LETTER I.

I TAKE the first opportunity that busi­ness will permit, of answering your Letter, dated the beginning of last month, by informing you, that I have read Mr. POTT'S book upon Fractures, which contains many valuable directions; and I know, that putting the muscles, as he advises, in a state of relaxation, both at the time of reduction, and during the re­mainder of the cure, will, on many ac­counts, be attended with great ease, and great advantage to the patient.

I imagine the rigid discipline of keep­ing fractured legs in a state of extension, has not been so steadily adhered to, since Mr. PUGH ^(a) in 1754, proposed, by the [Page 2]use of his splints, to move the patient from his back to his side, in order to give him relief in his situation; and wherever this method was practised, the leg must frequently be laid on one side with the knee bent, though, probably, often with­out being aware of all the advantages ari­sing from this posture. Ever since the first of May 1758 ^(a), I have constantly laid fractured thighs in the manner Mr. POTT directs, and believe it has been practised by others, to whom I pointed out the ad­vantages of this situation; in particular, it seems impossible to make a good cure, where the neck of the thigh bone is frac­tured, without putting the limb in a state of flexion ^(b); but by this method I have [Page 3]seen this accident cured without lame­ness.

The old method of violent extension to reduce fractured limbs, I do believe has been long disused, because quite un­necessary, and evidently, to every capa­city, injurious; nor do I remember ever seeing it practised, the bones being always capable of being laid strait by gentle ex­tension; and Mr. GOOCH ^(a), ten years since, recommended this kind of treat­ment, in his Cases and Remarks in Sur­gery.

I imagine the limb, in simple fractures, has not frequently been disturbed, after be­ing properly placed, except by those, who use no other than liquid discutients. We ne­ver unwrap or move it, till it will bear mov­ing, unless great swelling has made the use of poultices necessary; for by applying a ce­rate, that, without irritating, is capable of attenuating the obstructed fluids, and of preserving the vessels in a state of acting upon their contents, we keep the part in a continual state of perspiration; so that we have nothing to do, but to see that the limb lies easy, and is not displaced; or, where a moderate swelling has taken place [Page 4]before this application is used, we gradu­ally draw our bandage and splints a little tighter as the swelling subsides. Whereas, those who use embrocations, &c. only, are daily disturbing their bandage, and, after all, neglect that principal point of preserving the natural elasticity of the fi­bres, to which, where the parts are neither much bruised nor swelled, a proper degree of pressure, by bandage may greatly contri­bute, by not suffering the vessels to be di­stended beyond their natural state; whence less inflammation, less pain, and conse­quently less disturbance will follow. This may be accomplished by the eighteen tail bandage, which has been long used in sim­ple fractures: and Mr. GOOCH publickly took notice of the advantages that would arise from its supplying the place of the common roller, in the Cases and Remarks we have referred to; but it must be ob­served, that Mr. POTT'S contrivance, of making the tails fold over each other in an oblique direction, is a considerable im­provement.

Mr. PUGH'S long splints were made to secure both ends of the fractured bone. Mr. GOOCH ^(a), some years after, advised the same practice; and both Mr. WATHEN [Page 5]and Mr. SHARP have since made an im­provement, by adapting long splints to the shape of the leg.

So that you see the practice recommen­ded has been gradually taking place: tho' putting the limb in a state of flexion to as­sist reduction is entirely new, except that Mr. SHARP, of Mincing-lane, assistant Surgeon of the same Hospital, has got the start of Mr. POTT, by laying, in Novem­ber, 1766, a paper before the Royal So­ciety, wherein he advises,

—Nevertheless, in ju­stice to Mr. POTT, it must be observed, that he is the first writer who has scienti­fically proved, that putting the muscles in a state of relaxation, and non-resistance, is the most proper method both of reducing [Page 7]and curing fractures; and he has further demonstrably shewn, that this part of Sur­gery, as well as the rest, can only be re­gularly practised by those who understand the structure and use of the several parts of the body: notwithstanding many bone­setters have acquired reputation by pre­tending to have cured fractured limbs, which were never broken.

I shall take the first opportunity of re­suming this subject; and the next Letter I send you, may, perhaps, be of a more interesting nature.

LETTER II.

NOtwithstanding I so much approve of the directions Mr. POTT has given about treating simple fractures, and pay the greatest deference to his opinion, yet I think what he has said about the necessity of immediate amputation in very bad compound fractures, is too general; for tho' the practice he recommends may be right in the Hospital, to which he is Surgeon, it does not follow, that the same steps should be taken in the situation, in which you intend to place yourself.

Indeed, if amputation is to take place whenever the probable chance of destruc­tion, from the nature and circumstances of the accident, is greater than it would be from this operation, every limb must be cut off, where the bones are shattered, and the muscles considerably torn, as I Imagine, in general, in sound habits am­putation would be attended with much [Page 9]less trouble and more absolute certainty of recovery, than even a compound fracture, where the bone has made its way out in such a manner, as to give free admission to the air, without causing any violent laceration of the muscles. And yet frac­tures, thus circumstanced, so frequently admit of cure, as to justify every attempt to preserve the limb. Nor can I think, in private practice, the consideration of am­putation (where it is not fully evident, that the limb cannot hereafter be useful) often requires immediate determination; that a minute's delay will, many times, be to the patient's disadvantage; or that a small space of time will frequently make all the difference between probable safety and fa­tality; if, according to Mr. POTT, imme­diate amputation is only to prevent gan­grene, or a large suppuration, with forma­tion and lodgment of matter; for gan­grenes following injuries must be either local, from the violence of the injury, or succeeding inflammation, or they must arise from a bad habit of body, or both causes joined.

If a gangrene is only local, we need not be precipitate in our determination; be­cause, by proper management, it will cer­tainly stop, when it comes to the parts [Page 10]which are not injured. If it is likely to arise from a bad habit of body, amputa­tion will not prevent it, as the wound fol­lowing the operation will most likely mor­tify; for in a gangrenous disposition of the fluids, this disease as frequently manifests itself in simple, as in more complex wounds; and surely there are other methods to re­medy large suppuration or lodgement of matter; or at least we ought not to am­putate, till we see the discharge is greater than the patient can bear. So that you see, there will always be time for delibe­ration; whence we shall act with a cer­taintly that cannot be known, except in particular cases, when we are first called to the patient, and if necessary we shall have opportunities of performing the ope­ration, before he becomes incapable of un­dergoing its consequences.

But Mr. POTT is of a very different opinion; he says,

Now, I have not any doubt, but, in St. Bartholomew's Hospital, what is here said about the rapidity and untractableness [Page 13]of mortifications, arising merely from in­jury done to the limb, is exactly true; for I can readily conceive, in this situa­tion, local, will often be converted into the most malignant spreading gangrenes, in opposition to the utmost care and good management. Otherwise it has always been thought, that gangrenes from a bad habit of body are more difficult of cure, than those which arise from the wounded state of the parts; for from the days of HIPPOCRATES, down to RUSHWORTH, gangrenes, from a bad habit of body, were always, by the ablest Surgeons, deemed to be incurable; whereas instances abound of mortifications from the violence of the injury alone being cured by amputation ^(a), cauterization, caustics, &c. and though since the use of the bark in this disease has been known, we can often cure gan­grenes arising from an internal cause, yet in the country, I have constantly found, [Page 14]that those, which arise simply from the injury, are with more certainty relieved.

