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Cis X'-X
ARMY MEDICAL LIBRARY
FOUNDED 1836
WASHINGTON, D.C 
 
 
A
SYSTEM
OF
OPERATIVE SURGERY,
FOUNDED ON
THE BASIS OFAXATOMT.
volume n.
BY CHARLES BELL.
FIRST AMERICAN EDITIO.Y
   HERTFORD :


PRINTED BY HALE & HOSMER

I■  I
  »

"&• 
i 
TO THE READER.
       Many of the members of our profession are accustom-
 ed to draw a distinction betwixt the knowledge obtained in
 classes or  dissecting-rooms, and that practical  know ledge
 which they have gained by experience; and they seem will-
 ing to extend  this distinction in favour of themselves, by
 maintaining the superiority of practice over theory.
   There  may be a defective system of education which gives
 too much importance to theory, but certainly the ignorance
 of what  has been done by men of the  first genius in  this
 way, does not make the surgeon more an observer or a disci-
 ple of nature.   Ignorance or weakness is as prone to theory
 as to superstition, and  it requires a mind of a higher cast,
 strengthened by education, to subdue the natural inclination
 to generalize on a few limited facts.
   In conversing with  medical  men,  the most  remote from
 the Universities and practical schools of anatomy and surge-
 ry, I  have found  them indulging  in the most fanciful and
 wild theories.   No one ought to be more ready than myself
 to acknowledge the benefit he has derived from the conver-
 sation of practical men; at  all times impressed with the im-
 portance  of their information,  I  have cultivated their  ac-
 quaintance  with a view to improvement; but even these ve-
ry men, whose chief value  consists in the number  of facts
which they can attest  from their  actual observation, have
always ready a theoretical interpretation which obscures the 
IV
10 THE READER.
truth.   It is not easy for a man altogether to divest him-
self of this disposition, nor is it to be wished that he should;
for then his lively interest  in the profession would abate;
but it is a propensity that requires to be chastened by edu-
cation,  and by  acquaintance with  the errors which have
been committed in theoretical reasoning.
   In  what I have now 6aid, the persons to  whom I allude
arc those  who, indifferent to what is doing in the profession
at large,  over-rate their own resources, and are not fully
sensible how little  any individual can do  in improving the
general practice of medicine or surgery.   Men who assume
the merit of having learned  all they profess from  practice,
and who would raise a distinction  betwixt  principle and ob-
servation, are not aware of the extent of their admission.
They confess  themselves to have  entered  on the profession
but poorly prepared;  which is a great offence, since  they
must long have groped their way in the dark, doing mis-
chief before they have learned to do good.   They want the
only secure  foundation of experience, acquaintance with the
structure of the  body ; and, by entering  on a high and re-
sponsible  duty,  with  a thoughtless boldness,  they render
even their very testimony suspicious.
   Ever since  I became aware of the true means of improve-
ment, it has been my study  to  seek the  conversation of  the
elder members of  the profession.  In this search I may con-
fidently say, that I  have found their conversation pregnant
with information, and their  practice safe as well as bold, in
the proportion  of their acquaintance with anatomy.  The
best  surgeons are, for the most part, the best men in a more
extended sense;  for humanity of disposition does not merely
insure  careful study before  the duties of the profession  are
undertaken, but  stirs on  to active and  virtuous  exertions
through a whole life.
   So far, therefore, from desiring to put myself in opposition
to men of observation and experience, during the writing of
these volume?, I have held myself as in their presence, and
 j confidently hope that they will receive this book favour 
TO TUE READER.
V
ably, if I shall be found to have laid the ground-work secure-
ly.    I propose to  form a System of Operative Surgery,
founded on Anatomy;  and between the title of the book
and the execution I hope there is  a  due connexion: for, if
it be only in the title and  preface that I have made  use of
anatomy, I have done nothing more than what has been
done by all writers of systems.
   As I  have built  my  expectation of being  useful on the
union of the studies  of anatomy and surgery ; and as I eve-
ry day see reason to believe that the neglect of surgical ana-
tomy  is still  a common defect of education;  I have felt
myself as called  upon at all  hazards  to prove the necessity
of this union.  It will  not  be denied, that there  are enter-
ing on the practice of the profession crowds of students who
are ill provided with a knowledge of surgical anatomy ; and
there are many in practice who seem never to have acknow-
ledged anatomy to be a science from which  the principles
and  the rules of practice are to be deduced.  In short,  I
cannot help concluding, that though the higher departments
of surgery are successfully cultivated  by a few, there is not
yet  a proportionate  diffusion of knowledge.   Men  of the
first eminence have sought to obtain that rank by exerting
the  strength of their talents  upon particular subjects; and
who is there  that can  regret this ?  But still I think I am
borne out in saying, that the general subject has been  in con-
sequence more remissly cultivated.
   It  has been my  endeavour, throughout  this work, to re-
claim my reader from a loose  method of considering the sub-
ject ; to carry  him back to the study  of anatomy; to make
hiin have recourse to the principles, nay, the very elements of
the  science.   I acknowledge that in the dissecting-room the
student learns the elements only ;  that to let loose upon the
world a young surgeon, whose education has been confined to
dissection, is  like arming a man bereft of reason.  He is ac-
customed to  use the knife ; and desirous of doing it on all
occasions;  dexterous, perhaps, he  may  be, but  he has not
Etudicd the structure farther than it has reference to the dea,d 
yi
TO THE READER.
 body ; while the acknowledged use of anatomy has reference
 to the living body.   He can perform operations, but does not
 know the fit occasions for them ; nor how much the powers of
 life will bear ; nor how the  constitution varies, and disease
 affects the natural powers of life.
   Having acknowledged thus  much, I take  this position in
 favour of anatomy, that there is no doing without it;  no ad-
 vancing in  safety  one step,  either in  study or in practice,
 without its  guidance.  The ignorance of it makes a surgeon
 shy and deceitful; and what a commentary might be written
 on these two  words !   I am in hopes that, when  my reader
 peruses the chapters in  this volume, which treat of  Fractured
 Bones,  of Dislocations, and of Wounded Arteries,  he will
 think, that, although it be  possible to cull from dissertations
 on the diseases which fall under the care ftf the surgeon, and
 from the lectures of eminent men, what might form a book
 having more of the external character of a system than these
 volumes ; it is impossible to enter on the discussion, to go to
 the depth of the subject for the principle of practice, without
 a continual reference to the structure ;  and that by keeping
 the anatomy continually in  view, the rule of practice comes
 out more  correctly, with more simplicity and force.  It is in
 this  sense  that I have  ventured to  call the  present work a
 System ; for I hold a  system to be distinguished more by the
governing principle than by the apparent order of  enumera-
tion.
   I have to regret, that in the very first part of this volume
I  have not been able  to  speak  decidedly, as to the rule of
praefaee  I allude to the operation of bronchotomy.   I have
not performed the operation , and  surgeons  witk whom  I
have conversed upon this, subject, have not, in my ODJon
taken  the whole circumstances into con^de atiom iToT 
TO THE READER.
vii
however, that I have explained the action of the throat and
glottis, and the accidents in practice, so as to  prevent the re-
currence of some errors which have come to  my knowledge.
One thing I cannot avoid mentioning : when  the patient has
struggled  for  some time with the spasmodic  difficulty of
breathing, the face is swelled, and of a leaden colour ;  an ap-
oplectic insensibility follows ; when you raise him up, the
head falls upon the shoulder; he now breathes with less diffi-
culty in the throat, but if the operation be performed  it will
be too late ; formic difficulty of breathing through the larynx
has ceased in  c6n?equence of the general debility having re-
solved the  spasm.   This debility of the muscular  fibre and
insensibility, has resulted from the effusion  having taken place
in the lungs.
   What I  have said on the subject of the artificial pupil I
wish my reader to consider as a suggestion hitherto unground-
ed on the observation of the human eye.
   I have considered fractures and dislocations as forming the
principle matter of the volume ; and before treating of them,
I  have thrown the subjects of abscess, and of disease of the
spine and of the great joints, into short dissertations, as form-
ing the best introductions to the surgery of the bones ;  a sub-
ject so important to  the practical and military surgeon.  By
the liberality of my friends, and increasing opportunities of
observation, even since these sheets have been printed, I have
had cases and dissections which would more fully have illus-
trated some part of this subject; but I am happy to say, that
no circumstances have occurred,  which in any degree, leave
me to regret what I have said under this head.
   I hope the manner in which I have set forth the anatomy
of the  arteries will be acknowledged to  be  useful.   For I
have found students  satisfied w ith repeating Murray's  tables
of the arteries, and by that test estimating their knowledge of
this important and difficult subject.
   I have laboured to discountenance this idea, and to convince
them that there is  a  minute  knowledge of the  arteries  to
which they have little turned their thoughts.  It is not yel 
vlii
10 THE READER.
four-and-twcnty hours since I have seen a remarkable exam-
ple of the effects of inattention to the exact seat of arteries, as
they bear reference to the superficial  parts, to the nerves and
tendons.
  To the military surgeon,  the  book would  have been quite
incomplete without  this last  addition of  Lessons  on the
Arteries.

    losuox,
           10 & 11, Leicester Street,
                       Leicestet Square. 
CONTENTS
OF
                       VOLUME II.




                         CHAPTER I.

                OF OPERATIONS ON THE THROAT.

Suffocation from Bodies sticking in the (Esophagus, or entering
    the Trachea         ....    Page 1
Of the Probang         ....        a
Of extracting Bodies from the QZsophagus         -                4
Of Ulceration of the Glottis          ...         5
Of Bronchotomy          -         -         -         -       6
Of Bodies lodging in the Larynx      -  •         •             10
Of Stricture in the ffisophagus          -          -          -     12
Use of the Flexible Tube                                       13
Of Wounds in the Throat          -          -         -         16

                 OPERATIONS IN THE MOUTH.

Of Ranula        -        -        -       •                  17
Of the Salivary Fistula       ....        19
Of the division the Frxnum Lingua        -                       20
Ulcer and Tumour on the Tongue                               21
Operation  on the Amygdalae        -       -                   22
Of the Uvula        -       ....        23
Cancer  of the Lip                                         ib.
Of  the  Hare  Lip       ....          27
Abscess in the Frontal, or Maxillary Sinus                       38
Perforating the Maxillary Sinus from the Alveoli        -            30
Wry Neck        .....         31

                 of operations on the eye.

Of the Cataract    -                                *     33
Of Couching, or Depressing the  Cataract       *       -      »  35
  VOL. IT.                    A 
CONTENTS.
                                                          Page
Of the Extraction of the Cataract       -       -        '        41
Of Inflammation of the Eye, and Treatment after Operation      -     52
Relaxation of the Eyelid        ...       -       55
Eversion of the  r.yeiid, (Ectropion)        -       -        -    56
Of the Inverted Eyelid         -        »        .   •     -        ib.
Of Tumours of the Eyelids        •       •        •       -    58
Encanthis        •        •       -       •        -        -  60
Of thePterygion       •       •        -        -       •     61
Opacity of the Cornea        ....        62
Application of Caustic to the Cornea        •        -        -    63
Of Uie Staphyloma        •       -        -        -       -   64
Operation        -        •       -        -        -       -   65
Protrusion of the Iria       «        •        •                 66
Dropsy of the Eye        -       -        -                    67
Of the Artificial Pupil        ....        68
Extirpation of the Eye                                         70
Operations for the Fistula .Lachrymalis        -        72

                         CHAPTER II.
Diseases of the Ear                                       78

                         CHAPTER m.
Of the Psoas Abscess       ■        •                .        82

                         CHAPTER IV.

                   Diseases of the spine.
Of the Curved Spine        ....          88
Comparison betwixt the Skull and Spine       -        -       -    92
Of Fracture of the Spine                 ...       93
Of the Dislocation of the Vertebrae        -        -        •       96

                         CHAPTER V.
Diseases of the Hip Joint        ...         99

                         CHAPTER VI.
Diseases of the Knee Joint        -       «        .       jo2
Of Collections in the Bursas       .        .       .        „    10w
Loose Cartilage* in th« Knee Joint        .        •        -       108

                         CHAPTER VD.
                         OF FRACTURES.
Kstinetiona relativo ta Fractured Bones    -            '      -    110 
CONTENTS.
si
                                                             Page
How to Examine a Fracture      -      •      »      -            112
To distinguish Fracture from Dislocation      -        -             ib.
General Treatment of Fracture        -       ...      114
Fracture of the Clavicle        -        -        -        -       124
Fracture of the Acromion Process of tlie Scapula       -      -      125
Fracture of the Body of the Scapula      -      •      »      -     1~T
Fracture of the Humerus    ......   128
Fracture of tlie Olecranon      -      •      •      -      -      129
Fracture of die Radius        ....        130
Fracture of tlie Bones of the Hand and Fingers    -      •      -    lc'2
Fracture of the Thigh Bone       -        -        •         -     ib.
Fracture oftiie Shaft or Cylindrical Part of the Bone     -      -    133
Fracture of the External Condyle of the Thigh Bone     -      -      13?
Fracture of the N\ck of tlie Thigh Bone      ...     138
Of the Fractured Patella                                         142
Fracture of the Fibula         ....        146
Oi the Fracture of the Tibia      .....     147
Of the Period of Confinement      ....      149
Of Fractures of the Ribs, Sternum, and Pelvis    ...     150
Of a Fractured Rib     -        -        -        -        -      ib.
Fracture of the Sternum       .....       134
Fracture of the Bones of tlie Face        -        -        -   .   155
Fracture of the Bones of the Xos'e      ....      158

                         CHAPTER VHI.
                         OF DISLOCATION.
Of Dislocation      -      -       -       -       -       -       159
Dislocation of the Clavicle      -        -        -'        -       165
Dislocation of the Head of the Humerus      -      -     167
Of tlie Reduction in Simple Cases        -        -        -       1 ~Q
Accidental Reduction of the Humerus        -       -       -       172
Reduction Impeded by the Muscles      ....     173
Position of the Humerus necessary to Dislocation     -        .      174
Position of tlie Humerus when Dislocated       ...      175
Dislocation of the Elbow         ...        130
Subluxation of tlie Elbow Joint    .....     i«i
Dislocation of the Head of die Radius at the Llbow Joint       .       182
Dislocation of the Wrist                                           ib.
Dislocation of the Bones of the Hand      •      •      -       .183
Dislocation of the Thumb and Fingers    .  -        -         -       ib.
Dislocation of the lower Jaw     • j            -      -     186
Dislocation of the Os Hyoides      ....     137
Dislocation of the Rib from its Cartilage       ...       188
Dislocation of the Bones of tlw PJv«         .         .        .     ib. 
xii
CONTENTS.
                                                            Page
 Dislocation of tlie Os Coccygis    -      -      •      -      •    190
 Dislocation of the Hip Joint       -        -        -             ib,
 Dislocation of the Thigh Bone    ....    19$
 Sprain and Dislocation of the Knee Joint     ...     198
 Dislocation of the Ancle Joint       *      -             201

                         CHAPTER IX.

                          of tumours.

 OfTumours        ....        -        204
 Opinions regarding the Nature and Fprn.ation of Tumours     -     208
 Classification of Tumours      ....       215
 Treatment of Tumours      ......  223
 Operations to be performed on them      •       -       226

                         CHAPTER X.

                    OF WOUNDED ARTERIES.

 Of Wounded Arteries     -      -      -      -      *      •      238
 Classification of Arteries in the Order of their Importance when wounded 239
 Of the Difference of an Artery opened by Gun-Shot, by Splinters, and
    by a Knife, with Cases       ....     243
 Of the Scat of the Vital Parts in the Thorax                         257
 Description of the manner of cutting to take up the
    Arteries       .....     259
To Cut for the Carotid Artery     -----    ib.
To Cut for the External Carotid Artery       ...   260
Of the Thyroid Arteries       -----      ib.
To Find the Lingual Artery      ....      261
Of the Exact Place of the Occipital Artery      ...      ib.
To Find the Subclavian Artery      -        -        -        -    ib.
The Lower Part of the Axillary Artery, or Beginning of the Hume-
    ral Artery.....-      .    262
The Humeral Artery lower in tlie Arm        -  '      -       .    263
The Radial Artery      .      .            .             -      ib
 The Ulnar Artery        -                                      264
To Take up the Femoral Artery low in the Thigh      .       -      ib.
To Find the Gluteal Artery       .                              -v
The Ischiatic Artery      -                                     „g_
To Cut for the Anteripr Tibial Artery, high in the Fore part of the Leg  ib.
To Cut for the Anterior Tibial Artery, lower in the Leg               266
To Cut for the Fibular Artery     -                              ..
 To Cut for the Posterior Tibial Artery       .                       "
                         ~    .     ~                  -     ib.
 APPENDIX, containing some Remarks on Gun-Shot-Fractures        <7g« 
 
Plate J.
FIG. i.
 
  EXPLANATION

           OF

THE  PLATES.
                              PLATE I.

     V igure 1.  This figure represents the lower head of the femur, with
 tlie capsule of tlie knee joint; the bone is suspended by the capsule; the arti-
 culating cartilage is destroyed, and tlie face of die bone ulcerated, in conse-
 quence of white swelling of the knee joint ; the capsular ligament is in part
 destroyed by ulceration.
   A, The face of the bone, rough and carious.
   BBB, Small portions of the articulating cartilage remaining,  the rest
 being destroyed by ulceration.
   C, Part of tlie capsule suspended.
   D, Ulcerated holes in the capsule, by which sinuses running round the
 bones in the outside communicated with the cavity of the knee joint.

   Fi g. 2. This represents tlie thigh bone, with the head fixed and anchylos-
 ed in the acetabulum ischii.  It is one of tiiose cases of diseased hipjoint,
 where the inflammation subsided in consequence of the granulation and ex-
 ostosis of the bone interrupting tlie motions of the joint.
   A, Dorsum of the ilium.
   B, Tuberosity of the ischium.
   C, Femur.
   D, The neck of the femur.
   E, The margin  of the acetabulum.  It may be observed, that the margin
 of the acetabulum is contracted and eked  out, so as to enclose the  head
 of the femur ; and even in the macerated state of the bones, though they are
 loose, they will not separate.
   F, The lesser trochanter, which has approached the  pelvis so closely,
whilst a granulation, has formed upon the pelvis, that the two surfaces meet-
ing have formed a connexion,-by means of a ligament which checks the mo-
tion of the thigh. 
XIV
EXPLANATION
                             PLATE II.

   Fig. 1. This represents the os innominatum and thigh bone destroyed by
 tlie hip disease.  There had taken place an absorption of the bottom of the
 acetabulum, as well as of the head of tlie thigh bone ;  so that here the neck of
 tlie thigh bone is represented as projecting into the pelvis.  Here no anchy-
losis took place, and  tlie motion of the thigh bone in this  unnatural position
 continued tlie inflammation so as at last to exhaust the patient by hectic.
   A, The os innominatum.
   B, The os pubis.
   C, The thigh bone.
   D, Tlie head, or rather only the neck, of the thigh bone, projecting into
 tlie cavity of the pelvis.

   Fig. 2. In this figure  is represented the caries of the vertebrae, which pre-
cedes their yielding,to the  pressure of the upper part of  the trunk, and the
confirmed disease described under the term curvature of  the spine.

                             PLATE  III.

  In tliis  plate is represented the section of a part of the  thigh bone, in the
progress  of union after fracture.
  A, The upper portion  of the thigh bone.
  B, The lower portion of the thigh bone.
  C, An intermediate portion of the bone, which is in a manner isolated.
  D D, A tough substance,  by which the bones are united,  before the new
bone is deposited.  We  may call  this the callus, being a tough bed, into
which the bony  matter is afterwards secreted.
  E E, The periosteum much thickened.
  F F, The bony particles begun to be deposited in tlie callus.

                             PLATE  IV.

  Fig. 1. The fractured patella, with its ligament.
  A, The newly-formed ligament intermediate betwixt  the portion of tlie
fractured bone.
  B, The upper portion  of  the patella, which was broken off, and receded
with the quadriceps muscle of die thigh.
  C, The lower portion oi the patella.
  D, The ligament by which the patella is connected with the tibia.

  Fig. 2. Another specimen of the fractured patella.
  A, The natural ligament of die patella.
  B, The lower portion of the fractured bone.
  C, The intermediate tendon formed betwixt the fractured portions of the
patella. 
Plate II.
FIG. \.
FIG. 2.
 
 
V
 
 
#
r 
FIG. 1
     Plate IV,
FIG. 2.
 
©F THE PLATES.
XV
  D, The upper portion of the patella.
  In the case from which the first figure was taken, the portions of tlie pa-
tella still lay on tiic surface of tiie tliigh bone, and playing over die head of
that bone in its motion, threw die action of the tendon oft'from  the centre of
the joint, increasing consequendy the force of die muscle.  The nearer the
fractured portions  of the bone are to each other, die stronger is the union
betwixt them.   In the second fig. the intermediate portion of new ligament
is longer and proportionally weaker, and, in the next plate, the effect of diis
will be seen.

  Plan.   Fig. 3.
  A, The lower head of the thigh bone.
  B, The head of the tibia.
  C, The patella fractured.
  D, The ligament of the patella, which connects the lower fractured por-
tion of the bone with the tibia.
  E, The muscle inserted into the upper portion of the patella.
 %"his plan shews that when the patella is mounted on the convex surface
of the articulating  head of the thigh bone, the sudden and violent  action of
the muscles on the thigh may 6nap it across,  without the knee toucliing the
ground.
        t
  Plan.  Fig. 4.
  This-plan is designed  to shew the similarity in effect of the fracture of the
olecranon at die elbow joint with that of the fracture of die patella.
  A, The humerus.
  B, The ulna.
  C, The olecranon broken off.
  D, The cavity into which the point of the olecranon should enter, when
the arm is distended in the natural state of the parts.
  If the arm be kept  bent during the cure,  then the space marked by the
dotted line betwixt the olecranon and the ulna will  be occupied by callus or
new bone, and it will  then  be impossible to extend the arm, for before the
fore arm is extended,  the olecranon, C, w ill strike on die back of the hume-
rus, A.   We  may easily understand,  too, that if the arm be too much ex-
tended, the ulna, B, will press the olecranon, C, out of the cavity, D ; con-
sequently, after the union, the natural check to tlie extension of die arm
will be lost, and there will be danger of a strain of the elbow joint, from the
insufficiency of the anterior ligaments to restrain die motion backward.

                             PLATE V.

  This plate represents die fore part of the knee joint torn  open.  It is
intended to exemplify the consequences of allowing the upper portion of
the patella to be drawn up by the action of the quadriceps fiemoris muscle 
XVi
EXPLANATION OF THE rLATJEfi.
  This man had a fractured patella.  The new ligament which was forme'd
betwixt the portion of the bone incorporated with the integuments on the
fore part of the joint,  so far as to destroy their elasticity in a considerable
degree. The man carrying a burden, slipt, and  fell backward, and the
knee bending under him, the ligament, and with it the integuments of the
knee joint burst  up, and disclosed the cavity of the joint.
  A A, The torn integuments.
  B, The  articulating surface of the femur exposed.  The attempt to unite
the integuments failed and amputation was necessary.

                            PLATE VI.

  This represents a  section of the diseased nerve, spoken of in the text
under the head of Tumours.
  A A, The tibial nerve.
  B B, The fibular nerve.
  C C, The tibial nerve enlarged into a great tumour, which occupied {jke
ham.
  D D, The surface exposed by  cutting the tumour in two parte.
  E, The red granulating matter which occupied cells in tlie tumour.

                            PLATE VII.

  This is a slight etching of the knee joint and popliteal artery.   This case
is given as an example of the effect of a torn popliteal artery, as distinguish-
ed from the common aneurism in this artery.
  A, The popliteal artery.
  B, The hole torn in the artery.
  C, The irregular projection of the shaft of the femur which tore the artery.
  D D, The coagulated blood condensed and united to die cellular mem-
brane, so as to make an irregular sac.
  E, The capsule and integuments of the joint greatly dilated,  in conse-
quence of the aneurismal blood having been driven into the joint.
  F,the patella raised from the femur, in consequence of the dilatation of
the cavity of the joint.
  G, A pencil introduced betwixt die heads of the bones, to shew the com-
munication betwixt the irregular aneurism and the joint.
  N. B. The irregular bone which projects at C, is a consequence of a pre-
vious fracture of the femur ; or rather a kind of diastasis; for, when a lad,
the leg was forcibly twisted, and the apophysis of die femur broken off from
the shaft of the bone.  The patient was of mature years before  this  aneu-
rism took place, from an exertion of the muscles forcing the artery against
the projecting bone. 
I'f<tf<  I'
 
 
r 
Hate Vt. 
Plate VII.
 
r 
CHAPTER I.
OF OPERATIONS ON THE THROAT
  SUFFOCATION FROM BODIES STICKING IN THE (ESOPHAGUS OR
                 ENTERING THE TRACHEA.


      It is on no occasion a mechanical  obstruction to the
trachea which we have to dread from bodies sticking either
in the trachea or oesophagus.   It is the spasmodic constric-
tion by the muscles of the glottis.  There is a provision in
the muscles of the glottis, and in the laying down of the epi-
glottis, against any particle of the food in swallowing passing
into the trachea.  The same correspondence and sympathy
which protects the trachea, is the cause of suffocation when
either any small body has passed the glottis, or when a bone
or a piece of meat sticks in and distends  the pharynx.   In
neither of these  cases is the  tube of the trachea filled up or
compressed, but  while life remains, the presence of these bo-
dies occasions a spasmodic contraction of the glottis and great
difficulty of breathing, or actual suffocation.
   Even when a piece of tough meat, or cartilage, or a large
bone,  distends the oesophagus, it does not compress the wind-
pipe, but  affects the muscles of the glottis only.  The mo*t
common accidents are these :—A piece  of meat or cartilage
in swallowing, sticks betwixt the cornua of the  os hyoides or
thyroid cartilage : coins  swallowed by children and stick in
the pharynx : fish-bones which stick and irritate very much r
a crumb of bread, which being popt into the mouth at play,
   vol. n.                   u 
2
OP THE PROBANG.
enters  the  trachea:  or a  husk of grain drawn in by the
breatli and adhering near the top of the wind-pipe.  Even in
difficulty of breathing, and of deglutition, proceeding from
tumours pressing on  the  trachea,  as well  as  from  these
causes,  the obstruction  of  breathing  is  not  continual, but
comes  in paroxysms, at intervals, and still depends on the
same occasional spasmodic affection of the  muscles of the
glottis.  Every kind of obstruction will of course be aggra-
vated  upon  violent exertion.   This  in  some instances we
ought to provide against, as in labour.  If a  woman have a
tumour pressing on the wind-pipe with occasional paroxysms
of difficult breathing, we should be  prepared to give relief
during the  exertion and determination of the blood  to the
head, in consequence of labour: or by free scarifications, pre-
vent the tumour  from being gorged  with blood  during
labour.
  If we are called to a patient having a  bone in the throat,
we ought not in an impressive and rapid manner to seize up-
on him; for this puts him into terror and anxiety that in-
creases the difficulty of breathing.   Without much loss ol
time, it is  possible to set down before him in that compos-
ed manner  which will give  him confidence of relief.—Open-
ing his mouth you press down  the tongue with a spatula or
~poon,  and endeavour to see  the bone—(we shall often be
able  to see  it, for it may be grasped just upon the  entry of
the fauces).  When we can observe  it, we should seize it
firmly  with a pair of forceps,  and extract it.   Should we
not be  able to  see it, we may put in the  finger  by the side
of the  mouth, and so deep into the throat as to touch the
bone, and  unfix its sharp  points, when the effort to  cough
and vomit from the presence of the finger in the  throat, will
throw it out.

               OF THE USE  OF THE PROBANC.

  In the first place, we may recollect, that if a neighbour.
be choking, we ought not to run in search of a probang, for
rimost  any thing may do,  to push the morsel down*   The 
                     OF THE PROBANG.                   vJ

£nger, if dexterously put in by the side of  the mouth, will
often unfix a body, when lying across the  pharynx.  The
end of a table-spoon, or a wax  candle, and on some  occa-
sions, the end of a whip, has done  good service.  Nothing
is better for pushing down a morsel than a leek.  In a  child
and sometimes in the adult, the finger will extricate the sub-
stance, either by pushing it down, or hooking it out.
   The probang is introduced by forcing it against the back
part of the pharynx.   The yielding  of the pharynx, and
the elasticity of  the instrument, directs it  down into the oeso-
phagus.  The rule may be taken, that all  soft or digestible
substances  are to be thrust down into the stomach, whilst we
must endeavour to catch,  or pull, sharp  and indigestible
ones up.   But when a large piece of meat, or cartilage, or
a crust of bread, or piece of tripe, sticks firmly in the pha-
rynx, we should rather endeavour to bring it up, though it
be a digestible  substance; for it sometimes is so wedged in,
that it will not  pass down, and our efforts only fix it  the
more firmly.    If  it be within  the reach of the finger so
that it  may be  unfixed, Ihe effort of the throat will proba-
bly throw it out.  Or if this be impossible, the polypus for-
ceps is the best instrument to take hold of it, and pull it
forth*.  In short, this  must be accomplished in some way,
or at  least we must have it unfixed  from  the grasp of
the horns  of the  thyroid cartilage, else the struggle of  the
patient will soon be over.
   People suffocating,  may be able  to speak  at  first;  but
this is soon over, and the surgeon will generally know nothing
further, than that the patient is struggling in imminent dan-
ger of instantaneous suffocation, and of course the first  thing
to be attempted, both  because bodies in the oesophagus  are
the most frequent occasion  of suffocation, and  because it i6
in  that case chiefly where  we can instantly relieve the  pa-
tient, ic, to examine the pharynx.
   * Forceps of various sizes should be an indispensable part of surgi-
cal apparatus—A pair of curved forceps on these occasions will perhaps
prove a more usesui  instrument, than the probang, 
4      OF EXTRACTING BODIES FROM THE (ESOPHAGUS.

  A bone we should be  unwilling  to thrust down, because
being sharp, and sticking:  to force it down with violence, is
to lacerate the oesophagus ;  we rather endeavour to pass the
hook end of the probang  beyond it, and endeavour to pull it
up.  All indigestible bodies,' pins, pieces of money, stones of
fruit and shells, we should  endeavour to pull up with the
hook end of the probang.—And it may be remembered, that
such bodies sticking about the top of the larynx, have been forc-
ed into it, by the use of the sponge end of the probang.  As
we have mentioned a substitute for the probang, in order to
push a piece of meat or cartilage down, it is equally necessary,
to suggest a contrivance  for a hook, with which to pull up
bodies from the oesophagus, or pharynx.  For this purpose
nothing is so good, as a Diece of wire bent in this manner.—
  The advantage of this is that it can be made of any form
or take any curve,  enabling  us to adapt it  so, as to operate
upon that side where the pin or stone is supposed to lodge.
 In nine of ten cases they stick across the throat within sight.)
In the way of a regular  instrument nothing is  superior to a
pair of long slender steel forceps with a slight curve, for ex-
tracting pins, or feathers, from the gullet.
  We  are particularly anxious to bring up pins from the
throat,  because if they pass  down into the  intestinal canal
they may stick there and occasion fatal inflammation, though
more frequently foreign bodies swallowed and sticking in the
intestines, open a way outwardly by abscess and ulceration.
Let us not however take the most unfavourable  supposition
in the event of a pin  being swallowed, for  it generally hap-
pens that it is passed by stool.
  We  should not forget that often the soreness left by the bo-
dy which has stuck in the throat,  gives to the patient the
sensation of its being still in the place after it has gone down. 
OF ULCERATION OF THE GLOTTIS.
  Very often  small bodies, as crumbs of bread, peas,  and
cherry-stones, or nut shells, fall at once into the chink of the
glottis.   Then the  breathing becomes sonorous or stridulous
with  heaving of the chest, and  long and difficult respiration.
—there is not that  action, partaking both of  coughing and
vomiting which is the effect of something sticking in the up-
per part of the pharynx.
  Yet even in this  case the patient will not die immediately.
Dr. Jeffery of Glasgow has a preparation in which a piece of
coal fills the trachea almost entirely, yet the patient  lived for
three days.
   When the foreign body passes entirely into the trachea and
does not stick  in the more irritable glottis, I  believe it  gives
less distress, though there is every moment danger that the
breath may throw  it  again into the grasp of  the glottis and
suffocate the person ;  but of this presently.
   The inflammatory affections  of the  trachea which I  have
known  to  prove fatal arc, ulceration of the glottis; pustule
on the rima glottidis ; many instances  of croup with the for-
 mation of the membrane in the trachea.  In all these instances
 the high excitement occasioned spasmodic contraction of the
 glottis ; that again excited paroxysm,  or  continued difficulty
 of breathing ; and the difficult breathing, watery exudation
 into the cellular texture of the lungs.  Which last has always
 appeared to me, on dissection,  to be the immediate cause of
 death.
    In two cases of ulceration of the epiglottis where I  lately
 examined the  parts I regretted that mercury had  not been
 thought of: for from the history of the case I imagined that
 there was a considerable probability that the'ulceration was
 venereal.   It  is I fancy the slight  degree of irritability  so
 peculiar to venereal sores,  which allows of a continued ulce-
 ration of this delicate  valve without producing immediate
 suffocation.  I have found too that with nearly similar  symp-
 toms an ulcer had made considerable progress in the samihis
 Iaryngcus, and evrn lower in the larynx. 
G
OF BROKCHOTOMY.
  The fact that those who die by suffocation from irritation
or obstruction of  the trachea are at length carried off by an
infiltration into the cellular substance of the lungs, suggests
with it an important  consideration in surgical practice, viz.
that in this  as in many  other operations,  those performed
for the relief of the immediate paroxysm are unsuccessful, be-
cause they have  been too long delayed and another disease
has supervened to the first.

  The occasions which may, according to general opinion, call
for the operation of bronchotomy are, swelling of the tongue;
or swelling of the glands from  salivation; tumours of the
amygdala*; ulceration of the upper part of the trachea or
epiglottis; sudden and violent inflammation of the top of the
larynx ; bodies wedged in the pharynx, or upper part of the
cesophagus from  which there  is instant danger of suffoca-
tion, while our efforts to extract  the bodies  are  ineffectual.
In these emergencies if the operation is to be done ten to one
that no regular apparatus  is prepared, but if it should be de-
liberately  set about, then we may thus perform it.

               OPERATION OP BRONCHOTOMY.

  There  are two places at which the operation may be done.
1. Above  the cricoid  cartilage.   2. Nearer to the sternum
and on the face of the trachea.  The latter of these  places I
should prefer where there is inflammation.   In the first place
because it is more removed  from the moveable  glottis, the
spasmodic constriction of which is probably the cause of the
suffocation;  and  also  because I conceive the operation may
be performed in the trachea by merely making an incision and
holding the edges of the trachea asunder with a small spatula,
or any such instrument.
  To perform the operation betwixt the thyroid and cricoid
cartilages, the surgeon, placing his finger  upon  the  promi-

  * These I suspect may cause much alarm, but not actual suffocation. 
«F BR0NCH0T0MY.
i
nence of the thyroid cartilage, or pomum Adami, carries his
finger down upon the fore part of the throat for the space of
a full inch ; he finds there a depression and softness; moving
his finger further  down he feels the cricoid cartilage like a
ring encircling the throat, but it is above this ring and in the
spot where he feels  the depression into which  he is to intro-
duce his canula.  A large silver catheter, or the canula  of a
trocar, or even a large goose quill, or best of all, a piece of
sheet lead rolled into a tube and smoothed, will be a substi-
tute for regular apparatus.  These I mention  now, because
it is an operation which requires to be done on the spur of the
occasion.   The regular instrument with the double canula is
to be found in the shops; but I imagine a simple canula, hav-
ing a slight but equal curve, and with a blunt stilette would
serve every purpose.   For the perforation being made  into
the trachea by the common lancet, the conical point of this
instrument would easily follow.
   The size of the canula should be that of one of the nostrils.
   The surgeon makes an incision over this place with a small
scalpel  if he has it, or with his common lancet.  He then
clears the blood away and if possible waits until the bleeding
is stopt, (using what  means  he canto that effect) then with
the point of his lancet he perforates and introduces his canula
obliquely downward and backward.
   In performing the operation on the fore part of the trachea
these precautions ought to be observed.
   As in the other case we  ought to have a scalpel, a lancet,
eanula, and stilette.   When the finger is carried from  the cri-
coid cartilage downward, a softer eminence is felt on the fore
part of the trachea, immediately after the finger has passed
the cricoid cartilage:—This is the isthmus of the  thyroid
gland, and is carefully to be avoided.  Below  this, then, the
external incision ought to be made, and carried  downward an
inch and a half.  In the next touch of the knife the thyroid
veins are to be avoided,  and the stcrno-hyoidei  and thyroidei
muscles put aside.   If the veins have been put carefully aside,
not cut across, and the thyroid  gland ha? been avoided, there 
3 '
OF BRONCHOTOMY.
will be no bleeding to interrupt the  further operation of cut-
ting into the trachea, and introducing the canula.  The cut
into the trachea is made betwixt two of the rings, with the
same knife  which is used for the first part of the operation, or
with a lancet.   It is recommended by some to push  in a
sharp stilette and canula,  without a previous incision of the
trachea.   The intention of pushing a trocar and canula into
the trachea without making a cut, is, that the canula may so
exactly fill the opening  in the trachea that no drop of blood
may fall into it.
   Authors speak on this subject, as if a drop  of blood en-
tering the  wind-pipe at this place, would irritate and excite
the lungs, as an excoriating humour, or a hard substance does
the glottis or epiglottis.   Bleeding is if possible to be avoided,
and I  believe it always will be possible; but  this dread  of
bleeding is not  to make us defer this  operation under the
idea, that  it requires  a very particular apparatus.   As we
have the  tube in  the hand, cannot  the incision be adapted
to it, and if there is an oozing of blood, can we not tie a dos-
fil of lint round the canula, and which pressing  upon the tra-
chea around the opening, may either  suppress the bleeding,
or  at least hinder the blood from falling into the wind-pipe,
should the opening be twice the size  required to pass the
tube ?   Hurry and confusion however in this  operation, and
inattention to this subject, will lead to the most terrible con-
sequences.  A friend of mine and a very celebrated surgeon,
told  me he  saw a  gentleman die of loss of blood, and the
falling of  the blood into the trachea; I suppose the opera-.
tor must have cut upon the substance of the thyroid gland.
   In a child the  trachea is very small, and operating with
canula and stilette it  has  happened that the trachea was
 transfixed!
   The tube  being introduced,  the surgeon  Avill naturally
hold it with his fingers until the  respiration is fully restored,
it may be then fixed and the process is this: folding a large
piece of lint  together, it is  cut into a circular form, then it
 is «Jit up  to the middle and a part cut out to  answer to the 
OF BRONCHOTOMf.
9
canula.  This compress (now consisting of distinct pieces) is
to be put betwixt the wound and guard of the canula, so as
to keep  the end of the canula its due length, inserted  into
the wind-pipe.  Now a band put round the neck may be
fixed to the tube  and compress it sufficiently, without forc-
ing it too far into  the wind-pipe.
   When the  skin and perhaps the thyroid  gland  swell i&
consequence of the operation, then may several of the  pieces
of cloth be taken from betwixt the wound  and the  guard
of the canula;  so as to allow the extremity of the canula
still to  keep its  place in the Avind-pipe.
   Having secured tlie present safety  of the patient, our at-
tention  will be  naturally called in the next place, to remove
the cause of the obstructed respiration, whether it be a fo-
reign body sticking in the  glottis, or something  in the pha-
rynx, or an inflammatory swelling.
   I  have been  several times on the eve of  performing the
operation of bronchotomy, but I have never  done it.   And
this  is the  case with many  surgeons.  I cannot  therefore
speak with the same certainty on this subject that other au-
thors have done.  But to bring the subject into as short and
practical a view as possible, I  have thus concerted it on these
occasions:  viz. first to introduce a flexible tube into the tra-
chea through  the glottis, and  if this should not be attended
with  the desired  effect  of establishing a free  respiration,
then to  perform  the  operation of bronchotomy.
   I introduce  the  tube through the glottis, because  in every
case I have yet seen, the occasion of the difficulty of breath-
ing was to be  found in the spasmodic closing of the glottis,
and if the  tube  is  introduced  into the  rima glottidis so as to
secure the passage of the air, the play of the lungs will be free.
The only question  which remains is, whether  the presence of
the tube in the larynx will not (in the intimate connexion
which exists betwixt tliis part and the respiratory muscles)
produce such  irritation, as still to cause a spasmodic cough
Ing.   But  I believe that it will not be found  to have  this
effect.
   VOT,. II.                    C 
10          OF BODIES LODC1NG IN THE LARYNX.

  The substitution of this simple introduction of a tube to the
formidable operation of bronchotomy, would have this happy
consequence, that it would be resorted to with less unwilling-
ness, and frequently early enough, to save the patient.
  When the operation is to be done for a body which has fall-
en into the larynx or trachea, there may be some circumstan-
ces peculiar in the treatment.

            OF BODIES LODGING IN THE LARYNX.

   When a body is drawn into and lodges in the larynx, it
may be known from the convulsive cough, wheezing and rat-
tling in the throat, the weakness and hoarseness of the voice.
Sometimes when there is a  dreadful difficulty of breathing,
the symptoms will suddenly remit, and the person become
easy.  After several changes  from tranquility,  to laborious
respiration, and from difficult to easy breathing, the patient
may  be at the end of some days, suffocated suddenly.   It
happens thus I believe, the body is loose, and is sometimes
lodged in the trachea, sometimes near the glottis.  When in
the trachea, (the sensibility of which is much less than that of
the upper part of the larynx), the patient breathes easily, but
when the  body is moved towards  the more sensible glottis,
then comes the spasm of the muscles of the glottis, and great
 difficulty of breathing.  Mean time with each successive at-
 tack, the parts are inflaming and becoming more irritable, and
 the violence and difficulty of breathing, is producing a degree
 of effusion in the lungs which  increases the evil.  One more
 severe paroxysm succeeds and the patient  is suffocated.   It
 would be easy to furnish many striking cases of children thus
 suffocated.
    1.  We have to ascertain  the nature of  the accident.  See.
 that the cause of suffocation, be  not in the upper part of the
 pharynx,  and ascertain the  nature, and  size of the foreign
 body. 2. Observe, whether posture by throwing down the
 body into the wind-pipe, does not relieve, and if the sense of
 suffocation, has been preceded by posture or circumstances, 
OF BODIES LODGING IN THE LARYNX.
11
which would favour the shifting of the body, into the rima
glottidis.   3. We  have to observe, if  the breathing become
more difficult even in the interval of the spasmodic attack.
4t. If from the greater violence of the paroxysm, the mem-
brane of the larynx be inflaming and  swelling, then the dan-
ger is imminent, and the operation seems to be the only reme-
dy.   5.  If there be any puffness, or emphysematous tumour of
the neck, during the previous stage of suffering,  before the
operation is determined on, there may have occurred a burst-
 ing of the trachea.
   We bleed frequently, and give an opiate in a mucilaginous
 mixture, which is to be taken by  frequent  sipping, rather
 than as a draught.  For this will often give relief of the tcaz-
 ing, tickling  sensation  that precedes the paroxysm.  It has
 been recommended that we should excite vomiting, or sneez-
 ing, which by the suddenness of the action of the respiratory
 muscles, may throw  out the body from the larynx.   But
 should the body be removed more directly into the current of
 air, by this means and yet not altogether discharged, the con-
 sequence would be sudden suffocation.
   There are two  operations proposed, the one may be thus
 conducted.
   1. To lay bare that part of the trachea, which is inferior to
 the isthmus  of the thyroid gland.   2.  Let the bleeding be
 entirely stopt.   3. Slit across three of the rings of the trachea,
 that it may be held  open by introducing a small spatula,
 which will  allow the patient to breathe freely,  and having
 established free respiration, will then enable you to introduce
 a probe, or  bougie, upwards through the larynx.  So that
 the foreign body may be pushed forth.
    But if the body should be fixed as I  have seen it, after
 death, it will be no easy matter to dislodge it, in short we may
 not find it, and we  may not be able to extract it!  which
 makes the operation precarious and dangerous.  Before think-
 ing of such an  operation, the surgeon will of course provide
 the complete apparatus for the operation of bronchotomy, lett
  he should be obliged to introduce the tube, without extract- 
12
OF STRICTURE IN THE (ESOPHAGUS/
ing the foreign body.   And he ought to accomplish himself
with  what variety of probes, probangs, and forceps, he may
think eventually necessary, either  to  extract the body, or to
push  it out from the glottis.
   The operation recommended by Desault is  this.  The in-
struments are a sharp pointed knife, spatula, and forceps.
   The patient is to be seated, and the head held to the breast
of an assistant, who stands behind.  The skin over the thy-
roid cartilage, is to be a little drawn aside.  An incision is now
to be  made through the skin, laying bare the prominence of
the thyroid cartilage  and  the  cricoid cartilage.  Then the
two lateral parts of the thyroid cartilage are to be slit asun-
der, and being held so, the foreign body can be  extracted with
forceps.

            OF STRICTURES IN THE (ESOPHAGUS.

   When we consider that the oesophagus is a powerful  mus-
cular  tube, and that it is liberally bedewed with mucus, and
consequently is of a glandular  structure, we  have a key to
the knowledge of its diseases.
   It is  not  wonderful that a muscular tube, connected with
the stomach,  (which  is the source or  the seat  of so  many
strange  and varying symptoms,) should frequently suffer  by
the irregular  action of  its muscular fibres*.   It is however
the permanent stricture of the oesophagus I have to mention
here.
   The stricture of tlie oesophagus is marked by a gradually
increasing difficulty  of  swallowing, there occurs often irregu->
lar pain in the stomach, and frequent reaching with  the dis-

  * Spasmodic affections of the oesophagus,  may be removed by rubbing
camphor and opium, or xther, on the sides of the neck; or by swallowing a
very litde tincture of opium.  Valerian and camphor may be given by the
mouth or by injection.  The irregularity of the uterine action, the general
state of the system, and of the uterine discharges, must be attended to.
When  the spasm continues obstinate,  the dexterous use of a bougie v$J
sometimes relieve it. 
ITSE OF THE FLEXIBLE PIPE.
IB
charge  of mucus collected in the oesophagus.   Sometimes
there is a considerable general irritation, with fits of  suffoca-
tion ; the voice is remarkably weak.
   For this complaint, as in the stricture of  the urethra, the
bougie  and caustic are used.  We sound with the bougie to
ascertain if there be a confirmed stricture, and not merely a
spasm or paralysis.   We are to endeavour  to accommodate
the form and size of the bougie so as gradually to stretch the
contracted part;  and this failing of its effect, or being attend-
ed with an increase of the mischief, we have still the use of the
caustic in reserve.  This  practice is  strongly recommended
by Mr.  Home.   I cannot at present take the merit of making
a single  observation on the subject.

 OF THE USE OF THE FLEXIBLE PIPE, INTRODUCED INTO THE
                       (ESOPHAGUS.

   It is not long since, the only means suggested to us of nour-
ishing a patient who had an obstruction of  deglutition, was by
clysters, or by forcing down solid food into the oesophagus by
the probang.
   It was therefore a very happy invention of Mr. Hunter, in
a case of impeded action of the throat, to  cover the probang
with  an eel-skin, which, being introduced into the stomach,
enabled him to inject  nourishing soups.   For the same pur-
pose we now use the flexible  gum-tube, having adapted to it
the nozzle of a syringe, or injecting bag and pipe.
   In  the introduction of the tube, we must be careful  that we
do not commit a blunder, which though not likely to  happen,
yet because it may happen and prove fatal, we must always
consider; I mean the introduction of the tube into the wind-
pipe, instead of the gullet.  In the first place then it is AtTong
to make the patient open  the mouth wide and push out the
tongue, and at that instant to introduce the tube quickly, for
by the projection  of the tongue, the epiglottis is raised to the
utmost; and if the patient should have such  a command over
himself, as to persevere in keeping the tongue thus, while the 
14
USE OF THE FLEXIBLE PIPS.
tube touches the throat, the point of the tube may pass into the
glottis.   On the contrary the patient should be directed to do
that, which indeed he will  naturally do, when he feels the
tube in the fauces; let him imitate the action of swalloAving,
draw back the tongue, and consequently push down the epiglot-
tis :  and the tube should not be passed quickly into the throat,
but slowly, moving the point of it off the soft palate to the
back part of the  pharynx, when (being flexible) it will be di-
rected into the bag of the pharynx and into the oesophagus.
   Yet after this precaution, and Avhen the tube is in the oeso-
phagus, we pass the upper part of it through a sheet of paper,
and then hold  the flame of a candle  to it.  It has happened
that in this experiment the air rushing  from the tube, has
shewn it to be  in the trachea, and not in the oesophagus!
   The liquid food which is to  be thrown into the stomach in
this way, must be cooler than Avhat a person could take by the
spoon, for it flows continually hot upon one part of the sto-
mach.  And I have  dissected  a body where I suspected a
patch of inflammation, in  the inner surface of the stomach,
proceeded from this cause.
   If it should be thought necessary  to keep the tube in the
oesophagus for any considerable time, it must then be intro-
duced through the nostril; and here it is necessary to be still
more particular that the throat, be exerted, as in swallowing,
in order that the tube may pass  into the pharynx.
   There are many occasions on which the tube is to be used
to convey  nourishment into the stomach: for example,  in
young women affected with hysteria, paralytic affection  of
the oesophagus is  not unfrequent, and they would die of this
trifling  complaint but for this  invention.  I have attended
a girl who was nourished for  two months in this way, the
affection of the throat Avas entirely cured, but some months
after she died of a complication of disease.—The oesopha-
gus on dissection  was quite natural.   Ulcerations in the tract
of the oesophagus I imagine are perpetuated and increased
to a fatal  degree by the perpetual irritation of the ossopha-
gus in swallowing.  The action itself is an  excitement, and 
USE OF THE FLEXIBLE PIPE.
15
the matters swallowed  cannot fail to lodge about the ulcer-
ated surface.   In this case the  use of the tube will form a
necessary part of the cure.
   The oesophagus is subject to a cancerous ulceration.   It
becomes hard,  and irregular, and ulcerated, and the mus-
cular structure of the tube being destroyed, the continuous
action, by which the food is carried into the stomach, also
fails, and the flexible tube is necessarily employed.
   Sacs are sometimes formed of the pharynx.  At first, by
some accidental lodging of the stones of fruit, perhaps, and
afterwards by  the  accumulation of the food.  Each meal
forcing a little more into this hole or sac, it is at last enlarg-
ed into a bag, which  having formed by  the  side of  the
oesophagus, and being crammed  with the food in the attempt
to swallow, presses upon the oesophagus, and obstructs the
passage into the stomach.  If the flexible tube  be used, the
food will no longer accumulate in the lateral sac, and this sac
may shrink and be obliterated.
   Abscesses, forming by the side of  the pharynx, and open-
ing  into it, afterwards receive the food in the act of  swallow-
ing, with even a worse effect than in the last instance;  this
too the flexible tube may palliate or cure.
   When a person has attempted self-destruction by firing a
 pistol into his mouth,  and the  brain and spinal marrow and
 carotids have escaped, there is danger of suffocation from the
 inflammation and  swelling of the throat, and the action of
 swallowing is for a long time impeded.  Here  the  tube has
 been of essential service.
   When the attempt at suicide is made by cutting the throat,
 the action of swallowing impedes the cure, because the larynx
 is pulled up  in swallowing, and by this means the union of
 the trachea is prevented, and even the outAvard Avound  torn
 open; and here the flexible tube is also of great  service. 
 Itt             ©F WOUNDS IN THE THROAT.


                OF WOUNDS OF THE THROAT.

   The cutting of the throat, in the attempt at suicide, is so
 eery common an occurrence, and requires the assistance of the
 surgeon so frequently, that it becomes necessary to speak of it,
 under a distinct head.
   Of all the ways of putting a period to existence, the cutting
 of the throat  is the most dreadful, to the sane imagination.
 But it is the horror  of the deed, on Avhich the insane wretch
 broods.   It is  the vulgar idea, that  it is the cutting of the
 wind-pipe, not the opening of the great vessels, by Avhich the
 man  dies.  So the suicide very often cuts only on the  fore
 part of the throat, and does not perpetrate the  deed.  Or not
 liking the experiment,  or perhaps the edge of the knife strik-
 ing on the firm cartilage, or  bone, the wound is small and the
 deep vessels are not touched.
  Sometimes he draAvs the knife across the throat, higher than
 the os hyoides,  and then the root of the tongue, and the lin-
gual  artery are cut;  the muscles uniting  the jaAv, and os
 hyoides are cut; the  lingual artery  bleeds profusely.  Per-
haps  the  ninth pair of nerves, and  the  salivary  ducts are
wounded.   The saliva and fluids attempted to be sAvalloAved,
 floAv from the wound.   The voice is  feeble and inarticulate,
and there is danger of suffocation, from the- fluids and blood
falling into the larynx.  Sometimes he cuts down loAver than
the os hyoides, and betwixt  it and the thyroid cartilage, and
then the epiglottis may be separated from the larynx.  Speech,
deglutition and respiration are difficult.  When he cuts upon
the thyroid  cartilage, he does little harm, but when he cuts
loAver down  he strikes the thyroid gland, and opens its vessels.
  In Avhatever  way the throat be cut, the bleeding is the im-
mediate danger ; the person  dies of hasmorrhagy or from the
blood, entering the wind-pipe, and  suffocating ;  and  the
source of the blood is from the  deep angle of the Avound, gene-
rally the superior thyroid artery, or the lingual artery;  if the
carotid is  touched, the patient is gone.  Before the surgeon is 
OF RANTJLA.
U
called, perhaps the vessels have emptied themselves, and the
faintness prevents the full jet of blood, and immediate death.
  The thumb is to be pressed  into  the  angle, or a piece of
sponge is thrust in by the  side of the  throat, until a liga-
ture is throAvn over  the tenaculum ; then lifting the finger
from the spot from which the  blood flows, one vessel will be
observed  to  project Avith each  pulsation, Avhich  being taken
up, other lesser branches may  require  to be tied.   During
this operation,  the posture must be such as to prevent the
blood falling into the trachea.
   When the bleeding has entirely stopt,  the integuments are
to be brought together by two  or more stitches ; then a band-
age is put about the head, and the ends of it brought doAvn
from the sides of the head to  a circular  band  round the
chest, by Avhich the  chin is  kept down upon the breast, and
the trachea  and  the lips  of  the Avound kept together.  A
strait jacket  is now put upon the  person.  The food and me-
dicine is to  be given by the  flexible tube, introduced  into
the gullet, if a great part of the trachea is cut across; for the
motion of the throat in swalloAving, impedes the union of the
 Around.
   What proves the most distressing circumstance during the
 cure, (especially if the wound has been near the glottis), is the
 rising of inflammation, and the consequent  irritation and
 cough.   It is difficult to allay the thirst Avithout varying the
 position ; lying on the back for example, the patient will be
 able to swallow a little, or moisten the parched fauces.

                          RANULA.

    Ranula is, in general, a semipellucid tumour lying under
 the tongue and in its commencement situate to one side of the
 frenulum linguae.  It is described as having its origin in the
 obstruction  of  the salivary glands;  and accordingly  it  is not
 confined to the  seat  of the  sublingual gland, but  appears
 sometimes in the cheek, in the place of the parotid duct, and
 then it is more fleshy and vascular.  It is described as begin*-
    VOT.. V-.                    d 
13
Ui RAN C LA.
 ning Avithout pain, the feeling of distension being alone trou-
 blesome.  Such indeed has been the account of the patients I
 have seen Avith this complaint ;  but I knoAv that an  obstruc-
 tion of the salivary ducts is an  extremely painful complaint,
 and  so  peculiar in the pain and distension of the  salivary
 glands, under the tongue, upon  tasting sapid food, or on the
 action of the muscles of the jaAV, that the patient Avould not
 be apt to overlook the beginning of the disease.
   If Ave say that Ranula is a  semipellucid tumour, like  a
 frog's belly, under the tongue,  then there are tAvo kinds, the
 one arising from the distension  of the  salivary  duct;  the
 other, a simple  incysted tumour. I  believe they have been
 much confounded.   If Ave define it to  be a distension of  the
 salivary ducts, then it is not always under the tongue, but is
 common  to  the other ducts.   This  complaint,  under  the
 tongue I have seen in an infant, and I believe it is frequent in
 them, from original obstruction of the duct.  In adults, it is
 sometimes found to be complicated Avith, and to have taken
 its origin from salivary calculi in* the mouth of the duct.
   When  it is in its most frequent place, under the  tongue,
 and is alloAred to grow, it forces back the tongue,  and occa-
 sions difficulty of swalloAving, and inarticulate speech ; and in
 children it prevents sucking.
   It Avould appear that this is sometimes a much firmer  tu-
 mour than those I have seen,  insomuch, that, by pressing
forward, it has affected the teeth, and so far pressed back the
tongue, as to occasion difficulty of breathing.   When formed
in the cheek, it has forced itself  under the zigoma, and has
prevented the free motion of the jaAV.
  The practice is, to lay these tumours freely open.  Unless
this be done freely, it Avill  return.  In its return it will often
lose its transparency, and by  the  necessity for frequent punc-
tures, it becomes a thick and fleshy bag, requiring either  ex-
tirpation, or escharotic and caustic dressings.
  Calculi form in the salivary ducts;  sometimes they lodge
near the mouth of the duct, without producing a tumour, and
then Avith the touch of a lancet over the extremity of the 
OF THE SALIVARY FISTULA,
19
 duct, they may be drawn out Avith forceps; or the calculus
 produces much irritation,  and a suppurating sac  is formed.
 After the extraction of the calculus, the injection of a slightly
 astringent  fluid,  with the  syringe  for fistula lacrymalis,
 cures it.

                 OF THE SALIVARY FISTULA.

   This  fistula  differs essentially from other  fistulous sores,
 connected with the natural ducts, or passages.   It is not the
 consequence  of obstruction, but of cuts upon  the cheek : for
 it is on the cheek that they chiefly occur,  from the very ex-
 posed situation  of the duct of the parotid  gland.
   This sore forms  a fistula of a very  unpleasant kind ; since
 while sitting at dinner, or wnen masticating, the flow of sali-
 va, is very  profuse, and a failure of appetite,  we are told, is
the consequence of  this discharge.   I  doubt the truth of this
 latter circumstance.
   If there occur a recent division of  the duct, by a Avound
 penetrating the cheek, near its termination, Ave have only to
 take care that  in using the twisted suture, the skin of the
 cheek be very accurately united, while the inside of the cut
 is left free, for the  discharge of the saliva, from the duct, in-
to the mouth.   When Ave do this, the duct may chance to
 unite again, or though it do not, yet if the outward skin be
united, the  saliva a\ ill find its Avay into the mouth.
   The chance however is,  that the case presents in the form
of callous holes, discharging saliva.  In which vain attempts
have been made to cure the sore, by compresses, and escharo-
 tics.   The duct may have been divided,  as it passes over the
masseter muscle, and of course w ithout the Avound penetrat-
ing the mouth.
   In this case of a fistula  of some continuance on the  cheek,
we have  to establish  a communication  betwixt the duct,
and the mouth, and then to heal the outward  wound.  Our
first  attempt  Avill  be, to pass a small  silver  probe, fiom the
mouth into  the natural opening of the  duct, and enlarge it, if 
20
OF THE DIVISION OF THE FR.ENUM LINGUA.
it shall be contracted; then to substitute a small tube, which
being introduced  from the mouth, shall also pass some way
into  that part of the  duct,  Avhich  discharges  the saliva.
Lastly, while the tube is retained in its place, the outward
lips  of the Avound are to be made raw, brought  together,
and healed.
  But the circumstances of  the case may be such, that  it
will  be better to make a hcav duct, from the fistulous open-
ing  into  the mouth.   To do  this, we must push a straight
needle, obliquely from the bottom  of the fistula, into the
mouth, and draAv through a small seaton, which is to be
Avorn until the  passage is callous.   Then either  Avith or
Avithout  introducing the tube,  Ave  have  to  endeavour  to
unite the edges of the outward opening.

            DIVISION OF THE FR^NUM LINGUA.

   There are few surgeons who have not cut the  fraenulum
linguae.   Notwithstanding this, I  venture to  say  that it is
never absolutely necessary.   There  may be an  expediency,
when the surgeon has not weight enough with the mother
to  convince her  that  her child cannot be prevented  from
sucking  from  this cause.  Sucking is effected chiefly by the
motion  of the lower jaw;  and the tacking  of the tongue
even forward to the gums, will not prevent the motion ne-
cessary to sucking.  I doubt even whether this tying of the
tongue, will impede the speech.  But at the age,  which has
 such a motive for the operation, I have less objection to it.
 In infancy, the consequences have been well ascertained to
 be suffocation from  swalloAA-ing the  tongue, and death from
 sucking, and sAvallowing the blood  during sleep.
   To do this, or any other little operation under the tongue,
 an assistant having the child on his  knee, puts his  fingers in-
 to each  side  of the mouth, and  under the tongue so that
 he  pushes it up.  With blunt pointed scissors, the surgeon
 cuts the membraneous part of the fraenum, taking care  to
 avoid the larger veins,  and  that in the motion of the child^ 
OF THE TUMOUR ON THE TONGUE.
?1
he does not cut into  the  substance of the tongue, so as to
touch  the ranine arteries.

           ULCER AND TUMOUR ON THE TONGUE.

  There occurs very frequently on the tongue, an ulcer,
with a foul cineritious coloured bottom.  We have to exa-
mine  Avhether it may not have arisen in consequence of its
being  incessantly torn, and irritated  by a spoiled  and rag-
ged tooth; in which  case the tooth must be drawn, or filed
doAvn and smoothed.   But chiefly Ave must be careful to ob-
serve  the connection with the stomach, for I believe  this to
be  a frequent cause of this ulcer.  This will readily be be-
lieved, when  Ave consider the intimate sympathy betwixt the
tongue, and  stomach, made apparent to us on many occa-
sions ;  as by the state of the secretion of the tong\ie, influ-
enced by the healthy  and diseased action of the stomach.
  When neither medicine, nor diet, have influence  on the
ulcer of the tongue; when it becomes painful, and the edges
rise and  are  ragged, the ulcer may be cut out, after which
the tongue quickly heals.
  To  do this the common tenaculum is  introduced  into the
substance  of the  tongue,  so  as to  pass  under the  ulcer.
Then Avith a common scalpel, run along the convexity of the
tenaculum, the diseased  part together with the instrument
is cut out.   The  tongue may be  cut very  freely, but let
the operator  be aware of the situation of  the ranine arteries.
  When, however, the disease of the tongue  is deep, when
excrescences  with  deep roots  grow upon it, or when there
are small,  firm tumours, formed in its substance, we adopt
the means  suggested  to us by Mr. Home*.
  Ha\ing  Avell  examined the depth, and utmost extent  of
the disease, a crooked needle (draAvn to the middle of the  li-
gature) is passed through the substance of the tongue, be-
yond  the diseased part, the middle of the ligature being cut,
* See his Observations on Cancer* 
22
OPERATION ON THE AMYGDALiE.
the needle is taken away, and  the  ligatures remain.   There
are noAv of course tAvo ligatures one of Avhich is to be tied, in
each side of the diseased part, so as totally to obstruct the
circulation in the insulated portion.   As is here represented.
   A, the diseased portion ;  B, B, the  ligatures tied ; C, the
point at which the needle was passed.

