which still remain attached must be pressed into their place, and they should only be removed if they produce inflammatory nervous symptoms or abscesses (7). If the wound suppurate it requires, should the suppuration be slight, the usual treatment; if it be more copious, care must be taken for the free outlet of the pus either by sufficient enlargement of the wound or incisions, and by suitable position of the limb every collection and burrowing of the pus must be prevented. If, during suppuration, splinters become loose, they must be dextrously removed; the dressings must be renewed as often as the quantity of pus renders it necessary (8).

Injuries of large vessels in open wounds are of little consequence, as they may be tied, either at once, or after enlarging the wound. Deeperseated vessels are generally injured by the ends of the bones, and the blood collects in the cellular interspaces of the limb. In this case the wounded vessel, or if that be not possible, the trunk of the artery above the wound should be laid bare by a proper incision and tied (9).

Mortification may take place, either as a consequence of a high degree of inflammation, or of the weakly constitution of the patient, or from severe bruising and tearing of parts, from very great violence employed in setting the fracture, or from too tight bandaging. Sometimes therefore a strict antiphlogistic treatment must be employed, and every irritant and pressure removed. Sometimes strengthening remedies internally and externally must be used. Opium is frequently of most important service (10).

In delirium nervosum tremens, which occurs particularly in old persons, in drunkards, also in great corporeal irritability, from mental emotions, severe pain and so on, generally two or three days after the accident, but often later, during suppuration with restlessness, confused ideas, talkativeness, screaming, raging, insensibility to pain, sleeplessness, with weak or small, soft or quickened pulse, opium must be given in large doses till the patient is kept constantly asleep; only in great determination of blood to the head may careful blood-letting, leeches to the temples, mustard poultices, and so on, be previously necessary. I have always noticed the best effects from opium; not so however from tartar emetic in divided doses, assafoetida, valerian, which have been recommended by different persons for this disease. Spirituous liquours must not be withdrawn entirely from drunkards during this treatment. If sleep do not take place, death is the consequence. On dissection no disease is found (DUPUYTREN); frequently there is exudation on the arachnoid, pus in the joints, and in the sheaths of the tendons (JÆGER).

[(1) In the consideration of compound fracture it must be carefully remembered that the existence of a large wound with fractured bone does not constitute a compound fracture, but that a fracture is only compound when a wound, however small, communicates with it, so as to expose the broken bone to the air. A fracture with a wound may, however, become in a shorter or longer period compound, by this communication being established. And even a simple fracture, where the soft parts are very thin above the broken bone, or where they are much bruised, may, and often does in the course of two or three days, become compound; or the same result may be produced in simple fractures, (especially if the bone be broken obliquely,) either by spasm of the muscles, or by the patient's restlessness thrusting the broken end of the bone through the skin, almost immediately after the accident, of which I have seen instances, and one from the latter cause but very lately.-J. F. S.

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Compound differ from simple fractures," observes JOHN HUNTER, "in the first and second modes of union being lost; and, therefore, the third, by granulation, takes place. The granulations between the ends of the bone and on the lacerated surfaces take on an ossific disposition, and the suppuration is always more or less surrounded by the adhesive inflammation, so that it extends pretty far, and consequently the callus is large.

Hence these fractures are so tedious and dangerous, especially when in the lower extremity, which is their usual situation. There are no bounds to the mischief done by a compound fracture; the loss of the uniting substance by the wound, and the loss of the living principle to what remains by the exposure, are causes of the failure of the first process, and besides, the ends of the bone are sometimes so locked together, as to require to be sawed off, or so denuded of their investing membrane, as to lose their living principle, and to exfoliate, as the dead part must be thrown off before the wound can heal. This sometimes takes six or eight months, and is so extensive, as to be very dangerous. The inflammation too which follows the accident is commonly very cousiderable, and may proceed to mortification." (pp. 508, 9.)

