the tumor should always be attempted; while others assert, that when this does not succeed, it often does mischief, by inducing scirrhous affections, which cannot afterwards be dissolved, and which are apt to terminate in cancer. So far as I can judge from my own observation, there is no room to hesitate. Our practice in inflam— ed breasts should be the same as in every case of in— flammation, wherever it may be seated. In the first stages of the disorder, discussion of the tumor should be 24 Of Acute or Chap. XXXVIII. be always attempted; while it would be in vain, and highly improper to advise it when the swelling has been of such duration as to have any tendency to sup— purate. The risk of our inducing scirrhus by this practice, seems to be in a great measure imaginary: It rather appears, indeed, that cancer is more apt to oc— cur from the improper management of those sores which ensue from collections of matter in the mamma, than from any means that can be used to prevent the matter forming. We are farther induced to follow the practice, from the great distress which always at— tends suppuration in the mamma: Indeed, the pain and misery of the patient is in such cases often so great, that no doubt can remain with unprejudiced practi— tioners of the propriety of endeavouring in every case to prevent it. It is scarcely necessary to remark, that the same remedies prove useful here that succeed in the discus— sion of inflammation in other parts: But it is truly surprising, that there should be almost an universal prejudice in every inflamed breast against the most powerful of all discutients, blood letting. Afraid of this evacuation tending to diminish the quantity of milk, we avoid it entirely. In this, however, I am convinced we are wrong. In every case of this kind I have been in the practice of bleeding freely. It has not appeared to diminish the flow of milk; while its effects in preventing suppuration are very great. The quantity of blood to be taken away, must always be determined by the violence of the inflammation, and by the strength of the patient: But in general, the practice will be more effectual, when as much as the patient can easily bear to lose is taken at once, than when the same, or even a greater quantity, is tak— en at different times. Purgatives prove particularly useful; and a cooling diet is equally necessary here as in any other case of inflammation. As nothing tends more to prevent the discussion of inflamed tumors than pain, nothing should be omitted that 25 Sect. II. Inflammatory Tumors. that can in any degree alleviate this symptom: And as no remedy with which we are acquainted, proves so effectual in removing it as opium, it should always be given in such doses as are found to be sufficient. With a view to remove the tension of the breast, it should be gently rubbed over with althea ointment, or even with oil: but the external applications which are most to be trusted, are those of a cooling astringent nature; such as a solution of sal ammoniac in vinegar and water; spiritus Mindereri; and all the saturnine applications. Cloths dipped in any of these should be kept constantly applied to the breast; by which, and by attention to the rest of the treatment advised above, almost every tumor of this kind will be remov— ed; unless the inflammation has been of long contin— uance before the remedies are employed; in which case, if the pain and tension are considerable, it will always be more advisable to endeavour to bring the tumor to suppurate, than to attempt any other meth— od of cure. For this purpose, we rely with most cer— tainty on a frequent renewal of warm fomentations and poultices; and when matter appears to be fully formed, it should be discharged by an opening made in the most depending part of the collection: At least an opening should always be advised, when it is found that the matter is pointing at an improper part where it would not find a free vent. In the treatment of those cases of tumefied inflamed breasts which occur in nursing, it is a doubt with ma— ny practitioners, whether the milk should be drawn off or not. Indeed many assert, that drawing it off, ei— ther by continuing the child or with glasses, does mis— chief; and therefore they advise it not to be attempt— ed. I have never observed, however, that any incon— venience ensued from it; and as it always procures re— lief, I advise it in every instance. When the breast is much swelled, the nipple cannot be laid hold of by the child: In such cases the glasses represented in Plate LXV. may be used with advantage. C § 6. 26 Of Acute or Chap. XXXVIII. § 6. Of Inflammation of the Testes. Inflammation of the testes may be induced in vari— ous ways: By the application of cold; by external violence; and by every other cause that tends to ex— cite inflammation in other parts of the body. But the most frequent cause of it is a gonorrhœa virulenta. The common opinion respecting this was, that it oc— curred from the matter in gonorrhœa falling down, as it was termed upon the testes: And this appeared the more probable from its being observed that the testes were apt to swell upon the discharge being stopped, at the same time that the affection of the testes was com— monly relieved by a return of the running. It is now known, however, that no communication subsists between the urethra and testes by which mat— ter can be conveyed from the one to the other: And the most probable opinion is, that in the swelled testes occurring from gonorrhœa, the inflammation is com— municated from the urethra, and spreads along the va— sa deferentia to the testes. A sudden stop being put to the discharge, whether by the use of irritating injections or by any other cause, is very commonly attended with an increased degree of inflammation; to abate which, nothing proves more effectual than a return of the running. In this way we account more clearly than in any other man— ner for the effect produced upon the testes by the state of the running. Inflammation of the testes very rarely terminates in suppuration: but this should not prevent the most timely application of those remedies which we know to be the most powerful discutients. Blood letting is perhaps the most effectual remedy; but it always proves most serviceable when the blood is taken di— rectly from the part affected by means of leeches. After discharging a sufficient quantity, the swelling should be kept constantly moist with a solution of Saccharum Saturni; the scrotum and testes should be properly 27 Sect. II. Inflammatory Tumors. properly suspended; the bowels should be kept mod— erately open; a low diet should be prescribed; and the patient should be strictly confined to a horizontal posture. When there is the least reason to suspect that the constitution is tainted with lues venerea, noth— ing will prove serviceable if a mercurial course be ne— glected. And when it appears that the disease has been induced by the discharge having been too sud— denly checked, we should endeavour to promote a re— turn of it, by bathing the penis in warm water; by injecting warm oil into the urethra: or by the use of bougies. By due attention to a course of this kind, almost ev— ery case of inflamed testicle will terminate favourably; that is, the tumor will be discussed. But when the contrary happens, either from the use of the remedies not being persisted in, or from the inflammation be— ing particularly violent, and when suppuration is found to take place, the matter must be discharged by an opening made in the most depending part of the abscess; which in every respect should be treated like collections of pus in other parts of the body. § 7. Of Venereal Buboes. Swellings in the lymphatic glands from the absorp— tion of the venereal virus are termed Venereal Buboes. They may appear in any gland seated between a ve— nereal sore and the heart: but they are most frequent in the groin, in consequence of the absorption of ve— nereal matter from sores in the penis. For the most part they are produced by matter absorbed from chan— cres, and in some cases from the matter of a gonor— rhœa: But instances likewise occur of buboes arising without any previous ulceration or discharge from the penis, where the matter appears to be absorbed with— out any perceptible erosion of the skin. The most material point to be determined in the treatment of a bubo is, whether we should endeavour to discuss the swelling, or to bring it to suppuration? C2 While 28 Of Acute or Chap. XXXVIII. While it was imagined that buboes were produced by a deposition of venereal matter from the system, it was not surprising to find practitioners advising us in eve— ry instance to promote their suppuration: for on this supposition it was probable that nature meant to throw off the infection. But now when we know that buboes arise from matter passing into the system; that the quantity of venereal matter is increased instead of being diminished, by their being brought to suppu— rate; and that the sores which ensue from them are often extremely difficult to cure; scarcely any will doubt of the propriety of endeavouring to remove them by discussion. With this view the patient should be put upon an antiphlogistic regimen. His bowels should be kept open by the use of purgatives; leeches should be ap— plied to the hardened gland; and it should be kept constantly wet with a strong solution of Saccharum Sa— turni. Along with these, however, mercury should be given in quantities sufficient for eradicating the dis— ease: And as we know from experience that mercury proves most effectual when it is made to pass through the diseased glands, it should always be applied in the form of unction to those parts in which the lymphat— ics of the affected glands are known to originate: a practice which will almost uniformly be found to prove more effectual than the direct application of the mercury to the glands themselves. Thus in the dis— cussion of a bubo in the groin, friction with mercurial ointment upon the thigh and leg will prove more suc— cessful than rubbing it upon the gland itself. To ma— ny this has been long known; and it would appear that the practice could scarcely fail of occurring to any who have paid attention to the discoveries made by the moderns in the anatomy of the lymphatic system.* When buboes are early noticed, the course we are now recommending will seldom fail in discussing them, if * Farther information may be obtained on this point in a late elabo— rate publication on the venereal disease, by the very ingenious Mr. John Hunter of London. 29 Sect. II. Inflammatory Tumors. if the mercurial frictions be properly applied and con— tinued for a sufficient length of time. It often hap— pens, however, that all our efforts fail, either from the disease being too far advanced before the mercury is applied, or from the tumor not being altogether vene— real, but of a mixed nature; a circumstance which is not unfrequent. Thus it frequently happens that buboes are combined with scrophula and scurvy, and in some cases with erysipelas or with common phleg— mon. In such cases we are not surprised at the fail— ure of mercury: and accordingly we sometimes find, that instead of forwarding the discussion of the swell— ing, it tends evidently to bring it to suppurration. Cases of this kind prove often very perplexing both to the patient and practitioner; so that no point in prac— tice requires more exact attention and discrimination: For by proceeding to throw in great quantities of mer— cury, as is usually done while buboes continue obstinate, we often do harm, not merely to the local affection, but to the system at large; at the same time that in every instance the safety of the patient requires such a quan— tity to be exhibited as is sufficient for eradicating the venereal virus. In all such cases, the best practice, I believe, is, to desist from the use of mercury as soon as it appears that no advantage is derived from it. In the mean time, by a change of diet and other circum— stances, such an alteration may be effected in the con— stitution that a second trial of mercury may prove successful: At least, in different instances this has suc— ceeded with me, where I had much reason to think that persisting longer with mercury at first would have done much harm. When it is found that a bubo cannot be discussed, and that it will probably suppurate, a frequent renew— al of warm emollient poultices and fomentations are the remedies to be most depended upon. The opening of buboes when suppuration has tak— en place next demands our attention. Some dissuade us from opening buboes at all, alleging that they heal C3 sooner 30 Of Acute or Chap. XXXVIII. sooner when allowed to burst of themselves: while a small puncture with a lancet, a longitudinal cut through the whole extent of the swelling, or the appli— cation of caustic, have all had their abettors. When a bubo is altogether venereal, and not con— nected with any other disorder, any of these methods will succeed, provided a sufficient quantity of mercury be exhibited: But when a bubo terminates in a sore difficult of cure, we are too apt to blame the particu— lar method in which it was opened; for in whatever manner it is done, we know that the cure will often prove tedious and perplexing. The object of practitioners should be nearly the same here as in collections of matter in any other part. Such an opening should be made as affords a free vent to the matter; but there is seldom any necessity for making it larger. In very large buboes, indeed, the teguments are apt to be so loose and flabby, and the texture of the skin so much destroyed, that the cure would be rendered tedious, were it allowed to re— main. In such cases it is advisable to discharge the matter with caustic applied in such a manner as to de— stroy any part of the teguments that are superabund— ant. This, however, is seldom necessary; and for the most part it will be found that an opening made from the centre of the tumor, where the matter commonly points, down to the most depending part of it, will prove sufficient. Even a smaller opening than this would often answer; but is better to make it of a suf— ficient size at once, than to be obliged to repeat a ve— ry painful operation perhaps once and again, as is of— ten necessary when buboes of a large size are opened by small punctures. In small buboes, a mere punc— ture will sometimes prove sufficient; nay in these, the matter being allowed to burst, often answers extremely well: but when the collection is large, this should never be depended on. When buboes come forward to full maturation without much injury being done to the skin, I have in 31 Sect II. Inflammatory Tumors. in different instances discharged the matter by the in— troduaion of a small cord; and the practice has suc— ceeded. This requires, however, the teguments to be firmer than they commonly are when a bubo is ready to be opened. We all know that it is of much importance to pre— vent the air from finding access to sores; and as we sometimes observe buboes ooze out the matter which they contain by a number of small openings over their surface, and as these commonly heal easily, I conclude that they do so from the openings being so small as to exclude the air entirely. In different cases, I have at— tempted to imitate nature, by making a number of ve— ry small punctures with the point of a lancet over the whole extent of the bubo; and for the most part with success. The matter comes slowly off: the sides of the abscess contract gradually; and when it is com— pletely emptied, we commonly find the whole parts that have been affected sufficiently firm, without any sores or sinuses remaining. While means are employed to promote the suppu— ration of a bubo, the patient should still continue the mercurial course, by which no time will be lost; and the sore, which is the consequence of the opening, will afterwards heal more quickly than if the mercury had been interrupted. The sore, however, often proves tedious, even where we are convinced that a sufficient quantity of mercury has been given, and where there is every reason to suppose that the siphylitic virus is eradicated. The edges become hard and livid; the matter thin, sharp, and fetid; and instead of healing, the ulceration gradually becomes more extensive; or if it heals in some parts, it breaks out in others, giving a honey comb appearance to all the under part of the abdomen and upper part of the thigh. The situation of patients with such sores is truly de— plorable. The pain with which they are attended is, often intense; the absorption of acrid matter induces hectic fever; they become hot and restless through C4 the 32 Of Acute or Chap. XXXVIII. the night; and almost a total want of appetite renders them soon very emaciated. As I have happened to be concerned in a consider— able number of such cases, I can speak with some con— fidence of the method of treatment. In the first place, we must conclude that the patient has taken a suffic— ient quantity of mercury, and that no sinuses are left in which matter in any quantity will be allowed to lodge. Cicuta in such circumstances has sometimes proved useful; and I have had different instances of the external application of it healing the sores when no advantage was derived from any kind of ointment. In such cases it was applied in the form of poultices, by mixing the juice of the fresh herb with the common emollient cataplasm. I have sometimes observed too, that in the internal exhibition of cicuta, the recent ex— pressed juice has proved more effectual than any other form of it. I have given the hyoscyamus and bella— dona very complete trials in various instances; but no material advantage has ever ensued from them. I have not seen any evident effects either from sarsapa— rilla or guaiac; but mezereon has in different cases proved useful. In two instances of very extensive sores of this kind, where the whole groin and contigu— ous parts were ulcerated, and where none of the rem— edies mentioned above, nor any of the usual dressings, had any effect, the patients were evidently cured by mezereon alone. A drachm and a half of the rhind of the root, with two drachms of liquorice root, boiled in three English pints of water into a quart, makes a decoction of a sufficient strength. This quantity may be used daily. But the most effectual course I have hitherto tried, is the application of caustic round all the edges and hardened parts of the sores, at the same time that opi— um in considerable quantities is given inwardly. For a considerable time I trusted entirely to dressings of the emollient kind, being afraid of irritating parts al— ready extremely sensible. In some cases a saturnine ointment 33 Sect. II. Inflammatory Tumors. ointment has proved successful; and in others the common calamine cerate has answered: but for the most part, on those days in which caustic is not appli— ed, I have found more advantage from the use of red precipitate than from any other remedy. In some cases it is necessary to sprinkle it over the surface of the sore in the form of a dry powder; but in others it proves sufficient to add it to any of the common oint— ments. Instead of creating pain, it commonly re— moves it, and it seldom fails to alter the discharge from a thin sharp sanies to a thick well digested pus. At first the application of lunar caustic sometimes gives pain: but this soon subsides, and especially when opium is used at the same time. Indeed opium of itself proves often useful in sores of this kind. It has been highly extolled of late for the cure of every stage of the venereal disease. I have had no proof of its ever curing any symptom truly venereal; but I have had several instances of sores remaining after the venereal disease, even where large quantities of mercu— ry had been given in vain, being completely removed by it. It often appears that sores of this kind, as well as others proceeding from different causes, are kept up by that pain and irritation with which they are uni— formly accompanied when the matter is thin and acrid. To me the utility of opium seems to depend entirely on its narcotic or anodyne powers. By removing this state of irritability, it destroys the disposition in the vessels of the sore to form that kind of matter which by its acrimony serves to perpetuate itself: and this being accomplished, if no other interruption takes place, nature alone will seldom fail to complete the cure. If this idea be well founded, there can be no necessity for giving opium in such large quantities as of late have been advised. On the supposition of opi— um being possessed of some specific powers in the cure of the venereal disease, it has been given in as large doses as the patient could possibly bear; and by be— ginning with small doses, and increasing them gradu— ally, 34 Of Acute or Chap. XXXVIII. ally, there have been some instances of its being taken to the extent of half a drachm or more two or three times a day. I have not heard, however, that any advantage has been derived from giving it in these large quantities, that did not accrue from a more mod— erate use of it: And in the course of my own expe— rience, I have found it equally effectual when it mere— ly lessened or removed pain, as when given in the largest doses; while the inconveniences which usually arise from these have in this manner been avoided. § 8. Of Lumbar Abscesses. Every collection of matter seated on any part of the loins, may be denominated a Lumbar Abscess. But it is that variety of the disease we are now to consider, which originates about the superior part of the os sa— crum; and in which we find, by dissection that the matter contained in a cyst, is lodged on the anterior surface of the internal iliac and psoas muscles. These abscesses are always preceded by pain and tension over the loins; which often shoots up along the course of the spine, and down towards the thighs; and often with difficulty of standing erect. In some cases, these symptoms are suspected to be nephritic; but for the most part the disease assumes the appear— ance of lumbago. When suppuration ensues, shiver— ing fits are apt to occur: but the pain, which at first was acute, becoming dull and less perceptible, the pa— tient is led to conclude that he is getting better, till the matter, after falling down in a gradual manner behind the peritonæum, is observed to point outwardly, either at the anus by the side of the rectum, or on the upper and sore part of the thigh where the large blood ves— sels pass out, beneath Paupart's ligament, from the abdomen. When the matter takes the course of the gut, and appears near to the anus, it either soon bursts, or is laid open on the supposition of its being an abscess o— riginating in the contiguous parts. But when it passes down 35 Sect II. Inflammatory Tumors. down with the fœmoral artery, which we find to be most frequently the case, as it lies deep and is covered with the strong tendinous fascia of the thigh, instead of pointing at any particular part, it falls gradually low— er, till in some cases it reaches near to the joint of the knee. The tumor is seldom attended with more pain than might be expected to occur from the distention of the fascia and contiguous parts by the matter collected be— neath. There is no discolouring of the skin; the teg— uments, for the most part, retaining their natural ap— pearance to the last. A fluctuation of a fluid is evi— dently discovered through the whole extent of the tu— mor, particularly when the patient is erect; for at this time the swelling is always much more tense than when the body is lying in a horizontal posture, when a considerable part of the matter runs along the sac to— wards its origin in the loins. We have already observed, that this variety of ab— scess, when the matter falls down towards the anus, may be mistaken for a common phlegmon originating in the neighbourhood of the rectum. But no farther inconvenience can occur from this mistake, than that the sore, which ensues from laying it open, or from the matter bursting out, will not so readily heal as when the disease is merely local: And it is probable that this is one cause of abscesses in these parts being in some instances so difficult to cure. But in the more ordinary form of the disease, where the matter falls down beneath Paupart's ligament, the tumor exhibits appearances so similar to those of a crural hernia, that the one has often been mistaken for the other. Of this I have seen different instances, even where prac— titioners of experience were deceived. This proceeds, however, from inattention; for the two diseases may be clearly distinguished from each other. The history of the rise and progress of the swelling should be first attended to. A crural hernia usually appears 36 Of Acute or Chap. XXXVIII. appears suddenly, without any previous symptom, af— ter some unusual exertion; and for the most part it is attended with obstruction to the passage of the feces, with vomiting, and other symptoms of hernia: And from the first, the tumor is attended with pain on be— ing handled. But in the lumbar abscess, before the matter appears at the top of the thigh, the patient is previously distressed with the symptoms of inflamma— tion over all the under part of his back and loins. No obstruction of the bowels takes place, nor any symp— tom of hernia; and the patient admits of the tumor being freely handled. In the crural hernia, the swell— ing seldom arrives at any considerable bulk; and when it does become large, it is by slow degrees: no fluctu- ation is perceived in it; but, on the contrary, it feels either soft like dough, or knotty and unequal, accord— ing as the omentum or feces contained it have been long lodged in it or not. But in the lumbar abscess, the tumor commonly falls quickly down the thigh for the space of several inches; a fluctation is always per— ceived; and no inequalities are observed in it. In the hernia, even when it is not strangulated, some degree of pressure is usually necessary, even when the patient is in a horizontal posture, to make the contents of the tumor recede. But in the lumbar abscess, the tumor becomes flaccid immediately on the patient laying down, whether any pressure be applied to it or not: And it often happens when the matter has fallen any considerable way down the thigh, that the upper part of the cyst at the top of the thigh is found perfectly clear; that is, a certain space can be discovered between the upper part of the matter and the inferior boarder of the abdominal muscles, which can never be done in any kind of hernia; and which, therefore, in this state of the disease, is always a certain means of distinction. It is scarcely necessary to observe, that in this examin— ation the patient should be erect. By 37 Sect. II. Inflammatory Tumors. By due attention to these circumstances we may al— ways distinguish one of these tumors from the other. Both indeed may occur at the same time in the same thigh, by which a mixture of appearances will be pro— duced. This, however, must be extremely rare; and when it does take place, as the matter of the abscess and the parts protruded from the abdomen will always be contained in separate sacs, the combination will be easily discovered. In the treatment of these affections, the period of the disorder first requires our attention. In the in— flammatory state of the disease, the strictest antiphlo— gistic course mould be adopted, in order, if possible, to prevent the formation of matter. For the most part, we discover, that it has been induced by the small of the back or loins having received some considerable injury, either by a twist or a severe bruise: and if ac— cidents of this nature were immediately treated with that attention which their importance merits, those dis— agreeable consequences which are apt to ensue from them might frequently be prevented. Whenever it is found that a patient, who has suffered in this manner, complains of severe pain in the injured part, blood let— ting should be immediately advised; and as local blood letting proves always in such cases most effec— tual, it should be done by cupping and scarifying the pained part. The affected parts being deeply cover— ed, the lancets of the scarificator should be made to go to a considerable depth; for which purpose the spring of the instrument should be stronger than usual, by which means any quantity of blood we may judge proper may be taken with ease; and I am convinced, that by carrying this practice a sufficient length, we might very commonly, in the early stages of the dis— ease, remove it entirely. It is difficult to say when injuries of these parts would terminate in suppuration or otherwise; but I have met with different instances, where, from the severity of the pain and other symp— toms, there was much cause to suspect that matter would 38 Of Acute or Chap. XXXVIII. would have formed; if it had not been prevented by a timely and plentiful discharge of blood from the in— jured parts; a remedy which commonly gives imme— diate relief to the pain, however violent it may be. But at the same time that we depend chiefly on local blood letting, other remedies which experience shows to prove useful in inflammation should not be neglect— ed: Of these, blisters, opiates, and gentle purgatives, are to be most relied on. These, however, as well as every other remedy, will in some instances fail; and in others, practitioners are not called till suppuration has taken place, and till the matter has actually begun to point, either in the neighbourhood of the anus or on the sore part of the thigh. In this situation, what are we to do? Are we to allow the matter to remain, or to discharge it by making an opening into it? In my opinion there is no room for hesitation: The matter should be evacuat— ed as soon as a fluctuation is distinctly perceived in the tumor. I know, however, that practitioners are of different opinions upon this point: for it is alleged, that as these abscesses are so deeply seated, it would be in vain to attempt the cure of them; and therefore that no advantage can be derived from their being laid open; while much harm, they observe, may accrue from the air being freely admitted to them. But it does not appear that this reasoning is founded on observation. I have always held it as a leading principle in surgery, that the matter of every abscess seated near to any of the large cavities of the body should be discharged as soon as its existence is clearly ascertained: So that in the treatment of the lumbar abscess, I have uniformly given vent to the matter, without any bad conse— rences ensuing; while much mischief may occur from this being omitted. We find by dissection after death, that these abscesses, when of long duration, af— fect not only the softer parts covering the vertebræ of the loins, but the substance of the vertebræ themselves; which 39 Sect. II. Inflammatory Tumors. which in some cases have been found carious, and e— ven partially dissolved in the matter of the abscess. Now these accidents are surely more likely to happen when the matter is allowed to continue in the abscess, than when it is discharged: at the same time, by emp— tying the sac, the matter is prevented from bursting into the cavity of the abdomen: which in different instances has happened, to the great inconvenience and hazard of the patient. The matter, however, ought certainly to be discharged in such a way as to prevent the air as effectually as possible from getting access to the cavity of the abscess. With this view a trocar may be used with advantage. By pressing the matter down to the most depending part of the abscess, the skin is made so tense, that a trocar is readily introduc— ed. I tried this in one case with very complete suc— cess; and the patient wore a small canula in the open— ing for several months, by which the matter was free— ly discharged. But when the case is not perfectly ob— vious, and when the least doubt remains in the mind of the surgeon with respect to the contents of the tu— mor, instead of pushing a trocar into it, the opening should be made in a slow gradual manner with a scal— pel, in the same manner as is practised in cases of her— nia; so that in the event of any of the contents of the abdomen being down, no injury may be done to them. After the matter has continued to slow for some time, and if at the end of two or three weeks the quan— tity does not become considerably less, it may prove useful to throw up with a syringe a weak solution of saccharum saturni, lime water, or some other gentle astringent; by which the discharge will be gradually diminished, till at last it ceases entirely. But although this should never happen, and although the patient during life should submit to the inconveniency of a constant stillicidium of matter from the sore; yet even this would be preferable to the risk of allowing every abscess of this kind to remain unopened. As 40 Of Acute or Chap. XXXVIII. As I have happened to meet with many instances of this disease; as practitioners are divided in opinion respecting it; and as no distinct account of it is given by authors; I have considered it more particularly than I otherwise might have done. § 9. Of the Paronychia or Whitlow. The paronychia is a painful inflammatory swelling, occupying the extremities of the fingers under the nails. Several varieties of this disease are described by au— thors; but there are three only which require to be distinguished, and even these are all of the same nature, the one being only more deeply seated than the others; In the first, the patient complains of an uneasy burning sensation for several days over the point of the finger; the part becomes tender and painful to the touch; a flight degree of swelling takes place, but with little or no discolouration; and if the inflamma— tion be not removed by resolution, an effusion is at last produced between the skin and the parts beneath. On discharging this by an incision, it is found to be a thin, clear, acrid serum; and the removal of it, in gen— eral, gives immediate and complete relief. In the second variety of the disease the same set of symptoms are produced; only the pain is more severe, and it is attended with some uneasiness over the whole finger and hand. The effusion which takes place is not so perceptible as in the other; and on laying it open, it is found to lie beneath the muscles of the fin— ger, between these parts and the periosteum. And in the third, the pain is still more intense in the point of the finger, at the same time that the whole hand and arm becomes stiff, swelled, and painful. The lymphatics leading from the finger, and even the glands in the arm pit, swell and inflame; and on mak— ing an incision into the effusion, it is found to lie be— tween the periosteum and bone, the whole phalanx being in general carious. Swellings 41 Sect. II. Inflammatory Tumors. Swellings of this kind may be produced by various causes. They frequently occur from external vio— lence, particularly from punctures and contusions: But they happen more frequently from causes, the na— ture of which we are not acquainted with. There are two sets of remedies employed in parony— chia: The one consists of fomentations, poultices, and other emollients; the other of ardent spirits, vinegar, and other astringents. As we find from experience that no advantage is ev— er produced by the effusion which occurs in this dis— ease; but on the contrary, that it is always productive of much additional pain, all those applications should be avoided which have any tendency to promote it. Some practitioners have been induced to make use of warm poultices, with a view to promote the suppura— tion of the swelling, after they have had reason to be— lieve that effusion has taken place. But I have never observed any advantage to accrue from them; and as the serum which we meet with in these collections is produced entirely from membranous parts, I do not suppose that it can be converted into pus; at least none of the remedies I have known employed have ever been able to effect it. I endeavour therefore in every instance to prevent this effusion from taking place; by local blood letting, and by the use of astringents. Indeed the same remedies prove most effectual here which are useful in the removal of inflammation in other parts. I have had different instances even of very violent degrees of pain being almost immediate— ly removed by the application of several leeches over the diseased phalanx of the finger. But in the more violent degrees of it, where the arm swells, and by which fever is sometimes produced, general blood let— ting is likewise necessary, at the same time that large doses of opiates are indicated. After as much blood is discharged by the leeches as is judged proper, the immersion of the pained parts in strong brandy, or even in spirit of wine or alcohol, is D one 42 Of Acute or Chap. XXXVIII. one of the best remedies: And when the bites are somewhat healed, or when leeches have not been em— ployed, spirit of turpentine or strong vinegar may be used in the same manner. It is proper to remark, however, that it is in the first stages only of this affection that remedies of this kind can prove useful: for when effusion has actually taken place, that state of the disease is produced which they were meant to prevent; and it does not appear that they have any effect in removing it. As soon as we are convinced that effusion has occurred, an opening should be made without delay: For we have already observed, that it is in vain to attempt to convert the effused fluid into pus; and being in itself acrid, it is apt to injure the contiguous parts, while at the same time the patient is kept in an extreme degree of pain as long as it remains confined. When the collection is superficial, and merely covered with skin, this is a very simple operation. A puncture with a lancet commonly proves sufficient: But when the matter is more deeply seated, it requires some attention to avoid the flexor and extensor tendons of the finger. When the matter lies above the periosteum, all that we have to do is to make the opening sufficiently large for discharging it, and to dress the sore as if it was produced by any other cause. But, when the matter lies between the periosteum and the bone, in every case that I have met with, the bone has not on— ly been laid bare, but it has been found to be carious. The common practice is to endeavour to keep the in— cision open till an exfoliation of the diseased parts of the bone takes place; but I have never observed any advantage accrue from this. The process is not only extremely painful, but tedious. The matter is apt to lodge beneath the nail; painful fungous excrescences sprout out over the sore, which it is difficult even with the strongest caustic to keep under; and at last it has very commonly happened, after the patient has suffer— ed several months of distress, that instead of a partial exfoliation, 43 Sect. II. Inflammatory Tumors. exfoliation, the whole diseased phalanx has come a— way. I am therefore convinced, that much time and trouble would be saved both to the patient and sur— geon, if the diseased bone were immediately removed on making the opening to discharge the matter. By making a free incision along the whole length of the diseased phalanx, the bone is easily removed with common forceps. The pain attending it is indeed se— vere, but it is only momentary: and the measure, which does not deprive the patient of the use of the joint so much as might be imagined, is seldom opposed when the surgeon advises it. I have had several in— stances of people who had in this manner lost the last phalanx of bone in one of their fingers, having such a degree of firmness in the parts which remained, as to experience very little inconvenience from the want of it. When the diseased bone is removed, the remaining sore commonly heals with ease. It requires some at— tention, however, to preserve the lips of it from adher— ing till it fills up from the bottom. This is done in the easiest manner by insinuating a small pledgit be— tween them of soft lint, spread with any mild emol— lient ointment. In every variety of the disease, excepting in a few cases of the mildest kind of it, we find that the nail is apt to fall off: But this proves only a temporary in— convenience; for when the parts are properly protect— ed, nature never fails to supply the deficiency. In the commencement of paronychia, it is the last phalanx of the finger only that is affected: And to whatever extent the pain and swelling of the softer parts may spread, we never find that the bone of the contiguous phalanx suffers, unless from improper management in allowing the diseased bone to remain, or the acrid matter to lodge too long. In such cases, the surrounding teguments are apt to swell and in— flame, and small ulcerations to occur over the whole extent of the carious bone. In this situation we are D2 often 44 Of Acute or Chap. XXXVIII. often under the necessity of advising the finger to be amputated, in order to prevent the disease from spread— ing to the hand. § 10. Of Chilblains. These are painful inflammatory swellings, to which the fingers, toes, heels, and other extreme parts of the body, are liable, on being much exposed to severe de— grees of cold. The tumor is for the most part of a deep purple, or somewhat of a leaden colour: the pain with which it is attended is not constant, but shooting and pungent; and in general, it is accompanied with an insupportable degree of itching. In some cases the skin remains entire, even although the tumefaction be considerable; but in others it bursts or cracks, and discharges a thin somewhat fetid matter. And where the degree of cold has either been very great, or the application of it long continued, all the parts that have been affected are apt to mortify and to slough off, when a very foul ill conditioned ulcer is always left. We have observed above, that it is the extreme parts of the body chiefly that are liable to be attacked with chilblains: and we likewise find that delicate children and old people are more apt to suffer by them than those who are robust. It is also remarked, that they are particularly severe in people of a scrophulous habit. The best preventative of chilblains is to avoid ex— posure to cold and dampness: And when once a per— son has suffered from swellings of this kind, if the in— jured parts be not protected by sufficient coverings, he will be liable to a return of them every winter. Much distress, therefore, and inconvenience, may be prevented by due attention to this circumstance. The utmost care, however, will not always prevent chilblains. In this case, it is often in our power to mitigate the complaint, by bringing the affected parts gradually to their natural heat, instead of warming them more quickly. The patient should not be al— lowed 45 Sect. II. Inflammatory Tumors. lowed to approach a fire: instead of which he should be put into a cold apartment; and the frost bit parts should first be well rubbed with snow, and afterwards immersed in the coldest water that can be procured: for nothing so certainly proves hurtful to parts in this state as heat being suddenly applied to them. Even snow and cold water afford a warm sensation to parts attacked with chilblains; but it is found by experience that no detriment ensues from this. After the parts have been treated in this manner, the patient may in a gradual way be brought into a greater degree of heat; but he should for a considerable time keep at a dis— tance from fire. Rubbing the parts with salt will in this situation prove useful; and immersion in warm wine is likewise employed with advantage. A patient much benumbed with cold should not even have cordials given to him suddenly. A glass of cold wine may at first be allowed. Afterwards warm wine may be given, either by itself or mixed with some of the warmer spices: and when stronger cordials are required, ardent spirits may be employed. Remedies of this kind, however, are only necessary in the more severe degrees of these affections. In common cases of chilblains that occur in this country, as soon as the part is perceived to be affected, it should be well rubbed either with spirit of turpentine or with camphorated spirit of wine; and pieces of soft linen moistened in one or other of these should be kept con— stantly applied to it. In this manner we have it often in our power to remove swellings which otherwise would be productive of much distress: But we must again observe, that the best advice that can be given to such patients as are liable to them, is to protect the parts that are most exposed to suffer from cold as much as possible during the winter; and when they accidentally get wet with snow, which proves more particularly hurtful than any other kind of moisture, they should be as quickly cleared of it as possible. D3 As 46 Of Acute or Chap. XXXVIII. As there are some patients who suffer severely with chilblains every winter, either in their fingers, arms, toes, heels, or lips, our being able to prevent them without that inconvenience which always occurs from confinement and much caution, would often be an object of importance: and it is a point upon which practitioners are frequently consulted. I have had different instances where sea bathing during the sum— mer season has appeared to prove useful: and in one patient who had suffered severely from the effects of cold for several winters, I advised a chamber bath to be used even during the winter; by which the parts which used to suffer were so much strengthened, that several years have elapsed without any return of the disease. When chilblains ulcerate, by the teguments being altogether thrown off, or merely cracking and oozing out matter, warm poultices and emollient ointments are commonly employed. For the purpose of cleans— ing the sores, and inducing a discharge of right matter, poultices may with propriety be advised for a few days; but they should never be long continued: Nor should emollient ointments be much persisted in; for they very universally induce fungous excrescences over the sores, which afterwards it is sometimes diffi— cult to remove. The daily application of caustic to the edges of the sore, and dressing the sore itself with common digestive ointment, mixed with a large pro— portion of red precipitate, are the best preventatives of this. The common simple diachylon plaster, spread upon thin leather, makes an useful application for sores of this kind. § 11. Of Sprains and Contusions. Contusions of the softer parts of the body, and sprains of the tendons and ligaments of joints, are us— ually productive of immediate painful inflammatory swellings. The 47 Sect II. Inflammatory Tumors. The slighter affections of this kind seldom meet with much attention ; but when the injury is severe, it often requires the utmost skill of the practitioner, as well as the greatest caution on the part of the patient, to remove those effects which ensue from it, and which otherwise might continue during life. An increased action in the arteries of any part, by which red globules are forced into vessels which nat— urally do not admit them, will account for all the phe— nomena which usually attend inflammation: But in the severer degrees of sprains and contusions, along with an increased action of the arteries in the part, which must necessarily result from the pain with which they are accompanied, it is evident that instantaneous effusion likewise takes place, from the rupture of many of the smaller vessels of the part. In no other way can we account for those very considerable tumors which often rise immediately after injuries of this na— ture. For the most part the effusion must be of the serous kind, as the skin usually retains its natural col— our for some time after the accident: But the tume— fied parts are sometimes of a deep red, and on other occasions of a leaden colour, from the first; owing to a rupture of some of the vessels containing red blood. In the treatment of sprains and contusions, there are two circumstances which chiefly require attention. In the first place we should endeavour to prevent the swelling, as far as it can possibly be done; and after— wards those remedies should be employed which we know to prove most powerful in preventing or remov— ing inflammation. It is alledged, indeed, by some practitioners, that the swelling which occurs from this injury never does harm, and therefore requires no particular attention. In contusions of the cellular substance, or even of the muscles, I allow that this is often the case; for to what— ever extent the tumefaction may proceed, the effused fluid is in these parts very commonly absorbed. But even here the swelling in some cases proves extremely D4 obstinate: 48 Of Acute or Chap. XXXVIII. obstinate: and in sprains of the tendons and liga— ments, a very troublesome, painful thickness of the parts that have been injured is apt to continue for a great length of time; in some cases, even for life: And I have commonly observed, that this has in general been nearly in proportion to the size of the tumor which occurred at first; for it would appear that effu— sions thrown out by ligamentous parts are not so read— ily absorbed as those which occur in other parts of the body. Hence in every accident of this kind, it is an object of importance to prevent the swelling from ar— riving at any considerable magnitude. With this view, astringent applications are most to be depended on; such as the lees of red wine, ardent spirits of every kind, and vinegar. By immersing a sprained or contused part in any of these immediately on receiving the injury, if the effusion be not altogeth— er prevented, it will at least be rendered much less than otherwise it probably would be. And it often hap— pens that the immediate application of cold proves equally useful. Plunging a sprained limb into the coldest water that can be procured, or even into water rendered artificially colder than natural, is a practice that often proves useful; and it should be always ad— vised in the first place, till one or other of the articles mentioned above can be procured; for as the effusion takes place, as we have already observed, very quick— ly, no time should be lost in the application of the remedies. It fortunately happens, that those applications which prove most effectual in preventing the effusion that ensues from sprains prove likewise useful in pre— venting inflammation. But as this symptom is in se— vere sprains apt to proceed to a great height, other remedies are required in the treatment of it; and none that I have ever employed prove so effectual as local blood letting. By the time that the cold water and other discutients we have mentioned may be supposed to have produced any effect, which will be in the space of 49 Sect. II. Inflammatory Tumors. of an hour, a number of leeches should be applied over all the tumefied part; or, in contusions of fleshy mus— cular parts, cupping and scarifying will be found to answer equally well. But in whatever way it be done, a quantity of blood should be drawn off somewhat proportioned to the strength of the patient and vio— lence of the injury. For a considerable time I have been in the constant practice of employing local blood letting in sprains and contusions of every kind; and in all of them, whether the injury has been slight or severe, it has proved an useful pleasant remedy. In the slighter kind of sprains, one plentiful evacuation of blood by means of leeches, will in general prove sufficient. But when the parts are much injured, we are under the necessity of applying them repeatedly. They should be order— ed indeed from time to time as long as any consider— able pain remains in the affected parts. Even when the inflammation and swelling of the teguments are entirely gone, a fulness or thickening is often discov— ered in the tendons and other deep seated parts; and we conclude, that they continue inflamed, as long as they are much pained either upon pressure or upon motion. In this situation nothing ever proves so ef— fectual as the application of leeches: The remedy in— deed seems to prove equally useful, whether the in— flammation be seated entirely in the skin, or in the more deep seated parts; so that it should not in any case be omitted. In violent sprains the pain is often so severe, as to in— duce quickness of pulse and other symptoms of fever. In such cases, along with local blood letting, it is sometimes necessary to take blood from some of the larger vessels. Opiates become necessary, together with all the remedies that prove useful in fevers aris— ing from inflammation. After blood has been freely evacuated from a sprain— ed part, the best application that can be used for some days at first, is a solution of saccharum saturni: and afterwards, 50 Of Acute or Chap. XXXVIII. afterwards, when a thickening of the tendons contin— ues, as sometimes happens notwithstanding the utmost attention, pouring warm water upon the part two or three times daily, for the space of a quarter of an hour or so each time, proves often an useful remedy. Even common spring water frequently answers the purpose; but it seems to prove more penetrating when slightly impregnated with sea salt: and we have likewise rea— son to think that the warm waters of Bath and Buxton are rendered more effectual in cases of this kind by the impregnations which they contain, than they other— wise would be. Along with warm bathing, frictions with emollient applications prove often serviceable in removing this thickening of the parts induced by sprains. But in order to prove useful, they should be persisted in for a considerable time. During the cure of a contusion or of a sprain, the injured part should be kept as much as possible in an easy posture. In every instance this should be attend— ed to: but it becomes more particularly proper when the pain is more severe than usual; an occurrence which we often suppose to happen from the fibres of some of the sprained tendons being ruptured, and which nothing will cure so readily as the limb in which it has happened being kept for a considerable time in a relaxed easy posture. We have already mentioned the warm bath as a remedy in sprains. In various cases cold bathing also proves serviceable. After sprains have been of some duration, the injured part is apt to continue weak and relaxed, even when the pain and swelling are mostly gone. In this situation, cold water being poured up— on the part from a height, or being suddenly dashed upon it, and repeated once or twice daily, will prove more effectual in strengthening the weakened limb than perhaps any other remedy. It is for the remov— al of debility only, however, that it should be employ— ed; and there is much reason to think that it has done mischief 5l Sect. III. Of Indolent Tumors. mischief when used in the more early stages of sprains. While that thickening of the tendons and ligaments remains, which we have mentioned above, and which often proves the most formidable, as well as the most obstinate symptom which accompanies sprains, cold bathing seems to do harm, by rendering it more firm than it was before, while the contrary effect often re— mits from a proper application of warm water. A bandage or roller applied over the injured parts, as tight as the patient can easily bear it, proves often useful in sprains. By supporting the relaxed parts, it not only prevents pain, but the œdematous swellings also, to which sprained limbs are often liable. The roller should be of flannel, which yields more readily than linen to any variety in the size of the limb, and is the most effectual preventative of the rheumatic af— fections with which limbs that have suffered much from sprains are liable to be attacked. The roller must be carried spirally upwards from the inferior part of the limb, with an equal pressure on every part of it, in order to prevent œdema, which might otherwise take place. SECTION III. Of Chronic or Indolent Tumors. THE general character of this class of tumors is, that they are slow in their progress, and not nec— essarily attended with inflammation. Tumors of eve— ry kind may eventually, indeed, induce inflammation: Thus swellings which have long remained indolent, by an increase of bulk will often distend the skin so much as to become inflamed; and all the varieties of hernia, although not necessarily accompanied with this symptom, for they frequently take place without it, yet they often tend to induce it, for reasons too obvi— ous to require being mentioned. But in these, we consider 52 Of Chronic or Chap. XXXVIII. consider inflammation as an accidental occurrence on— ly, and in no way connected with their rise or forma— tion. Of the chronic tumors we shall first consider the encysted. § 1. Of Encysted Tumors. Every tumor might be considered as encysted, the contents of which are surrounded with a bag or cyst, as is the case with all the variety of hernia and of hy— drocele, as well as with some other tumors; but in common practice those tumors only are termed En— cysted that are contained in cysts of a preternatural formation. In common language, these, as well as various tumors of the sarcomatous kind, are termed Wens. The different parts of which an animal body is composed, are connected together by a common medi— um termed the Cellular Substance; which is so univer— sally diffused, that it seems to form a very considerable part of every fibre. In a state of health the cells of this substance communicate with each other; and, like the large cavities of the body, they are kept soft and moist by a secretion that is constantly passing into them by the exhalents, and returning from them by the absorbents. In some parts of the body this secre— tion would appear to be entirely of a serous nature; while in others, it consists evidently of oil or fat. While the absorption of this fluid is in proportion to the quantity exhaled, no accumulation will take place: but various causes may concur to destroy the equilibrium; and in whatever way this may be done, if more be secreted than is carried off by the absorb— ents, a fulness or swelling must necessarily ensue. Where this superabundance is of the serous kind, a dropsical swelling will be produced; when of an oily nature, obesity or fatness will take place. A general disposition in the system to this kind of accumulation is a frequent occurrence; but causes. sometimes occur by which collections are produced in particular 53 Sect. III. Indolent Tumors. particular parts. In a found state of the cellular sub— stance, that natural communication we have mention— ed as subsisting between the different cells of it, must necessarily prevent any partial or circumscribed col— lection. And accordingly we know, that all serous ef— fusions very readily pass from one part of it to anoth— er. But this communication may be interrupted by different causes, and accumulation of the natural fluid may take place in a particular part. We thus account for the formation of encysted tu— mors; to which different names have been applied, according to the consistence or supposed nature of their contents. When of the consistence of honey, the tumor is termed Meliceris: when of a soft cheesy consistence, or resembling dough, it is termed an Ath— eroma; and Steatoma, when it is formed of fat. But it is proper to remark, that there are various degrees of consistence to be observed in each of these. Thus the steatoma is sometimes soft like butter, and at other times firm like suet: and the same kind of variety occurs in the contents of the atheroma and me— liceris, which in some cases are equal in firmness to new cheese, and in others are not firmer than the thin— est honey. The matter forming the steatomatous tumors, we conclude to be from the first of an oily or fatty na— ture; and that their different degrees of consistence will depend upon the remora of their contents, and upon the quantity of the thinner parts of them that have been absorbed. And we think it probable, that the atheromatous and melicerous tumors are originally formed by a deposition of serum, with perhaps a con— siderable proportion of coagulable lymph; and that the degrees of consistence of which we find them, will depend upon various causes: Upon the particular quantity of coagulable lymph contained in them; up— on their being of longer or shorter continuance; and particularly, upon their having been inflamed or not; and 54 Of Chronic or Chap. XXXVIII. and to the extent to which the inflammation may have proceeded. For the most part, a practitioner accustomed to this branch of business will be able to distinguish pretty exactly the nature of these tumors before laying them open. Thus, in general, the steatoma is of a firm con— sistence: it is commonly loose, and rolls more readily than the others under the skin; and its surface is apt to be unequal: The atheroma is soft and compressi— ble, but no fluctuation is observed in it: While, in the meliceris, the fluctuation of a fluid or thin matter is in general very distinctly perceived. It is proper, how— ever, to remark, that neither these, nor any other means of distinction, will at all times prove sufficient: for in some cases the steatoma, instead of being firmer than the others, is considerably softer; insomuch that I have met with different instances of the fat of which they are formed, fluctuating or moving between the fingers like thin purulent matter; and where accord— ingly the opinion that was previously formed of it was commonly erroneous. The atheroma and meliceris are sometimes combined in the same tumor: One part of it will be evidently of a soft pultaceous nature, and contained in a separate cyst or cell from the rest, which is probably of nearly the same degree of consistence with purulent matter. In a few cases too, the steato— ma is conjoined with these; but this is not a frequent occurrence. In judging of the nature of these tumors, some ad— vantage may be derived from attending to their situa— tion. Thus we observe, that in some parts of the bo— dy, fat is much more apt to be secreted and deposited in the cellular substance than in others. In some parts, indeed, fat is scarcely ever found in it; as is the case over a great part of the head; while in others, particularly over the prominent part of the abdomen, we commonly meet with it even in the leanest subjects. Now I believe it will be observed, that the steatomat— ous tumors are seldom if ever met with in those parts of 55 Sect. III. Indolent Tumors. of the body which are not usually in a state of health supplied with fat: at least this has been so uniformly the case in the course of my practice, that I have never met with an instance of it; and it tends much to con— firm the idea which I have endeavoured to establish of the formation of these tumors. The head, as I have observed, is very sparingly supplied with fat, at the same time that we find it more liable than any part of the body to encysted tumors; but they are very uni— versally of the atheromatous or melicerous kinds.* Nor have I ever met with the steatomatous tumor but where fat is usually deposited in the contiguous cellu— lar substance. They are rarely indeed observed on that part of the body which, we have just observed, is plentifully supplied with fat. We seldom meet either with these or any other variety of encysted tumor on the abdomen; and at first view this may be consider— ed as an objection to our theory: On farther atten— tion, however, it will rather appear to support it. The parietes of the abdomen being formed of soft yielding parts with no bone or hard body beneath, we may readily suppose that they will be little if at all affected by any ordinary pressure: so that this cause of ob— struction will not here have the same effect as it evi— dently has on the head and other parts where the cel— lular substance lies immediately contiguous to bone. All the tumors of the encysted kind are small at first, and increase by very slow degrees. They are of very different shapes and sizes: In some they resem— ble a walnut; on the head they are commonly round and smooth, and do not often arrive at any great bulk; but in other parts of the body they are often of very irregular forms, at the same time that they are more apt to acquire more considerable degrees of bulk. I have met with steatomatous tumors weighing upwards of * By Atheromatous and Melicerous, I mean to express different de— grees of consistence of a curdy pultaceous matter. By some, the firmer kinds of this have been mistaken for and described as the contents of the steatomatous tumor; but they will be found to be in every respect different from the fatty substance contained in the real steatoma. 56 Of Chronic or Chap. XXXVIII. of twenty pounds; and they are sometimes double this weight. They are never at first attended with pain; and the skin for a considerable time retains its natural colour. But when they become large, the veins of the skin, as well as those of the sac, be— come large and varicose; and the prominent part of the tumor acquires a clear shining red colour, similar to that which accompanies inflammation: but it seems to be different from this, as it is seldom attended with pain, excepting it be injured by external violence. In this situation, indeed, a blow or a bruise will readily excite inflammation, by which the skin will become tender and painful, and by which it will soon be made to crack or burst, if it be not prevented by the con— tents of the tumor being discharged by an operation. This is the ordinary progress of these tumors: But it is proper to remark, that although they never ad— vance quickly, yet in some situations they terminate much sooner than in others, and without arriving at the same degrees of magnitude. Thus, in the head they do not usually become bigger than a large egg. In a few cases, indeed, they are larger; but for the most part they terminate before they acquire this size, by the teguments becoming tense and thin, and even bursting if they be not prevented in the manner we have mentioned. But on other parts of the body, particularly on the back, on the shoulders, and thighs, the teguments will sometimes retain their natural appear— ance long after a tumor has acquired a very great bulk. This seems to proceed from a greater or lesser degree of laxity in the skin. In the head, the teguments are firmer, and do not yield so readily to distention as in other parts of the body, by which any tumors lying beneath them must necessarily be more quickly brought to a period. This circumstance of situation has likewise a con— siderable effect on the firmness with which tumors are attached to the contiguous parts. In some situations they are so loose and moveable, especially while they continue 57 Sect. III. Indolent Tumors. continue small, that they readily yield even to slight degrees of pressure: but in others, particularly when they are covered with any fibres of muscles, they are sometimes very firmly fixed from their commence— ment. The attachment of tumors is also much influ— enced by their remaining free of inflammation, or their being to a greater or lesser degree attacked with it; for they never become inflamed even in the slight— est manner without some degree of adhesion being produced between the cysts and corresponding tegu— ments. In the treatment of encysted tumors, we are direct— ed by authors to attempt the cure in the first place by resolution; and if this fails, by extirpation. With a view to accomplish a cure by resolution, frictions with mercurial ointments are recommended, together with gum plasters and a variety of other applications. No practitioner, however, of the present age, will depend upon this management; nor will he expect to be able to remove these tumors in any other way than by the assistance of surgery. We shall therefore suppose that the removal of one of them by an operation is agreed upon: The next point to be determined is the mode of effecting it; and this in a great measure should depend upon the con— tents of the sac. If they appear to be of the thin me- licerous kind, which for the most part will be the case if a distinct fluctuation be discovered through the whole body of the tumor, it ought to be treated like a common abscess. In the smaller collections, the mat— ter may be discharged by laying the teguments and cyst open in the most depending part of the tumor with a common lancet, and treating it in the ordinary way till it fills up or adheres from the bottom: But in large swellings of this kind, as a free admission being given to the air proves always hurtful, the opening ought to be made in a manner the least apt to be at— tended with this inconvenience. In a former publi— cation, we have recommended the passing of a seton or E cord 58 Of Chronic or Chap. XXXVIII. cord through large absceses as the best method of o— pening them; and as the same method may with e— qual propriety be employed in those encysted tumors which are formed by collections of thin matter, we shall refer to what was then said upon the subject.* We shall just observe, that the cord should pass through the whole extent of the tumor, from the superior part of it to the most depending point; and that the infe— rior opening at which it passes out should be sufficient— ly large for admitting the matter to be very freely dis— charged. In this manner I have had many instances of large encysted tumors being healed with much more ease than almost ever happens under the ordina— ry method of treatment. Several years ago, I gave my opinion upon this point at considerable length in the publication above alluded to; and farther experi— ence of the advantages which result from it has tended much to confirm it; This method of cure, however, is only applicable where the contents of tumors are so thin as to be easi— ly discharged by a small opening. When they are too firm to admit of this, they must either be emptied by an extensive opening into the cyst, or the cyst with its contents must be dissected out. Where a cyst containing matter adheres so firmly to the contiguous parts as to require much time to re— move it by dissection, it should never be attempted. It will be sufficient to lay it freely open through its whole extent by an incision, and to remove any loose portion of it. The contents of the tumor will in this manner be completely removed: and the cure may ei— ther be effected in the usual way, by preserving the wound open till it fills up with granulations from the bottom; or it may be attempted by drawing the di— vided edges of the skin together, and trusting to mod— erate pressure and the ordinary effects of inflammation for producing a complete reunion. I have succeeded in both ways; and I think it necessary to observe, that both are equally certain, when a considerable part of a cyst * Vide Treatise on Ulcers, &c. Part I. 59 Sect. III. Indolent Tumors. cyst is left as when the whole is carefully dissected off in the usual manner. To those who are accustomed to think that it is necessary to remove the cysts of these tumors entirely, it will at first appear to be unsafe to allow any part of them to remain: Experience, how— ever, will soon convince them that it may be done with safety. In common practice the removal of the cyst is always advised; but where it is to be attempted, it is better to open the cyst by a longitudinal cut through the whole tumor than to remove it entire. When the cyst is empty, it is more readily laid hold of with the fingers or forceps, and more easily dissected out, than when the bag remains full and distended. When the bag is thus removed, the teguments should be laid together and retained with adhesive plasters, or with two or three futures, as the operator may incline: and if an equal pressure be made over the whole, a cure may thus be obtained by the first in— tention. In every part of the body this is an object of importance; as it tends to shorten the cure; but it is particularly proper in the face and other external parts of the body, where the cicatrix produced by a tedious sore proves frequently very unseemly. The arteries which supply the cysts of these tumors are sometimes so large as to pour out much blood when they are cut. In this case, they should be im— mediately secured with ligatures: and if the threads be left of such a length as to hang out at the lips of the wound, they prove no obstacle to the cure being com- pleted in the manner we have directed; for when they are applied with the tehacculum, as they ought to be, they may be drawn away with ease and safety at the end of the second or third dressing. By an ill tim— ed caution, some practitioners, from an apprehension that ligatures in such circumstances may do harm, have advised that none of the arteries which appear in the re— moval of these tumors should be tied. Nay, some have gone so far as to say, that it is seldom or never nec— essary to apply ligatures to such arteries as are cut in E2 the 60 Of Chronic or Chap. XXXVIII. the removal of scirrhous brests: But as I have known different instances of patients dying suddenly from loss of blood where this precaution was neglected, and as I never met with a single case of any harm being done by attending to it, I would advise every artery to be secured that does not stop immediately on being divided. Besides the real danger which sometimes oc— curs from this being neglected, the very intention of healing the sore without the formation of matter is apt to be frustrated by it. In the removal of cancer— ous breasts, where the edges of the divided skin have been drawn together so as to cover the sore, by the bursting of an artery which had not been secured, such a quantity of blood has been effused between the teg— uments and parts beneath, as has either prevented them from uniting, or has rendered it necessary to remove the bandages, and to lay the parts again o— pen in order to discover the bleeding vessel. Of this I have met with different instances; and every prac— titioner of experience must probably have done the same. In tumors of an ordinary size, there is never any necessity for removing any part of the skin. By a sin— gle incision along the course of the tumor, in the man— ner we have directed, the sac will either be sufficiently opened, or it may be removed with equal ease as if it were opened by a crucial incision; and although the skin may at first appear to be too extensive, yet in the course of a short space of time it will contract so as merely to cover the parts beneath. But in very ex— tensive tumors, where the skin is so much distended as to give cause to imagine that it will be much pucker— ed if part of it be not removed, it will be better to take away some portion of it. This will be best effected by two semilunar cuts including as much of the skin as ought to be taken away; and this being done, the portion of skin thus separated must be removed along with the cyst. And in the same manner, when we are operating upon a tumor where the prominent part of the 61 Sect III. Indolent Tumors. the skin is either ulcerated or rendered so thin by di— stention that we cannot with propriety attempt to save it, such parts of it as are thus affected must be includ— ed between two semilunar cuts, and removed in the manner we have mentioned. In other respects, the cure must be conducted as if none of the skin were taken away, by drawing the divided edges of the tegu— ments together, and endeavouring to make them unite by the first intention in the manner we have advised. Where the tumor is so large as to render it proper to remove any part of the skin, we are desired by some practitioners to do it with caustic; and by others cau— stic is used for opening every tumor. The only in— stance, however, in which caustic should be employed, is where patients are so timid that they will not sub— mit to the use of the scalpel. § 2. Of Ganglions. By the term Ganglion, we here mean an indolent moveable tumor which forms upon the tendons in dif— ferent parts of the body, but most frequently on the back part of the hand and joint of the wrist. Tumors of this kind when pressed upon are found to possess a considerable degree of elasticity; by which they may in general be distinguished from the encyst— ed tumors described in the last section. They seldom arrive at any great bulk; they are not often attended with pain; and for the most part the skin retains its natural appearance. On being laid open, they are found to contain a tough, viscid, transparent fluid, re— sembling the white of an egg. It seldom happens that tumors of this kind become so large as to render them objects of surgery: and when duly attended to on their first appearance, they may often be removed entirely, either by moderate friction frequently repeated, or gentle compression ap— plied to them by means of thin plates of lead or any other pliable metal. In this manner, they are more readily discussed than any other kind of swelling: but E3 neither 62 Of Chronic or Chap. XXXVIII. neither the friction nor the pressure should be carried too far, otherwise the skin may be so much fretted as to give rise to inflammation; by which suppuration, and abscesses difficult of cure may be induced. When this method of removing a ganglion does not succeed, nothing farther should be attempted as long as the tumor remains of a small size: But when it be— comes so large as to prove troublesome, either by im— peding the motion of a joint, or in any other manner, it ought to be removed by excision, in the same man— ner as we have advised in the treatment of encysted tu— mors when the cyst is to be taken entirely away; that is, by making a longitudinal cut through the teguments over the whole extent of the tumor; and after separ— ating the skin from it on each side, to dissect it off from the tendon: Or, when it is found to adhere so firmly to the contiguous parts as to render this im— practipable, an incision may be made into it of such a depth as to discharge the contents of it, when a cure may be effected by preserving the wound open till it fills up with granulations from the bottom. In general practitioners, are averse to operate in tu— mors of this kind, on the supposition of the wound being difficult to heal; but I have seldom known this to be the case. § 3. Of Swellings of the Bursœ Mucosœ, The bursæ mucosæ are small membranous bags seated upon or very contiguous to the different large joints. They naturally contain a thin transparent, ge— latinous fluid, which seems to be intended for lubric— ating the parts upon which the tendons move that pass over the joints. They are met with in other parts of the body, but chiefly about the hip joint, that of the knee, ankle, shoulder, elbow, and wrist.* In * I am happy in having it in my power to announce to the public, that a description of all the bursæ mucosæ which have yet been discov— ered, with an account of the diseases to which they are liable, will soon be published by Dr. Monro. 