   In a few days the diseased part drops off, and the surface
left  by this separation looks sloughy, but becomes soon clean,
and fills up  in  a Avonderful  degree.    The  pain is much
less  than we should be led to expect.  A salivation is some-
times the effect of the  operation.

              OPERATION ON  THE AMYGDALAE.

   In the inflammatory sore throat, these glands  sAvell  enor-
mously,  so as to produce  an apprehension of  suffocation.
But when  they suppurate fully, they burst and  the relief is
perfect.  In imitation  of this, we have  sometimes to pierce
them in order to evacuate the matter.   Often this does not
succeed, that is  to say, the matter is not  fully evacuated.
But shortly after the  matter is spontaneously  discharged.
Perhaps this is, because the matter is behind the glands, or 
OF THE CANCERS OF THE LIP.
23
 in the duplicature of the arches of the palate.   Be this as
 it may, deep  scarifications of the glands of the throat do no
 harm.  When the  tumefaction is thus great  in  degree, and
 although the  matter be  not evacuated,  the  discharge of
 blood relieves  the  sAvelling and tension.
  All the glandular apparatus of tlie mouth, and throat, is
 subject to disease; none more frequently than  the  amygda-
 lae, for often after SAvelling ennormously in their inflammatory
 affections, instead of  entirely subsiding, or suppurating, they
 degenerate into  hard tumours, if not scirrhosities.   These
 tumours of the amygdala>, besides occasioning much inconve-
 nience, from the  difficulty of sAvalloAving, produce a remarka-
 ble change on the voice, and require to be taken  out.
  These diseased glands have been violently torn away, an
 operation not  to be  imitated.   The  French surgeons  cut
them Avith a  concealed knife, but I conceive the ligature is
 still  preferable.
  The ligature may  be  throAvn on the tumour,  in the man-
 ner  I have described in speaking of the operation on tu-
 mours in the rectum.

                      OF THE UVULA.

  The uvula often hangs down relaxed, producing  a feeling
 Avhich the patient is most anxious to be rid of.   Very simple
means will often succeed  in causing it to be drawn up, viz. to
touch it once, or tAvice, Avith a little Cayenne pepper and to use
astringent gargles.
  When this does not succeed, and there  is  a  real enlarge-
ment, and prolapsus, the ligature, or scissors may be used to
free the patient of it entirely.

                 CANCERS OF THE LIP, &C

  When  the  lip is the seat of cancer,  the disease seems to be
less virulent in its nature, than when in any other part of thf
body.  Here excision promises perfect security. 
21
OF IflL CANCERS OF THE LIP.
  This disease I believe is not often a true cancer but arise?
from some accidental irritation, and is kept up by the inces-
sant motion of the part.  And this too I believe to be the rea*
son why the disease is so frequent in the lower lip, and in the
angle of the mouth, for the  upper lip has  least motion.
While other remedies have been applied, I have always strong-
ly recommended the use  of an adhesive strap, to retain the
Up, as much as possible from motion.   And this fixing of the
lip, is the advantage gained by poulticing those sores.  My at-
tention was draAvn to  this circumstance, from  observing that
in very bad cases, some of the slighter ulcerations situated by
the side of the  greater diseased portion, and which could not
be included in the portion cut out, healed while the pins Avere
iu the lip.   I haturally conceived  this to arise  from the per-
fect repose of the lip, after the operation.
  I need here only state the fact, that venereal ulcers have
been cut out of the  lip, being  mistaken for cancers, and that
the disease has broke out again, and yielded  to mercury.
This avUI be a sufficient caution, to make us examine both the
history of  the disease,  and the concomitant symptoms  before
we operate.
  The most frequent beginning of this cancer  of the lip, is an
irregular warty excrescence with  a broad base, or an obscure
tubercle as ithin the lip.  When a sore, or disease is spreading,
from such a commencement, I would not delay extirpation.
  The following method I prefer to the common  one of using
forceps.  A flat piece of Avood, is shaped to go down betwixt
the lip, and the gums, having a rude handle, which the as-
sistant  holds, at the same time that he stretches the lip  upon
the piece of wood, and presses it down upon its edge, so as to
prevent the bleeding of the labial artery.
  Noav the surgeon thrusting his tenaculum or hook, into the
diseased part, makes  an incision on each side, down to the
wood, and meeting so  as to make a neat angle  below, he cuts
out a triangular portion of the lip, including the disease.
  The nicety, if there be any in  this operation,  consists in
adapting the tAvo incisions, so that the cut surfaces may come 
OF THE CANCERS OF THE Lip.
25
accurately together, without puckering, or ruggedness at the
lower angle.
  For example, if the incision of one side should be in a curv-
ed direction, and the other more direct, the effect will be, that
when the parts are brought together, the side Avith the curved
incision is deeper than the other.
  Fig»  1. represents the part cut out.
  Fig. 2. represents the pins introduced, and the divided Hp
brought together.
         FIG. 1.                          FIG. 2.
   The triangular piece being cut  away, the assistant with-
 draws the piece of wood, on Avhich the incisions Avere made,
 and holds the two portions of the lip, betwixt his fingers and
 thumbs.   Then  bringing  them  together and applying  the
 surfaces accurately to each other, the surgeon introduces his
 first needle, about a fifth part of an inch from the surface of
 the lip, and  rather towards  the inner part of it; the other
 (for  tAvo are  sufficient)  is introduced in the middle betAvixt
 this  and the lower part of the cut.
   The surgeon should noAv, put tAvo or three  turns of the  li-
 gature, about the pins, until the  bleeding stops  altogether.
 Then loosening it, he should more accurately ay ind his thread
about the pins, by throwing the middle part of it over the tAvo
 extremities of the pin, then crossing the ends under the points,
so as to form the figure of 8.   Having done this Avith the
upper pin, he proceeds in the same way Avith the loAver.
   If the disease be in the angle, or commissure of the lip?,
then must there be made tAvo semilunar incisions, terminating
in an acute angle on the cheek.
   VOL. II.                    E 
20
OF THE CANCERS OF THE LIP.
  In making the tAvisted  suture, the lip is  more frequently
too firmly braced, than  not  brought  together  sufficiently-
When the ligature is draAvn to stop the bleeding, as  in the
first instance, and not afterwards loosened, but the  operation
thus finished, the SAvelling of the part makes the ligature
much too tight, producing in consequence an irritation, Avhich
sometimes  brings on suppuration,  and bursting up of the
wound.
  But  when after a short delay,  which allows the bleeding to-
stop, and the parts which  are in some degree already swollen,
are brought  accurately "together.  I have always found the
operation succeed better, and Avithout deformity.
  When a great part of the lip  is taken aAvay, and when the
surfaces meet Avith difficulty, there is a straining on the pins,
and a  consequent fretting of  the Avound.  This is another
cause of failure.   It may  be often prevented, by  carrying an
adhesive strap, from cheek to cheek, and bringing it over the
lip  betwixt the pins, or perhaps nearer the chin, so as to sup-
port the pins, but chiefly to act as a monitor, and to check the >
unwary motion of the lips.
  The  Avound should  be kept dry, and if possible Avithout
motion, that a scab may be formed.   If a little matter should
form, Ave are not  to throAv the parts loose, but let  it out, Avith
tlie point of a fine needle,  and  still retain the parts in contact.
  On the fourth day, I take out the loAvermost pin, (alloAving
the threads to remain if they Avill) first carefully Avashing  the
pin with a camel's hair pencil, and clearing it of the adhering
hard mucus,  or blood.   When the pin is withdraAvn, Avithout
the point  being  previously cleaned, it comes through with
pain, and difficulty, and  may even tear the new  adhesions.
After a slight suppuration has loosened the pins,  they should
not be alloAved to remain, for they are in danger of deforming
the lip.
   There  occur incysted tumours of the fleshy part of the lip,
 which  nothing  but the  knife will  remove.   I  have taken
 them out by dissection, rather than as the cancerous lip is
cut.  Stretching the lip over the finger of an assistant, and ex 
OF THE HARELIP.
2.;
posing its inner surface, we can dissect out the tumour, with
out cutting its sac, and  here as Avell as in accidental cuts of
the lip, the edges will be best brought together by ligature.

                     OF THE HARELIP.

  The operation for the harelip, is  the  same Avith that jusi
described, only that in some instances the irregularity of the
cleft lip, requires a more peculiar nicety in adapting the in-
cision, so as afterwards to bring the parts accurately together.
  Of the simple cleft av e need say nothing further, than that
the edges of it are to be pared off, Avith an uniform, firm in-
cision, and then to be brought together, as Ave have described
in the case of cancer.' We  first separate the  lip from the
gums, if they are adhering, then we may either cut the lip on
a piece of wood, put in betAvixt the lip and gums, or use the
harelip-forceps, to hold the lip Avhile the edge is cut off.
   In this form of the disease also,  there can be but one Avay
of operating,  although it is sometimes performed Avith  dif-
ficulty.
   The patient's head rests on the assistant's breast.  The sur-
geon separates the lip from the gum, if it be necessary, then
takes hold of the lip, of one side, Avith the harelip-forceps,
leaving out from under their edge, Avhat he means to cut off,
and Avith one motion of the scalpel he cuts  this portion off—
Then moving his instrument to the other side, he places it so,
that he may pare off the edge of that also,  and  bring the ter-
mination of the cut accurately up, so as to form an angle Avith
the first. 
28
ABSCESS OF THE FRONTAL SINUS.
   Tlie disadA-antage  of the harelip-forceps is, that they do
not take a firm hold of the lip.  They grasp unequally, and
Avhen the incision is but half performed, the lip is apt to slip
from them—Sometimes the dryness of the lip in the first cut,
gives a firm hold, while in  the second, the forceps or lip, be-
ing bloody, they slip.
   The pins are introduced as in the instance of cancerous lip,
and the precautions are of course the same.
   The operation may be done as successfully in an infant, as
at the age of 14 years.
   Sometimes the fissure of the lip is accompanied with a cleft
in the  palate, and a deficiency of the bones.   When part of
the maxillary bone stands projecting out of its place, it may
in young subjects be violently pressed doAvn, and made to ad-
here in its proper  place.  The deficiency of the  palate  will
diminish, as the child advances in years.
   On examining the bones of the face of children, with a cleft
palate, I have found that the diminutiveness of the upper
maxillary bone of the one side, Avas more apparent than real.
The fissure  is oAving  to the bone  of one side, being thrust
laterally, and of course made also  to project somewhat.  If
this centre piece of the palate project irregularly, I have said
it may be broken  down, and forced into its place.  But  if
the jaAv-bone of one side be only pushed  laterally, Avhich is
the most common kind of deformity, then I imagine by a
compress operated upon, by an elastic steel bandage, coming
round the head, the  bones may be gradually brought into
their places, so as  to fill up the  fissure of the palate.   The
cure may then be completed, by the usual operation on the
cleft of the lips.   Or the operation being done on the lip, the
after treatment will be, to bring the pieces of  the  superior
maxillary bone together.

     ABSCESS IN TIIL FRONTAL AND MAXILLARY SINUS.

   The sinuses both of the frontal bone, and the superior max-
illary bone, are subject to disease.   The  membrane of  these 
abscess of the frontal sinus.            29
passages, always acutely sensible and subject to inflammation,
becomes either from such general  inflammation as Ave see iu
catarrh, or from injuries, or the neighbourhood of disease, the
seat of a more confirmed disorder, and of suppuration.
   In the frontal sinuses inflammation  is attended Avith  dull
heavy head-ach, and pain, in the  part.  The pain is more
severe on  stooping; the integuments over the  sinuses are
swelled, and puffy.  The patient is sensible of a peculiar of-
fensive smell, and it Avill probably be found, that at intervale,
there has been discharge of matter from the  nose.  All this
may be, and still Ave must use general  remedies, nor think of
performing so formidable an operation,  as applying the trepan,
on  the frontal sinuses.  It is much more likely to be a com-
mon catarrhal affection, than a formidable disease, or it may
prove  merely head-ach, assisted by the imagination of the
patient.   But Avhen there has been injury previously, AAhen
there  are symptoms of a beginning affection of the brain,
when there is occasional sickness, or much languor, or oppres-
sion, or any thing like epilepsy, or  paralysis, a slighter  indi-
cation will satisfy the surgeon of the propriety of an opera-
tion.  If  there be a collection  of  matter,  and an inflamed
sinus slowly affecting  the brain, the  delay of an  operation
may leave us full of regret.
   If the frontal sinus is to be opened,  we must proceed Avith
all the precaution?, which we  should employ in the more
common occasion of using the trephine.
   1. We have to recollect the thinness of the outer shell of
the  bone.   2.  The obliquity  of the  inner table.    3.  The
partition which divides  the  tAvo cells.  4.  We have to re-
member, that the  lining membrane of  the cells will probably
be thickened, and that if  diseased it looks like a suppurating
brain, and has actually been mistaken for  such!   5. That,
when the trephine has taken out the circle of the outer table
very neatly, the membrane will still be entire, and require to
be opened with the lancet.  The cure will then be conducted
by emollient injections.  No tents or dressings ought to be
introduced into the cavity. 
30
abscess of the maxillary simus.
   PERFORATING THE MAXILLARY SINUS FROM THE ALVEOLI.

   The abscess of the maxillary sinus is marked by a colourless
 swelling of the cheek, over the bone, by a pulsating pain, deep
 seated in the cheek, generally fixed to the cheek, though some-
 times extending over the whole side of the head, but not in-
 creased on pressure, by an oozing of matter by the side of one
 of the molares, sometimes by a discharge of matter from the
 nose.  We find indeed  that the most frequent complaint of
 our patients is that of foul matter fknving  into their mouth,
 when they lie in bed.
   We are to be careful to distinguish  it  from rheumatism
 tooth-ach and a nervous affection of the face.   When it arises
 from tooth-ach, succeeded  by high  inflammation,  or comes
 after fever, or succeeding to injury of the bones of the face, or
 has any such  ostensible cause, it is favourable; and  by the
 drawing of one of the  molares, or perforating the sinus,  and
 thus allowing a free exit to the matter, the disease  will be
 cured.
   All  the treatment necessary in this disease, is to draw the
 second molaris, and then to pass up a stilette of the size of a
 writing quill, into the sinus; nature seems to point out that
 this is the better place for perforating, though it be sometimes
 done just above the alveolar process of the molares.   The ob-
jection to this last place is that without taking away a piece of
 the gum, it is difficult to keep the perforation open.
   If the perforation be made in the side of  the  sinus, then
 the instrument, which makes the hole for the point  of the tre*
 phine, Avill answer.
   When a patient presents Avith the sinus opened, and  the
 matter running from it,  the operation having been done some
 time before, Ave are not to despond, but to enlarge the opening
 for it has probably been made too small.
   After the operation the swelling may require fomentations,
 or astringent washes.   When the swelling has subsided, and 
             OF THE OPERATION FOR WRY-NECK.           31

the discharge  remains foetid, the patient can  force the fluid
from the mouth into the cell by the tongue merely*.
   If in this disease there should form an ulcer on the cheek, or
just under the orbit, the disease is still to be relieved, by the
operation performed beloAv, since that opens into the  floor of
the antrum while the attempts to preserve the  opening on the
cheek, and to throw in injections there, will increase  the de-
formity, even if they should be in the end successful in curing
the disease.                                             t

                        WRI-NECK.

   In the case of wry-neck,  which is submitted for operation,
the mastoid process, is as it were drawn toAvards the sternum,
the head is inclined to that side, and  the chin is pitched up.
On examining the cause of this,  tlie mastoid muscle of that
side, will be found  to be smaller than that of the other side;
it feels stringy and hard; it a\ ill not stretch when the muscle
of the other side acts so, that it suddenly checks the turning
of the face toAvards the same side.
   The  disease of the muscle which occasions this, is a very
singular one.   The  muscle is changed into a  firm substance,
Avhich to the knife cuts like gristle, and Avhich is equally inca-
pable of contraction, or stretching.  I have chiefly seen the
portion of the muscle Avhich arises from the sternum, diseased
in this manner ; it Avould appear that to others the clavicular
portion, lias oftener  presented thus changed  in its texture.
   In one instance I traced this  disease, to a fall, and twist of
the neck.   One cannot  imagine a more  likely cause  of this
disease, than a strain upon the muscle.   I have seen a similar
disease, in a portion of the biceps cubiti, producing the effects
of an anchylosis, in fixing the elbow-joint.
   The  only thing that the surgeon has to consider deeply is,
whether the twist of the head proceeds from this disease or
not.  Whether the  vertebra have not greatly suffered, or it

  * Tincture oi myrrh, and a little camphorated  spirit diluted, is the be*+.
v-hen the discharge is foetid. 
                  /
32          OF THE OPERATION FOR WRY-NECK.

may be, there is almost an anchylosis of the cervical vertebra?.
We  have to see that there be no paralysis of the muscles;
of the opposite side, rather than a permanent induration of
this.  If the distortion proceeds from a  contraction of the
skin  of the  neck, it will be sufficiently apparent, and distin-
guishable.

                        OPERATION-

  The  patient may be supported upright on a chair, then
examining avcII the tract of the stringy part of the muscle, an
incision is made tAvo inches  and a  half, or three inches in
length, through the integuments over this diseased part of the
muscle.  This will be found to carry the  loAver part of the
cut, Avithin an inch of the sternum.
  Having cut down fairly to the surface of the muscle, the
muscle is to be  relaxed by moving the face to the contrary
side, and then the finger, or the handle of a knife or hook, is to
be insinuated behind the contracted and diseased part of the
muscle.  This part is to be cut across by successive lesser cuts,
the handle of the knife, or hook which is under it, guarding
the parts beloAv ; or a directory is  introduced, by aa Inch the
knife is guided under the  muscle, Avhen the diseased part  of
the  muscle  is divided  by draAving the knife outAvard; the
part as  I have said, cuts firm like a  tendon or  cartilage.
When the Avhole diseased part is cut across, the patient feels
as if a cord Avhich had long bound down the side of his head
was cut across; he can turn the head toAvards the other side.
but  he  brings it round again Avith more difficulty, and for a
time the position of the head is aAvkAvard.
  Noav we will see the advantage of the first incision, being iu
the length of the neck, for the more Ave make the patient hold
the head toAvards the other side, the  closer the lips of the
wound are drawn, though the space betwixt the cut surfaces
of the muscle be considerable.   I have not found the bandage
to be necessary, during the cure of young people, the antago-
nist  muscle  answering the purpose ; but if after a long con- 
OF THE CATARACT.
33
 tinuance of the disease, there should be such a change in the
 form of the vertebrae, that it requires the continued operation
 of a bandage, then a roller is to be put around the head, and
 brought over the opposite ear, so as to come doAvn fonvard and
 pass under the arm-pit.
    If the distortion be owing not to the rigidity of a  particu-
 lar muscle, but to a more general  defect of the muscles of
 the side  of the neck, or to general thickness, and induration
 of the integuments, Ave must be  contented Avith the  trial of
 such remedies as friction, Avith mercury  and camphor, and
 tlie  use  of the bandage, electricity, &c.  If the cicatrix of
 the  skin should  be the  cause, it is advised that it be cut
 through, and the head kept in an opposite direction.   It is a
 very troublesome business, and I  Avould rather endeavour
 perseAeringly to relax  the  contraction  of the skin, by giving
 motion to the head, and here  emollient  embrocation may also
 be recommended.

                     OF THE CATARACT.

   The cataract  is the crystalline  humour of the eye, be-
 come opaque. It is characterized in the beginning by these
 symptoms.   The  person  has  a haziness before his eyes, he
 thinks he sees black  specks or  flies, or streaks  of black  moving
 before him, the vision is indistinct and  rather diminished in
 strong light.  Upon inspecting the eye, there is a Avhitencss
 and turbid opacity in the pupil.  This  is an  affection not pe-
 culiar to any age, though more common after the middle age.
 Sometimes it comes suddenly, though oftener very gradually.
 It may arise from inflammation, in some rare  cases it has been
 dispersed by a casual inflammation.   Sometimes there is  only
 a  cloudy opacity to be seen in the pupil, oftener the Avhole
 pupil is of a greyish colour, or it is of a  deep milky Avhitencss.
   When the cataract comes as a consequence of a blow, or of
 inflammation, it ought to be a reason  of delaying the opera-
 tion,  as long  as possible, for  these  oparitie- will sometime
spontaneously  disappear.
   vol. ir.                   ¥ 
31                  OF THE CATARACT.

   The following circumstances previous to  the  operation,
have to be attended to.  1. Is the patient though blind, still
sensible of the variations of light, does he distinguish a\hen an
opaque body  is passed before his eyes, or can he distinguish
light from darkness ?  The reason of attending to this circum-
stance is, that Ave may discover if the retina be yet sensible,
though the rays of light are  Avith  difficulty transmitted,
through the opaque crystalline  humour.   2. Is the  iris still
moveable? because if it still enjoys its motion, light being its
only stimulus, and the retina being  alone sensible to light, it
indicates the sensibility of the nerve.  3.  Further in the mo-
tions of the iris, Ave have to  observe if the pupil remain per-
fectly regular.   The irregularity of the pupil, may, most pro-
bably, be owing to some adhesion of the cataract, to the edge
of the iris, and indicates to us, that there  has been a deep in-
flammation there.  The irregularity of the pupil, is an unfa-
vourable circumstance, but not a total bar to the operation.
   4. The cataract Avhich has arisen  from a bloAV on the eye,
or after violent and deep ophthalmia, is, for the same reason,
unfavourable.   Since it is  reasonable to suppose,  that  the
membrane of  the lens has  been thickened, and has formed a
firm adhesion  to the surrounding parts.  But fortunately the
cataract is not often preceded by this inflammation.
   5. When we look into the eye, to discover the seat of opaci-
ty.  We look  first nearly perpendicularly into the pupil, but
then Ave must  turn the patient's head gradually until Ave  see
the profile of  the cornea;  and noAV  if  the opacity should  be
caused by an  effusion in the back part of the cornea, it is dis-
tinctly seen to be before the iris.
   6. The deep black transparency of the pupil, and the Avarit
>f motion in the iris, will sufficiently distinguish the amauro-
sis (the insensible state of the retina) from the cataract.
   7. The  cataract may be of a consistence  firmer than  the
lens  is  naturally; it may  be soft as cheese ■, it may Aoav li-
quid like milk, Avhen  punctured, but I knoAv not hoAv to fore-
see these distinctions by attending to the appearance of  the
cataract, before operation. 
        OF COUCHING, OR DEPRESSING THE CATARACT.      35

  Surgeons of eminence, and oculists, still dispute this point,
viz. Avhether the  depression or extraction of the cataract, be
the preferable operation.   The depression of the cataract is
done by introducing a needle into the eye, and  removing the
opaque lens from the axis of the eye.  The extraction is a
very improper term, but it means the making an incision into
the cornea, by which the cataract escapes, being pressed for-
Avard by the  vitreous humour.   In the performance of these
operations, the  utmost delicacy is required,  and they have a
result the most interesting of any of the operations of surgery.
Although the general opinion, at present, be in favour  of the
operation of  couching or  depressing  the cataract, yet all >
have  seen makes me prefer  the operation  of extraction.  I
shall, however,  describe the operation of couching the cata-
ract, first.

        OF COrCHINC, OR DEPRESSING THE CATARACT.

  The operation should not be performed  on one eye, whih>
the other is sound; and  when both eyes have  cataracts,
though Ave have great temptation  to operate on both, (by
which on the Avhole Ave increase  the chance of success) yet I
conceive the operation should be done on one side only at a
tune.  If the eyelids be much affected Avith a chronic inflam-
mation, Ave ought to endeavour to  correct  this, previous  to
the operation.  But if this is obstinate and habitual, and to no
great extent, it makes no objection to the operation.   No cross
light must be admitted into the room; tlie north light is to be
preferred, and it should strike obliquely on the eye.
  1. TI12  patient is seated on a chair, Avith a  long upright
back.  A pillow  is placed to receive his  head; the assistant
stands behind him  to press his head upon the pillow, and in
part to support it with his breast.   A napkin is thrown over
the other eye.
  2. The assistant  puts the points of his fore and middle fin-
ger, on the upper eyelid, and raises the eyelid, at the same
time he gives a slight pressure to the eyeball, but rests his  fin- 
3(i      OF COUCHINC, OR DEPRESSING THE CATARACT.

gcrs at the same time on the margin of the orbit, so that Avhat
pressure they give to the eye may be steady.
  3. The surgeon sitting  doAvn before the patient, places his
foot upon a  stool  of such  a height, that when the  elboAv rests
on the  knee, tlie hand may be opposite the eye.   Noav Avith
the fingers of one hand, he presses down the loAver  eyelid, and
when he Avishes to fix the eye, as he is about to introduce his
needle, he pushes upon the eyeball Avith the point of his fingers.
It is to be particularly observed, that any change of the de-
gree of pressure on  the eyeball during the operation, is to be
made by the motion of the operator's fingers, the assistant has
only to keep steady.
  4. The surgeon having dipt his needle in oil, he takes it as
he Avould a Avriting pen, he rests his little finger on the bone of
the cheek, and he pierces the Avhite part of the  eye, in the
middle  betAvixt the margin of the cornea, and the angle for-
med by the  eyelids, the patient's eye being  directed straight
fonvards.  The needle should pierce the sclerotica in a direc-
tion perpendicular to the convexity of the surface,  or, in other
Avords, pointing to the centre of the eye.
  5. The needle is  noAv to be someAvhat changed in  its direc-
tion, and carried horizontally until the point appears behind
the pupil, for it is to be observed that, although the opacity of
the lens is considerable, yet the needle is  seen through it, or
Avhen it is immersed in its substance.   The flat surface of the
point ought to be towards the irk, as the sharp edge might
cut the iris.
  6. The first motions of the needle, I conceive, ought to be
calculated to pierce  and tear the anterior part of the capsule of
the lens.  And this for two reasons.   Before the cataract can
be displaced from its seat in front of the vitreous humour, its
capsule must be broken, and this being done, by  piercing it
on the fore part, of course facilitates  the descent of  the cata-
ract.  Again, Avithout this precaution, it happens  that  the
cataract being couched, the fore part of the capsule remains,
and in the inflammation Avhich necessarily folloAvs  the opera-
tion, it becomes opaque, and forms Avhat is called the mem- 
OF COUCHING, OR DEPRESSING THE CATARACT.
37
uraneous cataract.  We have, therefore, to push the needle in
a direction  parallel to the iris, and get  before the lens, then
carry the point through the pupil, so as to burst through, or
cut the fore part of the capsule.
  7. Supposing that on the first touching the capsule of the
len?, a white fluid escapes, and makes the aqueous humour
turbid, Ave are not on this account to despair of success; for
this  milky and dissolved state of the cataract promises a
quick  absorption, and restoration of vision.   It is our busi-
ness in this case to tear the anterior half of the capsule, as
widely as  Ave may, without hurting the iris, and to plunge.
the needle  repeatedly into the  cataract, and then to tie up
the patient's eye as usual.
  8. Having torn the capsule,  the surgeon  AvithdraAvs  the
needle a little, and puts  it over the cataract, or pierces the
cataract  high on its disk.   Now the  point of the needle is
to be  depressed, by  raising the handle  of  the instrument;
but at the same time that the point of tlie needle is depressed,
 carrying the cataract Avith it), it must be moved backAAard.
A
                            i)

  For example A, being the lens in its natural situation, to
remove it from the axis of the eye, or course of the  rays of
light B,  C, it is not to be  pressed directly doAvmv ard in the
line D, but in the circular line E, which  answers'to the con-
cavity of the  coats, and by this movement it will be carried
down and lodged at F.
  9. When by raising the handle of the needle, the operator
has carried the opaque cataract thus beloAv the level of the
pupil, and the pupil is clear,  the operation is not done, for 
 38     OF COUCHING, OR DEPRESSING THE CATARACT.

 in all probability, the cataract has not escaped from its cap-
 sule,  and,  on  Avithdrawing  the  needle,  it will rise again.
 He therefore would have to blame himself, if, having with-
 drawn the needle from the  eye, he saw the cataract again
 forced up, and take its place behind the pupil, for the ope-
 ration would be  still to do.  When, perhaps after repeated
 efforts, he  has  sunk the cataract  out of  sight, he must cau-
 tiously  withdraw the necC.d from its hold upon the  cata-
 ract,  but not altogether upon the eye;  then, if the cataract
 does not appear in the pupil, the needle is to be sloAvly  Avith-
 drawn.
   The fact is,  that when  the needle has carried  down the
 cataract, the cataract is not yet unseated from its capsule,
 and instead  of being separated  from the vitreous humour
 that body has revolved Avith;  by the elasticity  of the mem-
 brane it  will resume its former relation,  and of course carry
 up the cataract,  so as again  to present it in the axis of the
 eye.  But  the  cataract  may have been separated from its
 connexions to the fore part of  the vitreous humour, and yet
 rise in a partial manner, on withdraAving  the needle ; this is,
 because it had not been so forced into the vitreous humour,
 as to break on its capsule, and make a lodgment for itself;
 the elasticity of the vitreous humour throws it out again.
 It is incorrect to  say, that  the  cataract has been buoyed up,
 since  it is specifically heavier than the vitreous  humour.
   There is a possibility, that the cataract may escape  from
under the pressure  of the needle, and pass through the pu-
 pil, into the anterior chamber  of the aqueous humour.  If
 the whole or part of  the cataract escape thus, we  ought  to
let it remain;  it Avill dissolve in the aqueous humour, and
be finally absorbed.   The  cataract may start backAvards,
too, so as to be  deeply immersed  in the vitreous  humour.   I
have seen it faintly shining half an inch  behind the pupil.
I fancy this is not a frequent accident; if it should happen,
Ave are  to  do no violence in endeavouring to remove it, as
Ave are assured it will dissolve, since it  must, in this  case,
be freed  of its  capsule. 
        OF COUCHING, OR DEPRESSING THE CATARACT.     39

  10. It is a more difficult thing  to fulfil the intention of
the operation, when the cataract is soft  or cheesy, for when
the needle is pressed  upon  the cataract, the needle  passes
through, Avithout dislodging it from its place, nor does the
matter Aoav out from the capsule.
  We ought,  in this  case,  to break, or  burst through the
capsule, and, as  freely as  possible, admit the aqueous  hu-
mour through the anterior part of the capsule; and a second
intention ought   to be to break down the  cataract, which
is increasing  the chance of  its dissolution aftenvards.  By
perseverance in pressing with the  broad edge of the needle,
Avithout injury to tlie eye, it av ill often be possible to remove
the cheesy matter from the centre of the pupil, so that af-
tenvards the patient shall see a little.
  11. If there be an adhesion of the cataract to the iris, we
shall discover this by the  irregular figure Avhich  the pupil
assumes upon the variations of light, admitted to the eye.
During operation, if the  depression of the cataract should
disorder  the regular circle of the  pupil, it is OAving to an
adhesion, and we must endeavour  to separate the cataract,
and iris, by the edge of the needle, before Ave attempt final-
ly to depress the cataract.
   12. If after a feAv days the eyelids are opened, and there
appear any fragments of the cataract, they  are again to be
depressed, or pushed before  the pupil  by the needle;  but,
this is not to be done until  the inflammation and irritability,
the  consequence of the first operation,  have entirely sub-
sided.
  13. The remains of opacity behind  the pupil,  may  be
Avhat is termed  the membraneous  cataract.  To  tear aAvay
these shreds, and to push them below the level of the pupil,
or through the pupil into the anterior chamber of the aque-
ous humour, a needle should be used so curved near the point,
that by  merely  rolling the needle,  betwixt  the  finger and
thumb, the point of the needle may  be moved pretty exten-
sively.  With such a needle the operation may be done with
less violence, and a smarter  motion  may be given to the poinl 
 40     OF COUCHING, OR DEPRESSING THE CATARACT.

 of it, than where, in order to give motion to the point of tlie
 needle, Ave have to raise the handle.
   14. Any portion of the  cataract, or any shreds of the cata-
 ract, or its capsule,  which are accidentally pushed into the
 anterior chamber of  the aqueous humour, are to be allowed
 to remain there,  for they will be dissolved, and carried away
 by absorption.
   15. The secondary cataract is the opacity of the remaining
'capsule, which is not carried doAvn Avith the opaque lens, but
 remains in its situation.  The secondary cataract may be per-
 fect or partial.  It may be said to be perfect when the lens
 has escaped from the back part of the capsule, and has been
 immersed in the vitreous  humour, Avithout the anterior half
 of the capsule being torn from  its connexions to the ciliary
 process, or rent in any way.   This is more apt to take place,
 than  Ave at first AA-ould imagine likely, from the greater tenuity
 of that part of the capsule which is toAvards the vitreous hu-
 mour, than the anterior portion of it.   The imperfect, or par-
 tial secondary cataract, is the remaining shreds of the anterior
 part of the capsule.   It is  an  opinion,  that only  the  anterior
 part  of the capsule is liable to become opaque, and I think
 this is very likely ; there is a  foundation in anatomy for sup-
 posing that the anterior, and  posterior part of the capsule of
 the lens, are of a different nature.  It is this conviction, that,
 the fore part  of  the capsule is most frequently opaque, and
 that it is the most liable to be so after the operation, that in-
 duces us to be careful to  pierce, and  break  doAvn this fore
 part,  before couching the opaque lens.
   If this has been done, only shreds of opaque membrane cas*
 be visible in the pupil, after the operation. And if t hey ap-
 pear,  Ave ought to let them remain for some time,  in the ex-
 pectation of their wasting,  and acquiring transparency again.
 I have seen, on dissection, an opaque  spot on  the back of the
 capsule, and therefore I am forced to say, that the secondarv
 cataract may be in the posterior segment of the capsule of the
 lens.   But Avhether ths opacity be in the buck, or fore part of
 the capsule, is of little consequence, since it cannot be distin- 
OF THE EXTRACTION OF THE CATARACT.        41
-guished in the living eye, (because the vitreous humour forc-
 es the back  part of the capsule into contact Avith the iris, aftei
 the depression of the lens itself,) and happily it is of little con-
 sequence to know  Avhat part of the capsule is thus diseased,
 as  this supposed distinction would make no variation in the
 practice.
   16. In operating for the membraneous or secondary  cata-
 ract, the intention Avith which we use the needle may be some-
 Avhat varied.   We first endeavour to tear doAvn the opaque
 membrane, and to place it under the level of  the pupil, or we
 may attempt to gather the shreds of the membrane together,
 to loosen them from their natural attachment, and to  push
 them through the pupil,  into the anterior chamber of the
 aqueous humour Avhere they will be dissolved and absorbed.
 We ought not to  be too persevering in  our attempts  to clear
the pupil of the membraneous cataract at once, on the contra-
 ry we should be  careful to do little injury, so that we may
avoid raising inflammation.  We repeat the  attempt after  a
 time.  The needle should be very fine, and curved  at the
point, not like  that which is adapted for pressing down the
cataract of the body of the lens.


          OF THE EXTRACTION OF THE CATARACT.

  The extraction  of the  cataract, I allow to be a more for-
midable  operation than couching;  but when it is Avell done, it
is more uniformly  successful.   I do not  know that it  is more
difficult to perform extraction, than it is to perform couching;
but the blunders in this operation are at once apparent, while
in couching the errors are concealed;  and even the initiated
cannot precisely say from the motion of the  hand, whether
the operator be, with delicacy and niceness of intention,  re-
moving the  opacity from  the pupil, or making unmeaning,
and consequently, unsuccessful motions of the needle.
  Freedom  from tumefaction and inflammation of the  eye-
lids, and  of all tendency to ulceration in their edges, or to opa-
  VOI. if.                  c 
 12        OF THE EXTRACTION OF THE CATARACT.

 city in  the cornea,  is more essentially necessary,  previous ta
 performing the operation of extraction, than of couching.
   Extraction, let me say, is a bad term, as it indicates that
 the  intention of the operation is to make, an incision, and to
 pull out the opaque body.   This idea is  as dangerous, as it is
 incorrect.   The principle on  which the  operation is done, is
 simply this.  The coats of the eye are tense over the contain-
 ed humours.   Over the coats  of the eye, are expanded the
 tendons of the muscles, while the eyelids have in them the
 fibres of the orbicularis muscle.   The moment that the eye
 is Avounded therefore, the humour escapes at  that part.  If
 an accidental Avound be made on the Avhite of the eye, the vi-
 treous humour escapes in part.   If the  cornea be Avounded,
 the aqueous humour escapes.   But although  the cornea  be
 punctured, and the water escape,  it does not  fall flaccid.
 But the iris and the lens are pushed forward by  the  tension
 of the coats on the vitreous humour, and  they take  the place
 of the aqueous humour.  Should the cornea not be punctured
 merely, but cut with so wide a wound, as to allow the lens to
pass,  the  pressure  on the  vitreous humour  by the coats
 and  muscles of  the eye  will be so great,  that  the lens
 w ill be thrown in  through  the pupil,   and  escape by  the
 wound.
   The operation to be performed, then, is  not to extract the
cataract, as Ave speak of extracting the  stone from the blad-
 der ;  but only to make such an opening in the cornea, as to
 alloAv the cataract to be forced out by the tension of the coats
of the eye, Avhich is continual;  or by the action of  the mus-
cles of the eye.   The necessity of attending to this  principle
 during the operation, I hope Avill be presently evident.


                      INSTRUMENTS.

   If the operation is successfully  done, no other  instrument
need be used, but a knife, of  a form someAvhat peculiar, and
adapted to make the proper incision of the cornea.   The knife 
OF THE EXTRACTION OF THE CATARACT.
43
    is of the form seen  in the succeeding marginal plate p. 45.
    The point  must be very sharp,  the back straight, not sharp,
    and yet not thick; the curved edge very sharp, and the  mid-
    dle of the  knife the thickest, and strongest part of it; in the
    first place,  that the knife may  have strength to be pushed
    through the cornea, and in the next place, that it may effect-
    ually fill up the Avound as it is pushed fonA'ard.  The broad-
    est part of  the knife must be fully tAvo thirds of the diameter
    of the cornea.
      The incision  is made,  by passing the point  of the  knife
    through the cornea, and  across the  fore-part of the eye,  Avith
    one uniform motion, and the point entering on one side the
    cornea, near its attachment to the sclerotica, transfixes the op-
    posite point, and being still carried forward, the Ioaa'ci*  edge
    of the knife cuts freely through  the Avhole  loAver segment of
    the cornea, until it is disengaged.   But if the breadth of the
    knife be  not sufficient to make  its Avay out, Avhen thus uni-
    formly pushed onAvard, the edge requires to be pressed doAvn ;
    an incision  larger than the knife can fill up is consequently
    made, the  aqueous humour escapes, and the iris  is pushed
    forward on the edge of the knife!  A little oil should be on
    the  point of the knife.
      To suspend the eyelid, and in some degree to fix the  eye;
    the  Avire speculum is best  in the hands of the assistant; the
■   pressure to  fix the  eye must be made by the tips of the sur-
    geon's fingers, at the same time that he holds doAvn the lower
    eyelid.
      A gold needle is among the apparatus of the oculist.   The
    use of this  is, to break or cut the capsule, Avhen after cutting
    the cornea,  that membrane strongly resists  the  effort of the
    muscles, to protrude  the lens.  The point  should rather be
    rough than sharp,  whether it be made  of gold or of any
    other metal, is of little consequence.
      Forceps  too  are necessary, and  they  must be of such a
    form and niceness, that Ave may introduce them under the flap
    of the cornea, and seize any shred of opaque membrane,  that
    may present in the pupil. 
'H         OF THE EXTRACTION OF THE CATARACT.

  For the same purpose, and to extract any broken piece of
the cataract that is detained, a very delicate hook is to be
provided.
  The cornea scissors are absolutely necessary too, to increase
the incision of the cornea, if it shall be necessary, or to sepa-
rate any protruding  capsule.   A fine  probe will be found
convenient to replace the prolapsed iris, Avhen it shall have
fallen  out from the incision.  Such a probe will also serve to
dilate the pupil, if it be necessary; but of this, we will speak
presently.

                        OPERATION.

   The patient is seated on a low chair ; the surgeon is seat-
ed  opposite to him;  the light must be  steady,  and without
glare.  A cloth is put over the other eye.  The surgeon turns
the patient's  head until the light falls a little obliquely on
the eye to be  operated upon;  the depth of the pupil,  and
its  nearness to the cataract, is then distinctly seen.
   1. Tlie assistant standing behind the patient brings  his
breast so as to support  the  back of the head;  puts his left
hand under the chin, and with the right taking the speculum
of  Pelier, he  raises the upper  eyelid by pressing in the in-
teguments of the eyelid, betwixt the eyeball and the margin
 of  the orbit.
    2. The surgeon, Avith the tips of his  fingers, presses  the
 loAver eyelid against the eyeball,  so as to fix it; the margin
 of the eyelid is at the  same time  carried down so that  the
 cornea stands prominent.   The  other hand holds the knife.
 He rests the elbow on the knee,the Uttle finger on the cheek.
 hone.
    3. When the  eye is steady,  the point of the knife is made
 to  pierce the cornea, Avithin half a line of the sclerotica, and
 on the outside and a little  above the  middle of the cornea,
 the flat side of the knife is  toAvards the eye, its straight back
 upAvards.  The  knife is  noAV  carried in a direction toAvards
 the nose, and at the same time downwards.   The nicety  of 
OF THE EXTRACTION OF THE CATARACT.
4j
this part of the operation is to carry the knife uniformly for-
ward, to press in that degree Avhich Avill keep the eye steady,
and yet so to manage the pressure, that the aqueous humour
does not escape by the side of the knife.
   4. The point of the knife is made to pass  over the  lower
half of the pupil, and enter the opposite  side of the cornea,
at the  same distance from the  sclerotic coat, as Avhere the
point first entered.  Noav, being carried  uniformly forward,
the loAver edge of the knife will cut the lower segment of the
cornea, at the distance of half a line from its  connexion Avith.
the sclerotica.
   The knife is here represented, passed, not directly across the
eye, but entering near the margiu of the cornea, a little fur-
ther up than usual, and the point coming out a little lower.
   The intention of this is, to prevent the eye from  turning
towards the nose during the operation ; Avhich it is very apt
to do, Avhen the knife is pushed directly from without hiAvard.
Although in pushing the knife in this direction, the eyeball
should be turned as much doAvnward, as in  the other way it
would be inward, yet, Avhen the eye is turned doAvmvard,  we
can better proceed Avith the operation, or more easily turn the
eye to the proper direction.
   When the eyeball moves before  the knife, Ave must suspend,
as it Avere, the progress of the knife, but not in the slightest
degree AvithdraAv  it;  Ave Avait a little for the ceasing of the
spasm, and then Avith the  knife, bring back the eye to its
original position.   Often, I  may say, the oculist distracted by
» 
46
OF THE EXTRACTION OF THE CATARACT.
this simple accident, brings out the point of the knife too soon,
and instead  of making a semi-circular  incision of the cornea
near its margin, makes a cut, terminating nearly in the middle
of the cornea, thus :
   A. The proper course of the incision, marked by a dotted
 line.   B. The course which the knife has taken in cases, where
 I have seen the  operator embarrassed,  by the eye turning in-
 ward.

   5.  It  is to prevent this motion of the pupil toAvards  the
 nose,  that practitioners have exerted all  their ingenuity, to
 form  a speculum to fix the eye.   The first objection to  the
 use of the speculum, is, that it engages the hand of the sur-
 geon, when he should have his finger free, to press upon  the
 surface of the cornea ; and secondly, that the speculum ope-
 rating by pressure on the eye,  is apt to force the aqueous hu-
 mour out, before the incision is completed.
  6.  Some oculists have recommended, that the capsule of
 the lens,  should be punctured, before the incision of the cor-
 nea be completed, viz. as the knife is carried through  the
 anterior chamber of the aqueous humour, they depress  the
 point  into the pupil, to pierce the capsule.  But  this is a
 practice not to be imitated, as the advantage of it, bears no
 proportion to the danger.   The consequence of  this manoeu-
 ATe, too often will be, that the aqueous humour will escape  ;
 then the iris will press fonvard on the edge of the knife, and
the incision cannot be completed with the knife.
#» 
           OF THE EXTRACTION OF THE CATARACT.         47

  f. If by any accident the aqueous humour should escape,
and  the margin of the iris should fall before the edge of the
knife, in this manner, we cannot then carry fonvard the knife.
   This accident  requires calmness.  We knoAV how it  has
happened, and, this knoAvledgc  teaches us to  remedy it.   A
little of the aqueous humour  has escaped, and the iris is
pressed forwards: Ave  must restore the equilibrium then, by
pressing gently on the cornea.  This throAvs back the margin
of the iris behind the edge  of the knife, and again we  can
carry the knife straight forward*.
   8.  But  if the  aqueous  humour, has  escaped in  such a
quantity, that the iris has come in contact Avith the cornea,
and lies before the edge of  the  knife, we  cannot  finish the
section of the  cornea Avith  the  knife.   The point of the knife
must be AvithdraAvn a little, and  brought before  the  edge of
the iris,  and made to pierce the cornea loAver  down, than
Avould be  necessary to make  an incision of  due  extent.   By
this change of the  direction of the knife,  Ave have  made a
section of the cornea, Avithout injury to the iris, but it is  not
of sufficient size to let  the  cataract  pass, Ave  must therefore
have recourse to the scissors to  enlarge it.
   9.  When Ave have made  the  section  of the cornea  too
small, and the lens or cataract does not come  spontaneous-

  * Baron AVenzel and Mr. Ware, give the direction to rub the cornea, as
if there was a sympathy betwixt the cornea and iris: but as I have not been
able to ascertain that any connexion subsists betwixt the rubbing of the one,
and the contraction of tlie other, I  have given this intelligible reason fei
pressing the cornea. 
48         OF THE EXTRACTION OF THE CATARACT,

ly forward, Ave must insinuate one of the blades of the fiue
scissors under the flap of the cornea, and enlarge the incision.
  10. I shall suppose that the section of the cornea has been
duly made, and  the cataract does  not immediately follow.
Some oculists have  recommended that  Ave introduce a  cu-
rette into the pupil, and  enlarge it.  This is an ignorant a\ ay
of dilating the pupil.  We ought simply to shut the eyelids,
and cover the eye with the hand, so as to relieve the excite-
ment of the eye, and by  excluding the light the pupil will be
dilated, and ten to one but the cataract will be seen coming
from under the eyelids, on lifting up the flap of the cornea.—
If the cataract be still retained,  then it is not the contraction
of the pupil Avhich prevents its  discharge,  but a particular
strength in the capsule.   And noAv the gold needle, or some
such instrument, must be passed under the flap of the cornea,
and into the pupil, to break or  puncture the capsule, Avhen the
cataract Avill be discharged.
  11. The Baron Wenzel and  other oculists Avho have gained
dexterity by practice, without ascertaining the principle, have
asserted that " The incision of the cornea is not the most diffi-
cult  part of tlie operation, and that  it afterwards requires
much dexterity as Avell  as judgment  successfully to extract
the cataract."  AH that I know of the structure of the eye,
and Avhat I have seen of these operations, and the difficulties
I have myself experienced,  contradict this opinion.  The suc-
cessful incision of the cornea is the operation, and all the un-
toward  circumstances that may trouble the operator, have
their source in the imperfection of the section of the cornea,
oi- from some  previous disease  of the eye, as for example, the
thickening of the membranes,  or the adhesion of the capsule
of the lens to the  iris, &c.
  As soon  as  the knife has cut  itself out,  the upper  eyelid
 hould be alloAved to fall; for  the uniform support of the eye-
lid prevents the cataract from being throAvn out too quickly,
or the vitreous humour from folloAving it, if it should  escape
before the  eyelid can be closed.   If upon raising the eyelid
the lens does not make its appearance,  the capsule is  to be 
OF THE EXTRACTION OF THE CATARACT.
49
punctured, and  the eyelids  again closed to allow  the pupil
to dilate.   If it  does not noAv come forward, the small probe
is to be introduced  under the flap of the cornea, to examine
if the  incision  be large enough;  for, from the thickness of
the cornea  and the  oblique direction of the knife, the inci-
sion of the cornea may seem to be of sufficient length on the
surface of  the cornea, when the knife has not penetrated to
the  inner  surface  nearly to  the same extent: if the  incision
should prove too small, it  must be a little enlarged with the
scissors, as  I have said.  If  the cataract does not noAv come
out  spontaneously Avhen the incision  is  eAddently  sufficient,
and Avhen the capsule is punctured, Ave are forced to press
the eyeball.
   12. We  ought not to press the eyeball if it can be avoid-
ed ;  for there  being  a  difficulty  in  forcing  the cataract
through the pupil, when that difficulty is overcome  the vi-
treous  humour is apt to folloAv the cataract;  and often it
will happen, that the  Artreous humour will  escape without
the lens being discharged.   By  this pressure the lens is not
carried through the pupil, but  only the edge  of  it is  pro-
truded, and the  Adtreous humour escapes under  it, while the
firmer cataract is retained*.
   13.  When the iris is cut  by the  edge of  the knife, no
pressure must be made on  the eyeball, or the vitreous hu-
mour Avill  escape while the cataract is  retained.  When  the
pupil  is of its natural form, and the iris entire, the cataract
presents behind  the pupil, and no  part of the  vitreous  hu-

  * Thus we find the  Baron  de Wenzel describing  a thing which
should never be seen—" The cataract did not give  way to the gentle
pressure that is usually found sufficient to dislodge it.  Its upper edge
repeatedly advanced into the pupil, and sometimes almost came through
it," &c.  Every time the crystalline  advanced, a small bladder was per-
ceived on Its posterior  and inferior edge, strongly adherent to it,  and
formed by the hyaloid membrane, &c.  To press the eyeball in such a
state of the lens, and the bladder  which is here described, is out of
all rule.  The bladder is simply the vitreous humour pushing forth un-
der the lens  or cataract, which has turned its ed
being carried bodily through the pupil.
  VOL. IT.                    H
 
50         OF THE EXTRACTION OF THE CATATtACT.

mour  escapes  before it is protruded, but Avhen  the iris h
cut, the vitreous humour being softer, is carried  through
the slit of that  membrane, and  the lens is only turned a lit-
tle, but not unfixed, and pressure may force out all the vitre-
ous humour before the  lens will come.  By inattention to
this consequence of the iris being cut, I have seen a great part of
the  vitreous  humour lost.   If the  iris be cut,  Ave  should
then  indeed  extract the  cataract by piercing  it Avith  the
crooked  needle; unavoidably, I am afraid, some part of the
A'itreous humour will escape.
   14.  When  there is  a  detention of the cataract by adhe-
sion, it is recommended that  Ave should carry  the  golden
needle all round the cataract, and in different directions, to
separate these adhesions.  This appears to me as absurd as
dangerous.   The adhesion is betwixt the capsule and the ci-
liary processes  and iris ; Ave have then only to pierce the an-
terior  part of the capsule, to  open  it freely, if  it  be very
tough, and then the cataract is discharged, for there is no
adhesion betAvixt the  capsule  and the  cataract*.  If, after
the discharge of the opaque crystalline or cataract, opaque
membranes fill the pupil, we may  be tempted  to extract
them ; but if the anterior part of the capsule of the lens bG

  * "After the cornea and capsule had been properly divided, my fa-
ther found that the cataract did not come through the wound on his
making the usual pressure.  He was therefore  obliged to introduce the
needle  and carry  it in different directions round  the crystalline, in or-
der to  destroy tlie adhesions  it had formed to Uie posterior  parts of
the iris.  This part of tlie operation took up  at  least fifteen minutes."
This is the recommendation of the  Baron de Wenzel, his  son, and the
commentator, Mr. Ware.
  On this account we first ask ourselves, why was the capsule  punctur-
ed, but that it might burst freely open, and allow the cataract  to escape;
and if the cataract did not escape, was it not  owing cither to a bad in-
cision,  or if  that is not likely in so dexterous hands, to the strength
and toughness of the capsule ; why therefore  was  the intention of the
operation  changed;  why,  because the lens  would  not  come  forth,
and drag the capsule  with it ?  To have cut  the capsule freely open,
and to have  dilated tlie pupil, was what should have occurred to us
as proper to  be  done. 
           OF THE EXTRACTION OF THE CATARACT.        51

ruptured, though the shreds of that membrane may be visi-
ble, (oAving to their opacity), yet I conceive we have nothing
farther to do, but to  close the eye. By holding the patient's
eye  thus exposed to the light, and introducing  instruments
under the  cornea, we excite spasm in the muscles,  and a^
the membranes  Ave arc tearing aAvay, are connected Avith the
vitreous humour, it is  scarcely possible  in this attempt to
avoid losing much of that humour.
   If the anterior part of the capsule be opaque, the lens hav-
ing  burst through it, it will, I imagine,  be belter to let it
take  the chance of Avasting  in the aqueous humour, than by
tearing it aAvay to endanger the entire loss of the organ, in
consequence  of  the discharge of the vitreous humour.
   15. When the  cataract is discharged entire, Ave ought to
have little further anxiety, I imagine, that to see that the
iris does not hang relaxed  into the incision of the cornea;
as light contracts the pupil, so will opening the eyelids make
the  relaxed  iris draw  up;  but if it  be  at all engaged be-
tAvixt the edges of the cornea, it Avill. require to be replaced
by insinuating the small probe into the incision.
   16. When the operation is finished, Ave must see that the
edges of the  incision come accurately together, then the eye-
lids should  be closed, and  some plies of wet lint, hung be-
fore the eye;  the clothes  must  not  press much upon the
eyelids.  Before putting  the patient  to  bed, Ave must see
that  the margins  of  the eyelids are  properly  together, and
that none of the eyelashes are turned in upon the  eye.   The
eyelids should be looked to the next  morning, and if neces-
sary, bathed  and  cleaned of any  secretion;  the  eye  should
be examined carefully on the third day, but the eyelids in-
stantly replaced, and the patient enjoined repose  and dark-
ness  for ten days.
   17. It is, in my opinion,  entirely out  of the question, to
perform the operation of extracting the cataract a second
time.  If there  occurs any necessity for removing a remain-
ing opacity of the pupil, after the  crystalline humour h;r 
J2
OF THE TREATMENT OF THE EYE
been  discharged, and  the incision of the cornea healed, it
must be done by the needle, as practised in couching.


 OF INFLAMMATION OF THE EYE, AND OF THE TREATMENT AF-
                     TER OPERATION.

  The  eye is necessarily the most delicate  structure, and
exposed more than any similar part of our frame.  The na-
tural delicacy and transparency of its membranes are preserv-
ed in a manner truly admirable.  The tears which wash its
surface, we must have observed, are acrid and stimulating,
and when they run over the cheek, inflame and excoriate the
surface.   But the delicate  surface of the eye and eyelids are
accommodated to the presence of this fluid, and the advan-
tage resulting from this is, that the surface is  not disordered
or irritated by any lesser degree of stimulus, and consequent-
ly it  bears the variations of the atmosphere, and  the excite-
ments it is necessarily exposed to.
   Yet Avhen Ave consider the exposure of the surface of the
eye, and the delicacy and vascularity of  its  membranes, we
cannot  wonder that it  should be often inflamed, and often
suffer from those derangements of the constitution which art
not to be remarked but by  some such local affection as
chronic inflammation of the eye.
   I  see chiefly  these  distinctions in the inflammation  of
 the eye : 1.  An acute inflammation, Avith evident symptoms
 of constitutional derangement, marked by nausea and a fur-
 red tongue, or accompanied with inflammation of the  mu-
 cous membrane of the nose, and sinuses, and symptoms of in-
 flammatory fever; or  an inflammation similar in .symptoms,
 but  most commonly resulting from outAvard  impression.
 2. A lower degree of inflammation, chronic, and resisting lo-
 cal remedies, Avhich is  resulting from some  derangement of
 the system.   3.  Lastly,  an inflammation only resembling the
 others  in appearance, the effect of local debility in the eye,
 and  characterized by a relaxed  state of the vessels, and  a 
AFTER OPERATION.
53
fulness of the membranes, the consequence of a preceding vi-
olent inflammation.
   1. In the first example, while the inflammatory action is
to be subdued, all that will excite, is to be removed in the
first stage; every surgeon of good practice  forewarns us to
notice  Avell that change  which takes place,  Avhen instead of
the violent throbbing, the  acute pain,  and hot Avatery  dis-
charge, there is only a SAvelling and turgessence in the mem-
branes, Avith a diminished  irritability,  the eyelids more flac-
cid, the  fieriness being gone though the redness remain, and
the pupil be more dilated ; noAv the  evacuations, the sooth-
ing and emollient applications,  Avhich Avere necessary at first,
will only continue the symptoms, and tend to  fix the com-
plaint, Avhile  cold stimulating and astringent  applications,
are to be employed.
   The mere consequences of violent ophthalmia, and Avhicli
are not to be considered as fixed or peculiar diseases, are the
phlyctenaz, Avhich are small vescicles formed on the surface of
the eye; the chemosis, which is the swelling and projection of
the conjunctiva;  the puriform discharge from the eyelids,
(which when in a remarkable degree, I am inclined to believe
is always  owing to matter  communicated to the eye); the
hypopion, Avhich is a deposition of coagulable lymph in the
anterior chamber of the aqueous humour ; the bursting  and
total destruction of the eye ; all these, as sure consequences of
the high inflammation, are  to  be prevented  or  cured by re-
moving the inflammation.  But the several diseases  I have
noAv to mention, as requiring operation, we may better consi-
der as the  consequences of the continued chronic ophthalmia,
and Avhich from the sloAvness of their formation do gradually
acquire a kind of constitutional permanency Avhich requires
excision.
   I may say once for all, what I conceive to be necessary in the
examination of these diseases, in order to discover if any thing
should be  done previous to  operation, and what  treatment  is
to be pursued after the operations upon  the eye, Avhen  inflam-
mation is a consequence 
 54         OF THE TREATMENT OF THE EYE, &.C.

   When any neAv membrane seems to be formed on the eye,
 any pustule, ulcer,  or opacity, accompanied with clusters of
 turgid veins, or a general relaxation and fulness of the vessels,
 before taking the knife to these, Ave ought to examine if any
 accidental cause has existed Avhich is now happily removed ;
 or whether or not by the foulness of the  tongue, the want of
 appetite, the languor  and sickness, the occasional rheumatism
 in the face and head,  or head-ach, or any such slight affec-
 tions, there exists derangement, in the system, or- debility and
 consequent  accumulation in  the  stomach and boAvels.  We
 must examine Avell Avhcther the local disease partakes of the
 character of scrophula or syphilis.—The influence of these
 causes ought, if possible, to be removed before operating on
 the eye.
  Previous to an operation the patient should take a smart
 purge;  from the immediate debility proceeding from this he
 ought, hoAvever, to be recovered.   The immediate effect of a
 severe or protracted operation on the eye will often be a nerv-
 ousness  and  sickness,  or  coldness, shivering,  and head-ach;
 this state an opiate with an aromatic will remove, and as it
 will often happen,  that the  irritability of the stomach will
 prevent the medicine from being retained, if the opiate be
 given in the  form of clyster to the quantity of what Avould be
 a double dose if taken  by the mouth, it will cause the commo-
 tion and sympathy of the  frame Avith  this  most irritable
 organ to subside.
  If blood flows from the eye in consequence  of the operation,
it is to be promoted by bathing the  eye with tepid Avater.
 After all operations  on the eye the patient must be condemn-
ed to darkness, and Ioav diet; a Avet rag  be put on the  eye,
the bowels must be kept open.   He must not indulge in bed,
nor lie Avith his head low, nor have his head and eye loaded
with bandages and  dressing.  Opiates should be held in re-
serve as long as may be.   That inflammation which proceeds
 from the stimulus of the knife, should be treated with emol-
lients, and the eyelids washed with tepid water.  The astrin-
 gent collyria should be reserved for that stage when there re- 
RELAXATION OF THE EYELID.
55
mams not the smart action of vessels, and the acute sensibility,
but, on the contrary, a relaxed state of the parts only.  There
is a niceness of observation necessary, to be able to say Avhen
the operation has ceased to produce its effect, Avhen it may be
repeated or when a  caustic may be applied  to assist in  the
cure, supposing  an excrescence or tumour has been cut off.
Even after this effect of the mere irritation of  the knife might
be expected to have subsided, there will often come on symp-
toms of general disorder, head-ach, and increase of heat, with
restlessness and watching.  But the tongue,  the bitter taste
of the mouth, and nausea,  point  out to us the necessity of
gently moving  the  bowels; these  symptoms wiU yield to
quietness, low diet, and occasional clysters.
  This loAATiess  of diet, we must remember,  is not to be the
universal order,  but observing Avhen there is a tendency to
high action,  or irritability of Aveakness present, Ave must half
starve some,  and give more generous diet to others.   Above
all Ave must guard against the complaint being fostered and
supported by confinement and bad air, Ioav diet and despond-
ence, for this reduces the system to that state Avhich, though
not actually disease, is particularly unfavourable to the cure
of surgical diseases.

                RELAXATION OF THE EYELID.

  There may  be a difficulty of raising the eyelid, from an
irregular motion and  spasm of the orbicularis  palpebrarum*.
There may be a difficulty of raising the eyelid, from a loss of
poAver in the levator palpebrze superioris.  There  may be a
relaxation of the upper eyelid, in consequence of inflammation
long since subsided ;  a  fulness of the  cellular membrane,
which prevents the action of the levator muscle.   In this last
case a portion of it may be cut off, so as to relieve  the eyelid,
Avhich otherwise hangs over the cornea, and obscures vision.

  *  An irregular nervous affection producing it, as in hysteria. 
56
OF THE INVERTED EYELID.
         EVERSION OF THE EYELIDS.  (Ectropion).

   The conjunctiva having been inflamed, there sometimes re-
mains a tumefaction  in the conjunctiva, with a weak chronic
inflammation.  The edge of  the eyelid is turned outAvard,
and there  is a semilunar, pale, fleshy tumour  betwixt it and
the eyeball.   The cornea  sometimes appears sunk  within a
circular tumour.   The eyelids no longer wipe the dust from
the cornea  ; they are removed from it; the  eye is hot, and
the tears fall over the cheek, there being no  longer the gut-
ters left betAveen the meeting of the ciliary cartilages, to con-
vey the tears to the  puncta*,  and there occur of course fre-
quent attacks of more violent inflammation, and in the end aa
opacity or ulceration  of  the  cornea takes place. ' In slight
cases  the tumours are only to be scarified, or the surface, (if it
shall  have granulated) may  be destroyed with the lunar
caustic.  The object in both these Avays is to produce a cica-
trization and consequent contraction of the conjunctiva.
   When the disease  is  more confirmed and the semilunar tu-
mour of the conjunctiva considerable, the Avhole protruding
part  is to be cut off.   To do  this,  it is seized Avith the hook
or forceps,  and Avith the  crooked scissors it is to be cut off.
After  this a few  touches of the knife may still  be necessary,
and during the  cure  the end may be further secured,  by
touching any prominent granulation Avith the caustic and by
the use of astringent Avashes.

