Chapter 17 - Surgical Diseases
Modern Surgery
Suppuration and Abscess
Ulceration and Ulcers
Malignant Pustule
Burns and Scalds
Frost Bite
Septic Wounds
Incised Wounds
Rules for Examining and Dressing Wounds
Antiseptic Dressings
Way Wounds Unite
Punctured Wounds
Lacerated Wounds
Granulation and Scarification
Gunshot Wounds
Poisoned Wounds
Way Broken Bones Unite
Different Diseases of Bones
White Swelling
Stiff Joint
Water in the Scrotum
Blood in the Scrotum
Varicose Veins
Deformities and Irritations of the Spine
Wry Neck
Foreign Bodies in the Eye
Inflammation of the Edge of the Eyelids
Disorder of the Lashes
Chronic Inflammation of the Lachrymal Sac
Inflammation of the Cornea
Inflammation of the Iris
Weakness of Sight
Imperfect Vision
Short and Long Sight
Affections of the Ear
Inflammation of the Meatus
Wax in the Ear
Inflammation of the Tympanum, Deafness
Bleeding from the Nose
Ingrowing Toe Nail
Chafing and Excoriation
Foreign Substances
Bleeding from Wounds
Proud Flesh
Compression of Arteries to Stop the Flow of Blood
Care of the Teeth
Rotting of the Teeth
Filling Teeth
The First Teeth
Cleaning the Teeth
Ulcer of the Stomach
Riggs' Disease

17.25 Way Broken Bones Unite

The Way in which Broken Bones Unite.

THE union of broken bones is much slower than that of severed flesh. The ends of the bone being kept steadily together, they soon become surrounded by a swelling of the soft parts, which change to a sort of osseous substance, making a kind of bony hoop, to act as a splint or support, nature not being willing to trust the surgeon to keep the fragments exactly in their place. This is called a provisional callus, because it only has a temporary use.
This First Stage lasts about ten days. At the end of this time, a spongy substance appears between the ends of the bone. This sub. stance is not bone, but in the swelling around the fracture specks of bone begin to be deposited; the fibrin here poured out becoming first cartilage, and then receiving into itself phosphate of lime, it be. comes bone. A similar work is going on within, in the part called the medullary membrane.
This Second Stage lasts from the tenth to the twenty. fifth day.
Then begins the Third Stage, which goes to the end of the sixth or eighth week. During this period the external swelling, and the internal medullary membrane, become completely ossified and firm; though the ends of the bone are not yet grown together.
The Fourth Stage goes to the end of the fifth or sixth month. During this time, the external swelling, or provisional callus, becomes covered with a periosteum, and the ends of the bones themselves are fastened together by a bony union.
The Fifth Stage extends from the fifth or sixth to the twelfth month.
During this time, the ends of the bone become grown together so strongly that the bony ring, or provisional callus, is no longer wanted, and it becomes absorbed, and disappears; in other words, having no further use for it, Nature takes off her splint. The place where the fracture was is now as strong as any other part.

Union in Compound Fractures.

THE union of compound fractures takes place in a different way from that of a simple fracture, just described. The bones remain disunited several weeks, and there is no provisional callus formed; but after some weeks the ends of the bone soften and granulate, and these granulations are gradually changed into bone.
In nothing have the benefits of antisepsis been shown so vividly as in the treatment of compound fractures. Twenty years ago a large percentage of all compound fractures either suppurated or caused the death of the patient; but now suppuration and high mortality are not seen. The wound is treated exactly like any other wound, on aseptic principles, the bones being held in place as usual. Union thus results without suppuration, and a cure is completed in one half the time, with over fifty per cent less mortality than was the case previous to the introduction of aseptic and antiseptic surgery.
The first thing in event of a compound fracture is to render the parts aseptic as soon and as completely as possible. This may be done by a thorough scrubbing with tincture green soap and water for five or ten minutes, and then, after washing off the soap with alcohol, to thoroughly scrub the skin adjoining the wound with some one of the disinfectant mentioned under the heading of Sepsis and Asepsis; as, for instance, corrosive sublimate, one par~ to two thousand parts of water. The wound is to be dressed precisely as any wound, and is to be so arranged that access may be had to it for future dressings. When skin and flesh are much torn they may be sewn together with a needle and thread or silk which has been boiled five minutes. The stitches are to be removed from the fourth to seventh day. The bones are to be approximated just as in simple fractures, and splints applied.
Formerly the mortality of compound fractures was very high, owing to the invasion of the tissues by germ life, but since the introduction of antiseptic measures in surgery, the death rate has fallen so markedly as to be a matter of great pride to surgeons and the world at large.
In cases where the wound does not allow of good cooptation, and much mangling of the tissues has occurred~ it may be well not to suture the parts, but to dress them with some antiseptic gauze drainage, and do them up like an open wound,

