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THE
PRINCIPLES
OF
SURGERY.
By JOHN BELU burgeon.
               ABRIDGED BY


        J. AUGUSTINE SMITH,

OF THE ROYAL COLLEGE OF SURGEONS, LONDOV, AND
 PROFESSOR OF ANATOMY, SURG! RY AND PHYSIOLOGY
      IN THE COLLLGE OF PHYSICIANS AND
          SURGEONS  IN THE UNIVER-
            SITY OF THE STATE OF
h'T-1^"   '
"0^1
\
SECOND EDITION WITH NOTES AND ADDITIONS.
            NEW-YORK :

PRINTED AND SOLD BY COLLINS & CO. NO. 189,
            PEARL-STREET.
1S12. 
     Dijirict of Neiv-Yori,f>.

            JLjE  IT REMEMBERED that on the twelfth day of December, in
           the  thirty fixth  year of the Independence  of the United States of
  (L. S.)  America, Collins & Co. of the faid Diftrid, have depofited in  this
           office the title of a book, the right whereof they claim as proprietors,
           in the words following, to wit:

  " The  Principles of Surgery—By John  Bell, Surgeon—Abridged by J. Augustine
Smith, of the Royal College of Surgeons, London, and profejfor of Anatomy, Surgery and
Physiology, in  the College of  Phyficians and Surgeons in  the Un'foerfity of the  State
of Nciv-York—Second Edition, ivith Notes and Additions.'

  IN CONFORMITY to the  Ad of the Congrefs of the United States, entitled,
" An Ad for the Encouragement of  Learning,  by fecuring the Copies of Maps,
Charts, and Books,  to the Authors  and Proprietors of fuch  Copies, during the
time therein  mentioned;" and alfo ro an Aft, entitled, "An Ad  fupplementary
to a;. Ad, entitled, An Ad for the Encouragement oi Learning, by fecuring the
Copies of Maps, Charts, and Books, to the Authors and Proprietors of fuch Copies,
during the times therein mentioned, and  extending the benefit^  thereof to the Arts
of Defigning, Engraving, and Etching Hiftorical and other Prints."
                                                CHARLES CLINTON,
                                        Clerk of the  Difrict of New-York 
EDITOR'S
PREFACE.
 1 HE great celebrity and acknowledged merit of MrV
John Bell's  Principles of Surgery,  render  it
entirely unnecessary for me to say  any thing in their
praise.   In the Edition of them  now presented to the
public,  care has been taken to  select those parts which
were deemed most useful and important.   Mr. Bell's
descriptions of diseases and operations, which are un-
rivalled by any modern surgical  writer in  animation
and  effect, are  retained  almost  verbatim, and where
they were thought not sufficiently full  and minute,
the  additions  which were deemed  requisite  will be
found in  a note distinguished by the  letter S, at the
foot of the page.   Where  I have differed in  opinion
from Mr. Bell on a point  of  practice,  his opinion  is
stated in the text, and mine in a note, so that  the reader
can adopt that which he may think preferable.

   Since the chapter on Adhesion was printed,  I have
read Mr. Young's animadversions  upon  the practice
there recommended by Mr. Bell, but think no further 
IV
PREFACE.
 cautions necessary with regard to the use  of sutures in
 promoting the re-union of divided surfaces.

    Since the publication of the first volume of the Prin-
 ciples of Surgery, Dr. Jones has written a most valua-
 ble work on Haemorrhage ;  in the Appendix the reader
 will find an account of his discoveries and observations
 on that subject;  and in the third number of the New-
 York Medical and Philosophical Journal  and Review,
 a most ingenious defence of Mr.  Bell, by Dr. Davidgc
 of Baltimore.

   Since that period also, the celebrated Scarpa has writ-
 ten a work upon Aneurism,  in which he differs from
 Mr. Bell, and indeed all his  immediate predecessors,
 as to the manner in whfch these tumours are formed.
 Appendix D will enable the reader to judge of the cor-
 rectness oi  Scarpa's doctrine.

   I have deemed it unnecessary to transcribe Mr. Bell's
 observations intending  to  prove that the inosculating
 vessels  are  sufficient to  support a limb  when the main
 artery is tied, as no  Surgeon is now deterred by the
 fear of mortification from tying any accessible artery
 in the human  body.  Three  instances of this have
 however occured, two are related in  Wishart's appen-
 dix to Scarpa, and one  in the  Medical and Physical
 Journal for April  1800.