Perhaps there is not any thing which contributes more to a true method of treat­ing mortifications, than making a proper distinction betwixt one mortification and another; and my practice several years ago led me to discover the difference in them already mentioned; which distinc­tions have ever since been of great use to me in the management of this disorder: But as I cannot find, that what I said a­bout this matter, in my treatise of Gan­grenes, is attended to, I shall here describe separately the symptoms accompanying a mortification, arising from a gangrenous disposition of the juices; and a local mor­tification, when merely the consequence of external injury.

When a mortification in compound fractures arises from a gangrenous disposi­tion of the juices; soon after the injury is received, whether a large wound is made by external violence, or a small wound by protrusion of the broken bone, the lymph, which stagnates about the wound, imme­diately inflames and corrodes the vessels which contain it; when air bubbles in the membrana adiposa, and other membranes, are instantly formed; which air bubbles, [Page 15]by increasing the inflammation, are in­creased, and extended immediately, upon the smallest degree of obstruction taking place, all over the limb, &c. an Emphy­sema often first discovering the tragedy that is acting under the skin, not yet apparently diseased. A fever at this time frequently comes on, accompanied with a delirium, great dejection of spirits, and often a par­ticular wildness in the looks; the pulse is either quick, low, weak, and fluttering, or quick, unequal, and hard, and the scene is frequently closed with a rapidity that will not admit of assistance.

If an incision is made into the affected part, when the air bubbles are first formed, it is sensible, and blood is discharged from the arteries in a florid state, as free as usual; the membrana adiposa is of a dark­ish yellow colour, and the muscles only appear browner than common. Afterwards the skin becomes inflated, and the mus­cles, not yet having lost their shape, fre­quently force themselves out immediately upon making an incision, with a large dis­charge of wind, and a quantity of frothy matter; the blood in the vessels is now turned to a black, coagulated mass, the membrana adiposa and the membranes in the interstices of the muscles and fibres, [Page 16]and the muscles themselves putrify; and lastly, the skin also becomes livid, and pu­trid; from all which it seems evident, that a gangrene brings on a sphacelus, while the blood is yet circulating in the vessels.

On the contrary, when the mortifica­tion arises simply from injury done to the limb, it is not preceded by a gangrene, but comes on in consequence of an abso­lute stagnation of the blood and juices alone; and accordingly the skin and all the injured parts become dead and putrid at the same time, without any previous Em­physema ^(a). If an incision is early made, the part is insensible; no other than ex­travasated blood is discharged; nor do I ever remember seeing a mortification arise from this cause, except in gunshot wounds, without the skin suffering equally with the subjacent parts; for if the muscles are only lacerated by the ends of the broken bone, suppuration, instead of mortification, as in other lacerated wounds, is always the common consequence, if no other cause [Page 17]interferes; because the circulation, except in the divided parts, is not entirely inter­rupted.

In this kind of mortification, the coun­tenance continues serene; nor does any other fever supervene, but such as is com­mon to contused wounds; and unless the affected part is very near the body, the disease slowly extends itself (not by air bubbles taking possession of the cellular membrane surrounding the large blood ves­sels and nerves, some times before it makes its appearance in the integuments, as when it arises from a bad habit of body, but) by the acrid fluids corroding the neighbouring parts, in the manner of a caustic, till mat­ter enough is absorbed to contaminate, un­less prevented, the whole mass of blood. But so far as I can judge about this mat­ter, a stop may always be put to a local sphacelus; for I have never seen a morti­fication arising merely from the injury done to the part, which did not give way to pro­per management. The same kind of suc­cess probably induced Mr. GOOCH, after forty years experience, to say, that a mor­tification, attending a compound fracture, should not alarm the Surgeon to a hasty determination of the loss of the limb; and I am apprehensive, you will often commit [Page 18]mistakes, greatly injurious to your patient, if you suppose every local mortification as fatal as those in the Hospitals.

However, the chief reason which in­duces me to differ in opinion from Mr. POTT, is the success of the country Sur­geons; who, unless the parts are so de­stroyed as to be evidently irrecoverable, seldom amputate, and as seldom fail in their attempts to cure. From the best in­formation I can procure, I do believe the country Practitioners, who have been really bred Surgeons, do not take off more than one limb in twenty, which has received a compound fracture; nor do they, upon an average, lose more than one in ten of those they attempt to cure without ampu­tation. And surely, if matter of fact is of any consequence, tho' Mr. BILGUER is far from having proved the inutility of am­putation; yet he certainly has given proof enough to shew, that immediate amputa­tion is not often necessary.

These circumstances may seem to call in question the judgment of Mr. POTT, in so strenuously recommending immediate amputation; but their success in the Hos­pital, I dare say, fully justifies all he has said; for I do verily believe, in very bad compound fractures, their attempts to pre­serve [Page 19]limbs have most frequently been fru­strated by the death of the patients, and that the escapes are much too rare to be made precedents. It therefore is certainly from a principle of humanity, that he re­commends a remedy, from which, in his situation, it has been found, that the chance of death is by no means equal to that arising from such kind of fracture; which leads us to examine, how it comes to pass, that the country Surgeons are more successful in the cure of compound fractures, than those Gentlemen who have the care of great and crowded Hospitals.

For this purpose, it will be necessary to enquire, what is the immediate cause of death in compound fractures; and, if we except a loss of blood from the principal arteries beihg divided, (which, I believe, is very seldom fatal,) it will probably appear owing to a putrid state of the fluids; for this is manifestly the case, when death is brought on by a gangrene, arising from a bad habit of body; and when, by a mor­tification, brought on simply by injury done to the parts, the patient is chiefly destroyed by an absorption of putrid mat­ter. If he perishes by a putrid fever, it is also inconsequence of an absorption of pu­trid blood, or putrid matter arising from [Page 20]bruised flesh; if, by a colliquative fever, the putrid matter which is absorbed, being less active, produces its effects more slowly. But it sometimes gives rise to internal ab­scesses, always weakens the fibres, and destroys the crasis of the blood; whence the discharge from the sore, and other eva­cuations, become too great, and the patient is exhausted.

It is no wonder, then, that rapid morti­fications, and great discharges of matter, should frustrate their attempts to cure bad compound fractures in a large Hospital, in the midst of a great and populous city, where the air the patient breathes, not­withstanding the greatest care, combines with the cause of these disorders in his de­struction; for it is well known, where a great number of people breathe constantly in the same room, the air is not only destitute of its vivifying spirit, so necessary for the preservation of life, but it really be­comes putrid from being confined, and re­peatedly inspired, and from being loaded with the putrid exhalations arising from mortifications, different kinds of sores, dis­eased bodies, &c. &c. &c. And perhaps, too, the general methods used here, may contribute to the dispatch of many of these unfortunate people; for porters, and those [Page 21]who have been used to drink plentifully of drams, beer, and the like, will sink even under the full diet of the Hospital, and die for want of some indulgence in these bad habits, which are now, from custom, be­come necessary assistants in supporting the strength of the body; so that the Gentle­men of the Hospital labour under the greatest disadvantages, and we may won­der, that any recover, rather than that most die. Whereas, in the country, the patient has every possible advantage from purity of air: nor are we tied down to sett rules; but from learning the former man­ner, in which the patient has lived, we supply him properly with those things to which he has been accustomed; and I have repeatedly seen the most salutary ef­fects follow a due allowance of ale, wine, or brandy; where a few days low diet has brought on want of sleep, delirium, loss of appetite, and an ill state of the wound.

