Surgeon General's Office
LIBRARY

Section,...... Shelf,......
No. 85147
Presented By
Dr. J. H. Pooley.






















Put this in the book.

Columbus, Ohio
Jan. 16th 1882.

Dear Doctor,
   I send you this
time a unique, it is a manuscript
volume of notes on Sir Asttey Coopers (with a check mark above)
lectures, taken by Dr E. G. Ludlow, who
was at the time of his death (at nearly
ninety) the oldest trustee of the College
of Physicians & Surgeons of New York,
  He gave it to me not long before he
died, and I send it to you to help to
fulfill your own statement that the
treasures of the private collector are des-
tined at last to the large libraries.
Yours Truly J. H. Pooley

Dr. J. S. Billings U.S.A.
Washington,
D.C.

On Scrofulous Inflamation of Joints

The stages of inflamation of the diseases of Joints
are the same as those which have already been des
=cribed of the Glands, and they are marked by the
same degree of indolence they are vulgurlary de
=nominated white swellings, this name is probab(ly)
given them on account of the skin not undergoing
any change with respect to its complection you
will find that these diseases of the joints are
generally going into three stages, the adhesive
suppuration and ulceration. First, of the adhesive
inflamation of the joint, the child has at first
but very little pain, there is only a degree of stif
ness, and he is less able to move about than usual
This is succeeded by a swelling which is at first
inconsiderable, on entending the joint there is
some degree of pain which arises from 
the swollen state of the sinovial membrane
this when the limb is shattered is [preped?] between
the extremeties of the lower and thereby occasion,
the pains and impedes the motion of the joint.



2

generally however there is but little pain, the 
constitution does not suffer much under this stag(e)
of inflamation of the joint, except the person
is irritable, but indolent scrofulous habits
it is scarcely affected. after the joint has been
considerably affected you see the swelling suddenly
increase cold or more exertion than usual will bring
this in and then suppuration is induced. The
matter seldom fills the whole cavity of the joint
but is separated into cystes, owing to previous ad
=hesive inflamation. It is confined to a small
part instead of the whole joint, when matter is
formed you find the constitution becoming affect
but this depends on irritability of the patient. 
the diseases is different in different subjects, in one
it will be very indolent in all its stages [&?] in
another more rapid. When matter has once
formed it generally produces ulceration, but not
always it may be absorbed, you should not
therefore open the abscess too early, but endea
=vour to promote its absorption by stimulating



3

[placiters?]. When matter is formed in a Joint it does
not make its way directly the the surface, but makes
its appearance at a considerable distance, this takes
its place sometimes above, below, or behind the
knee I have seen it as much as two inches &
a half below the knee, it most generally makes
its way downwards appears at the insertion
of the semitendinosus semimembranosus,
Sartorius, in depecting these joints, you find im=
=mediately under the skin a quantity of a adipose
Matter even if the person is elsewhere thin, on cutting
through this you find the ligaments considerably
thickened, it has the appearance of Jelly, under
the ligament of the joint you find the seurial
membrane (which is the principal seat of the
disease) highly vascular, it is this which is the
first place inflamed. The ligament of the joint 
is of a tendenous structure, & is not liable to
scrufulous affections. The ligaments of the
joint only become occasionally diseased.
The inflamation occuring in the sinoreal



4

membrane entends to the extremeties of the bones.
the cartilage becomes entirely absorded, the ends
of the bones are becoming ulcerated, holes are
formed through them and they look as if worm
eaten, sometimes however an [apific?] inflamation
is producing a deposit of earthy matter on the
bone, whereby considerable enlargement takes place
The bones are ulcerate in the beginning of afterwards
there is a deposit of earth on them, If the Joint
recovers its motion after the cartilages are
absorbed, the ends of the bones become highly
polished so as to resemble ivory. As to the
causes of these diseases in joints the most
common is over exertion, walking for a conside
=rable time, especially children walking by the
side of the mother & obliged to take several step
to the mothers one, on the succeeding
the child will complain of a pain in the
knee. The patent will generally refer you to
some fall as the cause of the disease, but
generally accidents do not produce it_



5

Treatment of Scrofulous diseases of the Joints

If called to a child when the disease is in its 
incipient stage, you immediately direct it to be put
at rest. Rest is one of the most essential objects
to be observed, the child is to be ordered a sofa
until the pain and swelling is removed, but it is
difficult to force children to submit to it, and
therefore it is necessary to give motion to the rest
of the body, for this purpose the use of crutches
will be advisable, when the disease is in the ancle
or kneee, but it does not answer when the hip joint 
is affected, for the weight of the limb adds to the
inflamation going on and the motion gives pain,
it is necessary to give to the child every night or
every other night, Sub mur, Hydearg, and Scammony
every fourth evening, or Rheubarb your object is
to reduce inflamation, when the inflamation
is slight and good deal of indolence then you 
should give good aperients more frquently. But 
if the inflamation is considerable and the con=
=stitution very irritable, an aperient should be
given only occasionally. The mercurial aperient 



6

is the best, it subdues the inflamation the most
readily, altho' the disease orginated in debility, you 
are not to make use of strengthening remedies
immediately. In the first place you are to subdue
the inflamtion and the support the constitution
in addition to rest, you must apply evaporating
lotions, as Spiritus vini, zss, with Sig Ammon, acct
z ofs, when these plans are found to be unsuccessful
then you must resort to external irritation by
means of blisters. For apply a Blister over a 
small part of the knee only at a time, this
should be healed in a few days, & then another
applied on a different part of the joint, in this 
manner you keep up irritation the best, and
injure the constitution the least, if it resists
this apply a perpetual blister and keep it open
by Ung. Sabina or Ung. Lyttoe, when the irriation
is considerable and the constitution becomes
affected then it will be necessary to apply
leeches or Cupping, or the Tartar emetic oint=
=ment 
Rx. Tart. Emet. ʒi  iij
    ung. bet. ℥j.  m.





7

Let this be rubbed in twice a day near the fire &
in two or three days an eruption will be brought to
some extent but take care it does not react on the 
constitution else it will do harm & if you find the
irriation carried so far as to affect the constitution
it is wrong to apply it in that way, it always does
mischief if fever is induced, it was formerly the
practice to make use of setons if issues, but
they should not be applied to the knee, the ancle
Elbow or Wrist, It will add to instead if taking
array from the inflamation, it extends from the exter
=nal to the internal part of the joint, But in 
the Hip where there is a thickness of the parts they may
be [imployed?] and in consequence of which the en
=ternal inflamation will not extend to the inside,
your means of external irritation should be as gentle
as possible Setons are worse than Issues. I have
seen setons produce such as a degree of inflamation
as to increase the disease of the joint & constitutions
irritation. When Suppuration has taken place in
the joint, the treatment is very simple, make use
of fomentations and poultices, & bring forward the



8

process and as the constitution is affected give small
doses of Opium to allay the irritation, it may be given
in the form of the Lig: Ammon acct with Tinct Opii, or
to a child the syrup of Poppies, when the matter is 
discharged it is right to make use of external irritation
which lessens the discharge from the interior, & next
produces an union of the sides of the joint, Tartar
Emetic ointment may be employed and Blisters,
but at the same time attend to the renovation of the
constitution. The result of the Ulceration process
is one of the Kinds of anchylosis_
   The First is only an adhesion with still
some degree of motion remaining although the
Cavity of the joint is obliterated. There is a High
degree of motion & that may be increased by the
absorptin of the adhesive matter, so that the
powers of the joint may be in some measure res=
=tored. But the limit is not to be immediately ex
=posed to passive motion on the subsidence of the 
inflamation, Friction & motion will afterwards
be of service & on this ground Mr. Grosvenor of Oxford
has obtained great credit in releiving the Stiffness,



9

but it is very wrong in the inflamatory stage.
  In the Second there is an alteration in the
form of the extermity of the bone, some parts of the
joint project & this interrupts the motion & occasions
a partial Archylosis. If the patient be young the
projecting parts will be in a great measure removed
by absorption, by cautiously endeavouring to produce
some motion, But let the disease be suspended
before this plan is adopted.
   The Third is complete Anchylosis by a bony
process, when it is about to take place the joints
are to be placed in such a position, as to render
the patient the greatest possible service after they
have become stiffened. If it be in the ancle the
foot should be bent at a right angle with the
leg. If it be in the Knee joint it should be a 
little bent forward, else he will be obliged in
walking to carry the limb around, whereas in
the other case he walks on the toe, with a slight
degree of lameness. The wrist should be straight
the Elbow at right angles for if straight it is



10

useless for all but underhand motions_
   With regard to amputation of diseases of the
joints, it is scarcely ever necessary to amputate the 
limb on account of the local disease, but on account
of that of the constitution, you can save them and
give to the patient a tolerably useful limb saving
some degree of Anchylosis, now and then if the bones
are ulcerated very extensively we amputate but
this is different from the scrofulous disease, then
the constitution is not much affected by it. The
constitution generally bears up well against the
Scrofulous diseases of very severe character, expect
the knee joint, and in chronic diseases, when it
is of some extent. The Cronic inflamation arises 
from an altered constitution, the effect of bad
habits, and you may generally bring it back to
the healthy standard, But the constitution feels
these worse than in ordinary Scrofulous Cases,
there is not one operation for amputation in these
cases for twenty that were performed Thirty
years age. When a joint is in a very indolent



11

State, & there is an enlargement, it is best to strap
it with the Emp. Hydiars: C Ammonica. the straps
applied very firmly, the pressure of this produces absorp
=tion, and a tight bandage over the expedites the process
at the same time keeping the limb steady_

Of Diseased Hip

The disease of the hip differs from those we have
described. It is known by pain in the limb in the
course of the siciosiatic nerve usually from this
nerve being the seat of the disease, sometimes the
anterior Causal nerve is affected & then the pain 
is felt in the anterior part of the thigh & at the in=
=sertion of the muscles that surround the joints
as the pectineus, adductor brevis &c but more frequent
=ly the knee & outer part of the leg are most consider
=ably affected. How do you learn it is this disease
If a child is brought to you & the mother says
it has pain in the knee, and there is an enlargement  
of it you will examine the Hip and find that
the diseased sides will measure from the cleft
to the trochanter major a greater distance than




12

the sound one. It is also very flat, on the sound side
there is a roundness advancing gradually to the
trochante & the difference is particularly remarkable
if you lay the patient on his face. The line of the notes
are an inch lower on the diseased, than on the the
healthy side, to ascertain further the existence
of this disease, roll the thigh & immediately he
complains of pain, if you roll it outwards, you
thereby stretch the ligamentum tires & pain is pro
=duced, ask him to sit down & instead of doing
it with his thigh bent at a right angle with his
body. he stretches out his leg by the side of his chair
ask him to kneel & touch the toe of the leg in which
there is pain and he will say, and he will say "Oh
I can't sir" If you lay him on his back, at first
sight the limb of the affected side seems larger
than the other, but it is not, the appearance is owing
to obliquity of the pelvis, Whether the ancle knee
or hip is affected the effect is the same, that the
weight of the body is borne upon the opposite limb
so far from the leg being really longer when the dis=
=ease has made some progress it is in fact



13

shorter from the diminution of head of the bone
& the cup being enlarged. This takes place in all direction,
but more particularly upwards & at length the absorption
going on, absolute dislocation of the thigh bone takes
place. The Cuprular is ulcerated when it arises from 
the run of the acetabulum, the head of the bone slips
from the socket and rests on the dorsum of eleium
this only the result of long continued disease. When
the suppuration process takes place matter forms away
the muscles & the abscesses break at some distance,
from the joint below it and the further off the better
is the situation of the patient, and the less does he 
Suffer. Abscesses sometimes make their way through
the acetabulum & burst into the cavity of the pelvis.
Somtimes they open into the rectum & occasionally
into the Vagina & in one instance which I saw
the patient recovered. This is the only case that I
have known of then breaking into the Vagina
for it is more frequent for them to open into the
rectum, sometimes the head of the bone is ulcerated
away, entirely absorbed_



14

Treatment In the adhesive stage if you are to adopt
the same plan in these diseases as in the other joints
during the adhesive inflamation, but it is necessary 
to make use of external imitations issues & Setons
are to be imployed, but not so as to excite consti=
=tutional irritation, the external inflamation should
not extend so as to communicate with the inter
=nal. Issues in disease of the spine even are now
very much out of practice. they are doubtful as
as to their influence & add to the disease often.
Issues and Setons are inferior in value to bli(s)ters
which may be healed & applied again, this is a 
better plan than a perpetual blister which in irrita
=ble children are often very injurious. 
   When suppuration comes on it is better that
the matter should travel to some distance before
it breaks. In Absecess from joints do not open them
unless they are of very considerable magnitude & then
then will be less constitutional irritation. If you
find an absecess & open it directly over the joint, infla
-mation will succeed & extend directly into the joints



15

the higher degree of constitutional will ensue & be dis-
=tructive of life let it burrow & be opened by a process of
nature, in the latter case the joint will be filled by
adhesive matter & in the other the whole cavity will be
opened. There is not a worse practice than making 
early openings into abscesses in the vicinity of joints.

Disease of the Spine

The joints of the Spine are liable to similar dis= 
=eases with the other joints of the body, inflamation
takes place between the bodies of the vertebrae, a
thickening takes place from alluminous deposit, & a
subsequent absorption of the intervertebral substance
which gradually extends to the bodies of the vertebrae,
the body of the bone being absorbed the spinous process loses
its support and projects posteriorly the projection being
more or less according to the number of the vertebrae
that have given way. The Spine falls forward & the
spinal marrow is pressed upon by the alteration of possi
=tion & by an effusion into the canal in consequence
of which prepare paralysis is produced, this paralysis
differs from common palsy, the muscles are rigid



16

instead of being in a relaxed state, the limb does not hang
lifeless, but the joints are with difficulty moved. The
muscles cease to act altogether in common palsies, but
in this disease they are thrown into Spasmodic contraction
the patient is disturbed by cramps during sleep, and
the heels are drawn towards the buttocks. The thigh
towards the abdomen, this arises from the irritation
of the nerves going to the limbs. There is no sensibility
in the parts, they may be cut without sensation, where
pressure on these nerves is considerable. Before any
disease is appearent the extremeties are weakened, the
actions of the muscles are irregular the legs are crossing
 each other, being directed out of their proper
course which the mind intended & thereby fall. The
disease will remain for weeks & even months in the
adhesive stage, before it proceeds to the Suppurative
and the collections of matter form on the forepart
of the Vertebrae, the course of these abscesses an various
either towards the Thigh or Loins, or of the disease be
in the dorsal vertebrae, it may make its way into the
lungs and be discharged by the bronchiae. Here is a



17

Specimen, A woman who was an equestrian in the royal 
Circus, fell while performing some feat & injured her
Spine, matter was coughed up, She died, on examination 
it was found that an abscess situated on the forepart
of the vertebrae communicates with the lungs_
  Another Specimen of the same disease, the number
of vertebrae which become absorted is very various, some
=time, one or two or three. The greatest number we have
in the collection is five and but three of them are entirely
taken away, parts of the other two remain, after a person
has long sustained a paralysis, a cure gradually takes
place, from the vertebrae falling together and the spine
anchylosisig, one of the first cases which I saw was
a boatman who laid in one of our wards two years
with paralysis of the lower extremeties, he gradually re=
=covered and returned to his former occupation, generally
however Suppuration takes place and they sink under
the disease, but they do not necessarily die. The cure
can only be produced by anchylosis, we have different
Specimens of the cure of this disease, and you will
see it is by the upper vertebrae falling upon the lower
that a cure is produced. It is necessary for you to be 



18

acquainted with the circumstamce in order that you may
not resist nature in her efforts to effect it.
Treatment  The first and most essential point to atten
=ded to is rest. The patient should be kept in a re=
=cumbent posture, but not constrained to one positon
let him turn from side to side. The shoulders should
be raised when he lies on his back in order that the
edges of the ulcerated bone may be brought in contact
The second object of attention is to preserve the general
strength as much as you can, give him animal 
food also Porter & Wine of not too stimulating, they
should be used to give rigour to the system, but let
them never be given so as to produce feverish heat, or
fur on the tougue or flush on the cheek, for them they
will do harm, you must also at the same time attend
to the state of the bowels, Give two grains of the sub.
mur. Hyd q five grains of Rhubarb twice a week 
this will prevent feverish heat & give vigorous action
to the bowels_
   In these cases it has been recommended
to apply a machine for the purpose of keeping the spine
extended but nothing is so erroneous, you will never



19

succeed in a cure, if you keep it spine straight, and
if it does not keep it straight it is only an incumberance
The vertabrae must be brought together in order thus a cure
may be produced, if a fractured limb is seperate the
bones will not unite. Mr Levain had a boy with
a fracture of the Tibia, he sawed of the end of the
bone & they were kept apart so that no union took
place. The distance of the ends of the bones was so
great so as to prevent bony matter shooting from one 
to the other. I saw the other day a patient who
had worn machines & it was the most crooked, I
had ever seen. They not only prevent the cure, but
ulceration process is sill continuing during their
use. If a person had an ulcer on the inner side
of the arm, you would not tell him to extend
but flex it, so as to bring the edges of the ulcer
in approximation so with an ulcer of the spine.
Anchylosis must take place, no machine should
be used it is excessively wrong. With regard to
external imitation, this should be used to a degree
so as not to produce, any constitutional affection. Issues



20

if extension produces considerable constitutional irritation
Setons produce less therefore are better. It is best I think
to rub the part with Ung. Tart Antim. If the external
irritation produces constitutional affection it should be
stopped, external irritation has an effect of lessening deep
seated disease, what I advise is a stimulating plaster to the
spine in the course of the disease & by it endeavour to produce
a determination to the surface, but if the disease still
goes on. I advise the Tartrite of antimony ointment,
this produces an eruption which can easily be commanded
We now depend more upon rest, diet & aperients than
constitutional irritation. I cannot but think that
my friend Mr. [Bayuton?] of Bristol is wrong in his 
advice in respect to the treatment of this disease, he
recommends a constrained position of the back. I have 
been informed by those who have been under his care
that he keeps them on the back for six or twelve months
If he would but come and see one preparation, he would
be convinced that instead of producing a cure it retards
it. I attended the wife of a Russian Nobleman on whom
this plan had been adopted, and the disease still
continues. She laid on the mattress twelve months.



21

& when she got up the disease remained, she went to
Naples & I have since heard she had not recovered.

   Of Psods and Lumbar Abscess

Psods & Lumbar abscess are a part of the discan I have
just described, They only differ in situation, They origi
=nate from the ligament of the spine & the matter is
situated between this ligament & the vertebrae on the
for part of the spine, it proceeds downwards following
the course of the psods muscle, it enters the muscle
and becomes encased in its tendanous covering, as the
matter passes down, it gets under ligaments,
until it gets there it is within the substain of the Psods
muscle. After it reaches the tendanous structure of
the sods it cannot hold its course any longer & it
ulcerates into the Psods muscle & makes its appearance
at the upper & inner part of the thigh. If the disease of
the spine begins near the transverse processes it makes
way to ward the loins & thus lumbar abscess is produced
but it is virtually the same , It is only an extension of
the disease of the spine, the matter breaking near the
transverse processes instead of the bodies of the Vertebrae
This may be resembled to abscess of the knee from



22

discan of the knee joint or of the Hip. It does not point
when it forms. The first indication of the disease is a 
pain in the loins which continues for some weeks
then there is a difficulty of retracting the thigh, you
can at first distinguish it by telling the patient to throw
one thigh behind the other, this produces pain in the 
course of the Psods muscle from its being put on the
stretch, The matter after a while points at the surface
and the inner part of the thigh about the situation of
the Femoral Hernia, If the matter is allowed to dis=
=charge of itself it will be only partially & by a small
opening, a clot will then fill up the opening & stop
the discharge after a while this will ulcerate, then more
is discharged, a larger clot fills the opening and so it
goes on gradually until the whole is discharged, before
the matter is discharged no constitutional irritation
is produced, but as soon as it is evacuated, the con
=stitution begins to suffer, shivering, heat, copious
perspiration, & other Hectic symptoms ensue, the
patient generally falls a victim to the disease
but if the ulceration of the spine is small the
patient may recover, sometimes then is an exfoliates



23

of the vertebrae & spicula of bone may be discharged from
the Groin. Treatment  Until they acquire some con
=siderable magnitude it is best not to meddle with
them but apply some simple plaister on the surface
so as to excite a perspiration from the part, If you
find however that inflamation of the skin has taken
place & the abscess is about to burst, then it is best
to puncture it according to the plan of Mr Alburnethy
you may make the puncture with obliquity, discharge
the matter and allow adhesion to take place, discharge
it again & again, at first discharge about half, the
next time rather more than half & so go on in the 
hope that it may ultimately heal, This is doing
all that art can effect. You should puncture
it obliquely so as to have a good surface for adhesion
& it is thus more readily effected.
Sometimes the wound continues open, the manner
I generally do it is by a small Trocar & I think
it leaves a wound more ready to adhere. Rest is gen
=erally essential as with diseases of the spine &
the same constitutional treatment should be resorted
to as therein directed_



24

Lumbar abscess requires the same treatments_

Strumous Pimples on the Face, These
are very common in young persons, it is of no conse
=quince in men, but young women are often deformed
by them, the proper mode of removing them is by
improving the general health, Then is a foolish
idea spread about that there is a necessity for keep
=ing them low & on vegetable food, but it is not
by keeping them low that you are to cure them
but on the contrary by giving vigour to the circulation
& the system. The best local treatment to prevent
deformity, is as soon as the matter has formed to
puncture the pustule with a needle, this will
prevent it burrowing under the skin & making
a deep pit like small Pox.
   Lippitude is a Serofulous inflamation
of the eyelids, we should give to the patients
the oxymuriate of Mercury with bark & apply to the
eyelids Ungt. Hydia: Nitrate ʒii mixed with ℥ss
of the Ungt. Cetacei, The Testicle is sometimes
the subject of Scrofulous disease it occurs in boys



25

from the age of puberty to the age of twenty years. It may
be generally cured by the sublimate of Mercury with
bark or bark with soda. I have seen both Testes enlarged
with this disease without any pain, now & then it
goes on to suppuration & abscess, but it is only when
it is badly managed_

Ricketts

Ricketts are occuring in children who are born with
a considerable degree of constitutional debility. It is the
first disease with which we see Scrofulous children
affected, coming on generally between the ages of
six months & two years but sometimes as early as
two or three months. We first find the head excess
=ively enlarged, the forehead exceedingly prominent
projecting beyond the nose, There is on the upper part
of the head a considerable degree of the flatness, the
size of the head is owning to a want of power in the
bones to resist the force of the blood. The teeth of
children disposed to ricketts are decayed or soon
decay & drop out. The chin is generally pointed
the spine has the lateral curve not the posterior
that indicates ulceration, the arches of the ribs



26

are lost, they are flattened at the sides and cause the
Sternum to project, producing what is called chicken
breasted, or sometimes there is a sinking at the
lower part of it, the Tuberosities of the Ischii
approach each other, the Pelvis is narrowed in every
direction, the thigh bones have joints formed in them
from the defect of bones matter of the cartilage yields
so that when the bone dries a [chasm?] is formed.
it gives you an idea that they are broken, the
Tibia bends forwards & inwards, There are joints in
the [os Humen?] also, in this [Haleton?] there are two
joints in each, in the Ulna there is two & in the
Radius one, These bones so easily break that they
sometimes give way even in nursing, these then
are the deformities, the disease itseld consists in
a want of vigorous circulation. The secreting
arteries of the bone are in capable of depositing
the early matter & more is absorbed. The bone
has more cartilage, give to the child a vigorous
circulation and you will produce in the bone a
considerable degree of firmness. The want of pure
air, sufficient excerise & nourishment are the 



27

three causes which give rise to the disease_
Treatment  Your first object is to allow the
child animal food, let this be but little done
give it frequently & but small quantities of it at
a time, so as to form for its blood better crassamen
=tum & give to the stomach & Intestines greater
however, animal food is infinitely more digestable than
vegetable & when digested contains one third more nour
=ishment in proportion to its bulk. If you give then
vegetable food they are unable to digest it. How
it has got about that vegetable food is more easy
of digestion than animal. I know not no man
who has examined the structure of the human sto
=mach could believe it, or who as seen the vege
=table food passing thru the bowels undigested, where
the animal food was assimilated. Having on this
way endeavoured to give vigor to the sytem, you
went give to the blood its proper circulation in
dry & pure air, place them in situations where they
cannot be exposed to cold and damp, they must ha(ve?)
fresh air & excerise not to fatigue, young women
are often liable to an alteration in the spine 



28

from want of exercise, advise them to ride on horseback
with a saddle having a moveable pummel & then
tell them to learn to ride on both sides more on one
than the other according to the deformity_
As to the medical treatment, you may give them
Hydrag. Camr: creta with calonas fesri, two grains
of the former to five of the latter, or with five grains
of bark. It is very proper to advise ablution with
a large sponge dipt in a solution of salt & water
in the proportion of [munor?] of soda ℥i aqua lbj it
should be made use of twice a day & rub them well
with a dry towel, it is recommended to apply ma 
=chines to the spine in these diseases, a machine
has been contrived which rests upon the pelvis &
is to be carried to the back of the head to prevent
its falling forward, as if the spine gave way as
if it had the head to support, They are improper
I have never seen a child cured by them, a child
puts on the machine at nine or ten years of age
& when she comes out the mother takes care to
have all the inequalities padded up in order
that she may make a good appearance, "oh, I recok(en?)
that child was very crooked", someone will tell



29

the mother "How much she is improved" "Oh yes" "She has wore a machine
but look at her table when she is in bed and you will see it filled with the
pads with which her figure was propped up. These machines not only
do no good but they do harm. A Lady requested me to see her daugh
ter for an exostosis which was growing from the lower jaw, which was ow
ing to the pressure of a machine. I went into the room and she was
sitting with a yoke under chin. She appeared of a good heighth
Well says I led the the young lady down and she became fule 4 inches
shorter. When these machines are worn some time the patient becomes
incapable of supporting the weight of the body. The inelastic ligaments
are put so much on the stretch and are weakened when the machine
is removed. If any thing be done never let them be used for the pur-
pose of stretching the spine. What I have seen of most use in these
Cases is a backpiece of Tin. This is of the form of what the back
should be it rests on the pelvis and have pieces going from the sides
and running up under the arms with a crotch. This does not stretch
the spine does not expose her as it may be worn under the clothes
It does not prevent their going out to take excercise and gives to
them support at even consent to have the spine stretched.

	On Wounds.

Wounds are generally divided into 4 different kinds by Surgeons. The
Incised. Lacerated. Contused and Punctured
Incisded wounds consists in a division of parts by a sharp cutting In
=strument Lacerated wounds are when the parts are torn asunder. In
contused wounds the parts are not only seperated but there is destruction
of the organization. In punctured wounds the parts are not so divided



30

that the structure is changed but by the Instrument acting like a wedge
Incised Wounds. When a wound is occasioned by a cutting instrument
there is a considerable haemmorhage. The parts retract in an equal pro
portions so that the two surfaces are even and the arteries retract but lit
=tle the cellular membrane contracts beyond and the artery therefore then is
more blood lost by a clear cut than one produced by other instruments
In other kinds of wounds the arteries contract good deal more and this
is the reason why a Lacerated wound bleeds less. Thus the danger of an 
Incised wound in the lungs is so great than persons recover from it
with great difficulty but contused wounds on the contrary as from a 
bulles are not dangerous. The reason is that in one a good deal of blood
is lost and in the other but very little. In an incised wound of any con
=siderable importance fainting takes place and this has a tendency to
diminish the loss of blood, it diminishes or suspends the action of the
heart and the blood remains on the extremities of the vessels whereby
it has a disporition to coagulate. This then is the first step which na
=ture takes to restore the part. It has been supposed than the fainting
state induces the blood to coagulate more freely than it otherwise would
Mr Trey of Leeds from a great number of experiments denies that the
opinion of Mr Steuron on this subject is correct but I am astonished at
the result of these experiments for from all my observations I had reason
to believe the contrary vis. that the blood had an increased tendency to
cogulate. Fainting however must not be continued too long. If the con
=stitution is weak and fainting is produced there is a difficulty in re
=storing the person to animation. This is the case of those with the
Fungoid disease. This I do not find to be the case with those who
have operated from other diseases. Therefore I do not think it advisable 
in person when constitutions are weak. In order to arrest Haem
=morhage



31

pressure applied to the surface of the wound and kept undisturbed is the best
way. This gives you an opportunity of going with the process of union with
but subsequent interruption. After we have succeeded in stopping the blee
=ding the blood should be removed from the edges of the wound. Sponge it
well clear it of the coagulated blood or it will prevent the process of adhe
-sions, so it often takes place in amputated breasts. When this has been done
bring the parts into as close contact as you can and retain them by adhe
sive straps. The adhesion takes place in about 36 hours. In man the
process is not so rapid. I have seen it in 12 hours in a very considerable
degree and in a wound of the Instestines I have seen it as early as 19
hours_ There is no process of union in the body by what Mr. Staunton Calls
the first intention. He thought that blood became the bond of union. A
coagula of blood remaining between the lips of a wound always retards
its union and if you do not removes it you defeat the object which you
have in view. There is nothing like this process in the body except in the
large vessels where the blood coagulates and is forming a plug. A subre
=quent process takes place more on the external part of the vessel than
the internal more on the external surface of a vein and more on the
internal surface of an artery. The blood does not seem to have the
power of receiving blood vessels. The blood itself does not receive Injections but
becomes absorbed. When in an artery it is encased in an adhesive mat
-ter and produces adhesion to the surrounding parts. There is no such
process of union as what Mr Staunton Calls the first intention. When 
adhesion has taken place the blood vessels shoot into the adhesive substance
the vasa vasorum- are elongated by the force of the blood and may even
extend half an inch from each side as takes place in adhesion be
-tween the pleura Pulmonalis and Cortalis. The vessels are procuding



32

from one surface to another and meet in the centre. In ten days the effused matter
receives its blood vessels. There is a portion of the Tends actully of a dog which uni
-ted in that time. The vessels shoot from each extremity and the surrounding
cellular substance. Tendons unite by Tendons_"_ The substance by which
parts are united is similar to that which produces new vessels. With respect
to the skin we find new skin is produces as likewise rete mucosum but
it is not in some time. With regard to the cellular membrane new cellular
membrane is produced by it but it is a long time before it recovers its
elasticity with regard to the tendons they are reproduced and they are of
the same structure as before, so with bone the cartilages is deposited and
in the cartilage earthy matter. But there are exceptions in the body to the 
similarity of connection. If the Patella is broken it is not united by bone
but by ligamentous substance which is poured out by vessels of the ligament
If a muscle be divided it will be united by tendons instead of muscle
If the cartilage is divided in the adult it will be united by bone but in young
by cartilage Glands also are not united by the same structure. The excutory
duct does not pass into the new formed substance only arteries veins and absor-
bents are found in it. If an abscess takes place in the Liver and heals you
will always find a white scar at the place but the excutory ducts never pass
through it. Reunion by adhesion will take place between the soft and hard
parts of the body when seperated from one another as for instance when
the skin and periosteum are seperated from the bone. There was a Surgeon
of the Hospital a Mr Warner who when the scalp was torn from the Cra 
=nium and hanging by a portion of the integuments would cut it off and 
of course then would be an exfoliation of bone equal in size to that of
the integuments removed but at present Surgeons know by putting it down
it will unite and thus a wound may be cured in Ten days which it would
otherwise take weeks.



33

When parts are very nearly seperated from the body they will often readily unite. If
a finger be cut off except by a small portion of the skin it will be united. The
smallest channel remaining seems to be sufficient for this purpose. Thus the
Ear has been united again when it was attached by only an extreme small por
=tion of skin and portions of the nose have been joined when almost seperated
and hence the faculty with which new noses have been made in India and
in this country too with great success. Tippo sabe was in the habit of cutting
off the noses of his prisoners in order that they might be known in case
they were taken a second time and some persons not Surgeons undertook
to make new ones. They took a piece of wax and modeled it after the shape
of a good nose they covered the whole with a sort of cement called Gee and
left it for a few days. After a little time it required pruning to give it
shape Tallocatius used to make noses out of the arm but then it was very 
inconvenient to hold the arm up to the face for so long a time. (Mr Cooper
has been given an account of two noses which he has made) after a time the new
noses swells to an enormous size and you would think it was about to drop
off. It becomes oedematous secretion going forward but not absorptions. After
a short time there is an absorption of the effused fluid and the nose is
lessened in size. It is surprising the readiness with which it bleeds. If the
skin be in the least degree detached it bleeds profusely. This was the
case with Mr Carpures operation when he was trimming off the edge of
the shine. After a while the skin is cut at the place where it was twisted
and the whole is smoothed down. An objection to these noses was that they
became frost=bitten in winter and dropped off but this is not the case
Mr Lina has performed a very pretty operation of this kind. There was
a man in love who had his mouth deformed by the loss of his under lip
and the lady thought that she could love him better if he had a new 



34

lip made & advised to have the operation performed. Mr Lina found it im-
possible from the great deformity to operate as for hare lip so he took a tri- 
angular piece of skin from below the chin and turned it up and thereby formed 
a very nice lip and he was afterwards very well pleased to find that the
beard grew upon it. This operation was not only ornamental but usefull
for a person who has lost his under lip has the saliva continually running
over his mouth wetting his neck both excoriating his neck and thereby becoming
offensive to himself and others. Parts of the body will grow like parts which
an engrafted to those which they are oppostite. A tooth will thus grow to the
comb of a a cock and will not be easily detached the tooth may afterwards be
injected from the comb. The spur of a cock will grow to the comb and it will
become attached to the bone. Mr Hunter made a very curious experiment
he took out the testicles of a cock and put them in the belly of a hen and they
remained and were united within the belly of late years it has been stated
that parts might be seperated entirely from the body and yet be made to ad
=here. Dr Balfour has related such a case. Mr Clark took me to see a man
who in cutting Tobacco cut a piece off from his thumb yet it afterwards united
the part however was so far divided than I did not think is a fair case
Last Summer there was a lad in Guys Hospital who had a disease of
the phalanx of the thumb and I said it would be a fair case to ascertain
whether a part would unite after being seperated. I amputated the thumb
at the first joint and taking up the amputated portion cut a thick slice
from it of sufficient size to cover the stump. I laid it down upon the thumb
and secured it with 4 straps of adhesive plaister. On that day week I found
that the skin had united except by a very small portion and in a week
more it had perfectly adhered. I said I should like to try if it would
bleed I made an Incision with the point of my lancet and it bled with
freedom. 



35

Previous to this I thought there must be an elongation of the vessels from the surrounding
part but in this case there must have been an anastomosis for there was not sufficient 
time for it to have been supplied by the vara vasorum. It has the natural color
on Injecting parts which have been united you see the vessels conjoining at cicatrix
The sensibility of the part was very restored. When union by adhesion can be excited
all the danger from wounds cause. So with large wounds of the abdomen but there
may be parts injured within the cavity. When so Inflammation may take place
in it and go on to the destruction of life. Various circumstances tend to
prevent adhesion by Inflammation the production of a great number of ligatures
Sutures should as much as possible be avoided & adhesive plaster substituted
in place of them. There are some parts however to which adhesive plaister
cannot be applied such as are suppurated as wounds of the face more par
=ticularly when they extend to the mouth, the lips & eyelids. The edge of a 
wound of the scrotum are also found not to adopt themselves well to one an
=other unless sutures are applied for the skin is apt to turn in. This apporition
is secured by sutures. It is right in the removal of the Testicle or in operations
for Hernia when the scrotum is concerned in it to apply sutures. You will
find that surgeons are too apt to put ligatures on small arteries. This is also
in opposition to the healing of wounds by adhesion. It would be a great object
if some material could be used that could prevent the necessity of the ligature
being removed. Silk does not generally lie quiet but seperates & forms a small
abscess & ulcerates. Sometimes however it will remain quiet. I have tried Cat
=gut & the patient remained a long time without any bad symptoms occuring
from it. It adds nothing to the risk of primary haemmorhage it rather prevents
it. It obviates the necessity of dividing the artery & to its producing secondary
haemmorhage is requires experience before it can be decided on. I applied a
ligature of silk on the Left Carotid of a dog & on examination of the Left Ca



36

rotid I found that the silk was making its way thro the side of the Trachea toward
the skin, the catgut remained precisely at the place where the ligature had been
applied with a cyst formed around it. The ulceration process had continued to the
side of the Trachea where as the other had remained in its place with a cyst
formed around it._ _ _ Another circumstance that prevents adhesion is the
impatience of the Surgeon. It is anxious to remove the dressings in order to see if
the parts are united which is a very bad practice. About the 4th day he should
remove a single portion of the adhesive plaister in order to see if there is any
matter confined and putting another immediately in the same place. On the fol
=lowing day remove two more pieces & places two others in their stead they removing
them gradually and if by the eighth day the whole are changed it is sufficiently 
early. If the dressings are removed early the union being very tender the less
of the wound are liable to be seperated and this makes it necessary to renew
the adhesive process or let nature set up the suppurative_ _
When poisons are introduced into a wound they will prevent union by adhesion
it will be necessary in these cases to excite the part & in Hydrophobia the part
should not only be excised but caustic should be afterwards applied so as
to excite the suppurative process. When numerous absorbent vessels on woun
=ded this will also prevent union by adhesions then will be a considerable quantity
of lymph effused as for instance in wounds of the groin axilla I have seen
it more in the groin than axilla secreting surfaces prevent union by ad
hesions you see a patient cut for the stone you see that the urethra does not 
close as other parts do but the parts in perineo are healing very speedily
The urethra goes into the suppurative process. Whenever you find a secuting
surface & it is mucus it will not adhere except by granulations



37

Lacerated Wounds

When parts are torn as under the bleeding that takes place from it is very slight
I find on dissection of those who have had a limb torn off that then is a twofold
states of artery produced so as to prevent that artery from bleeding. One state of the
artery is produced by its bursting the other by its being torn from its bed. The common
cause of preventions is that the laceraled artery is torn off short & the cellular mem
brane is fringed over the extremity of the vessel & thus catches the blood & this coa
gulating forms a plug for the mouth of the vessel. Here is the artery & vein of a
man whose thigh was torn off & the cellular membrane tied around them. Thus
you see that nature sometimes supplies a ligature. I have seen the Radial Ar
-tery not bleed after being torn across although the extremities of it remained opens
I could put the blunt end of a probe into it & yet there was no haemmorhage
What you find is that the artery becomes shut as a considerable distance from
the place when it was torn through for being extended beyond the bounds of its
elasticity. Its Calibre is obliterated above. I laid bare an artery & drew it out
with the handle of a knife & it was impervious above. Lacrated wounds
are more apt to produce Tetanus than incised therefore be on your guard
about depressing the strength & increasing the irritability of the patient If in
lacerated wounds you take away considerable purge the patient freely & put
him on low diet he will be no more liable to Tetanus than if you was to allow
him to eat as before [&c ?] but if you keep the bowels open & the patient free from  
irritation by giving him opium you will prevent the probability of it. When
there is dirt or any other extraneous matter in wounds you must wash it away
else you will have suppurations. In lacerated wounds there is much more In
=flammations than in Incised wounds then is a greater disposition to diffused Inf
=lammations. After you have applied adhesive plaster then put a roller gently round
it & keeps the parts exceedingly cool by evaporating lotions. If you find a tendency
to diffused Inflamation then apply Leeches in the neighborhood but if suppurations



38

take away the plaisters & apply fomentations of poultices

Contused Wounds

When the wound is contused you are to consider the part as disorganised & thus they differ from
a lacerated. There is a destruction of vitality & organizations. Whenever you see a contused
wound that cannot unite by adhesion ulceration will occur & the dead part be thrown off
When wounds are occasioned by contusion you are to consider them as wounds that are to
go through extensive suppurations. You are not therefore to apply adhesive plaisters for it will
only add to the Inflammations which must necessary take place. From the want of a know
=ledge of these principles medical men are apt to take persons who receive a contusion as of
the Tibia for instance that it will get well in a few days. but it is not so. A constusion
will not get well under a month & probably not under 6 weeks for it must seperate &
heal by granulations. Thefore you should increase sections by the application of fomenta
=tions & poultices. The nitric acid lotions in proportion of 40 drops to one quart of water
is the best application under the sloughing process that you can employ it acts as a 
gentle stimulus to the parts. The seperation takes place in from 14 to 20 days depen
ding on the size of the contused wound & then granulations begin to fill up the cavity
You must now approximate the edges of the wound if you do it before you only excite
Inflammations seperation then in these cases necessary

Constitutional Treatment: opium is quite necessary in these wounds you should
also keep the bowels free. Bark is of much less importance unless the constitution
suffers and the strength is exhausted.