63 Sect. III. Indolent Tumors. In a state of health, the fluid contained in these bur— sæ or sacs is in such small quantity that it cannot be discovered till they are laid open by dissection: But in some cases it accumulates to such an extent as to produce tumors of a considerable size. This is not an unfrequent effect of contusions and sprains; and I have often met with it as a consequence of rheumatism. The swelling is seldom attended with much pain: it yields to pressure, but is more elastic than where ordi— nary matter is contained: at first it is always confined to one part of the joint; but in some cases the quanti— ty of accumulated fluid becomes so considerable as nearly to surround the joint. The skin always re— tains its natural appearance, unless it be attacked with inflammation. The contents of these tumors are found to be of dif— ferent kinds: and this variety seems to depend on the cause by which the swelling is produced; a circum— stance which merits particular attention. Thus when a swelling of this kind is induced by rheumatism, the contents of the tumor are commonly thin and alto— gether fluid, resembling the synovia of the different joints; at least this has been the case in any of those which I have known opened: While in such as pro— ceed from sprains, there is usually found mixed with this transparent fluid, a considerable quantity of small firm concretions. In a few cases I have met with these concretions of a softer texture, so as to be easily compressed between the fingers; but in general they are too firm to admit of this. We may commonly, however, judge of this by the kind of fluc— tuation which is discovered in the tumor: when the concretions are soft, the fluctuation is usually distinct; but when they are firm, it is not so clearly perceived, and they are easily felt beneath the fingers on being pressed from one part of the sac to another. In practice it will be found to be an object of im— portance to be able to distinguish between those col— lections which proceed from rheumatism, and such as E4 are 64 Of Chronic or Chap. XXXVIII. are the consequences of old sprains: For in the for— mer, I believe, it will be seldom necessary to propose any operation; as in most instances, perhaps in all, the swelling will disappear in course of time, merely by keeping the parts warm with flannel; by frequent frictions; by warm water being frequently pumped upon them; or by the application of blisters. At least this has happened in almost every rheumatic case of this kind in which I have been concerned. But in those swellings of the bursæ mucosæ, which originate from sprains, although the quantity of effused fluid may remain stationary, it will seldom if ever disappear entirely. In such cases, therefore, when the tumor arrives at such a size as to prove troublesome, we are under the necessity of proposing an operation for re— moving it. The only operation that is admissible, is the open— ing the sac, so as to discharge the matter contained in it, and to preserve the wound open till it fills up with granulations from the bottom. In most situations this may be done with safety; but in some parts, particu— larly about the joint of the wrist, these collections are so covered with tendons that a good deal of caution and attention is required in the treatment of them. When it is found that the contiguity of tendons pre— vents the sac from being opened to such an extent as may probably ensure a cure, it will be better to lay it open at each end; and after pressing out the contents, to pass a small seton or cord from one opening to the other. In this manner a slight degree of inflamma- tion will be excited on the inside of the sac, when the cord may be withdrawn, so as to admit of a cure being attempted by gentle pressure, applied with a roller over the course of the tumor. I have sometimes suc— ceeded in this way, when a cure could not be obtained by any other means; and when the cord is cautiously introduced with a blunt probe, no harm occurs from it, even when it passes beneath some of the tendons. The cord, however, should not be continued so long as to 65 Sect. III. Indolent Tumors. to induce any great degree of inflammation; for in the neighbourhood of large joints this might prove alarm— ing: And we know from experience, that even a slight degree of inflammation answers the purpose suf— ficiently. A considerable degree of stiffness commonly remains upon that part of the joint where the tumor was situ— ated. The most effectual remedy for this, is frequent frictions with emollients, and a proper application of warm steams to the part affected. § 4. Of Collections within the Capsular Ligaments of Joints. Collections of various kinds are met with in the capsular ligaments of joints. Blood may be effused within them. Inflammation is here, as in other parts, frequently succeeded by the formation of matter; and serous effusions occur in them, forming what are com— monly termed Dropsical Swellings of the joints. Swellings of this kind should be distinguished with as much precision as possible. They are most apt to be confounded with collections in the bursæ mucosæ, or with matter effused in the cellular substance cover— ing the joints. From the first of these they may in general be distinguished, by the contained fluid pass— ing with freedom from one side of the joint to the other; and from its being diffused over the whole of it: Whereas, when it is contained in one of the bursæ, the tumor is more circumscribed; being for the most part fixed above or upon one side of the joint. And in these there is seldom any great degree of pain; while collections of every kind within the capsular lig— aments are apt to be painful. They are more easily distinguished from matter col— lected in the cellular substance covering the joints. In the last, the collection is evidently very superficial; and it is not so much confined to the joint itself, being in general found to extend in every direction farther than the boundaries of the capsular ligaments. We 69 Of Chronic or Chap. XXXVIII. We judge of the nature of the fluid collected in these swellings by the circumstances which have pre— ceded them, as well as by the symptoms with which they are accompanied. When a violent bruise of a joint is immediately succeeded by a large effusion within the capsular ligament, it will probably be found to consist chiefly of blood. This is not a frequent occurrence; but as I met with a remarkable instance of it in one case, I conclude that it may happen in others. When inflammation of a joint terminates in effu— sion within the capsular ligament, there will be reason to imagine that the matter forming the tumor is of a thin serous kind, with some tendency to purulency; for well conditioned pus is seldom met with in liga— mentous or membranous parts. And lastly, when collections within the capsular ligaments succeed to rheumatic affections, there will be much reason to sup— pose that they are entirely serous; for we know that these effusions which take place in rheumatism are very commonly of this kind. The importance of our being able to distinguish the nature of the matter contained in these swellings, be— comes obvious from the different practice which they require: As the making an opening into a large joint is always hazardous, from the pain and inflammation which it is apt to excite, it should never be attempted but in cases of necessity. One of the causes which in general are supposed to require it, is matter collected within the capsular ligaments: But when by experi— ence we discover that a particular kind of matter may be allowed to remain in this situation without any det— riment, we rather allow it to lodge, than to incur the risk which often ensues from letting it out. Now this is uniformly the case with those effusions which we have mentioned as the consequences of rheumatism. Whether they be collected in the bursæ mucosæ, as mentioned in the last section, or within the capsular ligament of a joint, they should never be laid open. Of 67 Sect. III. Indolent Tumors. Of whatever size they may be, they will very com— monly be discussed by the remedies we have mention— ed, namely, by frictions; the pouring of warm water upon the parts affected; by proper covering with flannel; and the use of blisters: or, when these fail, supporting the tumefied parts with a laced stocking, or with a roller, applied with such a degree of tightness as the patient can easily bear, will often prove success— ful. But whether we are able to dissipate the swelling entirely or not, when we are convinced that it is of the rheumatic, kind, no opening should be made into it. The patient may continue to complain of some uneas— iness and stiffness in the joint, but this will always be trifling when compared with the pain and inflamma— tion which may occur from laying it open. But when matter is collected in the cavities of joints, which may do mischief by lodging, or which does not readily ad— mit of absorption, an opening should be made for dis— charging it. The matter which forms in consequence of high degrees of inflammation, and effused blood, are of this kind. Blood is indeed frequently extrava— sated among soft parts without much detriment; but when in contact with cartilage or bone, it soon hurts them materially; and the same effect follows from the lodgement of matter formed by inflammation. The danger which attends this operation, seems to depend in a great measure upon air finding admission to the cavity of the joint; it ought, therefore, to be done in such a manner as may most effectually pre— vent this occurrence. For this purpose the opening should be made with a trocar; and if the skin be pre— viously drawn tight to the upper part of the tumor, by pulling it down immediately on withdrawing the canula after all the fluid is evacuated, the risk of air being admitted will thus be lessened. A piece of ad— hesive plaster should be directly laid over the opening in the skin; and the whole joint should be firmly sup— ported, either with a laced stocking, or a flannel roller properly applied round it. As 68 Of Chronic or Chap. XXXVIII. As a farther preventative of bad consequences from this operation, if the patient be plethoric, he should be blooded to such an extent as his strength will bear: He should be put upon a strict antiphlogistic regimen; and in every respect should be managed with caution: for inflammation being very apt to ensue from it, we cannot be too much on our guard against it. § 5. Of Concretions and preternatural Excrescences within the Capsular Ligaments of Joints. We sometimes find joints become painful, and their motion much impeded, by the preternatural formation of different substances within the capsular ligaments. In some cases they are small loose bodies, of a firmness equal to that of cartilage; and in others, they are of a soft membranous nature, sprouting from an eroded surface of one of the bones forming the joint, or from the inner surface of the capsular ligament. In some cases, these substances remain always in nearly the same situation, without being much affect— ed either by pressure or by the motion of the joint; particularly in the soft membranous kinds of them, which are in some degree fixed by their attachments. But the others, which have nearly the firmness of car— tilage, are commonly so moveable, that their situation is altered by the least degree of motion; and they slip so easily on being touched, that it is difficult to fix them even with the fingers. In the former, which remain fixed nearly to the same situation, the pain is constant, but it is seldom se— vere; whereas in the latter, it is only felt in particu— lar situations, perhaps when the connecting membrane passes between the ends of the bones: but in these cases it proves often so excruciating as to be altogether unsupportable. I have known different instances of this, where in some particular postures of the leg, for it is in the knee in which these concretions seem chief— ly to occur, the pain became suddenly so exquisite as to induce fainting. And where this, returns frequent— ly, 69 Sect. III. Indolent Tumors. ly, the patient is so much afraid of it, that he chooses rather to avoid walking almost entirely than to run any risk of inducing it. Nay, in some cases, I have known the patient roused from the most profound sleep, by the limb being merely moved when in bed. As these substances are of a nature which will prob— ably forever resist the powers of every medicine, and as they can only be removed by the joint being laid open, the question to be determined is, Whether this ought to be attempted or not? Many speak of this as an operation attended with so little risk, that practi— tioners are apt to advise it in every case where the pain induced by the disease is in any degree severe. In two cases, indeed, which fell within my own manage— ment, the joints of the knee were laid open; the for— eign bodies were removed; and the wounds healed al— most with the same ease, as might have been expected in similar injuries in any other part of the body. But since that period different instances have occurred where this operation induced the most alarming symp— toms; which even terminated in such a manner as to render it necessary to amputate the limb. I never ob— served indeed such high degrees of inflammation from any other cause; neither is it confined to the joint it— self. The whole limb, both above and below the wound, becomes stiff and swelled in a remarkable de— gree, with a painful inflammatory tension, extending from one end of it to the other. The uncertain success of this operation may make us doubtful in every instance of advising it. The fol— lowing is the opinion I have formed on this point, drawn from a good deal of experience in cases of this kind. Where concretions formed within the capsular ligaments of joints appear, upon examination with the fingers, to be perfectly loose and detached, if the pain which they excite is very severe, rather than submit to a long continuance of it, we should venture in a cau— tious manner to take them out, by making an incis— ion into the joint: But wherever there is much reason to 70 Of Chronic or Chap. XXXVIII. to suspect that they are connected with any part of the joint, the patient should rather be advised to submit to the pain which they induce, which in general will be rendered moderate by avoiding exercise, than to run the risk attending the extirpation of them. The pain indeed, even in a retired life, may some— times become unsupportable; In this case I would advise the amputation of the limb. The remedy is no doubt severe; but it is less painful, as well as less hazardous, than the excision of any of those concre— tions have ever proved that have been attached to the capsular ligaments. The opening into the capsular ligament for the re— moval of these loose bodies may be made in the fol— lowing manner: If it is the joint of the knee or ankle that is to be opened, the patient should be laid upon a table or on a bed; but if any of the joints of the arm are to be opened, he may be allowed to fit; only, in whatever posture he may be; the limb should be secur— ed in the firmest manner by assistants, in that posture which admits of the body to be taken out being felt in the most distinct manner. On this being done, the surgeon should endeavour to fix it with the fingers of his left hand towards the upper part of the joint, after an assistant has been desired to draw the skin as much as possible upwards from the part where the incision is intended to be made. The surgeon, with a scalpel in his right hand, is now to make an incision through the teguments and capsular ligament directly upon the substance itself, of such a size as will admit of its being easily taken out; which may be done either with the point of one of the fingers, or with the end of a blunt probe passed in beneath it. If it is found to be con— nected by any small filaments, either to the capsular ligament or to the cartilages of the joint, they should be cautiously divided, either with a probe pointed bis— toury or probe pointed scissors, after drawing the sub— stance itself as far out as it can be got, with small point— ed forceps, or with a sharp hook when it is of a texture that 71 Sect III. Indolent Tumors. that admits of a hook being used. When more con— cretions than one are found, they should all be taken out at the same opening when this can be done: but when they lie on opposite sides of the joint, two open— ings will be necessary; only in this case it will be bet— ter to allow the first incision to heal before attempting the second, so as to avoid as much as possible the ex— citing of inflammation. After the concretion is removed, the skin should be immediately drawn over the wound in the capsular ligament; and the lips of the opening in the skin be— ing laid together, they should be secured in this situa— tion by pieces of adhesive plaster, so as to prevent the air from finding access to the cavity of the joint. Till the wound be completely healed, the patient should not only be confined to bed, but the limb should be kept as much as possible in one posture; and a strict antiphlogistic regimen should be observed. But for the farther management of such cases, and of the symp— toms with which they are apt to be attended, we must refer to Chap. XXXVI. Sect. VIII. on the subject of Wounds in the Ligaments. We have desired, that in making the incision into the capsular ligament, it may be done at the upper part of the joint. The intention of this is to prevent the synovia, after the skin is drawn over the opening in the ligament, from finding such ready access as it otherwise would do to lodge in the cellular membrane immediately beneath the skin; a precaution that is easily attended to, and from which some advantage may be derived. § 6. Of Anasarca or Oedema. The terms Anasarca and Oedema are applied to that variety of dropsical swelling where the water is col— lected, not in any distinct cavity, but in the cellular substance. The part is generally cold, and of a pale colour; and being possessed of little or no elasticity, it retains the mark of the finger when pressed upon. In 72 Of Chronic or Chap. XXXVIII. In general, swellings of this kind are connected with some general affection of the system; but in some cases they occur in particular parts, from causes which affect these parts only. Thus, legs or arms which have been much weakened by contusions or sprains are apt to become œdematous. Tumors pressing upon any of the larger lymphatics are apt to induce them. And they sometimes occur from the lymphatics of a limb being cut, either by accident or by some chirur— gical operation. In the treatment of these swellings, this circum— stance of their being general or local requires particu— lar attention. When they are induced by tumors pressing upon the lymphatics, the removal of these tu— mors will alone effect a cure. And when weakness of a limb, in consequence of sprains or contusions, seems to be the cause of them, the best method of cure will be to support the weakened parts either with a laced stocking or a flannel roller, to prevent their yielding to distention, till in course of time, and by the effects of cold bathing and moderate frictions, they recover their natural tone. But in those anasarcous swellings of the feet and legs which take place as a symptom of general dropsy, we must not venture upon removing or preventing them by compression; for if the serum be prevented from falling down to the legs, it will be apt to fix upon parts of more importance. In these cases, we trust to the general tendency in the system being removed by pro— per medicines, for obtaining a complete cure: But when the swelling becomes considerable, we have it in our power to procure a temporary relief, by discharg— ing the water by small pundures made through the skin into the cellular membrane, which will often empty the swelling of a whole limb. The relief which this procures is often so considerable, that we ought to advise it more early in the disease than is commonly done. It will seldom have any material effect on the cure of the disease; but besides the present ease which it 73 Sect. III. Indolent Tumors. it gives, it prevents that loss of tone which the cellular substance must suffer, and which must always be det— rimental where anasarcous swellings are permitted to go to such a height as they often do. In general the water is discharged by incisions in— stead of punctures: But small punctures made with the point of a lancet answer the purpose better: they give a sufficient vent to the water, at the same time that they are not so apt to inflame and mortify. But as we had occasion to speak of this when treating of the Anasarcous Hydrocele in Chap. VI. Sect. II. we shall refer to what was then said upon it. Where the swelling is induced by any of the lym— phatic vessels of a limb being cut, as sometimes hap— pens in extirpating indurated glands from the arm pit, small punctures made in the under part of the limb afford immediate relief; while little advantage is de— rived from any other remedy. § 7. Of the Spina Bifida. The term Spina Bifida is applied to those small soft swellings which sometimes appear in the course of the spine in new born children, most frequently at the in— ferior part of it, between the two last vertebræ of the loins. A fluduation is distinctly perceived in them: and the fluid which they contain can in some measure be pressed in at an opening which takes place between the spinous processes of the two vertebræ on which they are seated. In some cases this opening is found on dissection to proceed from a natural deficiency of bone; in others, from the spinous processes of the vertebræ being merely separated from each other: in all of them, the disease proceeds from serum collected within the natural coverings of the spinal marrow. In a few cases it is connected with hydrocephalus; but this is not common. For the most part it is a local affection. This is perhaps one of the most fatal diseases to which infancy is liable; for as yet no remedy has Vol. IV. F been 74 Of Chronic or Chap. XXXVIII. been discovered for it. In some cases, however, chil— dren labouring under it have lived for two or three years; but in general they linger and die in the space of a few months. All the assistance that art has hith— erto been able to afford, is to support the tumor by gentle pressure with a proper bandage. In this man— ner it has for some time been prevented from increas— ing, by which life has been protracted; but this is all that we have yet been able to do. It has sometimes unfortunately happened, where the nature of these tumors has not been understood, that they have been laid open with a view to discharge the fluid contained in them. Experience shows, how— ever, that every attempt of this kind should be avoid— ed; for hitherto the practice has uniformly proved unsuccessful. The patient has either died suddenly, or in the course of a few hours after the operation. If conjecture may at any time be indulged, and pro— posals for innovation mentioned, it must surely be al— lowable in cases hopeless as the one we are now con— sidering. If the swelling in the spina bifida be pro— duced by real disease subsisting in the vessels of the spinal marrow, or in those of its membranes, it is not probable that any remedy will ever be discovered that will remove it: But if the opening between the spin— ous processes of the vertebræ with which it is always accompanied, be not the effect of the disease, as it is commonly supposed to be, and if the want of support which this deficiency of bone must create to the mem— branes of the spinal marrow be the cause of serous ef— fusions within these membranes, might not some ad— vantage be derived from applying a ligature round the base of the tumor, not merely with a view to remove it, but also to draw the bottom of the cyst so closely together that it may act as a proper support to the parts beneath? Whether any benefit may be derived from it or not, is no doubt very uncertain: But in a disease which we know will otherwise terminate fatal— ly, we are warranted in proposing whatever can afford even 75 Sect. III. Indolent Tumors. even the smallest chance of safety; so that I mean to attempt it in the first case of this kind that falls under my care. After applying a ligature as closely as pos— sible to the base of the tumor, and as soon as the tu— mor itself has fallen off, I would propose to apply a firm stuffed pad, similar to that of a rupture truss, to the opening between the vertebræ; and by means of a proper bandage, to secure it with such a degree of tightness as may serve to support the parts within. Whether or not this method may in any case effect a cure is uncertain; but it appears to be the most probable one of prolonging life: for wherever the tu— mor has been opened, death seems to have ensued more by the removal of support from the contained parts than from any other cause. Now, no method of treatment we could advise would so readily com— press the parts within, and at the same time remove the tumor. The tumor termed spina bifida occurs, as we have already observed, in different parts of the spine; but a swelling of perhaps the same nature is sometimes met with on different parts of the head. A tumor is ob— served at birth; and on examination, it is found to be formed by a fluid lodged beneath the membranes of the brain, which have been forced out at some unoffi— fied part of the skull. In some cases the swelling re— mains stationary for a great length of time; but for the most part it becomes quickly larger, and at last terminates in death. Hitherto the same effect has re— sulted from laying this kind of tumor open, as was mentioned to occur in cases of spina bifida. The patient has commonly died in a few hours after the operation. § 8. Of Scrophulous Tumors. In a former publication, when treating of the Scro— phulous Ulcer, we offered some general observations upon scrophulous tumors. We shall now, therefore, refer to what was then said, and at present advert to F2 the 76 Of Chronic or Chap. XXXVIII. the method of treating them. It is not the cure of the scrophulous constitution which we mean to consider: This subject belongs more to the province of medi— cine. The first question that occurs in the chirurgical trea— ment of a scrophulous tumor is, Whether we should endeavour to promote the suppuration of it or not, by means of poultices and other external applications? For a considerable time I adopted this practice in the Freest manner of applying warm poultices and fomen— tations to every tumor of this kind; but by experi— ence I was at last convinced of its inefficacy. Nay, I now think that it often does harm: for scrophulous tumors being formed of matter which is not converti— ble into pus, poultices and other warm applications have little effect in bringing them forward; and when long used, they weaken and relax the parts so much, that the sores which ensue are more difficult of cure than when poultices are not employed. In every scrophulous sore, the parts are apt to remain long soft and spongy, by which they are prevented from heal— ing. The effect of these emollient relaxing applica— tions is to increase this tendency to softness to a degree which often proves prejudicial. As I know of no application which in the real scro— phulous tumor ever proves useful, either in retarding its progress or in bringing it forward, I now advise even every covering to be laid aside, unless the patient wishes to prevent the swelling from being seen; in which case he is desired to cover it in the manner that is most agreeable to himself. But as I do not observe that exposure to the air does harm, and as in some cases I have thought that this exposure of the tumor renders the subsequent sores more easy to cure, I would prefer this mode of treatment whenever it can be done with propriety. Even the external application of hemlock, which in the form of poultices is often ad— vised in scrophulous tumors as a discutient, should be laid aside. In scrophulous sores, I have observed some 77 Sect. III. Indolent Tumors. some advantage derived both from the internal exhi— bition and outward application of hemlock: but al— though I have often known it used in tumors of this kind, I cannot say that it was ever productive of any benefit. The only remedy I have ever known to act with any apparent efficacy in preventing scrophulous tumors from coming forward, has been a long contin— ued use of the cold bath, particularly of sea bathing, and of mineral waters, especially those of Moffat: but in order to produce any effect, they should be begun early in the disease, while the tumors are small, and long persisted in. Indeed, as soon as it becomes suf— ficiently obvious that a patient is attacked with scro— phula, I would advise him, whenever it can be done, to resort to such a situation where one or other of these remedies can be employed with perhaps little inter— ruption for several years together. In what manner the drinking of these mineral waters, or even of sea water, operates in preventing the formation of tumors in scrophulous patients, will be difficult to determine: But it seems to be probable, that cold bathing proves chiefly useful by invigorating the system at large, and particularly the lymphatic system, which in scrophula appears to be remarkably weak and relaxed. The next question to be determined with respect to scrophulous tumors is, when they have become soft and even full of matter, whether they should be open— ed, or allowed to burst of themselves? This should in a great measure be determined by their situation. When they are seated upon any of the large joints, or upon the cavities of the thorax or abdomen, as there might be a risk of the matter bursting into them, it ought certainly to be discharged by a free opening made with a lancet or scalpel; or in very large collec— tions, where it might prove hurtful to expose the cav— ity of an extensive abscess to the air, it may be done with more safety with a trocar, or by passing a seton or cord through it. But where the tumors are so sit— uated that no harm can arise from the matter remain— F3 ing 78 Of Chronic or Chap. XXXVIII. ing in them, it is better that they should be allowed to break of themselves; for even when they are man— aged in the most judicious manner, the sores which ensue will prove tedious and difficult to cure, while a scar will be the consequence whether the tumor has been opened or not; and the patient and his friends, from ignorance of the nature of the disease, as well as from other motives, are apt to blame any opening that is made, as the cause either of a tedious cure or of an unseemly mark. As an additional reason for this practice, I believe it will be found that sores which en— sue from scrophulous tumors will for the most part heal more kindly when allowed to burst than when they are opened. I have only to observe farther, that tumors of a scro— phulous nature are sometimes met with, which from inadvertency are apt to be mistaken for those of the real scirrhous kind. And there is cause to suspect that mistakes of this kind have tended to raise the rep— utation of different medicines, particularly of cicuta, as well as to have been the cause of the extirpation of tumors, which ought not to have been touched. When scrophulous tumors are deeply seated, they have commonly a degree of firmness which they do not possess in the more external parts; and when they are in a suspicious situation, as in the glandular part of a woman's breast, they are apt to be mistaken on a slight examination for swellings of a bad nature. But a moderate degree of attention will always prevent mistakes of this kind: Even the firmest kind of the scrophulous tumor is soft and compressible when com— pared with the real scirrhus: It is always of a smooth equal surface; it is seldom in its early stages attended with pain; and for the most part similar affections appear in other parts of the body; whereas the real scirrhus is always somewhat unequal or knotty: Al— though it does not for a considerable time become uniformly painful, a stinging disagreeable pain is com— monly felt in it from time to time, even from its first appearance; 79 Sect. III. Indolent Tumors. appearance; and it is not necessarily connected with symptoms of scrophula. § 9. Of the Bronchocele. Every tumor of an indolent nature occupying the sore part of the neck, is in common practice termed a Bronchocele. In the English language we have no precise denomination for it. In French this disease is termed Goitre. Swellings in this situation would with more propri— ety be termed Tracheacelæ: But with a view to pre— vent confusion, we think it better to retain that appel— lation under which they have commonly been de— scribed. Authors mention different diseases under this de— nomination: Some contending, that the term Bron— chocele should be confined to one variety of tumor; and others, that it may be applied to swellings of very different kinds. Disputes of this nature, however, answer no good purpose; and as practical observa— tions are the chief objects of this work, I think it bet— ter to mention the varieties of the disease, which I have either seen, or which have been accurately described by authors, with the treatment suited to each, than to enter the lists of controversy upon this subject. 1. The sore part of the neck, like every part of the body supplied with large arteries, is liable to swellings of the aneurismal kind. They do not frequently oc— cur in this situation, but instances of them are some— times met with. This variety of the disease may be distinguished by all the ordinary symptoms of aneurism: By its ap— pearing suddenly after some violent exertion, particu— larly in coughing or laughing; by its being soft and compressible from the first; by the tumor being at first seated directly on the course of one of the carotid arteries; by the pulse in the advanced stages of the disease being evidently affected by it, so as to become Y4 intermittent: 80 Of Chronic or Chap. XXXVIII. intermittent; and by a strong pulsation being discov— ered through the whole extent of the tumor. 2. Encysted tumors, particularly those of the meli— cerous kind, are frequently met with on the course of the trachea. They are characterised by the same symptoms in this situation by which they are marked in other parts of the body: They are soft and com— pressible; the fluctuation of a fluid is evident upon pressure; although they are always small at first, they frequently become so extensive, as to extend from one ear to another; and the skin usually retains its natur— al appearance to the last. The seat of this variety of the disease is evidently in the cellular membrane. 3. Instances have occurred of tumors forming in this situation, by the lining membrane of the trachea being forced out between two of the cartilages by violent fits of sneezing, coughing, or laughing. In this case the swelling will at first be small; and although soft and compressible, no fluctuation will be perceived in it. 4. The lymphatic glands of the neck have in some cases of scrophula become so swelled, as to produce tumors of considerable magnitude over the whole course of the trachea. They are distinguished by the symptoms which usually accompany scrophulous swellings. 5. The thyroid gland has in some instances been known to swell to a great bulk, so as to induce tumors of an enormous size, extending from each side of the trachea to the angle of the corresponding jaw. In this variety of the disease, the swelling is at first soft; but no fluctuation is perceived in it: the skin retains its natural appearance; and no pain takes place in it: But as the tumor advances in size, it becomes une— qually hard; being firm or elastic in some parts, and perfectly soft in others: The skin acquires a copper colour, and the veins of the neck become varicose; and in this state of the disease the face becomes flushed, and the patient complains of frequent head achs, as well 81 Sect. III. Indolent Tumors. well as of stinging pains through the body of the tu— mor. This is mentioned by authors as that variety of the disease which occurs so frequently among the inhabit— ants of the Alps and other mountainous countries, and which in general is supposed to originate from the use of snow water. 6. Whatever may be the nature of those varieties of bronchocele which occur in other kingdoms, I have reason to believe, that in this country it does not so frequently proceed from swellings of the thyroid gland as is commonly imagined. At least in two cases of bronchocele, the only ones where I had an opportu— nity of discovering the seat of the disease by dissection, although it was firmly believed in both of them that the swelling originated in the thyroid gland, yet on lay— ing the parts open it was found to be much otherwise. This gland, instead of being increased, seemed evi— dently diminished by the compression produced by the tumor; and the swelling itself was chiefly formed of a condensed cellular substance, with effusions in dif— ferent parts of it of a viscid brown matter. In one case the tumor was chiefly fixed on one side of the neck; but in the other it occupied both sides, and reached from one ear to the other, and from the ster— num to the chin. In both cases the swelling subsisted for a great number of years; and in one of them the patient died at last of another disease. At first they had no other appearance than might be expected from a natural increase in the parts lying contiguous to the trachea: they were soft and compressible; but no fluctuation was perceived in them, and the skin retain— ed its natural colour: But as they increased in size, they likewise became firmer; for although at last a softness, and even a fluctuation, was discovered in dif— ferent parts of them, yet the principal part of the tu— mor continued hard, while others had a peculiar springiness or elasticity, similar to that of a tin canis— ter: The veins on the surface of the tumors became turgid; 82 Of Chronic or Chap. XXXVIII. turgid; and the face of a livid colour, evidently from the blood being impeded in its course from the head. In one case, the patient complained of much giddi— ness: in both, the breathing was much obstructed; and the patient, who died of the disease, seemed to suffer chiefly from this ciicumstance. These are the varieties of bronchocele, for which one method of treatment cannot be applicable. And hence appears the absurdity of specifics for this disease, such as calcined egg shells, proposed and recommended by authors: for although a medicine may be useful in one, yet it cannot prove so in all the varieties of it. In the aneurismal bronchocele, the treatment suited to aneurism in general must be observed. To secure either of the carotid arteries with a ligature, will no doubt be considered as a hazardous operation: But here there is no alternative; whether it be a true or a false aneurism, death will ensue if it be not prevented by this operation. This chance, therefore, ought al— ways to be given; as in other cases of aneurism the artery should be tied both above and below the affect— ed part. In cases of bronchocele produced by encysted tu— mors upon the trachea, what we have said upon the treatment of these tumors in general will prove appli— cable. While they are small, the cysts with their con— tents may be removed in the manner we have men— tioned: And even in the most enlarged state of them, we need not despair of being able to afford effectual relief. When they are of the steatomatous kind, con— sisting of real fat, however large they may be, we may with propriety attempt to remove them: for in almost every instance, the connection of tumors of this de— scription with the contiguous parts is so slight, that they are removed with ease. The vessels on the sur— face of the tumor may be enlarged; but these will be chiefly veins, and they may be easily avoided. In tu— mors consisting entirely of fat I have never seen any of the arteries of such a size as to be productive of any disturbance; 83 Sect. III. Indolent Tumors. disturbance; they are always small, and are easily se— cured by compression when they lie beyond the reach of ligatures. When, again, the contents of the swelling are fluid, they may be discharged either by an incision with a scalpel, or by passing a seton or cord through the cyst; and when the contained matter is of a pultaceous con— sistence, forming what is termed an Atheroma, it must be discharged by a large opening in the most depend— ing part of the tumor. Where the tumor is formed by a hernia of the lin— ing membrane of the trachea, gentle compression is the only remedy to be depended on; and all such exer— tions should be avoided as might have any influence in producing it; particularly violent laughter, sneez— ing, coughing, and crying. In scrophulous swellings of this kind, we must depend chiefly on those reme— dies which prove most useful in other scrophulous af— fections: and with a view to remove the compression produced upon the trachea, as well as upon the veins returning from the head, the contents of the tumors should be discharged as soon as they are found to be in any degree fluid. In that variety of the disease which originates from a tumefaction of the thyroid gland, frequent frictions prove useful, particularly when employed early, be— fore the swelling has become large; and saponaceous and mercurial plasters have in some cases appeared to prove serviceable. Practitioners, however, are seldom consulted in that stage of the disease in which remedies of this kind may be usefully applied: For as the swell— ing does not often occasion uneasiness at first, it is sel— dom mentioned by the patient till it has subsisted for some time. In the enlarged state of this gland, I do not suppose that any remedy will ever be found pow— erful enough to discuss it: so that the only questions we have to determine are, Whether or not we should attempt to remove the tumor by an operation? and whether it should be done with caustic or the scalpel? We 84 Of Chronic or Chap. XXXVIII. We know that this gland is very plentifully supplied with blood, and that the arteries which belong to it are usually much enlarged in the disease we are now considering. This, together with the contiguity of the thyroid gland to the carotid arteries, which in this enlarged state of that gland are even apt to be com— pressed by it, renders the extirpation of it in an ad— vanced period of the disease extremely hazardous. For the arteries are of such a magnitude as to pour out a great deal of blood in a short space of time; while they lie at such a depth in this enlarged state of the parts, that they cannot be easily laid hold of with liga— tures, nor can much compression be applied to them from their situation with respect to the trachea, I therefore conclude, that when tumors of this descrip— tion have acquired any considerable bulk, it would not be advisable to run the hazard of attempting to remove them with the knife, and that the patient should rather trust to the treatment usually employed in such cases for palliating the symptoms as they occur.* And al— though we are informed, that in this situation the po— tential, and even the actual cauteries have been em— ployed with advantage, yet the practice has not become so general as to make it probable that it has ever been successful; nor can we, from what we have learned, presume to recommend it in any stage of this disorder. But although the reasons we have mentioned ap— pear to be sufficient for deterring us from attempting the removal of these tumors in any way when they are much enlarged; yet, while the gland is not much in— creased; when frictions and other remedies fail; and when * Mr. Gooch relates a case, where, in an attempt to remove a bron— chocele by excision, such profuse hemorrhagy took place, that the ope— rator, although very intrepid, was obliged to desist betore the operation was half finished. No means that were employed could put a total stop to the blood; and the patient died in less than a week. Another case had very nearly terminated fatally; and the patient's life was only preserved by having a succession of persons to keep a con— stant pressure upon the bleeding vessels day and night for near a week with their fingers on proper compresses, after the operator had been repeatedly disappointed in the use of the needle and ligature. —Vide Gooch's Medical and Chirurgical Observations, page 136. 85 Sect. III. Indolent Tumors. when the disease is continuing to advance; I think any practitioner would be warranted in advising it to be removed by excision: for in this early period of the disease, the difficulty of securing the arteries with ligatures will be much less than it is found to be in the more advanced stages of it: at least the risk occurring from this will be inconsiderable, when compared with that which will probably ensue from the tumor being allowed to remain. In the sixth and last variety of the disease which we have mentioned, frictions with mercurial ointment have in the first stages of it appeared to prove service— able. And in one case the progress of the tumor was evidently retarded by repeated blisters; but the pa— tient going to a distance, they were neglected, and at last it arrived at a very enormous size. In this state I saw him at the distance of several years, but I did not learn in what manner the case terminated. I have reason to think, however, from the appearance of the swelling, both at its commencement and its more ad— vanced stages, that it proceeded from an effusion into the cellular substance of the neck, attended with that condensed state of this substance which was discover— ed by dissection in the two cases mentioned above. But however serviceable blisters, as well as other remedies might prove in the early stages of the dis— ease, no advantage can be expected from them when the tumor has acquired any great bulk. In this situ— ation palliatives only should be employed; for the basis of the swelling usually runs so deep, that it could not be removed but with the utmost hazard; and it is not probable that any advantage would be derived from laying it open; for, a considerable part of it be— ing firm and solid, the size of the tumor would not be much diminished by the discharge which might be pro— cured, while the sore that would ensue might degener— ate into cancer. § 10. Of 86 Of Chronic or Chap. XXXVIII. § 10. Of Nævi Materni. By Nævi Materni are meant those marks which we frequently find in different parts of the body at birth; and which are supposed to originate from impressions made on the mind of the mother during pregnancy. They are of various forms, being frequently found to resemble strawberries and cherries, and in other in— stances grapes, figs, pears, &c. Their colour is vari— ous; but for the most part they are of a deep red, re— sembling the colour of claret or red port. Many of these marks are perfectly flat, and never rise above the level of the skin; and as they are not painful, they never in this state become the objects of sur— gery. But in some cases they appear from the first in the form of small protuberances, which frequently in— crease so quickly as to arrive at great degrees of bulk in the course of a few months. I once saw a tumor of this kind in a child of a year old of the size of a goose's egg, which at birth was not larger than a pea. No fluctuation is discovered in these tumors; on the contrary, they feel to be firm and fleshy. In some cases they are pendulous, and hang by slender attach— ments to the contiguous parts; but for the most part they are fixed by broad extensive bases. Various remedies have been recommended for the removal of these excrescences; and in ancient times different charms were proposed for them. The mys— tery proceeding from this is perhaps one reason of the general aversion which still prevails against any at— tempt being made to remove them. But so far as I have seen, no greater danger attends the removal of these swellings than the extirpation of any other tumor of the sarcomatous kind. They are supplied indeed more plentifully than other tumors with blood: for in many instances they appear to be entirely form— ed by a congeries of small blood vessels; but the arte— ries which go to them are in general easily secured with ligatures. It is proper, however, to remark, that the operation should never be long delayed: for as the 87 Sect. III. Indolent Tumors. the size of the vessels depends upon that of the tumor, they sometimes become so large as to throw out a good deal of blood before they can be secured; so that the operation should always be proposed as soon as it is observed that the tumor, instead of remaining station— ary, acquires a greater bulk. The operation is of a very simple nature. The tu— mor, with all the discoloured skin, is to be dissected off with a scalpel; and the arteries being secured, the edges of the remaining skin should be drawn together, and kept in this situation either with adhesive plasters or sutures: Or, when they cannot be drawn com— pletely together, they may at least be made to cover a considerable part of the sore; by which the cure will be much shortened, and the cicatrix lessened. In this case, that part of the sore which is left uncovered must be treated like a wound from any other cause. It is scarcely necessary to mention, that where the tumor is pendulous, and connected to the parts be— neath by a narrow neck only, it should be removed by tying a ligature round it of a degree of tightness suffic— lent for putting an immediate stop to the circulation through the whole of it. § 11. Of Warts. Warts are indolent, small, hard, colourless excres— cences, which appear on different parts of the body, but chiefly on the fingers and hands. They take their rise from the cutis and cuticle. They occur at every period of life, but more frequently in infancy than in old age. When from their size or situation, warts do not prove troublesome, they should not be touched; for generally in course of time they either fall off or waste gradually away. But sometimes warts are so large and so situated that we are under the necessity of em— ploying means for removing them. When they are pendulous, and have narrow necks, the easiest method of taking them away is with liga— tures: 88 Of Chronic or Chap. XXXVIII. tures: for this purpose a hair is sometimes used, but a fine thread is preferable. But when their bases are broad, we remove them either with the scalpel or with escharotic applications. There are few patients, however, who will submit to the scalpel; and as we seldom fail with escharotics, they are generally em— ployed. The lunar caustic, or lapis infernalis, are the strong— est applications of this kind; but warts commonly be— come very painful after being two or three times rub— bed with them. The same objection takes place to a solution of quicksilver in aquafortis, otherwise it proves a very powerful escharotic. Mercury dissolved in an equal quantity, or even in double its weight, of strong spirit of nitre, is a remedy that will not fail in remov— ing warts of every kind; but as it is apt to spread, it should be used with much caution. Pulvis fabinæ be— ing daily applied to warts, will for the most part re— move them in the course of two or three weeks; but this likewise is apt to induce inflammation. The best application I have tried is crude sal ammoniac: It acts slowly, but induces neither inflammation nor pain; and excepting in the very harder kind of warts, it sel— dom fails in removing them. They should be well rubbed two or three times daily with a piece of the salt previously moistened in water. Liquified salt of tartar sometimes answers the purpose; and I have known spirit of hartshorn prove successful. Warts frequently appear upon the penis as a symp— tom in venereal affections; and as they are nearly of the same nature with those we have been considering, the same method of treatment will apply to them. In general, the tendency in the system to produce them does not continue long; and if the parts be kept clean, they will at last begin to decay, and go entirely off whether any application be made to them or not. But as patients are always anxious to get free of them, practitioners are often induced to make trial of reme— dies which should be avoided: For till this tendency to 89 Sect. III. Indolent Tumors. so their formation is removed, they rise almost as quickly as they are rubbed off. Nor has mercury any good effect here: I have known different mercurial courses advised for the removal of warts; but they have never produced any advantage, and they very commonly do harm. When we have reason to sup— pose that every other symptom of the disease is eradi— cated, the continuance of warts should be no induce— ment to the exhibition of more mercury. When they are tender on the surface, and produce matter, as is sometimes the case, washing them morning and eve— ing in lime water, or in a weak solution of saccharum saturni, will commonly remove this; and at last they will disappear in the manner we have mentioned. But when this delay will not be agreed to, one or oth— er of the escharotics mentioned above must be em— ployed, or if the patient consents to their being re— moved with the scalpel, the parts from whence they are cut may be touched with lunar caustic, in order to prevent them, with as much certainty as possible, from returning. It is proper to remark, that in the treatment of warts of every kind, we should be cautious in avoiding eve— ry application which we have once observed to excite inflammation; for this symptom, when it arrives at a— ny height, is difficult to remove. For the same rea— son, when a wart is to be removed with the scalpel, we should rather encroach a little upon the sound skin, than run any risk of injuring the wart itself, or of leav— ing any part of it. By want of attention to this pre— caution, I have known the most formidable symptoms induced by what at first appeared to be such a trifling excrescence, as not to deserve notice. In one case, in— deed, such a painful obstinate sore ensued on the leg from the removal of a small wart, that amputation of the limb was rendered necessary, in order to save the life of the patient. Vol. IV. F § 12. Of 90 Of Chronic or Chap. XXXVIII. § 12. Of Fleshy Excrescences. No part of the body is altogether exempted from the formation of fleshy tumors or excrescences. They differ from warts in being softer, and in their being apt to become large. They are seldom painful. In general they are somewhat more red than the skin in natural health; and for the most part they have a firmness of consistence resembling that of the lips. When laid open, they have at first sight nearly the same appearance with a piece of muscular substance newly divided; but on farther examination, no fibres can be discovered in them. They seem to consist chiefly of cellular substance, with a great proportion of blood vessels infinitely ramified. In the treatment of these tumors, no external appli— cations are found to have any good effect. Escharot— ics have sometimes been employed for removing them but they seldom prove effectual, and they are very apt to irritate and excite inflammation. Whenever it is determined, therefore, to remove a tumor of this kind, it should either be done with a ligature or with the scalpel. When the neck is narrow, the method by ligature should be preferred; but when the attach— ment to the parts beneath is broad, this is inadmissible When the scalpel is employed, care should be taken that no part of the tumor be left; and the edges of the divided skin should be drawn so together, as to cover as much of the remaining sore as can with pro— priety be done. When any part of it does not heal by the first intention, it must be treated like a wound produced in any other manner. § 13. Of Corns. Corns are small hard tubercles, which occur on dif— ferent parts of the body, particularly on the toes and soles of the feet. In some cases they appear to be of a horny inorganic nature: But in others, it is evident that they are supplied both with blood vessels and nerves, from their being painful, and discharging blood on 91 Sect III. Indolent Tumors. on being cut. For the most part they are seated in the skin: but in some instances they pass to such a depth as to reach the periosteum: by which much pain and swelling are apt to occur on the contiguous parts. This is more, especially apt to happen when they are seated upon any of the joints, or upon parts thinly covered with flesh. The best preventative of corns, is the wearing of wide shoes, and avoiding every kind of pressure: and unless this be attended to, it is impossible in any case to remove them. Various remedies are recommend— ed for the cure or removal of corns. The most effect— ual I have ever tried, is the paring off all the inorgan— ic part of them after bathing for, the space of half an hour or so in warm water, and immediately thereafter applying over them slips of soft leather spread with emplastrum gummosum. If the soaking in water and paring the corns be repeated from time to time, and the application of this plaster be continued, the corns will be kept easy, and the hard knots will often separ— ate and fall out; when, if pressure be avoided, the vacancy produced by their removal will soon fill up with cellar substance, and no return of them will be experienced. § 14. Of a simple Exostosis, Venereal Nodes, and Spina Ventosa. An Exostosis is an indolent hard tumor originating from a bone. In some cases it is altogether a local af— fection; being produced by a superabundant callus in fractured bones; by bones being deeply wounded, or their substance eroded by an ulcer. In others, it appears as the symptom of some general affection of system, particularly of the lues venerea and scro— phula. In the first of these diseases, the tumor is termed a Venereal Node. When it appears as a symptom of scrophula, which it frequently does, it is usually termed a Spina Ventosa. G2 Exostoses, 92 Of Chronic or Chap. XXXVIII. Exostoses, when local, and proceeding from an effu— sion of osseous matter in fractured or wounded bones, are seldom attended with pain; and after arriving at a certain size, they commonly remain stationary. But when they originate from an internal cause, they are com— monly painful from the first; probably from the disten— tion of the periosteum, which being a firm membrane, and closely attached to the bone beneath, does not read— ily yield to the tumefaction. And in this case the swell— ing continues to advance, either till it bursts into a sore, or till the disease in the constitution by which it was produced be eradicated. In venereal nodes, the periosteum is often found in— flamed and much thickened; and in some cases a small quantity of a thin acrid serum is effused between this membrane and the bones. Hence, in those cases, the swelling in the bone appears to be much larger than it really is; for on being laid open, it is often found to be inconsiderable when compared with the previous size of the tumor. This has made some sus— pect that the swelling which we term a Node in lues venerea, is not originally an affection of the bone, but a thickening of the periosteum, and that the bone on— ly suffers from its connection with this membrane. There is much reason, however, to imagine, that the reverse of this is the case, and that the bone is the part primarily affected. For it is worthy of remark, that it is in the advanced stages of the syphilis only, that the bones are apt to be affected; and even then, that it is the hardest parts of them, such as the sore part of the tibia and the bones of the cranium, which are most apt to suffer. In scrophulous patients we frequently find the whole substance of a bone swell, particularly the ex— tremities of the large bones forming the joints of this knee, ankle, elbow, and wrist. Various conjectured are met with in authors of the origin of the term Spi— na Ventosa, given to this swelling; but whatever may have been the first cause of it, or whether it be proper— ly 93 Sect III. Indolent Tumors. ly applied or not, we think it right to retain it, in or— der to prevent that confusion which is apt to ensue From different names being given to the same disease. In the spina ventosa a pain is first discovered in the affected bone, and it is usually so deeply seated, that the patient is led to think from his feelings, that it pro— ceeds from the very centre of the bone. This some— times takes place for several days before any swelling is perceived; but for the most part a slight degree of fulness is observed from the first. When this occurs in a patient with other symptoms of scrophula, and es— pecially when it fixes on, any of the large joints, there will be much cause to suspect the nature of it. But it often happens that this is the first symptom of scro— phula, especially when it occurs in childhood: in which case both the parents and surgeon are apt to suspect that it proceeds from a contusion or sprain; nor does the delusion cease with the former, till the disease becomes evident by breaking out in other parts of the body. When these swellings occur in the middle part of bones, as sometimes happens in the bones of the hands and feet, they are apt to advance quickly; and on the soft parts bursting above them, a thin, ill conditioned matter is discharged, and the bones are discovered to be carious on the introduction of a probe. But when the disease fixes on any of the large joints, although it seldom fails to terminate in a sore at last, yet it com— monly proceeds to this state in a more gradual man— ner; nor does any remedy with which we are ac— quainted prevent the progress of it. In this situation it lays the foundation of what is usually termed a White Swelling; a disease we have formerly considered at full length.* When these swellings burst and terminate in sores, the soft spongy parts of the bones are found to be dis— solved; and on the matter which they produce being discharged, the remaining cavities have the appearance F3 of * Vide Treatise on Ulcers, &c. Part III. 94 Of Chronic or Chap. sXXXVIII. of being formed by all the interior parts of the bones having been scooped out, there being nothing left but a thin osseous covering formed of the hard external lamella of the bone. In this state of the disease, the appearances which the bone exhibits are very similar to those of scrophulous sores in the softer parts of the body: And as the spina ventosa is, in one stage of it or another, almost always accompanied with other symptoms of scrophula, I am clearly of opinion, as was elsewhere observed, that we should consider it en— tirely as a scrophulous affection, it being the same in the bones what scrophula in its more usual form is in the lymphatic glands. In the treatment of an exostosis, the cause by which the tumor seems to have been induced requires par— ticular attention. Where it is perfectly local, and formed merely by an exuberance of callus, although some deformity may ensue from it, yet it is seldom productive of so much pain or inconvenience as to in— duce the patient to speak of it. But when tumors, even of this local kind, become so large as to prove troublesome or painful, they necessarily excite the at— tention both of the patient and practitioner. As they are of a nature that will not yield to any medicine, we must trust entirely, in those cases where it is necessary to remove them, to a chirurgical operation. The patient being placed upon a table, and proper— ly secured by assistants, if there be any risk of contigu— ous large arteries being cut, a tourniquet should in the first place be applied so as to compress them above: An incision should now be made through the tegu— ments covering the tumor; and in order to give suf— ficient freedom in the remaining steps of the opera— tion, it should not only be carried along the whole course of the swelling, but an inch or even more past each end of it, when it is so situated as to admit of it. The cut is now to be continued down to the bone, at the same time that the operator should avoid as much as possible doing any injury to the contiguous muscles, tendons, 95 Sect. III. Indolent Tumors. tendons, veins, arteries, and nerves. By a little atten— tion to this part of the operation, much distress may be prevented; which might probably occur were it to be done in a more hurried manner. On the bone being laid bare, we are next to deter— mine on the best method of removing that part of it which forms the tumor: and this will depend upon the size of it. If it is merely a small knob that can be admitted into the head of a trepan, it may be taken off with that instrument: or if it be too large for this, it may be removed with a common saw; and after taking away any spiculæ which might create irritation, the sore may be treated like woulds produced in any other manner. The soft parts should be drawn over the bone, and the edges of the skin being laid together and secured with adhesive plasters, a cure may possi— bly be obtained by the first intention. In some cases, indeed, this may be prevented by small exfoliations taking place from the site of the tumor. I know, how— ever, from experience, that it will sometimes succeed, and therefore I would always advise it to be attempt— ed; for even where small exfoliations take place, the pieces of bone will be forced to the surface, and may be afterwards taken out long after the cure of the soft parts is completed. An exostosis, however, is sometimes found to sur— round a bone entirely. In this case the treatment now advised will not apply. In this situation, that portion of the bone must be taken out on which the exostosis is fixed, when the bone is of such a length and is so situated as to admit of it: But as this can scarcely be done in the small bones of the hands and feet, when any of these are affected, it becomes neces— sary to remove the diseased bone entirely. In a case of this kind which occurred on one of the metatarsal bones, and where the exostosis surrounded the whole circumference of the bone, I thought it better to take out the bone altogether, than to leave the two ends of it only. The one operation was performed with no G4 great 96 Of Chronic or Chap. XXXVIII. great difficulty: the other would have been much more painful as well as more tedious, and it would not have proved more successful. For although the part did not fill up with bone, it became sufficiently firm to enable the patient to walk as well as he did be— fore. In the long bones, however, of the thighs, legs, or arms, we may safely venture to remove any portion of them on which an exostosis is fixed: and where the constitution is healthy, we need never despair of na— ture supplying, the deficiency; for instances have been often met with, even of entire bones being regenerat— ed. When a portion of bone is to be removed, after laying it freely bare by an extensive incision, a piece of pasteboard, or a thin sheet of lead, should be passed beneath it, in order to protect the parts below from the teeth of the saw. Where a portion of the fibula or tibia is to be removed, the splint must be passed in between these bones; and when either of the bones of the sore arm are affected, it must be passed between the radius and ulna. Different forms of saws have been employed for dividing the bone; but the com— mon saw used in amputations answers better perhaps than any other. When the portion of bone is removed, the sore should be dressed with the mildest applications; a piece of soft lint spread with the common wax lini— ment, or merely dipped in oil, should be inserted be— tween the lips of the wound; and it any thing be em— ployed for retaining them, it should be the many tail— ed bandage, which can be undone without moving the limb. It is a matter of importance to place the limb in a situation the most favourable for the discharge of matter; and as the operator has it commonly in his power to make the wound more or less inclined to any side of a limb, this circumstance should be attended to in the first part of the operation. When the operation has been performed upon ei— ther of the bones of the leg or fore arm, the remaining sound 97 Sect. III. Indolent Tumors. sound bone will always keep the limb at its full length, so that there will be little or no risk of its becoming shorter. But when a portion of a single bone is taken out, some attention is required to prevent the limb from becoming shorter during the cure. For this pur— pose different machines have been invented; but I have never found any assistance of this kind necessary: for if the patient be informed of the great importance of keeping the limb in a proper posture, he will give it all the attention that is requisite: and besides, much inconvenience, pain, and inflammation, are apt to en— sue from any instrument employed for this purpose, when applied with that tightness that is necessary for keeping a limb in a state of extension. During the cure of the sore, the chief object is to prevent matter from lodging and passing between the contiguous sound parts. If this be prevented, and the lips of the wound kept open by the easy dressings we have mentioned, till it fills up with granulations from the bottom, the rest will be accomplished by nature alone. Those soft granulations which at first occupi— ed all the vacancy between the ends of the divided bones will soon acquire the consistence and strength of bone; and in the course of a short time, if the gen— eral state of health continues good, the limb will be— come equally useful as it was before. Hitherto we have supposed the disease to be seated in the extremities. But tumors of this kind are also found in other parts of the body: on different parts of the skull; on the under jaw; on the ribs and clav— icles; and I once saw a large exostosis on the upper part of the scapula. But wherever they are situated, the treatment is the same. While they give no un— easiness, nothing should be done; for they will some— times continue small and stationary for life: But when they increase and prove troublesome, the sooner they are removed the better; for the earlier the operation is performed, the more easily will it be done. In 98 Of Chronic or Chap. XXXVIII. In that variety of exostoses termed a Node, pro— ceeding from the lues venerea, the first point to be de— termined is the state of the system. The patient should be immediately put upon such a course of mer— cury as can be depended upon for the removal of any infection he may labour under; and if the tumor in the bone be recent, and not far advanced, it may be carried off by the mercury alone. With a view, how— ever, to make the medicine as effectual as possible, it should be thrown in as quickly, and in as great quan— titles, as the patient can bear: for the system being completely infected with the virus before nodes ap— pear, it requires, for the most part, a very consider— able quantity of the medicine to check their progress. At the same time that mercury is given inwardly, it is a common practice to rub the part itself with mer— curial ointment, or to keep it covered with mercurial plaster. I have never observed, however, that any advantage is derived from this; and I think it is apt to do harm. In tumors of this kind there is much reason to suppose that the periosteum becomes inflam— ed from the first. In different instances, the inflam— mation has appeared to be aggravated both by the ap— plication of plasters, and by the friction used with mercurial ointment. Till we know whether the inter— nal exhibition of mercury is to prove effectual or not, some mild sedative application, such as a solution of saccharum saturni, or the unguentum nutritum, which is a preparation of lead, should only be employed. These keep the parts easy; and by tending to remove inflammation, they may even have some influence in removing the tumor. But if we find, after there is full evidence of the mercury having entered the system, that the local af— fection of the bone still continues to advance, that the tumor becomes larger and the pain more severe, other remedies should be advised. In this situation, I have sometimes found the pain relieved immediately by the application of several leeches over the tumor; and the pain 99 Sect. III. Indolent Tumors. pain being rendered moderate, we are thereby enabled to delay every other remedy till a more complete trial be given to the mercury. In some cases, where leech— es have failed, blisters applied directly upon the parts affected have proved successful. Neither they nor leeches can have any influence on the original disease: they will not lessen the tumor of the bone; but by lessening the tension of the periosteum, they will prove more useful than perhaps any other remedy we could employ. Sometimes, however, when these means are too long delayed; when the tumor advances with more rapidity than usual; or when acrid matter is perhaps confined beneath the periosteum; neither leeches nor blisters afford relief. In such cases, an incision made along the course of the tumor to the depth of the bone, will often give immediate ease. The mat— ter evacuated from these tumors is frequently a thin brown sanies; at other times, it is a viscid transparent mucus. In some cases the incision heals kindly by common treatment, even when the tumor of the bone is by no means inconsiderable. Healthy granulations will form, and a cure of the sore will be accomplished, even before the patient has taken as much mercury as may be judged necessary for the cure of the disease. In such cases, the tumefaction of the bone is not to be re— garded: It may probably, indeed, continue during the life of the patient; but no inconveniency will af— terwards ensue from it. So that unless it be so situat— ed as to produce much deformity, it should never be touched. But, on other occasions, the sore, instead of healing easily, will remain obstinate, notwithstanding all the remedies that can be employed. In such circum— stances, the obstinacy in the sore is for the most part supposed to arise from the venereal virus not being destroyed, and a farther continuance of mercury is therefore advised. The mercurial course should no doubt 100 Of Chronic or Chap. XXXVIII. doubt be carried so far as there is any chance of its proving useful. But beyond this, it will commonly prove hurtful, and will rather tend to protract the cure of every sore. This, however, is a point upon which no precise directions can be given; the judgment of the practitioner in attendance must determine it. When the obstinacy of the sores depends upon oth— er diseases of the system, the removal of these will for— ward the cure. But when there seems to be a tend— ency in the diseased bone to exfoliate, the completion of this process will alone prove effectual. In such circumstances, the treatment adapted to promote ex— foliation ought to be pursued: But as we have else— where considered this subject fully, it is unnecessary now to enter upon it.