Perhaps it may be worth while to en­quire, too, whether free and frequent bleed­ing, to prevent or remove inflammation in every compound fracture, may not some­times hasten the dissolution of the patient; for, notwithstanding it may seem proper during the state of inflammation, yet by thinning the blood, emptying the vessels, [Page 22]and reducing the strength, a greatel ab­sorption of matter follows after the inflam­mation is gone off, and produces more vio­lent effects.

I have constantly observed, whenever the patient has lost much blood at the time of the accident, or whenever I have been called where there has been a free use of the lancet, that colliquative sweats, loose­ness, and a greater discharge from the ul­cer is sooner the consequence of the ab­sorption of matter, and with much more violence, than when the patient was less reduced; and it is very probable, if these people had lived upon spare diet, and breathed the air of an hospital, their com­plaints had still been aggravated, till death had been the consequence.

I well remember, that the Gentleman I served my apprenticeship with, very sel­dom bled in compound fractures; and, what may seem strange to those, who are fond of bleeding, it was impossible for any man living to have better success; and many accidents of this kind fell under our care. Nor was this treatment confined to his practice alone; for, upon enquiring, I have been informed by others of long ex­perience, who have also had remarkable [Page 23]good success in the cure of these acci­dents, that, like him, they always hasten­ed the digestion of the wound without much bleeding.

For my own part, I have always been cautious in reducing the patient's strength; yet in strong plethoric habits, where much blood has not been lost at the time of the accident, especially if heated by liquor, which is not infrequent, I commonly take blood away, to prevent great inflamma­tion, &c. But, on the other hand, where the haemorrhage has been considerable, or where the patient is rather of a weak con­stitution, I defer the operation, and only afterwards bleed, if the symptoms of in­flammation peremptorily demand this eva­cuation: But this rarely or never happens; and I have seldom found the tumor, pain, and inflammation or fever, rise so high, as to make repeated bleeding necessary, if proper care has been taken of the limb; not only by placing it in a proper position, and then leaving nature to accomplish her own work; but by using such applications, as are capable of giving her assistance. And even where improper applications have been used, or the injury for some hours intirely neglected, &c. so that great tumor and inflammation have come on, [Page 24]even till blisters have arisen upon the part, yet so much bleeding is not here necessary, as theory may lead us to think; for the discharge from these blisters, when pro­perly promoted, assists in taking off the tension by unloading the lymphatic vessels; and if to the topical remedies, moderate bleeding, antiphlogistic sudorifics, and me­dicines which purge, are joined, the tu­mor commonly declines in a few days; for I find, when these symptoms arise from simple inflammation, they are not so for­midable, as their appearance might lead us to think. Repeated bleeding, in these cases, is only required to prevent an increase of inflammation, by lessening the im­pulse of the blood against the obstructed vessels, when too violent, for which pur­pose the loss of a moderate quantity is suf­ficient; and if you will have a little pa­tience, the discharge from the sore will most effectually remove every disagreeable symptom; for wherever the obstructed flu­ids can be outwardly discharged, it makes a material difference in the treatment from those inflammations where no evacuation can be made from the affected part.

There is not any doubt, but antiphlo­gistic medicines, a spare, cooling diet, and an open belly, are, in general, proper, [Page 25]while the limb is in a state of inflamma­tion; but where this treatment has been carried much farther, I do think, with Mr. POTT, that ‘it has not unfrequently been the cause of the loss both of limbs and lives.’ We therefore do not wait till the appetite begins to fail, and the pa­tient sweats and purges without assignable cause, or in consequence of a large dis­charge of matter from the limb, before we alter our proceedings; for when things are come to this pass, it may often be im­possible to find remedies sufficient to cure the disease. These symptoms, therefore, must be guarded against, rather than suf­fered to take place; for which purpose, as soon as digestion appears, and the pulse becomes quieter, the bark should imme­diately be given, which may be done with the utmost safety, and a more generous diet gradually allowed, as the appetite re­turns; for tho' excess should be carefully avoided, yet entirely altering the way of living of the patient, certainly leads to de­struction; and I believe the best way of treating him, is only to abridge him a lit­tle of his usual diet, when it has been of that kind which has a tendency to inflame, or greatly enrich the blood, remembring the aphorism of HIPPOCRATES, that ‘ a slender and strict diet is, in lingering dis­eases, [Page 26]always dangerous.’ So much for the general method of treating the pa­tient; now let us more particularly consi­der the injured limb.

What Mr. POTT says about the reduc­tion of the limb, carries conviction along with it; but much of your future good success depends upon removing loosened, and detached, or sharp pointed bones, ex­traneous bodies, &c. at the first dressing, by the practice of freely dilating the wound where it is too small for this purpose; by which means, you reduce the wound nearer to a simple state, and not only prevent irri­tation, pain, and their consequences; but render future probing and examining into the sore unnecessary; and thus avoid many inconveniences that might arise from that indiscreet practice.

This operation should always be done without violence; but I am fearful you will scarce always be able to remove loos­ened or sharp pointed bones, which ought to be taken away, without giving pain; but the patient will suffer much less, if they are removed just after the accident has happened, while the parts are rather insensible, than after inflammation has ta­ken place. Indeed it appears to me, that we should not, if it can be done without [Page 27]great violence, or lacerating any large blood vessel, omit removing, at the first dressing, whatever may cause irritation; for I have constantly found, when these, along with the coagulated blood, are in­stantly taken away, the patient always re­covers with much more ease both to him­self and his Surgeon.

But tho' what is said about the reduc­tion of the leg appears to be perfectly right; yet there are some other things which require consideration; for if the wound happens to be on the out, or under side, must not the leg be moved every dressing? — This circumstance has escaped Mr. POTT'S notice; but Mr. SHARP ^(a) says, ‘the leg may be supported by a steady hand against the upper splint, and put into any posture that may be neces­sary to dress a sore on the fibula, or un­der part.’ But I am very apprehensive, let the hand be ever so steady, this moving will overbalance all advantages from situa­tion. Again, if the wound happens to be on the inward or upper side, the matter will lodge till the wound is full enough to run over; and part being absorbed, pro­duce those evils so loudly complained of in [Page 28]the hospitals ^(a). On the other hand, if the wound is on the shin, or on the back part of the leg, the side position is most favourable for the discharge of matter; so that it may be well worth considering, whether the wound ought not to direct us in what manner to place the leg. If it should be thought prudent, under some circumstances, still to place it after re­duction in the old posture, the practice of sawing off the protruding bone must some­times take place, which operation is done without much trouble, or any hazard, and always with great advantage to the pa­tient. Whereas the lodging of matter is always capable of producing mischievous, and frequently fatal effects, and should be guarded against, not only by an enlarge­ment of the wound, when too small, but by every other step that can be taken.