Time Required for Uniting Different Bones.

FRACTURES of the arms unite sooner than those of the legs.
The ribs and collar bone unite with tolerable firmness in about a month; those of the arm in six weeks; of the thigh and leg in eight weeks. I only mean the firmness derived from the provisional callus.
A broken bone will unite much sooner in a healthy person than in an unhealthy one; much sooner in a young than in an old person.
As a general rule, the apparatus should be kept on thirty days in the case of children; forty days in that of adults; and much longer in that of aged persons.

False Joint.

THE union of a broken bone is sometimes prevented by a frequent moving of the limb. The ends of the bone, having failed to grow together, will sometimes become rounded and smoothed, uniting only by a kind of ligament, and acquire the habit of sliding upon each other, and thus form what is called a false or artificial joint, the limb being permanently capable of bending to some extent, at the place of the fracture.

Fractures of the Skull.

These are always dangerous in their nature, and the aid to be derived from surgery is much less than in other fractures. If a fracture of the skull produce deep sleep and snoring, and the patient does not show any symptoms of pain when pinched, etc., we are to infer that a piece of bone is pressed down upon or into the brain.
In this case, if the position of the blow be known, a cut is to be made through the skin, two or three inches long, down to the bone. If arteries bleed, they must be taken bold of with a pair of forceps, and tied with a silk thread, the ends of which are to be cut off. The bone being well exposed by one or two incisions, the piece which is pressed down upon the brain is to be raised with a chisel, or some similar instrument, to a level with the other bones. The surface must then be cleansed antiseptically, the hair around shaved off, the skin brought together, and the cut edges reunited by sticking plaster.
When the inflammation appears, twenty four hours after, it is to be kept down by doses of from five to ten drops of tincture of veratrum viride, given every one or two hours.

Fractures of the Bones of the Nose.

INJURIES ' of this kind may generally be rectified by passing a strong probe up the nostril, and pressing out the bones to their natural place, at the same time using the fingers on the outside to prevent their being pressed out too far. Inflammation must be kept down by cloths wet in cold water and Wd on, and by light diet.

Fracture of the Lower Jaw.

THIS usually takes place near the chin. It may occur also near the angles of the jaw. It may be simple or compound, and is known by the pain, the swelling, the inability to move the jaw, the indentation felt by the finger, the irregularity of the teeth, and the grating sensation felt while moving the jaw with the hand placed on the back fragment.

Treatment. Let one or both thumbs be introduced into the mouth. With these, keep the back part of the jaw stationary, and pull forward the fore part with the fingers on the outside. In this way the fracture can soon be put right. This done, shut the mouth firmly, and place a thick compress of lint over the broken part; over this put a piece of pasteboard, wetted so as to bend easily to the parts, and over this a strong bandage of muslin, two and a half inches wide, with a small bag to fit and hold the chin; all which is represented in Fig. 159.
For a fortnight the patient must feed on gruel, broth, arrow root and milk, that the jaw may not be displaced by chewing.

Fracture of the Collar Bone, or Clavicle.
This accident generally occurs about the middle of the bone, and is generally caused by falls on the arm and shoulder.

Symptoms. Pain and tenderness at the place of the injury, and inability to lift the arm; a small bunch or prominence at the point of the fracture; the distance from the point of the shoulder to the breastbone shorter than on the other side; and the dropping downwards, forwards, and inwards of the shoulder. To make the case sure, compare the two bones, and see whether they agree.