* After all the diseased parts of the bone are removed, the sore will for the most part heal readily. But in some cases, such a fullness and thickening of the peri— osteum and other contiguous parts has been produced by the long continuance of the disease, that the cure still proceeds slowly. In such circumstances, mild emollient applications do harm: and nothing in gen— eral proves so useful as those ointments that are strong— ly impregnated with red precipitate, or with verdigris. In some cases, even these do not act very speedily; when touching the surface of the sore once in two or three days with lunar caustic, or with lapis infernalis, will make the sloughs throw off, and for the most part their place will be supplied by healthy granulations; after which, the cure will probably proceed without interruption. In describing this variety of exostosis, we have re— peatedly mentioned the pain which attends it; a symp— tom which always takes place; at least I never met with an instance of the contrary. Venereal nodes, particularly those on the head, are not indeed always accompanied with much pain, but merely with a slight uneasiness. * Vide Treatise on Ulcers, &c. Part II. Sect. VII. 101 Sect. III. Indolent Tumors. uneasiness. But this variety of node does not origin— ate from the bone, but proceeds merely from an affec— tion of the periosteum. In this case the tumor com— monly subsides entirely, either by the effects of mer— cury alone, or by the application of a blister; and no advantage is derived from making an incision into it. But in the other, if the bone be affected in any con— siderable degree, the tumor never subsides, if it be not by a portion of the bone exfoliating. Even after ev— ery other symptom of the disease is removed, these tu— mors in the bones continue equally fixed, and large as they were at first. We judge that a node proceeds from the bone itself; by the pain, as we have just ob— served, being in general acute; by the tumor being considerably harder than when the periosteum only is affected; by its advancing much more slowly than the other; and by its continuing fixed and permanent, notwithstanding all the remedies we can employ to re— move it. We come now to speak of the treatment of the spi— na ventosa, or that variety of exostosis which we sup— pose to originate from scrophula; and I am sorry to observe, that I have nothing satisfactory to offer upon it. Fomentations, ointments, plasters, and a variety of other remedies, are recommended; but I know of none that any advantage has ever been derived from. Tumors of this kind which appear formidable at first, will sometimes indeed continue stationary, either from the scrophulous disposition in the system being check— ed by cold bathing, or some other similar remedy; or from some change taking place in the constitution, with the nature of which we are perhaps altogether unacquainted. But this is a rare occurrence: for in general, notwithstanding all the remedies we employ, a spina ventosa, from its first appearance, proceeds in a gradual manner to turn worse. When the disease appears at the same time in dif— ferent parts of the body, all we can with propriety at— tempt, is to support the constitution with a proper di— et. 102 Of Chronic Tumors, &c. Chap. XXXVIII. et. To advise bark and cold bathing as the best strengthening remedies; and when the pain is severe, to endeavour to render it moderate by adequate doses of opium. But when it is confined to one part, as of— ten happens in the knee and other large joints, in cases of white swelling, it becomes frequently advisa- ble to remove the diseased part by an operation. In affections of the joints, it has been the common prac— tice in this situation to amputate the diseased limbs en— tirely. But an attempt has lately been made by Mr. Park, an ingenious surgeon in Liverpool, to save the limbs that are thus diseased, by removing the heads of the affected bones only, and afterwards healing the sore at which they were taken out. When we come to treat of the operation of amputation, we shall enter more fully into the consideration of this; for we think it highly deserving of notice: and at present shall on— ly remark, that there is cause to suspect that it will not be found to prove so generally useful, as at first view might be expected. But in local swellings of this kind which occur on the middle of bones, we think it right to observe, that the same practice may be pursued which we have already recommended for the removal of those cases of exostoses which proceed from exter— nal violence: The swelled portion of bone may be cut out when it is situated on any of the long bones of the extremities; and on any of the short bones of the hands or feet, the diseased bones may be removed en— tirely. CHAPTER 103 CHAPTER XXXIX. Of FRACTURES. SECTION I. General Observations on Fractures. SOME practitioners denominate every solution of continuity in a bone a Fracture; but the term may, with more propriety be confined to those divis— ions in bones which are produced by external violence. Thus, we do not say that a bone is fractured, the parts of which are separated from each other by the effect of any internal disorder; while we say that it is frac— tured when this happens from a fall, a blow, or a bruise. Fractures are of various kinds, and are distinguished by different names. A bone may be fractured either directly across, in an oblique direction, or longitudi— nally: Hence the terms Transverse, Oblique, and Longitudinal Fractures. When a bone is split into small pieces, we call it a Splintered Fracture. When the teguments remain found, a fracture of a bone is denominated Simple; and we term it Com— pound when the fracture communicates with a wound in the skin, and other corresponding soft parts. By some a fracture is said to be Compound when a bone is broke into different parts; and those fractures they term Complicated, which are accompanied with wounds in the corresponding soft parts. This subdi— vision, however, of fractures, seems to be unnecessary: for unless a bone is splintered, no essential difference arises 104 General Observations Chap. XXXIX. arises merely from its being broke at one or two parts; whereas the slightest communication between a frac— ture and a wound in the surrounding soft parts, is apt to change the nature of it so entirely, as to induce dan— ger, and even death, in cases where no alarming symp— toms would otherwise have been dreaded. The existence of fracture is, for the most part, easily discovered by manual examination. A fracture of a single bone, where there is only one in the fractured part of a limb, and the fracture of both bones when there are two, as well as a fracture accompanied with an extensive wound of the contiguous soft parts, are easily detected: But in simple fractures, where only one bone of a limb has suffered, it is often difficult to judge with any degree of precision; and more partic— ularly so where the contiguous parts have become tense and painful before a practitioner is called. In such cases, our opinion must be informed by a minute attention to different circumstances: The age and habit of body of the patient; the site of the supposed fracture; the situation of the limb when the injury was received; and, lastly, to the attending symptoms. In old people, bones are fractured more easily than in those who are at an earlier period of life. In in— fancy, bones will rather yield than break upon the ap— plication of a moderate force; whilst in old age they become so brittle, that the largest in the body are fre— quently broke upon the most trifling falls and bruises. Different diseases induce, this brittle state of the bones, particularly the lues venerea. Of this I have met with several instances. In two cases, the largest and hardest bones were broke solely by the ordinary action of the muscles of the limb. It is also the effect of the sea scurvy: bones that have been fractured and long united having been frequently separated in ad— vanced stages of the real scurvy, the callus being either dissolved or rendered too soft for the purpose of re— taining them together. Besides 105 Sect. I on Fractures. Besides these general affections of the body, the bones themselves are liable to a disease which renders them soft and flexible. It is usually termed Mollities Ossium. In some cases, it goes no farther than to produce that state of the bones we have mentioned, in which they are apt to be fractured by slight falls, and other similar accidents: But in others, it has been known to proceed to such a height, that every bone in the body has become crooked and distorted. I have. seen a skeleton in which the condyles of the knee joints were turned up to the pubes, and in which ev— ery other bone was crooked in nearly a similar de— gree. In judging therefore of the probability of a fracture from the degree of violence applied, these circum— stances deserve particular attention: For it is evident that in old age, and in the diseased states of bones we have mentioned, a degree of force will occasion frac— ture, which in other situations would not be equal to this effect. The site of a supposed fracture is also to be taken into consideration. Bones are more apt to be broke in those places where they are hard and brittle, as in the firmer parts of all the long bones, than towards their extremities, where they are of a more soft and yielding texture; and bones that lie deep under the cover and protection of muscular parts, as in the thighs, are not so frequently fractured as those of the arms and legs that are not so well protected. Further, the situation of a limb when an injury is inflicted, is an object of inquiry. Thus, a very incon— siderable weight passing over a bone lying on an un— equal surface, will readily produce a fracture; while the same bone, equally supported, will bear a heavy load without being injured. In forming an opinion of the probability of a frac— ture having taken place, we ought, lastly, to take into consideration the symptoms which usually accompany fracture. These are, pain, swelling, and tension in H the 106 General Observations Chap. XXXIX. the contiguous parts; a more or less crooked and dis— torted state of the limb; a crackling or grating noise on the parts being handled; and loss of power to a certain extent in the injured limb. It is true, that the mere fracture of a bone, is not necessarily attended with much pain; for the bones, not being so plentifully supplied with nerves as the softer parts of the body, they are therefore of a less ir— ritable nature. But pain arises from two circumstances with which fractures are usually attended; the con— tiguous soft parts being bruised and otherwise hurt, in the first place by the force producing the injury, and afterwards by the displaced ends of the bones. For the most part the pain indeed is not very severe: but in some cases it becomes so violent as to be productive of the most alarming symptoms: spasmodic affections of the muscles in the injured limb; high degrees of inflammation; fever, accompanied with subsultus ten— dinum; general convulsions and delirium; and if the cause by which these symptoms were induced be not soon obviated, they very commonly terminate in the death of the patient. In general this is preceded by mortification of the parts contiguous to the fracture; but in some instances, affections of this kind prove fa— tal from the violence of the fever, and without any tendency to gangrene being perceptible. When the force by which a fracture is produced has been extensively applied over a limb, we may readily suppose that the severest symptoms may be in— duced by this cause alone; but in general it will be found, when the pain, tension, and convulsive twitch— ings of the muscles are violent, that they chiefly orig— inate from the adjoining membranes, muscles, or other soft parts being lacerated, punctured, or compressed by the ends of the fractured bones: And although this may happen in fractures of every description, yet it will necessarily be a more frequent occurrence in those that are so oblique as to admit of the bones pass— ing easily over each other, than in transverse fractures, where 107 Sect. I. on fractures. where the parts, on being replaced, more readily re— main in their natural situation. The other diagnostic symptoms of fracture we enu— merated, a grating noise on the parts being handled, and distortion and loss of power to a certain extent in the injured limb, will be found on a minute examin— ation to accompany almost every accident of this kind. They will indeed be much more evident in some frac— tures than in others: but in all they may be discover— ed where the parts are not much swelled, excepting in the case of a longitudinal fracture. A bone may in— deed be split in this direction without any of these symptoms taking place: for unless the divided parts be completely separated from each other, neither dis— tortion nor crackling will be perceived on handling them; nor will the bone be rendered incapable of sustaining those parts of the body which usually rest on it. In such cases, we judge of the probability of a fracture having happened, from the violence of the injury, the severity of the symptoms, and other cir— cumstances already enumerated. Besides these leading symptoms of fractures which take place immediately on the injury being inflicted, there are others which occasionally occur from the first, and some which we are to consider as conse— quences rather than symptoms. Of the first, the most remarkable are, that great degree of ecchymosis which in some cases appears instantaneously, from the ends of the fractured bones having penetrated a contiguous artery or vein; and the wound or laceration of the teguments in compound fractures. The most important consequences of fractures are, stiffness and immobility of the injured limb; distor— tion of the parts chiefly affected, either from a fulness or thickness remaining in the contiguous muscles or ligaments; an exuberancy of callus; a contracted state of the contiguous joints; or a marasmus or wasting of the limb itself. All these we shall consider more par— H2 ticularly 108 General Observations Chap. XXXIX. ticularly when we come to speak of the treatment of fractures. In judging of a fracture, and the probable event of it, various circumstances are to be considered: partic— ularly the age and habit of body of the patient; the situation of the bone, and the part of it that is injured; the nature of the attending symptoms; the circum— stances with which the fracture may be complicated; and the kind of fracture. With respect to the first of these, namely, the age and habit of body of the patient, we all know that they are points of much importance in the cure of every injury to which the human body is liable; and in none more than in fractures. This in youth, partic— ularly in infancy, fractures in general cure much more quickly than in old age; and in found healthy conti— tutions, much more readily than in such as are diseas— ed. We have observed above, that the bones are apt to become very brittle in lues venerea; and it may here be remarked, that the existence of that disease, or of scurvy, is found to be particularly adverse to the reunion of fractured parts. I have met with some ex— ceptions to this, where fractures have been easily cur— ed even in advanced stages of the lues venerea: but there is much reason to think that this is not a com— mon occurrence; and that where this disease has at— tacked the bones, no callus will form till the virus be eradicated. In speaking of the effect of age on the cure of frac— tures, although I admit that the divided parts of bones unite more speedily in infancy than in old age, yet I think it right to remark, that it does not appear to happen with more certainty. By many we are told, that in advanced periods of life the union of fractured bones is often not to be accomplished. I have never, however, seen an instance of this, although I have had the management of many fractures even in extreme old age. The 109 Sect. I. on Fractures. The situation and part of the bone that is injured are both circumstances requiring attention. Thus we know, that fractures of the small bones of the arms and legs, of the feet and hands, and of the ribs, in general heal quickly and easily; while fractures of the larger bones, particularly of the femer and humerus, are managed with much more difficulty. In the last, in— deed, one principal cause of the cure proving for the most part very tedious, is the difficulty of retaining the ends of the fractured bones together. But what— ever the cause may be, it will necessarily have the same effect on our prognosis. When any of the large bones are fractured near to their extremities, we find the danger to be much great— er, and the prospect of complete cure much less, than when they are broke near to their middle: For here the shortness of one end of the bone makes the retention of it difficult; and the symptoms which en— sue from a fracture in this situation are apt to be par— ticularly severe, not only from the contiguity of the capsular ligaments of the joints, which may thus be injured, but from the numerous tendons inserted into these parts of the bones; which may not only be lac— erated and bruised, but even tore from their insertions. Besides, the ends of bones are not only soft, but even spongy or cellular in their texture: Hence fractures near the extremities of bones are more tedious in the cure, and give rise to more troublesome symptoms, than in the harder parts of them: for the fractured parts do not here unite with such equality; they more frequently exfoliate, and matter is more apt to form in them. It is also proper to remark, that fractures near the extremities of bones are frequently productive of stiff immoveable joints, unwieldy limbs, pains and swell— ings; which, in various instances, even under the best treatment, continue obstinate for a great length of time, and in some cases during the life of the pa— tient. H3 We 110 General Observations Chap. XXXIX. We are in general led to suppose, that these conse— quences are solely owing to mismanagement, either on the part of the surgeon or of the patient. That in some cases they are so, no person will, deny. The ends of a fractured bone may be improperly placed from the first by the practitioner, or they may be af— terwards misplaced by the patient; and in either case we may readily imagine, that all the symptoms we have mentioned will take place. But in justice to the profession, we must observe, that they are more fre— quently to be attributed to the situation and nature of the fracture than to any other cause. Nor is it sur— prising that it should be so. When we consider the various circumstances with which a fracture is often accompanied; the degree of violence required to break a large bone; the severe contusion of the con— tiguous soft parts which this must produce; and the laceration of nerves, muscles, and ligaments, which must occur from the spiculæ of the fractured portions of bone; we should rather be apt to suppose that they would be more frequently productive of troublesome consequences than we actually find to be the case. In forming a judgment of the nature and probable event of fractures, the symptoms which take place merit particular attention. If the symptoms are mod— erate, when compared with the apparent degree of violence the parts have suffered, our prognosis should be proportionally favourable: But whenever the at— tending symptoms are severe, particularly if the pain be uncommonly violent, and the swelling and tension considerable, however trifling the force may have been by which the fracture was produced, the case will probably be difficult to manage, and uncertain in the event. In such circumstances, therefore, even in what is usually termed a Simple Fracture, our prog— nosis should be guarded. The circumstances with which a fracture may be complicated, are likewise of importance; and unless they are duly weighed, no accurate judgment can be formed 111 Sect. I. on Fractures. formed of the event. The contiguous muscles and other soft parts may be severely contused; some of the ligaments and tendons of the injured part may be ruptured, or even tore from their insertions; and the fracture may be combined with a dislocation of one or both of the contiguous joints. These accidents ag— gravate the danger in every case of fracture. The last consideration on this subject respects the kind of fracture. The greatest difference is observed between the event of a simple and of a compound frac— ture. A great proportion of cases of simple fracture are of a mild nature from the first; and with very or— dinary attention complete cures are obtained: But in compound fractures, the smallest external wound com— municating with the injury in the bone, will often be productive of the greatest danger. I do not mean to say that this happens in every case; on the contrary, we know that even the worst cases of compound fractures will, with proper attention, often terminate in the most favourable manner: But every practitioner much versant in this branch of business will allow that this is not to be depended on; and that even under the best management such cases are so apt to go wrong, as to warrant the opinion we have given of them, and to render it. proper in almost every instance to give a guarded prognosis. Authors lay down various indications for the cure of fractures; and these we are desired to have strictly in view: Namely, extension; counter extension; co— aptation, or replacement of the fractured parts; deli— gation, in so far as is necessary for retaining them; position of the injured part; and prevention or re— moval of bad symptoms. The subject, however, may be simplified, and the indications with propriety restricted to three: To re— place the parts of the bone that have been moved from their natural situation; to retain them in this situa— tion as long as may be necessary; and to obviate such symtoms as may supervene during the cure. H4 In 112 General Observations Chap. XXXIX. In some few favourable cases, where the bones are fractured directly across, they are either not moved out of their natural situation, or the alteration is so incon— siderable that they are easily replaced. But when the bones of a limb are broke in an oblique direction, they are apt to pass one another so as to produce much de— formity and pain. The contiguous muscles are thus severely injured, and excited to violent action: Hence in all such affections the malady is increased by every natural exertion either of the whole body or of the part more immediately injured; and nothing will re— move it but an artificial replacement of the distorted bones. To accomplish this, various methods have been pro— posed. In former times it was effected by much vio— lence and force; by what was termed Extension and Counter Extension: but we now know that our pur— pose may be accomplished in an easier manner, with less pain to the patient, and less trouble to the opera— tor. As long as it was imagined that much force ought to be employed, the limb was extended by one or more assistants pulling at each end of it; and when this, was not sufficient to draw the bones into their natural situation, different machines were used for this purpose. The necessary force was in general applied while the limb was on the stretch; a circumstance which added much to the difficulty of reducing the fractured parts of the bone: for in this manner all the contiguous muscles were put into action; nor could the bones be replaced till this was overcome by the application of a superior force. The mischief which this would often produce, it is easier to imagine than to express. When it is considered, that in the reduction of a fractured bone the chief resistance we meet with is the action of the neighbouring muscles, the propriety of putting the limb into such a posture during the oper— ation, as favours the relaxation of the different mus— cles 113 Sect. I. on Fractures. cles connected with it, is so obvious that we now re— flect with surprise, that it was left to the practioners of the present age to propose this measure. For, what— ever may have been the ideas of a few individuals, it is certain, that till very lately it was the general prac— tice to keep every limb in an extended position while any attempt was making to replace the fractured bones, and that it is chiefly to Mr. Pott we owe the intro— duction of the contrary practice. In the treatment of a fracture, if we take care to re— lax all the muscles of the limb, it is surprising with what ease the ends of the bones may in general be re— placed. When a limb is laid completely in this re— laxed posture, the surgeon will in most cases be able to replace them without any assistance whatever; But when he does not succeed, a flight degree of extension may be employed, by the upper part of the limb being kept firm by one assistant with his hands placed be— tween the fracture and the contiguous joint, while the under part of it is gently extended by another; care being still taken, however, to keep the muscles as much relaxed as possible. As it is of the utmost importance in replacing the fractured parts of the bone to do it with exactness, the nicest attention should be paid to this part of the op— eration. Every inequality depending upon any por— tion of bone being displaced should be removed, so as to render the injured part as similar as possible to the corresponding sound limb; which, for the purpose of a more attentive examination, should be placed as near to it as the conveniency of the operator will per— mit. The necessity of attention to this part of the treat— ment will appear from this, that when the fractured bones are not properly reduced at first, the limb must either remain always distorted, or it must be put right during a future stage of the treatment; when it will necessarily be done with more pain to the patient, and more trouble and perplexity to the surgeon. The 114 General Observations Chap. XXXIX. The bones being put right, our next object is to retain them in this situation as long as may be neces— sary. This we do by proper compresses and bandages, and by placing the limb in such a state of relaxation as will admit of its resting with ease, and without being disturbed, till the cure be completed. When we come to treat of fractures of particular parts, the pos— ture in which they should be placed, and the bandages that appear to be best adapted to them, will be de— scribed. At present we may observe, that no bandage should be applied with more tightness than is neces— sary for retaining the bones in their situation; and that this may, for the most part, be easily effected, if the limb be kept in such a posture as to relax the va— rious muscles connected with it. The time required for rendering the, union of frac— tured bones sufficiently firm, depends upon various circumstances: Upon the size of the bone, and the weight which it has to support; on the age and habit of body of the patient; and on the cure having pro— ceeded with more or less interruption, from the limb having been kept more or less steadily in its situation, as well as from the attending symptoms of swelling, pain and inflammation, having been mild or severe. In a healthy middle aged patient, when no untoward symptoms have occurred, and when the injured parts have been retained exactly in their situation, a cure of a fractured femur, or of the bones of the leg, will be accomplished in two months; of the humerus and bones of the fore arm, in six weeks; of the clavicles, ribs, and bones of the fingers and toes, hands and feet, in three weeks. In infancy and childhood, fractures in all these parts heal much more quickly; while in old age this uniting process goes on more slowly, and therefore requires more time to accomplish. In simple fractures, to which these general observa— tions more particularly apply, the pain, tension, and other symptoms, are in general moderate, and usually subside entirely in the course of a few days, if the bones be 115 Sect. I. on Fractures. be properly retained in their situation; but in some cases, instead of diminishing, they become daily more violent, so as to be productive of much distress to the patient, as well as trouble and embarrassment to the practitioner. When the muscles and other soft parts of the limb have not been much contused, there is perhaps no ne— cessity for any application, with a view to the preven— tion either of pain or tension: but for the most part it is proper to guard against the violence of these symp— toms, by the early use of some astringent applications, such as, a solution of saccharum saturni, of crude sal ammoniac, or spiritus Mindereri; and when these fail, by a free application of leeches over all the pained parts. Indeed, the practice of taking away blood by leeches proves in every case of this kind so beneficial, that I always advise it whenever the tension is in any degree considerable, or whenever the pain continues severe after the bones have been replaced. In every case of fracture, inflammation is the symptom which, in the first place, we have most reason to dread; and as nothing tends with such certainty to prevent or re— move it as local blood letting, it should never he omit— ted when the surrounding soft parts are much injured: Nor should the practice be delayed after it appears to be in any degree necessary; for it proves always most effectual when employed soon after an injury has been inflicted. Besides the immediate advantage of relieving the pain in the injured part, nothing prevents with such certainty the troublesome consequences of contusion in cases of fracture as the early application of leeches. Of these consequences, the most remarkable are, deep seated abscesses, which in some instances form within the cavity of the bone itself, and in others in the sur— rounding cellular substance; long continued pains, resembling rheumatic affections, stretching over the injured limb; a thickened enlarged state of the peri— osteum and other soft parts; a stiff contracted state of the 116 General Observations Chap. XXXIX. the contiguous tendons; an exuberancy of callus; and an unwieldy state of the whole member. It is well known to all who are versant in this branch of business, that all of these consequences are apt to succeed to fractures accompanied with much contu— sion: And nothing proves more perplexing to sur— geons, or more distressful to parents; for when they are not soon removed, they are very apt to prove per— manent; and for the most part they are attributed to some mismanagement in the reduction of the fracture. In many instances they no doubt arise, from the ex— tremities of the fractured bone not being properly re— placed, or not retained with exactness afterwards: but they more frequently proceed from the inflammation which follows from contusion. It is therefore evident, that early leeching can alone be useful. When swell— ing and pain in a fractured limb have continued long, the most effectual relief is obtained from frictions with emollient oils, and from warm bathing, particularly from a proper use of the waters of Buxton, Bath, and Barreges. We are sometimes disappointed in obtaining com— plete cures of fractures, by the limbs remaining unseem— ly from an overgrowth of callus. It is not a common occurrence; but every practitioner must have met with it. As far as I am able to judge, in fractures at— tended with much inflammation, where this inconven— iency is most apt to occur, local blood letting proves more useful than any other remedy in preventing it. In some cases, however, the tendency to form callus is so great that if can scarcely be checked. The ap— plication of ardent spirits, and of other astringents, is here supposed to prove useful; and I have in some instances derived advantage from a continued gentle pressure, which is best applied by means of a thin plate of lead adapted to the form of the part, and re— tained by a proper bandage: But as neither this nor any other remedy will prove successful in every case, and as patients are apt to regret nothing so much as a disappointment 117 Sect. I. on Fractures. disappointment in obtaining a complete cure of a frac— ture, our safest course, as soon as the callus begins to be too luxuriant, is to acquaint the patient with the probable event; and he must be very unreasonable indeed, if he afterwards repines at what the utmost care and attention could not prevent. Among the consequences which sometimes result from fractures, there is one which we must consider more particularly; namely, a difficulty of obtaining. an union between the ends of the fractured bones, by which they regain loose and detached long after they should have been firmly knitted together. This may proceed from various causes: From some constitutional disease, such as rickets, scurvy, or lues venerea; from the ends of the fractured bones not being kept steadily in contact till their complete reu— nion be accomplished; from a portion of a muscle, tendon, or ligament, falling in between the ends of the fractured parts, so at to prevent them from being plac— ed in contact; and in some cases it proceeds from a bone being broke in different parts, and the interme— diate detached pieces being so small as to prevent them from adhering, even when kept in close contact. It has been observed, too, that occurrences of this kind happen more frequently during pregnancy than in other situations. This has not indeed fallen with— in my observation; but it appears to be the general opinion of practitioners, and different instances of it are recorded by authors. When this want of union proceeds from any gener— al disease of the system, those remedies must be em— ployed which are known to prove most effectual in re— moving it: For no attention on the part of the surgeon will produce any advantage till this be accomplished; and as much mischief is often prevented by an early application of remedies, they should always be advised as soon as the cause is observed to exist. It would even be a proper precaution, where it is known that a pa— tient at the time of receiving a fracture labours under any constitutional 118 General Observations Chap. XXXIX. constitutional disorder, to advise such a course imme— diately; by which means cures might be accelerated, which otherwise would be unnecessarily protracted. When the union has been prevented by the fractur— ed bones not having been kept steadily in a proper sit— uation, the bones should be replaced and retained in their situation with as much exactness as possible; and when the injury is still recent, a perfect union may by this means be still accompished. But where a fracture has continued long without any union being formed between the ends of the bones, the osseous matter by which they should have been knit together becomes hard, smooth, and totally unfit for the purpose, insomuch that no advantage could be derived from their being replaced. Of this I have met with different instances, where the ends of the fractured bones were become perfectly smooth, and moved on each other with the same ease and freedom as the bones of any of the joints: and various cases of it are to be met with in authors. In this situation, when no great inconveniency is experienced, the patient should be advised to submit to it, particularly in fractures of the small bones, such as those of the fingers and toes, the bones of the meta— carpus and metatarsus, the clavicles, and ribs: but in the large bones of the extremities, where much firm— ness is required, and where any injury of this kind must be productive of almost a total loss of the use of the limb, as we may be able by an operation to restore it, we ought perhaps in every instance to propose it. By making an incision through the surround— ing soft parts, so as to lay the ends of the bones bare, and removing a small portion of each of them either. with a common saw or with the head of a trepan, we reduce them to the state of a recent fracture; when, by taking care to retain them in a proper situation, we may in due time expect a complete cure. The operation is no doubt painful and tedious: for the incision should be extensive, in order to admit of a free 119 Sect. I. on Fractures. a free application of the instruments; and for the most part it must be conducted with much caution, in or— der to avoid the large blood vessels of the limb: But it may be done with perfect safety by any person ac— customed to the operative part of surgery.* Nor should we be deterred from proposing this method of cure from any apprehension about the ex— tent of the vacancy that may be produced by the re— moval of the ends of the bones: for if the limb be kept steadily in its situation, and, if the constitution be healthy, nature will not probably fail in supplying the deficiency. Thus we have many instances upon rec— ord, even of entire bones being regenerated; and, in a lesser degree, the powers of nature on this point must have fallen within the observation of every practi— tioner. A bone is often broke in different parts, and a cure notwithstanding obtained: but when the detached parts are so small that the circulation will not proba— bly be kept up in them, as they will thus be rendered incapable of furnishing the secretion by which their re— union should be accomplished, it would be better to remove them at once, than to impede the cure by any attempt to save them. Accordingly, in all compound fractures, where the injured bone is already laid bare, it is the practice of our best surgeons to remove all such detached portions as might not probably unite with the remaining parts of the bone. But in simple fractures, where the skin remains entire, as we cannot judge with such certainty of the nature and extent of the injury, nor of the probability of our being able to preserve all the loose portions of bone, we endeavour in the first place to accomplish a cure in the easiest manner, by placing the parts in such a position as will most readily admit of their union being effected: but when this does not succeed, when the ends of the bone. remain loose long after they should have been united, and * Vide White's Cases in Surgery, where two instances of this are re— corded. 120 General Observations Chap. XXXIX. and one or more detached pieces are discovered, these are to be considered as extraneous bodies, and ought to be removed with the fingers or forceps, at an open— ing made through the soft parts for this purpose. Experience enables me to recommend this method of treatment with confidence. I have met with dif— ferent cases where a cure being considered as imprac— ticable from no union having formed between the ends of fractured bones, was at last accomplished in the course of a very short time by the removal of some loose fragments. But the most perplexing cause preventing the reun— ion of fractured bones, is a portion of muscle, a liga— ment, or some other soft part passing between them. We judge that this is the case when the pain and ten— sion of the injured part have been more severe than usual from the first; when particular movements of the limb occasion severe pain and twitchings of the muscles that serve to move it; and when the ends of the fractured bone do not unite at the usual time. As soon as there is any reason to think that a cure is prevented by the cause we have just mentioned, we should endeavour to remove the portion of interpos— ing membrane or muscle, by putting the limb into all the variety of postures by which it will be most readily effected. But when this does not succeed, as will of— ten be the case, and when the bones still remain loose long after the usual period, we ought, without farther hesitation, to make an incision upon the fractured part. When the injury has not been of long duration, a cure will be accomplished merely by bringing the ends of the fractured bone into contact: But when this meas— ure has been too long delayed, and when the osseous matter poured out by the fractured extremities of the bone has become hard, a small portion of it should be removed either by a saw or with some sharp instru— ment, so as to convert the injury once more into the state of a recent fracture; otherwise no advantage will be gained by the operation. Besides 121 Sect. I. on Fractures. Besides these causes I have mentioned, which tend to impede the cure of a fractured bone, it may not be improper to remark, that the effusion of much blood around the injured bone is very apt to be productive of the same effect. It is seldom, in cases of simple fracture, that any of the larger blood vessels are injur— ed; and blood effused from small arteries is for the most part soon absorbed, and no bad effects result from it. But instances sometimes occur, even in simple fractures, of a large blood vessel being cut by the sharp spiculæ of bone. When the quantity of blood thrown out is considerable, the tumefaction of the limb be— comes so great, that it is necessary to lay it open in or— der to secure the divided vessel with a ligature: but where the swelling does not arrive at any alarming height, we rather trust to the natural contractility of the artery for stopping the hemorrhagy, and to the powers of the absorbents for removing the blood al— ready effused. In some such cases, where blood has remained long in contact with the extremities of the fractured bone, the power of forming callus appears to have been destroyed by it; the periosteum separ— ates for a considerable space from each end of the bone; and on laying the parts open, no union is found to have taken place; the spiculæ produced by the fracture remain equally sharp as at first; and, for the most part, a thin fetid sanies is discharged from the sore. In this situation, a cure will not be obtained till those parts of the bone which have been denuded of the periosteum have exfoliated. As exfoliation is in general a tedious process, we would rather advise the removal of the denuded bone by means of a saw. A more expeditious and more certain cure will thus be obtained. Having premised these general observations, we pro— ceed to the consideration of fractures in particular parts. Vol. IV. I SECTION 122 Of Fractures of the Chap. XXXIX. SECTION II. Of Fractures of the Nose. THE arch formed by the bones of the nose pre— vents them from being so frequently fractured as they otherwise would be. They are necessarily, however, liable to every variety of fracture when ex— posed to any great degree of violence. Besides the usual symptoms of fractures, injuries of this kind in the bones of the nose are apt to impede respiration; they affect the speech and the sense of smelling; polypi and tedious ulcers sometimes ensue from them; and they are rendered more particularly hazardous from their contiguity to the brain. These fractures therefore require the most exact attention. When we have ascertained the nature and extent of the fracture, our next object is to replace the bones as nearly as possible in their natural situation. When any part of them has been elevated or raised above the level of the rest, it must be pressed into its situation with the fingers; while such parts of them as may have been forced into either of the nostrils must be elevated with the end of a narrow spatula, or any other instru— ment of a similar form. Any portion of bone that is quite loose, and nearly separated from the rest, should be removed immediately, whether it be raised up or forced into the nostril; but whatever adheres to the remaining portion of bone with much firmness, should be replaced in the manner we have mentioned. If the bones be properly replaced, they will for the most part remain in their situation without any assist— ance. If there is a wound, it must be dressed in the usual way; and whether the teguments be injured or not, we should endeavour to prevent inflammation by the use of saturnine applications, and by local blood letting when the violence of symptoms renders it nec— essary. But 123 Sect. III. Bones of the Face. But when the parts that have been replaced do not remain firm in their situation, we are under the neces— sity of endeavouring to retain them. If they fall into the nostrils, the best method of effecting this is to in— troduce such tubes into them as are represented in Plate XLIII. fig. 2. If the tubes are covered with soft lint, spread with any emollient ointment, they may be kept in the nostrils as long as may be necessa— ry: While, on the contrary, if any part of the bone is raised above the rest, it must be kept down by a prop— er application of a double headed roller. If the teg— uments are injured, the sore must be first dressed; care being taken in doing it to prevent deformity as much as possible: a compress of soft old linen must be next applied; and over the whole an equal pressure must be made by the bandage we have just mentioned. In this manner a cure may be obtained of almost every injury of this kind, unless the bones have been so much shattered, that their reunion cannot be accomplished. In which event, all that art can do is to extract the detached pieces, and to co—operate as much as possible with nature in healing the remaining sore. SECTION III. Of Fractures of the Bones of the Face. WHEN treating of fractures of the skull, those of the upper part of the face were considered. At present we have only a few observations to offer on fractures of the superior maxillary and cheek bones, being those which form the most prominent parts of the sides of the face. The vicinity of those bones to the eyes and to the nose, and the situation of the antrum maxillare, mak fractures of these important. When the fractur stretch toward the eyes, they are apt to induce mu I2 inflammation, 124 Of Fractures of the Chap. XXXIX. inflammation, which often proves dangerous; and when they penetrate the antrum, they not only prove extremely tedious, but very commonly occasion a good deal of deformity: for when the anterior part of that cavity is laid open, and any portion of the bone removed, the face becomes flat, and the teguments puckered, notwithstanding all that can be done to pre— vent it. In every injury therefore of this kind, we ought to be careful in replacing any portion of bone that may be fractured, so as to favour its reunion with the rest; and any wound that accompanies the fracture should be dressed with much attention, that deformity, as far as it is possible, may be prevented. After the bones are replaced, which may be done either with the fingers where there is no wound, or with forceps or a narrow spatula when the parts are laid open, a piece of adhesive plaster will answer bet— ter than any bandage for retaining the necessary dress— ings. Blood letting and an antiphlogistic regimen must be advised to obviate inflammation of the eye or contiguous parts, which otherwise might ensue. The remaining part of the cure, namely, the reunion of the fractured parts of the bone, must be left entirely to nature. When the fracture penetrates the antrum, the mat— ter which collects in that cavity cannot be properly evacuated from any opening that may take place on the prominent part of the cheek. In consequence of this, I have known sinuous ulcers formed that have con— tinued open for a great number of years. They can only be healed by giving a free vent to the matter, by an opening made in the most depending part of the cavity, in the manner we have advised in Chap. XXX. Section V. SECTION 125 Sect. IV. Inferior Maxillary Bones. SECTION IV. Of Fractures of the Inferior Maxillary Bones. ALTHOUGH the bones of the under jaws are very strong and compact, yet fractures of one, or even of both, are not unfrequent. This seems to arise from blows or other injuries to which these bones are exposed, being most apt to fall upon their anteri— or flat surfaces, where they are less capable of resisting violence than in any other part. We judge of the existence of a fracture in the jaw, by the deformity which it occasions; by the crackling of the bone when handled; by inability to move the jaw; by the violence of the injury, and the degree of pain with which it is accompanied. When both jaws are broke, the injury becomes obvious; as in this case a considerable separation takes place at the fractured part: but even where one bone only is fractured, it may be always discovered with a little attention. The site of the fracture being exactly ascertained, our next object is to replace the bones with as much care as possible: which is done by placing the patient in a proper light, having his head firmly secured, and the fingers of one hand pressing upon the inside of the jaw, while the other hand is employed externally in guarding against any perceptible inequality of the bone. One of the teeth is commonly seated in the course of the fracture; and in this situation acting as an extraneous body, and thus tending to retard the cure, it should be a general rule to extract it immedi— ately: But when any of the teeth not seated in the course of the fracture, are forced out of their sockets, it may be right almost in every instance to replace them, and to endeavour to fix them by tying them to the contiguous firm teeth. This being done, our next object is to retain the fractured bones in a proper situation till they are firm— I3 ly 126 Of Fractures of the Chap. XXXIX. ly reunited. For this purpose a variety of splints have been invented, both of pasteboard and other ma— terials; but as a compress and bandage either of soft old linen or cotton answers the purpose with equal certainty, and as they fit with much more ease to the patient, they should always be preferred. The parts being kept firm by an assistant, a thick compress should be laid over the chin, and be made to extend from ear to ear along each jaw; and over the whole a four headed roller should be applied in the manner we shall mention when treating of bandages. In using this bandage, it should not be made so tight as to give much uneasiness, or to endanger the circulation, at the same time that it should be applied in such a man— ner as to keep the fractured parts of the bone in close contact. During the cure the patient should be kept perfect— ly quiet. He should be fed entirely on spoon meat. He should be enjoined to avoid speaking and laugh— ter, or the use of his jaws in any manner of way. To prevent the displacement of the bones, which is apt to happen from frequent inspection, the bandage should be applied with such attention, that there may be no occasion to move it oftener than is altogether necessa— ry. In compound fractures of this part, there is in— deed a necessity for moving the bandage daily, as the sore cannot otherwise be regularly dressed. It ought always to be done, however, with the utmost attention, an assistant taking care to support the parts with his hands during the removal of the old, and the applica— tion of the new dressings. The management of a fracture of one or both jaw bones is exactly similar; only where both bones are broke, there is still more attention required than when one only is fractured. In a fracture of one of the bones, the patient may be allowed to eat soft meats, and to speak with freedom, in the space of three weeks: But where both bones, have suffered, this should not be permitted till the conclusion of the fifth week. SECTION 127 Sect. V. Clavicles and Ribs. SECTION V. Of Fractures of the Clavicles and Ribs. THE clavicles and ribs are more liable to fractures than any other bones. This proceeds not only from the slender structure of these bones, but from the transverse position in which they are placed, with their flat broad sides exposed to every injury that may be applied to them. A fracture of the clavicle is in general easily distin— guished. A grating noise is produced by the ends of the bone rubbing against each other, on the arm of the same side being smartly moved. The ends of the fractured part readily yield to pressure; and, for the most part, the end of the bone connected with the humerus, is pulled to some distance from the other by the weight of the arm. The motion of the humerus is impeded, and some degree of swelling, accompani— ed with more or less pain, takes place over the injured part. In examining a fractured clavicle, we almost always find the end connected with the sternum higher than the other, which has suggested an idea that has pre— vailed very universally in the method of cure. It is supposed that the height of this part of the bone pro— ceeds from its having started or risen out of its natural situation: In the reduction, therefore, of the fracture, a good deal of pains is commonly taken to press it down, and very tight bandages are employed to pre— vent it from rising during the cure. I believe, how— ever, it will be found, that this part of the bone rises very little out of its natural situation, and that the ap— pearance of its doing so proceeds almost entirely from the other end of the bone being dragged downwards by the cause we have mentioned, namely, by the weight of the arm. At any rate, no advantage is ob— tained from this practice: for a force that would be I4 necessary 128 Of Fractures of the Chap.XXXIX. necessary for pressing down the end of the bone, can— not be applied without the effect of cutting the tegu— ments, by pressing them against that part of it which is supposed to be elevated; while our purpose is fully answered by raising the arm, and supporting it at a proper height. The depressed portion of the fractur— ed clavicle is thus raised and brought into contact with the superior part. In some cases, indeed, of very oblique fractures, it may be impossible to bring the ends of the bone in every point exactly opposite to each other: but this may be always so far accomplish— ed as to enable us to avoid deformity, and to render the bone sufficiently strong. When the ends of the bone are brought into con— tact, our object is to retain them in this situation till they are united; and, as we have observed above, this can only be done by affording a proper support to the arm. The arm is usually supported by a sling and the neck, adapted to the length of the arm, every where equally applied to it. But the leather case rep— resented in Plate LXXXI. fig. 1. answers this pur— pose with more ease and neatness. By means of it the fore arm and elbow joint are more equally and more effectually supported: and this last is a point of no small importance; for if the elbow be allowed to drop, the humerus and scapula will both fall down, by which the ends of the fractured clavicle will again be separated. We are commonly directed in the treatment of frac— tures of this bone to have the shoulders drawn back and the head raised; and instruments are described for effecting these purposes. No general rule, how— ever, of this kind can be laid down: for in some cases we find that the fractured parts of the bone are kept most exactly together when the head is bent down upon the breast; while in others, it is better accom— plished while the head and shoulders are raised. In 129 Sect. V. Clavicles and Ribs. In other points, fractures of the clavicle must be treated like similar injuries in other parts of the body. When there is much pain and swelling, bleeding with leeches becomes proper; but in general, injuries of this kind are so slight, that the common saturnine ap— plications prove sufficient for removing any inflamma— tion or swelling that occur. When the fracture is ac— companied with a wound, any splinters of bone that may be discovered must be removed, and the wound itself dressed in the usual way. It is proper, however, to remark, from the vicinity of the subclavian artery, that the removal of any portion of the clavicle must be attended with danger, and ought therefore to be man— aged with caution. When the ends of the fractured part are supported with exactness, they will in general be firmly united in the space of a fortnight; but the corresponding arm should never be used with freedom till the end of the third or fourth week. We discover fractures of the ribs by the seat of the pain, and by pressure with the fingers. For the most part, the symptoms which take place are moderate; the pain induced by the fracture is inconsiderable, no fever occurs, and the patient soon gets well: But in some instances the pain is severe from the first; the breathing becomes difficult, attended with cough, and perhaps a spitting of blood; and the pulse is quick, full, and sometimes oppressed. It will readily be understood, that a fractured rib cannot of itself induce any of these symptoms: But in some instances the ribs are not only fractured, but pushed inwards upon the pleura and lungs; when, from the compression and laceration of these parts, we may easily perceive how pain, oppression in breathing, and fever, should be induced; and at the same time be able to account for the emphysematous swellings described in Chap. XXII. Sect. V. In every case of fracture of the ribs, it is a safe and proper practice to discharge a quantity of blood pro— portioned 130 Of Fractures Chap. XXXIX. portioned to the strength of the patient. If any ine— quality is discovered, by one end of the rib having risen above the other, we ought to endeavour by mod— erate equal pressure to replace it; and to prevent it from rising, a broad leather belt should be applied, and drawn as tight as the patient can easily bear it. When a belt of this kind is properly lined, either with quilted cotton or flannel, it sits with ease even when tolerably tight; and it ought to be continued for sev— eral weeks after the accident. Even where the symptoms have at first been severe, they will commonly subside upon the patient being freely blooded and kept quiet and on a low regimen: But where the oppressed breathing is kept up by air escaping from a puncture in the surface of the lungs, or by blood discharged from a ruptured intercostal ar— tery into the cavity of the chest, or when the pain is prevented from subsiding by the fractured rib being forced in upon the pleura; it becomes necessary to make an opening with a scalpel. Where a portion of rib is merely forced inwards, this should be done di— rectly upon the injured part; and on the rib being laid bare, we ought to elevate that part of it that is de— pressed, either with the fingers, forceps, or a spatula. When the symptoms proceed from air or blood col— lected in the cavity of the chest, an opening should be made to discharge them, in the manner pointed out in Chap. XXII. Sections III. and V. Fractures of the ribs should in every instance be treated with attention; but particularly where there is any tendency to phthisis, pulmonalis, when the ir— ritation produced by a fractured rib is very apt to do mischief. SECTION 131 Sect. VI. of the Sternum. SECTION VI. Of Fractures of the Sternum. THE support which the sternum receives from the ribs, and the degree of elasticity it possesses, ren— der it less liable than it otherwise would be to injury from external violence. It necessarily suffers, how— ever, from the application of any great degree of force. In some cases, it is fractured without being displaced: in others, it is not only broke, but at the same time beat in upon the pleura. A simple fracture of the sternum is to be considered in the same light with similar injuries done to the ribs, and ought to be treated in the same manner. But more danger is apt to ensue from any portion of this bone being forced into the chest from the vicinity of the large blood vessels of the breast, while the symp— toms with which it is accompanied are nearly the same; namely, pain in the injured part, cough, oppressed breathing, a quick and sometimes an oppressed pulse. In slight affections of this kind, we are told, that the depressed portion of bone may be raised by desiring the patient to make deep inspirations; by placing a barrel or a drum under his back, and keeping him ly— ing for some time in this posture; and by the appli— cation of adhesive plaster over the corresponding teg— uments; when, by elevating the soft parts, the bone beneath it is said, may frequently be raised along with them. It is not to be supposed, however, that any advan— tage is to be derived from any of these methods; on the contrary, it is more likely that they may do harm: nor would they have been mentioned here, had it not been with a view to caution the younger part of the profession, who, finding these modes of practice rec— ommended by all the older writers, might have been induced to adopt them without weighing their conse— quences. 132 Of Fractures of the Chap. XXXIX. quences. As the skin is no where very intimately connected with the bone beneath, it is not probable that any portion of depressed bone will ever be raised by the external application of adhesive plasters; and we may do harm by trusting to a mode of treatment that is to prove ineffectual. But the practice of ad— vising deep inspirations, and of laying the patient up— on his back over a large barrel or any other convex body, must often do mischief, by pushing the Lungs with more force against the depressed portion of bone than they otherwise would be. When it therefore happens that the pain, cough, oppressed breathing, and other symptoms, do not yield to blood letting and other parts of an antiphlogistic course, some other method of cure should be attempt— ed. An incision should be made upon the injured part, of a sufficient length to admit of a free examin— ation of the bone; when the depressed piece may be raised either with a common scalpel or a levator, if there be an opening that will admit an instrument; or when this is not practicable, an opening may be made for this purpose with the trepan, in the manner we have advised in similar injuries done to the skull in Chap. XXVI. I know that this will be considered by many as haz— ardous; but when a patient is in danger either from a portion of a depressed rib or of the sternum, and which cannot otherwise be raised, I would never hes— itate in advising it. If the operation be performed with caution, the bone may be raised with safety; and this being done, the sore must be treated in the usual way. SECTION 133 Sect. VII. Vertebræ, Os Sacrum, &c. SECTION VII. Of Fractures of the Vertebrœ, Os Sacrum, Coccyx, and Ossa Innominata. FRACTURES of the vertebræ may be produced by falls and blows; but they are more frequently the consequences of gunshot wounds than of any oth— er cause. Injuries of this kind, for the most part terminate fatally: for although many have survived such frac— tures for a considerable time, yet they generally linger and die of the consequences. The spinous and ob— lique processes of the vertebræ may indeed be broke without immediate danger; but very commonly the force which effects this, gives such a shock to the spinal marrow, as at last terminates in the death of the pa— tient: and a fracture extending through the body of a vertebra will probably, in every instance, prove fatal. We judge that the vertebræ are fractured, by the feel, by the violence of the injury, and the severity of the pain, and by the parts lying beneath the injured vertebra becoming paralytic when the spinal marrow is affected. When any of the external parts of the vertebræ are loose, we may in general replace them with our fingers; and confining the patient as much as possible to one posture, we may, by means of the napkin and scapulary bandage, and proper compresses, retain them in their situation till they unite with the rest of the bone. Where this cannot be done, a patient is in general left to his fate, as it is not supposed that we can with propriety expose any of the vertebræ for the purpose of replacing such parts of them as may be deranged: But wherever we find that the spinal marrow is com— pressed, 134 Of Fractures Chap. XXXIX. pressed, as the immediate effect of an injury done to one or more of the vertebræ; and where there is rea— son to think that the compression is produced by a fracture and depression of a portion of bone, as we know from experience that every such case will ter— minate fatally if the cause of compression be not re— moved, it would surely be better to endeavour to raise it than to leave the patient under an absolute certain— ty of suffering. By laying the injured parts freely open, we may be enabled to raise that portion of bone by which the compression is produced; while it is not possible that the situation of the patient can be render— ed more hazardous, even allowing the attempt to prove abortive. In a case where symptoms of paralysis were induced by a musket bullet lodged in the substance of one of the vertebræ, a complete recovery was obtained by extracting the bullet. A portion of depressed bone might in many instances be removed with equal ease and safety; and we have reason to suppose that simi— lar effects would often result from it. In fractures of the os sacrum, the method of treat— ment must be nearly similar to what we have just ad— vised in fractures of the vertebræ; only, where the injury is seated near to the under part of the bone, as well as in fractures of the coccyx, when any part of it is pressed inward, we may in some cases be able to re— place it, by pushing it out with the finger of one hand introduced into the anus, while with the other we co— operate externally. Where any of the ossa innominata are broke, if the injury be deeply seated, the patient ought to be placed in that posture in which he finds himself easiest, and confined as much as possible to that situation till it is probable the bones may be united. Blood letting, and an attentive regimen, suited to his strength and the violence of the symptoms, may prevent the inflam— mation which usually supervernes, from becoming con— siderable. In 135 Sect. VIII. of the Scapula In more external fractures of these bones, we have it often in our power to replace such parts of them as have been forced out of their natural situation; and by a proper application of bandages, we may also be able to retain them till a cure is completed. I have had different instances of a considerable portion of the ileum being fractured and separated from the rest, and of a cure being easily accomplished, by replacing the parts that were separated, and retaining them with a broad roller passed several times round the pelvis and upper part of the thigh. With respect to the application of such a bandage, no general directions can be given: It must depend entirely on the judgment of the practitioner; who will apply it in the way which he thinks will make it an— swer the purpose of fixing the bones in the most effect— ual manner. SECTION VIII. Of Fractures of the Scapula. THE scapula, from its situation, is not so liable to be fractured as other bones; but every practi— tioner must have met with instances of this accident. It may be fractured either in the thin plate, of which it is mostly formed; or in one or other of its processes. As the motion of the arm depends much on a sound and entire state of this bone, and as fractures of any part of it are difficult to cure, they very commonly produce a stiff unwieldy state of the corresponding arm, which usually continues during the life of the pa— tient. We discover that the scapula is fractured, by the seat of the pain; by the violence of the injury; by the feeling on pressing the injured parts; and by stiffness and immobility in the corresponding arm. We are told, that fractures of the scapula are apt to be accom— panied 136 Of Fractures Chap. XXXIX. panied with emphysematous swellings. These can only appear when the lungs are wounded by a splinter of the scapula, or of a fractured rib being forced into their substance. When this takes place, air will no doubt escape; and if it passes into the cellular sub— stance, emphysematous swellings will necessarily occur. In the treatment of fractures of the scapula, our first object is to replace the bones with as much exact— ness as possible; and in doing so, we will be much as— sisted by relaxing all the muscles connected with the injured part. By raising the head and shoulders we relax the muscles of the back; and if, at the same time, the humerus be supported, the deltoid muscle will be so much relaxed, that any fractured portion of the sca— pula may be easily replaced. There is more difficul— ty, however, in retaining the bones during the cure, than in replacing them: for the detached portion be— ing in general small, it is often impossible to retain it with a bandage. A proper application of a long roller is perhaps the only method by which it can be done; and in using this bandage, we should still take care to have the head and shoulders supported, and the arm suspended, so as to keep all the muscles of the injured part as much relaxed as possible. As fractures in every part are apt to excite inflam— mation, we have elsewhere observed, that this symp— tom should at all times be guarded against. It is no where, however, more necessary to be attentive to this than in fractures of the scapula, where inflammation is more apt to proceed to an alarming height than in any other part. Blood letting should therefore be freely practised; particularly local blood letting with leeches, or cupping and scarifying; which we have often had occasion to recommend as perhaps the most effectual means of removing inflammation wherever it may be seated. SECTION 137 Sect. IX. of the Humerus. SECTION IX. Of Fractures of the Humerus. AS the humerus is not thickly covered with soft parts, any fractures to which it is liable are in general easily discovered. When they run obliquely, they become often evident to the sight; as in that case the bones are apt to overlay one another: but we have seldom any difficulty in discovering even transverse fractures; which we do by the seat of the pain, the violence of the injury, inability to move the injured arm, and a grating noise being heard on handling the parts affected. In reducing fractures of this bone, we do not find that much extension is necessary; but in order to ac— complish it with ease, the muscles of the arm should be put as much as possible into a state of relaxation; which is done by bending the elbow moderately, at the same time that the limb is raised nearly to a hori— zontal direction, and not carried so far forward as to put the latissimus dorsi, inserted into the back part of it, on the stretch, or too far back to stretch the pectoral muscle. The patient being properly placed, and the arm put into this situation, the surgeon will in general be able to replace the bones without any assistance: But when extension is necessary, it may be applied by one assist— ant grasping the arm between the fracture and the joint of the shoulder, and another above the joint of the elbow. In this manner the fractured bones are to be exact— ly replaced; and with a view to secure them in this situation, one splint, of a proper degree of firmness, such as are represented in Plate LXX. figs. 5. and 6. should be laid along the whole outside of the arm, and another along the inside of it, each of them covered Vol. IV. K with 138 Of Fractures of the Chap. XXXIX. with soft thin flannel, to prevent them from galling the arm; and while these are secured by one assistant, and the fore arm supported by another, a flannel roller should be applied over the whole, of such tightness as to support the ends of the fractured bone without in— terrupting the circulation of the limb. The fore arm should be supported in a sling, such as is represented in Plate LXXXI. fig. 1. and the pa— tient may be either put to bed or allowed to sit, as is most agreeable to himself. It may not, however, be improper to remark, that it answers better to have the arm in a hanging position than laid horizontally upon a pillow; particularly in oblique fractures of this bone, where the weight of the limb has a considerable effect in preventing the ends of the bone from over— lapping each other. Even in bed, therefore, where there is any danger of this taking place, the patient should be placed in such a manner, that his arm may hang instead of being laid in the usual posture. In transverse fractures this precaution is not altogether so necessary, as the ends of the bone, if they be once properly replaced, serve effectually to support each other. But even in these, it is the best practice to support the fore arm in such a manner that it may have, some effect in pulling the under part of the humerus gently downwards. If no urgent symptom occurs, such as much pain and swelling of the arm, the bandage should not be moved for several days: But about the seventh or eighth day, it is proper, in every fracture, to remove all the coverings, in order to see whether the bone be perfectly in its place or not; for at this period any accidental displacement may be easily put right, and a cautious inspection may be made with the utmost safety. We have advised a roller to be employed for frac— tures of this bone; and perhaps it is the only instance in fractures of the large bones of the extremities in which it should be preferred to the many tailed band— age. 139 Sect. X. Bones of the Fore Arm. age. But whoever has used them both will find, that in simple fractures of the humerus, the roller is not only more easily applied than the other, but that it answers the purpose better. Fractures of the humerus commonly heal more kindly than similar injuries of any other part; and when properly managed, they seldom leave either lameness or distortion of the arm. When no inter— ruption occurs to the cure, either from severe pain, swelling, or inflammation, or from accident or mis— management, the bone will in general be firmly united in less than a month; but the limb should not be us— ed with much freedom till the sixth or seventh week. SECTION X. Of Fractures of the Bones of the Fore Arm. THE bones composing the fore arm are two in number, the radius and ulna. From their be— ing much exposed to accidents, they are very liable to fractures. When both bones are broke, the nature and seat of the injury are for the most part easily dis— covered; but when one bone only is fractured, espec— ially if it be the radius or smaller bone, as the firmness of the other prevents it from being displaced, it re— quires some attention to discover it. The seat of the pain points out the injured part; and when either of the bones is fractured, a grating noise will be heard if the surgeon grasps the limb firmly above and below this part, and endeavours to move it in different di— rections. In this examination, it is of much importance to distinguish the direction of the fracture with as much exactness as possible, particularly if it be near to the wrist; for upon this the chance of our making a pro— per cure in a great measure depends: and in this sit— K2 uation, 140 Of Fractures of the Chap. XXXIX. uation, whether both bones or only one of them be broke, the utmost nicety is required to prevent a stiff uneasy state of the arm from continuing long after the fracture is healed. It is not unfrequent, indeed, to hear patients complain of this inconvenience after these fractures, during the remainder of their lives; and I think it is more apt to happen when the radius is broke by itself than when the ulna only is fractured, owing to this bone having a rotatory motion independent of the other, by which it is with more difficulty kept in its situation. And as there is nothing for which prac— titioners are more apt to be blamed than for those in— conveniencies which patients suffer after the cure of fractures, we ought in every case of this kind, to treat it with the utmost attention. After discovering the seat of the injury, if any part of either of the bones be displaced, we ought, as soon as it can be done with propriety, to put it right. The patient being properly seated, and the muscles of the arm relaxed by bending the joints of the wrist and el— bow, the limb should be extended to such a degree, by one assistant grasping it above the fracture, and another beneath it, as is just sufficient to allow the surgeon to replace the bones with exactness. This being done, one of the splints represented in Plate LXX. fig. 3. 4. or 5. covered with soft flannel, and of a length to reach from the elbow to the tops of the fingers, and of such a breadth as to incase rather more than one half of the arm and hand, should be placed along the ulna. Another splint not quite so broad must be placed along the course of the radius; when both may be secured either with a flannel roller or a twelve tailed bandage, of such a degree of tightness as to prevent the bones from slipping out of their place, but without impeding the circulation, or giving the patient any uneasiness. The last mention— ed bandage answers the purpose extremely well; but the roller may be used in all simple fractures of these bones without any impropriety. In PLATE LXX  141 Sect. X. Bones of the Fore Arm. In applying the splints, the palm of the hand should be turned towards the breast, as being not only the most convenient posture in which the arm can hang while in a sling, but as being the best in which it can at all times be placed, even when the patient is in bed: for the palm of the hand can neither be turned up— wards nor downwards; that is, it can neither be put into a prone nor a supine posture, without giving that rotatory motion to the radius which we have men— tioned, and which tends more than any other to dis— place any part of this bone that is fractured. It ought therefore to be carefully guarded against; and I know of no method by which it can be done with such cer— tainty as securing the arm with splints in the way we have pointed out. It must now be hung in the sling represented in Plate LXXXI. fig. 1. and allowed to remain in the leather case during the night, or in any small box of a similar construction, and of a size just sufficient to receive the arm when placed upon its side, but without admitting of its turning either one way or another. In speaking of the splints, I have advised them to be of a sufficient length for stretching along the whole course of the arm from the elbow to the top of the fingers. The under one ought more especially to be of this length: for the arm not only rests with move ease and equality upon a long splint, but it serves to cover the fingers, by which they are prevented more effectually than in any other manner from moving; a circumstance of much importance in all fractures of the fore arm: for when a free motion of the fingers is permitted, it not only tends to keep up inflammation and pain, but is often the cause of the bones being a— gain displaced, when otherwise they might have been kept in contact. A partial dislocation of the bones forming the joint of the wrist, is not an unfrequent concomitant of a fracture of the radius; by which the risk of a stiff joint, or of a painful permanent swelling of the arm. K3 becomes 142 Of Fractures of the Chap. XXXIX. becomes considerable. In such circumstances, it is therefore always proper to inform the patient of his danger: for even under the best management, a dislo— cation of the wrist, and a fracture of the contiguous bone, are apt to be productive of this effect. For the method of reducing the dislocation, we must refer to the ensuing chapter; and we have already pointed out, in the first section of this chapter, the most effec— tual method with which we are acquainted, of pre— venting and removing inflammation; which we have there shewn to be the most frequent cause of that stiff immoveable state in which fractured limbs are often left. The olecranon, or upper end of the ulna, is some— times fractured without any injury being done to the rest of the bone; this part of the bone being particu— larly apt to suffer from falls and bruises upon the el— bow. In this case, in order to keep the fractured parts in contact, the fore arm must be extended; And with a view to preserve the arm steadily in this situation, a long splint should be laid along the sore part of it, from the middle of the humerus to the tops of the fingers; and this being properly secured with a roller, the arm should be allowed to hang by the patient's side, to which it should be fixed by one or two straps. It is proper, however, to remark, that the arm should not be kept long in this situation, otherwise a stiffness of the elbow joint will very probably happen. With a view to prevent this, the bandage and splint should be removed about the eighth or tenth day; when the fore arm being for some time moved slowly backward and forward, and the joint rubbed with any emollient oil, the arm may be again secured as before. A cau— tious and daily repetition of this practice, while it pre— vents the occurrence of a stiff joint, does not retard the cure. SECTION 143 Sect. XI. Bones of the Wrist, Hands, &c. SECTION XI. Of Fractures of the Bones of the Wrist, Hands, and Fingers. THE bones of the wrist being small, round, and somewhat moveable, readily yield to any ordi— nary force that may be applied to them. On this ac— count, they are seldom fractured except by shot from fire arms, or a heavy weight passing over them. The bones here are so small that they do not readi— ly reunite. For this reason, as well as from the con— tiguity of tendons and ligaments, which gives rise to high degrees of inflammation, a complete anchylosis, or great stiffness of the joint, are common conse— quences of fracture of the bones of the wrist. After replacing the bones, nothing proves such an effectual preventative of these effects as copious blood letting from the injured parts by means of leeches, in propor— tion to the violence of the symptoms and the strength of the patient: and this being done, the arm and hand should be supported by a splint put beneath them, with another above, in the manner we advised in the last section: and both should be secured by a similar bandage and sling. In fractures of the metacarpal bones, after replacing them with as much exactness as possible, a firm splint, either of timber or strong pasteboard, should be appli— ed over the whole palms of the hand and inside of the arm, from the ends of the fingers to the joint of the elbow, in order to keep the hand as much extend— ed as possible, as the flexor muscles of the fingers can— not be bent in any degree without altering the posi— tion of these bones; and in order to guard against this with as much certainty as possible, the long splints K4 mentioned 144 Of Fractures of the Chap. XXXIX. mentioned above, with a similar bandage, may be ap— plied over the whole. Fractures of the fingers are frequent; but when properly treated, the bones readily unite, and the fin— gers become equally useful as before. The best splint for a fractured finger is a piece of firm pasteboard exactly fitted to it, and softened in water till it is easily moulded into the form of the part. The finger being stretched out and the bone replaced, this splint should be applied along the whole length of it, and secured with a narrow roller: And in order to prevent the injured parts from being dis— turbed, a large splint, either of the same kind of paste— board, or of a thin piece of wood glued upon leather, as is represented in Plate LXX. fig. 3, 4, 5, or 6, should be applied over the inside of the hand; and the fingers being stretched upon it, another roller should be put over the whole, to secure the fingers and hand, so as to prevent them from having any kind of motion. With a view to preserve the motion of the joints of the fingers, the bandage and splints should be removed about the tenth or twelfth day; when the several joints of the finger being cautiously bended and ex— tended different times, the whole should be tied up as before: And this being repeated daily, the splints may with safety be removed at the end of the third week; when, by this piece of attention, the motion of the finger will be found complete, unless more than one bone has been broke, and at the same time so much splintered as to render this precaution im— practicable. SECTION  PLATE LXXI. 145 Sect. XII. Femur or Thigh Bone. SECTION XII. Of Fractures of the Femur or Thigh Bone. EVERY, part of the femur is exposed to fractures; but it is more frequently broke near to the mid— dle than in any other part of it; and next to this, that part of it termed the Neck of the Femur is most apt to suffer. Fractures of all the under part of the femur are for the most part easily distinguished, by the usual grat— ing noise of the ends of the bone on their being forci— bly rubbed together; by the limb being much short— ened if the fracture be oblique, or if the ends of the bone have been displaced in cases of transverse frac— tures; by much pain and tension over the injured part; and by the limb being rendered unable to sus— tain the body. It is often difficult, however, to distinguish fractures of the neck of the femur from dislocations of this bone. A due attention to the following circumstances will enable us in most instances to avoid mistakes of this kind, which are always attended with serious conse— quences. In a great proportion of cases, perhaps in nineteen of twenty, the head of the femur when dislocated is pushed inwards and downwards, owing to the brim of the acetabulum being not so deep in this part as in others, as well as to the muscles at this particular part being not so strong; while perhaps in an equal num— ber of fractures in the neck of the femur, the bone is pushed upwards, owing to accidents of this kind hap— pening most frequently from falls upon the knees, or perhaps upon the feet when the legs are stretched out, by which a very considerable force is necessarily brought to act against the neck of the thigh bone, where it is least able to give resistance. In all such fractures, 146 Of Fractures of the Chap. XXXIX. fractures, the leg is much shortened, often to the ex— tent of several inches. The trochanter is accordingly found to be much higher than the trochanter of the other thigh; and the knee and points of the toes are turned inwards. On the other hand, in those disloca— tions of the thigh joint which we have mentioned, the leg is considerably lengthened, the head of the bone and the trochanter are discovered near to the groin, with a corresponding vacancy where the trochanter ought to be, and the toes are turned out. In every fracture a grating noise is discovered on the ends of the bone being rubbed against each other; and in all fractures of the neck of the femur, it is ob— served that the leg and thigh may be turned with much more ease from one side to another, that is, the knee and foot may be moved with more ease outwards or inwards, than when the head of the bone is dislo— cated. We may likewise remark, that in dislocations the tumor formed by the head of the bone and tro— chanter together, must be always greater than in frac— tures, where the tumor is formed by the trochanter alone. In no part of forgery are we more apt to be disap— pointed than in the treatment of fractures of the thigh, particularly where the neck of the bone is broke. This proceeds from various causes; all of which should be kept in view in forming a prognosis of the probable event of such cases. 