Dry lint is very properly advised, as the best application, where the fracture is likely to heal by the first intention; for in order to promote a reunion of the parts, [Page 29]we should avoid every step that usually brings on digestion; and dry lint, in itself, has no property of promoting digestion. Mr. SHARP says, ‘by this new position, if the fracture be compound, the wound generally heals by the first intention, the great impediment (irritation) being pre­vented;’ and there is no doubt but this practice may contribute much to a reunion. But on the contrary Mr. POTT says, ‘the cure by the first intention is the case of some of the lucky few.’ And from what I have seen of this matter, the cure by this method can only take place, when the bone is simply broken, and comes thro' the skin, without causing great laceration; for when the wound is so large as to give a free admission to the air, suppuration follows. Therefore, when from this cir­cumstance it appears, that the cure by suppuration must be pursued, the wound should be dressed with a digestive balsam suited to the degree of irritability of the pa­tient, instead of dry lint; by which treat­ment you will find ease and digestion much sooner procured; for the inflammation will not rise so high as when dry lint is used ^(a); and it is most certainly not only [Page 30]your duty to avoid doing mischief, but also to assist nature, by removing every thing in­jurious, and by supplying her with what is wanting to perform a cure; in which the whole art of Surgery consists.

However, this dressing must be conti­nued no longer than till the tumor and in­flammation [Page 31]are intirely gone, digestion is compleat, and the sore becomes clean; lest too great a discharge should be pro­cured, when dry lint, or lint dipped in simple tincture of myrrh, may be applied; for tho' these spirituous dressings manifestly do injury till the state of inflammation is over; yet afterwards, where the discharge is great, I think they do service, by bra­cing up the relaxed fibres.

What Mr. POTT says about relaxing cataplasms, well deserves your attention; for tho' great inflammation requires great relaxation, yet by over relaxing parts, which are not much swelled, the juices stagnate, and abscesses, or large suppuration, is the consequence: and I make not any doubt, but many have fallen victims to this prac­tice.

But, on the other hand, I do not think the form of the applications used to keep off inflammation, where poultices are im­proper, immaterial: for tho' some of the liquid discutients generally applied, are powerfully capable of attenuating obstruct­ed fluids, yet they are destitute of the other properties, which are necessary to prevent inflammation; for, as I take it, the topi­cal remedies, calculated for this intention, should both attenuate obstructed fluids, and [Page 32]at the same time preserve the vessels in a state capable of acting upon their contents; whence the circulation and perspiration are carried on regularly in the neighbour­ing parts about the wound, and great in­flammation is thereby prevented. Where­as, when embrocations alone are used, a stagnation of the juices does, in a greater or less degree, ensue, from the skin be­coming hard and dry betwixt the times of dressing.

This I do not assert from the nature of things only, but from experience; having frequently been called to people, where lo­tions, dry lint, a pledget of digestive, and the eighteen tail bandage were the only applications that came in contact with the limb, which I always found remarkably tense and painful; sometimes the swelling and inflammation were risen to a very great height, and abscesses, which might have been prevented, were the conse­quence. It would be well, therefore, for those who pursue this method of practice, to consider whether it is not owing to this kind of treatment that they are obliged to have recourse to large and repeated doses of opium to ease pain; for I do aver, that we who follow a different method of cure, are seldom or never under any sort of ne­cessity [Page 33]of having recourse to that remedy. Indeed, if our applications are not com­pounded with a view both of attenuating obstructed fluids, and of preserving the vessels as near their natural state as possi­ble, we fall very short of the true inten­tions of cure. And I am very certain, if this circumstance is duly attended to, and these lacerated wounds, which cannot be cured by the first intention, are brought speedily to digestion by the method already recommended, even in bad habits, and where the case is not fortunately circum­stanced, the inflammation will, for the most part, be kept within due bounds, without hazarding the consequences of losing a great deal of blood by venesec­tion.

From what I have already said, you see I entirely agree with Mr. POTT, that per­fect quietude is absolutely necessary in the cure of compound fractures; but we have at the same time shewn, when the leg is laid on one side, this injunction cannot al­ways be complied with; and I imagine, as soon as the fractured bones acquire some degree of firmness (but not before) the knee-joint should be gently moved ^(a), to [Page 34]prevent that contraction of the tendons of the ham, which might probably take place, if the knee was suffered to remain bent eight or ten weeks without stirring.

The chief reason, which has ever indu­ced Surgeons to remove compound frac­tures, has been to keep them clean. But to defend the bandage from matter, and to prevent us from being under any neces­sity of changing it often, Mr. GOOCH ^(a) recommended the green oil-case cloth to be placed on the outside of the compres­ses; to which I have found it necessary to add pieces of spunge, both above and be­low the wound, to prevent the matter from running out at each end; by which means, I have frequently kept the ban­dage clean enough, six weeks or two months, without once moving the limb, where the discharge has been considera­ble.

JUNKS, you know, have commonly been used in compound fractures, to keep the limb steady, which purpose they an­swer very well, when properly made, and properly applied; nevertheless they cannot be used in the side-position of the limb; and Mr. POTT, you see, advises the long [Page 35]splints, which supply their place, and lie very commodiously upon the part in this situation. However, it is worth consider­ing, whether they are not liable to one of the principal objections against the use of short splints, in the cure of compound fractures, which is confining the matter, that ought to be discharged, as they lie flat upon the leg. The fracture box kept the leg steady; but by pressing up the sides of the pillow, it often confined the matter; whence I soon laid aside this piece of trumpery, and always succeeded with the most ease, when my apparatus was most simple. Indeed there is simpli­city in these long splints, and when the wound is conveniently situated for the pur­pose, they may often be very useful, if bolsters to prevent their pressing upon the sore are at the same time applied. I have often used long splints towards the close of the cure, in compound fractures, with advantage; and, I imagine, Mr. POTT can only mean to recommend them under particular circumstances; for you will cer­tainly meet with accidents of this sort, in which splints at first, either long or short, would be improper, on account of the vi­olence of the injury.

Strengthening the injured limb, when it is become soft and flabby, by relaxing ca­taplasms, is another material circumstance: But this, I am apprehensive, cannot be well effected by the application of corro­borating medicines alone; and I shall therefore just observe, that amongst all the remedies, no one can contribute more to the cure of compound fractures, than a due degree of pressure by the eighteen tail bandage properly timed. And, I ima­gine, it can only be owing to a general disuse in the hospitals, that so many Sur­geons have not attended to the advan­tages arising from this valuable branch of Surgery. We were before told by Mr. SHARP ^(a), that ‘the chief purpose of bandage was to maintain the due situa­tion of a dressing, or to make a com­press on particular parts;’ and I cannot find that Mr. POTT uses it in fractures for any other purpose, than keeping the dressings in their proper place; and yet, where a compound fracture will admit of cure by the first intention, it certainly promotes a reunion; and in every case, where it can first be applied, it prevents inflammation and pain, and forwards a re­gular [Page 37]suppuration; for, if by the assist­ance of a due degree of pressure, a disten­sion of the vessels and fibres is not suffered to take place, nor their sides drawn nearer together than usual, the nerves will be put less upon the stretch, the vessels will be less loaded, and more capable of acting upon their contents; of course the circu­lation will be more regular, and the fluids will be transmitted properly into the sore.