   With regard to the best method of treating fractures
of the low?r  extremities, I never doubted that a state
of fl« xion and consequent  relaxation of the  muscles
during the tendency to inflammation, was the best po.. 
PREFACE.
--  v
bition in which they could be placed, until I understood
that Dr.  Physick  entertained a different opinion and
taught a contrary practice.   So  great is  the deference
which I pay to the judgment of Dr.  Physick,  that  I
am now not without my doubts on the subject; as how-
ever I have uniformly practised the plan recommended
by  Mr. Bell, and have never seen any ill  consequences
from it, I have deemed it unnecessary to state any ob-
jections to his mode of treating  these accidents.   But
where the thigh-bone is fractured at its neck or near its
trochanters,  then undoubtedly the straight position  is
the best, and Boyer's apparatus* I should think superi-
or to Desault's ; either, I am  afraid, would  fail in  a
strong muscular subject, the latter certainly has.f

   Mr. Bell gives the diagnostic symptoms and appear-
ances  which distinguish  fractures of the neck  of the
thigh-bone from luxations of the hip-joint,  but  says
nothing of the method  of reduction to be employed in
this latter case.   In the appendix G, the reader will-
find directions for that purpose.

   * For a description and plate of this apparatus, the reader may
 consult Boyer's Lectures on the Bones, translated by Fane!, Havts-
 horne's edition, p. 124.
   11 cannot speak of this machine from experience, not having met
 with a case since I procured one of them.   There  is a case related
 in the third Supplement to the Medical and Physical Journal, of com-
 plicated fracture of the trochanters, where this machine was used,
 in which the fractured portions were found in apposition after death.
 This proves nothing.  There can be  no difficulty in overcoming
 the action of the muscles, in a debilitated patient and one dying
 from mortification and diarrhoea, so that the fractured bones should
 he found in their natural position after  death. 
VI
PREFACE.
  I have retained all that Mr. Bell says upon the symp-
trnis of the stone, on which he is perhaps  rather con-
cise, but I thought  there was no occasion for making
any further observations upon them as the distinct per-
ception of the stone, by the sound, can alone warrant the
operation  of Lithotomy.   I  have  omitted the history
of the operation and the various ways  of performing it,
convinced that the Gorget is the best instrument and
the • .mly one which moat Surgeons will use.   As to its
occasionlly passing  through the fundus of the bladder,
or between that viscus and the rectum, the former  oc-
currence is certainly very rare, and both are to be attri-
buted to the operator  rather  than  to  the  instrument.
And v hat mischief would  not that Surgeon do who
should attempt to cut for the stone with the knife alone,
v  en he was incapable of passing the Gorget into the
bladder ?

  It is unnecessary for me to point out all the omissions
which I  have made.   They will be  found to  consist
principally of histories, anecdotes,  and operations, and
machines now no longer in use.   Some apology may
be thought due to Mr. Bell for thus abridging his work,
but when it  is remembered that his object in writing
musthave been the benefit of his profession, and through
it the good of mankind, he can not be offended  at hav-
ing his fame and usefulness thus diffused through this
extensive country. 
CONTENTS.
DISCOURSE  I.
                                                      Page

Uf Adhesion.......     .     1
Of Sutures       ......       3
Rules for the re union of wounds of the Skin       .       .      5
Rules for the re union of oeep muscular wounds      .       .   7
Rules for the re-union of complicated wounds, where there
    is a  wounded artery or fractured bone       .       .       8
Of cutting out the stitches         .       .       .       .10
Description of those wounds in which adhesion is not easily
    obtained, and of the accidents by which it is prevented      ib.

                     DISCOURSE II.

Of ill conditioned and complicated wounds       .      .       12
Of ulcers       ......       20
Of Hospital sore or gangrene      .       .              .25

                     DISCOURSE  III.

Of the various uses of bandages      .      .       •    .    3®
Of the four-tailed bandage       .       .             .       37
Of applying a roller to the  head and jaws       .      .       $9
Of bandage for the body        .       .      .      .       41

                     DISCOURSE  IV.

On hsemorrhagy       .       .       .      .      .       43
Of the natural causes by which an haemorrhagy is stopped       44 
Vlll
CONTENTS.
                                                       Page
Of the artificial means of suppressing haemorrhage              45
Ol the condition of an artery when tied with a ligature          48
Of the causes of secondary hamorrhagy, and first of the burst-
    ing of the artery from the diseased state of its coats         49
Of the bursting of the artery from ulceration of its coats        51
                      DISCOURSE  V.


