751 
SURGERY. 
general, attended with any symptoms of acute pain and in¬ 
flammation, nor with any febrile disturbance of the consti¬ 
tution. There is only a dull uneasiness in the region of the 
loins. The matter is formed slowly, and imperceptibly, and 
occasions, at first, no manifest swelling, nor fluctuation, 
and no material symptom whatever, excepting the uneasiness 
in the loins, and a slight weakness of the thigh and leg on 
the affected side. 
The outward swelling, at length occurring, may take place 
in various situations. For the most part, the matter descends 
by its own gravity, in the course of the psoas muscle, passes 
forward under Poupart’s ligament, and occasions an external, 
fluctuating tumour, quite free from pain and inflammation. 
The exemption from the latter circumstance is a clear indi¬ 
cation, that the matter is not originally formed at the place 
where it first makes its appearance. The enlargement of the 
swelling, when the patient draws in his breath; its diminu¬ 
tion in an horizontal posture, and on pressure being made; 
and lastly, the fluctuation perceptible to the surgeon’s fin¬ 
gers, when the patient coughs, are circumstances which, 
combined with the other preceding complaints, clearly 
evince the nature of the case. 
The swelling in the-groin seldom becomes exceedingly 
large, because the matter in general soon insinuates itself be¬ 
neath the femoral fascia. In some instances, it descends as 
far as the knee, and forms there a prominent swelling. Some¬ 
times it makes its way downward, into the pelvis, and oc¬ 
casions a swelling in the neighbourhood ot the anus. Some¬ 
times it tends towards the loins and sacrum, giving rise to a 
swelling exactly in the place where abscesses often make 
their appearance in the disease of the hip joint. In a few 
instances, the matter causes a swelling in the vicinity of the 
vertebrae; and, less frequently still, it makes its way through 
the abdominal muscles, and occasions a tumour at some part 
of the abdomen. 
The disease, even before it bursts, or is opened, is fre¬ 
quently attended with loss of appetite, weakness, nocturnal 
sweats, and other hectical complaints. 
Lumbar abscesses are sometimes attended with a carious 
state of the vertebrae. 
Experience shows, that, when a psoas abscess is opened 
in the common manner, death in general follows sooner 
than when the swelling is allowed to burst of itself. The 
formation of a large opening, but particularly the aperture 
being afterwards left unclosed, causes an inflammatory affec¬ 
tion of the whole cyst of the abscess, and the most violent 
description of constitutional disturbance. The discharge is 
profuse, thin, and fetid. The patient’s pulse becomes small, 
rapid, and irregular 5 copious perspirations, unremitting di¬ 
arrhoea, and even delirium, ensue, and death very commonly 
closes the scene. 
Mr. Abernethy’s method, which is that universally fol¬ 
lowed, is to open the tumour with a broad abscess lancet, 
observing to introduce the instrument somewhat obliquely. 
Such an opening is generally sufficient for the discharge of 
the coagula, which are commonly blended with the contents 
of lumbar abscesses. 
The abscess being completely emptied, the lips of the ori¬ 
fice are to be brought together by means of lint and sticking 
plaster, in the same way as after phlebotomy, and a com¬ 
press and bandage are to be applied. The wound generally 
heals without trouble. 
The matter of course collects again, and, regularly as it is 
secreted, descends to the lower part of the cyst, on which 
account the upper part of the cavity will remain a good 
while undistended, and have an opportunity of contracting. 
When the integuments are again sufficiently elevated to 
allow a puucture to be made, without hazard of wound¬ 
ing the subjacent parts, the abscess is to be emptied again, 
and the wound healed, in the manner above described. 
Thus the operation is to be repeated as often as may be 
necessary. 
By this method, the cyst of the abscess, particularly its 
upper part, gradually unites. 
Of the Lower Extremity. 