1. The thigh bone is so thickly covered with mus— cles and other soft parts, that it is often with difficulty we can discover the direction in which a fracture runs. 2. We must often, therefore, be uncertain whether the bones be rightly replaced or not; for where the course of a fracture cannot be ascertained with ex— actness, we can never be sure of this being precisely effected. 3. But even where we are able to accomplish the reduction of the fracture with the utmost nicety, we know  PLATE LXXII. 147 Sect. XII. Femur or Thigh Bone. know from daily experience that it is extremely diffi— cult to retain the bones in their situation with such exactness as to prevent deformity. For when a frac— ture is either seated in the neck of the bone, or runs obliquely in any other part of it, it is so difficult to prevent the bones from being displaced merely by the ordinary action of the muscles, that the limb is for the most part rendered considerably shorter than the oth— er; for in all such cases, if the different parts of the bone cannot be so placed and retained as to support each other, the under part of it will very certainly be drawn upwards. In fractures of the thigh too, other causes concur to render it difficult to retain the bones in their situation. They are more affected than fractures of other bones by every unusual exertion of the body; particularly by sneezing, coughing, and laughing; nor can the posture of the body be in any way altered without af— fecting the thigh. In the reduction of a fracture of this bone, much difficulty was formerly experienced from the position in which the limb was put during the operation. The body being placed either upon the floor, on a table, or in a bed, the limb was then extended, by which all the muscles connected with it were put upon the stretch; and as the extension was continued till the bones were replaced, when this was accomplished with difficulty, the muscles were often either violently tore asunder, or so much weakened as not to be afterwards fit for use; for some of the muscles of the thigh being among the strongest in the body, a very considerable force was required to overcome the resistance they afforded. But if the muscles of the limb are relaxed, by making the thigh form an obtuse angle with the body, while the joint of the knee is moderately bent, it is surpris— ing with what ease we may, in most cases, place the bones in their natural situation. The cause of resist— ance is thus almost entirely removed; so that if there be not much tension or swelling, the ends of the bone may 148 Of Fractures of the Chap. XXXIX. may in general be easily brought into contact, by one assistant securing the upper end of it, while the lower part of it is supported and gently drawn down by a— nother, the surgeon in the mean time being employed in putting the fractured parts together with as much exactness as possible. There is most difficulty in reducing fractures of the neck of the bone; for the muscles, in that situation, being exceedingly strong, and running in various di— rections, they cannot be relaxed so completely as those of other parts of the limb. But even here we may, for the most part, succeed in the manner we have mentioned, the body being secured by one assistant, while moderate extension is made by another at the lower part of the thigh. It is proper, however, that practitioners be provided with instruments for more powerful extension when the method now recommend— ed fails. Different instruments are delineated for this purpose in Plates LXXVI.LXXVII. and LXXVIII. but these should never be employed till every attempt in the usual manner proves abortive. It is not, however, in replacing the bones, but in re— taining them when replaced, that we encounter the greatest difficulty. In transverse fractures of this bone the practice is very easy. After the fractured ends of it are brought into contact, they would for the most part support each other with sufficient firmness even without any bandage, if the patient could be con— fined to a proper posture: But to prevent any risk from sudden exertions, the limb should be as firmly secured with splints and a proper bandage, as is con— sistent with a free circulation through the injured parts. For this purpose two splints are represented in Plate LXX. fig. 4. and 6. One to reach from the top of the hip joint to a little below the knee, of a breadth sufficient to cover at least one half of the thigh; the other to reach from the groin to a little below the knee, and in breadth covering about a third part of the 149 Sect. XII. Femur or Thigh Bone. the thigh. Of these, covered with soft flannel, the longest laid upon a twelve tailed flannel bandage, is to be placed upon a thin pillow nearly as long as the thigh. The patient being placed in a bed made as tight as possible with a firm hair mattress, so that it may not sink or yield, his knee being moderately bent, and the bones accurately set, the surgeon must order the pillow, with the bandage and splint above it, to be placed so as the splint may reach from the hip joint along the outside of the thigh to the knee. That this posture of the leg and thigh may be easily preserved, the patient should not be laid directly upon his back, but turned somewhat towards the affected side; and the knee and leg should be raised rather higher than the body. The limb being thus placed in the posture in which it is to be kept, the short splint mentioned above must be laid along the inside of the thigh from the groin to the knee, when the bandage previously placed beneath the other splint must be applied, of such a tightness as to make an equal moderate pressure over the whole thigh. As the cure would be much interrupted, and might at last be very incomplete, were any part of the dress— ings to give way, it is a proper precaution perhaps in every case, to insert a long splint of firm timber be— neath the middle of the pillow, and to secure it in its situation by two broad straps firmly buckled on the upper part of the limb. To obviate the motion of the limb, in consequence of involuntary startings, the pillow should be fixed to the bed by straps; and to prevent injury or uneasi— ness from the weight of the bed clothes, two or three hoops fixed in a proper frame should be placed over the thigh. When no untoward symptom occurs, the limb might be left in this situation till the cure was completed; but left the bones should by accident be displaced, and especially if the limb should swell and become painful, the 150 Of Fractures Chap. XXXIX. the bandage should be undone, and the upper splint removed, in order to admit of the parts being exam— ined with accuracy. The twelve or eighteen tailed bandage admits of this being done without the limb being disturbed. In the event of pain, swelling, or inflammation, it may be proper, before renewing the dressings, to apply leeches and other remedies to the parts affected; but when none of these take place, and when the bones are found in their situation, the splint should be immediately replaced and secured with the bandage as before. In healthy adults, when the cure proceeds without interruption, it will in general be completed in the course of six weeks; but violent exertion of every kind should be avoided till the eighth or tenth week has passed over. We have advised the limb to be placed in such a posture as tends most effectually to relax all the mus— cles connected with it. But although this may be highly proper at first; yet there is no necessity for persevering in it during the whole course of the cure. On the contrary, it proves often very prejudicial, as the limb, if it be kept invariably in one posture for six or eight weeks, as is too frequently practised, is very apt to become stiff and unwieldy, so as to be after— wards productive of much uneasiness and distress. At the end of a fortnight, or even in less time than this, the patient may be allowed to turn more towards his back, and the joint of the knee may be somewhat stretched out. If this be done with caution, it may be repeated daily; that is, the leg may be alternately stretched out and bent; by which the motion of the whole limb will be much more free and entire at the end of the cure than we usually find it to be. In a great proportion of cases where cures are pra— ticable, the mode of treatment we have here pointed out will prove successful. It will never fail in trans— verse fractures, if all the parts of it meet with proper attention: but although it will often succeed where the bone  PLATE LXXIII. 151 Sect. XII. Femur or Thigh Bone. bone is broke very obliquely; yet it must be confess— ed, that cases of this kind sometimes occur in which it fails entirely, the ends of the bone flipping past each other, and the limb becoming much shorter than it ought to be, notwithstanding all our efforts to pre— vent it. Indeed, an effectual method of securing very oblique fractures in any of the bones of the extremities, and especially of the thigh bone, is perhaps one of the greatest desiderata in modern surgery. In all ages, the difficulty attending this has confessedly been very great; and frequent lameness from shortened limbs proceeding from this cause, evidently shows that we are still deficient in this branch of practice. The treatment of fractures being one of the most important branches of surgery; to prevent lameness, one of our first objects, much ingenuity has been shown in the invention of some method by which this purpose might be answered. It has been proposed, and by several practitioners has been attempted, in fractures of the thigh, to secure the patient's body, as one fixed point, by means of different bandages, to the upper part of the bed, and by an axis in peritro— chio at the foot of the bed, to make such a degree of extension as might be fully equal to the purpose of re— taining the fractured bones. But all who are ac— quainted with the fretful irritable state in which pa— tients with fractures commonly are, and with the pain which tight bandages always excite, will know, that al— though proposals of this kind may appear to advantage in theoretical disquisitions, they will never probably be of real utility. And accordingly none of them have ev— er been admitted into general practice. The invention of the late Mr. Gooch of Norwich, is the one which promises to be of the greatest utility in oblique fractures of the thigh. This instrument is de— lineated in Plate LXXII. and in an improved state by Dr. Aitken in Plate LXXIII. A broad 152 Of Fractures Chap. XXXIX. A broad firm strap of leather, lined with quilter cotton or soft flannel, is placed on the upper part of the limb, and secured by buckles of such a tightness as the patient can easily support. A similar strap is put round the under part of the thigh, and made to rest chiefly on the condyles of the femur. Two or three steel splints, connected with the straps, pass from one to the other in such a manner, that by means of them the straps can be forced asunder, and retained with the greatest certainty at any distance during the cure. For a more particular account of this apparatus, the explanation of the plates may be consulted. In some cases, however, the pain, swelling, and in— flammation, are so considerable, as to preclude the ap— plication of the most simple bandage. After endeav— ouring to relieve the symptoms by local blood letting and other remedies, Mr. Gooch's method, or Dr. Ait— ken's, may be adopted, if practicable; if not, the cure must be conducted in the usual way, with the hazard of the ends of the bone passing one another, and of the limb being shortened. But in this event, under the circumstances we have just mentioned, although the patient may regret his misfortune, he cannot with pro— priety or justice blame the surgeon. SECTION XIII. Of Fractures of the Patella. THE patella or knee pan is liable to fractures from falls and bruises upon the knee. Transverse fractures are most frequent; but we meet with in— stances of longitudinal fractures in this bone, and in some cases it is broke into three or four different pieces. In fractures of the patella, we are in general desir— ed to make a very guarded prognosis; as by most wri— ters upon this subject, it is said that they almost con— stantly 153 Sect. XIII. of the Patella. stantly terminate in a stiff joint, owing, as is supposed, to the callus forming in too great quantity, and to its finding access to the cavity of the joint. I have not found, however, that fractures of this bone are so apt to produce stiff joints as we are led to expect. In different instances which I have had of them, scarcely any degree of stiffness remained in any of them after three or four months: and when any per— manent affection of this kind does take place, I can— not imagine that it proceeds from superabundancy of callus, as the quantity which such a small bone will afford, must be extremely trifling. It rather seems to originate from the inflammation with which these fractures are usually accompanied affecting the inter— nal parts of the joint; or from the knee being kept too long in an extended immoveable posture. From a dread of separating the fractured parts of the bone before they are firmly united, the leg is usually preserved in an extended posture for six, eight, or perhaps ten weeks; a much longer period than is necessary, and by which alone even the soundest joint would be apt to become stiff and immoveable. In the treatment of fractures of this bone, in what— ever direction they may run, the leg should be extend— ed, in order to relax the only muscles with which it is connected, those forming the ligament inserted into it. With this view, the patient should be placed upon a bed rendered so firm that it will not yield during the course of his confinement; a precaution particularly necessary in all fractures of the lower extremities, where long confinement to bed is almost always neces— sary, and where unequal sinking of the body is often the source of much uneasiness to the patient, and may be the cause of a separation of the newly replaced bones. This being done, a long firm splint of timber thick— ly covered with soft wool, or with several plies of fine flannel, should then be placed beneath the thigh and leg, from the upper part of the one to the extremity of L the 154 Of Fractures Chap. XXXIX. the other; and to this the limb should be secured by two straps between the ankle and knee, and one or two between the knee and top of the thigh. This will ef— fectually preserve the leg in a state of extension; and it does it in the easiest manner when the splint is suf— ficiently broad and properly covered in the way we have mentioned. The different parts of the fractured bone are now to be brought as nearly together as possible with the hand; but no bandage is yet to be applied to them Our great object at first is to prevent inflammation; for which purpose as much blood should be taken from the joint by means of leeches as the patient can properly bear; and for two or three days, or so long as much pain, swelling, or tension continue, saturnine and other astringent applications should be used for removing them. This being accomplished, we again examine the state of the bone; and if the different parts of it be all as nearly in contact as is necessary, they ought not to be disturbed. The joint may be covered with a large pledgit of Goulard's cerate, by which it will be kept soft and easy; and a hooped frame should be employ— ed to support the bed clothes. But if the different parts of the bone, instead of be— ing nearly in contact, are found separated to any con— siderable distance, it becomes necessary, in the first place, to replace them, and afterwards to retain them with bandages as far as this can with propriety be done. In a longitudinal fracture of the patella, this is easi— ly accomplished; for in this direction we meet with little resistance in replacing them, and they are easily retained with very moderate pressure, either with the common uniting bandage, or with slips of leather spread with glue or adhesive plaster. But in trans— verse fractures of this bone, as that portion of it con— nected with the extensor muscles of the thigh is apt to be drawn forcibly upwards, we cannot always replace it; 155 Sect. XIII. of the Patella. it; or if this is practicable, it cannot always be retain— ed in contact with the inferior portion, but by a force that would excite pain, swelling and inflammation. It is a fortunate circumstance, however, that it is not absolutely necessary to a complete cure, that the different pieces of bone be kept in exact contact. Where it can be easily done, it ought always to be put in practice; but I know from the result of several cas— es where this was impracticable, that a cure may be obtained, and the joint be equally firm and useful as it was before, even although the separated portions of bone cannot be brought within an inch of each other. We should not therefore be very anxious about this; and instead of using much force for the purpose of drawing the bones into close contact, no more should be employed than the patient can bear with perfect ease. Various bandages have been invented for drawing the divided parts of a fractured knee pan together; but all of them have been formed upon erroneous princi— ples. They are made to press equally upon the up— per and under portion of the bone: whereas the least reflection on the anatomical structure of the parts must render it obvious, that no advantage can be de— rived from much pressure on the inferior part of the bone, which always remains in its natural situation; and therefore, that any force we employ should be al— most entirely applied to that part of it connected with the ligament of the extensor muscles; by the action of which, particularly of the rectus muscle, this portion of the bone is drawn upwards. In plate LXXV. a bandage is represented; from which, while it sits easily upon the parts to which it is applied, every advantage which can be expected from this kind of assistance may be derived. It consists of two circular straps, A B, of firm leather, lined with soft flannel, with two perpendicular straps, C E, that pass from one to the other, and a semilunar firm compress G; with another strap of a greater length D, reaching L2 from 156 Of Fractures of the Chap. XXXIX. from the point of the toes to the buckle on the upper circular strap round the thigh, as is more particularly represented in fig. 3. of the same Plate. The leg being extended and elevated to a proper height for relaxing the extensor muscles of the thigh, the upper edge of the under circular strap A should be applied to the under part of the inferior portion of the bone, so as to support it in its natural situation without forcing it farther up. The strap must be then buckled to such a degree of tightness as the patient can easily bear it; and the upper half of the bone being pulled gently downwards, the semilunar compress F in fig. 3. must be applied round the upper end of it, when the upper circular strap must be also buckled. By means of the two perpendicular straps and buckles, we now make an easy gradual extension, which will not move the under circular strap if it be made sufficiently tight; but which will draw the other downwards if it be not made too tight, which we ought carefully to endeav— our to avoid. This will, in some degree, draw down the upper part of the bone, by gently pulling down the compress previously applied to the upper end of it; but it will be more effectually done by the strap D made sufficiently tight by fixing it to the correspond— ing buckle in the upper circular strap B. In this manner the different parts of the bone may be made to approach each other as far as this can be done with propriety; but for the reasons already men— tioned, the pressure should never be carried so far as to endanger the excitement of pain, inflammation, or swelling. The limb being secured in the manner we have mentioned, the bandages should not be removed till the twelfth or fourteenth day, if pain and inflamma— tion do not render a more early removal necessary. But about this period the joint should be exposed, when the limb may be moderately bent; and this be— ing cautiously repeated every second or third day, no interruption will be given to the cure, while the mo— tion 157 Sect. XIV. Bones of the Leg. tion of the joint will be effectually preserved; which it seldom or never is when this piece of attention is neglected. There is another injury to which the joint of the knee is liable; so similar in its effects to the one we have been considering, and in the mode of treatment, that I think it right to mention it here; namely, a separation, by external violence, of the ligament or tendon of the rectus muscle from the patella. The usual effect of a smart stroke, or a severe fall, upon the fore part of the knee, is a fracture of the patella: but where a person carrying a heavy burden upon his back, falls with his knee much bent, a rupture of the tendon is a more frequent consequence; at least I have met with three cases of this accident from this cause, in which the tendon, after separating from the bone, retracted to the distance of two or three inches. The treatment we have advised for a fracture of the patella proves equally successful here: Only it will be understood, that in this case no advantage can be ob— tained from pulling down the retracted tendon: for no part of the bone being connected with it, we cannot lay hold of it; so that we have to trust solely to the extended posture of the limb. But although the ten— don and bone cannot be brought close to each other, yet a cure may always be accomplished in the manner we have mentioned. SECTION XIV. Of Fractures of the Bones of the Leg. IN fractures of the leg, one bone only is often broke; but a fracture of both is more frequent. In this case the seat, as well as the direction of the fracture, are readily discovered. When one bone only is broke, these are discovered with more difficulty. This, how— ever, is of no great importance; for when one of the L3 bones 158 Of Fractures of the Chap. XXXIX. bones remains entire, it serves so effectually to support the other, that nothing is necessary for effecting a cure but confinement till the fractured bone be united, Fractures are more frequent near the joint of the ankle than in other parts. We find a great propor— tion of fractures of the fibula seated an inch or two a— bove the under extremity of this bone, this being the weakest part of it. In the management of a fractured leg, the same general principles apply which we advised in the treat— ment of a fractured thigh hone. In replacing the bones, the muscles of the limb should be as much re— laxed as possible; and we do it in the most effectual manner by bending the joint of the knee, and slightly extending the foot. When the leg is in this position, there is seldom much difficulty in putting the bones into their natural situations; and with no more ex— tension than can with great ease be given, by one assist— ant at the upper end of the limb, and another support— ing it at the ankle. This being done, and the patient placed in such a man— ner that the injured leg may with ease be laid upon its outside, with the knee bent, the splints, fig. 3, 5, or 6, Plate LXX. should be applied and retained with the twelve tailed bandage; the splint on the outside of the leg reaching from a little above the knee to beneath the ankle, with a view to prevent the motion of either of these joints, by which the bones are apt to be dis— placed. Whether the splints are of firm paste board, or such as are represented in Plate LXX. they would, for the most part, prove sufficient: but when the patient is ei— ther very restless, or troubled with spasmodic affections of the muscles of his leg, an additional splint of wood, shaped to the form of the leg, as is represented in fig.1. and 2. of the same plate, should be applied along the outside of it; and, if it be slightly excavated and filled with soft wool, it fits with perfect ease, while it pre— vents, with the utmost certainty, the ends of any of the bones PLATE LXXIV.  159 Sect. XIV. Bones of the Leg. bones from falling downwards. It is fixed with any degree of tightness by two straps and buckles. The leg, when dressed in this manner, has the appearance represented in Plate LXXIV. fig. 2. We have already observed, that after the dressings are applied, the leg should be laid upon its outside, with the knee bent, and the foot should be somewhat supported by a turn of a bandage, as represented in the figure just mentioned. The intention of this is to relax the muscles of the limb; by which the patient lies with more ease, while the bones are less liable to be displaced, than where the muscles are kept fully stretched out, as was almost the universal custom till very lately. But although it is proper to place the leg in such a posture as tends most effectually to relax all the mus— cles; yet the knee should not be more bent than is nec— essary for this purpose: for when the joint is much curved, it is almost equally irksome to the patient as when the leg is fully stretched out. The knee should not therefore be more bent, nor should the patient be laid more towards the affected side, than is just neces— sary for allowing the leg to be placed upon its outside. There are some patients, however, who, from long custom, as well as from other causes, cannot rest when lying on either side; and some practitioners think, that fractures of the leg mend better when the patient is laid upon his back, and the limb placed upon the gas— trocnemii muscles, with the toes upwards. In such cases the patient may be placed upon his back, and yet the curved position of the leg retained. This may be done in different ways; but the easiest method is, by raising the leg, and supporting it upon a frame, at a proper height above the level of the body. This ad— mits of the limb being placed in the posture we have mentioned, and with any necessary degree of curva— ture. Even where a fractured leg is placed on the outside, it is a pleasant variety to the patient to have the pos— L4 ture 160 Of Fractures of the Chap. XXXIX. ture altered: And by means of such a frame it can be easily done. A limb placed in this situation is represented in Plate LXXX. fig. 2. This variety of posture is even admissible in fractures of the thigh. The patient may from the first be placed with his leg curved in the man— ner here represented; or he may afterwards turn up— on his back, and the cure be completed while he re— mains in this posture, or he may alternately change from one to the other. The inconveniency usually complained of, from the leg resting upon the heel when it is stretched out, is avoided by an excavation or opening made in the bottom of the frame for re— ceiving the heel; or it may be done by allowing the heel to project over the edge of the frame al— together. No change of posture, however ought, to be permitted for the first ten or twelve days. A— bout this time the patient may be turned with caution upon his back, and the leg moved from one position to the other, care being taken to preserve it in the same degree of curvature. In fractures of the leg where the fibula only is in— jured, it is apt to pass unnoticed, and to be considered as a sprain of some of the muscles: But as very seri— ous consequences are apt to ensue from this mistake, it ought to be strictly guarded against. When treating of fractures of the clavicle, we had occasion to mention an appearance which, of itself, is extremely simple and of easy treatment; but which, from want of attention to the cause of it, has often been productive of much perplexity, both to patients and practitioners; I mean what is commonly termed the Rising End of a Bone: and as this frequently oc— curs in the leg, I think it proper to mention it here. When the bones of the leg are broke directly across, they sometimes serve to support each other so effectu— ally that neither of them are displaced. In such cir— cumstances no inequality appears in the limb, if it be not from some temporary swelling of the soft parts. But  PLATE LXXV. 161 Sect. XIV. Bones of the Leg. But when both bones are fractured, and at the same time displaced, the under extremity, or that portion connected with the foot, is almost always drawn to— wards the back part of the leg; by which an unequal prominency is produced by the projecting end of the upper portion of bone, or that part of it which still re— mains connected with the knee. It is this which in general is termed the Rising End of the Bone: and in reducing such fractures much pains has often been taken to force a bone in this situ— ation into contact with the others. It is obvious, however, that it is not the upper part of the bone which rises, but the inferior portion which falls, or is drawn out of its natural situation by the weight of the foot, as well as by the contraction of the muscles on the back part of the leg: Hence no advantage can be gained by any pressure made upon the su— perior part of the bone, while much harm may be done by it; as has often happened by bandages being put so tight upon it as to cut all the teguments with which it was covered; and thus forming a compound fracture of what otherwise would have remained of the most simple kind. The upper part of the bone never rises out of its natural situation; so that any inequality that occurs on the form and appearance of the leg, must be pro— duced in the manner we have mentioned, namely, by the inferior portion of the bones being drawn out of the situation which they ought to occupy: so that in our treatment of such affections, instead of forcing down the upper part of the bone, our sole object should be to raise the inferior part of it, so as to bring them into contact; and by supporting it in this situa— tion, to endeavour with as much certainty as possible to effect their reunion. In this manner a cure may be often accomplished, which would not in any other way have been practicable. SECTION 162 Of Fractures, &c. Chap. XXXIX. SECTION XV. Of Fractures of the Bones of the Foot and Toes. THE foot is very liable to injuries of this kind from a variety of causes; but particularly from its being more exposed to bruises than other parts of the body. Fractures of these bones are distinguished in the same manner with fractures of other parts. We judge that one or other of them may probably be fractured when the foot has been violently bruised; and we dis— cover with certainty that it is so by the grating of the fractured parts when they are rubbed against each other. Fractures of the bones of the foot and toes are to be managed nearly in the same manner with similar inju— ries of the hands and fingers. Any portion of bone that is displaced must be put into its natural situation with as much exactness as possible; and we endeavour to retain it by a splint fitted to the form of the part, supported with different turns of a roller. When any of the bones of the foot are fractured, a large splint should be applied over the sole, so as to support the whole of it; and no freedom should be permitted in the motion either of the foot or ankle during the cure; for nothing tends more to displace a fractured portion of bone than the action of contiguous muscles. SECTION 163 Sect. XVI. Of Compound Fractures, SECTION XVI. Of Compound Fractures. AS the term Compound Fracture has been appli— ed to injuries of different kinds, I think it right to define with precision the meaning I wish to affix to it. A fracture of a bone communicating with an ex— ternal opening or wound in the corresponding tegu— ments, I denominate a Compound Fracture. It is not the circumstance of a fractured bone occurring with a wound in the contiguous soft parts that consti— tutes a compound fracture: This may happen with a fracture of the most simple nature. Unless the exter— nal opening communicates with the fracture of the bone, the nature of the injury is not affected by it, even although the wound be extensive; while the smallest puncture passing directly to the substance of a fractured bone, adds much difficulty to the method of cure, and hazard to the event. Compound fractures are produced by external vi— olence, and frequently by the bones, in cases of simple fractures, being pushed through the corresponding teguments. In some cases, this happens from a bone being fractured so very obliquely as to terminate in a sharp point; while in others it is an evident effect of too tight a bandage, applied with the improper view, as we have seen in one of the preceding sections, of bearing down the upper end of the fractured bone. But in whatever way a compound fracture is produc— ed, the consequences resulting from it are nearly simi— lar. The admission of air to a fracture adds evidently to the risk attending it; and whether this takes place as an immediate effect of external violence, or as the consequence of pressure upon the ends of the bone, no difference is perceptible in the effects which result Various 164 Of Compound Fractures. Chap. XXXIX. Various reasons might be adduced to prove that it is the admission of air alone which renders compound fractures more hazardous than others. We may shortly mention, however, one of the most obvious proofs of it. The worst variety of simple fracture, where the bone is broke in the most oblique manner, and where it is difficult or perhaps impossible to re— tain it in its situation, will continue to do well, and to excite no severe symptom, as long as the skin remains entire: But if, by any accident, the point of the bone is pushed through the teguments, from that moment the pain becomes more severe; the inflammation, which before perhaps was trifling, becomes now con— siderable; fever takes place; the limb is apt to be at— tacked with violent spasmodic twitchings; and to these there frequently succeeds either gangrene or extensive suppurations. In compound fractures, our first object is to restrain profuse hemorrhagies when they take place, by a pro— per application of the tourniquet: Our next is to consider, whether we are to attempt to save the limb, or to recommend immediate amputation. From the difficult treatment and uncertain event of compound fractures, practitioners have been very uni— versally disposed to consider the amputation of the fractured limb as indispensably necessary. At all times indeed individuals have opposed this general o— pinion. Among others, Mr. Bilguer, of Berlin, wrote on this subject; and he asserts, that amputation is scarcely ever requisite, and that a greater number of patients would recover by proper treatment than by the operation. To me it appears that both opinions are in the ex— treme; and that they have been formed without that attention to, and discrimination of, circumstances, which the importance of the question required. In private practice, where patients can be kept qui— et and perfectly at rest from the date of the injury, and where proper attention can be insured on the part of 165 Sect. XVI. Of Compound Fractures. of the practitioner, as well as of experienced nurses, compound fractures should receive a different treat— ment from those that happen in a field of battle or in an engagement at sea. There are so many instances in which, from amputation being objected to by the patient, from the limb being too much swelled or in— flamed before assistance was called to allow of its be— ing performed, or from intention on the part of the practitioner to endeavour to save the limb, of cures being made, that I am now convinced that immediate amputation should never be advised in private prac— tice, unless when the bones are so much shattered that they cannot reunite; or where, from the violence of the injury, the texture of the soft parts is completely destroyed. On the other hand, I am satisfied that it would be a good general rule, both in the navy and army, to amputate immediately in every case of compound fracture received in battle, where the accident is either in the humerus or thigh, or where both bones of the sore arm or leg are broke. In this situation the patient is exposed to a variety of hard— ships which tend to aggravate his danger; and no ac— commodation can be procured nor attention given to lessen it. In opposition to this it may be alleged, that many cures of compound fracture are daily made in military hospitals. Indeed this is the argument on which Mr. Bilguer rests his opinion: but like every prejudiced inquirer, he states it partially. I readily admit, as every one accustomed to the treatment of fractures will do, that cures are sometimes unexpectedly accomplished under the most untoward circumstances: But the favourable termination of a few cases ought not to invalidate a rule of such conse— quence as this, which is founded on the sure basis of experience and observation. When an officer of rank and fortune receives a com— pound fracture, and where circumstances admit of his being 166 Of Compound Fractures. Chap. XXXIX. being soon conveyed to comfortable quarters, with a prospect of his remaining there during the cure, the case must be a bad one if we do not attempt to save the limb. But cases of this kind are not in the usual routine of military practice; and I mention them par— ticularly, because the accounts we have received of the success of the practice inculcated by Mr. Bilguer, are chiefly, if not entirely, drawn from such instances; and they therefore afford no conclusion relative to military and naval practice in general; Even in private practice, I am far from thinking that our attempts to save fractured limbs will always succeed. I know they will not; and, in the course of much business, that cases will occur in which the best conducted measures will fail, particularly where the large joints are much injured, and where the long bones are not only fractured but broke into splinters in different places: But I know from experience, that in a great proportion of the whole, we will prove suc— cessful; and that in those cases in which we are at last obliged to advise amputation, more will recover than probably would have done if the operation had been performed soon after the accident: at least this has been very commonly the case in the course of my ob— servation. Of those who have died soon after the op— eration, either from the fever induced by the extensive wound; from the great and sudden change produced in the circulating system by the removal of a consider— able part of the body; or from the perturbation and violent agitation of spirits which the unexpected loss of a limb must always induce, a great proportion has been of those cases where the operation was performed as quickly as possible after the accident. In these, the various causes we have mentioned concur to render the subsequent fever, and every concomitant symptom, more violent than we commonly find them in patients who have been reduced by confinement and a low reg— imen, and who, from having full leisure to reflect upon the danger of their situation, are, from their own con— viction  PLATE LXXVI. 167 Sect. XVI. Of Compound Fractures. viction of its being necessary, very readily induced to submit to the operation. A patient may indeed be brought so low as to make the success of the operation doubtful from this cause alone: But a practitioner may always guard against this, by proposing the operation when his attempts to save the limb prove abortive, and when the patient's strength declines. Amputation proving more successful in the more advanced stages of compound fractures than when practised immediately after the accident; and in the more advanced stages of chronic affections, particu— larly in white swellings of the joints, as we have else— where remarked, than in the more early periods of them; is a point which merits the attention of practi— tioners. So far as my observation goes, I consider the fact as ascertained; and if the experience of others leads to the same conclusion, it will prove the most convincing argument against early amputation. In the course of my own experience, I do not recollect an instance of death occurring from the operation a— lone, where the affection for which it was advised was of some duration; and in several instances it has been performed where the patient was very much exhaust— ed: Whereas several have died merely from the op— eration, where it has been put in practice soon after the accident. When I speak of death as the conse— quence of the operation, I do not mean such instances of it as occur from hemorrhagies breaking out in the course of a short time after the patient is laid in bed, as these may happen at whatever period a limb may be amputated; but such as take place about the sec— ond or third day, and in some instances at a later peri— od, from the violence of the fever induced by and commencing soon after the operation. When amputation is not performed immediately, or soon after the injury is received, it is agreed upon all hands, that it cannot, for several days at least, be ad— missible. 168 Of Compound Fractures. Chap. XXXIX. missible. Different causes may afterwards render it necessary. 1. Hemorrhagies under certain circumstances. 2. Extensive mortification. 3. The ends of the fractured bones remaining long disunited, while a copious discharge of matter endan— gers the sinking of the patient's strength. When hemorrhagies take place immediately, we have it always in our power to command them, either by compression alone, or by enlarging the wound when it is too small, and securing the bleeding arteries with ligatures. Sometimes, however, when no dis— charge of importance occurs at first, profuse hemor— rhagies will take place at the end of several days. It may be difficult in some cases to account for this; but we can frequently trace it to the effect of friction; the coats of an artery being destroyed by beating or rub— bing upon the sharp edge of a splintered bone. Even in this advanced state of the injury, we may frequently be able to secure the wounded arteries with ligatures. But the limb is sometimes so much swelled and inflamed before the hemorrhagy appears, that the original opening will not admit of this; and on pro— ceeding to enlarge it, such confusion is met with from effused coagulated blood between the interstices of the muscles, as well as through the whole cellular mem— brane of the affected parts, that the divided arteries cannot be all brought into yiew, but by such extensive incisions as in this state of the parts would be attended with more hazard than amputating the limb at a pro— per distance above: and although it is not a common occurrence, yet instances happen where the most ex— pert surgeons are obliged in this situation to ampu— tate. Mortification is the second motive we mentioned for amputating in this stage of compound fractures; and when it takes place to any considerable extent, it must be allowed that it is a very powerful one. We shall have occasion to consider this subject, however, more particularly 169 Sect. XVI. Of Compound Fractures. particularly when we treat of amputation; and with respect to the third cause we mentioned, when the bones do not unite, and when the patient declines un— der a copious discharge of matter, no practitioner of experience will, in this situation, dispute the proprie— ty of amputation. It is this state of a compound fracture, when the original inflammatory fever excited by the injury is subsided, and before the patient is too much weaken— ed by the discharge, which of all others we consider as the most favourable for amputation. The exact time cannot possibly be fixed by any general observation: It must depend upon the particular circumstances of every case, and chiefly upon the quantity of the dis— charge, and strength of the patient; and these again are points which the judgment of the practitioner in attendance can alone decide upon. We may remark, however, that as long as the patient does not seem to be much hurt by the discharge, however great it may be, the operation should not be advised; for while his strength is not much impaired, we may with safety proceed in our endeavours to save the limb. From what has been said, it will appear, that, in private practice, very few cases can occur of compound fractures, in which we should not attempt to save the limbs. In the treatment of compound fractures, our object is the same as in the management of those of the most simple nature; namely, the replacing of any bones that may be deranged, and retaining them till they are united. In the first place, all extraneous bodies should be removed, as well as all those small pieces of bone that will not probably unite with the rest; for which pur— pose the opening should be enlarged with a scalpel, if it be too small to admit of their being easily taken out. And this being done, we will in general find it an easy matter to replace the bones if we relax all the muscles Vol. IV. M of 170 Of Compound Fractures. Chap. XXXIX. of the injured limb in the manner pointed out in the preceding sections of this chapter. There is just one exception occurs to this: A sharp point of a bone is, on some occasions, so far pushed through the tegu— ments, that it cannot be replaced by any ordinary force; and to a certain extent, the greater the force that is applied to it, it is the more firmly fixed between the skin and parts beneath. In such cases there are two methods by which the difficulty may be removed: By sawing off the end of the protruded portion of bone, or enlarging the wound. When a long sharp point of bone is much protrud— ed, we should not hesitate in removing it; for al— though it should be reduced, it would not readily unite with the rest of the bone, at the same time that it would be apt to excite much pain and irritation. When the portion to be taken away is very small, it may be done with the cutting forceps usually employ— ed in amputations: but when it cannot be easily done in this manner, it may with safety be taken off with a saw, a piece of pasteboard, or of thin sheet lead, be— ing previously inserted between it and the teguments beneath. But whenever the protruded portion of bone is broad at the base, and not of any considerable length, as there will be cause to hope that it will unite with the rest of the bone if they be brought rightly into contact, we ought certainly to endeavour to save it; and in general we will be able to do so by enlarging the opening through which it has passed. If we take care to avoid any large blood vessels and nerves, which those acquainted with the anatomy of the parts will readily do, no danger will occur from the operation. Instead of adding to the danger of the patient, it tends often to lessen it, by removing a powerful cause of pain and irritation, and thus preventing that inflam— matory tension to which limbs in this situation are particularly liable. To  PLATE LXXVII. 171 Sect. XVI. Of Compound Fractures. To those not much accustomed to treat compound fractures in this manner, the practice we now recom— mend may be supposed to be attended with hazard; and to convert a small puncture into an extensive wound, may often appear to be cruel and unnecessary. But as the admission of the air has already occasioned all the mischief which can arise from this quarter, we do not thus increase the danger of the patient; and it is generally well known, that a free incised wound heals more readily than a small punctured one. It is the skin only which, in most cases, we have to cut here: But even where the bone cannot be easily re— duced without carrying the incision into the substance of the contiguous muscles, we should not hesitate in advising it: Only, in this case, the opening should be made as much as possible in the direction of the fibres of the muscles. The splinters of bone, coagulated blood, and other extraneous bodies being removed, any artery that may be cut being secured with a ligature, and the protrud— ed portion of bone replaced, the fracture is, in other respects, to be reduced in the manner we have advised when speaking of simple fractures; that is, by relax— ing the muscles of the limb, and extending the bones no more than is altogether necessary. This being done, a pledgit of soft lint, spread with any emollient ointment, should be laid over the wound, when the limb should be placed upon a firm splint, and still kept in a relaxed posture. As it is of much import— ance that the wound be regularly dressed without moving the limb, it should, if possible, be so placed, that this can be done; and with the same view, the many tailed bandage, in every instance of compound fracture, where it is in any respect applicable, should be preferred to the roller. As it is a point of the utmost importance to place the limb in such a posture as will admit of the sore be— ing dressed without moving it, various inventions have M2 been 172 Of Compound Fractures. Chap. XXXIX. been proposed for rendering this in every case practi— cable. Very few of these, however, have answered the purpose for which they were intended. The best I have met with is a fracture box invented by the in— genious Mr. James Rae of this place; of which, with some improvements made by his son Mr. John Rae, I now give a delineation. The leg may be laid in it ei— ther bent or straight, and a wound, wherever situated, may be dressed without altering the position of the limb, as will be more clearly understood from the representation of the instrument, Plate LXXIII. fig— ure 3. In whatever situation the limb be placed, it is an object of the first importance to endeavour to prevent inflammation: for when mortification ensues, it may be almost always traced to too great a degree of in— flammation; and the same cause very often gives rise to those extensive abscesses with which fractures of this kind are apt to be accompanied. We are there— fore from the first to guard against the accession of this symptom; by one or more general blood lettings, pro— portioned to the strength of the patient; by the ap— plication of leeches to the edges of the sore, when the inflammation becomes severe; by the use of opiates; by gentle cooling laxatives; a low regimen; and oth— er parts of an antiphlogistic course. The dressings should be removed once or twice daily, according to the quantity of matter; and instead of dry lint, pledg— its of any emollient ointment, or Goulard's cerate, will be preferable: for I have not found in any state of these sores that ointments do harm; and they al— ways fit easily, and are more easily removed than when dry lint is applied alone. Warm emollient poultices are very commonly ap— plied at first, and continued for a good many days: But as they prove always troublesome, and cannot be removed without in some degree altering the posture of the limb, I think it better to avoid them till we see whether 173 Sect. XVI. Of Compound Fractures. whether or not they become necessary by the approach of inflammation. In that event they should be im— mediately employed as the surest means of exciting a discharge of matter: For although we would rather wish the sore to heal by what is termed the First In— tention, without the formation of matter; yet this be— ing a very unusual occurrence in wounds attending compound fractures, and a plentiful discharge of good pus being the most certain preventative of mortifica— tion, we should not hesitate in endeavouring to pro— mote it whenever a limb with a compound fracture is attacked with inflammation. As soon, however, as our views are accomplished, by the inflammation subsiding, and a free discharge of pus excited, the poultices should be laid aside: for in many instances, when too long continued, they have certainly done harm, by relaxing the parts too much, and exciting too profuse a discharge of matter. When matter is discharged from a compound frac— ture in too great quantities, besides laying aside the use of emollient poultices, we ought to dress the sore with gentle astringents, such as soft lint dipped in a solution of saccharum saturni; and the patient should now be supported with a nourishing diet, a free use of wine, Peruvian bark, and elixor of vitriol. A free vent should be procured for the matter; and when this cannot be obtained by putting the limb in a pro— per posture, it should be done by making a counter opening in a more depending part. The necessity, however, of this may often be prevented by employing soft lint, or covering the sore with soft sponge to ab— sorb the matter, and by frequent dressings: for al— though the sores should never be more exposed to the air than is necessary, yet whenever the discharge is co— pious, there will be more risk from allowing the parts to be long immersed in matter, than from the most frequent renewal of the dressings. M3 When 174 Of Compound Fractures. Chap. XXXIX. When the discharge from a compound fracture be— comes excessive, and cannot be lessened by the means we have mentioned, it will often be found to originate from a portion of loose bone that has not been earlier noticed. In such circumstances, therefore, we should always examine the sore with as much attention as possible; and wherever a piece of loose bone is dis— covered, we ought to take it out either at the sore it— self, or by a counter opening, if it appears that in this manner it can be more easily done. In making an examination for this purpose, the finger alone should be employed when the opening is so large as to give it access: for in this manner we do less harm than with a probe; and at the same time we discover the real state of the parts with more precision. When it is necessary to use a probe, it should be done with cau— tion, for much mischief is frequently done where this instrument is employed too freely. If, instead of producing a discharge of matter, the inflammation should terminate in gangrene, the situa— tion of the patient becomes still more hazardous than under the most extensive abscesses. We have else— where had occasion to treat of the subject of gan— grene; and we must now refer to that part of the work.* In a following chapter, we shall have an opportunity of mentioning the period at which am— putation of limbs, attacked with gangrene, should be advised. In considering this subject, some will suppose that I should have given more particular directions for se— curing fractured limbs in their situation, especially in cases of compound fracture: But as I know of no method of effecting this with such certainty and ease as the one I have described, I consider it as unneces— sary even to enumerate the various means that have been proposed for this purpose. In particular cir— cumstances, those we have described in the eleventh section * Vide Treatise on Ulcers, &c. Part I. Sect. III. 175 Sect. XVI. Of Compound Fractures. section of this chapter, Mr. Gooche's machine, and Dr. Aitken's, may prove useful for keeping the frac— tured bones extended; and much advantage may cer— tainly be derived from them in keeping the bones steady when it is necessary to move a patient with a fractured limb from one part to another: but in ordi— nary practice, I can without hesitation say, that no advantage is derived from any instrument I have ever known used for this purpose. M4 CHAPTER 176 CHAPTER XL. Of LUXATIONS. SECTION I. General Remarks on Luxations. A BONE is said to be luxated where that part of it forming a joint is displaced. In some cases, the end of a bone is forced entirely out of the cavity where it is naturally lodged: This we term a Com— plete Dislocation. Where any part of the bone rests upon the edge of the socket, we say the Dislocation is Incomplete. Luxations may with the same propriety as fractures be divided into simple and compound. Where the end of a bone is merely displaced, we term it a Simple Luxation; but where this is accompanied with a cor— responding wound in the soft parts, laying open the cavity of a joint, we say the Luxation is Compound. By some practitioners the term Compound is applied to dislocations accompanied with fractures of the con— tiguous bones, whether the teguments be injured or not. We say with more propriety, however, that a luxation in such circumstances is of a Complicated Nature. For the most part luxations are produced by exter- nal violence, and appear as the immediate conse— quences of some considerable force applied to the in— jured parts. They are particularly apt to occur in leaping and falling, from blows, and violent twists and distractions 177 Sect. I. On Luxations. distractions of the different bones of a limb: But they are also produced by other causes; by a morbid weak— ness or relaxation of the ligaments and muscles of a joint, which sometimes occur as the consequences of palsy and long continued rheumatic affections; and by the end of a bone being pushed from the cavity in which it was lodged, by matter collected in it, or by sarcomatous tumors and exostoses. Those cases of dislocation that occur from external violence, are chiefly the objects of surgery. The symptoms usually induced by these, are, inability to move the injured limb; pain, tension, and deformity in the part affected; and in some cases inflammation, subsultus tendinum, and fever. In general, the motion of the limb is impaired in proportion to the extent of the luxation; but in some cases, even the most partial affection of this kind ren— ders the joint perfectly stiff and immoveable, and cre— ates the most exquisite pain on every attempt to move it. This is particularly the case in partial dislocations of all the large joints. The deformed or altered appearance of a joint, with which a luxation is always accompanied, must necessarily be in proportion to the extent of the inju— ry; but this is not the case with the other symptoms we have mentioned: for subsultus tendinum, inflam— mation, and fever, are often excited to a greater height by partial dislocations, where the ends of bones are not much moved from their natural situations, than where they are altogether forced from their sockets, owing to a circumstance which we shall presently en— deavour to explain. The first approach of swelling in cases of disloca— tion, is always of the inflammatory kind, and is a nec— essary effect of the violence done to the injured parts. This, however, should be distinguished from a secon— dary swelling to which these affections are liable, an extensive tumefaction which in some cases spreads o— ver all the under part of the limb, and which seems to originate 178 General Remarks Chap. XL. originate from a different cause. Instead of being red, tense, and painful, the teguments are pale, soft, and œdematous; owing, I suppose, to the lymphatic vessels of the limb being compressed by the end of the displaced bone. Swellings of this kind are most fre— quent in dislocations of the humerus and femur; in which also considerable numbness or diminished sens— ibility is apt to be excited by the compression of the nerves of the limb. It is of much importance to distinguish dislocations from other affections of the joints, and to ascertain to what extent the bones are moved from their situations. In compound luxations the nature of the injury is ob— vious; and for the most part it is sufficiently evident in cases where bones are completely dislocated; but partial dislocations are often not to be discovered but by the most minute examination: They therefore fre— quently pass unnoticed, or are considered as sprains and contusions; and thus, in cases where complete cures might be performed by due attention on the part of the practitioner, patients are often rendered lame and miserable for life. The symptoms enumerated above are common to all dislocations. In speaking of particular luxations, we shall have occasion to mention the peculiarities of each, and shall endeavour to do it in such a manner as may with most certainty prevent such unfortunate oc— currences as we allude to. In forming a prognosis of the event of luxations, that is, of the practicability of reducing them, and of the termination of the symptoms with which they are attended, various circumstances require attention: The form and structure of the different joints; the nature and extent of the luxation, together with the degree of violence by which it was produced, and the circumstances with which it may be complicated; and lastly, the duration of the injury. The skeleton is commonly had recourse to for a knowledge of the joints; but although it is proper that 179 Sect. I. on Luxations. that every student should be acquainted with the ar— ticulations in a dry state, we should by no means rest satisfied with this. In the treatment of luxations, it is equally necessary that we have an exact knowledge of the joints in a recent state; of the cartilages, liga— ments, and tendons, with which the bones are con— nected, as well as of the contiguous parts in which the heads of the displaced bones may happen to be lodg— ed: Otherwise our ideas of the nature of these inju— ries, and of the means that will most probably prove successful in the treatment of them, must be very im— persed. We cannot enter upon a minute description of ev— ery joint, as it would lead to an extent of discussion in— consistent with the nature of this work. Referring to the proper sources for more particular information, we shall here only observe, that it is chiefly those joints that are possessed of much motion in which we meet with luxations. Of these, there are two varieties. The one termed the Junction by Ball and Socket, where the head or end of one bone is received into the cavity of another; and the other termed by anato— mists Ginglimus, or the Hinge—like Joint, from its re— semblance to the hinge of a door. In this the joint is formed by different parts of one bone being receiv— ed into cavities or indentations of another. The former admits of the most extensive motion, as is ex— emplified in the joint of the humerus with the scapu— la, and in that of the femur with the ossa innominata; while the latter does not admit of more than that of flexion and extension, as is the case in the elbow and knee. In these we accordingly find, that this more limited motion to which they are confined, renders them less liable to luxations; while the free motion of the others exposes them to frequent injuries of this kind, as is more particularly the case in the joint of the humerus, from the cavity in which the head of that bone is lodged being of no great depth. Besides 180 General Remarks Chap. XL. Besides the usual coverings of teguments, muscles, and tendons, in common to joints with the rest of the body, every joint possessed of much motion is provid— ed with what we commonly term a Capsular Liga— ment; which is a firm somewhat elastic substance, forming a kind of pouch or bag, which completely surrounds the articulation, and serves at the same time to retain the ends of the bones together, and to con— tain a thin transparent fluid, the synovia, for the pur— pose of lubricating the cartilages which cover the ends of the bones. Practitioners are not agreed whether in cases of lux— ation the capsular ligaments are ruptured or not. As it has appeared on dissection, in a few instances, that the ligament was ruptured, some have concluded that it is the case in all; while others are of opinion, that the ligament always remains entire, except where the luxation has been the consequence of very severe and unusual degrees of violence. The result of my observation on this point is, that partial luxations may happen without any rupture of the capsular ligament; but that it is always ruptured in complete luxations produced by external violence; nay, that it is often almost entirely tore from its inser— tion round the neck of the bone. Where the head of a bone is gradually pushed from its socket by the slow formation of a tumor within the joint, and where the ligament is perhaps much relaxed by disease, a luxa— tion may no doubt happen without either rupture or laceration: but we cannot suppose that such a firm substance as a ligament is in a state of health, will yield, without bursting to the sudden impulse produc— ed by the complete dislocation of the head of a bone, and where the displaced bone is in some cases almost instantaneously forced to the distance of several inches from its natural situation. Different instances are up— on record of this opinion being supported by the dis— section of dislocated joints after death; and were it necessary, 181 Sect. I. on Luxations. necessary, I could add others that have fallen within my own observation. We mentioned above, that the pain attending par— tial dislocations is commonly very severe on any at— tempt being made to move the joints. For the most part, indeed, it is more exquisite than it usually is where the luxation is complete; and we conclude that it proceeds from the capsular ligament being over— stretched, and from the ends of the displaced bones continuing to act against it instead of passing freely through it. In judging of a luxation, the distance to which the head of the displaced bone is forced, and the degree of violence by whichit was produced, require particular attention. Where a bone is only partially dislocated, although the pain attending it may be very acute, yet the reduction of it will be accomplished both with more ease and certainty than if the same bone had been forced completely out of its situation. And where the joint has not suffered any extraordinary vi— olence, the inflammation and other concomitant symp— toms will not prove so formidable as they commonly do where the capsular ligament and other soft parts have been much stretched, or otherwise severely in— jured. One of the most unfavourable circumstances with which a luxation is ever attended, is a fracture of one or both of the bones concerned in it. Even a frac— ture of the displaced bone is always a disagreeable oc— currence, and this especially if it be broke near to its neck, as in this case it can scarcely be laid hold of for the purpose of reducing it; but the risk attending it is much more considerable when the bone forming the socket into which it should be received is also broke: for we know from experience, that fractures of these parts are more apt to be attended with severe degrees of inflammation, as well as with extensive suppura— tions, than fractures of any of the long bones. And when the socket is broke, there is always much hazard of 182 General Remarks Chap. XL. of the joint being rendered stiff for life, even when the reduction of the displaced bone is accomplished in the easiest manner. A dislocation being more or less recent, is the next point requiring our attention: for we know that lux— ated bones are, cæteris paribus, more easily reduced soon after they are displaced than when much time has elapsed. While the injury is recent, the bone will necessarily pass with more ease along the parts which it has just traversed, than it possibly can do after lodg— ing several weeks or months among the contiguous muscles; where the head of it, instead of being loose, as is usually the case at first, will have formed a sock— et for itself, and will probably be firmly grasped by some of those muscular fibres which more immediate— ly surround it. At this period too, the cavity from whence it was dislodged may probably be in some de— gree filled up by the contiguous soft parts: Not that the synovia ever becomes inspissated, so as to produce this effect; for although this has by many been supposed to happen, and various means have been proposed for preventing and removing, it, yet we now know that the opinion is ill founded. No inspissation of this fluid has ever been discovered by dissection, although stiff joints, where this state of the synovia was previously considered as the cause, have often been laid open for the purpose of detecting it. But although the cavity of a joint may not be filled up in consequence of any particular affection of the synovia, there is much rea— son to suppose that in course of time it will be dimin— ished by the constant action of the contiguous mus— cles; which will not only force the cellular substance, fat, and other soft parts with which it is covered, into it, but may even have some effect in compressing the bone itself, or the cartilaginous brim with which the bone is usually covered. These are the circumstances in dislocations which more particularly require attention; but we have also to remark, that the patient's age and general state of health, 183 Sect. I. on Luxations. health, influence the reduction of a dislocated bone. Dislocations are more easily reduced at some ages and in particular habits of body, than in others. Thus, in advanced periods of life, and in weak delicate consti— tutions, where the muscles give little resistance, dis— placed bones are more easily moved than in the vig— our of youth and in robust habits of body where the superior strength of the muscles has a considerable ef— fect in preventing it. In the treatment of dislocations, the objects we have in view are, to put the bone that is displaced into its natural situation, with as much ease and expedition as the nature of the case will permit; to retain it in this situation till the injured parts have recovered their tone; and to obviate pain, inflammation, and any oth— er symptom that requires attention. Before proceeding to the reduction of a dislocation, we should examine the contiguous soft parts, to see whether they be in a fit situation for it or not: for al— though the sooner the operation is attempted, the more certain we will in general be of succeeding; yet when— ever the surrounding teguments and muscles are much contused and inflamed, it is better to allow the pain and swelling that takes place to subside before any tri— al is made for reducing the bone; at least I have al— ways been in the practice of this. I never observed any bad consequences ensue from it; and I have known much mischief done by a limb being much stretched while the parts surrounding a dislocated joint have been in an inflamed state. In such circumstances, therefore, we should endeav— our, by local blood letting with leeches, by the use of saturnine applications, by a low regimen, and putting the limb in any easy relaxed posture, to remove the inflammation before any attempt is made for reducing the bone. In almost every dislocation it is one bone only that is displaced, the other bone or bones of which the joint is formed remaining in their natural situation; and it will 184 General Remarks Chap. XL. will be found perhaps universally, that it is the bone connected with the inferior part of a limb that is forc— ed from its situation; the bone forming the upper part of the joint, if it be not fractured, being seldom in any respect altered: In the reduction therefore of a luxation, the only attention we have to give to the upper part of a limb, is to keep it firm and steady, while we endeavour by the easiest and most effectual means to replace the under part of it. A person not acquainted with anatomy, might be led to suppose that this may always be readily accom— plished; as he will be apt to conclude, that the same degree of force which pushed a bone out of its place, will with equal ease replace it. This would no doubt be the case, were it the bone only that we had to act upon, or if it was merely connected with inorganic matter that would not give any resistance to the means employed to reduce it: But every joint being either partly surrounded by, or much connected with, mus— cles, the contratile power with which they are en— dowed acts with much force and advantage against ev— ery attempt that is made for the reduction of the bone; for they not only draw it beyond the end of the con— tiguous bone against which it ought to be placed, but they often pull it out of its natural direction, and fix it firmly in some neighbouring cavity, from whence it is dislodged with difficulty; while the stimulus cre— ated by every trial we make for replacing the bone, is apt to excite a further exertion of the muscles, and in— creases the difficulty which accompanies the reduc— tion. It is therefore obvious, that in the reduction of ev— ery dislocated bone, the muscles with which it is con— nected should be put as much as possible into a state of relaxation; for in this situation, the resistance they give to the force employed for moving the bone is in— considerable, when compared with what is required for the same purpose when they are kept in a state of extension. In the one, it is usually done with ease, both 185 Sect. I. on Luxations. both to the patient and surgeon; while in the other, that is, while a limb is much stretched or extended, it is with the utmost difficulty that a dislocated bone can be moved. By relaxing all the muscles of a limb, we may in general obtain as much force as is requisite for reduc— ing a luxation merely from assistants; but in some in— stances more is required than can be applied in this manner: In such cases, various instruments have been proposed for increasing our powers of extension; some of which, and perhaps the most useful, are delineated in Plates LXXVII. and LXXVIII. But whether we find it necessary to use machines of this kind or not, no more force should be ever employ— ed than is just requisite; and it ought always to be ap— plied in a slow gradual way, by which there is much less risk of any harm being done, than when the mus— cles of a limb are forcibly and suddenly stretched: And it will also be understood, that the whole force used for the reduction of a dislocated one, should be applied to that bone only, and not to any other part of the limb. Besides the resistance arising from the action of the muscles, we sometimes meet with a good deal of diffi— culty from the projecting end of a dislocated bone, hav— ing passed that of the contiguous bone. In this case the extension is to be made in such a direction as will best obviate this occurrence. In extending a limb for the purpose of reducing a dislocation, it is absolutely necessary to carry the ex— tension so far as to dislodge the displaced bone, and to bring the end of it on a line with the end of the other to which it is to be opposed, otherwise no advantage will be gained by the operation; for while any part of one bone projects past the extremity of the other, no means we can employ will be able to replace it, unless a sufficient force be applied to it, as has sometimes happened, for breaking off the projecting part; while, on the contrary, the reduction is always accomplished in the easiest manner, as soon as the displaced bone is Vol. IV. N drawn 186 General Remarks Chap. XL. drawn freely past all the projecting parts of the other: nay, when the end of a displaced bone is brought to this situation, it would be difficult to prevent it from passing instantaneously into the situation where it is naturally lodged. So that in the reduction of dislocations, our chief object is to make a sufficient degree of extension in the easiest manner, when the ordinary action of the muscles will for the most part replace the bone: Or when this fails, the most gentle pressure will be suffic— ient for the purpose. The dislocated bone being reduced, there is seldom any difficulty in retaining it in its situation, unless it has often been displaced before: The surest means of effecting it, is by putting the limb into a relaxed pos— ture, and supporting the bone that has been just re— placed with a proper bandage, till the surrounding soft parts have recovered their natural tone. The symptoms that prove most urgent in disloca— tions, both before and after the bones have been re— duced, are, pain, inflammation, and swelling. For the most part they abate after the reduction is com— pleted; but while any degree of inflammation continues, repeated applications of leeches should be advised as the most effectual remedy: and as this symptom is to be considered as the cause of all the others, as well as of those chronic pains which joints are liable to that have ever been dislocated, it requires particular atten— tion. But having considered this subject very fully when treating of contusions, we must refer to Chap. XXXVII. Section II. §2. for what was then said upon it. In the first part of this section, we have said that luxations are sometimes combined with fractures of the displaced bones. When a bone is fractured at a con— siderable distance from the luxated joint, we may for the most part be able to reduce the luxation immedi— ately, when the fracture should be treated in the usual way: But when a bone is fractured so near to the lux— tion that it cannot be laid hold of, the case is thereby rendered both difficult and uncertain. In the small— er joints, as in those of the fingers and toes, the dis— placed 187 Sect. I. on Luxations. placed portion of bone may in some instances be push— ed into its situation; but in all the larger joints, par— ticularly in the hip joint, and in that of the shoulder, we must first allow the fracture to heal, and the union of the fractured bones to be perfectly firm, before we attempt to reduce the luxation. In compound luxations, that is, where joints are not only luxated but laid open by external injuries; the treatment we have advised in compound fractures will prove equally applicable. Indeed the nature of these affections is so similar, that almost all the observations made upon the one will apply with nearly equal pro— priety to the other; so that at present we shall refer to Section XV. of the last Chapter, where the subject was particularly considered. We may just shortly observe, that after the luxated bones are replaced, and the limb laid in a proper pos— ture, our next object is to prevent inflammation; which we do with most certainty by copious blood letting with leeches applied as near as possible to the injured parts; dressing the sores with Goulard's cerate, or any other mild ointment; moderating the pain with ade— quate doses of opiates; and a low regimen. This being done, we have to endeavour to prevent any matter from lodging about the joint, by placing the limb in such a manner as will readily allow it to run off: if this fails, by dressing the sore more fre— quently, and absorbing the matter with a bit of sponge; or, when the quantity of matter is considerable, by a counter opening made in a depending situation. When mortification takes place, it is to be treated in the manner we have advised, when speaking of this subject in a former publication.