Description of aneurism        -       -      -      -       55
Of various anomalous cases of aneurism         •       •       65
Aneurism from fracture of the bones       .       •       .67
Peculiarities of popliteal aneurism        .       •       •       71
Of the progress of aneurism and their cure      •       •      73
Hunter's operation       .      .      •      •       .76
                     DISCOURSE VI.

Of the formation of an aneurism over a wounded artery    .    7*
Of the operation for such an aneurism       •       •       .79
Rules of practice        .....       84
                     DISCOURSE VII.

Of wounds of arteries       -       •       •       .       .85
Of wounds of superficial arteries        ...       86
Of an artery wounded with a lancet       ...      92
Of aneurysmal varix       .....     93
Of obuque wounds of arteries       .       .       .       .95
Of wounds of the thoracic artery      .      .      .       101
                    DISCOURSE VIII.

Of aneurism from anastomosis      .       .       .    .    102


                     DISCOURSE IX.

On fractures of the limbs       .       .       *       .       m
OT'he fii.suion of callus      •       •      •       .      ib.
Definition of Fractures       .      .                       lie 
CONTENTS.
DISCOURSE X.
                                                        Page
Rules for the management of simple,  compound and gun-shot
     fractures       .       •       •       •       •       .121
Of simple fracture       .      •       •       •       .123
Ofthe fracture of the humerus     •       •       •       •     ib.
             of the fore-arm.....124
             of the clavicle   ....       125
             of the sternum.....l26
             ofthe ribs      ......     ib.
             of the spine       •       •       •       .127
             ofthe lower extremity    .    •     •     •     128
             ofthe thigh       .       •       •       .129
             ofthe patella      •       •       •       .132
             of the olecranon     •    •    •     •     •     133
Rupture of the tendo achillis    .     •     .   .  .     .       134
Concluding observations on simple fractures    .    .     .136
Rules for compound fracture       .     •     •    •     •     138
Of gun-shot  fracture........145
Of complicated fracture      .       •       •       •        147

                     DISCOURSE XI.

On the accidents and diseases of the hip-joint    .    .    •   150
Diagnosis of the various affections of this joint    .     .       ib.
Of luxation ofthe femur downwards  .    •     •     •     .158
Of luxation of the femur upwards      .    .    .    .    .   162
Pathology of the diseased acetabulum       .      .       .163
Of the scrofulous disease of boys, affecting this joint   .    .   164

                     DISCOURSE XII.

Oflithotomy  ....••       171
Of the external incision       .       .      •      •       179
Of cutting the urethra.......181
Of introducing the gorget......182
Of extracting the stone       ......183
Of the causes of the slipping of the gorget    .     .     .     184
Operation of lithotomy    *......188

                     DISCOURSE  XIII.

Of obstruction of urine.......192
Of introducing the catheter        •              •            ib 
CONTENTS.
DISCOURSE XIV.
 Of the various causes of obstruction of urine
 Of stricture
 Of fistulas in the perineum and urethra
 Of the causes of fistula:
 Of the cure of fistula

                     DISCOURSE XV.

 Of total obstruction of urine and puncturing the bladder
 Of distention and rupture of the bladder
 Of the several methods of puncturing the bladder
 Of puncturing above the pubes          ....
 Of cutting into the bladder from the perinaeum
 Of passing a trocar into the bladder from the perinamm
 Of tapping the bladder  from the rectum  ....
 Of forcing the catheter into the bladder

                     DISCOURSE XVI.

 On the anatomy of the cranium, and the rules of practice to
     be deduced from it       ....       243
 Of trepanning the frontal sinus        .       .       .       251

                    DISCOURSE XVII.

 Pathology ofthe integuments, scull and dura mater
 On the vitality and connections of the scull
 Of injuries of the scalp
 Of separation of the dura mater
 Of contusio cranii       .....
 Of suppuration of the brain      ....

                   DISCOURSE  XVIII.

Of fractures of the scull......301
Of fractures of the scull with depression     .    .     .     .312
Of cases requiring  the trephine and lever   ....   327


                     DISCOURSE XIX.


On the states of concussion and depression       .       .     343
Of concussion     .                    ....     345
Ofcompression           ••••...   343
  Page
   199
    ib.
   209
.   210  .
.   220
224
226
232
233
234
2o7
239
240
256
 ib.
259
274
280
291 
                       CONTENTS.                       xl

                                                     Page
Of the operation of the trepan      ....  360
Aphorisms or rules of practice            .              .   366

                    DISCOURSE  XX.