Treatment. Place the knee between the shoulder blades, and grasping the round ends of the shoulders with the two hands, draw them gently back till the ends of the bone come to their proper place; or place the elbow of the patient close to the body, and a little forward, and then push it upward.
I To retain the shoulders in this upward and backward position for some weeks, pass a flannel bandage, four inches wide, around the front of one shoulder, under the arm pit, across the back, over the opposite shoulder, under the other arm pit, and again across the back, in the form of the figure oo. To prevent the bandage from cutting the skin, put pads under the arms. (Figs. 160 and 161.)

Fracture of the Shoulder Blade.

When this accident happens, the body of the bone is generally broken across by some great direct violence. In a few instances, the end next to the collar bone is broken.

Symptoms. Great pain in moving the shoulder, and the grating sensation which may be felt by placing one hand on the upper end of the bone, and moving the lower portion with the other.

Treatment. A bandage must be passed round the chest, and a few turns be made around the upper arm, so as to fasten it to the side, and prevent all motion. Purging, low diet, and the tincture of veratrum viride will be required to keep down inflammation.

Fracture of the Acromion, or the end of the scapula which unites with the collar bone, may be known by the flattening of the shoulder, the broken part being drawn down by the action of the deltoid muscle.

Treatment. It must be supported by the same bandages as are used for a fracture of the collar bone; and the elbow must be well raised, so that the head of the upper arm bone may be lifted against the upper portion of the scapula, and act as a prop to keep it in place. No pad should be put in the arm pit, for this would push the broken part too much outward. Gentle motion of the arm may be begun about the sixth week..

Fracture of the Upper Arm Bone.

THE, bone of the upper arm is most frequently broken near the centre, though it may be fractured near the ends. It may be known by taking hold of the arm above and below the suspected fracture, and attempting to move the ends of the upper and lower fragments upon each other. If '0 "ere be a fracture, the grating of the broken ends against each other will either be heard or felt. The arm will also be bent and helpless; and if the ends of the bone be slipped by each other. it will be shortened.

Treatment. Let a powerful man take hold of the arm and pull gently and gradually, but with considerable force, till the arm is brought to its natural length, another man taking hold of the body of the patient, and pulling in an opposite direction. In the mean time, the surgeon is to adjust the ends of the bone to each other, and apply a bandage, but not very tightly, from the elbow to the shoulder, and over this, four splints, with pads under them; one in front, reaching from the shoulder to the bend of the elbow, with a few turns of the bandage over it; another behind, reaching from the shoulder to the point of the elbow, with a few turns of the bandage around it also; another on the inside, extending from the arm pit to the inner projection of the bone at the elbow, also secured by a few turns of the bandage; and the fourth one on the outside, reaching from the shoulder to the outside knob at the elbow. The whole is now to be secured either by a bandage or tape. (Fig. 162.) The arm is to be confined to the side, and the hand and fore arm placed in a sling. In from seven to ten days, the dressing should be taken off to see if all is right.

Fracture of the Elbow.
THIS may be known by the patient being able to bend the arm, but not straighten it, and by the grating which may be heard or felt when the arm is moved back and forth by the operator, and also by the severe pain felt in the fractured part.

Treatment. First apply leeches and evaporating lotions to reduce the inflammation. When this is effected, straighten the limb, and apply a bandage snugly from the fingers to the elbow. The broken end of the bone must now be brought to its place, and the bandage continued over it, and for a few inches above it. Secure it here, and bring it back, carrying it above and below the elbow for several times; and then extend it up to the shoulder. A splint must now be applied to the inner side of the arm to prevent its being bent, extending from the band nearly to the shoulder, and another, of similar shape, to the outside. The joint should be kept quiet for four or five weeks, during which time the splints may be taken off three or four times, to see if there is any chafing of the skin or any disturbance of the bones.

Fractures between the Elbow and Wrist.
THE part of the arm between the elbow and wrist, called the for&. am, has two bones, one extending from the elbow on the inside to the wrist at the root of the little finger, called the ulna, and the other on the side next the thumb, a shorter and a smaller bone, and called the radius.
When both these bones are broken at the same time, the fracture may be easily discovered; when only one, the sound bone keeps the other in place, and the injury is not so easily made out.