Punctured Wounds.  With regard to the punctured wounds they are the worst
that occuring in the body exceedingly dangerous to life if you examine the fibres
you find that they are seperated laterally but not divided the instrument



39

acting as a wedge therefore you will see that they are attended with much more inflamma
tions than where the parts are divided. The influence on the brain is considerable. The influ
nce of punctured wounds are upon 3 different structures the absorbents tendinous coverings
and nerves. Dr Ludlow from Came was shooting & run a thorn in his Thumb & deeply
too but it was a wound one would not regard. He was a man of a very irritable
constitutions & on that day a week he was dead. He was seized with Tetanus. A boy
punctured his finger on the Thursday following he was seized with symptoms of Tetanus
& on Saturday week from the reciept of the wound he died
of their influence on the absorbent vessels.  If a puncture is made thro the cellular mem
=brane inflammation takes place & extends to the mouth of the absorbents opening into
the cells this inflammation runs along the abosorbents & you find red lines in the Course
of the vessels extending to the axillary Glands (if the wound is on the superior extrem
=ity) The Glands of the axilla become tender & very much swollen. Sometimes the in
=flamed absorbents go on to suppuration & then an abscess forms below the Elbow
joint in between it & the axilla. The glands of the axilla frequently suppurate and
then the matter extends greatly. This was the case with a young Gentleman this winter
in whom it produced an extensive suppuration in the side. These cases simply arising 
from punctured wounds. I have known them occur from the pricking the finger
with a needle. Buckle every now & then they are owing to a puncture from a com
=mon scissors & frequently produced by a common surgeons needle although it is
clean. It depends greatly upon the state of the constitutions they must be extreme
=ly irritable at the time. If a man begins to dissect in October & pricks his finger
he does not suffer from it but if he wounds himself in February or March when
he is exhausted from his studies & has been a considerable time breathing the
Contaminated air of London an extensive Inflammation will be excited. It is
supposed than thru is putrid matter absorbed in these cases but I am disposed
to think otherwise. I thought it was connected with extreme irritability. I have
known them arise from different causes such as a thorn Knee buckle needle &c.



40

when the constitution was in an irritable state. But are not these proofs to the contrary
of putrid matter being absorbed. Yes 1st If purtid matter be injected into a vein it
kills directly. I took some putrid matter from a macerating tub and injected into the
Jugular vein of a dog very soon he vomited then there came on a trembling as if he
had a rigor he became very weak & in 9 hours he died. 2d Mr Alcock after opening
a body in the other Hospital while sewing it up pricked his finger. This was at
12 oclock on Monday he came to me at 9 oclock in the evening after Lecture and
shewed me his hand it was swelled & he had a monstrous pain in his finger
He went home & on the following day he was excessively ill & on Tuesday night he
became delirious & on Wednesday he died. Mr Fitzpatrick was supposed to have
died from this cause. Mr Key punctured himself lately & several days
there was a distinct circle of Inflammations then another in [dish?], which gradu
ally extended. The slightest constitutional irritations would produce an increase
of the Inflammations. It was not a common inflammation but appeared to become
of the specific kind. It does not appear to be matter in the extreme degree of
putrefactions. It has occured more frequently from recently dead bodies. I punctured
my thumb, my arm became inflamed & my throat sore. Inflammation came
on in one knee I blistered it & then the other became affected. I did not get
will in some time. The treatment is immediately to introduce the point of a
Lancet into the wound & make it incised then with a little nitrous acid
or argentum nitratum cauterise the surface. The destorying of the parts in
=jured by the puncture generally prevents the effects which might otherwise
arise from it

Constitutional Treatment

Calomel should be given at night & carried off the next morning by Salts.
opiates should be given occasionally. If Inflammation arises you must apply a
bread poultice moistened with the Liquor Plumbi acetatis. A number of Leeches
should be applied. you must not take up the subject as if stimulants were
required I have known two persons killed by it. One took an immense quantity



41

of wine. the other was a Clergyman who thinking it was the Pox rubbed in a quantity
of mercury. My knees became inflamed in consequence of Wine which I was desired
to take which excited fever when the Inflammatory symptoms have passed. I find it
necessary to give Bark. The 2d Influence produced by punctured wounds is
Inflammation of the fasciae. If the instrument has passed thro' Fascia Lata of the 
thigh & matter collects between it & the muscles it will occasion considerable con
stitutional Irritation. A Gentleman sitting down on a hook ran it into his thigh
The matter collected on the inner part of the Thigh beneath the Fascia and pro
=duced considerable constitutuional irritation. I made an incision & the symp
=toms declined__ The 3rd Influence of punctured wounds is on the nervous
system. Puncture of the nerves themselves produces great constitutional irritation
A gentleman came to me this morning with his hand in a sling. he said Two
years ago I was bitten by a Dog between the fingers & there was a numbness of the
little & half of the ring finger. The first effect was an excessive pain & a
wound that lasted five months after that I had a great pain in the arm
& now I have felt a fresh pain in the wound & extending to the shoulder. It
was a punctured wound of the nerve from a bite which produced all the dis
=tant symptoms. A Gentleman who had a wound of the median nerve is liable
to chilblains in the winter but in the summer he is well. I saw a lady who in
consequence of a wound from a nerve who had such Inflammation & tenderness
in the arm that you would have said she had phlegmasia Dolens. she recov
=ered rather from the disease exhausting itself. Sometimes a punctured wound
produces universal spasm attended with Tetanus. A boy fell on a pale fence
& one of them entered the perineum he had unusal spasms & from them he died
but the jaw was not locked. A Boy had an oblique fracture of the Thigh Bone &
the point of the bone pushed into the rectus muscle. He complained excessivly when
ever attempts were made to straighten him & he could not bear to have the limb
touched spasms of the muscles of the Thigh came on they became general and



42

he died in a few hours. On examination of the limb the joint of bones was found passing
 against the Rectus & this was the cause of his death. The slightest wounds
sometimes produce the greatest nervous irritation as when a person runs a rusty nail
into his foot. In about ten days he feels some stiffness about the neck & thinks he
has caught cold. In an hour or so his jaw is locked & muscles of the abdomen
back thigh & legs an affected & the body is stiff as this time the pulse is
extremely quick from 120 to 130 & even sometimes to 150 at  length the muscles of 
respiration become affected the mixed ones are exhausted & in proportion as
those of the other parts of the body are to the jaw becomes less locked & when he
falls asleep it is relaxed but shuts when he awakes. The patient dies not from
a want of food but exhausted from nervous irritation. There has been various
opinions as to the cause of the disease & why it arises from affection of ten
=dinous more than nervous parts. It appears to be the result of the difficulty
of restoration of the nervous system sympathising more than with others. It is
not a disease of the muscles only. You may allay the spasms by opium
& cold & not subdue the disease. There is a fever which attends it. I put
a young man with Tetanus into cold water his jaw became relaxed and 
the muscles of his limbs were less severely affected. I put my finger on his
pluse but it was not lowered. When he came out of the bath he was convulsed
as before but he was much debilitated_ There are two kinds of Tetanus
acute & chronic. The former has no remedy in this Country. If the disease is ever cu
=red it is the chronic for this gives you time to use medicine a patient was brought
into the other Hospital & the physician had tried everything before and they
thought they would leave this one to himself they did to & he did very well. In
the acute there is no advantage in giving opium except in the first influence
which it has over the disease. Mr Stocker was excudingly anxious to give it
a fair trail & did so. He gave repeated doses of the Tinctum about 1/2 Zaa



43

with very little effect. Sometimes he was a little relaxed. The afterwards gave 
larger doses or Zi every two hours but it had very little more effect than so much
water. He lived sometime & died exhausted by the influence of the irritation
Mercury has no effect whatever. Tobacco has been injected into the bowels & 
for a moment relieved it. Digitalis had not its usual effect of lowering
the pulse. Arsenic has been tried too but I have never seen a case of acute
Tetanus cured. The Chronic has been repeatedly cured. Sulp: Ferri has
been given because Mr Cline Senr had observed that it allayed spasm &
the patient has done well. The shower bath has been successfully employed. They
have been purged freely & have got well. Bleeding only increases the disease when
acute & makes the chronic give way with more difficulty the best remedies
are purging, the cold & shower bath. The acute Tetanus is Constitutional
a fever is excited & until you can get a remedy for the fever you are acting
on the symptoms not the cause.

Trismus.

Is only locked state of the Jaw. I have never seen it fatal. There was a 
nurse of this Hospital who fell & struck her head she had Trismus for a
length of time & was eventually cured by Blisters & Electricity. I would give
Calomel of opiums.

On Wounded Arteries

Whenever an artery is wounded the circumstance is known from a discharge of florid
coloured blood & from the stream issuing out with a pulsating motion or per Saltem as 
it has been called. But it is right to mention one can which is an exception to this
If an artery in the lower extremity is completely cut through the lower portion by means
of anastomosing vessels will send out blood which is not florid so that a man un
acquainted with this circumstance would suppose it did not require to be tied.
When an artery is cut through accepts the following methods to prevent its fatal
consequences. The first step she takes is the production of fainting which is the result. 



44

of a smaller quantity of blood than is natural being sent to the brain and the action
of the mental as well as the corporeal functions are suspended. Fainting therefore 
a consequence of an incomplete action of the heart. The reason why the bleeding
under these circumstances stops is that the blood is not sent with such force to the
vessels and a coagulum is permitted to form in the extremity of the bleeding vessels
which prevent further haemmorhage. We should therefore endeavor to support &
encourage this process in dangerous bleedings rather than to stop it. We should
not be too anxious to stimulate the patient & recover him from fainting by let na-
=ture alone who can do better without our assistance. The next step is the forma
=tion of a clot. This is not to much on the inner side of the artery as the outer. The
whole surface of the wound is filled with it & it is almost the same as if a Tourna
=quet was applied to the limb et donate portion is formed on the inside of the vessel
but it is principally on the outer. The Quantity of coagulum on the inside of the 
artery is very small the bleeding stops more on account of the pressure from that
portion of it which is outside. Jones first made this circumstance known & proved
by this experiments that the opinions formerly entertained on this subject were
erroneous. The 2d circumstance which assists in the stopping of haemmorhage
is the retraction of the vessels as soon as an artery is divided it has the power
of drawing itself into the surrounding cellular membrane. This is the case not
only with arteries which are tied but thou which are not. A 3d circumstance
is the contraction of an artery by which its diameter is diminished. This may
be easily seen by any who has divided an artery. Thus retraction and con
traction are the means which nature employs to put a stop to haemmorhage
& when an artery is not completely but only partially divided She is deprived of
one of the chief means by which mischief is to be prevented. In this case a clot
of blood forms but not adhering completely it is thrown off by the action of the heart
& haemmorhage takes place every two or three days. This is generally stopped by
the application of pressure but not effectually it comes on again & an operation



45
is rendered necessarry. The proper course of treatment will be to open the wound a 
little & dividing the vessel tie it above and below. When an artery is lacerated
it bleeds but very little. The foot has been known to be torn from the body & no great
haemmorhage ensued. The patient was obliged to undergo an amputation and 
died afterwards from Tetanus. When an artery is torn through it is torn short &
the cellular membrane long so that is hangs over the end like a rope. In this manner 
nature ties a ligature herself. Another mode by which the haemmorhage
is stopped is that being put so much upon the stretch it looses its elasticity
& its sides fall together. I have seen this take place in such a degree on a Dog
on whom the experiment was made that a probe could not be passed into the
vessel afterwards. Contused wounds of arteries do not show their worst conditions 
at first. It is necessary in such that a sloughing process take place
before they can be cured & as the sheath of the artery is tendinous this process
will be very slow. Seventeen days is the usual period that elapses before the
artery seperates so we must be cautious in giving our opinion of such wounds
Bleedings may take place at any time & a tournaquet must be always kept
ready. A punctured wound of an artery sometimes occasions a pulsatory
aneurismal swelling & must be treated like such. It is best that they should
always be tied some distance above the place where the wound was inflicted
When an artery is divided by any means the blood is carried in by Anastomosis
vessels. Those arteries which an produciaty anastomosis always assume a
Curve or Sinial directions & have an appearance like the spermatic artery
When arteries become enlarged it is not only in their breadth but also in their
length so they must necessarily become serpentine. There is not a part of
the body in which it is not believed that there will not be sufficient anastomsis
to restore the circulation after an artery is divided except at the portion of the
Aorta just above the heart. Experiments have shewn that ligatures will succeed



46
in all other parts. But in cases where a good deal of blood has been previously
but they will not be successull. In the treatment of incised wounds of the artery 
of the arm pressure should be made on the Subclavian artery so as to 
stop the haemmorhage. Then a large incision at least 3 inches long should be
made down to the vessel & tied in two places above and below & then divided
The incision should always be as long as this. We shall be disappointed if it is
smaller. The Dutch twine is best for ligatures around arteries It is small and
very strong the intersual coat of the vessel should be divided. By doing
this the adhesive process is set immediately whereas if it is not does not take place
till sometime afterward. The effects of broad ligatures is that adhesion takes place
more slowly & the crats of the artery are much more injured by them. Ulceration
occurs not only at the place when they are tied but above & below it also. Two ligatures
should always be used. I know by experience it is the best practise. I have given
both methods a fair trial. Ligatures should never be loosened or removed but
allowed to come away of themselves. I have tried to get them away sooner than this
but was always under the necessity of repeating the operation. An artery which is
lacerated requires to be tied as much as if it was incised by any sharp instruments
A contused artery must be tied higher up than others. It must be tied as much as
an inch above when it is in a healthy state. Having spoken of arteries and the
injuries to which they are liable in general we come now to consider the wounds
of particular arteries. Those of the head don't require ligatures to be applied
in order to stop the haemmorhage. When either the Temporal or Occipital artery is
wounded the first thing to be ascertained is whether the vessel be completely divided
or not & if it is not it will be proper to cut it through & allow it to retract. If this is
neglected the principle agent in stopping the blood will be lost a dopie of lint
over the wound & compression with a double headed roller that crosses over the part
will completely command the haemmorhage & render the use of Ligatures unnecessary



47
If the Temporal artery is in a state of Aneurism it will be right to cut into the sac
& then make pressure upon the divided portions of the vessels. If ligatures are admissible 
in wounds of the vessels of the head it is in this case. The Carotid arteries
are seldom wounded. Dr Cheston informed Mr Cooper of a case in which it was wounded 
in the extirpation of a tumour. The case is published omitting however this
circumstance. In securing this artery it should always be bore in mind that
the par vagum lies a little to the outer side & behind it for should this nerve be
included in the ligature the consequences might be fatal. When this nerve in other
animals has been divided in both sides death has been the consequence but not so
when only one has been cut through. The subclavian artery has been only tied once
successfully. An ulcer below the clavicle gave rise to the operations. It was performed
by Mr Keate. Mr Cooper has not known the axillary artery to be tied. Dr Gooch
mentioned a case to him which was an injury of this vessel and it was proposed
to secure it but it was cured spontaneously. There is a case on record of a
spontaneous cure of an injury to the Carotid artery. A sac seems to have been
formed in such as manner as to prevent the increase or disportion to growth in
the Tumour hence it will be proper in such cases not to be in a great hurry to
perform the operation. In this case the artery continued to perform its functions on
that side. It occured to a Gentleman in the East Indies who came to England
for advice. The Brachial artery frequently requires to be tied & this is most
frequently in consequence of accident from Bleeding. Mr Chandler tied the
Brachial artery on this account. In this case the sac was opened the artery tied
above & below but a considerable haemmorhage continued. It was necessary to secure
a third vessel which communicated with the sac. The Sac was dissected out. In
tying the Brachial artery care should be taken to exclude the median nerve
should it be tied much inconvenience & danger would ensue. The Radial
artery is often injured by persons falling & thrusting their hand through glass



48
in a state of intoxication. If the artery is not completely divided the best plan
will be to raise it & cut it through & then tie it above & below. Pressure does not answer 
well in this case it produces considerable swelling of the hand & bad effects
The Ulnar artery is sometimes injured. When it is to be secured the nerve must be
carefully avoided. The Tenaculum or Forceps is the instruments to be used. When the
artery in the palm of the hand or between the fore finger & thumb is wounded it will
be best stopped by pressure. The application of Ligatures will be difficult on account
of nerves especially in the palm. The ligatures may be applied between the Thumb &
fore finger but even then it will depend on the situation of the wounded vessel. The
Femoral Artery is now & then wounded by a knife falling from the hand of a person
who attempts to catch it between the knees should mortification takes place after
the vessel has been secured Amputation should not be performed with a view to
stop it but still the operation is not necessarily delayed until seperation has commenced. 
It is wrong to allow them to excerise too soon after such an operation
as it causes the ligature to come away & occasions secondary haemmorhage. He
should not be allowed to sit up at least a week after the operation for the adhesion 
untill then is but slight. Mr Cooper has known the Popliteal artery to be
tied on account of an injury. It was an injury of it which first induced him
to study the profession of Surgery. A Boy wounded his Popliteal Artery so that
it required a ligature two surgeons were sent for were both afraid to come 
& the boy died. Mr C thought it a great pity & was stimulated by it to turn
his attention to Surgery. The posterior Tibial Artery is not unfrequently wounded
high up. When so it requires some knowledge of anatomy to secure it as it is deep 
seated & accompanied by the nerve, Mr Pollard secured this artery in a case of 
compound fracture. If the vessel be not laid low by the longitudinal incision there
will be no harm in dividing a few fibres in a transverse direction this will be reducing
the accident to the same state as if the muscles was ruptured & the patient will be obliged



49
afterwards to wear a high healed shoe untill the wound unites again. This artery is 
often injured lower down by the edge in securing it the nerve must be carefully excluded
Pressure will not answer in this case. Mr Stey sawed the Fibula to secure this artery. Mr
Cooper supposed it had been the Interossal but Mr Stey assured him that it had been the
posterior Tibial Artery. The Interossal Artery may be tied without saving the bone it
is only necessary to cut close behind the Fibula & to the inner side. This artery becomes
more deep seated lower down & consequently more difficult of access. Mr Cooper has
seen but one case in which the anterior Tibial Artery was wounded high up it was
occasioned by the patient falling upon the nail of a cart pressure was made so as
to stop the bleeding for a time but as it afterwards returned the Femoral Artery was
tied but even this did not prevent a haemmorhage from the part it bleeding also
occured from the Femoral Artery after the ligature had come away. The lower part
of the anterior Tibial Artery may be wounded by bone in cases of fracture or by some
cutting instrument. In either case it is readily secured. Mr White of Manchester stated
that he was unable to tie the vessel high up & was obliged to lay ban the artery 
& make pressure with a piece of sponge. But this was bad Surgery for so distinguished 
a man. The artery can be secured Mr Cooper has not seen a division of the Plantar
Artery. Various Styptics & nostrums have been employed for the stopping of haemmorhage 
but a piece of dry lint answers as well as the best of them. The Spirits of Tarpentine on
Lint seems to habe some power in constinging the vessels & thus restraining haemmorhage
The super acetas Plumbi from its known power of coagulating the blood has been recommended. 
Caustic is sometimes applied. There is a favorite parts used by the Surgeons of
St Thomas Hospital vij - Rf Bole Asmen
Terra Jopen aa ʒij
Sulph Alum - ʒi
[?r:] opii Q. S. mf- But Mr Cooper has no faith at all
in its virtues in stopping haemmorhage



50
Wounds of the Veins.
The veins sometimes inflame after bleeding the operation of which the slight occasionally
followed by the most severe consequences. In some cases life has been destoryed by it. The operation 
of amputation has been obliged to be performed for the injury of the vein in the arm
by bleeding. Inflammation of the veins of the lower extremity has been frequently followed
by the destruction of life. A case of this kind occurred in the other Hospital under
my own observations in a man from Woolurich. The circumstances of the vein after
bleeding are that it is not well closed the vein is hard above & below it has two or 3
knotted places between it & the axilla its size is very much increased & after a time
abscess form. If then abscess break through the adhesions into the veins they destroy
life they generally break externally. The treatment is simple. As soon as Inflammation 
comes on Leeches must be applied & if requisite general bloodletting had
recourse to. Evaporating Lotions should be applied to the parts & thereby heat will be
diminished & the diameter of the vessel lessend so as to take off much distention
The hand & arm should be laid on an inclined plain so as to facilitate the
return of the blood & prevent congestion. This last Mr Cooper is induced to reccommend
upon finding the speedy return of Inflammation after injury the lower extremity 
when it was allowed to hang down or remain even in the horizontal position. 
When an abscess forms on account of a wound of the vein the earlier it is 
opened the better for it prevents much constitutional irritation. When a vein has 
been tied or divided in the lower extremity the inflammation Comes on below and
seldom above the application of the ligature hence in Inflammation after bleeding
are that tends to distend the vein should be avoided in the treatment. The tying
of a vein is in all cases attended with great hazard. Many cases of death have
been produced by it. I know three at Guys Hospital & at the west end of the town
& at Nottingham Induce if the division or ligature of the vein prevented the return
of the disease there might be something hazarded by it. But it does not an ulcerous &
a varicose state of the veins will not withstanding return. The principal cure is bad



51
Wounds of the Nerves.
Wounds of the nerves were formerly supposed to be production of the most serious consequnce 
but in proportion as knowledge has advanced this opinion has changed. When a nerve
is divided the voluntary motion of the part supplied by it are suspended for a time but
involuntary motion still continues. The circulation will go on as before a blister applied
to the part will rise warmth remains in the limit in a word all the involuntary functions 
continue. The same is the case in Hemiplegia. In these wounds indeed or after the
operation of aneurism the heat is greater than usual. There is not merely a feeling of
greater heat to the patient byt it is actually greater as there are 2° more when measured
by Fahrenheits Thermometer. When a nerve has been divided it very soon begins to
unite again & there is always an enlargement at the part when the union takes place
This is so evident that it appears to one ignorant of its nature like a naturally formed
Ganglion with regard to its interior appearance we are not acquainted as it has only
been examined in other animals. The time which it requires for a nerve to unite
varies according to its size. If it is small it will not require longer than 2 months
when a nerve of the arm is wounded by the lancet as in bleeding the numbness which
is occasioned will cease entirely about that time. If the nerve is larger the time for
its union will be greater. The Celebrated Polish General Kosciusco was wounded
by a Lancer in the great Sciatic nerve & he had not recovered the use of his
12 months after. He came over to England to ascertain if any thing could be done
for him to cure him. The last time I heard of him he was better whether he has yet
recovered entirely the power of using it I am unable to say I have not noticed
in these Injuries any other symptoms except such as arise from the diminution
of the general functions of the limb. Last Christmas day a Gentleman in Lombard
street going into his wine cellar fell over some broken bottles & receives a wound from
them which partially divided the median nerve. The motions of the fore middle &
ring fingers were suspended by it. Now according to the commom opinion very alarming 
symptoms might be expected from it but it was not so he recovered the use



52
of these parts in a few weeks & without any unfavourable circumstances. But they will not always
terminate this easily & kindly. I have seen under partial divisions of the nerves pricking
sensations produced in the fingers & a feeling in the hand as if red hot wires were placed
in it. I knew a lady who had received such an accident & who was obliged for a long
time afterwards to keep the arm fomented & the fingers up or the pain was so great
as to deprive her of all comfort & to prevent her sleeping. Lock Jaw has been supposd
to arise from this but however it is not common result of it. Little is to be done in these
injuries the parts are to be brought together as much as possible. I cannot myself help
believing in the idea of the restoration of nervous influence by Anastomosis. In the division
of the nerve in Tic Dolereaux notwithstanding a numbness remained in all the parts
under its influence for a great while yet the painful sensation returned very soon in
as great a degree as before. Therefore I am disposed to believe that it was by anastomosis
I have seen it occur where Caustic was applied.
Wounds of the Tendons
Tendons are sometimes cut & sometimes torn through. The Tends achillis is very often
ruptured. It frequently happens from the muscles being unprepared for the shock. Thus
a man very often when walking in the dark places his toes on a door scraper without 
being aware of it & then his heel suddenly & unexpectedly coming down causes
the tendon to be ruptured. If he had known beforehand that he should have tread on
the scrapes the gastrocnemii would have been prepared for it & the accident thereby
prevented. In the same way it is often occasioned by a mans pointing his toes on
the ground in order to back the force of the descent in jumping from a heighth
Mr Hunter did it once in dancing & immediately fall. He however was rather pleased 
than displeased at the accident for he learnt by it the proper mode of treatment
which he did not know before. The following is the way in which it should be treated 
a long pica of adhesive plaster is to be applied to the bottom of the foot at one end
& at the other to the Gastrocnemii muscles & each of these parts is to be secured by a 
roller



53
The roller answers 2 good purposes. It binds down the plaster & prevents the involuntary contractions 
of the muscles which will almost always occur if this precaution is not taken 
The inflammation at the part is to be prevented by application of Evaporating [Soliv??]
& sometimes even leeches will be required No roller should be applied on the part itself
because it makes the integuments sink in between the ruptured ends of the tendon &
adhesion is very liable to be produced between the integuments & tendon as soon as the
Inflammation has subsided the patient should put on a high heeled shoe which
will keep the parts from seperating & he may then be allowed to walk about. This
is a fact which Mr Hunter learnt from his own accident. He was very soon called to
the Duke of Queensbury who had met with the same accident & he treated him
after this manner & gave him liberty to walk as usual. The Duke frequently met his medical 
friends who said that they were astonished that he should be walking about in his condition
They represented it as one of Mr Hunters dreams & beg'd him for Gods sake to go home & remain
there untill he got well such remarks occasioned some uneasiness in the Dukes mind and he
mentioned them to Mr Hunter. But he persuaded him not to pay any attention to them &
he continued to practice walking. He got well in a few weeks without any unpleasant
consequences. The fact is it is not necessary to confine the patient in this disease after
the first Inflammation is over. when other tendons are wounded they are to be healed
upen the same principles as the Tendo Achilles. A Carpenter came into the other Hospital 
with a wound of the Tendo achilles which had long existed upon examining
the parts it was found that the integuments had insinuated themselves between the
broken ends of the Tendon. When the dresser asked him under whose can he had
been be answered that it had been on board ship & met with the accident at sea
that he tied his silk handkerchief around it & applied such salves only as the ship
afforded. An operation was performed to alter the state of the integuments which were
thus turned in but the man was not cured & he walks lame to this to this day. This case
exemplifies the impropriety of putting any bandages around the part ruptured. The



54
Consideration is at what time the high heeled shoe may be left off. It should be
done gradually & never all at once. After these weeks one portion of the heal may be removed 
& so on untill it is the heighth of the other it will be generally from 5 to 6
weeks before the foot should be suffered to be flat on the ground. The muscles particularly 
the Gastrocnemius are very often partially torn through in these accidents. 
It is commonly supposed when this is done that is the Plantars which are injured
but it is not. The symptoms which the persons feel at the time it takes place are
as if some person had struck him behind or hit him with a stone & he turns
round immediately to see who has done it. I have known many instances of this
kind. Mr Turner is going to a midwifery case partially ruptured the Gastrocnemius 
muscle. From the sensation which it occasioned he supposed that some one
had struck him from behind but on turning round he could discover no one. Mr
Travers father met with the same accident while he was playing with the children 
& thinking that some one of them had struck him he spoke very sharply
being considerably irritated by it. But they denied the charge & on examination
the true nature of the case was discovered. The treatment is the same as if the 
tendon was ruptured. Inflamation is to be prevented & a high heeled shoe is to be
worn. If it is not the muscle in acting  will be torn more & more & become a serious
accident other muscles are sometimes torn through Mr Wales tore his Gracilis
muscle through by the exertion he made to prevent his being dismounted when
his horse made a plunge. It has never united since. From the Inflamation
which took place the upper end of the lower end became adherent to the
surrounding parts & he has still some power over it



55
Wounds of the Joints.
Wounds of the Joints are dangerous on 3 accounts 1st on account of the great extent of surface
which becomes inflamed. Thus if the Synovial membrane of the knee Joint was dissected 
off & spread out it would be found to cover a great extent of surface great irritation is 
occasioned to the system from the Inflamation of so large a surface alone if there was
no other cause. And again when Inflamation is set up in a joint it is impossible that ad
hesion should take place without previous ulceration. If the adhesive process ensues
at once Inflammation ends & all is soon well. But if it does not go on in this way
higher Inflamation is set up which is necessary to affect the process of granulation
& before this can take place the cartilages must be absorbed. To prior to Granulation 
suppuration must be set up which will be a very tedious process & attended
with a great degree of Constitutional irritation In all these processes the surfaces exposed 
to each other instead of being smooth will the rough surfaces of the bones which 
are constantly rubbing together & increasing the oils so that in other cases generally we
have no right to expect a quick nor always a favourable termination. A 3d circumstance 
which renders their cure difficult is that the Synovial membrane is at all
times secreting very abundantly & When Inflamation is set up instead of adhesive
matter Pus is thrown out. It is the same as when Inflamation is set up in then urethra its
secretion does not produce adhesion but suppuration is the consequence of it. The 1st
great object in wounds of the Joints is if possible to produce adhesion of the external 
parts. Besides this they must be kept perfectly still. If you are successful in affecting 
these suppuration may not come on. All sutures should be avoided as much as
possible but the parts must be brought closely togehter & for this purpose you must
principally depend upon adhesive plaster same time Lotio Ammon Acet or some
other Evaporating Lotion should be applied in order to keep down all unnecessary
Inflamation. Some Inflamation is necessary in order to affect adhesive but little however 
is different. When adhesion has taken place all danger ceases. But should



56
suppuration be set up notwithstanding all our endeavours it must then be treated like suppuration
generally. Poultices & fomentations are to be applied. There will then be a good deal of constitutional 
irritations which is to be subdued by the common means by Opium & Aq Ammon Acet. From 20 to 30 drops
Tr Opii with Zi Aq Amm Acet. in any convenient vehicle two or three times a day such are the remedies
on which we chiefly reliy in continual constitutuional irritation Opium is always necessary
unless perhaps when the head is affected. The nerves appear very much irritated & it can
not be overcome without the aid of this remedy. A fungus sometimes, indeed frequently 
arises from this joint & closes the wound & some surgeons who are ignorant of its nature have 
opened into it with a probe to let the matter out. But they have always done a good deal
of mischief by such practice This fungus is one of the means which nature adopts and
she should not be interrupted. A man in this hospital had an operation performed for 
the extraction of a Ganglion in the knee Joint. Afterwards a fungus Aron the matter
was confined & prevented by it from escaping & the mans constitutional suffered a great deal 
in consequence of it. Mr Chandler ordered nothing but rest the fungus accumulated &
after a while the wound closed the matter was absorbed & he got well The constitutional 
symptoms were in this case so great that it was supposed that he would never
recover from them If the surgeons had gone to work to pick out the fungus in order to
evacuate the matter it probably would not have terminated favourably. When a patient 
in these cases recovers a little motion he generally recovers the whole after a little
while. Wounds of the joints do not generally occasion necessity for amputation. There is
more danger of this result if the Knee Joint is wounded than any of the others. In
young subjects when the constitution is good I never perform the operation but if the
Constitution is impaired by age or disease it is then very often required.
Wounds of the Abdomen.
Wounds of the abdomen are of two kinds those where the Parits only are divided and
those when the viscera sustain Injury. The treatment is very much the same as a
strangulated Hernia. It is always necessary to make a suture. The loosed suture is



57
is the most proper in these wounds. Thus in the Caesarean Section this is used & adhesive plasters 
should be afterwards employed. It is very curious to see how the viscera will elude injury 
in very extensive wounds of the Abdomen. In the 1st case that Mr Cooper ever saw of
this kind a woman had ripped the belly up from the Os Pubis to the Ensiform cartilage
& the bowels were all protruded & yet none of them injured by the razor by which she
done it. With respect to wounds of the different viscera Mr Cooper has never seen one
of the stomach A good case is related by a Surgeon by the name of Scote. The plan of
treatment was merely to close the external wound opium & Broth Glysters even given
the opium to make them be retained at the end of the week the patient was allowed
to take jellies by the mouth & retained them very well. The nature of the wound was
known by the unusaual cold sweat & the faintness which immediately ensued & by the 
vomiting of blood. The proper plan of treatment in transverse wounds of the intestines
is by Sutures. If the mesentery is included in the wound four sutures are necessary
If not 3 will be sufficient because this will then serve as one. Mr Travers from experiments 
which he made has proposed that the ligatures should be cut off close
In trials on animals they were uniformly found to slough out into the intestine and
pass off in that way. The result of these experiments is certainly very curious but if
I had a wound in my own intestines. I should consider myself more safe if a 
portion of the ligature was left at the external orifice of the wound. If a wound in
the intestine is longitudinal the uninterrupted suture should be employed the common
Glove stitch should be used. The diet should be the same as in wounds of the
stomach the patient to be supported a week by bowel Glysters & afterward by light
food such as jelly broth &c. If it is in the large intestines he is to be supported by
the mouth. When the Liver is wounded the abdomen becomes soon afterward
tense & painfull. A patient in the other Hospital was stabbed [bled] several times in the
Liver & bile came with the blood but he was cured by applying adhesive plasters
to the wound & proper Constitutional treatment. A wound in the Gall bladder is 
always fatal.



58
Wounds of the spleen occasion death by the quat haemmorhage which takes place into the abdomen. 
Dr Gooch relates the case of a man from whom he cut out the spleen entirely & he
did well. But if it is wounded & remains in it is fatal. When the kidneys are wounded
blood always comes away with the urine
Wounds of the Throat
These are very common & there is a great deal of error in the treatment from the want of 
knowledge of the Anatomy of the parts. The distance between the Chin & Sternum is about
9 inches & for the purpose of illustration we will divide it into these parts. The 1st 3 inches is
occupied by the Tongue on the fore part of the Pharynx behind & a wound at the part
allows both air & food to escape from it. This inclines people to think that the oesophagus
& Trachea are uninjured. It is the 3d & lower portion which has the ocsophagus behind
& the Trachea before. Hence when a wound is made in it the air & food readily pass though 
The part which is most frequently wounded when a person attempts to commit suicide is
the upper portion & when you are called to such a case you generally find the person
lying with a large gaping wound & air passing so forcibly through that it would extinguish 
a candle. As to the treatment of these wounds it is extremely simple the 1st object
is to bring the parts close together & for this purpose sutures must necessarily be employed
If the wound is at all extensive there is no hope of safety without them. The parts must
be brought in as close contact as possible, this is one of your principle means. It is right
to deprive the patient of nourishment for some days as every attempt at deglutition
by the great number of muscles which are brought into action would serve to tear the
wound asunder. What drink he takes should be by wetting the corner of a handkercheif 
& introducing it into his mouth. This will prevent his being as much parched
with thirst as otherwise he might be We should give him nourishing Glysters frequently 
they may assist in suppurting him for some time When the patient first begin
to swallow he gets down solid substances as jellies are much more easily managed than
more fluid things. Fluids are apt to excite coughing & should be avoided when we believe that
the adhesive Inflamation has commenced.