* All that we have hitherto said relates in general to luxations produced by external violence. When they proceed from the heads of bones being pushed from their sockets, either by tumors of a fleshy or osseous nature, * Treatise on the Theory and Management of Ulcers, &c. Part I. Sect. III. N2 188 Of Luxations of the Chap. XL. nature, or by collections of matter, they may almost in every instance be considered as incurable: When the joint is so situated that the diseased parts can all be removed, this measure should be advised; but when this cannot be completely effected, all that art should attempt is, to give as free a discharge as possi— ble to any matter that may form, and to support the constitution with a proper diet, to prevent it from be— ing too much reduced by the discharge. Dislocations are sometimes the consequence of too great a relaxation of the ligaments and tendons which serve to connect the bones in a healthy state. This relaxation is seldom so completely removed as to pre— vent the bones from falling out from time to time: but the inconveniency may be in some measure obviated by supporting the limb with a proper bandage; by endeavouring to restore the tone of the relaxed parts by cold bathing; and, in some instances, electricity has appeared to prove useful. We shall now proceed to speak of dislocations from external violence as they occur in particular parts. SECTION II. Of Luxations of the Bones of the Cranium. THE bones of the cranium are frequently separat— ed from each other at the sutures in cases of hy— drocephalus internus. This, however, can seldom be— come an object of surgery. If the collection is remov— ed either by the use of medicines, or by an operation, all that art can do farther is to support the parts with a proper bandage. We also find in some instances, that openings are produced at the sutures by external violence, particu— larly by falls from great heights. Accidents of this kind, 189 Sect. III. Bones of the Nose. kind, however, very commonly prove fatal. I have only met with one instance of a patient under such circumstances recovering. All that can with proprie— ty be done, is to support the parts by gentle regular pressure with a proper bandage; to prescribe blood letting and other remedies, according to the violence of the symptoms; and to keep the patient quiet and confined to a proper posture during the cure. SECTION III. Of Luxations of the Bones of the Nose. THE bones of the nose are so firmly united, and they serve so effectually to support each other, that they are seldom dislocated. Instances of it, how— ever, are sometimes met with. As these bones are only thinly covered with soft parts, luxations in any part of the nose are easily dis— covered by the touch, as well as by the deformity which they occasion. In the reduction of a luxation of these bones, the patient should be seated opposite to a proper light, with an assistant behind supporting his head: and the surgeon standing before, should endeavour to replace the bones with as much exactness as possible. In gen— eral this will be practicable with the fingers alone; but when one of the bones is pushed inwards, it will be more easily accomplished by pushing one of the tubes in Plate XLIII. fig. 2. up the corresponding nostril, in order to elevate the depressed piece; and if the tube be guarded with some plies of soft lint, it may be re— tained in its situation till there is no longer any risk of the bone slipping out. When either of the bones of the nose is pushed out— wards, it must first be exactly replaced, and afterwards retained in its situation by a proper application of a double headed roller. N3 SECTION 190 Of Luxations of Chap. XL. SECTION IV. Of Luxations of the Lower Jaw. THE lower jaw is connected by a piece of very beautiful mechanism with the bones of the head. There is in each temporal bone an irregu— lar oblong cavity, immediately before the external me— atus auditorius. In these cavities, the two condyles of the lower jaw are lodged; and by means of two in— termediate loose cartilages which move along with the condyles, and which correspond with the irregular sur— faces of the cavities in which they are placed, such a degree of firmness is given to this joint as would oth— erwise be inconsistent with the freedom of motion of which it is possessed; for although the condyles of the jaw are secured by different ligaments, as well as by strong muscles, to their situations, particularly by the strong tendons of the temporal muscles inserted in— to the coronoid processes of the jaw; yet the variety of motions which the under jaw is constantly performing, would render it very liable to dislocations, were it not for the intervention of these moveable cartilages, which admit of every necessary freedom; while such a loose, extensive motion is prevented, as must have happen— ed if the heads of the condyles had been placed in large smooth cavities without these cartilages between them. The under jaw cannot be dislocated either up— wards, backwards, or laterally; it can only be dislo— cated forward and downward. In every other direc— tion, the condyles are so much surrounded with bone, that they cannot be forced out of their corresponding cavities, as will be readily seen on an examination of the skeleton: But when the mouth is widely open— ed, as happens in yawning, the condyles are apt to slip too 191 Sect. IV. the Lower Jaw. too far over the anterior boundaries of these cavities. In this manner a dislocation takes place, as we discov— er by the chin being thrown forward and downward, while the mouth remains open, at the same time that pain is produced by every attempt to close it; nor can the patient speak distinctly, or swallow but with much difficulty. In some cases one side only of the jaw is dislocated, that is, one of the condyles remains nearly in its nat— ural situation, while the other is thrown entirely out. In this case, the jaw, instead of falling directly down, is pushed downwards, and somewhat towards the side opposite to that in which it is dislocated. Besides the symptoms we have mentioned of pain on any attempt to close the mouth, and of difficulty in speaking and swallowing, we are told by all the an— cient writers on this subject, and by all those who have copied from them, that luxations of the jaw are apt to induce convulsions, and even death. I have never, however, met with an instance of this, nor is it proba— ble that it will ever happen, unless from great misman— agement on the part of the surgeon. A luxation of the jaw being very distressing, and e— ven alarming to those not acquainted with the real nature of it, immediate assistance is commonly desired; and with due attention we can seldom fail in reduc— ing it. The patient being firmly seated on a low chair, with his head properly supported behind, the surgeon standing before, with his thumbs sufficiently guarded, should push them as far as they will go between the teeth of the upper and under jaws, the under or flat part of the thumbs being applied to the teeth of the under jaw: the palm of each hand should be applied to the outside, while with his fingers he lays a firm hold of the angles of each jaw. With the fingers ap— plied in this manner, he should pull the under jaw forward till he finds it move somewhat from its situa— tion: and this being done, but not till then, he should N4 press 192 Of Luxations Chap. XL. press the jaw forcibly down with his thumbs, and moderately backwards with the palms of his hands; when, if the different parts of the operation be rightly managed, the ends of the bone will immediately slip into their situation; upon which the thumbs should be instantly withdrawn. In general, we are directed to press the jaw down- wards and backwards: but although this might suc— ceed in some instances where the jaw is dislocated only on one side, yet even there it would often fail; and it would seldom answer when both condyles are out: For till they be quite disengaged from the bones on which they rest, and which they can only be by pull— ing the jaw forward, all the force we can employ in pulling them down will be of little avail, as I have seen in different instances. I have desired, in pressing down the jaw, that at the same time it should be pressed moderately backwards: The slightest force, however, in this direction will be sufficient; nay, in some cases it will not be found nec— essary: for as soon as the condyles are sufficiently de— pressed, they are almost instantaneously drawn into their natural situations by the ordinary action of the temporal muscles, whether any force be applied for this purpose or not. The treatment we have advised answers equally well, whether the jaw be luxated on one side, or on both; but where one condyle only is thrown out, the force used for depressing the jaw should be chiefly ap— plied to that side. A luxated jaw being reduced, the patient should be advised to avoid every cause that might have any ef— fect in throwing the bone out again; particularly much speaking, gaping, and yawning, as the condyles are apt for a considerable time to be turned out by any of these. In the reduction of a dislocated jaw, the thumbs are very apt to be bit if they be not well protected, or if they be not instantly withdrawn on the bones slipping into 193 Sect. V. of the Head. into their situations. For the most part the end of a handkerchief is wrapped round them; but a covering of firm leather answers better, or a case of thin iron covered with leather, would be still preferable, as it would not occupy so much space. It would pass far— ther into the mouth, and would thus act with more advantage in forcing down the jaw. SECTION V. Of Luxations of the Head. THE head is connected in such a manner with the atlas or first vertebra of the neck, that it moves upon it with ease and freedom backwards and for— wards, the two condyles of the os occipitis being re— ceived into corresponding cavities in the superior ob— lique processes of that bone: But the lateral and ro— tatory motion of the head proceeds from the immedi— ate connection between the head and second vertebra of the neck by means of the processus dentatus of that bone; which passing through the back part of the large cavity of the atlas, is fixed by means of different ligaments to the os occipitis. The connection between the head and the first of these bones is so firm that it is not probable they are ever separated; at least I have not heard of any in— stance of this being discovered on dissection. It ra— ther appears that in luxations of the head the connec— tion is destroyed between the head and the second vertebra, the head being forced with such violence forward as to stretch or rupture the ligaments by which the tooth—like process of this bone is fixed to the occiput: at least this has been found to be the case in different instances of these dislocations; and it has 194 Of Luxations of the Chap. XL. has been commonly observed in people who have suf— fered by hanging. In every dislocation of the head, the head falls for— ward upon the breast; the patient is instantly depriv— ed of sensibility; he lies as if he were dead; and soon dies if the luxation be not quickly reduced. Injuries of this kind are produced most frequently by falls from great heights or from horseback. Luxations of the head for the most part terminate fatally; but as several instances have occurred where this has been prevented when timely assistance has been given, we have reason to suppose that recoveries from this accident would be more frequent if this could be always procured. Different means have been proposed for the reduc— tion of these luxations; but every thing requiring much preparation is here inadmissible. In all such cases, our views must be instantly carried into execu— tion; and it fortunately happens, that in perhaps ev— ery instance they may be accomplished without any preparation. The patient being seated upon the ground and sup— ported by an assistant, the surgeon standing behind should raise the head from the breast; and the assist— ant being desired to press down the shoulders, the head, should be gradually pulled straight up till the disloca— tion is reduced; or if this does not happen with mod— erate extension, it may at the same time be gently moved from side to side. A sudden crack or noise is heard on the reduction being completed; and if the patient be not entirely dead, it is immediately ascer— tained by a partial recovery of all his faculties. In some cases they have been completely restored on the head being replaced; but in others they have re— mained long impaired, and in some have always con— tinued so. The reduction being effected, the patient should be immediately laid in bed. His head should be kept elevated, 195 Sect. VI. Spine, Os Sacrum, &c. elevated, and retained by a proper bandage for a con— siderable time in one posture. And with a view to prevent inflammation, blood letting should be pre— scribed in such quantities as the patient can easily bear; his bowels should be opened with proper laxa— tives; and he should be confined to a low regimen. SECTION VI. Of Luxations of the Spine, Os Sacrum, and Os Coc— cyx. THE vertebræ or bones of which the spine is com— posed, are so intimately connected by the proc— esses of one bone running into corresponding parts of another, as well as by strong ligaments and muscles, that they are very seldom dislocated. They are so firmly united indeed, that I do not suppose that any of them can be dislocated by external violence without being fractured. Besides the means of connection we have mentioned, the vertebræ of the back are much strengthened by the support they receive from the ribs, I never met with a complete dislocation of any of the vertebræ; nor do I suppose that it ever happens, even when accompanied with a fracture, without pro— ducing immediate death: for the force necessary to move one of the vertebræ from its situation, would not only be attended with the compression, but even with the laceration, of the spinal marrow, while the contents of the thorax or abdomen would be essential— ly injured. I do not suppose, therefore, that a com— plete dislocation of any of these bones can ever be— come an object of surgery. We know, however, that one or more of the verte— bræ may be partially dislocated, and that the patient may 196 Of Luxations of the Chap. XL. may survive for a considerable time. In some cases, perhaps, complete cures may be obtained; but I be— lieve these will not be frequent. These luxations are usually produced by falls from great heights, or by violent blows, or by the passing of heavy weights over the body. They are distinguished by the body being distorted, by examination with the fingers, and by the symptoms which they induce; which are such as usually occur from compression of the spinal marrow; particularly a paralysis of all that part of the body lying beneath the injured part, and either a total suppression of urine, or an involuntary passing of both urine and feces. There is reason to suppose, from the mechanism of the parts, that the vertebræ will seldom or never be dislocated outwards: They are usually forced direct— ly forward, or in some degree to the right or left side. On this account it is extremely difficult to accomplish their reduction, as the contents of the thorax or abdo— men must always lie between the injured parts and the means used for this purpose. Various means have been proposed, and different machines invented, for the reduction of dislocated ver— tebræ. These machines, however, should be laid aside, as being not only useless but dangerous; for whoever has paid attention to the anatomy of the spine, will see, that in dislocations of the vertebræ scarcely any advantage is to be gained from the appli— cation of much force, while a great deal of mischief may evidently ensue from it. When one or more of the vertebræ are luxated for— ward, of which we can only judge by an accurate ex— amination with the fingers, the most certain method perhaps of reducing the displaced bones is, to bend the body slowly and gradually forward, as far as it can be done, over a cask or any other cylindrical substance of a sufficient size. If the bone by this position regains its situation, the body should be immediately raised; and 197 Sect. VI. Spine, Os Sacrum, &c. and the attempt should be repeated when it does not succeed at first. When the displaced bone is pushed much out of its natural situation, neither this nor any other method will probably succeed; but it has certainly done so in different instances of partial dislocations. In bending the body forward, the two vertebræ lying contiguous to the one that is pushed forward are somewhat far— ther separated from each other; by which the displac— ed bone may, either by the compression produced up— on the abdomen, or by the ordinary action of the con— tiguous muscles, be forced into the situation it for— merly occupied. When the dislocated bone, instead of being pushed straight forward, is forced in any degree to one side, the body, while the reduction of it is attempting, should not only be bent forward, but somewhat to— wards the affected side; by which means the two con— tiguous vertebræ will be separated to a greater distance than they possibly could be by bending it either di— redly forward or towards the opposite side. When any part of the os sacrum is luxated, all we can do is to replace it with as much exactness as possi— ble by external pressure, and by bending the body for— ward in the manner we have mentioned. The coccyx is more frequently luxated than any of these bones, as it is equally liable to the same kinds of injuries, besides being more exposed to the effects of falls, &c. This bone may be luxated either outwardly or in— wardly. It is apt to be forced outwards in laborious births, when much violence is used in pulling down the head of a child. And in some instances the same accident has occurred from large collections of hard feces in the rectum. We judge of this injury having occurred, from the pain which takes place all over the region of the loins, particularly about the junction of the os coccyx with the sacrum; and from the displac— ed 198 Of Luxations Chap. XL. ed bone being discovered upon examination with the fingers. When the coccyx is luxated inwardly either by falls or blows, the patient complains of much pain, and a sensation of a tumor or some other hard body com— pressing the under part of the rectum; he is liable to tenesmus; he finds much difficulty in passing the fe— ces; and in some instances a suppression of urine takes place. On the finger being introduced at the anus, the displaced portion of bone is readily discovered. In outward luxations of the coccyx we seldom find much difficulty in replacing the bone by external pressure with the fingers; but it is often difficult to retain it in its situation. It can only be done by sup— porting the parts with proper compresses and band— ages. The T bandage answers for this purpose better than any other. In the reduction of an internal dislocation of this bone, the sore finger of one hand, after being immers— ed in oil, should be passed as far as possible up the rec— tum. By means of it the bone should be pressed into its situation; while with the other hand we support the parts which correspond with it externally. As dislocations of these bones, particularly of the coccyx, art very apt to excite inflammation, and as this is apt to terminate in abscesses which do not read— ily heal, we should omit nothing that may probably tend to prevent it. Blood letting should be prescrib— ed in proportion to the strength of the patient, partic— ularly local blood letting by means of leeches, or cup— ping and scarifying; a lax state of the bowels should be preserved; and the patient should be confined to that posture in which he is easiest, and to a low regi— men. SECTION 199 Sect. VII. of the Clavicles. SECTION VII. Of Luxations of the Clavicles. THE clavicles are joined externally to the scapula at the acromion, and their interior ends are sup— ported by the upper part of the sternum. As the clavicles are not possessed of much strength, and being tied at their articulations to the contiguous bones by ligaments, they are more exposed to frac— tures than to luxations. In some cases, however, they are luxated. This may happen at either extremity of these bones, but it is more frequent at their junction with the sternum than at the acromion: for the force by which luxations of the clavicles are produced, is for the most part applied to the shoulders, by which their opposite ends are most apt to be pushed out. As the clavicles are thinly covered, luxations of ei— ther of their extremities are easily discovered: They are commonly attended with a considerable degree of stiffness and immobility in the corresponding joint of the shoulder; for the neck of the scapula having lost its support, it is apt to be drawn out of its situation; by which the motion of every muscle connected with the joint necessarily becomes affected. A dislocation of the clavicle is easily reduced by moderate pressure with the fingers, especially if the arms and shoulders be at the same time drawn back; by which the space which the clavicle should occupy may be somewhat lengthened. It is more difficult, however, to retain the bone in its situation, as it is apt to be again displaced on the pressure being removed, by the ordinary action of the flexor muscles of the arm. We derive little advantage here from supporting the arm. On the contrary, when the end of the clav— icle 200 Of Luxations Chap. XL. icle connected with the sternum is displaced, raising the arm does harm, as it tends to push the bone far— ther out of its place. It is, therefore, highly neces— sary to attend to this distinction in the management of fractures and luxations of this bone. In the latter, the raised posture of the arm does mischief: in the former, it is of service, as we have shewn in Chapter XXXIX. Sect. VII. It is necessary, however, that the weight of the sore arm should be moderately supported, to prevent the shoulder from being too much drawn down. Besides this, the head and shoulders ought to be supported, and a moderate pressure made upon the displaced end of the bone. Various bandages have been proposed for this, particularly the long roller applied in such a manner as to form the figure of 8 upon the shoulders and upper part of the breast. No advantage, how— ever, is gained from any bandage of this kind, as it cannot be retained so firmly in its situation as to pro— duce any effect without impeding respiration. The machine represented in Plate LXXXVIII. fig. l. nearly the same as is commonly used for supporting the head, answers the purpose better than any other: for while it necessarily raises the head and keeps back the shoulders, the straps which pass over the upper part of the breast may be made to act with some force upon the dislocated end of the bone. It is scarcely necessary to observe, that the use of this machine should be continued for a considerable time, otherwise the bone will be apt to start, when the whole will be to do over again. SECTION 201 Sect. VIII. of the Ribs. SECTION VIII. Of Luxations of the Ribs. IT has been generally supposed that the ribs cannot be dislocated; and accordingly this variety of lux— ation has passed unnoticed by different writers on this branch of surgery. It is only at the articulation of the ribs with the vertebræ that luxations can happen; and as they are connected with these bones by very strong ligaments, it is usually imagined that they will break before they yield at the joints. It will readily appear, however, by an accurate ex— amination of the junction of the ribs with the verte— bræ, that they may be dislocated inwards. They cannot indeed be pushed either upwards, downwards, or backwards; but we know from experience, that a strong force applied near to their articulations will rupture their connecting ligaments, and thus push them forward. The fact has been proved by dissec— tion after death. The symptoms induced by dislocations will be near— ly the same with those which ensue from fractures of the ribs, viz. pain in the part affected, with difficult respiration; and if the end of the bone be pushed in— to the substance of the lungs, emphysematous swell— ings may ensue from it. A dislocation, however, may be distinguished from a fracture, by the pain being most severe at the articulation, and by no part of the bone yielding to pressure excepting at this very spot. I believe it will commonly happen, that the end of a luxated rib, in consequence of its elasticity, will re— turn to its natural situation when the cause which pro— duced the luxation is removed; but when it does not, the best method of reducing it will be to bend the body forward over a cask, or other cylindrical body, Vol. IV. O while 202 Of Dislocations of the Chap. XL. while the vertebræ immediately above and below the rib are pressed inward with as much force as can with safety be applied to them. After this, a thick com— press of linen should be laid over the vertebræ we have mentioned, and another long one along the most prominent part of the dislocated rib and the two im— mediately contiguous ; when, by means of a long broad roller passed two or three times round the body, such a degree of pressure may be made upon the ver— tebræ as will retain them in their situation; while the pressure made upon the projecting part of the rib tends to keep the end of it as steadily as possible in its situation till the ligaments that were ruptured be again united. No bandage used for this purpose should be applied with such tightness as to give any impediment to the breathing. The best method of preventing the roller from moving, is by the scapulary bandage passed over the shoulders, and a strap connected with it behind carried between the thighs and fixed to it before. No dislocation whatever is more apt to induce in— flammation of the contiguous parts, and other dis— agreeable symptoms. For the prevention and removal of these, nothing proves so effectual as copious blood letting, preserving the patient cool and at perfect rest, a low diet, and opiates if a cough ensues and becomes troublesome. SECTION IX. Of Dislocations of the Humerus at the Joint of the Shoulder. THE joint of the shoulder is formed by what is usually termed a Ball and Socket, the round head of the os humeri being lodged in a superficial cavity on the anterior part of the scapula. This cav— ity is so superficial, that in the skeleton it does not ap— pear 203 Sect. IX. Joint of the Shoulder. pear to contain above a tenth part of the head of the humerus; but in the recent subject it is much more considerable, by means of a cartilaginous brim, the capsular ligament, which surrounds the whole joint. By this mechanism, the shoulder enjoys more free motion than other joints: but it is at the same time exposed to more frequent luxations; insomuch, that there are more dislocations of the shoulder than of all the other joints of the body. The os humeri is most frequently luxated down— wards directly into the axilla, owing to the head of the bone meeting with less resistance in falling into this situation than in following any other direction. The head of the bone is sometimes pushed downwards and forward, and lodged beneath the pectoral muscle, when we find it resting on the ribs between the cora— coid process of the scapula and the middle of the cor— responding clavicle. In a few instances it is dislocat— ed downwards and backwards: but it can never be luxated upwards without being accompanied with a fracture of the acromion; of the coracoid process; or perhaps of both. The head of the bone, as we have already observed, for the most part takes that direction in which it meets with the least resistance; but this also depends in some degree on other causes, particularly on the part of the joint which received the injury, and on the sit— uation of the humerus at the time. Thus, if a blow falls upon the upper part of the joint, while the arm is in a direct line with the body, any dislocation that takes place will be downwards; while the head of the bone will most probably be forced downward and in— ward by any stroke given to the outside of the joint while the elbow is stretched back, and vice versa. We judge that the humerus is displaced by the patient being unable to move the arm; by severe pain being excited on every attempt to press the arm near to the side; by the arm being of a different length from the other; from its being longer or shorter O2 according 204 Of Dislocations of the Chap. XL. according as the head of the bone is lower or higher than its natural situation in the acetabulum scapulæ by the head of the bone being felt either in the arm pit beneath the pectoral muscle, or backwards below the ridge of the scapula; and by a vacancy being dis— covered beneath the acromion. If the two shoulders be examined together, which should always be done, the sound one will be found round and prominent, while the fore part of the other, if much tumefaction has not taken place, will appear to be flat, or even somewhat hollow. In luxations of long duration, the whole arm is apt to become œdematous, and to be in some degree de— prived of sensibility, from the pressure produced upon the nerves and lymphatic vessels of the arm by the head of the bone. All the other appearances we have mentioned, are likewise so obviously induced by the displacement of the head of the humerus, that scarcely any of them require to be explained. The head of the bone being thrown out of its natural situ— ation, must necessarily affect the action of every mus— cle of the joint: Some will be too much relaxed, while others are too much stretched out: The motion of the joint must of course be considerably impaired. It is obvious too, that much pain must be excited by the arm being pressed down to the side, as the head of the bone will not only be forcibly rubbed against some part of the scapula, but the soft parts on which it rests must be greatly compressed, at the same time that some of the contiguous muscles will be stretched to a degree which they cannot easily bear. In a simple dislocation of the humerus, our prog— nosis should in general be favourable; for in recent cases we seldom fail in reducing the bone. It must be allowed, however, that instances sometimes occur, in which the utmost difficulty is experienced in effecting a reduction; but this is seldom the case where the treatment has been properly conducted from the first. In dislocations, indeed, of long continuance, the most expert 205 Sect. IX. Joint of the Shoulder. expert practitioners often fail; for in such cases, the head of the bone has often formed a socket among the contiguous parts, from whence it cannot be dislodged without tearing asunder some of the muscles with which it is surrounded; and when dislodged, our en— deavours may be rendered abortive by the cavity where the bone should be lodged being too much di— minished for receiving it. In all cases, therefore, of long duration, although it may be proper to make some attempts to replace the dislocated bones, yet none that requires any great degree of force should be much persisted in, for there is always some uncertain- ty of their succeeding, while they necessarily produce a great deal of pain, at the same time that they are apt to render the motion of the head of the bone in the artificial socket, which it generally forms for itself, more stiff than it was before. In general it is supposed, that the reduction is more easily effected when the head of the bone is in the ax- illa than when it is pushed forward beneath the pec— toral muscle; and that in this situation it is more readily done than when it is lodged backward beneath the spine of the scapula. The latter I believe to be so; but I have not found in the treatment of the oth— ers that there is any difference between them. In the reduction of a dislocated humerus, we are in general told, that it is to be done by extension, coun— ter extension, and the subsequent application of such a force as is sufficient to replace the bone. These three indications, however, may all be comprehended in one. If a sufficient degree of extension be applied for drawing the head of the bone on a line with the acetabulum, the surgeon will seldom have any thing farther to do; for when brought to this situation, the reduction will almost in every instance be completed by the ordinary action of the muscles. All we have to do by counter extension, is to fix the body steadily while the arm is extending, and to prevent the scapula from being drawn forward by the O3 force 206 Of Dislocations of the Chap. XL. force necessary for moving the arm; for if this bone be not fixed, it in some degree moves forward with the humerus, by which the force employed for extending the arm is much lessened, at the same time that the cavity in the scapula in which the head of the bone is to be placed, is thus kept in a state of motion, by which the reduction cannot be so readily effected. This being done, our powers of extension are ap— plied to the arm, till the head of the bone be drawn on a line with the brim of the socket; when, as we have observed above, it will instantaneously slip into its place by the action of the contiguous muscles; so that there is no necessity for the application of any force for this purpose. Much mischief has often been done by force applied with this view, as we shall pres— ently see on considering the different modes of reduc— ing luxations of this joint; for it is obvious, if the force used for raising the humerus be applied before the end of it be drawn past the most projecting point of the scapula, that the two bones must be thus press— ed together so as to obstruct the reduction. Various modes have been proposed for the reduc— tion of dislocated shoulders, insomuch that we seldom meet with two practitioners who do it in the same manner: But as one or other of these must be prefer- able to the rest, and as it is of much importance to have this ascertained, we shall offer a few observations upon each of them, and shall more particularly de— scribe the one which we think should be adopted. 1. The humerus is often reduced by pressure with the heel upon the head of the displaced bone. The patient being placed upon the floor, the surgeon also sitting upon the floor, puts the heel of one foot, that of the left foot when he is operating upon the left shoulder, and vice versa upon the head of the bone; and laying hold of the sore arm with both hands, he extends the arm, at the same time that he endeavours with his heel to push up the bone. When 207 Sect. IX. Joint of the Shoulder. When the head of the bone has fallen directly downward into the arm pit, we are directed by some to place a small tennis ball or any other round sub— stance between it and the heel; by which the pressure may be continued with more certainty into the bot— tom of the axilla than where the heel alone is em— ployed. This method, however, is liable to three very im— portant objections. By laying hold of the sore arm, the joint of the elbow is considerably stretched, by which it may be much hurt, while a great part of the force is lost upon it which ought to have been applied entirely to the os humeri: By extending the sore arm, several of the muscles of the arm itself, as well as the biceps flexor cubiti, are put upon the stretch; by which the extension is made with much more diffi— culty than when these muscles are relaxed by the joint of the elbow being properly bent. And, lastly, whe— ther the heel be employed by itself or with a ball, it is much more apt to do harm than good; for if it be not applied with such nicety as to push the head of the bone directly towards the socket, it must necessa— rily force it against the neck of the scapula, or some others of the contiguous parts, and will thus tend in the most effectual manner to counteract the extension of the arm. Besides, in this manner, the arm must in every in— stance be pulled in a very oblique direction down— wards by the relative situation of the surgeon and pa— tient; whereas it should in some cases be raised near— ly, though not altogether, to a right angle with the body, and kept in that position while the extension is making. It may be alledged, indeed, that this method often succeeds, and that it has long been employed by some of our oldest and most experienced practitioners. This I admit: but I also know that it often fails, even with those who speak most favourably of it; and that other modes of treatment have in various instances O4 completed 208 Of Dislocations of the Chap. XL. completed the reduction, where this had previously proved unsuccessful. 2. Others attempt to reduce this dislocation, by en— deavouring to force the head of the bone into the socket with a rolling pin applied beneath it, while a sufficient force is employed for extending the arm, and for fixing the body in its situation. With a view to prevent the pin from hurting the skin, we are desired to cover it with flannel, and that part of it which passes into the axilla is directed to be more thickly covered than the rest. But however this may in some instances have suc— ceeded, it ought by no means to be received into prac— tice. It is evidently liable to most of the objections we have mentioned to the mode of operating with the heel; particularly to the risk of forcing the head of the humerus in beneath the neck of the scapula, and thus counteracting the force employed for extending the arm. It is obvious, too, even on the principle upon which it is recommended by those who practise it, that this, as well as the mode of operating with the heel, cannot be applicable where the head of the bone is lodged either backward, or forward beneath the pec— toral muscle: for the sole intention of both is to raise the head of the bone; and yet by some they are used indiscriminately, whether the bone be luxated down— wards, backwards, or forward. 3. The patient being properly placed, the body fixed by assistants, and the arm extended in the man— ner we shall afterwards direct, some surgeons make use of a towel or girth for pulling the head of the bone into the socket. The ends of the girth being tied to— gether, one end of the double is put over the arm, and carried near to the head of the humerus; and the other being passed over the neck of the operator, he forces up the end of the bone by raising his neck; and if this could be done with sufficient exactness, just when the head of the humerus has cleared the brim of the socket, no harm would arise from this part of the operation; 209 Sect. IX. Joint of the Shoulder. operation; but if the force for elevating the bone be applied before a sufficient degree of extension is made for this purpose, it must evidently do mischief, by locking the head of the humerus and neck of the sca— pula together: so that this is in some measure liable to the same objections we have stated to the mode of op— erating with the heel and rolling pin. These were the means usually employed for reduc— ing luxations of this joint; but being frequently found to fail, others have at different times been proposed in order to increase the powers of extension. 4. Of this nature is the Ambe of Hippocrates, as it is termed: It is the one that was chiefly employed by ancient practitioners, and in some parts of Europe it is still the only instrument used for this purpose: For this reason I have given a delineation of it in Plate LXXVI. fig. 1. but I do not by any means advise it to be employed. The powers of which it is possessed are great, but they cannot be properly applied; so that they are pernicious in proportion to their extent. It is liable in a tenfold degree to the objection we have stated above to the three preceding modes of reducing this bone, that of pressing the head of it against the neck of the scapula; by which one or other of them must frequently be broke, as must readily occur to whoever examines this instrument with attention; for instead of extending the arm before raising the end of it, the first action of this instrument is to raise the ex— tremity of the bone, by which it must frequently be so firmly pushed in beneath the neck of the scapula, as to counteract with much effect the power that is after— wards applied for extending it. 5. The method of reducing this joint by means of a ladder has been long known, but we hope not often employed. The dislocated arm being hung over the upper step of the ladder, to which height the patient must be previously raised, and being secured in this situation by assistants, the seat on which he is placed is suddenly drawn away; by which the whole weight of 210 Of Dislocations of the Chap. XL. of the body falls upon the luxated joint, and by which we are told the bone may often be reduced when other means have failed. The top of a high door is some— times used for the same purpose. Whether the door or ladder be employed, that part upon which the arm is made to rest should be well covered with several plies of soft cloth. 6. The patient being laid upon the floor, the bone has in some instances been reduced by two or three stout men standing upon a table and lifting him up by the luxated arm. 7. Upon the same principle, it has been proposed to raise the patient by the luxated arm with ropes run— ning over pullies fixed in the ceiling of a high roofed apartment. The jerk produced by the body being suddenly raised and let down, has in some cases suc— ceeded where other attempts to reduce the humerus had failed. This was first practised, I believe, by the ingenious Mr. White, of Manchester; and I have known it succeed in different cases of old luxations: But these methods are all liable to great objections. The force is too suddenly applied; by which more mischief may be done to the surrounding soft parts than can be com— pensated by the reduction of the bone. We know that muscles, blood vessels, and ligaments, will stretch to a considerable degree, if the extending force be ap— plied in a slow gradual manner: but we also know, that they very readily break when powerfully and suddenly stretched. Of this we have a remarkable instance in the bursting of the capsular ligaments of joints, which I believe to happen, as has been already remarked, in almost every case of luxation from ex— ternal violence. This leads us to say, that any force that is used for the reduction of luxations should be applied in the most gradual manner, and that the mode of operating we are now considering must frequently do mischief by tearing and lacerating the soft parts sur— rounding the joint. Of this I have had various in— stances 211 Sect. IX. Joint of the Shoulder. stances even where the teguments have been protect— ed in the most cautious manner, by covering them with soft flannel, and afterwards with firm leather, be— fore applying the ropes for extending the arm. Besides, in these modes of reduction, the arm must be always extended in the same direction, whether the bone be luxated forward, downward, or backward: Whereas the direction in which the arm is extended should vary according to these circumstances; as must be obvious to whoever attends to the anatomy of the parts concerned in the luxation. Nay, in one va— riety of luxation, irreparable mischief may be done to the joint, by extending the arm in a direction which, in another variety of the injury, might not only be proper but necessary. Where the head of the hume— rus is pushed forward beneath the pectoral muscle, or directly backward, we may readily suppose that it may be easily reduced by pulling the arm upward, as is done when the body is suspended by a pully in the manner we have mentioned; while much harm may be done by it where the head of the bone is lodged in the axilla, and pushed beneath the neck of the scapula. In this case the end of the humerus is often so firmly wedged between the scapula and ribs, that one or oth— er of these bones would necessarily break by the sud— den application of much force in this direction; and it can only be prevented by extending the arm some— what obliquely downward till the head of the humerus be quite disengaged. 8. A machine has been invented for conjoining the power of the ambe with the mode of operating we have just been considering; in which the patient's body is nearly suspended by the dislocated arm, and is sudden— ly raised and let down again while the operator en— deavours with the lever of the ambe to elevate the head of the bone. The invention is ingenious, and the instrument is evidently powerful; but if our ob— jections to these two modes of operating, taken separ— ately, are well founded, they are no less so when they are 212 Of Dislocations of the Chap. XL. are combined. The powerful action of the lever must be hazardous in proportion to the uncertainty of its application. While the body is quickly rising and falling, the lever cannot possibly be applied with ex— actness to the end of the bone; and if it be made to act with much force before the head of the humerus is cleared of the scapula, one or other of these must nec— essarily be fractured. 9. When the more simple methods of reducing lux— ations have failed, ropes and pullies have sometimes been employed for dislodging the displaced bones, Of these, different forms may be seen in Plate LXXVII. fig. 2. in Scultetus, Plate XXII. fig. 1. and in Plate X. fig. 7. of Defagulier's Experimental Phi— losophy. By means of one or other of these, any de— gree of force may be applied that can ever be requir— ed for this purpose. 10. But when recent cases are properly managed, luxations may in almost every instance be reduced without any assistance from machinery. I have often succeeded by the moderate extension I was able to make of the arm with one hand, while the other was employed in pressing back the scapula. This, howev— er, requires all the muscles of the arm and fore arm to be as much relaxed as possible; which we accomplish by bending the elbow moderately, raising the arm to a height somewhat less than a right angle with the body, and preserving it in such a direction as to pre— vent either the pectoral or extensor muscles of the arm from being stretched. When the arm is in this situa— tion, we often find luxations easily reduced which had previously resisted the greatest force: for in this man— ner we not only relax the muscles of the arm, but the capsular ligament of the joint; by which the head of the bone returns more readily by the opening at which it was forced out than it otherwise possibly could do. For when the ligament is much stretched, the neck of the bone will be firmly grasped by it, by which our being 213 Sect. IX. Joint of the Shoulder. being able to return it will necessarily be rendered more uncertain. More force, however, is sometimes required than can be applied in this manner; and the following is the method by which I have in every instance of re— cent luxations succeeded. The patient is seated upon a chair, and his body secured by a long broad belt passed round it, and given to assistants, or tied round a post: a firm band of leather, four or five inches broad, and lined with flannel, as is represented in Plate LXXVII. fig. 3. is now to be tied round the arm im— mediately above the elbow. The three straps or cords connected with this band being given to assistants, they must be desired to extend the arm in the relaxed po— sition we have mentioned, and in a slow equal manner, while another assistant standing behind is employed in pressing the scapula backward. The surgeon himself stands most conveniently on the outside of the arm: His business is to direct the assistants in the degree of force they are to employ, and to point out the direc— tion in which the arm is to be extended; he may also support the fore arm and retain it bent at the elbow, in the manner we have mentioned. As soon as the head of the bone is drawn clearly past the brim of the socket, the extension of the arm should be somewhat relaxed, when the reduction will for the most part be accomplished by the action of the muscles of the joint; or it will be readily effected by moving the arm gently in different directions. A crack is heard on the bone slipping in; the patient finds immediate relief; and the anterior part of the shoulder acquires its usual prominent form. The direction in which the arm is extended must depend upon the situation of the head of the bone: that in which it will meet with the least resistance is always to be preferred. When the head of the bone is pushed forward, and lodged beneath the pectoral muscle, the arm should be raised to a right angle with the body, and the same direction will answer where it is 214 Of Dislocations of the Chap. XL. is pushed backward: But in the most frequent kind of luxation of this joint, where the head of the bone is lodged in the arm pit, the arm should uniformly be drawn somewhat obliquely downward: If extended when raised to a right angle with the body, it would be drawn against the neck of the scapula, by which much pain would be excited, and the reduction frustrated. Of this I have seen many instances, as every practi— tioner must have done. It should be a general rule in the treatment of eve— ty luxation to vary the direction in which the exten— sion is made as soon as we meet with any considerable resistance; but in luxations of the humerus, attention to the observations we have just thrown out will for the most part prove sufficient. In reducing luxations of this joint, it has been the prevailing practice to press the scapula forward and downward: Nearly the reverse of this, however, should be adopted. By pressing the scapula down— ward we force it against the head of the humerus, the very thing we ought most carefully to avoid: and by forcing it forward, it is evident that the end of the hu— merus will not be so easily drawn out from beneath it as when the assistant is desired to pull it backward in the manner we have mentioned. 11. The mode of treatment I have just been de— scribing will succeed in almost every instance of recent luxation; and it will seldom fail even in cases of long standing, where reduction of the dislocated bone is practicable: But when a greater force is required than can be applied in this manner, the instrument repre— sented in Plate LXXVIII. maybe employed. It was invented by the late Mr. Freke of London; and it answers the purpose of extension better, and with more exactness, than any other I have seen. It is de— lineated exactly from the plate given of it by Mr. Freke; but it admits of some improvements. The strap AA, which passes over the shoulder, presses down the scapula, and thus impedes the reduction of the bone: PLATE LXXVIII.  215 Sec. IX. Joint of the Shoulder. bone: It should therefore be either entirely wanting, or made with a slit to pass over the arm so as to draw back the scapula: in which case, instead of passing ob— liquely downwards to be fixed in the floor, it should pass straight across, and be fixed in a post on a line with the shoulder. We have already observed that the use of a lever in raising a luxated humerus is both unnecessary and dangerous: The lever of this instrument, therefore, instead of being moveable, should be fixed so as only to serve as a support to the arm; or if it ever be used as a lever, it should be managed with the utmost cau— tion. The principal advantage derived from this in— strument is our being able by means of it, to apply any force that may be necessary in the most gradual man— ner, an object of the first importance in the reduction of luxations: It also extends the arm in any direction we may judge proper; by which it can at once be adapted to any variety of such injuries. Swelling, pain, and inflammation, when they occur as consequences of luxations of the arm, are to be re— moved by the remedies usually employed in such cas— es, but chiefly by local blood letting by means of leeches. The round head of the biceps flexor cubiti, which passes through the joint of the shoulder, and is lodged in a groove in the head of the humerus, is apt to be separated from this bone when it is forced far out of its natural situation, and thus induces a stiff unwieldy state of the arm: for the most part it returns immedi— ately to this groove on the dislocation being reduced; and we suspect that it continues to be displaced when any unusual pain, stiffness, or tension remain. The most certain method of replacing it is to move the arm from time to time in every variety of way; and we know that it is replaced, by an instantaneous removal of the distress. The glenoid cavity of the scapula being very super— ficial, the head of the humerus is apt to fall out again, even 216 Of Dislocations of the Chap. XL. even after it has been completely replaced; particu— larly when it has been frequently luxated. The most certain method of preventing this is to support the arm in a sling, as is represented in Plate LXXXI. fig. 2. till the parts recover their tone. Blisters applied to the shoulder, and pumping cold water over the joint, have also proved useful for this purpose. SECTION X. Of Luxations of the Fore Arm at the Joint of the Elbow. THE bones of the sore arm at the elbow are more frequently dislocated upward and backward than in any other direction: They can scarcely be luxated laterally or forward, if the injury be not at the same time accompanied with a fracture of the olecranon or top of the ulna, as will be readily perceived on exam— ining the connection of that process with the cavity in the posterior part of the os humeri. As the joint of the elbow is not deeply covered with soft parts, any luxation of the bones is easily discover— ed as long as swelling and tension have not taken place. When these symptoms occur to any extent, it is often difficult to distinguish either the nature or ex— tent of the injury with which they are connected. When the luxation is backward, the olecranon is felt on the back part of the arm, and the condyles of the humerus are pushed forward. When the olecranon is broke, and the ulna and radius pushed forward, they are also apt to be drawn upward on the anterior part of the humerus, when the condyles of that bone are discovered behind. The extent of the joint is so con— siderable from one side to the other, that the bones composing it can never be completely luxated laterally, unless 217 Sect. X. Fore Arm at the Elbow. unless the soft parts with which they are covered are much lacerated. In whatever way they are displaced, the joint becomes immediately stiff and immoveable. In the reduction of these dislocations the patient should be seated on a chair of a convenient height, and the arm firmly secured by an assistant: where the bones are luxated backward, the fore arm should be moderately bent, in order to relax the flexor muscles: while in this position it should be slowly and gradual— ly extended; and if care be taken to increase the cur— vature of the elbow in proportion as the extension is made, we will seldom or never fail in completing the reduction. Where the olecranon is broke, and the ends of the radius and ulna pushed forward and drawn up upon the humerus, we are under the necessity of extending the arm while in a straight position, as in this case the heads of these bones are pushed back up— on the anterior part of the humerus on the least at— tempt to bend them. The extension should be con— tinued till the ends of both bones are pulled some— what lower than the most depending point of the hu— merus, when they will either regain their situation by the action of the muscles, or be easily forced into it. In lateral dislocations of these bones the extension must also be continued till they have clearly passed the end of the humerus, when by moderate lateral pres— sure they will for the most part be easily replaced. Of whatever kind the dislocation may be, the ex— tension should be made by assistants grasping the arm immediately above the wrist; and while they are thus employed, much advantage may be gained by the sur— geon pressing down the heads of the bones. In two cases of dislocation of these bones, where their heads were drawn up upon the back of the hu— merus, the reduction was not accomplished, although a great force was applied, not only in pulling at the under part of the arm, but in pushing down the heads of the displaced bones. In one of them, where the olecranon was pushed through the teguments, that P part 218 Of Dislocations, &c. Chap. XL. part of the bone was sawn off, by which the reduction was effected: In the other, this expedient was not ad— vised; and the practitioner finding all his efforts to reduce the bones prove abortive, the limb was ampu— tated. As the extension in both was applied while the arm was stretched out, and as I have never failed in similar cases where the arm was bent, I conclude, that in the one the arm would have been saved, and in the other the joint preserved entire, if this practice had been adopted. The reduction being completed, the fore arm should be kept in that position which tends most effectually to relax all the muscles connected with it. The el— bow being moderately bent, answers this purpose in the most certain manner. These bones, when reduced, do not readily fall out again; but it is proper in this, as in every case of lux— ation, to preserve the limb as much at rest as possible till the injured parts have recovered their tone. The bones of the fore arm are also liable to be dis— located in their connection with each other. At the joint of the elbow a projecting part of the radius is lodged, and moves in a corresponding cavity of the ul— na; and below, a portion of the ulna is received by a similar cavity in the radius. Instances have occurred of these bones being separated from each other at both these points of connection; but any separation of this kind is more apt to happen at the wrist than at the el— bow. It is known to have occurred, by all the usual signs of luxations: By pain, swelling, and distortion in the injured part; by the motion of the joint being impaired; and by manual examination. In general the displaced bone is easily put into its situation; but for the most part we find it difficult to retain it. The most certain method of effecting this, is to put a long firm splint along the outside of the arm from the elbow down to the points of the fingers, and another of the same length on the inside; the whole to be secured with a flannel roller, and the arm hung 219 Sect. XI Of Luxations, &c. hung in the sling represented in Plate LXXXI. fig. 2. By this the rotatory motion performed by the radius, and the pronation and supination of the hand, is pre— vented; and if this is guarded against for a sufficient length of time, a cure may at last be expected: While want of attention to this point is frequently the cause of the joint at the wrist remaining stiff for life; of which I have met with various instances. SECTION XI. Of Luxations of the Bones of the Wrist. THE bones of the wrist are not so frequently lux— ated as might be expected from the smallness of their size, owing to their being firmly connected by ligaments, as well as to the strength which they derive from the whole tending to form a kind of arch; the convex part of which being on the outer or back part of the hand, where it is most exposed to injuries, is particularly well calculated for preventing any of the bones from being displaced. Degrees of force, however, are sometimes applied to them which they are unable to resist. From their form, it will appear that they will most readily be dis— located outward. The three superior carpal bones that form a kind of projecting head, that is lodged in a superficial cavity in the under extremities of the ul— na and radius, may either be dislocated at this joint, or they may be separated from the five inferior bones of the wrist. In some instances one or more of these bones are separated from each other; and in others they are dislocated at their connection with the bones of the metacarpus and the superior bone of the thumb. P2 As 220 Of Luxations of the Chap. XL. As these bones are not thickly covered with soft parts, the nature of the injury becomes immediately obvious when they are completely luxated: But in some cases, where perhaps a single bone is only par— tially displaced, if the parts be not examined with at— tention, the symptoms which occur are apt to be at— tributed to a sprain; and the real cause of them be— ing overlooked, a permanent lameness is thus induc— ed, which with much ease might have been prevent— ed. Of this I have met with various instances. Similar occurrences, however, may always be prevent— ed by an early and attentive examination of the in— jured parts. In reducing luxations of these bones, we are in general desired to stretch the arm and hand upon a table, and while they are in this position to push them into their situations: But it is better to have the arm and hand supported by two assistants, as in this situation the surgeon gets ready access to each side of the wrist. The assistants should be desired to keep the parts sufficiently firm, but not to stretch them; and when in this situation, the surgeon will seldom find it difficult to push the bones into their places. They must be retained by splints and bandages in the man— ner mentioned in the last section; and as dislocations of these bones are very apt to induce inflammation of the ligaments and other contiguous soft parts, repeated applications of leeches should be advised as the most certain preventative. SECTION PLATE LXXIX.  221 Sect. XII. Metacarpus and Fingers. SECTION XII. Of Luxations of the Bones of the Metacarpus and Fingers. WE have seen in the last section that the meta— carpal bones may be dislocated at their junc— tion with the bones of the wrist; and they are some— times displaced at their under extremities, where they are connected with the bones of the fingers. They are not so frequently luxated, however, as at first view might be expected; probably from the joint of the wrist being so moveable, that the whole hand readily yields to any force that is applied to it. The bones of the fingers and thumb are also some— times luxated; but we likewise consider the mobility of these bones as the principal reason of their being less frequently dislocated than many of the largest and strongest bones that are much more firmly connected together. Dislocations of these bones are easily discovered by the usual symptoms which take place in luxations; but particularly by the deformity which they produce, which in this situation is always conspicuous. When any of the metacarpal bones are displaced at their connection with the bones of the wrist, the best method of reducing them is, by keeping the arm stead— ily fixed, and pushing them from above downward, while the hand remains loose and moveable. When the first phalanx of any of the fingers is moved from its junction with the corresponding metacarpal bone, it is to be replaced by one assistant fixing the hand, while another draws down the dislocated finger, which should be done by grasping the first phalanx only, in order to prevent the other joints of the finger from be— ing hurt. Dislocations of all the other joints of the fin- P2 gers, 222 Of Luxations of the Femur Chap. XL. gers, as well as of the thumbs, are to be managed in the same manner. In the reduction of these dislocations, the bone should not be pulled down till it be somewhat raised or elevated from the contiguous bone; for as all the bones of the fingers and thumbs, as well as those of the metacarpus, are considerably thicker at their ex— tremities than in any other part, these projections are apt to be forced against each other when the extension is made in a straight direction. In this manner the greatest force has frequently been employed in vain; nay, fingers have been amputated where this cause alone prevented luxations from being reduced, and in which a very inconsiderable force would have proved successful, if the displaced bone had been somewhat separated from the other before any force was applied for extending it. SECTION XIII. Of Luxations of the Femur at the Hip Joint. THE socket or acetabulum formed by the ossa in— nominata for lodging the head of the thigh bone is so deep; the brim of the socket in a recent subject contracts so much as even to grasp the neck of this bone; the head of the bone is so firmly tied down to the bottom of the socket by a strong ligament; and it is so confined by strong muscles, that we would not a priori suppose that it could be luxated by external violence: We would rather imagine that it would break at the neck where it is weakest, than that the head of it should ever be forced from its socket: This opinion has accordingly been adopted by many in all ages. For a considerable time I was disposed to favour it, from 223 Sect. XIII. at the Hip Joint. from having observed several cases which at first were supposed to be luxations, but which proved to be frac— tures of the neck of the femur. In the course of the last few years, however, I have seen several cases in which I was convinced that the thigh bone was lux— ated. The nature of the symptoms gave reason to imagine that they arose from luxations; and they were proved to do so by the patient's being instanta— neously and completely relieved, on the head of the bone being replaced. In treating of fractures of the thigh bone, we men— tioned the circumstances by which fractures of the neck of it may most readily be distinguished from lux— ations: We must therefore refer for this part of our subject to the eleventh section of the preceding chap— ter. It is said by authors, that the head of the femur may be luxated in various directions, namely, upward and backward, upward and forward, downward and backward, downward and forward, and I may add di— rectly downward. That all of these may happen, I cannot take upon me to deny; but I believe few prac— titioners have met with an instance of the first and third. The second variety, where the head of the bone passes up upon the os pubis, may happen; as may likewise the last, where it is forced directly down: but I have never seen any variety except that in which the head of the femur is pushed downward and forward, and lodg— ed in the foramen ovale. All practitioners admit, that the bone is most frequently dislocated in this direc— tion; and an examination of the skeleton, as well as of the recent subject, will show why it should be so. The brim of the socket over all the upper and back part of it, is not only stronger, but more elevated than in the rest of it. It falls away as it descends; and on the anterior under part of it there is a considerable va— cancy in the bone, the space being filled with a liga— ment only: and as this opening is sufficiently large to P4 admit 224 Of Luxations of the Femur Chap. XL. admit the head of the femur, we are led to imagine that luxations will be most apt to occur here. Every luxation of the femur must be productive of lameness, and of pain, tension, and other symptoms with which luxations in general are accompanied. When the head of the bone passes upward and back— ward, the leg will be considerably shorter than the other; insomuch that the points of the toes will only touch the ground when the patient is standing upon the other foot; the great trochanter of the thigh bone will be much higher than in the other side; the knee and foot will be turned inward; and a good deal of pain will be induced by every attempt to turn them out. When the femur is luxated upward and forward, the leg will be shortened; the head of the bone will be felt resting upon the os pubis in the groin; the great trochanter will be on the upper and anterior part of the thigh near the groin, while a vacancy will be discovered in that part of the hip which it ought to occupy; the knee and toes will be turned outwards; and if the dislocation be not soon reduced, pain, ten— sion, and inflammation, will probably occur in the spermatic cord and testis, from the pressure made up— on the cord by the head of the bone. If ever this bone be luxated downward and back— ward, the leg will be considerably longer than the oth— er; the knee and toes will be turned inward; and the great trochanter will be much lower than the same protuberance of the other limb. When the head of the bone passes directly downward, the leg will also be longer than the other, and the trochanter will likewise be lower; but the knee and toes will retain nearly their natural situation; only, every attempt to move them will be productive of pain. In the most frequent luxation of the femur, the leg appears to be considerably longer than the other; the knee and points of the toes are turned outward, nor can 225 Sect. XIII. at the Hip Joint. can they be moved either farther outward or inward but with much pain; all the muscles in the internal part of the thigh are tense and painful; the femur cannot be felt on the outside farther up than the mid— dle of the thigh; a vacancy is discovered in the usual seat of the great trochanter, which is found farther down and on the anterior part of the the thigh, while the head of the femur is plainly felt a little below the groin, being seated, as we have observed above, in the foramen ovale. In all luxations of the femur, the difficulty and un— certainty of reducing them has been considered as so great, that in general we have been advised to give a very doubtful prognosis of the event. In cases of long duration this should always be done: for besides other causes which add to the difficulty of reduction, the muscles here are so strong that they resist, in the most powerful manner, every attempt to dislodge the head of the bone after it has been long fixed among them; by contracting round the neck of the bone, they must even be tore asunder before it can be re— duced: But in recent luxations we have not this dif— ficulty to encounter; and we know that with proper management the bone may in almost every instance be reduced. The reduction of this bone is always attempted by pulling the limb downward; and it seems to be an opinion very universally received, that any force we employ should be applied in this direction. Some advise the limb to be drawn directly down from the part in which the head of the bone is lodged; others desire it to be pulled exactly in a line with the hip joint, while others turn the knee somewhat inward. The patient being placed upon his back and properly secured, the limb is extended in one or other of these directions, either till the reduction is accomplished, or till such a force is applied as makes the operator afraid of doing harm were he to proceed farther. It 226 Of Luxations of the Femur Chap. XL. It must be allowed that dislocations of the femur have in various instances been reduced in this man— ner: it might often succeed where the head of the bone is forced upwards; but I may without hesitation assert, that even in this case the reduction might be effected with less force in a different manner; and in a great proportion of cases where the head of the bone is lodged in the foramen ovale, or where it is forced directly downwards, that we must necessarily fail entirely by confining the line of extension to any of the directions we have mentioned. In whatever way the head of the femur is luxated, it must pass over some inequalities or prominent parts of the contiguous bones: These it must again pass over before it be reduced; at least this must be the case if we wish it to return by the same route: And it will be admitted in the treatment of luxations to be a good general rule, to endeavor to replace the bone by the opening at which it passed out. But where the limb is only pulled downward in the usual way, the head of the bone will be forced against the projecting brim of the socket, if the dislocation is upward; or it will be drawn to a still greater distance from the joint where the bone is dislocated either directly downward, or lodged in the foramen ovale in the upper and inner part of the thigh. Wherever the head of the bone may be lodged, it should be completely raised above any projecting part of the contiguous bones before any other attempt is made for reducing it. As this will remove the principal impediment to the reduction, if the muscles of the limb be at the same time relaxed, it will easily be drawn into the socket when the disloca— tion is upward, or pushed into it where the head of the bone is already beneath it. In the most frequent variety of this luxation, where the head of the bone is pushed downward and for— ward, I have succeeded in the following manner: The patient is laid upon his back across a bed, and firmly secured by an assistant or two: A broad strap, or ta— ble  PLATE LXXX. 227 Sect. XIII. at the Hip Joint. ble cloth properly folded, is passed between his thighs and over the groin on the sound side, and given to two other assistants: A similar strap is passed round the luxated thigh as near as possible to the head of it; the ends of which must be given to an assistant standing on the opposite side: The belt represented in Plate LXXVII. fig. 3. being previously fixed upon the under part of the thigh, the straps connected with it are given to an assistant or two, while the knee is sup— ported by another assistant with the leg moderately bent. The thigh is now to be moderately stretched by the assistants who have the charge of the straps at the under part of it; but the extension should not be carried farther than what may be considered as neces— sary for drawing the head of the bone down to the un— der part of the foramen ovale; and this we may al— ways effect with a very moderate force. The strap round the root of the thigh must now be firmly pulled by those who have the charge of it; who, standing somewhat higher than the patient, should draw the thigh upward and inward; and the extension should be continued in this direction till there is reason to suppose that the head of the bone is clearly raised from the foramen in which it was lodged. At this time the person who has the charge of the knee should be de— sired to move it somewhat inward, and to push the thigh upward and obliquely outward: he will do this with the greatest certainty of succeeding, if he secures the knee with one hand and the foot with the other, at the same time that he takes care to keep the leg just so much bent as may relax all the flexor muscles with— out stretching the extensors. If the different assistants perform their parts properly, the first attempt will prove successful; but if any of them have failed, par— ticularly if the head of the bone has not been suffic— iently raised from the hollow in the foramen ovale before being pushed upwards, the attempt must be re— peated. As 228 Of Luxations of the Femur Chap. XL. As the head of the bone may for the most part be felt outwardly, the surgeon may in general ascertain with certainty whether it be sufficiently raised or not. If he finds it rise easily, the force may be continued till it appears to be about an inch higher than when it was first applied: while, on the contrary, if it yields with difficulty, there will be reason to suspect that some part of the head of the bone is fixed or locked in the upper part of the foramen ovale; in which case the force in this direction should be discontinued, and the other assistants at the knee being directed to in crease the extension downward, it will afterwards be more easily raised. In whatever direction the bone may be dislocated, this is the point requiring most of our attention, to raise the head of the bone sufficiently before any at— tempt is made to force it into the socket. When this is effected, a very slight force will in general draw it down when the dislocation is upward; and when dislocated downward, whether it be somewhat back— ward or directly on a line with the socket, it will be easily pushed up. In this manner recent luxations of this joint may for the most part be reduced; and the same treatment is perhaps the best even in luxations of long duration. In these it will sometimes fail; but it will succeed, I believe, as frequently as any other that has yet been proposed, while it is not productive of the dreadful pain which commonly ensues from the use of some of those machines that have been invented for making a greater extension of the limb. When any additional force, however, is judged to be necessary, it may either be obtained by a proper application of Mr. Freke's machine represented in Plate LXXVIII. of Mr. Pe— tri's in Plate LXXVI. fig. 2. or of the pullies and ropes represented in Plate LXXVII. It should be remarked, however, that no assistance of this kind can ever be applicable where the luxation is downward. Extension of the limb having been considered 229 Sect. XIII. at the Hip Joint. considered as necessary in every variety of luxation, it has often been indiscriminately employed, whether the head of the bone was placed above or below the socket: It is obvious, however, that it is in the former only that it can ever prove useful; and in the latter, that much mischief may ensue from it. The violent distension of the muscles, and extensive laceration of the articular ligaments, with which luxa— tions of this bone must always be accompanied, ren— der much care and attention necessary long after the reduction is accomplished, Local blood letting with leeches, or cupping and scarifying, proves particularly useful here, and should be repeated more or less fre— quently according to the violence of the symptoms and age and habit of the patient; and till the parts may be supposed to have recovered their tone, the patient should be kept as much at rest as possible. By many it is imagined that the femur may be par— tially luxated; and the appearances which are sup— posed to arise from what is termed a Subluxation of this bone are described by authors: Of these, how— ever, I have taken no notice, as it is not my opinion that this bone can be partially luxated. The head of it is so round, and the brim of the socket so narrow, that whoever examines them with accuracy will be convinced that it cannot happen. The head of the bone may in a gradual manner be pushed out of the acetabulum by a tumor at the bottom of it, but I do not suppose that this can ever occur from external vi— olence. SECTION 230 Of Luxations of the Chap. XL. SECTION XIV. Of Luxations of the Patella. THE patella may be either partially or completely luxated, and it may be displaced either upward or downward, outward or inward: It may also be lux— ated by itself, or it may be displaced along with the tibia and fibula in luxations of these bones. It can— not, however, be completely luxated in any direction, if it be not accompanied with a rupture of the liga— ment which ties it to the tibia, or of the tendon of the rectus muscle connected to the upper part of it; or perhaps of both: and it will be more readily dislo— cated inwardly than in any other direction, owing to the internal condyle of the femur being somewhat less prominent than the other: for as this bone is placed in some degree between these condyles, it will neces— sarily be most easily forced out at that side where it meets with the least resistance. Luxations of this bone are for the most part easily discovered, as it is thinly covered with soft parts: But when it has been long displaced, it is apt to induce so much tumefaction, not only about the joint, but over all the contiguous parts, as to be distinguished with difficulty. Even the most partial luxation of the pa— tella always gives considerable lameness and much pain on every attempt to move the joint. In the reduction of a luxated patella, the patient should be placed either on a bed or on a table, and his leg should be stretched out and kept in this pos— ture by an assistant. The surgeon should now lay hold of the bone and endeavour to push it into its sit— uation; but instead of pushing it directly forward, it should first be somewhat raised, otherwise we will be apt to force it against the condyles of the femur or head 231 Sect. XV. Tibia and Fabula. head of the tibia. The best method of effecting this is to press down the side of the bone most distant from the joint; by which the opposite side of it will be el— evated, when a very moderate force will press it into its place. When the patella is drawn out of its situa— tion by the tibia and fibula being displaced along with it, it cannot be replaced till the reduction of these bones is accomplished. SECTION XV. Of Luxations of the Tibia and Fibula at the Joint of the Knee. THE tibia is the only bone of the leg that is im— mediately concerned in the joint of the knee; but as this bone cannot be dislocated without drawing the fibula along with it, we think it right to mention them together. As more strength is required in the knee than in any other joint of the body, the bones of which it is chief— ly formed, the femur and tibia, are connected together by the strongest kind of articulation, namely by Ging— limus or the Hinge—like joint: the surfaces of the two bones are very extensive, and they are firmly tied to— gether by strong ligaments: There is also reason to suppose that the moveable cartilages placed between the ends of these bones have some influence in lessen— ing the friction of the joint, and in thus rendering it more firm than it otherwise would be. The great strength of this joint is the reason of its being less frequently dislocated than any other in the body: It cannot indeed be completely dislocated but by the application of so much force as will not only rupture the teguments which cover it, but the strong ligaments and tendons which tie the bones together. As 232 Of Luxations of the Chap. XL. As this requires a very unusual degree of violence, these bones are seldom forced entirely past each other; and the same reason even prevents then from being often partially luxated. When either a complete lux— ation, however, or a partial one, is produced, it may happen nearly with equal ease on either side; but the bones will be more readily forced backward than for— ward, owing to the flexor muscles and tendons of the leg being much stronger than the extensors. The most partial luxation of this joint is readily distinguished, not only by the violent pain which it excites, and the lameness with which it is attended, but by the deformity which it produces, and which is al— ways obvious on comparing both knee joints to— gether. When the patella is dislocated at the same time with the tibia and fibula, it will for the most part be reduced along with these bones; but when this does not happen, is may be afterwards replaced in the man— ner we have mentioned in the last section. Luxations of this joint are to be reduced by fixing the thigh with sufficient firmness, and extending the leg till the ends of the bones are entirely clear of each other; when the tibia and fibula connected with it will be easily replaced. In partial luxations, the de— gree of extension necessary for this will be inconsider— able; but where the bones are completely displaced, more force will be required. It is scarcely necessary to observe, that the muscles of the leg should be as much relaxed as possible while the force for extending it is applying. Scarcely any joint is so apt to suffer from inflam— mation as that of the knee; so that in all such inju— ries as this, where the surrounding soft parts are so li— able to inflame and become painful, the most strict an— tiphlogistic course becomes requisite; local blood let— ting should be prescribed, and repeated according to the violence of the symptoms and strength of the pa— tient; 233 Sect. XVI. Foot at the Ancle. tient; and the limb should for a considerable time be kept at perfect rest. The upper end of the fibula, as well as the under extremity of it, is sometimes separated by external vi— olence from the tibia. As the symptoms which this excites are similar to those which occur from sprains of the muscles, the real nature of the injury is often overlooked. It may almost always, however, be dis— tinguished by an attentive manual examination. The only method of obtaining relief is by replacing the bone, which for the most part is easily done, and re— taining it with a proper bandage till the parts have re— covered their tone. SECTION XVI. Of Luxations of the Foot at the Joint of the Ancle. THE joint of the ancle is formed by the upper part of the astragalus or first bone of the foot, being received into a cavity in the under extremity of the tibia; which is bounded externally by the end of the fibula, projecting a considerable way past the end of the tibia. The astragalus may be dislocated either backward or forward, outward or inward, but is more frequently pushed inward than in any other direction. The great strength of the tendo achillis prevents it from slipping easily backward, and it has also some effect in preventing it from going forward. It cannot be push— ed outward without breaking the projecting end of the fibula. Dislocations of this joint are in general easily dis— covered by the pain and lameness which they pro— duce, as well as by the obvious alteration which they occasion in the appearance of the foot. When the Vol. IV. Q astragalus 234 Of Luxations of the Chap. XL. astragalus is pushed forward, the foot appears to be lengthened and the heel shortened; when pushed backward, the foot is shortened and the heel length— ened; and when luxated either outwardly or inward— ly, there is always a preternatural vacancy on one side, of the joint and a prominency on the other. In the reduction of this luxation, the patient should be placed either upon a table or on a bed, and the leg with the knee bent should be firmly secured by an as— sistant or two. The foot is now to be put into that situation which tends most effectually to relax all the muscles which belong to it; and being given to an as— sistant, he must be desired to extend it in that direc— tion till the most prominent point of the astragalus has clearly passed the end of the tibia, when the bone will either slip into its place, or may be easily forced into it. As the upper part of the astragalus is not perfectly round, but rather somewhat hollow, this joint is more apt to be partially luxated than any other formed by a ball and socket, as this in some measure is: Partial luxations of it, however, are easily reduced. Besides the usual antiphlogistic course which we have recommended to be observed after all luxations of the large joints, it is particularly necessary in luxa— tions of the ancle to keep the limb for a considerable time at the most perfect rest, especially where the un— der extremity of the fibula is broke by the foot being forced outward; for as the stability of the joint de— pends in a great measure on this bone, if it be not ei— ther rightly replaced or retained in its situation till the cure of the fracture be effected, it may afterwards con— tinue weak during life, or be attended with stiffness and pain to a great height. Any weakness which suc— ceeds to injuries of this kind, if it be not removed by these measures, will be most effectually obviated by a firm splint of thin iron connected with the shoe, and applied along the outside of the leg; or by an instru— ment invented by the late Mr. Gooch, represented in Plate LXXXIII. fig. 4. SECTION PLATE LXXXI.  