                OF THE INVERTED EYELID.

   Inversion of the eye is Avhere the margin of the eyelids
and consequently the eyelashes are turned inwards  upon the
eye, proving a continued source of irritation and inflammation.

  * There is a lesser degree of this disease, common to old people, which is
not meant to be spoken of here. 
OF THE INVERTED EYELID.              5/
   No spasm or violent action of the muscles of the eyelids will
produce this inversion, nor will the paralysis of the same mus-
cles have  any tendency  to form it.  It is one of the many
consequences of chronic  inflammation, which making,  as  it
were^ a permanent groAvth of the superficial part of the eye-
lid, while the conjunctiva remains contracted it folloAvs  of
course, that the edge of the eyelid is turned in.  It is then  in
all respects the exact reverse of the eversion, and tumour  of
the conjunctiva.  But perhaps this position of the tarsus is not
merely the consequence of a fulness of the cellular membrane,
or groAvth of the skin, but in consequence of ulcers; the in-
ner surface of the eyelid and tarsus may be contracted by the
forming of the cicatrix.
   The surgeon then has to determine by careful examination,
whether or not the  inversion be owing  to the growth or  re-
laxation of the outward skin and cellular  membrane of the
eyelid, and if  it be, there is this method recommended of re-
moving the evil.
   With the finger and thumb a portion of the skin of the
eyelid is raised, so as to hold a  ply or  double of the  skin,
parallel to the margin of the eyelid.  In doing this the sur-
geon will be able to distinguish betwixt the skin and the mus-
cle, and Avill  of  course be  careful to avoid catching hold  of
the orbicularis muscle.   The scissors are now applied so that
an oval piece  of skin, or rather a piece of the form of a  myr-
tle leaf is cut  out.   The  appearance of the eye  is frightful,
but first by means of an adhesive plaister, and then by a  com-
press and bandage the skin  of the eyebroAv is brought doAvn
so as to allow  the margins of the Avound to approach.  The
cicatrix forming consolidates and gives firmness  to the out-
ward skin, so as to keep the cilice from being longer inverted
upon the eye.
   But if this inversion of the eyelid be a consequence of ul-
cers and contraction of the  inner and cartilagenous  edge  of
the eyelid, forming a kind  of stricture  Avhich prevents the
inner edge from rising fully over the eyeball, and which drags
in and inverts  the margin of the eyelid, then a different ope-
   vol. n.                   i 
58
•F TIMOVRS OF IHE EYELIDS.
ration is performed.   Having forcibly turned out the inside
of the diseased eyelid, the inner membrane of the eyelid, and
the ciliary cartilage  are to  be cut across by the point of a
lancet.  If the inversion of  the eyelid has arisen from the al-
leged cause, it will be immediately relieved.

               OF TUMOURS OF THE EYELIDS.

   There are tumours of the eyelids  Avhich the patient is
very willing to have taken off, and Avhich should be  taken off
because they push in the tunica conjunctiva, and pressing
upon the  eyeball, in the motions  of the eyelid, they inflame
it.  These are  small  incysted tumours growing in the place
of the meibomean glands,  and it is natural to suppose  that
they are the enlarged glands.
   But we must observe, that there are,tumours of  the  eye-
lids Avhich ought  not to be cut.   These are  small  tumours
Avith a broad  base, and of a  dark red colour.   Sometimes
they have the appearance of a small boil, being white on the
most prominent part: yet this is not pus#.   On the contrary,
the tumour Ave have to cut out is colourless, only in  as much
as sometimes by exciting the eye there may be some general
inflammation.
   These  incysted tumours of the eyelids, it is needless to at-
tempt to remove either by local remedies, or by  attention
to general remedies,  they must  be cut out, or  the patient
must submit  to  the  inconvenience;  I  must  add, hoAvever,
that there is more pain and bleeding than Avould be imagin-
ed to be the consequence of so trifling an operation.
   The  first thing to be examined is, Avhether or not the tu-
mour be  so united to the inner  membrane of the  eyelid as
to force us to cut through the eyelid altogether, before Ave

   * Hordeolum.  In this tumour of the eyelid we should do very little, un-
less it be  to  move the bowels.  When, however, the little swelling advances,
this white speck bursts and discharges a little fluid, and then a slough is seen
within, which is by and bye pushed out, and the sore closes, to promote
Which, fomentation and poultices are used. 
OF TUMOURS OF THE EYELIDS.
SO
can take aAA'ay the tumour,  if AA-e should operate by making
our first incision on  the outAvard skin.  If the conjunctiva
seems intimately united to the tumour upon our everting the
eyelid, Ave have to proceed thus ;
  As in all operations on the eye, the patient is firmly seat-
ed, and an assistant standing behind  him supports  the head
against his breast   1. The assistant must invert the eyelid, by
catching the eyelashes and margin of  the eyelid with his fin-
ger and thumb, and  turning his fingers, so that the fore-fin-
ger pushes forth the tumour and everts the eyelid.  2. The
surgeon noAv draws his lancet  pointed scalpel  across the  tu-
mour,  so as to diAdde the tunica  conjunctiva in a direction
parallel to the edge of the eyelid.   3. Having  by scratching
a little separated the membrane, so that the tumour is thrust
out, he has to push a hook or small tenaculum into  it, and
then to dissect it away altogether.
   But if the conjunctiva be not diseased or very firmly unit-
ed to the tumour,  Ave had  better operate without everting
the eyelid,  and this  is possible without leaving an observa-
ble scar on the eyelid.
   1. The surgeon fixes the eyelid  by pressing the tAvo angles
doAvn by the points of the fore and middle fingers, and having
stretched  the outer skin of the eyelid over  the tumour, he
draws his knife directly over the tumour and  parallel to  the
edge of the eyelids, consequently separating  the fibres of the
orbicularis, not cutting them across.  2. Having exposed  the
outAvard half of the tumour he pushes the fine  tenaculum
round  under it, and then dissecting it a little more, he applies
the curved scissors, and cuts it off from the tunica conjunctiva.
   The orbicularis muscle  holds  the lips of Uie Avound  to-
gether, Avithout our  assistance, and then it is  only required
that Ave bind lightly  on the  eye a cloth wet with cold solu-
tion.

   When tumours grow Avithin the socket, they are to be early
extirpated, for though they should be of a harmless  nature,
yet their increase, simply by pushing the eyeball fonvard, and 
60
ENCANTHIS.
stretching the optic nerve, will cause blindness and deformity,
while by filling the socket and pressing more and more on the
eye, the operation of cutting them out  becomes daily more
difficult.

                       ENCANTHIS.


  The EncaHthis is a tumour arising from or at least involv-
ing the caruncula  lacrymalis, it is of a pale red colour, and
irregular on its surface ; as it increases it draAvs into its sub-
stance the semilunar fold of the conjunctiva and stretches its
root  along both eyelids.   When this tumour is of a darker
hue and  hard,  and has lancing pains in it, and  still more
when becoming more active and vascular, it bleeds easily or
ulcerates, it is becoming cancerous.
  Even before  the tumour shews  this cancerous character
there occur good reasons for cutting it off.  When it becomes
rooted in the eyelids, and the cancerous disposition has spread,
nothing but the extirpation  of the Avhole eye will avail, if
even that is effectual.   When the tumour is not of a malig-
nant nature, and when it has  only produced  the lesser evil of
a Aveeping eye, by its pressing the puncta, and caused inflam-
mation of the eye, by preventing the eyelids from meeting, it
may be cut out Avith more hopes of success.  We may do it
thus:
  1. The  assistant turns doAvn the lower  eyelid  with his
finger, or with the assistance of a flat and blunt hook; the sur-
geon then Avith a pair of nice forceps, and very sharp knife, dis-
sects off the root Avhich the tumour has shot along the inside
of the eyelid.  2. The assistant then turns  up the superior
eyelid, when the surgeon in the same Avay dissects off the root
of the tumour from this eyelid.  3. Now the body of the tu-
mour is to be pierced with the hook and drawn outward, and
if it should appear that the caruncula lacrymalis is natural and
distinct from the tumour, then the latter is to be dissected off
from the caruncula lacrymalis; but if they shall be incorpo- 
OF THE  PTERYGION.                 Ol
rated, the whole is to be taken aAvay.  4. The last part of the
operation is to dissect  up the diseased conjunctiva from the
surface of the eye-ball.
  After the operation,  the eye may be fomented until a con-
siderable quantity of blood be lost, and aftenvards  emollient
fomentations will only be required, if no cancerous affection
has prevailed.

                    OF THE PTERYGION.
                                                     «•
  The Pterygion is a pale red film, Avhich stretches generally
from the inner angle of the  eyelids, across the cornea.   It is
one  of the pure  consequences  of continued  inflammation.
When  this web covers the Avhole eye it is called pannus.   But
the terms film and Aveb deceive us, for this is not a neAv mem-
brane formed on the surface of the eye, but only a  congestion
in the cellular membrane, under the conjunctiva, Avhich, as it
were, loosens it from the sclerotica, at the same  time that its
vessels are increased in number, and become tortuous.   This
diseased state of the conjunctiva encroaches  in a conical form
on the lucid cornea : it- is there too of the same nature; the
transparent outer lamina of the cornea  becoming opaque, and
feeing at the same time loosened in its texture.

                        OPERATION.

  1. The patient being seated Avith a cloth under his chin,
(he assistant stands behind him and supports his head, having
in one  hand a sponge full of tepid  water, Avhich from time to
time, in the progress of the operation, he  pours into the eye,
as it becomes  obscured by blood.   The assistant opens Avide
the eyelids.
  2. The surgeon noAv Avith very  fine forceps raises the apex
of the  pterygion which is on the cornea;  he then pushes the
knife, used for the extraction of the cataract, under the fold of
the membrane which he has raised;  he carries the knife for-
ward until the edge shall have cut itself out, and have sepa-
rated the very apex of the membrane from the cornea. 
62
OF OPACITY OF THE CORNLa.
  3. Now holding the membrane up it  is to be dissected a
little from the Avhite part of the eye, and lastly the scissors are
to be applied (pointing upAvard or downward), so as to cut
across the middle of the membrane, where it is attached  to
the albuginea.
  The eye is to be noAv washed Avith tepid water, while the
blood flows, and then a light compress  of  wet  linen is to  be
put on  the  eye.   The surface  which has  been  diseased ac-
quires a peculiar  yellow colour ; it is some weeks in contract-
ing fully, and forming a cicatrix.  The treatment after this
is only such as Avould be prescribed to suppress any appear-
ance of returning inflammation.
   That part of the cornea from Avhich the pterygion has been
cut off, does never entirely recover its transparency.

                  OPACITY  OF  THE CORNEA.

   1.  The cornea becomes opaque in several Avays.  Inflam-
 mation may leave in it a milky opaque spot or spots, from an
 effusion under the outward lamina.   There is at the same
 time a flaccid state of the conjunctiva and tortuous or varicose
 veins lead to the opaque spot  of the cornea.   This has been
 called  nebula, from its producing only a cloudiness in  the
 vision.
   2. If the cornea be opaque in consequence of a preceding
 very violent attack of ophthalmia, the effused matter will be
 found to be deposited deeper in its substance, and is supposed
 to be coagulabie  lymph ; this is the albugo.
    3. Again, there occurs  in consequence  of inflammation, a
 postular opacity, Avhich,  breaking, forms an  ulcer,  which
 leaves a firm opaque cicatrix, viz. leucoma.
    The practice  in the first instance of opacity (the  nebula)
 is to extirpate the tortuous fasciculus of vessels, whose elonga-
 tion over the cornea caused, or necessarily accompanied the
 formation of this opacity, and Avhich we may noAv suppose,
 feed and support it as it Avere.  Tlie fine eye-scissors and a
 common houseAvife  needle, stuck witk its head in a piece of 
©F OPACITY of the cornea.
63
wood, are sufficient apparatus  for this end.  The head of the
patient is supported against the breast of an assistant, and the
eyelids held asunder Avhile the eyeball is at tlie same  time
pressed so as to steady it.
  2.  The surgeon passes the  needle under  the fasciculus of
vessels, so as to lift them from the sclerotica near the margin of
the cornea.   He then places the scissors so under the needle as
to cut out a considerable portion of the conjunctiva and the
congeries of vessels.  Tlie eye is to be fomented so as to continue
the bleeding from the cut vessels.   The opacity of the cornea
will often disappear the first or second day after the operation.
When a young man asks hoAv is this supposed deposition in the
cornea absorbed, I cannot give him a satisfactory ansAver.
   The practice in the more permanent opacities of the cornea,
viz. the albugo and leucoma is very vague, because of the
great difficulty of removing them, and  the frequent disap-
pointment in tlie attempt to cure them.   All that is  to be
said, seems to resolve into this—if there be a remaining in-
flammation or laxity of the vessels  of the eye, this is to be re*
moved by local and general means;—if, on the contrary, all
inflammation has subsided, and the speck is  stationary, we
endeavour to excite such an action in the part by stimulants,
as  may produce eventually some change in the disposition of
the part.

           APPLICATION OF CAUSTIC TO THE CORNEA.

    Ulcer in the cornea may be a consequence of  violent in-
 flammation, or a direct effect of external injury.  It has been
 roundly asserted that  the ulcer of the cornea  is oftener the
 cause of the ophthalmia, Avhich accompanies it, than the ulcer
 is a consequence of the ophthalmia.  This teaches us  not to
 trust to general remedies for the removal of the inflammation.
 The ulcer  then is  to be touched with the  lunar caustic.
 This of course  deadens the very sensible surface of  the ulcer,
 and it being no longer sensible to the acrid stimulus  of the
 tears, the irritation subside*. 
w
OF THE STAPHYLOMA.
   The best way of applying tlie caustic is to have it set in a
quill, and put on the stick of a pretty large camel-hair brush;
the caustic must be cut down to a small point; a little milk
is beside the surgeon, in Avhich he dips the brush.   He then
raises the eyelids, and at the same time presses them to fix the
eyeball, he touohes the ulcer with the caustic, and presses it
to the bottom of the  ulcer,  and when he has done this  he
brushes the liquified caustic from the eye Avith  a motion of
his brush.—In a day or tAvo the irritability of the eye returns,
for the deadened surface of the ulcer has separated,  and the
tears again come in contact with the sensible surface, but the
pain and  intolerance of light is less than before ; it is to be
touched again Avith caustic, Avith a more permanent  relief of
symptoms.  And if things go on successfully on the clearing
of the ulcer in successive times, instead of being eaten deep it
is shalloAver, and fills up, and the inflammation subsides.
   The caustic need not be applied after the irritability ceases,
and the ulcer looks red and granulating, instead of being irre-
gular and cineritious in colour.

                   of  the staphyloma.

   The  Staphyloma is an opaque conical tumour of the cor-
nea, it is often  of a white or pearl colour, sometimes dark or
variegated by the accretion of the iris to it.   The staphyloma
is most generally a consequence of small-pox.
   The  opacity of  the  cornea produces blindness of that eye,
but the worst circumstance of the disease is, that although it
has no malignity, it is always liable to be aggravated, and to
affect the other eye also.   The tumour of the cornea project-
ing from betAvixt the eyelids, remains dry,  and becomes ulcer-
ated ; there is a continued inflammation of the eye produced,
and from the intimate sympathy which  exists betAvixt the
eyes, the other becomes sore also, and even ulcers form on the
cornea of it.   When Ave knoAv  this  to be a  consequence  of
the staphyloma, avc cannot hesitate about cutting it off. 
OF THE STAPHYLOMA.
65
   The intention of the  operation is to evacuate the humours
of the eye,  that  the coats may contract, and be  Avithin  the
margin of the evelids-


                        operation.

   The patient is seated as for the extraction of the cataract*
and the  assistant supports the eyelid in the same manner.
The surgeon takes the largest of his knives for the extraction
of the cataract,  and pushes it  through the  tumour,  in  the
direction he Avould cut the cornea in  the operation of extrac-
tion ; but he does not enter the knife so near the margin of the
cornea as in that operation.  Having made  a section of the
loAver half of the tumour, he takes hold of the flap Avith the
forceps or  sharp hook, and completes the  circular incision.
The tumour being cut off, and the chamber of the aqueous
humour largely opened, the  humours of the eye are  gently
squeezed out of  the coats, when the eye subsides Avithin the
eyelids.
   The cornea being the only part cut in this operation,  and
this being a part neither vascular nor very sensible,  the in-
flammation is some time of commencing.  On the fourth  day
the eyelids are inflamed, and on the seventh or eighth  there  is
pus on the poultices applied to the eye.  Scarpa in particular
recommends the operation to be performed as I have here de-
scribed,  saying,  that very terrible consequences result from
including the sclerotic coat in the incision.   But I have  seen
the operation  performed by cuttiug  off the  whole anterior
segment of the eye Avithout any bad consequence; notAvith-
standing this,  the reasoning as well  as the facts  alleged by
Professor Scarpa, must sway us, Avhere there is no advantage
resulting from a practice opposed to his.
   After the operation a  pledget of soft lint soaked  in oil, may
be applied over the eyelids, and Avhen the inflammation rises,
if the fever and pain be great, Ave must bleed largely, and, as
we wish to produce suppuration on the surface of the mem
   VOT. Tf.                   k 
66
OF THE PROTRUSION OF THE IRIS.
brancs, avc must foment and apply poultices, not repellent cold
applications.

                 PROTRUSION OF THE IRIS.

   The protrusion of the iris is marked by  these characters.
There is  a small prominent tumour or speck on the cornea of
the colour of the  iris.   Around its base the cornea is opaque.
The pupil is a little removed from the centre, and somewhat
changed  from its regular form, and the plane of the iris is
more oblique than natural; the vessels of the conjunctiva are
large and numerous, and the eye is particularly irritable.
   This is a  kind  of hernia of the iris, which is apt to occur
after  the  operation of extracting the cataract, or  in  conse-
quence of Avounds or ulcers of the cornea penetrating to the
chamber of the aqueous  humour.   This is not a relaxation
and falling doAvn of the iris, but it  is pushed out as an intes-
tine is in hernia,  by  the  contraction of the eyeball, and in
the narroAv opening of the cornea it is sometimes strangulat-
ed too like a hernia.   It is  impossible to reduce  this pro-
trusion Avhen it is the  consequence  of ulcers of the cornea;
for supposing that the iris Avas separated from the cornea,
would not the aqueous humour again be discharged, Avould
not the lens again press fonvard the iris, so that it  Avould be
pushed through the opening of the  cornea ?   The entangling
of the iris in  the  ulcer is  not owing to this membrane float-
ing Avith the current  of the aqueous humour, toAvards the
opening;  but, as I have described in speaking of the extrac
tion of the cataract, the Avhole contents of the eye  press for-
Avard to the breach, and the iris presents first.  It has been
well observed that this  presenting of the iris in the ulcer,
saves  tlie eye from total destruction, though it be  a painful
disease in itself.   The  practice in this disease is simple.  We
have  to touch it  with the lunar caustic ; this must be done
with  the precautions already recommended; the small black
tumour  formed by the protruded  iris  must be  eat  down
Avithin the level of the cornea by repeated application of the 
DROPSY OF THE EYE.
fit-
 caustic.   After  this Ave are  to  endeavour to promote the
 cicatrixation of the ulcer.
   In the same AAray are treated the small lymphatic tumours,
 which project from  the cornea,  after an  ulcer or Avound.
 Scarpa proves that this tumour is tlie protrusion of the vitre-
 ous humour and  its capsule.

                   DROPSY OF THE EYE.

   Like  every other part of the  body the vessels of the eye
 receive a constitutional  disposition that keeps the form  and
 proportions of the humours and coats  to a limited form.  If
 this natural  action of vessels  be  changed, the effect is some
 defect of transparency, or some preternatural groAvth; there
 is an atrophy or  Avasting of the  eye, or a  great increase of
 the humours, a distension and groAvth of the coats—a dropsy
 of the eye.
   Dropsy is  sometimes a consequence  of injury done to the
 eye, or of high  inflammation;  sometimes  it attacks slowly
 and Avithout any very evident cause.   The symptoms  are,
 a sense of distension with pain  in the  orbit and difficulty
 of moving the eyeball.   Blindness ensues,  and there is no
 longer contraction of the pupil.   In a  still greater degree of
 the disease, the  eye  projects  conically from the eyelids, and
 they no longer shut upon the eyeball; the exposed surface be-
 comes acrid ; there is inflammation and ulceration of the eye-
 lids ;  the eyeball  is inflamed, Avith great pain and head-ache ♦,
 the other eye i- affected, by sympathy ; and  an  operation be-
 comes absolutely  necessary.
   The Operation is sufficiently simple.   The eyelids  arc
 held open; a sharp tenaculum is  thrust through the anterior
 half of the eyeball, and all the projecting part is cut off Avith
 tAA'o motions of the scalpel.  The humours arc of course spon-
 taneously evacuated, and the  eye shrinks Avithin the eyelids.
 But Scarpa again frightens us, and recommends instead of
this, that the middle of the  cornea be cut, as in  the  Stn-
 phyloma. 
OS
Of THE A1UIIICIAL PLfll
                 OF THE ARTIFICIAL PUTIL.

   In deep inflammation  of the eye,  following the operation
of extraction or depression of the cataract, the pupil contracts
and closes altogether; for during the inflaniniation there being
also great irritability of the eye, attended Avith contraction of
the pupil, the iris fixes and adheres, so that there is an  entire
obstruction to the light.  The contraction of the pupil is some-
times more unaccountable, being gradual, and only accompa-
nied Avith a slight degree  of unusual irritability in the eye.
The contraction of the pupil is, hoAvever, a rare complaint.
One  should naturally suppose that  it Avould be an easy opera-
tion to introduce the couching needle, and cut the iris in  the
middle part,  so as to enlarge the contracted pupil, or form a
neAv  one.  But it is found, that Avhen the pupil is made  in the
centre of the iris it quickly closes again.   So it happens Avhea
the circle of the iris  is divided from the circumference through
its edge,  Scarpa has substituted another operation, of which
I should say little, not having performed it on the human eye,
Avere I not certain of its practicability by trial on brutes,  and
did I'not conceive  that it is a means of restoring sight in a
case  not yet  thought  of.—Scarpa performs the operation in
this  Avay:—
  The patient is seated as for the operation on  tiie cataract.
The surgeon  uses a very small, straight couching needle.  He
perforates the scleroLic coat, as for the depression of the cata-
ract, and about Iavo lines from  the margin of the cornea; tin
point of the needle is  carried behind the iris, and before the
lens, if it has not been extracted.   It is made to advance as far
as the upper  and internal part  of the outer margin of the iris,
viz. on the side next the nose.   The point of the needle is then
made to pierce the root of the  iris, Avhere it is attached  to the
ciliary ligament, and Avhen the surgeon sees the point of the
needle projecting through the outer  margin of the iris, he
draAvs the instrument towards  him, so as to separate the iris
from the sclerotic coat.  Blood is effused  dming the  oper^ 
OF THE ARTIFICIAL PUPIL.
69
lion, so that the aqueous humour becomes turbid,  the pain is
greater than in the depression of the cataract, and for these
reasons the motion of the needle should lie decided and quick.
   Some time ago, before I had occasion to consider this sub-
ject of the contraction of the natural pupil, a patient applied
to me Avho had an opacity of  the cornea, covering  the natural
pupil.   As the gentleman possessed the sight of the other eye,
I did not advise an operation, Avhich yet I thought practica-
ble, if  he had been  blind altogether.   I thought  of opening
the iris opposite to the transparent part of the cornea.
FIG. 1.                         FIG. 2.
   These sketches of the eye aa ill illustrate Avhat I  conceived il
possible to  do.   In figure 1. the opaque  cornea at A, covers
the pupil, the relative place of Avhich is marked by a circular
line of dots.  In  figure 2.1 have represented a  pupil formed
by cutting  the iris opposite the transparent part of the cornea.
A, the opacity of the cornea covering the  natural pupil.  T>,
part of the iris seen.   C, the artificial pupil*.


   • I have at present a gentleman under my care for stricture in the urethra,
who has submitted to the operation of extraction of the cataract on one ej i\
The operation has been very successful, but on the other eye the operator
has been obliged to bring the point of the knife out at a wrong place, and
now the scar of the incision begins at the margin of the cornea and turns in
with  a spiral line so as to cover the pupil.  With this eye the gentleman
cannot see but very obliquely, and imperfectly,  although the pupil is quit*
clear of cataract.  In such a case as this, supposing that vision was not per-
fect in the other eye, the sight might be restored, by making an artificinl pu-
pil in th^ iriq opposite to the tran-Mwren* part of the cornea. 
ro
LX1IRPATION OF THE EVE.
   It was Avith  great  satisfaction I read Scarpa, on the sut>
ject of the artificial pupil.   The cause for Avhich he performs
that operation is rare, but if it shall prove effectual for those
opacities which are opposite  the natural pupil, Iioav  much
more extensive must the benefit prove.

                 EXTIRPATION OF THE EYE.

   The patient is placed on a chair, Avith his head resting on
the assistant's breast.  The assistant should hold in his hand
a blunt hook with which he is to raise the eyelid.   The sur-
geon is seated before the patient.  He now pierces the anteri-
or segment of the eye with his tenaculum.   The first strokes
of the  knife are tAvo semicircular incisions, to cut through the
tunica conjunctiva, and to separate the eyelid from the eyeball.
Then if the  eye is very much distended and fills the socket,
the  next motion of  the  surgeon's knife ought to be to punc-
ture the eyeball, and alloAv some of the humours to escape ;
for, if this is not done, he is cutting in a constrained and nar-
row way, betwixt the distended eye and the socket, making a
tedious operation, and endangering more than necessary, the
bones of the socket.
  When  tlie conjunctiva is cut, and the  knife has gone quite
round  the eye and tlie attachments of the tAvo oblique muscles
are cut through, the eye would lie loose,  only  that the optic
nerve retains it very  strongly.   I have seen the surgeon unac-
countably forget this, and make repeated and most painful ef-
forts, by  cutting and pulling, when it only was required that
he should have cut across the optic nerve.
  To cut across  the optic nerve, the knife ought to  be carried
flat under the superciliary ridge, and made to glide along the
orbital plate.  When passed over the eyeball  in this direction,
a single cut will sever the nerve and muscles  Avhich  surround
it, so as to relieve the diseased parts, and they may be draAvn
out Avith only a little adhering cellular membrane.
  A good deal of blood  should be  allowed to Aoav.   If it
be required to stop  the too profuse bleeding, it may be done
by pressing a little dry lint in the inner angle. 
                 EXTIRPATION OF THE EYE.             • *


                       INSTRUMENTS.

   A strong flat tenaculum may do to  pierce the ball of the
eye Avith;  or a large ligature is put through the eye Avith the
common surgeon's needle, or Avhat -will be found more useful,
and which will much shorten  the  painful period of prepara-
tion, is a hook of the form of the tenaculum, with a shoulder,
to prevent its going farther into  the globe of the eye than
just to permit the point to transfix it.   A crooked knife is re-
commended for this operation,  but it  Avill be found a bad
exchange for the common scalpel.
  The  disease sometimes returns.  It may be expected if
the disease has been really cancerous, and  if the parts exter-
nal to the eyeball'have been the seat of the disease.  From
the confined nature of the part, the whole soft parts Avithin
the bone may have been tainted.   If so, it Avill probably hap-
pen that Avhen the Avound has  gone on regularly towards a
cure for some time, Avhen you Avould expect that it Avas about
to close finally, it will stop, and instead of merely filling  up,
a fungus a', ill rise from the orbit.   When this has got to some
head, the acute lancinating pain in the head will follow.   Or
if the wound has healed some months perhaps after the ope-
ration, hard tubercles will be felt in the surrounding integu
ments.  Then comes pain striking to the  back of the head,,
uith burning pain deep in the orbit, and the brain being at
fast affected, the patient d'>c. 
tz
EXTIRPATION OF THE EYE.
        OPERATIONS FOR THE FISTULA LACHRYMALIS.

  The Fistula Lachrymalis is a disease of the lachrymal
canal.—In what may be called its complete state, there is an
obstruction of the duct Avhich carries the tears into the nose,
and a fistulous sore discharging the tears and pus near the in-
ner angle of the eye; the patient only complains of a weak-
ness of sight, the eye is Avatery, and on every little excitement
the tears fall over the cheek, Avhich is sometimes excoriated,
the nostril  of that side is dry.  But this complaint will not
admit of a  description in  the form of a definition ;  in common
discourse Ave call all the various degrees of the disease of these
passages, Avhich might in a latter stage form an open Aveeping
tore, fistula lachrymalis.
  1. The first state of disease I shall describe is  this:  the
eye is considerably inflamed and irritable ;  the  edges  of the
eyelids are tumid, and the glands secrete profusely ; the inter-
nal membrane of the eyelid  is very red, and flakes of mucus
are seen upon turning doAvn the eyelid ; the integuments over
the lachrymal sac are full and puffy, and  on  pressing these,
mucus and pus escape from the puncta.  To account for this
appearance, there is no occasion to suppose that there is an
obstruction in the  nasal duct, the disease  is general, and all
the continuous  surface of the  eyelids,  puncta, sac, and duct;
are unusually vascular and spongy.
  The  natural resource  against such  symptoms is to endea-
vour to subdue and counteract this  general  tendency to a
chronic inflammation in  the Avhole  mucous  membrane and
ducts.   By astringent injections  or collyria, the  general re-
laxation may be removed, and the soreness and SAvelling of
the eyelids relieved by the citrine and tutty ointments; then
the sac and ducts must  be  kept also  clear, pressing out the
accumulated mucus, and injecting into the ducts until the
fluid passes into the nose.
  2. When there is not only a Avatery eye, and tumid  eye-
lid, but a distinct tumour of the lachrymal sac and an exco- 
EXTIRPATION OF THE EYE.
73
riated cheek, something must be done to make  the duct per-
vious.  In this state of the disease, it seems to  be ill-judged
practice to endeavour to  give firmness and  resistance to the
sac, to make it contract, by cutting open and stuffing it Avith
dressing.   This is  the same as  if a surgeon  Avould continue
to scarify and dress a fistulous sore in the perineum, after
he  kneAv urine was  discharged  from it,  and that there Avas
an  obstruction in the urethra.   The only questions to be de-
termined on previous to the operation are these: 1. Is this a
disease owing to a  general sponginess and thickening of the
mucous membrane ?  2.  Has this general diseased state ter-
minated in a particular stricture, or  obliteration of the lach-
rymal duct ?   3. Js there a stricture, or  obliteration of the
passage Avhich has  been the primary  cause of the symptoms,
and still keeps up the disorder ?
  But even the answers  to  these  questions are of no great
importance, because if an operation is to be  done, the  entire
operation is  not  more severe, or troublesome,  than a more
partial attempt to  cut into  the sac and make it contract and
fill  up.  If it should be found that a more general disease of
the  membrane prevails,  or  even if the  general affection be
proved to be  the original cause, this only teaches  us to be
careful to correct the slight and chronic inflammation of the
surface, after the course of the tears is established,  and dur-
ing the progress of the cure.
  A great part of this disease consists in the constant excite-
ment Avhich the suppurating sac gives to the eye; and that
again is a consequence of the absorption still continuing by
the puncta, after the  duct is obstructed—for  if the sac be
closed up and obliterated, and there be no disease originally
in the coats of the eye, a great deal of the irritation and even
the Avatering of the eye will subside—and if the puncta be
closed,  so will the inflammation of the sac subside, because it
has no longer the irritation of the acrid  tears.  Accordingly
it is  one  kind of operation,  attended  with  much  relief of
symptoms, to obliterate and fill up the sac altogether.
  VOL. it.                   l 
n
EXTIRPATION OF THE EYE.
  The intention  of  the  folloAving operation,  however, is to
restore the course of the tears into the  nose,  and entirely to
cure the disease.
OPERATION.
  The  patient is placed before the surgeon, and  they are
both seated.   The patient's head is supported on the breast
of an assistant, who  stands behind him.   The surgeon ap-
plies his thumb, (in this manner) to the eyelids, and stretch-
es them from the inner angle, so  that the small tendon of
the orbicularis muscle A, is made particularly distinct.   Be-
ginning his incision by  piercing  the skin just beloAv this ten-
don, he carries his small knife in a  semicircular direction, B,
(viz. folloAving the curve of the edge  of the orbit); raising
the point of the knife again, he thrusts  it deeper into the up-
per part  of the incision, and penetrates the  sac, and slits  it
doAvmvards.
   Or again, if the opening be  free  enough, it is better to in-
troduce into it a  small probe,  and  following the probe Avith
a sharp-pointed bistory, to cut open the sac.  The next part
of the operation is to pierce the bone  with the stilette.
   In piercing the bone, we have, in the first  place, to take
care that the point of  the instrument be lodged within the
natural sac before the perforation is made; for if it is not,
as I  have known it  happen, the latter treatment  will  only-
serve to obliterate the  sac, and  I  believe  to close  the tubes
leading from the puncta.  Noav, if the young surgeon does 
EXTIRPATION OF THE EYE.
75
aot perfectly recollect the relation of the os unguis to  the
nasal process of the upper jaAv-bone, and if he  points the in-
strument  directly into the nose, he may chance to hit upon
the very strong process of the maxillary bone.  But if after
being fairly in the natural sac, and of course Avith the point
beyond the sharp ridge of the  maxillary bone, Avhich forms
the margin of the orbit toAvards the nose, he carries on his
point obliquely downAvard and inward, he comes to be op-
posed only  by the thin plate of bone, (as delicate as a piece
of paper), Avhich  is called the os unguis, and now he will find
this part of the  operation very simple indeed.  By keeping
the  side of the instrument pressed upon the nasal process of
ef the  maxillary bone,  and carrying the point  for Avar d  it
Avill pierce  this thin lamina of bone the os unguis, and  then
the  point should be more turned toAvards the  cavity of the
nose, so as  to enter it just before the lateral cells  of the eth-
moid bone and above the lower spongy bone.  That we are
right in the direction of the instrument, is  known from the
very slight resistance Avhich we meet Avith, and the floAving
of a feAV drops of blood from  the  nostril,  or which may fall
into the  throat,  according as the head  is thrown backAvard
or fonvard.
   The instrument being AvithdraAvn, a piece of leaden  wire
is introduced.   This,  being Avorn for a week or a fortnight,
is taken  out  and replaced by a piece  of bougie.  In the
 course  of tAvo months, Avhen  the passage is become like a na-
tural  canal, the bougie  is  Avithdrawn  and the  wound al-
IoAved to heal; and the tears Avhich have been all this  time
 absorbed by the puncta and carried into the sac, and  have
 passed by the side of the bougie into the nose, continue, up-
 on  its  being AvithdraAvn, to run  by  this new passage into
 the nose.   The perfection of the cure is ascertained by the
 eye having no more than its natural  moisture, and that side
 of the nose Avhich was before dry having now as  moist a dis-
 charge as that of the other side.
   The following is the method of Mr. Ware .-—Having open-
 ed the sac, or supposing that it has been opened by ulcera- 
76
EXTIRPATION OF THE EYE.
tion, he introduces the blunt end of a probe,  (of  a size
rather smaller than the common dressing probe), and pushes it
on gently and steadily in the course of the natural duct.  He
overcomes the obstruction by force, and he passes the instru-
ment into the nose by the nasal duct*.
   The probe being AvithdraAvn, a small silver style of nearly
the same  size of the probe, and with  a flat head, which is to
prevent its sinking altogether into the nose, is  now introduc-
ed, and the operation  is finished.  This little style, passed
doAvn into the nose, keeps the duct permeable,  A\hile its head
being  covered a\ ith  black  Avax,  or  a bit  of  court  plaister
stuck upon it, has every appearance of a common patch.
   This operation is ingenious, Avhilst  its simplicity ensures
success.   It is not followed  by the high inflammation and
quantity  of matter Avhich will sometimes  follow  the use of
the  bougie, and  does not  therefore endanger  the closing of
the upper part of the sac or puncta, while from the begin-
ning there is  neither confinement  nor unseemly dressing re-
quired.
   Few people, liOAvcver, will submit  to a palliative remedy,
such  as this operation is, Avhen it  is intended  that the style
shall  remain in  the nose, and if the operation  be performed
Avith  the intention of removing the style,  and closing the
sac,  I Avould recommend that it should  be  performed  as
first described, viz. by  piercing the os unguis, and then sub-
stituting the style for the bougie, with the  expectation that
the patient  will  submit longGr to its  use.  By this  means
Avhile the patient enjoys comfort during the cure, he has the
better chance  of its being perfect in the end.
  When we perform the operation by Avearing  the  leaden
wire and bougie,  or  perform it in Mr. Ware's method, Ave
must withdraAv  the bougie  or .style, and wash the passage
by  means of  the small syringe;  at  first every day,  after-
wards only occasionally, as  it may  seem to  be required.

  * The full descent of the point of the probe into the n»se will sijufc
the instrument fully an inch and  a quarter. 
EXTIRPATION OF THE EYE.
V
This prevents the lodgment of matter, and the formation of
abscesses.
   From Avhat has been said, it Avill readily be  understood
that during the  cure we  must carefully  attend to the state
of the conjunctiva, and the general secretion of the eye.
   As we have already hinted, there was  formerly a method
practised, the object  of  which was to fill  up  the  abscess
Avith granulations, and entirely to  obliterate the sac, treating
the disease like a common abscess.  This, on first thoughts,
would appear to be a method of increasing the  evil, but a
great part of this complaint of fistula lachrymalis arises from
the excited  state of the lachrymal sac and ducts, Avhich pro-
duces,  by sympathy, an irritation  of the eye  and of the
lachrymal gland.
   There may occur ulceration and  much internal disease in
the part, Avhich may make us still prefer this method to the
long continued  use of the bougie or the introduction of a
style.
   Where the ducts are merely obstructed, there is  only an
occasional Aoav of the tears over the cheek, Avhen the eye is
accidentally excited.   The  patient complains little of the
disease until the sac inflames; and I knoAv there are  cases of
the common operation producing abscess, followed by total
obstruction, without the patient having an idea of any fail-
ure in the operation  he has suffered.
   Scarpa has thought it necessary to recommend in  a parti-
cular manner, that the sac should be dressed with escharotics
to the bottom.  I have always seen that the presence of the
bougie in the passage was sufficient  to inflame and cause the
due contraction of the sac.   He has thought it necessary too
to recommend the use of the actual cautery, to destroy the
os unguis, Avhen a new passage is  to  be formed; a  thing
which I think I can  say with confidence, is never necessary,
and must be kept altogether out of the enumeration of our
resources. 
78
OF THE EAR.
CHAPTER 11.
OF THE EAR*
      Matter Avhich Aoavs  from the ear may be a mere
change of secretion in the glandulas ceruminosae.  In this
case we may inject any mild astringent, as lime Avater, for
cleanliness, and anoint the passage with the diluted citrine
ointment.
  Sometimes the passage ulcerates, and there is a great puru-
lent discharge from the ear, or after some occasional increase
of the inflammation, an abscess or sinus forms behind the tube
of the ear.   The following consequences may ensue from this
suppuration.   1. The thickening of the membrane of  the
tympanum.   2. The  growth of fungous excrescences from
the passage.  3. The destruction of the membrane  of  the
tympanum by the progressive ulceration.  4. The communi-
cation of the inflammation and suppuration to the cavity of
the tympanum.
  We must  then  in  suppuration keep a free outlet to  the
matter, by preventing the SAvelling of the tube from closing
the passage,  and by opening the abscess if formed by  the
side of the tube ; Ave must prevent the lodgment of the mat-
ter by every possible attention.  Our injection should be some
mild fluid at first, and afterwards Ave may endeavour to cor-
rect the diseased surfaces: for this purpose a common injec-
tion is the muriate of mercury with lime Avater.
  If the hearing be dull to all outAvard sounds, but increased
to all vibrations of the head or javrs, and there is a confused
and loud noise often heard, there is  probably only an adher-
ence of  tough mucus,  about the opening of the Eustachian 
OF THE EAR.
79
  tube into the throat, or perhaps an inspissation of the ear-wax,
  which b6th prevents the sound from entering the tube freely,
*  and by pressing on the membrane of the tympanum prevents
  the free motion of the membrane.   In this deafness from the
  inspissated wax, we need only wash out the tube  with a sy-
  ringe and tepid Avater.
     When the Eustachian tube has been obstructed by a disease
  in the throat, deafness is the consequence.   It  is in this case
  that it is proposed to puncture the membrane of the tympa-
  num, that like the hole in the side of a drum it may give free-
  dom to the contained air, and free play to the membrane of
  the drum ; the  perforation  becomes a  substitute  for  the
  Eustachian tube.
     The patient is placed Avith the ear toAvards the direct light
  of the sun ; the surgeon is behind him, and he turns the head
   until the light is admitted into the bottom of the tube.  The
   point of the silver probe,  (a small stilette is  used by Mr.
   Cooper), is pushed through the  loAver and fore part of the
   membrane of the tympanum.   As it is found that the perfo-
   ration in this membrane very soon heal=, it has been thought
   necessary to lacerate it pretty freely, but  the greater the in-
   jury the greater is the probability of the membrane inflaming,
   becoming  thick, and of consequence, incapable  of delicate
   vibrations.   I should imagine that it Averc better for a time
   to alloAv a small probe of silver to remain in the passage of the
   ear, supporting it by a little cotton  in the passage.  It is an
   operation of great uncertainty, and  leaves the patient to re-
   gret the very short enjoyment of the benefit he has been led
   to  expect from it.
      But I deem it to be of  more consequence to speak here of
    the dangers of deep suppurations in the cavities of the ear.
       Suppuration may take place in the cavities of the ears, and
    in the mastoid cells, either from the communication of inflam-
    mation from the outAvard  tube, from the throat,  by the Eus-
    tachian tube, or it may be a scrophulous disease, originating
    in the bone itself.'  Any  one who thinks of the  principle of
    Pathology, which guides us in our surgery of the head, must 
80
©F THE EAR.
 at  once foresee danger  from suppuration and caries of the
 temporal bone, for though it contain the organ of hearing, yet
 it takes more  importance, in this  instance, as a bone of the
 cranium.
   The worst character of the disease is when, after the patient
 has had violent pains, he is attacked with shivering and fever,'
 and the organ is destroyed, and the passages of the ear are
 full of pus, and the bones of the tympanum have come away.
 This discharge may continue long, without any further appa-
 rent bad consequences than  the loss of the organ, but if there
 comes  drowsiness, and oppression, and a feebleness or degree of
 paralysis in the opposite  side of the body, then the petrous
 portion of the bone is carious, the dura mater attached to it
 has partaken  of the disease, and the side of the cerebellum
 and base of the cerebrum are diseased and covered with pu-
 rulent matter.
   The abscess sometimes forms in the mastoid cells, and mak-
 ing a slow progress, such as  characterises the scrophulous ac-
 tion, after a time the tumefaction of the integuments over the
 mastoid angle of the bone betrays its presence.   The bone in
 some instances becomes carious, and the finger can depress the
 integuments into the bone,  and, when this is opened, it is not
 merely a disease of the bone  which Ave diseover, but the sur-
 face of the brain is exposed,  and  the probe can be introduced
 deej>er than the thickness of the temporal bone ; a circum-
 stance  Avhich sheAvs the danger of the experiment.   Thrice I
 have seen such suppuration fatal by the communication of dis-
 ease to the brain, before the spoiled bone gave Avay outward-
 ly ; and I have ascertained  the nature of the disease by dis-
 section.
  We  learn from this view of the subject, hoAv carefully we
 ought to attend to  symptoms when there is disease in the ear,
 lest it should become irrecoverably bad, and end in communi-
 cating  the disease to the brain.  We must bleed, and purge,
 and foment, to allay the pain and inflammation, if it be active.
 Blisters are to be applied behind the ear, if a sIoav continued
action is proceeding within;  and where we can ascertain that 
                       OF THE EAR.                     $1

there is caries in the posterior angle  of the  bone, Avith dan-
ger of the confinement urging the progress  of the  diseased
action to the brain, we have to apply the trephine and pen&
trate into the cells of the bone;  even Avhen this is done, if
the petrous portion of the  bone be  carious, there remains
only a hope,  that  by great care, soothing  the action,  and
guarding against the matter collecting,  we may gain time, so
that the diseased bone may  separate, and an abscess  in the
brain be prevented from forming.
VOL. II.                  M 
82                OF THE PSOAS ABSCESS.
CHAPTER HI.
OF THE PSOAS ABSCESS.
      In the treatment of sinuses and abscesses, the most es-
sential point to be known is, what has produced the collec-
tion of matter, and Avhether the cause be removed—for if we
are to cut up fistulae during their tendency to form, we shall
find  that only  deeper and larger  passages open themselves.
If vre are to open an abscess, Ave  ought first to consider by
Avhat means Ave are to produce a change in  the action of the
part.  The matter  of an abscess is not  collected, but, like
the fluids of the cavities of the body, it  is  suffering a change;
the absorption of the pus is performed  at the same time that
pus is throAvn out by the vessels; and the increase or dimi-
nution of the matter of the  abscess depends on the relative
action of the arteries or absorbents.  We have to  observe
Avjiat further change, besides evacuation of the matter, is ac-
complished by  opening an abscess.
   Experience teaches us that a scrophulous abscess will seem
to point, being soft and prominent, and having fluid evident-
ly in it; and yet that Avhen the  lancet  is  thrust into this
tumour,  only a pale Avatery  fluid escapes, and the walls of
the tumour acquire an inelastic, but irregular,  firmness, like
a cake:  and the progress of the action, or at least the soften-
ing of the  tumour towards the surface is not promoted but
checked.   The scrophulous action is  here, I suppose, of a
slow  and sluggish nature, and the phlegmonous action, the
consequence of the wound, has somewhat of a contrary ten-
dency, so that  the original progress  of the disease is not pro-
moted, 
OF THE PSOAS ABSCESS.
83
  Again, in the scrophulous action about joints Avhich has
produced abscess, by cutting into  this abscess  the sIoav na-
ture of the disease is changed; the  matter, though evacuat-
ed, collects again, no longer bland or mild, but putrid and
acrid, and an irrecoverable caries may be the consequence*.
  It is of little importance Avhether the change in this par-
ticular instance is to be  attributed  to the air getting access
to the secreted  matter, and producmg  an alteration upon  it,
making  it  acrid  and  stimulating;  or whether the incision
changes  the nature  of  the action in the surface of the caA-i-
ty, so as to produce bad and foetid matter.  But it is  par-
ticularly of consequence  to observe this  contrast, that by
stimulating the surface and making counter irritation on such
a  scrophulous joint,  the original  action  might have  been
changed, and the  limb and patient saved ; Avhile  under this
surgical  treatment the disease has rapidly advanced.
   Where an abscess or extensive fistula  forms, in consequence
of  a wound,  it may be permitted  to  rouse the  activity of
the surface by an  injection or seton, for perhaps there is
nothing  peculiar in the action ; there is only a Aveakness and
inactivity ; and by habit the  secretion continues.—But even
here it Avill in general be better to raise the life and activity
of  the  whole  limb, by  admitting freer  motion,  by  warm
stimulant fomentation and rubefacients.—For though  these
communications and abscesses have formed after an injury,
it by no means follows that they are merely the consequence
of that injury ; they have often a scrophulous action; and
the injections or seton raise a violent inflammation, and ge-
neral tension of the limb,  which  instead of promoting the
adhesion of the cavities form others in  succession.
    All abscesses or fistulae connected av ith  ducts or natural
 passages form a class by themselves, which ought not to en-

   * Experience teaches us that it is useless to open scrophulous and venere-
 al abscesses ; but further, we find the practice bad as complicating the case,
 and dangerous as sometimes productive of the phagedenic ulcer.  Read the
 section on abscess in Ford's Observations on the hip disease, which is very
 valuable 
84
OF THE PSOAS ABSCESS.
ter into the present inquiry.  Such are fistula in ano, fistula
lachrymalis,  fistula in perineo.   In these  the  difficulty of
discharging the natural fluids, produces an inflammation in
the ducts ; abscess forms by the side of the passages; and a
communication is made betwixt the duct and abscess by ul-
ceration, and an irritation is kept up; until the passage be
freed the abscess a\ ill not heal.
   WTiere an  abscess is very  large, there is  one circumstance
requiring particular attention ; it is this, if the abscess burst,
that is, if the ulceration proceeds outwardly to the skin, the
Avhole  surface of the  abscess will inflame, the discharge Avill
become bad,  and the patient will die.   We open  such ab-
scesses, not with the intention merely of evacuating the mat-
ter, nor for the  purpose  of  procuring an adhesion  and ob-
literation of its  sides, but to alloAv the cavity gradually to
contract so that A\hen it fills again it may not be so extensive
nor apt to disorder the system Avhen it is finally opened.
   For example, if a large abscess be  pointing, and about to
ulcerate and  burst, it is to be punctured,  and the matter
evacuated; but it is not to be lanced just upon the most
prominent, and thinnest part.  The opening should be made
by the side  of that  part of the  abscess Avhere it naturally
may be expected to open.  The opening  is thus to be made
in the  healthy skin, so that the Avound may close again Avith-
out any ulcerative action taking place, and without the risk
of inflammation being propagated over the sides of the cavi-
ty.  From the evacuation of the matter, and contraction of
the cavity, the Avails of it  thicken.   When the cavity fills
again,  it is less extensive; it is to be punctured again, and
the opening immediately closed ; the abscess still further con-
tracts, and perhaps by the  third or  fourth opening the ab-
scess is so much diminished that no  care need be  taken to
close the opening; it may be left to common treatment.

   These introductory observations Avill be found necessary to
the understanding of the short statement I am now to give of
the nature of the lumbar abscess, and the treatment of it. 
OF THE PSOAS ABSCESS.
85
          PSOAS, OR LUMBAR ABSCESS, CONTINUED.

   The Psoas Abscess is tlie consequence of a sIoav and almost
imperceptible inflammation of tlie cellular membrane, by tlie
side of the lumbar vertebra;, and around the psoas muscle*.
These deep parts, from their nature as Avell as their situation,
being little sensible, and the disease being a sIoav, scrophulous
action, the  nature of the complaint is only  suspected Avhen
there is a weakness in the loins, a numbness and Aveakness of
one thigh, and a dull Avearying pain in the loins like rheuma-
tism ;  nor is there at first general symptoms to mark the diag-
nosis more distinctly.  Sometimes the pain in the loins is very
severe, with a total inability of raising the thigh.   But AAhen
a compressible tumour appears  in the groin, the fluctuation is
perceptible in the tumour, and pulsation is felt in it Avhen the
patient coughs; then the nature of the  case is too evident,
and the surgeon has that painful conviction of a patient being
in the utmost degree of danger, Avhile he is little conscious of
it himself, and but imperfectly comprehends hoAv a matter so
trifling in appearance, and so  little troublesome, is pregnant
Avith so great evil.
   If  there  precedes  or  accompanies the appearance of ab-
scess at the groin, a  curvature of the spine, the prognosis is
still more unfavourable, for  caries of tlie bodies of the  ver-
tebrae is sometimes the origin, or at least, the  precursor  of
the psoas abscess.  As might be naturally expected, especial-
ly Avhen the disease is complicated Avith a caries and sinking
of the spine, the abscess sometimes  makes its  Avay outAvard
upon the loins, forming a tumour by the side of the spine.
   If  the tumour in  the groin is  opened, and the  matter of
the abscess  evacuated,  the sac  inflames, the  loins become
Aveak and painful—rigors, a rapid pulse, Avhite tongue, and

  * The abscess is sometimes in the centre of the psoas magnus. This dis-
position to form abscess in the centre of the larger muscles, I have seen very
generally prevailing; on dissection, I have found them in the psoae, the gas-
trocnemii. and in the muscles of the thigh. 
8(3
OF THE PSOAS ABSCESS.
hot skin succeed—the discharge becomes thin and foetid, and
often profuse, the appetite entirely fails, the nights are rest-
less,  and a rapid hectic is confirmed.
  The cure  is to be thus conducted:—1. To evacuate the
matter and yet endeavour to prevent the inflammation of the
sides of the abscess.   2. To produce  a counter irritation by
an artificial ulcer on the loins.  3. To correct or change the
action, or produce an absorption of the remaining matter by
emetics or by electricity.
  If the abscess  has formed a  tumour  in the groin, and
the fascia be  yet  entire, and the integuments  on the promi-
nent part of the tumour thick and  not yet possessed of much
increased vascularity, the abscess lancet is to be thrust into
the most prominent part, a little slantingly through the skin;
but if the tumour be threatening  to  burst, Ave should punc-
ture  it not on the highest part, but more towards the base of
the tumour,  so that the opening be made  in sound skin,
which will more readily close and heal.
  When the  pus and coagulable matter are  evacuated, the
Avound must  be treated  tenderly, united by a  small piece of
piaister, and  bound doAvn with a soft compress and band-
age.   We must be  careful that  nothing  intervenes betwixt
the lips of the  Avound, that the union of the skin may be se-
cured ; and by the compress the integuments are pressed up-
on the fascia  of the thigh, so that the opening through it is
closed also, and the matter of the abscess prevented  from
passing under the skin.  The patient for a time must be con-
fined to the  horizontal posture, and  use no exertion in rais-
ing himself, or  in moving  the abdominal muscles.
  When the  small Avound is healed, then more freedom is al-
lowed to him, and gradually the tumour appears again. When
it has acquired a size and prominence sufficient, it is  to be
punctured a  second time  and healed; and this successively
until the matter evacuated be no longer considerable.  When
only a few ounces are evacuated, and the state of the  pa-
tient is favourable, Mr.  Abernethy leaves the puncture open,
being no longer solicitous  to prevent the inflammation of the 
                  OF THE PSOAS ABSCESS.                87

sac; or rather  it is better to endeavour to  cause  an absorp-
tion of  the remaining matter of the sac, by giving emetics
and sending the electric  spark  through the loins and side.
If there should occur much debility during the cure, bark
and wine and free air  will do  much; and  opium  with the
bark will be required if there be  much irritation in the sac
or diarrhoea.
   Another resource for  correcting the internal disease in the
loins is  the formation of issues by the side of the vertebrae,
as for the disease of the  spine; and this treatment is parti-
cularly necessary when  there is  a  tenderness  on pressing the
spines of the vertebra?, or a degree of curvature of the spine
accompanying  the abscess.
   It is to Mr.  Abernethy that we are indebted for this plan
of treatment of the  lumbar  abscess,  Avhich affords  us hopes
of curing a disease before considered fatal. 
3&
OF THE  CURVED SPINE.
CHAPTER IV.
OF THE DISEASE AND INJURY OF THE SPINE.
                  OF THE CURVED SPINE.


      1 his term does not include the distortions of the spine,
from rickets or mollifies ossium, but that only which is the
consequence of an ulceration and Avasting of the bodies of the
vertebra?, a disease most frequent in the lower vertebra? of the
back.
  In an infant these are the symptoms: the mother tells you
that the child was strong and healthy, and perhaps that he
had begun to use his feet, and could stand upright with little
assistance, but that of late he does not try to stand, and Avhen
laid over her knee, he does not struggle as children naturally
do Avith their feet.   You find the child's flesh soft;  and par-
ticularly the  skin and muscles of the loAver extremities, soft
and Avoolly; upon examining his back, you find one or tAvo of
the spinous processes of the vertebras  particularly prominent.
  If the child be old enough to have walked, he is gradually
deprived of the use of his legs; he complains of languor and
fatigue; he is listless and unwilling to move ; his legs  are apt
to cross, and he stumbles  often, being unable accurately to
direct the foot.  He leans forward, and there is a projection
in  the  spine.  Large abscesses sometimes  form and drop
doAvn upon the loins, and appear externally in the top of the
thigh, or a tumour is formed by the side of the vertebras of
the loins. 
OF THE CURVED SPINE.
89
    in the latter stage of the disease there is pain of the back or
 loins, which even in bed is tormenting and incessant; the
 breathing, and indeed the whole functions of the thoracic and
 abdominal viscera, are oppressed by the chest falling down in
 consequence of the great curvature of the spine.   The urine
 and  faxes  are  passed insensibly, and in consequence of this
 perhaps as much as by sitting on the insensible buttocks, (the
 perpetual  pressure on which gives no token of the  degree of
 injury  they sustain), deep sloughing or horrible ulcers take
 place.
    This is a scrophulous disease, which begins in the bodies of
 the vertebrae of the back or loins.  By dissection I find that
 the first stage  of the disease is not an increase  of vascularity
 and softening of the bodies of the vertebrae, so that they sink
 under the weight of the body; but  the progress of the de-
 struction of bone proceeds by the entire absorption of several
 intermediate portions of the body of the vertebrae, leaving the
 spine supported by the remaining firm parts, which are some-
 times like columns standing betAvixt  that which is decayed.
 (I have given a plate of this early appearance of the disease).
   The destruction  of  the bone  having gone  thus far, the
 affected bodies of the  vertebrae  sink under the incumbent
 Aveight of the head, chest,  and arms.    The paralysis of the
 lower extremities is noAv for the  most  part distinctly marked,
 but as I  have seen this symptom before the sinking of the
 vertebrae, I have concluded  that the neighbourhood of the dis-
 eased bone has involved the spinal marroAv in the morbid
 action, so that its function has suffered.—The cessation of the
 disease relieves the paralysis; which is accounted for by sup-
 posing that the spinal marrow and the  tube of the  vertebrae
 become adapted to each other ;  but  the circumstance is
 equally well explained by supposing this to be the result of the
 cessation of the diseased action.
  In a young person who has shot up to great height, and
 whose muscular strength is not great, there is a possibility
that a curve of the spine may arise from a bad habit merely,
 but these curvatures are generally lateral.   In  th«» tru* dfc-
  A'OL. IT:                    V 
 00               OF THE CURVED SPINE.

 ease, the pain or uneasiness deep in tlie spine, with that coun-
 tenance and habit peculiar to scrophula, will urge  us to exa-
 mine the spine, and if Ave should not find that there is a be-
 ginning prominence  in the spinous process of one  or tAvo of
 the vertebrae, yet by pressing Avith the fingers along the spine,
 some one of the spinous processes Avill be found to  give pain
 perhaps, and in this case we should not delay the remedy*.
   The grand remedy for this disease is the making of issues
 or setons by the side of the affected spine.  But I cannot
 think that the good effect of these artificial ulcers is  from their
 acting as drains.   I see them lose their effect when they be-
 come stationary ; I  see, even in the first violence of  the irri-
 tation and inflammation, a remarkable change on the disease
 for the better, Avhich does not continue if the surrounding skin
 and  deeper part  lose  their inflammatory action.    Once  I
 found quick and remarkable relief given by the caustic eating
much deeper and broader than I intended or thought right;
and I have on another occasion Avitnessed the remarkably good
effects  of the hospital sore catching the issue, and destroying
the soft parts to  a great extent.—In this  last instance the
healthy inflammation  Avhich  succeeded the sloughing of the
sore made an immediate change on the disease, and the patient
got quite well.   In short, I  conceive that the inflammation
excited in the neighbourhood  of the disease, (Avhich is of the
nature of a slow and sluggish scrophulous inflammation), invi-
gorates these affected parts, and reaching even to the vessels
of the bone changes the nature of their action, and restores the
natural influence.
   In this  vieAv I  prefer the making of issues Avith the caustic
of a longitudinal form by the  side of the curve  of  the spine,
first one, and when the surrounding inflammation is contract-
ing, and the ulcer likely to become stationary, I make anoth-
er in the other side of spine, for a time neglecting the first;
and afterwards I conceive it necessary to keep up a  considera-
 ble degree of irritation in the  one or other of the  issues.   I
* See Sir James Earle, On the Curred Spine. 
OF THE CURVED SPINE.
91
 believe pain, or in other words irritation, to be absolutely ne-
 cessary to the effect, and I cannot prefer the seton to the caus-
 tic because it giAes less pain.
   If the child he young, it will only he necessary to take care
 that he be not carried in the usual way  in the nurse's arms,
 but lie horizontally.   If tlie child be more advanced, it is of
 the first importance  that the spine be supported, and tlie
 weight of the upper part of the body taken from  the diseased
 vertebrae.  For this  purpose, Le Vacher's  apparatus is the
 best.   But I may remark upon this subject, that our object
 should be to support, not to stretch the spine.
   If Ave find that by an apparatus we can elevate  the verte-
 brae which have sunk, yet this should not be done,  for the
 final cure is to be obtained by the anchylosis of the vertebrae;
 if they have been once destroyed, and  have sunk, to separate
 them is to prevent the natural process of cure.
   Here, as  in most  cases, pain is the indication  of mischief,
 Avhile  relief from it  gives hopes of an amendment; noAv a\ hen
 we see a poor creature moving Avith much distress, seizing on
 every object for assistance, and leaning  with his hands on his
 thighs to give relief  to the pain of the spine, how can Ave
 doubt but that to take off ihe pressure of the head and chest
 will promote the cure.
   The success of our  endeavours to cure this  disease in the
 spine,  is to be judged of by the allaying of the complaint of
 pain, or of fatigue of the loins; by the sleep  and appetite be-
 ing good ; by the ceasing of involuntary spasms of the limbs,
 the flesh of the thighs and legs being firmer to the feeling;
 lastly by the diminution of the curvature of the  spine, and
 by the patient perceptibly growing taller.

