the external wound, and this can only be effected by steadying the broken bone, as well as the soft parts, by the immediate application of the apparatus; which done, the limb is to be put into the position determined on, and so propped by pillows, or fixed by bandages to convenient parts of the bedstead, that all motion should be guarded against. The wound now alone remains to be dressed; and ASTLEY COOPER says:-" If there be a slight hæmorrhage, do not be searching for a small vessel, but place a little lint over the wound, and by making gentle pressure on it you may easily suppress the hæmorrhage. Next bring the integuments as neatly over the parts as you can, and dip a dossil of lint in the blood and put it on the surface of the wound, which irritates the least of any application I know of, and appears to approach the nearest of any other to the natural covering of the parts. In this way the wound unites by the adhesive process, and the union of the bone goes on as in simple fracture, and is cured in one-fourth part of the time which would be required if the wound wer allowed to be filled by granulations." (p. 646.) I must confess I prefe some slips of sticking plaster to the dossil of lint over the wound, fe as it rarely happens that the surface of the wound immediately unites by adhesion, although the parts below may, the oozing serum, or the pus which speedily forms, is confined under the hard crust of the lint, and certainly produces a sore, which will be deep, according to the quantity confined; whilst, on the other hand, the fluid soon manages to find its way out between the interstices of the plaster, and thus this inconvenience is avoided.

It is also advisable, in compound fracture, to cover the fractured limb with a piece of linen dipped in an evaporating lotion of spirits of wine, liquor of acetate of ammonia and water, a fourth of each of the former, and two-fourths of the latter; and the linen should be re-wetted by gently squeezing a sponge over it as often as it dries. For the more effectual cooling of the limb, a cradle should be put over it, over which merely a sheet is to be thrown. And this is no trifling part of the treatment, for if, as not unfrequently happens, a heap of bed-clothes be put upon the cradle, on the plea of the patient feeling cold, all evaporation is put a stop to, the limb is put in a steam-bath, and might as well be wrapped up in a poultice. The patient's feelings as to temperature should not be overlooked; the body and other limbs should be covered so as to render him comfortably warm, but the injured limb must only have the cradle and a single sheet.

Even if the wound in the skin be torn and its edges shreddy, a condition far from uncommon, it is always best to attempt its union by adhesion, for though the whole may not unite, very commonly a large portion of it will, and the danger of the injury will be proportionally diminished.

But if the wound be much bruised, together with the tearing, there is little hope of union by adhesion, and therefore either a poultice alone should be at once applied, or two or three adhesive straps far apart and a poultice over them, which must be changed three or four times a day.

In those cases where adhesion is attempted, the dressings should not be removed unless the patient complain of pain in the wound, either accom panied or not with surrounding inflammation. If the case go on well, there is rarely uneasiness till after four or five days; the dressings should then be removed, after having been moistened by the application of a wet poul tice for a few hours; and according to the appearance of the wound, it

must then be determined whether adhesive plaster is to be continued or poultice applied, which latter is necessary if the wound look angry and sloughy, and must be continued till it shall have become quiet and suppurate kindly, when it may be dressed either with plaster or ointment as may seem most suitable. I have, however, often known the wound unite at once, without a second dressing being needed.

I need scarcely observe, that the Surgeon, in the treatment of this injury, should most carefully avoid meddling or prying into what is going on, unless the patient complain of uneasiness or pain. He should attentively watch from day to day, that the limb retain generally the position in which it was placed; and if it have become materially displaced, it must be put to rights with the greatest tenderness and care, and such additional precautions taken as to prevent a recurrence. Especial inquiry should also be daily made as to the fitting of the apparatus, so as to guard against any digging in of the edge or corner of a splint or any other part of the apparatus; and if such have commenced, to relieve it, partially loosening the straps so as to insinuate gently with a spatula or probe some lint, wadding, or soft linen. Inattention to this point is often followed by tiresome sores, requiring sometimes the complete removal of the apparatus, which disturbs the progress of the cure, or even, as I have seen, causes the loss of the limb, and even of life.

It must, however, always be remembered, that the great maxim in the treatment of compound fracture is, "to leave well alone," instead of attempting to do better.-J. F. s.