Treatment. Relax the muscles by bending the elbow, and then, by extension and counter extension, put the ends of the bones in proper place; then place two splints, thickly padded in the centre, one upon the front of the hand and forearm, and the other upon the back of the band and forearm, the palm of the band being turned, not towards the chest, but downwards. They are to be covered with a bandage from the fingers to the elbow. The whole arm and hand should be placed in a sling, and remain in this position four or five weeks.

Fractures of the Wrist, Hands, and Fingers.
THE, setting of fractured bones in these parts is to be done by extension and counter extension, as in the case of other bones.
If the wrist be broken, a splint should be applied in front and one behind, and a bandage bound tightly from the hand half way to the elbow.
In fracture of the bones of the hand, a pad or compress must be put upon the palm of the hand, and a splint placed over this, with a bandage extending from the wrist to near the ends of the fingers.
If one finger only be broken, apply narrow pasteboard splints on four sides, and cover them with a narrow bandage; and then bandage the whole hand.
In all these fractures, place the hand in a sling. About three weeks will be required for the bones to unite properly, and several weeks more for the parts to acquire their natural usefulness.

Fracture of the Ribs.
This accident occurs either by blows, or by being crushed between two opposing forces. One, two, or more ribs may be broken at a time, according to circumstances.

Symptoms. A fixed, piercing pain, made worse by breathing, coughing, or any other motion, and also a grating sensation during the taking of a long breath, the hand being laid upon the injured part at the time.

Treatment. The ribs are to be held steadily in their place by pressure. To effect this, request the patient to draw in a long breath, and hold it. While the ribs are swelled out in this way, and the broken ends are thus brought to their proper place, pass a woolen bandage, five or six inches wide, several times tightly around the chest, from the arm pits to the pit of the stomach. This will confine the muscles of the chest, and the breathing will have to be done with the muscles of the belly, and the ribs will thus be kept still, and have a chance to grow together.
If the pleura be wounded, and inflammation follow from this or other cause, the patient must be confined in bed, kept on a low diet, and his pulse be kept down by tincture of veratrum viride. The bowels should be emptied by recipes 18, or 10, or 27, or 41, both to subdue inflammation, and to give the diaphragm a chance to drop down freely.

Fracture of the Breast Bone.

Symptoms. The injured part is frequently either sunk down or raised up; there is difficult breathing, cough, spitting of blood, pain, inability to lie on the back, and a grating noise caused by breathing.

Treatment. The same as that for broken ribs. Should the broken part be pressed down upon the lung, so as to cause serious difficulty of breathing, an incision may be made, and the broken piece raised up with a chisel, or stiff case knife, or some similar instrument.

Fracture of the Haunch=Bones, or Pelvis.

THESE, fractures are dangerous' being often connected with some other injury, as tearing of the bladder, lower bowel, or great veins or arteries. Fortunately, however, they are only caused by some great violence, and do not often occur.

Treatment. Place the patient in the easiest possible position, and keep him entirely at rest. Generally a catheter should be kept in the bladder, that the water may pass off easily ; and the whole Mps should be bound round tightly with a flannel or calico bandage, and made as firm and fixed as possible, to keep the broken bones together. The most perfect rest must be ordered for six weeks or two months.
If the extreme lower end of the sacrum, the os coecygis (Figs. 8 3) be broken, the separated portion must be put in its place by introducing the finger into the rectum; and the bowels must be kept loose by gentle physic, that the broken bone may not be pushed from its place by the pressure against it of hard stools.

Fracture of the Thigh-Bone.
The points where this bone are broken are at its upper portion of, neck, and near its middle. The break at this latter place may be straight across, or oblique, partially lengthwise. When oblique, the point of the bone may stick into one of the large muscles, and be made fast by it.

Symptoms. The fracture in the middle of the bone, if it be transverse, may be known by some Swelling or irregularity discovered by running the hand along the thigh, and grasping it here and there; and if it be oblique, the ends of the bone will be drawn by each other, and the limb will be shortened.