59
The second part of the Throat which is apt to be wounded is the Larynx, in the air passes through the
opening but the posterior part is rarely divided & therefore we do not generally find that food also
passes. We are informed of the nature of the wound by being able to measure the distance from
the chin. The treatment consists in approximating the cartilage & passing a ligature through
its perichondrium. The distress of the patient is very much relieved as soon as this is done
Before he was in such agony that he lay gasping for breath & now he is comparatively in
a state of care & will tell you that he feels quite comfortable. It is necessary to close the
external wound by means of adhesive plaster & by a regular prepare made with bandages 
or a handkerchief tied round the feet. But this alone will not succeed the struggles
of the patient are so great & he is under the necessity swallowing his saliva so often
that adhesion will be prevented unless sutures are at the same time employed. Sometimes 
a piece of the Cartilage is cut & hangs loose. If this is small it should be taken 
away. A piece of Cartilage will sometimes exfoliate & be a long time in coming
away It is generally converted into bone first. Mr Ludlow had a case in which this 
happened under Inflamation of the Cartilages they are almost all converted into bone
The 3d situation of wounds in the Throat is 3 incs above the sternum. They differ from
the others by the great bleeding which is produced by them. The blood which is brought up
is generally mixed with a good quantity of froth. Liquids in passing thro the oesophagus 
excite a good deal of cough. Our first object in the treatment will be to secure
the bleeding vessels & having done this we should examine into the state of the oesophagus. 
Suppose the wound should be a stab. I should close it with a ligature but
it is right to say Gentlemen that this is mere speculative opinion. I have never seen
a case of it. It might perhaps be done sufficiently by bringing the wound of the
Trachea together. The mode consists in raising the close substance covering the trachea
by means of a pair of Forceps & carrying a needle & ligature thro it. You can have no
idea of the relief the patient receives from the being done. His condition afterwards
is comparatively easier. It is absolutely necessary that this should be done & if not



60
done he will fall a victim to your inattention. If it should happen to be a small wound perhaps
it may do well without but if it is a large & transverse wound he will surely die. These symtoms
continue to increase untill he becomes delirious & death is the consequence. But if the parts are brought 
together properly all this mischief & irritation is prevented. If the oesophagus is wounded 
it is right to pass a tube down into it for the purpose of conveying food into the stomach. I recollect 
a man died in the other Hospital from this circumstance being neglected. A 
fistolous orifice was produced leading outwards & the food which he attempted to swallow
came partly through it & kept it open. He died at last from inanitions. In these cases it
is better to administer nutritious Clysters at first & when granulations have taken place
then nutriment should be injeccted thurough tubes introduced into the oesophagus
Wounds of the Chest
These like wounds of the abdomen are of 2 kinds 1st those in which the chest only is injured & 2d then
where the lungs also partake in it. These wounds are sometimes attended with less danger than
we would at first expect to imagine A boy was once brought into the other Hospital with so
large a wound in the chest in consequence of a fate across a rail that the lower portion
of the Left Lung projected considerably through it on expiration & returned again on inspiration 
It looked very formidable but the integuments were brought very carefully together
by adhesive plaster & kept so by a bandage & the boy did extremely well. Bounds of the
chest are dangerous on the accounts 1st from the haemmorhage which immediately follows
The patients sometimes coughs up a good deal of blood which occasions suffocation & [heals?]
loses considerable externaly by the wound. This then is the first source of danger. Blood
should be drawn away from the arm immediately & not sparingly. It should be taken 
away even untill faintness is produced which will cause the bleeding vessels to close & a 
clot to form in them & in this manner the danger is prevented. The wound is never to be
closed untill the haemmorhage has ceased or the blood will collect between the 2 pleura 
& thereby produce great irritation. The 2d danger in such wounds arises from the Inflamation 
which ensues. The patient will often after he has appeared to be doing very well for some



61
time complain of a violent pain in the head & difficult respiration & will have a labouring pulse which
symptoms are in consequence of supervening Inflammation. Under such circumstances we shall be
obliged to take away more blood. I have known as much as 80 ounces drawn away in such cases
But still a 3d danger remains when we have got rid of the Inflammation. It often happens that
after a few weeks have elapsed laborious respiration & febrile symptoms come on which are the
result of matter thrown out into the cavity of the Pleura & on dissection Pus is formed in the
cavity of the Chest mixed with adhesive matter & blood. A man was received into the other
hospital who had received a stab in the Thorax from attempting to resist an officer
endeavoring to press him into the service. He was treated in the common way & his urgent
symptoms were recovered & he was reccommended to go into the country for the further
restoration of his health. After a while his difficult respiration increased & continued
untill he died & the appearances on examination were as above mentioned Now
in these cases Gentle is becomes necessary that you should make an opening into
the Thorax for the discharge of the matter. It should be made in the lower part of
the chest between the 7th & 8th ribs. It should be obliged so that it may immediately 
afterwards be closed & prevent the ingress of air into the Chest & it should be made
close to the upper side of the rib so as to avoid injuring the Interocostal artery_
Emphysema is a frquent consequence of these wounds into the chest. When air is thrown
into the cellular membrane from this cause a crackling sensation is produced under the
Skin & this sometimes extends to a considerable distance. The mode of treatment is to
make punctures at a little distance from the wound so as to allow of the escape of air
Wounds of the Pericardiums
I have never had an opportunity of seeing a wound of the Pericardium but my friend
Mr Saundin had one under his case. The patient was stuck with a boat hook on
the Sternum which was followed by a good deal of bleeding from the Internal mammary 
artery but after a while it stopped & no danger was apprehended from the
wound. Its danger was not suspected until a few days after when a quat 



62
difficulty of breathing came on & the man died. On examination of the body the Pericardium
was found to have been pierced by the instrument & Inflamation & very considerable effusions
had taken place in the chest in consequence thereof. In fact Hydrothroax was produced by
it. From what I have seen of these kind of cases I am inclined to believe that whenever 
blood is extravasated into any of these cavities it will not adhere. It acts as a foreign 
body causes a great deal of irritation of the lungs Inflamation & Deaths. 
Wounds of the Heart
Are not so generally fatal as has been supposed. In one case which has been related
the patient lived 9 hours after the Injury had been inflicted Another case has been
related by Dr Barbington of a soldier who had been wounded in the heart by a bayonet
It entered the right Auricle. He survived the accident as much as 49 hours. He 
then died on making a violent effort on a low stool to evacuate the contents of his
rectum. He was quite unconscious of the danger of his situation or the important nature 
of his wound & had been considering the parts which were injured very comfortable
This mans pulse was very feeble & small after the accident
Wounds of the Absorbents.
The absorbents are very often becoming Inflamed from various causes no circumstance is more
common. It most commonly arises in consequence of superficial injuries almost any cause
is seen sometimes to occasion Inflamation & irritation of these vessels. It arises either from
Incised Lacerated Contused or Punctured wounds from bites, stings indeed from
almost any injury & they all seem to produce it with equal facility. An irritation of 
the sound cuticle will do it as a tight shoe which irritates the foot will produce
tenderness in the glands of the groin. This always appear before the absorbents
themselves give signs of Irritation. A hang nail cut too close will sometimes produce it
in an irritable constitution as also a corn or broken skin will give rise to a Bubo.
I have seen the same from a bite this last will generally cure it in irritable habits 
Injuries to the finger & toes very often produce it. I saw this last week



63
in a Girls arm very much inflamed & the glands in the axilla very much enlarged in
consequence of a bite which she received from an angry cat. In fact nothing is more common
The patient often suffer a great deal of pain & often when he does there is no appearance
of red lines & not uncommonly when the red lines are strongly marked he complains of no
pain at all. This shows it is not entirely referable to irritability but that sensibility is
more readily discovered in one case than another. Punctured wounds more freely produce
Inflamation of the absorbent vessels than others. Poisoned wounds also do the same
& more rapidly too. They cause Inflamation of the absorbent glands which is accompanied 
by a Typhoid fever. This fever is of a mixed kind, in its commencement
it is sthenic & soon after it becomes Typhoid. When the absorbents are inflamed
the cellular substance over them also become inflamed & it is marked by red streaks
along their course interrupted by the glands & valves. This causes a knotted appearance 
& feel. To the slightest contact they are exceedingly painfull. It is a remarkable 
fact that those wounds which produce Tetanus symptoms do not excite Inflamation 
of the absorbents. I will not say that they never do but it is very rarely 
the case. These wounds seem to produce no tendency to Inflamation in those
vessels. The Thecal abscess produce Inflammation of the absorbents an opening in the abscess
removes it at least allows it to subside. A good deal has been said about the ill effects
of extravasated lymph irritating the system but there is no substantial reason for supposing 
this to be the case. Practitioners have thought is right to reccommend a stimulating 
plan of treatment from observers the debility which poisonous matter occasions
when introduced into the system & the accompanying fever being of the Typhoid type
gave countenance to the mode. But 1st the same effects have been found to follow
from cuts made with clean instruments & 2d these stimulants have been observed
to aggravate the danger evidently. The plan of giving stimulants in cases of punctured 
wounds from dissecting needles &c is now abandoned. It is quite clear that
whatever view we have of the injury it meant be more or less active. I think it is of



64
quat importance not to carry the reducing plan too far which I believe we are apt to do
We deplete too hastily & too largely. Sometimes when Calomel is given to too great an extent
a diarrhea is apt to be produced which wears out the system too much. We should
not reduce the strength below par. If matter forms an early incision should be made
you should not for a moment defer its evacuation. The relief which is experienced 
by it is beyond calculation. I think that a change of air would probably be beneficial 
& should be tried when we see the system is waiting without any suspension 
of the disease. I should wish you to bear in mind that an Inflamation of
the absorbents is generally an inverse ratio to the (crossed out) violence of the local Inflamation 
Burns and Scalds.
As far as I have an opportunity of observing 3 different effects are produced by these
accidents. The first is when the cuticle is simply raised. There is not the least danger 
in this if the cuticle remains unbroken The 2d where the cuticle is removed to a 
considerable extent. This is very dangerous It occasions a very high degree of constitutional 
irritation & a quick destruction of life & no effort seems to be made by the
system to prevent this. It is exceedingly difficult to produce reaction as you have
a very frequent opportunity of seeing in extensive burns which are brought into our
public Hospitals. The 3d state is where the life of the skin is destoryed you
must then have extensive sloughs. The constitutional irritation is at first slight
It is not an immediate but a distant danger which you have to fear. In the 
first state of Burn it is of very little consequence what application you employ 
provided the skin remains unbroken. Your object is to prevent Inflammation 
as much as you can. If Inflamation is not prevented a suppurative 
process will follow & matter will form under the skin you should by
all means therefore prevent that state. Spirits of Wine & Water or Liquor
Plumbi should be applied. Do not treat the old cuticle untill you think a
new cuticle is formed underneath. If it is extensive there will be great danger if 
you do_ 



65
I will give you a case in illustration of this. A Boy was playing Hide & go peek with his
brother & he jumped into a large boiler not knowing that it contained Hot Water. He immediately 
sprung out again & his legs & feet were very severely scalded. The cuticle however was
not seperated after about a week he was doing well & a Surgeon very foolishly ordered
a poultice for the purpose of removing the cuticle. Refuse suppuration came on the
boy became comatose & very little hopes were entertained for his recovery. His father came
to the Hospital when he was in the state & requested to see him. I immediately ordered
wine to be given him & stimulating lotions applied to the part for the purpose of diminishing 
secretion & he recovered. In the 2d state when the cuticle was removed to a considerable 
extent the sentient extremity of the nerves being thus left uncovered a high
degree of constitutional irritation takes place. Your object in these cases is to coat the
extremities of the nerves & bring them to as natural a state as possible. The old
application used to be lime water & oil. It gave case & had a tendency to suppuration 
Lime water & milk is more generally subtituted because it is generally
more easily procured. It soothes the nerves & prevents much irritation. These
burns sometimes terminate very suddenly. I have seen a person come into the
Hospital with a burn of this kind at noon & die in the evening. Just before he
died he was seized with a shivering & his pulse was so small as to be scarcely 
perceptible. It is just such irritation as is produced by violent accidents It
is very necssary to give powerfull stimuli but very often they do not succeed. I
have known a child fall into a boiler at 4 oclock in the afternoon by which hes [?at?s]
were scalded & to die at 8 in the evening. You ought to be very carefull in your
prognosis in these cases for they often terminate unfavourably after they have appeared 
for a good while to be doing well. A Surgeon in the city of very considerable
practice & eminence told me that he once got himself into a good deal of difficulty
by not bearing this circumstance in mind. He was called to a child 
who had its breast scalded by some tea being spilt over it from the saucer



66
as she was carrying it to the mouth. The scald was not very extensive. He told the parents 
that it would not be at all dangerous that it would do well & that in a few
days it would be very well. In a few days he found it was dead from the irritation
which was produced only from the seperation of the cuticle. I am inclined to think
that there must be something peculiar in these burns which are the consequence
of combustion of Hydrogen Gas. A gentleman who is in the habit of seeing these
burns very frequently was in Town not long since & I showed him a bad burn
which was in the Hospital "oh said he that will be easily cured" by Turpentine"
We consider such a burn as that a mere flea bite in Leeds" on the same evening
this child died. Now I am inclined to believe that these injuries do not extend
to the same depth as when burnt by the heat which applied in the common
way by the Clothes being set on fire &c. These injuries go on tolerably well for two
or three days & the Dysphagia comes on & other symptoms indicating dangers That
is the common effect. I have observed that the same effect is produced by the
Hydrargyria just before the drath at the same time we are making use of our
local applications it is necessary to give opium wine & even Brandy if the patient 
has been accustomed to the use of it. There is a considerable degree of a
depression of the circulation & it is necessary to support the system by giving
stimulants. In the 3d state of Burns where the skin is destroyed a slough must necssarily 
take place. It is not in this case the constitutional Irritation which at first destorys it is
the copious secretion of matter & the excessive debility & irritation which arises in consequence of
it that we have to dread. In general it is best to apply Spirits of Turpertine at once with a
view to stimulate & produce a determination of blood to the surrounding parts &c to assist
in throwing off the surrounding slough at the same time the constitutuinal means which we
have been reccommending should be used. Mr Kentish who first reccommended this practice
in Burns & Scalds strongly advises its indiscriminate use in all cases & those who had
the best opportunities of seeing such injuries think it is the best. Mr Stey told me from what
he had seen of its use he considers it the best application



67
after Burns & Scalds are extensive there is a disposition to form a new cuticle. The Solution 
of acetate of Zinc in proportion of about gr.iss.xij-Zi Water should be applied. It assists
very much in the production of new cuticle. I have seen it in 3 or 4 days do it to a very considerable 
extent Now & then the sores which follow burns are exceedingly difficult to heal
the reason is that there is such an extent of ulcerated surface that the new skin has not
the power of sending out granulations sufficient to approximate the edges together. The
Murias Hydrary cum Liq Calcis is often a usefull applications as is also the oxyd of Zinc
This forms a crust over the sore & sometimes a new cuticle will form under it_ Great
deformities often arise after burns & the fault is often ascribed to the Surgeon but unjustly. 
They are produced by the subsequent contractions of the Granulations. After they have
become fully formed & healed over. It has been reccommended to divide them but I
have never seen any advantage arising from this unless when merely a loop of skin
requires it. You must be careful how you suffer yourselves to commit a Brother
in the profession by laying the faults to him when such occurences happen
On Carbuncle.
Carbuncle is a sloughing abscess in which there is mortification of the Cellular Membrane 
to a considerable extent. It is the same disease as a bite which is a small carbuncle. It begins 
exactly in the same way. It is at first a little pimple containing matter as it extends
it puts on a livid apperance & there is a small ulceration in the Centre. The pain sometimes 
is very considerable a good while before. I have known a Blister to be applied for the
Rheumatism & a carbuncle appear under it_  In the next stage there are a number of
little ulcerations the surface looks as if it was worm eaten & matter comes out from these
numerous little holes bubbling as if mixed with air. When opened the death of the cellular
membrane appears more extensive & with the matter large portions of it slough away &
more can generally be pushed away with the finger. They occur mostly in persons
who live freely & whose constitutions are bad. They are not commonly dangergous
They are frequently on the back & nates than anyh other parts sometimes they




68
appear on the neck & Head & when they do are exceedingly dangerous. I never knew a person to recover 
from a Carbuncle on the scalp. In two or three days he always becomes comatose & dies
In these cases the Brain is affected 
The Treatment is very simple Fomentations & poultices should be employed to cause a determination 
of blood to the part & to produce secretion. It is necessary to make an early
incision in order to get away the dead portion of the Cellular Membrane which will cause
great irritations & to save the sloughing process which will otherwise take place to a
great extent. Spirits of Turpentine is a very usefull application also the Nitrous Acid
Lotion. If the Spirits of Turpentine is employed it is always necessary to mix with it in
proportion of ʒii of former to ℥i latter The constitution is at the same time to be suppurted 
by Ammonia & opium & a generous diet & all the other treat is similar to that of
Mortification from other causes



(A drawing of a man)



68
Tumors.
There are but 2 kinds of Tumours in the body. The 1st are those in which there is an increased
growth in the natural parts & 2d are those wherein new parts are formed. The first are the
most frequent & increase to an enormous size. They are dependant on an increased action of
the vessels of the part & are called Heatomatous Tumours. The character of these tumours are
that 1st they are entirely devoid of pain. There is no pain generally in the progress & no pain
on pressure 2d there is an obscure sense of fluctuation but it is not a distinct fluctuation. 
It arises from this cause. The fatty matter of which it is composed becomes in a degree
softened by the heat of the body. It is so much like fluctuation that a man unaccustomed 
to feel it would think it was so. The 3d circumstance is that it appears to be
divided into different lobes. When you press upon it you find that the skin is sinking
into different depressions & stretching the skin over it you distinctly see the lobulated apperance. 
There is no discolouration of the skin generally & the skin possesses very little
vascularity under injections it is not reddened & under operations but very little blood is
lost. Therefore when called to such a case & you find it is not painful & not tender
on pressure & that it has not fluctuation & is apparently divided into lobes you may
always be certain that it is a fatty tumour. It very rarely goes on to the formation 
of matter It has scarcely any tendency to do this but now & then it will. I reccollect 
a Gentleman who had one of these tumours on the cheek I advised him to
have it removed but he would not consent to the operation. Afterwards he applied a
strong solution of Brine & Suppuration was induced the matter was discharged
& he did well but this is so rare an occurrence that it cannot be expected. Now and
then you will find patients who will not submit to the operation untill they have tried Brine
you may permit them to try this for if it does no good it will do no harm. These tumours
appear most generally on the shoulders back & nates now & then on the extremities they
grow sometimes to an enormous size. I have removed one from the breast which weighed
14 lb 10 oz Mr Youngs father removed one which weighed 22 lb



69
When dissected they are found to be not truly encysted they are formed like a Fatty membrane
in other parts of the body. Not contained in one particular cyst but connected processes of
Cellular Membrane which are passing from the surface of the Tumour to its interior. It is composed 
of a great number of cells like the orginal fatty membrane. It is therefore not merely 
a growth of the cells but a formation of new cells not simply a deposition of oleaginous
matter into the old cells very few vessels are found passing into it. It has no effect on
constitution & requires removal only on account of the inconvenience which its great size
occasions. The removal of it is very simple. It is a mere piece of dissection. If large
an eliptical portion of the skin must be removed with it. You are to measure with your
eye how large this portion ought to be. It is right to take away no more integuments
than is just sufficient to bring the lips of the wound close together. If you leave too much
adhesion will not take place equally all over its surface & suppuration will occur
partially & make the cure more slow. It is necessary to remove all the processes of Fat
sometimes it is difficult to distinguish the morbid growth [of] from the surrounding parts
However if you take hold of the Tumour & draw it out as you are dissecting it you will
generally be able to discover all which should be removed. If any portion is left behind the
Tumour will be reproduced as much as tho it was malignant altho its growth be very
slow. It will be a long time before it attains any considerable magnitude. I knew a case in
which it was necessary to operate three times from some portion of the tumour having been
left behind. Sometimes we can succeed in repressing the growth of these Tumours by bandages
If situated on the extremities this should be tried but when they are situated on the
Trunk this cannot be adopted & Extirpation becomes ultimately necessary. If the patient
is advanced in years its increase is so gradual that it is not advisable to operate unless
he is desirous of having it done There is no necessity for removing it. I lately saw a Gentleman
who had a number of these upon his arms & some on his Thighs they only required bandages 
to prevent their furthur increase. To those on the abdomen adhesive plaster
should be employed instead of Bandages



70
I ought perhaps to mention here that I have seen more than one case of Tumour which was an increased 
growth of the cellular membrane without any increased portion of fat. In these cases
it is very difficult indeed to distinguish the diseased from the surrounding healthy parts. It
is quite vascular. It is necessary to divide many vessels & the removal is quite tedious. One of
our pupils some years ago had a Tumour of this nature on his Forehead which was removed 
by Mr Saunders then Demonstrator of Anatomy. He told me be found great difficulty 
in the operation. A great flow of blood obscured his progress & when he had secured the
vessels from which it proceeded he found great difficulty in distinguishing the Tumour from
the surrounding parts. It took up a great deal of time & notwithstanding all the care
which he took there still remains some disposition to a return of the disease. He has
now a similar Tumour altho from the slowness of its growth it is quite small. I can at
present only call to mind three of these cases which have come under my notice.
Encysted Tumours
These most frequently grow about the Face neck & sometimes on the scalp. The character of these tumours
is that they are distinctly circumscribed & have a fluctuation as distinct as in Hydrocele. By this they
are readily distinguished commonly there is no pain altho sometimes they suppurate & become very painfull. 
They possess but very little vascularity. They are composed of a cyst which posseses a secreting
power & throws out the fluid which they contain. When openened a curd like sebacious matter
is discharged which has a very unpleasant sour smell acidity is its predominant character
They have very few vessels & then are distinct & widely operated. The divisions which have been
made of these tumours into Arthromatous Millicuous &c is very foolish & unimportant because
it cannot be known before they are taken from the body. These tumours seem to be hereditary
They seldom increase to any considerable size they appear at first like risings not
larger than a pea & gradually increase untill they are as large as a marble or small [illegible]
When situated on the scalp the cyst sometimes becomes very thick so as to mainatin its 
form after the discharge of its contents sometimes they appear about this part in great numbers. 
I have seen a patient who had 9 of them. The treatment consists in their extirpation
In removing them it is best in general not to cut round them that is if they are not very 



71
large but to cut into them & discharge their contents. By operating in this mannner you save a good
deal of time & pain. The other way is excessively tedious & very painfull. After the contents are removed 
you can take hold of the cyst & dissect it out in 3 or 4 cuts whereas if you attempt to remove 
it without opening it Thirty or Forty cuts will be necessary you thus save more than
half the time as to vessels there will be no necessity to take them up they are so small Generally 
when they are situated on the scalp we do not remove the hair with them. We let a
little blood remain by which the hair becomes matted together & no after dressing is required
I have known after the removal of these tumours the tendon of the Occipito Frontalis to be 
injured & the Inflamation arising in consequence extended down over the face159
 & neck and
the patient died the 7th day after the operation. It is best therefore not to dissect deep
but to let some cellular membrane remain between the tumour & tendon. If there should be 
any haemmorhage you should not introduce Lint into the wound for there is danger of
producing Inflammation but pressure should be made from witout. When these cysts
are large & there is no malignances they must be cured by injection as a Hydrocele
This may be known by the nature of the discharge. It is of a bilious color when malignant
and approaching more in its appearance to water when not. I remember one case which was
Cured by Injection in a child from which Zxvy fluid was discharged. If the cysts ulcerate 
& suppurate a horry excrescence sometimes arises from them of which we occasionally 
see examples
Glandular Tumours
This is one of the most common kind of Tumors. They are usually situated in the neck
about the angle of the jaw & often go on untill they attain are enormous size. These tumours
are what you hear often spoken of as Wens by common people altho this is not meant by
the term. It is the Fatty tumour only to which this term is properly applied. It is like the 2
others in one respect that it is unaccompanied by pain except when it ulcerates
& generally there is no tenderness on pressure. They are distinguished by their hardness
being of a very firm texture. They are distinguished from scrophulous Tumours by their
being single by their remaining stationary & they do not like these increase rapidly_



72
They are extremely gradual in their growth & are also very moveable. They are exceedingly vascular 
a great many vessels enter into them & they are generally situated over large & important 
arteries as the carotid so that their extirpation is attended with considerable hazard of
wounding these vessels. The operation requires a great degree of firmness & anatomical knowledge. 
They are the most difficult operations in Surgery such as no man would think of
courting. He is obliged to perform them sometimes but he is a blockhead if he seeks for them
They not only require a good deal of anatomical knowledge but a peculiar mode of
operating. It is in such operations as these that you have an opportunity of seeing
whether a man is a bungler or not. It is in such that the mind as well as the hand
is employed. They require removal because they will go on to increase untill they destory
life. In performing the operation there must be as much skin removed as is necessary
to make the wound come aptly togeter when the Tumour is removed. You must always
make it a rule to cut upon the tumour & not around it If you do not you are in
danger of cutting vessels which ought to be avoided. The integuments must be
drawn to one side & only those vessels divided which are going to the tumour & it is
best to secure them or the haemmorhage will obscure the operation. Another observation 
which I ought to make is that each gland is contained in a cyst which becomes 
much thickness when the disease has existed any considerable time and you
can carry your finger on the handle of your knife between this cyst & the tumour
& in this way avoid the danger of unnecessary haemmorhage. If there is any haemmorhage 
after the operation even if it arises from small vessels they should be
secured or you will be called to as after bleeding_ Setons have been used in these
Tumours & absurdly too. They do no good. Issues also & they too are absurd I have
never seen any good arise from them. The same may be said of Blisters Mercurial 
oitment &c.



73
Fungus Haematodes
This is a tumor consisting of new formed parts & is an extremely frequent disease. It was long
known to the vulgar under the name of the bleeding cancer. It was described by Hunter
under the name of Fungated ulcer but untill Mr Stey wrote about it we had no clear
idea about it even Hunter himself did not trace it from its commencement. If seated
near the skin it appears at first like an enlarged vein it looks blue but generally at first
it is so deep seated that this appearance is not observed. When deep seated it has the
character of a Heatomatous tumour. The only difference is its great hardness at its
commencement it is very firm. Early cut into it it appears to be divided into many
small portions like glands the fatty matter seems to undergo a change. It looks like
sweet bread it is devoid of pain untill it increases then it takes on suppuration
I believe all these diseases have their ulcerative & suppurative processes or stages
but it is not common suppuration but a peculiar one. therefore you know it from its
appearance. In the suppurative process the matter produced is not pure pus as in
Common Suppuration but it has a greenish tinge & when the bag is cut open a fungus
arises which secretes it. The growth of the Fungus is extremely rapid. The blood in this
disease does not appear to posses the common character. It is more dark than natural
The granulations have a very dark brownish hue. They secrete a very large quantity
of fluid. I know of no structure which secretes so much. If a napkin is folded
many times & laid over it & allowed to remain a little while each fold is soaked by
it. It is generally of a yellow or greenish tinge. When it reaches a considerable size
the constitution becomes affected the Liver and Lungs become diseased tubercles are
formed in the substance of the Lungs & in the Pleura. The patient generally labours
under & severe cough & dyspnea & generally has matter effused in the chest. This
disease seems to occur not only in the course of absorption but out of it. I remember one
of these tumours not twelve months ago which was commencing in the skin of the foot
& now the patient has a similar swelling in her groin. I asked her the last time I 
saw her if she had any other swelling about her & she said "Oh yes Sir I have them in my




74
Axilla. Now that in the Groin arose in the course of the absorption but then in the Axilla 
were certainly out of it. This disease is capable of appearing in any part. We shall
show it to you in the bone when we come to speak of its diseases. The tendons are most exposed 
to it & the aponeurosis covering the muscles. I have seen it commencing in the aponeurosis 
covering the Deltoid muscle. Mr Lucus found it originating in the sheath of the
Femoral artery altho it was quite moveable over it & the operation was excudingly difficult. 
It also arises from the Cellular membrane I have known it to arise from the
Tongue Indeed there is no structure in which it may not appear. When cut into it
appears to be composed in part of loosely constructed adhesive substance in part of
Clotted blood & in parts of cysts. When blood is drawn from persons in this disease its
Crassamentum is very loose. Under Inflamation an adhesive substance is produced
but it is very soft texture. The vessels are so constructed that they are unable to secrete
a firm substance. The fault in this disease is in the constitution & unless we can change
that we can do no good. I removed one of these tumours from the shoulder of a Gentleman 
sometime after it appeared in the eye & in a twelve month he died. A Lady
had such a Tumour on her foot. She applied to a Surgeon who however thought
lightly of it & burnt it down with caustic but it grew again. A fungus sprouted out
& she applied to me & by my advise it was removed. It notwithstanding appeared a
Third time & I again removed it still more carefully than before even taking away
the periosteum which was under it. The parts over it healed & cicatrised well. I was
asked by Mr Saunders a few months afterwards to see the same woman again for
some swellings which appeared in her groin. She was advised to go down to the Sea
Shore. After she had been there sometime she wrote me informing me that many
similar tumours had appeared in different parts of the body. In a little while after
She complained of a pain in her side & dyspnea & she died at last from the effects
of them on Examination the Liver & Lungs were found filled with tubercles & 
the ovaria was also diseased. It was a case of true Fungus Haematodes & I have



75
thrown several instances when the limit has been taken off without saving life. We have
two objects in view in the cure of this disease. One is to remove the Local complaints and
the other to repair the constitution. The surgical part of the treatment persists in the 
removal of the Tumour. We are not to be content with depicting the utmost limits of it
but we must pass beyond them & cut off parts even though they have not become hard
or they will become affected with the same complaint. We are often obliged to repeat
the operation. With respect to the part it generally succeeds but it will appear in either
situations. It is the constitution which is in fault. There is no danger of Haemmorhage 
unless we cut near the disease Near to it there is no retraction or contraction
of the vessels because they are so weak in this structure & thus the two means by which
haemmorhage is prevented & taken away. If you cut into the disease the bleeding
will be very free but if you cut into the surrounding parts it will be stopped as in
other cases. I have found nothing very particular in the operation there is a little
more bleeding but no immediate danger. In amputating in this disease we should
be cautious not to do it near the seat of it or the diease will be reproduced
All that can be said of it is that it is sometimes absorbed into the system & then
it is curable but before this happens early amputation will succeed in preventing 
it
Hydatid Tumour.
The Hydatid Tumor is of three different kinds at least there are three tumours called
so. The first is the common Hydatid. It is a cyst appearing to be a living animal. Its
interior is lined by a membrane which has the power of forming other cysts similar to itself. 
If you look on this membrane you will see a number of little white which when
looked at by a magnifying glass appear to be other Hydatids. The orginial Hydatid
grows untill it attains a considerable size it then bursts & the other escapes. After a while
it excites irritation in the surrounding parts, a suppurating process is set up by nature
for its discharging externally. The way in which these cysts are formed are orginally unknown



76
It is supposed to be by means of eggs deposited in the cellular membrane in the course of the
circulation. A person came lately to my house with a considerable swelling just below the Deltoid 
muscle. It was attended only by a slight pain. It fluctuated. I made an incision 
into it & a quantity of matter was discharged & with it a number of these Hydatids. A
Lady had a similar swelling on her neck. It inflamed & had the appearance as if it
would ulcerate which it did & from the point a small piece of white membranous
substance hung. I took hold of it with a pair of Forceps & drew out several Hydatids
The granulating process followed & filled up the wound & she did well. The most frequent 
seat of the Hydatids is in the Liver. They sometimes form there in great numbers 
a process of ulceration takes place & they are frequently discharged by an opening
in the side. Sometimes they escape into abdomen & form a Dropsy there. There is
no structure in which they are not occasionally found as in the Heart the Lungs
sometimes in very great numbers & in the ovaries. The 2d kind of Hydatids are those
in which several are found growing from a single stork. They are found principally
in the Placenta. I have not seen them in any other part of the body. The 3rd species is
one which does answer the title of Hydatid for it is merely a collection of water in
the cells of the cellular membrane. The cells become enlarged & by a process of adhesive 
Inflammation seperated from one another so that there is no communication
between them. The operation consists in their removal. This is attended with a good 
deal of Haemmorhage. The reason of this is that a great quantity of fluid is secreted 
in them & the vessels have become enlarged in order to supply it. When they
have once commenced they grow to an enormous size & they require the operation of
extirpations else they will involve other parts which are important to life. In some
parts as the Liver for instance. The tumours are particularly dangerous because they
will increase & involve the Femoral artery & vein 



77
Cutaneous Tumours.
A cancerous tumour is a swelling produced in the skin appearing at first like a small
pimple which resembles a watery excrescence only that its surface is not so much broken. 
By degrees it rises above the surface & projects hanging by a small neck by
which it is supplied with blood & increases. This neck increases in size in proportion to the
rest of the tumour. It is by no means uncommon. You very frequently meet with it in
different parts of the body. You often see them in children. All that is necessary is just
to tie a piece of thread around the peduncle & then remove them with a pair of scissors
when large it is necessary to dissect them out with a knife. There is very little bleeding
the arteries which supply them being extremely small.
Warty Tumours.
These are most frequently seen on the face they are generally malignant & if allowed
to remain they will extend themselves by absorption to the glands which become enlarged 
& take on a Schirrous character. They begin like a small watery excrescence
which afterwards becomes numerous & then unite together. They are excessively vascular
& bleed very plentifully if by any means they are broken. They afterwards form
a crust & produce so much constitutional irritation that it becomes necessary
to remove them on the face they assume the same character. In general tho at
this part there is no enlargement of the glands. When they ulcerate they have the common
characters of cancer. The mode of getting rid of them is by the application of 
arsenic to the surface. This produces an Inflamation which is followed by a destruction
of the parts a slough takes place & granulations arise from the bottom of the
ulcer & a healthy surface is produced. If allowed to go on it will increase the
glands of the neck will be enlarged. I have heard some men who have caught
the profession by practice but who have never been properly educated & do not understand
the principles of the profession say "oh I never will touch a mole because
if I do it will become irritated & produce a sore which becomes destructive to life



78
Now I ought to put you on your guard about these marks. I once knew a young lady who had
one growing between the scapula which came so high that it could not be perceived when
she wore a particular dress & from pride she went to a Surgeon to have it removed. He
applied Potass but it did not entirely succeed. In a little while the granulations became
everted then the absorbent glands became inflamed & affected with scirrhous swellings
& great irritation was produced & she died in consequence of it
Novei Materni
These are vascular tumours of the skin of two different species arterial & serous. They
appear soon after birth at first there is only a discoloration of the skin without any tumour
or rising. If it is arterial it is of a bright red color & becomes darker as it increases
in size. If venous it is of a bluish cast. The cause of these tumours is the vessels
not possesing the usual elastic structure they are therefore unable to resist the usual
impluse of the heart they dilate & continue to do so more & more until at least they
ulcerate when cut into they bleed most profusely possessing no power of retraction
like other vessels they bleed like fountains. It is founded in the elastic crat of the
vessels. The arteries around them are elastic & the haemmorhage is stopped when they
are cut into. It is only in the part itself in which the difficulty exists. On injection
these vessels are found to be exceedingly dilated. It is a disease of the skin
but tho it originates here it afterwards extends to the cellular membrane. But it is
sufficient in the operation to take away the skin only altho the cellular membrane
below appears discolored yet it need not be removed for the disease will not afterward
return. I have frequently seen it much discolored & no ill consequences occured from
allowing it to remain. I was sent for last week by a medical Gentleman to see a
child on whom I had been operating on account of the dark color which the granulation
presented. I smiled & told him he may rest assured that as soon as cicatrisation
took place they would disappear. I am quite confident of this fact. I have seen so
much that I do not regard it. The cellular membrane is not orginally diseased
it is only secondarily affected becoming more vascular than before



79
When a nevus maternus is placed near a bone it may sometimes be removed by presure
as when on the scalp but it is only in such situations a piece of silver should be applied
to the tumour. If compression is thus kept us for a month it will often times disappear
one Taraswell at Guys Hospital had such a tumour which in this way entirely disappeared.
It can only be sucessfull when there is a solid structure underneath. It is
generally necessary to remove them. The way in which they are to be removed is very
simple. It is a new piece of dissection you must pass a Tenaculum thro the swelling
by means of which you raise it you then make a cut round it & remove it with one
sweep of the knife & it is necessary to do this very quickly as you operate generally on
the very young who bear the loss of blood very ill indeed. Sometimes they will faint under
a very small portion as to saving integuments with a view to produce [?ni?a]
by adhesion it is quite useless because you cannot do it. The sticking plaster will
defeat your intentions by the irritation which it excites on the skin of the delicate subjects as
soon as you have made your cut so as to remove a portion of the skin you must put a piece of
Lint in the wound and apply pressure upon it for about Ten minutes when the haemmorhage on
it will generally be stopped. The Lint must not then be removed but be allowed to remain on & 
the blood will cragulate around it & thus all danger prevented. It should be pressed down pretty
firmly you must not leave the patient for some time after the operation as there will be danger
of after haemmorhage Every portion of the disease should be removed. It is not now believed
that these are produced by the impressions of the imagination of the mother. You often hear
ridicilous stories of old women on this subject but they do not deserve consideration. The venous
Noevus requires extirpation just like the arterial but not so early. A girl was brought to
me about 12 years ago with one of these tumours. I dissected it out & afterwards injected it
with Spirits. Vini. & thus I learned that it was venous. The arteries were very small
and the veins very large so large as almost to conceal the former.



80
Noli me Tangere.
A peculiar affections sometimes attacks the face which has absurdly been denominated Noli
me Tangere. It most commonly attacks the tip of the nose occuring generally in weak & debibilated 
Constitutions. It commonly begins by one of follicules being inflamed. Though it is not
simply a local disease depending in a great measure on the state of the constitution. It shows
itself particularly after the stimulous of taking food as after dinner & will continue 2 or 3
hours. There is some a small crust formed over it which being removed the folliculi is seen in an
ulcerated state. The sore begins to extend & sometimes affects the cartilage of the nose. In
this state it is difficult to arrest it untill all these parts are removed. There are two causes
which combine in preventing this ulcer from healing the state of the constitution & the nature
of the part in which it occurs. Glands & Cartilages ulcerate with difficulty. The constitutional
treatment is the same as in scrophula air exercise & nourishment & an alterative
course of medicine are the circumstances to be attended to. The local application which has
been found to be the most efficacious is a saturated solution of the nitrate of Silver. The liquor
Calcis c Calomel may be used afterwards by Lint kept wetted with it & placed upon the sore
This plan will generally succeed in the first instance. But if the disease has made much
progress the best application will be the arensic ointment. Take of Pulv Arensic Zi to Ung
Atacei Zi spread a piece of Lint with this ointment & apply it to the sore. It must not be
used to excess & if found stimulating it must be diluted otherwise it may be absorbed and
produce too extensive a slough. There are some ulcers occuring about the nose of a Carcinomatous
appearance looking in the first instance like a wart. It afterwards ulcerates
having everted edges & accompanied with a shooting pain. They are not truly cancerous
& they do not affect the Glands behind the ear & the neck. These are of easy management 
& certainly yield to the arsenic ointment which produces a slough in seven 
days making a clear & healthy sore



81
[Diseases of the Bones.]