On Tumours       .       ....       373
Ofthe parts most subject to tumours      .      .       .   376

                    DISCOURSE XXI.

On tumours ofthe bones       ....      383

                   DISCOURSE XXII.

On tumours of the nostrils, gums and throat       .       .   405

                   DISCOURSE XXIII.

Of the various operations practicable in the several stages
    of polypus       .....       427
Ofthe first stage or small and incipient  polypi       .      .   ib.
Of the  second stage of polypus, or  of large and guttural
    polypi      ......    439
Of the third and last stage of poly pus      .      .    .    465

                   DISCOURSE XXIV.

Of tumours of the gums, lips, cheeks and throat       .    .   472

                    DISCOURSE XXV.

On salivary tumours       .             .      .       .521


                       APPENDIX.

                            A

Of the process employed by nature in the suppression of
    hemorrhage      .      .       ■       .      .     551

                            B

On the effect of ligatures upon arteries              .    .   553 
xii                        CONTENTS.

                              C

                                                         Pag©
Further observations upon secondary haemorrhage      •       553

                              D

Scarpa's doctrine with regard to the formation of aneurisms     555

                              E

Further observations upon the same subject       .       .     559

                              F

Directions for performing the operation for popliteal aneurism   560

                              G

Directions for reducing luxations of the hip-joint     .     .     561 
PRINCIPLES
OF
SURGERY.
DISCOURSE  I.
                       SECTION  I.


                       Of Adhesion.


 JL HE modern doctrine and practice of procuring adhesion, for
which we are more particularly indebted to Mr. Hunter and the
London school, has done more for Surgery in a few years, and
most especially for the Surgery of Wounds,  than any other ge-
neral  observation, not excepting  even the greatest of all disco-
veries, the  circulation of the blood.  It  is now  well proved,
that skin will adhere to skin, flesh to flesh, bone to bone, and all
these parts to each other.   One part only of  the human  body,
cartilage, will not adhere.  I have seen many proofs that carti-
lage does not inflame, nor ulcerate, nor  give out granulations,
nor generate new  flesh ; or, at least it does so  very slowly :  a
wound freals over a cartilage without adhering to it.  We am-
putate a toe at  the joint, and the flaps unite in two days ; but
still they have united  with each  other only,  and not with the
cartilage at the joint: and in a luxated limb, we find that the
bone continues displaced, the cartilage never inflames, nor ever 
2
Of Adhesion.
unites with the lacerated parts, for the process  of adhesion is
really this : either the arteries of opposite surfaces inosculate
mouth to mouth, or each cut surface thx-ows out a mucus, into
which the lesser arteries of the divided  part  elongate them-
selves ; and it is thus, or perhaps by the generation ot a new in-
termediate substance, that the continuity of the part is so quick-
ly restored.   If any one point fail to adhere, there the wound
must run into suppuration, because at that point there is a sepa-
ration of parts, which, being equivalent to a loss of substance,
requires the generation of new flesh.
   When the opposite surfaces consent and harmonize with each
other in their  mode and period of action, then they immediate-
ly adhere ; but if one of the opposite parts enters instantly into
a lively action,while that of the other is comparatively languid,
such parts do not harmonize, and consequently will not unite ;
but they may live and thrive independently of each other; and.
perhaps in this way it may happen, that opposite  surfaces  of
skin or muscle may  seem to be adhering firmly  to the parts be-
neath them,  while they adhere to each other only, and  merely
cover the cartilage or  bone, without having any direct connex-
ion with them.   The bone, as we see in an old amputated limb,
lives and thrives, is not limited in its new formation by the ad-
hesion  of surrounding parts, but grows out into a broad knob'of
callus or new bone.  Cartilage also, as in an amputated or luxa-
ted joint, retains its pure and lubricated form.
   There are, no doubt, accidents both of the constitution and of
 the wound which will prevent adhesion; for if the patient be of
 a bad habit of body, if he be lying in a foul hospital, and breath-
 ing infected air, if he be ill of a fever or a flux, or  any general
 disease, then the powers  of his system  being debilitated, his
 wound will  not adhere ; or if the wound be foul, made with a
 poisoned weapon, or left with foreign bodies sticking in it; or if
 blood be poured out into the cavity  of the wound, for blood in
 this case is but a foreign  body*, or if there be a wounded lym-
 phatic, salivary duct, or intestine, or a bleeding artery or vein—-
 any of these causes will prevent an immediate adhesion of the
 wound : or if it be a bruised or gun-shot wound, and there is a
 destruction of parts, the loss must be supplied, and those parts
 which remain must enter into a new action for that purpose, and
  consequently cannot adhere.
    This adhesion,  then, is a property of the parts of the living