But these advantages cannot be ex­pected where the parts are much bruised or lacerated, or where inflammation has already taken place, because the vessels are become impervious. And, pressure, where the fluids are incapable of moving, must be injurious, by confirming the obstruc­tion, and by increasing pain, where sensa­tion, from the nerves being in a state of tension, is become acute.

Nevertheless, when in consequence of the discharge, and by the assistance of pro­per remedies, the obstruction and inflam­mation are removed, no application is so capable, as bandage, of preventing a large discharge, by strengthening the vessels and fibres, and restoring them to their pristine state. And notwithstanding sinus's and abscesses are freely opened, and counter openings made, which I would always re­commend, [Page 38]matter will lodge, if bandage is not applied, and be productive of much mischief; and indeed, when the use of this assistant is omitted, sinus's will often be formed, which it is impossible to open with any great advantage; for where the eighteen tail bandage, after being sprin­kled with an embrocation, had only been applied, with a view to keep on the dres­sings, or to make a compress on a particu­lar part; I have found, at the end of ten or twelve weeks, or sometimes longer, si­nus's penetrating deep amongst the mus­cles, and running, in different directions, almost all over the limb. Besides, the fleshy fibres had more the appearance of a jelly, than flesh; and the patients were sinking under a hectic fever, and a deluge of matter, which I take to be owing to the height of bad Surgery; because when the dressings and bandage have been from time to time properly adapted, and the patient's strength preserved from the be­ginning, this violent relaxation never hap­pens, fewer sinus's are formed, and the discharge is seldom or never ^(a) so great as [Page 39]to exhaust the patient, who is almost al­ways out of danger, by proper manage­ment, in ten or twelve weeks time. Nor do I believe there ever was a compound fracture which would not bear pressure with advantage, if properly managed, and properly timed; and I am fully persuaded, a clever recovery in a bad case, without it, must be merely accidental. But, on the other hand, no remedy is capable of doing more mischief, if injudiciously used; for if the pressure is not made with the nicest judgment, it retards digestion, confines matter, brings on inflammation, with pain, and all their consequences. It can, there­fore, only be made with advantage by those, who are become handy in this bu­siness by use, and are capable of distin­guishing, from the state of the affected part, when pressure, and what degree, is necessary; for it is as much impossible to apply it with propriety, from descrip­tion, as to play upon the HARPSICHORD without ever having learnt upon that in­strument.

Upon the whole, so far as I can judge of this matter, immediate amputation in [Page 40]compound fractures ought not to take place, where the joints have not suffered violently by the injury, unless the muscles and tendons are so crushed, or otherways destroyed, as to make putrefaction not a probable, but an inevitable consequence: And it evidently appears from the anato­my of the part, that when the mortified flesh, &c. is digested off, the limb cannot be made useful; and even when the joints have received considerable injury, the ne­cessity of immediate amputation will de­pend upon particular circumstances; for if only part of the ligaments are torn, and the fractured head of the bone can be ta­ken away, the patient may often be cured, so as to have a tolerable good limb: But if the greatest part of the ligaments con­necting the joint are spoiled, there cannot be any hopes of making a good cure; and, in such cases, by deferring amputation, we lose time, omit a good opportunity of per­forming it, while the parts are uninflamed, and suffer the patient to undergo unneces­sary pain from the subsequent inflamma­tion, without any prospect of future advan­tage ^(a).

But my connections with those of my profession have not only led me to know the success of many Surgeons, whose situa­tion affords them only common accidents; but also of several, who, as well as my­self, have had the care of the workmen in Collieries, Lime-kilns, Lead-mines, and the like, where the most violent injuries of this kind frequently happen. In these places, the bones are, for the most part, not only broken into many pieces, and their extremities, now and then, separa­ted, so as to come away; but they are also often forced into the ground, the principal arteries sometimes divided, and the mus­cles, &c. are frequently lacerated, and crushed with immense weights, even so much, that coal sleck, &c. in great quan­tities, is driven into the very substance of the flesh, so as to render the accident as formidable as possible; and yet, it is a no­torious fact, that, where the part is not absolutely destroyed, these desperate cases seldom fail of being cured, without the loss of the limb: From all which I am induced to think, that notwithstanding speedy amputation may be necessary and right in great hospitals, yet this ought to be no precedent for country practice, which certainly points out, that much more may be expected from the resources of nature, [Page 42]than some imagine; because the escapes with life and limb are not very rare, but most frequently happen. You see Mr. GOOCH, who has wrote well on this sub­ject, is not in general for speedy amputa­tion; and I am certain you will have much more satisfaction, and acquire more repu­tation by the discerning part of mankind, in preserving a limb, than in taking it off.

I know, indeed, Operations often make a great noise, and prejudice people in fa­vour of the abilities of the Operator; and some, with very little knowledge in Sur­gery, have raised themselves great reputa­tion by this mechanical part of the pro­fession, which requires no great genius, as it depends only upon a knowledge of ana­tomy, and a practical dexterity of the hand: For do not young Surgeons, of no great abilities, after some trials upon dead bodies, perform operations with the great­est success? And you see, the nicest ope­rations are daily performed by illiterate men upon brute animals, with a dexterity that cannot be excelled by those, who un­thinkingly dress themselves in a most for­midable habit, when they perform opera­tions on the human subject. And yet there have been men weak enough to lessen [Page 43]themselves, and their profession, in think­ing, that a dextrous application of the knife characterizes a good Surgeon.

Nevertheless, notwithstanding this part of practice is so readily acquired, it has of late years been more attended to by the student, and cultivated with more assi­duity, than the treatment of Fractures, Luxations, Wounds, Abscesses, Ulcers, &c. ^(a); and an able writer upon Opera­tions, some years since, overlooked these articles, because he thought the method of treating them was settled. The book Mr. POTT has now wrote, shews there was still room for improvement in the cure of fractures, and dislocations; and a little re­flection [Page 44]would have discovered, that the treatment of Ulcers was not arrived at its ne plus ultra: And indeed, I am fearful the study of that part of Surgery, which is most common, has been neglected, since the spirit of performing capital operations has so much taken place.

These things I mention to you, with an intent to stimulate you to apply your mind to the common ^(a) practice of Surgery; and I make not any doubt, if this part of the profession is duly attended to, there will soon be a decrease in the number of capital operations. And when an opera­tion is performed, you will better know how to treat the patient; for a true know­ledge in the cure of ulcers is required, wherever there is a solution of continuity, which comes to digestion. And not only Ulcers, but the cure of Obstruction, In­flammation, and Abscess, &c. will still admit of improvement. You will here find an ample field for the exercise of your ge­nius; and an enlarged mind will always have infinite pleasure in learning from na­ture, what methods are best to assist her. [Page 45]And the knowledge you acquire will soon distinguish you from those, whose chief enquiries are confined to the narrow limits of handling a knife.