   I am naturally called  upon here to say a few words on rest,
and  its absolute necessity in this, and in many other diseases
of the bones and joints.  Those who are bedridden  are gene-
rally suffering from disease, and the weakness induced by the
disease  is attributed to  the confinement: but the  contrary
holds good Avhen the disease is of  a nature to be relieved by 
92     COMPARISON BETWIXT THE SCULL AND SPINE.

rest;  for then lying in bed restores the patient:  under the
confinement he gets fat instead of wasting.  Lying in  bed is
too often a confinement to bad  air, the breath and exhalation;
are confined, and a free circulation of air  is not admitted.
But if, on the contrary, the person confined to bed be cheerful
and not despondent, and if he be as careful to change his ap-
parel  and bed-clothes, and to wash, as if seeing company, and
to eat and drink  in the moderation proportioned to the little
exhaustion  or exercise Avhich his situation allows  of, he will
get fat and enjoy health.
   In  very bad cases of distorted spine, therefore, I conceive
that it Avill be better to keep the patient in  bed or on  a  sofa,
until  there be a  favourable change in  the  disease, and  that
when the anchylosis has formed, or the diseased vertebrae con-
solidated, the patient may have the relief of moving about un-
der the apparatus for supporting the spine,  until the  cure is
established,

   That part of Pathology which explains the diseases of the
spine, and the effects of  injuries of the vertebrae, is very im-
portant.  We  find the  spine to be a  column composed  of
many bones jointed and united by ligaments.  We find that
Avhile the column has  to support the weight of the head and
trunk, it is at the same time  capable of a  certain slight de-
gree of motion betwixt its individual  bones.   Above  all Ave
can never forget  that  is  a tube protecting a prolongation of
the brain, the spinal  marrow.   We find  that  besides the
tube  of bone, the spinal marroAv  is surrounded Avith a sheath,
as a further protection.
   Considering  these circumstances, Ave see a strict analogy
betAvixt the effects of disease and injury of the vertebrae,
and of the skull; in both  instances the high importance of
the subject results from the nature of the contained parts.
The  brain  suffers concussion in  every shock given  to the
head; compression and injury from fracture of the skull; in-
flammation  and  suppuration from disease  or death  of the
bone  or of surrounding membranes. So does the spinal mar 
FRACTURE OF THE SPINE.
9?
tow suffer from a  blow on the spine:  so is it bruised or
compressed when there is fracture of the tube of the verte-
brae : so is it inflamed or compressed when there is caries of
the bone or disease  of the membrane; while it is exposed to
further injury by dislocation of the vertebra?.
OF FRACTURE OF THE SPINE.
  T have had an opportunity of examining by dissection
only one instance of fracture of the body of the verte-
bra.  The  bodies  of  the vertebrae are  not  fractured  by
blows, but by falls, in  AAhich the whole body is twisted, or
when a bank of earth  falls  upon and buries  a man.  This
fracture will not be known by the crepitation like a common
fracture of the limbs, but only by the derangement of  the
projecting spinous processes ; while yet they are not separat-
ed  as in dislocation, nor  crushed and crepitating  as Avhen
they are  themselves fractured,  or  a blow upon them  has
crushed in the arch of bone.
  I have given above, a sketch of the parts in the instance I
examined, and it is seen how the body of the vertebra at A
is broken, Avhile the intermediate tough and ligamentous sub-
stance B is entire; it will be seen too how the point of  the
bone C is forced against the spinal marrow D.  The crush- 
%
fracture of the spine.
 ing of the bones hurts the soft substance of the spinal mar-
 row, although it appeared entire, being covered  with its
 tougher sheath.
   I believe that the force which fractures the bone will at
 the same time destroy the spinal marroAv, and the effect will
 be paralysis of the loAver extremity, and in the end death.
   The substance or bodies of the vertebrae may be said to
 be fraetured when a bullet lodges there.  Gun-shot fracture
 is a desperate and generally fatal case;  for  if the ball  has
 entered from before, it  must  have passed through the  visce-
 ra of  the thorax or abdomen, and if from behind it must
 have injured  the spinal marrow.  If it has  entered by  the
 side into  the bodies of the lumbar vertebrae, it niay lodge
 there  Avithout being  fatal, and may drop  from its  place af-
 ter inflammation  and suppuration have reduced the patient;
 but the chance is, that by the concussion of the spinal mar-
 row or breaking  up  the tube of the spine into splinters,  the
 injury will prove  quickly fatal.
   If the spinal marrow be cut through by a bullet, a man
 may live a longer or shorter time, according as the  divi-
 sion has been made  in the  loins or higher, as in the  neck.
 If the  division has happened in the loins, there may be Inly
 paralysis  of the  loAver  extremities, and insensibility of the
 bladder and rectum.   If higher up,  the  bowels will suffer
 more by distension.  If the division has been made high in
 the neck, the  patient will die suddenly from the supply of
 nerves  to the muscles of respiration being cut  off.
   Besides fracture of the bodies of the vertebra?, and frac*
 ture by gun-shot, there  may be fracture of the  arch of the
 vertebra, Avhich forms the tube for the  spinal marrow.  A
man falling backward and having his spine curved and pro-
jecting, may,  by hitting a stone, fracture and beat in the
 arch of bone; or, supposing  that  he  is  driving a  carriage
 under  a gateway, stooping, thinking to avoid the arch, hut
 does not, he strikes the same part of  the chain of spinous
processes against the arch, then  the blow breaks the tube of
the vertebrae and forces in  the tube and spinous process, so 
FRACTURE OF THE SPINE.
95
that  he  becomes  paralytic in all the  lower part of the
body.
   In whatever way the vertebrae are broken,  the  danger of
moving the body must be apparent, since in every change of
posture,  or turn of  the body, the  broken bones may  be
thrust against the spinal marroAv.  Looking to the anatomy
as our only guide, AVe see no reason why in fracture and de-
pression  of the tube of the  spine,  the surgeon should not
make an incision, and draAv out the fractured portions, and el-
evate the arch! But when  we turn our attention to the real
circumstances of the case as it has actually presented itself in
practice,  we find the bones have been crushed, the swelling
general, and the paralysis complete.   If this paralysis  prov-
ed that a piece of bone stuck in the spinal  marroAv, then we
might proceed  to  operation.   But as a blow less than suffi-
cient to crush the spine will  by concussion produce the pa-
ralysis, we are  tempted to wait and hope.   But if the  bones
are evidently crushed in upon the spinal marrow, then raising
the bone  Avill not remove the injury to its substance.   In
short, the uncertainty of the circumstances of the case, joined
to the little probability that the  operation would do  good,
supposing  that  the bone has  been crushed  upon  the  spinal
marroAA', or has  entered its substance, deters us from laying
open the  canal, the more especially  as  Ave have the chance
of doing  more mischief than good.
   When called to a patient in this situation the 6urgeon car-
ries a catheter Avith him  to  draAv off the urine, because he
knows that the  sensibility of the  bladder  is destroyed, and
that there will be  in  a  short time, an accumulation of urine.
There will come flatulent distension of the abdomen too, and
vomiting or hiccup, for which (in this case)  terrible symp-
toms  we have only to  palliate by ordering  very stimulating
clysters, and frequent friction of the belly.  If the patient
survives  the first  shock,  the  insensibility of  the  hips and
lower extremities will allow him to lie pressing the hips and
nates till they mortify.  This  mortification and ulceration on
the sacrum may be  accelerated by the  insensible  discharge 
9t>
DISLOCATION OF THE SPINS.
of faeces or the dropping of the urine, and consequent moist-
ure of the bed.   After this the patient  soon sinks.

          OF THE DISLOCATION OF THE VERTEBRA.

  Dislocation  cannot take place in the vertebrae  of  the
back  and loins,  I  imagine; from the circumstance  of the
ligamentous connexions  being fully stronger than the bone.
But a species  of subluxation  may certainly  take  place in
the lumbar vertebrae.  This is a dislocation of the articulat-
ing processes, but not  of the  bodies of the  vertebrae,  the
intervertebral  substance  being  only  a  little  irregularly
stretched.
  This derangement of the bones may be a consequence of
the distortion of the body in Avrestling  or tumbling, or by a
weight falling on the shoulders,  when  the body is bent for-
ward.   By  this  means the ligaments  already stretched are
toai up, and the vertebrae stand thus:—
Plan  of dislocated Vertebra;.
  A,  the articulating process of  the upper vertebra.  B,
the articulating process of the lower one.   These, it will be
observed, should lie flat  on each  other,  instead  of  which
their points  stand opposed, so that the bodies of  the verte- 
DISLOCATION OF THE SPINE.
07
 brae C D  cannot come into  their regular approximation, but
 stand Avith oblique surfaces.
   From what is here expressed the symptoms Avhich cha-
 racterise the accident may be learned.   The person is bent
 doAvn, and unable  to  elevate himself; there is a projection
 of the spine, and there is an unusual space  betAvixt tAvo of
 the spinous processes.
   The  reduction of this dislocation is by no means easy to
 accomplish.  We cannot turn and twist, nor  yet stretch the
 body, as Ave Avould an arm or leg.  Wras our  strength equal
 to it, there is danger,  Avhere  Ave have the  soft spinal mar-
 row Avithin, and  Avhere the strong connexions of, the process-
 es are already  lacerated.  The  older surgeons have recom-
 mended that the  patients should be put over a barrel, and
 that the body be then bent forAvard until the processes of
 the  vertebrae are disentangled.  It has happened that after
 all methods have been tried in  vain, the patient  has been
 relieved by an  accidental jolt  or  exertion, and  the  bones
 have slipt  into their places.
   When the  reduction has not  been accomplished by the
 efforts of the surgeon, yet in length of time and by degrees,
 the  spinous processes have approached, and the patient  has
 regained tlie erect posture.
   Dislocation,  I  imagine,  cannot happen in the vertebrae of
 the back, becaoae of the firmer articulation of the processes^
 and the strength of their attachment by the double articu- »
 Iation  of the ribs.   But  Ave may  have subluxation in the
 vertebrae of the neck.   A  man,  having slid off a hay-stack,
 fell on some loose  hay that covered the  ground;  the skull
 Avas not injured, but he never recovered the shock, and died
 of the  concussion.   In this man I found  that  I could  intro-
 duce my fingers  betAvixt the third and  fourth vertebrae of
the neck;  and on opening the  tube of the vertebrae a  great
quantity of fluid blood flowed  from the  spine and base of
the skull.  These, I believe, will generally be the circum-
stances attending the subluxation  of the vertebrae of the  neck,
viz. that the shock of the head and spine  will  destroy the
   VOL. II.                   O 
lJ8              DISLOCATION OF THE SPINE.

patient  and that the  symptoms of concussion will be aggra-
Abated by the  blood effused  from  the  ruptured  vertebral
veins.
  But another  effect may be the result of a lesser degree of
injury to the ligaments of the spine, when the neck is thus
tAvisted  under  the pressure and falling  of the body.  The
Avhole soft parts around the bone, and Avithin  the canal of
the vertebrae, may be so injured that there  may  arise a
thickening  of the  sheath of the vertebral  canal, and conse-
quent pressure of the spinal  marrow;  or I have thought
that the injury to the spinal marroAv may  produce a slow
disease in it* Avhich at last destroys its function, and makes
all the body  beloAv paralytic.   If a  train  of symptoms, ush-
ering in paralysis,  should succeed to a twist  of the spine, or
to any  kind of injury, Ave shall be  led to employ all such
means as are proved in caries of the spine  to  be effectual
for  removing the deep-seated disease. 
DISEASE OF THE KIP JOINT.
*.»9
CHAPTER V.
OF THE DISEASE OF THE HJ.P JOINT
      1 ins is a  scrophulous  disease.—It is most common in
youth,  from  childhood to the twenty-fifth year;  but the
same disease attacks those of sixty years of  age.   The disease
begins with a deep-seated pain behind the trochanter major;
the pain being aggravated  by motion, the patient, in Avalking,
throAvs the Aveight of the body on the opposite side, and there
is consequently an aukward crippling gait.   Exercise, we are
told, in the beginning of the disease relieves the pain, but it U
aggravated in the stiffness after fatigue.
  When the disease is formed, and Avhile yet in its first stage,
the  limb is  lengthened.   This is not merely  a feeling  of
greater length in the  limb,  occasioned by the inflammation
and increased sensibility  of the  parts  Avhich form the hip
joint, but there is a filling up of the acetabulum, and a pro-
trusion of the head of the thigh bone from its socket.
  During this progress of the disease, there is as yet no dis-
colouration of the skin ; but the hip is swelled over the joint,
and, from  Avant of use,  the  muscles  of  the  hip are flabby.
The trochanter major is prominent, and in consequence thi
hip is  increased  in breadth.  Dr. Falconer observes, that
there is to be felt an enlargement and  projection of the tube-
rosity of the ischium as well  as prominence of the thigh bone.
  With the Avant of exercise  the leg and thigh Avaste, and, in
the advanced state of the disease, the limb instead of beJnp,
longer is considerably  shorter.  The difficulty in the motion
of abduction or throAving the leg out sideAvays is considerably
greater than that  which is felt in moving the limb in any 
100
DISEASE OF  THE HIP JOINT.
other direction.   This is owing to the relation of the bones,
or entire dislocation of the femur.   There is a peculiarity in
the seat of the pain, too, which must be held in remembrance,
else Ave shall be employed in  fomenting the knee and leg for
a disease in  the hip,   I have found a disease of the nerve in
the ham, producing pain in the sole of the foot, continued for
nearly tAvo years.   So I believe that in this case the ischiadic
nerve passing so near the  seat of disease, is affected, and pain
is the consequence, Avhich is attributed to the outside of the
thigh, the  knee, and leg.  When the  pain is deep in the
groin and in the inside of the thigh and knee, it is probable
that the  obturator nerve may be  involved  in the  inflamma-
tion.
  When suppuration takes place, there are  startings and
catchings during  sleep.  The pain  is increased, with much
tension and throbbing ; noAv the skin inflames, and the abscess
bursts either in the groin  or behind tlie trochanter.   Succes-
sive abscesses will  sometimes form around the joint, and still
the patient survives.  The limb being fixed, the granulations
of the inflamed joint run together, they ossify, and an anchy-
losis is formed,
  But often,  the  abscess advancing, and the skin being in-
flamed, hectic fever rapidly reduces the  patient, there is per-
spiration, diarrhoea, a white tongue, a face changing from the
hectic flush to the leaden  coloured paleness  of those who are
tabid; they linger thus, and die.
   This hip  disease is an inflammation  peculiar to the  scro-
phulous constitution.   It  attacks the ligaments and cartilage
in the parts jjpjoying a Jess active and vigorous circulation.
There is danger of  its being confounded with rheumatism,
gout, or the psoas abscess.
  As to the cause, it is scrophulous disease.   The bones and
joints of the lower extremity are most  liable to disease, and
of these chiefly the larger joints :  therefore the knee is  most
liable to disease ; next in frequency is the hip joint; then the
ancle joint.                       j 
DISEASE OF THE HIP JOINT.
101
  Dissections prove that the cartilage is absorbed, that the
bones of the pelvis forming the socket, and the liead and neck
of the thigh bone are Avasted and carious; or after the inflam-
mation of the bone, and the Avasting of the cartilage, the bones
unite and form an anchylosis*.
  Anchylosis is not necessarily the cure of the disease,  nor a
natural termination to it.  I believe it takes place thus:—
The inflamed bone not being under the influence of that "law
which contracts and directs the growth of  parts in their na-
tural action, irregular processed are formed, Avhich, pioject-
ing, hinder the motion of the joint; by the  loss of motion the
incessant  irritation of inflamed parts,  moving  on one ano-
ther, is taken off the joint, the latter  being now  preserved
steady; the  bones unite; and the surrounding abscesses be-
ing no longer festered by the pain and  irritation Avithin, they
are contracted and  dry.        /
  In the  cure,  I have  advised  repeated  small  mercurial
purges, Avith hot  fomentation, when the complaint seemed
doubtful.  If the complaint begin Avith a violence of the in-
flammatory symptoms proportioned to  the  injury to be pro-
duced afterwards, both to the joint and the system, bleeding
Avould first of all  be thought of.   But, Avhen the surgeon is
first called,  there is a Ioav irritability,  Avith a quick,  small
pulse, and he is more inclined to apply stimulants to the sur-
face, without further reducing the  action  of the part by
leeches ; or  supposing that the disease appears in a state so
equivocal that the patient thinks it still rheumatic or gouty,
a large stimulating  plaster may be  applied  to the hip and
thigh.  But  if the complaint  be distinctly marked, the caustic
js to be immediately applied.
* See what is said on the subject of tumours. 
102
DISEASE OF THE KNEE J01NI.
CHAPTER VI.
DISEASE OF THE KNEE JOINT.
      Operations are at least proposed to be performed on
 the knee joint, Avhich make it necessary to take  a general
 revieAv of the diseases of the knee.  Why Ave should take this
 joint in particular after the hip joint, is sufficiently evident.
 It  is  the  largest joint ;  it  carries tlie  whole a\ eight of the
 body and limbs; it is  Aveak in the structure of the bones, and
 consequently complicated in its ligaments.   The  ligaments
 and tendons about joints are very subject to disease,  and here
 they are exposed^  being only covered by  the integuments,
 whilst in the other larger joints  they are protected by large
 muscles.
   In White  Savelling, an uneasiness  and Aveakness in the
 joint are first observed ;  the pain increasing, it is observed to
 be fixed ; and hoav on each side of the tendon of the patella
 there is a soft, puffy tumefaction.   By some supposed strain,
 or  in  consequence of damp,  or cold, there is an increase of
 pain and  SAvelling ;  in  proportion  to the increase of  pain
 is the swelling becoming more  general.   When  the  pain
 increases, the constitutional irritation commences, and is mark-
 ed by an accession of fever in the evening.
  The  SAvelling of the  knee  in this disease has something
 peculiar in it; the skin is smooth  and clear, the tumour
 regular and  uniform,  covering  and  concealing the natural
 projections of the heads of the bones.
  The disease is yet in the ligaments and cellular  membrane
around the joint, and perhaps  not yet in the cartilages  of
the joint.  But now a very  peculiar appearance  is produc- 
                DISEASE OF THE KNEE JOINT.             103

ed.   To  save  the pressure  on the joint the  patient allows
the  toes only to touch the ground,  the knee  is consequently
bent, and the inflammation  Avhich surrounds  the hamstrings
produces a  permanent  stiffness, the  leg  and thigh  Avaste
from inaction, so that altogether the  SAvelling of the knee
appears more remarkable than it is in fact.
   The  disease proceeding in its course, and the hectic fever
being established, the strength and spirits fail;  the cartila-
ges  of the joint  are noAv consuming,  and about this  time
the  symptoms are aggravated by external   inflammation ;
the  skin  sometimes bursts and discharges pus,  Avhich  has
often no connexion Avith the general SAvelling, nor does  this
discharge  diminish the  SAvelling, or relieve the pain of the
joint in any considerable degree.   But matter is now formed
around the joint, and the sinuses will sometimes admit the
probe to pass in all directions.
   When the leg is amputated, this is the appearance which
is presented on dissection.  The  cellular membrane around
the joint is loaded AA-ith viscid fluid, Avhich, contained in the
cellular texture, resembles jelly.  The ligaments have  lost
their natural density and lustre,  and fistulous sinuses run be-
tAvixt  them and the  surrounding tendons; within the joint
there is lymphatic exudation, in the advanced state of the
disease the cartilages are corroded, and lastly, the bone itself
suffers by  ulceration.
   The  disease varies much  in  its  period.   I have seen it
rim  its course in  tAvo months, and I have  seen the constitu
tion  bearing up against it for years, though the disease Avas
most distinctly marked, and the suffering ahnost continual.
   To say merely this is  a  scrophulous  disease, is saying
very little.   It is a disease  falling peculiarly on  parts hav-
ing little blood circulating in them,  and Avhich consequently
possess low poAvers of life.  It  seems  first to attack the liga-
ments and cellular membrane, and then the cartilages.
   Often I have known  surgeons in consultation on the pro-
priety of amputating in a av hite SAvelling  of the joint, give
their  opinion  decidedly for  amputation, because  the  bone;' 
104
DISEASE  OF THE KNEE JOINT.
 were enlarged.  But on  dissection, there proved to be no*
 enlargement.  Mr.  Russel well  remarks in  his  treatise on
 tliis subject, that the bones are seldom  diseased when they
 appear to be so,  and  that the deception proceeds from the
 effusion that is around the joint.   But  the  bones are actu-
 ally enlarged sometimes: yet this is no cause for cutting off
 the limb.  There is no reason for determining on an  ampu-
 tation but the declining of the patient's strength to a danger-
 ous degree.  I have looked on the enlargement of the bone
 with satisfaction, as providing  for anchylosis  of the joint.
   If it  be denied altogether  that the  bones are enlarged,
 then  how does  it happen that a  patient comes to us saying,
 " It is very odd  that his  bad leg is longer than the other,
 although he keeps it thus bent;"  is there any  other Avay
 of accounting for this than by supposing that the  bones are
 enlarged ?  The enlargement of the bones favours the cure
 of  the disease in this manner: they do not ulcerate on the
 surface, but become  inflamed and  spongy in their Avhole sub-
 stance ;  the articulating  surface  becomes  irregular, and ill
 adapted for motion ;  the motion of the joint is lost, the bones
 unite ;  and there being no longer irritation from the incessant
 motion  of the joint, the disease fortunately subsides.
  In Avhite swelling, the patella is not forced  up from  its na-
 tural contact Avith the surfaces of the condyles ; Avhen press-
 ed it is  unyielding, and gives  pain.  We have to doubt the
 reality of there being a dropsical  SAvelling of the joint,  unless
 the patella yields on pressure, or the fluctuation can be dis-
 tinctly felt on one side of the tendon of the patella, when Ave
 strike smartly on the other side.
  When a patient, perhaps of a Aveakly constitution and pale
 countenance, is seized writh an attack of pain in the knee, I do
 not immediately think of applying leeches ; but, on the con-
 trary, foment, Avrap the limb in flannel, and keep it in perfect
 rest.
  If  the pain continues, and  is fixed, not diffused  over the
joint, nor lias shifted  to  any other joint, I dread that Ave are
 to have a confirmed Avhite  swelling.   I take blood by four or 
DISEASE OF THE KNEE JOINT.
105
five leeches:  but not with the intention of reducing the in-
flammation by this means, but to prevent a great increase of
action on the  application of  blisters to the  sides of the knee
joint.   Repeated blisters I conceive to be absolutely necessary
to  remove  a  deep-seated disease,  and I  have observed the
greatest difference in their effect, according  as they  have
been applied,  without previously taking a little blood or not.
When there has been a tendency to inflammation, and consid-
erable  power in the part, blisters have increased the  general
action in the joint, but  Avhen  the  activity of the vessels was
previously diminished, they seemed to have substituted the
superficial inflammation for the  deeper  disease.   A blister
should be applied on one side of the joint, the size of the palm,
and as the inflammation subsides, a similar one is to be put on
the other side, and thus a considerable action is to be kept up
on the surrounding surface.
   Unless there  is strong reason to suppose that there is an
active inflammation in the joint, I would  not recommend the
common cold application of linen wet  Avith the solution  of
cerussa acetata in vinegar and  water.   If the swelling and
general inflammation of a joint have succeeded to a bloAv, then
1 Avould bleed  freely with  leeches, and apply  the cold Avet
cloths to it; but  if in a constitution not prone to active in-
flammation, there comes a deep fixed pain, I would rather
order occasional warm  stimulating fomentations with flannel
or sinapisms to  be applied to the joint, and the application of
a stimulating plaster, as of gum ammoniac, with  vinegar  of
squills,  or  the  cummin seed plaster.   To weakly children
Avith diseased joints, there can be no better  applications  than
the latter.
   An inflammation of the joints (the knee joint for example)
 which has  no mark of the scrophulous action, nor any  thing
constitutional in  its nature, must be treated with  a more
rigorous intention of diminishing action.   Leeches, and after
them cold saturine solutions  are applied  to the joint, and if
the pulse and general fever be rising, blood  must be taken
freely from the arm,  the patient  must be  purged with the
   VOL. IT.                    p 
1UG
DISEASE OF THE KNEE JOINT.
neutral salts, and after the bleeding and purging, an opiate
at night Avill have the most soothing effect.
  When  high inflammation attacks the knee in consequence
of a blow, and is subdued by evacuations and cold applica-
tions, yet it will happen That the relief is only  temporary,
and the inflammation in all its violence will return.   We are
kept long in suspense by the great tumefaction, and the deep
pain, and are unable to say whether the  cavity  of the joint
have at length partaken of the disease.  When the violence
of the inflammation cannot be subdued, and the relief is par-
tial, then suppurations form around the  joint, which when
very distinct, may be opened ; but I must here give this cau-
tion, that we may not be deceived, and take effusions into the
bursa?, or into the cellular membrane, for abscesses.
  The inflammation will sometimes be continued and violent,
and yet the joint escape from the capsule, checking the pro-
gress  of the inflammation  from the outward parts into the
cavity.
  When the inflammation has been violent, there will be ad-
hesions betAvixt the tendons and  their sheaths,  and an oblit-
eration  of  the  bursae.  The consequence  is  a stiff joint.
Where the constitution  is uncommonly good,  we may ven-
ture by friction and motion to restore the joint; but where
the case has proved  obstinate,  and the  inflammation has
continued long, in a more obscure degree, we ought to try no
such experiments as extending -and moving the leg.   Where
the limb is longer  than the other after any disease of the
knee,  it Avould be quite wrong to make the slightest attempt^
for this circumstance sheAvs us that the bones of the joint are
enlarged.
   If  the capulse of the joint  should be Avounded,  pierced
Avith  a nail, or opened but in the smallest degree,  there is
great danger  to the joint, and even to life.   I have seen  a
man suffering from such an accident, delirious, with his face
flushed, the eye  brilliant, the limbs SAvelling in powerful
struggles, yet this high inflammation Avas long in coming, the
corner of his adze had been struck  into the joint, the Avound 
OF COLLECTIONS IN THE BURSJE.
10;
 appeared  trifling,  and there Avas not the slightest  pain  or
 discolouration for many days.   I have not seen such inflam-
 mation of the knee fatal, but I can Avell believe that it may
 be.
   It is possible  to mistake  Dropsy of the Knee Joint for
 White Swelling,  yet I should imagine it was easy to discover
 when there is fluid collected in the joint in any considerable
 quantity.   In the relaxation and  dropsy of the knee joint
 there is no pain ; when Ave press  the patella, the swelling is
 chiefly on the sides of the ligaments of the patella, it is soft
 and undulating, and putting the hand on one side of the pa-
 tella, and tapping the other \\ith the fingers, Ave are sensible
 of the fluctuation.   It is a disease of Aveakness.  The dropsy
 that occurs after fever is evidently so, and is  removed with
 the returning strength.  Often the swelling conies suddenly,
 without its being possible to assign a cause, and it has been
 considered as a consequence of syphilis and scrophula.
   The  first thing we have  to  think of, the most effectual,
 and  that too Avhich can do the  least harm,  is to apply a
 good elastic flannel roller.   I have seen sAvellings of the  knee
 Avhich were taken for  the most confirmed disease disappear
 in a night.  Stimulating frictions are  to be employed Avhen
 they do not interfere Avith the bandage, and moderate exer-
cise  is not only allowable, but  necessary to the recovery  of
 the joint, and to give vigour to  the circulation.
   From the violent inflammation Avhich I  have described,  as
 a consequence of wounding the joint, it will be evident  that
 my opinion must be entirely against opening the knee joint
 Avhen such collections are formed in it
   The BcrsjE Avhich are around the joints are sometimes dis-
 teffded  with  fluid,  Avhile the  joint is not affected.   The
 bursa under  the  ligament of the  patella,  or the large bursa
 under the union of the quadriceps femoris to the patella, are
sometimes  full of fluid;  these I Avould be averse from open
ing,  because the  opening will do no good unless there arise
 inflammation, and  inflammation under the ligaments of the
patella AArouId quickly  pervade the Avhole  knee joint 
108
LOOf.t CARTILAGES IN
iJif. KNEE JOINT.
   When  the large bursa under the deltoid muscle, and the
 acromion process of the shoulder is enlarged and full of fluid,
 compression  and stimulants failing,  it may be opened  if it
 have arisen as a remote consequence of a bruise.
   No tumours arising from the deep parts of the hip joint
 should  be opened;  even the lesser tumours about the ancle
 joint and Avrist ought not to be touched with the knife or lancet.
   The loose cartilages or moveable bodies which form with-
 in the knee joint are Avith difficulty  to be accounted for.  They
 are, hoAvever, a cause of great distress and lameness.  A fine
 young man shall be at cricket, in full career, when these bodies
 escaping from the corners in which they usually lie, and com-
 ing  betwixt the heads of the bones, he will be throAvn  down
 Avith a pain in the  knee, extremely violent and at the same
 time sickening and  subduing.  Assisted by the  experience of
 the  patient,  Ave are to endeavour to  get  the body from be-
 tAvixt the prominent parts of the bone6;  if the body remains
 long in a situation giving pain, the secretion of the joint is in-
 creased,  and a considerable inflammation will rise.   In this
 state Ave must allow  the loose body  to rest Avhere it is, and
 keep the patient from exercise until it shall, by some accident
 of position, drop into the place of rest.
   When Ave have got the body extricated from betAvixt the
 bones, we must endeavour  to keep it there by binding the
joint, and pressing down the patella, that no exudation may
 be poured out in any quantity, and that the  surfaces of the
 bones may be kept in contact, so that  the body cannot insinu-
 ate itself betwixt them.
   I  have said that  I  am averse from  opening the knee  joint,
 and  I have never  seen a case  of  loose bodies in the joints,
 where I could recommend it, or  Avhere the pain, laments!,
 and  confinement, attending the presence of the body,  wer«
 not outAveighed by the danger which the operation presented.
   If ever  the temptation to operate  should present itself to
 me it must be in this  form : the patient shall have been long
 tormented, the occasional  lameness and confinement must in-
terfere with his means of  living, he  must himself prefer thb 
          LOOSE CARTILAGES IN THE KNEE JOINT.        10,9

risk to the incessant pain and helplessness, and the body with-
in the knee must be loose, and distinctly felt prominent.
   The Operation may be thus conducted: The body hav-
ing presented in the side of the joint, and upon trial is found
to be so far stationary that it bears pressure, and the motion
of the skin over it, the assistant is to be employed thus:
   He must, Avith  the fingers of one hand, draAv aside the in-
teguments Avhich naturally  lie over the body to be cut out,
and hold them firmly; Avith the finger of the other hand he
must thrust upon the integuments by the side of the body,
and into the interstice of the margins of the bones, so that he
may prevent the body from moving on that side.#   The sur-
geon (having his instrument ready  to be handed to him) fixes
the finger of his left hand on the other  side of the body to be
cut upon ; then Avith a very sharp scalpel he cuts lightly on
the skin until the body starts out or is exposed.  As soon as it
is exposed the hook is to be introduced behind it, that it may
be brought forward.  If forceps of a common form be used
the  body is apt to start from them;  they should be armed
Avith sharp crooked claws at the point.
   If the  loose body  escape, the probability is that Ave shall
not be able to bring it to the same spot again, and the danger
of the operation will have been incurred Avithout advantage.
If the body adhere to the  ligaments by a neck, it can be cut
aAvay easily, but if it have a broad connexion and require tlie
first incision to be enlarged and a  dissection made, it is very
unfortunate.
   By all  means let the Avound be closed as quickly as possible.
I  cannot  refrain from expressing  my  wonder that any one
should  recommend the  incision to be left open for the dis-
charge of the fluid of the joint.  The  patient must be kept
long perfectly quiet,  and the wound must be entirely healed
before he be allowed to use his leg.
   * Some have recommended that the loose body should be moved up-
wards on the side of the condyle, towards the connexion of the capsule with
the thigh bone. If this can be done, it is certainly better than cutting in the
middle of the capsule.  But the general rule is to tako that position in wh V.h
the body stands roost prominent and secure 
110
Or FRACTURED BONUS.
CHAPTER VII.
OF FRACTURES.
DISTINCTIONS RELATIVE TO FRACTURED BONES.
      The several varieties of fractured bones may be notic-
ed under the heads of 1. Simple transverse fracture.  2. Ob-
lique fracture.   3.  Compound fracture.   4. Complicated
fracture.   The last of these has the greatest variety of im-
portant circumstances connected with it.
  Simple  transverse  fracture is that in  which  the bone is
broken directly across,  or nearly so.  It is  the consequence
of an injury lateral to the  bone; occasioned,  for  example,
by  a weight falling  on  the thigh; or  by a fall in which
the fore arm strikes  against a stone ; or by a  stroke on the
arm bone.  There is in  general, comparatively, little injury
to the surrounding parts, and no shortening of the limb from
the retraction of the muscles.
  Oblique fracture is a consequence of  force applied in the
direct line of the shaft of the bone. 
DIFFERENT KINDS OF FRACTURE.
Ill
  The points of the broken ends of the bone are longer and
-harper,  and are  driven more  into the  flesh,  than in the
simple fracture; the fracture is not directly across but ob-
lique, and sometimes the bone is riven up.
  There is,  in this fracture, a greater difficulty of setting the
ends of the  bone  in due apposition, and in preserving the
length of the limb, for the obliquity of the fracture allows tlie
extremities to pass each other.
   The Compound fracture is Avhere the bone has not only been
fractured, but has also  pushed  through the skin.   This in a
remarkable manner  changes  the nature of the case, and the
chance of cure is diminished.
   The Complicated fracture,  as I have said, has many varie-
ties, in which the difficulties of the case are increased, and the
cure becomes more precarious and tedious.  One is  where the
bone is not merely broken across, but shattered or  broken in
more than  one  place.   Another is a fracture  by  gun-shot,
which has  several  essential  circumstances  quite peculiar.
Another complicated case is, Avhere the broken bone has been
forced against an artery, and the fracture is complicated with
aneurism, or there may be both fracture and dislocation, as
frequently happens in the ancle joint.  A fracture,  where the
fissure of the bone is continued into the neighbouring joint. 
112    TO DISTINCHHSH FRACTURE *R03T DISLOCATION.

must be classed  under this head.  In  fracture of the spine
too there is more danger from the injury to the spinal marroAv,
than from the fracture of the bone; and in fracture of the rib,
with  injury of the lungs, the  importance  of the  case rests
chiefly on the  latter circumstance.  The danger and all the
circumstances  of the  cases now  enumerated being peculiar,
they may be ranked under the class of complicated fracture.
   Fractures of the skull form a subject quite distinct, on ac-
count of the peculiarity of symptoms, and the treatment to be
followed, the whole case coming under the influence of a very
different principle from that Avhich regulates the practice in
cases of the fracture of other bones.

   When,  in consequence of a fall, the limb is distorted, and
evidently fractured, the greatest precaution should be used in
replacing it in its natural position, and the patient  ought not
to be moved from the place until such temporary support be
given to the limb, that he may  be carried without pain or
farther injury from the motion and twisting of the shattered,
ends of the bones.
   When a surgeon is  sent for to an accident of this nature,
another surgeon being expected, he ought  to wait before he
examines the limb, that they may together observe the mo-
tions and feeling of the limb without occasioning any unne-
cessary pain.
   But if the accident be recent, and the SAvelling coming on,
the surgeon ought not to lose the favourable opportunity for
examining the position of the bones and the joints.  When
the swelling and inflammation have arisen, such examination
will often be found impracticable.
   If a surgeon  come to the side of a patient in this situation,
or perhaps after the limb has been dressed, he cannot make the
due examination, and ought not to hazard an opinion.
   The bone is ascertained to be fractured  by the  unnatural
position of the limb, the hand or foot being generally tAvisted,
or having fallen doAvn; by the harsh grating feeling commu-
nicated to the finger, Avhen placed on the injured part, during 
T,0 DISTINGUISH FRACTURE FROM DISLOCATION.
113
the movement of the limb.   In feeling the part, Ave continue
to trace some projecting spine (as of the tibia or ulna), the bet-
ter to ascertain the displacement of the bones.   But this being
insufficient fully to inform us of the nature of the accident, Ave
must take the Avhole limb in our hands, or make a careful as-
sistant do this while we have our hands surrounding the injur-
ed part, or, should it be an injury of the  chest, Ave place the
hand broad on the side, Avhile the patient breathes.
  In performing this necessary office, I need not say that the
bone is insensible in its natural state, and before inflammation
has arisen, and  that the pain  occasioned by the  accident is
owing to the injury of the soft parts: the pain of the opera-
tion is merely that of the repeated  injury of the surrounding
parts by the ends of  the bones; so  that  every unnecessary
motion is to be guarded against.  But it is of more import-
ance to say that, in the first examination of a limb, Ave ought
to be fully satisfied so as to leave  no doubt of the nature of
the accident, for if Ave cannot ascertain the nature and extent
of the injury at  first, we shall be less able to do so when the
swelling  and  inflammation have advanced ; and  when  that
SAvelling and pain have subsided, the time for remedying the
distortion is past; we have lost an opportunity not  to be re-
gained.
  Where great arteries or nerves run close upon the fracture,
(as in fracture of the thigh bone a little below its middle),
we must be particularly careful hoAv Ave  move the bone; for
by incautiously tAvisting it, or by the rough carriage of the
limb, the artery may be  torn  upon the sharp ends of the
bone.
  It may in  general  be said  that, in distinguishing fracture
from dislocation, there is in fracture  less distortion, and less
rigidity  of the muscles and tendons, Avith greater pliancy in
the  limbs;  and that though there is  pain,  there is yet
free motion when the surgeon moves the limb ; Avhile in dislo-
cation there is a checked and interrupted motion.
  The mere fracture of the bone Avould in no instance require
attention to the system, or any. genera! treatment ; but the
  VOL. TI.                    0 
114         GENERAL TREAOIENT OF FRACTURE.

bruising and laceration of the soft parts which accompany thfc
breaking of the bone Tnay, by producing and propagating au
action distinct from that Avhich would knit the bones, prevent
the formation  of the callus or new bone.   Either the high
and inflammatory state of the general system, or an inflamma-
tion  tending to suppuration  of the part injured, will  retard
the cure; and  therefore all that is necessary, all that Ave can
do, is to relieve the system from its high action, to sooth the
local inflammation, and as it Avere, to procure time and  oppor-
tunity for the ends of the bones to take upon them the change
necessary for the formation of the callus.
  When,  therefore, we  have reduced and  adapted to each
other, the broken bones, (the manner of doing which I am
presently to describe), Ave have to consider the nature and ex-
tent of the general or local injury, and comparing it Avith the
circumstances and constitution of the patient, to proceed ac-
cordingly.  If  a person in the full  vigour of health be  thus
suddenly  confined to a posture, Avith a  rising pulse and con-
siderable  pain, bleeding is indispensable.   When there  is
much SAvelling  in the injured limb, it should be placed in a
natural  and easy  position,  but  not bandaged ;  on the con-
trary, we bleed with leeches, and by fomentation promote the
bleeding and allay the swelling.   If, from the violence of the
injury, and the shock, and the alarm of the patient, fever and
delirium succeed, or restlessness with shaking and spasm  of
the limb, the fracture should be covered with compresses and
soft slight bandage, and pilloAvs rather than  splints should be
applied around the limb.   We must Avait for returning com-
posure,  and the subsiding of the swelling,  before we finally
adjust the limb.
  In this state we  must by no means give opiates Avith the
intention of quieting the perturbations before very free  evacu-
ations have been made.
  If we  find restlessness and  irritation prolonging the  pain
and retarding  the  cure, it  most  probably proceeds  from a
neglect  of the bowels.   By procuring regular motions and by
?»n attention to  diet, this irritable state will subside.  By still- 
GENERAL TREATMENT OF FRACTURE.
115
 oess an4 want of exercise in a habit perhaps naturally actiAT,
 accumulation in the boAvels  is particularly  apt to happen,
 which produces a feverish state.   During confinement, free air
 and a change of the bed-chamber, if it can be accomplished,
 and recreation, is very  necessary, for there is a  healthy  and
 aatural action to perform.

              TREATMENT OF A SIMPLE FRACTURE.

    By  the same force Avhich broke the bone, but oftener by
 the contraction of the muscles, the broken ends of the bone
 are  pushed past each other.   Our first object is, by extension
 of the limb, again to place the extremities of the bone in their
 natural relation to each other; next we have to take care that
 the part of the limb which is beloAv the fracture be made to
 lie in its natural position, that it is not twisted, and not suffer-
 ed by  gravitation or any other cause, to decline from its pro-
 per direction.  Thus, if Ave do not take  precautions against it,
 when the fore arm is fractured,  the palm will fall prone and
 distort the bones :  the  foot will naturally, by gravitation,
 fall  outAvard, and lie  upon  its outer edge Avhen  the thigh
 bone or the tibia is broken.
   When the limb is put into Avhat  Ave  conceive to be the na-
 tural position, Ave have to observe Avhether  it spontaneously
 retracts, Avhich it is apt to do  if the fracture  be oblique.
 This we must endeavour to counteract.
   If I  can  procure it  at the time, I  use a pledget of  soap
 plaster, which I put  upon  the limb,  especially on the  part
 Avhere  the splints are expected to chafe.   But oftener along
 the limb and in those parts where there are hollows, or a flat-
 ness which will not be  uniformly embraced by the splints, 1
 lay some layers of lint or old linen soaked in brandy or a solu-
 tion of crude sal ammoniac in vinegar and water.  When avc
 wish to give  unity and firmness to these applications, Ave soak
 them in gum or in the white of an egg.  When stiff unyield-
 ing splints are to be used, much of the security and  ease of
, the limb depends upon laying  this ground AA-ork.   By the 
116
GENERAL TREATMENT OF FRACTURE.
placing of these aright, all pressure of the bandage or splints
may be prevented on the sharp spines, or on the fractured ex-
tremities of  the bones, and, Avhere the bones are only thinly
covered by integuments, or where the skin is tender.
  Further, by the management  of these pieces of linen, and
these compresses, the necessity of a bandage under the splinti
is avoided;  for by this means the splints, coming to  press
equally over the  Avhole limb,  (unless on  the guarded parts),
the limb is uniformly  supported by the bandage, Avhich  is
placed above the  splints.
  I believe that the bandaging of a fractured limb, before the
splints are applied, may be of use, when well done ; but it is
always attended Avith the danger of being applied  too  tight
at first, or becoming so from the SAvelling of the parts, for  in
that case it is  not  merely the undoing of a superficial  roller
which is required to give ease, but the splints are to be taken
off, and the bandage undone, to do which it  is necessary  to
raise the limb from its position.
   The splints are to be had  in the  shops, and every young
man can make them.   But I would recommend pasteboard
to  be much used, especially in  the lesser  splints Avhich may
be  required, Avhile  one larger, of wood, or leather and Avood,
gives strength  to the  Avhole.  The  only disadvantage of the
pasteboard, is,  that in the event of  rising inflammation and
tumefaction, Ave may wish to apply wet and cool cloths to the
part, by which the splints are softened ; but still if the larg-
er  splint be firm, it will  be a sufficient guard.   When there
is an  evident necessity, in the  beginning, for  fomenting the
limb,  it  ought to be laid out on the tin splint.
   It Avill be understood that I apply the bandaging over the
splints.  I have only to add, that we ought not to use one very
long roller, but lesser ones, distinct in their attachments; and
that the one last applied should always  be the tightest, for if
the limb SAvells too much, or there is  pain and uneasiness,  Ave
 ought to have  it. in our power to ease  the Avhole, by undoing
 the outermost bandage. 
           GENERAL TREATMENT OF FRACTURE.         H7

  If the first turns  of a roller be tight, the Avhole must be
undone before Ave  can loosen these; but if it be lightly  put
round  at first, and then with increasing tightness, then mere-
ly to unpin  it, and  undo one or tAvo turns, gives relief.   In
most cases the eighteen tailed bandage  is to be preferred to
the roller.
  When Ave  bandage a  limb for Avhatever cause,  Ave must
support the loAver  part of it by a feAV turns of the roller;  else
a fulness and kind of strangulation, as it Avere, will take place
in the  hand or foot.
   In  regard to the position in which the broken member is
to be laid, Ave may say in general  that  the joint is to be re-
laxed, or the limb placed  in  a half-bent position ; there  are
exceptions to this rule, but Ave shall reserve this part of the
subject until  Ave come to speak of the particular accidents.
   In laying  a limb  Avith  a compound fracture while  the
general principle remains the same,  some things must be dif-
ferently managed from the simple fracture.
   We  have already  remarked that there is a real and import-
ant distinction in the simple and compound fracture, arising
from the mere breaking of the skin, or the external Avound.
Our first care then is, if possible,  to reduce the accident to
the nature of  a simple  fracture, by securing the healing of
the external wound.  But perhaps the bones project  and
cannot easily be withdraAvn from the wound.
  This plan will shew that Avhen the end of the broken bone
projects, the direct extension of the limb is improper, it forc-
es the sides of the bones against each other,  and the upper 
na
GENERAL TREATMENT OF FRACTURE.
broken portion of the bone into the flesh.—If we Avere to pull
this leg in the direction A, then B, would be forced against
C,  and the sharp point C, forced into the flesh,  and the
wounded  integuments would be girt round the  ends of the
bones.   We  must therefore extend the loAver part  of the
leg in the axis of the loAver end of the bone, in the direc-
tion B, D, until the two ends of the bone are no longer thus
locked  into each other ; then  raising  the foot into  the posi-
tion A, the parts are adapted to each other.
  If there project through the skin a long splinter of the
bone, which we foresee  cannot Avell be retracted, or perhaps
without injury to the surrounding soft parts, then it had
better be taken off with the saw.—To saw or break off the
projecting point is better than to cut up the integuments.
  When the bones are replaced, our next object ought to be
so to adapt and bring  together the integuments, that they
may unite by the first intention.  They ought to be brought
together by a slip of plaster, if they admit of it, and over
this a piece of  dry lint  should be laid on  lightly,  so  as to
absorb the first exudation; this may be  covered by a piece
of cerate; but nothing, oily should touch the wound, where
we  hope for the scabbing and healing  of the broken  skin.
  In other respects the limb is to be managed as  a  simple
fracture, only that in the bandaging  Ave should not  use a
roller, but the eighteen tailed bandage;  and in applying
it by leaving such tails, as cover the wound, hanging out un-
tied, till the rest are bound  up, they can at any time be un-
pinned and taken off,  to expose the Avound for the  conve-
nience of  dressing, without moving the rest of the bandage,
or disturbing the limb.
  But a compound fracture in the common application of
the term,  may be a bruised  and lacerated limb, complicated
Avith fracture of the bone;  not the effect for example of a
shock in falling, which breaks the bone and pushes it through
the  skin; but of the injury received by a  waggon  wheel
going over the limb,  bruising and cutting and laying open
the shattered bone.  Here, of course,  the reduction and po- 
GENERAL TREATMENT OF FRACTURE.
119
sition of the bone  is our least care.  The  inflammation  in
a good constitution must rise to a great height;  in  a bad
constitution the natural high action, (a necessary consequence
of a previous healthy state of the body in these circumstanc-
es), may be converted into bad inflammation, and have a
tendency to gangrene*.    We have to study the previous
state, and Avatch the present symptoms;  relieve the high ac-
tivity by bleeding and every relaxing means, lower the irri-
tation, or correct the habit; and as to the limb, to lay it ea-
sy is our only aim,  until  the high tumefaction and pain shall
have subsided ; then suppuration will also have taken place.
   Good suppuration ensures the subsiding of the  inflamma-
tory tumour, and of the high tension and irritability.  But
if after a  time, the discharge continues and becomes pro-
fuse, there is either a cause of irritation in the Avound Avhich
may be removed, or the constitutional poAvers have been al-
lowed to go too low.  By probing gently, perhaps,  a loose
piece of bone may be removed, with an immediate change in
the complexion of the Avound; or  on examination of the
parts we may discover a lodgment or sinus, which AArere bet-
ter opened.
   When the pulse indicates rather the quickness and irrita-
bility of langour or exhaustion, than of  inflammatory fever,
by changing the plan of diet, and general remedies, and
by supporting the system, we may restore due energy to the
bodily powers.
   When the languor  increases, the  appetite  fails the per-
spiration is copious and easily excited, and a purging threat-
ens to reduce the patient to a  still greater degree of weak-
ness ;  then bark and Avine, mild nourishing diet, and free air,
if possible,  are our resources.  After this,  the patient still
sinking, and the integuments losing  their tumefaction, and
becoming loose and flabby ; and from the unfavourable state
cf the boAvels, the food having ceased to be  nutritious Avhile

  * In practice it is of the utmost consequence to ascertain the state of the
soft parts—a fracture with contusion, though we must call it a simple fra<-
'ure, is often •worse than a com^cu^d fracturr. 
120'
GENERAL TREATMENT Of FRACTURE.
wine and brandy give but a temporary excitement,  Avithout
returning vigour, the  question of amputation comes  to be
discussed.  If the powers of the constitution be not entirely
exhausted, so that  there is not vigour to produce the ne-
cessary tumefaction, and adhesion of the flaps on the stump,
amputation will be safe.
  There is one point of doctrine on which I believe it neces-
sary to say a feAv Avords in these  introductory remarks.  It
regards the nature of callus, and the question concerning the
extent of motion which may be allowed to a fractured limb.
  If this book possess any merit  in proceeding directly to
that point, the consideration of Avhich most embarrasses the
surgeon, it results from my having observed the difficulties
Avhich my house pupils experience in fully  comprehending
their teachers, and from attending to their remarks and their
reasoning.  It Avas only a  few days ago that I heard a very
ingenious young man, who  lives Avith me, say, that the frac-
tured thigh bone should not be set until the end of the third
Aveek;  and he supported his opinion by the practice of an
hospital  surgeon of some reputation.  A short and energe-
tic expression of my conviction of the folly of this dogma
Avould  not carry the same  Aveight with it here as I hope it
did Avith my pupil.   I shall therefore insist upon it more at
length, and discuss also the question of the degree of motion
to be alloAved to a limb in fracture, someAvhat largely.
  I  have before me  the  short notes of  three dissections,
which, if I mistake not, afford me  full ground upon  Avhich
to reason securely.
  1. The first describes the state of the parts  immediately af-
ter  the  fracture.   The bones  have  suffered a  complicated
fracture,  being much shattered; they hang together by the
surrounding  cellular  membrane,  and the periosteum—they
are surrounded Avith coagulated blood.
  2. The second refers to a fracture of the thigh bone, if I re-
collect, three A\reeks after the fracture occurred.   " The bone
has been broken across in two places, leaving an intermediate
portion.  The intermediate portion is  immersed in a sub- 
GENERAL TREATMENT OF FRACTURE.        131
 stance, which to the eye is like jelly, but which has a consid-
 erable degree of toughness.  It appears as if the periosteum
 were continued from the circumference of the bone ; yet this
 cannot be.  There is here a new formed membrane, which in
 time would have been the periosteum of the new formed bone.
 This  periosteum is remarkably strong and thick, and the
 toughness which it has in a remarkable degree is  possessed also
 by the callus to  a considerable depth.   In this mass I disco-
 ver with my hook or probe  many distinct particles of bone."
   3. In a preparation of a fractured bone, Avhich had been
 firmly knit together, and which after being injected had been
 made in a degree transparent, I observe the old bone white
 and little porous, but the neAv formed bone Avhich unites the
 old portions  is more vascular, and deprived in a greater pro-
 portion by the acid of its phosphate of lime.
   From these facts, Avithout entering  upon a physiological
 view of the subject, I shall endeavour to draw the practi-
 cal lesson.
   When the injury is first committed, the cellular membrane
 around the broken bone is torn ; the lesser vessels  are open-
 ed ; and  the blood is  unusually effused.  At this  time any
 slight motion of the bone does no  harm unless  it tears up
 new parts.  Presently the blood is absorbed; the injured
 parts throw  out  a more regular secretion; the  membranes
 form neAv adhesions to the bones; a tough membraneous sub-
 stance unites them, and in the apparently confused mass,
 which surrounds  the extremities of the  bones, small irregular
 points of bone are formed.   Is not this sufficient to give con-
 viction that if the limb be rudely moved after the new adhe-
 sions are formed, these adhesions must be again torn up ?  and
 if these particles  of bone be formed, must not the motion of
 the limb  cause them to cut  and tear the vessels and mem-
 branes by Avhich  they are surrounded ?  so that at last if this
 motion be allowed to any extent, the disposition to the forma-
tion of bone is destroyed,  and the process baflled as it Avcre, in
its design,  stops short of the true effect, and the bones are
united not by bone  but by  a tough ligamentous substance,
VOX. u.
i? 
122
GENERAL TREATMENT OF FRACTURE.
and the extremities of the broken bone are rounded off, so
that an artificial joint is formed.   It is surely no erroneous
conclusion to draw, that motion, to a certain extent, Avill de-
stroy the disposition in the action to unite the bones by bone;
and that in a lesser degree it retards the cure, and makes the
confinement longer, increasing the chances of failure.   On the
other hand, no argument -will ever be discovered against giv-
ing absolute rest to the limb.
   But Ave must not be so blinded as to carry the argument too
far.  If, on examining a limb, Ave find that it is distorted or re-
tracted, Ave place it again in its proper  position, and endeavour
more perfectly to secure it, because by this twisting or exten*
sion we do not, as by a perpetual teasing interference Avith the
process going forAvard,  destroy  the usual  disposition.  Here
the neAV adhesions may  be  broken, and they -will readily unite
again, and the cure go on.
   To say, however, that because Ave can thus interfere with a
broken limb, Avithout essentially interrupting the cure, it  is
time enough to  set  the limb  in its position after four weeks
have elapsed, were  to carry the doctrine  to a dangerous as
Avell as a ridiculous excess; for at such a  distance of time
from the accident,  the connexions must be strong, and the
violence necessary to replace the limb in its natural situation
proportionally great.  It is but at best bringing  matters to
their original state, and of course the previous time is lost; the
confinement being in this way  much increased.  We can  as-
cribe such extravagant  practice as this, only on the one hand
to ingenious argument pushed rather too  far for common
readers, and on the  other to stupidity in taking the illustra-
tion of a doctrine for the enunciation of a principle.  A frac-
tured bone will feel  quite  loose towards the end of the third
Aveek, and in three or four  days more it will be firm.  This,
I suppose, is the  origin  of the opinion, but the  fact is insuifi
dent to establish the rule of practice 
GENERAL TREATMENT OF FRACTURE.
lO-'
1 ^V,v>
 OF THE  MEANS PROPOSED  FOR EXCITING  THE OSSIFIC ACTION
   WHEN A JOINT HAS BEEN FORMED IN CONSEQUENCE OF THE
   MISMANAGEMENT OF FRACTURE.       ,

   When, in consequence of using the limb too freely a joint
 has been formed, instead of the bone uniting, it has been pro-
 posed, to cut doAA*n through the  flesh, and to cut off the cal-
 lous extremities of the bones.  I do not recollect that this
 has ever been done Avith success, but I knoAv that it has been
 done with  continued pain, during the operation,  almost to
 death, and  with no good effect.  The thigh has been cut so
 that the bone has  been exposed, but lying deep in  the flesh ;
 the disentanglement of the end  of the  bone has been found
 most difficult, painful, and tedious; the saAv moving in these
 deep parts requires a large Avound and moves with  difficulty,
 and in one case, long before one extremity of the  bone Avas
 cut  off, the patient Avas  pale and  feeble, and incessantly
 vomiting from  pain and  irritation.   I believe  hours have
 been spent in the attempt, and Avhat has been  the result ?
 an extensive open wound, the ends of the bone consequently
 exposed, and these  ends  injured by the Avorking  of the saAv.
 A disposition in short is left upon the part the very reverse
 of the quiet ossific action.  There follows inflammation and
 suppuration, (ever at variance, Avith healthy ossification), the
 inflammation has subsided, and aa hen the parts  may be ex-
 pected to granulate and take the disposition to unite by bone
 —that disposition has been already destroyed by the a iolence
 of the inflammation, the time for their union is past, and the
 bones remain loose as before.
   In  one case  I thought  myself,  by observations made on
 animals, authorized to propose that a long and sharp instru-
 ment should be pushed obliquely doAvn upon the bone, so as
 to Avork upon  and penetrate the extremities of the bones.
 By this means I imagined the wound made by the transit of
the instrument Avould immediately heal,  and yet the extrem-
 ities of the bone be fo excited a? to resemble the state of 
 124            FRACTURE OF THE CLAVICLE,

 simple fracture more than can possibly happen after cutting
 down upon and sawing their ends.   But perhaps the patient
 reasoned better  than his  surgeon since he would not submit
 I still insist on the necessity of absolute rest after 6uch opera-
 tion for re-imion of bone.

                FRACTURE OF THE CLAVICLE.

   The clavicle may be broken  by a  Woav  directly  upon it;
 but it  is  most commonly broken in consequence of  the per-
 son  pitching  on his shoulder as in falling from  horseback.
 The fracture of this bone is ascertained by remarking that
 the  shoulder is fallen doAvn towards the breast,  and, on
 feeling along  the bone, the crepitation  of the broken ends
 is  perceived, or the broken ends are found to have passed
 each other and one  of them to ride upon the other.
   The motion Avhich the patient makes Avith the  greatest
 difficulty, is  to touch the shoulder of the opposite  side, or
 to raise  his hand to his forehead:  for this motion  tAvists
 the broken clavicle,  and forces  the broken  ends into  the
 cellular membrane.
   The indication is to keep the  shoulder from falling for-
 Avard and the arm from dragging.   If the patient be drunk,
 compresses are to be put over the  tendons of the pectoralis
 major, and a figure of 8 bandage to  be  so  applied as to
 draw the shoulders powerfully  back, that no struggling or
 thoughtless motion be allowed,  Avhich might  tear the parts
 against the sharp bones.
   When the  bone is to be set, an assistant draws  back tlie
 shoulder,  Avhile the  surgeon examines  the position of the
 bones; and when the  broken ends have  been draAvn  into
 their natural relation, some flat compresses of linen are to be
 placed as  directed  before the arm-pits, that the  bandage
 may not cut the skin.  The double-headed roller is now to
be applied: putting the middle of the roller across the back,
the surgeon brings two turns under  the arm-pits,and over
 the shoulder, then,  by crossing the  roller on  the back and 
FRACTURE OF THE SCAPULA.
125
again bringing the turns to bear on the shoulders, they are
retained braced back:  after a  few yards of the  roller  are
thus applied, the shoulders are fixed, and the arm cannot
fell forward,
   Noav a soft cushion, or pad of lint, is to be placed in the
axilla, and the turns of the  roller  being secured,  the end is
to be brought down upon the back and outside of the arm,
so as to bear on the elbow and brace it to the side.  This in
consequence of the compress being in the axilla, still further
removes the shoulder from the sternum, and keeps the brok-
en ends of the bones from passing each other.
   If the bones come easily into their place, then the pad need
not be applied in the axilla until after  a time the roller is
somewhat loosened by stretching, or it be necessary to make
some substitute for the severe bracing of the roller.
   When the shoulder is braced back, Ave must notice if the
bones be on the exact level.   And, at all events, it is necessa-
ry to sling the arm, to prevent the falling down of the outer
portion  of the clavicle;  for this  purpose  the fore arm is put
in a large  handkerchief, the ends of which are  to be  tied
round the neck.
  No kind of compress  must be  allowed on the ends of the
broken  bones, for they are ineffectual  as to keeping the bones
in their place, and only press  the tender  siin against  the
sharp bone.  If it be  found that  the  patient is  often  feel-
ing and pressing  the bone,  it may be well  to put a piece of
leather  spread with  adhesive plaster, over  the clavicle,  sim-
ply to keep off his fingers.

   FRACTURE OF THE ACROMION  PROCESS OF  THE SCAPULA.

   When the shoulder is black and blue, and it is found that
the patient has pitched on it, but yet the clavicle is not brok-
en ; and when there is crepitation on pressing  the  prominent
part,  and  some disfiguration of the shoulder joint, we shall
find that the acromion  scapula;  is broken.   But the fracture
of the acromion is even more apt  to be  a consequence of a 
126
FRACTURE OF THE SCAPULA.
weight falling on the shoulder, than of a person pitching
with the shoulder to the ground.
   If the acromion process be broken, we see on taking hold of
the arm of that side and either pulling  it doAvn, or letting it
drop Avith  its OAvn weight, an  evident  sinking of  the top of
the shoulder;  or on applying  one hand  to  the shoulder,
Avhile Avith the other Ave moArc the arm, a crepitation is felt.
On pushing up the arm  bone,  there is pain, and  Ave see the
point of the acromion unnaturally elevated.
   In fracture of the acromion scapulas (which, by the bye, is
not a frequent accident, oAving to the Aveakness of the clavicle,)
Ave raise the arm, and relax the deltoid muscle, and examine
and replace the pieces of the bone.   Then the arm being al-
lowed to fall  gently doAvn, the fore arm is to be suspended in
a handkerchief,  so that  the head  of the humerus may be
made to push up the  extremity of the broken acromion, and
preserve it  in its place.   As this injury  proceeds from a  di-
rect blow on the part, the pain and tumefaction of the integu-
ments of the  shoulder Avill be great, and no bandage can be
applied with  advantage until  the  SAvelling  has  subsided:
then the spica bandage  may be put on.  The spica  band-
age is  a form of applying the  double-headed roller.   The
middle  of the  roller  is  put under the arm-pit  of  the  oppo-
site side; then the ends are  brought  up  and  crossed  on
the top of the wounded shoulder; then they are crossed
under the arm-pit  of the same side; they are then  carri-
ed across the back and  breast, and the heads of the roller
are again crossed under the arm-pit of the opposite side, and
so are carried up on the injured shoulder again—and this is
repeated until the shoulder and the broken  bones  are cover-
ed with a firm lacing of the bandage.   It may be necessary
to relax the  deltoid muscle, in order to keep the bone in its
place.   If the  acromion be  alloAved to unite  Avith its point
depressed, it  will check the motion of ihf, arm bone. 
FRACTURE OF THE SCAPULA.
127
        OF FRACTURE OF THE BODY OF THE SCAPULA.

   Of the other parts of the scapula, the inferior angle is ex-
posed to be fractured next in degree of frequency to the
acromion process.   It  may be  broken  by falls or bloAvs.   I
have been consulted by a peison complaining of  a great pain
in the loAver part of the shoulder blade from a  fall, and yet
I have found that this part never touched the ground or re-
ceived a direct injury; but had been injured by the sudden
action of the latissimus dorsi on the angle of the  scapula in
the sudden twist of the trunk, and in the exertion to save
himself from falling.
   There is sometimes a dislocation of the tendon of the latis-
simus dorsi, in consequence of the angle of the  scapula get-
ting over the tendon, so that the arm cannot be carried for-
Avard or lifted.
   When there  is fracture of the loAver  part of  the scapula,
avc have to press the  fingers around the lower  angle of the
scapula, as if to fix it; then, raising the  patient's arm, so as
to roll the body of  the scapula, if the loAver angle be broken
off, it does not folloAv the motion of the body  of the bone.
It is not practicable to bring the lower piece to ansvver to
the body of the bone; but by managing the position of the
arm,  the body of  the scapula may be brought to meet the
lower piece, and to  come into accurate contact Avith it.  To.
effect this, Ave carry the patient's elbow  forward  on the chest,
and when Ave feel  that the parts of the scapula correspond,
Ave place the palm of his hand on the opposite pap and bind
the arm to the chest:  for this purpose the fore arm is to be
slung in a handkerchief, and pads  or compresses put betwixt
the arm and scapula;  and then  a  broad roller is  applied
round the body, including  both the chest and the arm of the
injured side„ 
128
FRACTURE OF THE HVMERVS.
                FRACTURE OF THE HUMERUS.