    * If the extravafated blood be in reality a foreign body, how can it ever become
  the medium of re-union between the divided furfaces, which it certainly  does in
  fome inftances ? For a much more ample and fatisfadtory account of adheCon be^
  ^ween divided furfaces,  vide Hunter on the Blood, p. 189, and feq.  S.        - 
Of Sutures.
-3
 body, which is perfect only when their structure is entire,'which
 operates  only when the opposite surfaces touch each other by
 the fullest contact, and sympathize with each other in their pe-
 riod  and degree of action.  Adhesion then is interrupted if anv
 foreign body is interposed : it is less perfect in every unhealthy
 condition of the system, but it is  a property of which we are
 now  so weil assured, that we look for its good effects in the
 greatest  as well as in  the smallest wound, and the union of an
 hare-lip,  after it has been cut and pinned, represents the perfec-
 tion of that cure, which we attempt in every greater operation,
 and more confidently in every smaller wound, succeeding some-
 times as perfectly after an amputation of the thigh as  alter the
 most trivial cut in the cheek.
   This property of re-union between divided parts is proved by
 every day's  experience to be so perfect,  that when we do fail,
 which no doubt is sometimes owing to a bad habit of body, we
 have some reason to suspect some negligence on our own part,
 some extravasated blood, some open  artery,  some portion of
 detached bone  left in  the wound, or some  awkward piece of
 dressing laid in betwixt its edges ; we have reason, in short, to
 blame the want of that absolute contact which is so essential to
 perfect adhesion, as every part of a wound  which does not
 touch some opposite surface, must suppurate before it can heal;
 and this is my chief motive for  putting down carefully, in short
 distinct rules,  the several ways in  which the sides of a wound
 may  be brought together, so as to  adhere perfectly.
   There is no incised wound in which we may not try, with safety,
 to procure this  adhesion*:  nothing surely can be more kindly
 when applied to a wounded surface, than the opposite surface of
 the same wound.  It has been but just separated, it may immedi-
 ately adhere to it, and  though it do not, no harm is done :  still
 the wound will suppurate as kindly, as freely, as if it had been
 roughly dressed with  dry lint, or some vulnerary balsam or
 acrid ointment.

                        SECTION  II.

                        Of Sutures.

  For the purpose  of bringing divided surfaces  into  contact,
 surgeons employ what are termed sutures : these are either dry
 or bloody : the  former are made with sticking  plaster, the lat-


  *  In injuries of the head, this rule fhould not be too ftridly obferved.  Read
%\ hat is faid upon that fubject in the Chapter on Injuries of the Head. S. 
4
Of Sutures.
 ter with needles and  thread.   The dry suture is made some-
 times  with gum, as  in  our common court-plaster, which is
 merely gum arabic, with a little laudanum added to it, spread
 upon black silk.   The older surgeons often used glue, some-
 times whites of eggs,  for we find that their agglutinative plasters
 took  two hours in  drying,  which shews that they were made
 merely of glue.  But  these are dissolved by the moisture which
 flows from a great wound, therefore in amputation and all great
 wounds, we are obliged to betake ourselves  to adhesive plas-
 ters, made of wax,  resin, and oil*;  though straps of that kind
 are far from being pleasant to use, for they  must be applied ex-
 ceedingly warm, and the slightest degree of moisture on the ad-
jacent skin prevents their adhering.
77V",V  f>    /
mv
  The bloody suture is of various forms, the first the inter-
rupted suture, (Fig.  1st.) when in place of making the stitches
close, and continuous, as in a seam of cloth, the surgeon just pass-

  This plate reprefents the various futures ufed by the modern furgeon and  as
each future is defcribed, the particular figure in this plate explaining fuch future
will be marked.                                      °
  • By far the beft adhefive plafter, for all purpofes, is the Emp. Lythargyri cum
refina of the Pharm. Lond. S.                              6' 
Of Wounds ofthe Skin.                  5
ed the needle once through both lips of the wound, taking care that
the needle passed as near the bottom  of the  incision as pos-
sible, tied the ligature and cut the ends away, and repeated the
stitch from point to point,  all along the  wound: the several
stitches are usually about an inch distant from each other, care be-
ing taken to put one at every angle ofthe wound.  From this it
was named the interrupted suture, and is almost the only one
of this  class now  employed.    Some surgeons  yet  retain the
hare-lip suture, as it is called, from being principally used after
operating tor that deformity.   It is  made by thrusting pins or
needles through both lips of a wound, and twisting a fine thread
around  their projecting  ends; whence it  is often named the
TWISTED  SUTURE*.
                        SECTION  III.