Not that I would have you neglect in­structing yourself properly about the man­ner of performing Operations, it being a very useful, and necessary part of the art; but when the nature of diseases, and the consequence of wounding particular parts are understood, so that you know when to cut, and when to let it alone, this know­ledge will easily be attained; for there are few difficulties that occur in Operations, but what you will be able to surmount, if you can preserve a calmness and a presence of mind; for which purpose I would advise you not foolishly to imitate those, who va­lue themselves upon being quick; for if any accident happens, you will be discon­certed; but go on without too much haste; nor be unnecessarily slow: and if I can judge from experience, you will not only always be guarded against any thing that may happen to frustrate your proceed­ing, but you will also be less liable to com­mit any error that may be injurious; for I am very apprehensive that great quick­ness in chirurgical operations, often ends quickly in the death of the patient. But [Page 46]I am running from my subject; and as no­thing but matter of fact can be depended upon in these cases, shall only add, that I desire you will inquire amongst the coun­try Surgeons, who have been regularly trained up to practice, whether I have not farly stated their success in the accidents under consideration; i. e. whether they do not cure nearly eighteen compound frac­tures out of twenty, without amputation; and if it appears, that you have not been misinformed, I hope you will think I have done right, in pointing out to you a me­thod, by which the country folks, at least, who have the misfortune to meet with very bad compound fractures, may, by proper management, end their days, for the most part, with two legs, instead of one.

LETTER III.

NOTHING is of greater use in Surgery, than ascertaining the principles upon which we are to act, as it leads us out of uncertainty, and directs us to proceed with every advantage to the patient. What Mr. POTT, therefore, says on Dislocations, deserves your greatest attention; as it is designedly wrote to ascertain the principles upon which their reduction depends. An improvement much wanted, as they seem not hitherto to have been generally under­stood, or fully considered, by any writer.

Indeed, it cannot be said, that he is the first who pointed out, that great extension was wrong, and that the muscles ought to be put into a state of non-resistance, in or­der to reduce a dislocated bone, with pro­priety and ease; as you will see, if you examine Mr. THOMPSON'S Paper, in the second volume of the London Medical Ob­servations and Inquiries; but he is the [Page 48]first, who has considered the non-resistant state of the muscles as a general principle, and has endeavoured to prove, that the difficulty attending the reduction of every kind of dislocation, is wholly owing to the resistance of the muscles, and ten­dons, attached to, and connected with the bones composing the joint. Whereas Mr. THOMPSON imagines, that one cause of difficulty is from the head of the bone not being able to get readily back thro' the opening, which, he thinks, it always makes in the Capsular Ligament; for, in dissect­ing the arm of a man, who had a disloca­ted shoulder at the time he died, it was found, on the second day of enquiry, that this ligament was torn off from the neck of the humerus; in which notion, he has the sanction of PETIT, who forty years ago was of the same opinion ^(a); and from considering the anatomy of the joints, and from experiments made upon dead [Page 49]bodies, we find the same sentiments since adopted by Dr. HUNTER ^(a).

This doctrine, you see, Mr. POTT has considered; his arguments about it have weight; and, so far as I can judge from ex­perience, I believe, if the advice of GALEN, which has been copied by almost every wri­ter, of ‘ returning the dislocated bone the same way in which it was displaced,’ is followed, you will, in recent dislocations, never meet with any obstacle from the Ligament, if care is taken, that the muscles do not make resistance to the reduction.

If you look back into the writers on Surgery, you will find the best of them advise, if possible, the practice of reducing dislocated bones by the hand, without much extension; and where extension is necessary, when it is properly made, they direct the bone to be conducted into its place in the same manner. They must mean, when it is not instantly replaced by the muscles upon coming near to the ca­vity into which it is to enter: And it will be worth your while to consider, whether this part of practice should not occasionally be continued, even when we proceed upon Mr. POTT'S principles.

Mr. Serjeant WISEMAN copied the practice of ‘reducing dislocations of the thigh, in young patients, of tender con­stitutions, by laying one hand upon the thigh, and the other on the leg, and having somewhat extended it towards the sound leg, the knee must be sud­denly forced up towards the belly, and the head of the femur pressed into its acetabulum and it will knap in.’ For (he says) ‘there is no need of so great extension in this kind of luxation, for the most considerable muscles being up­on the stretch, the bowing of the knee as aforesaid reduceth it.’

You will readily recollect, that Mr. TRAVIS of Scarborough, about twelve years ago, reduced a thigh which was dis­located inwards towards the foramen ovale of the pubis, by ‘fixing his patient upon his back upon a bed, with his heel against a high raised bedstead, where he had sufficient foot-hold, and the extension was made by three men, with a towel fixed above the knee upon a napkin folded and rolled on to prevent the skin from being chafed. The patient's, right knee was bent so as the leg made about a right angle with the thigh; and an assistant was placed on his knees upon [Page 51]the floor, holding the ancle, with di­rections, on a certain signal, to push the leg outwards; by which, as with a le­ver, the head of the thigh bone would be twisted inwards and downwards. Mr. TRAVIS placed himself on the patient's right side at the bed foot, with the palm of his left hand on the head of the lux­ated bone, and his right near the pa­tella. The extension being made gra­dually and steadily by the towel-men, until Mr. TRAVIS thought the bone might be moved, the signal was given to the assistant who held the ancle, which he punctually obeyed; at the same instant, with a smart jerk, Mr. TRAVIS pushed the head of the bone downwards and outwards, and the pa­tella inwards; and immediately the bone rushed into its proper place with a snap, that was perceived by all present.’

About twenty-eight years ago I saw Mr. HOLBROOKE reduce a dislocated thigh in a hearty young fellow, about twenty-one or twenty-two years of age, much in the same manner, except that the exten­sion was made by pulling at the ancle, as well as at a cloth fixed above the knee.— A Gentleman, bred up to Surgery, living in the same town, was first called in; who [Page 52]soon discovered the nature of the accident; but having declined every part of the pro­fession, except midwifery, and not having before seen a dislocated thigh, he directly sent for Mr. HOLBROOKE, in whose ab­sence it fell to my share to attend; but be­fore I set out, I thought proper to look what had been said about an accident I had never seen, and had the misfortune to take down TURNER, who seems to have copied from WISEMAN; but has omitted the material circumstance of making his extension towards the sound leg, and push­ing the knee up in the same direction. When I came to the patient, the round head of the bone in the groin near to the foramen ovale, and a cavity where the great trochanter ought to have been, at once discovered what was the matter; and we therefore set about reducing the dislocation in the manner Dr. TUR­NER directs ^(a): But after repeated at­tempts without success, we tried whether the strap would assist, by one pulling on the outside the thigh, while the other pushed upon the head of the bone; but this did not help us; and seeing we were not likely to accomplish the work we had [Page 53]undertaken, I dispatched a messenger away for my master.