   This is the simplest of all fractures.   It requires only two
pasteboard  splints, one on the  inside  and the other on the
outside of the arm.  The fore  arm should be  hung  by a
handkerchief, in such a manner  that the wrist may be more
supported than the elbow, so  that  the weight of the arm,
counteracting the action of the muscles, may serve to keep the
ends of the bone in their proper  place.
   I have seen the imperfect joint formed in the arm bone
oftener than in any other.   We must endeavour, in this case,
by rude motion, to excite inflammation in  the  ends of the
bones, after which the steady binding of the arm Avith splints,
Avill certainly succeed in uniting the bones.
   The humerus may be broken very near its head;  the neck
of the humerus cannot be  broken, because there is, in fact, no
neck;  but, in a young person,  the head  may  be broken off
at the joining of the apophysis.  This has been the conse-
quence of the recoil of a  musquet, AAhen a lad, in firing his
piece, has not rested it on  the shoulder, but on the arm bone.
   Fracture  of the humerus, near the head of the bone, is un
favourable,  because of the strength of  the muscle which sur-
round it: the pectoralis major and latissimus dorsi,  the del-
toides and teres  major, act on  the lower piece of the bone,
and make an essential difference  in the  case from that of the
simple fracture of the middle part  of  the bone.  The force
of these muscles should be counteracted by the weight of the
arm, slinging it by the wrist only and not supporting the
elboAv.   We must  in this case  too, be  careful  to  adapt  a
splint to the inside of the  arm,  with such a pad  as may fill
the axilla without too much encroaching on the head of the
humerus, or in the  least pushing it from its place; then  a
piece  of pasteboard is to  be  moulded  to the shoulder, and
the spica bandage applied and continued in the  form of  a
roller  on the arm. 
FRACTURE OF THE OLECRANON.
129
            OF THE FRACTURE OF THE OLECRANON.

   The olecranon may be fractured Avhen a person in running
 falls, and strikes the elboAV on the ground.
   No marks are required to distinguish when the prominent
 process of the ulna at the elboAV is broken off.  It Avill, how-
 ever, be observed that this makes quite a peculiar case from
 the circumstance of the strong triceps muscle being inserted
 into the process of the bone which is broken off.  The bent,
 or relaxed position of the limb, which is the position of ease
 in most fractures, would here have the worst effect, by mak-
 ing the body of the ulna recede from the process Avhich is
 broken off and attached to the tendon of the triceps.
   Let the  fore arm be extended;  yet not to the utmost
 stretch.   Then the triceps is to be pressed, Avith a vieAV to relax
 it, and the olecranon brought doAvn to its place.   Dossils of
 lint are then placed on the  sides and above the olecranon ;
 and over these  a roller is put on the arm and fore arm.  A
 splint  must then be applied on the fore part of the elboAV
joint with lint beneath  it, to fill up the inequality of the joint,
 so that the fore arm may be prevented from extending fully
to the straight  line ; and, at the same time, prevented from
 being bent at all.
   These cautions are to be attended to ;  because, in the first
place, by extending the arm too much, the olecranon, which
has been broken off  is pushed from its notch in the lower
head of the humerus;  and consequently it does not perfectly
and correctly unite with the body of  the  ulna.   In the na
   A'OL. it.                     s 
130
FRACTURE OF THE RADIUS.
tural state of the joint, the olecranon checks into the holloAv of
the humerus so as to stop the motion at its due limit, but that
check being iioav done aAvay, the fore arm may be bent back
unnaturally, and the ligaments of the joint strained.
   In the second place, it must be observed, that if the joint
be  not enough extended AAhen the bone is set, callus or neAv
bone Avill be formed betAvixt the ulna and the process which
has been broken off, and a land  of anchylosis  is the conse-
quence ;  for the olecranon process projecting noAv too far, will
strike into the IioIIoav of the humerus,  before the fore arm can
be fully extended.
  See plan plate IV. fig. 4.  A, is the humerus;  B, the ulna;
C, the olecranon, broken off; D, the  holloAv of the humerus,
into which the olecranon should sink, AAhen the arm is fully
extended.  But it is evident, that  if the dotted  line betAvixt
B, and C, be filled with hcav bone, there must be a stiffness
in the joint, of the nature of anchylosis.

                 FRACTURE  OF THE RADIUS.

 •  The  fracture of the radius may be the consequence of a
direct bloAV on the fore arm  ; or of a person's falling and  en-
deavouring to save himself, by  extending the hand;  for the,
carpus being articulated with  the  radius, the whole shock
and weight of the body falls on  this bone.
   The nature of the injury will be ascertained  by the usual
symptoms of fracture: and, besides, it will be found that the
hand falls prone, with  much pain,  because the Aveight  of
the hand bears so that the carpal bones and loAver head of the
radius turn on the small head of  the ulna, while the upper
part of the radius, not folloAving the loAver in its rotation, the
broken ends are separated, and the surrounding parts injured.
   The patient therefore comes to you,  holding the palm of
the injured arm  with his other hand, to prevent the motion
either of pronation or supination, but especially  the former.
   The effect of pronation will be understood by looking to the
annexed sketch of the bones of the fore arm.   A, is the upper 
FRACTURE OF THE RADIUS.
131
broken part of the radius;  D, the lower portion :  now by
the falling of the palm C, prone, the portion D, turning in the
circle A, B, is separated from the upper portion of the bone,
and the tearing of  the  cellular substance, or the  bearing of
the sharp bone against the parts, is the cause of the pain.
  It will be manifest, at the same time, that, if the bone be
alloAved to remain in this position, a great, irregular  callus
must  be formed betAvixt the ends of the bones;  and that,
when they are thus fixed together, the hand will be no longer
capable of supination.
  In setting the radius Avhen fractured, Ave have to apply the
splints thus:  one along the  inside and the other on the out-
side of the fore arm :  The one on the inside should be long
enough to reach to the palm, that it may prevent pronation.
It is important to observe that  if a splint be laid  along  the
ulnar edge of the fore  arm, and be made to reach  to the
palm; or if the arm and  hand be laid carelessly  in a sling,
the  following bad consequence results : the ulnar edge of the
palm is pressed up, the head of the radius receives that pres-
sure, and the broken ends of the  bone are pressed doAvn upon
the  ulna, as is expressed in this sketch.
  A, is a splint, on which the arm and hand rest.  Noav it is
evident that, when the ulnar edge of the hand is thus raised,
i 
 132           iRACTURL OF THE THIGH BONE.

 the radius can no longer keep its natural shape,  as indicated
 by the dotted outline, C;  but that, on the contrary, the sharp
 and broken  part of the  bone will be pressed near the ulna,
 as at B.
   The consequence of this is, some  distortion of  the wrist,
 and an impediment in the rotation  of the radius and hand.

    FRACTURE OF THE BONES OF THE HAND AND FINGERS.

   The bones of the carpus and metacarpus are seldom brok-
 en, Avithout being accompanied by a bursting, or laceration of
 the integuments.  The hand is caught in machinery, or injur-
 ed by the bursting of fire arms—the fracture of the bones then
 is the least of the evil.   As to the  setting of the bones, that is
 an easy matter :  to preserve  them in their natural situation,
 the palm of the hand is laid over a cushion or pad, accurate-
 ly adapted to the hollow of the palm and fingers, and then a
 roller is to be brought down from the fore arm, over the hand
 and Avrist, including the pad.
   When the bones of the fingers are broken, they are to be '
 neatly set,  Avith  pieces of paste-board, moistened  and soft;
 over Avhich a small roller  is applied, and to secure the posi-
 tion of the fingers, if several  have  been shattered, they may
 be laid over a small cushion,  so as  to embrace it.

           OF THE FRACTURE OF THE THICH BONE.

   It is evident, on the first consideration of the subject, that,
 in the  fracture of the thigh  bone,  these circumstances must
 make a peculiar case :
   First, The great strength of the bone which  implies that
 there must be great violence and injury done to  the  limb, at
 the same time that there is fracture.
   Secondly,  The magnitude of  the thigh, and  the great
 proportion Avhich the injured part bears  to the whole body
 should lead us to infer  that the injury to the system and the
effect on the constitution, will be, in a good measure, propor- 
FRACTURE OF THE THIGH BONE.
133
tioned to the size of the member Avhich is injured and the vio-
lence it has suffered.
   The Third consideration is, perhaps, the most  important
one—it relates to the great mass of flesh by AAhich the bone is
surrounded.  For this great mass of muscle being in unceasing
action, the loAver portion of the bone, on  Avhich it operates,
is drawn toAvards the body, so as to make the broken extremi-
ties of the bone ride over  each  other; which, in the end,
often occasion a short and lame thigh for life.
   Lastly, AA'e must take into account the position of the thigh
bone:  for,  as  it  stands  nearly perpendicularly  under the
weight of the body, and is broken  most commonly by a shock
perpendicular to the pillar of the bone, it must be liable to be
rent and fractured obliquely.

   There are very important distinctions to be made in rela-
tion to fracture of the thigh bone, from the  circumstance of
the place and direction of the fracture.

FRACTURE OF THE SHAFT OR CYLINDRICAL  PART OF THE BONE.

   When the cylindrical part of the thigh bone is broken, Ave
should consider well the place and degree of obliquity of the
fracture, before we speak of the event.  The higher the bone
is fractured, the greater  probability is there that the limb
may be shortened during the cure.   The reason  is that  the
nearer to the upper end of the bone the fracture is, the great-
er is the number of muscles inserted into the loAver portion,
and the greater the retracting force.   But  if the fracture
should be at the Ioavct head of the  bone, and also oblique,
 (as it is apt to be in that case), then is there danger of  the
 bone uniting Avith  an oblique position of the condyles, pro-
 ducing distortion and Aveakness of the knee-joint.
   In the treatment of the fractured thigh bone, Ave have  ma-
 ny things recommended, and a variety of apparatus advised,
 because, in truth, every surgeon has  experienced difficulty
 and disappointment jn managing it.  What I have now to 
134
CRACTURE OF THE  THIGH BONE.
offer will, I hope, be found simple, and, in proportion to its
simplicity, effectual, for securing the limb in the best position.
                      FIG. l.
  It Avill be necessary for the first night to secure  the lhnb
with the common splint and bandage and lay it out on a pil-
low.  In an hour this frame may be constructed: tAvo boards,
A, B, Fig. 1, of  ten or eleven inches in breadth and of a
length equal  to the distance of the heel from the back of the
knee-joint, are to  be united at an angle answering to an easy
and relaxed flexion of the limb, and  secured by a horizontal
board C.  Near the edge of the inclined boards, holes are to
be made and pegs of wood fitted to them,  D, D.  Cushions,
like Figs. 2 and 3, are then laid on this frame, when it is ready
to receive the limb.
  The limb.is to be laid over the cushions or mattresses thus
supported on their frame.   The bone is noAv to be accurately
set, (if it has not been already done), by the assistant taking
the knee and  gently extending  it, while the surgeon  puts his 
FRACTURE OP THE  THIGH BOffE.
135
hand wide over the thigh and the fractured part, that he
may feel the crepitation and the motion which the broken ex-
tremities of the bone suffer.   Now one long splint is to be
laid on the outside of the thigh, reaching from the hip to the
side of the knee,  another upon the inside of the thigh and
over these the eighteen-tailed bandage is to be applied.
  It  is now to be observed hoAv far the thigh ansAvers to the
inclined plane, A; for it  will be understood, that the thigh
and body, in some degree, now hang upon the angle of union
of the tAvo boards, and that if this board, A, be much longer
than the thigh, the muscles of the thigh will be strained.  If,
on the contrary, it be shorter the muscles of the thigh will act,
and the broken ends  of the thigh bone may ride  over each
other, notAvithstanding the lateral splints and  the bandage.
To  ease the muscles of the thigh, Ave must raise the hip, by
placing a thin cushion under it at F: To stretch it, we must
take the cloths from under the hip, or make the pad larger
under the knee joint at E.   To support the foot from rolling,
the  edges of the pilloAvs or mattresses are folded up and fixed
by  the pegs so as to give a lateral support to the Avhole limb
from the hip to the ancle.
  If  the thigh has been much bruised  and be now savoui,
perhaps it will be better simply to lay it out on this frame
without splints, for it will be soft, and  be equally supported,
and moderately stretched.
  What is the most frequent kind of defect in the  limb after
fracture of the thigh bone ?  There  can be  no doubt that it
is shortening of the thigh, together with a tAvist of the limb,
which lames the patient  by depriving him  of the strength
from the muscles of the leg, and takes at the same time the
length of the foot from the step of that leg.   We  have now
only to consider the latter of these effects of inattention ;  hav*
ing, as we hope, done all that can be done, by the substitu-
tion of a simple contrivance, and by making the weight of the
body the counterpoise to the strength of the muscles, to pre-
vent the retraction of the limb, and consequently the perma-
nent shortening of it. 
136
FRACTURE OF THE THIGH BONE.
  When the limb is merely laid on the outside, and gently
bent, as  directed by Mr. Pott, and secured by splints and
bandages, the  body and limbs of the patient lie well, for
some little time; the thigh rests on its outside, and the body
is inclined the same way: but, by and bye, the patient turns
directly on his back, Avhile the leg remains lying with the
outside of the foot  flat to the bed!  Or, again,  if the limb
has been set Avith the patient  lying on his back, and the heel
of the broken limb  to the bed, the Aveight of the foot in a
short time tAvists the leg, so that at last it lies flat on the fibu-
la, while the patient continues on his back.   This could  not
take place  Avas the  thigh  bone entire; but noAv the loAver
piece of the thigh rolls outwardly, while the upper part re-
mains in its place.  The bones thus twisted, unite, and, Avhen
the patient rises from bed,  Ave find  that he points the toe too
much out in walking, that he carries the side of his foot for-
Avard, and  has consequently lost  the use of the  elastic arch
of the foot.
  This sketch will illustrate my meaning.
         FIG. l.
  In Fig. 1,1 have given a sketch of the limb, as I have seen
it lying—the knee bent, the side of the foot flat on the bed,
the  leg shorter; (though  this is not easily ascertained, from
/ 
FRACTURE OF THE THIGH BONE.
137
 the different aspects of the limbs), Avhile the  patient lies flat
 on his back.
   Fig. 2. shows Avhat has taken place—that the broken ends
 of the  bone have shot past  each other, by the retraction  of
 the muscles, AAdiile  the lower part of it is tAvisted outward,
 by the falling of the foot on the outer ancle, there being no
 impediment to this motion from the trochanters and the hip
joint as when  entire.

  FRACTURE  OF THE EXTERNAL CONDYLE OF THE THICH BOND.

   When we turn our attention to the natural position of the
 thigh bone, or when we place the condyles of the  bone  on
 the table, we  find that the shaft, or cylindrical part of the
 bone, stands  obliquely.   So it  happens  that,  in a person
 who falls on his feet, the weight of the body operates oblique-
ly, and the external  condyle receives the shock.  In this
way, there  is sometimes an oblique  fracture of the lower
head of the thigh  bone, and  the external condyle is broken
off.  The utmost care is required to prevent the  inflamma-
tion rising in the first instance, and to provide against obli-
quity in the joint.
VOD. II. 
136           TAaCILRL Ul  iJIE 1H1U11 IJONS'.
01 FRACTURE OF JRE. NECK OF THE TniGH BONE.
   This is a  sketch  of the bones of the person mentioned in
flic text.  The right thigh bone is natural, the left one much
.shortened by  the fracture of the neck.   A, the os Innomina-
tum ; B, the  shaft of tlie  thigh bone ;  C, the neck of the bone
fractured; D, the trochanter major broken off.  The compa-
rative elevation of this point above the level of the head of the
bone, will mark the reason of the shortening of the limb.   The
pieces of bone were united by a ligamentous substance, not by
bone.

   When we hold the thigh bone before us, and consider the
position of the great shaft of the bone, and the obliquity of 
              ERACTURE  OF THE THIGH BUNI-.           l'V-J

the neck,  standing off at an angle to  the shaft or pillar of
the bone; a\ hen Ave consider the strength of the shaft, or cy-
lindrical  part of the bone, that it stands almost directly un-
der the weight of the body, and  that the neck of the boneT
on the contrary, is smaller and Aveaker, as well as oblique,—
Ave see Avhy,  in all shocks from the descent of the body up-
on the thigh bone, the neck is the most apt to be broken across.
  The  neck of the  thigh  bone  then is broken  Avhen the
Aveight of the trunk falls upon it; as when a person  falls
from a height upon his leg", or Avhen thinking that he has
come to the landing of a  stair, he steps fonvard and  falls
doAvn tAvo or three steps, with a shock which the neck of the
thigh bone cannot bear.   A direct bloAv on the joint injures
it, but there is no fracture: a twist of  the limb dislocates
or injures the  apparatus of the joint, but  there is  no frac-
ture.  It is  only the perpendicular impulse  that can  frac-
ture the neck of the thigh bone*.
   I  have  dissected the joint some months after the  fracture
of the neck  of the thigh bone, and have found the bones
still loose.   There was at least only a very imperfect union
betwixt them, by a strong and  irregular ligamentous  mat-
ter.   I mention  this not as a curiosity, but in confirmation
of a general opinion, that the neck of the thigh bone will not
unite,  not readily, in the usual Avay by bone.
   It is of importance to notice the motion  of the hip joint
on almost every occasion;  in the  natural state of the parts,
indeed, Ave are aAvare of every motion  to  Avhich it is liable ;
but  Avhen the  sensibility of the joint is  increased by disease
or injury, we discover,  that scarcely a muscle of the  limb
moves without moving the thigh bone in the acetabulum:
and that the patient does not move his  trunk in  the slight
est degree, but the pain of the joint is excited by the motion
of the joint.

  * Although  at tins time, when I am correcting the  sheet, I  am made
sensible that a man may fall on  the trochanter, and break the neck f«i'
the thighbone; yet I am convinced it is so Uttle likcty to happen, ih.r
I venture to keep the text as it stands. 
140
TRACTURE OF  THE THIGH BDNR.
  This perpetual motion of the head of the thigh bone, is a
principal cause why, being broken, it does not unite.
  Certainly too, there is something unfavourable in the cir-
cumstance of the neck of the bone being surrounded by the
secreting and lubricating capsule of the joint, not by the
cellular membrane, and vascular muscles, which embrace
the broken ends of the bone in other fractures.  The broken
head and  neck of the thigh bone, must be  deprived of that
due degree of  inflammatory action of the surrounding parts
Avhich is necessary to sustain and consolidate it.   But hav-
ing seen the fracture  of the neck of the bone, with a break-
ing up of the whole trochanter major, and part of the shaft
of the bone, while yet there was no  union  by callus;  I can-
not attribute  the  defect of ossification entirely to this cir-
cumstance of the difference in the nature of the surrounding
substance.
  The  great strength of the muscles surrounding  the joint,
sufficiently  explains that most untoward circumstance, the
shortening of the limb, in fracture of the neck  of  the bone.
The Avhole strength of the muscles of the hip, of  the psoae
muscles, and of the muscles of the thigh,  is operating inces-
santly  in the retraction  of  the cylindrical part  of  the bone.
To counteract this dragging of the  muscles, I knoAv nothing
more  effectual than laying the limb on the frame Avhich I
have already described, I do not imagine that any  splints
about  the thigh or joint, or any  kind of bandaging, will be
more effectual to retain the limb in its natural position.
  It is particularly necessary to point out the distinctions
betwixt this fracture and the dislocation of the head of the
thigh bone.
  1. In the first place the surgeon has to  attend to the cre-
pitation, and for this purpose he  puts his hand  on the joint,
while the limb is  moved.   But it must be recollected, that
the effect of mere inflammation in the joint is to change the
secretion of the sinovia so much, that  the cartilages move
Avith  less  facility,  and  produce  a jarring  sensation,  Avhich
may be mistaken for crepitation. 
FRACTURE OF THE THIGH BONE.
141
   2. We next attend to the ease with  which the limb is
 stretched.   By a majority of consultants,  I Avas  induced,
 contrary to my own opinion, to  put the apparatus on an old
 woman,  and to endeavour to reduce Avhat Avas  supposed a
 dislocated hip; but placing my hand on  the trochanter ma-
 jor, and pressing  a finger of the same hand on the promi-
 nence of  the ilium, I knew decidedly at  the first motion of
 the assistants to pull the limb, that it was no fracture, from
 the ease  Avith which the trochanter moAred, and from the in-
 crease of the space betAvixt the ilium and the trochanter.
   3. In  dislocation, the limb is locked as  it Avere; but  in
 fracture, it  is easily moved, in as far  as regards the surgeon,
 though Avith  pain to the patient.  And Avhen the limb is
 moved in fracture, it is  Avith a certain degree  of elasticity;
 but in dislocation, by starts, and unequally.
   4. When  avc make an assistant  take hold of the knee and
 ancle, and bending the,knee joint make the rotatory motion
 of the  thigh bone by using  the leg as a  lever, we  may ob-
 serve the folloAving distinctions betAvixt fracture and disloca-
 tion :—When the heel is moved out, the head of the thigh
 bone checks against the back of  the ilium in dislocation;
 Avhereas in  fracture it has no  such  impediment.   Again,
 when we  make the assistant  roll the  thigh, while Ave keep
 the fingers on the  trochanter major, Ave feel it, in dislocation,
 making a movement describing a part of a large circle ; but
 in fracture, it moves  on the centre of the cylindrical part of
 the thigh bone, to Avhich it is  nearly parallel, and  conse-
 quently does not escape from under the finger.
   See further under  the  head of Dislocation of the Tliigh
 Bone.
   As I have  caid, I conceive that the frame Avhich I have re-
 commended,  in the fractured  thigh bone,  will do all that  it
 is possible to  perform in the present case;  it will  retain the
 thigh bone, and the great trochanter,  in their natural place
and  relation  to the neck of the bone.   But lest my reader
should object to this, and think that it  is better to assist the
on' ration  of  this frame work by bandaging and  splints, or 
112
tRACi-UULD PAXELLA.
Avould rather trust to the general experience of  the  profits-
sion, than to my suggestion, he may take the following me-
thod :—
  You  extend the limb until by marking the relation of  the
trochanter major to the  ilium, you find you have brought
the bones into their due relation to each other.   You then
lay compresses above and on the sides of the trochanter; then
a roller is put round the  pelvis and thigh, so as to keep these
compresses  and the bone firm.  (So far it may be well to do
before laying the limb out on the inclined planes—I object to
what follows, as inefficient).   A long splint of wood is  noAv to
be put along the Avhole thigh, fixed at the upper part by hav-
ing the end pushed into the folds  of a bandage or  belt, which
goes round the pelvis ; while to the loAver part are attached
bandages, which go round the knee and ancle,  and Avhich
may be drawn so as to stretch the limb.

               OF THE FRACTURED PATELLA.

   The fracture  of the patella, or knee  pan, happens in conse-
quence of a sudden and  very strong action of the four mus-
cles Avhich are inserted into it while the knee is in  that degree
of flexion that the  patella is raised upon the convex  surface
of the loAver head of the femur.   Sometimes the  patient ob-
serves that the crack of the fractured bone Avas before he fell
to the ground;  while, for the most part, deceived in  the cir-
cumstances, he supposes that in striking the ground, the knee
pan has been  fractured.  It must,  at first view,  appear
strange, that the patella can be broken by the mere force of
the muscles! but tAvo things are to be considered, the great
massiness and strength of the muscles Avhich operate on it,  and
the position of the patella.
   The  muscles Avhich operate on the patella, are the rectus,
the vastus  externus and internus, and the  crureus.  These
which  may be called a quadriceps muscle, raise the whole
weight of the body, and are poAverful in their ordinary action.
But when a man slips his foot, and I may say the whole mus- 
FRACTURED PATELLA.               143
cular frame is brought into sudden and almost spasmodic ac-
tion, the  power  of those  muscles is inconceivably great.
Again,  the patella cannot be broken  Avhen  the muscles pull
directly in the line of the bone;  that is,  when  the limb is
straight; nor yet Avhen the knee is so bent that the patella
lodges betwixt the bones, and  is supported by the condyles.
But when the knee  is moderately bent, and  the patella is
raised on the  convexity of the  loAver head of the thigh bone,
the muscles act at an angle with the ligament of the patella,
and then  the patella is broken across.  The patient falls to
the ground,  and the surgeon finds that instead of the usual
prominence of the knee, the joint is flat, and he feels the great-
er portion of  the patella drawn upAvard on the thigh,  while
the  other part is still attached to the  ligament, and the two
condyles of the thigh bone, are prominent.
   Treatment.—Let the surgeon avoid all motion in the limb,
or at least  bending  of the knee joint, else there  will be fur-
ther danger  of laceration.   If the patient is to be carried
home, in order to be quite safe, he has only to  be carried sit-
ting upright in a chair, with his leg extended.   There is no
occasion for a bandage to secure the upper portion of the pa-
tella, from being draAvn further up on the thigh.
   When the  patient  is laid in bed,  we have to bring  the
fractured portions together: first, by position  ; secondly, by
bandage.  It will be manifest, that the leg is to be laid (in
opposition to  the general rule) extended ; so that the lower
portion of  the patella may be  raised  on the fore part of the
joint.  The body must be brought forward in the sitting pos-
ture, that the point of origin of the rectus from the pelvis,
may incline toAvards the knee,  and relax the quadriceps mus-
cle.   Or instead of the patient  sitting  in an uneasy posture,
he may lie on either side, only  having  the hip joint bent, and
the leg extended.
   When the extensor  muscles  of the leg, which  are inserted
into the patella, are thus to the utmost degree relaxed,  the
pieces of the  patella will have come into their natural posi
f?on.   A bandage must now be applied to guard them against 
144
t'RACTURED BATELLA.
 the accident of an unwary movement, producing action in the
 muscles of the thigh.
   A long double neckcloth is tAvisted together, then laid over
 the knee above the upper portion of  the patella; it  hangs
 doAvn on either side;  take  hold of  the hanging parts of the
 cloth,  and with the fore finger of the left hand, hook that
 which is held by the right, and Avith the fore  finger of the
 right hand hook the cloth where it is held by the left, so
 as to  bring them across under the knee: then bring the ends
 of the cloth over the lower part of the joint, and below the
 inferior portion of the patella, and pass them through their
 respective  nooses, formed  as described by the fore fingers,
 draw the Avhole tight, and then approximate the two circu-
 lar turns of the bandage,  which are above and below  the
 knee pan, by finally passing the ends through  the upper cir-
 cular, and  fixing them there.
   We have noAv to inquire why there is so remarkable  a
 lameness after the fracture of the patella, and why the patel-
 la of the other side is so apt to be fractured in a person Avho
 has once met with the accident.
   The second  accident  folloAvs naturally from  the lameness
 Consequent on the first;  and  this lameness, which  is so fre-
 quent a consequence of the fractured patella,  proceeds from
 two circumstances.  1. The fractured pieces are not brought
 into  accurate correspondence; but OAving to the imperfect
 relaxation of the quadriceps muscle, the upper portion is kept
 too high to be in contact with the lower, and instead of bone
 uniting the two parts of the patella, there is a long intermedi-
 ate ligament,  (such  as  I  have  represented in  the annexed
 plate).  One consequence  of  this is, that the muscles being
 alloAved to remain contracted, they lose their power of giving
 a perpetual tension and support to the limb, and also of ac-
 commodating themselves readily, and with sufficient strength
 to the necessary motions.  2.  The patella, in its natural posi-
 tion on the  top of the knee, being somewhat removed from the
 centre of the joint, bestows a power on the muscles, by ex-
tending the lever on which they act;  but when, instead of 
FRACTURED  PATELLA.
145
the bone, the neAv-formed  tendon runs  over the articulating
head of  the thigh  bone, this lever is lost.   It is  possible to
make a perfect recovery, in cases  of  broken patella, by pro*
ducing a close union betwixt the broken pieces in the way
that I have described.
   If  unfortunately the patella should be united  by a  long
intervening ligament, Ave  need not despair of bringing the
muscles  to  accommodate  themselves to  this  lengthening of
their tendon.   Often, though the thigh bone be remarkably
shortened afl sr fracture, yet the muscular action of the limb
is by exercise restored to full power.   So in this instance, by
exercise, the shortened muscles become capable of still fur-
ther  contraction.   To facilitate  this,  Mr.  Hunter recom-
mended  that the patient should seat  himself on a table, and
by giving motion to the leg, exercise these muscles, and that
he ought to put a Aveight on  the foot, to be increased as
the power of the limb Avas regained.
   When the patella is fractured by a bloAV, as I have seen it
by the kick of a horse, the  connexions of the muscles Avith the
joint, independent of the  patella, keep it from being drawn
up, as in the  fracture I have already described.  Here the
injury to the joint is so great, that Ave cannot apply  a band-
age if it  were required.  We trust to the position alone, and
are careful  to bleed  largely, and apply cold  cloths so as to
keep off inflammation.
   I have seen a very terrible accident folloAv the imperfect
cure of the  fractured patella.  The bone had united by li-
gament,  and this ligament had incorporated with  the skin in
such a manner that it  lost much of its pliancy.  The poor
man was carrying a burden and fell backAvard, the knee sunk
under him, and the  whole  fore part of  the joint was  laid
open by  laceration.   The case terminated in  amputation of
the limb.
VOL. II.
f! 
146
FRACTURE OF Tilt FIBULA.
                FRACTURE OF  THE FIBULA.

   In this sketch Ave may discover the  nature of the case uf
fractured fibula.   In the first  place, it  brings to  our recol-
lection that the fibula does not support the weight of the bo-
dy, and that it will never be broken by the shock of the body
on the leg, unless the tibia first gives Avay.  But remembering
the constitution of the ancle joint, and that the fibula  reaches
doAvn upon the outside of that joint,  it is pretty  evident that
the fibula can be broken only by a force  directly applied to
it, or by a twist of the foot.   The first example, is  Avhen a
man falls, and the side of the fibula strikes a stone, over Avhich
it is broken ;  or Avhen he receives a bloAv  on it;  or Avhen his
leg is pressed betAvixt his horse's side and the ground : thi^
is the simplest case.   On the contrary, tlie fibula fractured in
consequence of the foot being  Avrenched on an uneven pave
ment, is bad, because it is complicated Avith a strain, if not
absolutely a dislocation of the ancle joint.
   When the heel only touches the ground, and the balance
of the foct is not preserved by the resistance of the ball of the 
CRACTCRE OF THE TIBIA-
117
great toe, as the heel bone does not stand perpendicularly  un-
der the tibia, the end of the tibia, Avhich forms the malleolus
intcrnus, bursts, or at least strains tlie deltoid ligament, Avhich
unites it to the astragulus.   Then the point of the fibula, B,
forming the malleolus cxtcrnus, preserves the joint; or if the
violence be great, it falls on this small bone in the direction of
the dotted line, C, C ; so that it yields and breaks a few inches
above the ancle, as at D.  It folloAvs from tiiis, that Avhen Ave
find a patient complaining of a strain of the inner ancle, avc
examine the fibula, &c. if in any other instance we  see plainly
that  the fibula is broken, Ave are careful to examine the inner
ancle knowing  that it  must haA-e suffered  in  some degree,
though there may not be a subluxation.
   A splint, Avhich will  reach from the knee along the outside
of the foot is prepared.  In the holloAv of the splint,  soft lint
is placed,  so that it equally supports the limb, an eighteen-
tailed bandage is put under the splint; and tliis apparatus is
so placed on the mattress,  that  the patient's leg being  laid
upon it, rests on the outside of  the leg and foot.   Having  laid
doAvn the  leg on the splint, Ave examine again the degree of
prominence of the inner ancle, and see that  there is no tA\ist
or obliquity of the foot.  We are careful to notice, that  tlie
lower head of  the fibula, and the side of the foot, are equally
supported ; that the side of the foot is neither alloAved to hang
over  the end of the splint, nor too much  pressed  up;  the
bandage is then applied.  From  time to time Ave must  exa-
mine, lest the  integuments of the inner ancle indicate too
great a degree prominence in  the tibia ; and also  to see  that
the heads  of the fibula, on  which the limb tioav lies, are  nqt
suffering by the pressure.

               OF THE FRACrURE OF THE TIEIA.

   There  is no difficulty in  ascertaining the nature  of the case,,
when the  tibia is fractured.
   The splints to -be applied  are, first, one strong  splint of
Avood and leather, or of tin, which is to reach from the ou1r 
148
FRACTURE OF THE TIBIA.
side of the knee to the side of the foot.  It must be made to
receive the upper and loAver heads of the fibula, and holloAved
to receive the prominent muscles of the outside  of the  leg.
Another splint, shorter than the last, is to be adapted to the
plane surface of the tibia, on the inside.   This splint should
be straight, and reach only to the heads of the tibia.
  The fracture of the tibia is often of the Avorst kind.  The
tibia  is Aveak, Avhen  we  consider that the  bone of  one leg
only,  often  sustains  the  whole weight and shock  of  the
body.
  Like the thigh bone, it is often broken obliquely, because it
receives the shock of the body perpendicularly on  its shaft;
but a worse circumstance in the state of this bone is, that it is
covered only by the thin integuments.   These-together, are
the causes of the compound fracture of the tibia being so ve-
ry frequent.   They explain too, hoAV a compound fracture, of
any other bones, which are deeply imbedded in the soft parts,
can be Avith so much more ease converted into simple fracture
than  that of the tibia,  viz. because the bones can be with-
draAvn from the wound, and the integuments healed so much
more easily.
   In the  treatment of the  fracture of  the bones of the leg,
there is only one thing more to be noticed in the  way  of a
leading principle.  I allude to the strength of the muscles of
the leg, (muscles sufficiently strong to raise the Aveight of the
whole body) being on the back part only ; and that immedi-
ately on the  accident, they are apt to cause the tAvo pieces of
bone to stand at such an angle as to thrust the broken  ends
through the integuments.
   When  during the cure, the broken ends of the tibia are
made to project more and more at the shin, it is to be attribut-
ed to the action of these muscles: and I conceive the best
way of counteracting this, is to turn  the limb, so that the
heel may rest ©n the bed, while the toes are extended.   This
fully relaxes the  muscles,  while it gives the weight of the
limb to counteract the curvature which is taking place. If
the foot rests so that the toes are perpendicular to the heel, 
OF THE PERIOD OF CONFINEMENT.
149
 then there is a stress upon  the muscles  of  the leg; because
 the  Achillis tendon is stretched.
   When  the heel is  made to rest on the bed, care must be
 taken that the foot do not fall outward, else the tibia will be
 tAvisted, and there  will  be an  irregular prominence of the
 broken bone, on the inside of the shin.

             OF THE PERIOD OF CONFINEMENT.

   The last observation I shall  make, regarding fracture of
 the limbs, relates to the length  of time ay hich is necessary to
 the  complete union of the bones.   Different periods are pre-
 scribed to us before it shall be permitted that the  patient
 should rise and use his limbs.   Yet as far as I  have been able
 to judge, the period of confinement ought not to be determin-
 ed, on the idea that fliere is any distinction in  the commence-
 ment or termination of the process of ossification in the small-
 er and in the larger  bone.  The arm bone will unite as soon
 as the  clavicle; and  if the derangement of the surrounding
 parts, in the case of fractured thigh bone, be not much great-
 er than in the fractured arm bone, the greater bone will be
 united as soon as the lesser.   But in giving liberty to  the pa-
 tient, Ave should have regard to the use of the limb, and the
 stress to Avhich  the bone  is to be exposed.   And then, in-
 deed, a  proper  difference  arises between the bones of the
 arm, and those of the lower  extremity; in the former, the
 bone bearing the weight of the limb only;  in the  latter,
the bone  sustaining  the Aveight of the  Avhole body  and
limb.
   Tlie bandage around the fractured clavicle, may be eased
before the expiration  of the month; but the arm  ought not
 to be moved till the end of the month.
   Indeed tlie fractured humerus is not secure before the end
 of six weeks; and the same time is required for the bones of
the fore arm.
   But  Ave cannot alloAv the patient Avho has had a broken
thigh b_one, to rice till after the six Aveeks; and then he is 
IdO
FRACTURE- OP THE RIB.
not to risk the weight of the body on the limb, but the limb
is to be lifted and carried ; so in fracture of the tibia, the con-
finement, or at  least the precaution against resting  on the
limb, must be continued as  long as in the instance of fractur-
ed thigh bone.
  A difference may be  observed in the time of the knitting
of the fractured bones, ascribable to the state of the patient's
health, and of course this will depend on air, diet, and consti-
tution.
  When there is pain in the attempt to use the limb, it in-
dicates, that the inflammation has not subsided, or that the
natural action is not yet established.  It ought, therefore,  to
make us cautious of using the limb.

     OF FRACTURES  OF THE  RIBS, STERNUM, AND PELVIS.

  The  cases of fractured  ribs, sternum,  or pelvis,  form a
distinct class, because  they resemble  injuries of the  skull
more than the fracture  of the bones of the extremity, in this,
that they are dangerous only in so far as they do mischief
to the contained viscera.

                   OF A FRACiTRED RIB,

  The  principal security of the bones of the chest is their
elasticity.  While the  perfect  elasticity of the cartilaginous
joinings of the  ribs remains, they  are much  protected, be-
cause they yield, and by that means are  saved from shocks
which would break  them; therefore, men  are more liable
to have fractured ribs in mature years.
  The ribs are  often fractured by the person falling  on a
projecting corner, as of  a table or chair.   If he be reachuig
to take doAvn something above him, and, stepping on a chair,
he falls and strikes  his  side  upon the corner  of the chair,  he
will  probably  break his  ribs.   But  I  have  had strong
grounds of suspicion that patients have been braced up for
weeTss without any necessity, and that  both surgeon and pa- 
F-RACTURE OF CHE RIB.
151
tient have  mistaken the  pain of the bruised muscles, which
lie on the side of the chest for the effect of fractured bone.
  To find  Avhether the rib be broken or not,  Ave must feel
along its whole course : but if there be a particular spot very
painful, and yet Ave do not distinguish the fracture, Ave must
press in the rib at a part remote from  this; Avhen,  if it be
fractured, it will yield, and produce the same pain as before;
but if the bone be entire, there Avill be  no pain, because the
bruised integuments are not affected by the pressure.   When
the patient insists that there is something particularly Avrong,
because he finds a sharp pain when he moves, it should  still
be considered whether this be not oAving to the bruised flesh
of the descendens abdominis or scrratus  magnus.  You make
him breathe, and there is no pain nor crepitation  while you
place  the fingers on the part;  you make him exert those mus-
cles while the  breathing is suspended, and then he feels the
sharp pain caused by the action of the bruised muscles.
  When a rib is  broken, Ave have only to keep  it from mov-
ing by preventing the motion of the chest in respiration;  for
it is unnecessary to attempt to keep the rib in  its place, this
being already accomplished by the neighbouring ribs, and by
the connexion of  the rib with the intercostal muscles.   It is
to be remarked,  that  the lower ribs have  so free a motion,
and so much elasticity, that they are not apt to be broken;
while the upper one is defended by the clavicle.
  If a fractured  rib be neglected, there is  much pain, and
much danger of  inflammation in the  chest, and,  in the
end, of caries of  the rib ; for, by  the motion of respiration,
there  is an incessant rubbing and grating of the broken ends
of the ribs which prevents their union.
  I have dissected the body  of a man who died in  conse-
quence of the fracture of two ribs; or rather, I ought to say,
in consequence of  their being neglected, the  nature of the
case having been misunderstood.  There was an abscess under
the pectoral muscle, and a caries of the ribs ; and, from th«
irritation spreading Avithin the chest, much matter had been
formed ia the cavity, awd even the pericardium contained 
10*2
FRACTURE OF TH« RIB.
pu-\  It will be  said, that this extensive mischief could not
have proceeded from the fracture of tAvo ribs had not the con-
stitution been bad.  This may be true, but from this we can
only infer, that we should be more careful of such accidents
Avhere there is constitutional weakness.
   The mention of this terrible consequence of neglected frac-
ture, reminds  me of the necessity  of cautioning  my reader
against  the consequence of a mere bruise  of the chest.
For, if abscess form under the broad muscles  of the side, ca-
ries of the bones and abscess Avithin, may be the consequence.
It becomes our duty, therefore, to take precautions that matter
do not collect under the pectoralis major or serratus muscles,
and still more, that disease of the sternum does not folloAv con-
tusion of that bone.
   A compound fracture of the ribs  will  not readily happen in
consequence of the ribs  projecting, for the ribs are, in truth,
beaten in Avhen  fractured.   But owing to this latter circum-
stance, the  fracture of  tlie  rib  is often complicated with a
puncture of the lungs, or the rupture of  the intercostal artery.
   If the lungs be Avounded by the  end of the ribs,  Ave know it
from the frothy  blood spit up.   If a man dies from the ribs
being beaten in upon the lungs, after surviving the immediate
effect of tlie accident, the chest of  that side is found full of
bloody serum, and the lungs are compressed.
   When one or more of  the  ribs are fractured, a broad roll-
er is put about  the chest, and  a split cloth  is laid over the
shoulders, to the ends of Avhich the roller is  pinned.   This
bandaging forces the patient to  breathe by  the  diaphragm
and muscles of  the belly, Avhile the chest  is relieved from
motion.   The patient is then to  be bled  and put to bed.
Bleeding, in tlus. case, not only prevents the membranes  of
the  chest from  inflaming,  but, by diminishing the quantity
of circulating blood, it  relieves the respiration, because the
extent and  frequency of the distension of the lungs is pro-
portioned to the quantity  and  velocity of  the  circulating
blood.  If there be  a tickling cough, after the bleeding, opi-
ates may be given. 
FRACTURE OF THE RIB.
153
   If, after the patient is put to bed, there should come on a
 difficulty of breathing, with oppression in  the chest, the  end
 of the rib has probably pierced the pleura and penetrated the
 lungs, and the cavity of the chest contains air Avhich has es-
 caped from the lungs.   If  a tumour on the  broken rib  suc-
 ceeds to this, Avhich crackles under the finger, it is the emphy-
 sematous tumour, so peculiarly characteristic of this accident.
 The air has been forced from  the cavity of the chest into the
 cellular membrane by the  compressson  of the chest, and  it
 may  be forced from the  cellular membrane, Avhich covers
 the  Avounded rib,  over the whole body, until  it closes the
 eyelids and distends the scrotum and  integuments of  the
 penis.'
   When  the tumour  merely  betrays  its nature, Avithout
 much inconvenience, we need not mind it; but if it increas-
 es rapidly, and is attended  A\ith much oppression, punctures
 must be made in it Avith the lancet and the air pressed out,
 that both the cellular membrane may be freed from air, and
 the breathing from great oppression.
   While, in consequence of the accidental puncture of the
 lungs by the rib, the air distends the cavity and compresses
 the lungs on one side, the breathing and circulation may be
 oppressed and difficult; but still there  is no interruption of
 the  function of  respiration: at last, hoAvever, by the great
 distension of one side, the mediastinum  suffers,  and the ca-
 vity of the other side is  encroached  upon ; and  both the di-
 aphragm and the external  muscles of respiration are imped-
 ed in their action.  There is a sympathy Avhich  pervades all
 the muscles  of respiration, and  even if the  cavity of one side
be distended, the muscles of that side cannot act, and their
impeded action prevents the free motion  of those of the oth-
er side.  Therefore it is that  in emphysema there is, in the
end, great anxiety and oppression, and the heart partaking of
the influence, there is a feeble pulse and cold extremities.
  When the emphysema has proved the nature of the case,
and the symptoms are thus  pressing, Ave have to  make an in-
cision through the  integuments and  intercostal muscle,  and
  YQY.. II.                  W 
F51
FRACTURE OF THE STERNUM.
then puncture the pleura; by this means, the lunge of the
wounded  side will not be restored, but the play of the chest
will become free, and the lungs  of  the  other side will  re-
sume their action.
  When a rib is fractured, tlie intercostal artery  may  be
torn;  and should it happen that the artery is opened, and
yet not torn across, it will bleed until the lungs are oppress-
ed.  Then Avith the  common marks of haeuaorrhagy, the pa-
tient finds himself greatly oppressed.   He has a sense of suf-
focation, and cannot lie down; and  he breathes with con-
tortion of the body, to allow  the side of the  chest opposite
to that which contains the accumulated  blood, to expand in
respiration-  It is, in this case,, the business of the surgeon
to make an incision on the lower  edge of the rib fractured,
and a little  further back than the broken  point of the rib,
taking care  not  to cut the artery which lies just under the
rib ; and, having cut through  the integuments and intercos-
tal muscles, he ought to puncture the pleura.  If  he finds
coagulated  blood,  he*  will  be tempted  to  enlarge the
Avound, and introduce his finger to give vent to the blood
and coagulum.   If, after this, the blood accumulate again,
it must be again evacuated, and  a compress of sponge put
into the wound, so  as to press the  artery  against the rib.
Should  there be bloody froth discharged from the mouth,
the lungs are Avounded, and then probably emphysema wiU
unequivocally betray the nature of the case.

                FRACTURE OF THE STERNUM.

  The fracture  of the  sternum is a  very alarming accident,
both from the parts contained  under  it, and from the spongy
nature of the  bone.   Like the ribs, during respiration, the
sternum is in  incessant motion; and the thorax being of a
conical form, and the lower part admitting of a much great-
er extent  of motion than the upper part, it follows, that
when the 6ternum  is fractured across, there is a perpetual
grating of the broken parts of the  bone; the lower part of 
           FRACTURE OF THE BONES OF THE FACE.       155

the  sternum, being attached to  the  longer ribs,  moves
through a larger space than the upper portion.  This  rub-
bing and grating of the fractured bones  will produce inflam-
mation and suppuration under  the bone, viz. in the interior
mediastinum.
   The danger from the mere motion of  ordinary respiration
is, of course, much  increased Avhen the almost inevitable con-
sequences of the accident  supervene—irritation and  inflam-
mation in the chest, and a  troublesome cough.
   From these considerations it will be understood how the
patient,  having happily escaped  the  immediate shock and
injury to the thoracic viscera,  is in danger of caries of the
bone,  and abscess under it; and it Avill be seen too, that the
swathing, or bandaging of  the chest is equally necessary here
as in  the  fracture  of the ribs, and  that  bleeding must be
oftener repeated, and  eArery  possible  cause  of  irritation
avoided.
   It may happen  that we require to draw out and  pick
away  broken pieces  of the sternum ;  but fracture  of the
sternum, I am inclined to hope, does not  ever  require the
trephine.  We have however  observed that the sternum is
a very spongy bone, and therefore a part that is not always
secure from scrophulous action  Avhen it is bruised.  The ca-
ries  of the sternum does, in some measure, hold analogy  with
the caries of the skull: it is the communication of the disease
to the contained parts which we have to dread  in both;
and  here it may be necessary, in some cases to apply the tre-
phine to allow the free  discharge of matter, or to take away
a dead piece of bone which is the source of irritation.

           FRACTURE OF THE BONES OF THE FACE.

   The loAver jaw bone, being  much exposed and moveable,
is very often fractured.  It is  fractured by blows and falls,
and  is often found to be broken in two places.   The reason
of this complicated fracture we may see in the arehed form
of the bone, and  the support it has at the condyles; for if 
156        FRACTURE OF THE BOXES UF-THE FACE.

is impossible that  one  side of the bone should be beat in,
Avithout some other part of the arch suffering,  at  the same
time, in  nearly  an equal degree with  the  part  which  is
struck.
  I cannot conceive how a difficulty can arise  in  ascertain-
ing the nature of the  case when the jaAV bone is fractured ;
yet I have had  occasion to set it  after an eminent surgeon
had  dressed all the other hurts, but taken no notice of this—
and  authors insist  on the marks of fracture as of the first im-
portance.   To examine the jaw bone, we place  the fingers of
the left hand on the  angles of the bone, and then  take hold
of the alveolar part of the jaw bone in front, and endeavour
to move it laterally. We in the mean while, keep the eye  on
the teeth, when  we shall easily discover whether  there has
been any  fracture of the lateral part of the bone :  or Ave feel
and press along  the base of the jaw.  In boys there is some-
times a splitting of the lower jaw  at the symphysis which is
not so readily ascertained.   The patient has perhaps fallen
from a height; he  has lost one or two of the front teeth, or
they are  loose, and a greater  space than  natural is betwixt
them : By taking hold of the alveolar  part of the  jaw^ Avith
the  finger and thumb on  each side of the symphysis, the
fracture is at once ascertained by the  usual symptoms.
  If a boy has split the  symphysis of the lower jaAV, Ave  re-
place the teeth,  and then  bring the 6ides of the  jaAV  toge-
ther.  Wc then take  a bandage  Avith four tails,  and cut a
hole- in the  centre of it, which will  just admit  the  chin.
The  centre of the bandage being placed over  the chinj the
Iavo upper tails are brought  round the back  of  the head,
and the two lower tails are carried over the vertex.   I have.
found this quite sufficient to  keep  the jaAV bone and  teeth in
accurate contact.   The bandage may be made more  secure
by covering that part  of it which  embraces the face with
an adhesive plaster.  If it be thought necessary  to  tie the
teeth together, the Avhole of the front teeth ought to be in-
cluded in a cord  of silk; but this cannot  be done, if the
teeth have been shaken and are.loose. 
            FRACTURE OF THE BONES OF THE FACE.       15i

   In the case of fracture of the base of the jaw, and especially
if there be a fracture of both sides, it is more difficult to keep
the pieces in their place.   This is owing to the same circum-
stance that disorders all other fractured bones, viz.  the  une-
qual action of the muscles.   We may recollect that the mus
cles which close the lower jaAV  are poAverful, and are fixed
into the coronoid process, or the angle of the jaAV.  The mus-
cles which draw down the jaw are Aveak, but inserted into the
bone more forward, so that they operate with a longer lever.
These different insertions of the tAvo classes of muscles cause a
distortion of the jaw bone, Avhen it is broken  as Ave have de-
scribed ;  for then the  back part of the bone is held firmly up,
while  the fore part is pulled down by the muscles of the
throat and the digasti icus.
   If the teeth  be very regular,  and those of the upper and
loAver jaAV correspond, those of the upper jaAV serve the  pur-
pose of secure splints, when the base of the jaAV and chin are
bandaged.   If  the patient has  lost a tooth previously, and
Avhen the pieces of the broken jaAV are brought together, there
is a deficiency or inequality in the teeth, then a piece of  cork
may be adapted to the teeth  of each side in such a manner as
to serve the purpose of a splint.   The chin being brought up,
 and the hindmost pieces of the bone pushed back so that there
is an adjustment, the jaw is  to be secured on the outside.  A
piece of pasteboard is to be  cut  into such a shape as may  be
accommodated to the chin and jaw : It is to be notched round
the edge, and then moistened, that being applied on the lower
part of the chin it  may be brought up  on the base and
sides of the jaAV on both sides.  Over it  is to be applied the
four-headed roller as already described.
   There can be no occasion, in this case, for feeding the pa-
 tient with a pipe, or attempting to nourish him with clysters.
 Perhaps he may fortunately on tlus occasion have lost one of
his teeth, and tlirough the interstice he can suck his nourish-
ment.
    But if the teeth be altogether perfect,  in that case, rather
 than that he should have to live altogether on liquid, the 
158      . FRACTURE OF THE BONES OF THE NOSE.

cork splints may be laid along the teeth, which, Avhile they
give firmness to the bandaging, alloAv an interstice in front for
giving food.

           FRACTURE OF THE BONES OF THE NOSE.

  No doubt the ossa nasi suffer fracture, but they are oftener
in a manner dislocated, that is to say, one of them is beat in,
Avhile the other lies over it.   When they are fractured and
entirely beat down, the shock sometimes reaches the septum
nasi, and it is also fractured.  Nay, a Avorse effect may yet be
a consequence of a  bloAv on the nose.  It has happened that
the delicate cribriform plate of the ethmoid bone has been
fractured and pushed up on the brain, from the shock com-
municated to it through the septum !
  The arch of the nose is to l>e raised by a strong probe co-
vered with lint: by putting oil on  the little finger, we may
push it into the nostril, so as to replace the cartilage and bone
of the  septum ; tubes of any kind, I believe cannot be intro-
duced so as to support the broken bones.   When the bones are
replaced they will not readily move from their place; there
are no  muscles, no motion of the part to change their position,
and very soon a SAvelling of the nose and membranes comes on
which supports them sufficiently.
  If, in consequence of a blow on the nose, and a fracture of
the ethmoid bone, there should succeed  discharge of matter
with symptoms of  a beginning affection  of the  brain, then
ought  we to probe gently and perhaps pull upon the perpen-
dicular plate of the ethmoid  bone, that we may bring down
any part of the horizontal plate which may be irritating the
brain.   In the mean time, by every means in our power, we
ward off inflammation.  Happily  the case is not likely to
«?ccur. 
OF DISLOCATION.
159
CHAPTER VIIT.
OF DISLOCATION.
      .Luxation or dislocation is the displacement of the
articulating surfaces of the bones.   Dislocation is the conse-
quence of a tAvist of the limb not the effect of direct injury to
the joint Avhich is deranged.  Mistakes both in the  diagnosis
and in the efforts to reduce the bonep, will arise from overlook-
ing this very obvious fact.  There is a division of dislocation
into  kinds.   Dislocation implies that the articulating sur-
faces of the  bones no longer correspond  in any  degree, that
the bone is entirely displaced ; as  when the head of the hu-
merus lies  in the axilla, or the head of the femur has  been
forced from tlie acetabulum, and lies on the back of the ilium.
Subluxation is the derangement of the articulating heads of
the bones, while yet  they are in contact and rest  against each
other.  The  entanglement of the articulating processes of the
vertebras of the loins is a subluxation : there may be a subluxa-
tion of the knee, or more frequently of the ancle joint.
   Then we have the distinction of simple and compound dis-
location, analogous to that of simple and compound fracture.
In compound dislocation there is a wound of the integuments
with dislocation of the bone ;  and  it is dangerous, as there is
united an inflamed and suppurating Avound of the soft parts
with the wound of a joint, which consists of parts Avidely dif-
fering in  economy, parts  sIoav to inflame, but of which the
inflammation Avhen excited is violent in degree.
   Diastasis is  a mere separation of the bones.
   There  is  yet another  distinction, viz. into old and recent
dislocation.  This is a distinction sometimes important to tlie 
I GO
OF DISLOCATION.
surgeon, for lie has to consider the consequences of the  bone?
remaining long displaced before he determines on attempting
to reduce the dislocation.
  I need not remind my readers of the nature of the ligaments
and  cellular substance.   The ligaments  are  dense,  white,
strong,  and possessed of little vascularity; they are of two
kinds ;  first, such as are Aveak, but  destined to preserve the
sinovia, and to separate the articulating surfaces from the sur-
rounding parts;  these capsules are  very weak.   The second
kind  possess no elasticity,- pass from point to point of adjoin.
ing bones, and are the strength of the articulation.  Perhaps
with these may be classed such tendons of muscles as surround
the joint, and are incorporated with the  capsular ligament.
Now  it is possible,  that one side of a joint only is sprained,
the stronger uniting ligaments are  partially lacerated, and
there  is a weakness and yielding  of the joint, or there is, per-
haps,  a subluxation.   But when there is a dislocation, and
actual displacement of the bones, both the capsular and unit-
ing ligaments must be torn ; sometimes in the Avhole circle of
the bones, always for more than one half the circumference of
the head of the  bone.   From this it folloAvs, that there can-
not be a noosing of the head of  the dislocated bone  in  the
slit  of the  capsule,  as some have imagined to be the case,
Avhen  the reduction has proved difficult.   (See further under
the head of Dislocated Shoulder.)
  In  dislocation, then, the  head of the displaced bone  lies
among the cellular membrane, and  is either lodged betAvixt
the muscles, or presses upon a bone.  Where the smooth ar-
ticulating cartilage is in contact Avith the cellular membrane,
it presses and condenses the cellular membrane so  that it  be-
comes a substitution for  the natural capsule,  AA'hile the toiu
capsules and ligaments adhere to the surrounding parts.   If
the head of the dislocated bone presses on  a flat bone, as  the
os innominatum, or scapula,  an imperfect articulating surface
is at last formed.  In  the mean time, the head  of  the bone
no longer resting in  the natural cavity,  the surrounding soft
parts  encroach upon the cavily. and adhesions fr-m a parti- 
OF DISLOCATION.                  l^-l
tion betwixt the head of the bone and its former place.   Be-
sides, there is another unfavourable circumstance, the muscles
adapt themselves to the state of the bones, and are permanent-
ly shortened, so that they strongly resist the  reduction.
   The meaning of the distinction into recent and old disloca-
tion will noAv be understood.   WThen the dislocation is of long
standing, the neAv adhesions are  to be torn up, and violence
must be done  to the limb, as great, perhaps, as  that which
caused the displacement of the bone, before it can be reduced:
while in a recent dislocation there is no obstruction to the re-
duction but in the muscles, or natural ligaments.
   In speaking of the  degrees of derangement of the joint
from violence, it is proper to mention sprains, and to explain
that degree of weakness Avhich remains after them.
   A sprain is a momentary derangement of the articulating
surfaces of  bones, by Avhich a stress is put on the ligaments,
and those of one  side are  either partially torn, or they  are
stretched so that they inflame.  In every sense of the word I
deny that the capsules and ligaments of a joint are insensible
—sensibility to pain is the grand safeguard to the body; and,
although the joints do not feel in the same manner and de-
gree with the skin and superficial parts, yet they have that
degree  of sensibility which suits their, condition ;  is there not
excruciating pain Avhen a man sprains his ancle ? and yet  the
pain is not in the skin, it is quite different from the shock of a
superficial part;  and except the skin, there  is nothing to suf-
fer pain but tendons, and sheaths, and ligaments,  which phy-
siologists' say are insensible.   Physiologists have erred because
they have not perceived the end of this sensibility, and  the
variety in kind, as well  as  in degree, Avhich is suited to tlie
functions of the several parts.   If the end of a bone, and the
capsule, were sensible as .the skin or eye, or other delicate or-
gan,  their  common  and  necessary  function Avould  lay the
foundation  of inflammation, a greater  degree of sensibility
would be the consequence, and the evil Avould  increase until
the mobility of the joint Avere destroyed.  In the common and
necessary motion of the joints there is no sensation, no injury
   VOL. IT'.                    -x 
Jte
On DISLOCATION.
 from the friction of the parts.  But, if in tlie violent and ir-
 regular motions of the joints there should be no sensation com-
 municated, then Avould there be an absence of the governing
 principle, and no restraint, and no means of renovation.   We
 may  see  now, why, in experiments on the tendons and liga-
 ments by pouring acids upon them, and pricking them with
 needles, the animal gives no sign of pain ;  and yet in sprains,
 and dislocations there is extreme torture ;—Ave wonder only
 that the distinction should have been overlooked.
   To preserve the natural state of a joint that inferior degree
 of activity of vessels only is necessary, which, perhaps errone-
 ously, we call a weak action.
   However, it is important to observe, that whenever this na-
 tural state of action is changed, there is also a change in the
 nature of the part.  Tlie pain I have described is folloAved by
 its usual effect,  inflammation:  the ligaments when inflamed
 lose their density  and firmness, they swell, become weak, and
 acquire a new kind of sensibility, and no longer bind the bones
 with  their former strength.  This is the explanation of the
 weakness of a joint after a dislocation, or a sprain : Avithout
 this increased activity of vessels there could be no regenera-
 tion of the ruptured  parts; injury to  a joint would be like
 the breaking of the parts of a machine which possess no pro-
 perty of restoring themselves.   Nothing, however, is more dif-
 iicult, than to change this Ioav degree of continued inflamma-
 tion, and  to restore the state of the parts  to their natural den-
 sity and  firmness.   In the  scrophulous  constitution there is,
unfortunately, a tendency to this  inflammatory action in the
joints, which it is very difficult to allay.  It  is not bleeding
and purging which will reach a local disease of this kind; far
less will this do good if  there be any constitutional tendency
to scrophulous actions.  We  may take a hint  from quacks
and bone-setters ;  I have knoAvn them remarkably successful
by employing severe  and continued irritation on the surface
Avhile they have forcibly moved  the stiff and pained joint.
 But this has been after the surgeon has exhausted the patient 
OF DISLOCATION.
1(53
by ineffectual applications, or, in other words, after all active
inflammation has subsided.
  To ascertain the nature of the accident when Ave have rea-
son to think there is dislocation, Ave must consider these points:
  1.  We, perhaps, find the  joint much  discoloured, and
marks of a bloAv received upon it  This implies,  though it
be no absolute proof, that the bones are not dislocated, but
only the joint bruised;  because, as I have said, it is the long
lever of the bones receiving the force upon the extremity dis
taut from the joint, which does violence to the connecting  li-
gaments.   For example,  if there has not been a blow on the
shoulder,  but the  patient falling on the Avrist, has pain and
lameness of the shoulder joint, then sprain or dislocation qf
the shoulder  is the probable cause of the pain and incapacity;
if, on the contrary, there shall be evident marks of a  bruise
on the shoulder, it is probably  not a dislocation.
  2. The knoAvledge of the natural form and position  of the
limb will often enable us Avith a glance of the eye, to dis-
cover the distortion caused by  dislocation.   Generally the
limb is shorter,  though  sometimes it  is lengthened;  when
Avith this there is joined  a  stiff and aAvkward position, from
which the limb is not moved Avithout great pain, and Avhen.
upon examining it more particularly, there is a rigidity of one
set of  muscles, the dislocation is ascertained.   We consider
the new position of the head of the bone; the effect  of this
change, on the muscles  inserted into it; we  feel those muscles,
and they are rigid like  cords;  and this, Avith  the circum-
stance of the accident having produced this immediate conse-
quence, is decisive of the nature of the case.  There may oc
cur a contraction and stiffness of the muscles from spasm, pro-
ducing a  resemblance to  the unnatural position  of the dislo
cated limb, but  there  will not  be the actual distortion pro
ceeding from the new position of the bone,  and the change in
the angle of insertion of the muscle ; there will be no shorten-
ing of the limb.   In dislocation, the motion Avhich is allowed
to the limb is often interrupted and unequal.   There is also
a particular checking occasioned by the head of the bone strik- 
164
OF DISLOCATION.
ing against a flat surface, not rolling  in its natural  socket.
But let us recollect, that there may  be a roughness and im-
peded motion in the joint, occasioned by inflammation  having
diminished the natural secretion of sinovia, Avhere there is no
degree of dislocation.
   Another diagnostic may be sometimes found in the pressure
of the displaced head of the bone.—I not only mean that we
may sometimes discover the displaced head of the bone, but
that the effect of its  pressure on the neighbouring parts de-
clares to us its new position: as  for example, when the head
of the humerus, resting in the axilla, presses on the nerves, or
artery, or causes numbness of the hand  and arm, or Aveakness
in the pulse at the Avrist.
   Before Ave attempt to  reduce  a dislocation it behoves us,
in a particular manner, to think of the  position in which the
patient stood,  and the nature of the force  Avhich displaced
the bone.   It must be very evident, that the bone ought to
be brought to the same position in which it  received the im-
pulse  which dislocated it,  before  it  can  be  easily reduced.
We shall find examples as Ave  proceed,  Avhere  the ligaments
impede the reduction, oAving to the neglect of this plain rule.
   Tlie muscles too Avill ahvays, in a  certain degree, impede
the reduction.   On attending to the origins and insertions,or,
in other Avords, to the action of the muscles, it is possible, by
bending the joints, and relaxing the flexor muscles, to free the
head  of the bone from its confinement.  It is a commonly re-
ceived opinion, that the  action of the  muscles  is not  ahvays
direct against the elongation of the limb,  but that they bind
the heads of the dislocated bones together, so that the pro-
cesses of the bones check into each other,  and absolutely pre-
vent any degree of direct force from  disentangling these pro-
cesses, or stretching the limb.
   Next in importance to the relaxation of the muscles, and
the due direction of the shaft of the dislocated bone, is the
providing of proper laques; but  especially applying  them
avcII,  and to their proper place.   The  two bones, whose sur-
faces  are dislocated, must, if possible, receive the whole force. 
              DISLOCATION OF THE CLAVICLE.          165

To reduce the shoulder joint, the chief difficulty is to secure
the scapula;  and the efforts to reduce the dislocated  thigh
bone are often ineffectual oAving to the pelvis being left free,
and only the other thigh secured.
   It is customary, and right, to fatigue the  muscles  of the
limb before the full effort is made to reduce the bone.  The
tackle is pulled tight, and the force gradually increased ; the
surgeon feels the progiess of the head of the bone, and directs
the efforts of the assistants; and by rolling the head of the
bone, and sometimes by lateral pressure, (such  as may serve
to disentangle the processes of bones), he assists  their efforts :
or, Avhen the bones have  been brought as near to a corres-
pondence as the direct pulling on the limb will affect, by a
sudden effort he changes the angle of the joint, and Avith the
poAver of the long bone, as a lever, reduces the dislocation.
   The  marks of  the reduction may be learned from what  I
have said of the signs  of  dislocation;  or they may be sum-
med up by saying that the limb  is  brought to its natural
state, and the patient suddenly gains the power of complete
motion.   The bone Avill often return Avith  a  distinct and au-
dible jirk into its place, such as might be expected from the
smooth round head  of the bone being  drawn over the mar-
gin into the well-luhricated holloAv of the  socket.   The free-
dom from the painful and unequal extension of the muscles,
makes the patient satisfied that the bone is  reduced,  before
the surgeon can be aAvare of it.
   The mechanical poAver of the  double pulley ought to be
preferred to  the force of many assistants,  from its being  so
much more easily managed and directed.  But let it  be re-
membered,  that  the surgeon may make a miscalculation  of
this mechanical increase of power very hurtful to the patient.