        Rules for the Re-union of Wounds of the Skin.

   In all  cases  where the divided  edges of  the skin  can be
brought into  contact, and retained so by sticking-plaster and
bandage, they are to be preferred to ligatures, as the latter, act-
ing as extraneous bodies in the wound, always excite some de-
gree  of inflammation;  but  they  answer  the  intention with
which they  are used much  more certainly than the former;
particularly in many parts  of the face, to  which  bandages  can-
not be applied with any considerable  effect, and the  adhesive
plasters alone are not sufficient where the parts have a strong
tendency  to retract.  The manner of  applying the plaster is to
have it nicely spread upon strips of soft  leather or linen,  and
upon this much depends;  after the wound has ceased to bleed,
and the skin on each side  is wiped dry, an assistant draws the
edges into accurate contact, and the surgeon  applies the  plaster,
previously warmed over a chafing dish of coals, first on one side,
and waiting till it adheres, draws it with moderate force, and at-
taches it to the other.   Successive strips are  to be applied, until
the wound is covered,  so that the edges may be kept in  contact
throughout its whole length.
   In cuts ofthe lips or cheeks, much neatness is required, as
indeed in all sutures; but here especially, since a slight irregularity

  * I have drawn two figures, one to fhew the proper manner of putting in the
pins, the other to fhew a very common error, which is, often  as in fig. 3, the lower
pin is put in a little above the red part of the lip, a confiderable part of which
lails to be re-united: but in fig,  2, 1 have fhewn the loweft pin introduced as it
fhould be, ftuck through the loweft point of the lip,  and introduced firft fo as to
fecure the oppofition of the loweft points of the cut edges, for on that chiefly de-
pends the deformity or neatnefs of the fear. 
6
Of Wounds of the Skin.
in the lip is a great deformity, and a great reproach to the sur-
geon.   In the lip we can have no security  but  from the firmest
kind of suture : the lip hangs loose, and is  quite unsupported on
its inner surface ; it is very dilatable ; it moves with the slight-
est motions ofthe mouth or jaws;  or it is so  strongly retract-
ed in laughter and other emotions by  the muscles of the cheek,
that it must be particularly weli secured.    Though some have
pretended to re-unite the hare-lip by plasters, I know that even
in a  grown  person nothing will secure it but the pin.   In acci-
dencai cuts  we  operate exactly as  after operations for hare-lip
or tor  ;ancer.   We  take the pin, fixed in the instrument, called
port?, -aiguille, in  the  right hand, and holding  the edges of the
lip together with  the fingers  of the left, transfix both lips with
the pin, at points exactly opposite to each other, pushing the pin
with the right hand; and  resisting  and managing the lips with
the left hand, we  pass two pins*, one exactly in  the tip of the
lip, through the red and fleshy part,  for that secures the even-
ness and just form of the lip, and  another through the middle
of the  iip, and then twist a wax thread round both pins firmly,
but ger.tlv, in  the form of a figure of 8f.
  The pin should be drawn out the second day ;  they are usu-
ally left too long, and the tension of the pins occasions a suppu-
ration, a puckering of the wound, and a visible  scar.    Pins are
recommended in other wounds  of  the face, but are in no case
except in the single one  of a divided lip, equal to the interrupt-
ed suture   Where pins  are used, I think  common  sewing
needles, or those used by glovers, which have triangular edges,
are in all cases superior  to the gold pins.    When you are going
to use the interrupted suture, let your needles  be smaller and
nicer than they are usually  made, less curved,  and flat, with
two  very fine cutting edges; let your threads also be smaller
than they are commonly used, and let them be  a little waxed in
order to flatten them and unite the two threads, but draw them
aft rwards through your fingers dipped in oil, in order to make
them glide through  the flesh.   Allow the bleeding to cease en-
tirely : if it do not stop, use an astringent, as vinegar and water;
make a stitch  of the needle at each angle  of the wound ; repeat
them one for each irich in length of the wound; draw them un-