Treatment. Place the patient on his back, and let two strong men use extension, one taking hold near the hip, and the other grasping the limb at the knee and pulling steadily and strongly till the limb is of the proper length, and the ends of the bone are in their place. The man who takes hold of the upper end of the limb may hold it more firmly and with less fatigue by passing a folded sheet around the groin.
The extending force being still continued, the operator is now to apply the splints, which are to be four in number, one in front, reaching from the knee pan to the groin; one behind; one t)n the inside, from the upper part of the thigh to the inside of the knee; and a fourth one, about four inches wide, reaching from the arm pit to a distance of two or three inches beyond the sole of the foot. Cotton must be placed under these splints to prevent their injuring the skin, and they must be of a width to nearly, but not quite, touch each other. These being properly adjusted, and the extension still continued if the fracture is oblique, the bandage is now to be firmly applied from the foot to the upper part of the thigh, and then passed a few times around the body. This fracture is sometimes treated without splints, as represented in (Fig. 163). during which time the patient will need to lie upon his back. But the dressing may now and then be taken off and put on again.

Sometimes only a single long splint is used; sometimes no splint; in still other cases, four splints, the outside one being short, and the limb resting on a double inclined plane,

Fracture at the Neck of the Bone. When the bone is broken at the neck, close to the hip joint, the injury is known by the knee and foot turning outward, and by the limb being an inch or two shorter than the other (Fig. 164). This is an accident to which old persons are particularly liable. When the bone is broken here, it seldom grows together again. The union which is formed is generally by a ligament

Treatment. This requires a very long splint, reaching from the armpit to beyond the sole of the foot, and bound firmly with a bandage, as in fracture in the middle of the thigh. The limb should be kept extended, and the injured one must be bound to the other by a bandage, keeping both legs straight and immovable. A broad leather strap, bound firmly round the hips and thighs will be serviceable.
Two or three months will be required for the injury to become repaired, so that the limb may be used. The patient must get up cautiously, and be careful not to use the limb much so long as pain is produced.

Fracture of the Knee Pan.
THE knee pan (patella) may be broken up an d down, or across; the latter fracture is the more common. It is a troublesome fracture, and is very apt to leave a stiff knee.

Symptoms. Men the bone is broken across, the patient cannot stand upon the limb; the leg may be flexed or crooked, but cannot be straightened, the upper part of the knee pan is drawn up away from the lower portion, leaving a wide gap, into which the fingers nay be laid, at the top and bottom of which the rough edges of the movable bones may be felt.

Treatment. First, reduce the inflammation by applying antiphlogistine. Then straighten the limb, and put a well padded splint behind, to keep the knee motionless; place the patient's body in a half sitting posture, and raise, the foot considerably above a level. Put a bandage over the splint, beginning half way up the thigh, and extending down to the knee pan, and being made very tight just above the broken bone, so that it cannot easily slip under it. The broken bones must now be brought together, and the bandage be passed below and again above the knee several times in the form of a figure 8, to keep the bones from parting.
The bandage, generally, may not be removed for a fortnight. After this period, if everything has gone on well, the limb may be carefully bent a little every day, to avoid a stiff knee.

Fracture of the Bones of the Leg.
THE, leg is that part of the limb between the. knee and ankle. It has two bones; the smaller on the outside, called the fibula; the larger on the inner and front side, called the tibia, or shin bone.
One or both of these may be broken at the same time. If both are broken, it is impossible to walk upon the limb; there is a change in its shape; it may be bent; and the grating of the broken ends of the bones may be felt or heard.

Treatment. First, adjust the bones by means of extension and counter extension, as in other fractures.

