The principal points to be considered in forming a determination on the necessity, for no other reason can be admitted, of immediate amputation in compound fracture, are:1st, the nature and extent of the injury: 2ndly, the present condition of the patient, and his capability of bearing immediately the second severe shock of amputation: 3rdly, the consequences immediate and remote of compound fracture: 4thly, the advantage hoped for, by the immediate removal of the injured parts, in preference to the attempts at saving them.

1st. Of the nature and extent of the injury.—In examining a wound of the soft parts, the condition of the skin is to be especially looked to. If the wound in the skin be small, and the surrounding parts not much bruised, it is favourable; but if the wound be large and torn, if the skin be much stripped and accompanied with much bruising, it is unfavourable. If the bone do not protrude much, often, indeed, it does not protrude at all, and if it be not so tightly girt by the skin as to prevent its drawing back into its natural place, so much the better; but if it stick out considerably, and if it be so tightly grasped by the skin that it can only be drawn back with great difficulty, or not at all without dividing the tight skin, and not always then, so much the worse: but if the wound be cleanly cut, and do not oppose the return of the bone, I do not think it of very material consequence whether an inch of bone, more or less, be protruded. Thus far is ascertained with little or no interference with the injured part. But the next thing to be thought about is the depth of the wound, and the injury of the tissues contained within it. This is one of the most important parts of the point under consideration, and upon the proper conduct of which the patient's safety, and the probable success of any attempt to save the limb, will mainly depend. If meddlesome midwifery be most justly eschewed, meddlesome Surgery should be most utterly abhorred. The thrusting in of fingers, and poking about, for no other term is applicable, under the pretence of examining the depth of the wound and the condition of the fracture, is most improper, and ought most carefully to be refrained from. It matters not whether a wound be more or less deep; and if the Surgeon recollect the size of the bone and its natural relations to the soft parts, he can pretty well decide what the extent of the wound is beneath, and by a little gentle passing of the fingers over the skin in the neighbourhood of the wound, so that he inflicts scarcely any pain, he will be able to ascertain whether the fracture be comminuted or broken into many pieces; and he can do no more if he thrust his finger in and grope about, except that he will put his patient to much unnecessary pain, and increase his danger by disturbing the injured parts still more than already, and thus set up still more irritation, instead of endeavouring to soothe.

The proceedings of a Surgeon on such occasions, more, perhaps, than any other, show his greater or less knowledge of the principles of his profession. He may be an excellent operator, but unless he pay the most strict attention to points of practice like this, which are often too lightly considered, and risk the patient's well-doing, he is no Surgeon; and should have no credit for the well performance of an operation, the necessity for which has been caused by his own improper conduct at the onset of the case. He should recollect that, as has been often said, operations are the opprobria of Surgery, and should never be desired nor performed but when all other means have failed. These views were strongly impressed on my mind when a student, by the precepts and practice of my dear master, the younger CLINE, whose early death deprived our profession of a most highly-gifted member, and those who enjoyed his society of an amiable and kind-hearted friend. I gratefully acknowledge his able and continued professional advice and guidance in the early part of my career, and deeply grieve that he was not longer spared to increase the reputation of his distinguished family name, and to add to the high character of English Surgery.

If there be much tearing of the muscles and tendons, or of the tendinous covering of the limb, either or all of which are commonly seen by gently sponging the wound, there is great danger of trismus or tetanus, and amputation should be forthwith performed. The flow of blood from the wound, and the probability of a wounded artery, must enter into the consideration of the nature of the wound. Very frequently there is considerable loss of blood, but it must not be supposed that this always comes from an artery, or that even if it do, that the vessel needs tying. More commonly the bleeding is certainly only from the small muscular branches, and soon ceases. But it may and does occasionally happen that a large artery in the leg or fore-arm is wounded, pricked by the broken end of the bone or partially torn, in either of which cases it will continue to bleed; or it may, as I believe, be torn through, and, retracting, be plugged up by a clot in its mouth whilst the patient is faint, and at the same time compressed by the coagulation of the effused blood in its neighbourhood, and thus a hæmorrhage, violent at first, ceases spontaneously, without any very apparent cause. Often, though there has not been much bleeding before the frac