235 Sect. XVII. Os Calcis, &c. SECTION XVII. Of Luxations of the Os Calcis and other Bones of the Foot. THE os calcis, which is the largest bone of the foot, is sometimes dislocated laterally, where it is con— nected with the astragalus. It is prevented from be— ing pushed forward by the other bones of the foot; and the tendo achillis, which is inserted into a large rough process of this bone, which projects backward and forms the heel, prevents it from being luxated in this direction. The astragalus and os calcis are sometimes luxated at their junction with the os naviculare and os cu— boides; and as this joint, if it may be so termed, is at no great distance from the ancle, this variety of luxa— tion has, in some instances, been mistaken for luxa— tions of that joint. The foot may at this part be pushed either outward or inward, or it may be forced directly downward: It will rarely be luxated upward, as it can scarcely be exposed to external violence in such a direction as could have this effect. Luxations of any of these bones are readily discov— ered by the pain and lameness with which they are always attended; as well as by the alteration which they produce on the shape of the foot. The os calcis, when displaced, is more difficult to reduce than almost any other bone of the foot: It can only be done by fixing the leg and foot in such a po— sition as tends most effectually to relax the different muscles which belong to them; and while they are in this position, by endeavouring to force the bone into its situation; and this will be more readily effected, if during the operation the foot be moderately extended. Q2 In 236 Of Luxations, &c. Chap. XL. In luxations of the astragalus and os calcis with the os naviculare and os cuboides, as the anterior part of the foot is apt to be drawn towards the heel, it be— comes necessary to extend it to such a degree as may clear the bones on the opposite sides of the joint of each other; for till this be done, the reduction can— not be effected, while the bones will immediately slip into their situation as soon as they are drawn past each other. The other three bones of the tarsus, usually termed the Cuneiform Bones, as well as the Metatarsal Bones, and the Bones of the Toes, are all liable to be luxated, and they may be displaced almost in every direction. But it is not necessary to speak of the method of re— ducing them; for the observations we had occasion to make on dislocations of the bones of the hand are e— qually applicable here: so that we shall now refer to what was said on that subject in the XIIth Section of this Chapter. CHAPTER 237 CHAPTER XLI. Of DISTORTED LIMBS. LIMBS may be distorted in various ways and by different causes; either from a morbid state of the bones, or from a contracted state of the muscles, or the bones and muscles may both be affected. In some cases the distortion is owing to an original mal—con— formation; in others it occurs in infancy, and in some at more advanced periods of life. For a considerable time after birth the bones are soft and pliable, and are easily affected by the postures of the body. The bones of the legs are apt to be crooked, by children being made to walk too early. It is also the effect of some diseases, particularly of rickets, to soften the bones so much that they easily yield to the posture of the body, as well as to the or— dinary action of the muscles. But the most frequent cause of distorted limbs is that contraction of the flexor muscles of the leg and fore arm, which is often induc— ed by an inflamed state of the knee and elbow, and of which we have a very common example in those cases of white swelling to which these joints are more par— ticularly liable. As the limb lies easiest while the muscles are relaxed, the patient naturally keeps it al— ways bent; and when this posture is long continued, it almost constantly terminates in such a rigid contract— ed state of the flexor tendons, as keeps the under part of the limb at an angle with the superior part of it: Of this we meet with daily instances in the leg; where from this cause alone a patient is often altogether de— prived of the use of his limb. Q3 As 238 Of Distorted Limbs. Chap. XLI. As it has been a very prevailing opinion among practitioners, that little or no advantage can be obtain— ed from any remedies that we may employ for distort— ed limbs, they have seldom made any attempt to cure them: In consequence of which this branch of prac— tice has been almost universally trusted to itinerants, or to professed bone setters. In this, however, we are wrong; and in saying so, I can speak with confidence from much experience in cases of this kind: Having early in life observed the misery to which patients with distorted limbs were reduced, I was resolved to make some attempts for the relief of such as might ap— ply to me, however small the chance might be of suc— ceeding; and in various instances I have had the sat— isfaction of relieving, and in some cases of curing com— pletely, patients who had been lame for several years, and where it was not expected that any thing could be done for their advantage. Where an anchylosis is formed by the ends of two bones forming a joint hav— ing adhered together, it would be in vain to make any attempt to remove it, unless the inconveniency attend— ing it be very great: In which case, if it be the pa— tient's desire, it may be a reason for amputating the limb; or in particular instances, it may be removed by taking out the ends of the bones forming the joint, in the manner to be afterwards pointed out in the last Section of Chapter XLIII. But when the stiffness of a joint depends on a contracted state of the muscles and tendons that serve to move it, which is by much the most frequent cause of distorted limbs, we may al— most in every instance afford considerable relief: And where a limb is crooked by a bone being bent, whether it may have happened from improper management during childhood, or as the effect of rickets or any other disease, we may very commonly, by timely at— tention, either remove it entirely, or render it much less considerable. Where a limb is distorted from a stiff contracted state of the muscles and tendons which belong to it, a free 239 Chap. XLI. Of Distorted Limbs. free use of emollients, with a moderate gradual exten— sion, is the remedy from which I have derived most advantage, and which never in any instance does harm. Those who have not been in the practice of using e— mollients for this purpose, may imagine that they will not penetrate to the depth of the muscles and tendons; and when I first employed them, I must own that I did not expect they were to do so in any remarkable degree: But as I did not know any other remedy that was likely to lubricate so effectually parts that were become stiff, I was resolved to give them a com— plete trial; and I was soon convinced that the most beneficial effects might be expected from them. In a former publication I had occasion to mention this, and since that period various opportunities have oc— curred of employing the same remedy with advan— tage.* In order, however, to gain this end, emollient ap— plications must be used in a very ample manner. All the contracted muscles and tendons, from their ori— gins to their insertions, must be well rubbed with the emollient we are to employ for at least half an hour three times a day; and the limb should be kept con— stantly moist with, or as it were immersed in, the e— mollient, by being covered with flannel well soaked in it at every repetition of the frictions. While the fric— tions are applying, the limb should be slowly, though firmly, extended to as great a degree as the patient can easily bear; and the instrument represented in Plate LXXIX. fig. 1. may be afterwards applied, in order to prevent the muscles from contracting. It is necessary, however, to remark, that the exten— sion should not be made quickly: By doing so, much mischief has been often produced, insomuch that joints have become pained and inflamed, where there was not previously any other disease than stiffness of the flexor muscles; while it may be done with the utmost safety in the slow gradual manner I have mentioned. Q4 In * Vide a Treatise on Ulcers, &c. Part III. 240 Of Distorted Limbs. Chap. XLI. In the one way, indeed, several months may be re— quired for effecting what a greater force might accom— plish in as many weeks: but the latter must always be attended with pain and hazard, while with the other we proceed with ease and safety. Even where extension is not necessary, the effects of emollients are often conspicuous. We frequently meet with stiff joints, particularly in the ancle, with— out any contraction or distortion of the limb. In this case, emollients alone, if duly persisted in, will com— monly answer the purpose of relaxing them. Every kind of greasy application will be useful here, but animal fats prove more relaxing than vegetable oils. The grease of geese and ducks and other fowls answers well; also hogs' lard, and the oil obtained from boiling recent bones of beef and mutton in wa— ter. Butchers usually keep this oil in quantities: When properly prepared, it is quite pure and trans— parent, and has no smell. Where the distortion of a limb proceeds from a bone being bent, if this is not of long duration, and espec— ially when it occurs in childhood, we may very fre— quently be able to remove it by making a constant pressure, gradually increased, on the convex side of the limb, till the bone is brought into its natural direc— tion. This kind of deformity occurs frequently in pa— tients labouring under rickets; but we find it most commonly in new born children, either from an orig— inal mal conformation, as we observed above, or from some singularity in the situation of the child while in the womb. It is most frequent in the legs, when it also affects the direction of the feet and ancles. When the bones of the leg are bent outward, the foot is turn— ed inward; and vice versa, the foot is turned outward when the leg is bent inward. Patients affected in this last manner are called Valgi, and Vari when the feet are turned inward. These 241 Chap. XLI. Of Distorted Limbs. These distortions of the feet and ancles have been supposed to originate in almost every instance from a mal conformation of the joint of the ancle; and the means that have been proposed for removing them, have been intended to effect an alteration of that joint: They may in some cases arise from this cause, but I have scarcely seen an instance of it. At first view of the disease, we are indeed apt to imagine that the fault lies chiefly in the ancle; but it will be very universal— ly found, on a more narrow inspection, to proceed from the form of the leg. When the leg is bent out— ward, the toes are turned inward, and the side of the foot downward; or if the curvature of the leg be con— siderable, the sole of the foot will be turned nearly alto— gether upward, while the top of the foot will rest on the ground on every attempt to walk: And on the contra— ry, when the bones of the leg are bent inward, the toes and sole of the foot will be turned outward and upward. Whoever will examine with attention the effect produced upon the foot by the bones of the leg being curved in the manner I have described, will find that the maladies we are now considering must necessarily result from it: And although it may happen, in a few cases, that the joint of the ancle is affected by a long continuance of the distortion, yet in almost every in— stance the disease will be found to proceed originally from the cause I have mentioned: so that in the man— agement of the disorder, our views should be chiefly directed towards this affection of the leg. By removing the curvature of the bones, the foot will gradually re— gain its natural situation, while all our endeavours will prove fruitless if we only attempt to alter the di— rection of the ancle joint. When cases occur of the foot and toes being turned inward, solely from a mal conformation of the ancle joint, it will no doubt be necessary to endeavour to give the joint a better direction; but as I never met with an instance of this, I must leave the particular mode of effecting it to those who may happen to see it. 242 Of Distorted Limbs. Chap. XLI. it. The easiest and most effectual way of applying pressure to the bones of the leg when bent, is by fix— ing a firm splint of iron in the shoe, on the concave side of the leg: and if the head of the splint be made to rest against the corresponding condyle of the femur, and the other end of it upon the foot, an easy gradual pressure may be made upon the opposite side of the leg by one or two broad straps passed round both the leg and the splint. If the splint is covered with soft leather and properly fitted to the parts, it gives no un— easiness; and by drawing the strap surrounding it and the leg a little tighter from time to time, the pressure will be increased in the gradual manner I have men— tioned. In Plate LXXXIII an apparatus is repre— sented; which in one case, where the curvature of the leg was very considerable, and where the sole of the foot was turned almost entirely upwards, answered the purpose very completely. It is sometimes sufficient to fix the small end of the splint in the shoe, and the broad flat pad at the top on the condyle of the femur. A splint for this purpose is represented in fig. 2. This gives it two fixed points, by which we have it in our power to make any necessary pressure with the straps passed round the leg: but in some instances, as in the one I allude to, the sole of the foot cannot be kept so much down as to admit of this, without fixing the shoe to a frame, as is represented in fig. 3. for in every case of this nature, the sole of the foot should be kept as much as possible in a natural situation, otherwise the pressure made upon the leg for removing the curvature in the bones will be apt to give a wrong direction to the joint of the ancle by the under end of the splint, which in this case must be made to rest upon it. I have thus given a general view of the idea I enter— tain of the nature of this affection, and of the manage— ment best adapted for removing it: But whether limbs be distorted from a contracted state of the muscles be— longing to them, or from a curvature in the bones, much variety must occur in the application of the remedy,  PLATE LXXXII. 243 Chap. XLI. Of Distorted Limbs. remedy, particularly in the manner of applying the extension. The treatment, indeed, which suits one case is seldom exactly applicable to another; it must therefore be varied according to the judgment of the practitioner. Other modes have been proposed for removing curvatures in bones: Of these the best I have seen is an invention of an ingenious artist of this place, Mr. Gavin Wilson, who has long been much employed in this branch of business. In Plate LXXXII fig. 1. and 2. I have represented one of Mr. Wilson's instru— ments for distortions of the leg. CHAPTER 244 CHAPTER XLII. Of DISTORTIONS of the SPINE. THE spine may be distorted in various directions, outwardly, inwardly, and laterally; and in some cases we meet with it in all these directions at the same time, and in the same person. This sometimes arises from external violence; but it is more frequently a symptom of a weakly, delicate constitution. Besides the deformity which these distortions pro— duce, they are very apt to injure the health, by com— pressing the abdominal and thoracic viscera, and by in— ducing paralytic affections of the lower extremities, from the pressure which they make upon the nerves which supply those parts. They occur in all ages; but more frequently about puberty than at any other period, and more commonly in girls than in boys. In general, the effects which result from them are ob— served before the cause is suspected; for there is sel— dom much pain in the part immediately affected. When distortion of the spine occurs during infancy, the patient appears to be suddenly deprived of the use of his limbs; but at more advanced periods, he com— plains for some time of feebleness and languor, and of numbness or want of feeling in the under extremities. By degrees this want of sensibility is found to in— crease; and he is often observed to stumble and to drag his legs instead of lifting them cleverly, nor can he stand erect for any length of time but with much difficulty. At last he loses the use of his legs entirely, which become altogether paralytic; and when the spine is distorted much forward, so as to compress the viscera of the thorax or abdomen, he becomes distress— ed  PLATE LXXXIII. 245 Chap. XLII. Of Distortions of the Spine. ed with dyspnæa, or complaints in the stomach and bowels, according to the part of the spine that is af— fected. In some cases the loss of power in the extremities takes place in the course of a few days from the first approach of the disease; and it sometimes becomes gradually less remarkable, although it never is, so far as I have observed, entirely removed. When the deformity in the back is discovered, we sometimes find that one of the vertebræ only is dis— placed: on other occasions two or more are affected; and in some cases there is reason to imagine that it arises solely from a thickening of the ligaments which connect the vertebræ together, without any particular affection of the bones. When one of the vertebræ only is affected, it is observed that the patient is more completely deprived of the power of his, limbs than when two or more of them are displaced, owing per— haps to the angle being more acute, and consequently the pressure on the medulla spinalis greater when one bone only is thrown out of the range. This also ac— counts for the paralytic symptoms in some cases be— coming less remarkable in more advanced stages of the disease than they were at first; for although one bone only is sometimes displaced at first, yet one or both of the contiguous vertebræ almost constantly yield at last; and the difference which this occasions is so great, that patients almost always linger and die in the course of a year or two, often in less time, when one bone only is deranged; while they live for a great length of time, frequently as long as if no such circum— stance had occurred, when the curvature of the spine becomes more extensive. As distortions of the spine often proceed from deli— cate weakly patients indulging too much in particular postures, every habit of this kind should be rigidly guarded against on the first appearance of the disor— der. If the patient has been accustomed to lean much to one side, the reverse of this should be advis— ed; 246 Of Distortions Chap. XLII. ed; and that the body may lie as much as possible up— on an equal surface during sleep, he ought to use a hair matress laid upon boards instead of a feather or down bed. By attention to these points; by the use of an in— vigorating diet; the cold bath, bark, and other tonics; the disorder has been in some cases prevented from advancing so far as it otherwise probably would have done: but where any of the bones have been affected, I have never seen an instance of a complete cure be— ing obtained. Mr. Pott, to whose observations upon this subject we are much indebted, speaks highly of the effect of drains placed as near as possible to the tumor. He advises an issue to be opened with caustic on each side of the tumor, large enough to admit a kidney— bean, and the bottom of the sore to be sprinkled from time to time with powder of cantharides. This I have practised in various cases, and in some instances with obvious good effects: But in all of these there was reason to suppose that the seat of the disorder was in the ligaments, and not in the bones of the spine. When they have appeared to prove useful where the bones have been affected, I conclude that the mitiga— tion of symptoms has arisen from the cause I have mentioned, the pressure upon the spinal marrow be— ing lessened in the progress of the disorder. Various machines have been invented for the re— moval of distortions of the spine by pressure: All of these, however, do harm, and ought never to be used. It must at once appear, to whoever is acquainted with the anatomy of these parts, and with the nature of this disease, that the displaced bone is never to be pushed into its situation by any assistance of this kind; and if this cannot be accomplished, it is obvious that no ad— vantage is to be derived from the practice, while it is evident that much mischief may ensue from it. In all distortions of the spine, it is an object of the first importance to support the head and shoulders. If this be not duly attended to, the weight of the head tends 247 Chap. XLII. of the Spine. tends almost constantly to increase the disorder. The collar usually employed for this purpose answers near— ly as well as any other. In Plate LXXXVIII. fig. 1. a representation is given of one with some improve— ments, by which both the head and shoulders may be very effectually supported; and in fig. 3. another is delineated for supporting the shoulders only. CHAPTER 248 CHAPTER XLIII. Of AMPUTATION. SECTION I. General Remarks on the Operation of Amputation. BY the term Amputation, we usually understand the removal of a limb. We speak of the Extir— pation of a tumor; of the mamma; of a testis: but we say the Amputation of a leg and of an arm. The mutilation, which is a consequence of this op— eration, renders it one of the most dreadful in the prac— tice of surgery; yet as the only means by which life can be saved, it is frequently necessary. It is an ope— ration, however, so repugnant to humanity, so distress— ful to the unfortunate sufferer, and in some circum— stances, so fraught with danger, that nothing but a clear conviction of this necessity can warrant our pro— posing it in any case. The operation indeed is not difficult: every prac— titioner accustomed to handle instruments may per— form it. But to distinguish with precision the cases which require it, from those which might do well un— der a different treatment, and to determine the partic— ular periods of each when it ought to be performed, are circumstances which require more deliberation than perhaps any other in surgery: We shall therefore enumerate the causes which may make amputation necessary, before proceeding to describe the method of performing it. SECTION 249 Sect. II. Of Causes, &c. SECTION II. Of the Causes which may render Amputation necessary. THIS operation may be rendered necessary by va— rious causes; all of which may be comprehend— ed under the following heads. 1. Bad compound fractures. 2. Extensive lacerated and contused wounds. 3. A portion of a limb being carried off by a cannon ball, or in any other manner, if the bones be une— qually broke and not properly covered. 4. Extensive mortification. 5. White swellings of the joints. 6. Large exostoses, whether they be confined to joints, or spread over the whole bone or bones of a limb. 7. Cases of extensive caries, accompanied with bad ulcers of the contiguous soft parts. 8. Cancer, and some other ulcers of an inveterate nature. 9. Various kinds of tumors. 10. Particular distortions of a limb. Each of these causes we shall consider in the order they are here mentioned. In Chapter XXXIX. Section XV. we had occa— sion to speak particularly of compound fractures: I shall at present therefore only remark, as the substance of what was then fully pointed out, that in the army and navy, where ordinary patients cannot be duly at— tended, and where they must be much jolted, and of— ten removed from place to place, immediate amputa— tion should be advised in cases of compound fractures that are in any degree formidable. Cases will often indeed occur in the worst situations, in which it will be improper to amputate the limbs. Thus, in a com— pound fracture, where little violence has been done, Vol. IV. R and 250 Of Causes that render Chap. XLIII. and where the bones have been broke so much in a transverse direction, that when replaced, they support each other with firmness, and especially if one bone only is broke, it would no doubt be a severe, and often an unnecessary measure, to propose the removal of the limb. But whenever much violence has been done to a limb; when the bones are broke in such a man— ner that they do not, even when exactly replaced, sup— port each other firmly; in all such situations, I be— lieve, it would be a good general rule to advise imme— diate amputation. Unless the operation, however, can be performed soon after the accident, it cannot again be admissible for a considerable time; for when— ever a limb has become swelled and inflamed, it can never, but with the utmost danger, be taken off till these symptoms subside. In private practice, however, where the patient can from the first be placed in an easy comfortable situa— tion, from which he need not be removed till his cure be completed; where he can be kept perfectly quiet, and have all the advantages of good air, a proper regi— men, and the assistance of able practitioners, very few cases will occur in which amputation should be advis— ed. The only cause, as I have observed elsewhere, which in such circumstances can render immediate amputation proper, is the bones of a limb, together with the muscles and other soft parts with which it is covered, being so shattered and bruised that there will be no chance of the limb being rendered useful by any attempt that might be made to save it: In such circumstances it should be removed immediately; but this not being done, the operation, as we have observ— ed above, must be delayed, till the swelling, inflam— mation, and fever induced by the accident, be remov— ed. Although early amputation, however, is seldom necessary in private practice, yet, in the after treat— ment of compound fractures, it is sometimes proper: 1. In 251 Sect. II. Amputation necessary. 1. In consequence of profuse hemorrhagies, which cannot otherwise be stopped. These sometimes hap— pen from one or more arteries being cut by the ends of the fractured bones, as well as from other causes. 2. In consequence of extensive mortification. This we shall have occasion to consider more particularly when we speak of mortification as one of the general causes of amputation. And, 3. By the ends of the fractured bones remain— ing long disunited, attended with the discharge of such large quantities of matter, that the patient runs some risk of sinking under it. We have elsewhere observed, that fractures are sometimes prevented from uniting, by a loose portion of bone being left which ought to have been removed; and nothing more readily keeps up a profuse discharge of matter: But when all such pieces of bone have been removed, when no union takes place, or when the discharge still continues in such quantities as to weaken the patient, notwithstanding every thing that can be done to prevent it; such as preserving the limb steadily in one posture, regular dressing of the sore as often as may be necessary, a nourishing diet, and a plentiful use of bark; nothing will in such circum— stances so certainly save the patient as the removal of his limb. We mentioned extensive laceration and contused— wounds as the second general cause of amputation. Wounds not accompanied with fractures of the con— tiguous bones are seldom so bad as to require ampu— tation in any stage of them: But when a limb is so severely laceraced or contused as to have all the large blood vessels belonging to it destroyed, so as to leave no ground of hope that the circulation can be preserv— ed in it, immediate amputation should be advised, whether the bone be safe or not. As in such circum— stances no effort on the part of the practitioner could save the limb; and as wounds of this description are R2 more 252 Of Causes that render Chap. XLIII. more apt to terminate in mortification than any oth— er, the sooner the operation is performed the better. It will also happen in lacerated and contused wounds, that amputation may afterwards be rendered necessary, although it did not appear to be so at first. In this respect they are similar to compound fractures; and the same observations will apply to them. He— morrhagies may occur which cannot be stopped; ex— tensive mortification may take place; and such large quantities of matter may form, that the patient will not be able to bear up under the discharge. In any of these events, we have to consider the removal of the limb as the only remedy. The removal of a portion of a limb by a cannon ball or other violence, we mentioned as the third gen— eral cause of amputation. This is one of those cases which many contend can never require amputation: for the limb being already removed, it will be better, they allege, to endeavour to heal the sore, than to add to the pain and danger of the patient by an operation. The argument is plau— sible, but it will not bear examination. In wounds of this kind the bones are commonly much shattered, and even splintered; and the muscles and tendons are left of unequal lengths, and much lacerated and contused. In this situation it is allow— ed by all, that the separate pieces of bone, as well as the sharp ends of the remaining bone, should be re— moved, together with the ragged extremities of the muscles and tendons. Now all this could seldom, I believe, be done in less time than the operation itself; while by amputating above the injured part, and by covering the bone with sound muscles and skin, we diminish the sore so much that it will probably heal in a third part of the time that the original wound would have required; at the same time that the patient will have a good stump, which in the other method he never could have. With me this argument of itself would be sufficient for advising the operation under the circumstances 253 Sect. II. Amputation necessary. circumstances we are describing: for as I do not sup— pose it would add to the patient's risk, any additional momentary pain it might occasion would be amply compensated by the advantage he would afterwards derive from it. When the practitioner has it in his power, the operation should be advised immediately: for, however necessary it might be, many patients would not afterwards have sufficient firmness of mind to submit to it; and, from ignorance of the advantag— es to be derived from it, would prefer present ease, to future conveniency and advantages, however great they might be. 4. Mortification is the next cause we have to con— sider by which amputation may be rendered necessary. They who are determined to oppose the practice of amputation as much as possible, affect to consider it as unnecessary in mortification: for all the lesser de— grees of it, they observe, may be cured; and when very extensive, that the patient will commonly fall a sacrifice to the disease, whether the operation be per— formed or not. This opinion, however, is so directly contrary to fact, and to the experience of every un— prejudiced practitioner, that we shall not attempt to refute it: for although it would be highly improper to advise the removal of a limb in slight degrees of gangrene; yet when it has spread so extensively as to destroy all or even a great proportion of the soft parts of a limb, an occurrence too frequently met with, what remedy could be employed instead of it? As I know of none, and as I never heard of any which could in any way prove useful, I shall conclude, that in mortification proceeding to such an extent as we have mentioned, amputation of the limb becomes in— dispensable. But although this doctrine will be generally admit— ted, yet practitioners are not agreed with respect to the period of mortification at which the operation should be performed. Some contend, that in almost every case of gangrene, and especially where it arises R3 from 254 Of Causes that render Chap. XLIII. from external violence, the limb should be amputated as soon as mortification is evidently formed, and while it continues to spread: Others are of opinion, that amputation should never be advised till the gangrene is not only stopped, but till the gangrenous are sepa— rated from the remaining sound parts. Those who advise immediate amputation observe, that by taking the limb off above the diseased part, we may prevent the progress of the mortification, and may thus save the patient's life. Although the argu— ment is specious, it does not appear to be well found— ed; and so far as my observation goes, I would say that it is a practice fraught with danger, and ought universally to be discarded: For however attentive we may be in amputating at a part of the limb which appears to be sound, even the most experienced prac— titioner will be liable to be deceived. The skin may be perfectly found, and may be free from pain, in— flammation, and swelling; and yet the deep seated muscles and other parts contiguous to the bone may be in a state of gangrene. Of this I have seen differ— ent instances: But even where the whole divided parts are found to be altogether sound, if the operation is performed while mortification is advancing, the dis— ease scarcely ever fails of seizing the stump; at least I never knew an instance of the contrary, and I have unfortunately happened to be concerned in different cases where this practice was adopted. On convers— ing with practitioners, who, from peculiarity of situa— tion, have much employment in those accidents which are most apt to terminate in gangrene, I also find that their experience tends to support this opin— ion: It was also the decided opinion of the late Mr. Sharpe, as it is of Mr. Pott, and of every modern prac— titioner of observation.* I think it right to mention this, * Mr. Pott's words upon this point are very strong: "I have more than once seen the experiment made of amputating after a gan— grene has been begun; but I never saw it succeed:—It has always hurried the patient's destruction." Vide Remarks on Fractures, &c. 255 Sect. II. Amputation necessary. this, as attempts have of late years been made by some speculative practitioners to introduce a contrary prac— tice; which if admitted, there is much reason to sus— pect would prove extremely hurtful, although from its proving so universally unsuccessful, there is reason to hope that it will soon be laid aside, even by those who at present patronize it. I would not think it necessary, however, to delay the operation so long as is advised by some practition— ers, and particularly by Mr. Sharpe; who thinks that it should never be performed till the separation of the mortified parts is considerably advanced.* As Mr. Sharpe was a man of much experience, his observa— tion may prove to be well founded; but so far as I have yet seen, I would consider it as sufficient to wait till the mortification is fairly stopped, but not much longer: In this manner, we seem to reap all the ad— vantages which the caution we have advised can give; and the earlier after this that the mortified parts are removed, the more readily will we prevent the system from suffering by the absorption of that putrescent matter which a gangrenous mass universally yields. The opinion we have given relates to every variety of gangrene. In whatever way it may have arisen, the practice should be the same: for although some stress has been commonly laid upon the circumstance of its proceeding from an internal or external cause, yet no utility is derived from this. The operation should in no instance be advised till the period we have mentioned; and at that time, whatever may have been the cause of the disease, no delay should be admitted. 5. In mentioning white swellings of the joints as a cause of amputation, we must refer to a former publi— cation for the management of the disease, as well as for a more particular account of those symptoms which more * Vide Treatise on the Operations of Surgery, Chap. XXXVII. R4 256 Of Causes that render Chap. XLIII. more especially indicate the operation.* At present we have only to observe, that as long as there is the least reason to hope that by any means the limb may be saved without hazard to the patient, the operation should never be advised. As a farther motive for this, I may remark, that the opinion I gave in the treatise alluded to above, has been greatly confirmed by much experience, namely, that amputation more frequently succeeds, that is, a greater proportion recover from the operation when it is delayed till the patient is consid— erably reduced by the disease, than when it is per— formed in the more early stages of it. The cause of this may be nearly the same as what we have given a— bove, when advising late Amputation in cases of Com— pound Fractures. 6. In one of the preceding Chapters, we have en— tered upon the consideration of the various kinds of exostosis;† so that at present we have only to remark, that when a diseased portion of bone cannot be taken out in the manner we have formerly advised, and when the tumor is either hurting the patient's health or has become unsupportable from its size or any other cir— cumstance, amputation of the limb, when no particu— lar reason prevents it, should be advised as the only remedy. The next cause we have mentioned by which am— putation may be rendered necessary, is an extensive caries attended with ulcers of the contiguous soft parts. When speaking of caries, in the seventh Section of the Treatise on Ulcers, we pointed out the different means employed for the cure of the disease, that is, for pro— moting an exfoliation of the diseased part of the bone. In addition to what we had then occasion to say, it may be observed, that although an extensive caries is in general considered of itself as a sufficient reason for amputating a limb, yet it certainly should be admitted under * Vide Treatise on the Theory and Management of Ulcers, &c. Part III. † Vide Chapter XXXVIII. Section III. § 14. 257 Sect. II. Amputation necessary. under much restriction. However extensive a caries may be, even although it occupies the whole length of a bone, it may be removed; and we have many in— stances on record of deficiencies produced in this man— ner being amply supplied by a regeneration of bone: So that where the constitution is sound, and more es— pecially when the patient is young, a carious bone will seldom of itself prove a sufficient motive for removing a limb, at least the chance of saving it by removing the diseased bone should first be given. But when a ca— rious bone is conjoined with deep and extensive ul— cers of the corresponding soft parts, which might give much cause to suspect that a cure would not be ob— tained even although the diseased bone should be tak— en out, amputation should be preferred; for in this situation, besides the difficulty of healing the sores, the formation of any considerable quantity of bone would be rendered very uncertain, and therefore the risk should not be incurred. 8. The next cause we have to advert to, by which amputation may be rendered necessary, is cancer, and some other ulcers of an inveterate nature. When speaking of Cancer in the Treatise on Ulcers, we endeavoured to show, that no dependence is to be placed either upon internal medicines or outward ap— plications in the treatment of it; and that the removal of the diseased part is alone to be trusted. It must be acknowledged that cancer does not frequently occur on any of the extremities: but every practitioner must have seen it on different parts of them; and wherever it appears, the removal of the diseased parts with the knife should be advised immediately. They may be often taken away without amputating the limb; but when the disorder has proceeded so far as to attack the ligaments or bones, and especially when the sore is extensive, nothing but the removal of the limb above the parts that appear to be affected can be depended on. In such circumstances, I have known attempts made to save the limb, but always without success. 258 Of Causes that render Chap. XLIII. success. Even the removal of the limb will some— times fail; but I have known it prove effectual where the disease had returned, after being removed in the usual way, Besides cancer, other ulcers may, in particular cir— cumstances, render amputation necessary: Where an extensive ulcer, not induced by any general affection of the system, is hurting the health of a patient; and when, instead of yielding to the remedies employ— ed, it becomes evidently more extensive and more in— veterate, as it might at last proceed so far as to endan— ger life; we ought rather to advise the limb to be tak— en off. Such ulcers as are usually termed Phagaden— ic, sometimes terminate in this manner: But this ter— mination is most frequent in sinuous ulcers; such as arise from deep seated abscesses, where the matter has found access between the interstices of the large mus— cles, and where, notwithstanding our endeavours to accomplish a cure, the discharge continues to be so profuse as to endanger the life of the patient. 9. The next cause we have mentioned which may require amputation, is various kinds of swellings. Encysted tumors seldom lead to this necessity; but in some instances where they are deep seated, origin— ating perhaps from the periosteum, if they are allowed to remain till they acquire a great bulk, all the contig— uous parts come to be so injured by them, that noth— ing but the removal of the limb will answer any salu— tary purpose. In some cases, by a long continued pressure, the contiguous bones are not only rendered carious, but are altogether dissolved; at the same time that the cellular substance, and even the muscles of the limb, become so much diseased as to give no cause to hope that we could be able to save them. We sometimes find a portion of a limb considerably enlarged with an uniform hardness in some parts, and in others with a degree of softness which gives cause to suspect that a fluid of some kind or other is collected beneath. The skin at first retains its natural colour; but 259 Sect. II. Amputation necessary. but at last it acquires a livid hue. The commence— ment of the disease is not attended with pain; but at last it not only becomes painful, but extremely troub— lesome from its weight. It usually arises without any evident cause, and often in people who are otherwise healthy: At first the swelling commonly appears on the inferior part of a limb, and proceeds gradually up till it occupies the whole of it. Swellings of this kind are at first often mistaken for common œdema or anasarca; and they seem to be so far of this nature, that they are evidently produced by an effusion into the cellular substance: but instead of being of the serous kind, the effused fluid is found to be tinged with blood, and of an acrimonious nature; at least this has been the case in all that I have known opened: and it has likewise happened, that the mat— ter has never been discharged in such quantities as to have much influence on the size of the tumors, the swelling usually remaining of nearly the same bulk af— ter the operation as before it: Hence no advantage is derived from it; on the contrary, the operation always does harm. A painful sore is produced; and it al— ways accelerates the progress of the tumor. Indeed, nothing I have ever known employed has any effect in retarding it; so that I consider amputation as the only resource, whenever the tumor has become so large as to create any material uneasiness. Whether this will always prove effectual or not, I cannot pretend to say; but hitherto I have met with no instance of the disease returning where amputation was performed on a sound part of the limb. Swellings of the aneurismal kind have also been considered as a cause which, in particular situations, may give rise to amputation. This has originated from the operation for the aneurism having failed in different instances when performed upon the crural artery, and from the amputation of the limb having in similar affections saved the life of the patient. Where an aneurism in the ham, or on the thigh, is very large, and 260 Of Causes, &c. Chap. XLIII. and has been of such long duration as to hurt the tex— ture of the soft parts, as well as to injure the bone, which effused blood is apt to do, it will no doubt be better to amputate the limb than to make any attempt to save it: But in such a case, it is not the aneurism for which amputation is advised, but a morbid state of the parts, induced by the disease being allowed to con— tinue too long before any effectual measure is adopted for its removal. In the commencement, and for a considerable time thereafter, of the femoral or popli— tean aneurism, I should never advise the amputation of a limb: for different instances are on record of limbs being saved by the operation for the aneurism, even where the artery was injured in the superior part of the thigh: But where such an extensive œdema— tous swelling is induced all over the under part of the limb, as to leave no room to hope that it could again be restored to use, even allowing the operation for the aneurism to succeed, it will no doubt be better to am— putate immediately than to attempt the operation. The aneurism we here allude to, is that which pro— ceeds from a dilatation of the artery, and in which the coats of the vessel have burst, so as to produce a con— siderable effusion of blood into the surrounding cellu— lar substance, probably before any proper assistance is desired. This will seldom happen but with the poor— est class of people; and therefore this disease, in the state we are now speaking of, is chiefly found in hos— pitals. At first it is always attended with a good deal of pulsation; but in its later stages the swelling be— comes so large that the beating of the artery is scarce— ly, if at all, discovered; by which it is apt to be mis— taken for a tumor of a different kind: But for the most part, a due attention to the history of the case from the beginning, will lead to a knowledge of its real na— ture. The 10th and last general cause we enumerated, by which amputation may become necessary, is particular distortions of a limb. Where 261 Sect. III. General Remarks, &c. Where a limb is in other respects perfectly sound, it will seldom happen that any distortion to which it is liable will be considered as a sufficient reason for this operation: But in the course of much business, cases are sometimes met with in which limbs are so much distorted, and are productive of so much distress, that patients rather incline to have them removed than submit longer to the inconvenience. When in such circumstances we are not able to remove the distortion by means of a more gentle nature, we are under the necessity of complying with the patient's request. These are the several causes by which the amputa— tion of a limb may be rendered necessary. As they are very various, and as the loss of a member is to every patient an object of much importance, they mer— it, in every instance, the utmost attention from prac— titioners. Indeed this point of practice, namely, that of fixing with precision those cases in which the am— putation of limbs should be advised, with the most suitable periods in each, is attended with such difficul— ty, and a surgeon is so apt to be blamed if he proceeds to the operation so long as the smallest doubt remains of the propriety of it, that it should be held as a fixed regulation with every practitioner, never to operate but with the advice of some of his brethren in consult— ation, when this can possibly be obtained. We shall now proceed to describe the method of operating. SECTION III. General Remarks on the Method of Amputating Limbs. SURGERY is not perhaps in any instance brought to greater perfection than in the method of am— putating limbs. Before the invention of the tourni— quet, this operation was attended with so much haz— ard, that few surgeons ventured to perform it: Nay, long 262 General Remarks Chap. XLIII. long after the introduction of this instrument, the dan— ger attending it was so great, that more than one half perished of all who had resolution to submit to it. In the present improved state of the operation, I do not imagine that one death will happen in twenty cas— es; even including the general run of hospital prac— tice: And in private practice, where due attention can be more certainly bellowed upon the various cir— cumstances of importance relating to the operation, the proportion of deaths will not be so great. The circumstances in this operation which more particularly require attention, are, the choice, when this is in our power, of the part at which a limb should be amputated; the prevention of hemorrhagy during the operation; the division of the skin, muscles, and bones, in such a manner as to admit of the stump be— ing entirely covered with skin; the tying of the arte— ries alone, without including the nerve or any of the contiguous parts; securing the teguments in a proper situation, so as to prevent them from retracting after the operation; and a proper subsequent treatment of the case. Next to securing the patient from loss of blood, the most material of these is the saving such a proportion of the soft parts as will cover the stump, so as to heal the sore as nearly as possible by the first intention: for without this, the wound produced by the removal of a large limb is always extensive; the cure accord— ingly proves tedious; and in many cases the discharge proves so copious, that the patient's health is irrepara— bly hurt by it. The inconveniences arising from this were so obvious, that various attempts were made from time to time, to improve this part of the operation. At first, all that was done in amputating a limb, was cutting the soft parts down to the bone by one stroke of a knife, and afterwards dividing the bone with a saw at the edge of the retracted muscles. It was af— terwards proposed by Mr. Cheselden to divide the soft parts by a double incision; to divide the skin and cel— lular 263 Sect. III. on Amputation. lular substance with a circular incision; and then to cut through the muscles at the edge of the retracted skin: by this means the saw was applied higher in the bone, and the stump was better covered both with muscles and skin. Still, however, an extensive sore was left; insomuch that in amputations of the thigh, a cure was seldom performed in less than three or four months; often five or six were required; and after all, the stumps were commonly pyramidal, by the bone projecting beyond the soft parts: It often happened too, that another sore was produced, by this part of the bone exfoliating, long after the patient considered himself as perfectly well. To prevent this Pyramidal or Sugar loaf Stump, as it is termed, a bandage or circular roller was employ— ed, with a view to support the muscles and teguments, and prevent their retracting; and when properly ap— plied from the upper part of the limb downwards, it in some degree answered the purpose, but never so effec— tually as to prevent the cure from being tedious. In order to shorten it farther, it was proposed by the late Mr. Sharpe, in his Treatise on this Operation, to draw the teguments near together by stitches or pieces of tape passed through them, and tied across the stump: But the pain and inconvenience attending this was so great, that it never was generally practised; and Mr. Sharpe himself at last desisted from it. It was now thought impossible to improve this method of operating, so as to shorten the cure, and in place of a pyramidal, to give the stump a plain surface. In consequence of this, about twenty years ago, differ— ent surgeons attempted to revive the flap operation; which had been first practised, upwards of an hundred years ago, by an English surgeon of the name of Loud— ham. It was effected by saving a flap of the muscles and skin, in the manner we shall afterwards describe, laying it over the stump, and securing it in this situa— tion by proper bandages till it united to the parts be— neath. As 264 General Remarks Chap. XLIII. As this afforded a thick muscular cushion to the stump as well as a complete covering of sound skin, the highest expectations were formed of it: but the objections to it, which we shall afterwards mention, were so great, that the utmost exertions, even of ex— pert surgeons, to render it more perfect, have not been able to introduce it to general use. This failure again excited the attention of practi— tioners to the improvement of the common operation of amputation; and their endeavours have not proved unsuccessful. By the present improved method of operating, such a quantity of teguments is saved as completely covers the stump; by which, in some in— stances, a cure is obtained by the first intention with— out the formation of matter: And in all, unless there be something particularly bad in the habit of body, or unless the inflammation unexpectedly runs to a very unusual height, a cure is completed in the course of two or three weeks. As I consider the improvement by which these ends are effected as one of the most important in modern practice, I hope to be excused, if I shortly state the share I have had in the introduc— tion of it, before proceeding to describe the operation itself. In the course of my education, while attending the hospital here, as well as the hospitals of London and Paris, the inconveniencies arising from the want of at— tention to the saving of skin in different chirurgical operations, struck me strongly; so that I was resolved to take every proper opportunity in my own practice, of treating this point with particular attention. From the year 1772, when I settled in business, I laid it down as a maxim, not to be deviated from, to save as much skin and cellular substance in the removal of tumors, whether cancers or others, when the sound— ness of parts admitted of it, as would completely cover the sores; and in amputating any of the extremities, to save as much of them as would entirely cover the stumps. I first performed amputation in the course of 265 Sect. III. on Amputation. of that year; and finding the improvement of saving skin to answer even beyond my expectation, for the cure of a large stump in an amputation of the thigh was completed in three weeks, I did not fail of putting it afterwards in practice both in public and private. The practice was likewise adopted by my friend Mr. Hay, and more lately by some other gentlemen in their attendance at the hospital; and ever since that peri— od, Mr. Hay and I have invariably adhered to it, some deviations being occasionally introduced in the mode of doing it, with a view of rendering it more per— fect; by which the cures have in every instance been greatly shortened. In various cases, large stumps, which by the usual method would have required sev— eral months, were cured in as many weeks: In a few, as was observed above, the parts united by the first intention: and in all, a plain uniform stump was pro— duced. After this had been practised for several years, Mr. Alanson, of Liverpool, in the year 1779, published some Observations upon Amputation, in which a method of operating is described, which after nine years experience, he recommends in the warmest man— ner, as answering every object to be expected from this operation; and more especially, that of curing the stumps in a great measure by the first intention. As Mr. Alanson's mode of operating has of late been very deservedly preferred to every other that was before published, I shall afterwards give an ac— count of it; but in the mean time, I shall describe that which I have long been accustomed to practise, and which after various trials of every other of which I have yet heard, I still continue to prefer. In the first place, we shall describe the operation as it is per— formed upon the thigh, and shall afterwards speak of the method of amputating in other parts of the ex— tremities. SECTION S 266 Of Amputating Chap. XLIII. SECTION IV. Of Amputating the Thigh. IN amputating either the thigh or leg, the patient should be placed upon a table of an ordinary; height, with the leg properly secured and supported by an assistant sitting before him. The other leg should likewise be supported, at the same time that the arms should be secured by an assistant on each side to prevent interruptions during the operation. The flow of blood to the limb should now be stop— ped by the application of the tourniquet, in the man— ner we have mentioned in the first volume of this work: and as it is a matter of importance to have the instrument placed as near as possible to the top of the thigh, the cushion placed upon the femoral artery should reach the groin. This becomes absolutely necessary when the opera— tion is to be performed on the upper part of the limb: But it may likewise be done with safety where it is to be taken off immediately above the joint of the knee: And we may just observe, with respect to the most proper place at which a thigh should be ampu— tated, that no more of it should be taken away than is rendered necessary by the disease; for the more of it that is left, the more useful it proves. An assistant should now be directed to grasp the upper part of the limb with both hands, and to draw up the skin and cellular substance as far as possible: While they are in this state of tension, the operator, standing on she outside of the patient, should divide them with a circular incision down to the muscles: This may in general be done with one stroke of the amputating knife, fig. 3. Plate LXXXV. but in large limbs it is easier done at twice. The assistant contin— uing PLATE LXXXIV.   PLATE LXXXV. 267 Sect. IV. the Thigh. uing to draw the teguments upwards, the cellular sub— stance connecting them to the muscles beneath, should be divided with the edge of the knife till as much of the skin is separated as the operator thinks will cover the stump completely. The skin being still drawn tightly upwards, the muscles should be divided close to the edge of it down to the bone by one perpendicular stroke of the knife, beginning with the upper part of the large muscles on the inside of the thigh, and continuing the incision round through those beneath, and on the outside till it terminates where it commenced. During this part of the operation, some attention is necessary to avoid the edge of the retracted skin: but it may always be done if the operator be upon his guard, for he may with little difficulty have his eye upon the course of the knife from first to last; nor can this part of the oper— ation be done with safety in any other manner: Even where different assistants are employed to protect the skin, it will be apt to be wounded, if the operator does not follow the knife with his eye. In the usual method of operating, the bone would now be sawn across at the edge of the retracted mus— cles: but we are more certain of having a good stump, if the muscles be previously separated from the bone for the space of an inch; and it is easily done by inserting the point of the common amputating knife between them, and carrying it freely round from one side of the limb to the other. This being done, the muscles and teguments must be drawn up as far as the muscles have been separated from the bone; and it is easily done, either with a bit of slit leather, such as is represented in Plate LXXXIV. fig. 4. or with the iron retractors in the same Plate, fig. 2. and 3. The periosteum should now be divided at the place where the saw is to be applied, and it should be done with one turn of the knife; for where much of it is scraped off, very tedious and troublesome exfoliations are apt to ensue: The knife should therefore be car— S2 ried 268 Of Amputating Chap. XLIII. ried round the bone directly beneath the retractors, At this place the saw should be applied, and with long steady strokes the bone should be divided. The saw represented in Plate LXXXV. fig. 1. answers much better than the usual form of the instrument with a heavy iron back. In performing this part of the operation, the assistant holding the leg should be directed to support it with much equality; for if it be raised too far, the motion of the saw will be impeded, while the bone will be apt to be splintered if it be not sufficiently raised. Any points or splinters which may be left, should be immediately removed with the nippers, Plate LVI. fig. 2. The retractors should now be taken off; and the trunk of the femoral artery being drawn out with the tenaculum, a sufficient ligature should be made upon it before the tourniquet is loosened: But as the mus— cular branches of this artery cannot be discovered as long as any compression remains upon them, the screw should be immediately untwisted so far as to remove it entirely. All the clotted blood should be now re— moved from the stump with a soft sponge soaked in warm water; and every artery that can be discovered should be secured with a ligature, care being taken to leave the ends of the threads of a sufficient length to hang out without the lips of the wound. The blood vessels being all secured, and the surface of the wound cleared of blood, the muscles and tegu— ments should be drawn down till the skin completely covers the stump; and should be retained in this situ— ation by an assistant till a flannel or cotton roller, pre— viously fixed round the body to prevent it from slip— ping down, be applied in such a manner as to support and fix them: for which purpose it should be passed two or three times, nearly in a circular direction, round the top of the thigh; and should afterwards, with spiral turns, be brought down near to the end of the stump, of such a tightness as to prevent the muscles and skin from retracting, without compressing them so much 269 Sect. IV. the Thigh. much as to prove painful, or to impede the circula— tion. Here the roller should be fixed with a common pin, while as much of it is left as will pass two or three times round the stump, for a purpose to be afterwards mentioned. The ends of the divided muscles being placed with as much equality as possible over the bone, the edges of the skin must be laid exactly together, so as to form a straight longitudinal line along the centre of the stump. When there are only one or two ligatures, they should be left out at the inferior angle of the wound; but when there are several, they should be divided between the two angles, to prevent the parts from suffering by a large extraneous body fixed at any one place. While an assistant retains the edges of the divided skin in exact contact, two or three flips of adhesive plaster should be laid across the face of the stump, to preserve them nearly in this situation; and the whole surface of the stump should now be covered with a large pledgit of soft lint spread with Goulard's cerate, or the common calamine cerate of the Dispensatories: Over this there should be placed a soft cushion of fine tow with a compress of old linen. For the purpose of retaining them, as well as with the view of making a gentle pressure upon the stump, a slip of linen, of three inches in breadth, should be laid over them; and should run directly across, and not from above down— wards. On being properly placed, the remaining part of the roller should be employed to fix it, by passing it two or three times round the stump; and the pressure formed by the cross strap may afterwards be increased or diminished at pleasure, by drawing it with more or less tightness, and fixing it with pins to the circular roller. While we apply the roller, the tourniquet should be removed, and replaced immediately when the stump is dressed. If left loose it gives no uneasiness; and it enables the attendants to check any hemorrhagy which S3 may 270 Of Amputating Chap.XLIII. may happen: a circumstance which merits attention for several days after amputation of any of the ex— tremities. The patient should now be carried to bed; but in— stead of raising the stump to a considerable height with pillows, as is usually done, it should be laid some— what lower than the rest of the body: for this pur— pose, the bed should be made with a gentle declivity from above downwards, and nothing should be put beneath the stump but a little fine tow. To prevent the patient from moving the limb in— advertently, as well as to guard in some measure against the effect of those spasms which often prove trouble— some after this operation, I commonly employ two slips of linen or flannel to fix the stump down to the bed. It is easily done, by laying one across near the extremity of the stump, and another near to the root of the thigh. They should be pinned to the circular roller round the limb; and the ends of each of them should be pinned to the bed: or they may be tied to it by pieces of small tape previously sewed to the bed or to the matress; which answers better than a feather bed for any patient that is to be long confined. A basket or hooped frame should now be put over the stump, to protect it from the bed clothes; and whether the patient complains much or not, I make it a con— stant rule to give him an anodyne, by which he re— mains quiet and perfectly easy through the remainder of the day, instead of being restless and distressed, which he is otherwise apt to be. As hemorrhagies will sometimes happen, even many hours after the operation, the attendant who takes the charge of the patient should be strictly enjoined to ex— amine the stump frequently with the utmost care; and on any quantity of blood breaking out, to twist the tourniquet sufficiently tight to put a stop to it, till assistance is procured. I think it right, however, to observe, that in general it is the fault of the practitioner when this very perplexing occurrence takes place; for 271 Sect. IV. the Thigh. for it seldom happens when the arteries are searched for in the time of the operation with that accuracy which the importance of the case requires. Indeed hemorrhagies are less frequent after this method of operating, than when the muscles are left uncovered; and this is one material advantage that results from it: for however attentive a surgeon may be in securing the arteries, the irritation produced upon an extensive wound, and the spasms which ensue, very frequently terminate in fatal hemorrhagies. Of this I have known several instances; while no discharge of any importance has ever happened in the method of op— erating we are now describing; I believe too, as I have elsewhere remarked, that some additional securi— ty is derived from the use of the tenaculum: for al— though those who have not been in the habit of using it, are apt to consider it as more uncertain than the needle, yet it is far from being so. I will not say that hemorrhagies will never ensue where the tenaculum is employed; but it has so happened in the course of my observation, that the needle was used in every case of hemorrhagy that proved fatal. Where there is only a trivial oozing of blood we need not be alarmed; nor will it be necessary to re— move the dressings: But whenever the discharge is so considerable as to give cause to suspect that it proceeds from a large artery, nothing but the securing it with a ligature can be depended on. This being done, the dressings must be renewed in the same manner as at first. The only other symptoms we have reason to dread, during the first three or four days after the operation, are those spasmodic affections of the muscles which we have alluded to above, and the inflammation and ten— sion of the stump, with the consequent fever which in some degree succeed to every case of amputation, but which always prove hazardous when they proceed to any great height. S4 When 272 Of Amputating Chap. XLIII. When the arteries are tied without including the nerves, or any part of the contiguous muscles, these spasms seldom become troublesome: But when they do take place, if laying the limb in as easy a relaxed state as possible does not render them moderate, we must trust to opiates for their removal. For the prevention of inflammation, the patient must be confined to as low a regimen as the state of his strength will permit. In weak emaciated habits this must be managed with much discretion, as the constitution might be materially hurt by too low a diet: but where there is much plethora, with a sense fibre, together with a strict antiphlogistic regimen, the patient should be blooded as soon as quickness and fulness of pulse or other symptoms of fever take place: he should take plentifully of diluent drink; and his bowels should be kept open with any of the cooling neutral salts. It is proper, however, to observe, that it is during the first days only after the operation that remedies or this kind are in general necessary. When the inflam— matory stage is over, evacuations of every kind are to be dreaded; even laxatives are apt to do mischief if they are ever carried farther than is just necessary for preserving a regular state of the bowels. At the end of the third day, whatever the previous symptoms may have been, the stump should be exam— ined. Where a free suppuration is expected, as al— ways happens when the stump is not covered with skin, the parts should not be looked at till the fourth or fifth day: but here there is no reason for this de— lay; and the patient is always rendered more easy and comfortable by the removal of the first dressings. For this purpose the stump should be gently supported by an assistant, till the last turns of the roller are undone, and till the cross flips, tow, and even the large pledgit of ointment next the sore are removed. In a few cases the parts will be found to be united by the first intention; but for the most part it will be otherwise: There 