Then apply two splints, one on the outside from the knee to the sole of the foot; the other upon the inside. Over these a bandage is to be firmly applied, reaching from the toes to the knee. The leg may rest upon the side or the back, as the comfort of the patient may require. Upon the side is generally the easiest position, with the knee a little bent "Fig. 165).
The dressing may be removed in six or seven days, to see that the bones are in their proper place. Five or six weeks will be required for recovery; and at the end of this time, the dressing may be laid aside. But the patient must use his leg very gradually.
In the treatment of fractures of the shafts of the bones of the lower extremities, three indications should be fulfilled: First, cooptation and fixation of the fragments; second, moderate extension; third, gentle compression and support. Provided these requirements are carried out, it matters little what apparatus may be employed; but that which can be applied with the least disturbance of the fractured bone, and is most comfortable to the feeling of the patient, should be preferred.
The best mode of extension and counter extension now in use is by raising the foot of the bedstead about eight inches, by a block of wood placed under each foreleg. This makes an inclined plane, and the body consequently tends to incline towards the head of the bed; this is the counter extension.
Then extension is made as follows: A strong piece of adhesive plaster, about two and one half inches wide and about three feet long, is applied to the sides of the leg, extending from a little below the knee, leaving a loop under the foot four or five inches long. This is secured firmly in place by a bandage to the whole length of the leg. A piece of cord is fastened to the loop and passed over a pulley, which is fixed to the foot board of the bed. To the other end of this cord is attached a weight. This need not exceed ten or twelve pounds.

In this way we get our counter extension and extension: the body is drawing one way and the weight is pulling the other all the time.
This is a simple and comfortable way of treating fractures of the shafts of the bones of the lower extremities which require extension. It may be applied to the different fractures of the neck of the thigh bone, to fractures of the shaft, and also to fractures in the shafts of the bones of the leg
It is the best and most effectual way of preventing undue shortening that we have in use, and what is of as great importance to the patient, a most comfortable way of keeping the painful limb in the proper shape.
The object of this weight is to cause extension and counteract the pull of the muscles, and paralysis is caused by the weight used in proportion to the size of the patient, his age and muscular development. After two or three weeks use of the weight recommended, namely twelve pounds or so, it is desirable to diminish the weight by degrees until such time as the weight can be dispensed with entirely, which is usually after four or five weeks, and the splints themselves may be allowed to remain three or four weeks longer. In the impacted fracture, which variety occurs when the main part of the broken bone is forced into the lesser fragment, no unusual motion is present. This form of fracture is very common in the aged and it may result in some permanent displacement and lameness, but the best treatment is not to break up the impaction which would be done in a younger patient, as in the aged a fracture after being changed from an impacted to a simple one might not unite readily. The treatment then for this class of cases, especially after sixty or seventy years of age, would be to let the leg lie quietly in bed with heavy oblong bags filled with sand placed on each side of the limb to prevent motion until the bones are set and healed in the new location.

Fractures of the Bones of the Foot.
THESE are to be treated in the same manner with fractures of the hand. They are often attended with much other mischief, as laceration of the flesh, ligaments, etc. Hence, cutting off the foot, or a part of it, is often necessary. Pasteboard splints are frequently used in these fractures. If matter forms, it must be let out by opening the parts.
A useful and simple expedient that may be used in all fractures and, in fact, any troubles of the lower extremities where dressings are needed, is the building of a cradle to prevent the clothes coming in contact with the injured parts.
This may be made by taking three laths or thin strips of wood about an inch wide, one eighth to one fourth inches thick and from two to four feet long, nailing three or four half barrel hoops at right angles to this piece and equal distance from one another, so that when placed on the bed and encircling the leg, the clothes will be kept away and pressure averted. This arrangement is desirable dm* the heat of the summer months.

Compound Fractures.
IN many simple fractures, as, for instance, a fracture in the shaft of the lower leg and in certain selected cases of breaks at the ankle joint, the use of plaster of Paris casts enables the patient to go around somewhat with the use of crutches, when if using the splints it would not be advisable to allow him to leave the bed. This bandage may be made by taking thin meshed cheese cloth, about four inches wide and three or four yards in length, spreading it out on a board and winding the bandage tight after rubbing plaster of Paris on the surface of the cloth. These are then ready for application after being entirely covered by water for two or three minutes or until the bubbles of air cease to rise. After the fracture has been in splints long enough to be sure that all swelling has ceased subsiding or surely will not increase any more, the temporary splints which have been used to hold the parts in position may be removed and a thick dressing of sheet wadding may be wrapped around the limb. Over two or three thicknesses of the wadding the prepared plaster bandage is then rolled. These may be smoothed over and the limb held in proper position until the plaster is set, which usually takes fifteen to twenty minutes. Absolute inability to move the joints and broken bone can now be assured if the plaster has been put on in the proper manner, though care must be taken in the application of this as in any bandage not to stop the circulation, and a pulse must be sought for beyond the bandage, that is, on the side of the bandage farthest away from the heart. These bandages may be left on from two to three weeks if the leg does not become loose inside of that. Then the bandage should be cut down lengthwise from top to bottom with a sharp knife, care being taken not to go through suddenly and injure the leg. The use of cider vinegar will make the plaster cut more easily.
When, in connection with a broken bone, there is a wound of the flesh, which leads to, and communicates with the space between the broken ends of the bone, the whole injury is called a compound fracture. The wound in the flesh may be caused by the same force which breaks the bone, as a bullet from a gun, or a cart wheel, or some machinery in which the limb is entangled. Quite often the flesh wound is caused by one of the ends of the bone being forced through the flesh and skin.
But, however caused, a compound fracture is of a much more serious nature than a simple one; and it is particularly dangerous when a joint is involved. It is more serious above the knee and elbow than below, and more to be dreaded in the lower limbs than in the upper.