Of the Thigh.—The thigh may be dislocated upwards on 
the dorsum of the ilium; downwards on the foramen ovale, 
backwards and upwards or into the ischiatic notch, and for¬ 
wards and upwards or upon the pubis. Dislocations down¬ 
wards and backwards are improbable, though some have 
(through mistake perhaps) described them. Upwards—The 
bone is here shortened from 1 J to inches, as we see by 
comparing the malleoli of each limb. The toe is turned 
inwards, resting against the tarsus of the opposite foot; the 
thigh cannot be drawn outwards, but may be brought over 
the other limb a little way, unless there is much tumefaction; 
we may feel the round head of the femur on the dorsum ilii, 
and when we roll the thigh bone inwards, we feel this head 
rolling also. The trochanter is not quite so distinct as in a 
natural state, but is placed nearer the anterior superior spine 
of the ilium ; the natural curve of the hip is nearly lost, and 
the knee advances a little over its fellow. This accident is 
distinguished from fracture of the neck of the femur, by these 
marks. In fracture of the cervix femoris, the knee and foot 
are generally turned outwards; the trochanter drawn up¬ 
wards and backwards on the dorsum ilii; the limb can, 
though with pain, be bent freely on the trunk, but above 
all, the limb can be pulled down to its original length, with 
a slight force, in which reduced state crepitus is felt on 
rotation, but when this force is removed, the deformity 
returns, and now crepitus on rotation is of course not per¬ 
ceived; the limb is shortened from one to two inches. 
Whether the cervix be fractured within or without the liga¬ 
ment, the position is the same. Fractures within the liga¬ 
ment rarely occur, but in the aged, and are effected by slight 
accidents. Fractures external to the capsule, occur at any 
period of life, and are easily detected, “ if the limb be ro¬ 
tated, and the trochanter compressed with the'hand.” Dis¬ 
location of the hip may arise from disease, not violence ; but 
here the history of the case is the safe guide. “ The gradual 
progress of the symptoms, the pain in the knee, the apparent 
elongation at first, and real shortening afterwards; the capa¬ 
city for motion, yet the pain given under the extremes of 
rotation, as well as of flexion and extension, are marks of 
difference which would strike the most careless observer.” 
In this dislocation the pyriformis, glutei, triceps, pectineus, 
semitendinous semimembranosus, iliacus and one head 
of the biceps are shortened. The obturator externus 
is also shortened, but the obturator internus gemelli and 
quadratus are stretched. This accident happens when the 
patient falls, or receives a blow when the knee and foot 
are turned inwards. To reduce this dislocation (constitu¬ 
tional means, mentioned under the general head of disloca¬ 
tions, having been used) the patient is to lie on a table, be¬ 
tween two strong posts, or on a floor with two rings fixed 
in it, about ten feet asunder; then a strong girth is to be 
passed between his pudendum and thigh, and fixed to one 
staple. A wet linen roller is put light round, just above the 
knee, and upon this a leather strap is buckled, “having two 
straps with rings at right angles with the circular part. 
The knee is to be slightly bent, but not to a right angle, and 
brought across the other thigh a little above the knee.” The 
patient being thus adjusted, the pullies are slightly stretched, 
till pain is felt, then suffered to remain, then tightened, and 
so on. The surgeon, when he feels the bone approach the 
acetabulum, gently rotates the bone, which then slips into the 
socket, but seldom with a snap, when pullies are used. It is 
sometimes necessary to lift the bone, by placing the arm or a 
napkin under it close to the joint, and raisingthe head over the 
edge of the acetabulum. The dislocation downwards into 
the thyroid hole, is marked by lengthening of the limb to the 
extent of two inches; the head of the femur is felt at the inner 
and upper part of the thigh in very thin persons; the trochan¬ 
ter major is not prominent; the body bent forwards by the 
iliacus and psoas; the knee advanced if the body be erect; 
the leg adduced to a great extent and incapable of being 
brought inwards, without great difficulty; and the feet, though 
widely separated, neither inverted nor turned out. The head 
bone 