273 Sect. IV. the Thigh. There will be a small quantity of matter over the sur— face of the stump, chiefly at the inferior angle of the wound; and the parts will be red, tense, and painful to the touch, with a small separation or opening be— tween the edges of the divided skin, not with standing the plasters employed to retain them. As in this state the plasters will do no service, they should likewise be removed; and it is easily done when they are thus moistened with matter. The surface of the stump should now be covered with a pledgit of the same oint— ment as at first; and a cushion of soft tow being laid over it, the cross slips of linen and circular roller should be again employed; but with no more pressure than is merely necessary for supporting them. In this manner the dressings should be renewed ev— ery second day; when, by the seventh or eighth day, the inflammation and tension will in general be so far diminished as to admit of the ligatures on the arteries being easily removed; at least they may now be gen— tly pulled daily, and for the most part they will yield on the second or third trial: when allowed to remain longer, they not only prevent the wound from heal— ing, but are apt to be more difficult to remove after— wards. As long as the roller is preserved clean, it may be allowed to remain; but as soon as it becomes sullied with matter, it should be removed and another applied in its place; nor should it be entirely laid aside till the third or fourth week from the operation. After this period, however, it should be removed, as when longer continued it is apt to render the limb smaller than the other. As foot as the sore is observed to be perfectly clean, with granulations sprouting up in different parts of it, as the pain and tension will now be quite removed, we may with safety venture to complete the cure, by drawing the edges of the wound together by adhesive plasters. In this state of the sore no harm ever en— sues from it, and it shortens the cure considerably. By 274 Of Amputating Chap. XLIII. By this management, even the largest stumps will for the most part be healed in three or four weeks; often in less. But it must be remarked, that although we may in general depend on this in private practice, where every circumstance that can conduce to the welfare of the patient will meet with attention, and where especially we may always obtain a well venti— lated apartment and proper diet; yet in public hos— pitals, where these points cannot be duly attended to, and where the patient often suffers more from the bad air which he breathes, than from the operation itself, the success attending it will not in every case be so great. Instead of the teguments adhering readily to the parts beneath, large quantities of matter sometimes form between them, which always renders the cure more tedious, and which in some cases cannot be ac— complished but by sending the patient to a more free air, and by a more plentiful allowance of wine and other cordials than can in general be obtained in hos— pitals. But for one instance of this kind, in the ope— ration we have described, I may with safety affirm, that twenty will occur in the usual mode of conduct— ing it: In the former, those obstacles to a cure do not commonly occur; in the latter, they are often ob— served. When speaking of the time in which stumps may be expected to heal, I think it right to observe, that it should not be our object to accomplish a cure in the first instance without the formation of matter: It commonly answers better when effected in the more gradual manner we have pointed out. When a stump heals suddenly, and the edges of the divided skin ad— here by the first intention, the teguments are apt to be puckered and uneven, and the ligatures of the arteries are removed with difficulty. Of this I have had dif— ferent cases, when such strong adhesive plasters were made use of, as kept the edges of the skin in close con— tact: But when the common court plaster is made use of, or any other composition possessed of the same de— gree 275 Sect. IV. the Thigh. gree of adhesive property, although the teguments will be prevented from separating to any considerable ex— tent, yet they will readily yield to the retraction which usually takes place on the accession of tension and pain. In this manner, a slight separation is usually produced; by means of which the ligatures are easily taken out; any matter that may form is readily dis— charged; the corners left above and beneath, by the teguments being drawn together, are much lessened; and the stump is always left smooth and equal: Hence those stumps which take three weeks or per— haps a month to heal, are usually better than those which heal much sooner. The advantages attending a speedy cure, and the covering the stump with skin, are so great, that they need not be enumerated: but I thought it right to mention the inconveniences which occur from our endeavouring to hasten the union of the divided skin too quickly, either by adhesive plas— ters, or sutures, which last has in some cases been at— tempted. It will be readily perceived, that the principal dif— ference between this operation and the usual method of amputating, consists in the saving of as much of the muscular substance of the limb as will completely cov— er the bone, together with as much skin as will cover the whole surface of the stump: But it is proper to remark, that we may err in saving more of each of these parts than is requisite, and that some attention is therefore necessary to guard against it. In leaving too much muscular substance, we must necessarily shorten the limb too much, by sawing the bone high— er than we otherwise would do; and by saving too much skin, we render the surface of the stump puck— ered and uneven. With respect to the quantity of muscular substance that should be saved, I have hitherto found, that the directions given above, in general, answer the purpose, By separating the muscles from the bone for the space of an inch, and sawing it at this height, above where it is 276 Of Amputating Chap. XLIII. is divided in the ordinary method of amputating, the bone will always be sufficiently covered with flesh; and a very little experience enables us to judge of the quantity of skin that should be saved for covering the stump: But even when more is saved than is altogeth— er necessary for this purpose, a little attention will en— able us to prevent inequalities. By an assistant draw— ing down the teguments, in the manner we have direct— ed, before the roller is applied, as much of them may see pulled down as is just necessary; and if they are preserved in this situation till the application of the roller is finished, any inconveniency which might have occurred from too great a quantity will be pre— vented. It will likewise be observed, that in making the first incision of the teguments, I have not desired a circu— lar piece of tape to be made use of, as is usually done, to serve as a direction for the knife. This deviation from the common practice has been long adopted by some individuals; but so far as I know, it was first suggested by the late Doctor Hunter of London; and I think it a material improvement of this part of the operation; for besides the saving of time, which is al— ways of importance in that state of anxiety to which a patient is reduced who is placed upon a table for the purpose of losing a limb, it in reality puts it in our power to make the incision with more neatness, more speedily, and with less embarassment, than when the tape is employed. Those who have been accustom— ed to the tape will at first be of a different opinion; but whoever will lay it aside, will find that the circu— lar incision may be made with more exactness merely by following the knife with the eye; and I am certain that it may be done in one half of the time. When the tape is employed, a good deal of time is lost in en— deavouring to keep the knife exactly in a line with it; and if it be not applied with the utmost exactness, it necessarily renders the incision ragged and unequal; an occurrence I have observed in different instances, even 277 Sect. IV. the Thigh. even with expert surgeons, while I never perceived a— ny inequality where the tape was not used. It has been objected to the operation now describ— ed, that being more tedious than the usual method of amputating, it must necessarily create more pain. The difference in this respect, however, must be trif— ling; for it must be remembered, that the incision of the skin, which is the most painful part in every ope— ration, is the same in both. The division of the cel— lular substance is quickly performed, and little or no pain ensues from it: And the third incision, if we may so term it, or the separation of the muscles from the bone, may be performed in the tenth part of a minute. In different instances I made use of a scalpel for sepa— rating the cellular substance from the muscles beneath, as well as for separating the muscles from the bone; but I now find that both these parts of the operation may be done with the common amputating knife, with equal ease and expedition: and we should avoid mul— tiplying instruments, wherever the intention can be answered equally well with a smaller number. The knife delineated in Plate LXXXV. fig. 3. is the one I now prefer, after trying various forms of it: It is of a middling size, somewhat shorter than the one in com— mon use, and perfectly straight. The curved knife is still used by some practitioners, but I have never heard any good reason given for it. If any surgeon should find it difficult to separate the muscles from the bone with this knife, the instrument recommended by Mr. Gooch, and delineated in Plate LXXXV. fig. 4. may be employed. I shall now describe such parts of Mr. Alanson's method of performing this operation as are peculiar to himself; and in order to convey the meaning of the author with exactness, I shall give it in his own words, from the second and last edition of his book, page fif— ty first. "Apply the tourniquet in the usual way; stand on the outside of the thigh; and let an assistant draw up the 287 Of Amputating Chap. XLIII. the skin and muscles, by firmly grasping the limb cir— cularly with both hands. The operator then makes the circular incision as quickly as possible through the skin and membrana adiposa down to the muscles: He next separates the cellular and membranous attach— ments with the edge of his knife, till as much skin is drawn back as will afterwards, conjointly with the fol— lowing division of the muscles, cover the surface of the wound with the most perfect ease. "The assistant still firmly supporting the parts as before, apply the edge of your knife upon the inner edge of the musculus vastus internus, and at one stroke cut obliquely through the muscles upwards as to the limb and down to the bone; or, in other words, cut in such, a direction as to lay the bone bare about two or three fingers breadth higher than is usually done by the com— mon perpendicular circular incision: now draw the knife towards you, so that its point may rest upon the bone, still attending to keep it in the same oblique line, that the muscles may be divided all round the limb in that direction by a proper turn of the knife; during which its point is kept in contact with, and re— volves round the bone. "The part where the bone is to be laid bare, wheth— er two, three, or four fingers breadth higher than the edge of the retracted integuments; or, in other words, the quantity of muscular substance to be taken out in making the double incision, must be regulated by con— sidering the length of the limb, and the quantity of skin that has been previously saved by dividing the membranous attachments. "The quantity of skin saved, and muscular sub— stance taken out, must be in such an exact proportion to each other, as that, by a removal of both, the whole surface of the wound will afterwards be easily covered, and the length of the limb not more shortened than is necessary to obtain this end. However, it is to be observed, that the more muscular substance we save, by fully giving the oblique direction to the knife, in— stead 279 Sect. IV. the Thigh. stead of dividing the membranous attachments, the better.” Mr. Alanson now gives some directions for the use of the retractor; for securing the divided arteries with ligatures; and for the application of the flannel roll— er. Afterwards he proceeds thus:— “ You are now to place the skin and muscles over the bone in such a direction as that the wound shall appear only in a line with the angles at each side; from which points the ligatures are to be left out, as their vicinity to either angle directs: The skin is easily secured in this pos— ture by long slips of linen or lint, about two fingers in breadth, spread with cerate or any other ointment: if the skin does not easily meet, it is best brought into contact by slips of linen spread with sticking plaster. These are to be applied from below upwards across the face of the stump, and over them a soft tow pled— git and compress of linen, the whole to be retained by the many tailed bandage, with two tails or slips to come from below upwards, to retain the dressings up— on the face of the stump.” Mr. Alanson uses a knife with a double edge, which he thinks preferable to the one commonly em— ployed. As I wish the author's ideas to be clearly under— stood, I think it right to add, that in page 17, he di— rects the bone to be laid bare three or four fingers breadth higher than is usually done by the common perpendicular incision of the muscles; that is, that by the oblique direction of the knife, three or four fingers breadth of muscular substance should be scooped out. And in page 21, he observes, that “ a stump formed in the thigh, agreeably to the foregoing plan, if you bring the parts gently forward after the operation, and then view the surface of the wound, may in some degree be said to resemble a conical cavity, the apex of which is the extremity of the bone; ” and the parts thus divid— ed, he observes, are obviously the best calculated to prevent a sugar loaf stump. From 280 Of Amputating Chap. XLIII. From what has been said, it will appear, that Mr. Alanson's method of operating differs chiefly from that which I have advised above, in the manner of dividing the muscles, and in the after position of the skin. Every surgeon is apt to be partial to that mode of operating which he has been accustomed to practice; but being always anxious to have this very important operation improved to the highest possible degree, I was resolved to give Mr. Alanson's method a fair trial, being hopeful from the accounts received of it, that I should find it answer better even than that which I have spoke so highly of. I can with truth however, assert that it did not answer my expectation. The stumps formed by it are indeed much better than can be made by the usual method of amputating; but the removal of such a large portion of muscular substance, as is done by Mr. Alanson's oblique in— cision, produces a hollow, which not only retains the matter, but which prevents the stump from be— ing so smooth and equal as when the skin is support— ed by a flat muscular surface in the manner we have advised. Mr. Alanson, who is in the daily practice of it, may be able to obviate these difficulties; but I know that I cannot make such a good stump in this manner as I always do in the other method of operat— ing; nor is Mr. Alanson's own idea so completely answered by his method of operating. He very prop— erly observes, page 63, that in the thigh we want a sufficient cushion between the bone and machine to be used in walking; that the more muscular substance that is saved, the farther will the point of bone on which the pressure principally produces inconveni— ence, be removed from the surface of the machine; and likewise, that a more vigorous circulation will be kept up all round the extremity of the bone and stump, which lessens the danger of exfoliation. Now it is obvious, that the end of the bone will not be so much covered with muscular substance when a con— siderable portion of the muscles is removed by the ob— lique 281 Sect. IV. the Thigh. lique incision as when they are allowed to remain; nor will the circulation be so vigorous round the end of the bone. But admitting Mr. Alanson's method of operating to be in every point equal to the other, the greater difficulty of performing it is a weighty objection to it. Indeed few, I believe, will be able to divide the mus— cles by the oblique incision without mangling the skin, even with the explanation given by Mr. Alanson in the last edition of his book. Accordingly we find, in page 204, that this actually happened in the hands of an expert surgeon, Mr. Lucas, of Leeds, even where the division of the muscles was not begun close under the retracted integuments, but a little lower. Nor will this be an uncommon occurrence, if the muscles are divided with the edge of the knife, as is directed by Mr. Alanson. I have divided them with the point of the knife, but with difficulty; for the point cannot be easily carried round to the height of three or four fingers breadth above the retracted skin, so as to make a smooth equal cut. I do not see how the edge of the knife can be applied to cut so obliquely upwards with— out hurting the skin; and yet Mr. Alanson's words are, “ apply the edge of your knife, and at one stroke cut obliquely through the muscles,” &c. He desires in— deed, that the incision may be finished with the point; but I do not understand how it can be done without cutting the skin, if the point be not employed from first to last. Indeed Mr. Alanson himself admits that there is difficulty in this part of the operation; for in page 18, he says, “ that while one assistant continues a firm and steady elevation of the parts, another should attend to preserve the skin from being wounded as the knife goes through the muscles at the under part of the limb. ” This of itself appears to be a material objec— tion to this method of operating: For two assistants, whose hands are all employed nearly at one point, must be apt to embarrass not only each other but the T operator: 282 Of Amputating Chap. XLIII. operator: And besides, it must often happen that two assistants cannot be procured. With respect to the line of direction in which the wound should be closed, Mr. Alanson observes, page 67, if it be formed from above downwards, the cica— trix will generally be found directly opposite to the bone; by which, in walking with an artificial leg, the point of pressure must be upon the new formed skin; which he thinks will be avoided by forming the line in the contrary direction from side to side: in which case, after the cure is complete, it will be found, that in consequence of the more powerful action of the flexor muscles, the cicatrix is drawn downwards, and the extremity of the bone is therefore covered with the old skin; by which the greatest pressure falls upon this part, and not upon the new formed skin. I have not found, however, that this argument is of much importance; for this retraction of the flexor muscles which Mr. Alanson alludes to, is in a great measure owing to the custom of elevating the stump after the operation, and may be prevented by keeping it lower than the rest of the body, in the manner we have mentioned. And besides, the bone is so well covered with muscular substance, and the cicatrix is so narrow when the operation is rightly done, that I have not met with a single instance of any incouveniency a— rising from this circumstance mentioned by Mr. Al— anson: whereas, the lodgement of matter proves al— ways so troublesome and pernicious, and would in all probability occur so frequently, were the practice gen— erally adopted of making a transverse opening instead of a longitudinal one upon the face of the stump, that this appears to be a sufficient reason for preferring the former. With a view to prevent that inequality on the sur— face of the stump, which arises from the retraction of the flexor muscles of the thigh, I have in some cases divided these muscles an inch lower than those of the rest of the limb. After dividing the skin and cellular substance 283 Sect. V. the Leg. substance with a circular incision in the usual way, this is easily done; and it prevents this inconvenience effectually: but it is not necessary when the stump is treated in the manner we have mentioned. Whether others may deem these observations upon Mr. Alanson's method of amputating important or not, I cannot determine; but as they appeared to me to be of consequence, I thought it my duty to offer them. It is but justice, however, to remark, that the pub— lic is much indebted to Mr. Alanson for his assiduity in endeavouring to improve this very important ope— ration, and for the many useful practical remarks con— tained in his publication. SECTION V. Of Amputating the Leg. IN amputating the thigh we observed, that as much of the limb should be saved as can be done with propriety; for the longer the stump the more utility is derived from it: But in the amputation of the leg, it has hitherto been almost a general rule to take it off a little below the knee, even where the disease for which it is advised is seated on or near the ancle, and where accordingly the operation might be performed much lower. The reason given for this is, that a few inches of the leg being saved, answers as a sufficient rest to the body in walking when the limb is inserted into the box of a wooden leg; and when much more of it is left, that it proves troublesome both in walking and sitting, without being attended with any particu— lar advantage. Were we to conclude, that the common practice or bonding the joint of the knee and resting upon the an— T2 terior 284 Of Amputating Chap. XLIII. terior part of the leg was necessary, this method of op— erating a little below the knee would be admitted as the best: But as we have now had many instances of patients walking equally well with machines so con— trived as to admit of the use of the knee joint; as these machines, by resembling the human leg, are much more pleasing to the eye than the wooden ones in common use; and as the operation may be done with much more ease and safety to the patient a little above the ancle, I am of opinion that it should always be ad— vised to be done here whenever it is practicable, in— stead of the ordinary place a little below the knee. The operation is easier done a little above the ancle than at the upper part of the leg, by the parts to be divided being less extensive: for the diameter of the leg is here considerably less; and it is done with more safety by our being able to cover the bone more com— pletely with soft parts, so as to accomplish a cure in the same manner and equally soon as in the thigh: Whereas, immediately below the knee, the bones are not only larger, but there is such a scarcity of soft parts, that the cure proves always much more tedious, notwithstanding all our endeavours to promote it; in— somuch, that in operating at the usual place, about four inches beneath the patella, the sore, with all the attention we can give to it, will seldom heal in less than ten or twelve weeks; and in the common method of forming the double incision, it will even require four or five months: Whereas, when the operation is right— ly performed a few inches above the ancle, a cure may for the most part be effected in a fortnight or three weeks. It is true that a method of amputating beneath the knee has been proposed, by what is termed the Flap Operation, and by which a cure may be more speedi— ly effected than in the usual way of operating; but still it is tedious, and at the same time is liable to oth— er objections, which we shall have presently occasion to mention. I therefore conclude, that in every case that 285 Sect. V. the Leg. that admits of it, amputating a little above the ancle is preferable to operating immediately below the knee. We are next to determine the most proper place for the operation, when we are prevented by the ex— tent of the disease in the leg from amputating lower than the usual place beneath the knee. Where the upper part of the leg is sound, it has hitherto been a fixed maxim to amputate below the joint of the knee rather than above it. While practitioners were unacquainted with the present improvements in the operation of amputation, they seem to have adopted this maxim, chiefly from finding that the body rested more easily upon the sound skin on the fore part of the leg than on the stump of the thigh: But now that the operation may be done above the knee, so as that the sore will heal in less than one half of the time that is required when a leg is taken off immediately below the joint, and in such a manner that the stump is covered with sound skin, as well as with some muscular substance, which admits of the patient resting upon it with freedom; this reason, upon which the practice is chiefly found— ed, falls to the ground. We have observed above, that the cure of a stump immediately below the knee is always tedious, owing to the great extent of bone at this part, and the natur— al deficiency of soft parts. Upon the whole, therefore, I conclude, that ampu— tation immediately below the knee should seldom or never be advised: But as no innovation will at first be generally admitted, I think it right to describe the method of operating when it is determined to ampu— tate at this part. The patient should be placed upon a table and se— cured in the same manner as in operating above the knee. The tourniquet should be applied a little a— bove the knee, with the cushion upon the artery in the ham. The foot and leg should be secured by an as— sistant sitting before the patient, while the teguments T3 are 286 Of Amputating Chap. XLIII. are drawn up by another assistant towards the knee. The surgeon, standing on the inside of the leg, should now with the knife, Plate LXXXV. fig. 3. make a circular cut through the skin and cellular substance down to the muscles, so far down upon the limb, that when as much of the teguments are separated from the parts beneath as will cover the stump, the muscles and bones may be divided immediately below where the flexor tendons of the leg are inserted. The interosse— ous soft parts must be divided either with the point of the amputating knife or with the catline, Plate LXXXV. fig. 2. The retractors, Plate LXXXIV. fig. 2. and 3. must now be applied so as to support and protect the skin and other soft parts from the saw employed for dividing the bones. This being done, and the vessels secured, the teguments should be drawn over the stump and retained with adhesive plasters, in the manner we have advised in amputating the thigh. The practice, indeed, should be the same during the whole course of the cure; only in the application of the flannel roller, there is no necessity for beginning at the top of the thigh: It should receive, however, two or three turns above the knee, to prevent it from slip— ping down. In separating the adhesions of the skin from the parts beneath, as much of the cellular substance should be taken along with it as can be got; otherwise the circulation in the skin itself is apt to become so lan— guid as to prevent it from adhering to the parts on which it is applied. It will be found too, that more attention is necessary to destroy the attachments of the skin in this situation, particularly on the sore part of the leg, than on the thigh, owing to the cellular sub— stance being more condensed where it lies so contigu— ous to the bone, than in the thigh, where the muscles intervene. And as this state of the cellular membrane prevents the teguments from retracting freely after they are divided; and as they cannot even be pulled sufficiently up by the assistant, it is necessary to fold such 287 Sect. V. the Leg. such of them as are separated from the parts beneath back upon the sound skin, before the division of the muscles be attempted; otherwise the skin will either be cut with the knife, or the muscles will not be di— vided so high as is necessary. Always at this part of the leg, and in a saw cases immediately above the ancle, I have found it necessa— ry to fold the skin back in this manner; but hitherto no instance has occurred in the thigh, but where the operation might have been done merely by pulling the teguments up, in the manner we have formerly mentioned. We have desired above, that in this operation the surgeon should stand on the inside of the leg: By this means, if the knee and foot be turned inwards, so as to raise the fibula, the saw may be applied in such a manner to both bones as to divide them nearly togeth— er; which is the surest method of preventing them from breaking when they are nearly sawn through: Whereas, on standing on the outside of the patient, the fibula will be more apt to be left to the last; at the same time that the saw will be applied upon the ridge of the tibia so as to act upon its longest diame— ter, by which it will not be so quickly divided. In operating above the ancle, that spot should be fixed upon which will leave the stump of the most convenient length for being fitted with a leather ma— chine resembling the other leg. And I find from ob— servation, as well as from the information of Mr. Wil— son, an ingenious tradesman of this place, that nine inches from the joint of the knee is the best length for this purpose; for it affords a sufficient support to the machine, and at the same time prevents it from being so heavy and clumsy as when the leg is left of a great— er length: for when taken off immediately above the ancle, the stump must go down to the very bottom of the machine, which must therefore be made thicker and heavier at the ancle than would otherwise be re— quired; at the same time that it will prevent it from T4 corresponding 288 Of Amputating Chap. XLIII. corresponding so exactly as it otherwise would do to the size of the other leg. In addition to what we have said upon the method of amputating the leg immediately below the knee, we may observe, that in operating above the ancle, it should be done exactly as we have advised in describ— ing the amputation of the Thigh: Only in this situa— tion, instead of muscles, we find a portion of both bones covered merely with skin and cellular substance; but as the cellular membrane is here commonly suf— ficiently lax, and in greater quantity than in the up— per part of the leg, it is not only more easily separated from the periosteum, but serves to give the bones a more complete covering: By which, when the opera— tion, is properly done, the cure for the most part is accomplished in less than three weeks, and the surface of the stump is equal and every where covered with sound skin. SECTION VI. Of Amputating with a Flap. IN performing the operation of amputation in the usual way, the cures were so extrememely tedious; the health of the patients was thereby so much injur— ed; and the stumps, when healed, were so pyramidal, and so thinly covered with soft parts, that another method of operating, as we have observed above, was proposed upwards of a hundred years ago; in which an attempt was made to obviate these difficulties, by preserving a flap of muscles and skin for the purpose of covering the stump. This was first proposed by one Loudham, a British surgeon: It was afterwards pactised in Holland, Ger— many, Switzerland, and France; and more lately by some 289 Sect. VI. with a Flap. some individnals in Britain and Ireland: but it has never been received into general use, nor is it proba— ble that it will ever be frequently performed. The chief objections to it were, the difficulty of re— straining the hemorrhagy when it happened to recur af— ter the flap was applied and fixed in its situation by sutures; for in order to discover the bleeding arteries, it was necessary to undo the whole; the flap not ad— hering uniformly over the whole surface of the stump; and the pain, inflammation, and tension, which su— pervened, being much more severe than after the usual method of operating. To remove these difficulties, it was proposed, a— bout twenty years ago, by Mr. O'Halloran, an ingen— ious surgeon of Limerick, to dress the stump and slap as separate sores for the first twelve days; when the risk of hemorrhagy being over, the symptoms of pain, inflammation, and tension, subsided, and suppuration established, we are directed to turn the flap back upon the surface of the stump, and by means of plasters, com— pression, and bandage, to secure it in this situation till they unite together. By this improvement, the operation was rendered more safe and certain: and it is probable that it would gradually have come into general practice, if the im— proved method of operating, which we have already described, had not in the mean time been introduced: But although this method will probably continue to be generally preferred, yet in particular situations, the operation with the flap may with much propriety be employed. Wherever the divided parts cannot be properly covered with skin in any other manner, it ought certainly to be done with a slap: and this will always be the case in amputating the arm at the shoul— der, and the thigh at the hip joint, as well as in remov— ing any of the fingers or toes: It may likewise by some be preferred to the method of operating which we have described, when it is resolved to amputate immediately below the knee; for the teguments be— ing 290 Of Amputating at Chap. XLIII. ing in this part extremely thin, some will be apt to imagine that the stump cannot in any other manner be sufficiently covered. But for the reasons we have already mentioned, it can never be necessary, either above the knee; in operating above the ancle; nor in the arm or fore arm. Some, however, may con— tinue to prefer it, even in these parts: so that it will be proper to describe the method of doing it in all of them. This we shall attempt in the following Sec— tions. SECTION VII. Of Amputating the Thigh at the Hip Joint. THE amputation of the thigh at the hip joint has always been considered as one of the most haz— ardous operations, and therefore we have very few in— stances of its being performed. Indeed surgeons in general have spoke of it as one of those operations which authors might describe, but which would never be practised: And when we consider the great size of the blood vessels which supply these parts; the diffi— culty of commanding the hemorrhagy during the ope— ration; and the very extensive wound which, in the usual method of operating, must necessarily have en— sued here; we will not be surprised at the aversion which has generally prevailed against it. But if these difficulties can be removed; if danger from hemorrhagy can be prevented during the opera— tion, as well as afterwards; if the sore can be so com— pletely covered with skin as to be healed in the course of a few weeks; and if cases ever occur which would otherwise end in the death of the patient; we surely would not hesitate in advising it. Now, we hope to make 291 Sect. VII. the Hip Joint. make it appear, that the operation may be done with very little loss of blood; and that as much skin may be saved as will cover the sore entirely: and no prac— titioner will doubt of diseases taking place at the top of the thigh, which cannot be removed but by amputat— ing the limb. Having already treated fully of the causes by which amputation of limbs may be rendered necessary, we shall now refer to what was said upon that part of the subject; and at present shall only observe, that gun shot wounds, accompanied with fractures of this part of the bone, spina ventosa, or caries of the head of the femur, will be the most frequent causes of amputating at the joint of the hip. When the operation is re— solved upon, it may be performed in the following manner. The patient should be placed upon a table; and it will be found that the parts that are meant to be divided will be brought most clearly into view by laying him on the sound side. In this situation he should be se— cured by two or three assistants, while another assistant takes the management of the limb. Let a small pad or cushion be now placed upon the femoral artery, immediately after it passes out from be— neath Poupart's ligament into the thigh; and, by means of a tourniquet applied as near as possible to the top of the limb, let the circulation be completely stopped. Let the skin, membrana adiposa, and ten— dinous fascia of the thigh, be divided by a circular in— cision six inches from the top of the thigh; that is, at at least three inches beneath the circular band of the tourniquet. Let the retracted skin be pulled an inch upwards; and at the edge of it let the amputating knife be applied, so as with one perpendicular circular stroke the muscles may be cut down to the bone. If the muscles be freely divided, they will retract so much as to admit of sufficient space for securing not only the femoral artery but all the muscular branches. This being done, take a strong round edged scalpel, larger than the common size, and commencing at the upper edge 292 Of Amputating at Chap. XLIII. edge of the circular cut on the posterior part of the thigh, make a deep incision down to the bone, and carry it up of the same depth to a little above the great tro— chanter into the joint. Let a similar cut be made on the opposite side of the limb, at a sufficient distance from the femoral artery, and completely down to the bone. Let the two portions of flesh be now dissected from the bone, and the flaps formed by them be tak— en care of by assistants, while any artery that may be cut should be tied as soon as it is observed. The joint being laid bare, some dexterity will be required to dis— engage the head of the femur from the acetabulum; for it is rendered difficult from being tied down to it by the ligamentum rotundum: But by turning the bone in different directions, and particularly by press— ing it inwards, where it yields most readily from the brim of the acetabulum being lowest, the head of it will be so far turned out of the socket on the opposite side as to admit of the ligament being reached with the point of a scalpel or a firm probe pointed bistou— ry; but to accomplish this, the muscles must all be previously detached from the bone. The head of the bone being taken out and the limb removed, we may examine the state of the acetabu— lum: for if it be sound, our prospect of a cure will be more favourable than if any part of it be carious. But in whatever state the bones may be, our treatment of the sore must be the same: we must endeavour to cure it as nearly as possible by the first intention: For which purpose, after removing all the coagulated blood from the surface of the wound; placing the muscles as nearly as possible in their natural situations; and drawing the two flaps together, so as to cover the sore as neatly as may be: they should be secured in this situation by three or four sutures introduced at the most proper points: by adhesive plasters; and by proper compresses retained with a broad flannel roller passed different times round the body, and spirally o— ver the stump; care being taken to leave the ligatures upon 293 Sect. VII. the Hip Joint. upon the arteries, of a sufficient length to admit of their being afterwards drawn out. The patient should now be laid in bed, and treated in other respects as we have advised in general after the Operation of Amputation: Only it must be re— marked, that more than ordinary attention will be re— quired to prevent and remove such febrile symptoms as usually succeed to amputation; for where such a considerable part of the body is suddenly taken away, almost a fourth part of the whole, we may reasonably conclude that the effect produced by it upon the sys— tem must be considerable. If the patient is plethoric, it will be proper to diminish the quantity of blood; in the first place by venæsection, and afterwards by a low diet: Indeed moderate living should be persever— ed in, if not for life, at least for a great length of time. The dressings may be removed at the usual time, and in the course of ten or twelve days the ligatures may be all taken away; when any part of the sore that remains open may be covered by drawing the skin over it, and securing it with adhesive plaster. In such an extensive sore, it is indeed probable that mat— ter may collect in different parts beneath the skin; for the pressure applied upon it, will not be so equal as in common cases of amputation: but the inconvenience arising from this will not be great; for if the matter cannot be discharged by altering the pressure, it will be easily done with the point of a lancet, by which this obstruction to the cure will be removed. At all times this will necessarily be considered as a very formidable operation: But when performed in the manner we have advised, much of the hazard, and many of the inconveniences usually supposed to at— tend it, will be removed: nor should any practitioner accustomed to operate, hesitate in performing it, when the life of a patient will otherwise be endangered. By the tourniquet, we effectually command the circu— lation in the limb till all the large blood vessels divid— ed by the circular incision are tied; and by securing the 294 Of Amputating, &c. Chap. XLIII. the different arteries that are cut in making the longi— tudinal incisions as soon as they appear, the loss of blood will be inconsiderable: Nor will there be any risk of hurting the femoral artery in the course of sep— arating the flap in which it is seated from the bone, if it be done with caution. It may be alleged, that by this method of operating; more of the teguments and muscles will be saved than are necessary for covering the sore: But it must be re— membered, that the sore will here be very extensive, and that the divided muscles will retract considerably. And besides, the tourniquet could not be applied if the first cut was much higher than we have directed; by which the operation would necessarily be rendered much more dangerous: Nor can any risk occur from the teguments and muscles being left somewhat longer than might be just required for the purpose above mentioned, while much inconvenience would ensue from their being deficient. In the sixth volume of the Medical Commentaries; of Edinburgh, a case is recorded, in which the thigh was amputated at this joint by Mr. Kerr, surgeon in Northampton. In this case, the division of the femo— ral artery was reserved to the last; nor was the tour— niquet employed. No hemorrhagy indeed occurred; but there was surely more risk of this than if the ope— ration had been done in the manner we have advised: Nor could the operator use such freedom with the bone, in removing the head of it from the socket, as long as the blood vessels remained undivided. We may remark, however, that this case affords an instance of this operation being practised with safety: For al— though the patient died, yet she lived eighteen days af— ter the operation, and at last died from a different cause, when all risk of hemorrhagy was over, and when the sore had even a favourable appearance. SECTION 295 Sect. VIII. Of the Flap Operation, &c. SECTION VIII. Of the Flap Operation immediately above the Knee. WHEN this operation is to be performed above the knee, it may be done either with one or two slaps, but it will commonly succeed best with one. It is most convenient to have the flap on the sore part of the thigh; for here there is a sufficiency of soft parts for covering the bone, and the matter passes more freely off than when the flap is formed in any other di— rection. The patient being placed upon a table, the tourni— quet being applied in the usual way at the top of the thigh, and the teguments drawn firmly up and retain— ed by an assistant, the extent of the intended flap should be marked with ink. A person much accus— tomed to this operation may not require this assist— ance; but it will be done with more neatness and ex— actness if the form and extent of the flap be previously marked. The extreme point of the flap should reach to the end of the limb, unless the teguments be in any part diseased; in which case, it must terminate where the disease commences, and its base should be where the bone is to be sawn. This will determine the length of the flap: and we must be directed with respect to the breadth of it by the circumference of the limb: For, the diameter of a circle being some— what more than a third of its circumference, al— though a limb may not be exactly circular, yet by at— tention to this circumstance, we may ascertain with sufficient exactness the size of a flap for covering a stump. Thus, a flap of four inches and a quarter in length will reach completely across a stump whose cir— cumference is twelve inches; but as some allowance must be made for the quantity of skin and muscles that 296 Of the Flap Operation Chap. XLIII. that may be saved on the opposite side of the limb by cutting them in the manner we have directed, and drawing them up before sawing the bone; and as it is a point of importance to leave the limb as long as possi— ble, instead of four inches and a quarter, a limb of this size, where the first incision is managed in this man— ner, will not require a flap longer than three inches and a quarter, and so in proportion according to the size of the limb. The flap at its base should be as broad as the breadth of the limb will permit, and should be continued nearly, although not altogether, of the same breadth to within a little of its termina— tion, where it should be rounded off so as to corres— pond as exactly as may be with the figure of the sore on the back part of the limb. This being marked out, the surgeon standing on the outside of the limb should push a straight double edged knife with a sharp point to the depth of the bone, by enter— ing the point of it at the outside of the base of the in— tended flap; and carrying the point close to the bone, should push it through the teguments at the mark on the opposite side. The edge of the knife must now be carried downwards, in such a direction as to form the flap according to the figure marked out; and as it draws towards the end, the edge of it should be some— what raised from the bone, so as to make the extremi— ty of the flap thinner than the base; by which it will apply with more neatness to the surface of the sore. The flap being supported by an assistant, the teguments and muscles on the back part of the limb should, by one stroke of the knife, be cut down to the bone, about an inch beneath where the bone is to be sawn; and the muscles being separated to this height from the bone with the point of the knife, the soft parts must all he supported with the leather retractors, Plate LXXXIV. fig. 4. till the bone is sawn; and any splin— ters that may be left, are cut off. All the arteries that discharge much blood must now be secured in the usual 297 Sect. VIII. above the Knee. usual way with the tenaculum, the ligatures being left of a sufficient length for hanging out at the edge of the flap. The muscles and teguments should now be drawn down and secured with a flannel or cotton roller, in the manner we have advised when a leg is amputated with a circular incision; and the flap may now be laid down over the surface of the sore, so as to effect a cure as much as possible by the first intention; or it may be dressed as a separate sore, agreeable to the practice of Mr. O'Halloran, according to the judg— ment of the operator. If it is to be applied immedi— ately, the coagulated blood should be carefully spong— ed out, and it should be secured to the muscles and teguments surrounding the rest of the stump by three or four sutures passed at least three quarters of an inch into the muscular substance of the flap: But care should be taken not to draw the ligatures so tight as to create much irritation or pain. The under part of the stump should now be covered with a large pledgit of common cerate; and a cushion of soft tow being laid over it, the whole should be secured in the man— ner we have formerly advised, with cross straps of lin— en and a few turns of a circular roller. In three or four days the dressings may be renewed; and as soon as the ligatures are all removed, and the tension and inflammation induced by the operation abated, any part of the sore which was not covered at first may now have the skin drawn over it, and secur— ed with adhesive plasters. But if Mr. O' Halloran's method is to be adopted, the easiest mode of proceeding is this. The muscles and teguments being drawn down and secured with the roller, let the whole surface of the stump be cover— ed with a pledgit of soft lint spread on both sides with any soft emollient ointment: Let the flap be laid down upon this; and another pledgit of the same kind being laid over the whole with a cushion of tow and a compress of soft linen, the cross straps and circular Vol. IV. U roller 298 Of the Flap Operation Chap. XLIII. roller should be employed to support them, but with no more pressure than is necessary for this purpose. At the end of three or four days the dressings may be renewed in the same manner; and about the twelfth or fourteenth day, or whenever the tension induced by the operation is removed, the ligatures all taken out, and a proper suppuration established, the flap may be brought into contact with the sore beneath with a view to make them unite. For this purpose, any matter that may be observed upon the surface of either of them should be gently removed with a soft sponge; and the flap being laid down with as much exactness as possible, it may either be secured with ad— hesive plasters supported by the bandage above men— tioned, or two or three sutures may be employed. This last method will give more pain than the other; but this will be amply compensated by the flap being retained in its situation with much more certainty and exactness. Farther experience must evince which of these methods should be preferred, for as yet it is not deter— mined. It is my own opinion, that the secondary union recommended by Mr. O'Halloran is the best: for the pain, tension, and inflammation which ensue from the other, run often so high as to render it nec— essary to remove the dressings and even the ligatures; by which a great deal of additional trouble is given to the practitioner and much distress to the patient: whereas, when the tension and inflammation are gone before the flap is laid down, little or no pain is induc— ed by it; nor is the cure effected in this manner more tedious: On the contrary, it would appear to be in general accomplished more quickly in this way than in any other. Even where the flap has not been appli— ed to the sore till the fourteenth day, the cure has been completed before the fourth week: Whereas few, if any, cures have been effected so early where the flap has been applied immediately after the operation. In 299 Sect. IX. below the Knee. In operating with two flaps, the following is per— haps the easiest method: The patient being placed upon a table, and the tourniquet applied, let the skin be drawn up by an assistant, and a circular incision be made through the teguments and muscles down to the bone at the most inferior parts of the limb, with the edge of the knife turned obliquely upwards: Let the sharp pointed knife, mentioned above, be now pushed through the skin and muscles on one side of the limb down to the bone, at that part where the bone is to be sawn; and the under edge of the knife being turned obliquely outwards, let the muscles be divided down to the circular incision. The teguments and muscles on the opposite side of the limb must now be divided by a similar incision, when any of the intermediate soft parts that may have been left must likewise be cut; and the bone being sawn, and the vessels secured with ligatures, the cure may either be attempted by laying the flaps together immediately, or they may be kept separate twelve or fourteen days, and treated after— wards in the manner we have advised above. SECTION IX. Of the Flap Operation below the Knee. IN speaking of this operation below the knee, it is not necessary to describe all the steps of it. The views of the operator are the same here as in operat— ing above the knee, and the method of effecting them is nearly similar. After the previous steps of the op— eration are taken, the size and form of a flap sufficient to cover a considerable part of the sore must be mark— ed out with ink; this must be separated from the parts beneath in the manner we have already advised: The rest of the soft parts must be divided, taking care to U2 save 300 Of the Flap Operation, &c. Chap. XLIII. save as much of the teguments on the side of the limb opposite to the flap as with the flap itself will nearly or entirely cover the sore; and the cure must after— wards be conducted either by applying the flap im— mediately, or after the symptoms of pain, tension, and inflammation induced by the operation are gone, and treated in the manner we have advised in the last sec— tion. It must be observed, however, that in operating be— neath the knee, the flap cannot be formed on the fore part of the limb as is done in the thigh; for on this part of the leg there is no muscular substance; and for this reason, we are advised by authors to form the flap on the back part of the leg. But this is liable to one very important objection, the difficulty of pre— venting matter from lodging between the flap and the sore after they are brought into contact: for it must be remarked, that it is moderate pressure only which we dare venture to apply to the flap; so that it is scarcely possible to prevent the matter from collecting where it does not find a free vent below. Instead of forming the flap from the muscles of the back part of the leg, it may be done with more pro— priety upon the outside of the limb, where there is a sufficient quantity of muscular substance for this pur— pose. The point of the knife should be entered on the outside of the ridge of the tibia at the part where the bone is to be sawn; and being carried backwards in a direct line, and at a proper depth to the opposite side of the base of the flap, the edge of it must after— wards be carried down the line previously marked with ink as a direction for the form and length of it. In this manner the bones may be covered with a flap of a sufficient thickness, while the matter which forms in the progress of the cure, finding a ready outlet by the inferior edge of the flap, will not be allowed to lodge. In operating immediately above the ancle, there is a necessity for leaving the flap behind, for there is not 30l Sect. X. Of Amputating, &c. not a sufficient quantity of soft parts to admit of it in any other situation. But we have elsewhere observ— ed, that the leg should never be taken off so immedi— ately above the ancle, as it leaves the stump too long for a machine to be rightly adapted to it for the pur— pose of walking: But at nine inches from the condyles of the femur, which in an adult is the most proper length for this purpose, the flap may with propriety be formed, in the manner we have mentioned, on the outside of the leg. SECTION X. Of Amputating the Foot, Toes, and Fingers. WHEN the whole foot is diseased, it becomes nec— essary to take off the limb at the part we have mentioned above the ancle; nay, this should be done e— ven where the parts above the joint are sound, if all the rest of the foot is diseased: For although some have recommended the amputation of the foot at the joint of the ancle, yet the practice should not be adopted, as the sore cannot be properly covered, nor is the stump when of this length, so useful: But when any consid— erable part of the foot remains found, it ought un— doubtedly to be saved, and the diseased part of it only removed. I have seen a whole foot taken off where two of the metatarsal bones only have been diseased: while, on the contrary it should be laid down as a fix— ed rule, to remove the diseased parts alone even where two of these bones only remain sound; for with the assistance of a shoe properly stuffed, and with a firm unyielding sole, even a very small part of the foot proves useful in walking: And thus especially when the bones on the inside of the foot, or those corres— ponding to the great toe and those next to it, are left U3 When 302 Of Amputating the Chap. XLIII. When the middle part only of the foot is diseased, the metatarsal bones on each side remaining sound, these should be left, and the diseased part only taken out. In this case, the affected bones should be taken out at the joint whether they be diseased through their whole length or not; for although instruments might be invented for cutting even a single bone across in the centre of the foot, the operation would necessarily be much more tedious, and more painful, than the re— moval of the bone at the joint, at the same time that little or no advantage would be derived from saving a small portion at the end of it. But where one, two, or three of the bones on either side of the foot are on— ly partially diseased, as in this case it becomes an ob— ject to save as much of the foot as possible, the opera— tion should be so conducted that the bones may be sawn across nearly at the termination of the diseased parts. In every case of amputation, it is an object of im— portance to save as much of the skin as will cover the sore; but it is particularly necessary in amputating a— ny part of the foot where the effect of friction is much to be dreaded in walking. In making the incision, therefore, at that part of the bone where the saw is to be applied, it should be done in such a manner, that a flap may be saved of a sufficient size for covering the sore. With a little attention this may always be done, nor is it often attended with any difficulty; for the flap may be formed either above or below, or on one side of the toe, according as the teguments are found or otherwise. But it is proper to remark, that where the skin is sound, it answers best to save it below; as in this situation it is firmer, and therefore more able to resist the effects of pressure. This operation is most easily performed when the patient is placed upon a table. The tourniquet should be applied above the knee, with a compress placed up— on the artery in the ham; the limb should be firmly secured by assistants; and on sawing the bone, a piece of 303 Sect. X. Foot, Toes, and Fingers. of pasteboard, or thin splint of timber, should be in— serted between it and the contiguous sound bone, to protect the latter from the teeth of the instrument. The diseased parts being removed, and any artery that is cut secured, the flap should be applied as ex— actly as possible to the sore, and retained with slips of adhesive plaster and gentle pressure with a flannel roll— er. If sutures are employed, they should be inserted in such a manner as to avoid the flexor and extensor tendons of the toes and foot. In amputating the toes and fingers, the operation used formerly to be done by one stroke with a chisel and mallet; but this is liable to many objections, and has been long in disuse. In general, fingers and toes are amputated in the same manner with the larger ex— tremities, either by preserving a flap sufficient for cov— ering the sore, and afterwards dividing the bone with a small spring saw represented in Plate LXXXIV. fig. 1. or by the double incision, performed in the manner we have advised in Section IV. of this Chap— ter. But instead of this, it has for several years been the practice of some individuals, to amputate fingers and toes at the joints; and whoever will give it a fair trial, will readily prefer it. The patient being placed upon a table, and the limb properly secured, a flap should be marked with ink of a sufficient size for cov— ering the sore. This being dissected from the bone with a scalpel, and supported by an assistant, a circu— lar incision should be made through the rest of the soft parts, a little below the joint, and on a line with the base of the flap. The lateral ligament should now be cut; and in order to determine the point at which this should be done, an assistant should be directed to move the finger. This ligament being divided, the joint is easily dislocated, when the remainder of the operation may be quickly finished. If it is necessary to tie an artery, it should be done with the tenaculum. The flap must be applied to the sore, and secured as U4 neatly 304 Of Amputating the Chap. XLIII. neatly as possible with adhesive plasters, and mode- rate pressure with a flannel roller. The only objection that has been made to this prac— tice is, the supposed uncertain union of the contigu— ous soft parts with cartilage. But we now know, that there is no cause for this apprehension, and that a flap will uniteas readily with cartilageas with bone, at least I have uniformly observed this to be the case; and we find from Mr. Alanson's publication, that the practice has proved very successful in the course of his experi— ence. SECTION XI. Of Amputating the Arm at the Joint of the Shoulder. THIS operation having always been considered as hazardous and difficult to perform, it has not frequently been attempted: But although it should never be advised when our purpose can be accomplish— ed by amputating lower, yet no practitioner of mod— ern times will decline it, when the life of a patient cannot in any other manner be saved. Abscesses in the joint, caries of the humerus reaching to the joint, compound fractures extending to the head of the bone, gunshot wounds and mortification, may render ampu— tation of the arm at the shoulder necessary. The operation may be performed with safety by a— ny surgeon of steadiness and experience, and who is possessed of an accurate knowledge of the anatomy of the joint and contiguous parts. It may be done in different ways; but the follow— ing I believe to be the best. The patient should be placed upon a table of a con— venient height, covered with a matress and blanket; and 305 Sect. XI. Arm at the Shoulder. and he should be laid upon his back, and properly se— cured by assistants, as near as possible to one side of the table. The next object is to guard against hemorrhagy: for this purpose we might advise the tourniquet to be placed upon the upper part of the limb, in a manner similar to what we have proposed in amputating at the hip joint. But here it is unncessary, as the blood may be completely stopped in its flow to the arm, by compressing the subclavian artery as it passes over the first rib: for this purpose, an assistant should be prop— erly placed, with a firm cushion or compress applied upon the course of this artery directly above the cla— vicle, who with his fingers should make such a pres— sure as may be necessary: It will readily be known whether it proves effectual or not, by its influence on the pulsation at the wrist. The circulation being stopped, the diseased should— er should be made to project somewhat over the side of the table; and the arm being stretched out and supported by an assistant at nearly a right angle with the body, a circular incision should be made through the skin and cellular substance just at the insertion of the deltoid muscle into the humerus. The teguments may be allowed to retract about half an inch; and at the edge of the retracted skin, the knife may be appli— ed so as to divide the muscles with a perpendicular cir— cular cut down to the bone. Thus far we proceed with the common amputating knife; but the remaind— er of the operation should be finished with a scalpel. With a firm round edged scalpel a perpendicular in— cision should now be made down to the bone, com— mencing at the acromion, about half way between the centre of the deltoid muscle and the inner edge of it, and terminating in the circular incision about an inch above, or rather on the outside of the brachial artery. This being done, a similar cut must be made on the back part of the arm, commencing at the same height with the other, and ending in the circular incision. This 306 Of Amputating the Chap. XLIII. This should be at such a distance from the first, that the two flaps formed by them both may be nearly of an equal breadth. The brachial artery should be ti— ed as soon as it is cut by the circular incision through the muscles; and any anastomosing muscular branch— es of arteries that may be cut on the upper and back part of the joint should be tied immediately on being observed. The two flaps should now be separated from the bone, care being taken to avoid the large ar— tery in dissecting off that part of the flap with which it is connected. An assistant must support the flaps so as to bring the capsular ligament of the joint into view: when an opening being made into it, the head of the bone will be easily dislocated by drawing the arm backward: and this being done, the operation will be easily finished by dividing the remaining part of the ligament. Any arteries that may have been cut about the joint being tied, the ligatures hanging out at the most de— pending part of the wound, and the parts cleared of coagulated blood, the two flaps should be laid togeth— er so as to cover the joint as neatly as possible, and re— tained in their situation by two or more sutures. A pledgit of lint spread with any emollient ointment should now be laid over the joint; and a soft cushion of tow or of lint, with a compress of old linen, being applied over the whole, a flannel roller should be em— ployed to make a moderate pressure upon the joint; by which the flaps will be kept in contact with the parts beneath, which will not only facilitate their un— ion, but will be the most effectual method of prevent— ing matter from lodging. In other respects, the patient should be treated as we have advised in the preceding Sections, when speak— ing of Amputation in the Lower Extremities. With a view to prevent any risk from hemorrhagy after the operation, an assistant of experience should fit with the patient for the first two or three days, with direc— tions to apply pressure above the clavicle in the event of 307 Sect. XI. Arm at the Shoulder. of any considerable quantity of blood being discharg— ed, till the bleeding vessel can be secured with a liga— ture. In the course of eight or ten days the ligatures upon the arteries will come easily away. If matter collects beneath any part of the skin, it must be dis— charged; and if the patient is healthy and no untoward circumstance happens, a cure may soon be expected. Till of late, it was the practice in this operation to tie the brachial artery and veins with a ligature before proceeding farther. This gave much unnecessary pain, at the same time that it did not render the pa— tient more secure. In the way we have mentioned, the operation maybe performed with no risk from the hemorrhagy; and by tying the artery at the extremi— of the flap, several muscular branches will be saved which would be cut off by tying it near the axilla. Mr. Bromfield, in the first volume of his Observa— tions and Cases, has given the best account yet pub— lished of this operation. The principal difference be— tween this method of doing it and the one we have described, consists in the latter being more simple, and therefore more easily performed. By dividing the muscles down to the bone with a circular incision, the operation is more speedily done than by cutting first one muscle and then another, in the manner mention— ed by Mr. Bromfield. And as the attachments of the latissimus dorsi, the deltoid and pectoral muscles, as well as of all the other muscles of the arm, are remov— ed by the arm being taken away, there is no necessity for proceeding with slowness and caution in dividing them; nor is it necessary to employ two ligatures up— on the brachial artery, one considerably higher than the other, as is advised by that author; one ligature applied in the usual way with the tenaculum is quite sufficient, if it be done with care and attention. And Mr. Alanson very properly observes, in speaking of this operation, that there is no necessity for scraping off the cartilage from the acetabulum of the joint, as is recommended by Mr. Bromfield; for we find by ex— perience, 308 Of Amputating the Arm. Chap. XLIII. perience, as we have observed in the last Section, that the teguments adhere to cartilages as readily as to bone. SECTION XII. Of Amputating the Arm. THE general observations we have made upon the method of amputating the thigh and leg, apply with the same propriety to the amputation of the arm and fore arm. At present, therefore, we shall only observe, that in amputating the arm, no more of it should be removed than is diseased; for the longer the stump is, the more useful it proves: And the same attention should be given to the saving of teguments for covering the sore that we have advised in Ampu— tating the Leg. But it is proper to remark, that this may always be done both in the arm and fore arm without the assistance of a flap: For there is in every part of both a sufficiency both of muscles or cellular substance, for admitting of the sore being completely covered by amputating with the double incision, in the manner we have pointed out; and wherever this can be done, it should be preferred to the method of operating with a flap. CHAPTER 309 CHAPTER XLIV. Of removing the Ends of BONES in Diseases of the JOINTS. THE amputation of limbs is more frequently ad— vised for affections of the joints than for any other cause; and as this often happens where the rest of the limb is found, it were to be wished that with safety and propriety we could remove such parts as are diseased, and leave those that are found. In com— pound fractures and dislocations, the ends of large bones have been frequently been sawn off, when such parts of them have protruded as could not be replac— ed. The deficiency thus produced, has in most in— stances been supplied by nature; and thus the limbs have remained almost equally useful as before. In a few cases too of diseased joints, a cure has been obtain— ed by the head of a bone being sawn off. Among other instances of this to be met with in books, a re— markable one is recorded by a very ingenious and ex— pert surgeon, Mr. White of Manchester, who preserv— ed an arm by sawing off the head of a diseased hume— rus.* But Mr. Park of Liverpool was the first who ventured to propose it as a general remedy in affections of the joints.† Whether or not it will stand the test of experience, farther trials must determine; but in the * Vide Cases in Surgery with Remarks, Part I. by Charles White, F. R. S. &c. † Vide An Account of a New Method of Treating Diseases of the Joints of the Knee and Elbow, by H. Park. 310 Of removing Ends of Chap XLIV. the mean time, the public are much indebted to Mr. Park for the pains he has taken to introduce a less formidable remedy in place of amputation. What Mr. Park proposes is, that instead of ampu— tating a limb for any external violence done to a joint, for a white swelling, a caries, or any other affection, that the diseased ends of the bones should be sawn off; when nature, he thinks, will commonly supply the de— ficiency of bone; by which the limb will be preserv— ed, and will prove more useful than any machine that artists can invent. Mr. Park supposes that this operation will be chief— ly applicable to affections of the knee and elbow, and more particularly to those of the latter; and he relates a case of white swelling of the knee in which it was practised with success: The under extremity of the fe— mur and the upper end of the tibia were sawn off; no ar— tery of importance was injured; the vacancy produced by the removal of the ends of the bones was supplied with callus: in the course of ten weeks a cure of the sore was obtained; the limb became so firm that the man has since been able to go to sea as a sailor, and he does not even use a crutch. This, however, is the most favourable view of the proposal; and it is proper to remark, that in the course of the cure, much perplexity occurred from va— rious circumstances; particularly from the difficulty of preserving the limb in a steady fixed situation; from the great depth of the wound; from the lodge— ment of matter; and from the formation of sinuses. By much attention on the part of Mr. Park, all these difficulties were surmounted: But although the mer— its of the operation must be determined by farther tri— als, yet the risk attending it appears to be so great, that there is much reason to suspect that it will never be generally practised. For a more particular detail of the method of doing it, and of the after treatment of the sore, the publica— tion 311 Chap. XLIV. Bones at the Joints. tion itself must be consulted; but for the advantage of those who may not easily meet with it, the following short account of the operation is inserted in Mr. Park's own words. “ An incision was made, beginning about two inch— es above the upper end of the patella, and continued about as far below its lower extremity: Another, crossing this at right angles, immediately above the patella, the leg being in an extended state, was made through the tendons of the extensor muscles down to the bone, and nearly half round the limb; the lower angles formed by these incisions were raised so as to lay bare the capsular ligament: The patella was then taken out, and the upper angles, were raised, so as fairly to denude the head of the femur, and to enable me to pass a small catlin across the posterior flat part of the bone immediately above the condyles, taking care to keep one of the flat sides of the point of the instrument quite close to the bone all the way. The catlin being withdrawn, an elastick spatula was intro— duced in its place, to guard the soft parts while the femur was sawing through: Which done, the head of the bone thus separated was carefully dissected out; the head of the tibia was then with ease turned out and sawn off, and as much as possible of the capsular ligament dissected away, leaving only the posterior part covering the vessels; which, on examining, I had the satisfaction to find had not only escaped unhurt, but that it was not a very narrow escape: They had still a pretty good covering, and had been through the whole operation far enough out of the course or the knife. It must be confessed, that the appearance of the wound was somewhat formidable, exhibiting a a very large cavern with very thin parietes; and in short, there seemed little wanting to complete the am— putation: Yet as the limb below would not be de— prived of any part of its nourishment, and as every healthy incised surface, as well of bone as of soft parts, has a natural tendency to granulate, I could not see any 312 Of removing Ends of Chap. XLIV. any room to doubt that nature would be able to repair the breach.” Mr. Park afterwards informs us, that he attempted to perform the operation without making the trans— verse incision: But he found it could not be done; and after spending some time in the attempt, it was thought advisable to desist from it. More than two inches of the femur, and rather more than one inch of the tibia, were removed; which were but just enough to admit of the leg being brought into a right line with the thigh, the previous contraction of the flexor muscles being such as to keep the two sawn ends of bone in close contact: This produced a considerable redund— ance of the teguments. To support this, that it might not fall inward, and to keep the edges of the incision in apposition till they should acquire some degree of firmness, a few stitches were passed through the skin; not merely along the course of the transverse incision, but upon that part of the longitudinal cut that extend— ed up the thigh. The lightest superficial dressings only were applied, and the limb placed in a case of tin from the ancle to the insertion of the gluteus mus— cle. Mr. Park very candidly enumerates several objec— tions which may be made to this operation; but at the same time, he thinks that all of them may be obviated. There are two, however, which, in my opinion, will always appear with force against it: The first is, that where the bones of large joints are so much diseased as to render it necessary to remove them, the surround— ing soft parts are for the most part so much thickened, inflamed, or ulcerated, as to render any attempt to save them very uncertain, and much more hazardous than the amputation of the limb: And the second is, the high degree of inflammation which commonly succeeds to wounds of the larger joints. With respect to the first of these, Mr. Park himself wishes it to be understood, that it is chiefly in affec— tions of the joints produced by external violence, that he 313 Chap. XLIV. Bones at the Joints. he thinks this operation will be peculiarly useful; and with respect to the last, he observes, that the heads of large bones have been frequently sawn off, without a— ny violent symptoms ensuing: and as he supposes this to be owing to the very free division of the capsular ligaments, which in such cases must always take place he thinks that the total removal of this ligament, which he advises in this operation, will in a great measure prevent it. We have observed above, that experience alone can determine upon the merits of this opera— tion; but we cannot avoid remarking, that no necessi— ty appears for the removal of any part of the capsu— lar ligament. It may be highly proper to make the opening into it free and large; but to remove it, by dissecting it off from the contiguous parts, must prob— ably add to the risk of the operation, by rendering the inflammation more severe than it otherwise might be; at the same time that it must necessarily render it much more painful as well as more tedious. Farther expe— rience may perhaps set this in a different point or view: but at present we see no more reason for remov— ing any part of the capsular ligament in this opera— tion than for the removal of the tunica vaginalis testis in the operation for the hydrocele; a practice now altogether laid aside, even where the cyst is much thickened. Vol. IV. W CHAPTER 314 CHAPTER XLV. Of Preventing or Diminishing PAIN in CHIRURGICAL OPERATIONS. TO be able to alleviate the misery of those who are obliged to submit to dangerous operations, must afford the highest gratification to every practitioner: And as pain is the most dreadful part of every ope— ration, it necessarily demands our most serious atten— tion. The pain induced by operations may be lessened in different ways: By diminishing the sensibility of the system; and by compressing the nerves which supply the parts upon which the operation is to be per— formed. Narcotics of every kind might be employed for the purpose of lessening general sensibility; but noth— ing answers this with such certainty and effect as o— pium. But as medicines of this kind, when given in such large doses as to prevent or diminish pain, are apt to induce sickness and vomiting, I seldom venture on giving them before an operation. In general they prove most useful when given immediately after, when they very commonly alleviate that pungent soreness of which patients at this time usually com— plain; and by continuing to give them in adequate doses from time to time, we are often enabled to keep the patient easy and comfortable, till relief is obtained by  PLATE LXXXVI. 