Treatment. An attempt should always be made to preserve the limb; it should not be cut off, unless the compound fracture is of the worst kind. But if there be no hope of saving the limb, the amputation should be performed at once, while the constitution is tranquil, and before it has been shocked and injured by suppuration, abscesses, and sepsis, which sometimes follow such grave injuries.
But, suppose it be determined not to cut the limb off, as it generally should be, the first thing is, after the bone is set, to close the wound against all entrance of air, and to cause it to heal by the first intention, that is, without suppuration. To do this, one method is to cover the wound with lint dipped in blood; but the more usual mode is to bring the sides of the wound together, and secure them very carefully by strips of adhesive plaster, in the same way as in common cuts. The bandage should be kept wet with cold water, by squeezing a sponge over it, or by sprinkling cold water upon it as fast as it becomes dry.
It will be necessary, in this case, to keep the bed clothes away from the limb while it is thus wet, which may be done by cutting a barrel hoop in two, and nailing it to two pieces of lath. There should be air circulating under the sheet, that the heat of the inflammation may not keep the limb in a steam bath.
Should the wound heal by the first intention, the danger will soon be over, and the treatment may be the same as for simple fracture. But this, unfortunately, does not always occur.
It occasionally happens, that after three or four days, the patient grows restless, has very short and disturbed sleep, is hot and thirsty, has headache and shivering fits, is more ill towards evening, wanders in his mind, or becomes delirious, and perhaps dies in ten days or a fortnight from the sepsis or blood poisoning that has taken place. If the symptoms are a little less severe, the wound will at first discharge a small quantity of dirty, bloody matter, which, if everything goes well, will, by degrees, change to healthy matter, without smell, of a straw color, and about as thick 9,s cream.
The fever, and other bad symptoms, will now subside; the sleep and appetite come back, and a new process begins, that of healing by granulation, or the formation of new flesh to fill up the gap made by the wound.
For old persons, or those whose health has been broken, this stage is full of danger, and is apt to result in death, if the lower limb be the injured part.
If the. constitution proves unable to bear up against this stage of the injury, alternate beat and sweating set in, the face is flushed with a pink color, the pulse becomes weak and quick, the body wastes, the appetite disappear, ,, the tongue becomes dry and brown, restlessness, wandering, and delirium follow in quick succession, and all are speedily terminated by death. With the setting in of these symptoms, the wound stops discharging, or throws out only a thin, water and stinking matter. Quite often the skin and other parts mortify, and if there be strength enough to throw off the dead parts, the broken ends of the bone stick out, looking dead and white.
When the constitutional symptoms begin, open and thoroughly disinfect the wound and provide for free drainage; a poultice may also be used if much pain be present. The poultice must be continued till the wound is filled with new flesh nearly to the surface.
It must be said in justice to modern surgery, that, if antiseptics are used at the first dressing of the wound, we expect union by first intention, and the avoidance of pus formation with all the dangers this entails. The wound is to be treated just like other fresh wounds, aseptically; the limb may then be done up like a simple fracture, but the dressings should be so arranged as to allow of sub. sequent inspection. (See article on Asepsis, etc., p. 572.)

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