82
Diseases of the Bones
You are already aware that the Bones are composed of two parts an Earthly Salt
& are animal substance. They are organised like other parts possessing arteries, skin &
absorbents & therefore are liable to the same diseases they are affected with inflamation
both acute & chronic to the malignant disease & poisons these produce the common
effects & are healed by the same processes. You find when they become inflamed all
the changes we see in inflamation of other parts are produced as adhesion
suppuration ulceration & mortification. When a bone sloughs the process is
called Exfoliation but the principal on which it depends is the same as in
the softer parts of the body. Bones are also like them liable to diseases
from a broken state of Health &c
As bones derive their vessels from the sources from 
the Periosteum & Medullary membrane the effects of Inflamation are
seen in both in some they are very distinct. Thus we see inflamation of
Periosteum without any effect on the Medullary membrane & on the other
hand inflamation of the Medullary membrane without the Periosteum
being Inflamed. When the Periosteum is inflamed a Swelling is produced
over the surface of the Bone having the characters of a Node but 
this Swelling is not permanent in the begining it comes on & disappe
again. There is a pain but this is of an obtuse kind & considerably
more difficult to bear than if it was acute. Sometimes only a
particular part is affected with it but generally it is more extensive
spreading over the whole length of the limb it is seldom accompanie
with any redness of the skin. This is only when suppurartion has
taken place. Then a slight blush of redness appears on the



83
Surrounding skin it is always to be considered as a sign that this process
has occured this pain affects the constitution it is always accompanied
with a Fever the constitution Sympathise Highly.
The principal seats of Inflamation are the periosteum
& Medullary membrane but the first is the most common seat of adhesion
& the second of Suppuration arising from the Medullary Membrane
being naturally a secreting surfaces running so readily into Suppuration
when they become inflamed
The effects produced by inflamation of the Periosteum are these
first it becomes seperate from the Bone to some considerable distance
by a slight Serious effusion afterwards this becomes [deposited] absorbed 
& a cartilagenous substance becomes deposited in its place. It is exactly
similar to that in which the Earthy Salts are embedded into this 
the vessels extend themselves it becomes more vascular & afterwards
[a?i?ie] matter is deposited into it & thus a new shell of Bone is
formed thus You have an addition & it is after of a permanent
kind & cannot be removed by art but frequently if early attended
to it may be prevented. In Inflamation of the Periosteum
its vessels are enlarged as the vessels are in Inflamation of the
Softer parts on examining the pores of the Bone they are also found
to be enlarged this is not the case in the original bone but it is
always so in the newly deposited Bone if Inflamation continues
long the original bone becomes absorbed. You may always know a
Bone which has been inflamed by this enlargement of its pores
it is a Universal consequence if you steep this nearly formed



84
Bones in an acid You will find that it contains Cartilage like bone that
is formed in any other way the Inflamation continuing the effusion of
Cartitage sometimes extends over a very considerable portion of the Bones
I have seen the Tibia & Fibula compleatly unite by this means So as
to become inseperable but not only between the two Bones but also
between the muscles this is the adhesive process of Inflamation in
Bone. Hunter used to call it the osific Inflamation
The Medullary membrane & artery is occassionally subject to Inflamation
& the result is the same as in Inflamation of the Periosteum
1st Cartilage is deposited then Earthy Matter is effused &
the cancellated structure becomes obliterated & Solid Structure remains
these are the 3 effect then which are produced the cancellated
structure Solid the Bone is considerably thicker & there
is a deposit on the surface. There is rarely an inflamation
on the inside This way without a corresponding inflamation
on the outside. The Bone Thus acquires great additional
weight & size & it is this circumstance which makes them
so much heavier than common Bones. The shell of Bone is Sometimes
subject to Inflamation although it is not so common
a Seat of it but when it does a deposit takes place into it so
that it becomes as hard as marble. We sometimes see this in 
the ad [?ronti?] & in sawing through such a Bone the Saw passes
with much more difficulty than through the rest of it
& they are susceptable of a much higher polish with regard
to the causes which produce inflamation of Bone they are



85
various sometimes they are heal the most common cause is a blow
received over it. A man is falling strike his shin & an Inflamation
of the Periosteum will be the conequence of it but the most
common cause is a disease state of the constitution from various
causes whenever the Health is broken the slightest accidents are liable
to give rise to it the improper use of Mercury after occasions
it. When persons are taking this medicine if they are at the 
same time exposed to the charges of the matter. this Inflamation
will be the consequence of it. There is not a taking-in
day scarcely at our Hospitals which does not afford You [Num]
numerous opportunities of witnessing this circumstance. You find these
patients complaining of pain in the ends of the Bones & along their
Thigh Bones, arms, & legs, ask these people if they have been
taking Mercury & they will say "O Yes Sir" & what for & "Oh Sir
I had a running" they never should have taken a grain of
Mercury it was most unnecessary. You will find in these cases
Inflamation of the periosteum with Subsequent deposit. I call
it the Mercurial Rheumatism very little attention is necessary
in that treatment. It is easily cured. The patient Should be
kept from exposure the inflamattion is very common in Young
persons who use of a Scrofulus Habit. In such m frequently
see it arise from very slight blows it goes on & leads to abscess
as You after see in the Bones of the Fingers & Toes. The Tibia also
in such is not unfrequently affected with Nodes which are sometimes



86
sometimes going into the suppuration process they [illegible] see that whatever
causes debility will produce this disease. The Medullary membrane 
has it after excited from the same cause.
The treatment is very simple these causes are of course more
tedious than the same disease in the other parts of the Body because
the arteries of the Bone are small & their [argne?] of vitality less
It therefore requires a great which to go through these processes
which are necessary for the cure. But remedies are easily found. They
are indeed the same as in Inflamation of other parts of the Body
As soon as the Inflamation has commenced Leeches & Evaporating
lotions as the Liq: Am: acct: c Spt: Vini should be applied. In this
way the vessels are unloaded by the one & contracted by the other
at the same time it is right to give him purgative medicines even
when the disease is heal then have considerable influence.
Luck is the treatment when it is the result of accident
If enlargement of the parts remain afterwards a blister is the
best application which can be employed & it should be kept open
by the ung: Salinae & Lyttor the savina alone will seldom answer the
purpose. It will be proper in some cases when the blister fails to use
some other application as the Tact: antim: c ung: catacci & it should
be applied not only to the part which is diseased but to some
extent wound it is usual to procede it by leeches. When the
Inflamation is the result of ill Health; if the patient is worn out
by intemperance or the improper use of Mercury he should
take such remedies as will restore the natural Secretion as



87
Plumers Pills this is the best it opens all the secretions, it is not upon
the Skin & bowels only that it acts but upon all & it is upon their
restoration that depends the cure at the same time the decoc:
Sarsaparella should be given this has the effect of diminishing the
irritability & quickness of the Pulse which is always present [on] upon
this principal it is employed sometimes Calomel antimony. opium
about gr: iss: gr: iif & gr. j are used instead of these remedies. This should
be taken at night & followed by a purgative in the morning. By 
the combination of these general & local means the disease will
generally yeild. but its progress must be slow. It is right to state
to the patient that he must expect this. That as the disease was long in
coming on so will it be long before it is cured such is the simple
treatment upon which you are to depend external irritation as it
regards the local means & the restoration of the secretions & the diminution
of irritation as it regards the constitutional means. When
Mercury has been the cause of the inflamation You don't find that
Plumers Pills are objectionable provided that it is given only so as to
restore the secretions & not permitted to excite any Fever if it is carried
further than this You only add to the difficulty. In these cases
the constitution is so much broken down by Mercury that is will not 
do to give it at all. In such cases the nitrous acid must be employs
as a Substitue. The one or the other may be resorted to according to the
State of arbility. The treatment of enlargement from Scrofulous causes
has already been given in a former ticture upon thus Subject



88
It consists in uniting a slight Mercurial to a tonic plan. The Hyd: c
creta & steel. This perhaps may be a preferable Medicine in Some respects
ti the Oxy: murias: Hydrasg: It is not so apt to excite unpleasant
consequences does not require so much caution & occassions No alarm to
the mind of the patients much very much depends in such cases upon 
diet but still medicine does considerable good & we cannot ultimately
succeed without it. The treatment of the veneral affections
of the Bones too has already been given in another place.
Fractures of the Bones
A Simple fracture is the solution of the continuity of a Bone, when
the broken extremites are not exposed by a wound. The periosteum is
torn through & then is a compleat Separation the connecting Vessels are also
torn through the Medullary artery is always torn through the Signs
by which it is known are hardly necessary to be mentioned to you
they are unnatural motion of the limb crepitus when the ends of bone are
rubbed together though this is not always to be depended upon then
are some cases is which it cannot be perceived as in a fracture of the
neck of the thigh bone sometimes in this case it may be perceived by
drawing the Limb down but this is a point which cannot be depended
upon there is after a crepitus when then is no fracture. If a severe
blow is received upon the Shoulder a crepitus is frequently produced after
24 or 48 Hours & if You give way to it You might be at first led to
Suppose that there was a fracture but it is merely the effect of Inflamation
In as locatons too when there is no Fracture You after
find a crepitus: in fractures the form of the limb is altered



89
In general other symptoms are produced is a very short time. The
Limb is affected with Spasmodic contractions of the muscles this
happens particularly when the patient is just going to sleep or waking
this is caused by the muscles under going an Inflamatory process.
These are the Symptoms: The changes which the Bone under goes
in the process of restoration are the following 1st a quantity of Blood
is deposited between the extremity of the bones & around them in
about 4 or 5 Days this is absorbed [by] from between the extremities
but still some is formed afterwards in about 48 Hours after this, the Periosteum
is seperated some distance from the Bone for about an
inch so that is easily seperated from the Bone near to the Fracture
but it adheres & very firmly for about an inch. this is only a preparatory 
step. Between the periosteum & the Bone a serious effusion takes
place. The Inflamation increases & after a while this serious
effusion is absorbed & a cartilaginous Substance is deposited in its
place. This is elastic & about the consistence of the cartilage in the
Foetus it adheres most firmily to the surface of the Bone as the
Inflamation continues more & more cartilage is produced until the
12 day then the vessels shoot into it & secreet Bony Matter. This is
not secreted regularly but in patchy here & thin it gradually increases 
until the cartilage is absorbed & Bony Matter is Secreted
throughout it is then so solid that you will not be able to cut
through it with a knife this process is compleated in animals in
about 17 days. The Blood which is first deposited between the end
of the Bones is not as has been supposed the blood of Union it ha



90
nothing to do with the formation of callous & if those that suppose it
has will but take the trouble to examine a broken bone 3 or 4 days afterwards
they would certainly change their opinions this blood is afterwards
entirely absorbed & it is the Secretion then poured out that goes to form
the bond of Union, by new bony matter. Whoever expects to find it otherwise
will be entirely disappointed. Blood is not the bond of Union in any
part of the Body. Union can only take place in simple Fracture by adhesion
& in compound fracture by granulation. What I have here been
describing is only when the bones overlap each other. When the two bones
are in direct opposition a circular splint of cartilage is deposited around
the fractised part & [they it] becomes consolidated & afterwards a
deposit takes places from the ends of the Bones themselves. The outer shell
is thus formed from the periosteum & the internal union [pro?rray] 
from the internal potion of the Bones a curious circumstance
in the union of bones when they are fractured is that Inflamation only
takes place at the sides when they are in contact on the opposite side
there is scarcely any. There is no simular process on the outside. Another
curious circumstance is that this new callous [that] though it is 
at first compleatly Solid becomes cancellated & this not only when
the Bones happen to be in direct opposition but also when they overlap
each other to a considerable degree even in Birds whose bones
have air cells instead of Medullary membranes There are also formed
anew nature does not rest satisfied with repairing the part
but she also convery it into the same substance & original structure 
callous when Stresses in acid is found to be composed of cartilage
& earthly matter just like originaly formed Bone



91
The newly formed callous is more vascular than when it has existed Sometime 
as it advances in age it becomes less & it loss in degree its living
power it is exactly the same as in cicatrices of the Skin at first
they are very red from their great number of Blood repels & after a while
they become almost colourless like cicatrices too they are weaker than
other parts of the Bone & are most liable to be broken. This appeared
in Anton Vazage a great number of his men were attacked with
Scurvey & such as had previously had fractures had their Limbs broken
again in the same places without any accident as soon as their
Health become restored. The callous was renewed. Callous is sometimes
thrown out in such abundance as to produce deformity. This depends
upon too great a degree of Inflamation hence the necessity of keeping
it properly done by Evaporating Lotions &c if any swelling remains
after the union of a Bone it may be rumoved generally by mercury
& friction &c. The time required for the union of broken bones depends
very much upon their size. The fracture of the Forearm would
take 3 or 4 weeks. The union of the calvicle would take 2 or 3 weeks.
but is best not to depend upon this We should wait as long as &
the Tibia will not unite under 5 weeks & ought not to be trusted
to before 6, have elapsed it depends a good deal upon the
age of the patient if he happens to be young it will acquire
a good deal of firmness in less time than if he is old.
When a person is considerably advanced in Years the union
will be comparitavely more slow. A man Sometimes gets into 
a great deal of discredit by permitting the patient to
use his Limb too Soon after Fracture. A surgeon with
whom I was well acquainted once gave his patient Liberty



92
to walk about 5 weeks after the Fracture of His thigh Bone & it
happened unfortunately as he was given on his crutches over the floor
his foot accidently slipped & he fell & the Bone seperated again at
the place of union & he was compelled to go to bed & lie 5 or 6 weeks
before it was again united. The result was that he thought his
first Surgeon an ignorant fellow & sent for another. A Man
therefore should be cautious how he gives his patient permission 
to make use of his Limbs too Soon after a fracture.
with regard to the danger arising from the accidents. You would
Most of you say there was none but I can't say that you are to
not suppose that a simple fracture is entirely devoid of danger
they will sometimes be the cause of destroying Life & they do it
in the two following words. 1st by the degree of contusion by which
the accident is accompanied. Thus when the Bone is fractured
by a heavy cart going over the Limb even if there is no wound.
Yet there may be such contusion occasioned that it will go on
to mortification & destroy the life of the Patient. In indolent
debilitated habits these accidents often prove unfavourable.
as 2nd Cause is when thus occur is very aged people. I have
seen a case terminate fatally where there was a fracture just
above the Condyles of the os. Femoris in an old person I [nun]
mention these cases in order that you may be guarded in
Your prognosis & not give too decided an opinion that they
will be cured. I once had a case of oblique fracture of
the Tibia which terminated fatally. In a few days Inflamation
came on abscesses formed & the matter burrowed



93
burrowed among the muscles. Amputation was performed above the knee
but the man only lived a few days after. On examination it was
found that the Tibia was broken into several pieces part of them
had adhered by the priosteum but others had not united & caused
these abscesses which in a debilitated condition destroyed the patient
this then is a 3rd Cause which Sometimes makes these accidents terminate
unfavourably.
Fracture of the Fibula
The nature of this fracture is generally very easily ascertained
in the following way. You have to apply one hand upon the Malleby
firmly & to take hold of the foot with the other & rotate it &
as You do it a crepitus will be perceived if there is a fracture
a many-tailed bandage is first to be applied or a roller may [ti??d]
with the Lig: ammon: acct in order to keep down all unnecessary
inflamation by this will not be sufficient to effect
a complete cure without the aid of Splints if they are not
used the injured leg will afterwards be rather shorter than
the other on our Side so that he will only be able to walk
on one side of the way. This arises in consequence of the Permei
Muscles drawing the outer portion of the foot towards
the leg. I early learnt the necessity of this precaution from
the case of Dr. Rlan. He broke his Fibula in consequence
of a fall he received at sea by the ship having suddenly
from one side to the other while he was unprepard for it.
The nature of the accident was not discovered & he lay in



94
his birth untill he got well. The result was he could walk very well
on one Side of the street where the descent favours the obliquity
of his foot, but whenever he goes on a level surface when his foot
comes down flat on the ground he is Lame, Therefore never attemps
to cure a fracture fibula without Splints
Fracture of the Tibia
There is no difficulty in telling the accident. You take hold of
the foot & apply your hand gradually up to the knee & You will feel
the fractured part, rotating will cause a crepitus. You are first
to apply a many tailed bandage which consists of 9 slips of
lin[n]en serred at righs angles to a larger one the advantage
of this bandage is that it is not necessary to disturb the Limb
as is the case if the roller is applied, no Roller should ever be used 
except in the very Young. The bandage, if it is in the Winter
season should be made of Flannel, but in the Summer
of linnen because the other would occasion too much heat it
should be kept over with evaporating lotions if the Inflamation
is inclined to run too high & by this means we keep
it down & prevent irritation. The following is a very good lotion
Kj. Spt: vine ℥j. Ay: Com ℥v. m. A Sponge should be dipt in
to this & squeezed over the part. but take care that you do not
continue thie evaporating Lotion too long for if you do. You
will prevent the process of adhesion by entirely overcoming 
the Inflamation. The want of union which we so often witness



95
is frequently owing to this cause over the many tailed bandage
splints are to be applied they are of different Kinds they are to be found
made of wood whalebone Iron or tin the whalebone or the Wooden Splint
are sufficient for the simple Fracture. The advantage of the 1st
over all others is its convenience to the Surgeon because it will by its
Yielding fit either leg but it will not be safe in compound Fractures
because it may admit of a warping of the Limb. The objection to the
Iron splint is its weight. They should all be padded & the pads are
to be fitted well to the Limb, in our Hospitals tin is used for this purpose
but wool is better. The position which I generally prefer in fractured
Tibia is on the side in this the muscles are considerably
relaxed & the Tibia forming nearly a straight line the pressure
is most equal & the patient feels less pain than in the straight
position & another considerable advantage is that the patient
can change his position from the back to the side as he becomes
weary of the one or the other which he cannot do if
the leg is straight but when the leg rest on the Heel the Heel
forms one projection & the calf another & the Limb is very
apt to sink down & become deformed, further, when a fracture
of the Tibia is difficult to reduce. The case with
which it is effected, is always increased by the degree in 
which the muscles are relaxed whenever difficulty occurs
therefore the Limb should be always bent before the reduction
is attempted. The exception to this rule is when the
Fracture is very obligue; then the position on the Heel is
best when this position is adapted it is necessary to bend



96
the knee slightly as it is easier to the Patient. I am persuaded 
that in proportion to as your practice much & try them both
You will find the bent position best on many accounts
Fracture of the Os Femoris
This is generally very easily discovered all that is necessary to be
done is to grasp the limb firmly below the knee in one hand
& rotate it while the other is applied above the fractured part
& in this way a crepitus is very easily perceived the many tailed
bandage is to be applied here as in fracture of the Tibia
& it will be necessary to put on three Splints a long one on the
outer Side of the limb a short one on the inner side & an intermediate
one between the two on the inner but in children
it is best to use four one behind - or from the great difficulty
of keeping them quiet it will be scareley possible to
prevent deformity. These splints should be well guarded or lined
with casting of Tow. - They require also a pillow to reach
from the Trochanta to the Heel _ Having applied the Splints
the next consideration is what is the best position of
the limb. This is different according to the different opinions
of Surgeons, a according to the opinion of different Surgeons.
the old Sureons were in the Habit of using the Straight position
all together that was the treatment until the time
of Mr. Pate & was not altered till 30 years age. When it was 
observed that patients notwithstanding they were laid in the 



97
straight position unconsciously moved the Limb to the flexed one &
did well & were much more easy but it was observed that the foot
after become permanently turned outwards when this position was
adapted & on this account it was given up for the mode at present
adapted in Guys Hospital which is by having the thigh raised &
the knee bent & supported in that position by a pillow or by the 
the common wooden machine if the Bones overlap much it should
be elevated much & if but little it need be but slightly 
elevated but of late the straight position has been strongly recommended
by Boyes & Roux & I am told that in our armies Surgeons
have been in the Habit of using the straight position altogether
& that these fractures have succeeded very well I ha
late tried it in a case which did well. But in all the cures of 
the Fractures of the thigh Bone which I have seen. There has
been some overlapping & I have never seen a Specimen without
it. I would not say these has been one but I have never seen
one the extended position is more liable to produce it. The muscles
are all upon the stretch & it is a position which is more
painfull than when the limb is slightly bent upon the whole
Gentlemen, if My  own thigh was broken I would have it inted
according to the plan adopted at Guys Hospital. I think
that the other processes upon a wrong principal by it the muscles
are put compleatly on the Stretch & the Bones upon which thus
act must necessarily be shortened unless it be prevented by some
counter extension. I think bent position upon the Heel is the best





98
Fractured Clavicle
In fracture of the Clavicle an end of the bone projects over the other by the falling forwards of the shoulder.
You have therefore in its treatment 2 objects one is to prevent the shoulder from advancing the other
is to draw the bone out to its natural length. Both of these are affected by drawing the shoulder back
& keeping it so. For this purpose you put a pad in the axilla (it will be advantageous to have one in
both sides) This acts by throwing out the scapula from the side & also by throwing out the head of the
of Humeri & then the bandg which is to be used is the stellated roller which is to be carried
from one shoulder to the other in the form of a figure 8 crossing on the back. It is not to make any
compression on the part of the fracture Clavicle. No application is to be made except some simple
plaister for the purpose of preventing the Rheumatic pain which is otherwise to come on
after this accident Then you will put the patients arm in a sling & this will be as short as possible
in order that the arm may be elevated. This is all the treatment required 
Fractures of the upper Extremities
Os Humeri. This happens in almost any part of the bone but generally a little below its middle
It requires first a roller then 2 splints 1 on the outer & 1 on the inner side & then a second roller
applied on the opposite side to the first. In this way you prevent any twisting of the bone. The
arm should be supported in a sling. This should not be short. If it is the bones will overlap each
other & it will heal in a bended position. I have seen it almost bent to an angle by is attention to this
circumstance. The Elbow should just reach the sling but not be supported by it. The patient
should not be kept in bed. If he is a deformity of the arm is apt to be produced. I have frequently 
seen it from a want of attention to this caution.
Radius & Ulna. Fractures of the Radius & Ulna require the same treatment. A Roller a
splint on the outer & inner side (the splints should not rest on the bones) & over the splints a 2d
roller. But here I ought to make an observation. Fractures of the Radius are apt to produce
considerable deformity without considerable attention from this circumstance. The Pron: Quadiatus
draws the Radius out of its place & causes the ends of the bones to project between the tendons
& the motions of the fingers will be thus afterwards impeded. This will should be avoided 



99
by carrying the splints over the back & palm of the hand. If the hand is suffered to be twisted inwards
the Radius will be apt to be twisted out of its place. But the bandage in this case should not
be carried farther than the wrist. The nicety in the treatment of this fracture consists wholly is confining
the hand
Olecranous. When this point of bone is broken it is drawn up as much as an inch by the action of the
Triceps muscle. As in fractured Patella it can only be united by the ligament & the treatment is just
the same. You are first to reduce Inflammation & then to make the Ligament as short as possible
by proper bandages. It is necessary to keep the arm extended as in fracture of the Condyles it is equally
necessary to keep it bent
Condyle. This occurs most often in children & less in Adults. Sometimes both & sometimes only one Condyle
is broken. This Crepitus may be readily distinguished. The treatment is only to apply a roller & a
splint made of pasteboard & notched when it is to be applied at the Elbow. This will allow of
motion which is to be begun in about Ten days or a fortnight & be continued each day unless this is
attended to the motions of the Joint will be impaired or completely destroyed. This fracture is frequently
badly managed. When the internal Condyle is broken it is often mistaken for a Dislocation of the
Elbow & there is danger of anchylosis from mismanagerment. If the bones will become anchylosed it is
best they should become so in the fixed portion. A child will recover in 10 days An adult in 3 weeks
During the cure passive motion is to be used & it is even best to begin too soon than to defer it to a 
later period. For a ligamentous union it is better than one by Anchylosis.
Neck of the Os Humeri. This is the most difficult to be distinguished. A fracture of this part
occurs for the most part in old & weakly constitutions & may be mistaken for a dislocation The
appearances are sinking of the shoulder The head of the bone is not on the axilla but the upper
portion of the bone is there itself & the fractured end is felt & mistaken for the head of the bone. It
may be ascertained by placing the hand on the shoulder & embracing the head of the bone & then
rotate the Elbow. If it is broken the body of the bone will have motion while the head of it remains
fixed.
Metacarpal Bones. The Metacarpal Bones are liable to be fractured & when this happens to



100
the Metacarpal bone of the fore finger it gives the appearance of Dislocation. The knuckle falls or
sinks & the natural appearance never returning. If often occurs in fighting & this occured to Mr Cline
when he was a Boy I have often observed this appearance in old Gentlemens hands & laghed at him for
it. Scapula This bone is liable to 3 accidents. 1st to be taken in the middle. The treatment is the
same as that of Fracture Ribs & the state of the parts is easily ascertained by fixing the applied part
of the Scapula & taking hold of the Suferia Angle with fingers & moving them on one another
& the Crepitus will be readily felt. A sli'ng should be used 
The Acumion is sometimes broken When this accident occurs the shoulder falls & it is liable to be
mistaken for a Dislocation. The state of the parts may be ascertained by raising the arm the fractured
portion of the process is restored to its place & a Crepitus is felt. The shouler in the first instance
looses its roundness but it is restored as soon as it is raised unless the arm after being raised is supportion
in that place it will fall again & be united by means of Ligament. The union by ligament
only occurs when attention is not paid to rest & the proper application of the Sling. It unites by
bone when the treatment is judicious
This bone is also frequently broken in the Cervix & this to is apt to be mistaken for dislocation
now the head of the Os Humeri does fall into the axilla. The shoulder falls but still the head
of the Bone is in the Cavity of the Joint. The mode of ascertaining the nature of this fracture is by putting
the hand over the Shoulder the finger resting in the Coracoid process & the Thumb which is behind
the Joint is to be traced along the spine of the Scapula till you feel the place of fracture then by
rotating the arm a Crepitus is communicated to the finger by the Coracoid Process which by being attachted
to the Glenoid Cavity will partake of the motion. The treatment is the same as in fractured
Clavicle. It will unite in about 12 months & sooner in the young subjects
Fractured Patella
When this fracture happens as the vasti & Rectus Muscles are attached to it the upper part is immediately 
drawn up to a considerable distance from the lower usually 1/2 to 1 inch & sometimes more
I have seen a Ligamentous union of this fracture which was as much as 5 in long. The patient in
this accident immediately looses the use of his limb so far as it requires extension. The union of 



101
this fracture is by means of ligament & not by specific matter. The reason of this is that the intervening
substance is rendered vascular by ligamentous vessels which shoot into it & form ligament. Bony
matter can only be formed by bony vessels which in this case do not supply it. To a small extent
there is bony matter in this but it is very slight you therefore see after an examination of a fractured 
Patella both ends of the bone smooth when called to a case of this kind you first direct the extended
position of the limb as completely as possible. It is best generally not to use Bandages at first
Evaporating Lotions should be employed for 3 or 4 days untill the Inflammation & Tumour have abated
before you begin with application of bandages. If you use them before this is done you will
find that they occasion a deal of pain & increase the swelling. At a proper period the roller is to
be applied in the following way. You first press down the Patella as much as you can put a pad
above the Patella & over that a roller which is to be carried around the part 3 or 4 times in a
Circular direction. It is then to be carried across the Ham to the head of the Tibia around which
part you are to make 3 or 4 Circular turns. It is then to be carried across the Ham again to
the head of the Tibia so as to form a figure 8 & so on in this way untill it is sufficiently secured
Another mode which has been reccommended is to put a roller firmly around the Thigh above
the Patella & another below it around the Tibia in the same direction & then to approximate together
by means of tape attatched to one & the other. From day to day this approximation is
to be increased untill the fractured ends of the bone are brought near to each other. Either of these methods 
will answer the purpose very well
In proportion to the length of the Ligament afterwards will be the weakness of the limb. The patient
will be very liable to frequent falls afterwards & also the fracture of the Patella of the opposite
limb unless it is pretty well united. The muscle is shortened & in proportion its shortness
is its power diminished
After this plan has been pursued for 5 or 6 weeks passive motion should be adopted. If it is not the
patient will not recover the power of using his joint at all but if it is he can move it a little
he will generally recover the use of it entirely. He should be seated on a table & the leg moved frequently
backwards & forwards under it.



102
Case A child was brought to my house in her fathers arms who had had a fracture of both Patella
for several years. This plan had been neglected untill she had lost the use of her limbs entirely I directed
him how it should be done they followed my advice & ultimately she recovered the use of her
limbs which she never would have done otherwise. You will be surprised sometimes to have patients
come to you with fractures of the Patella & yet had no fall. It is often broken simply by the
action of the muscles without any other cause or violence. Thus a person should be walking down
stairs & shall place his heel on the edge of the stair when his toes will immediately sink down
Finding he is in danger of falling forwards he immediatly & forcebly leans himself backward &
in this muscular effort the Patella breaks. I knew a Gentleman who broke his Patella on
jumping a ditch. When he reached the opposite side he found himself falling & ran scrambling
forwards to save himself. He did not fall & yet the Patella of both legs were broken
Fracture of the neck of the Os Femoris
In fracture of the neck of the Thigh Bone the foot & toe are turned outwards. The Leg is rendered shorter
you are able readily to draw it down again to the length of the other by extension but as soon as your extension
is removed it again becomes shortened. There is a free motion upon the Hip you can readily
bend the knee towards the body but not without its giving the patient some pain. He can bear it
more easily if you give it a diuction inwards towards the navel. You can hardly mistake this
fracture for a dislocation. In dislocation the foot is turned in in this fracture it is turned out. It
occurs generally in age & from very slight causes as for instance an old person shall be
walking in the street & slip off the side walk & thus have the neck of the of the Os Femoris fractured
When it occurs outside the ligament it may unite by ossific matter but when it is within the ligament 
it can only be united by ligamentous substance because it is not covered by periosteum
at this part but by the living membrane of the Joint & it is the vessels of this part only which shoot
into it & supply it. Therefore no ossific matter can take place. Now this is a doctrine which
I have been endeavouring for 20 years to convince the pubic of & I have been abused like a 
pick pocket for so doing & now what do you see? Why it is just beginning to appear in

a/= The finish effect is the effusion of a glairy fluid between the Periosteum & Bone Matter is not at finish
secreted by the Periosteum but still on an examination of the part you feel a distinct fluctation &
think pus is secreted but on cutting down to it you only find a fluid apparently of a serous nature 
When the Inflammation proceeds you find the color of the skin changed the fluctuation is then
distinct & on making an Incision true pus is evacuated

103
publicating that this part of the bone is not covered by Periosteum & therefore cannot be united
in the common way. Even Desauls has been in the habit of keeping his fractures in an extended
position from a want of knowledge of its mode of union. There has lately been a paper upon a
case of united fracture of the neck of the Thigh Bone. The specimen was sent to the College
of Surgeons. I went to do it & Mr Clift I found had writtten upon Glass "A Supposed Case of
united Fracture of the os Femoris" & very properly too fix it was a fracture this the upper part
of the Prochanter Major. It never can happen. There is a law stamped upon it by nature 
which forbids it
Therefore all attempts of Extension in this fracture are foolish & not grounded on Experience on a
knowledge of the parts & they give the patient a great deal of unnecessary pain & suffering
The Treatment is simply this. You are to place the patient upon his back with a pillow under the
knee this is the easiest position & one in which the parts are best accommodated to one another. In
three weeks he may be allowed to get out of bed & walk on Crutches. In three weeks now he 
may bear lightly on the foot & go on one crutch & after a while he may change his crutch for
a stick. If he is a heavy man he will always be obligated to wear a stick If a light man he
can go without one.
Compound Fractures
Bones are liable to take on Suppuration like other parts. Then are 3 parts of the bone in which matter
has been found viz between the Periosteum & Bone in the substance on shell of it & in the Medullary
part of it a/= When matter forms between the Periosteum & Bone a considerable absorption of positions
of it is occasioned so that its surface becomes rough externally from the Ulcerative process
It goes into a slough. This was formerly called Caries by which was understood only this that the 
bone becomes irregular on its surface the processes by which it happened being then unknown. It
was not understood which were the circumstances which occured. This term only implies rottenness
but it implies nothing. It means now only Exfoliation & Ulceration of the Bone
When an exfoliation has taken place granulating arise & fill up the excavating just as in other parts
The principle is the same but it is Cartilage which is at first thrown out & ossfic matter



104
is thrown out & deposited the same as in the original formation of bone. This then is the mode by
which the cavity is filled up. Without this process no compound fracture can be united.
When matter forms in the Interior of a bone a great excavation of that bone is occasioned. Its interior
becoming in a greater degree absorbed but at the same time the bone is very much enlarged 
& the way in which it is done is one of the most curious processes in the body. This internal Inflammation
is accompanied by an Inflammation of the Periosteum Cartilage is deposited under this
Inflammation & ossific matter afterwards thrown into that & the numerous layers are deposited
one after the other untill a very thick shell induce a new bone is formed. This while the 
bone is becoming absorbed on the inside it is thickened on the outside. If it was not for this
the bone from its thinness would not be sufficient to support the weight of the body & in this
beautifull manner does nature provide against such an evil. When a new bone is in this
way formed she makes holes in it for the escape of the matter. When the disease takes place
near the Joint a very great swelling is produced which is called Spina Tentora. These holes
generally take place thru the part which is nearest to the external surface of the limb. Thus
if matter is formed on the the Tibia it is discharged not on its outer but its inner side. They
never ulcerate on the side where they are deeply covered but only when they are most supeficialy
covered. Altho this appears at first sight extraordinary yet it is a law stamped on the
original structure of the bone. It is always formed most thin at these parts. If an abscess
forms in a bone where the constitution is unfavourable this thickening process does not
take place & the process of absorption going on the bone becomes so thin as to be unable to
support the weight of the limb & the result is that it breaks.
When an abscess forms in the interior of a bone it becomes filled with granulating but they
are not so strong in the Cancellated Structure as if on the outside of the bone so that afterwards
the Cancellated Structure is formed again. When there is an Abscess in the interior
of a bone it is generally very sensible to the touch as appears in using the probe in order to
ascertain the extent of such disease. These remarks have been made in order that you
may better understand Compound Fractures & their union

a/= A Fracture may be accompanied with a wound & yet be a simple one
b/= First serous fluid is effused
c/= If the bones rides past one another the external surface of the periosteum as well as the end of the bone secretes
matter but if in opposition the end of the bones form granulating. If the ends of the bones pass
one another the lateral parts unite them & there is an effusion of Cartilage all round but it is more
abundant where the bones are nearest. Steep the Callus of a compound fracture in an acid & you will
find it has Cartilage for its basis.
d/= If you cannot get the ends of the Bones readily in opposition bend the limb in order to relax the muscles

105
A Compound fracture is a solution of Continuity in a bone Communicating with an external wound
The extremities are laid bare a/= It is of no consequence whether the Integuments are wounded by
the bone itseld only any other wounding Causes. The difference between Simple & Compound Fractures
is that the one unites by the adhesive process & the other is obliged to unite by the Suppurative
Process with Granulations. It cannot be effected without this. If you trace the condition of
the compound fracture of a bone from the day of the accident untill its cure the following process
will be found to take place. Soon after the Inflammation arises in the Periosteum as in
simple fracture & a fluid is secreted by which it is loosened so that it might be stripped off
easily. Then from the outer side of the Periosteum Granulating arise (also from the Cancelli
& afterwards from the bone & from its inner side the adhesive process of Inflammation. First 
b/= Cartilage is deposited & afterwards it becomes filled with bone by means of which the surface
of the Bone becomes encased. While this is going on from the surface Cartilaginous Granulating
arise also from the Cancelli & afterwards from the Bone. These then you are to understand 
to be the difference. From the Periosteum outwardly matter & Granalating & inwardly Cartilage
& bone & from the extremities of the bone also Granulating & matter. At the end of 21
days bony matter is secreted from bone to bone. When the bones overlap each other c/= the deposit
takes place from each bone & after it is finished the Periosteum is absorbed & the 2 Cartilages coalesce
Into this bony matter is afterwards deposited & thus the union is completed. It is similar to the originial
formation of bones.
From the nature of the injury this deposit does not take place so soon in a compound fracture as
in a simple one. The same differences exists in the processes of adhesion & Granulating by which 
a bone is united as in the soft parts. This has already been explained. The vessels in the one shoot
directly in the adhesive substance & become continuous & in the other they open externally & it becomes
a secreting surface. It generally requires from 20 to 30 days.
When called to a Compound Fracture d/= the first circumstance to be considered is the haemmorhage
which generally takes place. He should endeavour to stop it by pressure. It is unwise generally to
apply a ligature. The next circumstance to be considered is the mode of treating the wound 

a/= With regard to bandages & the position of the limb it is the same as in simple fractures. The position
of the limb should be such as to give you an opportunity of seeing the wound without disturbing it
b/= It is not by adhesive Plaister only that you are to make the attempt but [di???ent] in the wound
untill filled with Blood then lay it down on the wound & apply Adhesive Plaister
c/= The time occupied in curing a Compound fracture is various for exfoliations often occur & greatly
retard the cure. Three months often six & frequently more are taken up in this cure Uniting a Compound 
fracture by adhesion should be attempted if possible. If there is a small wound leading down to
the bone you must try Adhesion & no time will be lost you cannot do any mischeif by the attempt &
many limbs will be saved by so doing. There was a case in which the Elbow Joint was opened by a
fractures I could pass my finger into it. Induced it to the state of simple fracture & the patient did
well. But if the limb be broken by a Carriage running over it the attempt would be made in vain
I would then immediately poultice it. If there is a wound made only by the bone only a sharp in
& treatment of if it be lacerated I would still try for adhesion but if there is contusion there will be 
no use of the attempt. A Gentleman jumped from the top of a coach at full speed. He had

106
Poultices are commonly applied for the purpose of producing Suppuration. If the fracture is accompanied
with much contusion then contused parts must of necessity come away & in such cases
then applications are required. But they should be small covering the parts only which are to slough
& the surrounding parts are to be covered with Evaporating Lotions in order to prevent all unnecessary
Inflammation in them. This is for the most part much the best mode of treatment but it is not
always the best plan. Our great object must be to render these parts these Compound fractures
simple ones if possible. All that is required frequently is to apply a piece of Lint over the wound
This by mixing with the effused blood is firmly bound down the adhesive plaister & bandages are
to be applied & evaporating lotions are to be frequently applied over these. By such means Compound 
fractures are often converted into simple ones a/= It is only under an extreme degree of Contusion that
Poultices are necessary. Our primary object is to produce Adhesion b/= Those Gentlemen who
have had an opportunity of attending to the practice our Hospital for the last 7 years
must be well aware of the truth of these observating. They must well reccollect how many more
fractures were unfavourable formerly than at present. They know that this mode is comparatively
a favourable one, extremely so. It is one under which many limbs are saved which
were formerly lost. If any person doubts it I wish he would take 4 Compound fractures &
treat 2 in one way & 2 in the other & he will then be convinced over the Lint the many tailed
Bandage is to be applied & the splints. If there is much Contusion only one splint should be employed
& when Inflammation arises & contusion ceases more. The position of the limb must be varied
according to the nature of the wound c/= Compound Fracture of the Thigh requires Lint a many tailed
bandage & 2 splints & the same position as the simple fracture. It will generally terminate better than
you expect. The wound is small will commonly heal well. The same observations apply to the upper
extremities. The Constitution generally suffers a great deal from Irritation in Compound fracture
It is therefore best generally not to take away much blood perhaps none. If you do a great reduction of
strength follows which makes you regret it. The patients often become excessively reduced by the long
continuance of the disease. This is the general principle upon which you are to act but I know
that there are exceptions to it. For the same reason you are to be upon your guard not to purge

a compund fracture of the Leg & a compound fracture of the other extending into the ankle Joint. He
was a man of very temperate habits he lived in this country & he was not loaded with much fat
the edges of the wound were brought together & evaporating lotions were applied. The wound healed with
out interruption scarcely producing anxiety of mind. He is now living & walking with very little halt
Had the Leg been poultied Suppuration would have taken place he would have been swimming
on matter & as it was hot weather he would have probably not recovered
x If the fracture be transverse make an incision into the Integuments & relax it

107
your patient too much. It is bad because it produces great disturbance to the limb & it is
apt to unite in a bad position & it occasions a high degree of Constitutional Irritation. You should
avoid it. I have often seen a great deal of mischeif produced by the physician going round the wards
& looking at the tongue & feeling the pulse & because he found a degree of Irritation prescribing purgatives.
I would not practise in a Hospital where a Surgeon was not allowed to prescribe for his own
patients. Physicians (at least as most of them are educated at present) are not capable of judging
of Constitutional Irritation. If they will practise for surgical patients let them first be taught
Anatomy & then observe well the effects of Local Disease in producing Constitutional Irritation
It is not so at Guy's Hospital, that's all. The most gentle evacuants are all that is required
Constitutional Irritation is to be removed more by acting on the other secretions than on the bowels
with this view opium & Antimony are to be given. That the patient may be disturbed as little as
possible a sheet should be slipped under him & his stool received upon that when it must be removed
as gently as possible. If you attempt to get a pan under him the motion which it occasions is sometimes
so great as to alter very considerably his posture for the worn. The opinions respecting the proper position
of the Limb in Compound fractures are various. 30 years ago in the time of Pote they were always
placed straight. The same is thought best by Boyer & Rouex but it being observed that patients often changed
their straight position for a bent one Mr Pote changed it & most Physicians prefer it now.
In compound fractures on the foreside of the Limb the lateral position is the best. If the fracture is very
oblique the straight position resting on the heel is the best
Compound Fractures are various from various causes & require particular treatment. Sometimes the wound
of the surrounding parts is so small that the bone cannot be returned. In such a case you will either
dilate the wound on saw off the end of the bone. It will depend a great deal upon the appearance of
the bone. x If the Periosteum is a great deal denuded from it it will exfoliate & therefore should undoubtedly
be sawn off. Mr Hey always saws off the ends of the Bones whenever they are denuded
& oblibuely fractured & he reccommends the practice. I consider the opinion of such a man of the
highest value. He is a man who is amiable in his private character of a strong judgement and
very desirous of advancing his profession. 