"The only peculiarity in compound fracture," says JOHN HUNTER, "by which it differs from other lacerated wounds, is the breach of continuity of the bone, which admits of motion in the part where none was intended. This singularity it is which requires a peculiarity in the treatment, as this motion and the operations of nature are in contradiction to each other. A variety of inventions have been employed to prevent this motion; but the dressing of the wound every day counteracts the effect of every invention that has been thought of, and it is perhaps impossible to dress the sore without motion. [Since HUNTER'S time, as has just been shown, many very efficient contrivances have been hit upon, by which this inconvenience, or rather actual ill, is avoided.—J. F. S.] At first the part is generally put into a poultice; but changing this must give considerable movement. Instead of a poultice, I would lay the leg or arm in cloths, doubled several times, and wetted with goulard, and lap them over so as to come into contact. These should be wetted occasionally, and continued until the inflammation is over and the suppuration takes place. The time of union of a compound fracture is necessarily much longer than that of a simple fracture, from the processes they have to go through, and is very uncertain; but the union of the bones is generally effected long before the external wound is healed up, for whatever retards the cure of the bone retards also the cure of the sore. When granulations have been formed, and bony union is late in taking place, and the wound is healed up, or nearly so, it should be treated like a simple fracture in the same circumstances, and gentle pressure is of use, as walking, with a machine to take off the weight of the body; here necessity acts as a stimulus for bony union to form.

"Compound fractures do not always take on the bony union; but there is never a want of soft union, as there is at times in simple fractures, and therefore new joints are never formed, as they are sometimes when simple fractures do not unite by the first or second modes of union." (p. 509.)

With regard to the union of compound fractures, ASTLEY COOPER observes :-" The mode of union is ultimately the same, but in the one kind of injury ossific matter is deposited in cartilage, without a suppurative process, and in the other with it. If you do not procure an union by adhesion, it is brought about by granulation, and in the following way.

"The blood which is at first poured out, in consequence of the division of the vessels of the medullary membrane and the periosteum, instead of being confined in the surrounding structures, passes off by the external wound: yet it must be remembered that

this effused blood has no share in producing union of the ends of the bone, as it becomes after a few days entirely absorbed. Next there is a fluid poured out between the periosteum and the bone which separates the periosteum from the surface of the bone, for about an inch or an inch and a half beyond the place where the bone is frac tured. This fluid does not cause a laceration of the vessels of the periosteum, but rather an elongation of them. Now here is the difference between the simple and the compound fracture; for, in the former, the fluid, after accumulating for a day or two, becomes in a great measure taken up by the absorbents, and adhesive matter is poured out in its stead, but in the latter a suppurative process is established, and granulations arise from the broken surfaces. In these granulations cartilage becomes deposited, and continues to be formed for some time; the discharge of pus gradually diminishes, and in compound fracture cartilage continues to be formed until about the twentieth day. It is deposited between the internal surface of the periosteum and the external surface of the bone. At the place where the fractured ends are brought into contact, the periosteum becomes absorbed and cartilage is deposited between them, in which patches of bony matter are formed, and these, when completed, are covered by an extension of the original periosteum. **** Under the granulations arising from the cancellater structure cartilage is also found, and from the seventeenth to the twentieth day the are bony patches deposited in the cartilage. It is by the accumulation of these patche that ossific union gradually takes place. A compound fracture is necessarily slower in its progress towards recovery, from the causes just explained, than a simple fracture, and the union is frequently retarded by exfoliations of bone, which will often take up a tedious time to separate, and keep up considerable irritation. Three months may be considered a short time for the union of a compound fracture to take place; sometimes the accident is not recovered from in nine months, and occasionally not even in twelve.” (p. 644-46.)

The following is the summary which MIESCHER gives of his experiments on rabbits to ascertain the processes under which suppurating fractures are united :

"If the circumstances which occur in the progress of suppurating fractures be com pared with those noticed in simple fractures, it will be seen that the mode and way of cure is precisely the same in both. The soft parts swell, coalesce, and together form a capsule around the fracture, from the internal surface of which, and from the medalla, although from the latter, according to circumstances, not always, a new substance proceeds, and when sprung from both, at length envelopes the several fragments untied together; whence it is self-evident that this is the same substance as that which I have called intermediate. At a subsequent period, as seen in the fourth experiment, this substance produces a sort of fibro-cellulous membrane, easily separable from the other soft parts, and comparable with the periosteum, which, in simple fractures, is presented as the recent investing callus; this, therefore, is the only difference, that in the fractures of which we are now speaking pus is formed, and the new substance at its commence ment presents the appearance of granulations. The substance of the callus which fills up the medullary cavity is produced by simple exudation, as in simple fractures, and no less are the first fruits of the external callus, by which the periosteum still adheres to the bone, produced by simple exudation; but so soon as the callus has stretched beyond that part, the rest is formed by the granulations growing with a secretion of pus. Why all these formations should proceed more slowly is easily understood, from the circumstances generically connected with suppurative inflammation.