  * Three pins or flitches will be generally required: as many mult be employed
as will bring the parts into accurate contact.  S. "
  f In operating for the* hare-lip, it is neceffary in the firft inftance to remove all
the fkinut the edge ofthe cleft. The piece of fkin taken off refembles the letter
^ inverted. Pins or  needles are by no means neceffary for this operation : the
interrupted future is I believe in more general ufe : it is the method 1 have uniform-
ly feen employed by others, and it is the one which I have always praclifed with
fuccefs.  8. 
Of deep Muscular Wound's.
7
   ill the edges are brought into contact ; cross each intermediate
m  space with a  strap of sticking-plaster ; over the  whole apply a
   bandage, if one can be  adapted to the part,  so as to aid in keep-
   ing the wounded surfaces in contact.
     Although the lip, nose, or any other part be almost entirely
   cut off, if there be the smallest portion of flesh connecting it to
   the general system,  you are not to despair of re-uniting it;  for
   this purpose you will retain the newly divided piece in its natural
   situation, by the means above pointed out.   It is wonderful how
   parts will re-unite after they seem to be irrecoverably separated,
   and deprived of any adequate supply of blood*.
     If the  tongue be partly cut across, as  by falling  on the  chin
   when it is lolling out, or by being caught between the teeth,
   in convulsions, the part which is divided may be joined by
   a stitch ofthe needle.

                           SECTION  IV.

         Rules for the Re-union of deep Muscular Wounds.

     In deep muscular wounds we are obliged to rely principally
   upon compresses and  the uniting bandage, for stitches can re-
   tain the edges only of a wound in contact^, even this however is
   of use ; they should therefore be employed, although it will  be
   frequently necessary to cut them  out,  in  consequence of the.
   violent inflammation  or  some unfavourable symptoms "which
   may supervene^.   But you are to recollect that you do not sew
   such wounds with the expectation that the divided  parts will
   adhere, but if you can keep them nearly in contact for 24 hours
   or a little more,  they inflame, they are thickened, blood and
   lymph are extravasated, the cut muscles adhere to the parts un-
   derneath, and though no union takes place between themselves,
   they cannot retract.   By this alone a great advantage is gained,
   for if you allow the muscles to retract while they are bleeding
   and  moveable,  and let them continue so till the wound is stiff

     * Even  if a part  were entirely feparated, if called to the cafe immediately, the
   furgeon mould endeavour to re-unite it.  Adhefion may take place, and fhould it
   not, the attempt can be of no injury to the patient.  S.
     J This point is well illuftrated by the cafe of a foldier, who being wounded at
   the Corps de Garde, acrofs the fhoulder through the belly- of the deltoid mufcle,
   his furgeon fewed the wound that night with many deep flitches: thafe Mr.  Pi-
   brac was next morning obliged to cut on account of convulfions of the arm, which
   ceafed the moment he had done fo.
                                     Memoires de.L' Academie de Chirurgie.
     f If flitches are ufed at all, I think they fhould pafs to a'confiderahle depth, and
   fhould they caufe convulfions or other unfavourable fymptoms, they fhould be im-
   mediately cut out.   S. 
' S                 Of Complicated Wounds.
 and inflamed, they become fixed in that position, and  will con-
 sequently heal with a gap; and besides betng weakened by loss
 of substance, their action is still more impeded by their being fixed
 to the skin and the parts beneath.   If the wound then be broad,
 you must sew it  with such stitches  as its size and the mass of
 parts you have to support may require, aiding your  ligatures
 with plaster,  compresses and bandage.   But if the wound be
 exceedingly deep, as that made by the stab of a sword, or of a
 pike or bayonet, you must not think of stitching it, for the mouth
 of such a wound  bears a very small proportion to its size :  you
 squeeze it, wash it, and trust entirely to the compresses, one of
 which you put upon the mouth of the wound, and should the
 blade have passed slantingly along, you must lay a long  compress
 wherever you think by means  of it you can put the sides ofthe
 wound in contact with each other.    Gentle pressure is here pe-
 culiarly useful.  This is a proper case for the uniting bandage**

                         SECTION v.

 Rules for the Re-union  of Complicated Wounds, where there is
           a Wounded Artery  or Fractured Bone.