ASTLEY COOPER says:-"The effect which compound fracture produces on the consti tution is to set up a violent re-action, so as to bring about a restoration of the injured part. The degree of this effort of the system will very much depend on the manner in which the accident is treated; and I should say that it was an important injury or otherwise, according to the plan of treatment which is pursued; for if you are careful in the management of the case, you may procure adhesion of the external wound, and thus reduce the accident to the state of a simple fracture." (p. 644.)

The truth of these observations is fully confirmed by even the most limited expe rience; and it may be worth mentioning, as confirmation of the propriety of attempting to unite the wound, and so to produce a simple fracture, that MIESCHER found difficulty, in experimenting upon rabbits, to produce suppuration in a compound fracture. I broke," says he, "the shin-bone of a rabbit in the usual way, and by cutting into the soft parts, down to the fracture, endeavoured to excite suppuration, but the wound covered with a scab, was shortly closed, and the fracture united by adhesion. I then thrust the end of one of the fragments through an artificial wound; this, however, failed of exciting such suppuration as I wished, the projecting part ran into necrosis, and was afterwards thrown off, but the lips of the external wound girt tightly around it, were covered with a crust, and the cure went on within just as in simple fracture. At length I succeeded according to my wishes, by thrusting a small pencil of charpie through the external wound down to the fracture, and there leaving it.” (p. 219.).

(2) If in simple fracture general blood-letting, or even leeches be rarely expedient, in compound fracture, at least in towns, they should never be resorted to, for patients living in such districts have not sufficient constitutional power to admit of its diminution in the long run, although it might seem requisite at the onset. In country prac tice, however, where the people are more generally healthy, and less addicted to the abuse of spirits or malt liquor, general bleeding is sometimes required, but should always be resorted to only upon the most careful consideration of the case.

(3) As regards opium, in healthy persons, it is better not to administer it, as by affecting the head, its common effect, it masks the symptoms of constitutional disturb ance, and renders them apparently more severe than they really are. If, however, the patient be of drunken habit, and there be reason to anticipate an attack of delirium tremens, then opium must be resorted to as an absolutely necessary part of the

treatment.

(4) I always prefer poultices of warm bread and water, as a tepid evaporant, according to ABERNETHY's method, rather than cold applications, because they relieve the tension of the skin, lessen the inflammatory disposition, do not retard quick union, if the wound be disposed to it, and encourage the separation of sloughs, and the production of healthy granulations, if the skin be so injured as not to unite by adhesion.

(5) Enlargement of the wound in compound fracture should not be lightly undertaken, and as far as my experience goes, is not often requisite; for if the Surgeon have a little patience and dexterity, a protruding fracture may often be coaxed, if the expres sion may be permitted, to recede into its place, when force is quite unavailing. Should it, however, be necessary to enlarge the wound, the operator should carefully select such part of it as with least division will permit the return of the bone.

(6) Sawing off the protruding portion of the fracture is still less necessary than enlargement of the wound, and should never be resorted to but on the most urgent necessity. I believe that in but exceedingly few instances its needfulness depends rather upon the incapable conduct of the medical attendant than on the nature of the accident itself.

of

(7) Loose pieces of bone, if not of large size, but lying between the main parts the fracture and near the surface, especially if the wound be large and there be much bruising, are best removed at once, as they rarely unite, and commonly keep up irritation till they are thrown off; not unfrequently also they prevent the union of the main pieces, and render amputation necessary.

(8) During the progress of compound fractures, abscesses often occur, sometimes near to, sometimes more distant from, the wound. If after a few days they do not make their way to the wound, and empty themselves by it, or if after having so done, they burrow beneath the skin, it is best to puncture them, to favour the ready escape of the matter; but large wounds for this purpose are neither necessary nor advisable.