tured bone has been returned, yet almost immediately after a free oozing, or perhaps a stream of fluid will continue to escape for many hours, and only gradually subside after two or three days. This, however, must not be mistaken for blood, as by careful inspec tion it will be found only the serum escaping from the blood which has clotted below. But should it be undoubted, that the fluid is arterial blood, and if it flow in sufficient quantity, that after a few hours the circulation show itself considerably weakened, and the patient's condition be much depressed, then it is an unfavourable sign, and as I think, and have already mentioned, amputation should be performed in preference to disturbing the wound in search of the wounded vessel, which is often far distant from the part where the blood seems to come up, for the purpose of tying it, or in prefer ence to cutting on the vessel and taking it up above the wound, because it will often bleed from the lower end, more or less readily, by the supply furnished from the anastomosing vessels, and because by cutting off the supply of blood, mortification of the parts below the ligature is very likely to follow, and require amputation when the pr tient is less able to bear it. For these reasons, in undoubted and free arterial bleedin I prefer immediate amputation.

2ndly. Of the present condition of the patient, and his capability of bearing in diately the second severe shock of an amputation.-The condition of a patient after com pound fracture depends partly on his constitutional power, and partly on the severity the injury. Much that has been already mentioned, (par. 335, note 3,) in treating d the shock in gun-shot wounds, is applicable here. Some persons will suffer a very severe compound fracture and be scarcely at all knocked down by it, whilst others with a comparatively slight one, will seem to sink without possibility of restoration, or will only revive with great attention and management after many hours. In the former case, if the Surgeon thought immediate amputation requisite, there would be no objection to its performance; but in the latter, even though the injury were very severe and accom panied with bleeding which could only be arrested by pressure on the great arterial trunk of the limb, the operation would, without doubt, destroy the patient during its per formance, of which I have seen more than one or two examples. We must therefore be guided by circumstances; if the patient be healthy, and heart-whole, and if the pulse be good, the operation may be performed at once. But if he be delicate, and half senseless, if he be very faint and the pulse very languid, or it may be scarcely percep tible and intermitting, if there be yawning and sighing, restlessness with much jactitation or throwing the arms about, and occasional convulsions, and if there be vomiting, which, however, sometimes though not always acts as a re-excitant by sending blood to the brain, of which it is in great need, then we must wait till, by the cautious adminis tration of warm water and brandy, by presenting strong liquor of ammonia to the nostrils, by fauning and bathing the face with vinegar, at the same time that warmth is applied to the feet, hands, and arm-pits, reaction is brought about and kept up for a few hours; for occasionally it happens, that though there may be a seeming revival for an hour or two, all at once the powers sink and the patient dies.

It must not be supposed that by the expression immediate amputation it is meant that a limb should be cut off directly after the receipt of the injury. In general practice the Surgeon rarely sees the patient till some time has elapsed, and except in hospital practice, it also requires still more time to make the necessary arrangements; at the very earliest, therefore, it usually happens that the operation cannot be performed till four or five hours after the accident, which is ample time, except in cases of extreme sinking, for the patient to recover himself, and screw up his courage to the sticking place; but earlier than this time I should not be inclined to operate, and if the shock be very great, it will often be necessary to wait for twelve or twenty hours, according to circumstances, before it will be either prudent or safe to amputate.

When, as happens in very rare cases, that the amputation of two limbs is neces sary, it is a point of great difficulty to determine what course is best to pursue. Cases have occurred in which both limbs have been immediately removed, one directly after the other, or one immediately, and the other some time after, and the patients have done well; whilst, on the other hand, these practices have been adopted and the patients lost, almost immediately after the operation or operations. These cases are beset with extreme danger, and it is next to impossible to give any positive directions on the subject, beyond employing the most careful attention to the patient's constitutional powers, before proceeding with one or other mode of practice. But it may be presumed, if after the first operation the patient's powers seem declining, that the second opera tion would be deferred. Whilst on the contrary, if he bore the first operation well, i would be encouragement to perform the second immediately, so as to put him in the best condition possible.

