717 
SURGERY. 
violent symptomatic fever takes place if they are large, and 
the adjacent dermis commonly suppurates. In severer cases, 
or even sometimes in the preceding, mortification on the 
skin takes place, and then occur shivering, convulsions and 
delirium. Though they should be treated on general anti¬ 
phlogistic principles, their peculiarities cause some deviations 
from any uniform plan. When the skin is unbroken, cold 
applications may be applied. These, however, should not 
be at first of the coldest possible nature, and indeed we have 
some reason to suppose, that if we acted in this respect on 
the same principle as when we apply warmth to frozen 
parts, namely, by beginning with very slight changes of 
temperature, and gradually increasing them, our success in 
the cure of burns would be greater. In severe burns, it is 
useless to attempt to prevent suppuration, and violent de¬ 
pletory measures are to be avoided, partly on the same ac¬ 
count and partly because they weaken the constitution, and 
disable it of the powers necessary to support the secretion of 
pus. Emollient poultices are, therefore, the only applica¬ 
tions that are required. A liniment composed of oil and 
lime water, is in general use: all that can with j ustice be said in 
its favour, is that it does no harm. The constitution requires 
a great deal of management in severe burns. The support 
of the system during the formation of pus or the separation 
of sloughs, must be sedulously attended to. Medicines are 
of little use; but wine and occasionally brandy require to be 
administered, in small quantities and in conjunction with 
nutritious matters, very frequently. 
Fractures of the bones are known by various signs as 
they occur in different parts; sometimes the limb is found 
flexible; sometimes it is shortened, lengthened, or other¬ 
wise distorted; but the most general sign is, that by taking 
hold of and irritating it, a grating or crepetus is produced 
by the friction of the irregular broken surfaces. When bones 
are broken, coagulable lymph is thrown out between them, 
which gradually hardens and becomes callous. Into this, 
vessels shoot, which deposit osseous matter, and by this 
means union is effected. This deposition takes place only, 
however, when the bones are in contact, and occurs as 
quickly if the two bones lie side by side as when their 
broken surfaces are in opposition. The process of union 
is completed in various periods of time, being most rapid 
in the smallest bones; usually from four to six weeks are 
required to consolidate a broken bone. ' 
The treatment of simple fractures consists, 1st. In extend¬ 
ing, by pulleys, or by manual strength, the distorted limb, 
and then placing the broken ends in the position they natural¬ 
ly occupied: as the muscles, however, seldom offer so great a 
resistance in fractures, as in dislocations, violent extension is 
not generally necessary. 2d. In retaining the bone in its 
natural situation: this is effected by placing the limb in 
such a position, as shall relax the majority of the muscles 
tending to displace the bones, and by antagonizing the action 
of others by means of unyielding splints, fastened tightly 
• round the limb, or in other situations by bandages. Then, 
the moderation of inflammation, and the subduction of irri¬ 
tation, which sometimes causes violent twitchings of the 
muscles, are all we have to attend to. 
Sometimes the deposition of callus does not occur, and 
the bones consequently remained unconnected. In these 
cases it is usual to rub the ends of the broken surfaces to¬ 
gether; if this fails, to pass a set on through the fracture, or 
open the fracture and saw off the broken ends. These 
measures are, however, hardly ever called for, and the latter 
is very dangerous. 
A fracture, which is accompanied with a fissure or lacera¬ 
tion in the integuments, is very dangerous; because these 
cases are nearly always effected by a violent contusing force, 
and because the suppuration or mortification which may be 
set up, debilitates very much the restorative powers of the 
constitution. The treatment, however, of compound frac¬ 
tures differs not from that of simple fractures, unless the 
injury has been so severe as to preclude the hope of pre¬ 
serving the limb-. In these cases amputation should be 
Vol. XXIII. No. 1603. 
performed. In this, as we stated when treating of gun-shot 
wounds, much must be left to the individual judgment, and 
no certain rule can be laid down. A large wound, much 
laceration and contusion of the soft parts, but above all 
considerable splintering of the bone, should induce us to 
amputate. 
Dislocations are accidents whereby the articulating sur¬ 
faces of bones are thrown out of their places. 
The general symptoms of dislocations are alteration in the 
length of the dislocated limb; alteration also in its position, 
which is owing to the altered axis of the muscular move¬ 
ments, not as some have thought to the remaining and un¬ 
broken portion of the ligaments, for the ligaments may be 
(according to the violence of the accident), either stretched 
only, or partially, or completely torn; yet the position of 
the limb is in all these cases much the same. The loss of 
motion which (with a few marked exceptions) attends dislo¬ 
cations, is to be attributed to the “ permanent contraction of 
the muscles.” When the limb is shortened the muscles are 
relaxed; but when lengthened they are so much stretched 
as to be sometimes torn. Considerable tumefaction from 
effusion of ruptured vessels sometimes obscures the promi¬ 
nences of the bones. Severe and obtuse pain is felt from the 
pressures of the dislocated heads of bones on the muscles, or 
paralysis of the whole limb may come on when a large nerve 
is thus compressed. The head ( of a dislocated bone may be 
sometimes felt in its new situation, and on rolling the shaft 
of the bone we feel rotation of the head also. Crepitus 
(from the inspissation of the synovia) comes on frequently, 
but not at first, and is thus distinguished from the crepitus 
arising from broken bones—though it is audible, we have no 
jarring sensation communicated to our hand. Suppuration 
seldom follows dislocations, when reduction has been made, 
when it happens it is generally eventually fatal. Unreduced 
bones form by pressure new beds, and some motion (to a 
greater extent in the upper than the lower limbs) is reco¬ 
vered. On dissection, laceration of the ligaments of the ten¬ 
dons of muscles going over the joint, and sometimes of the 
muscles themselves, is met with. These lacerations cause for 
some time weakness of the joint, or disposition to be dislo¬ 
cated. In old dislocations we see that when a bone’s head 
is imbedded in muscle, its pressure on the cellular membrane 
causes inflammation and thickening of that structure, and 
thus a substance sufficiently dense to furnish some support is 
formed, which new capsular ligament surrounds the whole 
articular surface of the bone, but does not adhere to it. 
When the surface of another bone forms the resting place of 
the dislocated head, the pressure incurred produces absorp¬ 
tion on the one hand of the periosteum, on the other of the 
articular surface. “ A smooth hollow surface is formed; the 
ball becomes altered in shape to adapt itself to the new sur¬ 
face; and whilst absorption proceeds upon the part on 
which the head of the bone rests, an ossific deposit takes 
place around it from the periosteum which is there irritated, 
but not absorbed. This bony matter is deposited between 
the periosteum and the original bone, by which a deep cup 
is formed to receive the head of the bone.” The socket 
smoothed on ils internal surface to allow motion, it some¬ 
times so completely surrounds the ball of the bone that the 
part cannot be separated without fracture. The muscles 
gradually accommodate themselves to the displacement of 
the bones. 
Dislocations are sometimes produced by relaxation of the 
ligaments without force, as in case of scrofulous patients, 
and sometimes in dancers, and other persons who practice 
unnatural postures, or in old and paralytic persons. It may 
arise also from accumulation of synovia in a joint. Disloca¬ 
tions are sometimes complicated with fractures, as when 
(which is very common) the fibula is fractured in the ancle- 
joint, or the acetabulum in dislocation of the hip or the 
head of the os humeri in displacements of the shoulder 
joint, or the coronoid process in those of the ulna, which 
last produces a species of luxation which does not admit of 
the preservation of the natural site of the bone. In disloca- 
8 U tion 