(9) Wounds of large vessels in compound fracture are not of so little consequence as CHELIUS thinks; nor is either tying them in the wound, or tying the trunk above, so lightly to be undertaken as his recommendation would seem to infer. Active arterial bleeding in compound fracture is always a very important circumstance, and requires grave consideration as to the treatment to be adopted. The first point to be determined is the possibility or propriety of taking up the vessel in the wound. If the bleeding orifice be exposed, the vessel may be tied above and below the wound, if it be only wounded; but if it be torn through, both ends should, if possible, be tied, as unless that be done there is no certainty that bleeding will not recur from the untied end at any time that the general wound be unhealed. If the vessel cannot be found by carefully and gently sponging out the wound, then comes the question, should the wound be enlarged in the direction presumed most likely to discover it? I think not, as it is commonly a very uncertain and unsatisfactory proceeding, the torn state of the parts, and the effusion into them, rendering the discovery of the vessel very difficult and often impossible; besides which, the bleeding vessel may be almost certainly ascertained to be so deeply situated and so lodged, that it cannot be got at from the wound, even though enlarged, as when the posterior tibial or the peroneal artery is injured, and the wound is on the front of the leg. The second point then presents itself, that of tying the principal vessel of the limb above, and at a distance from the wound. This is open to two objections, first, that there is no certainty of the bleeding not recurring when the circulation has been restored by the collateral branches, under which circumstances the patient is again placed in the same dangerous condition as originally; second, that there is always fear of the limb becoming gangrenous from the supply of blood having been cut off, under which state the patient's recovery can only be hoped for by having recourse to amputation whilst in a most unfavourable condition.

With these views, it seems to me preferable, if the bleeding cannot be stopped by taking up the vessel in the wound without much disturbance of the injured part, to amputate the limb at once, as being the safest course to pursue; for if there be much groping in the wound, it will most assuredly slough, and the patient suffer severely from, if not be destroyed, by the consequent constitutional irritation.

(10) Mortification may occur at almost any period after compound fracture, and when setting in early, most commonly depends on the severity of the bruising and tearing, which the constitution feeling it has not power to repair, makes no effort towards restoration, but immediately sets about throwing it off. If there be sufficient strength, the extent of the slough is soon defined by the ulcerative inflammation, which forms a groove, at first superficial, and then gradually deepening and following the dead parts till their final separation. Sometimes, however, the sloughing commences below, and the skin remains for a time sound, until the pressure of the slough and pus, with which it is sodden, causes ulceration for its discharge. At other times the mortification remains undefined, and from day to day continues creeping on till the powers of the constitution are worn out, and the patient sinks from the accompanying hectic fever.

The constitutional treatment is, in these cases, of the first importance; not loading the stomach with medicine, but judiciously providing it with easily digestible and nutritious diet : strong beef tea with arrow-root, blanc manger, jelly without acid, eggs, and oysters if in season; the latter I have often induced patients to take when nothing else would be taken. The patient's habits in regard to beer, wine, or spirits, are to be carefully inquired into, for that quantity of either which, with moderate persons, would be considered large, is to others of not the least benefit. I have known a pint of brandy taken in the course of the day, and absolutely necessary to carry a porter through safely whose leg had been amputated for compound fracture. A pint of wine, or four or six ounces of brandy, or three or four pints of beer, or portions of all three, are commonly required in our treatment of these cases in the hospital. Sometimes it is necessary to give gin or rum, to which the patient has been accustomed, and which suit him better than any thing else. If the stomach will bear it, I prefer good porter far before wine or spirits; the effect of the latter are scarcely more than stimulating; but the porter is less stimulating, its effect more enduring, and the large quantity of mucilage it contains renders it at once both victuals and drink, and affords much nutriment to the constitution. If purging come on, the porter must be omitted, and brandy in arrow-root must supply its place. As to external applications, simple bread-and-water, or linseed-meal poultices are best

when mortification has come on; and if there be offensive smell, a cloth dipped into solution of chlorate of soda may be put next the wound.-J. F. S.]