The next untoward circumstance is a considerable haemmorhage from the wound & which is often proceeding
from a very considerable Artery.
a/= A Brewers servant having a compound fracture & Bleeding. The dresser took up the Anterior Tibial
Artery & the man did well. Mr Mourian in similar cases has also succeeded in securing the end
of the Artery & the patient recovered. Mr White of Manchester cut down upon this artery very high
up between the Tibia & Fibula. It was so deep seated that he could not secure it & he was under
the necessity of using the sponge. Haemmorhage from the Posterior Tibial Artery generally gives
rise to the necessity of amputation but not always. Mr Polland secured it. Mr Hey had a case
of injury of the posterior Tibial Artery. He sawed this the Fibula & secured it a very curious case
occurred which occasioned the destruction of Life. The fracture of the Tibia was comminuted. The man had a
haemmorhage which they succeeded in preventing. It came on again but before I reached the Hospital the blood
had stopped. A copious suppuration afterwards took place & the man was so much reduced by it
that the Leg was amputated. The Artery was ossified Copious Suppuration took place from the stump
& the man died. On examining the Limb one of the Comminuted parts of Bone was found sticking in
the artery & it was the occasional Irritation produced by this which has caused the repeated bleedings.
With respect to Injury of the Interosseal Artery with Compound fracture I do not reccollect to
have seen a case of it but if I did I would cut down to the side of it. It would be difficult to secure
it in the middle of the Leg.
b/= If it were secured I believe mortification would take place below. A Gentleman was stabbed by a
Portugese in the Femoral Artery but a surgeon happened to be near & it was secured. The result was mortification
of the Leg which led to the necessity of amputation. When a wound of the Femoral Artery is accompanied
with Injury of the bone I believe it more liable to mortify. In fractures of the Sup. Extremitis

108
When the fractured bone is very much splintered every position should be removed which does not 
adhere by Periosteum. If the opening is too small it will be right to make the opening of a Sufficient
size to take them out. To attempt to unite it by adhesion would be absurd. I remember a case of this
kind where the patient died from after haemmorhage & on examination of the limb it was found that
a punctured spicula of Bone has entered the Femoral Artery. After several days a haemmorhage
came on. It was stopped by pressure but it broke out a second time. Afterwards extreme
suppuration came on in the Leg & it was amputated. Haemmorhage came on in the stump and
he died. The arteries on examination were found of ossified. Compound fractures of the Tibia sometimes
occasion a division of the Anterior Tibial Artery a/= Wounds of the Posterior Tibial Artery are commonly
dangerous. If wounded low down they may be tied if high up the bellies of the Gastrocnemii
Cover it & it is best to amputate. A man fell from a high cart & had a compound fracture of the
Tibia & Fibula with the Artery injured high up. There was not any haemmorhage at first. It was
not known that it was out. By pressure for the moment it was stopped but it came on again as to
making an incision among these Inflamed parts it would have been highly improper. He had another
repetition of the Bleeding & instead of securing the Artery there it was done in the middle of the thigh
As the Anastemosis principle in the Leg is supported by so many branches as soon as the circulation
was restored the bleeding returned & ultimately the man died. The best plan here would have been to
have amputated the Limb. If the Posterior Tibial be wounded near the ankle it is accessible as
any other artery.
Wounds of the Femoral Artery with Compound Fracture require immediate Amputation b/= The same
observation may be applied to Compound Fracture with wound of the Brachial Artery mortification will
take place if amputation is not performed. Another reason for this is that the median nerve is generally
torn thro at the same time. I have known two instances of mortification from this accident
I should still tie the Brachial Artery & if mortification took place then amputate. Compound fractures
of the Fore Arm are not more dangerous on account of the artery being torn. If tied the Interosseal
Artery will carry on the circulation. Injuries of the ankle Joint with Compound Fracture will not
necessarily lead to Amputation. This is the case even in town frequently & particularly in the Country

with a wound of the Brachial Artery what is to be done? Secure the Artery. There was a woman in the
other Hospital who had fallen & broken the lower part of the Os Humeri into the Elbow & the Artery
being wounded was secured. In a few days the whole of the Limb below the wound Mortified. The arm
was amputated & she did not sustain any Injury from it. The next point to be attended to in the
treatment is when the fracture extends into a joint. If the opening in the Integuments is occasioned
by the point of the Bone it is best to heal it by adhesion. Set as take a case of Compound fracture extending 
into the ankle Joint. Here you would bring the edges of the wound together Do not amputate
without there is much Contusion or Laceration. In the Country you should particularly endeavor to
save the Limb. Lint dipped in Blood should be placed in the surface of the wound. If a compound
fracture is extending into the knee you generally amputate but this depends on the size & state of the
wound (If a compound fracture is extending into the knee you generally amputate) If small & there is
no contusion bring the edges of it together & attempt to produce adhesion. If a ball enters the knee joint
& the Bone is comminuted it will be best to amputate But if it merely divides the integuments & makes
but a small wound opening the capsule of of the Joint there are a great number of such cases doing
well. If the bone has been comminuted all the endeavours to save the Limb have been followed by the 
destruction of Life. Compound Fractures extending into the Elbow Joint generally are not dangerous to life
A suppuration from the Joint does not prey so much upon the Constitution as when occuring in the
lower extremities the power of restoration is greater. If suppuration does take place the person
not much advanced in years you have hopes of its doing well. In cases of compound fractures of the
wrist you are not called on for immediate Amputation
Compound Fractures are not unfrequently causing exfoliating & these lead to protracted Cure on
totally prevent it. They support so high & so long continued Irritation that they are liable to wear out
the Constitution. Sometimes from portions of exfoliate bone being locked in you will be defeated in producing 
a cure. Compound fractures are sometimes followed by a very considerable degree of Inflammation.
This is owning to a laceration of the muscles which are sometimes torn from their origin when the
Limb has been much bent out of its course. It generally occurs however in Irritable Constitutions for
such persons are very liable to have Inflammation after Injuries

109
& if the patient is young & unhealthy you act very unwisely in such cases if you amputate immediately.
They can frequently be saved. When the knee Joint is Injured by a Compound Fracture it will
generally require Amputation. I have seen a Compound Fracture of the Patella do well. Compound
fracture of the wrist is very doubtfull as to its favourable termination one of the worse Compound
fractures of the Joint I even saw was a Compound fracture of the Elbow. The finger could be passed
directly thro from one side to the other. I proposed immediate Amputation to him as the only means
of saving his life but he would not consent to it. I tried hard to persuade him to it & yet this
man recovered without ever having had an unfavourable symptom. Sometimes in a few days after a
compound fracture has taken place an Inflamation comes in around which it has the appearance
of an Erysipelatous Inflammation altho it is not exactly of that nature. It seems to extend up
the Fascia Lata of the Thigh in the course of the absorbents It does not appear in red lines as
in the Inflammation of these vessels but it is on the contrary a broad surface which is Inflamed
I mention this thus particularly because it generally happens when it accompanies Compound fractures
that it is fatal. It denotes a great degree of Constitutional Irritation. The must never deplete in such
cases by which the Irritation would be increased but we should strengthen the system by every means
in our power. Opium should be given combined with Ammonia. With respect to Bark in these
cases it is uncertain whether is produces beneficial effects or not. If it does no good in 30 or
36 hours it will always do harm. If the patient has been accustomed to habits of Intemperance
a little spirits may be allowed or none if he has been much used to it. At the same time with these
means Local means are sometimes usefull. These are commonly spiriterous applications around
the part & Poultices to the part itself. When these means are properly applied they will sometimes
occasion a cure. If the Inflammation is more active & of the Erysipelatous kind it
must be treated like Erysipelas from any other cause by the Exhbibition of Bark which may
be considered as a specific Remedy It is so considered by Dr Baillie who is considered one
of the best perhaps the very best Physician in England.
Tetanus is sometimes occasioned by Compound Fracture a/= When this unfortunately happeng amputation
of the Limb has no power whatever of putting a stop to it. Indeed so far from

Treatment. Supposing the lower extremity to be injured & the Inflammation extends to the knee or even to the groin
Purgatives should be given merely to keep the bowels slightly relieved in the 24 hours. Do not produce many
evacuations. The best medicine you can give is Calomel griss opium grss to gj at night & some slight aperient
in the morning as sulph magnes. This disposes the bowels to an increase of their action & the opium 
is diminishing the nervous Irritability & tending to Constitutional Irritation. As the best local means of
preventing the extension of the Inflammation apply over the wound a poultice & on the surrounding Inflamed
surface Evaporating Lotions your object is to produce on reston secretion & in the surrounding
part to prevent extension & subdue Inflammation. But if you poultice too much you will see the limit
drowned in matter & will diminish the power of Restoration by relaxing the vessels. This rule is more particularly 
to be observed in warm weather when suppuration is liable to be more extensive. If the Inflammation
is still proceeding apply Leeches but you must guard the Bleeding. When abscesses are forming during
the process of cure make early openings & let out the matter. The patient suffers & the discharge of matter 
burrows & thinks keeps up the Constitutional Irritation.
Page a/= Its accession is soon after the accident from 3 days to 3 weeks generally however at the end of
the first week Where Tetanus has been once estabished I have seen no instance of recovery. With respect
to acute Tetanus Amputation only precipitates the fatal went. Calomel & opium have the quotes & influence.
Purgative medicines have been employed & as the patients reovered they attribute it to these remedies
but these were cases of Chronic Tetanus & they would most probably have recovered without any medicines
b/= The thought it best to defer the operation untill the Suppurative process was set up if he thought his
patient could survive the suppurative fever. Dr Babington told me that while at Hastas Hospital
23 men were landed who had the operation of amputation performed immediately after the accident
out of this number 3 lived to come into this Hospital one died afterwards. I reccollect that while a 
pupil at Guys Hospital I took note of 11 cases where Amputation was performed immediately after
the accident 6 of these died very soon after the operation & three out of the remaining five did well
The reasons why amputations now do well when peformed immediately after the receipt of an injury
is from the saving of Skin to cover the ends of the stump. But let the extremitus of the nerves be exposed
local Irritation & Constitutional affection will be produced & death be the Consequence 

110
diminishing it increases it by the loss of Blood occasioned thereby & in this way it expedites the death of the
patient. But this is not of so much importance since his death is certain as the unnecessary & cruel pain
it occasions. I have seen the finger & the leg both amputated in Compound fracture which has occasioned
Tetanus & in both cases the patient died sooner on account of the operation
with regard to the opinion whether Amputation in Compound Fracture should be performed immediately
or delayed. Formerly Mr Hunter thought they should always be delayed. This opinion was
the result of his observations on the Amputating in the war by which the Americans gaind their
Independance a/= But in the late war they have all been performed early & did well. It should
be observed that operations were not performed at that time as they are at present. In amputation
so much care was not taken to save Integuments which circumstance would cause a very great
difference as to their result. The present opinion on this subject which is certainly founded on a 
great deal of experience is that they should be immediately performed. The Constitution is not
labouring under so much Irritation which is certainly increased from the Continuance of this disease
& is certainly in a great degree prevented by earlier operation. Generally when a person
meets with this accident in full health & looses a great deal of Blood in the operation he will do better
than those who loose less which indicates the propriety of Bleeding by the Lancet afterwards. x It
appears decided from the result of the observating of many of my young freinds who were out to Brussels
after the Battle of Waterloo that those Amputations did best which were early performed.
Ununited Fracture
After fractures of the Bones union will sometimes occur & sometimes there is only a Ligamentous union which
is effected by a Fibrous Elastic Substance which is just such as is sufficient to keep them together. This
often arises from an ill state of the constitution but sometimes from a Local cause as a piece of bone 
remaining between the extremities of Bone will prevent union & sometimes it is produced by a piece
of muscle insinuating between them. In general it is extremely difficult to excite a degree of action
in the ends of the bone sufficient to make them unite. The roughest modes of practice have been
attempted such as cutting down to the Bone & applying the Red nitrate of Mercury to its extremities

I have seen after Amputation for aneurism when a man is in high health if much pains were
taken to secure all the small vessels he would be liable to have great Constitutional Irritation. I
am therefore disposed frequently after operating of amputation to bleed. Do not wait untill Constitutional
Irritation is excitedly the accident before you amputate. A man got his foot into a Threshing
Machine whereby it was torn off. The Tibia was broken thro' & his foot remained in the boot. On the following
day Amputation was performed 24 hours after the accident Constitutional Irritation had began
soon after the operation. His pulse was small & frequent. The accident happened on Thursday on
Friday the operation was performed on Saturday he became weak & on Tuesday he died. On examination
some of the muscles were found to have been torn from their origin on the Tibia. As the
Threshing machine had made so clean a cut a consultation was held whether it would be proper
to perform the operation at all. If you leave the case for a few hours it is attended with the
greatest danger.
a/= It is rough on its external surface & holes are afterwards formed in it by the granulating beneaths

111
but yet very little Inflammation was occasioned. In general sawing off the ends of the bone has not
succeeded There was a case in the London Hospital which did. Dr Physic of Philadelphia cured
2 cases by passing a siton thro' between the extremities of the Bones & this was a very good thought Dr
Physic is a man who had acquired a great reputation in his own country & deservedly so. He is an excellent
Anatomist & a good observer & such a man as that must always rise. Nothing can keep him down all
the world cannot crush him. Tho you tread upon him he will rise again. This ununited fracture
has been united by buckling a bandage around the Limb as tightly as it can be borne so that the
parts shall be perfectly made to come together. When this is done bearing lightly upon the limb assists
the cure. I saw a case of fractured os Femoris cured in this way which had not united for 11 months
I had the seton on a child who had both his Thighs broken 5 years before at its birth by the accoucheur
but it did not succeed
Another mode of cure is in the Introduction of Caustic betwen the bones I have seen 3 examples
under which this succeeded. The first was a patient who had broken his Radius & Ulna. The 2d was
a case of Mr Henry Clines in this Hospital. They both succeeded. The 3rd was a case of a man
from Seastro' in the other Hospital last winter at first the leather bandage was tried but without
success. Then the Caustic was tried. It excited a high degree of Inflammation in the part
& caused a great deal of Constitutional Irritation but in the end he was cured & walked very well
Mr Cline Sents removed the extremity of an ununited bone & thro' each end he bored a hole passed a
ligature & thus kept them in contact twisting it. There was no union but the ligature came
away in a short time
Necrosis
The organised parts of bone are liable to mortify & seperate like other parts of the body. It is very common.
This process is of 2 kinds according as the external surface or the internal becomes the seat
of it. The death of the external part of bone is occasioned by Inflammation of the Periosteum Matter
forms between them & the portion of bone immediately underneath dies. If you open into the Periosteum
under such circumstances you find the bone of a black color a/= & it exfoliates. But this depends 
however upon the state of the Constitutions at the time. Whether abscess of the Periosteum destorys the

a/= There granulating discharge a serous matter instead of Pus. It is more irritating & offensive to the
smell.
b/= By depriving it of the Phos. Lime. Even acids which are not so acrid will faciltate the process
The actions acid softens the dead bone but Nitria or the Muriatic have the most effect. The
Proportion is 2 drops Acid sit to water Zi deeping the surface of the bone with it very frequently. The
old Surgeons used to make perforating in the bone to facilitate its exfoliation. Saws might be made
use of to remove them.
Internal or Medullary Exfoliation. When the membrane lining the Cancelli of Bone is inflamed
the result is the formation of matter. This insulates portions of bone & kills them & the slough that
is formed is called Exfoliations.

112
life of the Bone. If it is weak it will otherwise it will not The destruction is only confined to the surface of
the bone it does not extend to the centre which lives while the other part dies (external). As soon as portion of
bone becomes dead a sloughing process is instituted which is called Exfoliation. It depends upon absorption
of the living parts in contact with the dead. The absorbents beneath it begin to act & a channel is formed
between the living & the dead parts new granulating arise & fill up the part a/= This channel gradually
extends under the whole deadened portion of bone untill it becomes loosened & is thrown off. This is the
mode by which it is seperated. It is rather an effect than a cause as has been supposed
But it is not necessary that a dead portion of bone should exfoliate. It may be taken into the system
by the absorbents instead of being thrown out. It is in this manner that holes are often found in
the skull without any ulceration in the scalp. It is often found that if the living soft parts are
brought together by adhesive Plaister over the dead portion that it will be absorbed. Thus Surgery
say incautiously that it must necessary seperate when it does not It is found that granulating 
have the power of removing portions of bone. Sir Wm Blizard first made this clearly known He
found that by placing shavings of bone over the granulating arising arising from Bone & allowing them
to remain then he found that they were sensibly diminished in weight but this is an external tedious
process. The surface of an exfoliating bone is always uneven & scabrous you never find it smooth
you may expediate the process of exfoliation by the application of diluted Nitric Acid on the Mur
acid in proportion of ʒi Nit:Acid, Water ʒfij or ʒi m. a to ʒvij. It acts in 2 ways. It destroys
the dead bone chemically b/= & by penatrating the Animal Portion stimulates it to throw it off. The
mode of applying it to external exfoliations is by a piece of sponge wet with it & laid over the
surface & adhesive plaister anything. It was formerly the practice to perforate the bone but surgeons
have now abandoned that practice. The exfoliation of an Internal portion of Bone when
it becomes dead is a most curious process. It is so unlike the other process that it would seem
to be altogether a difficult thing. It consists not only in the seperation of the dead portion
but in a new bone being formed around it. Exfoliation of the Internal portion of bone is sometimes
caused by a violent blow. Inflammation comes on in the Medullary Membrane & destroys
a considerable portion of the Bone. When the matter has found its way this thro' the skin if you introduce

a/= And an effusion of Cartilage takes place between it & the bone
b/= According to the powers of the Constitution at the time is the new bone formed more or less perfectly
c/= Under the Circumstances the Periosteum is very thick Here is a preparation where the periosteum
is 1/2 inch thick & the Femoral Artery is imbedded in its substance
d/= And a small aperture is formed in the skin opposite to it which leads down to the bone 
Mollities opium is a praeternatural softness in Bones by which they readily give way to accident or are
broken even by the action of the muscles. There was a man in the other Hospital in whom the bones had got
into such a soft state that in cutting a Quarter loaf he broke his os Humeri. This bone united slowly
& then possesed a considerable degree of firmness. The Cancillatii structure is commonly increased in thou

245
113 
a probe into the wound you come down directly on the dead part. But how is it that nature removes this
without the usefullness of the Bone being diminshed? Why she excites an Inflammation in the Periosteums a/
& a great quantity of new earthy matter is deposited in it so that the dead portion becomes Completely encased
by it. b/= Thus here as in other cases of necrosis the periosteum is the principle source of renewal & not the Medullary
Membrane. Then it appears that the object of nature is to preserve the strength of the limb so that 
instead of going to work at once to open a hole for the discharge of the dead portion she previously forms
a new bone around it. c/= If this was not the case the result would be that the bone would not be afterwards
sufficiently strong for its duties & would break thro'. Sometimes the process is imperfect & then it is
necessary to amputate the Limb after the new bone has in this manner formed a 2d process takes place 
vis Holes ulcerate thro' it d/= thro' which considerable matter is discharged & these gradually
increase untill the dead portion is able to make its escape. The whole dead portion of bone is sometimes
completely loosed from the external by means of the absorbents surrounding it which are excited
to increase action. The treatment is the same as in External Exfoliating you must inject the
same acids day by day in the same manner. They are found to produce a very healthy state of granulating.
If the dead portion of bone is very large it will require a great portions of time before it is
thrown off & the Constitution will become much impaired. In order to prevent this it will sometimes
be necessary to expedite its discharge by removing a portion of bone by means of Hey saw
By this very large portions of Bone may be got away easily. The operation is tedious but it is attended
with but little pain. Exfoliations of bone are not without danger I have seen them prove fatal
in the head by matter forming in between the Dura Water & Crasium. It is necessary in
such cases to use a perforator so as to get at it & if this is not sufficient we must Trephine you
not unfrequently have exfoliations after the operation of amputation & you find it most frequently 
in healthy adults after accidents when there is not sufficient skin saved.
Mollities Ossiums
This disease is a very Curious one & is generally but very little known. Physicians know but very little of its
nature. The preparations shich have been made of it are but very few. I have never seen but one dissection

cases so that there is but little shell of bone remaining & that is more porous than when in a healthy
state. It appears to me to be the result not only of Absorption of Bony Matter but also of the Cartilaginous
nidus. I should say that in Ricketts their want of deposition of Phos Lime & a quarter deposit
of Cartilaginous Matter but that in Mollities opium there was an absorption of lime & an absorption
of Cartilage. The space of the Cancelli is increased. In those persons a great quantity of
the Triple Phosphate is carried off by the urine which is of a white color. I have known it occuring
in Children who have paralytic affections of the Limbs & in them the bone breaks easily
& unites very slowly and as it does not produce much pain sufficient Cure is not taken
to keep the Limb steady & the bone becomes broken several times. As to the treatment nothing
is known about it.

114
dissections. Some have supposed it to depend upon a deficiency of bony matter like Ricketts but it is not it depends
upon a few formations. A considerable quantity of matter is deposited as in Exostosis. The result is that
such pressure is produced as occasions the bony matter to be absorbed. The quantity of original bone
remaining behind is very small. It is to add with Cartilage it is very spongy in its texture it seems to be
a deposit of adhesive substance similar to that when about to be formed by medullary substance. The
Bone is somewhat enlarged & the result of the disease is that it breaks very easily No cure is at present
known for it.
Hydatids in Bones.
Sometimes numerous Hydatids are formed in the substance of Bone. You sometimes see the bone 
filled with them to the extent of several inches. The Medullary Substance is completely absorbed in consequence
of them & the shell of the Bone rendered so thin as to be unable to support the weight of the
body. It requires Amputation
The Bones are subject to cancerous affections. The Bones of women who are the subject of Cancer of
the Breast are also liable to the same kind of disease. They complain at the same time of pain
in the limbs & Loins which they consider as Rheumatism but it is much worse than common
Rheumatism. After these symptoms have continued for some time the bones break on the slightest exerting
such for instance as getting out of bed or walking across the Room & they cannot be made
to unite again. Indeed I am inclined to think that the Cancerous Affections of the Glands in them
unfortunate people is but a small share of the disease
Anchylosis
Anchylosis is a diminution of loss of motion in a Joint & is either partial or complete. This is sometimes
scarcely to be considered as a disease in its origin altho' a disease is effect. Old people are subject to it
without Inflammation preceding or accompanying it. In old people there is a disposition to form earthly
matter in order to support such parts as are feeble in their actions as the Arteries &c. The ligaments
are undergoing a similar process therefore you see in old people the bones becoming Coalescent as in
the Bones of the Cranium the sutures becoming perfectly obliterated. With respect to the pelvis



115
the Cartilage which formerly unite the Bones of the foetus becomes bony in age. But it is the spine in
which this charge is most frequently taking place. Sometimes the whole of the spine is united into one
bone from a deposition of Earth in the Ligaments covering the Vertebrae. A Physician at Chelsea Hospital 
Dr Munsary who left his body for dissection died at the age of 90 years. His heart was exceedingly 
ossified the Semilunar & Mitral valves were fitted with earthy matter & the Anterior Ligament
of the spine was ossified thro' out. It is not the Intervertebral substance which undergoes
this change but it is a deposit of the Ligament covering it. This is not always occuring in age
neither. Young persons who are in the habit of bearing heavy burthens are also subject to it. Also
it takes place in those bones tht bear very considerable weight disproportionate to their strength
The different vertebrae become united by bone. You find this taking place also in old persons in
other Joints in the extremities as in the bones of the fingers. They are afflicted with a species of
Rhuematism properly called Rheumatismus Senilis. In this disease 2 changes are taking place
in the Bone. The first is that the Capsular Ligament becomes converted into bone & forms a less
of bone over the Joint & the 2d the Cartilage is absorbed. Here is a preparation of this kind a lip
of Bone is projecting from the Condyle at the place when the Capsular Ligament was inserted the
Cartilage has been absorbed & the surface of the Articulating Extremity of the bone becomes polished
Thus then you observe ossific depositions take place by which motions are impeded & often entirely
destroyed.
The 2d cause producing Anchylosis is a wound made into a Joint & of this it is of importance
to be acquainted with for you may prevent it. When a wound is made into a Joint
& Synovial Capsule & Inflammation takes place over the Synovial membrance. Thus thrown
into a state of Inflamation it pours out a copious secretion & by this the wound is prevented from
being closed from the pressure of the Synovia on the Surface forcing the edges of the wound open
when they first begin to adhere. If the wound does not close a Suppurative Inflammation is set
up & immediately after the Increased action takes place is secreted & then the cavity of the Joint
is filled with matter. Thus very often produce ulceration in different parts & the matter is
discharged by several openings. It often burrows to the calf of the Leg & generally opens very distant



116
from the Joint. This produces a great degree of Constitutional Irritation & generally more than the
other parts do when they undergo the Suppurative process. Still nature has not performed her part
Granulations cannot arise for the end of the bone is covered by Cartilage therefore previous to the
Granulations arising the Cartilage is absorbed. You therefore find a very different process required
from what takes place in common wounds. When the Ulcerative process has removed the Cartilage
Granulations arise from the surface of the Joint & Ligament. These extend from Bone to Bone into
them bony matter is effused. These fill up the Joint & thus complete Anchylosis is produced
therefore you see the necessity of closing up the external wound to prevent the Synovia from getting
out & the wound from healing
The 3d Cause of Anchylosis is that disease which is regularly called white swelling. It occurs
in weakly children & is founded in original formation. It is a disease which differs from
the Common Chronic Inflammation. When Inflammation takes place in the Joints of [stru??ous]
children it becomes considerably enlarged by an effusion of Cheery Matter which fills the
Joint. It is a Gelatinous Substance incapable of organization & of supporting vessels. It is not renderd
vascular by Injections any more than the Tubercles of the Lungs. This remaining cannot be removed
except by the absorption of the surrounding parts. After this an additonal Inflammation
disposes the part to suppuration & the matter thrown out is not pus but similar
to whey with Curd like matter in it. This Suppurative Inflammation produces an Ulcerative
Process this occasions an absorption of the Cartilage & produces several openings in
different parts of the Joint & then the Granulating process is taking place very slowly
from the Internal surface of the ligament & from the Articulating extremities of the bones
Thus you see there are 3 modes of producing Anchylosis. The effects of Inflammation of the
Joint are 3. Sometimes there is an adhesion by a substance of the Gelatinous kind. The result
is that the Cartilages are absorbed & the extremities of the bones laid bare by the Ulcerative process.
The adhesions extend from bone to bone & the extremities are thus glued together & the cavity
obliterated. These adhesions admit of subsequent restoration. When the Inflammation 
has subsided if there is a slight degree of motion remaining by friction much more may
be acquired



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If a man apparently healthy comes to you with an affection of the knee if you tell him to remain
at rest bend up the Joint.
A Gentleman received an Injury of the Knee Joint by which considerable swelling & Inflamation
was produced. 2 months afterwards there was a slight swelling & a degree of motion the joint
was advised to be bound & kept at rest but finding that the stiffness increase he took other advice
I advisted him to get on Crutches Let the Leg be slightly bent & have the Joint rubbed
frequently In not more than 3 weeks afterwards I saw him walking in Lincolns Inn fields
then the Joint had in a great degree recovered When stiffness occurs in a healthy person
from accident treat it as you would Fractured Patella give it motion. Rest if it occurs in
a diseased Constitution then rest must be enjoined & after the recovery friction & passive motion
should be gradually attempted. In the 2d stage of Anchylosis there is not only this adhesion but
also a considerable alteration in the form of the ends of the bone. This is after the disease has existed
for a considerable length of time. A change takes place in their figure which their actions are
impeded. But even in this state if the patient is young it is right to try to give more motion Children
thus often acquire a very considerable degree of motion as their bones are so small & more pliable
than those of adults
The 3d state is different Here Granulations have arisen the Cartilages are absorbed & a perfect state
of stiffness is produced. The Granulations of Cartilage have extended from bone to bone into them
bony matter has been effused & thus they are completely united In this new bone a Cancellated structure
is afterwards produced. This is a preparation in which the Cancellated structure of the
os Femoris extends to the Tibia The different Joints of the body are thus anchylosed. There is a
preparation in the College in Dublin when almost all the Joints are completely united. Great alterations
are also produced in the form of the Joints in these cases. Sometimes such deformity a produced
that Amputation is required to be peformed
Exostosis
Exostosis has 2 seats in the body. It is sometimes the result of disease of the Meduallary membrane & at
another is situated in the Periosteum. The latter is most numerous & generally very manageable but 



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the form is of a Malignant Nature & requires to be Amputated. They are of the Fungous kind like Fungous
Haematodes or of the Cartilagious kind in which Cartilage is the nidus & often Phas Lima thrown into it
as to the Fungus disease of the Medullary membrane. This is producing very considerable enlargement
without pain. This enlargement is generally taking place in the whole circumference of the bone. When
of a considerable magnitude these small tubercles form on the general enlargement these increase in
size & at length ulcerate & there is a fungus protrudes which gives rise to the effusion of bloody serum
The fungous projections are increasing untill they slough & then they are followed by others which exhuast
the body by their discharge. It is 2dly acting on the Constitution which also exhausts the body on cutting
into them the bone is absorbed the skull almost removed what remains is forming a net work over
the Fungus. They are not so solid as the External Exostosis & all more like Fungus in any other parts
of the body. They begin from the Medullary Membrane & a tumour is produced of very considerable 
magnitude. It does not consist entirely of bone but a very considerable portion of it is a soft medullary
substance. Nothing will be effected in this disease of the Bone but Amputation.
Whether it is the true Funguoid Disease or not I am uncertain A case of Mr Clines in the other 
Hospital seems to indicate that it is a Constitutional disease After the operation of amputation
was performed on this man for a time he was seemed to be doing well but he was seized with a great difficulty
of breathing. there was enlargement in the Glans of the Groin he became dropsical & died as with
Hydrothorax. On examination Fungus Excuscences were found in his heart where the Right Auricle
opens into the Ventricle & the Liver & Lungs were filled with Tubercles. This disease is also
found in the Liver. I have known but 2 cases of it where it was seated in the heart. It springs
from the Constitutional & the Local disease action. It is not simply a Constitutional disease
for if it was you would produce it by an Incision which is the mode for its removal. But if
you remove it the wound heals there is a healthy Inflammation occuring.
As to the Treatment. We are generally under the necessity of Amputating. But they are so often occurring
that you must be on your guard occasionally they arise from Absorption & often
times it is produced in other parts of the body by a similar action being set up. You must
therefore not only remove the limb but alter the state of the Constitution disposing to it. We



119
have no power of putting a stop to it by medicines when the Local disease is set up. But altho you
cannot cure it by medicine when once set up you can alter the state of the Constitution by Alterative
Medicines after it has been removed & by that means prevent its recurrence. We have no medicine by
the means of which we can arrest the progress of fungus or Cancer. They are 2 specific diseases of the body.
The Cancellated structure of the bone also produces Cartilaginous Exostosis you have seen this in
the Girl from where Jaw I removed the Tumour this last winter. When I cut down upon the part
I found the shell of the Jaw formed a nest for the Cartilage which I removed & this Cartilage rested on
the nerve proceeding thro' the bone. This Cartilage if suffered to increase would produce most enormous
tumours. These case require Amputation. There is no other mode of cure for them.
The Cartilaginous Exostosis sometimes arising from the skull is producing a swelling which may be
removed. But the Fungus Exostosis from the skull if removed occasions death by producing Inflammation
of the Brain. There was one removal from a patient in the Hospital & the man died
on Examination one was found on the interior of the skull opposite to this. Therefore be carefull in
distinguishing the Fungus which is composed of Considerable vascularity & less hardness. Periosteal
Exostosis is now manageable & allows the diseased portion of bone to be removed. The manner 
in which periosteal Exostosis arises is as follows. The Periosteum is affected with a Chronic
Inflammation which occasions an effusion of Cartilaginous substance between the Periosteum
& Bone. This adheres to the surface of both & from both. Bony matter is secreted & goes on untill
it is completely ossefied whiile this is taking place if you make a small opening in the skin
& introduce a probe into the Tumour you will find ossified matter breaking down among the
Cartilage. In this way the disease (its nature) is often ascertained. The growth of an external
Exostosis is just like the growth of a Callus. Cartilage is first effused & afterwards ossific matter
into this. If you macerate it in an acid say muriatic acid Zi to water Hss for 3 weeks
you will find it deprived of its Phos Lima & having nothing left but its Cartilageious bed.
you will see this in any of the old Exostosis so also with the Meduallary Exostosis. Cartilage must
always precede the formation of Bone. But not only is Cartilage deposited but a Cancellated
structure afterwards formed in it. It is during the whole process covered by a piece of Car



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tilage. Strip off the Periosteum & you will see a portion of Cartilage under it not get converted into
Bones. Sometimes there is a particular Bone from which Exostosis is growing frequently at the Thigh
Bone at the place where the abduction Longus Femoris is inserted. Lads of about 14 or 15 years old
which are of very feeble Constitution are very often subject to this kind of Exostosis. They are occasioned
in consequence of their exerting themselves more than is proper. They generally grow smaller than in
age. They cannot be considered dangerous & do not acquire more than 2 inches in length & then they
generally stop. Those who have the knee turned inwards are the most subject to them. There is
not any necessity for removing them unless they interfer with the motions of the muscles of the
Limb. When I became a Surgeon at Guys Hospital a case was left me of a large Exostosis
of the Tibia. It was attatched like a Polypus to a neck. This woman had had it 44 years
She was 4 years old when it began. After it was removed small flakes of bone came away & it
healed most kindly. If an Exostosis grows upon the Tibia having a large body & a small neck
it will be necessary to cut down upon it centre thro the Integuments turn the flaps down & saw
it off at the smallest part. But where the Exostosis grows between the muscles this cannot be 
done in the same manner. An instrument has been invented by Mr M . which is very ingenuous
& which will be very usefull in the cases. It is a circular saw turning on a wench
after their removal granulations arise from the bone & they readily heal over. Exostosis which
grow from the bones of the skull are not like Common Exostosis. They are as hard as Ivory
you would cut a Biliard Ball as easily as you would cut one of them. 
Of Polypi.
There are 4 different species of Polypi one of which is very frequent & is relieved & sometimes entirely
cured the others are more rare. The most common species is growing from between the Inferior
& Sup. Turt d Bones rarely originating from the Septum indus so rare that I have never seen
any arising from that part. On the Schneiderian Membrane on the outer part of the nose it is more
frequent. It prevents the free passage of air thro the nostrils & the obstruction produces the sensation
like that of Common Catarrh. In a foggy day & early in the morning & during the evening the patient 



121
[I have seen after amputating for aneurism where a man is high health if much pain were]
heather less truly. This probably arises from a want of Evaporation from the nose. The appearance
of this species of Polypi is like a Bag of Jelly. It is connected with the Schneiderian Membrane by
a narrow Penduncular & is not very vascular. Its interior is composed of a loan Cellular Texture
containing a Jelly like fluid. They very in their size & are sometimes divided into 2 or 3 portions
Sometimes they are of enormous Magnitude. There is often more than 1 often 1 on each side of the 
nose. Sometimes more but this is rare. It is rather a Polypus broken into several portions than 
a distinct Polypi. For the purpose of removing them we generally use
the Forceps. When scissors are used they should be probe pointed. Ligatures at best are of but very little
use. You cut off only a part of the Polypus & there is great difficulty in applying them. 
In Extracting them with a Forceps you first Introduce a probe & feel for the neck of the Polypus
you then take hold of it with the Blades of the Forceps as near its origin as possible then by pulling
gently you extract it. In this way you sometimes bring away a portion of the bone. If so the Polypus
will not return but if broken thro' the neck it will return & you will have to repeat the operation
in about 2 years. You are not to pull it away with a sudden Jerk but by gentle motions
in order that you may tear thro' the root of the Polypus.
If the Polypus is but small you first feel with a Probe for its origin & withdrawing it introduce
a pain of probe pointed scissors & strip it off at this place. If it is exceedingly large considerable 
haemmohage will be produced by cutting it off but this is of no importance.
If you have a Polypus of great size you perform quite a different operation I took one away
from a patient of Mr Bings which hung down in the fauces. It was of great size. I put
a ligature on & removed a portion of it but it soon returned to its former dimensions I then
carried a pair of scissors thro the posterior part of the nares & cutting its root & then putting
my finger behind the [??lum] I hooked it away. There was another cure where the polypus
was broken into many pieces for it had been attempted to bring it away. It was situated
in the posterior nares & they were quite occupied with the Polypus. I cut the neck through
& with my finger nail hooked it down as the last. You cannot bring them thro' the nostril



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There is another of Polypi of the Fungoid Kind. Here is the cast of one which grow from the
Schneiderian Membrane near the opening in the Antrum He was the son of a Naval officer. It was
connected by a narrow neck & protruded into the nostril & hung down on the upper lip. There was
a great discharge from it. I removed a portion of it by means of a Ligature but it grew again
Mr Hunter removed another portion. I heard he was still living but whether at present or not
I do not know. The Brain is affected in those cases. They are seldom confined to the nose itself
Sometimes they extend into the Anteum Ethmoidal cells & Ductus ad nari. These cases are owing
to a fault in the Constitution. They are of a Malignant nature there is no use in removing them
with a view to permanant relief they grow again & appear to be more rapid in their growth
the more they are meddled with
The next species is the Hydatid Polypus. They produce great alteration in the form of the
face. The first I saw was in a girl 14 yrs of age. When I applied the forceps to it it broke & a
quantity of mucus spirted out & when I attempted to remove it but a small portion of it came
away. She was very much exhausted by it. There was another case in which the nose was cleared
by the application of the Mur Antim with a Camels hair pencil. It was applied untill entirely
removed. The 4th species occurs in old people. It is hard of a purple color & discharging
bloody serum. There is great pain. The nerves of the head appear to be affected & the suffering
is extreme. Nothing can be done but to soothe the patient by applying opiates to the part. Leeches
give them considerable relief.
On Hare Lip
Hare lip or Fissure in the upper Lip resembling that which naturally exists in the Hare. Sometimes it
exists on both sides of the upper Lip at other times there is a deficiency of bone extending from the Lip
thro' the Palate. Here is a skull in which the fissure extends thro' the Palatine Portions of the Supn.
Maxillary & Palate Bones the Palate is raised more than usual & that part which is opposite the
lip itself projects. Sometimes the fissure is in the Velum alone at others in the Uvula or on both 
sides the Uvula now & then there is a hole thro' the soft Palate. There is every now & then a projection
of the upper Jaw so that the teeth have their edges projecting at right angles with the face



123
thereby rendering the person quite hideous when the teeth begin to grow.
What is the period for which the operation of Hare Lip should be performed? A person would be disposed
to say the eariler the better but the operation in Infancy is dangerous to life & if successfull is
only in part it becomes necessary to perform it again. What a child die of Hare Lip? yes & not
unfrequently. A Gentleman whose child was quite an Infant had Hare Lip I said I would perform
the operatioon & in the next day it was done. A Surgeon who was present asked "Are you not
afraid to perform the operation on so young a child. Let me tell you I have seen children die from
it & with Convulsions" I performed the operation notwithstanding the child did very well. I went on
however continuing to perform the operation on very young children & with success. At length Mr
Price told one he had a child just born with Hare Lip in whom he wished me to operate I
did so ongoing some days afterwards to dress the Lip I met the Gentleman at the door who said
"It is not necessary for Mr C to visit my child for she is dead. A Clergyman had a child
born with Hare Lip. I told him he had better wait untill the child grew older. She did for
6 months & then told me that the mother expressed so much horror whenever she looked at the
child tht he begged the operation might be performed. While the Ligatures were still on the Lip
of the child it was seized with Purging which I could not stop. I took away the Ligatures but
the child died very soon after. A child was brought to me by her nurse on Monday with Hare
Lip. I performed the operation & told her to bring the child on Thursday. On that day she called
to tell me that the child was dead. It is even probable that the operation may in some
degree succeed but I am now convinced of the impropriety of it. Besides the danger attending it it rarely
succeed at this early period. The Lip is thin & its power of adhesion so slight that it seldom
completely occurs there is within an fissure below or at the upper part of the Lip which you
cannot close & the operation will be required again. You will not only be wrong therefore but union
for you will very rarely succeed. When I say early I mean from to two years of age that is
the earliest then the Lip becomes of considerable firmness & thickness & the ligating a lip liable
to ulcerate before that age the Irritability being greater the absorption goes on quicker. Do not operate
before the teeth are formed for fever is produced. Let the teeth be complete before the operation
is performed



124
The operation for Hare Lip we formerly performed with pins & the twisted suture. In doing this you
take hold of the Lip in order to pare away the edge of the fissure & you carry your incision to the
bottom of the Lip. Then on the opposite side the same is to be done. you must take away more of the
Red than of the upper part so as to make it in the form of a wedge. If you do not a hollow
will be formed at the upper part of the Lip. 2 Ligatures are to be employed 1 of which is to be passed
thro' when the red portion of the Lip joins the common integuments. A straight needle is the best
for the purpose. The next ligature you pass thro Midway between the first ligature & the angle
of the wound. Then the lower ligature is first secured. You are not to bring the parts together by drawing
the Ligatures for if you fo the first will cause Inflammation & quicken relceration & swelling occasioned
thereby will occasion the Ligatures to cut thro' Press the edges of the wound together & them tighten the
ligature. When you put the Ligatures in the Lip what are you to do with the Jaw supposing it projects
By the pressure of the lip the Jaw will generally be brought to its natural position. If the bone be removed 
before the operation is performed you have lip liability to adhesion from the lips having no support.
When there is a fissure on both sides adhesion of the first is to be produced before you perform
the other 3 months should elapse between the first & second operations. The ligatures should
be left so long as not to produce redness of the upper lip not as long as matter begins to form
If the Inflammation is great they should be taken away the 4th day if less in the 5th In the
adult it very rarely happens that Inflammation begins before 5th & Suppuration on the 6th day
therefore you can wait a little longer in the adult before you remove them. With respect to closing
the opening in the Bony palate it is done by a piece of silver which is connected by a spring
to the back part of the nostrils It prevents the nasal sound being given to the voice. Formerly
sponge was made are of but the secretions collecting in it it was apt to stink without it
was often changed. When there is a fissue thro' the soft palate nothing can be done. An Instrument
cannot be worn but when there is an opening only or perforation then an Instrument
may be used or worn 



125
Cancer of the Lip is a disease which give rise to the necessity of performing the same operation 
that is done in Hare Lip. When this disease first comes on a hardness is produced & in that there
is what is called a Crack on looking at this you see an ulceration which is succeeded by considerable
hardness. After the ulceration Fungous excuscences sprout up & depressions here & there
exist. When these go on to ulceration Shooting Darting pains take place & these affect the head
When you rub it no fuling scarcely is produced. The next effect which takes place is that of
occasions an enlargement of the glands in the neck. This ulcerates & extends greatly in its dimension
& haemmorhage at length takes place in it the patient is at length worn out by irritation
& exhausted by Bleeding
This disease is generally seated in the Lower lip rarely in the upper. Sometimes it begins in the
lower lip & extends along the angle of the Jaw & then attacks the upper lip. I have never seen
but one case in which it commenced in the upper lip. In the operation for hare lip in the
child very little is to be pared away but in Cancer of the Lip in the Adult very considerable
is to be cut away 2 thirds of the Lip may be pared away & yet the Lip drawn out you
must cut out a wedge of the Lip & bring the wound together. It makes an excudingly round
mouth but it makes a very pretty kissing Lip afterwards.