3rdly. Of the consequences, immediate and remote, of compound fracture.—The immediate consequences of compound fracture, should the shock of the accident not be so great as at once to check all attempt at reparation, and destroy the patient in a very few hours, make their appearance sometimes within twelve hours, but more frequently about the third or fourth day, assuming the character of

Sympathetic, symptomatic, or irritative fever; or, as JOHN HUNTER chooses to call it, "sympathetic inflammatory fever," of which ABERNETHY has given a concise but excellent description. A person," says this able teacher (a), “has a compound fracture; here is local injury acting on a sound constitution. He does not sleep, and if he doze, he soon wakes up in agitation and alarm; the pupil of the eye is contracted, that organ becoming more susceptible; his pulse is more strong, firm, or hard, more full and frequent than usual; there is diminution of the secretions, the skin is dry and hot, the urine scanty and high-coloured, the tongue dry and white, and the digestive organs disordered, and disposed to costiveness; there is much thirst; no appetite, or if the patient be inclined to food, it is for the vegetable acids. If the person be bled, the blood is slow in coagulating, the surface of the clot contracts; in short, it has an inflammatory appearance. If any vital part is affected, there is more disturbance of the system; the pulse is more hurried and not of the same strength as before; but the general symptoms are the same. No explanation of these symptoms is required; there is excitement of the nervous system, with increased action of the sanguiferous, accompanied with diminished secretions and disturbed digestive organs. But with these symptoms there will be no sinking or depression of strength, no consciousness of debility. Sometimes this fever is preceded by shivering or sickness, both probably arising from the state of the stomach; but a healthy person will often be affected with neither. There appears to be in some persons a susceptibility for this fever, so that the slightest accident will occasion it; whilst others, on the contrary, show much less susceptibility under more extensive injuries."

"These symptoms," to use JOHN HUNTER'S expression, "are the sympathies of the constitution with a local disease or injury, and will vary according to a vast variety of circumstances. They will vary according to the nature of the constitution, which admits of great differences, and which will include different ages; they will vary according to the nature of the part in a state of disease, which also admits of great differences; they will vary according to the quantity of mischief done, as well as the manner of its being done; that is, whether so as to call forth immediate inflammation, as a wound; or not so immediate, as from having only killed a part; they will vary according to the situation of similar parts in the body, and they will vary according to the stage of the disease." (p. 396.)

HUNTER further observes :-"The constitutional symptoms arising from a local complaint may be divided into three as to time; the immediate, indefinite, and remote. Of the first, or immediate, there appears to be but one; of the second there is probably a variety, at least appearing in very different forms and at very different periods, in respect of the original cause; of the remote there is probably only one. The immediate I shall reckon that which is called the symptomatic fever; and what I shall reckon the second are nervous affections, as spasms, both temporary and permanent, and delirium. Whether the symptomatic fever, the spasms, or the delirium come first, is not certain, for often all concur or occur at the same time; but as the sympathetic fever is the most constant, and is more an universal principle, it is to be reckoned the first. And the third, which I have called remote, is what is understood by the hectic; to which may be added the symptoms of dissolution, which is the last stage of all, and may be the consequence of the above or any other disease." (p. 406.)

In symptomatic fever, which is now under consideration. "the symptoms," still using HUNTER'S words, " continue more or less according to the degree of the injury, the nature and situation of parts, and the constitution; but as they arise from a local cause, which subsides, they of course subside also. *** The subsiding of these symptoms is the cure; and where they are simply the effects of violence the fever cures itself, therefore the only thing necessary to lessen its violence." (p. 409.)

The sympathetic fever in compound fracture almost invariably begins to subside as suppuration commences in the wound, and gradually disappears as healthy suppuration is established; hence it has been generally considered as "necessary for the operation of suppuration," an opinion which JOHN HUNTER very stoutly, though not very satisfactorily, combats, for it cannot be denied that, with scarcely an exception, when suppura

(a) MS. Lectures. I have preferred this account to HUNTER'S on account of its brevity. But the reader will do well to study carefully that writer's

observations on the effects of the suppurative inflammation on the constitution, (p. 326,) in his work on inflammation.-J. F. S.

tion is set up the febrile excitement diminishes, and hence it may be fairly inferred that it plays an important part in setting up that process; and simultaneously with the latter, generally, commences granulation, by which the reparation of the injury, as well of the bone as of the soft parts, is effected. And thus, under the most favourable circumstances, are most compound fractures cured.