              DISLOCATION OF THE CLAVICLE.

   Although the clavicle be united to the sternum by strong
ligaments, yet it is a weak joint, seeing  that it  is small  to
bear the Aveight, and allow the free motion of  the upper ex- 
 166           DISLOCATION OF THE CLAVICLE.

 tremity.   In truth it is the weakness of the bone more than
 the strength of the joint that prevents the dislocation of the
 clavicle at the nearer extremity.   When the clavicle  is dis-
 located from the sternum the nature of the accident cannot
 be mistaken.   The intention in the treatment is also sufficient-
 ly evident.
   The shoulder is to be bound moderately back,  and the
 arm slung, whilst a compress is to be put on the clavicle, and
 the roller brought round from under the arm pit of that side
 obliquely across the shoulder and side of the neck, in order
 to press down the end of the clavicle into its place.
   The clavicle is sometimes dislocated  from its  connexion
 with the acromion scapulas.  This dislocation  may at first
 sight be mistaken for a dislocated humerus,  until the nature
 of the  injury being understood,  we find that the  force used
 has not been such as  is likely to  turn out the humerus from
 its place.  And  although their appears to be at first that
 holloAv under the  projection of the shoulder which implies
 the dislodgement  of the head of the humerus from its place,
 yet presently we discover that this is only occasioned by the
 comparative projection of the scapular end of  the clavicle;
 or rather more strictly speaking, that the shoulder has fallen
 nearer to the breast, Avhile the clavicle is left Avith its further
 extremity  projecting; we find that the  humerus admits of
 easy and uninterrupted motion.
   I have said that the clavicle projects, yet properly this is
 rather the receding of the Ecapula and humerus,  which are
 now no longer kept off the breast by the clavicle.   With
 more propriety therefore in  this instance, we should term the
 accident the dislocation of the scapula than of the clavicle,
 as the clavicle remains in its place.  The operation is  to re-
 place the scapula: this is to be done by holding the arm and
 scapula in due relation to the clavicle until the sjpica bandage
be applied over the shoulder joint.  When Ave suspend the
fore arm, and put a pad in the arm pit to keep the scapula
at its proper distance from the sternum. 
DISLOCATION OF THE HUMERUS.
16?
        DISLOCATION OF THE HEAD OF THE HUMERUS.

  It  is not in general a shock communicated to the joint
which dislocates the humerus from the scapula,  but a t\vist
of the arm.   If, for example, a boy stand holding a horse by
the bridle, and the horse tosses his head, then the boy's arm
is  raised, and the head of the humerus is displaced from the
glenoid cavity of the scapula.   Or again, if a man slip his
foot and fall, and if to save himself he stretches out the arm,
then the full weight of the body being sustained by the hand,
and operating with the  advantage  of the  long lever of the
arm,  it turns the head  of the  humerus off the articulating
surface of the scapula.
  It  will be remembered, that the very free  motion of the
scapula is the safe-guard of the shoulder joint; for the sca-
pula following the motions of the arm prevents the arm bone
from  rising to  an angle Avith the  glenoid surface, which
would in a manner facilitate  dislocation.   This gliding mo-
tion of  the scapula keeps the humerus,  even  in its highest
elevation, still perpendicular to the glenoid cavity.
  Still the  position of the arm favourable to  dislocation is
when th  arm bone is raised to its utmost limits, and until it
be checked by  the acromion process of  the scapula.  The, 
168
DISLOCATION OF THE HliMERLS.
bones then stand in  the relation to each other  that  is here
represented.   A is the scapula.  B the acromion scapulas.  C
the humerus: Avhile D may represent the loAver part of the
capsule.  If the arm be  thus  raised, and there is a force
suddenly raising the  arm  further, a spasmodic action of the
muscles  inserted into the scapula fix  it, and then  the arm
bone, C, comes in contact with the process,  B,  as  here re-
presented,  and the force operating on the long lever of the
arm, the head of the bone bursts through the  capsule,  D;
tears the ligaments of the joint, and lodges in the axilla.  In-
deed, as to the place of the head of the  humerus in disloca-
tion it  depends  on the direction of the force  combined Avith
the operation  of the muscles.  If, for example, while the hu-
merus is made to act like a lever, tearing up  the ligaments
of the joint, it at the same time receives an impulse in the
line E D; that is in the direction of the shaft of the bone,.
then will the head  be urged deep into the axilla,  or under
the pectoralis  major muscle.
   A, The scapula,  seen on the inside.   B, An outline repre-
senting the humerus  in its natural place.  C, The humerus re-
presented dislocated.  D, The humerus in outline representing
the consequence of pressing the elbow to the side, viz. that the
head rises and presses against the neck of the scapula. 
              DISLOCATION OF THE HUMERUS.           169

  The signs of dislocation of the shoulder are these :—
  1. There is a hollow, in tlie middle of the deltoid muscle,
and directly under  the acromion process; because the head
of the humerus is removed  from the glenoid cavity of the
scapula, and no longer serves to give roundness to the shoulder.
  2. The head of the humerus is to be felt in the axilla.
  3. The elbow  cannot be pressed to the side  Avithout  diffi-
culty xand pain.   (This however is an indication Avhich be-
comes less distinct in old cases.)
  4. The patient cannot make the circular motion of the arm.
He raises his hand to his head aAvkwardly, and with pain.
   5. There is an unusual bend or depression near the middle
of the arm, from the change in the  angle of insertion of the
deltoides in consequence of the new direction of tlie bone.
   6. The fore arm is not freely extended, and there is a tense-
ness in  the biceps  muscle.  This proceeds from the origin
of the  long head of the biceps retauiing its hold on the edge.
of the glenoid cavity, while the tendon being engaged in the
groove of the humerus must follow that bone, and consequent-
ly draw  upon the belly of the muscle.
   7. There  is a numbness of the arm sometimes,  and the
pulse may be oppressed, or there may be oedema of the  arm.
This arises from the head of  the humerus pressing on the ax-
illary artery,  or veins, or plexus of brachial nerves, and de-
pends therefore on the accidental position of the head of the
bone.

          POSITION  OF  THE HEAD OF THE HUMERUS.

   1. No force can  be applied  in a-direction to dislocate the
humerus, and push its head  behind the scapula, for this very
evident  reason, that the chest prevents  the necessary position
of the humerus.
   2. Neither can the  arm bone be dislocated upAvards, be-
 cause of the  protection afforded to the joint  by the promi-
nence of the acromion  and  coracoid process; but chiefly, I
believe,  this is to be taken into consideration that there can
   vox. u.                     Y 
i?0
DISLOCATION OF THE HUMERUS
 be no  tAvist given to the bone when the arm is by the qjde*
 consequently the ligaments are not burst up.
   3. But the head, of the bone may be lodged foj ward, that
 is, the  arm may be bent backward,  the ligaments burst up,
 and the force such as to direct the head of the humerus un-
 der the pectoral muscle.
   4. DoAvmvard, or downward and forward, is the most com-
 mon position of the head  of the  humerus Avhen dislocated.
 The reason is already explained, viz. that the arm can be cx»
 tended in the opposite direction, that is upward and outAvard,
 and in that direction there is  no check to the motion of th$
humerus but in the processes of the scapula: Avhich however,
being unequal to  resist the force of 50 long a lever as the
arm, serve only to throw the head of the humerus off the ar-r
ticulating surface of the scapula, and to tear up the ligaments
of the joints.
            OF THE REDUCTION IN SIMPLE CASES.


   We 6hall not at present stop to  consider whether therq
ought properly to be any distinction made in dislocation of
the shoulder joint,  but merely observe, that often  a slight
force by the hands of the operator is sufficient to  reduce it.
The cases of difficulty I hope shall presently be explained.
   The patient is seated in a chair;  a table-cloth is  put un-
der the arm-pit and round the chest, while the ends are tied
to some secure post or bench; a hand-towel is then put over
the shoulder so as to press the acromion and scapular end of
the clavicle; the ends of this cloth are put round the larger
table-cloth, where it crosses the back and breast; they are
drawn tight there and secured.
   Something in form of a noose is now put above the elboAV
joint, and perhaps a hand-towel is the best thing we  can use.
It is twisted like a rope, and then applied in the form of a
sailor's knot,  in such a manner, that the more  the ends  are 
DISLOCATION OF THE HUMERUS*
in
jhilled the more securely it grasps the arm*.  It must take
firm hold of the condyles of the humerus.   An  assistant
standing a little above the level of the patient, takes hold of
these laques, and pulls gently at first, increasing the force gra-
dually to the utmost.  When the arm of tlie patient is  some-
what fatigued, the surgeon takes hold of the arm  Avith  the
right hand, placing the palm of his  left on the  top of  the
patient's shoulder; he directs the  dislocated bone into that
line in which it  was dislocated, i.  e. elevated and a little
backAvards ; and increasing  the  force, he  brings  the arm
round until its direction is  forAvard and upAvard, Avhen  the
bone Avill be in general reduced.   The reduction is known by
the audible jerk Which the bone  makes ; by the immediate
ease of the patient, by the holloAv under  the acromion being
filled up, and  by  the easy motion of the arm being  restored,
During  this  operation  it may be useful to bend the  elbow
joint, and use the fore-ann like a lever to roll the humerus,
which will in  the first instance serve  to disentangle the head
of the bone from  its neAv connexions, and in the course of its
motion  towards the glenoid cavity facilitate the tubercles
passing the edge of the scapula.
   *WTren the  humerus  is draAvn out to that degree that the
head  is nearly on a level with the glenoid cavity of the sca-
pula, and yet it does not slip into its place, we must vary the
position of the arm by  drawing  the arm more upward, or
what is  the same thing, by allowing the shoulder of the pa-
 tient to  drop more, and  the upper part of the trunk to fall a
 little to  the side.
    Though I have found, that when the  head of the humerus
 lodged against the margin of the glenoid cavity, that it was
 reduced by suddenly depressing the elbow, and lifting the
 head of the bone with my fore-arm, pressing upwards in the
 axilla, yet I can see strong objections to it; nay, often instead
 of facilitating the reduction, this position of  the humerus
    • It is a knot formed by twisting the cloth into two nooses,  through
 which the arm  is put, and  on drawing the ends we  have the firmest
 hold possible. 
172      ACCIDENTAL REDUCTION OF THE HUMERUS.

dowmvard directly opposes it.   I shall first state the fact of
the great difficulty which sometimes occurs to the reduction
of the dislocated shoulder,  and then explain it from the con-
sideration of the anatomy.
   We are told that cases have occurred where no effort has
succeeded in reducing the humerus, until by some unintentional
motion, and by accident, the head of the bone has slipt into
its place.  What are wc to  think of this ? not that the reduc-
tion is an accident, and that Ave are to move the arm in vari-
ous directions until by a lucky chance the dislocation is reduc-
ed ! A little further enquiry teaches us that there is a certain
position in which the bone resists, and one also in Avhich it
as certainly yields.   I have experienced this  in the living
body,  and produced the same effect in the dead body.   I
have found that upon pulling the arm directly out from the
body, horizontally, that not the smallest progress was  made  ;
but that at last the  patient's body yielding somewhat,  the
effect was, that in relation  to the scapula the position of the
humerus  Avas  considerably raised, and that then the head of
the bone slipped into its place.
   The explanation Avhich has been. given of this accidental
reduction is, that the head of the humerus when it was dis-
placed burst through the capsular ligament Avithout tearing
it entirely away, and that the head of the bone was retained
noosed in a  slit of the capsule, so that it could not be reduded
unless the arm was brought exactly to the position  in which
it was when displaced.  To this it lias been  objected,~ that
the head of the humerus does not merely burst through  the
capsule when  dislocation  takes place ;  the capsule  is tern
largely aAvay from the edge of the glenoid cavity, so that the
head of the bone cannot be retained in the slit of the capsize.
It has been very resolutely affirmed, that the cause of this dif-
ficulty of reduction  is to be found in the muscles : that  the
head of the bone  when it burst from the capsule was pushed
through betwixt the teres  major and the subscapularis in this
manner. 
REDUCTION IMPEDED BY THE MUSCLES.
17S
   A, the clavicle.  B,  the scapula.   C, the head  of the
humerus  thrust betwixt the muscles.   D,  the  subscapulars
and teres minor.  E, the teres  major.   F, is pari of the la-
tissimus  dorsi.  G, the deltoides.   H, the coraco-brachiafis.
I, the biceps.
  This sketch was taken from a dissection after an experiment
on the dead body.   It proved more than is  shown here, for
on pressing down  the arm bone to the horizontal direction I
found that the  reduction was prevented, and  keeping the
parts in the exact position.  I cut away all the muscles, and
still the humerus was retained checked ; but then what made
the obstruction became apparent, viz. the upper part of the
capsular ligament.   But T must now explain in what manner
the capsule is torn. 
I74f           DISLOCATION OF THE HUMERUS.
   In this sketch the scapula and humerus are represented in
the relation to each other as if the humerus Avas just slipping
from its position.   Here it is evident, that as  the line C, from
the upper margin of the scapula to the  nearest point of the
attachment of the capsule to the humerus is shorter than the
line D, which encircles tlie head of the bone, so will the side
of the Capsule AA'hich answers to C, be less stretched than the
loAver part at D, during dislocation.   Indeed the upper  part
of the capsule of the joint is not more stretched when  the hu-
merus has slipped from the articulating surface of the scapula.
than when the arm hangs naturally by the side.   If in th$
dead body we cut the lower part of the capsule of the joint the
humerus is  easily dislocated, but if  we cut the upper  part
only, and let the lower part of the capsule remain entire, it is
very difficult to dislocate the bones, and not without tearing
the loAver part of the capsule. 
POSITION OF THE HUMERUS AVHEN DISLOCATED.    1T5
   In truth, Avhen the humerus is dislocated this is the state of
 the bones and ligament.  A,  the scapula.  B, the humerus
 dislocated.   C,  the capsule still entire  on the upper  part,
 though completely torn aAvay on the lower and fore part.   D,
 the rough protuberance of the head of the humerus checked
 under the neck of the scapula.  And now it  is evident, that
 when  the arm is brought to the  direction  of the line E, the
 capsule C, resists the depression of the bone, and throws  up
 the point D, under the neck of the scapula, and the greater the
 force employed to stretch the arm the firmer are the humerus
 and scapula tied together at the points C D. But if on the con-
 trary we desist from this direction of the force horizontally,
 and  raise the arm into the direction of the line G H, then the
 capsule C, is relaxed, and the point D, escapes from under the
 neck of the scapula and the bone is reduced.
   In conclusion then, though by  placing the fore arm in the
 axilla  of  the patient, and raising the head of the humerus
 while we  depress the elbow, we facilitate the reduction when
 no part of the capsule remains, yet if there remains any shred
of the capsule this  manoeuvre will directly impede the reduc-
tion.   We must on the contrary elevate the elbow, or let th«
body of the patient fall  somewhat more laterally,  in order to
facilitate the reduction. 
176
DISLOCATION OF THE HUMERUS.
  There is no occasion for any bandage being used after re-
duction to keep the humerus in its place, that is effected by
the bracing of the muscles round the joint.  If any thing be
required it is that some check may be given to the raising of
the elboAV too far from the side until the ligament  has united.
The surface may be rubbed with warm stimulating oils, and
the arm gently and regularly moved.
  In this violent operation one can imagine, that if the axilla-
ry artery Avere at all  diseased it  might be torn; but  I have
not. known of such an accident, though I have knoAvn such an
ecchymosis succeed the operation of reduction, as would im-
ply the rupture of some considerable vein.   In employing the
ambe in the NeAvcastle Infirmary both the axillary artery and
the muscle have been torn! so that they were obliged to am-
putate on the instant: one  would expect  that  such  a proof
Avas not Avanting to show that it was not the muscles but the
ligaments which caused the  very great difficulty in reducing
the bone in dislocations.
   Having  proceeded thus far in Avhat I had  to say on the
dislocation of the shoulder, I recollected that there Avas much
ingenious observation in  Mr. Hey's Surgery on this subject;
I find too that there is much for animadversion.   The stu-
dent finds an example in that work under the head of Dislo-
cation, of what most  surgeons have experienced  in their prac-
tice, a Avant of principle, and consequently a Avant of method.
   In the three  first cases we have an example of the easy re-
duction where the bone, we might almost  say  spontaneously,
falls into its place.  The conclusion  Mr. Hey draAvs is, " that
reduction might sometimes be effected with less extension than
is commonly used, and consequently Avith less pain:"  it ap-
pears to him, " that the muscles Avhen so far stretched as te
be rendered painful, begin to re-act and resist the efforts made
for their further elongation."   The fact  seems to me to b«
still this; it is the direction of the humerus more than the
force employed which occasions  the seeming difference in the
various cases of dislocation. 
DISLOCATION OF THE HUMERUS.
  Mr. Hey observes, « When the head of the bone has desert-
ed the axilla, and has slipped under  the  pectoral muscle, I
have  observed that it is brought back into the  axilla the
more  readily if the extension is made in a direction opposite
to that in Avhich it has passed from the axilla.   This effect is*
often greatly promoted by making the extension with the arm
elevated as Mr. White has advised.   But Avhen the head  of
the bone has advanced far under the pectoral muscle, strong
extension by closing the passage through Avhich the protube-
rant part of the bone should return, often prevents instead of
promoting reduction."  p. 291,
  The first part  of this quotation resolves into  the advice,
that  the bone must be elevated to the position in Avhich it
was wdien dislocated, before the force be used to extend the
arm.   The second part of the excerpt has, however, a refer-
ence  to  the  opinion  that the bone passes through a  noose,
Avhich I hope I have shown to be a groundless  supposition.
   In Case IV. Ave have these words: " The body being sup-
ported,  and counter  extension  made by  means of a broad
towel put  round  the  thorax of the  patient, the extension of
tlie arm Avas made by three or four men, first in a direction
at right angles to the body, and Avhen the extension Avas in its
greatest degree,  by pulling the arm towards the ground at
an  acute angle Avith the body, while  I attempted to raise the
head of the bone by my  hands  placed as near it as I could.
This method failed; so did that Avith the heel in the axilla."
   So I conceive the attempt in this Avay will ever do  if  the
state of the ligament  be  as I have alleged.  Then it will be
 asked, hoAV does  it happen that simply by extending the arm
 at  right angles with  the body the dislocation is so often re-
 duced ?  I believe the fact to be, that the arm is not at right
 angles with the body in most of the cases thus reduced, but
 that the counter extension being made imperfectly, the body
 of  the patient falls so far towards  the assistants, that the in-
 clination of the humerus is changed to that direction which
 I have so  much  insisted upon as being necessary to reduction.
 For  it is not the position of the arm, or of the patient's body,
    VOL.  IT.                   Z 
178
DISLOCATION OF THE HUMERUS.
but the relation betAvixt the humerus and scapula that is im-
portant.
   There  is a method by Avhich the operator's neck is yoked
to the patient: a toAvel is put  under the arm-pit and over the
surgeon's  neck, who raises  himself while the assistants  pull;
he thinks  he assists the reduction by raising the humerus over
the edge of the glenoid cavity, Avhile he is  only pressing the
head of the humerus against the neck of the scapula.  This is
someAvhat more  harmless, but no less unscientific, Avith the
operation of the ambe, or the  dragging by the wrist a^ ith the
heel in the axilla.   In all these cases it is still locking of the
bones, or the ligament which resists, by preventing the exten-
sion of the limb.
  I return to Mr. Hey's Cases :—In Case  VI. after several
methods had been tried, as Freke's improved ambe, that by
the toAvel round the operator's neck, &c. he proceeds,  " Mr.
Lucas and Mr. Jones aftenvards tried to reduce the bone by
the heel in the axilla, and Mr.  Lucas perceived a noise during
one effort as if the bone  had returned to its place.  While the
last method was in use it occurred to me, that extension made
in a direction  parallel to that of the  body Avas not likely to
succeed, while the head of the bone lay so deeply sunk, and
behind the pectoral muscle.  I therefore advised, that one
person should extend the arm  at right  angles to the body, by
a hold of the fore-arm, placing his foot  against  the  side of
the patient's thorax.  In this  Avay  the  person making the ex-
tension  Avould not only have  a  firm support, but would also
be enabled to repress the loAver part of the scapula by his heel
placed  against it.  That during this  extension another per-
son lying by the  side of the patient,  should  place  his heel
against the upper  part of the os humeri, as  near to its head as
possible, and should push it in a direction parallel to that of
tlie patient's body.  By this method the bone altered its situ-
ation with, such a  noise  as is usually heard in reductions, and
we-  concluded that the  head of  the bone  had  re-entered the
socket ; but Avhen  the arm Avas  brought close to the patient's
.ide, Ave  found that the head of the bone Avas still in the 
DISLOCATION OF THE HUMERUS.
1:9
axilla.  This appearance of success encouraged us however to
repeat the operation, but the event Avas the same.  Wre now  •
imagined that some portion of the capsular ligament might be
folded so as to be intercepted botAvcen the head of the bone
and the  glenoid  cavity, into Avhich a\ e judged the  bone to
have  been  twice brought.  On this supposition, after making
the reduction  the third  time,  the os humeri was moved in
various  directions* sometimes upon its oavii  axis, sometimes
upwards and  doAvmvards, before Ave attempted to bring the
arm to the patient's side.  Also while the extension was con-
tinued, a flattened ball of low Avas thrust up into the axilla by
the heel, to prevent the head of the bone from retiring again
into the  axilla ;  the arm  was. then brought into contact Avith
the patient's side, &c.  by this means the reduction Avas com-
 pleted and confirmed."   See p. 297.
   Remarks.   This is a just picture of the bustle, the varied
 and ill directed efforts a\ here there is  no principle drawn from
 anatomy to direct the operator.
   The next Case Mr. Hey gives, is one where after some inef-
 fectual  endeavours the bone was reduced by  the assistants
 elevating the patient  by toAvels round the arm from his seat
 on the ground, and then, ay bile the arm Avas thus stretched,
 carrying it forward.
    Further experience must determine, says Mr. Hey, Avhether
 this method of reduction is superior to those  which he has
 mentioned.   Now  Ave believe that what is called experience
 has  kept  this part of surgeiy in unusual darkness.   Let any
 person  take  the dissected shoulder joint  in  his hand, and
 there will be no occasion for further experience to inform him
 that this  is the best of all the methods employed by Mr.  Hey.
 The reason  I hope  I have sufficiently explained  already.
 One more observation I  am  led to by Mr. I ley's  Avork ; in
 page 304 he says, that in several of the cases the counter ex-
 tension was applied so as to press back the inferior angle of
 the scapula, contrary  to the directions given by Mr. Brorn-
  field, Avho used to cause the acromion to be pushed backAvard.
  These different methods of practice, he adds  merit an atten- 
180
DISLOCATION OF THE ELBOW.
 tive comparison, that it may be decided on which side the su-
 periority lies.  I hope the question is  easily decided ; when
 tlie surgeon pulls the arm at a right angle Avith the body, and
 at the same time pushes back the lower angle of the scapula,
 he  brings the bones into that position Avhich relaxes the re-
 maining connexions of the joint, and relieves the check Avhich
 impeded the reduction.  The truth  is,  I  believe, that Ave
 cannot throAv back the acromion, but in as much as Ave can Ave
 prevent  the reduction in difficult cases, unless we at the same
 time elevate the arm bone.
  From considering the position of the head  of the humerus,
 and effect of the ligament; and the position of thetAvo great
 processes of the scapula, it appears to  me, that the motion to
 be employed completely to relax the ligament, and move the
 head of the humerus over the brim of the glenoid cavity, is
 this, let the arm be extended until the head of the humerus
 is felt to be draAvn  from the holloav of the axilla ;  the arm is
 then to be raised and moved  in a circular direction towards
 the side of the patient's face.  In this  movement the neck of
 the humerus first bears on the acromion, and then on the cora-
 coid process of the scapula; against the last  process the lesser
 tubercle of the humerus bears so, that with the lever power of
 the humerus its articulating head is  raised over the edge of
 the glenoid cavity, and slips into its place.

                DISLOCATION OF THE ELBOAV.

  The  dislocation of the ulna from its connexion Avith the
 loAver end of the humerus happens in young people chiefly, in
 AArhom the  coronoid process of the ulna is not so complete  a
 guard to the joint as it becomes in the  adult.  A person  who
 running idils on his hands and Avrist may dislocate the ulna,
 because the Avhole Aveight and shock  is received on the elboAV
joint, in  the line of the ulna ; and in this direction the coro-
 noid process is  the sole guard against  dislocation.   The  ulna
 >tarts backAvard, and the olecranon and articulating part of
 the ulna is  thrown  out behind the arm  bone.  The pronrU 
DISLOCATION OF THE ELBOAV.
181
Hence of the olecranon behind the joint, and the painful rigid-
ity of the arm, sufficiently distinguish the nature of the acci-
dent.   I need scarcely add, that so firm is the union of the
radius with the ulna, that both bones are dislocated when the
ulna is felt thus out of place.
   To reduce the dislocation of  the ulna, the surgeon bends
the arm;  he puts a handkerchief round the patient's arm,
and gives it to an assistant to hold, A\ho stands behind ; then
with the. left hand he takes hold of the arm, and with the
palm of the right hand on the olecranon, he endeavours, by
 pushing,  to restore the bone to its place.  An  assistant may
 facilitate the  reduction by taking hold and pulling by the
 wrist, and gently bending the arm at the same time.
   However, this will  not always  do, and a coarser and more
 dangerous  means  has been  used.   The surgeon has been
 forced to grasp the arm Avith one hand, and the  Avrist Avith
 another,  and then thrust, his knee into the fore part of  the
 elbow joint; and by this means bend the joint and reduce the
 dislocation.   It will be observed, that the difficulty of reduc-
 tion proceeds from the coronoid  process of the ulna checking
 into the posterior  fo=?a of the humerus, and this operation by
 bending, and at  the same time pulling separate the  hones, is
 the most effectual way of reducing the dislocation.   It Avould,
 however, be a very terrible accident during this operation, to
 find that Ave had separated the  apophysis, AAhich may cer-
 tainly happen in a child !

              SUBLUXATION OF THE ELBOAV JOINT.

     The  subluxation of the elbow joint is when the segmoid
  cavity of the ulna is forced laterally, and passes over the pro-
  minent part of the trochlea of the humerus; the articulating
  surface of  the ulna sits in that part of the humerus appropri-
  ated to the head  of the radius.
     The nature of the accident is ascertained by  the circum-
  stance of the great increase of the space betwixt the inner con- 
JL82
DISLOCATION OF THE WRIST.
 dyle of the humerus and the prominence of the olecranon ;
 the motion of the joint is impeded.
   To reduce this subluxation the fore arm must be extended
 and drawn ;  Avhile it is kept stretched, the surgeon uses lateral
 pressure, by putting the thumb strongly over the inner con-
 dyle of the humerus, and grasping the head of the radius Avith
 the fingers of the same hand.

     DISLOCATION OF THE HEAD OF THE RADIUS AT  THE
                      ELBOAV JOINT.

   Dislocation of the lesser head of the radius is a conse-
 quence of a violent and sudden twist given to the wrist.  It is
 accompanied Avith a diastasis of the bones of the fore arm.
   The distinguishing marks  of this  dislocation are, that the
 fore arm cannot be bent, and the rotation of the Avrist  is pain-
 full  The reason  Avhy the elbow joint cannot be bent, is be^.
 cause the small head of the radius has burst from the coronary
 ligament and capsule, and  noAv stands prominent forwards, so
 that Avhen the fore arm is bent upon the arm, the head of the
 radius  strikes against the fore part of the humerus.
   To reduce this dislocation Ave pull upon the Avrist,  and di-
 rect the hand so as to make the force bear more on the radius
 than on the ulna; at the same  time, by twisting the hand to
 pronation Ave pull the radius still more.  Whilst this is doing
 by grasping the upper part of the fore arm as if to crush the
 bones together, Ave endeavour to force the radius into its place.
 We Ioioav Avhen the reduction takes place by the flexion of the
 arm being no longer  impeded.  When the dislocation is re-
 duced, as the action of the muscles has no tendency to retain
 it in its place, it will be necessary to use a bandage, to bind the
 fore arm, and to keep the arm in a bent position.

               DISLOCATION OF THE AVRIST.

   The os scaphoides and the lunare forming a pretty regular
ball are sometimes dislocated from the articulating surface of 
         DISLOCATION OF THE THUMB, AND FINGERS.      183

the  radius, viz. the scaphoid cavity.   This may happen in
consequence of the wrist being tAvisted; but still oftener from
endeavouring in a fall to support one's self on the palms of
the hands; by the shock the carpal bones are driven past the
head of the radius.
   To reduce this  dislocation let an assistant interweave his
fingers with those of the patient and pull; the surgeon Avith-
holds the loAver part of the fore arm Avith his left hand, Avith
the right moves the patient's hand, and occasionally adds his
strength to the effort of the assistant.

          DISLOCATION OF THE BONES OF THE HAND.

   As the bones of  the Avrist are of a Avedge  form, and in
their union constitute an arch;  the central bones are, by la-
teral pressure on this arch, liable  to  be forced from  their
.place.  By a bruise of the Avrist then, Ave may have one of
the carpal bones  luxated and standing prominent.   Let not
the prominence formed by the  thickening of the periosteum
and  ligament in  consequence  of a Avrench, or bloAv on the
back of  the  hand  or Avrist, be mistaken  for this dislocation.
 When the bone is displaced, it may be reduced by pressure.
 I have been told  of bone-setters Avho could strike them into
 their places Avith  a blow of the hand.

      OF THE DISLOCATION OF THE THUMB, AND  FINGERS.

   To the young  surgeon it is most unsatisfactory to be told
 merely, that when the fingers or thumb are dislocated, they
 Lie to be reduced  and  bandaged; while he  finds that by
 using all his force he cannot reduce them.  That such gene-
 ral expressions shall usurp the  place of precise and intelligi-
 ble rules of practice is much to be regretted, since it  often
 happens that a  patient returns even from  eminent surgeons
 with his thumbs still dislocated; and  the  thumb has been
 absolutely torn off  at the second joint in the attempt  to re-
 duce the dislocation of the  fir=t! 
184
DISLOCATION OF THE THUMB.
   From the same cause there is a difficulty to be encountered
in the reduction of the thumb, and  of the fingers!   But the
bones of the thumb being shorter and thicker, and the liga-
ments of the joints stronger, it is only in  the  dislocation of
the thumb  that Ave have remarkable examples of the inef-
fectual violence used in the attempt at reduction.
   To REDUCE A DISLOCATION OF A FINGER, AVe must not pull
directly on the end of the finger; for that will be  found to
fix the bones by their oavh ligaments, so  that they cannot
come into their place.  It is by grasping the finger forcibly,
and bending it, that we shall succeed in bringing the heads
of the bones  into their natural relations.
   Thus far I speak  from experience, but  as to the disloca-
tion of the  thumb I must reason from  the  anatomy, for  it
has not been my fortune to reduce a dislocated thumb.
   We find,  that in  the  attempt to reduce the first joint of
the thumb, the second phalanx has been torn off;  this should,
conyince us that the difficulty proceeds from the ligaments;
for the muscles of the thumb could not bear such a degree
of violence.   When  Ave have recourse to the anatomy Ave
find, that the bones are united by a proper hinge joint; that
there are strong lateral ligaments ; and that the articulating
heads of the  bones are  square, and have  someAvhat of  a
Avedge form.  Mr.  Hey,  taking these circumstances into con-
sideration, has been led to the conclusion, that the difficulty
of reduction proceeds from the head of the bone being push-
ed between  the ligaments, in AA'hich situation the ligaments
bind  the  bones together,  and  retain   them locked.   I
should have expected that Mr. Hey would have folloAved up
these  observations  with the rule  of practice, viz. that Ave
must bend the thumb at  the dislocated joint, so as to carry
the head of the bone Avhich is dislocated in a semicircular
movement round the articulating  head of  the  metacarpal
bone, before Ave can expect it  to be brought through the
two lateral liganienK 
DISLOCATION OF THE THUMB.
185
   I shall suppose  that  A  is the  metacarpal bone of the
thumb;  B is the first bone of the thumb dislocated from the
metacarpal bone; and C  is the lateral ligament.  Now let us
suppose that the hitch is put over the thumb at B, and that
it is drawn in the  direction of the line  D D.   It must fol-
low, that the point E will rise to  D, and the heads of the
bones be consequently locked at F.
   To reduce the dislocation Avithout lacerating the lateral
ligament, it is evident that  the  dislocated head of the bone
must be  moved in the circular dotted line, which is the ex-
act reverse of its motion Avhen dislocated.
   I have a conviction, though I cannot give the proof, that
by attending to the principle  laid  doAvn here, the dislocat-
ed thumb may ahvays  be reduced.  But  should  it be oth-
erAvays, should  a case occur Avhere many ineffectual endea-
vours have been made, and  the patient resists all further vi-
olence, so  thoroughly am I convinced  that  the  difficulty
proceeds from the  lateral ligaments embracing the head of
the bone, that I would insinuate  the  couching needle under
the skin  (obliquely), and cut  one  of the lateral ligaments,
AAhen I  think there  would occur no further difficulty in re-
ducing the bone.  After  this the joint Avould  require to be
supported by a  small splint and bandage.  This is a mere
opinion,—a proposition to stand contrasted Avith the alterna-
tive of the thumb remaining unreduced and lame.
VOL. II.
A 2 
m
DISLOCATION" OF TJTE LOWER JAW.
DISLOCATION OF THE LOWER JAAV.
   If Avhen the mouth is open a man receives a blow on the
chin, the jaAV  may  be dislocated.  The jaw  being in this
case dropt to its utmost limit, the angle of the jaw becomes
the fulchrum, and the blow on the chin forces the condyloid
process  forward from its seat in  the articulating holloAv of
the temporal bone ;  it starts over the root of the zygomatic
process.   One or both condyles may be dislocated.
   The marks of the dislocation are these :—1. The mouth is
open, and the teeth  do not correspond.  2.  On  putting the
finger on the root  of the zygomatic process before  the ear,
and making the patient attempt to move the jaw, if the bone
be in its place Ave ought to feel the  prominence of the con-
dyle of the jaAV ; but if dislocation has taken place there is
a holloAv before the ear.  The coronoid process of the lower
jaAV is felt prominent in the cheek Avhen the bone is  dislocat-
ed.  3. The jaAV is  protruded forward, or is distorted.   4.
Saliva flows from the mouth ;  the  speech and deglutition are
someAvhat impeded.
   When one condyle only is dislocated it is knoAvn by the de-
pression being felt before the ear of one side only, and by the
lateral position of the chin. 
DISLOCATION OF THE OS HYOIDES.
187
   In reducing the dislocation of the loAver jaAV we must pro-
 vide a protection to the thumbs, by Avrapping a bit of linen
 round them, or by Avearing a  strong glove.  The patient is
 seated low, and his head is held  firmly by an assistant.   The
 surgeon puts his thumbs deep into the mouth, so that they rest
 upon the grinding teeth, the fingers grasp the chin and base of
 the jaAV.  The back part of the jaAV is to be forced doAvnward by
 the strength of the thumbs, while the chin is lifted  by the
 palm and  fingers.   By this exertion  the surgeon endeavours
 to carry the condyle under the level of the root of the zygo-
 matic process; which stands an eminence before the articulat-
 ing surface of the temporal bone ;  Avhich protected  the jaAV
 from dislocation when in its  natural  situation; and Avhich
 noAv prevents its reduction.  As soon as  the condyles of the
 loAver jaw are freed from the eminence of the temporal bone,
 the muscles of the jaw draw them into their places, and some-
 times Avith so much spasmodic force as to close the teeth and
 bruise the surgeon's thumbs ; to avoid Avhich, he slips them
 off the grinding teeth upon the gums and cheek.
   If the surgeon does not succeed in reducing the  jaAV by at *
 tempting to  push both condyles  into their place at once, he
 then attempts to reduce first one side, and then the other.
   To preserve the jaAV  in its place  it is only necessary to put
 some check upon the opening of the jaw further than is neces-
 sary to eating and speaking.

       DISLOCATION OF THE HORN OF THE OS HYOIDES.

   The  dislocation  of the horn of  the os  hyoides  is  a conse-
 quence  of swalloAving  a large  morsel.   The nature of  this
 case  Avas discovered by Valsalva.   It is attended with a sud-
 den difficulty of swalloAving, Avith an  uneasy sensation Avhich
 excites the muscles of deglutition into frequent action.   There
 is a  painful prominence of the bone, to the  feeling like a tu-
mour on the throat.
 * I  have not seen  this kind of dislocation.   The manner of
replacing it is by pressing and molding the parts on the out- 
188      DISLOCATION OF THE RIB; OF THE TELVIS.

side of the throat Avith the fingers of one hand, while the fore-
finger of the other hand is put into the mouth,  and as far as
possible over the root of the tongue, so that the tongue, and
consequently the body of the os hyoides, may be pressed for-
Avard.
  I am at some  loss, however, to understand how a bandage
can be applied here so as to keep the bones in their due rela-
tion.

  DISLOCATION OF  THE  CARTILAGE  OF THE  RIB FROM THE
                        STERNUM.

  A young  man playing the dumb bells, and throwing his
arms behind him, feels something give Avay on the chest; and
one of the cartilages of the ribs has started and stands promi-
nent.   To reduce it we  make the patient draw a full inspira-
tion, and  with the fingers knead the projecting cartilage into
its place.  We apply a compress and bandage: but the luxa-
tion is with  difficulty retained.

  OF  THE DISLOCATION, OR DIASTASIS, OF THE BONES OF THE
                         PELVIS.

  In the many dissections which I haA'e made of women Avho
have died in delivery, I have not seen one instance of sponta*
neous separation, or loosening of the bones of the pelvis.—
Though I have dissected  three Avomen who have  died, I
may say of distorted pelvis, (since the difficulty of the birth
from the narrowness of  the pelvis was  the  cause of death,)
and, though after opening the Avomb I  have with great dif-
ficulty pulled the head of the compressed child from the
bones of the mother, yet I have not found the joining of the
ossa pubis loosened or relaxed.   If there had been any provi-
sion in nature in the dilatability of the bones of the pelvis for
the easy birth of the child, surely  it  must  have  been appa-
rent in the only  case Avhich could  require such a provision,
viz. where the  pelvis is distorted, and the diameters dimi-
nished. 
DISLOCATION OF THE PELVIS.
189
  When the symphysis pubis separates in pregnant women,
a Aveakness and pain of the loins are remarkable symptoms
previous to labour;  and after delivery there is an inability of
moving, or standing, all a\ hich indicate disease, and not a na-
tural provision for easy labour.   I believe then,  that the se-
paration of the bones of the pelvis may be considered as a
spontaneous, but not a natural loosening  of  the  bones; and
that the force of labour succeeding to this looseness of the
joinings actually burst them up.
  When the  bones of  thfc pubes separate in  labour, the
symptoms  are,  (besides  Avhat I  have already mentioned,) a
jarring of the  bones felt during delivery ;# pain  and fever
succeeding the delivery; Avhen the Avoman attempts to rise
she cannot stand, or even sit for any considerable time; hec-
tic fever succeeds, and she is for a long time bed-ridden.   If
the separation of the ossa pubis has been  considerable, then
the  posterior symphysis of  the pelvis also suffers; and  if the
disposition to disease be great,  suppuration  may take place,
both behind the pubis, so as to be discharged from the vagi-
na, and on the hip from the sacro iliac symphysis.
  When there has been much suppuration, it is possible that
the bones may at last unite, and anchylose by a medium of
bone.  By neglect,  if I mistake not, in  cases Avhere there is
less  tendency to caries, this species of subluxation produces a
moveable joint where there should be a  symphysis,  or firm
union by cartilage.
   I have not  attended a case  of diastasis, or separation of
the  bones  of the  pelvis; but I have ascertained, by  dissec-
tion, the effects of the spraining of the joinings of the pelvis.
I found an abscess within the pelvis; the ilium and sacrum
were disjoined, and  the cartilage Avas  Avasted, and the liga-
ments destroyed,  and the  bones extensively carious.   Such
was  found to be  the consequence of the operation  of the
sectio symphysis  pubis  Avhen that horrid operation was per-
petrated in France.
* Pee TVnman, vol. i. p. 24-. 
 190 DISLOCATION OF THE OS COCCYGIS ; OF THE HIP JOINT..

   The surgical treatment of the diastasis of the bones of the
 pelvis, I am afraid must be confined to the binding together
 the circle of the bones; for external applications, though re-
 commended on the best authority, cannot avail nor reach the
 seat of disease.  A  broad bandage of  leather softly quilted,
 and made to draw Avith buckles, ought to  be put round be-
 twixt the spine of the ilium and the head of the  thigh bone.
 This Avill prevent the jarring of the bones, and allay the ir-
 ritation.  We  knoAv how incessantly the pelvis  rolls on the
 thigh bone, and Ave know how this motion keeps up, and fos-
 ters the inflammation in the hip joint.   So in the present in-
 stance, the perfect circle of the  pelvis being interrupted, and
 the junctures loose, every change of  posture causes  a motion
 of the bones, and continues  the injury.
   Should there be a diseased joint thus formed, either in the
 anterior or the posterior symphysis  of the pelvis,  I see  no
 treatment more likely to effect a cure than the counter irrita-
 tion by issues.

             DISLOCATION OF THE OS COCCYGIS.

   By a kick, or fall, the os coccygis may be dislocated.   The
 injury to the parts from the violence rather  than the Avrong
 position of the  bone, occasions retention of urine, or tenesmus,
 or even abscess, near the rectum.
   To reduce this bone the  finger of one hand is introduced
 into the rectum, while by  tlie co-operation of the fingers of
 the other hand on the outside, the dislocated bone is brought
 into its place:  no bandage will be required to keep this bone
 in its natural situation.

              DISLOCATION  OF THE HIP  JOINT.

   The dislocation of the thigh bone from the acetabulum of
 the os innominatum  is a most  serious accident;  as, besides
 the dread naturally  arising  from the application of a force
equal to the bursting up of this strong joint, we have to fear the 
DISLOCATION OF THE THIGH BONE
191
Avasting of the bones, or a partial destruction of the joint, and
permanent lameness.  Yet these consequent effects are apt to
foUoAv only Avhere, besides the dislocation, the internal part of
the joint has been bruised, or there is a tendency to scrophu-
lous action in the system.

OF DISLOCATION AVHERE THE  HEAD OF THE THIGH BONE LIES
                ON THE BACK OF THE ILIUM.

   The dislocation of the thigh bone upwards is marked by
the  shortness and strained position of the limb.  It is dis-
torted ; the  knee and toes are turned inward, and the thigh
is bent.  When Ave turn the patient on his belly, and bend-
ing the leg, take hold of the heel, move the leg, (like  a le-
ver), laterally, and at the same time put the hand upon the
trochanter, Ave feel that the motion is interrupted and check-
ed, and particularly  that when the heel is rapidly moved
inward, that the head of the thigh bone strikes against the
back of the ilium, so that the  motion of the thigh  bone on
its own axis is much limited.   The  attempt to stretch the
limb is not successful without much  force, and is very pain-
ful.   The head  of the thigh bone  may be felt as well as the
trochanter, both lying on the  ilium.   There is pain in the
groin,  and  a bent position of the thigh to relieve the pain
and  tension.
  The position  of the parts considered anatomically is this:
the  head  of  the thigh  bone having been started from its
socket  lies on the back of the ilium; the articulating head
of the  luxated bone is towards the sacro-sciatic notch; the
trochanter  is more forAvard, and rests upon the ilium also;
the capsular ligament,  and  the round central ligament  of
the hip joint, are torn; the head of the thigh bone has torn
up  the cellular membrane  under the  gluteus raediu«, and
lies under that muscle. 
195
DISLOCATION OF 1HL THIGH BONE.
   A, the back of the ilium ; B, the thyroid hole ; C, the aceta-
bulumlcft empty ;  D>, the head of'the femur ; E, the trochanter
major ; F, the shaft of the thigh bone.

   The limb operating like a long lever is here also the cause
ii dislocation.  When  a man is  pushed doAvn  on his  side,
and the haunch strikes the ground; when carrying a heavy
"burthen he falls down with the leg and thigh obliquely under
him ; or, when, in riding,  the horse falls on his side, and the
rider's thigh is under the horse, the ligaments of the hip joint
may be burst up, and the thigh bone  dislocated.  I  haA^
found a man Avho had been buried under a bank of earth Avith
his thigh  bone thus  dislocated  upAvards  and  outwards;
though most frequently I am inclined to believe the head of
the  thigh bone will be dislocated doAvnward, if displaced at
all in these circumstances.

   Manner of reducing the thigh bone when dislocated upwards.
   If in an hospital, the patient is to be laid on a strong table,
which is screwed to the floor; folded blankets are to be placed
under him ; a soft compress is put in the perineum ;  if the
right thigh bone be dislocated then the patient is to be on his
left side, or so that he may rest on the left hip, and that we 
Dislocation of the thigh bone.
193
may feel and observe the  position of the dislocated bone.
A 6heet is to be folded so that it may be laid upon the peri-
neum, and its ends tied firmly to the table.  A quilted strap
is to be laid betwixt the spinous process of the os ilium and
the head of the thigh bone, and the ends of this are to be fixed
to the sheet.   The strong leather band with hooks, (Avhich are
to be found  in the shops for  this purpose,) are to be placed
above Ihe knee that  they may take hold of the thigh bone
above the condyles*.
   But Ave may have to reduce the dislocated  thigh  bone
Avhen we have no hospital apparatus, and  therefore Ave must
think of our means when in a private chamber.   We first fix
the bed, then Avrap around the bed post a sheet or blanket.
The patient  being laid on the bed with his thighs on each
side of the  post, he is then to lie doAvn inclined towards the op-
posite side from that Avhich is to suffer the operation.  In this
position when the pull is made on the dislocated thigh the tu-
ber  ischii  and perineum are  made to press against the  bed
post.  The patient's body is to be kept doAvn in this position
by an assistant.  It is the duty of this assistant  at  the same
time to observe that the  pelvis and trunk do not move upon
the sound hip joint; for which purpose he has to lay himself
on the bed, and keep hold upon the spine of the patient's ilium.
   The laques or hitches, may be made  of hand-towels,  and
placed above the knee, so that they take  hold of the condyles
of the thigh bone.  The knee is to be bent, and  the leg  and
foot used as a lever to  move the head of the bone in a rotatory
manner.   It  is said, that when one of the  towels is brought
on the inside of the knee this rotation is  impeded.  I do not
remember to have experienced any  difficulty in  reducing a
dislocated thigh in this manner, though it had continued un-
reduced for three weeks.   At  the  same  time, if Ave consider
the direction of the force to  be employed, and the position of

  * In cases  of dislocation where much force is to be used, a few turns of
■» flannel roller should be put round the limb before fixing this apparatus.
  VOL. IT                   * 2 
i94          DISLOCATION OF THE THIGH BONE.

the thigh bone, there can be no objection to the laques being
brought to the outside of the knee only.
  Whilst strong men pull the thigh by the laques in the line
of the body, and an assistant holds the knee and ancle to give
the rotatory  motion, the surgeon should be placed with his
hand on the joint; he may press doAvn the trochanter, but he
Avill do little good or harm by his efforts  there: he cannot
press the trochanter doAvn Avithout at the same time pressing
it to the  back of the ilium, a\ hich must have the effect of de-
laying the reduction.
  Sufficient elongation of the thigh I  believe to be all that is
absolutely necessary to reduction, but the elevation of the head
of the thigh bone over the brim of the acetabulum will be much
facilitated by the rotation of the thigh, especially by a pretty
forcible jirk of the heel  outward Avhen the head of the thigh
bone is brought to the level  of the margin of the acetabulum.
No cunning exertion on  the part of the surgeon is required  in
this stage of  the operation ;  the head of the bone goes with
an audible snap into the socket; the perfect relief satisfies the
patient that  the bone is reduced.  He is inclined to take as
little freedom in motion  after reduction as can be required by
the most cautious surgeon.  Unless the acetabulum is broken
or diseased, there is no fear  of the thigh  bone again escaping
from the socket.

    OF THE DISLOCATION OF  THE THIGH BONE DOWNAVARD.

   The  thigh bone  is sometimes  dislocated  doAvnward and
fonvard, so that the head of  the bone rests  in  the thyroid
hole, or rather on the obturator ligament and muscle.   I con-
ceive this to be a kind  of dislocation less frequent than the
last, though I see observations contradicting this opinion.
   It will be recollected, that the loAver margin of the aceta*
bulum is eked out by a ligament, but nevertheless that this
part of the socket is not  so Avell  calculated to restrain the head
of the thigh bone as the upper part of the circle.  The dis-
location  downwards, therefore, would often happen were the 
             DISLOCATION OF THE THIGH BON*E.          190

force as likely  to be applied so as to displace the bone doAvn-
wards as to dislocate it upward.
   When there is a resistance Ioav on the hip, and the trunk is
forcibly tAvisted over to the same side, the thigh bone may be
dislocated dowmvard and forAvard : or, Avhen a man is crushed
doAvn by a weight on the hip, or when the foot slips from un-
der  him, so that the perineum touches the ground, the head
of the thigh bone  may be dislocated in this direction, viz.
downward and forAvard.   If the head of tlie bone is displac-
ed by its slipping over the loAver margin of the acetabulum, it
must fall  a little fonvards and lodge on the thyroid hole.
   There can be no difficulty in distinguishing  this kind of
dislocation from all other accidents to Avhich the hip joint is
liable ; the thigh is lengthened, and the  knee and toe turned
outward; the limb straddl s, and is Avith difficulty and pain
brought U> the  line  of the body.
  We have the explanation of all these circumstances in this
sketch of the position of the thigh bone upon the ilium.
  A, the  hollow of the os ilii; B, the  acetabulum left empty;
C, the thyroid foramen ;  D, the head of the femur,  dislocated
and resting in the thyroid hole. 
 196          REDUCTION OF THE JfHlGH BONE.

 OF THE  REDUCTION OF THE  THIGH BONE WHEN DISLOCATE^
                       DOAVNWARD.

   The reader might imagine, that as the limb is already too
 long there can  be no  necessity for applying an apparatus, to
 stretch it as in the last instance ; nevertheless, the position, the
 manner of securing the patient and of applying the laques to
 the limb, may be the same in this case as in the last;  that is,
 on the idea that the limb must be somewhat further  stretch-
 ed before it can be reduced.  But it requires  to be particu-
 larly noticed,  that in this instance of dislocation of the thigh
 bone doAvnward, the head of the bone must be lifted from the
 place in Avhich it is lodged, and raised to the level of the aceta-
 bulum before it cau be reinstated in the socket.   It might
 at first appear, that by using the thigh bone as a lever, the
 ramus ischii being the fulcrum,  it would be possible  to raise
 the head of the bone  from the thyroid hole by pressing the
 thigh backAvard and inward.   But Avhen we consider  the po-
 sition of the knee and  toes, it is evident that the great tro-
 chanter is carried so far doAATiAvard,  that by this motion it
 would be carried under the ramus of the ischium, and that
 consequently, the reduction Avould be checked and impeded.
   A fulcrum,  or fixed  point, must therefore be  supplied to
enable us to operate Avith effect in this position of the limb
and trunk.
   For this purpose a large toAvel or table cloth is put round
 the thigh, and carried as near the perineum as may be.  The
ends of  this  cloth are to be held up  by strong assistants.
While the tliigh is gently draAvn so as to extend it, the cloth
is  at  the same time raised and carried a little backward, so
that the head  of the thigh bone may be lifted from the de-
pression in Avhich it lies.  The tliigh is then bent (by carry-
ing the knee forward) and drawn in that direction ; our last
resource  is to carry the knee to the ground, that is, towards
the other side of the  patient's  body.   In this operation avl
make the cloth Avhich is  put under the  upper part  of the
 thigh, a stay, or fulcrum, and by using the thigh as a lever 
REDUCTION OF THE THIGH BONE.
197
we unfix and  raise the head of the bone.  We may during
this operation, roll the thigh by taking hold of the knee and
ancle as heretofore described.
   We may perhaps find reason to prefer the folloAving method
of reducing the thigh  bone  when dislocated  doAvmvard.
Tlie patient is set upright on his breech, his  thighs on each
side of a strong pillar ; or he may be seated on the corner of
a  bed, the  bed-post betAvixt his thighs; something  soft is
Avrapt  round  the  post, and a person is placed behind him to
prevent him from reclining backAvard, and to keep him to the
seat.
   The extension of the thigh is accomplished by drawing it
at right angles Avith the trunk.   My reader will readily un-
derstand that by this operation the head of the thigh bone is
draAvn out of the IioIIoav in Avhich it lies, and lifted as it Avere
into  its proper socket.   If drawing in this direction simply
does not succeed, then the cloth is at the same time to be put
round  the thigh as before,  so  as to draAv the head of  the
tliigh bone outAvard, while the knees are brought together.
   There is mention made of a kind of dislocation which,
when looking  on the subject, I  should  say is little likely to
happenr-the dislocation of the thigh bone upward, Avhile the
articulating head is forAvard on the ilium, and the trochanter
backward; it will be characterised by the union of the two
most distinguishing signs of the other kinds of dislocation,
viz.  the shortening  of the limb  Avhile the knee and toes are
turned outward.
   When the thigh bone is reduced there is little fear of its
starting again from its place; all that is done on this account
is to put some slight binding around the thighs to check their
motion.   What is to  be feared is  inflammation in the joint,
and gradual wasting of the head of the thigh bone, of Avhich
I have lately seen a case.  This  I must suppose OAving to
some badness of constitution.   I Avould  treat  it  as  the  con-
secutive dislocation, viz. where the head of the thigh is  dis
placed in consequence of diseased  action filling up the acf la-
bulun}. 
198
INJURY OF THE KNEE J01V1.
              DISLOCATION OF THE PATELLA.

  The  dislocation  of the patella, or knee-pan, is not an un-
frequent accident.  A man falling, so that the outside of the
patella  is struck Avhile the muscles of the  patella  are not
firmly braced, and the limb is nearly extended, suffers this
dislocation.   From the nature of the  accident  I have de-
scribed, it is implied that the bone is dislocated  inward.  It
is most  frequently  displaced inward, OAving to the lesser de-
gree of elevation of the inner  condyle ;  but it is also driven
to the outside of the knee joint sometimes.
  This  dislocation of the patella  is easily ascertained, and
the reduction is not  difficult.   The leg  is to be  extended,
and the thumbs applied to the bone, while the fingers  grasp
the knee joint.   If  a difficulty occur it is OAving to the liga-
ment of the patella preventing that bone from surmounting
the condyle.   In this case, as it is impossible to stretch the
ligamentous connexion of the  patella with the  tibia, so Ave
must have recourse to the further relaxation  of  the  muscles
inserted into the patella, and press the patella downward be-
fore Ave attempt to carry  it to its place betAvixt the condyles.
  A  laced cap for the knee is to be used after the reduction,
to hold the patella in its proper place of lodgment.

  OF THE INJURY OF THE INNER LATERAL LIGAMENT OF  THE
                       KNEE JOINT.

  This is an accident Avhich I do not  see  noticed.  I  have
seen it  in various degrees, and have had an opportunity of
ascertaining the state of the parts in dissection. 
STRAIN OF THE KNEE JOIST.             199
  The internal lateral ligament of the knee joint must suffer
in a particular manner whenever there  is a stress and unusual
force  upon  the  joint  from  a shock  perpendicular  to  the
limb.  In this plate,  A, is the thigh bone ;  B, the tibia ;
C, the inner lateral ligament.   The force of the trunk bearing
on the head of the thigh bone in the direction of the dotted
line, must injure, or entirely burst up the ligament at C.
  So it happens, that a person descending a stair, and think-
ing that he  has  come  to  the landing-place Avhen one step is
still  to take, falls  Avith the av eight  of the body bearing  on
this ligament, and sprains it.  Hoav this  is most apt to hap-
pen to Avomen is  evident, considering the greater  Avidth of
their  pelvis, and  peculiar obliquity  of their  thigh bone.
For the more removed the thigh bone is from the  perpendi-
cular, the more apt is the inner ligament to be sprained.
  If the violence be great, we can  readily conceive hoAV the
ligament is actually torn, so as to produce

             A SUBLUXATION OF THE KNEE JOINT.

If this  accident  should occur, Avhich I confess I  have not
seen,  there  can  be no impediment  to reduction.   When ro- 
300
SPRAIN OF THE KNEE JOINT*
duced, our attention should be  chiefly directed  to restrain
the rising inflammation, and to sustain the limb in its natural
position by a splint and bandage.
  But I am bound to direct my readers' attention more par-
ticularly to what I  have seen and practised.  When the
inner lateral ligament is partially lacerated, or even strained
only, there  comes upon the  part, slowly, inflammation and
relaxation.  The  patient  feels great pain in walking; the
knee gradually falls inward, with increasing lameness.  The
yielding of the ligament on the inside of the knee joint being
attended Avith increased  obliquity  of the thigh  bone, the
chance of further  injury increases,  until  at  every step the
weight  of  the body bears on the relaxed and inflamed liga-
ment.
  On dissection I have found the cellular substance and late-
ral  ligament, and  capsule, on  the inside of the  knee much
thickened.   While they were thickened the ligamentous sub-
stance Avas at  the  same time extended,  so that there Avas not
sufficient guard to  the joint on this side.
  We understand  that this thickening  and  inflamed  state of
the ligament, being a change of texture and constitution, it is
followed by increasing weakness as an inevitable  consequence
of diminished density.  The method of Cure therefore, will
be in the first place to guard against all repetition of the inju-
ry, and  to change this chronic inflammation.  The first  of
these requires the application of a splint along the outside, of
the  knee, with such a bandage around the lower part of the
thigh and the upper part of the tibia, as may support the joint
while there is no pressure made on the injured part.  When
the  stiff splint has been used  for a time ; motion may be al-
lowed to the knee  by  a jointed splint applied  like the former,
which, Avhile it prevents the yielding of the knee joint inward
ly, allows the natural  flexion.   The  second part of the design
is accomplished by applying successive blisters to the inside
of tlie knee.
   I ought, perhaps,  to have mentioned under  the head  of
fractures, that if the  knee joint of a boy be twisted violently 
DISLOCATION OF THE ANCLE JOINT.         201
 in machinery, the apophysis of the  bones may be separated.
 I lately examined a case Avhere a young man being caught in
 the spokes of a carriage by the leg while riding behind, had
 the lower end of the femur separated by diastasis.

             DISLOCATION OF THE ANCLE JOINT.

  I have already explained the nature of the compound dis-
 location of the ancle joint, Avhere the lower head of the tibia
 has burst the deltoid ligament which protects the inner an-
 cle, and the fibula is broken a little  above  the external ma-
 leolus.  I have only at present to make some remarks on the
 degrees of injury to the joint.
  1. As in the  instance just now stated of the injury of the
 lateral ligament of the knee joint, we have to notice the con-
 sequences of the lesser and  partial sprains of the inner liga-
 ments of the ancle joint.   If, in stepping on an unequal pave-
 ment, the ball of the great toe be not supported so as to make
 a balance to the external position of the heel, the foot is twist-
 ed, and the  inner ligament of  the  joint is injured,  and al-
 though not ruptured, it inflames and becomes weak.
  2. I am often  asked by my younger pupils Avhat is to be
 done when the lower head of the tibia is actually forced from
 the astragalus, and the joint is laid open.   Undoubtedly the
 practice is still to save the  foot, and not to amputate.  We
 replace the bones, and bind them, trusting that by bleeding
 and cold we  can keep down  the inflammation.  No doubt
circumstances of the patient's  constitution and  situation will
 qualify the rule.
  3. A patient of a bad habit, and in a London hospital, will
 be doomed to suffer amputation, when in other circumstances
 he might be saved.  We  must too in all such cases take into
consideration the degree of contusion Avhich the part has suf-
 fered.
  4. If a man in leaping from a gig shall lacerate the ancle
joint, the foot may be saved.
  vol.  ji.                  c 2 
 202         DISLOCATION OF THE ANCLE JOINT,

   5.  If the wheel has passed over the joint, so as to displace
 the bones and  open the joint, though  in  exactly the same
 degree, amputation will be necessary, from the general contu-
 sion of the parts.
   I state the circumstances thus to prevent my reader from
 imagining that  in any such case he is to trust to an absolute
 rule or aphorism, for with the same degree of laceration in the
joint, the degree of injury may be greatly varied.
   The  ancle joint may be dislocated  by the tibia and fibula
 slipping before the astragalus.  It will be ascertained by the
 great projection of the heel.  It is to be reduced by applying
 the laques so as to catch upon the heel, and at  the same time
 to pull on the fore part  of the foot, by Avhich  means  the
 toes are pointed, and the gastrocnemius relaxed.