126
Diseases of the Testicle
There are 4 states of Testicle which require extirpation and you will find that there is
a considerable similarity between them and those of the Breast. The first of which we shall
speak is the Hydatid or Cellular Disease of Testicle. This is generally a disease of
young men. It occurs commonly in young persons between the age of 18 and 25 but I have 
known it however at a more advanced period (38) I have never seen it in old men
It commences at the Anterior part of the Epididymis and gradually extends to the body
of the Testicle so that it becomes diseased and after that the opposite side of the Epididymis
becomes affected. It is generally unattended with pain except perhaps when it 
has increased to a very good size. Then there is a slight sense of uneasiness in the loins
which is occasioned by the distension of the Tunica Albuginea. There is a slight sense 
of fluctutation. Its increase is extremely gradual and its nature not all malignant.
The veins of the spermatic chord are varicose and the vessels of the scrotum
become also enlarged. The disease is confined to the Epididymis & Testicle
and never extends to the spermatic chord. Tho' it increases to a very great bulk
yet it is a disease in which the general health is entirely unaffected. It is a local
disease and if the Constitution is even affected it is only on account of the extreme 
distension of the Tunica Albuginea. An operation is required on account of the inconvenience
which it occasions by its weight and size rather than from any danger inherent
in it. When cut off the disease is removed. Sometimes it attacks the opposite
Testicle but it is not produced by Absorption
Hydatid Testicle is distinguished from Hydrocele by the form of the Testicle being
preserved altho' its size is increased. I have seen cases however in which its shape
was pyramidal. Generally however it is never more flattened at its sides than on its fore
part. There is a cleft between Epididymis and Testicle pointing out the bounding
between them. It posseses more hardness than Hydatids and more solid substance.



127
It is said by some that there is a sense of fluctuation but this is not correct it is
rather a sense of yielding than a sense of fluctuation. If you place one finger one side
of the Testicle and with the other press on some distant part you do not preceive it
but if you apply them nearer together you do. There is a greater vascularity in the scotum
showing that slow Inflammation is going on. The vessels on the Scrotum are enlarged 
and the skin does not move so readily over the Tunica Vaginalis. If you press on
the Tumour you produce the peculiar pain which is observable in pressure the Testicle
in its healthy state. But in Hydrocele it is only produced when you press on the
part when the Testicle is situated. When you raise the Tumour you find it considerable
heavier than a Hydrocele. There is a great difference in the weight. The want of transparency
which exists in Hydrocele will also assist your diagnosis. But if a Hydrocele
is produced by a blow then this characteristic mark is generally lost. If you are
still in doubt however and cannot satisfy yourself as to its nature you must put a
Lancet into the Tumour which will at once decide the matter. This is the right
mode of proceeding in all doubtfull cases and will prevent all unpleasant mistakes
on cutting upon this swelling you find it completely filled with Cysts. There is scarcely
any part where they are wanting. They are of all sizes from that of a ping head to
a musket ball. The fluid which they contain is sometimes serous at others gluing &
thick. Each of these cysts posses considerable vascularity and there is a great danger
of after bleeding if you do not carefully secure all the small vessels. You may always
assure the patient that after the disease is removed there is no danger of its returning.
Scirrhous Testicle
The second disease of the Testicle requiring operation is the Scirrhous Testicle. This
is an extremely rare disease and you very seldom meet with it. The true Scirrhous
is beginning in the body of the Testicle by a swelling and you discover it by its excessive
hardness. It is very slow it its progress but gradually extends even the whole body 



128
of the gland before the Epididymis becomes affected. After the disease has passed slowly
thro' the Testicle it proceeds towards the Epididymis and there the Spermatic Chord becomes
thickened. It often begins on the surface of the Testicle in different points giving it a
lobulated or Tuberous feel. The Testicle does not always become large it is sometimes of
greater size than at others. It continues in those parts a great while and at length if neglected 
it takes the course of the Spermatic Chord gradually creeping to the abdominal covering 
and from thence to the abdomen. The Tubercles are extending toward the Loins and the
glands below the Kidneys become affected. The swelling is extended with very little pain for
a long time and the Constitution suffers but little then a Lancinating pain comes on & the
system is injured. The patient soon has Dyspeptic symptoms and his general health is becoming
altered. The disease is very slow in its progress. 2 years & often 3 are required for
the destruction of Life. A Tubercle is forming on the Inferior extremity of the same side
and this together with those in the abdomen by pressing on the vessels and obstructing the
return of blood occasions an oedematous swelling of the limb. The appearances on
Dissection are as follows. The substance of the Testicle is of considerable hardness tho'
not thro' out. Some portions of it appear more solid than others. It is in a tuberculated
state forming projecting appearing as if a number of tubercles were connected together
Cartilage is often forming within into which bony matter is sometimes deposited. From
the age of 50 to 70 the Scirrhous Testicle occurs. The operation is often unsuccessful
but not so much so as one ever will directly mention. Its character is the tuberculated
feel of the part usually accompanied with the shooting & darting pains like
those accompanying Cancer.
F.U.N.G.O.I.D. T.E.S.T.I.C.L.E.
This disease occurs nine times where Scirrohous does once. It is different in its character result
and operation. It was formerly called Cancer of Pulpy Sarcoma. It begins in the 
body of the Testicle but does not begin in hardness. There is generally in yielding & softness
in the commencement which would induce you to believe that a Hydrocelois forming 



129
The Epididymis is not becoming affected and the disease rapidly extends along the cord
forming a cyst on it. Pursuing its course in the abdomen it there produces a tumour under
the Kidney larger than that of the Testicle and very different in its nature so rapidly
does this disease extend that I have known it to kill in 13 weeks. The cyst formed on the
Chord proceeds to a very considerbale magnitude.
The Constitution is always bad. The Digestive organs of the patient are greatly deranged
his countenance is sunkin and his complexion sallow. If he has color it is rather a fixed Hectic
flush looking like the rose of health but circumscribed and surrounded by a sallow color.
This disease is very frequent and in this respect it differs from Scirrhous. You very seldom
see it in advanced years. Seldom after the age of 40 but any period between this &
puberty. I have never seen it before but in age you rarely quit.
When dissecting one of these Testicles you will find it very vascular in some parts and
incapable of being injected in others. Cysts are found in different parts of the Testicle
filled with a soft adhesive matter.
To distinguish it from other diseases of this part is a very difficult task on feeling it
you would say that there was a fluctuation but if you observe narrowly you will find
that it is not so. For if you press with the fingers at a distance from one another you
do not feel a communication of motion from one part to another as in Hydrocele. In the
beginning it is like Hydrocele unaccompanied with pain. The form of the Testicle
is preserved at first but not afterwards. It is every now and then combined with
Hydrocele.
This disease occasionally goes on to the Suppurative process but it is not true Suppuration.
The Inflamation goes on to the formation of a fluid but it is not pus. It is Serum &
mixed with red particles
The most difficult disease to distinguish from this is the Cellulous disease of the Testicle.
It is vascular it occurs at the same age but it does not preserve the form of the
Gland neither is the same sensation produced on pressure. This disease quickly affects



130
the chord but the other does not. The one has its origin in an unhealthy the other in a healthy
Constitution. But then is so little difference in the feel that a person may be deceived in his diagnosis
without having much examined the disease With respect to both these diseases however
before you remove the Testicle always make your incision thro' the Tunica Vaginalis and
then the Tunica Albuginea in ascertaining the nature of the disease go on with the operation.
A celebrated Hospital Surgeon having removed the Testicle and seen the man
from the Theatre he called the students in order that they might see the appearance
of this disease. He cut thro' the Tunica Vaginalis out gushed a quantity of water and
the Testicle was in a sound state. The instance of recovery in this disease are very
rare. They are much less than in true Scirrhous. There is no hope from the operation
unless it is performed very early before the spermatic cord is at all affected. I
have seen the operation very frequently but the result from my experience is quite unfavourable.
I do not remember but one case that did well and in that the Testicle
was removed before the Epididymis was affected. You should always endeavour
to avoid the operation in this disease.
Chronic Enlargement and Abscess of the Testicle
There is an indolent enlargement of the testicle arising from stricture in the Urethra & which
sometimes ceases on the removal of the cause but it does not always give way to the use
of the Bougie. Having cured the stricture however you may make the disease of the
Testicle yield to attention of the Constitution and the use of Mercury both internal and
external. They are common in the East Indies and often arise from broken constitutions.
This disease is one you can very frequently remove and by the following means
I will show you then the following cases. One of our most gallant offices on the penisula
had an enlargement of one of his Testicles which increase to so great a degree
that the operation of Castration was performed. When he came to England a
similar disease affected the other Testicle & he consulted Mr Ron & afterward Sir



131
Edward Home & myself were consulted. What we agreed upon was this That the patient
should lie in a recumbent posture on a Sopha continually removing from it only to go to
bed. Pt should apply Leeches very frequently to the part and make use of a wash consisting
of the Liq: Amma: Acct with Sub: Mus-Ammon in it. That he should at the same
time take Mercury as Sub: Mur: Hyd a opii so as to affect the mouth or rub it in externally.
The means advised were followed the Gentlemans testicle in a week began to decline
and at end of 6 weeks he was set at Liberty the disease at the end of that time having
entirely disappeared. I saw a Gentleman in the East India service with the same disease
The same means were employed and he recovered. I think no man is justifiable in performing
the operation of Castration untill he has affected the mouth freely with Mercury
when the Constitution is becoming excessively debilitated by its use it is best to stop. Do not
attempt a plan of this kind without the recumbent posture. But if you open a vein
in the Scrotum in the erect posture & if you want to stop it let the patient lie down
By this you see the great degree of Congestion produced by the Erect Posture and how it
is relieved by the recumbent. Hence the importance of the latter position during your
attempts to resolve the swelling. The Hydatia Testicle does not yield to this treatment
The Fungus & Scirrhous states are exasperated by it
This disease goes on sometimes to another state. It produces abcess of the Testicle in its
anterior part. When you cut into the Testicle you will find a quantity of matter in its Centre
The Tunica Albuginea has not yet given way but the Glandular part of the Testicle
is nearly destroyed. These Chronic abscess sometimes burst granulating then project this
the Tunica Albuginea & a fungus apperance is produced but it is not malignant. It
is like the Fungus which sometimes arises from the Brain. The way in which it takes
place is this. A hole forming in the Tunica Albunginea & thro this granulations pass out
having a narrow neck and spreading out in a broad luxuriant surface. In these
Cases the operation of Castration is very rarely necessary but there is a mode of removing
the disease. When consulted you are to make an eliptical incision around



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the Fungous. Cut off the root of the granulations as they spring from a small hole in the Tunica
Albuginea then by suture you will succeed in producing a closure over this you apply adhesive 
plaister and keep the parts well together for a week. If you remove the dressings before
you will occasion Inflammation and Suppuration This is always preferable to extirpating
the Testicle because tho unless the appearance of a Testicle is left & the patient is much
pleased even with that. In Indolent enlargement of the Testicle Castration is unnecessary
But in these cases where the disease is slow in being removed &c it may.
A Dragoon had a Chronic enlargement of the Testicle which did not yield to remedies
and as it prevented him from attending to his business he came to town & had it extracted. The disease
had existed two years and on cutting open the testicle a quantity of Curdy serum was
found in the middle of it so that it never would have got well if allowed to remain.
As to the operation of Castration it is very simple and easy. If the chord is diseased however
there is no need of performing the operation You only give the patient unnecessary pain for
he will certainly die on feeling the chord you will say "Oh it is only half diseased" But on
cutting into it you will find it diseased thro' out. The operation will be followed by Inflammation
extending along the cord into the abdomen & destroying the patient. I remember 
a case in the other Hospital where the cord was beginning to be diseased and on that
account I refused the operation. However one of the pupils believing in his superior knowledge
and thinking this a good opportunity to shew himself off persuaded the man to allow him to perform
the operation. For this purpose he took him to Blackheath when he hired lodgings
for him. When he removed the Testicle Inflamation took place in the cord and the man
died a week afterwards of Peritoneal Inflammation. In performing the operation by
making an Incision extending from the upper part of the abdominal ring quite to the Scrotum
bottom. you must always attend to this circumstance for if the cut be not carried completely
down a bag of matter will collect at the lower part of the Scrotum & Serous will
form. Having made this Incision then lay bare the Spermatic Chord. You put the
chord between the finger and Thumb & seperate the Artery & vein from the Vas Deferens



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You then pass the ligature between them and giving it to an assistant to hold you divide the Chord. This
you must attend to for if you neglect it the chord will be drawn up within the ring and you
will have great difficulty in securing the Arteries.
A Hospital Surgeon was requested to attend an operation for Castration. It was performed by
a person who cut thro' the Chord without making use of means to prevent its being drawn
up by the Cremaster muscle. When he had removed the Testicle on looking for the cord to
secure the vessels he could not find it occasionaly the Chord made its appearance
at the ring & he attempted to draw it down but could not succeed in catching hold of it
Mr Cline laid bare the cord higher up and secured the arteries for him. The Cord then
being held by an assistant you pinch it up between the Thumb and finger and divide it then
drawing the Testis forward by the portion of the chord attached to it you have no more
cutting to do except to touch the Cellular membrane slightly with the knife now and then
as you draw the chord out. This alone will be sufficient. It gives considerable less pain
than the mode of dissecting round the Testis and requires much less time. Therefore you should
not cut the Chord before you dissect out the Testicle. Then take up the Arteries besides the
spermatic you must tie the artery accompanying the Vas Deferens which you will find
behind it without you secure this you will have afer haemmorhage when the patient gets
warm in bed. Then draw out the first Ligature and close the wound by Sutures. Do not
trust to adhesive Plaister else the edges of the wound turn in 2 sutures are sufficient
It used formerly to be the practice to secure the whole chord but it is a very bad practice
both as it regards pain and danger. I have known it to produce Locked Jaw in this
Hospital. The pain which it occasions is similar to that caused by squaring the Testicle.
It is very cruel & very unnecessary.
Of Calculi of the Urinary Passages.
Of the different seats of Calculi. They are formed in 5 different parts of the Urinary
passages viz in the Kidneys. Ureters. Bladder. Urethra and Prostate Gland. The last



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however are hardly to be considered as Urinary Calculi.
When a Calculus is situated in the Kidneys the symptoms by which its presence is known are
first a pain in the Loins. An unusal sensibility of the skin opposite to the seat of the Stone
I knew a patient who could not bear to have his coat brushed because the light passing
of the Brush over the Loins gave him great uneasiness. His body was opened after
death and a stone was found in the Kidney. It is sometimes producing pain in the
Crista Ilii a numb sensation of the bowels an irritable state of the stomach occassions 
vomiting. You should therefore ask the patient if he often rejects his food. Now and
then especially under great exertion blood is discharged with the Urine and if he stoops
his urine is discharged mingled with it. The stone gradually assures the shape of the
pelvis of the Kidney and Infundibula. Therefore you sometimes have a good cast of these
cavities. The disease in its progress sometimes fills the Infundibula without any portion
of the Calculus being situated in the Pelvis. When a stone is so situated in the
Pelvis of the Kidney as to obstruct the passage of the urine the Glandular part is
absorbed & only the membranous portion and passages remain so that instead of a
glandular structure you find simply a bag
Now and then the Calculi discharge themselves by ulceration. They form abscesses in the
Loins and are making their way out in that situation. I know of but one discharge
thus. It was analysed and found to be composed of the Ammoniacal Magnesia Phosphate.
Very little relief can be afforded the patient in this disease. The bowels must
be kept open. Opuim given when the pain is severe. The Liquor Potass is to be exhibited
and much exercise is to be avoided. These have but little influence however over this disease.
The second seat of stone is in the Ureters. The symptoms are pain in the course
of the Anterior Crural Nerve extending along the inner part of the Thigh to the Knee
generally however it only extends to the Thigh. The Cremaster Muscle is spasmodically
affected so that its contraction produces considerable inconvenince. There is pain in the
Psoas Muscle & if the patient is thin & you press upon the abdomen in this situation 



135
he feels it very sensibly. There is pain also in the Crista Ilii in the Glans Penis
when a stone is Impacted in the Ureter it is generally distructive to life. I have seen 3 cases of
death from this cause. The first was a boy who was operated upon by Mr Cline sent(s/") in this
Hospital and a stone extracted from the bladder. He recovered from the operation and
seemed to be going on well but afterwards he complained of pain in his right side which
was succeeded by a swelling at the lower ribs which fluctuated. He was greatly irritated
and so exhausted by it that he died. On examination it was found that the swelling was 
owing to an abscess in the Kidney & the Ureter was enormously enraged. A calculus so
impacted in it that the urine could not pass & thereby occasioned Suppuration in
the Kidney. The next case was a patient of Mrs Swartz. She had great pain in her
Loins and Abdomen. I advised her to return to her Physician. A few days afterwards
he met me & told me that if I wish to examine the body that I might for the woman
was dead. On opening the body considerable matter and urine was found extravasted
in the abdomen in the Cavity of the Peritoneum which was highly Inflamed. We
looked for the source of this mischief and on examining the ureter a stone was impacted
in it and it was closer to the Bladder. Another case was in a patient of Mr Hollys
He had a considerbale discharge of matter by stool previous to death. On examination
it was found that then had been a communication between the Ureter & Colon
and there was Abscess in the Kidney on tracing the ureter downward a stone was
found completely impacted in it so as to impede entirely the passage of Urine
Sometimes nature affords relief in these cases by setting up the ulcerative process and discharging
the matter externally. A patient of Mr Stones had symptoms of stone in his
Urethea. He said he had a swelling on the Left side near the Crista of the Ilii. The
stone ulcerated and passed and the patient got well. There is no doubt that this
stone passed from the ureter but very great power of Constitution is required to complete
such as process & such powers as very few people passes.



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In cases in which stones are passing thro the Ureter put the patient in a warm bath so as
to relax the part and give considerable quantities of opium. The Third situation of Calculi is
in the Bladder. When stone exists in the bladder there is a continual & extreme irriation opposite
the Froenum not in the lip of the Urethra but about 1/2 or 3/4 in from it the usual seat
of severe Gonorrhoea. This is a pain not of the common kind but a burning and at the
same time a cutting pain. The patient comparing it to the cutting of red hot knives. There is
a frequent Inclination to pass the urine. When the stone is small still this symptom is
occuring. The least exercise producing pain. A person with stone in the bladder
does not lift his feet far from the ground. He goes up stairs with considerable care. There
for if you have suspicion of a mans having stone you see him creeping & crawling along
the ground. If he rides in a carriage great pain is produced generally much more than
a horseback. Every agitation of the body produces pain Tell him to raise on his toes
and sink down suddenly & he cannot do it without great pain. The urine is but little altered
in its appearance at first. Nothing is to be judged from this thro' out the greater
part of the disease When you ask "When you have taken much exercise do you pass
bloody urine" his answer will be "oh yes"
Sometimes the pain extends to the neck of bladder. It is unequal at times hence the
term. "Fits of Stone" The pain is very severe at one time and very little perhaps at another.
This arises more from the irritable state of the bladder more than from the form
of the Calculus. Tho' much has been attributed to this circumstance yet it happening
that so much pain has not been produced by a rough stone as a smooth one. When
there is much irritability the pain becomes much increased by Costiveness. A small 
stone causes more pain than a larger one because the bladder gradually accommodates
itself to the size more & does not contract so much when in an inflamed state in order
to expel the urine as it does when the stone is of a smaller size. The presence of a 
stone in the bladder soon occasions an Irritability in that viscus. Just after the
discharge of urine great pain follows This distinguishes it from irritability of the bladder



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bladder for in this disease the pain is increased by an accumulation of urine but in the other
relieved by it. A person with stone finds considerable relief in pulling the prepuce
and nipping the Glans Penis which benumb the sensibility of the part & thereby relieves
them on account of this you find the prepuce of boys afflicted with stone considerably 
elongated. The urine of these patients flows freely for a little while & then suddenly 
stops. This is caused by the stone falling down over the orifici of the urethra & so
preventing it from flowing. When this happens the patient makes violent efforts to expel
his urine till at length the stone falls back in the bladder & he succeeds. The urine is
generally but little altered unless the patient has used much exercise or the bladder
is in an irritable Condition in which cases it is tinged with blood & there is an appearance 
in it like whey with flakes of adhesive matter at the bottom. This last circumstance
is always an indiciation that the mucus membrane of the Bladder is uncommonly
irritated. But it is not always so. The urine is often as clean as under common circumstances
so that a man would be considered very ignorant who should suppose that blood urine
is a necessary symptom of stone in the bladder. But the urine is much changed however
when this disease has been of long standing. But this is to be considered as a distant
effect rather than as a necessary symptom of it. When the stone has existed long in the
bladder there is frequently a shivering. The Rectum is sympathetically affected & descends
when the patient is making water. This circumstance always occurs in Children
during the operation. They are generally troubled with Prolapsus Ani. It is not
uncommon in adults so that when they pass their urine they are compelled to evacuate
their Rectum at the same time. Piles are very frequently produced. Sometimes
there is violent spasms of the abdominal muscles. They contract so violently
that the patient cannot command the stream of urine it passes off suddenly. They
prevent his allowing the Urine to distill away as he generally learns to do & which renders
the evacuation less painfull. This was the case with the first patient on



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whom I ever operated in the other Hospital and it impeded my progress very much. It is not
common however. They who are much accustomed to seeing patients with stone can see it at once
by observing his position when he makes water. It bends all the different joints of his body and
relaxes his muscles all as much as possible. His legs are widely seperated he often rests with
his head against a wall & you see him bearing all his weight upon his hands & learning forward
in a bedstead or table in which position he is not obliged to make use of his muscles
for support. After a stone has been remaining in the Bladder for a long time it produces 
bad effects upon the Kidneys as well as Bladder. The Bladder becomes ulercated &
the stone sometimes becomes Encysted behind the Prostate.
Stone in the Bladder is not unfrequently combined with other diseases. You should therefore
be particular in your enquiries before you perform the operation. If you find the patient has
enlargement of the Prostate Gland you should not operate for he will die from the injury sustained
by the force necessarily made use of to extract the stone therefore we ought always 
to examine before we extract the stone or performing the operation by introudcing one finger
into the Rectum in order to ascertain if the Prostate is enlarged. If so we will be win 
in refusing to perform it.
Now & then a large Fungus is connected with stone in the Bladder. An operation under such
circumstances would not fail to destroy life. If a stone is extracted with enlarged prostate
the symptoms of stone are not relieved. Mr Cline found a stone in the Bladder of a Frenchman
& advised the operation. He took it out and looking at his watch left the room. The
symptoms of stone still contained and the man died. Mr Cline was in a hurry for his dinner
and left another stone in the mans bladder. The man died and left his guineas to any Surgeon
except Mr Cline who would examine his body. The Bladder was examined and it
was found that a portion of the Prostate had been carried before the Gorget & was found 
hanging like a Polypus attached to small neck. It was this which produced
the symptoms of stone and by getting over the Urethra at the commencement stopped occassionally
the flow of urine. Sometimes sacs are found in the Bladder with stones in them



139
Calculi vary in their size. The largest I have even known weighed ℥x44v. It is in the
Hunterian Museum & was taken from a Scots Gentleman. It was presented to the College
by Sir Jaz Earle. The next in size is one in Trinity College Cam. This was taken from the 
Bladder of a woman & weighed ℥xxxiy. Mr Foster has one which weighs ℥xxiv. Here is
a half a one which was sent to me & weighs ℥xij. One given me by Dr Back weighs
℥xiv. The largest even extracted during life weighed ℥vij. The largest I ever extracted
weighed ℥vj but the man died. Here is one which I extracted weighing ℥v and the
man is still living. Very few persons live who have stones extracted over ℥vj the violence
done to the part is so expire. A very small stone is often very difficult to
get out. A person had a stone in the Urethra had it pushed back into the Bladder.
I did not wait untill it should again be forced back into the above mentioned
canal but set down at once to the operation. I found it very difficult to extract and
the operation was most tedious
With regard to the number of stones extracted from the Bladder at one time the greatest
number that I have extracted from one person I removed from a Mr Alice. I cut
him & extracted a single stone. Two years afterwards I again operated & extracted 142. He
was 60 yrs of age & had a slight enlargement of the Prostate. I believe I introduced the Forceps
70 times. It took at least 50 minutes to perform it. This was in [??nster]. The next
greatest number was 37 & they were of considerable size. Dr Bailie was called to see
the gentleman. He had attended him & said that he could not suspect but that he had
a stone in the Bladder. He had a slight enlargement of the Prostate & when the sound
was passed no stone was felt. I afterwards introduced the sound and discover the
stones. The man is still living Desault gives an account of a greater number. Calculi
have a nucleus which is generally a small clot of Blood. Sometimes however an extraneous
body getting into the Bladder becomes a centre of attraction for Calculous matter.
Here is one formed over a portion of Slate pencil. A man came to me saying



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Sir I have piece of slate pencil in my Bladder. I ridiculed the matter thinking it
not true but at the same time wrote a Prescription for him. The next day he came again
and stated that he has it still Well I told him to come to the Hospital & I would take
him in. When he came I sounded him & struck something like a stone. I cut him and
extracted the piece of pencil with a Calculous matter forming a Concretion around it. On
Asking him how it came there he said he had an obstruction in his making water
& thinking this like a Bougii I introduced it into my Urethra & a portion of it broke off
a sailor took a Scare & introduced it into his Bladder & it broke off & a Calculs formed
around it. A portion of Bougii sometimes forms the nucleus of a Calculus & We
have 3 of these It is sometimes necessary to extract a Metallic Bougii Smiths metallic
Catheter if continued longer than 3 weeks breaks off & gives size to the formation of
a Calculi. A needle sometimes becomes the nucleus of a Calculus. They were supposed
to be swallowed. A child was sitting on a mat & began to cry. The nurse in 
order to pacify took the child upon her knee & began to dandle it. This drove the needle
which had caused the complaint further into her bottom & thus it got into her bladder.
The child afterwards had symptoms of stone for which she was operated upon a
Calculus having been extracted which had formed around the needle
Calculi are generally formed in lamina the different laying consisting of different materials
It is not uncommon to find stones composed of many different friable materials
a white color & easily broken down. This Species is the Triple Phosphate Those
who are subject to them are frequently passing small portions of it with their urine
& having a bad smell. They are connected with a diseased state of the Bladder
therefore you should be much on your guard how you cut for this kind of stone for if
the patient does not die they will soon return again. A Gentleman came to town
on whom I operated & extracted a stone. From this operation he received but again
came to town with symptoms of stone & his friends tho't that one had been left in



141
the Bladder. But it was found that he had portions of Calculi passing away with his urine
which was extremely offensive. A consultation was held & it was thought incorrect to perform the
operation. He went into the Country where 3 more were extracted but in some months afterward
he had symptoms of Calculus again of which he died. On examination of 5 Calculi were found
in the Bladder. Therefore I would not perform the operation when the stones were crumbling
down & passing away with foetid urine mixed with matter. Calculi in the Bladder are of 4 kinds
The first is the uric acid Calculi which is by no means the most common. It is rare in comparison 
with the others. You will know it by its yellowish brown color & its lamina being regular.
The 2d is the most frequent. It is called the Ammuniacs Magnesian Phosphate. It is
also called the fusible Calculus & is of a white color. The 3d is the Mulberry Calculus composed of
the oxalite of Lime. These seldom become of any considerable size. They generally weighs not more
than Zi or Zij. I never saw them of the size of the 2 others. The 4th was discovered by Dr Millerton
in a collection belonging to Mr Lucas' father. He called it the Cystic oxide. It has no regularity
of stratification but is composed of a number of Crystals irregularly combined. But this
name will not answer for they are also found in the Kidney of which there is a preparation
in the other Hospital which Dr Marcet has analysed. The proportion of these different species
of Calculi as examined by Mr Brandi in 150 are of Uric Acid 16. 45 composed of Uric
Acid to the ammoniaca Magnesian Phosphate 66 composed of Uric acid to triple phosphate
of the pure Ammoniaco Magnesian Phosphate. 12 of Uric acid with a nucleus of
Phos. Lime 5 Oxalite of Lime 6.
Of the Medical Treatment of stone in the Bladder & what circumstances are necessary
to be observed previous to the operation.
As to the medical Treatment with a view of removing stones from the Bladder it is in vain.
All the relief we can afford by Medicine is to diminish the Irritability of the Bladder or to
coat the stone with some soft stuff to prevent its irritating this viscus. The best medicine
we can make use of is the Sub: Carb: Soda It has very considerable power both in



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diminishing the Irritability of the Bladder & altering the surface of the stone. The proportion 
in which it is to be administered is 1/2 drachm 4 times per day in water or any thing which
does not alter its nature. The first case in which I saw it of benefit was that of Admiral
Douglass. While I was in Yarmouth he asked me about a set of symptoms which so resembled
those producded by stone that I sounded him. In doing this I broke off a piece of the 
stone which came away with his urine. I sent it to Dr Marcet who on examining it found it to
be of the Mulberry kind the oxalite of Lime in which he said either the Muriatric or Sulph 
Acids would dissolve it. After trying Muriatic Acid for a time & no advantage arising
from it I commenced with the Sub: Carb: Soda & gave him Zss 4 times a day in tbs of distilled
water. This prodcuced a great alleviation of his symptoms & the admiral thought himself 
almost well. I was afterwards consulted in another case of stone & I was told the reason
was on acct of my having cured Admiral Douglass. But I said I had not. Such a thing
was impossible. He had indeed derived great advantage from the use of this remedy. I
went to see him & he told me if I could get him a pretty girl he could dance down five
& twenty couple with her. He had since I saw him taken 2 journeys of considerable distance
which he bore with ease whereas before he took the soda he was scarcely able to cross
the room. He took the soda as long as he lived & was sensible of its utility & whenever he
left it off he suffered considerably. It could not have acted on the stone for it could
not dissolve it & he said that he felt it fall occasionally over the Urethra & stop
the flow of Urine. It diminished the Irritability of the Bladder & probably coated the stone
with the Triple Phosphate. I would never perform this operation untill I had tried this
remedy. I reccollect very well a case in Kent Road in which I employed it with much success
when I first saw the patient he was in much pain he had a great deal of fever and was
discharging much matter from his Bladder mixed with urine. I refused to perform the
operation untill I had first dimished his fever and Irritation by giving him the Liquor
Potass after which I performed the operation & he did well but I have no doubt that had



143
I performed the operation without having and this precaution I should have lost him. The Liquor
Potassa then has a similar influence to Soda Magnesia also has some but I have not the same
belief in its efficacy. It is known that only 14 stones out of 150 are Uric Acid. The quater proportion 
have magnesia for their base therefore in a chemical point of view we would not suppose
it the best remedy. It has considerable utility when combined with soda of acting on the
Bowels. In order to show the efficacy of alkalis or acids over the Uric Acid Calculus I will
relate a case. A Gentleman came from Birmingham passing a very considerable quantity of
white sand with his urine the Chrystals of which were the Triple Phosphate I reccommended
a Consultation with Dr Bailie. It was held to be right to give Muriatic Acid We did
so. He saw the man from day to day the same quantity of sand was secreted but it became
Uric Acid Calculus of a Red Color. Having been sometimes used it affected the bowels and on
that account the dose was diminished but the Triple Phosphate began to appear. The secretion
still went on & accordingly as we increased the Muriatic Acid in quantity the Uric
Acid began to reappear & as we diminished it it became the Triple Phosphate
It is the Digestive Functions that are wrong which produce a tendency to Uric Acid or formation
of Calculus in the Kidney & I have found that in those people who are subject to acidity in the
stomach Calculi is not an unfrequent occurance. Yesterday I saw a person who had all the
symptoms of stone. He has swellings on one wrist & both knees. His stomach is acid & that produces
frequently a secretion of stone. In looking over the ages of those who have been operated open
for stone I find that after the age of Puberty the time of life in which they are most frequent
is from 60 to 64. It is at that period in which Dyspeptic symptoms are most common
At what age is it the most safe to perform the operation for stone? If the person is
very old & the Constitution otherwise healthy there is nothing to prevent the operation. Such
persons will do as well as any other. But if you take a person extremely young I mean under
2 yrs of age they bear operating extremely ill. There is always great danger in operating
in Children younger than 2 years. I would advise the parents to leave the Child untill
it is 3 or 4 years old younger than this Convulsions are exceedingly apt to follow serious operations



144
The earliest period at which I ever performed the operation was at age of 1 year & 9 months old
The greatest age at which I ever operated was in a man of 76 & that man is still living. He
must be now 83. Mr Cline Sent(r/=) cut a Gentleman at the age of 82 & he did very well. This is
the greatest age I ever heard of. He was independent of the stone a very healthy man. What
is the worse subject for stone? Just such a one as I would make myself A man of middle
age a stout fat overgrown fellow with more Cellular Membrane than these should be
& the perineum deep & loaded with Fat. Under such circumstances the operation is more 
violent & the powers of restoration less. I believe I should die from such an operation. When
a Medical man writes to me & asking my advice about a patient of this kind. I always
direct him by all means to reduce him first & take away as much superfluous fat as possible.
If you cut a person for stone who has a thin perineum he will recover but I have
never known a large man with a large stone recover from the operation. In speaking of
stones being very large as an objection to the operation I will tell you how you can distinguish
it. By carrying the point of the sound over its surface giving it laternal motion &c. If the
person is thin you can ascertain it by the Rectum.
When you are thinking of performing the operation look well to the state of the Kidneys
If that organ is diseased your chance of success is small. Now whenever a patient comes
to me with a stone in his Bladder & pointing his finger over the situation of the kidney
says he feels a pain there I never like to perform the operation you should have a case
also that the Bladder is in a sound state that it is not ulcuated that there is no
Blood or matter discharged with the Urine If so you will know that Inflammation will
Supervene the operation & under the best circumstances your patient will die You
should always enquire carefully into the general health of your patient altho' there will
be no circumstance which will strike you at first sight yet if on closed examination 
you find any viscus to be out of order you may be sure that the operation will
be such a shock to the system that disease will be induced & you will not be successfull
If the Liver is out of order. If the stomach is weakened or Dyspepsia your operation




145
will fail. Take care that all is right before you go to work operating rarely succeed
when any of the viscera are out of order. Therefore when a patient who requiring my assistance
tells me that he has a Cough that his Chest or Liver is diseased I am extremely cautious how
I operate. Tho under such circumstances disease may not be fully set up in the organs yet
a new Irritations occasioned in the system at such a time will be sufficient to confirm &
bring it into action. Previous to the operation the patient should be prepared first by a proper
diet. The proportion of Animal food should be diminished & Alkalis be given if the
Bladder is Irritable. Now supposing you have made up your mind to the performance
of the operation. Let us consider the Instruments which will be required & trace the steps
of the operations.
The first Instrument which you will want is a sound. A sound which has a less curve
than usual passes with much greater readiness into the Bladder & the introduction is attended 
with less pain. In sounding a patient for stone you are likely often not to find it
a person once put himself under the care of Dr Bailie with symptoms of stone. The Doctor
reccommended several times that he should be sounded but he assured him that he had been
very carefully examined by a Surgeon & no stone existed. However he got no better & he went to
another Surgeon who sounded him and readily detected a stone & on cutting into the bladder
17 Calculi were extracted. Sometimes the reason why the stone is not felt is the Prostate Glans
being enlarged & a sort of bag is formed behind it containing the stone so that the point
of the sound passes directly over without touching it. This is by no means uncommom where
the middle lobe of the prostate is enlarged is right when the patient is in a recumbent
posture & you do not feel the stone that you should direct him to stand before
you when it will often fall toward the neck of the Bladder & then your Instrument
must be pointed in the direction. Sometimes you cannot touch it because the bladder
is full of water but this however is not common. When this is the Case however you
should tell him to evacuate his urine after which you may probably discover it Sometimes
in continuing you cannnot detect it you should therefore sound the patient in 	



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both states. With respect to the staff This should be considerably curved. Some Surgeons
think it ought to have a greater curve but this increases the difficulty of introducing it
you might operate 2 or 3 times while making the attempt to get the staff into the Bladder.
The staff should be of as large size as the Urethra will admit & this will allow the
groove to be of a larger size. The staff should be sufficiently long to let it rest on the stone
in the Bladder during the operation. In cutting into the groove in the staff it is best to use
a double edged knife. The one cuts upwards & the other downwards & facilitates the operation.
The next instruments is the Gorget. That now in most common use is the one invented
by Mr Cline which has the beak in one side & the cutting edge on the other.
If a cutting Gorget is made too wide it is every now & then cutting the Int: Pudie Artery
This is not of so much importance in a Hospital where the Surgeons have their assistants
to press upon the vessel. But even here in old people haemmorhage will recur so as
to destroy life. But where a Surgeon has to go to a distance to perform the operation where
he cannot remain long all possible means should be used to prevent such as accident
occuring. In order to lessen the risk I have taken off the angle so that the
Instrument dilates after the edge has cut thro' by its wedge shape. I have no idea
that the operation for stone has been improved by the cutting Gorget. The most successfull
& most Celebrated operation for Stone is Mr Martins of the Norwich Hospital
He makes use of the same means which Cheselden made use the blunt gorget
one cannot help believing that the effusion of blood which has taken place in the operation
of late years is the reason why it has been less successfull. When the Gorget has
been introduced then Forceps of different kinds are required. The best Constructed forceps
are those where the pivot is about 2/3 foward. If the blades are larger than this there is
danger of breaking the stone. Where there is any enlargement of the Prostate & stones behind 
it a curved pair of forceps are necessary. When the stones are small flat forceps. When
the stones are of considerable size you must use the Crotchet consisting of one blade
It is passed into the Bladder & resting against the stone the finger of the other hand