589. To keep the limb at perfect rest and firm after properly setting the fracture, and to prevent, at every readjustment of the apparatus, the easy occurrence of motion and displacement of the ends of the bones, various means have been proposed, which when once applied are to remain till the cure be perfected.

LARREY (a) describes the following as the best treatment for compound (as well as for simple) fractures. After enlarging the wound if necessary, the effused blood is, as far as possible, to be squeezed out, any wounded vessel tied, and the setting adjusted, the edges of the wound are to be brought together, and steadied with some perforated strips of linen spread with ung. styracis, and with soft charpie and compresses over spread with a glutinous tonic liquor, as wine or camphorated acid, mixed with white of egg. These compresses must surround the whole limb so closely that not the least space is to be left between them, and so that they should produce equal pressure on all sides; the usual splints may be profitably applied. After the application of a sufficient number of compresses the eighteen-tailed bandage (which is preferable to SCULTETUS's) should be put on. This dressing must be reapplied once or twice before the completion of the cure, and the secretion of the wound which has filtered through must be removed with a sponge. This treatment has the advantage of preventing the frequent and always dangerous movements which occur in the often necessary renewal of the ordinary contentive apparatus. But we obtain the same advantage from the use of the contrivance subsequently to be described, for permanent extension, by which also the injury is prevented arising from retention of the secretion of the wound and loosened splinters of bone, especially at a hot time of year. This mode of treatment, viz., the undisturbed application of the apparatus, is common with the Spanish military Surgeons, and may be also employed in gun-shot wounds (b), and so on. * Corresponding to this is the plaster of Paris apparatus, with which the whole broken limb is enveloped, and as it becomes firm it serves instead of splints and every kind of bandage; and by making apertures, either at first or subsequently, in the hardened mass, the wounds and so on can be attended to (c).

SEUTIN (d) envelopes the whole limb in the ordinary way with SCULTETUS's bandage, which he smears with starch paste, then applies a second SCULTETUS's bandage over it, and repeats the starching; two pasteboard splints softened in warm water and also smeared with starch are laid on both sides of the leg, and fastened with a third SCULTETUS's bandage, which is also smeared over with starch. In fractures of the upper extremity, the limb is to be surrounded with a circular bandage smeared with starch, over which softened pasteboard splints are applied, which are to be fastened with another circular bandage, and this again smeared with starch. When his apparatus has dried, it becomes so firm that the broken ends of the bone cannot be displaced by the motions of the limb, which even the patient himself can move from time to time; in fractures of the lower limbs he can, after some time, even walk with the apparatus. The apparatus must always be applied before much swelling comes on, and with the greatest accuracy, the particulars of which will be given in the several fractures.

[Some Surgeons have great preference for the several fracture-apparatus of AMESBURY (e), the general principle of which in those for the lower limbs is to make one part of the limb form a point of resistance from whence extension can be made and kept up at the opposite end without other aid than the machine itself. This having been done so

(a) Mémoire sur une nouvelle manière de réduire ou de traiter les Fractures des Membres compliqués de Plaies; in the Journal Complémentaire du Dictionnaire des Sciences Médicales, January, 1825, p. 193.

LARREY, F. H., Traitement des Fractures des Membres par l'Appareil inamovible. Paris, 1842.

4to.

KOCH, L., Ueber Behandlung mit Wunden complicirter Knochenbrüche; in Journal von GRAEFE u. WALTHER, vol. xiii. p. 564.

BALLING, uber Complicirte Fracturen; ib. vol. xiv. p. 1.

(b) ROCHE et SANSON, Elémens de Pathologie Medico-Chirurgicale. 2nd Edit., vol. iii. p. 422.

ETON, W., A Survey of the Turkish Empire; in which are considered its government, the state of the provinces, the causes of the decline of Turkey,

and the British commerce with Turkey, &c. London, 1798-9. 8vo.

MELIER, in the Journal Général de Médecine, December, 1828, p. 341.