Being come, he made the extension in the manner we had already done; but he placed himself betwixt the patient's legs, with both his hands upon the outside of the man's knee, and one of his own knees was fixed against the upper part of the thigh bone; and when he thought the ex­tension was sufficiently made, he at the same instant (as the patient lay upon a bed rather below him) pushed the femur down­ward, and outward, and pulled the knee inward; by which means the head of the bone went directly, with a considerable snap, into its place: — So that in all these cases the reduction was finally accom­plished by making a lever of the thigh bone.

Some years since, a child, about six years of age, was brought into my Sur­gery, on account of its having received by a fall, an injury in its hip; and upon in­quiry, I found the upper part of the thigh bone intirely at liberty, and under the edge of the gluteus muscle. Upon which, I of course set about examining, whether the head of the bone was dislocated, or broken off at its neck; for which purpose, I di­rected (as the child lay upon a woman's [Page 54]lap) the thigh to be put into a state of flexion, then extended by pulling gently at the knee, and moved from side to side, keeping my own hand upon the greater trochanter, which I could plainly perceive; but luckily, at the very first of our making these motions, while I was pressing upon the bone, it slipped from under my hand into its place; so that we cured the pa­tient, and learnt the nature of the acci­dent, both at the same time.

A similar case lately fell under my no­tice. A lad, about twelve or fourteen years of age, was thrown from a horse, and some bags of flour fell upon his hip; from which accident that leg and thigh were rendered useless. The Surgeon, who was first called, attended him several days; and the hip being swelled from the bruise, he honestly told the friends of the boy, that he could not tell with certainty, what was the matter: Upon which I was called in. I first saw him in bed, and observed, as soon as the bed-cloaths were removed, that the knee of the injured thigh lay over the middle of the sound thigh, in a loose, aukward manner; and upon taking hold of the knee, I plainly discovered, that the upper part of the bone was at liberty un­der the gluteus muscles; but whether it [Page 55]was dislocated, or broken, we could not yet tell. We therefore placed him upon a table, to make our proper inquiries; but in moving the thigh, as in the last case, I felt the bone slip from under my hand, the hip and thigh became perfectly right, and the patient from this time began to recover the compleat use of his leg, &c.

Hence it is plain, that a dislocated thigh may most easily be reduced in a state of flexion; and though these were only young people, yet it is probable, that those far­ther advanced in years may be cured in the same manner, by only making a stron­ger extension. CELSUS, PAREY, WISE­MAN, and many others, reduced thighs in this state, notwithstanding their exten­sion was made in a strait line; but unless they took great care to keep down the head of the bone, when they pushed up the knee, the bone would return to the place from whence it was drawn, and pre­vent the reduction; which inconvenience will be avoided, if the thigh is bent at the time extension is made. May not we, therefore, from these circumstances, from the cases we have mentioned, and from what Mr. POTT has said upon this sub­ject, select a practice that will effectually serve our purpose, whenever the accident [Page 56]immediately under consideration requires our assistance?

When a thigh is dislocated, inward, or outward, perhaps it will be best to follow the advice of CELSUS, in laying the pa­tient on one side, so that the part into which the bone has slipped, be always up­permost, and that from which it has re­ceded, lowermost; by which means the extension may be made in any direction you have a mind, and your own invention will point out to you twenty ways of se­curing the patient upon a bed, (for a table will be too high,) so that a proper resist­ance may be made to the extension.

This being done, the knee bent, and a towel fixed properly above it, you must place yourself on that side of the thigh, to which the bone is dislocated, with your knee near to the head of the bone, and both hands on the opposite side of the knee of the patient, an assistant being fixed at the ancle. The extension may then gradually be begun, by three or four men, with the thigh rather in a state of flexion; and when there is reason to think, that the head of the bone is drawn upon a level with the socket, the extension being stea­dily continued, the knee may be bent [Page 57]nearer to the abdomen, and at the same instant, while your knee pushes the bone towards its place, the ancle must be mo­ved in the same, but the knee of the pa­tient in a contrary direction; by which means, I imagine, the bone will, in ge­neral, be replaced, provided the extension is sufficiently made, before we attempt to return it into its socket.

I think it is generally allowed, that dis­locations of the thigh rarely happen other­wise than inward or outward, though wri­ters also talk of its being dislocated up­wards and downwards; but when we call to mind, how seldom this accident in any way is met with, it will appear, that our assistance may perhaps never once be re­quired to reduce dislocations of the thigh, thus circumstanced; and it may be much questioned, whether Surgeons have not copied this account from one another, without ever once having seen this acci­dent; for HIPPOCRATES first started the opinion, perhaps, from imagining there was a possibility of its happening in these dif­ferent directions: And I see it has been handed down, by almost every writer, in his very words.

However, if the dislocation upwards or downwards does ever happen, I imagine you will not be at any great loss about the reduction, if the same plan as we have just laid down is pursued; except that exten­sion must at first be made with the thigh in a strait line; and it seems most proper to place the patient, as PAREY advises ^(a), "on his sound side," and of a convenient height, that the pressure with your knee may be made in a strait direction.

When the shoulder is dislocated, the head of the bone, you know, often rushes into its place, when it approaches the cup of the scapula, even when the extension has been made with the muscles in a state of resistance; and it is reasonable to be­lieve, that it will more readily happen, when this impediment is removed, by their being relaxed. Nevertheless, further art will sometimes, I think, be required, to conduct the bone into its place, even un­der [Page 59]this advantage. Mr. THOMPSON, you see, proposes, that ‘the arm should be raised upwards, and a little inwards, to bring it in a line of direction, centering between the tendons of the subscapula­ris, and teres minor muscles; both of which, and the flap of the capsular li­gament, will be relaxed by that means; the arm is to be held in that position by one hand of the Surgeon; the infe­rior angle of the scapula must then be carried backwards towards the spine, and the acromion depressed downwards by an assistant. These motions will bring the head of the humerus to the outside of the brim of the glenoide ca­vity; and the Surgeon, who has hold of the patient's arm, making a gentle ex­tension upwards, and passing the thumb or fingers of his other hand into the axilla, and there pressing upon the head of the humerus, by way of fulcrum, de­presses the arm with a quick motion, in a line of direction, as before mentioned. Thus the reduction, I apprehend, will most likely take place, by the head slip­ping over the flap of the capsular liga­ment, and between the two tendons into its socket.’