315 Chap. XLV. Of diminishing Pain, &c. by the formation of matter, or by the removal of that inflammatory tension which usually accompanies eve— ry capital operation: And as this proves not only high— ly comfortable to the patient, but tends in the most effectual manner to moderate the febrile symptoms which commonly take place, it should never be o— mitted. It has long been known, that the sensibility of any part may not only be lessened, but even altogether suspended, by compressing the nerves which supply it: And accordingly, in amputating limbs, patients frequently desire the tourniquet to be firmly screwed, from finding that it tends to diminish the pain of the operation. The effect of this, however, being inconsiderable, it has lately been proposed by Mr. James Moore of London, to compress the principal nerves so com— pletely as to, render the parts beneath altogether in— sensible. In Plate LXXIII. an instrument is delin— eated, by which this may be very effectually done. Whether or not it will answer with ease and cer— tainty, experience alone must determine: But, in the mean time, we are much indebted to the ingenious author, for affording a hint which eventually may tend to mitigate the sufferings of those whom necessi— ty obliges to submit to chirurgical operations. All that this instrument seems to require in order to ren— der it perfect, is the power of compressing the nerves of a limb without affecting the veins: for as it is found that the nerves must be compressed for a considerable time, at least an hour, before the parts beneath are ren— dered altogether insensible, the veins could not be compressed for such a length of time but with the risk of bursting. With a view to prevent such a disagree— able occurrence, Mr. Moore proposes that one of the veins in the limb should be opened. But as this might prove hurtful to weakly patients, where it is often of importance to guard against the loss of blood, it would be better to avoid it, by having the instrument form— W2 ed 316 Of diminishing Pain, &c. Chap. XLV. ed in such a manner, that it might compress the prin— cipal nerves only, without materially affecting the veins. It will not indeed be easily done, as the nerves for the most part are at no great distance from the veins: But the same purpose may perhaps be answer— ed by compressing the arteries which supply the limb for a minute or two before any pressure is applied to the veins; by which the latter may be previously emptied. CHAPTER PLATE LXXXVII.  317 CHAPTER XLVI. Of MIDWIFERY. SECTION I. General Observations on Midwifery. MIDWIFERY being now considered as a distinct branch of practice, a minute account of it will not be expected in a System of Surgery. For more particular information, those authors who have wrote upon the subject may be consulted: but I have judg— ed it proper to delineate the instruments usually em— ployed in Midwifery; and to describe two operations, which, although immediately connected with this branch, are yet more frequently performed by the sur— geon than the accoucheur; namely, the Cæsarean op— eration, and the division of the symphysis pubis. A great variety of instruments have been invented by practitioners in midwifery; almost every publica— tion, indeed, upon this subject, announces some in— vention of this kind. It is only those instruments, however, which experience has shown to be useful, that we mean to describe: These are not numerous; they are all delineated in Plates LXXXIX. XC. XCI. XCII. and XCIII. With the forceps in Plate LXXXIX. fig. 2. we lay hold of the head of the child when the mother is much enfeebled, and the contraction W3 the 318 General Observations, &c. Chap. XLVI. of the uterus not sufficient toexpel the child in th eusual way: And when delivery cannot be effected even in this manner, or by turning the child, and bringing it away by the feet, as sometimes happens from the pel— vis being much distorted, we employ the crotchet re— presented in Plate XC. fig. 1. for bringing the child away piece—meal, after lessening the size of the head by an opening made in the skull for discharging the brain, with the scissors represented in fig. 2. of the same Plate. The necessity, however, of using any of these in— struments I believe to be a rare occurrence: they are indeed frequently employed: but this proceeds in a great measure from impatience on the part of practi— tioners, who often force the delivery of the child, when Nature, if left to herself, would effect it in a much more easy manner. This fact is so certainly well founded, and is of such general importance, that practitioners of every description, and more especial— ly those who are newly entering on business, should never lose sight of it. By not meeting with that at— tention which it merits, both the forceps and crotchet are daily employed with too much freedom, to the disgrace of the art, and often with irreparable injury both to the mother and child. In some cases it happens, that delivery cannot be effected even with the assistance of these instruments, owing to the brim of the pelvis being so narrow that it will not allow any part of the child to pass. In such circumstances, the Cæsarean Section, as it is termed, used formerly to be practised; but the danger attend— ing that operation being so great that the mother was seldom saved by it, Mr. Sigault of Paris, about ten years ago, proposed the division of the symphysis pu— bis, for the purpose of increasing the diameter of the pelvis, and for extracting the child in the usual way, by the vagina. SECTION PLATE LXXXVIII.  319 Sect. II. Of the Cæsarean Operation. SECTION II. Of the Cæsarean Operation. THIS operation may become necessary, as we have seen in the last Section, by the brim of the pel— vis being so narrow that it will not allow the child to pass; and it may also become proper where the child has been forced into the cavity of the abdomen by a rupture in the uterus, as sometimes happens from the uterus contracting with too much force before the os tincæ is sufficiently dilated. The Cæsarean section may be performed, either with a view to save both the mother and child, when it is found that the child cannot be extracted in any other manner; to save the mother only when we know that the child is dead; or to save the child im— mediately after the death of the mother. As there are few instances of the mother being sav— ed by this operation, some have advised that it should never be performed till after the death of the mother. I am clearly of opinion that an operation attended with so much hazard should never be advised as long as there is the least reason to hope that delivery may be effected in any other manner: but I also think, that it is the duty of every practitioner to propose it when this cannot be accomplished; for it is surely better to afford the small chance to the mother which accrues from it, than to leave her to a certain prospect of death; while by the same means we may be ena— bled to save the child, which otherwise would be de— stroyed. None will hesitate in advising it after the death of the mother, when the child is found to be living. The following is the method of performing it. W4 The 320 Of the Cæsarean Operation. Chap. XLVI. The patient should be placed upon a table of the usual height, and laid upon her back, her hands and legs being properly secured by assistants; her head should be moderately elevated with pillows, and her thighs somewhat raised, in order to relax the abdomi— nal muscles. The operator standing on one side of the table, is with a common round edged scalpel to make an incision, six inches in length, through the skin and cellular substance, on one side of the abdo— men: The cut should commence two inches above the umbilicus on the outer edge of the rectus muscle, and from thence should be carried in a perpendicular direction downwards. The uterus is now to be laid bare, by carrying the incision through the tendinous parts of the abdominal muscles and peritonæum; and this being done, an opening of the same length must be made in the uterus itself. The easiest method of effecting this is, to make a small opening with the scalpel, sufficient to admit the finger, which serves as a conductor to a probe pointed bistoury, with which the remaining part of the incision should be finished. I may also remark, that the bistoury inserted upon the finger, at an opening made for the purpose, is the best method of dividing the peritonæum and tendinous a— poneurosis of the abdominal muscles. If any large blood vessel is cut in dividing either the external parts or the uterus, it should be immediately tied with a ligature of a sufficient length to hang out at the wound. The child must now be taken out; the placenta, and any effused blood that may have es— caped during the operation, being also removed; and the intestines, if they have protruded, being replaced; the external opening should be secured with three or four sutures, in the manner we have advised in Chap— ter XXXVI. Sect. XII. § 3. The wound being covered with a pledgit of any e— mollient ointment, the abdomen should be supported with several turns of a broad flannel roller; when the patient PLATE LXXXIX.  321 Sect. II. Of the Cæsarean Operation. patient should be carried to bed, and strictly enjoined to avoid speaking and every kind of exertion. Various causes concur to render this a very danger— ous operation: Of these the extensive exposure of the abdominal viscera, and hemorrhagies from the uterus, are the most material. Any protrusion, therefore, which occurs of the bowels should be immediately re— placed, and no vessel of any importance that may be cut in the division of the uterus should be left untied: It is not advised by writers upon this subject, but I see no harm that can ensue from it. If the ligatures are applied with the tenaculum, they will soon sepa— rate; and by hanging out at the external wound, they may at any time be pulled away. It may be remark— ed, that it is internal hemorrhagies only that we have to dread, I mean such as occur from the vessels of the uterus: for, by carrying the incision on the outer edge of the rectus muscle, we avoid the epigastric artery; the only vessel of importance that runs any risk of be— ing hurt in the division of the teguments and muscles. In order to avoid the risk of hemorrhagies from the uterus, some have advised the incision never to be made at that part where the placenta adheres; while, by others, we are directed to make the opening into the uterus exactly in a longitudinal direction, by which we are told that the principal vessels with which it is supplied will most readily be avoided. No ad— vantage, however, is derived from this in practice: For the incision in the uterus must correspond exact— ly with the external incision; which cannot with pro— priety be made in any other direction than the one we have mentioned. Besides, it would often be im— possible to distinguish the part at which the placenta adheres; nor is there much ground to suppose that the hemorrhagy from the uterus depends so much up— on the direction as on the extent of the incision; and it ought not to be less than six inches in length, as the child could not be extracted with freedom at a small— er opening. It is scarcely necessary to remark, that the 322 Of the Division of the Chap. XLVI. the child and placenta, should be removed as soon af— ter the incision is made in the uterus as possible: It is thus allowed to contract, which it does instantaneously with great force; by which the hemorrhagy is more readily stopped than by any means we could employ for it. By others, we are advised to leave a large opening at the under part of the external incision, in order to give vent to any effusion of blood that may happen. No advantage, however, is gained by this, as the in— cision in the uterus, although opposite to the external opening at first, very soon falls beneath it when this viscus contracts; by which any blood that is discharg— ed falls into the bottom of the abdomen, where it co— agulates, and thus cannot be discharged at the wound. And as it is of importance to prevent the air as much as possible from finding access to the abdomen, the ex— ternal cut should be quickly and entirely shut by as many sutures as the length of it requires. The most effectual method with which I am acquainted of pre— venting hemorrhagies is, the tying of any large vessels in the manner we have mentioned; keeping the pa— tient cool and free from pain, by regulating the air of the apartment to a proper temperature, and adminis— tering opiates; and by preventing, as we have observ- ed above, every kind of bodily exertion. SECTION III. Of the Division of the Symphysis Pubis. IT has been long known, that the bones of the fe— male pelvis are connected in such a manner, that during the latter months of pregnancy, and especially during labour, they are separated in some degree from each other; by which the passage of the child is ren— dered PLATE XC.  323 Sect. III. Symphysis Pubis. dered much easier than it otherwise would be. It was a knowledge of this fact, and the great danger at— tending the Cæsarean operation, which first suggested the idea of dividing the bones of the pubis at their junction with each other in cases of narrow pelvis. It was proposed upwards of two hundred years ago, by a French surgeon of the name of Pineau; but Mr. Si— gault of Paris was the first who had the merit of put— ting it in practice, in the year 1777. The operation is easily performed. The patient must be laid upon her back on a table of a convenient height; the pelvis should be elevated with two or three pillows put beneath it, and the legs and arms should be secured by assistants. When in this situa— tion, the bladder should be emptied by the introduc— tion of a catheter, which should be retained in the u— rethra by one of the assistants till the division of the bones is completed. After shaving the pubis, the operator standing on one side of the patient, should with a longitudinal in— cision divide the skin and cellular substance covering the pubes at their symphysis: The cut should com— mence at the upper edge of these bones, and be con— tinued nearly, but not entirely, along their whole breadth: On the bones being laid bare, the cartilage by which they are joined must be slowly and cautious— ly divided; and as it is by no means hard, it is easily done. Both the teguments and cartilage may be di— vided with a firm round edged scalpel of the common form, which is the only instrument except the cathe— ter that is necessary in this operation. The intention of the catheter is, to point out the course of the ure— thra to the operator; for it lies so contiguous to the pubes at their symphysis, as to be in great danger of being cut, if this precaution be not attended to; even the bladder itself might be injured, were the division of the cartilage not conducted with caution: but with due attention to these points, and avoiding the total division of the soft parts at the under edge of the bones, 324 Of the Division of the Chap. XLVI. bones, all risk of hurting either the bladder or urethra may be prevented. On the division of the cartilage being completed, the bones recede considerably from each other. To prevent any consequences that might ensue from their separating forcibly and suddenly, the assistants who have the charge of the thighs should be desired to support them, particularly towards the end of the op— eration; and if a sufficient opening is not gained in this manner, the thighs may afterwards be slowly and gradually separated. The child is now to be delivered in the usual way by the vagina; and this being effected, and the pla— centa removed, the bones should be immediately put together, and retained as exactly as possible in their situation, by the proper application of a flannel or cotton roller round the pelvis and thighs; at the same time that the patient should be desired to remain as much as possible in one posture. The sore does not require any particular attention: in general it heals easily with light mild dressings; and for the most part the union of the bones is completed in the course of the fifth or sixth week. The patient, however, should not be allowed to walk, or to put the body into any posture that might effect an alteration in the situation of the bones, till nine or ten weeks have elapsed. The only objection of importance that occurs to this operation is, the small space that is gained by it in that part of the pelvis where it is most required. By sep— arating the ossa pubis at their symphysis, these bones do indeed recede to a considerable distance from each other; for the most part, the separation that takes place will be at least two inches in length: But this does not increase the narrow diameter of the pelvis; that is, the bones of the pubis will still remain at near— ly the same distance from the os sacrum as before the operation; and in almost every instance of diffi— cult labour from mal conformation of the pelvis, I we find it proceeding entirely from the ossa pubis and PLATE XCI. PLATE XCII. 325 Sect. III. Symphysis Pubis. and os sacrum being too near to each other. It may often happen, however, that the head of the child may be so situated, that even this separation of the os— sa pubis alone may allow it to pass, when otherwise it would have remained entirely above the brim of the pelvis; and as we do not find that the operation is in any respect hazardous, for in different instances it has been done more than once on the same person, it should always be advised, when we are convinced that the pelvis is so narrow that the child cannot possibly pass through it. It should always be advised in pre— ference to the Cæsarean operation. If farther experience shall show, that in all cases of narrow pelvis, the child may be delivered in this man— ner, it should even be preferred to the mode of deliv— ering with the crotchet, which is undoubtedly one of the most barbarous operations in surgery; for while the very intention of it is to destroy the child, it often tears and mangles the mother so much that the never afterwards recovers from it. CHAPTER 326 CHAPTER XLVII. Of OPENING DEAD BODIES. WITH a view to discover the seat and causes of diseases, and at the instance of the civil mag— istrate in cases of violent death, surgeons are employ— ed to open dead bodies. To do this with accuracy, every preternatural appearance should be committed to paper. After noting any external marks of disease, we proceed to examine the state of the different cavi— ties and of their contents. When the disorder has been seated in one cavity, we do not open the others; but when they are all to be examined, it is proper to begin with the head. The body being placed upon a table of a conven— ient height, and the head firmly fixed by an assistant, an incision should be made from ear to ear across the parietal bones. The scalp is now to be dissected from the parts beneath; and one half being turned back— ward and the other over the face, a common amputat— ing saw must be used for dividing the cranium: The division may be begun on the os frontis immediately above the frontal sinuses, and must afterwards be con— tinued backward through the parietal bones and os occipitis. The upper part of the skull is now to be raised with a levator; by this means the dura mater may be freely examined; and if we wish to go to the depth of the ventricles only, in order to discover whether any preternatural quantity of serum be col— lected in them, this may be done without removing the brain. But when our object is to examine the state  PLATE XCIII. 327 Chap. XLVII. Of Opening Dead Bodies. state of the brain and cerebellum, they must both be removed and examined at leisure. This being done, and all the extravasated blood taken off with a sponge, the brain and cerebellum must be replaced with the skull cap above them. The two portions of scalp are now to be drawn over the whole, and secured in their situation by sewing the edges of the cut together from one end to the other, either with the glover's stitch, or in any other way which the operator may prefer. For this purpose narrow tape is usually employed, and a large curved needle with a triangular point. The cavities of the thorax and abdomen are most effectually exposed in the following manner: Let an incision be made through the common teguments from the top of the sternum to the umbilicus, and let it be continued, on each side through the abdominal muscles, from the umbilicus to the top of the os ile— um: The teguments and muscles must now be dis— sected from the thorax, till all the cartilages which connect the sternum and ribs are freely laid bare; and being drawn backward, the cartilages must be divided with a strong knife as near as possible to the ribs; when the diaphragm being separated beneath, the un— der part of the sternum and cartilages connected with it, being raised and turned upward, the sternum must either be separated from the clavicles, or cut across near to the upper end of it. In this manner the contents of the thorax and abdomen are brought into view, when most of them may be examined without being removed; but when more accuracy is required than this admits of, the whole of them should be taken out: Or, when a partial examination is only required, that portion of them only may be removed which we mean to inspect. To prevent the inconvenience resulting from the effusion of much blood and excrement, two strong lig— atures should be passed at the distance of an inch from each other round the under part of the alimentary ca— nal and large contiguous blood vessels, and round the trachea, 328 Of Opening Dead Bodies. Chap. XLVII. trachea, œsophagus, and large blood vessels of the neck. The parts between the upper and under liga— tures being divided, the whole viscera of both the cavities may then be easily removed, by dissecting them from the contiguous parts, and raising them up as we go along. The necessary examination being finished, the ef- fused blood all washed off with a sponge, and the vis— cera replaced, the teguments must be drawn over them, and stitched together with as much neatness as possible. In opening bodies that have died of any disease, the operator should be as cautious as possible in avoiding cuts or scratches of his fingers and hands: Various in— stances have occurred of much distress being induced; and in some cases, even death has ensued, from inat— tention to this circumstance. CHAPTER. 329 CHAPTER XLVIII. Of EMBALMING. IN former times, embalming was practised with more care and attention than it is now. This was a necessary consequence of the desire which then pre— vailed, of preserving dead bodies for ages. At pres— ent it is seldom employed, except for the purpose of preventing bodies from putrefying, during the short space which elapses between the death and burial of the person; and not even with this view, if the corpse be not to be kept longer than is usually done in pri— vate life. The following is the present method of embalming. The brain, and all the viscera of the thorax and abdomen, being removed in the manner we have mentioned in the last Chapter, they are all, excepting the heart, put into a leaden box with a con— siderable quantity of an aromatic anteseptic powder, prepared with myrrh, frankincense, cloves, the leaves of lavender, rosemary, mint, sage, and other similar articles; and to these are added a proportion of any odoriferous oils. The blood being removed from the different cavities, and the heart replaced, they are all filled with the same kind of powder, with a due pro— portion of odoriferous oils or spirits, and the parts af— terwards sewed up in the manner we have already ad— vised. By some, too, the mouth and nostrils are stuff— ed with these powders and oils; and incisions are made into all the fleshy parts of the body, which are also stuffed with them, and afterwards sewed up: but there is no necessity for this, unless the body is to be kept for a great length of time, or to be carried to a Vol. IV. X considerable 330 Of Embalming. Chap. XLVIII. considerable distance. In which case, it is usual, after stuffing the incisions in the manner we have mention— ed, to roll all the extremities, as well as the trunk of the body, firmly up with bandages, and to cover the whole with varnish. The body is now to be laid upon a cerecloth of a sufficient size, which must be applied with as much neatness as possible to the head and every part of the body, and must either be firmly secured by sewing, or with tapes tied at proper distances. The cerecloth is made of linen dipped in a composition of wax, oil, and rosin; which should be of such a consistence as to be sufficiently pliable, without being so soft as to stick to the fingers of those who apply it: It may be coloured with verdegris, red lead, or any other article, according to the fancy of the operator. When two cerecloths are applied, one above another, they are usually made of different colours. The cerecloth being put on, it was formerly the cus— tom to employ a painter to colour the face; but this is now very commonly omitted: the dress intended for the corpse is immediately put on; and the body is either laid in the coffin, or allowed to be exposed, ac— cording to circumstances. CHAPTER 331 CHAPTER XLIX. Of BANDAGES. BANDAGES are employed for various purposes in Surgery; for the retention of dressings; for stopping hemorrhagies; for removing deformities; and for effecting the union of divided parts. As a proper application of bandages is an object of much importance, it is a branch of the art which au— thors have not neglected: Many treatises have been published upon it; but unfortunately it cannot be taught by description: Experience alone can give an adequate idea of it; nor is it possible to acquire it but by much manual practice. Hence, in the study of this part of surgery, more advantage is to be gained by practising upon a block, than by reading the most elab— orate dissertations. My only intention, therefore, at present is, to offer a few general observations upon bandages. 1. Bandages should be formed of such materials as are sufficiently firm for effecting the purpose for which they are intended, at the same time that they may fit with ease upon the parts to which they are applied. In some cases a degree of firmness is required, which cannot be obtained from materials of a soft tex— ture: Of this we have examples in the most part of trusses for herniæ, as well as in every bandage requir— ing much elasticity: But for the most part bandages are made of linen, cotton, or flannel. Till of late, linen was universally used for this purpose; but later experience has shown, that cotton and flannel are X2 preferable. 332 Of Bandages. Chap. XLIX. preferable. They, absorb moisture more readily, whether it be produced by sweat, or as the ordinary discharge of wounds or sores, at the same time that they are better calculated by their elasticity for yield— ing to the swelling which often takes place in luxa— tions, fractures, and other injuries for which bandages are employed. Flannel was first used for this pur— pose in the Royal Infirmary here, about thirty years ago, by Mr. James Rae, of this place; and since that period the practice has been generally adopted. The objection made to the use of flannel for bandages, by some practitioners, of its not being so cleanly as linen, is frivolous: Neither of them will be cleanly if they be not frequently changed, while either of them will be sufficiently so if this point be attended to. 2. Bandages should be applied of a degree of tight— ness sufficient for answering the purpose for which they are intended, without incurring any risk of their impeding the circulation, or doing harm in any other manner. No advantage will accrue from them, if they be not sufficiently tight to support the parts af— fected; while swelling, inflammation, and even gan— grene, will be apt to occur if they be too tightly ap— plied. 3. Every bandage should be applied in such a man— ner, that it may be as easily loosened, and the parts examined with as much accuracy as possible. Thus in fractures of the thigh and leg, where the limb can— not with propriety be frequently raised, we now pre— fer universally the bandage with twelve or eighteen tails to the common roller. The former can be un— done and fixed at pleasure without moving the limb, while a roller can neither be applied nor removed without raising every part of the limb to a considerable height. 4. Bandages should always be laid aside as soon as the purpose for which they are intended is accomplish— ed. This being obtained, no advantage can accrue from  PLATE XCIV. 333 Chap. XLIX. Of Bandages. from them, and they often do harm by impeding the growth of the parts upon which they are applied. 5. We have found it necessary in the course of this work to mention bandages for many parts of the body. In speaking farther of bandages for particular parts, we shall begin with the head, and proceed downwards to the trunk of the body and extremities. One of the best bandages for all the upper and back parts of the head, for the forehead, ears, and temples, is a night cap, with one band to tie it before, and another be— neath the chin, as is represented in Plate XCIV. fig. 1. The Couvre—chef of the French, represented in fig. 2. is most frequently used for these parts; but it can neither be applied with such firmness or neatness as the night cap. For the purpose of making compression on any par— ticular part of the head, the Radiated Bandage, as it is termed, may be employed, as is represented in Plate XCIV. fig. 3. It may also be used for compressing the temporal artery: but for this purpose, the ma— chine represented in Plate VII. fig. 3. answers better. In longitudinal cuts of the head, the Uniting Band— age, as it is termed, may be used with advantage. It is formed of a long roller with two heads, with a slit or opening in the middle, as is represented in Plate XCV. fig. 3. The sides of the cut being drawn neat— ly together, and covered with a pledgit of any simple ointment, the cure is to be effected by means of this bandage, applied in the manner represented in fig. 6. of the same Plate. In cuts of this description, their edges may sometimes be retained together with suffic— ient exactness by this bandage; and, when this can be done, it will always be preferred to the mode of doing it by sutures. When it is necessary to retain dressings upon the eyes, it has usually been done by placing a compress over them, and retaining it by several turns of a long roller, such as is represented in plate XCV. fig. 1. This bandage, when employed for one eye, is the X3 Monoculus. 334 Of Bandages. Chap. XLIX. Monoculus of authors, and it is termed Binoculus when applied to both eyes. But as a roller passed round the head is apt to slip, even when applied in the most exact manner, the couvre—chef in Plate XCIV. fig. 2. or the night cap in the same Plate fig. 1. are by many preferred for retaining the compresses. In fractures and cuts of the nose, the dressings are best retained by a proper application of the uniting bandage in Plate XCV. fig. 3. and a proper applica— tion of the same bandage answers best in longitudinal cuts of either of the lips. In fractures of the lower jaw, we employ a four headed roller, such as is represented in Plate XCV. fig. 4. The space left entire between the four heads at A, is applied to the chin, the hole in the centre of it being meant to receive the apex of the chin. The two superior heads are then carried backwards; and being made to pass each other at the occiput, they are afterwards brought forward over the os frontis: they may either be fixed there, or again reflected back, and fixed with pins on the sides or back parts of the head. The two under heads of the roller being reflected over the chin, are then to be turned upwards, and either tied or pinned on the top of the head; or before fix— ing them, they may be made to pass each other two or three times. Various other bandages are described by authors for the head; but those we have mentioned, with a proper application of the common roller, Plate XCV. fig. 1. for particular purposes, are all that can be ever required. 6. In Plate XXIII. fig. 1. an instrument is delin— eated for one of the most material operations upon the neck, Bronchotomy; and in Plate LXVI. fig. 1. another is represented for the wry neck: A common roller may be made to answer every other purpose that can be required of a bandage in any part of the neck. 7. A variety of bandages are used for affections of the shoulders and contiguous parts, particularly for fractures PLATE XCV.   PLATE XCVI. 335 Chap. XLIX. Of Bandages. fractures of the scapula, and fractures and luxations of the clavicle. In fractures of the scapula, a proper ap— plication of a long roller may, in most instances, prove useful; but in Chapter XXXIX. Section V. we have shown, that no utility is derived from bandages in fractures of the clavicles: They cannot be applied with such tightness as to compress the fractured bone without impeding respiration; and besides, we do not find that they are necessary, when the arm of the af— fected side is properly supported by the sling, Plate LXXXI. 8. The most useful of all bandages for the thorax and abdomen, at least for the retention of dressings on any of those parts, is that which we usually term the Napkin and Scapulary, represented in Plate XCVI. fig. 1. That part of it which goes round the body A, is termed the Napkin. When it is applied for making pressure upon a fractured rib, it should be in the form of a roller, and should pass two or three times round the body; when it is only used for retaining dressings, it should not go more than once round: It should be six or seven inches broad for an adult; and it should be secured by pieces of tape, tying it at each end instead of pins. The Scapulary BB, consists of a slip of linen, cotton, or flannel, about three inches broad, and of a length sufficient to reach from the up— per part of the napkin behind, to pass over the shoul— ders and be pinned to it before: It is sometimes made with a hole in the centre of it for passing over the head; but it answers better to divide the anterior end of it by a longitudinal slit into two, and, in applying it, to make one of these slips pass on each side of the head. This bandage answers the purpose better than any other, for making pressure on the parts at which the viscera protrude, in cases of umbilical and ventral her— niæ. As in such cases it is a point of much import— ance to have the bandage firmly fixed, we not only employ the scapulary for preventing it from slipping X4 down, 336 Of Bandages. Chap. XLIX. down, but a strap connected with it behind is passed between the thighs, and pinned to it before, to pre— vent it from slipping up. In Plate XXII. fig. 2. a bandage is represented for compressing the abdomen in the operation of tapping; and in Plate VIII. different bandages are delineated, or Trusses, as they are termed, for the retention of the protruded viscera in cases of herniæ. 9. As it is of much importance in various diseases, as well as in several operations, to have the scrotum properly supported, I have delineated some bandages for this purpose in Plate XCVII. The best bandage for the penis is a pouch, or bag of linen or cotton, to be fixed by a roller, or two pieces of tape passed round the body. The T bandage, as it is commonly termed, Plate XCVI. figures 3. and 4. is usually employed for the retention of dressings in affections of the anus and per— rineum, as well as in some disorders of the scrotum; but in the last, one or other of the suspensory band— ages, represented in Plate XCVII. will for the most part be found preferable. 10. In compound fractures of the arm, forearm, or hand where motion of the limb would prove hurtful, the twelve or eighteen tailed bandage is equally proper as in similar affections of the lower extremities; but in simple fractures, as well as in almost every other affection of these parts, we prefer a proper application of the roller. 11. We advised the uniting bandage for longitudi— nal cuts in the head; it answers equally well in wounds of a similar nature in every part of the extremities, as is represented in Plate XCV. fig. 6. EXPLANATION PLATE XCVII.  337 EXPLANATION OF THE PLATES. PLATE LXX. [Opposite to page 140.] Fig. 1. A splint of timber for a fractured leg, AA. Two loops for retaining leather straps, as represented in the front view of the same splint in fig. 2. CC. B, an opening for receiving the external maleolus, when the leg is placed upon the outside. Figures 3. 4. 5. and 6. are perhaps the best splints hitherto discovered for fractures of any of the extremi— ties. They may be made of different forms, but one or other of these will answer almost for any purpose: They are made by gluing a piece of thin timber, about the tenth part of an inch in thickness, upon leather. The timber is afterwards cut through to the leather, either with a fine saw or a knife set to a proper depth, in the manner represented in the figures. These splints are preferable to those made of paste— board; for while they are longitudinally perfectly firm, they are transversely sufficiently flexible for ply— ing to the form of the limb. For the method of using them, we must refer to Sections IX. X. XI. and XII. of Chapter XXXIX. Splints made in this manner have long been used by individuals; but Mr. Gooch was the first who gave any description of them. Plate LXXI. [Opposite to page 145.] As the splints used by Mr. William Sharpe are still preferred by some practitioners, I have given a repre— sentation of them in this plate. These splints, figures 3. and 4. are formed of strong pasteboard made with glue; they are fixed upon a fractured leg by three straps which surround the whole. Fig. 338 Explanation of the Plates. Fig. 4. Represents an under splint of an irregular form, suitable to that part of the leg it is meant to cover: It is a little convex externally and concave in— ternally. The length for a middle sized man, eight— een inches from E to E; the width, two inches and three quarters at the strap near the knee, and two inch— es and a quarter at both the other straps. DFDFDF, three leather straps from fifteen to twenty inches long, and one inch wide, having two rows of holes so placed, that every hole in each row may be opposite to a space in the other. These must be sewed fast to the middle and outside of the under splint. The portions of straps DDD, on the ante— rior part of the splint, must be shorter than those on the posterior, FFF, which are to surround the more mus— cular part of the leg. G, A part to support the foot from the point E to the heel H, five inches long at an angle of sixty degrees. C, The, foot strap, twelve inches long, sewed to the bottom of the under splint, within two inches of the point, to pass under the heel, and through the leather loop B on the upper splint, to the lowest pin A. I, An irregular oval hole, two inches long, and al— most one wide in the lowest part, but decreasing up— wards, to receive the maleolus externus, or lower ex— tremity of the fibula. Fig. 2. Represents the leg raised up, to show the situation of the under splint, when properly applied. Fig. 3. The upper splint. AAA, The pins upon which the straps of the under splint are to be fixed, by means of the holes DDD, FFF. B, The leather loop for receiving the foot strap C, in fig. 4. Fig. 1. Represents a fractured leg when laid within the splints, having the foot of a stocking and a shoe up— on it. Plate LXXII. [Opposite to page 147.] In this plate I have delineated the instruments rec— ommended by the late Mr. Gooch, for preserving a fractured 339 Explanation of the Plates. fractured thigh and leg in a state of extension, as is mentioned more particularly in page 152, and which I shall describe in his own words. Fig. 1. A machine for extending a fractured leg. The transom to which the sole is secured, is made to be opened and fixed by a pin; and the machine may occasionally be made wider, as appears by other holes in the transom; about which, on each side of the sole, fillets are to be tied, coming from a demity piece quilt— ed for ease, and laced round the heel and instep, to make the extension upon the working of the screws; but buff leather may possibly answer better for protecting the parts even than demity. Fig. 2. Shows the machine, and one of the splints in Plate LXX. together upon the limb. Fig. 3. The longitudinal parts of the machine for the thigh are designed to move upon the circular plates; by which means it may be accommodated to limbs of different sizes: and as there is a pin at each end of the circular plates, if the limb happens to be larger than ordinary, straps of leather may be added. Fig. 4. Shows the machine with the case upon the thigh. Fig. 5. The key to work the screws. There should be two such keys, that the machine may occasionally be wrought on both sides at the same time. Plate LXXIII. [Opposite to page 151.] In page 151, we observed, that some improvements had been made by Dr. Aitken upon Mr. Gooch's in— struments, represented in the preceding plate, for ex— tending fractured limbs: In this plate I have given a representation of them. Fig. 1. Represents a machine for keeping the frag— ments of the thigh bone in situ after setting, whether the fracture is simple or compound, on the neck or body of this bone. AAA, the upper circular which applies round the pelvis, like the top band of a pair of breeches. It rests on the same parts, and is fixed or buttoned 340 Explanation of the Plates. buttoned in the same manner, by the studs and cor— responding holes, H. BB, Two soft stuffed straps, fixed to the back part of this circular, of such length as to pass between the thighs from behind forward, to tie round the fore part of the same circular, by means of their forked extrem— ities, CC. These effectually secure the circular from moving upward. There are two obscure joints, KK, in the back part of this circular, to facilitate its appli— cation; but it applies readily enough without them. DD, The lower circular which fixes above, the knee at the gartering place. EEE, Three graduating steel splints which extend from the one circular to the other: Their upper ex— tremities are fixed to the upper circular by vertible flat headed studs, similar to those at FF: their lower extremities pass through the iron screw plates G, firm— ly rivetted to the lower circular. The splints are pro— vided with a number of impressions or holes, in which the screw nails which pass through the plates are fix— ed. By pushing the splints from below upward, the distance between the circulars is increased; and by turning the screw nails, it is maintained: consequent— ly that part of the thigh included between the circu— lars can be kept extended at pleasure. The splints here are fixed for the right thigh; the pricked lines on the other side, show how they may be accommodated for the left one, or for both at the same time. The largest circular AAA, consists of a piece of thick saddle—leather; all except its perforated part, and about a quarter of an inch on each edge, is covered on the inside with a flexible thin iron plate, such as is sometimes used by tin plate workers: Over this it is lined with the softest buff, or shamoy leather, between which and the plate a thin layer of hair or wool is interposed: The lining ought to project on both sides half an inch or more, to prevent it in any degree from pressing on the skin. The small circular DD, or inferior fixed point, is exactly 341 Explanation of the Plates. exactly similar to the large one in structure, the tin plate excepted; which, on account of its smaller di— ameter, was found to be unnecessary. The breadth of the upper circular, when extended for an adult, may be from three to four inches: That of the under circular should be in the same proportion. The graduating steel splints, E E E, must be suffic— iently long to extend from the upper circular to the lower, and to project over it about a hand—breadth: They require to be about four or five eighth parts of an inch broad, and about one eighth part of an inch thick. Fig. 2. A machine constructed on the same princi— ple with fig. l. for the retention of a fractured leg. A A, A circular, which applies below the knee joint. B B, Another, which fixes at the ancles. CCC, The graduating splints similar to those of the thigh machine, both in construction and action. Fig. 3. A fracture—box mentioned in page 172, as the invention of Mr. James Rae, Surgeon of this place, improved by Mr. John Rae, his son. A, the sole or base, which should be a firm deal, at least an inch and a half thick. B B, the two ends which support the side beams CCCC. D D, Brass hinges, which admit of the ends folding down so as to render the machine more portable than it otherwise would be. L L, two parallel grooves for receiving two projecting parts of the corresponding end of the machine, by which the same instrument may be ex— tended or shortened so as to fit any length of member. E E E E, Two lateral beams, which by the holes in their extremities will serve for any length to which the instrument may be extended: And by the pin at each end passing through them at the holes in the end beams, any one of the sides, or both of them, may be raised at pleasure. GGGG, &c. Twelve or fourteen buckles on each side of the machine, with corresponding pieces of girth two 342 Explanation of the Plates. two inches broad, on which the member is supported by buckling them exactly to the form of the limb. H I, H I, Two straps, with corresponding buckles for fixing the base of the machine to the bed. The limb is fixed to the machine by two straps and buckles, one fixed at each end. The advantages of this instrument are, that in com— pound fractures the sores may be inspected and dressed without deranging or moving any part of the limb, by removing such of the straps as are necessary for bring— ing the sores into view. Instead of a twelve or eigh— teen tailed bandage of the common form, separate pieces of flannel should be used; so that such of those as are wet with the discharge can be easily moved without touching the rest. In this manner the limb may be regularly dressed without being moved till the cure is completed, while the limb may be raised to any angle, by heightening one or other of the ends of the lateral beams by means of the holes and pins at each end. PLATE LXXIV. [Opposite to page 158.] Fig. 1. A fractured limb dressed with an eighteen tailed bandage, and laid upon the outside with the knee bent, in the manner recommended by Mr. Pott. Fig. 2. A fractured limb with an eighteen tailed bandage, and one of the flexible splints in Plate LXX. There is also placed beneath the limb a firm unyield— ing splint, such as is represented in the same Plate, fig. 2. Plate LXXV. [Opposite to page 161.] Fig. 1. A machine mentioned in page 155. for re— taining the different parts of a fractured patella. A, A strap to be fixed by means of the buckle at one end on the upper part of the leg immediately be— low the knee. B, A similar strap to be fixed above the knee. Fig. 2. A back view of the same machine. F, A semilunar compress of cork covered with shamoy leath— er, 343 Explanation of the Plates. er, to be placed immediately above the upper part of the patella. A, A similar compress for supporting the inferior part of the bone. These compresses being properly placed, they may be drawn to any degree of tightness by means of the straps and buckles C D E. Fig. 3. A limb with a fractured patella, and the bandage fig. 1. applied to it. In this figure the strap, H, is added to it: being fixed to the point of the shoe, and connected with one of the buckles above the knee, the limb is thereby kept extended; by which there is no risk of the fractured parts of the patella being forc— ibly pulled from each other, as would necessarily hap— pen if the limb should be suddenly bent before the cure be completed. PLATE LXXVI. [Opposite to page 167.] Fig. 1. This represents the Ambe of Hippocrates, for the reduction of luxations of the humerus: it con— sists of a fulcrum and moveable lever. As it is still used by some practitioners, I judged it proper to men— tion it; but we have elsewhere had occasion to re— mark, that it is a dangerous instrument, and ought never to be employed. My reasons for thinking so are enumerated in Chapter XL. Section IX. Fig. 2. Mr. Petit's instrument for reducing luxa— tions of the humerus. A A, Two arms or horns, by which the scapula is kept firm during the extension. B B, The other end of the instrument resting upon the ground; C, the pullies; D, ropes, by winding up which with the handle E the limb may be slowly and gradually extended to any necessary degree. Fig. 3. A C, an opening through which the arm is passed; F F, two apertures for receiving the ends A A of the instrument fig. 2. This being made of firm leather, the instrument is thereby prevented from fret— ting or galling the skin, PLATE 344 Explanation of the Plates. Plate LXXVII. [Opposite to page 171.] Fig. 1. The ambe of Hippocrates, represented by itself in the preceding Plate is here applied, and ready to be used. Fig. 2. Pullies for extending dislocated bones, as mentioned in page 212. Fig. 3. This is a very useful part of the apparatus for extending dislocated limbs: It is formed of thick shamoy or buff leather. By tying it firmly round the limb with the broad straps at each end, a very consid— erable force may be applied by assistants pulling the ropes or straps passed over the hooks: it answers the purpose both more easily and more effectually than the common method of extending the limb with tow— els. PLATE LXXVIII. [Opposite to page 214.] In this Plate I have delineated one of the best in— struments hitherto known for dislocations of the shoulders, when more than ordinary force is required. It is the invention of the late Mr. Freke of London. As instruments of this kind require to be very port— able, Mr. Freke has paid particular attention to this circumstance. The box, fig. 5. contains the whole apparatus: when shut, it is only one foot eight inches long, nine inches broad, and three inches and a quar— ter deep. Fig. 4. represents the instrument open, the two sides of the box being firmly fixed together by brass hinges at C, and with two hooks and eyes on the other side of the box. When one end of it is fixed on the ground, the other stands high enough to be— come a fulcrum or support for the lever B B, which is fixed on the roller E, by a large wood screw, which turning tideways, as well as with the roller, it obtains a circumrotatory motion, so that it may serve to reduce a luxation either backward, forward, or downward. The roller on which the lever is fixed, is just the diameter of the depth of one of the boxes, into which are driven two iron pins, the ends of which are receiv— ed 345 Explanation of the Plates. ed by the two sides of the box, which are an inch thick. The lever is two feet four inches long, and is cut and joined again by two hinges at C, to fold up so as to be contained in the box: on the back side of it is a hook to keep it straight; the other end of it is to hang over the roller an inch and a half, which is to be excavated and covered with buff leather for the more easy reception of the head of the os humeri. The iron roller E has two holes through it for re— ceiving two cords from a brace fig. 3. fixed on the lower head of the os humeri, for on no other part of the arm above the cubit can a bandage for this pur— pose be useful; for if the surgeon applies it on the muscular part of the arm, it never fails flipping down to the joint before the limb can be extended. The iron roller E has a square end, on which is fix— ed a wheel D, notched round, which works as a rotch— et on a spring ketch under the lever; by which it is stopped as it is wound up with a winch, so that at pleas— ure it may be let loose by discharging the ketch. The brace, fig. 3. consists of a piece of buff leather large enough to embrace the arm, sewed on two pieces of strong iron curved plates rivetted together, one of them having an eye at each end to fallen two cords in: the other is bent at the ends into two hooks, which are to receive the cords after they have crossed the arm above. In order to keep the patient steady in his chair, and to prevent the scapula from rising on depressing the lever, after the limb is drawn forward by the winch, there must be fixed over the shoulder a girth with two hooks at the end of it, as is represented in fig. 2. The girth should be long enough to reach the ground on the other side, where it must be hooked into the ring B, screwed into the floor for that purpose, as in fig. 1. PLATE LXXIX. [Opposite to page 220.] In this Plate I have delineated an instrument men— tioned in Chapter XLI. for the purpose of removing Vol. IV. Y contractions 346 Explanation of the Plates. contractions of the ham—strings or flexor tendons of the leg. Fig. 1. A front view of the instrument: A A, two curved steel plates connected together by a firm steel splint D, in fig. 2. One of these is to be applied to the back part of the the thigh, and the other to the upper and back part of the leg; while by means of the leather straps E E, such a degree of pressure is made as the patient is able to bear. B B, fig. 1. Is a soft cushion of quilted cotton for surrounding the limb to prevent the leather straps from fretting it. The curved plates A A should for the same purpose be lined with shamoy. Fig. 2. A back view of the same instrument. Fig. 3. A limb with the instrument applied on it. PLATE LXXX. [Opposite to page 227.] I have here delineated a fracture box, mentioned in page 160. It is formed upon the same principle, but somewhat more simple in the construction than Mr. Rae's in Plate LXXIII. fig. 3. Fig. 1. A A, The base or bottom of the instrument, formed of deal an inch and a half thick. B B, Two ends rising from the base, and terminating in the pil— lars C C C C. D D, An excavated moveable piece of timber for supporting the fractured limb. This move— able part of the instrument may be raised and sup— ported at any height by the pins E E passing through the holes in the pillars C C C C; and it may at pleas— ure be raised at one end and depressed at the other. H H. Two straps connected with buckles on the op— posite side for fixing the limb after it is properly plac— ed. Before laying down the leg, the dressings should be all applied, and the excavated part of the instru— ment should be completely lined with soft wool. G, A hole for receiving the heel to prevent it from being hurt when the leg is stretched out, as represented in fig. 2. The 347 Explanation of the Plates. The ends, B B, may either be fixed to the base of the instrument, or, in order to render it more portable, they may be made moveable, and fixed for use by a double pin at each end F. PLATE LXXXI. [Opposite to page 234.] In Chapter XXXIX. Section V. as well as in oth— er parts of this work, we had occasion to recommend an instrument for supporting the sore arm as being preferable to any bandage. A representation is given of it in fig. 1. A A, a case or frame of firm leather properly lined with flannel and wool, of a sufficient length for cover— ing the arm from the elbow to the point of the fingers. This is intended for the left arm: B, A collar of soft buff leather for passing over the right arm, in order to support the sore part of the case by the strap F passing over the left shoulder, to be fixed to a buckle at C, to prevent the collar B from slipping down. G H, Two straps and buckles for fixing the arm down to the in— strument. The application of this instrument will be better understood by the view of it in fig. 2. I was favoured with this instrument by Dr. Monro, to whom, I believe, it was sent by Mr. Park of Liverpool. Figures 3. and 4. Two artificial legs, delineated by Mr. White of Manchester in his Cases in Surgery. Fig. 4. A A, A hollow leg made of tin and covered with thin leather. B, A leather strap with a buckle on the outside, for fixing it below the knee. C D, Longitu— dinal steel bars, to be made as tough and light as pos— sible, with sufficient strength. These bars are joined by a moveable joint, to be placed exactly opposite to the knee joint. E, A steel bow made thin and elastic, to pass about two thirds round the lower part of the thigh, and fixed with straps of leather to buckle on the sore part. Fig. 3. Another artificial leg made in the same manner with fig. 4. with the addition of a foot made Y2 of 348 Explanation of the Plates. of light wood and moveable joints, so as to imitate pretty nearly the natural motions of the joints of the ancle and toes. PLATE LXXXII. [Opposite to page 243.] Fig. 1. A machine invented by an ingenious trades— man of this place, Mr. Gavin Wilson, for distortions of the leg. This subject was treated of in Chapter XLI. A A, A case of firm leather open before, for receiving the distorted leg and foot. B C, A splint of iron for giving an additional firmness. The leg be— ing placed in this case, the foot is fixed down to the bottom or sole of it by the strap H passed through the hole I; and the leg itself is gradually drawn either to one side or another according to the nature of the dis— tortion, and secured by a proper application of the straps D F, to be fixed upon the brass hooks G E. By a due perseverance in the use of this machine, many bad cases of distorted limbs have been completely cured. Fig. 3. A pair of shoes which have proved service— able in some cases of distortions of the ancle joint, where the toes have been turned too much inward. As they are light they may be used even in early in— fancy. After the feet are fixed in the shoes by the laces before, the toes may be separated to a proper distance, and preserved in this situation by the appa— ratus at A; which consists of three small iron plates, more particularly delineated in fig. 5. and at B, fig. 4. Fig. 5. consists of two parallel thin plates, fixed with nails to the outside of the sole of one shoe; and they are so far separated from each other, as to receive the round plate B between them, the end of which is fix— ed to the sole of the other shoe. The three plates are connected together by a nail passing through, the hole in the centre of each. This admits of a considerable degree of motion, by which the toes may be moved either outward or inward; but they can be easily fix— ed at any particular point by a small iron pin A pass— ed through one or other of the holes in the side of the plates B. PLATE 349 Explanation of the Plates. PLATE LXXXIII. [Opposite to page 245.] In this Plate I have delineated an apparatus men— tioned in Chapter XLI. for distortions of the legs. Fig. 1. A B, An iron splint properly covered with soft leather fixed in an iron frame C. The splint may be made to fix on either side of the frame according to the nature of the curvature. In a distorted leg the foot is to be fixed down to the frame C by means of the shoe represented in figure 3. This is easiest done by passing a nail through the heel of the shoe into the frame, upon which the shoe may move. If the leg is bent outward, the splint A B, fig. 1. is placed on the inside, and it should be of such a length that the pad B may rest upon the internal condyle of the knee joint, where it should be fixed by the strap E. When the bones are bent inward, the splint must be placed on the outside of the leg. The straps E F must be passed two or three times round the convex part of the leg, and should be made to press it with some degree of force toward the splint; and by increasing the pressure from time to time, the convexity or curvature will be gradually lessened till at last it may in many instances be totally removed. By means of the strap C, the toes are to be drawn from that side to which they incline, and fixed to the oppo— site side of the frame. The screw nail D determines what is gained from time to time, by moving it from one hole in the frame to another. Fig. 4. A machine invented by the late Mr. Gooch, for giving support to weak limbs as well as for remov— ing distortions. A A A, Three steel bows made thin and very elastic: They must stand clear of the tibia; must pass about half round the limb, and be fixed with straps of leather upon round headed pins. B B B, A longitudinal plate, to be made of tough stuff, as the workmen term it, and as light as possible with sufficient strength. Y3 C, The 350 Explanation of the Plates. C, The shank to pass into the socket, in that part of the machine which is to be fixed into the heel of the shoe or laced boot, and confined there by a screw at the bottom. D, The screw to keep the shank in the socket. Plate LXXXIV. [Opposite to page 266.] Fig. 1. A small spring saw used in amputating the fingers and toes. Fig. 2. and 3. Retractors made of thin iron plates for drawing up and supporting the muscles and other soft parts in amputating limbs while the saw is applied to the bones. They should be kept with openings of different sizes, so as to answer where the bone is large or small, or whether there be two bones or only one. Fig. 4. A piece of firm slit leather, which answers the purpose of a retractor extremely well. It is better suited for this than a bit of linen, which is generally used, but which does not support the parts with suf— ficient firmness. PLATE LXXXV. [Opposite to page 267.] Fig. 1. The saw I always use in the amputation of legs and arms: It should be seventeen inches in length, including the handle, and two inches and a quarter in breadth at its broadest part. Fig. 2. A small double edged knife, commonly termed a Catline, for the purpose of dividing the in— terosseous ligaments and other soft parts in amputating the leg and sore arm: It should be nine inches long. Fig. 3. An amputating knife, which answers either for the thigh, leg, or arm: It should be thirteen inches in length. Fig. 4. A small crooked knife for separating the muscles from the bone in the manner I have advised in the Chapter on Amputation, Section IV. PLATE 351 Explanation of the Plates. PLATE LXXXVI. [Opposite to page 315.] In Chapter XLV. I gave some account of an inge— nious proposal by Mr. Moore of London, for dimin— ishing and preventing pain in several operations of surgery. It is done by compressing the nerves of the limb upon which an operation is to be performed. In this plate I have represented the apparatus recom— mended by Mr. Moore for this purpose. Fig. 1. A, The compressing instrument, being form— ed of a curved piece of iron covered with leather, and of sufficient capacity to contain the thigh within its curve. B, A firm compress of leather at one extremity of the instrument, to be placed on the sciatic nerve. D, An oval compress fixed on a screw, passing through a hole at the other extremity of the instrument. This compress to be placed on the crural nerve. When this instrument is to be used, it will be nec— essary in the first place to search for the sciatic nerve: For this purpose let the operator feel for the tuberos— ity of the ischium, and then for the great trochanter; and supposing a straight line drawn from the one to the other, apply the compress B about an inch above the middle of that line. The crural nerve is found by the pulsation of the crural artery, which runs contiguous to it; the oval compress D must next be applied above it; and upon turning the screw connected with it, the sciatic nerve is pressed by B against the edge of the sciatic notch, and the crural nerve against the os femoris to any de— gree that is necessary. Fig 2 Represents the instrument adjusted to the thigh; and fig. 3. a smaller compressor suited to the Plate LXXXVII. [Opposite to page 316.] In this plate I have given a representation of an artificial leg and arm made by a very ingenious artist Y4 of 352 Explanation of the Plates. of this place, who I have in different parts of this work had occasion to speak of, Mr. Gavin Wilson. Fig. 1. An artificial leg made of firm hardened leather. A, An oval piece of the same kind of leather lined with shamoy, fixed upon a plate of iron C, and mov— ing upon an axis at the knee. The strap I, with the buckle connected with it, serves to fix it to the thigh. There must also be an oval piece connected with a similar iron plate on the opposite side of the thigh: These iron plates and oval pads should together go about nine inches up the thigh. B, A strap that comes from the sole of the foot, and goes up on the inside of the leg to the middle of the thigh, where it is fixed by a buckle to a strap coming from the opposite shoulder: This serves to support the leg, and to take the weight of it more effectually from the weak side than any invention I have met with. Fig. 3. The oval piece of leather and iron splint to which it is fixed. Fig. 4. A piece of soft shamoy leather which fixes by a buckle and strap round the condyles at the knee. In legs of this kind, the person's weight rests upon the condyles and patella, the stump itself hanging quite free within the leg. This band or strap serves in the most effectual manner to prevent pain and excoria— tion, which otherwise would probably ensue from the friction of the leg against the knee. Fig. 2. A fore arm and hand made of the same kind of leather, and made to fix to the arm and shoulder by the straps D E. These artificial legs and arms are preferable to any I have ever seen. The leg, when properly fitted, proves equally useful with the common timber leg, and it is preferable from being neater; at the same time that it is not liable to break, an accident to which the others are very liable: and it answers better than a leg made 353 Explanation of the Plates. made of copper, from being considerably lighter, and not apt to be hurt in its shape by bruises. Mr. Wilson makes three different kinds of legs cor— responding to the part at which the limb is amputat— ed. In amputating the leg lower than the usual part, that is, in such a manner that the motion of the knee is to be retained, it answers better at the distance of nine or ten inches from the condyles of the knee than either higher or lower. When higher, the remaining part of the leg is not sufficient to support the artificial leg in walking; and when much lower, it renders it necessary to make the machine thicker about the ankle than would otherwise be required, by which it is ren— dered clumsy and heavier. Fig. 1. in this plate rep— resents a leg for this part. The second kind of artificial leg made by Mr. Wil— son is intended for those cases where the amputation has been performed at the usual place below the knee, where the weight of the body rests upon the knee joint and upper part of the leg upon a soft stuffed cushion. These legs have no flexion at the knee, and the hollow for receiving the thigh goes up near to the hip: It opens behind to admit the thigh; it is fixed with three straps and hooks, which last are not only strong— er, but less bulky than buckles. When a limb is amputated above the knee, a joint is formed in the artificial leg at the knee. In walk— ing, the limb is made steady by a steel bolt running in two staples on the outside of the thigh being pushed down; and when the patient sits down, he renders the joint flexible by pulling the bolt up. This is easily done, and it adds much to the utility of the invention. The rest or support in this leg is obtained in part from its embracing the upper part of the thigh tight— ly, but chiefly from the back part of the thigh box be— ing stuffed in such a manner that the lower part of the hip rests upon it with nearly the same case that one does in fitting on a stuffed chair; and in fact, a person 854 Explanation of the Plates. person sits on it when he either stands or walks; by which, and by the strap carried up from the sole of the foot to the shoulder, the limb is very easily carried about. Mr. Wilson's artificial arms, besides being made of firm hardened leather, are covered with white lamb— skin, so tinged as very nearly to resemble the human skin. The nails are made of white horn, tinged in such a manner as to be a very near imitation of na— ture. The wrist joint is a ball and socket, and answers all the purposes of flexion, extention and rotation. The first joints of the thumb and fingers are also balls and sockets made of hammered plate brass, and all the balls are hollow to diminish their weight. The second and third joints are somewhat similar to that which anato— mists term Ginglimus, but they are so far different as to admit of any motion, whether flexion, extension, or lateral. The fingers and metacarpus are made up to the shape, with soft shamoy leather and baked hair. In the palm of the hand there is an iron screw, in which, a screw nail is occasionly fastened. The head of this nail is a spring plate, contrived in such a manner as to hold a knife or a fork, which it does with perfect firm— ness. And by means of a brass ring fixed on the first and second fingers, a pen can be used with sufficient exactness for writing. When only a hand and fore arm is needed, it is fixed to the arm above the elbow by a strap of leather sewed to one of the sides of the artificial fore arm. After making a turn and a half just above the elbow, the strap is fixed on the back part of the limb at D, fig. 2. When the arm is amputated above the elbow, the artificial limb is made with an elbow joint. This part of it is made of wood, and has a rotatory motion as well as that of flexion and extension. I have given this particular account of Mr. Wil— son's 355 Explanation of the Plates. son's invention, from a conviction of its being superior to any with which the public is acquainted: I am also pleased at having it in my power to let the merit of such an artist be more generally known than it other— wise might be. Indeed his merit in matters of this kind is so conspicuous, as well as in the management of distorted limbs, that his death I would consider as a public loss, at the same time that I have often wished that some public encouragement were given him, to enable him to communicate as much as possible the result of his experience to others. PLATE LXXXVIII. [Opposite to page 318.] In this plate I have delineated two machines for supporting the head and shoulders, commonly em— ployed in distortions of the spine. Fig. 1. A, An iron collar properly covered for pass— ing round the neck. By means of the long iron plate connected with it, it may be raised or depressed at pleasure. B B B, A broad iron plate fitted to the back and shoulders. C C, Two straps to be carried over the shoulders; and being brought through beneath the arm pits, to be fixed, of a sufficient tightness, on two knobs on the shoulder plates, as may be seen in fig. 2. D, a strap for fixing the plate going down the back, by being tied round the body. Fig. 3. An iron or steel instrument, delineated by Heister for the same purpose with the preceding. A A, Its transverse part, to which are fastened iron rings C C for retaining and keeping back the shoulders. B, The perpendicular part going down the back. D, A band or ligature passing through an aperture in the lower end of the plate B for tying it firmly to the body. PLATE LXXXIX. [Opposite to page 320.] In this and the four following plates I have deline— ated the instruments employed in midwifery. The 356 Explanation of the Plates. The forceps is perhaps the best, as it is the safest, instrument employed by the Accoucheur. Various forms of it have been recommended by practitioners; but the one delineated in this plate has been found to answer perhaps better than any other. It appears to be sufficiently long, and the blades ap— ply with perfect exactness to the child's head. This instrument should measure eleven or twelve inches in length. Some have alledged that they should be longer, in order to prevent their locking within the vagina, and that they may with more ease be applied when the head of the child lies high in the pelvis; but the length we have mentioned is by expe— rience found to be sufficient. PLATE XC. [Opposite to page 322.] Fig. 1. A single blade of the common crotchet: An instrument employed for tearing away the fœtus piece meal when it cannot be delivered entire. From the form of this instrument, it is obvious that it can— not be used but with much risk even of hurting the mother. The best rule for preventing this is to keep the point of it always towards the fœtus. Fig. 2. The two blades of the crotchet locked to— gether; in which way they may be used with perfect safety to the mother. Fig. 3. Scissors used for perforating the skull of the fœtus, where the pelvis is so narrow that delivery can— not be otherwise accomplished. After emptying the cranium of its contents, the child is extracted piece meal either with the crotchet or with the blunt hook, fig. 2. Plate XCI. or with the forceps, fig. 1. or 3. of the same plate. The scissors here represented are those recommend— ed by Dr. Denman. PLATE 357 Explanation of the Plates. Plate XCI. [Opposite to page 324.] The forceps, figures 1. and 3. as well as the blunt hook, figure 2. of this plate, are intended, as was men— tioned in the explanation of the preceding plate, for extracting the fœtus piece meal, when it has been judged proper to accomplish delivery in this manner. Plate XCII. [Opposite to page 325.] The instruments in this plate, and the fillet fig. 3. in Plate XCIII. are the invention of my friend Sir Thomas Bell, a practitioner of eminence in Dublin. They are chiefly intended for extracting the head of the fœtus, when by accident or improper management it is separated from the body in cases of narrow pelvis. By a proper application of the fillet just mentioned, he fixes the head steadily till it be sufficiently opened for discharging the brain; when by means of the for— ceps here delineated, he performs the extraction. These forceps consist of two blades; one nearly of the ordinary form; the other convex: and its con— vexity being adapted to the concavity of the other, the two occupy much less space than they otherwise would do; by which they are peculiarly well fitted for the narrow pelvis we are now speaking of. The teeth with which one of the blades is furnished, give these forceps a very firm hold of any part to which they are applied: And as it is an instrument that may be used with safety, I think it probable that it may in many cases supersede the use of the crotchet. Plate XCIII. [Opposite to page 327.] Fig. 1. A fillet of whale bone covered with a sheath, which by some operators is employed, in cases of dif— ficult labour, for pulling down the head of the fœtus. In general, however, the forceps is preferred to it. Fig. 358 Explanation of the plates. Fig. 2. A curved instrument, with an opening at one end, for applying ligatures round polypous ex— crescences in the uterus. It is the invention of the late Dr. Hunter of London, and it answers the pur— pose in the easiest and most effectual manner. Fig. 3. A fillet mentioned in the explanation of the preceding plate as the invention of Sir Thomas Bell, of Dublin: It is a material improvement of the com— mon fillet represented in figure 1. of this plate. Plate XCIV. [Opposite to page 333.] Fig. 1. I have here delineated a night cap, fixed in such a manner as to serve as one of the best bandages for the head. Fig. 2. The common triangular napkin, or couvre— chef of the French, usually employed as a bandage for the head. Fig. 3. The radiated bandage, as it is usually term— ed. It is commonly employed for compressing the temporal artery; and it will answer equally well for stopping hemorrhagies in any arteries of the head, as may be seen in fig. 4. where the knot or turn is made at the angle of the jaw. Fig. 5. The bandage usually employed for fractures of the lower jaw, as well as for wounds and other in— juries of the under lip and chin. The method of ap— plying it is mentioned in page 334. Fig. 6. A bandage for supporting the head. It is formed by a proper application of the double headed roller, fig. 2. Plate XCV. Plate XCV. [Opposite to page 334.] Fig. 1. A common tingle headed roller; a bandage that answers for various purposes in Surgery. Fig. 2. A double headed roller. Fig. 3. A double headed roller with a slit in the middle, forming what is termed the Uniting Bandage. Fig. 359 Explanation of the Plates. Fig. 4. A four headed roller, usually employed for fractures of the lower jaw and other affections of the contiguous parts. Fig. 5. A bandage with twelve heads or tails appli— ed to a leg. This, as we have had occasion to observe in various parts of this work, is the most useful band— age for fractures, as well as for many other affections of the thighs and legs. In fig. 7. I have represented a bandage of the same kind, made in a manner com— monly used in some of the London hospitals. Fig. 6. The uniting bandage, fig. 3. applied to a wound in the arm. Plate XCVI. [Opposite to page 335.] Fig. 1. and 2. A front and back view of the napkin and scapulary bandage; the most useful bandage for almost every part either of the thorax or abdomen. The particular parts of it, and mode of applying it, have been already described, page 335. Figures 3. and 4. different forms of the T bandage. This bandage proves particularly useful in affections of the anus and perineum. C, A hole for admitting the penis. At D, that part of the bandage which passes between the legs is divided into two; one part of it passing on one side of the penis and scrotum, and the other on the opposite side. Plate XCVII. [Opposite to page 336.] In this plate I have delineated the different forms of suspensory bandages for the scrotum. They may be made either of linen, cotton, or flannel; but soft cotton answers best. Each bandage consists of a circular A, which is fix— ed round the body above the bones of the pelvis, and a pouch or bag connected with this: The principal difference between them consists in the form of the pouch, and in the manner by which it is fixed to the circular. 360 Explanation of the Plates. circular. In figures 1. 2. 3. and 4. the pouch is con— nected with the circular both before and behind. Of these, fig. 3. I think is the best. Where the scrotum is of such a size, that the pouch or bag, when fixed upon it, will remain, the two bands, which pass between the thighs for fixing it behind, are unnecessary: Fig. 5. represents a form of it for this purpose. PLATES XCVIII. and XCIX. [Opposite to page 360.] In these two plates I have delineated instruments for a pocket case, which surgeons have daily occasion for. Plate XCVIII. fig. 1. Forceps. Fig. 2. A round edged scalpel. Fig. 3. Crooked scissors. Fig. 4. A case for caustic and red precipitate. Plate. XCIX. figures 1. and 3. Different forms of probes. Fig. 2. A spatula. Fig. 4. A director. These, with a probe pointed bistoury, fig. 2. Plate VII. a tenaculum, Plate 1. fig. 1. a scarificator, Plate XLIX. fig. 4. and a few crooked needles of different sizes, form a very complete set for a pocket case. FINIS. DIRECTIONS to the BOOKBINDER for Placing the PLATES in VOL. IV. Plate LXX. to face page 140 LXXI.—145 LXXII.—147 LXXIII.—151 LXXIV.—158 LXXV.—161 LXXVI.—167 LXXVII.—171 LXXVIII.—214 LXXIX.—220 LXXX.—227 LXXXI.—234 LXXXII.—243 LXXXIII.—245 LXXXIV.—266 Plate LXXXV. to face page 267 LXXXVI.—315 LXXXVII.—316 LXXXVIII.—318 LXXXIX.—320 XC.—322 XCI.—324 XCII.—325 XCIII.—327 XCIV.—333 XCV.—334 XCVI.—335 XCVII.—336 XCVIII.—360 XCIX.— PLATE XCVIII.  PLATE XCIX.