"However, there is this very great difference between the cure of simple and supparating fractures, that in the latter the ends of the fragments are bared, and that the evolution of the later callus takes place on them; but in the third and fourth experi ments there could be no doubt that the bared parts of the bone were dead, because very decided marks of incipient exfoliation existed; and in the other experiments, the white colour of the bone showed the presence of necrosis. On the one side only would there be necrosis, if the other, as it seemed, had not been at first deprived of periostean; but the entire extremity of the fracture would be involved if the periosteum had been torn from its whole circumference. If the medulla remained healthy to the edges of the fracture, the necrosis would attack only the surface of the bone, but if the medulla, killed as it seemed by the violence of the inflammation, were destroyed throughout the whole bone, so far as the medulla was dead the necrosis would be seen. The splinters had arranged themselves; those which were entirely separated, were, as might be expected, not contained in the callus, but, on the contrary, still adhered by one part to the periosteum, new bony substance proceeded from them, and that surface of them towards the cavity filled with pus, was alone dead, just as the bared ends of the fragments. "How the cure proceeded after the separation of the necrosis I am sorry I cannot from

observation state, as my experiments were not continued sufficiently long; but what more is needed can be easily supplied from what has been elsewhere observed about necrosis. It would, however, happen, that after the dead part was separated and thrown off, the bone would be covered with granulations, which growing, would by degrees be converted into cartilaginous and bony substance, producing what I call the SECONDARY CALLUS, and at length be united with the parts in the immediate neighbourhood.

"But this very point, that the parts of the fragments bared of periosteum pass into necrosis seems to be greatly impeached, because practical Surgery in suppurating fractures should propound that the prognosis is bad from the first; for although I would pass over that in such fractures the first callus proceeds much more slowly, and consequently that arising on both fragments does not so readily unite, the latter callus which is the principal cause of the fragments uniting firmly together, is completely unbegun until necrosis has ceased. But this separation is often effected too late; the formation of the soft parts of the intermediate substance, as it were proceeds more and more, whilst the necrosis ceases to be separated, and between the extremities forms dense membranous investments, pretty closely enveloping the broken ends, as seen in the fourth experiment. The exfoliation being completed the granulations at length spring up, and shortly coalesce with these investments: the inflammation, inasmuch as it has been kept up by the necrosis alone, soon ceases, and cicatrization takes place; therefore not only is there a loss of the substance, but even that by which the lost substance of the bone is repaired, is removed. Hence either the bony junction of the fragments is effected by the first callus alone, and therefore the union is little firm; or the fragments are merely contained in fibro-cellulous investments, and a spurious joint, as it is called, is formed.

"From the fewer experiments I have made, I certainly dare not conclude that the parts of fragments bared of periosteum, inasmuch as they are bathed in pus, always die, and that the doctrine advanced by GENDRIN, that "these parts are softened, changed into red tissue, and covered with granulations," is entirely refuted; for what is alleged by this writer from experiments, so far as may be judged from the manner of his narration, seems no less to be depended on, although he has not stated what the experiments were. Besides, my experiments on full-grown rabbits were not sufficiently numerous, that any thing could always be certainly collected from them. But they so agreed together, as also entirely with those which I have elsewhere noticed of acute inflammation of bone, that I cannot but at present rather doubt, that softening and swelling, which almost every one agrees existing in inflamed bones, and hence I am disposed hereafter to follow this matter further.

"It is doubtless very remarkable that GENDRIN, BRESCHET, MEDING, and KORTUM, make not the least mention of the necrosis which exists in suppurating fractures. MARRIGUES (a) had distinctly stated that the first callus could not be produced in suppurating fractures of bones, as the extremities of the fragments, if not entirely, at least the greatest part of them exfoliated. Most other writers speak only incidentally and without clearness on this point; thus for example BELL says large portions of bone separate, BOYER that granulations spring from the ends of the fragments, sometimes whilst exfoliation proceeds, and sometimes when it does not. In observations relating to the cure of compound fractures, in the Surgical Journals edited by RICHTER, LANGENBECH, GRAEFE and WALTHER, I have at present found few in which it is not stated, that single splinters, and often indeed long after the occurrence of the fracture, are thrown off; in most I have found distinct mention of separated necroses, nor did it seem doubtful but that the splinters also above mentioned should be referred to the necrosis. It follows that necrosis exists in suppurating fractures, if not always and necessarily, yet doubtless in the greater number. But indeed since necrosis itself is to be considered the main cause why compound fractures are either but little firm, or entirely unconsolidated, and the necrosis arises not so much from the injury (mechanical) of the bone itself as from the disturbance of the first intention, is it not worth while to try whether, often by uniting the external wound, and converting the compound into simple fracture, which spontaneously happens in rabbits by the formation of a scab, care might not be taken that the bone should not die? Whether by a proper treatment the prominent parts of the bone having been accurately adjusted, or as circumstances might require cut off with a saw, the lips of the wound united, and more violent inflammation prevented, that may not be effected by art in man which in certain animals is done by nature ?" (p. 223-25.)]