   In  closing my observations on the injuries of the bones and
joints it becomes a duty to remind the young  surgeon of the
great advantage to be derived from the general healthy state
of the body in the final cure of local  injuries of these  parts;
that is, of good air most especially, of  better diet than that to
AArhich the patient has been accustomed* ; even of exercise, if
 it can be allowed in the circumstances of the case.   It be-
comes him to observe too, if there be any scrophulous tenden-
cy in  his patient, and to endeavour to  counteract it; for inju-
ry of the bones and joints is apt to rouse scrophulous action if
 there  be the slightest tendency to it.  We are informed  that
the bones of scrophulous people contain a smaller portion of
earth than when the part has its  healthy constitution.  I
would not be understood to say, hoAvever, that on this account
they are more susceptible of diseased action, though they cer-
tainly are more  liable to disease ; they are more liable to be
fractured and the ligaments of the joint having a tendency to

  * Even although the patient has been nursed in luxury and great abun.
dance it is possible to ameliorate his condition ; though it must be confess-
ed we possess more advantage when from the privations to which an hospi-
tal patient has been accustomed he can be put on a more generous diet. 
DISLOCATION OF THE ANCLE JOINT.         203
inflame and soften, they are also more likely to be injured by
sprains.
   For these reasons it is necessary that we should know the cha-
racters  of  scrophula, that we should be able to recognize the
disease under its  symptoms,—the indolent sAvellings of the
glands of the neck ; the softness of the skin, and the laxity of
flesh;  the  largeness of the joints;  the light hair and fair com-
plexion, and smooth skin; the tender eye-lids and swelled lips;
or the dark sooty hair, Avith cheeks of a broken ruddy colour
and swelled features.   If there be ulcers, either  previous  to
the injury  or in consequence of it, we find them pale, shining,
and indolent, Avith little pain or inflammation.
   If such  should  chance to be the constitution of a patient
who has suffered injury of the bones or joints, the cure is more
precarious,  and certainly more  tedious; the predisposition
must be Avatched and counteracted.
   The  skin ought to be kept soft,  and the vessels of the sur-
face active, by the use of the warm bath  and friction.   The
glands and glandular viscera may be kept free of the conges-
tion of the indolent habit by occasional doses of calomel, and
perhaps bark, iron, or acids, eventually used as giving vigour
to the system. 
"9M
of tumours:
CHAPTER IX.
             OF TUMOURS,


                     AND


OF THE OPERATIONS TO BE PERFORMED ON THEM.
     Although it be my object  here, consistently with
my original plan, to treat only of the manner of extirpat-
ing tumours, it  appears to me that if I were to  proceed to
describe the manner of operating, without shewing the diffi-
culty of discriminating the cases  proper for  operation,  I
should be in danger of doing more harm than good.
  The subject of tumours is involved in unusual obscurity.-
There has been much done of late to draw the attention of
the profession to the subject; diseases have  been accurately
described, and most interesting cases brought forward; yet
I feel at this moment the difficulty of entering on the sub-
ject without altogether  deviating from modern  authority.
Theories have been entertained which I think defective ; au-
thors have supposed they were  making accurate definitions
Avhen they were only framing hypotheses: and explanations
of the nature of the oeconomy have been offered that to me
seem quite at variance Avith the laws of the animal oecono-
my.  The opinions  held  by Mr. Abernethy and Mr; John
Bell I  cannot adopt, hoAArever highly I appreciate their abi- 
OF TUMOURS.
205
lities, and though I feel, in common with the profession, that
they have done much to improve our knowledge of the sub-
ject.

                  DEFINITION OF TUMOUR.

   Mr. Abernethy defines tumours to be such swellings as
arise from some neAv production Avhich made no part of the
original composition of the body.   By this definition he con-
ceives  that he has excluded all simple enlargements of bones,
joints, glands, &c.  It appears to Mr. John Bell that every
tumour is a mere accretion of nutritious particles,  in skin,
bone, gland, or  muscle, according to the nature of the part:
tumour is  in short, says he, either an increased nutrition, or
an increased secretion, modified in its form and character by
inflammation and ulceration.
   There has been no  critical examination, surely no impor-
tant objection offered to the definition of tumour, " morbo-
sum voluminis augmentum," Avhich I conceive to be scientific
and correct.  To define Avhat is unnatural we ought to take
into consideration what constitutes the  natural state of the
parts of the body.
   There  is  an  influence governing the  growth, shape, and
magnitude of the body, and of the individual parts of it:
the changes from infancy to age are in a series: there is an
uninterrupted progression.   Before the  seed is put  into the
ground the tendency of its growth to the utmost maturity of
the plant is fixed.  In animals, before the first pulsation of
the punctum saliens is seen in the embryo, the actions of the
system AAhich lead to all the peculiarities in the mature  ani-
mal, are fixed also.  They follow in a natural course to per-
fection, in form, movement, and function.   As the Avhole ani-
mal is, so are the parts, governed in their groAvth ; the form
of a finger is prescribed; the action of its vessels is under an in-
fluence Avhich restrains the form and constitution.   If the pari
is cut, It unites again; not by a " stimulus of necessity," nor
by a  " disposition of renovation:"  there is no necessity for 
200
OF TVMOUKS.
using this unintelligible language if Ave will but acknowledge
our ignorance.   What governs the constitution of the part in
health unites it by adhesion, or circumscribes the neAv formed
granulations when it is cut, or injured, so that they rise to the
surface, but no further.  There is no necessity, nay, there is
no foundation for supposing, that an alteration in structure, or
in the action of  the part,  (further  than  in degree,) is ne-
cessary to its  closing  Avhen  cut,  to  its  restoration  when
injured.    When  Ave  reflect that  every part  in  its natur-
al state is continually changing, not for a day remaining ac-
tually the same in all its parts, but that absorption and depo-
sition are going forward perpetually, while the external cha-
racter and form, the internal structure and  the very constitu-
tion of the part remain the same, need Ave seek for any other
explanation of  the healing and the restitution of a part injur-
ed than the continuance of the same uniform influence, the
same  action of  vessels ?  A silent and imperceptible influence
preserves  the part during the necessary changes from youth
to age; by violence this influence becomes apparent, which is
owing to the demonstrable nature of its effects, not tq tlie
change of its action.   We cannot judge of the action of ves-
sels but by their effects; when Ave see that the tendency of
increased action is to the restitution of the frame to its origin-
al and perfect  state, we must consider the action as natural;
as still influenced  by  tlie  same principle Avhich originally
formed it, and  by which, during a course  of changes, it was
preserved.
   These considerations, I hope, will lead us to adhere to the
definition of tumour  given by  other  surgical pathologists.
We shall be enabled to distinguish betwixt mere tumefaction
and confirmed tumour, while, I hope, we 6hall be led to a ra-
tional principle of practice.
   A swelling is a mere consequence  of over-action in vessels
where yet there is no change or modification ; in this case the
mere  reduction of the strength and activity of the part Avill be
followed by the reduction of the tumefaction.         • 
OP TUMOURS.
207
   A tumour, on the  contrary, is  a circumscribed swelling,
 Avith new modification of the structure*, which arises in con-
 sequence  of a  specific action ; does not spontaneously disap-
 pear ;  and Avill not subside by the mere subtraction of blood,
 or diminution  of activity in the vessels.  A tumour is often
 superadded to  the natural body, but is constituted sometimes
 by the preternatural  augmentation of a part; for example,
 of a gland, in consequence of a specific change, and increased
 activity of the  Aressels of the part.
   In illustration of a\ hat I have here  delivered I venture to
 add this example:  When a man breaks his leg I conceive it is
 healed, not by  a neAv  action, not by a stimulus of necessity,
 Avhich implies the residence of an intelligent principle, but by
 the  continuance  of that uniform influence Avhich brought it
 from cartilage to bone, Avhich prescribed the form of the bone,
 which  preserved its form whilst its particles  were changing
 daily.   Those  operations Ave  did  not see :  neither  the  de-
 struction, nor the renovation of the parts; but now we see the
 renovation because  the destruction and injury were palpable ;
 and this, not from the change of action, but from the change
 of circumstances.   When, however, the new bone is not level
 Avith the old, when it  is different in structure and redundant,

   * On the term rumour,  the  following observations of Mr. Pearson  are
 most pertinent: "Chirurgical  writers  have generally enumerated tumour
 zs an essential symptom of the scirrhus ; and it is very true, that this dis-
 ease is often accompanied  with an increase of bulk in  the part affected.
 From long and careful observation I am  however induced to think, that an
 addition to the quantity of matter, is rather an  accidental, than a necessary
 consequence, of the presence of this peculiar affection.  When the breast
is the seat of a scirrhus, the altered part is hard, perhaps unequal in its
 figure, and definite ; but these symptoms are not always connected with an
 actual increase in  the dimensions of the breast: on the contrary, the  true
 scirrhus is  frequenUy accompanied with a contraction, and diminution of
 bulk, a retraction of the nipple, and a puckered  state of the skin.
  The irritation produced  by an indurated substance lying in the breast,
 will very often cause a determination of blood  to that organ, and a conse-
 quent enlargement of it; but I consider this as an inflammatory state of the
 surrounding parts, excited by the scirrhus acting as a remote cause, and by
 no means essential to the original complaint-. 
208
OF TUMOURS.
there is something out of course and unnatural;  there is dis-
ease ; the vessels have not merely received an impulse of acti-
vity, but there is  a new  influence.  If the diseased action
should here build up a large protuberance, I call that exosto-
sis tumour, though it be of the same blood and bone with the
original part.
   The changes which take place in the body are  not  so gross
and palpable as to be manifest to our senses ; Ave can see no
difference  often in a mild ulcer, and in one which will be
pregnant with mortal contagion.   If we are to take only the
grosser distinctions of matter as pointing out the difference
betAvixt tumour and SAvelling, we shall  be in perpetual diffi-
culty ;  if  an  exostosis be no tumour because  it  is only the
original matter, is an accumulation of flesh and bone a tu-
mour ?  or, is a large tumour, full of bone, and  membranes,
and vessels, and flesh, which groAvs amongst soft  parts, to be
considered as a proper tumour ?  or, is it only a tumour when
it contains grey matter, or  something unlike what we see in
the natural structure of the body ?   If this last circumstance
be taken as the true definition of tumour, then many circum-
scribed swellings of specific action, fatal from the  tendency of
that action, or the  peculiarity of their place, which resist all
known means  of cure, and absolutely require  the knife, are
left still to be classed.  Another important consideration in
practice is, that the place and  tendency of the action in the
tumour being  ascertained, the line of practice is clear ; but if
our  attention  be drawn to the distinctions of internal struc-
ture only,  to  distinctions which  have no  corresponding out-
ward sign to mark their existence in the living body, we are
led from the rule of practice, and left without a guide.
  Surely there is great imperfection in the very first step of
Mr. Abernethy's classification ;  his first  genus being known
from the tumour being composed of the coagulable part of the
blood rendered very generally vascular.  This vascular coag-
ulable lymph  is the fore-runner of all natural changes of the
parts in health and vigour.  So  Mr. Hey,  in describing the
fungus nematodes  remarks, that the origin of the tumour 
OF TUMOURS.
209
     must have  been extravasated fluid become organized; and
     then he asks, was it blood mixed with a large  proportion of
     lymph ? neither the microscope, nor chemical analysis  of the
     solid  or fluid contents of tumours, will ever serve  to point
     out the character Avhich is to guide us in practice; we must
     take into consideration  the peculiarities, constitutional and
     local,  and as far as we are able endeavour to recognize  the
     external character, and study  the course of the disease, as
     the most likely to make us acquainted av ith the  peculiarity
     and tendency of the action.  In this investigation we must
     often recur to the dissection  of the tumour,  and to the in-
     ternal structure as our guide ; but the knoAv ledge of the in-
     ternal structure  can  be useful  only as it directs our enqui-
     ries, or enables  us to judge of the patient's  danger by  the
     nitAvard sign.
       I hope my reader will allow me to detain him from  the
'    practical  part of this tract a little longer, in  order that  I
     may explain my opinion on  the subject  of tumours formed
     out of coagulated blood.   Tlie observations  of Mr. Hunter
     on this subject being, as I think, the foundation of the com-
     mon opinion,  the folloAving excerpt  may be  taken as  ex-
     planatory of it;—
       " In the course of his experiments  and observations, insti-
     tuted Avith a view to establish a living principle in the blood,
     Mr. Hunter was naturally  induced to  attend to the pheno-
     mena  which took place  when  that fluid Avas  extravasated,
     whether in consequence of accidental violence, or other  cir-
     cumstances.   The first change  which took place he found to
     be coagulation:  and the coagulum thus formed, if in con-
     tact Avith living  parts, did not produce an irritation similar
     to extraneous matter, nor was it absorbed and taken back in-
     to the constitution, but, in many instances, preserved its  liv-
     ing principle, and became vascular, receiving branches from
     the neighbouring blood-vessels for its support;  it afterwards
     underwent  changes,  rendering it similar to  the  parts to
     Avhich it  was  attached,  and Avhich  supplied  it with nou»
     rishment.
       vol. i*.                    D  2 
210
OF TUMOURS.
  " In attending to cases of this kind, he found that where
a coagulum adhered to a surface, which varied its position,
adapting it to the motions of some  other part;  the attach-
ment Avas necessarily diminished by the friction, rendering it
in some instances pendulous, and in others breaking it off
entirely.   To illustrate this by an example, I shall mention
an instance which occurred in the examination of a dead bo-
dy.  The cavity of the abdomen Avas opened, to examine
the state of its contents, and there appeared lying upon tht-
peritoneum a small portion of red blood, recently coagulat-
ed ; this, upon examination, was found connected to the sur-
face  upon  Avhich it had been deposited, by an  attachment
half an inch long, and this neck had been formed before the
coagulum had lost its red colour.  Thi9 steeped in water s«
as to become white, appeared like a pendulous tumour."
  " From this  case it  became easy to explain  the mode in
Avhich those pendulous bodies are formed that sometimes oc-
cur attached to the inside of circumscribed cavities, and the
principle being established, it became equally easy for Mf.
Hunter to apply it under other circumstances, since it is  evi-
dent from a knoAvn law in the animal oeconomy, that extra-
vasated blood, when rendered an organized part of the body,
can assume the nature  of the parts into which it is effused,
and consequently the same coagulum whieh in the abdomen
formed a soft tumour,  when  situated on a bone, or in the
neighbourhood  of bone, forms more commonly  a hard one.
The cartilages found in the knee joint, therefore, appeared to
him to originate from a deposit of coagulated blood upon the
end of one of the bones, which had  acquired  the nature of
cartilage, and had afterwards been separated."
   Mr. Abemethy continues the  subject in these  words:.,
a had vessels shot through  the slender neck,  and organized
the clot of hteod, observed by Mr. Hunter, it would then have
become a  living part, it might have grown to an indefinite
magnitude, and its nature and progress would probably ^ave
depended on the organization which it had assumed.  I have
in my possession a tumour, doubtless formed in the manner 
OF TUMOURS.
211
Hr. Hunter has described, which hung  pendulous from the
front of the peritoneum, and  in Avhich the organization and:
consequent actions have been so far completed, that the body
of the tumour has become  a lump  of fat Avhilst the neck is
merely of a fibrous  and vascular texture.   There can  be
little doubt, but that tumours form every Avhere in the same
manner.   The coagulable part of the blood being either ac-
cidentally effused^ or deposited in consequence of disease, be-
comes afterwards an organized and living part, by the groAvth
of  the adjacent vessels and nerves into it.  When  the depo-
sited substance has its attachment by a single  thread,  all its
vascular supply must proceed through that  part;  but in
ether cases the vessels shoot into it irregularly at various parts
of its surface.   Thus an unorganized concrete becomes a liv-
ing tumour, Avhich has at first no perceptible peculiarity as
to  its nature; though it derives a supply of  nourishment
from the surrounding parts, it seems to live and  groAv by its
oavii independent poAvers; and the future structure which it
may acquire,  seems to depend on the operation  of its oavii
vessels.  When the organization of a gland becomes changed
into tliat unnatural structure which  is observable in tumours,
it may be thought in some degree to contradict  those observ-
ations: but in this  case the substance of the  gland is the
matrix in ivhich the tumour is formed."
   When Mr. Hunter, Mr. Abernethy, Mr. Home, Mr. Hey,
and Mr. John Bell,  give up their time to the investigation of
the nature of tumours, it is an injunction on me to do my ut-
most to satisfy my reader on the subject.  Perhaps some of
these gentlemen may feel contempt and indignation at the
idea of controverting opinions so substantiated as these I have
transcribed.  But in a science so interesting, the  assumption
of superiority is a singular instance of inconsistency, and car-
ries Avith it a most ridiculous air of folly.  Whoever makes
the philosophy of the living body  his study may be taught
humility, and fpom his  oavh errors  learn to look mildly on
those  of  others. 
2A.2                   OF TUMOURS.
   I would have my reader to recollect the phenomena of the
formation of bone, in cartilage, in membranes,  or in  that
mass, Avhich Ave are accustomed to call callus, around the
ends of-a broken bone ; of the formation of neAv membranes;
of  the  adhesion of the soft parts  by an intermediate  sub-
stance ;  as Avell as of the formation of tumours from coagulum,
as it is imagined.  And I intreat him not to attach himself
entirely to a solitary fact, nor to give himself up  implicitly
to the guidance even of a Hunter, who, amidst all the splen-
dor of his talents, was often unintelligible.
   1.  I think the leading  error  of this  doctrine is the  inat-
tention to the distinction betAveen the coagulum thrown out
from  the organized extremities, and  that  which is spilt  as it
were  by the accidental rupture of a vessel.   In the one in-
stance it is a secretion; and in the other a mere extravasa-
tion, possessed of no power of reproduction;  absorbed, if in a
small quantity;  a  source of inflammation and suppuration, If
in a great quantity. I must see the coagulum of blood thrown
out in apoplexy, and in aneurism, full of vessels, before yield-
ing up the conviction that the coagulum of blood accidental-
ly thrown out is absorbed,  and a nevV deposition  secreted,
previous to the formation of vessels.
   2.  It is matter  of  surprize to me, how the physiologists,
who  support  the  original observation of Mr. Hunter, can
adhere Avith such devotion to the circumstance of this coagu-
lum forming a cpnnexion with the peritoneum obscurely ima-
gined* when if the fact Avere so, viz. that coagulum of  pure
blood formed adhesion  to that, or  any other  surface,  and
grcAv  there,  it Avould be as familiarly known to every surgeon,
as it is demonstrable that extravasated blood is absorbed, and
that a limb turgid with extravasated blood will resume its
form*
   3.  We frequently have coagulum thrown out from inflam-
ed surfaces with such a proportion of the colouring particles
of the blood, as to appear like a pure coagulum of blood some-
what  blanched ;  and I have no doubt  the  coagulum found
by Mr. Hunter was of this nature.   But while I believe that 
0F TUMOURS.
2X$
the pure coagulum of blood escaped from the rupture of an
artery, or a vein, has no power, of adhesion, or of forming ves-
sels within it, yet if circumstances should present  themselves
to convince me of my error, the following view of the subject
would stand uncontroverted by that circumstance.
   4.  Every part having a peculiarity of structure, preserve*
that peculiarity by the prescribed modification in the activity
of its vessels ; this modification is continued when the part is
injured, or cut, and  the  renovated matter  is consequently
like tlie original substance.   Violent injury will sometimes in-
terrupt this natural renovation; but on the subsiding of the
violent commotion, and the  return  of the natural action, the
part is reinstated.   As* however, the functions, (and  we may
perhaps venture to say the structure,) of some parts of the
body are more delicate and peculiar, these are not restored in
all their pristine perfection, though ahvays Avith such a rela-
tion to it  as to show that the bond of union of the divided
part* is not the same in all, but holds a  relation to the origin-
al formation.
   5. If a  bone is broken, a coagulum is throAvn out; the ves-
 sels of the bone penetrate this coagulum, and the vessels of
 bone deposit bone.  Such is the received explanation of the
 formation of new matter of bone, and a most imperfect one it
 is.  This  opinion does not  at  all correspond with the facts,
 which stand thus: The mass Avhich we call callus, and which
 surrounds the broken ends of  bones, is supplied with  vessels
 principally from the surrounding soft parts, and  yet bone is
 formed.   If,  therefore, the source from which  the  vessels
 chance  to be derived  influenced  their action,  muscle and
 membrane would be formed, instead of earthy matter  depo-
 sited.   The fact, as  it has appeared to my eyes, is, that the
 original coagulum of blood, which is by the  violence  of the
 accident,  and the rupture of vessels, thrown out  around tlie
 extremities of the bone, is absorbed, and a new deposition is
 slowly secreted ; the source of that secretion is the bone, and
 bone is formed in that nidus, although the vessels supplying it
 with blood be from parts entirely different  in structure and 
214
U4 TUMOUR^.
use.   The medium into which the vessels pass influence their
activity, wc might say, but I belieAre this is not  the  entire
truth;—an artery does not bore and Avork its way into a co-
agulum as has been described.  Some people's  minds are ea-
sily satisfied I  and Avhen they think of the force of the circu-
lation, they conceive it an evident and  likely thing that the
blood forces its way forward;  that the arteries  push out and
enter this substance, without  ever imagining it necessary to
consider how veins,  and  lymphatics, and nerves make their
way into this  new matter.  It appears to me, that this se*
creted coagulum in the very act of  its formation receives its
character; that its structure is already determined  -, that
the tract of its vessels is laid; that the parts are in embryo ;
when blood is received, the  previous determined structure
influences the secretion to be drawn from  it, as in all other
instances.
   Thus far we  have been speaking of natural changes of re-
novation;—tumours are  unhealthy superstructures.   If tu-
mour forms from coagulum, that coagulum is  not the mere
blood escaped from the vessels,  but a coagulable part  secret-
ed by the vessels of the surface,  under a peculiar influence in
their action; and according to that action is the growth of
the future tumour.   Its character, the matter secreted  into
it, and the proper  substance of it, depend on the original
formation; in other  Avords on  the influence of the  vessels
Avhich secreted the coagulum.
   The  folloAving scheme of  tumours, reduced under four
heads,  I  hope  will be found a suitable  introduction to my
observations on the manner of extirpating them. 
QF TUMOURS.                     215
                              I.

              INCYSTED TUMOURS.   (CySttdeS.)


  We  must  distinguish the term  cyst  from capsule, which
latter I think ought to  signify the condensation of the cellu-
lar  substance round a solid tumour.
  The incysted  tumours consist  of a  cyst, the  contents of
Avhich are secreted by  its inner surface.
Hydatides.   Delicate incysted tumours often gregate; and
               entangled in the cellular membrane.
                  The incysted tumours containing lymph, or
               serum, have been called hygroma.
        Even here, in the first step of our inquiry, we are at a loss to
      mark the distinction betwixt tumours of the cellular mem-
      brane, and those transparent bags uniformly round and
      smooth, filled with clear water, and which have no adhesion,
      which are distinct animals:  "they produce their like, and
      multiply."   Although these animals cannot be considered as
      tumours, being themselves animals, yet they become a charac-
      ter of disease, since I imagine that there is a previous nidus for
      them in a change of vascular structure, or action.  There is
      yet a third distinction under the head hydatid, more distinctly
      animals, the tenia hydatiginta. These I have found in the
      monkey, sheep, and hare.  They adhere to the vascular mem?
      branes of the viscera, by a pendulous membranous sac, which
      has vessels branching on it; within this, sac the hydatid is
      contained quite loose.  Some of diem hi the same animal 1
      have seen with one mouth, some with two, and others smooth
      without any, which led me to doubt whether these white cor-
      rugated projections on the sac were indeed the mouths of the
      animal.  I have found a worm like the tenia, and these tenia
      hydatiginea floating loose in the abdomen of the same animal.
 Ganolioh.  A solitary incysted tumour, connected with ten-
              dons, or ligaments.
 .RANUUi.     (See Diseases of the Mouth.)  An  incysted tu*
              mour under the tongue, or projecting on them-
              side of the cheek. 
21b
OF TUMOURS.
        I would place here, under the head of incysted tumours,
      sacs containing fluid blood, such as I have seen about the
      throat.
        Cysts containing matter dense, like these three last exam-
      ples, have been called lupia.
 Melic£ris.  An incysted tumour, the matter being of  the
              consistence of honey.
 \theroma.  An incysted tumour, the  matter contained be-
              ing pultaceous.
 Steatoma.   An incysted tumour, the contents of which are
              fatty, or like suet.

                            II.

            glandular tumours.  (Phymata*).

 I. Scrophulous tumours.
 2. Sarcoma.   A tumour, to  the feeling of the consistence of
              flesh.
                 Under this head AAre must place a very great
              variety of  diseased enlargement of the glands,
              varying in the kind of glands they attack, in
              their outAvard character, in the celerity of their
              growth, in their  termination, and in  the ap-
              pearance of their contents.
        There will of course  fall under this head several tumours
      of distinct glands : aR,
Bronchocele.  Enlargement of the thyroid gland.
 Sarcocele.     Fleshy tumour of the testicle, or cord-
 Z. Scirrhus.  A hard, irregular, and  indolent tumour  of a
               gland.  The knobby  hardness of a tumour is,
               no doubt an alarming circumstance, but such
               indolent affections of  the glands often appear
               in mature years, which  prove unconquerable,
               and yet continue innocent to the latest period
               of life.  When surgeons speak of the true and
               exquisite scirrhus they mean the carcinoma.

  ■* A tumour having its seat in a gland; " born of itself," and proceeding
from no evident injury. 
OF TUMOURS.
21?
4.  Carcinoma.  A tumour  of a gland, in a state of activity
                 approaching to cancerous ulceration*.  The
                 tumour is  hard and unequal ; there is a
                 lancinating pain in it; the skin is purple, or
                 livid red ;  and the  cutaneous veins are en-
                 larged.
             10° To  the term Cancer Ave find the  Avord6
                 apcrtus and ocultus joined ; the first meaning
                 the  open ulceration ; and the other,  the
                 sense  I have given  to Carcinoma.   The
                 spreading of varicose veins over the surface
                 of the  tumour being  considered as a symp-
                 tom of great malignity, aatis  the reason of
                 the  term cancer being used ; they conceived
                 they saAv a resemblance in the  branching of
                 the  veins to the claAvs of the crab ! A true
                 cancer, arrived at  ulceration,  has the edge
                 of  the ulcer  serrated, indurated,  retorted;
                 the  errosions betwixt the excrescences  are
                 deep, and bleed from time to time; there
                 is constant burning pain, and the discharge
                 is sordid, sanious,   and peculiar in its fretor.
        Internal parts and  canals  having a  glandular structure,
      though not the outward form  of glands,  partake of the scir-
      rhus and carcinoma.  We have the disease in the oesophagus,
      in the stomach, in the rectum,  &c.
-5.  Brr.n.        A hard,  phlegmonous, swelling of a  lym
                 phalic gland, from disease received through
                 the  absorbent system;  or symptomatic of
                 acute and malignant  constitutional derange-
                 ment.

  * When a surgeon writes that his patient is strumous, the case is unde
lined ; but there are swelled glands with suspicion of scrophula. If he says,
lie has scirrhus tumours about the neck, I understand, somewhat indefi-
nitely, that they are hard  and knobby,  and suspicious in their nature ;  but
when he says, that they are carcinomatous,  I imagine he has no doubt from
the veins about them;  from the hardness and lancinating pain, and inc.re«w
rd inflammation, that they are cancerous, and of a fatal kind.
   vor. it.                    R 2 
238                    WJ TUMOURS.
        We are quite unable to distinguish accurately the charac-
      ters of the tumours of which the glands are tlie nidus.  There
      is a very great variety of them, proceeding from the changed
      disposition of the vascular action. We sometimes find a solita-
      ry tumour about the throat, which will at last inflame, and
      become active and cancerous.  Another case  will present,
      where with  the same character, we see that the disposition
      spreads, and there are many glands diseased; and on occa-
      sions, that the disease is not confined to the lymphatic glands,
      but spreads to the salivary and thyroid glands.  Sometimes
      we see a disease commencing in the glandular structure,
      propagated  without seeming preference to parts of the same
      original structure with the gland ; but in\'olving skin, cellular
      membrane, and even muscle  and bone, in a diseased assimi-
      lated action.

                            HI.

                           VARIX.

  Varix is a tumour of enlarged veins.   When the  vessels:
are distended, it  is not  in breadth only, but in length also ;
and to accommodate  themselves  they must necessarily be
twisted.  But neither  varix nor aneurism  ought to be consi-
dered as tumours, for there is no peculiarity of action amount-
ing to disease ; it is but at most a derangement of mechanism,
the mere effect  of pressure.
  But as the derangement of the natural action always  endan-
gers the substitution of permanent disease, so in instances of
mere distension of veins Ave find diseased action to be a conse-
quence of it, as in the instance of haemorrhoids, (tumours on the
verge of the anus) which* though at first a mere distension of the
veins and cellular membrane by blood, or lymph, become firm
fleshy tumours.   (Marisca.)
  But it is of consequence we should particularly notice, that
besides venous distension being a mere effect of the pressure
of  the blood;  and  besides, being a sign  on the  surface of
solid tumours of virulence Avithin;  that there are tumours of
varicose veins, distinct altogether in character from these, and
which have a history so peculiar, that I deem it right to put
them under a different head altogether.   See Hypersarcosh. 
OF TUMOURS.
219
                           IV.

                      RXCRESCXNiriJF..

Folyfus.     A pendulous tumour from a canal, or cavity.
Cartilaginous tumours appended to the inner surface of
              the capsular ligaments of joints.
                 A question still remains  to be  decided;—
              are the loose cartilages in the knee joint of the
              same origin Avith those  attached  to cartilagi-
              nous bodies ?  If it is concluded that they are,
              and that they are excrescences of the natural
              cartilage, hoAV do Ave account for bodies of the
              same kind being found loose in the vaginal coat
              of the testicle.
Veruca.      A warty, cutaneous excrescence.
Exostosis.    The excrescence  from a bone Avhere there is no
      •       general enlargement.
Nodus.       The thickening of the membranes Avhich cover
              a bone ;  it is often the same disease Avith the
              last.
Fungus.      This terra implies the soft excrescence from a
              surface ; as of a  bone, or of the  dura mater.
N.«vus.       (Nawus matcrnus.)  A flat congenital  excre-
              scence  of the skin.   Sometimes  rough  and
              Avarty ; often with hair upon it; of a purple,
              redish, blue, or black colour.
  It is only in common language that Ave can call a corn, (cla-
ws,) a tumour; for it is a mere effect of pressure.   There is
no diseased action, but the continuation of a natural action ;
an action of a kind in other circumstances to preserve the bo-
dy.  The accumulation of the layers of the  cuticle  on the
palms of the hands and  soles of the feet, as a  consequence of
use and  pressure, is a happy provision for the  protection of
the parts beneath.  But Avhen  pressure  is on a point, there
the accumulated cuticle acquires a hardness  equal to horn,
and bears hard on the soft parts beneath, 
m
OF TUMOURS*
   Under this head of Excrescentim there might be enumerat-
ed many terms Avhich imply tumours of particular parts; as
for example:
Epulis.       A tumour of the gums and alveoli,
Pterygium, or Pterygion.  A thickening of the. tunica con*
, .             junctiva.
Encanthig.   A tumour of the inner angle of the eye, in th,e«
              seat of the caruncula lachrymalis.
Staphyloma. A tumour of the cornea, &c.

                            V,

THE DISJGASLD GROW 111 Of A VASCULAR, FLESHY SUBSTANCE,
 involvisc THE parts promiscuously.  (Hypcrsarcosis.)

   Under this head I put such tumours  as are of a fleshy con-
sistence, and  not distinctly  of  glandular origin, but Avhich
spread equally around.                            *
   Fungus  hjematodes of Mr,  Hey.  This disease may take
its origin in muscle, cellular membrane, or even bone.  Some-
times it begins as a distinct tumour ; sometimes  as a general
enlargement  of the part; as  of the leg, thigh, or shoulder;
generally it is not  painful.   It is irregularly soft, (of uneven
density,) and to the feeling there is a sensation of extravasatr
ed fluid, yet not of a fluid in a  distinct  sac.  There is no ir-
regular hardness; and no puckering of the skin.   If it  be
seated under the fascia the distension has a  considerable  elas-
ticity.  The veins on tlie surface are much enlarged.  In its
progress the tumour bursts ; and a soft, dark coloured, bloody
excrescence rises from the centre, Avhich  bleeds freely, and re-
duces the patient's strength.   The irritation, and the haemorr-
hagy together, carry him off.  When this tumour is opened
in  the life of the  patient, the  bleeding is profuse.  When its
contents are examined after extirpation, there is a greasy, ash
coloured substance in the midst  of a vascular bed.
   Aneurism by  Anastamosis of Mr. John Bell.—This tu-
mour, for the most part, has its origin in the skin,  but it in- 
                      OF TUMOURS.                   #21

solves every living  part  in its progress.   Its origin  is often
from  those marks on children called nasi materni;  but some-
times, apparently from injury of the skin in the adult.   The
disease is, for the most part  long stationary, Avhen,  Avithout
any apparent cause, the action of the vessels acquire vigour,
the pulsation becomes perceptible, and the tumour  sensibly
increases.   The colour of the tumour  is a blackish  blue  or
purple,  and on the most prominent part there is an excre-
scence like a  mulberry, Avhich bleeds  profusely from time to
time.  The substance of the  tumour is cellular, and  contains
pure liquid blood.   The blood  can be pressed from it, and,
to the feeling, the bags are soft and avooIIv.  It destroys the.
patient by hreinorrhagy,  When dissected it is like a mass of
placenta.
   This disease cannot be called an aneurism, which is a puh:
ating tumour of blood, from a mere  injury of the machine,
from  a yielding of the coats of the arteries Avithout any pe-
culiar action.   It is not a varix, Avhich is a mere venous dilat-
ation  in consequence of an impeded return of the blood.   In
this tumour, on the contrary, there is a specific and  very pe-
culiar action, and nothing resembling  either the impeded cir-
culation of aneurism or varix,
   Anomalous tumour.—Under this name, in various collec.
tions, Ave have both of the last mentioned cases; but besides
such as correspond AAith these of Mr. Hey and Mr.  John Bell,
there still remain many tumours of the bones, muscles, and
6kin, Avhich  entirely differ from  them, and  which have had
as yet no name given them.   I have dissected a tumour  of
large  size, Avhich it Avas impossible to  say resembled most the
steatomatous tumour, or the vascular tumour described by
Mr. John Bell, and in the substance of the tumour  there were
many cells full of liquid blood.  These  cells Avere  not the  ir-
regular cavities of varicose vessels, but of a perfectly regular
form, they had  a smooth secreting surface.  1 Avould have
called them hydatids but for their contents.
   The nature of the osteo-steatomatous and osteo-sarco-
matous tumour i<= but  little knoAvn; the first term implies 
222
st.:' i'UMOUitS.
 the growth of a steatomc in the marroAv of the bone, in which
 the bone enlarging becomes a shell to the fatty tumour, until
 perhaps the softer substance bursts through the bone*.  Tlie
 term  osteo-sarcomatous describes that  softening and  enlarge-
 ment  of a  bone in which the tumour exhibits a mixture of
 soft and bony matter and softer fleshy substance.  But the
 action of the vessels, the nature  of these tumours, partakes of
 a great variety.   Indeed the term steatom gives us an im-
 proper idea of tlie common fatty tumour of the body,  which
 is a diseased acretios of fat nourished by vessels, and often
 Avithout a cyst, or much to distinguish them from the com-
 mon fat hat their inordinate groAvth.
   It is not in vindication of the imperfection of this  sketch
 of a classification of  tumours that I venture  to  throw out a
 doubt of a possibility of making a perfect  catalogue and a de-
 scription of them.  Without  boasting of  how much I have
 seen, I may assert that I have seen a distracting multiplicity in
 the  character of tumours.  I have seen  lately,  and expect
 often  to see, tumours which bear  no accurate  resemblance
 to such as  I  have seen before, or such  as I  find described.
 Tumours are not like animals, each proceeding from a stock,
 and bearing the mark of that origin.  They  are not like the
 diseases of the natural body,  Avhich, in similar circumstances
 is always similarly affected.   But,  to  use the Avords  of Mr.
 Abernethy, they are edifices which are built up  by diseased
 actions, and in Avhich these diseased actions  reside.  There is

  - In the greatest enlargement of a bone it often occurs, that what appears
 like an immense bone is but a shell.  When the bony matter  is absorbed on
 one side of a bone, we see it accumulated on  the other; when wasting with-
 out, accumulated within ! in short, when there are the most decided ravages
 of disease the bone is strangely disfigured, but still the mass  of earthy mat-
 ter remains nearly Uie same.  Ii considering this disease of osteosteatoma,
 or of the cases which I have seen, when the tumour of aneurism, and the
 formation of bone went on together; it appears, that the bony matter forms
 a shell as long as the original quantity of matter is not exhausted;  at last,
 however, the  growth of the original tumour becoming too  Urge, the thin
shell of bone is absorbed over the most prominent part of the tumour, and
:he turno-jr seems to hires* through. 
OP TUMOURS.
223
in this opinion much to ponder on and to admire.  The mat-
ter in  which the action resides, is the result of disease; the
disease varies  in its  nature;  the structure of that matter, so
formed, slightly deviating, must affect the action residing in
it; and that action having no doubt the character of all de-
viations from  nature,  viz. a less definite and circumscribed
existence may be undoubtedly varied and modified.   Thus
it appears to me that neAv diseases are formed in many of the
individual tumours, though they are not propagated: a cor-
rect general classification may  no  doubt be expected from
careful observation, but I think it will ever be liable to de-
rangement by the observation of individual cases.

              OP THE TREATMENT OF TUMOURS.

  Of a swelled gland.   It is only by the continuance and ob-
stinacy of a tumour  in resisting remedies,  that we know it to
have such a peculiarity of action, as to afford little hopes of
its resolving.  In the beginning of every  tumour, therefore,
much the same  practice may be pursued \  and I shall state
what is right  to be done,  under the idea that  Ave still hope
that it is merely  a  gland accidentally swelled; and where
the diminution of the action may be folloAved by the decrease
of size, and the restoration of its natural function.
  When a  patient comes to us with a swelled  lymphatic
gland AA-e first consider the probabilty there is of its  being in
consequence of  some irritation in the course of the absorb-
ents ;  or  we  attend to the probability  of its being scro-
phulous and constitutional.   If Ave  find it a solitary swelling
of a lymphatic gland,  for example, in the neck, we take into
consideration its seat, and the course of the vessels; there is,
perhaps, a scabby eruption about the roots of the hair, a gum-
boil, ulcerated sore throat, discharge from the nose, &c.  If
there should not be one, but  many glands swelled, and indu-
rated, we must look to the age and constitution, and not com-
mit the error of treating wholly as a local disease that which
has its  origin in the prevailing tendency of the system. 
224
Of TUMOURS.
   When a gland enlarges, leeches arc to be applied, and the
part frequently bathed Avith tepid water;  on the second and
fourth day they are to be repeated; and Avhen the bites have
healed a blister is applied with the best advantage.   If, Iioaa-
ever, the gland shows itself to  have much inflammation, a
blister Avill aggravate and increase the swelling ; and even  in
cases Avhere the gland seems indolent, it is necessary to secure
a certain degree of Aveakness in the vascular action of the part,
before any thing stimulating be applied to the surface.   I am
very partial to the use of vomits in discussing inflamed glands.
   When glands enlarge from the action of  cold in a scrophu-
lous constitution, cold wet applications are to be.avoided ; in-
deed, in that case it will be better to have recourse to warm
fomentation of decoction of chamomile, and of sal ammoniac,
or of salt and water, or of gentle and long-continued friction
Avith the hand, or  Avith stimulating oils.   The part should
be kept warm ; and if the  above plan is found too trouble-
some to be employed, in the absence of affectionate  care, a
warm  plaster of cummin-seed may be applied.
   If we find that there is a concealed scrophulous action  in
the system, but  that Avhere the  skin is exposed there chiefly
the glands sAvell, it is most probable that the glands are suf-
fering'by sympathy Avith the skin ; which  is the reason I re-
commend the plan of fomentation and friction ; but when the
enlargement of a gland has no such origin,  avc may apply ei
ther cold solution of ammonia muriata, and  cerussa acetata on
cloths, or the blister, without deviating from the intention  of
diminishing the vascular action.   The general explanation  of
the action of a blister is, that it  excites the lymphatics, and
consequently  assists the absorption and diminution of the tu-
mour.   I imagine it is to be explained thus: if the blister he
applied Avhere there is a tendency to inflammatory action, the.
stimulus is propagated backAvard upon the trunk of the ves-
sels brought  into activity ; but if the power of re-action be
previously subdued, then this irritation makes a revulsion from
the deep parts, by bringing the blood which would otherAvise
pa*s to the deep pnrt? to supply the superficial vessel^: what- 
or TUMOURS.
225
 ever diminishes the activity of a swelled gland restores the
 balance to the absorbents, which  were previously overpower-
 ed by the activity of the arteries; for it would not be diffi-
 cult to prove that the lymphatics are less under occasional in-
 fluence than the arterial system.
   While we endeavour to reduce the activity  of a sAvelled
 gland by direct means, we must prescribe purgative medi-
 cines twice a week, and enjoin an abstemious diet;  tempe-
 rance is of the utmost consequence where there is danger of a
 eonfirmed scirrhus.  If the gland continues hard after this
 treatment,  our next  resource  is an alterative treatment,  by
 giAdng small doses of calomel, or corrosive  sublimate.  The
 extract of cicuta with calomel is a favourite remedy.   Elec-
 tricity is used, not as a counter irritation, but directly affect-
 ing  the  gland;  it rouses its  activity.   We must  be well
 aware of the mildness  of  the nature of a gland which  we
 rouse to activity: no doubt,  if there be no malignity in a
 gland, the rousing the vascular action  may  be productive of
 a change, and cause its final absorption ; as it is  sometimes
 observed, that a gland having been long indolent,  swells, be-
 comes painful, and then disappears.
   It is a different expectation  Avhich makes  the  surgeon ap-
 ply caustic to a tumour ;  he expects, that  being of a mild,
 indolent nature, with little capacity of action in it, the life of
 the  part, (being diseased),  may be too  Aveak for the violent
 operation of the caustic, so that the  whole  part may slough
 out.  Such is the common effect of escarotics and caustics to
 a Avart;  the life of the excrescence is weaker than that of the
 natural parts on which it groAvs, and consequently while the
 application is too  severe for the diseased action, the sound
 parts remain unhurt.   But this is a dangerous practice  in
regard to scirrhous tumours;  instead of destroying  the dis-
ease, we  may only rouse it to activity.
  When  a tumour is excited to virulence  by corroding,  or
stimulating applications, it is doubted, whether the latent ma-
lignity of the disease be merely roused,  or  a new action be
produced ; our most intelligent surgeons seem to think  that
  VOT. IT.                   F 2 
2S6
OF TUMOURS.
 there is no such  thing as the conversion  of disease i-  Mr*
 Pearson expresses himself thus: " Writers have indeed  said
 much about certain tumours changing their nature, and as-
 suming a neAv character:  but I strongly suspect, that the
 doctrine of the mutation of diseases into  each other, stands
 upon a very uncertain foundation.   Improper treatment may
 Avithout doubt exasperate  diseases, and  render a ^complaint
 which appeared to be  mild and  tractable,  dangerous or de-
 structive ;  but to  aggravate the symptoms, and to  change
 the form of the disease, are things that ought not to  be  con-
 founded.   I do not affirm, that a breast which has been the
 seat of a mammary abscess, or a gland that has been affected
 by scrophula, may not become cancerous;  for they might
 have suffered from this disease, had no previous complaint
 existed; but these morbid  alterations generate no greater pro-
 pensity to the cancer, than if the parts had  always retained
 their natural  condition."  I cannot entirely agree with  this
 opinion.  I conceive that a part deprived of its natural ac-
 tion, is in a certain measure throAvn out of the governance of
 the general ceconomy, and is left a  prey to irregular  action,
 to disease.  When a gland is* injured by a blow, and  the
 inflammation has gone  high;  if the natural structure  and
 osconomy be deranged, permanent  disease follows the subsid-
 ing of the mere  inflammation.  So Ave see  that there is  a
 period of life  when the breast and  Avomb  become useless,
 and the influence of the  system is no longer felt upon  them ;
 then disease fixes on them.   I am not able to give any other
explanation of the cancerous affections  of the womb and
mamma  being so  frequent at the turn of life.  By pushing
this discussion a little further I am led to  conclude, that  dis-
ease  is not the effect of circumstance, and impression,  but
that there is a latent tendency to certain diseases, which take
place in the absence of the controul of the healthy action.
  Of the extirpation of tumours by the knife.  Tumours of
glands are cut out, as being likely to propagate a malignant
disease; as apt to increase and press upon important  places,
as the eye, or throat; or lastly, from mere  unseemliness. 
OP TUMOURS.
22}
   Before AA-e think of using the knife, we must consider Avell
 whether the tumour be simply scirrhous, or if it be of  the
 nature of a carcinoma; or Avhether a capsule has been form-
 ed which  marks the limit of the diseased action, or the sur-
 rounding parts be imperceptibly assimulated into the disease.
 In carcinoma, Mr. Hunter observed a disposition in the  sur-
 rounding  parts prior to  the actual occurrence of  disease in
 them.   This remark, says Mr.  Abernethy, is ratified by daily
 experience, and has led to the folloAving rule of practice ; that
 a surgeon ought not to be contented with- removing merely
 the indurated, or actually diseased part, but  that he should
 take  aAvay some portion  of the surrounding substance.  The
 simpler statement I fancy to be, that long before  the eye can
 discover diseased texture in the substance, the action is pro-
 pagated which must necessarily precede this effect.
   HoAvever that may be, it is  particularly necessary to exa-
 mine the edges  of a tumour AA'hich has been cut out, and to
 see that  there is none of  the peculiar  texture of  the tumour
 terminating abruptly on the edge, as if cut through.  For ex-
 ample, the character of carcinoma, as exhibited on dissection,
 is in  the condensed cellular membrane, Avhich has a very pe-
 culiar appearance of irregular diverging streaks of a Avhiter
 colour, in  the darker substance of the  tumour ; noAv if these
 membranous bands  have reached into the cellular texture
 which has been  left after the tumour  is cut off, the disease
 will inevitably return, and grow Avith a rapid progress.   The
 tumour is, therefore, to be held in reference to the wound,
 and where these bands are  found to terminate abruptly, or
 where in the tumour there are any hardness and irregularity,
 or pulpy matter, or substance which does not appear of the
natural texture, the corresponding part of the Avound is to be
examined,  and the remaining  disease extirpated.   We must
ever remember,  that if tumours possessing malignity are only
 partially extirpated,  they resent the injury offered  to them,
and resume a Avorse aspect than  before.
   If Ave are to operate on a tumour Avhich has its seat in a gland,
and if it be a mere ccirrhiu', there is a circumstance, Avhich if du- 
238
OF TUMOURS.
Iy attended to, will greatly facilitate its extirpation; Avhilst the
body of the gland is hardening,  the  surrounding membrane
is condensed.  The pressure, and probably  the slight inflam-
mation, forms the cellular membrane into a distinct capsule.
By bearing in mind that these  hard scirrhous tumours are
surrounded by a membrane, Ave are enabled to cut out  a tu-
mour from a seeming dangerous  depth.
  I shall suppose that a patient  comes to my reader with a
hard tumour under the angle of the jaw, and which threat-
ens to push toAvards the throat.  The surgeon calculates the
place of the arteries.  He presses the root of the veins, and
when they swell, hje sees Avhich are  in his way.   He  then
moves the tumour to ascertain Avhether its roots be deep, or
if it has any firm adhesion;  in doing this,  he relaxes the
muscles, and  especially the platysma myoides.
  If the tumour has not  encroached  on the great vessels too
much, if if has not adhered, and  communicated its bad in-
fluence to the surrounding parts, it may be extirpated.   But
my experience prompts  me to say here,  in  the most confi-
dent manner, that  if the tumour be  not  sufficiently free in
its  attachments, but on the contrary,  has pushed deep, and
taken attachment to the  jaw,  or transverse processes  of the
cervical vertebra, no good will come  of the operation.   The
patient  after suffering considerable risl?, and being the sub-
ject of a most painful operation, will have the mortification
of finding the part grow hard  soon after the cicatrization,
and increase  in  its growth with a rapidity,  Avhich the pro-
gress of the tumour before the  operation shall  not have led
him to expect.
   If it shall be determined to attempt the extirpation of an
indurated and scirrhous  gland,  the  surgeon  has to provide
himself with knives, and a strong hook,  and a blunt  hook
for the assistant, with tenacula, and needles;  but above all,
Avith pieces  of  sponge having ligatures attached to them;
and Avith adhesive straps, and  a graduated compress and
bandage. 
or TUMOURS,,
229
  He begins his operation by cutting so that the fibres of the
platysma myoides are cut across.   To do this, it  is not ne-
cessary that he carries the incision across the neck, for in that
case he Avould  open veins needlessly; but I  mean to Avarn
the young surgeon against cutting betAvixt tAvo of the fasci-
culi of the fibres of that muscle by Avhich he Avill find him-
self restrained, in a most distressing manner, in  the prosecu-
tion of the dissection around the  base of the  tumour.  The
first incision being made through the skin, I have  seen the
operator begin his sweeping cuts round  the tumour, forget-
ful of the cutaneous muscle of the neck; and forgetful too of
that essential  circumstance, that the gland is  noAv surround-
ed with a proper  capsule.
   If  he begins to dissect round the gland before he has cut
down to it, he will find himself in much confusion;  and
vessels bleeding in the progress of his operation which ought
not to have been cut.  He has therefore to lay back this cu-
taneous muscle freely, and then he will find himself reAvard-
ed for his decision by the gland starting more forAvard, and
becoming, in  fact, more superficial.
   But still he has  not exposed  the proper surface of  the
gland; if  he  cuts perpendicularly on the cellular coat which
covers the tumour,  he  discovers that this cellular  substance
is a loose capsule, from which the gland can almost be turn-
ed out Avith  the  point  of the thumb!  Avith the handle of
the knife he separates the capsule from the glund :—he finds
a part Avhere there is  more resistance; a stronger union be-
twixt the gland  and capsule by a  cellular cord;  in this he
Avill  find the principal artery  which  supplies  the tumour;
and when he cuts  this tag across,  he  must be prepared to
 take up the vessel Avith the tenaculum.
   In our dissections, every day we  see,  that the lymphatic
 glands have one principal ramification of a neighbouring arte-
 ry running into their substance.   It is this same artery, Avhich
 by its activity enlarges the  gland;  and this artery,  for the
 most part, is  all a surgeon has to  take up in the extirpation of
 the gland- 
230
OF TUMOURS.
   If the operator is ignorant of this Avay of forcing the diseasw
 ed gland from its capsule, or  has to operate upon a tumour
 which has no such capsule, his dissection is more tedious and
 difficult; and much more blood must be lost.  If I am cer-
 tain  that a gland has this capsule,  I care not Iioav deep it
 may be seated ; I knoAv that I can extract it; but if it be of
 a different  nature,  and assimulated to the surrounding sub-
 stance, I am unwilling to attack it, because  I have no guide
 to show me the  extent of the disease; and because it hap-
 pens, that at every touch of the knife a vessel bleeds.
   If we have to extirpate a tumour of the nature  of a bleed-
 ing fungus, like that described by Mr.  Hey,  or Mr. John
 Bell, we shall find no capsule formed by the condensed cel-
 lular substance.   We must look well to the  extent of the
 disease before Ave begin the operation; for it  is not likely that
 we shall be able  to mark the extent of the diseased sub-
 stance during  the operation;  we  must  here too be aware
 that the disease does sometimes extend further than the dis-
 eased  appearance, and Ave must therefore cut freely away
 the surrounding parts if it be possible or safe.  Where the
 smallest speck of tortuous vessels of the skin  remains behind
 after  the amputation of that tumour called aneurism by
 anastomosis, the tumour  is quickly re-produced Avith an in-
 creased exuberance.   If the tumour  has  been seated in the
 neighbourhood of  a bone and has fixed upon it, though there
 be no appearance of disease in the bone apparent during the
 operation, yet from that source will the disease be  re-produc-
 ed and propagated.
   I have so often seen  bloody and painful  operations per-
 formed on these tumours Avithout any good finally resulting
 from it, that I beg of my reader not to undertake the extir-
 pation of them unless he be resolved at all hazards to take
 all away that is tainted with the disease.
   In operating on  these vascular tumours Ave  must  keep wide
 of their confines for another reason, to avoid  blood, and the
 confusion resulting from  it. If an adventurous young.sur-
geon cuts into the  body of a tumour  of tortuous  veins and 
OF TUMOURS.
231
arteries,  he has vessels throAving out their  blood over both
his shoulders, and his attempts to tie  these vessels are quite
unavailing.   But  if he keeps Avide of the diseased mass he
makes his dissection in the common cellular membrane, and
perhaps  only cuts across one  artery Avhich throws out  its
blood with no uncommon velocity, although sufficient to sup-
ply vessels with blood much more active than  itself.  I shall
not stop to  reason on this but state  it  as a fact worthy of
the surgeon's attention.
   In  operating on sacculated tumours, as we have understood
that the sac is  the source of the secreted contents, it  is evi-
dent that Ave must cut out the sac altogether, or Ave 6hall not
eradicate the disease.  If there be room enough, incysted
tumours  ought to  be  cut out entire.   It may happen, how-
ever,  that they are situated in the orbit, and pressing on the
eyeball, in which case after the integuments are dissected, as
the knife cannot be pushed by the side of the tumour, let it
be punctured, Avhich  Avill  give us room to proceed.
   The atheromatous tumours will sometimes  burst of them-
selves and discharge  their contents, and heal.   This circum-
stance may tempt the surgeon, on some occasion, to puncture
and press out the fluid from these tumours, and perhaps it
may happen that after this only a fluid like the original mat-
ter of the cyst  be discharged from time to time; but  the
greater probabihty is that an irritable fungus rise6 from the
opening.  So we  shall find that an  imperfect operation  on
one of these wens, where a part of the cyst is left, is followed
by inflammation,  when if the disease had  been extirpated
the inflammation Avould have quickly  subsided.
   These incysted tumours are cut off for the most part on ac-
count of their size merely, but they do sometimes burst and
push  out a fungus, and  become a source of irritation and
erysipelatous inflammation; nay, tjie erysipelatous Mamma-
tion from such a source has spread and sloughed, and  the
derangement of the constitution been  such as to destroy the
patient:  on this account therefore are  they to  be extirpated..
I may here  notice further that if we find that  a fungus lu- 
232                   OF TUMOURS.
 mour  has  arisen from  a  Aven or incysted tumour, it  is an
 encouragement to operate  upon it.   We hope that the  deep-
 er part of  the tumour is still separated from the surround-
 ing parts by the remaining cyst, and prevented from incor-
 porating Avith them*.
  An incysted tumour may be so situated that it cannot be,
 cut out, and yet something must be done to free the neigh-
 bouring parts from the pressure of it.   I do not speak of the
 incysted tumours, the atheroma and  steatoma, but of such
 sacs of fluid as wre may see about the tongue and throat, and
 which are imagined, but without any very direct proof, to
 be salivary tumours.  These cysts ought to be freely opened.
 When punctured they inflame  and thicken, and yeitf do not
close altogether; even the  seton does not obliterate their ca-
 vities, and Avhen they are inflamed  and yet are not obliterat-
 ed, the sac thickens and becomes itself like  a tumour.
  In  my scheme of tumours I have  mentioned  under the
head of incysted tumours, those containing blood.  It is not
always possible to  distinguish these tumours  of blood  from
such as have a proper  secretion within the cyst, yet when
they have  no stool or firm sac,  when by continued pressure
we can empty them  in a considerable degree, I am inclined
to conclude that there is fluid blood contained in the tumour.  *
These tumours are soft, colourless, and as  I have said  com-
pressible, and have no  pulsation, and are very slow  in  their
growth.
  These  tumours soft, compressible,  and without discoloura-
tion, I have seen on the side of the neck. I have contemplat-
ed the dismay of a surgeon on opening such a tumour  with
the lancet, when he found pure blood flowing from a  tumour
over the carotid artery! But there is nothing alarming in it:
they can  be compressed.
  The practice I would recommend in such  a case, were it
 again to occur to me, is, after you have proved that you can
 command the blood from  one puncture, to puncture and ex-
* See Mr. Abernethy's Treatise. 
QF TUMOURS.
233
press the blood, and puncture it again and again in several
places, then  use compression.   It  may naturally be asked,
why puncture to discharge the blood Avhen if can be pressed
from the tumour Avithout this ?   I propose puncturing not to
discharge  the blood, but to let it  escape from the cells in
which it is contained into the common cellular membrane, and
to inflame the tumour, by Avhich alone Ave can expect the con-
solidation of it, and the destruction of this cellular  structure
which receives and gives out the blood.
   I  hope I need not again put  my reader on his guard, to
warn him against such interference as I here recommend in
cases of such'vascular and bloody  tumours as are described
under the term aneurism by anastomosis, or tumours of blood
av here there is pulsation or discoloured skin, or tortuous veins.
   On  this last subject of tumours of the skin  Avith discoloura-
tion and tortuous veins, I have just to mention, that Avhen at
any time they sheAV  a disposition to greater activity, by a Avet
bandage,  by keeping  a spongy cloth perpetually  Avet over
them, their tendency to increase may be checked.
   Of a tumour forming in a nerve.   I have given a  plate of a
tumour in a nerve, which by the continued pain it gave wore
out the patient's health and destroyed him at last.  I knoAv
not whether to consider this as a tumour of the nerve proper-
ly, or only  as a diseased groAvth in the interstice of the ner-
vous filaments.  However  that may be, I consider  it as very
necessary to call my reader's attention to the symptoms of this
disease, and further to intreat him to attend to the course and
affections of the nerves someAvhat  more than is usual, being
convinced that by this he may be able to detect the nature
or seat of disease when otherwise  it will be impossible.   It
was but the other evening that a gentleman complained to me
of a pain  and numbness of the back of the  thumb and fore-
finger, this I found referable to a disease of the elboAV joint,
and an affection of the muscular spinal  nerve.  I visited a
 woman with a disease of the womb, who complained of an un-
 usual pain and frequent spasms of the legs,  I  imagined that
the disease had involved the  sacro ischiatic nerve, and found
   VOL. II*.                  G ^ 
*J-l
OF TUMOURS.
. it so on dissection ;  in the same manner, I have found suppu-
ration near the thyroid hole of the pelvis, attended Avith pain
on the inside of the thigh and knee.   So Ave ascertain the seat
of disease to  be in the loies from the numbness of the thigh,
and retraction of the testicle; and further from the knoAvledge
of the peculiar nature of the pain from the injury of a nerve,
I  have been able to ascertain that a disease of the  arm did
not proceed from,the injury of the'nerve, when others thought
it so evident that  they sought to cut the nerve across.  In
wounds too Ave shall often be able to ascertain the precise track
of the  ball, and  the very  artery Avounded, by attending to
the  loss of sense of certain parts.  lif a baltfhas  made its
(rack through the axilla I consult the sensation of tlie finger
and arm, to tell  me where it has  passed ;  and so indeed of
the wounds of the  pelvis, something  definite may be learned  *
Avlien avc find that parts are rendered insensible Avhich  are
supplied by the anterior, middle, or great posterior nerve.
   If my reader asks how such a representation of the neces-
sity of  attending to the distribution of the nerves comes into
this place,  my apology is in the folloAving case, which drew    [
my attention to the subject:—                                t
   About three years before I saAv the subject of the follow-
ing case ; he had fallen from the side of a ship.   It  happen?' ^
ed in this Avay :—Seeing his fellow-Avorkman falling, he threAY  r*^
himself forAvard  to break  his fall, and  succeeded;  but in ^
doing this, he fell himself; for ho Avas caught by the ham on   .
a projecting bolt  in the side of the ship, over which he turn-
ed, and hung  suspended.   He suffered much from the bruise
on the back of the  thigh, but in a short time it got entirely  t
well.
   Some time after  this, he began to be much troubled Avith
a  pain in his foot.  This pain  Avas in  a part not likely to
procure him much sympathy, and lie  suffered  much and
ion^ Avithout attempting to procure assistance, or only such
as the extremity of pain will put a man upon for the time.
   But the  pain continued to increase from day to day, until
it totally unfitted him for labour, exhausting and Avasting his 
                               OF TUMOURS.                   2'3a>

        frame by continued Avatching.  This  pain Avas of a peculiar
        kind—it Avas confined to  the bottom of the foot and Avas like
        an intense  burning, while there Avas not  the  slightest disco-
        louration or SAvelling in the place.  Often he  Avould rise at
        night from his bed and stand  on  the  cold  stones, or plunge
  -*    his foot into Avarm  Avater or  cold Avater, or into both alter-
  ^    nately.
          He noAv sought relief in  a public hospital, and the attend
        ants there disconcerted Avith the strangeness of the symptom,
        which  they did not  comprehend, put him,  as  is usual on
♦ ?      sucb^oxcasionf, on a course of mercury; but this  trial of a
.     .   medicine didj no good, and he went  home.   But still  suf-
   Tp   ferina continually, he was induced after  a  lapse  of some
 •    .  months  toJreturn  to  the hospital, and Avas again put on a
 •.   If  mqre severe and a  longer continued course of mercury than
        at first.  f By the time this Avas over he had suffered continu-
     \  ally for two years', and  was  reduced  to a skeleton, and he
  *   * Avas far gone in hectic.
  (P*1     When I saAv him, he gave me this account, and  then con-
J " "   tinued  to  complain of the extreme pain in the sole of his
   g, *'  foot.  He told me too that he had a strange numbness of the
        leg Avhen he sat down. On examining into this circumstance,
  i^r which I thought  Avould lead to some  explanation  of the
      "ianore prominent symptom, I found a  tumour in the ham,
        w hich when pressed  gave no  particular  pain, but rather  a
     *  Anse of prickling  numbness doAvn  the leg.   The tumour
        AA'as to the feeling  of  a  bony hardness.   I conjectured that
        there Avas some tumour pressing  and  Avedging upon the po-
      ''pliteal nerve, and that this injury to the  nerve in its course
        Avas referable by the  patient's feelings  to the extremity and
        final distribution of the  nerve.  I thought of an operation,
        yet I was deterred from it by the dying state of the poor
        man, Avho noAv suffered  but indirectly from  the disease of
        the leg,  and in all probability death  was  no longer to be
        avoided by  the removal of the original  cause.  I thought
        that he  might be brought round to have  some strength, but
        within the Aveek he died. 
-\><j
OF TUMOURS.
  Dissection.  On dissecting the  limb I found a turnout
under  the fascia  and about  three  inches higher  than the
usual place  of the popliteal aneurism.  I found some nerves
running over it of a remarkably pure Avhiteness.  On tracing
the sacro-ischiatic  nerve I found it  enter into the substance
of the  tumour;  but  on more careful observation, I found
that the Peroneal or Fibular nerve, though' close on the tu-
mour,  yet Avas not incorporated Avith it;  but that the tibial
nerve,  as is expressed  in tho plate, was incorporated with the
tumour.   On making a section of the tumour, it had much
the appearance of a large ganglion on the tibial nerve ; the
fasciculi of the nerve could be  traced but a little way into
its  substance, and in  the interstices of the fasciculated bands
a vascular fatty substance  could  be observed, which  resem-  ;
bled marroAv.
  I think it is impossible to mistake the nature of this case.
I have no doubt that the  injury received"'on the hsm Avas'  '
the cause of the  disease in  the nerve.  This hoAvever might
be  a mere  coincidence.  Yet I think Ave cannot close our-"
eyes to this striking" proof of  the affection of a nerve in it's,*
course being referable to its extremity.  Had the nature of &tA
this disease been understood earlier, I have little doubt thaty
cutting across the portion of the popliteal nerve Avhich forms  it
the tibial nerve, or the total extirpation of the tumour woukiA ▼
have been succeeded by  the perfect relief and> recovery  ofj
the patient.                                                ^ 
OF TUMOURS.                    ^37
•\--
»\,

   Section qf a cancerous eye representing the appearance  of
membraneous bands peculiar to this diseased structure.  A, the
centre and origin of the disease.  B, the seat of the humours
now occupied'by the diseased mass.   C, the lensconvertcd in-
to a  solid'concrete.  D, the coats of the eye terminating ab-
ruptly where they  have been destroyed  by the progress of the
disease.  E, the bands which have destroyed the coats of the
eye in their progress, and  have struck into the eye itself.
„** 
vw-
238               CF TVING OF ARTERIL-
                           CHAPTER X.