147
is used as the blade & thus you draw it forth. If the stone breaks then the scoop is necessary
operation.
Having passed the staff down to the stone you rest it upon its surface & then give it to an
assistant to hold. It should not be held (as is often done) with the hand depressed to the abdomen
but it should be held perpendicularly. The former is a very dangerous position
for the point of the staff is not in the Bladder but is in that part of the Urethra
where you are going to cut & if you are not particular when you are changing your
hand for an assistants the staff is liable to slip out of the Bladder into the incision
in the perineum & the Gorget on being introduced passes between the Bladder and
Rectum. The groove of the staff is to be inclined a little to the left side of the patient.
The stone operation should not exceed 4 mintues. When you begin your incision
your rule is to cut from the under part of the Symphisis Pubis. Above this
it is of no avail because there is bone beneath. Then it is to be carried opposite to
the middle of the Anus. The Incision should terminate midway between the Anus & Tuberosity
of the Ischium. This divides the skin & Cellular Substance & lays bare the acclaraton Urinar
Muscle so as to show its filus which crop from the Anus to the Bulb & also to divide the Transversus
Perinei & by this the bulb is laid bare. The Bulb being now laid bare the finger is to be 
put into the wound & the blub pushed to the right side. As soon as this is done the membranous
part of the Urethra is exposed & you are then to carry the point of your knife into the groove of
the staff & pass it up & down so that the division may be free. I always keep my finger nail
long in order to put it into the groove of the staff to ascertain that it is completely laid
bare. Then pass the beak of the Gorget into the groove of the staff not suffering the latter
to bear down upon the Rectum but lifting it up at the time so as to raise it towards the arch
of the Pubis & in directing the Gorget it should be inclined obliquely downwards. But here
is the dangerous part of the operation. Here it is that those who are not used to the operation
will generally fail. I have seen a Hospital Surgeon who never could perform
the operation without sending for some more skillful hand previous to be at his elbow



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during the time of its performance. He always passed the Gorget between the Bladder & Rectum. He
Introduced the forceps but found no stone. After fumbling about for some time he caught hold
of it but the coats of the Bladder were between it & the Forceps & there he tried to pull it down
& after the stone was drawn as far as possible it slipped from the Blades of the Instrument. This
was repeated again & again untill he was obliged to give over & the patient in 3 days by
Dissection unfolded the true nature of the case
I have seen the staff bent with the force with which the operation prepared upon it with the Gorget
for fear it might slip off. A Person down in the country wrote me requesting I would
buy him some Lithotomy Instruments as he had a case in which he was called to operate
& I sent him those which I had been in the habit of using. Well I heard no more of him
or the case for a long time untill one day Saundy came to me & said "Here said he
what sad work he has done to one of the staffs which you sent down in the Country
see how they are bent. Now the circumstances as they were afterwards related to me 
by a Gentleman from the place were that the Surgeon got the staff into the Bladder & on
Introducing the Gorget he prepared so hard upon the curve of the staff that it was
bent forwards the consequence of which was that the Gorget slipped between the Bladder
and Rectum. He then instead of perceiving & connecting his error introduced the Forceps
& was fumbling about for 40 minutes before he could find the stone. He laid hold
of something & pulled but it slipped again he caught hold of it & brought down the 
Bladder with the stone in the former never having been opened. At length the parents
of the child rushed into the room & took it from the Table saying It should be tortured
no more, It died in 2 days afterwards & on examination it was found that instead
of having passed it into the Bladder he had pushed the Gorget between the Bladder &
Rectum you then withdraw the staff & introduce the Forceps upon the Gorget and
then withdraw the latter. Then sieze the Stone and Extract it. If the Stone be very large
there is great difficulty in the extraction. Rather than use great violence in pulling it
away it is best to enlarge the opening by containing the incision downwards along the inner



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side of the Tuber Ischii for the greater facility is given in the extraction by extending the incision
obliquely downwards. Sometimes the stone is so large that it cannot be extracted without being
broken. This may be done by boring it with a perforation while holding it with a Forceps
& then you may easily break it. Then extract the Fragments
The stone may be so large that it cannot be extracted at the lower opening of the Pelvis as
was the case with the stone which weighed Zxtiv. Sir Ias Earle & Mr Cline were both
consulted in this case but would not extract it. The attempt was again made a week
afterwards & scraped but could not extract it. Its extraction after death was difficult.
A stone is so situated sometimes in a Sacculus at the posterior part of the bladder.
A child had a stone situated at the Posterior part of the Bladder toward the Rectum
& could not be moved. It did not produce any very violent symptoms of stone. A
Finger was carried into the Rectum & a cut made thro' the Perineum & the stone extracted
that way.
After the operation has been performed no dressings are to be applied. It is not right.
They prevent the escape of Urine & in that way are very injurous for the Urine Collections
forming an abscess & sloughing of the Cellular Membrane. The wound soon granulates
and thus the wound is closed up. The danger of the operation arises from the Inflammation
of the Bladder & Peritoneal Inflammation. This is to be prevented by the application
of Leeches by taking away blood as soon as pressure on the abdomen produces
pain by giving aperients putting the patients in a warm bath & Injecting warm fluids
into the Rectum. you will find that from x to xv drops of Liquor Potassa given in
Mist: Amygdal: Zi & frequently repeated will be of great service Great advantage
is also derived by applying Bottles of warm water to the Abdomen & fomentations of the
Flor. Cham. The time which it takes the wound to heal under the most favorable circumstances
is 14 days in Children more usual however from 17 x 20. In the adult from 4 to 5 weeks
If the stone which has been extracted is large a longer period will elapse before the 



150
cure is complete. The proportion of successful cases is from  15 x 2 deaths in a large Hospital
viz Norwich. In this statement you have the experience not only of an individual
but of many for a lapse of 40 years. There are individuals who tell you they have a larger
portion of successfull cases than this but in such & statement you can put no confidence.
I have known a person to go on & be successfull in 28 successive operations & then
loose 4. If from this he makes a conclusion that he has only lost [XXX?] 29 it is not fair
The greatest extent of success in one individual was that of Cheselden he lost but 4 out
of 56.
Of Stone in the Prostate Gland.
The Prostate Gland forms Calculi of the Phos Lime. They are small bodies from the size of a Pins head
to that of Peas. situated in different bags in the Prostate Gland 2 or 3 sometimes contained in one
bag or in the Excretory Ducts. They are generally round & usually of a small size. I was sent for by
Dr Moore to see a Gentleman who had retention of Urine. On Passing the Catheter into the
Bladder I heard it grate as it passed the Prostate Gland and putting my finger into the Rectum
I could make them rub distinctly against the Instrument. As he was young & healthy
then I proposed to a move them by an operation but to this he objected & he died a year ago
aged about 28. On examination 3 Calculi were found in the Prostate
General Burne had a stone in the Bladder which he discovered by the use of the Bougie
It was thought he had a structure for which a Bougie was introduced & when withdrawn
it was found roughened at the part where it passes the Prostate. I sounded him & found
a stone which I extracted. I then put my finger into the wound & found several in
the course of it & I extracted a number similar to those of the Prostate. It must
have been those which roughened the Bougie for I never knew it to take place
from a stone situated in the Bladder.
Of Stones in the Urethra
These are in three different situations requiring operations in the membranous part of
the Urethra at the Scrotum or Anterior to it. When called to a case in which a stone



151
has been stopped in the Urethra you are not to perform the operation immediately but introduce
a Bougie down to the Membranous part (supposing the stone to have lodged there) and
then allow the Urine to collect behind it so that the patient afterwards may force it out
in a full stream. But if you cannot get it out in this manner pass your finger behind
the stone & keep it from entering the Prostate else it will slip back while you are performing
the operation. When it is lodged in that part which is opposite the Scrotum push it
back towards the Perineum & then cut into it. For if you cut thro the Urethra at this
part an extravasation of Urine will take place in the Cellular Membrane of the Scrotum
& produce extensive abscess & sloughing. When you can feel a stone readily in the Urethra
you think you can extract it by means of a Forceps for on introducing the Instrument the
Internal membrane of the Urethra is doubled before it over the stone & you cannot extract
it. When a stone is appearing near the orifice of the Urethra you may draw it
forth by introducing a probe thus crooked (6) & getting it behind the stone hook it out
or if you use Forceps let them be like those made use of in Midwifery. Introduce
first one blade & then the other thereby you will be able to get these part the stone and
laying hold of it extract it.
When the stone is to be cut out Anterior to the Scrotum your external incision should be
large in order to allow the free escape of Urine after the stone has been removed. If the
external cut is small & the internal one of larger size the urine will escape into the
Cellular Membrane which connects the Integuments to the Penis surrounding it
a Gentleman was cured of the disposition to form Gravel by the use of Soda.
Female Lithotomy
You are less frequently called upon to operate for the stone in females than in males the reason
probably is that the Meatus Urinary is straight in its course & very short so that a
stone readily finds its way out of the Bladder which the small would be retained in 
the male. Otherwise we should suppose that females would be more subject to stone than
males.



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because they certainly retain their urine longer & on that account if there was a disposition
to form Urinary Calculi this would have a greater opportunity to do so
The symptoms arising from stones in the Bladder of a Female resemble those of the Male 
They have pain at the orifice of the Meatus Urinarius which is exceedingly severe, very
frequent inclination to make water & a discharge of Blood with their urine under exercise
But there are 2 Circumstances which are different between this disease in the Female and
Male 1st token they are going to make water they have a distressing sensation as if all
the parts in the Pelvis were going to protrude a bearing down sensation They suffer very
severely on this account indeed it renders their sufferings very distressing. 2d thus very early
after the formation of stone in the Bladder have an Incontinence of urine. After a
woman has had the disease but a very inconsiderable time she is unable to retain her
urine & is under the necessity of wearing a piece of sponge in the Urethea to prevent the
urine from dribbling away constantly & excurating the part surrounding. It also renders her
extremely loathsome & offensive which in fact it does not prevent. She generally suffers
extremely on this account.
Stones of very considerable size sometimes pass from the Urethra of females. I remember a
case in which a woman had suffered very much for a long time in this disease
when one day as she was making water she heard something fall into the pot & on examination
she found a stone which weighed nearly Zi. Dr Yeltoly shewed me one which
passed from a patient of Mr Headingtons nearly as large
Sometimes stones are lodged partly in the meatus urinarius & partly in the vagina. I remember
seeing Mr Cline perform an operation in this Hospital for that state of stone. He dilated
the Urethra & tried to extract it in that way but finding an unusual resistance
he was induced to pass his finger along the vagina & feeling it projecting there he cut it
out by that way. It was in shape not unlike a Bar shot. It was probably formed in
the following manner. It had sunk down at the neck of the Bladder & ulcerated down
the vagina & when there had gradually enlarged by a new Calculus Concretion from the 



153
urine which passed over it. I suppose if you had once seen a person with stone you would be induced
to think no person would be desirous of having one by way of amusement & yet we occasionally
see some very extraordinary instances in which women practice decepting apparently
only for the pleasure of being cut. I once operated upon a woman & extracted a pebble from
the meatus urinarius which she must have put in herself. But a still more extraordinary
case came into this Hospital under Mr Cline. The patient was a young girl about 19 and
a very good looking girl. She had considerable pain in making water & forcing pain
& she described all the symptoms of stone so accurately that there seemed to be no doubt
about its existance & Mr Cline said "Well, the next operating day we will take her into the
Theatre & remove it" On Friday she was brought into the Theatre & she lay bound hand and
foot. Mr Cline said on sounding her Here is a stone & making an Incision he took
hold of the stone but had some difficulty in drawing it out so that he was induced to
believe that it was contained in a Cyst. After some time he put his finger into the vagina
& feeling some hard substance he hooked it down & holding it close to his eyes he
said in his way Here is a piece of Coal. Well he put in his Forceps &  fished again &
again. He brought away 9 pieces. Then on examing the Bladder nothing like a stone
was found. We asked her what induced her to do it. She made no answer looked silly
& went away in a few days. I was called upon to operate on a curious case in the
other Hospital. I put the Instrument into the Bladder & felt it striking very distinctly
against some solid body. On cutting into the Bladder I found one end of the
solid body firmly situated within it. Putting my finger in I felt something very sharp
against it. At first I thought it might be a piece of bone sticking thro the Bladder
which had at some time been fractured from the Pelvis. Then again I conceived it might
be a pessary & thinking it probably too large to extract whole I sent over to Laundys
for a small saw with a view of dividing it in two. But while he was gone I got hold
of it again & drew it out & found it to be a Brass nail such as is made to hang
hats open. Upon enquiring how it came there she said she had long been a woman on 



154
the Town and in the habit of walking the streets at [?apping] & she supposed some sailor had put
it in to play a trick upon her. But she was a most miserable drunken woman & no a
pendance could be placed on what she said. I thought it probable that she had been
using it as a Pessary & that it had worked its way into the Bladder. On examination
an ulceration was found between the Bladder & Vagina & between the Vagina & Rectum
We have had a very curious case of stone in the Female over at the other Hospital
This is the history of it. A medical man was called for to this woman to draw off her
urine & having a very short Catheter he by some accident or other let it slip into the
Bladder. He made several attempts but was unable to get it out again. It produced
a great deal of pain remained in her Bladder 3 years & brought on a very foetid secretion
of mucus on cutting into the Bladder I found that the Catheter was laying transversely
& that its left side was firmly fixed into it of course I could not draw it out 
in this way. It would have torn the bladder in pieces. I then introduced my finger into
the Bladder & found that one extremity of the Catheter had gone at least 1 inch into the
Pelvis & that on its Centre there was a large stone. The mode by which I at last succeeded
was by taking hold of its moveable end & turning it down so that with a common pair of [dust??]
forcepts I took hold of & extracted it.
With Respect to the Operation. When there is a stone in the Bladder it is by no means
constantly required. They may frequently be removed when of considerable size without making
any Incision. 3 cases have now occured within my knowledge the 1st was where the
stone was of the size of an Almond in the Shell. Mr_ Thought he would be able to
get it out by enlarging the meatus by means of a waxed sponge tint. He introduced a piece
about the size of a Female Catheter about 2 inches in length with a piece of stones attached
to it to prevent it from slipping into the Bladder. On the Friday following it was
removed. A pair of Forceps was introduced & the stone extracted & on the Wednesday
following she left the Hospital quite cured without any difficulty whatever in passing her
urine. Mr Wright sent me another case which he had treated successfully in the same way



155
It was a Child 6 yrs old who had been afflicted with stone for 4 years. He introduced a
piece of sponge tent into the meatus urinarius & after wearing it but very little time he extracted
it by means of a common pair of Polypus Forceps a Calculus weighing Zi Averdupriz. He
took it out on the 5th & the Child was discharged cured in the 9th of May. Mr Oaky Sin: of
Cambrige shewed me a stone of similar size which he extracted in the same way. Under
these circumstances therefore you must not be too hasty to perform the operation. After
the operation has once been performed if a future stone should form it may be extracted
by another operation. There is no necessity to cut the patient more than once. 1 of the
Sisters of this Hospital has had several stones removed without a repetition of the operation
& I lately attended a Lady who had been previously operated open by another Surgeon & I extracted
another stone readily without Cutting her
In sounding your patient you will use a male sound in preference to a Female one. A
curved is better than a straight sound. The instrument which you next employ is a straight
staff. you are to turn the groove downwards at the time of using the knife because in
proportion as the Instrument is carried low you have room for extracting the stone & in
proportion as the Instrument is directed towards the symphisis Pubis will there be less room
It is to be carried then a little obliquely downward & not in a Horizontal Direction. you
should use the curved forceps because you will generally find the stone situated down on
the head of the vagina & the straight forceps would not therefore extract it. The staff
should rest on the stone at the time you are making your Incision. The knife which
we employ is a common curved Bistoury with a blunt extremity. The groove of the staff
is to be directed downwards & the cut is to be made with a slight obliquity downwards
but be carefull not to carry it so much towards the Vagina as to endanger its being cut
This is one of the simplest operating in Surgery. If a man can perform any operation
without a knowledge of anatomy it is this a child could almost perform it
Mr Hey advises after the operation that a piece of sponge should be introduced into the
vagina so as to support the meatus urinarius its sides & that it should be suffered to 



156
remain in during the granulating process. The sides of the wound are thus kept together
& its ready adhesion much promoted & much of the unpleasant consequences prevented
which are very apt to ensure after the operation from the wound not readily uniting.
B.R.O.N.C.H.O.T.O.M.Y.
This operation has been advised with a view of relieving suspended animation but I believe that
for this cause it is very seldom required & I mention the subject rather to acquaint you with
my opinion on the subject than to reccommend it. There are 3 causes which are said to require 
it occasionally viz. Submission. Suspension & the Influence of Noxious Ains on the pitae
Principle
1st Submission. The principle on which this produces its effects on the animal vital
Power is very simple. When an animal is first put under water violent struggling are occasioned
for the space of 1/2 minute & occasional ones for the space of half a minute
more during which time air is discharged from the Lungs. It would seem as if the Lungs
entirely emptied themselves of air but some still remains. It is as much as 4 minutes
before the Animal is apparently dead & he will continue to shew occasional motions
which proves that some involuntary power still remains untill that time. At the end
of 4 minutes he is apparently dead altho even then if you place your hand upon
the chest you will feel some slight palpitations of the Heart. Upon this principle
animal life is capable of being restored. If the heart has not ceased its motions altho'
the apparent actions have ceased there is an opportunity for restoration.
It has been thought that Submission destroyed life by producing extravasation of blood in the Brain. But
this opinion has been entirely overthrown by the experiments of Mr Coleman whose work contains
all that is at present known on this subject. He has shewn that the opinion of apoplexy being
formed is quite unfounded. Another opinion was that a great deal of water was admitted
into the Lungs but Mr Coleman has shewn that if any was admitted the portion was extremely
small. Not more than Zi x ij can be got from the Lungs after Submission. It appears



157
as if some Spasmodic Contraction of the Muscles attached to the Epiglottis took place
and closes it down so as completely to prevent the admission of water into the Trachea.
The opinion too that the stomach was very much distended with water is erroneous. It was
supposed that this prevented the descent of the Diaphragm but the quantity of water which
the stomach contains is very small
But all the opinions which we have related are set aside by the following experiment. If
you cut into the Trachea of an animal & introduce a pipe thro' which he can breath & then
Immerse him under water he will not only live a considerable time but sustain very little
Injury afterwards. This shews that Death is not produced by any influence of the effusion of
Blood upon the Brain or by the admission of water into the Lungs or Stomach but by the
want of a due oxygination of the Blood by the atmospheric air. It is owing to the suppression
of respiration & that only. If you introduce a pipe into the Trachea of a dog & draw a
chord tightly around the neck above it & hang him the result will be that he will recover
when he is let down. This has now been repeated a great number of times & it proves the
same thing as the other viz that death arises in suspension in consequence of Respiration being
suspended. The 3d Cause of Dissolution is by the Admission of Noxius Air into the Lungs. The
principle of these are the Carbonic Acid & Hydrogen Gases. The effects which these produce
are occasioned not only by the exclusion of common air from the Lungs but also from their acting
as a poison on the system. The proof of this is derived from the experiments upon animals.
Thus if you take a frog & shut him under a glass Ball which has but little air he
will live but 3 hours but if there is any Carbonic Acid in it he will die in 8 minutes
The difference of time shews that it is not simply the exclusion of a common air but the
influence of a poison which destorys life so speedily. In one it is slow in the other immediate.
Take a mouse & put him into water he will live 4 minutes but put him in
a vessel contains Carbonic Acid Gas & he will be dead before he reaches the bottom.
It has been thought that these airs were excluded from the Trachea by exciting the muscles
of the Epiglottis to Contraction whereby the opening into the Trachea was closed. But 



156
the quick influence which they have in destroying Animal Life proves this to be an error. But
another proof that they act upon the Nervous System is that when the Animal is exposed to them it
generally recovers with more difficulty than after immersion in water & there is generally a spasmodic 
action of the muscles produced which continues many hours which could only be produced
by its Influence on the Nervous System. Your principle in these cases is to act upon the
Right side of the heart. Its actions are prevented by Collapsed state of the Lungs & if you can
restore this directly its actions may be renewed & if one side be made to act the actions of the
other must also be renewed. Prior to Submission the Lungs were expanded & a full quantity of
Blood was sent out to the Heart. In their collapsed state the vessels are very much contracted
& even then some blood passes thro them yet it is insufficient for the support of Life=
you have 2 objects to fulfill in these cases one is to expand the Lungs & the other is to change the 
Blood so that it may have a proper influence on the nervous system then assist the circulation
of the Blood making use of Friction & Stimulants
It has been reccommended for the purpose of expanding the Lungs that a Tube should be introduced
into the Trachea But it is difficult to be done altho' it seems easy. There is danger
unless you are very perfect in the anatomy of the parts that the stomach & bowels will be
blown up instead of the Lungs. But it is not necessary. My advice is you do not try it 
What I do when called to a case of this kind is as follows. I turn a handkerchief round
the nosel of a pair of Bellows. introduce it into the mouth close the nose & lips around it
& close the Pharynx by pressing the Larynx & then inflate the Lungs without any danger of
Inflating the stomach & Bowels. This is all that will be required. All complicated means
are bad in our profession & ought to be avoided. But very often it is not necessary to introduce
a Bellows & pipe &c. You can Inflate the Lungs in the following simple manner
Make a considerable pressure by applying both hands upon the chest & then suddenly raising
them. By this first act you bring the Lungs into a state of Collapse & by the 2d the chest raises
a vacuum is produced & the external air rushes in. You then repeat the same process over &
over again. I first learned this accidentally during Lecture: I was forward on the 



157
subject & made pressure on the chest & when I rose I heard the air rush into the Lungs with a
considerable noise. Mr Crowfoot has lately received a medal from the Royal Humane Society
for restoring a drowned person to Life & he told me this was the only means he made use
of. I have known another instance in which it has succeeded Therefore if called to a person
who has been drowned & you have no bellows or pipes near do not wait for them but proceed
immediately in their manner
The operation of Bronchotomy is required for 3 occurrences. The 1st is some extraneous body getting
into the Larynx & by its pressure obstructing Respiration. 2d for a Tumour producing
the same effects 3d for the membrane which forms in Croup & stops up the Trachea. But
in this last it has not been successfull
In respect to the 1st Death is sometimes sudden from Immediate Suffocation. Extraneous
Bodies get lodged in the Trachea & interrupt Respiration only in part but remaining there they
finally produce Inflammation relcuation & Death We had a subject in our Dissecting
room once who died suddenly from an extraneous substance getting into the Trachea. He was
a Beggar & was standing in St Thomas' yard eating a Cabbage to excite the commisseration
of passing by & while doing it he suddenly fell to the ground & died immediately. One of our
Porters happened to be going by at the time & began most piteously to lament the loss of his brother
had him taken up & conveyed to the Dissecting Room on examining his Throat a portion of
a stem of Cabbage was found lodged in the Sacculus Laryngus. The operation is sometimes
required for Indolent Abscess in the Larynx & for tumours on the neck which press
upon the Trachea. I have lately had a very interesting case sent me in which it was
performed for Angina Laryngea. A person was seized with Inflammation of the Throat &
sudden Dyspnoea which continued for a week unabated. At that time his extremities
were cold he was breathing with much difficulty & it was thought he was too far gone
to recover. As a last resort an opening was made into the Trachea below the Thyroid
Gland. a tube was put in the aperture & he recovered. He came to town last week & called
upon me. He had then worn it 19 weeks. On the 4th January he coughed up a



160
portion of spongy bone which was ossified Cartilage on the 21st January be brought up another
He was unable to speak when he first called upon me without putting his finger on the end of the
Tube. I asked him if he could bear to have it taken away. He told me that at first it gave him
much uneasiness & that he could only bear it out for a few minutes but that he had been progressively
recovering in this respect & he could now support it for 2 hours sometimes. This case is
Interesting because it has been said that the irritation produced by the Tube would be so great that
a tube could not be worn but this has now been worn 19 weeks & has caused no inconvenience
It was made with a curve which hung down in the middle of the Trachea It did not touch
the sides & therefore produced no Irritation
The operation for Bronchotomy is to be performed in the following manner. It has been advised
that it should be performed in the Cleft in the Thyroid Cartilage but objection to this is
that it does not leave an opening thro' which the patient can freely respire. You must cut
away a portion of the Cartilage which in an old person is converted into Bone. It is not so
good a place as lower down. It has been advised that it should be performed thro the Thyroid
& Cricoid Cartilages but the objection to this operation is that unles the patients head is elevated
the opening becomes closed & he cannot respire
The 3d situation which has been reccommended for the operation is in the Trachea & here
it has been successfully performed. You should make an Incision 1 inch below the Cricoid
Cartilage thro' the Integuments & the Centre of this Incision is to be placed where the Trachea
is to be opened longitudinally. A small piece of the Cartilage should be cut out. A
transverse incision is insufficient to allow free respiration. The Thyroid Gland is avoided by
this operation which is cut would afford a most profuse haemmorhage. There is an
advantage in removing a portion of the Cartilage because a tube is worn much more
easy for it. The wound generally heals kindly when required & does not produces any dangerous
Consequences



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Fistulae Lachrymalis
This name has been applied to all disease states of the Lachrymal sac whether it is obstructed
Inflamed swelled or Ulcerated. I think it incorrect but in compliance with customs however I
shall use the same terms
It is an obstruction of the Ductus ad nasi by which the tears are prevented from flowing into the
nose. There are 3 states of this disease. The 1st is a simple swelling without Inflammation of the Lachrymal 
passages. In the 2d there is Inflammation & secretion of Pus & in the 3d an ulceration process
commences an opening is made & pus is discharged. The treatment is different according
to these 3 different states. In the first there is an oblong swelling below the Tendon of the
orbicularies about as large as the extremity of the little finger [rep?n] preparing a considerable quantity
of mucus is expelled thro' the puncture & the Tumour disappears
In this state it sometimes remains for years. The Duct is not completely obstructed [crossed out] little
pressure made empties it partly over the cheek & partly thro the nose An operation in this state of
the disease is never required. You may do good by using Anels Syringe. The French are very
much in the habit of using Injections. The fluid which is used is not very material whether it
is warm milk & water or a solution of the acetate of Lead. Then Injecting sometimes make
a passage & when they are employed early will sometimes prevent the disease from increasing
at the same time Purges should be made use of Leeches occasionally employed in order to carry
away the Inflammation. Injections of quicksilver are sometimes used which after remaining in
the sac awhile form a passage thro' the nose. This practice originated in Sir Wm Blizard some
have objected to it but I suspect it is on account of the Injudicious use of it. It ought never
to be employed during an inflamed state of the parts as it then may produce ulceration into
the cheek. If the obstruction does not give way under this treatment sometimes mercurial
ointment rubbed over the parts will affect an entire removal of it. The ointment which is
commonly used is the Ung Hyd Mit. In the second state the Lachrymal sac becomes Inflamed
you readily ascertain this state by applying pressure. Mucus is expelled by it are during
the first Pus during the second stage. This proves that Inflammation exists within



162
the sac. In this state you should ascertain the effect of Purgatives Leeches &c before you resort
to an operation. By these antiphlogistic means you may sometimes reduce it to its first state
But if these methods do not succeed you must proceed to an operation in the following manner=
The external Incision is to be made just below the orbicularis muscle (its tendon) from
1/2 to 3/4 inch in the direction of its fibres. You must then feel for the edge of the orbit below this 
tendon which is always distinctly enough perceived & it is about 1/8 inch anterior to the Lachrymal
sac. you are then to cut about this distance behind it & your knife will be carried
into the cavity in which the Lachrymal sac is contained. Then this being finished a probe
resting on the inner edge of the eyebrow is to be pushed into the Duct in a direction a little
downwards outwards & backwards. The obstruction being in this way removed the common
stile is to be introduced & kept in untill all appearences of suppuration are removed. It should
never be taken away untill this has been affected till the parts are restored & the Pus ceases
to pass up by its sides. No precise time can be stated how long it should be worn in. It will
sometimes be longer & sometimes shorter= This operation which is the one proposed by Mr
Wan must be considered as a great improvement when compared with the barbarous one
which was formerly adopted. He was in the habit of introducing a silver canula but it
was found to produce ulcerations & the tears did not pass thro it. Afterwards he proposed the
one above described
In the 3d stage when the sac has gone on to ulceration the incision is made with difficulty for 
the sides of the sac adhere together & there is a difficulty of passing the probe. A surgeon in this
case should make use of the Gold Probe. In this ulcerated state the Ductus ad nasum is sometimes
so far obliterated that the style or Probe cannot be passed into it. Instead of operating
then in this usual way you must push the probe thro the Os Unguis which readily yields under
a slight pressure. When you are performing your operation in this way instead of directing 
your probe downward & outward it should be downward & inward while it rests upon
the inner edge but about the middle of the Eyebrow. In this operation the Instrument is
passed into the nose between the Lup(n/=) & Inf(n/=)turbia Bones instead of below the latter.



163
As to the time which it is to be continued in, the principles are the same as in the other operation
The openings should be small because a sinus forms which ever afterwards remains open
This operation was probably the result of observing the natural cure when the disease is allowable to
take its own course It is now very rarely performed
The principle causes of Fistular Lachrymalis are Inflammation of the Duct's(4) lining(1) of(2) the(3) from
Scrophulous affections the Veneral disease & Scarlatina. It is best not to perform this operation
at an early period of life. The next means are to soothe the part as much as is in ones power
& preserve the general health. When an operation is performed this early it is rather an apparent 
than a real cure. In the ulcerated state there is a difficulty in finding the Duct. If
you try from the ulcerated opening it will mislead you. It is not opposite to it. The Gold probe
should be passed & then a cut made down upon it 
Mr Phipps who was one of our best oculists always used to Inject Quicksliver in structures of the
Duct. I knew a Gentleman who went to him in this stae & he immediately injected the
Mercury "And how long said the man shall I have it in" Oh as long as it will" he replied
In 2 or 3 days it forced a passage. I am acquainted with a Lady of great importance in
this country who has by this means prevented an operation for many years.
Enlarged Tonsils
This is a common effect of repeated Catarrhs in debilitated Constitutions. Commonly met with
in the young & often in the old. In general the Constitution is every & means should be used to
strengthen this. The best combination which & know is the Hyd Cum Creta with Soda. The Nitrate
of Silver as a local application lightly touched over the surface of the tumour has a
considerable effect. It diminishes it. The Sulphas Crepris also dissolved in the Saliva & allowed
to rest on it has considerable efficacy also alum made into a paste & laid upon it.
When they will not yield to any treatment Constitution or Local an operation will be required.
If it has a narrow neck you may tie it by means of a Tonsil Iron & thread



164
But if there is no peduncle & the base is broad as the apex & it is generally more so there is a necessity
for using the Tonsil Needle But this should not be of the form which is commonly employed. It should be
smaller & its eye transverse to its axis. The point should be as small as a Tenaculum. Then a double
thread should be carried thro' it & this passed thro' the centre of the basis of the Tumour & one
ligature tied above & the other below it. The Ligature should cut thro' in less than a week. It is curious
how little Irritation this produces. The child was about during the whole time & was very
little affected by it. The putting on the ligature produces considerable irritation by Cough & Nausea
which it excites but afterwards very little inconvenience is felt. It is seldom required to apply
a second ligature. One will generally do but if Ulceration goes in very slowly a second should
be applied. The Tonsil Glands may often in a great measure be removed without injury. You
often see a considerable portion of it projecting. It may be cut off. It bleeds but very little. There
is no danger unless you cut thro its base. But there are so many large & important vessels
coming off from the Carotid near the Tonsils that there would be very great danger in cutting
thro' its base. I am infomed that the French are much in the habit of cutting away the Tonsils
with the Scissors.
Ganglions
By a Ganglion is meant an accumulation of the Synovial Fluid which is secreted into a Sacculus
Mucosus. Sometimes this increases to a very considerable quantity & produces a great enlargement
In general they are attended with no pain altho they produce a considerable degree
of weakness in the Joint over which they are situated. They feel so firm on pressure that
you will be induced to believe that some bone was put out of its place. This depends however
upon the size of the Tumour & the degree of distension. Sometimes they are found Semitransparent
& when punctured they are found to contain a transparent gelatinous fluid. They are generally 
imputed to some violent & sprain. They appear most usually about the Knee & Elbow &
are generally the effect of Pressure. They are most frequently seen in the housemaids on account
of their being obliged to kneel a great deal. The ankle Wrist Knee & Elbow are their 



165
Common situations. Sometimes they are seen in men but not so often however as they are see in in females
The means of getting rid of them are 1st by pressure. The common plan is to bend a piece of sheet
lead upon them by means of a sticking plaister & a roller. This will generally succeed but sometimes
it is not sufficient & then it is necessary to use some stimulant applications as a Blister. Comp
Ammoniac C Hyd. Ung Tart Int. but the Blister is the most sure of these. It rarely fails of
success. Sometimes however it will not succeed. If you do not in this way remove them you may
burst them by a Blow with the back of a book. This should not be violent but quick. If it is not
done with considerable velocity it will not produce the effect. If it is done quick not half the
force will be required. Sometimes the cyst becomes so thick that you cannot burst it. Then a
surgeons needle should be passed into it & pressure should be made use of to prevent its
return. They should never be cut into to any extent. If you do Inflammation & Suppuration will
take place when tendinous structures of this kind Inflame them is great Irritation & danger of
surrounding parts. Excision is in some instances dangerous & in all a severe operation more 
so than the nature of the disease will justify. If situated on the wrist an attempt to excite
them is always dangerous there is hazard of opening into the Joint because their posterior surface
adheres so closely to the Ligament. On the Patella where the Tumour has increased to an 
enormous size I have sometimes done it but generally speaking it does not require so serious
an operation. The proper mode in such cases is to pass a needle & ligature into the Tumour
& allow it to remain about a week untill adhesive Inflammation is produced by it which is sufficient 
to prevent the recurrence of such a secretion. Sometimes as much as 7 or 8 days will be
required but at all events it should be continued in untill this is produced be it longer or
shorter & when it is produced it should be removed. It requires only a slight degree of Inflamation
then pressure should be applied & the sides of the Cysts be made to adhere. These are
the different modes then which we find it necessary to employ. Sometimes we succeed
by one & sometimes by another. It is exceedingly rare [but] that neither of these will affect a
cure. If the Ganglion is seated on the wrist or ankle you should never put in a seton
for it is attended with very great Hazard.