(c) MUTTRAY, J. A., Dissert. de Cruribus fractis gypso liquefacto curandis. Berol., 1831. 8vo. RICHTER, A. L., Abhandlungen aus dem Ge biete der prakt. Medicin und Chirurgie, Berlin, 1832, p. 1.

(d) Mémoire sur le Bandage Inamovible. Bruxelles, 1836.

BERARD; in Archives Générales de Médecine, 1833, June, p. 218.

ROGNETTA; in the Gazette Médicale de Paris, 1834, April, No. 17.

(e) Practical Remarks on the Nature and Treatment of Fractures, &c., 2 vols. 8vo. London, 1831.

as to bring the fractured ends of the bone into proper place, the splints attached to the apparatus are adjusted to the limb, and having been properly fastened, there is little possibility of displacement from whatever posture may be chosen to put the limb in. În the apparatus for the upper limb, the weight of the arm principally keeps up the extension; but the steadiness of the fracture is especially provided for by an angular splint applied in front of both upper and fore-arm. These contrivances are very effective in the treatment of fractures, and will occasionally be advantageous when most other attempts fail; but I think they are objectionable on account of their complicity, which requires especial instruction to understand, so as to apply them properly; for otherwise they are not merely useless, but injurious, by the unequal and misplaced pressure they produce, the result of which very commonly is, tiresome sores; and for their cure it is often necessary to free the limb entirely from any apparatus. They have also the inconvenience, especially those for the lower limbs, of rarely being capable of proper adjustment, on acount of the variety of people's size, to more than two or three persons; and hence at least half-a-dozen sets of various length should be always at hand, which in country practice cannot be expected, where also there is little probability of properly repairing the apparatus, in case of breaking or disarrangement.

I must confess that I consider the more simple are the means employed for treating either simple or compound fracture the better. The starched and gummed bandages have rendered this part of surgical practice as simple as it is efficient; but if the Surgeon prefer wooden splints, he can always readily furnish himself, with or without the aid of a carpenter, with pieces of deal about three inches wide and the sixth of an inch thick, which he can cut to the requisite length for the limb on which the splints are to be applied. These together with pads and bandages are sufficient for the treatment of almost every fracture, either simple or compound; for the Surgeon will do well to remember that the well-doing of the case depends rather on the way in which he adjusts the apparatus, of whatever kind it may be, than on the gimcrackery with which some mechanical Surgeons are fond of furnishing it.-J. F. S.]

[589.* After the protruding ends of the fractured bone have been drawn back, so far as possible, into their natural place, the choice of position in which the limb should be put, is the next point for determination. To this the Surgeon is directed by the situation of the wound, it being necessary that the limb should be placed, if possible, so that the daily or more frequent dressings may be effected without its being disturbed; but if, as sometimes happens, this cannot be avoided, that the position should be such as should permit dressing with least movement. Practical experience can alone specially guide the Surgeon as to the best mode of effecting this object; but the general rule is, so to place the limb that if suppuration be expected, the pus may have the opportunity of escaping as it is secreted from the wound, and not the probability of burrowing, which materially interferes with the cure, and wastes the constitutional powers, by the irritation it keeps up. The choice of the apparatus to be employed in the treatment of the case must also, in many instances, materially depend upon the seat and extent of the wound; for though the practitioner may have a preference for one kind over another, he will be much disappointed if he expect that one apparatus and one position is suitable on all occasions.

Having determined the position, and prepared the apparatus which he has selected, the fracture is immediately to be put up; and this, it will be observed, is a very remarkable difference from the treatment recommended in simple fracture. But in compound fracture, the swelling, if it at all occur, is but slight, as the serous part of the blood readily escapes by the wound, and more readily if the wound be large, so that there is little or no fear of mischief from the increase of the swelling tightening the bandages and causing the inconvenient squeezing of the limb, which happens in simple fracture, if the apparatus be immediately put on. The great object in compound fracture is to render it, as soon as possible, simple, by healing

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