I have never tried this method, be­cause, in the space of twenty years, though I have used nothing but the napkin and ball, I have not, in recent dislocations of the humerus, been once disappointed in my first attempt to reduce them, when the head of the bone has lodged in the axilla: though ever since I read Mr. THOMPSON'S Paper, I have made my extension with the fore arm bent, which is supported either by the patient himself, or a stander-by. I place the patient upon a cushion on the floor, and fix him, by proper assistance, that his body cannot give way to the ex­tension. Having put the arm through a napkin tied together in the common man­ner, and betwixt my thighs; I put the napkin over my neck, and fix a linen or a woollen ball in the middle of the napkin, so that it cannot move. This ball is three times as large as those commonly used, of sufficient hardness to make a resistance to the head of the bone, and yet soft enough to press into the axilla. The processus a­cromium is left intirely at liberty, and when three or four men (who, by sitting upon the bare floor, are rather lower than the patient) have by a towel, tied, with the usual cautions, above the elbow, drawn the head of the bone forward enough, in [Page 61]a direction that keeps it about the middle of the axilla; I press the ball in behind it, and by leaning backwards, instead of for­cing the head of the bone against the neck of the scapula, I push it outwards, so as to assist those, who make the extension, till I find it arrived at the edge of the gle­noide cavity, when I direct the elbow to be brought nearer to the side, and at the same time raise myself more perpendicu­lar, by which means the head of the hu­merus raises the processus acromium a lit­tle, and slips up; immediately upon which I push the acromium down again, if ne­cessary, though it is seldom required. Af­terwards I move the arm in all directions, that the long tendon of the biceps, &c. may again return to their usual place.

You will readily see, from this account, that the arm is drawn rather downwards; which, according to the opinion of some, is an improper position; for they say, if the extension is made in an horizontal direction, or downwards, ‘as the head of the humerus will press upon one or other of the tendons of the subscapula­ris or teres minor muscles, if the exten­sion be forwards or backwards; and if it be in the middle, it will be opposed by the united force of both tendons, and [Page 62]of the stretched capsular ligament, so as to render the reduction impracticable without a further laceration.’

Indeed, in regard to an horizontal po­sition of the arm, I can easily believe it improper, when the bone is dislocated downwards; but I assure you; the method of reduction just mentioned, has always been attended with the greatest ease both to myself and patient, besides a compleat recovery; and believe me, one grain of matter of fact, to a practical Surgeon, is worth a pound of reasoning.

I have some few times seen the head of the humerus under the pectoral muscle; but in making the extension, and moving the arm inward, it slipped into the axilla, and was then reduced in the common manner. I have oftener seen the head of the bone dislocated backwards towards the scapula. I remember being called to a case of this kind in a hard working fel­low, betwixt twenty and thirty years of age, many years ago. After discovering the nature of the accident, I placed the patient in a chair, and ordered the exten­sion to be made with the arm in an hori­zontal posture, which I assisted by push­ing with my own hand the head of the [Page 63]bone towards its place: but though we brought it near to the glenoide cavity of the scapula, yet these steps alone could not replace it. I therefore kept my hand fixed upon the head of the bone, that it should not recede, in which I was assisted by a steady extension at the elbow, which I directed to be bent, and to be pulled backward at the same instant that the hand was turned a little upwards; upon which the bone was immediately reduced. And I have since had the same success, under the same circumstances; but I took the management of the fore arm to my­self, and got an assistant to push at the head of the bone.

If you call to mind, you will remem­ber that a dislocation of the under jaw is put to rights by extending the jaw for­ward, pressing down the posterior part of it, and at the same time pushing the ante­rior part upward. The elbow, when dis­located, is reduced by making an exten­sion, till the fore-arm can be put into a state of flexion, and then it is easily ac­complished, by bearing upon the lower end of the humerus with one hand, and by taking hold of the wrist, and bending the elbow with the other: and if it is on either side, the hand of the patient must [Page 64]be turned inward or outward, at the same instant, as the case requires. Nearly the same steps are taken with the knee or an­cle, when out of joint, &c. From all which we may conclude, with CELSUS, that ‘whatever be the species of dislo­cation the method of reduction is the same.’

In dislocations of long standing, we find the head of the bone forms for itself a new socket ^(a); which, with the growing together of the lacerated with the neigh­bouring parts, in some cases, and the con­traction of the tendons, &c. in others, is probably the reason why they are reduced with difficulty, or that reduction is im­practicable ^(b).

The method of reduction Mr. WHITE recommends, of suspending the body by the arm, seems the most likely to over­come this obstacle: Though myself, and another Surgeon of much experience, used it without effect, with every other method we could think of, in an old dislocation, where the os humeri had slipped back­wards towards the scapula. Perhaps the [Page 65]case was incurable; for the same Gentle­man tried it where the bone had been a month under the pectoral muscle with suc­cess; and another Surgeon has since in­formed me of his moving the head of the humerus, by this method, from under the pectoral muscle, where it had lain some time, into the axilla.

It was a common practice, both with HIPPOCRATES and GALEN, to reduce dislocated thighs by tying ligatures about the ancles and knees, and suspending the patient with his heels towards the top of the room; but remember, whenever this mode of reduction in the shoulder is pur­sued, above the elbow is the part upon which the suspending ligature should alone be fixed.

By this time, I imagine, you heartily repent asking my opinion about these mat­ters; but as one link of a chain draws on another; so I have been led to say more upon this subject than I first intended; though I imagine joining practice to the­ory will always be acceptable to a young Surgeon. If the method of reducing a dislocated thigh had been clearly laid down, the Surgeons at the ^(a) Worcester [Page 66]Infirmary could not have been at a loss, in what manner to have relieved this ac­cident; and you see, at last, they were forced to have recourse to the vis percus­sionis, which I would chuse to translate, "Reduction at random."

If you take a view of the chirurgical writers in regard to dislocations, you will find they have chiefly copied what HIP­POCRATES has said upon this subject, and that much the greatest part of the im­provements which have been made, till within these few years, has been in an al­teration of, or an addition to, the ma­chines he sometimes used in reducing them, which was certainly improving the worst part of his practice. He gave us the dif­ferent methods, that were employed in his time, some of which have been copied by one writer, and some by another; and they have been handed down to us, as the work of different men, by the idle custom of every one implicitly copying a favourite author: Whereas, had they collected only the most eligible practice from HIPPO­CRATES, together with the few real im­provements made by other writers, I think they might have deduced a rational me­thod of cure. For they might have learn­ed, that the dislocation should be reduced [Page 67]as soon as possible, that the extension should be gentle, gradual, and continued till the dislocated bone is upon a level with the cavity from whence it receded, at which time, if it did not return of itself, it should be reduced the same way, in which it was displaced; or, as CELSUS has it, ‘from that side in which it was prolapsed, to the contrary, by pressing upon the head, and making a lever of the dislocated bone.’ PAREY expressly says, you should not fasten the ligature to the wrist in a dislocation of the shoulder, or to the ancle in a dislocation of the thigh bone; but above the elbow, or a­bove the knee; otherwise the joint of the elbow, or of the knee, will be more ex­tended than the shoulder or hip. The ex­tension in dislocations of these parts, was, in the days of HIPPOCRATES and GA­LEN, often made with the fore arm, and knee bent; and it evidently appears, from the practice of every writer, (and, I should imagine, from every man's own experi­ence,) that, whenever a dislocated limb was reduced, both with ease to the patient and his Surgeon, the muscles were in a state of flexion. But the reason these were not selected from the injudicious parts of practice, seems to be, because the princi­ples, [Page 68]upon which we ought to proceed, were not ascertained. But from observing Mr. POTT'S doctrine in preserving the mus­cles in a state of non-resistance, by the po­sition of the limb, and by retaining the practice of conducting the head of the dis­located bone into its place, I apprehend we shall make choice of that method which will relieve our patients with cer­tainty and ease.