CAPPED ELBOW. 325 



nature, we without hesitation pierce its substance with a trocar or 

 seton-needle, and fasten a seton of broad tape within it; than which 

 there is no more summary or better practice for its speedy and per- 

 manent dispersion. Should such procedure give rise to any pain- 

 ful or alarming inflammation in the tumour or parts adjacent — 

 which has rarely proved to be the case — withdrawal of the seton, 

 with fomentation of the part, and physic, will abate it, and speedily 

 enable us to re-introduce the seton. Indeed, it is possible, the pre- 

 sence of inflammation might from the first forbid, for a time, the 

 insertion of the seton. The insertion ought to be made in such 

 manner that the lower orifice may be completely dependent ; i. e. 

 in the vertical direction. And whether tape or hemp or silk be 

 used, the ends should not be joined together — for this would leave 

 hanging out of the apertures a loop, extremely dangerous from its 

 liability to catch in something, and so to be by force probably torn 

 out — but ought to have knots tied in them, large enough to prevent 

 their withdrawal through the holes in the tumour. The seton 

 ought to be retained until the swelling has become reduced to the 

 greatest reducible degree, or until it shall ulcerate its way out. 



Either from the hard consistence of the tumour, or from its long 

 duration, a seton being deemed or proving unavailing, we must turn 

 our thought to extirpation of it ; and there is no more ready and safe 

 mode of proceeding with this view than excision with the scalpel. 

 If the tumour happen to prove encysted, the first cut had better be 

 made directly across its free or posterior surface, from above down- 

 wards; which done, the tumour will, as the phrase goes, "shell 

 out," and so leave all that further requires to be done simply to the 

 stitching up of the integument When the skin, however, proves 

 on all sides adherent to the surface of the tumour, it will be better 

 to make a circular or ovoid incision, carrying it around the broadest 

 circumference of the tumour, or else varying its line of direction 

 according to any ulcerations or tubercular eminences there may be 

 upon its surface which we may be desirous of getting rid of. 

 Caution will be required whenever the tumour appears to have a 

 broad and undefined base ; since, as has been already stated, it is 

 not so very unusual for callous swellings of long standing to have 

 connexion with the capsular ligament of the elbow-joint. 