But oftentimes these injuries do not thus terminate; there is no subsidence of the sympathetic fever, no appearance of suppuration, the constitutional excitement increases, and the "secondary constitutional, or nervous symptoms," as JOHN HUNTER calls them, come on, oftentimes under peculiarly irritable states of constitution, within a very few hours after the accident, and "concur, or occur at the same time," as he justly observes almost with the onset of the sympathetic fever, so as it would seem really to be one of its conditions. And of these nervous symptoms the delirium is one of the most striking, and "appears to arise from nervous affection of the brain or sensorium producing a sympathy of the action of the brain with the materia vitæ of the parts; not sensation, as a head-ache, but action, producing ideas without the exciting impression, and therefore delusive." (p. 410.) Under these circumstances there is for a time also great vascular excitement, which may endure for four, five, or a few days longer, and is then followed by a change, frequently very rapid, to symptoms of a typhoid character, the powers of the constitution having been exhausted by the previous excitement, and the patient more or less quickly sinks and dies. Sometimes the nervous symptoms assume the tetanic form, which more especially happens when there has been much laceration; and I think I have not less frequently noticed that the tetanus makes its appearance without any very violent sympathetic fever, and occasionally when the case has appeared to be promising favourably.

When sympathetic fever have once set in, either without or with these nervous affeetions, there is no choice left but to wait till its subsidence; no amputation can then performed without every probability of hastening the patient's dissolution. The irritating cause must, therefore, still remain, and the contest between it and the constitu tion is kept up till one or other be vanquished. Too often, however, in these cases is it seen that though the constitution have power to struggle through the sympathetic fever, yet has it only sufficient strength to carry on to the remote or hectic period, when with much diminished powers the same course is again to run, with the additional drain of profuse suppuration,

Hectic fever," when a consequence of a local disease, has commonly been preceded," says JOHN HUNTER, "by the first process of the former, viz., by inflammation and sup puration, but has not been able to accomplish granulation and cicatrization, so as to complete the cure. It may be said to be a constitution now become affected with a local disease or irritation, which the constitution is conscious of, and of which it cannot relieve itself, and cannot cure; for while the inflammation lasts, which is only preparatory, and an immediate effect of most injuries, and in parts which can only affect the consti tution, so as to call up its powers, there can be no hectic. (p. 496.) Hectic may be said to be a slow mode of dissolution; the general symptoms are those of a low or slow fever, attended with weakness, but more with the action of weakness than real weakness; for, upon the removal of the hectic cause, the action of strength is immediately produced, as well as every natural function, however much it was decreased before. The particular symptoms are debility; a small, quick and sharp pulse; the blood forsaking the skin; loss of appetite; often rejection of all aliment by the stomach; wasting; a great readiness to be thrown into sweats; sweating spontaneously when in bed; frequently a const tutional purging; the water clear." (p. 499.)

Such is the condition into which the patient with compound fracture frequently falls, sometimes sooner, sometimes later after the establishment of suppuration, and of which it may be mostly truly said with HUNTER :-" We have as yet, I am afraid, no cure for any of the consequences above related; I believe that depends on the cure of the cause, viz., the local complaint, or in its removal; the effects I fear are not to be cured." (p. 503.) But even under these discouraging circumstances, hope is not to be lost; and whoever has had much experience will agree with this great Surgeon in the course to be pursued, and the results which often follow. "When the hectic," says he, "arises from local diseases, in such parts as the constitution can bear a removal of, then the diseased part should be removed, viz., when it arises from some incurable disease in an extremity, and although all the symptoms above described should have already taken place we shall find, that upon a removal of the limb the symptoms will abate almost immediately. I have known a hectic pulse at 120 sink to 90 in a few hours upon the removal of the hectic cause. I have known persons sleep sound the first night without an opiate who have not slept tolerably for weeks before. I have known cold sweats

stop immediately as well as those called colliquative. I have known a purging immediately stop upon the removal of the hectic cause, and the urine drop its sediment. It is possible too that the pain in the operation and the sympathetic affection of the constitution may assist in these salutary effects. It is an action diametrically opposite to the hectic, and may be said to bring back the constitution to a natural state." (p. 504.)