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Dropsy
There are 2 kinds of Dropsy the Peritoneal & Ovarian. The first of these is the most common. It is
an effusion of fluid from the extremities of the secreting arteries of the Peritoneum. In general it
begins at the bottom of the abdomen & gradually increases untill the cavity becomes very much
distended The causes of it are various. The first are those which act mechanically as diseases
of the Liver which give use to it to prevent'g the return of blood in the Vena Cava. The free
circulation of the blood is impeded. the vessels below become much distended & in consequence
excited to increased action. It is produced also by the enlargement of some other viscus as the
omentum spleen mesenteric Glands &c pressing upon the Peritoneum & exciting it to increased
action. You not unfrequently meet with it in Children from this last cause. It is produced
also by anxiety of mind which is found to lower the action of the blood vessels generally also
by Intemperance the use of ardent spirits which produce a quater determination of blood
to the Bowels. The Vena Porta is not able to carry it freely & Congestion & Effusion are the
Consequence. Sometimes it arises from general debility thus you will see it following Fever. I
once tapped a Gentleman of this class of Dropsy from this cause & he got well.
The fluid of Dropsy is commonly serum. It resembles it in color & consistance but it does
not contain to large a proportion of albumen. It does not coagulate therefore from the
same heat The quantity effused is commonly from 20 to 30 Hfs It is not generally so great
in the Peritoneal as in the ovarian species. Patients rarely recover after it has been drawn
off. Not from the effects of the operation but from a return of the disease. I have known
but very few cases & these were in very young persons
Dropsy very rarely occurs in Children but I have known 2 instances of it in patients not
more than 2 or 3 years old. In these cases cures were affected. From 1 of these children
I drew off as much as 13 lbs When the disease is local it may be cured by Tapping but
when it is in consequence of diseased liver & when the patient who is the subject of it is
advanced in years it is hardly ever successfull. He generally dies. The greatest number
of times that I have known this operation performed on one person was 21. & the



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quantity of fluid at each time was commonly 21 pints. You should be on your guard not
to mistake thickening of the Omentum for Peritoneal Dropsy. It is commonly attended with but very 
small quantity of water. A Surgeon from the Country told me the other day that he had made
this mistake he tapped a lady & but a very small quantity of water came away. She died
& the omentum was found very considerably thickened
Encysted Dropsy is of 2 kinds the first of the ovaria & the 2d a swelling suspended from it
when it first commences it is about the size of an orange & appears at the side. It is situated
just above Pouparts Ligament, It has no fluctuation at first for a long time is confined to one
side of the Body but afterwards extends across the abdomen & then this characteristic feature
of the disease is lost so that it is difficult to distinguish it. But you have commonly no difficuly
in ascertaining it for if you ask the patient when it began she will tell you at her
side. The fluid contained has sometimes the character of serum but it is seldom pure. Like
the water of Peritoneal Dropsy it contains but a small proportion albumen. Sometimes a
substance resembling mucus is mixed with it at other times it has the apperance of Treacle
now & then it looks yellow like Pus. These are not however the same indications which
accompany the productions of matter. The Tumour generally increases to an enormous
size & commonly contains from 9 to 10 gallons of fluid. I once drew off from one woman
with ovarian Dropsy 12 gallons & 1 pint. Dr Lryden used to shew in his lectures a cyst
which contained a larger quantity than this
When the friends of the patient enquire of you if you think she will be cured you must answer
very cautiously for in the many cases of this disease which I have seen I have never
known a cure to be affected but once & this I consider as pretty good evidence that much
encouragment should not be given to the expectation of friends
You should never attempt an early operation on 2 accounts. 1st because if it is not of considerable 
magnitude it is divided into a number of cysts. As it enlarges they become one 
by the absorption of the Septa. In this early stage therefore you do not entirely remove the
swelling for altho you may empty one cyst still another remains. Besides much




168
violence must sometimes by employed before you can draw it off & there is danger of Inflamation
being produced. Another strong objection to Tapping early is that the ovaria at that early period
does not adhere to the Peritoneum the omentum will project forward & there is danger of the
Intestines slipping down between the Cyst & Peritoneum & be wounded by the Trocar. Therefore
no more should run the risk who value their reputation
It has been attempted to cure this disease by Injections. 2 cases when it was done are related
by the Philosphical Transactions by ______ but he tried it twice afterward & it failed
He afterwards gave it up & reccommended it should not be done.
Sometimes a naturul cure of this disease takes place. The swelling goes on to increase untill
Inflammation takes place & an opening ulcerates thro' the navel by which the water is
discharged. Sometimes an adhesion takes place between the Ovaria & fallopian Tubes on Uterus
& it breaks into them & becomes discharged There was a woman in this Hospital in
whom this happened. The fluid sometimes finds its way into the Intestines & becomes cured
by repeated discharges. The bursting of the cyst will sometimes put a stop to the secretion
I knew a young Lady who had a very large ovarian Dropsy which was burnt on being 
thrown from a Chair the fluid was absorbed & did not return for 6 1/2 years afterward
The operation rarely prevents the return of the disease. I have only seen 3 cases where it did
not return & when you consider what a great number of cases I have seen (for it is a common
disease) you must conclude that there is very little probability of its succeeding Mr
Huncham lately had a case in which slight Inflammation came on after the operation &
the woman never had a return of the disease
Do not believe Gentleman that medicine does any good in this compliant a great variety of
medicines have been tried but all to no purpose. I have seen a man push Mercury to the
extreme in this disease. Oh Gentleman. It is ridiculous. I met Dr Baillie in Consultation in a
case of ovarian Dropsy the other day & I said to him "Dr. did you see any good from Mercury
in this case" & he answered he had not. then turning to the patient who spoke to me I
was surprised that she could open her jaws but a little way & on looking for the



169
cause of this we found she had been under such a course of salivation from Mercury that the
inside of her cheeks became ulcerated & when Cicatrization took place they became so contracted
that she could not open her mouth more than half the natural extent. All the medicine
in all the Apothecaries Shops in London will not reduce an Ovarian Dropsy one pint nor
a Hydrocele Zi. Would a man think of giving Mercury or any othe medicine to cure a
Hydrocele? And what is the difference between a Hydrocele & an Ovarian Dropsy? The
Cysts in both have very little vascularity & pray where is the absorption to come from? Ascites
& Encysted Dropsy are very different. In the one we see that Medicine does much in
the other nothing at all.
There are some cases where you ought to be much upon your guard how you tap for Dropsy. Now
I will just mention to you a case which came under my own observation which proves the necessity
of this caution. I was once requested in this city to come & tap a patient of his for Dropsy.
I called accordingly the next day with my Instruments. The Lady was indeed the largest
I ever saw. The size of her Abdomen was immerse. On enquiring of her I learned that
when she first perceived any Tumour was 8 months previous so I would not tap her at
present at any rate. I went down staring & asked the Physician if he had examined the
woman. He told me "No" I begged him to do it before we proceeded any further to which
he consented. I heard no more from him for some time. At last he met me in the street
one day & said "Well We shall not require your assistance in that case for a week ago
she was delievered of Twins. When the bag broke then was such an immerse quantity of
water that it ran down the Fire Place" Now from that time I have never liked to
Tap a woman under 9 months & I advise you not to do it either
It is not advisable to draw off the water all at once but to take away only a portion of
it & when the patient experiences faintness or any other uneasy sensation from the evacuation
desist from it untill she becomes accustomed to its effects. It was proposed by Mr
Guild to leave the Canula in & prevent a further flow of fluid than was necessary by plugging
its orifice. He tried this method in one case but I have not since haerd of the patient 



170
I should think that there would be danger of producing Peritoneal Inflammation by it. I am in
the habit of relating in this Lecture & curious operation which was performed by a Gentleman in
this Country who mistook a cure of enlarged Ovaria for Dropsy. The man (said the person who
told me of it) sent a line to me stating that he intended to tap for Dropsy & inviting my students
to attend the operation if they were desirous of seeing it which invitation they accepted with pleasure.
After they had assembled the man went to work as if he did not understand it very well
the necessary steps to the operation for he bared the womans belly & did not take the precaution
to put a shut round it to maintain pressure as the water was drawn away. He then took his
Canula & Trochar in his hand placed himself at an awfull distance from her & holding 
it as he would a small sword he marched up & plunged it in. Then looking round complacently
on the spectators he drew out the Trochar but Lo, no water followed. This is indeed
says he a very strange circumstance. He was a man however who was not to be alarmed
by not seeing water & so he introduced the Trocar again & thrust it forward 2 or 3 ins farther
& on withdrawing it a second time no water but only a few drops of Blood & Serum followed
He then turned round to the spectators looked very even & said "This is an operation 
Gentleman which is not very often performed & you may never have an opportunity of seeing
it again. This what we call dry tapping & now continued he you may do her up. In a few
days she died
In performing the operation of Paracentesis Abdominis the patient should be placed in a chair
somewhat elevated & the surgeon seated on one rather lower. Then a shut is to be doubled 
to about the breadth of 8 inches & placed round the abdomen which is to be drawn closer
& closer as the water flows away in order to prevent a sense of faintness which will otherwise
be occasioned. It is also observed that as the water escapes the sinking of the Diaphragm 
causes sometimes violent spasms of that muscle which is extremely troublesome=
The place at which the Instrument is to be introduced is an inch below the Umbillicus
Formerly it was made half way betwen the ant: Sup: Spin of the Ilium & the Umbillicus
But an accident happened to Mr Cline Sen(s/=) which gave rise to the performance of the 



171
operation below the Umbillicus. He had pushed in the Trocar at the usual situation &
as the water was escaping he found it tinged with blood. At length the patient became faint
he directed the Abdomen to be bound up but the patient died in a few hours. On examination
it was found that the Trocar had been pushed thro' the Epigastric Artery & it was a wonder
that this had not happened before for the Rectus Muscle is so much pushed out of its place
by the distension of the Abdomen that the Epigastric Artery becomes situated directly under
the place where the puncture was formerly made. Such a case has been published by Mr
Carlisle Smith in the Medico. Chir: Trans.
An objection has been made to puncturing above the Umbillicus because (it is said.) the
Umbillical vein is not always obliterated & there is danger of haemmorhage but however I
should not much fear the danger of this. The safest place is 1 inch below the navel
There is an objection to making it at the navel because a Hernia may be previously
existed then & though not apparent still the Bowel may be adhering to the Peritoneum
at that part. The same objection may hold an inch above the navel
An Incision thro' the Integuments should be made with a Lancet for it is the skin which affords resistance
to the Trocar. The latter instrument is then to introduced & the water drawn off
The Canula must be as much as 2 inches long sometimes in Encysted Dropsy it will be necessary
to have it longer because you sometimes have to push it thro' a thickened portion of ovaria before
it reaches the cyst. As the water is running off the shut should be gradually drawn tighter untill
the whole of it has passed off. Then you bring the wound in the Integuments together by adhesive Plaister
and apply a large flannel roller around the Abdomen & over this a belt as tight as the patient can
bear. Sometimes the fluid is mucilaginous & does not come away readily. Sometimes the omentum
gets before the Canula & prevents its ready escape. Then it should be pushed back with a probe introduced
thro' the Canula. It will escape more easily thro' the wound. If the whole of the water is
drawn off the patient will be less liable to have it return & pressure will also assert in preventing
a future secretion at all events renders it more slow. Women who suffer the abdomen to remain
lax after the operation very soon fill again. When the water has been drawn off if medicines can



173
do any thing it will be then. Previous to this they do not have a fair chance to act for the great
pressure which is made on the Kidneys prevents them from secreting. During the formation of Encysted
Dropsy great advantage will be derived from wearing a belt you cannot prevent its formation
by this means but you can retard its growth for a year or two so that an operation will be unnecessary
Diseases of the Breast.
The Breast is subject to those different diseases for which it is removed the first of which is the
Hydatid on Cellulous Disease. This is not so common as true Scirrhous & is easily distinguished by
the following marks. It is formed of numerous little cells. In a patient who has this disease you
will find a number of small tumours extending from the nipple towards the circumference
of the breast. They are Elastic Circumscribed very moveable & varying in size from one that is not
larger than a pea to the size of a Bullet. It begins as it were from a number small different
points. Sometimes there is only one swelling at others there is a number of smaller ones. It
is entirely unattended with pain. The whole of the Breast at length becomes involved in the
disease & sometimes it goes into an imperfect Suppuration & when opened a glairy mucus fluid is
discharged. When it has once undergone ulceration it has very little disposition to heal. Sinuses
are formed in the part & continue to form one after the other untill the whole breast at last becomes
involved in the disease & the patient suffers so much Inconvenience by it that she is extremely
anxious to have it removed. It becomes a burthen to her by the unpleasant discharge which
in constantly taking place from it & not from pain or any Constitutuional symptom which 
it excites. The operation is not attended with any danger nor is there any apprehension of a relapse.
I have never seen it affect the absorbent vessels or the Glands in the Axilla. If any portion
of the Gland of the Breast remain it must be removed or the disease will return
When the operation has been performed if you examine the Tumour you will find that it consists
of Cysts about the size of Peas containing a fluid the largest of them are nearest the nipple
& the parts surrounding them are extremely vascular.
Sometimes a single Cyst forms in the Breast of a large size. If you make an Incision & put



173
in a tint or Seton or Inject it it will get well= There is another disease in which a fluid is
discharged resembling bile. If the fluid is clear mucus it is a mild disease but if it be a
Bloody serum the disease is malignant. One of the best cases I have seen was sent me by Dr Watson
A girl who was very well in apperance & who came to the Hospital for the purpose of having
her breast removed on account of a swelling in it. As her general health was good however I advised
her not to have the operation performed. She left the Hospital but the Tumour not diminishing 
she returned. She was brought into the Theatre for the purpose of having her breast
removed. On feeling the Tumour I thought it had a sense of fluctuation & I thought we ought
to try what would be the result of letting out the fluid. I cut it open a quantity of glairy fluid
issued out the wound healed kindly & she recovered
The next disease of the Breast which requires extirpation is the Scirrhous Tumour. This
disease first commences with a slight discharge from the nipple of a fluid tinged with
Blood. A stain on the Linen opposite the nipple first calls the attention of the patient to
the part & on examining the Breast a swelling of a marble hardness is felt which is very
moveable & its limits circumscribed. In the beginning it is quite detached from the parts
underneath & the skin & nipple are very easily moved over it. When it grows of a larger
size it extends into the Gland of the Breast & its limits there are not cirumscribed & the patient
complains at times of severe larcinating burning pains. During this time a very considerable
increase of swelling is produced. It is not a constant growth but it augments
only at such particular times by the action of the Inflammation. It often happens that
just prior to the return of menstruation the Blood being sent in greater quantity to the
breast the Tumour increases rapidly but when the menstruations period is begun then considerable
is experienced. Sometimes the whole of the breast will take on hardness & the nipple adheres
firmly to it but this is not common. In this state of disease the Breast remains for a considerable
time & then the Glands in the Axilla become enlarged. The first gland which is affected
is situated at the edge of the Pectoral Muscle & after this the disease extends to others=
When the disease has existed for some time the heart contracts & adheres to the skin



174
in different parts in consequence of which a number of knots are formed upon its surface &
give it an irregular appearance. Little Tubercles form over the tumour which arise from the
disease having attacked the absorbent vessels. The skin becomes puckered from Cicatrices being
formed by absorption of the Glands underneath so that a portion of the Breast is removed
The swelling also extends posteriorly & adhesions are contracted with the Pectoral Muscle which
also become changed & you see a number of Tubercles on its surface. The next progress of the
disease is in the Suppurative Stage but the Suppuration is peculiar to it. The matter which
is thrown out is not Pus. When the Inflammation has gone on to a certain degree a secretion
is produced. When this takes place the Pus becomes livid. The purple appearance of the skin
ulcerates & a small quantity of a bloody serous fluid is discharged at different periods. The
ulcer in these cases is very irregular & the edges of it are everted. Granulating of a Scirrhous
hardness sprout out which possess but very little sensbility. Cancerous sores are very
apt to bleed a great deal & this often affords great relief to the patient for a little while
The Constitution is becoming exceedingly affected from the Local Disease. The Surgeon
getting into a disease state & severe asthma is the consequence of the disease extending
internally. A severe pain is felt across the right shoulder also across the Loins. Rheumatic
pains are felt in different parts of the body. The bones also are found to partake
of the disease particularly the Thigh Bone & the spine & are easily broken. The shell of the
bone becomes absorbed from the pressure of the disease. This occurred to a Lady from
merely sitting on the Bed & allowing the weight of the Leg to hang upon the Thigh. This
Disease is not a Local Affection It is arising from the state of the Constitution. Some say
it may arise from a blow but a mere blow on the Breast never produced a real Scirrhous
unless the Constitution was previously changed & had taken on a Cancerous disposition.
But if a woman who is disposed to Cancerous affections receives a blow on the 
Breast the disease is taking place in it= This disease is very apt to occur in persons
of the same family particularly if an old member has had it & this shews that there
is a Constitutional Disposition to it. I know a Physician in this town who has 4 daughters



175
affected with it. On examination of the body after death you find Scirrhous Tumours ulcerated or
not. The Pectoral muscle is diseased. The Glands in the Axilla & behind the Clavicle are enlarged
Tubercles are found in the Pleura & on the surface of the Lungs but not in the interior. The
Liver is generally tuberous & the Uterus is not free from Disease
With regard to the age at which this disease occurs from 35 to 50 is most frequent & it is thought
that the cessation of Menstruation produces a disposition to it but it is a mistake that
Cancer does not occur when this function is going on. Women have frequently came to me with
diseases of the Breast who have informed me with surprise that their Menses take place as
regular as ever. I have known persons to have true Scirrhous as old as 70 or 80. When it occurs
at so late a period as that we may tell the patient that she need not to trouble herself
about the operation because the progress of the disease is so extremely slow that it will
not be necessary to perform it. The youngest person in whom I ever saw this disease was
the woman on whom I operated yesterday. She was 28 years of age & said that it commenced
at 22. Prior to that period I have never had a patient with the disease under 29. It is
certain that those females who are remaining unmarried are more prone to this disease from
the breast not having been put into a natural state. So it is with the uterus. Women who
have had many children are not subject to the disease. Sometimes however it does not occur
after the cessation of the Menses rarely before it
Medical Treatment. We are under the necessity of confessing that no medicine will
cure this disease but still there should always be medical treatment for the Constitution is in
fault & if afterwards the operation is performed the medicines you have previously given will be
of service with regard to its success. If called on to a case of Scirrhous Breast you are to apply
Leeches about once a week or every ten days as the increase of the disease occurs about as often
as this & it is then that you should employ them. The Lig: Ammon: Acet & Spirits may be employed
with a view of promoting absorption provided it should not be a cancerous affection.
The Constitutional Treatment consists in giving the Plummers Pill with the Decoction
of Sarsaparilla. Swellings which have the appearance of cancer occasionally give way to 
this treatment



176
There are indeed medicines which are capable of relieving this disease & retarding its progress but
beyond this they have no effect. Our practice with this motive consists merely in keeping down the
Local Inflammation as far as possible. For this purpose one of the best medicines I know of is the
Carb: magnes & Cart: Soda. They should be given 2 or 3 times in the course of 24 hours in drops
of Zls of one to grxv of the other. They act as an Alterative when given in this way for a long
time= Steel Medicines have been reccommended in this disease but so far as my experience 
goes they have a bad rather than a good effect. It has the effect of producing too much excitement
& increasing the Inflammation. I think no man would administer these medicines who understood
the fundamental principles of his profession. They increase the pulse irritate the
Constitution & hasten the progress of the disease 
But gentle laxative medicines are usefull at the times of the regular increase of the malady
When you hear the patient say that she feels a fullness of the breast is the time that your
purgatives will be advantageous. Those which are gentle as the Sulph: Magnes. are the best
Leeches should be applied as before mentioned but you should be carefull not to weaken the system
by them. 2 or 3 at a time so as to take away the Local Irritation is always enough. The best
Local application is the common oiled silk which keeps up a gentle perspiration. It is to be
applied over the whole breast. If the disease is not subdued we believe it a Scirrohous Affection
the operation is to be performed if there are no signs of disease in other parts of the body
& having learned this the operation is very simple. 
Diet Vegetable food & low living is of no advantage but on the Contrary whatever hurries
the circulation is Injurious. Whatever has a tendency to weaken the Constitution has a tendency
to increase the progress of the disease. It will most certainly be increased by any thing which
abstracts from that which has a tendency to stung them the general system. That diet which
has best agreed with the patient during a state of health is the one which should be used
The food should be of a nourishing tho' not of a stimulating nature. She ought to abstain from
wine but she ought to be allowed a little meat milk cocoa or in fact any other light nutritious
article to which she has been before accustomed to



177
Climate has no Influence over this disease. A Lady had the operation of amputation of the breast
performed in this city. She went out to Demarara with her husband. She began to have an affection
of the breast while in the sea. When at Demarara it became so bad that she wishes
to return & when she arrived in England it had become so bad that no hope could be
entertained from the operation & she died. Here was an opportunity of ascertaining the full
effect of a change of Climate but it has no influence over the progress of the diseases
Fungoid Disease of the Breast.
This begins by a small swelling unattended with pain & appears to be situated on the surface of
the Gland being also very moveable you think also on feeling it that it is so much detatched
from the surrounding parts that if you only cut thro the skin covering it may be easily turned
out but if you take hold of it & pull it you will find it is connected with the Gland. It is not
of the same marble hardness as Scirrhous but there is a yielding as if it was distended with blood & you
can press out a little. In the space of 6 or 7 ms it is of very considerbale magnitude. The skin becomes
of a purple color the swelling bursts & there is a discharge of a greenish fluid & looking into the
Cyst a fungus is seen arising within which secretes the fluid. When you dissect one of the Tumours
you find that in some parts it is extremely vascular while in others it has not received vessels. It
is composed of a great number of Cysts. It is very slow in destroying life. The absorbent Glands do
not become affected very soon. The Lungs are next affected to the Breast & the Liver next. The
disease is very slow in the course of the Absorbents. Altho' it is a Constitutional Disease yet there is
a Local specific action in the part as well as a Constitutional disposition for if you make
a wound the disease does not occur in it
As to the powers of Medical Treatment there is none. As to the operation it very frequently does not
succeed. It is apt to return in the part in the Fungoid Disease & in the true Scirrhous it will occur 
from Absorption in other parts. When called to perform an operation in this disease take
care & do not cut into the parts which have the appearance of being Inflamed for there the disease
would again be produced. A Boy had a Fungoid disease on the fore arm for which it
was amputated at the usual place above the Elbow where there was slight Inflammation. As



178
the stump was healing a fungus started from the part & this went on to the destruction of life.
you must therefore go beyond the place where there is the least appearance of Inflammation 
Your operation in the Amputation of the Breast consists in making a semilunar incision over the part
diseased so as to divide all the vessels going to the Tumour. Then letting an assistant make pressure
on the vessels so that you may see your way clearly. Then you make another semilunar incision
at the lower part meeting the former & then dissect it out laying bare the Pectoral muscle. Every
portion of the skin which is diseased or has the least appearance of Inflammation should be removed.
For if it is not done when cut into it will take on the same disease. I have seen a cicatrix
take on the same disease & take on the same tuberculous disease notwithstanding the greatest 
pains were taken to remove it. If the Gland in the Axilla is enlarged you may cut it away and
the absorbents leading to it. The operation is generally unsuccessfull but this is owing to the want
of attention to the Constitution & without your operation be followed by the administration of
Plummers Pill & Decoct: Saraph it generally very seldom succeeds.
The Breasts are subject to Steatmatous Tumours. They increase to a very great size. Here is
one which I removed weighing 14 kg 10g. It thrust the breast forward being situated rather between
the Gland & Pectoral Muscle. It is not a difficult operation to remove them & the vessels do
not bleed much. They are removed more on account of the Inconvenience arising from their
size & weight rather than from any danger being apprehended
The Breast is now & then in Children the seat of Areolar Tumour surrounding the nipple
about the distance of 1 1/2 ins from it. The circle is extremely hard. It is occuring prior to the
age of Puberty. You do not see it afterwards. It takes place in Boys as well as Girls from 8 to 
12 yrs of age. I believe the swelling is connected with the sebacious follicles surrounding the
nipple & they are gettng into the Strumous State. It gives way to the stimulant plaisters as 
Emp Hyd or Imp Ammoniae @ Hyd 
An Indolent swelling like that which attacks the Testicle sometimes affects the Breast. It is an Indolent
Inflammation going on to slow suppuration producing sinuses thro' which matter is discharged not engendering
any of the malignant diseases. It is very difficult to remove but ultimately yields to alterative
medicines. Sometimes it continues a year & a half 



179
You must be aware that young women are subject to Scrophulous affections of the Breast. They are
not attended with pain & are greatly accompanied with Glandular swellings in other parts
of the body by which circumstance they may commonly be distinguished. They will yield under
the common remedies for Scrophula. They only require Medical attention
There is a disease which arises from an obstruction of some of the Lactiferous tubes near the
termination at the Nipple. It becomes occasionally very large is not painfull but inconvenient
from distention it has a distinct fluctuation. When opened by a Lancet a large
quantity of milk only is discharged. This is to be kept open & the milk will continue to 
flow from it for a great length of time on account of the obstruction in the Tube near its
termination in the nipple.
The male as well as the Female subject is liable to cancer of the Breast. It begins in the nipple with a
hardness a crust forms over this then Ulceration takes place & it becomes thrown off & a second crust forms
& ulcerates & then the disease extends. It affects in its progress the Glands in the Axilla & destroys as in
the Female. I have seen 3 cases of it & operated twice but without success. It is a fatal disease. I found
that in one of the cases an application of Chalk zi & opuim Zss gave great ease to the part & produced
& improved the appearance of it. The administration of Belladonna also affords much relief &
I found that this medicine occasions a dilatation of the pupil equally when applied to the external
ulcerated surface as when it was taken inwardly I consider this as a very curious circumstance
Irritable Swelling of the Breast
Young women are very subject frequently to an Irritable Tumour of the Breast. It occurs mostly
between the ages of 19 & 25. They are often subject about this time of life to slight swellings of the
Lobes of the Breast. It has no circumscribed vary. It seems to be rather an irritable Inflammation
of the Glandular substance of the Breast than a distinct swelling. It posseses hardship however
you distinguish it by its excessive tenderness. When you touch it with the finger the patient shrinks
back like a sensitive plant & cries. "Oh Sir you hurt me." She cannot bear even the pressure
of the clothes. This would remain for months & even years with different degrees of action.
Sometimes very painfull at others scarcely to be felt. They not only feel the pain at the 



180
at the time you are pressing on it but it continues all day & extends down the cutaneous nerves
of the arm. When you compare the pain with the appearance of the disease you are hardly able to 
account for it. In general it seems to be connected with diseased uterine functions. It is connected
with a state of Menstruation which is sometimes sparing at others profuse. You find it
occuring most frequently in delicate females who have strong passing & indulge lascivious ideas 
you can hardly touch them any where but you produce motion. You often find them extremely
pale from Irritability & want of rest. This disease never goes on to Carcinoma & does not require
any operation. The application of Leeches is extremely usefull. Ferri Ammoniac grvij
with Rhubarb should be given twice a day as an aperient. I commonly prescribe Bark with
small doses of Calomel & Hemlock at the same time about gi to iij. Both should be taken
the same day the pills late & early & the powders at little intervals between them
I have found that the application of an ointment composed of Celacii zi to Pulv Camph zi Constantly
worn affords considerable relief. Oiled Silk worn over the Breast is very usefull it seems to
keep up a Continual Perspiration from it. They require rather a generous diet but not a stimulating
one. You must deprive them of animal food for it is that they are in search of Matrimony
is an Infallible cure especially when it produces a pregnant state of the Uterus.
The Mode of Securing Arteries
When the Posterior or Anterior Tibial Arteries are wounded near the foot or on it it is necessary to
to tie them at that part. If an Aneurism is seated on the Tibial Artery on the foot it is necessary
to cut down upon the vessel & tie it above & below the Aneurismal Bag. The Posterior Tibial Artery
lies behind the Malleolus Internus. It is accompanied by the nerve. The direction of your
Incision should be about 3/4 of an Inch behind the Inner Ankle. The Anterior Tibial Artery is placed
on the upper part of the foot & is readily found by cutting between the Ext. Bre: Pol: Pedis & the Ex:
Brevis: Diy: Ped. It is resting on the root of the Metatarsal Bone supporting the great toe &
dips down between this & the next Metatarsal Bone. When the Post: Tibial is wounded under the
Calf of the Leg it is very difficult to secure it at that place. A Gentleman fell on a piece



181
of Iron. It went into the calf of the Leg between the two bones & produced great haemmorhage. The dresser
applied a Tournaquet & the bleeding ceased A few days afterwards the haemmorhage returned & I tied
the Femoral Artery. For a few days it commanded the bleeding but when the circulation had got thro'
the small vessels again it returned & the man died. To find the Posterior Tibial Artery you cut between
the Gastrocnemius & Bone & the direction there is between the Gastrocnemius & Tibialis Anticus. You
must seperate the former freely from the bone. The nerve is most deeply situated in this position
When the Anterior Tibial Artery is wounded in the upper part of the Leg you make a cut thro' the
Tibialis Anticus & tracing it to its outer edge you seperate it from the other muscles. Then situated
between the Tibialis Anticus & Ext: Sory: Pol: Ped you find the artery. In this you have a nerve
of no considerable size to contend with. I know of no example of the Interopeal Artery being
wounded. If it should be a portion of the Fibula might be removed in order to get access to it=
Operation for tying the Femoral Artery. When about to perform this operation either for an Aneurism
or wound you should make these inquiries: For what Aneurisms &c will this operation be
successfull? For aneurisms in the Ham & upper part of the Anterior & Post Tibial Arteries
Mr Lucas has tied it once for aneurism in the upper part of the Anter Tibial. I have twice
for aneurism of the upper part of the Post Tibial all of which did well. I could not depend
upon it when situated lower down. The place at which it is best to tie it Mr Hunter thought was
in the middle of the Thigh but it is not the best & the reason why is because the Artery is situated
at a greater depth & then gives off a number of branches (Anastomosis). One third of the length 
of the Thigh downward from the Ant: Sup. Spon: process of the Ilium is the place & the inner side
of the Sartorius the direction for your Incision. The length of it should be 4 inches. Draw the Sartorius
muscle to the outer side & then touching the cellular membrane on its inner edge you see
the sheath in which the artery lies. The next step is to open the sheath by a little cut opposite to
the edge of the Artery. The Artery is seperated from the vein by a process of the sheath going down
between them. When you have opened the sheath you readily pass the directon under the Artery
you seperate it to the extent of 3/4 of an inch & then carry under it the Aneurismal needle armed
with a double ligature made of Dutch [Turni?]. Then the upper ligature is to be secured afterward



182
the lower one. When thus applied the aneurismal needle is to be a little elevated & pointing a probe
pointed Bistoury under the Artery you divide it. Then the wound is to be closed by adhesive plaister If 
called to a case of aneurism high up it is a great deal better to tie the external Iliac than the Femoral
Artery below Pouparts ligament. The reason of giving the preference is from the number of nerves &
vessels that you are liable to cut through in attempting to secure the Femoral Artery just below Pouparts
ligament
In taking up the External Iliac Artery an incision should be made beginning just above the abdominal
Ring & carrying it within an Inch of the Cresta Iliaca the inner side. This lays bare the tendon of the
External oblique. You must divide this Tendon & lay bare the lowered of the Internal oblique & the
Transveralis. there the operation of the knife ends. Then you look for the opening for the passage of the
chord & immediately behind is the artery. You put the Aneurismal needle thro' the ring & get hold of
the artery. The vein is on the inner side the nerve 3/4 of an inch to its outer side not included in
the same shealth. Two ligatures are then to be passed round it & the artery is to be divided between them.
Of Wounds and Aneurisms of the Arteries of the Head
In wound of the occipital Temporal & Parietal Arteries it is required to divide the artery & make
pressure above & below & a dopil of Lint is to be placed over the wound. When you are connected
about an Aneurism formed by an Artery being incompletely undivided you make an Incision across
the Bag & then make pressure above & below. If you find that the pressure is insufficient then
you make a ligature both above & below. With regard to wounds of the Carotid or aneurisms
of this vessel the best place to take it up is when the Omo Hyodeus Crosses this artery. But
with regard to wounds you are obliged to place the Ligature when the wound requires. In the
first situation you draw the knife across the skin at the inner edge of the Sterno Mastoid Muscle
& then seperate its inner border from the outer Muscles & immediately you see the Omo Hyodeus
crossing the artery obliquely. With regard to the Jugular vein there is a difference which 
must be attended to. During Inspiration it becomes flaccid & during Expiration It is filled with
Blood so that if you are not very cautious you are in continual danger of wounding it avoid
the Par Vagum. Under the artery you carry the aneurismal needle armed a double ligament



183
& secure first the one which is nearest the Heart. Having secured both you divide the Artery
with a probe pointed Bistoury. When an Aneurism is situated in the Carotid Artery it generally
occurs at its bifurcation
The Ligature on the Subclavian Artery. This has not been done successfully in this Country
above the Clavicle but Dr Post in New York has tied it in that situation with success. Below
the Clavicle it has been done & the patients have recovered. The first was by Mr Keate. The operation
of tying the subclavian Artery above the Clavicle is one which requires a considerable share of
knowledge to perform it well & it requires that the shoulder should not be raised. Opposite to the
middle of the Clavicle the artery is situated. In performing this operation it is necessary to avoid
the External Irregular. [XX] It is situated over that part of the Artery where you wish to
apply the ligature & it is better to detatch it & let it be held aside by an assistant. This vein 
being turned aside then you dissect down for the Artery & in doing this the first parts which
make their appearance are the different branches of the Axillary plexus. The upper 3d branch
of the Axillary plexus covers the Subclavian Artery & if you are not much on your guard in seperating
them you will by including both increase the destruction of the patients life. You are obliged
therefore to draw it aside in order to get at the artery. The Axillary plexus then becomes the guide
by which you discover the vessel. This I think is the most difficult of all operations on the arteries=
Wounds of the Brachial Artery at the Elbow Joint. The place at which the
Brachial Artery should be secured is on the inner side of the Biceps Muscle half way down the
Arm. Here you first find the Median Nerve a little to the inner side you see the Brachical Artery
& vein. There is no operation so easily performed. It is required for aneurism of the Elbow & upper
part of the Fore Arm. But when called to an aneurism of wound of the arteries just above the wrist you
must cut down to the part & secure the Artery above & below. You will find the Ulnar Artery
situated directly on the Inner side of the Flex: Carp: reln tendon the nerve is close to the tendon
the artery more towards the Centre of the Fore Arm. With respect to the Radial artery you will
find it directly on the outer side of the Flexor Carpi Radialis. An Aneurism can be formed
as the Radial Artery by regurgitation alone. My Predecessor in operating at the other Hospital



184
found no haemmorhage & from the upper part of the Artery for it was closed & he only tied the lower
portion. When the Artery is divided in the arch make a longitudinal Incision & then drawing the
Integuments aside you see the vessel. If you make a transverse cut you will injure some of the
nerves. If you find the haemmorhage returning it is best to apply pressure at the wrist on both
the Radial & Ulnar Arteries without attempting to secure them
A.M.P.U.T.A.T.I.O.N.S.
The operation of amputating the fingers & toes is performed on two of the Joints in the same manner.
These 2 joints are the 2d or 3d & are performed to the following way. You first make a circular
incision below the Joint then you make an incision at each side & turn back the flap about
below. Then inclines the finger a little to one side you just touch one of the lateral ligaments with 
the edge of the knife & immediately the bone turns from the socket. It is not generally necessary
to apply a ligature merely press for a while untill the haemmorhage ceases & then apply your strips
of Adhesive Plaister. No other dressings are required. After the amputation of the Joint if you
dissect the stump you will not find any adhesion between the Cartilage & Integuments but a
quantity of Synovia is secreted by the membrane covering the former. Hence the necessity of saving
sufficient skin to cover the extremities of the bone. In amputating at the first joint of the fingers 
or toes you make 2 oblique cuts one at each side which meet at an angle. Then you divide the
Tendons & the knife is readily introduced and the Joint seperated. It is much better to amputate
at the 1st Joint than to amputate at the second for disease of the third.
Operation for Amputating the Foot. There is a Joint between the astragalus & the os naviculare
on the inner side & the os Cuboids & the os Calcis on the outer side where you may seperate
the foot. This operation was first performed by Mons Chaupart & is done by making a circular
incision thro' the centre of the foot then a longitudinal cut is to be made on the extent & another
on the inner side. Dissect back the flaps the Tendons are then to be divided & on bearing
down on the foot a little you see the extremities of the Astragalus & os Calcis & here you seperate the
joint. The parts are then to be brought together. This produces a good stump. This operation 
is founded on the principles of adhesion & Mons Chaupart was sometime in England when



185
he learned these principles. The flap operation in the middle of the Leg has been of late a great
deal reccommended & has been performed in order to allow the use of the patient Legs which have been
invented. You thrust the Catlin behind the Tibia & Fibula & cut out leaving a flap of sufficient
extent to cover the end of the stump then make a semicircular incision at the angles formed
by the flap. The rest of the operation is like the other. But this operation does not do well. I do
not speak as it respects the Country but the city where people are breathing an impure atmosphere.
The objections to it are first the flap is very apt to slough 2d if haemmorhage takes
place when the ligatures are about to come away it is very difficult to secure them 3d When exfoliation
takes place they are confined. 4th the muscles being left contract & continuing to contract
they bare the ends of the bones. The stump is disposed to heal at first but afterwards the lips
of the wound are drawn asunder by the contraction of the muscle. The operation is rather getting 
out of practice.
Of Amputation below the Knee at the Common Situation. The Tournaquet is to be applied 
The place of making your incision is as it regards the Integuments 6 inches below the point of
the patella & 4 inches from the bone. This is the general rule but it must vary according to the
accident. If a strong man with a large Gastrocnemius muscle receives an accident requiring 
amputation the skin must be divided 3 inches lower than the Bone but as for a man
who has been long labouring under the disease the proportions are as above. Do not attempt
to save muscles because their contractions will save the stump from healing & render it conical
When you are performing the operation of amputation do not grasp the knife in your
fist as if you was afraid it would fall out of your hand but hold it lightly between 
the finger & Thumb. Put the hand just below the Patella & where the little finger reaches
there you are to saw thro the Bone then take 2 ins more for Integuments. Make a circular
Incision & dissect up the skin an assistant drawing it back at the same time
Then make an Incision thro the muscles & pass the Catlin [thro] between the bones. then saw off 
the bone you have to secure the Anterior & Posterior Tibial Arteries & the Interopeal=
In bringing the parts together you must bring the ligatures as much as possible in a line 





186
with the Cicatrix for if your ligatures are under the flap a considerable distance sinuses will
form around them. The Cicatrix also should be perpendicular in order to allow the matter to
escape. Then put on Adhesive Plaister 3 or 4 strips across the stump & 2 circular ones to confine
these. That is all the dressing necessary.
Amputation of the Leg above the Knee. When you are about to perform the operation in
this place for disease of the Knee Joint take care that you do not make gown incision too
near the Joint for it is apt to be diseased above & if so sinuses will form. It should be above 
the Tendon of the Sacculus which is situated under the Rectus. The operation consists of 3
circular Incisions & sawing off the bone. The first incision is thro' the Integuments. They
adhere considerably to the Tendons of the Rectus Adducton Magnus & rartus. Draw back the
Integuments 2 inches. Then your 2d Incision is to be made thro' the muscles & after
this it is necessary to cut thro' the muscles which are near the bone 1 or 2 inches higher on
this depends a good stump. Then saw off the bone. The Arteries to be tied are the Femoral
an artery found nearly in the Centre of the Sciatic Nerve & a number of Muscular branches.
Amputation at the Hip Joint. The Femoral Artery may be compressed in
the first instance & as soon as cut may be tied. If a person has not sufficient command
over himself he may cut down on the Artery & secure it at once as it passes under Pouparts
Ligament. Make a flap of the Integuments on each side & in so doing you may avoid the
artery during the operation. Then you may make a cut thro' the Integuments which lie
over the Femorial Artery & then stop to secure it. In order to find the head of the bone
you cut just below Pouparts Ligament & having divided the Capsule of the Joint you turn
out the head of the bone & then divide the Ligamentum Teres. I prefer this more on
account of the matter making its escape more readily (from the Cicatric being perpendicular)
at the lower part. The Schiatic artery is the principle one to be tied.
Amputation at the Wrist Joint This is not unfrequently necessary from the bursting
of a gun by which some portion of the hand is carried away. The operation is began
at the coat of the Thumb then the integuments are to be drawn back as far as



187
Styloid process. This being laid bare is the direction for opening into the Joint. Divide the
ligament & you easily turn out the Joint. The Integuments should be long for no adhesion
takes place between them & the Cartilage. The arteries to be tied are the Radial & Ulnar
In amputating the Fore Arm cut thro' the muscular not the Tendinous for the Tendons
will slough. Sinuses will form & extend considerably up the arm so will matter. I have
known 2 persons die from this operation. One from Sinuses the other from sloughing. The
operation higher up is very like the other below the Knee. The place then to amputate is where
the muscles have not began to form Tendons. 2 Inches of Integuments are sufficient to
cover the bone & except the operation is performed for accident happening in a strong healthy
man. The Amputation of the arm is similar to that of the Thigh. The muscles near
the bone should be divided 1 inch higher than those which are external
Amputation at the Shoulder Joint. This is one which succeeds extremely well. It
is sometimes reccommended to secure the axillary artery first but all that is necessary is
to allow an assistant to compress it
The best mode of performing this operation is by making a simple flap of the Deltoid
muscle carrying the incision so far as to expose the head of the os Humeri. Then
make a cut into the Joint &c. In one case in which I operated I cut off the Cartilage
& in others not & I think if sufficient Integuments are saved the stump heals
as well as in one case as another
The End of the Second Volume Coopers Notes
May 23d 1822.



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Index.

Scrofulous inflammation of Points 1.
Treatments of scrofulous Points   5.    Noevi materni                 78    
On diseased hip                   9.    Noli me tangere               80
Disease of the spine             15.    Diseases of the bones         82
Of Psods & Lumbar Absess         21.    Fracture of the bones         88
Strumous pimples of the face     24     "  "  "  Fibula               93
Lippitudo                        24     "  "  "  Tibia                94
Rickets                          25     "  "  "  Femoris              96
On Wounds                        29     "  "  "  Clavicle             98
Lacerated Wounds                 37     "  "  "  Upper Extremities    98
Coutured "                       38     "  "  "  Patella             100
Punctured "                      38     "  "  "  Neck of Femoris     102
Trismus                          43     "  "  "  Compound            103
Wounded arteries                 43     "  "  "  Ununited            110
Wounds of the veins              50     "  "  "  Necrosis            111
"  "  "  nerves                  51     Mollities Ossium             113
"  "  "  tendons                 52     Hydatids in bones            114
"  "  "  joints                  55     Anchylosis                   114 
"  "  "  abdomen                 56     Exostosis                    117
"  "  "  throat                  58     Polypi                       120
"  "  "  Chest                   60     Hare Lip                     122  
"  "  "  pericardium             61     Cancered Life                125
"  "  "  heart                   62     Diseases of the Testicle     126
"  "  "  Absorbents              62     Scirrhous Testicle           127
Burns & Scalds                   64     Fungoid Testicle             128
Carbuncle                        67     Chronic enlargment and }
Tumours                          68     Abscess of the Testicle}     130
"        Encysted                70     Calculi of urinary passages  133
"        Glandular               71     Med: Treatment of stone}
Fungus Haemotodes                73     in bladder             }     141
Hydatid Tumors                   75     Lithotomy                    147
Cutaneous "                      77     Stones in Prostate Gland     150
Watery "                         77     Stone in Urethra             150

189

Female Lithotomy           151
Bronchotomy                156
Fistula Lachrymalis        161
Enlarged Tonsils           163
Ganglious                  164
Dropsy                     166
Diseases of breast         172
Fungoid disase of breast   177
Irritable swelling of do   179
Mode of securing arteries  180
Wounds and aneurisms   }
of arteries of the head}   182
Amputation                 184

















Scrofulous Inflammation of Joints - page 1
Diseased Hips                            11
Disease of the Spine                     15
Psods & Lumbur Abscess                   21
Strumous pimples on the Face             24
Lippitudo                                 "
Fungoid disease of the Testicle           "
Rickets                                  25
On Wounds                                29
Lacerated wounds                         37
Cousured or                              38
Trismus                                  43
Wounded Arteries                          "
Wounds of the veins                      50
"  of the Nerves                         51
"  of the Tendons                        52
"  of the Joints                         55
"  of the Abdomen                        56





Med. Hist.
MS.
B
67