590. Amputation may be necessary in Fracture of Bones; 1, on ac

(a) Cited at the head of the Article.

count of the severity of the injury, if the bone be broken into many pieces, if the muscles, tendons, ligaments, nerves, and important vessels be injured, the joint-ends of the bone split, and the ligaments of the joint destroyed, so that mortification may be predicted with certainty; 2, for mortifica tion; and, 3, because of profuse suppuration, which exhausts the powers of the patient.

[Of the three conditions, mentioned by CHELIUS, under which amputation is necessary in Compound Fracture, it must be remembered that although the decision on all requires great attention and practical experience, yet the first is most important, as it involves the question of immediate amputation, a point upon which Surgeons do not agree, bat which is of the utmost importance to the patient. To prove the fact of this difference of opinion I quote the opinions of the two first Surgeons of our time, ASTLEY COOPER and JOHN ABERNETHY, at whose feet the greater number of English Surgeons of twenty years' practice have had the privilege to sit, and whose opinions, as the most distinguishel disciples of the school of JOHN HUNTER, have largely contributed to the formation and still continue more or less to influence the practice of Surgery throughout Grø Britain.

ASTLEY COOPER, after enumerating the various conditions of compound fracture which require amputation, says:—“If it will be necessary to amputate in a few days after the accident, then the sooner it is done the better. If you amputate at one hour after the accident, the patient will do better than if you leave it twelve hours. For this reason; if you amputate immediately, the constitution has but one shock to sustain, and in general rallies much better than when the amputation is delayed; but if you leave it eight or twelve hours there is a great degree of irritation previously set up. The loss of blood is rather a favourable circumstance than otherwise to precede the operation. The persons in whom these operations succeed the least are such as are loaded with adipose matter; if you leave the limb, the constitutional irritation runs so high that it generally destroys life, and if you amputate they frequently die in twenty-four hours after the operation from the constitution being unable to bear the shock which that operation produces." (p. 680.)

ABERNETHY was decidedly averse to immediate amputation, and was accustomed to state his opinion on this point, in his own peculiar manner (a):-" If there is much injury, sloughing will come on, and we must then consider whether the patient can have his limbs saved, or whether amputation is required. And then we are in an awkward predicament; but I have no fear that Surgeons will be in a hurry to cut off limbs; they recollect that people will talk of it, and say, "I wish had been under my Surgeon, he would have saved, or at least endeavoured to save his limb," so that self-interest will make Surgeons attentive as possible to preserve limbs. In Surgery we must do as we would be done by, and then we shall be acquitted at the grand tribunal. I should be very shy of amputating, because I have seen many cases which, though it was said they would not do well, recovered. Ask the old Surgeons, men who have seen much of hospital practice, and they will tell you that what I say is the case. I hold that if there is not much likelihood to inflammation or slough, we ought to give the patient a chance for the salvation of his limb. We have no warrant for lopping off parts of another person's body but for the preservation of the remainder, of the whole. * * * I am averse to sudden amputations, for there is a shock already imparted to the constitution by the accident, and another is given to it by the operation, and they often die of the amputation itself; but even if not, at any rate we have a tremendous story, the muscles retract, the bone sticks out and exfoliates, and the case is a discredit to you. There have been numbers of cases of compound fracture since I have been in this (St. Bartholomew's) Hospital, but they have all done well, except where amputation has been performed, not a single case had a good stump, and many died. Two men, however, who had their limbs broken did well. *** It appears that in amputations those below the knee do worst, those in the thigh do better, and those of the arm best. Indeed I have no objection to amputating a lacerated hand or crushed elbow."

Such being the views of our most celebrated Surgeons, it must be allowed that it is no easy matter to lay down rules upon the important question under consideration, which cannot, on account of the improvement in the dietetic part of the practice of Surgery, if it may be so called, and to which, (although a most important part of the treatment,) till within the last few years, comparatively little attention had been paid, accord entirely

with either teacher.

(a) MS. Lectures on Surgery.