4thly. Of the advantage hoped for by the immediate removal of the injured parts in preference to the attempt at saving them.-From the amputation of a limb which has suffered compound fracture, we hope by removing an irritating cause, and by bringing about the adhesive instead of the ulcerative process, or in other words by making a clean cut wound, in place of a torn and bruised wound, and so causing union by adhesion, instead of by suppuration, to prevent or at any rate to lessen the irritative fever, which is always expected, and which indeed is only indicative of the constitutional excitement necessary for the repair of such injuries. Such was JOHN HUNTER'S opinion, for he observes:-"Simple violence, even with the loss of a part, is not of such consequence as we should at first imagine; for, in consequence of the loss of a limb, if the parts are allowed to heal by the first intention, the constitution is but little affected; it is, therefore, violence with loss of substance, and which is to produce inflammation and suppuration, that gives rise to the constitutional symptoms, and when these commence, or more probably when the part sets about these operations, the constitution becomes affected. It is more the new disposition in the parts than the quantity of inflammatory action in them by which the constitution is affected; for we shall see that upon the simple commencement of the suppurative disposition, before it takes place, rigors, &c., come on." (p. 400-1.) The object of immediate amputation is then to prevent, as far as possible, the constitution acquiring this suppurative disposition, and the accompanying irritative fever, and to encourage the quieting of the constitutional excitement necessary for the reparation of the injury, by converting a wound, which would, in course of its cure, greatly disturb the vital forces, into one which might be expected to proceed to union with comparatively little effort on the part of the constitution. It must be admitted, that sometimes after early amputation, the adhesive process will not take place, but the whole surface of the stump becomes sloughy, and the sympathetic fever runs high, and even destroys the patient. I do not, however, think the possibility of such occurrence an objection to the early operation, as it is probable, that the same kind of constitution producing these effects, would have equally produced them, had no operation been performed. So that in reality, the patient's condition is not, under any circumstances, rendered worse, and if he scramble through, is better, inasmuch as the operation having been performed, no repetition of violent shock to the constitution is called for in way of amputation. I have myself so frequently and successfully pursued the practice of immediate amputation, and have seen it practised in our hospital by my colleagues with advantage, that I have no doubt of its propriety. One important point, however, in the constitutional treatment must not be overlooked, as upon that I consider our success has mainly depended, viz., as far as possible to preserve the patients' ordinary mode of living, especially if they have been accustomed to large quantities of beer or spirits; for if these be withdrawn, or even not given in such quantity, as by some would be considered, highly improper, the patient will most assuredly sink. On this point, therefore, we must cautiously feel our way, and give either beer or spirits, or both, as the patient may seem to require, and may be able to bear. It is also right to observe that the constitutional excitement, whether amputation be or be not performed, is most to be feared in injury of the lower limbs. Whilst on the contrary, early amputations of the upper limbs almost invariably recover without the least drawback.-J. F. S.]

591. In the treatment of fractures, especially of those which are compound, and of the lower limbs, the use of a suspensory apparatus has been recommended, in which the broken limb lies entirely free, and the application of proper remedies to the wounded part, and the motions of the limb are possible. Greatly convenient, however, as this apparatus is to the patient, it can only be used in transverse fractures in which the contraction of the muscles is not so very much opposed to it. The swing, however, connected with continued extension affords great advantages. [There are two modes of treating compound fracture, which, from repeatedly pursuing, I am convinced are, generally, the best of all that have been proposed. The first is the bracket-splint used by ABERNETHY, which can be applied on any limb; and the second is the swing-box, or slings, which can only be used for the fore-arm and leg;