    * fiULls FOR TYING ARTERIES WHEN DIVIDED IN WOUNDS, AND
       A                                             -» -
     V  A DESCRIPTON OF THE MANNER OF DISSECTING FOR THEM.
    '•■* if  «
    ,  •       '                                        K

   \^.V>;   1 am aware that some may conceive that this fchapter
\ , .  contains matter foreign to the nature of a system of surgery.
      I cannot agree Avith them:  I Avrite for  my pupils in the firsf
    " instance, and I know in Avhat they are most apt to err.  Al-t
    * though I take all possible care in  nay lectures to teach them
      a proper and manly Avay of studying\he arteries, yet I find
      them deficient in  this branch of surgical anatomy, without
   *'   Avhich their other joiowledge  is useless.  I think I was the
      first  who taught  my  pupils the anatomy of the arteries in
      partial viewsrcut down upon them, and endeavoured to shew
     them in their natural confusion, and as they are seen in ope-
  '  ration,   I have done this in the hope that my  pupils might '
      not be at a loss when they came to seek for bleeding arteries
      in the living body, as are those ivho have been taught the ana-
     tomy of the arteries  on dried preparations, or at most shewn
     them on  the -injected subject, after the dissection of the parts.
     When I  say I  Avas the first who taught the arteries thus, JL
     knoAv not  that  it is done even now by others; but I am cer-
     tain that the labours of men of the highest ability" must be
     less useful than  those of the most  ordinary capacity, if tlie
     former continue to teach on  dry preparations,  whilst the lat<
     ter take this method.
        Young men are too apt to fancy that  when they have got
     a  knowledge of the  circle of operations, they are fitted for
     situations in the navy and army; but the first battle in Avhich
     they are engaged brings them  to a mortifying  conviction of
     their ignorance.  There is another class  of students Avho com- 
*>-•  **.r ,*tV
^
                  of avounded arteries. * "> , ^*"    239
                                       v     *' ,-
nnt a still greater error; they can tell the holeV of the dia*
phragm, the muscles which surround the shoulder joint, the
coats of the testicle, and what is contained  in the capsule  of   4r, •
Glisson, hoAV many arteries there are in the body, where tlie * ^t
os tineas is situated, on what bone Ave stand, and what is the  ^A
use of the urinary bladder!! &.c.  &c. yet it is  not strangle *^>'
that  being occupied in the learning  of these things, they Kf**
knoAv not aa hen or hoAV to take up a bleeding artery*.
   I conceive that even  the title of this chapter may be  «f
some use, by informing those aa'Iio seem  Avilling to forget that */
such things are necessary to be done sometimes, by causing &"
them to reflect that the very  first occasion they may have
to Avet their hands in blood, may be to stop a haemorrhage ir £
from the brachial or femoral artery.   For young  surgeons^. \
are often in situations Avhich require decision and dexterity,
Avhen the older member^; are placed Avhere  business may  be
done with deliberation  and the characteristic graAaty  of the
profession.
tl   CLASSIFICATION OF THE ARTERIES IN THE ORDER OF THEIR IM-
                     PORTANCE TO THE SURGEON.
   Class i.  Arteries the wounds of which are necessarily fatal.
   The aorta, and pulmonic arteries—the arteria innominata—
the cosliac—the superior and inferior mesenteric—the splenic
—the  emulgent—the common iliac, and the external and in-
ternal  iliac arteries, and the common carotids near the aorta.
 "Class ii.  Arteries from which the bleeding is fatal if the
vessel be not immediately stopped.
   The carotid artery—the femoral artery—the axillary bra-
chial arteries—the  profunda femoris and popliteal artery.

  * It is gratifying to find, however, that the college of surgeons are desirous
of discountenancing this disgraceful method of teaching by question, so con-
trary to the true spirit, and that when they discover the monotonous sound
of this baby lesson, the candidate is brought to tlie full disclosure of his ig-
norance, by some pertinent question, directly regarding the knowledge of
the dead bodv. 
».  « 24Q   ,.           OF WOUNDED ARTERIESv
   >
      Class hi.  Arteries, the bleeding from which is profuse and
    dangerous, and which require the ligature.
      These are the arteries of the leg—the ulnar and  radial
  *, arteries—the gluteal and ischiatic arteries—the sub-scapularis
    —the thyroid and lingual arteries,  and the branches  of the
    profunda femoris.
      Class iv.  Arteries which require careful  compression, and
    if that be not possible the ligature—the internal pudic—the
    epigastric—the arteries in the sole of the  foot and palm of
    the hand—the interosseous artery of the fore arm#;-the inter-
 **  costal arteries—the temporal and fascial artery, and occipital!
    arteries.
      Class v.  This is a class  of arteries that can be trouble-
    some only in  cases of great  weakness, or  Avhen  they  are hi
    bones or fungous surfaces.   ,

                               I.

      Ik there be bleeding from the hand or foot,  and the sur-
    geon is called soon after  the accident has happened, and be-
    fore any clumsy attempts have been made to stem the bleed-
    ing, he may put doAvn a piece of sponge into the wound, and
    then a graduated compress  being applied,  the vessel will be *
    effectually closed.   But if  the  blood has been driven from  »
    the mouth of the artery  into the cellular membrane, and un-
    der the aponeurosis, the  compress cannot be used Avith accu-
    racy and effect; neither can the tenaculum be used, because
    the mouth of the artery is  hid; and the needle cannot be
    used, because the mouth of the bleeding artery is amongst
    nerves and tendons.   So it happens that a wound of a trifling
    artery in the hand or foot requires the ligature of an artery of
    greater  size in the Avrist or at the ancle.
      My reader now enquires Avhether  all Avounds of the arte-
    ries of the foot  and  hand require a ligature ?  Certainly not.
    I have  seen  the hand pierced and shattered in all  directions
    by balls, and no ligature required.   I have seen in the same 
OF AVOUNDED ARTERIES,
211
day three  gun-shot wounds through, the palm of the hand,
without haemorrhage; or more than Avas to be wished for. -
  In the use of a compress, this is not enough considered—
that inflammation as well as pressure is required  to the ob-
literation of an artery.  If there be a considerable thickness
of cellular membrane, or a fascia, betwixt the  lint or  sponge *
and the artery, the pressure may very likely fail, whereas if
the compress had been  put doAvn in contact Avith the artery
it would surely have succeeded ; for then the pressure not on-
ly keeps the sides  of the vessel together, but the contact of the
foreign body causes inflammation and adhesion.
  It will accordingly happen that the ulnar artery being
wounded where it forms the arch in the palm of the hand, Ave
shall in vain try to compress it; because the cellular mem-
brane is charged  with extravasated blood, and the artery has
shrunk under the aponeurosis: the compress does not touch
the artery and there is a great thickness of a substance like
placenta over it.  On another occasion finding an open wound,
and the artery'displayed, and no such driving of the blood
into the palm of the hand, and no such general swelling as in
the last instance, the compress being put down  into the wound
and the hand bound  over a ball of cotton or lint, the ha^
morrhage will be effectually suppressed.

                           IL

   Ir is more difficult to  say what size of  an  artery requires
a  ligature than may be at first imagined.  It is very likely
that while I am describing the manner of cutting down upon
the arteries of  the third class, the tibial or fibular, or ulnar
arteries, a naval surgeon may say, « all this is superfluous, for
I have stopt these arteries by compression."  I have  to shew
that I know this, and yet that I deem it sometimes necessary
to take up these  A'essels with the needle.
   John Roe was shot in the arm and in the breast.  He stood
with the tackle in his hand ready to help in running out the
 gun, when a ehower of grape-shot shattered the men at the
   VOT.. IK                  H * 
m
OF WOUNDED ARTERIES'.
gun, killed two and wounded four.  Roe felt his breath gone,
and was  sensible of a shot in his breast.  The shot had pass-
ed through his arm, breaking  the ulna above the middle,
and wounding the ulnar artery; it then passed obliquely over
the scorbiculus cordis,  very critically passing betAvixt  the
muscles and skin.  Although there Avere  circumstances in
that Avound of the breast that might be interesting, yet it is to
the Avound of the  artery only that I have at present to call my
reader's attention.  The finger could be put into the  Avound
by which the ball entered, as well as that by which it passed
out of the fore arm.   These wounds  were filled  with lint,
compresses laid on each, and a tight roller applied.  There
was at first no pain ; very little even Avhen the surgeon thrust
his finger deep into the Avound ; but in half an hour  the pa-
tient felt the bandage tight, and became sensible of the cram-
ming of the Avound and soreness.   The shot holes Avere black
at the second dressing; the  dossils of  lint were drawn out,
but he had no recurrence of hasmorrhagy.
  It may be said that there was no absolute proof that the
ulnar artery was wounded in this instance : in my opinion it
was complete; but there can be no cavil about the  folloAving
fnstance.   M'Kenzie was on the covering party, on the retreat
from Villa Franca, and while reloading his piece he saAv  a
sharp-shooter of the enemy take  his aim at him; the  ball
struck him  in the fore arm; for the space of three miles of
the retreat he bled freely from the Avound,  but on finding the
surgeon the arm  Avas bound  up and the bleeding Avas stopt
and did not return. When  I looked on this man's arm some
days after, I was assured that the ulnar artery was in the di-
rect course of the ball, and that it must have been cut through:
the ulna was shattered,  and many loose pieces lay in the  bot-
tom of the wound.  I was confirmed in my supposition of the
artery being  divided,  by  the  unusual irritation and pain in
the Avound, which I attributed to the ulnar nerve being cut
across, and now engaged in  the fungous and ill-conditioned
sore.  The arm Avas amputated: the propriety of the opera-
tion turning on other circumstances than what is to my pre- 
OF WOUNDED ARTERIES.
2U
sent purpose.  When I examined  the  part  in dissection,  1
found the ulnar artery and nerve cut across, and on introduc-
ing the probe into the artery, I found it stopt for tlie length
of an kich and a half, in part owing to the contraction of the
artery, but principally from the adhesion through coagulable
lymph.
   I could give other cases of wounds which I have seen of the
ulnar and radial  arteries thus easily stopt by compression;
but Avhat I have said is sufficiently conclusive on this point,
viz. that Avhere these arteries are divided by gun-shot, com-
pression is sufficient to stem the blood.   I give here a sketch
of a wound of the lingual artery, Avhich being of the scco»d
order of arteries also, is I think conclusive on this head.
  The ball shattered the angle of the jaAV, passed obliquely
through the tongue, and came out by the edge of the mastoid
muscle of the other side.  This wound bled for half an hour
and then stopped.   I judge that  the lingual  artery  Avas
wounded here, first from the course of the ball, as apparent to
the eye; but also from this circumstance, to which I was care-
ful to attend, viz. the insensibility of the left  side of the
tongue, which implied that the nerve was cut, 
244
OT WOUNDED A&TERIEV'.
                           III.

   The next inquiry  which  the  intelligent young  surgeon
would naturally make, respects the necessity of tying arteries
of the third class, when Avounded by a splinter or by a knife.
The first question is not so easily answered as the second; let
ns for example take the  following case:-—In Lord Duncan's
victory John Niel Avas stationed at a gun, Avhen a shot struck
a bulk-head, and drove it in splinters, so as to throw doAvn and
wound all the  men at  the gun; Niel was cut about the
breast and throat with splinters,  but not  deeply.  He  went
to the next gun and  Avrought at it; Avhen as he carried a
forty-tAvo pound shot betwixt his hands, a shot passed through
the ship, and a very large splinter struck his arm and made
him quit  his hold.  While he was looking at  his arm two
men were dashed against  him, and all three tumbled down
the hatchway.   Niel was much sprained and bruised in the
back by his fall*.  When he could, he craAvled into the cock-
pit, and found his arm bleeding very profusely.   There  Avert
two  wounds on  the outside of the elboAV joint,  through the
belly of the supinator muscle.  In one of them a large splin-
ter Avas sticking, which Niel, while he Availed his turn  to be
dressed, endeavoured  to  pull away but could  not.  It was
from this wound the bleeding proceeded :  it was like a baH
wound, and admitted the point  of the finger, and Avas  very
deep.   When the firing ceased the surgeon set this poor feK
Ioav in a great chair, while he took his arm and tugged at the
great splinter ineffectually.   He  therefore, at last, cut the
wound open on one side, so as to free it, and it came out easily.
If he had carried his  knife into the other wound, which was
close by it, he would  have done good, for  it afterwards ap-
peared that there were many splinters in it, buried  deep in

  * The reason I transcribe these circumstances is to bring xay reader ac-
quainted with the very different kind of wounds aboard ship, from those to
which the soldier is- exposed from grape and musket shot.  The ease Walt
communicated to me by my brother, 
OF WOUNDED ARTERIES.
24S
the flesh, though not to be felt Avith the finger when it was
pushed  deep into the wound.   Both wounds noAv bled pro-
fusely ;  the  surgeon crammed them with  flour, and laid a
compress and a  tight  bandage over  them.  During two
nights and two days the bleeding Avas so profuse as to indi-
cate a wound of the ulnar artery; but partly because the
bleeding was in some  degree commanded by the compresses,
and partly  from  want of assistance, the surgeon  did  riot
undo the bandage.   Niel was by this bleeding reduced very
low.  When the bandages  were undone on the third day
the bleeding had stopped.
   In this case we have a wound in the same arteries, but in
circumstances materially  different.  The  splinter of wood,
although driven with the force of a bullet, yet wedged and
cut its  way no doubt; and while  a  ball, being round and
obtuse, bruises as it passes, this splinter cut the artery.  The
 bleeding was however stopped; but if the  artery had been
 cut by a knife, it might  have been more difficult: to shew
 which, I subjoin the following note of a case of wound of the
 radial artery, proving that a man may die from it :—

                           IV.

    A gentleman was wounded in the fore  arm by a pistol-
 shot   The arm  swelled prcdigfoudy; abscesses formed  in
 the fore arm; and it  was thought necessary to open them
 freely, and to rip up the fascia:  in doing this, unfortunate-
 ly, the radial  artery was touched.  The bleeding was pro.
 fuse-  and  from the. weakness of the patient, critical:  my
 reader may conceive from what has been described, that no-
 thing  would be so eaiy  as to compress this artery; but let
 him consider things as he will find them in practice,  ihe
 man's arm is swoln to half the size of the body ; great ab-
 besses are in it; it is inflamed and so painful, that a heavy
 foot in the room, or the lifting of  the thumb of the patient,
 gives excruciating pain.    It is evident that the wound can-
 net be effectually stuffed  and compressed Avhen m this state. 
245
Ul AVOUNDED ARTERIEfc.
I know not on Avhat grounds the surgeon determined  in the
preceding instance, but he took up the humeral artery, and
not the radial artery.   Still  the bleeding continued.   This
put my notions of the effect of ligature into strange perplex-
ity.   Still the patient bled, and what could be further done ?
—and in a short  time  he died.   On dissection, I found the
radial nerve with a firm ligature around it, but the humeral
artery was not included.  I never had seen the radial nerve
mistaken for the humeral artery, but this was the third time
I had found the radial nerve Avith a ligature  around it.
  This is a pure case of a division of the radial artery, by
the knife, proving fatal; and these cases  leave no room for
conjecture on the difference between gun-shot Avounds, those
by splinters, and the clean cut of a knife.  It is in this latter
case especially that we have to cut dow n upon the artery and!
take it up.

                            V.

  I have stated that the branches of  the profunda lemons
require the ligature; but  from the  difficulty of the dissec-
tion, the uncertainty in  regard  to the branch Avhich bleeds,
and the precise place of it, Ave shall be long held in suspense,
and perhaps obliged to trust to compression.   In gun-shot
wounds the case is still more  perplexing.
 
«F AVOUNDED ARTERIES.
247
  In this slight sketch I have represented the  place of the
Wound of J. Chambers, of the rifle corps.  He was wounded
ih the retreat at Villa Franca; the ball entered under the
edge  of the sartorius muscle, passed obliquely through the
flesh of the thigh, and round the  bone, and lay under the
skin near the trochanter  major.  The wound bled freely on
his  first receiving the shot.  He was thrown on a mule, and
for  three leagues on  the retreat he continued to bleed.  The
surgeon cut out the ball, and bound up the limb, and then
the bleeding stopt; but it broke out again, and continued to
bleed for ten days;  and after this, when  aboard the  trans-
port, there ay as great bleeding, so that they Avere obliged to
apply the tourniquet, &c.  The wound continued to bleed
till within two days  of his coming ashore.
 ' A Avound of the femoral artery would have prevented him
from ever rising from where he fell.  This has  been a Avound
of  the branch of the profunda,  which descends before  the
insertion of the long head of the triceps, and  which  is be-
hind the great artery; yet although a branch, it is as large
as  the brachial artery,  and its importance  is  shown by  its
continuing to bleed  for thirteen days,—from its requiring the
tourniquet eleven days after the Avound was received.  This
artery, however, was  at last stopped by the  compress and
roller—but had it been cut with a knife the bleeding would
most probably  have  been fatal, if the artery had been  left
unsecured.

                           VI.

    It will not be denied, (though I know not where the inu
 portant  fact  will be  found distinctly stated), that it is not
 the size of the artery which makes it to  be dreaded, but its
 comparative size;  and this not in comparison with the size
 and years of the patient only, but its principal importance
 hangs on the question  whether—is it the  main artery of a
 limb, or a branch ?    From a  branch of the profunda, equal
 to the brachial artery in size, tlie  man is less likely to bleed
 to death, than if the wound is in the brachial artery. 
248              OF TYING OF ARTERIES.
                          VII.

   If a man is wounded in the main artery of the thigh, or
arm, from the weapon entering in at the outside of the
limb, it must be evident that  the original wound cannot be
enlarged to seek the  artery, as has been proposed.   To take
the most favourable case  for  this proposal, I say, that if a
man be wounded through  the flesh of the triceps,  and the
sword  pass into the humeral  artery, we  cannot dilate the
wound to expose the puncture of the vessel.   We must pass
the gun-shot probe into the wound, and pass it forward un-
til Ave  can feel its point on  the skin  on  the inside of the
arm, and near the artery.  Here Ave cut upon the artery, and
make sure that this incision communicates  with the original
wound ;  and if we do this, there can be no embarrassment
from the artery continuing to  bleed by the  wound towards
the outside, Avhile Ave are dissecting for the artery on the in-
side of the arm.
  If in searching for the wound of an artery the blood does
not flow, although you are sure  that the side of vessels is
wounded, compress the artery below the supposed  place of
the Avound, and the blood will start out.

                         VHI.

  When we cut down upon the  artery of a limb, and hav
ing found it,  are about to separate the vein and nerve from
the artery, Ave must bend and relax the limb; by inattention
to this  rule I have seen the radial nerve  tAvice included in
the ligature put around the brachial artery.

                          IX.

  It does not appear to me that surgeons have determined
whether a single, or a double Jigature be required in case of
a Avounded artery.   I am sure that some nwv entertain these 
OF WOUNDED ARTERIES.
249
difficulties: viz. whether in certain cases a ligature being put
around the artery above the wound, the patient is  quite se-
cure ? or if it be not necessary to tie the loAver part of the
artery also ?   On this subject I shall state Avhat appears to
me to be the fact, and endeavour to draw the safe rule of
practice.
  While these papers are before me my assistant  is  called to
take up the  radial artery, Avhere it has turned from the fore
part of the Avrist.  He finds a man with a deep Avound of a
knife betwixt the fore-finger and thumb: the man has al-
ready  lost much blood;  and  introducing the probe it  is
found', that the point of the probe is at the head of the meta-
carpal bone of the thumb.   Tlie artery is taken  up by the
side  of the extensor tendons of the thumb.  The  bleeding is
stopped, yet in a short time the blood  Aoavs again ; but the.
wound being tied up, Avith a compress laid in the course  of
the wound, all  is Avell.  When a man is bleeding  from the
hand, or Avrist,  or foot, tying the artery only diminishes the
impulse of the blood, and  does  not entirely stop  the Aoav of
blood which comes  round by  the very free inosculations.—
But  the  direct  course of the blood being interrupted, our
dressing is sufficient  to stem the force  of the hacmorrhagy
by the anastomosing vessel; if the artery be not taken up, a
sponge must be thrust deep into the Avound,  and a tedious
sore  is the consequence ; but if the main supply be stopped,
the lips of the wound can be brought together, and  the com-
press put over the integuments, (not into the flesh), and the
wound healed by the first intention.
  If the surgeon be brought to a man who has received a
wound in the inside  of the arm,  and he has  reason to sup-
pose, from the dashing of the blood, that the humeral artery
is AArounded, ought he to be satisfied with pulling out some-
thing from the bloody wound, and tying it ?  nay, even sup-
posing that he distinctly sees the extremity of the  artery, and
the blood floAving from it,  is it sufficient to tie that mouth
of the artery ? I believe, that Avith common care  afterward,
and due compression, the patient will not die  of  harmorrha-
  VOL. II.                  i 2 
250
OF WOUNDED ARTERIES.
gy; but I am at the same time convinced, that when the
principal artery of a limb is thus  severed, or Avounded,  a
ligature  ought to  be applied both above and below the
wound ;  and then only can the limb be left free of bandage*
and compresses, Avhich in this case is especially necessary.
These bandages not only prevent the early  union of the cut,
which  is a minor consideration,  but they do not allow the
free circulation through the limb by the collateral arteries,
noAv that the main trunk  is cut and tied-   When  the  main
artery of a limb is tied we expect the free course of the blood
by the anastomosing branches still to supply the lower part
of the limb;  and surely, Avhen we  are  so  confident of this
expectation, Ave cannot doubt the propriety  of tying the arte-
ry both above  and below the wound,  so that  there may be
no fear of hajmorrhagy from the returning  blood, and no ne-
cessity  for a compress to be put into the Avound.

                           X.

  A question may still remain with my reader in the case of
a wound of the fore arm, or leg, Avhen the ball has torn both
arteries what is to be done ?  I take particular pleasure  in
producing the  folloAving case, presented me by Mr. Torbit,
of the Crescent, formerly a pupil of mine.

A  CASE OF  DIFFUSED ANEURISM AVHICH  HAPPENED AT THE
          SIEGE OF DANTZIC, MAY THE THIRD, 1807.

   A Polish  pilot was offered  a pecuniary reward, from the
British Consul, to carry  dispatches from General Kalkruth,
commanding the garrison of Dantzic, to General  Kaminski,
commanding the allied Russio-Prussian army in the  Fair
Water.   On his  passase in an open boat down the Vistula,
he Avas fired at by the French sentinels from  both banks  of
the river, and received a Avound from a musket ball, Avhich
 entered  the left  arm from without, about two inches below
 the elboAv joint,  the  ball made  its exit at the lower end  of 
OF WOUNDED ARTERIES.
251
the ulna, carrying away both radial and ulnar arteries.   A
profuse haemorrhage followed, but he continued to exert  his
strength to get clear of the sentinels, until  he fainted from
the loss of  blood; the boat Avas drifted d<nvn by the current
into the  Fair Water by the time  he recovered.  He made
another effort and regained  the shore, but Aveak and Avorn
out by the loss of blood he fell doAvn, and  av as taken up by
a Russian out-post, and conveyed to an inn.   A compress and
roller was applied, and  his strength supported by Avine and a
nourishing diet;  the arm became much SAvelled and painful;
fresh bleedings from the wound folloAved every two or three
days, and then fresh bandages or compresses Avere added to
the former, until  the seventeenth.   I w as called in to visit
him.   I found him pale,  Avith a livid countenance,  and his
eyes sunk in  his  head ; his pulse in  the right arm Avas one
hundred, and upwards, and  scarcely perceptible; the hand
was much SAvelled, and  soft to the touch, as if pus were form-
ed.   I recommended amputation ; dreading from the length
of time, and the state  of the cellular membrane and muscles,
that mortification  Avas approaching.  A consultation of Eng-
lish and  Prussian surgeons was  held at six o'clock the same
evening.   I entered the room a feA\  minutes too  late, av hen
a Prussian  surgeon w as undoing the last turn of the roller;
the blood  sprung from the Avound across the room ; the sur-
geon stood amazed—Avithout making any endeavour to stop it.
I laid hold of the arm, and compressed the artery on its pass-
ing out of the axilla, and applied the tourniquet.  On expos-
ing the arm, the Avhole  appeared marked  with  the roller,
whose spiral  pressure left evident marks of its inclosing a fluid
diffused  among the muscles,  and  the arteries still continuing
to  bleed internally, I amputated  the  arm above the joint,
Avhich the  patient endured as ith great resolution.  I gave him
an opiate, and ordered him a glass of port negus three times
in the course of the night.
   Dissection.   I made  an incision in  the course of the
wound and found both arteries  Avounded, and tlie Avhole of
the interstices of  the muscles  filled av ith coagulated blood; 
25:2
OF AVOUNDED ARTERIES.
 and continuing the incision from the lower Avound, doAvn in-
 to the hand, four ounces of Avell-digested thick pus escaped ;
 1 made another incision on  the back of the arm and found the
 blood equally diffused, the  muscles and cellular substance
 appearing one black mass, with every sign of approaching
 gangrene.   The next morning I found him sitting up in his
 bed, quite cheerful; pulse soft, full, and considerably reduc-
 ed ; fearful lest  adhesion might  not take place by the first
 intention, and having  no after inflammation to dread from
 the great loss of blood previous to the operation, I ordered
 him a dram of bark four times daily.  The  second  day I
 found him Avalking the room Avithout the smallest  degree of
 fever : cautioned him  to be careful, but did not confine him
 to bed.  The fourth  day I opened the stump, found that
 very  little adhesion had taken place; a great discharge of
 eoagulatcd matter from the stump ; dressed the stump, and
 continued his bark as before.  On the next dressing I found
 the matter better, and less in quantity than on the former
 dressing; the Avound discharging a thick pus, and skinning
 over very fast.   Continued his bark and dressings until  the
 twenty-eighth,  Avhen the  stump almost skinned  over;  but
 the French getting possession of the  Fair Water, he fell into
 their hands to complete the  cure, Avhich only wanted a feAV
 superficial dressings,
  TJiere is ahvays much difficulty in stating an aphorism in
 surgery ;  in other words, the circumstances of the  case are
 infinitely  varied, and  much  is left  to the discretion of  the
 surgeon.  A  mround of the  radial, or ulnar  artery, is no case
 for  amputation, nor would I amputate although  one  of the
 bones, and one  of  the arteries  Avere  pierced  by  the ball.
 But Avhere both arteries are  torn by  a raking shot, in  the
 manner above described, there can be no doubt of the pro-
 priety of amputation; because to compress these  arteries is
 to compress  the Avhole arm, and to allow no circulation ; to
 take them up requires extensive incisions, and  taken in addi-
 tion to the wound,  would  leave the arm too much mangled
to do good. 
OF AVOUNDED ARTERIES.
253
  To say, that in any case Avhere the radial and ulnar arte-
ry is cut by a ball the arm should be amputated, would be
wrong.   The arteries may both be taken up if the surgeon
be on the  spot;  but  Avhen  there is a raking  musket-shot
through the fore arm, and the arm is swelled, and the cellular
membrane  stuffed with extravasated blood, and the patient
reduced, the case is totally altered.

                           XI.

   While on this subject of wounded arteries, I am tempted
to state some further facts regarding the force of the circula-
tion by collateral anastomosing arteries.
   A man having suffered a fracture of the loAver head of the
femur, had the misfortune, at a considerable distance of time,
to have the popliteal  artery torn on the rough projection of
the  bone.   A tumour formed behind the knee ; the progress
of the  tumour Avas more rapid than  the common  popliteal
aneurism.   The operation  for aneurism  Avas performed on
the fore part of the thigh.   By the tying of  the femoral ar-
 tery the SAvelling Avas only  checked for a time ; by and bye
 it began to increase ; the knee joint became greatly distend-
 ed ; ulceration took place  near the head of the fibula; and
 from this  pure blood  escaped, so as to endanger the patient's
 life, and render amputation absolutely necessary.
   In the amputation the femoral artery  gave out  its blood,
 and was secured as usual.-----On Dissection, I found that the
 blood had continued  to pass from the popliteal artery into
 the sac of the aneurism, and that the main artery Avas plen-
 tifully fed by the  anastomosing vessels.   The blood which
 escaped from the ulcer had come directly from the popliteal
 artery, in which there was a ragged hole.
   This proves, that in the case  of common popliteal aneu-
 rism, where there is a proper sac, the ligature on the femoral
 artery checks, but does not altogether impede the course of
 the  blood into the  sac;  it  interrupts  the main  channel
 through the  trunk of  the femoral artery, Avhile the  blood 
254
OF AVOUNDED ARTERIES.
 continues to make its  Avay  into the part, evert of the trunk
 of the  artery Avhich is beloAv the ligature.  This  interrup-
 tion to  the blood, forcing it to take a circuitous route, gives
 opportunity for  the entire  coagulation of the blood  in the
 sac, and then the cure takes place much in the manner of the
 spontaneous cure of aneurism.   The preceding case, hoAvever,
 proves that where there is no regular sac and Avhere the artery
 is wounded, this tying of the trunk of the artery high in the
 thigh,  is not sufficient to stop the  flow of blood  from the
 wound  of the artery.
   I made another dissection which proved  to  me, that after
 the usual operation for the common case of popliteal aneurism
 the main artery continues pervious below the ligature ; and
 that it is the femoral artery  and its branches, (and not  the ex-
 tremities of the  profunda,  articulating with  the recurrent
 branches from  the artery below the aneurism,) Avhich carries
 on the  circulation.   Six Aveeks after the operation for aneu-
 rism, it Avas necessary, in consequence of partial mortification,
 and a caries of the fibula and bones of the  foot, to amputate
 the limb.   During the amputation I observed the blood flow
 in full jet from the  femoral  artery, on the face of the  stump.
 Now the artery Avas here cut across not more than tAvo inches
 beloAv the place of the ligature used in the operation  for aneu-
 rism.  On injecting the anterior tibial artery with  Avax, the
 injection passed freely into the branches of  the popliteal and
 femoral artery.  So it is certain that here the blood Avas car-
 ried into the leg by the trunk of the femoral and popliteal ar-
 tery, and that the main vessel remained pervious betwixt the
 ligature applied in the operation for aneurism, and the sac of
 the aneurism.
   It follows then, that where  there is a regular sac of an
 aneurism, the operation usually performed will be successful,
 by diminishing the  force of the circulation, and alloAving the
 blood in the  sac to coagulate.  But that  where there is an
 open wound in the artery, and an extensive irregular cavity
 into Avhich the blood Aoavs, this ligature applied so high in
 the limb is insufficient, and  the patient will most likely suffer
amputation at last. 
OF WOUNDED ARTERIES.
255
                          XII.

   I cannot close this  chapter Avithout saying something of
the secondary bleeding from gun-shot wounds, in consequence
of the slough coming aAvay.
   In  the first place I positively deny that because a gun-shot
wound bleeds, there must therefore be  a great artery wound-
ed ; for I have seen Avounds of the thigh, of the axilla, and
arm,  by musket balls, av here much blood flowed, and yet
there was  no secondary hemorrhage, and no great artery
wounded, as the event of the cases sheAved.
   It  would be great  presumption in  me to contradict the
opinion of Mr. Hunter  upon a subject of this nature, yet as I
have felt alarms in consequence of Avhat he  says and others
think they  have confirmed, and have found my fears ground-
less, I think it necessary to  state, that Avhile I Avould still take
the precaution recommended by so many in regard to  the se-
condary  haeinorrhagy  from gun-shot Avounds, yet I do not
think there is that occasion for trembling anxiety, which I at
first conceived there Avas.  On a  late occasion, when I Avent
among the wounded from Corunna, I  had two  purposes in
yieAv, first to satisfy myself on several points, of which I had
just knowledge sufficient to make  me doubt the received opi-
nion ; the  other av as that I might have striking  instances of
acknowledged facts, for the  purpose of teaching; and amongst
other accidents I thought we should have secondary h.tmorr-
hagy. I hope it w ill  not  be irrelevant that I state from my
notes  the opinion as it greAv.
   " It is singular that  of all the hundred wounds of balls in
these wards, with the sloughs hanging from the wounds, there
is no instance of haemorrhagy."   In succeeding  mornings I
find still the same expression in my notes.  " Now the slough
is just coming out of  several of these  wounds; in cases  too
where I  should imagine the artery must have been touched,
yet in bringing  the men ashore there  has been no bleeding.
I see  a man wounded  in the sartorius  very near  the femoral 
256
OF AVOUNDED ARTERIES.
artery.   I see a man Avounded Avhere the ball has entered by
the side  of  the insertion of the deltoid  muscle, and passed
out by the back of the arm,  it must have gone betAvixt the
bone and the  artery.   I see  another just brought in  where
the ham-string tendons are perforated, and  it is miraculous
that the  popliteal  artery could escape ; yet in these instances
no blood floAved on the coming away of the sloughs."
  " I have noticed to day a  great many wounded  in the ax-
illa, some where the ball has lodged, some where it has pass-
ed through.   I see a Avound  Avhere the ball has taken off
the preputium, and  passed into the thigh, and over the fe-
moral artery, and there was bleeding as I imagine from the
ramus inguinalis magnus,  but there  is no  secondary haemorr-
hage."   " In the  next bed a lad lies Avounded on the  inner
condyle of the humerus;  he Avas on the retreat, the firelock
trailed, he received the ball  on tlie inner condyle  of the hu-
merus, it was cut out upon the biceps, Iioav did  the  artery
escape ?   My inquiries were at last suspended*.  I  found
no instance  of secondary haemorrhagy.  I began to think it
was equally incorrect to say that every artery touched Avith
a ball must  slough and bleed, as it is to say that every bone
touched  by  a ball must exfoliate."
  In examining these fine felloAvs  it Avas  often  exclaimed
among us, Iioav could the artery escape here?  I can  only
suppose  that  the  artery is the most limber  and elastic, and
(being a tube) the most  compressible of any part  in the
limb, and that by its yielding to the push of the cellular mem-
brane before the ball, it escapes the degree of attrition w hich
Avould destroy life,  when any thing  opposing more resist-
ance would inevitably  suffer.
  Let my  reader, however, beAvare of the injunction in Mr.
Hunter's Avork, p. 525, regarding the  sloughing  of  arteries
and secondary ha:morrhagy.   I  neither object to the fact

  *  Let me hci'e intrcat those of my pupils who have been in  Spain or
Portugal,  or who have had opportunities of watching their patients on
the  shot-holes becoming moist  and the  slough coming away, to satisfy
me, further on this head. 
      OF THE SEAT. OF THE VITAL PARTS IN THE CHEST.   257

nor to the reasoning upon it.   I only offer  these observa-
tions  as  some relief to  the  anxiety from such a sentence a?
this:—" The patient lying easy even for ten  days, is  no se-
curity that in the end  he shall  not bleed to death."   When
large  sloughs hang from  the Avound, when  bags of matter
form  among the  muscles, &c. in the tract of cellular  mem-
brane AAhich accompanies the arteries, (a very frequent con-
sequence of gun-shot,  especially if  the bone  is injured) we
must  not consider all this extensive loss of substance as  the ef-
fect of the contusion of  the ball,  nor the bursting out of blood
as the consequence of the ball brushing by the artery.   This
case is in no respect different from the secondary haemorrhagy
after  amputation, Avhen there is a sloughing stump.
   I acknoAvledge that these  introductory observations to the
following description of the  manner of taking up the arteries,
Avhen cut in wounds, have been extended to a great compar-
ative length ■, but I hope my reader Avill make the best use of
the error, if it be one, and learn to consider it as a much more
difficult thing to determine on the propriety of an operation
than to do it.

      OF THE SEAT OF THE VITAL PARTS IN THE THORAX.

    A  thrust made Avith a small sword on the left side of the
 chest, immediately above the seventh  rib, perpendicularly to
 the convexity of the chest, will pass through the diaphragm
 into the stomach, the heart escaping.
    A thrust immediately above the left pap, and above the
 fifth rib, perpendicularly to the surface of the chest, transfixes
 the body of the left ventricle of the heart, perforating the an-
 terior and extreme margin of the right.
    A thrust  made  perpendicularly to the convexity of the
 chest,  immediately under the anterior head  of the fifth rib,
 will pass through the anterior edge  of the  right  lung, and
 pierce the apex of the  heart.
    Perpendicularly to  the convexity of the right side of the
 chest, and immediately beloAv the  anterior head of the third
    vol. ii.                  K ^ 
 258   OF THE BEAT OF THE VITAL PARTS IN THE CHBST.

 rib, the thrust made will pierce the lungs and mediastinum,
 and pass through the right auricle.
   A thrust perpendicularly down by the left side of the ster-
 num, betAvixt the fourth and fifth ribs, will pass through  the
 upper part of the  heart, near the root of  the pulmonary ar-
 tery.
   A  thrust perpendicularly to the convexity  of the chest, im-
 mediately under the right pap, and of course the fifth rib,  will
 pass through the root of the lungs among the  great vessels.
   A  thrust with the small sword, horizontally from the great-
 est lateral convexity and upper edge of the seventh rib,  will
 pass through the middle of the loAver portion of the posterior
 lobe of the right lung, behind the heart, into the posterior  me-
 diastinum, Avhere the aorta and oesophagus are about to pass
 through the diaphragm.
   The arch of the  aorta lies three-fourths  of an inch below
 the level  of the upper  part of the sternum.
   If the assassin strikes av ithin  the  clavicle, obliquely down,
 with  the stiletto, the point will, at the depth of  three quar-
 ters of an inch belowr the upper edge of the sternum, pass into
 the arch of the aorta, and occasion a more sudden death than
 if struck into the heart* ;  if the aorta should escape, some of
 the great branches will be Avounded; even if the great branch-
 es should  escape, and the trachea be wounded,  the patient is
 in danger of instantaneous death, from the  blood passing into
 the trachea suffocating him.
  In  regard to the course of balls through  the chest, Ave  are
 apt to be  much deceived.   The ball  will strike the sternum
or cartilages of the rib, and then glide betwixt the skin and
 the ribs, and  either pass out altogether  at the opposite point
 in the back, or lie there under the skin.   A  ball may pene-
 trate  the  chest and lie there; it may  pierce the  lungs; it

  * I have a very interesting letter from Mr. Fuge, surgeon of the Dorset
regiment, giving me an account of the case of a soldier, who  was wounded
at Corunna, and who lived fourteen days after a ball had pierced tlie right
 ventricle of the heart. The ball had entered on tlie left side of the sternum,
 betwixt the cartilages of the second and third ribs. 
       TO FIND THE WOUNDED ARTERY BY DISSECTION.   258

may pass through the chest and lie among the muscles of the
back;  or it may pass out altogether.  When the ball enters
the chest the shot-hole is evident to the finger or the probe,
and the  air is thrown  out  from the Avound in expiration.
When  it  has pierced the lungs frothy blood is spit up ; but
the question whether the ball is lodged in the chest,  or has
passed into the axilla, shoulder, or under the scapula,  will
not be so easily determined.
  When tlie  lungs are wounded, at first there is blood spit
up ; but that may cease from the vessels of the lungs closing,
and from the diminished strength of the patient, the cough
being  dry  and weak.   When with the weakness and dtadly
aspect, coffee-coloured  discharge  is poured out  from the
wound, it is an exceeding bad sign ; it proceeds from the re-
solution of the extravasated blood.

             TO  CUT FOR THE CAROTID ARTERY.

  To cut doAA-n for the trunk of the carotid artery, I Avould
turn the chin towards the same side, and then make an inci-
sion three inches  in length  along the  anterior edge of the
sterno mastoideus muscle.   In doing this, the firm cellular
membrane, and  some of the anterior fibres of the platysma
myoides  must be cut.   Having fairly  laid bare  the  edge  of
the mastoideus,  we ought to do no more Avith  the  edge  of
the knife ; we ought then to hold aside the mastoideus, and,
with the fingers  and handle  of the knife, dig down to the
artery, and free it from  the vein and par vagum, as we should
free the vas deferens from the rest of the spermatic cord.
  We  find a  small muscle, the omo-hyoideus passing oblique-
ly over the artery, about an inch and a half from the head
of the clavicle.  The great  internal jugular vein is  close on
the outside of the artery, the par vagum  betwixt the vessels,
the sympathetic nerve below, and close upon the vertebra-.
If a small nerve be observed running above the  artery, it is
the descendens noni. 
260    TO ITN'D THE AVOUHDED ARTERY BY DISSECTION.

  If vessels bleed in making this incision, they are muscular
branches of the thyroid artery.

        TO CUT FOR THE EXTERNAL CAROTID ARTERY.

  I have not in this place to speak of the propriety of taking
up this artery.  I describe the exact situation of it, first to
sIicav  the possibility of putting a  ligature round it; and in
the second place to give such an accuriite description of its
place, as may enable the surgeon to avoid.
  Cut through the skin from the lobe of the ear toAvards the
point of the os hyoides:  dissect through the platisma  myoi-
des ; Ave then come to the digastric muscle, Ave dissect a little
along its upper edge and  there Ave  find the  stylo hyoideus;
forcing this last muscle a little  doAviiAvard av e find the con-
tinued trunk of the external carotid artery.

                or THE THYROID arteries.

  The inferior thyroid lies in a situation not  to be tied.   It
lies near the side of the  vertebras,  where it  is,  on the  outer
side of the carotid artery, fully five fingers' breadth from the
clavicle.  It  might be sought  for directly under the'omo-
hyoidcus, and betwixt the carotid and the  anterior  edge of
the scaleni,   But in the  living body it cannot  be taken up
there,   In cutting for it,  I  cut  the sympathetic  and  the
phrenic  nerve.  It Avould be better to endeavour to  reach
the ramus thyroidius,  by turning over the side  of the  gland
Avhich lies before the carotid trunk.  By thus stretching  the
gland, Ave find the artery  as if descending from above, in two
branches, to the loAver part  of the  gland.
  It may be proposed, previous to the attempt of extirpating
the thyroid gland, to tie the four arteries Avhich supply it.
We cannot reach  the  inferior thyroid artery before it  has
passed under the carotid: the only possible way is, as I have
just said, to lift up the inferior lobe of the tumour, separat-
ing the carotid from  it; when we find the inferior thyroid 
OF WOUNDED ARTERIES.
2C1
artery rising in tAvo branches, to be distributed to the gland.
It Avould  appear that these branches Avere descending  from
the carotid, by  the  acute  turn they take dowmvards  from
their highest point on the neck.
  I hope none  of my  young  friends will  ever enter on the
extirpation of the thyroid gland from any  thing I have said
here.

              TO FIND  THE LINGUAL ARTERY.

  The lingual artery makes its great curve  (being tortuous)
immediately above the  great horn of the os hyoides; it then
passes  under the mylo-hyoideus.   Were it ever necessary to
cut upon it here, let the extreme point of the os hyoides be
the mark; for it turns  just above it to pass  under  the mylo-
hyoideus.   Cut through the platisma myoides, raise the low -
er edge of the sub-maxillary gland.
   Take care of  the nerve Avhich you see lying near it: it is
the ninth pair, and  is  betAvixt the  artery and the tendon of
the digastrical or biventcr maxilla?.

      OF THE EXACT PLACE OF THE OCCIPITAL ARTERY.
     ■
   The occipital artery is found immediately under the mas-
toid process; from  under  the  insertion  of the mastoid mus-
cle it runs backAvards, on a level  with the tip of the ear, un-
der  the insertion of the trapezius, and,  of course,  under the
superior transverse ridge of the  occipital bone.   On the side
of the  neck, the internal jugular vein is immediately under
it; it is under the origin of the  digastricus.

             TO FIND THE .SUBCLAVIAN ARTERY.

   The patient is seated ;  and the assistant  at his back, av ith
 his fingers in the cavity behind the clavicle, pushes forward
 and dowmvard to compress the artery. 
262
OF AVOUNDED ARTERIES.
   To cut  for the subclavian artery, I begin the incision an
 inch from  the inner head of the clavicle; I carry it in a di-
 rection slightly  deviating  from the line parallel with the
 clavicle, towards the acromion scapulas.   My second incision
 cuts the fibres of the pectoralis  major, where they arise from
 the clavicle; I here come upon a thick bed of cellular mem-
 brane, Avhich being lifted, I find- the great subclavian vein,
 with  the cephalic vein joining it; under this vein, and a lit-
 tle further backward (more under the clavicle) I feel the sub-
 clavian artery, and can put a ligature around it; the  nerves
 are behind the artery.
   N. B. If there should be a dangerous  haemorrhagy from
 the axilla,  and the patient  big and muscular, and the com-
 pression ineffectual ^ by making such an incision as is here de-
 scribed, (or perhaps somewhat  less extensive, but sufficient
 to alloAV the finger  to  go through the clavicular portion of
 the pectoralis muscle) Ave shall be enabled, Avith much ease, to
 put the point of the finger on the artery, and press it against
 the rib, until the vessel in the axilla be secured.

 THE LOWER PART OF THE AXILLARY ARTERY, OR  BEGINNING
                 OF THE HUMERAL ARTERY.

   If we have to turn up the edge of the pectoralis major, to
 tie the axillary artery, Ave find  the artery on  the inside of
 the coraco  brachialis;  the external cutaneous nerve is on the
 outside of the artery, the radial nerve on the inside and the
 muscular spiral below it; the vein is betAvixt the  artery and
 the muscle  ; higher up in the axilla  the artery is involved in
 the plexus.
   I need not repeat, that in these  descriptions of the  exact
seat of the  arteries I intend that they should enable the sur-
geon to avoid them, as Avell as to cut upon them and take them
up.  By attending to the above circumstances I cut a ragged
ball out from behind the artery  and nerves without hurting
either. 
                 OF WOUNDED ARTERIES.              <*05

         THE HUMERAL ARTERY LOAVER IN THE ARM.

   The humeral artery does not run a perfectly straight course
down the arm.  When the subjeet is laid on its back, the arm
by the side, and the palm of the hand flat upon the table, if
we push a point horizontally under the arm bone,  one  hands'
breadth  from  its head, the  artery escapes.   When  in the
same horizontal direction, tw o hands' breadth  from the head
of the  bone, the artery is transfixed.  Lower down the arm,
the artery again rises towards the fore part of the humerus.
   To find the humeral artery before passing over  the elbow
joint, we make  the patient bend the other arm against a force,
to sheAv  the expansion of the biceps.   Having marked its
place, Ave refer it to the Avounded arm, and make an incision
along the inner edge of the biceps, or rather,  we might say,
just  where it begins to throw off its tendinous expansion, that
is, tAvo fingers' breadth from the inner condyle of the os hu-
meri, and carry the knife upwards.  We do not immediately
find the artery, but the radial nerve covering the artery ; lay-
ing the nerve aside, Ave find the artery lying betwixt  its two
venae comites.

                   THE RADIAL ARTERY.

   To  find the  radial artery  in its course one third down the
arm,—cut on  the  inner  edge of  the supinator longus, first
through the thin fascia—then lift the edge of the muscle, and
under a second fascia you find the radial  artery, passing over
the tendon of the pronator teres.
   1. To take  up the radial artery on  the Avrist, we cut a
quarter of an inch from the  radial edge  of the Flexor Carpi
Radialis.  A fascia covers  the  artery here.   A small nerve
(from the external  cutaneous) runs above the fascia.   N. B.
The insertion of the Supinator Radii Longus is on the  outside,
 but flat, giving  no mark outAvardly.   The Extensor Primi
 Internodii Policis comes obliquely over the head of  the Ra-
dius, and the insertion of the Supinator. 
204
OF AVOUNDED ARTERIES.
   2. To cut for the Radial Artery, Avhen  it has passed from
 the fore part of the Avrist, we carry the knife on the outside of
 the insertion of the Extensor Primi Internodii Policis, and the
 inside of the  Extensor Tertii Internodii Policis.   BetAvixt
 these tendons the artery lies very deep, and over it the ex-
 treme branch of the Muscular Spiral Nerve.  We find the ar-
 tery going close in the notch,  betAvixt the os scaphoides and
 the trapezium.

                   THE ULNAR ARTERY."

   Ulnar Artery.  1.  In the middle of the fore arm the ar-
 tery lies  under the fascia and  under the margin of the Flex-
 or Ulnaris and Flexor Digitorum Sublimis, rather more  un-
 der the margin of the last.  To tie the  artery, Ave should
 have to cut doAvn betwixt these muscles.   The Ulnar Nerve
 lies on the ulnar edge of the  artery.

   2.  To cut for the  ulnar  artery near the Avrist.   We car-
 ry the knife upon the radial  side of the Flexor Carpi Ul-
 naris ; avc raise the fascia, Avhich binds doAvn the tendon;
 but  still Ave have  another  layer of the fascia, under Avhich
 the artery and its Vena. Comites lie.  The nerve is lying still
 more under the tendon of  the ulnaris than the artery, but
 close  upon the artery.

   TO TAKE UP THE FExMORAL ARTERY LOAV IN THE THIGH.

   See the operation  for   Popliteal Aneurism, Volume I.
 page  51.

              TO FIND THE CLUTEAL ARTERY.

   To strike upon the gluteal  artery, Ave cut in  the direc-
 tion  of the fibres  of the gluteus maximus, beginning about
 two fingers' breadth beneath the posterior spine of the ili-
"uni;  we cut through  the gluteus maximus and medius just 
OF WOUNDED ARTERIES.
265
upon the lower edge of the ilium;  we find the trunk of
this  artery rising to mount upon the back of the ilium ;  we
must observe too, that considerable branches are carried out-
wards through the muscle,  into Avhich we must cut to ar-
rive  at the seat of the trunk.
  In case  of a wound  of this  artery and  the formation of
a false aneurism, the surgeon has to push his finger  decid-
edly down upon the trunk of the artery, as it turns over  the
notch of the ilium;«<and compressing  it there,  he may gain
time to clear away the blood.

                  THE ISCHIATIC ARTERY.
                                        i
  To hit upon the  ischiatic artery as it comes out  from the
pelvis, begin the incision by the  side of the sacrum, three
fingers' breadth from the posterior spinous  process of the ili-
um ; and carry it down in the length of the fibres of the glu-
teous maximus, to the outside of the tuberosity of the ischium.
Even in a thin man, the artery lies two inches deep.   Now,
pushing in the finger as if under the sacrum, we there feel the
acute edge of the sacro-sciatic ligament; ontheloAver margin
of the sacro-sciatic  hole, (which is distinctly felt  Avith  the
finger amongst the looser parts,) the artery is felt crossing the
ligament obliquely;  near  it, upon its outer side,  are some
lesser nerves; the  great sciatic nerve  is removed an  inch
from it.

TO CUT rOR THE ANTERIOR TIBIAL ARTERY, HIGH  IN THE FORE
                    PART OF THE LEG.

   The  anterior  tibial  artery  comes  through  betwixt  the
bones, one inch beloAv the projection of the knob of the fibula.
To find it we cut through the strong fascia which is extended
betwixt the heads of the tibia and fibula; we then cut by
the  edge of the peroneus  longus, and follow the partition
fascia which is betwixt this muscle and the head of the Ex-
tensor Digitorum Communis. This partition carries us deep :
Ave find the artery lying on the interosseous ligament. 
266
OP WOUNDED ARTERIES-
   Wherever we have to pierce a fascia for such a purpose as
 this, it must be cut very freely.

 10 CUT FOR THE ANTERIOR TIBIAL ARTERY, LOWER IN THE LEG.

   To cut upon the anterior tibial artery about the middle of
 the leg, I take the spine of the tibia for my mark.   I should
 cut through the strong fascia at  such  a  distance from the
 ridge of the tibia, as to be able to carry'my knife between the
 tibialis anticus and Extensor Policis Longus.
   To cut upon the artery as it passes over the  lower end of
 the tibia to go forward upon the foot,  we  make our incision
 betAveen the projecting tendons of the Extensor Longus Policis
 and Communis Digitorum.

            TO CUT FOR THE FIBULAR ARTERY.

   It seems a shocking alternative to be obliged to saAv out the
 fibula, in order to tie this artery.  I recommend that  this
 should never be performed.
   To find this artery two hands' breadth from the heel, cut
 betwixt the Gastrocnemius  and the Peroneus  Longus, i. e. on
 the outside of the Gastrocnemius, where it is becoming tendin-
 ous ; turn up the edge of the tendon ; you then find the Flexor
 Policis Magnus covered Avith its sheath.  If you seek for the
 Fibular Artery, by going deep into the leg without piercing
 this  fascia or  sheath, you  find the Tibial Nerve, and may
 come on the Tibial Artery.  To find the Fibular, then, we
 cut doAvn by the side of the bone (fibufa) and raise the fibrous
origins of the Flexor Policis  We then find the artery by the
 acute edge of the bone, lying on the interosseous ligament, ac-
 companied only by its Venae Comites.

       TO CUT FOR THE POSTERIOR TIBIAL ARTERT.

   The Posterior Tibial Artery.  For complicated wounds in
 the sole of the foot, this artery may require to  be taken up 
OF WOUNDED ARTERIES.
267
behind the ancle joint, and before it pierces under the abduct-
or policis pedis.  We shall be directed to the exact place, by
observing the lowest projecting part of the tibia.   The ten-
dons, which run close upon the tuberosity of the bone, are the
Tibialis Posticus, and Flexor Communis ; the first lies *o
closely braced to the bone in its particular sheath, that it wiU
not be observed ; the artery runs a little nearer the heel than
the tendon of the Flexor Communis; a fascia braces down the
artery, the nerve is under the artery. 
APPENDIX.
      In the chapter of  fractured bones I have omitted to
give the varieties of fracture by gun-shot.   As it is a subject
neglected  also  by  other authors, I take this opportunity,
(though somewhat irregularly,) of remedying the omission.


  OF THE VARIETY IN THE FRACTURE OF BONES BY GUN-SHOT.

  I.  The surface of a  bone may be struck  by a ball sq
that the ball is flattened on it, and yet no exfoliation of the
bone takes place,   I cut out a  ball from  the arm seven
montlis  after it had struck  the  humerus, and although it
Avas flattened on the bone, the bone was not injured.   I have
seen the head  of the humerus struck by  a  ball, which ball
I found in the muscles of the back, as if divided, and yet
no exfoliation took place.   When the surface of a skull is hit
by  a ball, there is undoubtedly  great danger, but  still no-
thing is to be done in the  Avay pf operation ; the skull will
often escape unhurt, having  suffered neither contusion, nor
such injury of  its surface as to make it exfoliate.  My pu-
pils have  related many cases to  me where  they  have seen
the skull struck by balls  Avithout a bad symptom; but late-
ly,  I  have myself  seen three cases of this  kind, in one of
which the ball was flattened, and passed  tAvo inches  under
the scalp, and yet there  was no injury to the  skull.   How-
ever, Avhere the danger is so imminent, and where if  symp«
toins of an affection of the brain be allowed to commence,
It is so  seldom in our power to stop the progress  of suppu* 
FRACTURES BY GUN-SHOT,
269
ration, that it is of the utmost consequence to watch and to
keep the patient Ioav.
  II.  There  is a considerable difference of character  be-
tAveen the gun-shot fracture of the cranium and the fracture
from a bludgeon, or from  the head striking the ground;
the fissures do not run so extensively from the shattered cen-
tre ; the injury is more local; the fractured pieces are small-
er, and more numerous; often comminated.   In taking aAvay
these pieces  the trephine Avill seldom be necessary;  yet let
me here once more guard my reader against forcibly pulling
aAvay the pieces of the broken skull, for if he tear the dura
mater, a neAv and more dangerous case is established.
  III. WThen a ball strikes the  cylindrical and middle part  '
of a bone, it will break it into many  pieces ; but if it strikes
the head of a bone, it will enter into it. If, in putting the fin-
ger into the shot-hole, Avhere the ball has struck the centre of
the bone, many bruised pieces are found,—if the ball has not
merely hit the bone and struck off splinters, but has passed
through its substance, then, I believe, the limb must be  con-
demned, for no good comes of the attempt  to preserve it
The suppuration not  only takes place amongst the soft parts,
but in the  centre and medulla of the bone;  a bad discharge
comes from within the bone ; the shaft of the bone  dies, and a
kind of imperfect and irregular necrosis is formed.  The old
bone does not unite;  new bone is formed  round both  pieces;
the sequestra,remain loose, and yet so wedged, that it cannot
be taken out, and it is therefore a tedious  source of irritation,
and after months of suffering, amputation  must be had re-
course to.
   IV. There is a marked  distinction, hoAvever, betwixt such
a case and that Avhere the ball does not perforate the bone with
unsubdued violence,  but merely breaks the  bone ; and their
is of course a great difference betwixt the  ball perforating the
arm bone, the thigh  bone, or tibia, and Avhen the bones of the
fore arm, or the fibula, are broken.  I have seen the ami am-
putated for the shattered state of the ulna ; but I believe this
 was wrong; &p before and  since I have seen -mrse cases do 
U70
APPENDIX.
well, with but common care; nor is tlie combination of a shat-
tered radius and a torn radial artery a case for amputation.
  V.  In all cases of the ball entering the heads of bones it
does not follow that they pierce or lodge.  I have specimens
of all kinds of fractures by gun-shot, and amongst them the
head  of the humerus shattered to  pieces.   In Haslar hospital
there lay three men with the heads of the humerus shattered
by balls;  there lay many too struck about the shoulder joint.
If a man be struck on the top of the shoulder, and upon laying
the hand over the joint, and moving the arm, the bones are
felt jarring, and the bone be not merely fractured, but we dis-
cover by the finger in the shot-hole that they are crushed,  it
is a case for amputationat the shoulder joint.
  VI. When the ball enters into the lower head o£ the femur,
and lodges, we may  be long in suspense.   By and bye the
Avhole limb inflaming, and  becoming  greatly swelled, an ab-
scess forms, perhaps, in the calf of the leg v we are then tempt-
ed to think  that  the  ball has fallen down to that place, and
that the abscess being opened the ball will be found.  But I
have  twice found this  to be a  great mistake; the ball has
stuck in the bone; it is a source of great irritation ; that  ir-
ritation is not immediately shown by its  effects on the bone,
but on tlie  surrounding  soft part  of the limb, and, as I
have said, on  the  part of the limb below the seat of the
ball.   This  sAvelling and  great abscess in the leg, on dis-
section, shows  not the cavity of the abscess  formed in the
cellular membrane, but the inflammation goes so high that the
very texture of the muscle is destroyed.  Besides this conse-
quence of the injury to the bone there is  another effect to  be
taken into consideration, the swelling of the knee joint;  al-
though the capsule of the joint be not opened, yet the ball
being socketted in the head of the femur, or tibia, the effusion
of the joint will be converted into  purulent matter;  on dis-
section, after amputation from such  a cause, I have seen six
ounces of pus from the knee joint.  The ball immersed in the
loAver head of the femur followed by these consequences of
vielent inflammation,  make1? a case for amputation. 
FRACTURES BY GUN-SHOT.
271
   I know that a man has been shot in a duel, or on the high-
way, and has received a pistol-ball in the bones near the knee-
joint ;  I have been consulted on a pistol-ball lodging about the
knee;  and a case has been communicated to me of a pistol-
shot through the head of the tibia; and in all these cases the
limb was saved.   But this only shews the propriety  of the
distinction I have made, that it is not merely the lodging of
the ball,  or the transpiercing of  the  bones by the ball, but
this followed by the circumstances described, which makes
the necessity  for amputation.  The case will be essentially
changed if the wound is by a pistol-bullet, not by a musket-
ball.   The features of the case will be still  more essentially
changed if instead of the soldier being throAAn into a waggon,
or transport, Avithout medical attendance, he be laid  in quiet
and rest, and bled, and kept low, and the inflammation sub-
dued by  cold applications.   But I return to my position  by
saying, that I have seen the same case in all important cir-
cumstances, and the same necessity of amputation, from the
ball lodging in the head of the tibia, that I have described as
proceeding from a ball piercing the femur.
   VII. It must be remembered, that when inflammation has
arisen, and the whole constitution has sympathized with the
injury of the  part, it is more difficult to controul it than it is
to ward off inflammation, and save the limb, when we receive
 the patient before it has commenced.  If in such a case as 1
have described above, we are enabled by bleeding and cold to
 keep down the rising inflammation, yet the constitution is alive
to this impression of injury, and  the patient may suffer from
 6evere and threatening spasm ; but after the full and repeated
 evacuation an aromatic and an opiate have the most soothing
 and agreeable effect.
    VIII. In the examples which I have of balls that have en
 tered  the heads of bone6, and the  body of the vertebrae, there
 are none of them changed in figure.  I knoAv this does not ab-
' golutely follow, yet when we have to extract a ball from the
 centre of a bone, we may expect it to bi still a ball, whereas if 
272
APPENDIX.
it has struck a bone and glided amongst the  soft parts, L*.
scarcely ever keeps its regular figure.
   If, hoAvever, a ball strikes and splinters a bone, and  theu
lodges again, the probability is, that the lead Avill be quite ir-
regular, or ragged.  For example ; a ball has entered on the
Avrist, fractured the radius, passed out  of the fore  arm, and
entered again into the arm, or the axilla, or side ; we  need
not search for a ball, but a piece of lead.
   I have found the lead as irregular as  *f it.had been melt-
ed and cast into water.   In searching for the ball it may be
thought  very easy to distinguish betAvixt the surface of the
lead and the bone, but it is not always so; I have seen three
experienced and good military surgeons tug in succession on
the bone itself mistaking the edge of the perforated bone for
the ball.
   IX.  When a ball has entered and is lost, and Ave know not
the course it has  taken;  if suppuration  takes place  over the
surface of a bone, Avhich bone is in the probable track of the
ball, there is a strong probability that  it lodges there.   In
this case it is not the presence of the ball, so much as the in-
jury committed on the bone which is the cause of the  sup-
puration.   A man being shot in the fore part of the chest, a
suppuration above or under the scapula  implies that the sca-
pula is struck.  I have seen a Avound in the back Avhere  sup-
puration over the  sternum declared that the ball had stuck
in if, after passing through the  chest.
FINIS. 
 
 
Ma.. Hist,
   WZ


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