   In wounds in which large  arteries  are divided, the first thing
to be attended to is the  securing of the  bleeding vessel, by
means of ligatures ;  and after the   flow  of blood is entirely
stopped, you close the  wound,  and dress it as above directed ;
taking care to leave the ligatures hanging out at its most  depend-
ing angle.  Complete adhesion cannot be here expected,  as  a
slight  suppuration will  always  take place around the ligatures ;
but if the cut be extensive, adhesion  may take place to a consi-
derable extent, which will  very much  expedite the cure : the
ligatures may be easily taken  away in  a few days.
   When the  bone is broken or cut,  still we  pursue our great
general intention  of re-uniting the divided parts ;  we return the
bone into its place if it  projected,  stitch  the skin over it, draw
together all the open spaces with slips of adhesive plaster, and
dr,'.ss the wound with lint moistened with camphorated spirits ;
th-.jn apply a roller, with moderate firmness, about the part, in
order to keep all  firm ;  and finally, if it be a limb,  lay it as you
would do if it were fractured^.  The great object to be kept

  * Vide Difcourfe on Bandages, fig. n.  The uniting bandage is there reprc-
fented as applied to the forehead, but it is a bandage more appropriated  to the
 limbs or body.
  f This fubje&is treated more at large under the head of Compound Fracture,
—Which fee. S. 
Of complicated Wounds.                  9
 m view, is to put the divided  portions into contact, and to re-
 tain them in that position.   The same plan is  to  be pursued
 where a joint is laid open, even though the integuments should
 be greatly bruised and lacerated: try at least to save the limb ;
 the attempt  can do  no harm*.
   But there is one  case, and perhaps one only,  where adhesion
 is physically  impossible ;  and that  is   the case of gun-shot
 wounds; for the parts are not hurt and lacerated merely, but they
 are so bruised by the ball that they are killed, and a partial gan-
 grene and sloughing must precede their  cure.   It is only after
 the sloughing, and  during the granulation of the wound, that
 the parts can adhere; and the adhesion  dots not take place at
 once, but slowly and successively.  But we  have  every mo-
 tive,  especially  where  flaps of skin or  muscle are  torn up by
 shot  or splinters, to bring the  parts closer and closer, as  the
 sloughing proceeds, in  order to give each point, as it resumes
 its healthy action, a chance of renewing its connexion with  the
 sound adjoining parts; and thus there were certain cases, where
 a judicious surgeon, departing from the established  rule, will
 venture  to put a  stitch in even a gun-shot wound, drawing up
 the points not so firmly and closely as in  other cases, not with
 any expectation  of  the  wound's uniting  by adhesion  at  those
 points where it is sewed,  but with the design of merely sup-
 porting a flap, in order to preserve it, and keeping it nearly in that
 direction, in which  he would like it should adhere;  for it does
 adhere in  the  second period of the  cure, when sloughing is
 over,  and the  parts begin to re-unite.
   Even in wounds of the  belly and breast, it  is adhesion of
 the parts inwardly wounded which saves the patient:  it is quiet,
 perfect silence  and composure,  and the natural powers, that
 bring about  this adhesion.    You bring the  lips of the  wound
gently and softly together, and retain them so: you wait pa-
tiently the event of  this natural process :  you can do little to
assist, but you must do nothing to  disturb it.  Many a patient
died,  in consequence  of the older  surgeons thrusting lint into
the wounds of  the large  cavities : and even now,  we are apt to
do harm, by the unmeaning  and too curious probing of  such
wounds.
  * When the knee-joint has suffered compound luxation, it forms an exception
to this rule.  Under these circumstances, there is little prospect of union by the
first intention.  I should therefore advise the amputation of the limb, for fear
the patient should die from the symptomatic fever,  which would probably  ensue.
Amputation,  indeed, would afford no great chance of recovery, as a vast ma-
jority of those,  whose limbs are taken off immediately alter  an accident, die.
For this reason,  among others, 1 would always endeavour to save a patient wlv.
bad a compound luxation of the ankle-joint.  i>.
                              B 
10               Of cutting out the Stitches.
                        SECTION VI.    /,

                 Of cutting out the Stitehes.

   Adhesive inflammation is attended with  but a slight degree
©f fever,  pain, swelling,  or redness.   Adhesion  prevents or
stops the progress of inflammation ;  for  as it was the division
of the parts which would have caused it, it  will of  course be
prevented by their re-union*.   As every part, which is not in
contact, must inflame, that inflammation  may extend to frit
parts which do adhere ; so one point left thus  separate, endan-
gers the whole, for adhesion and  inflammatory action, to any
considerable degree, are  incompatible.   The stitches, if they
are drawn too tight,  are too numerous, or made with  too coarse
a  ligature, will cause  inflammation : this will endanger the
whole, by disposing  the wound  to burst open : this may some-
times be prevented by timely cutting the ligatures.  The  mo-
ment you observe much pain or swelling in  the wound,  a sepa-
ration of its lips, the stitches tense, and the points where they
were made particularly inflamed, undo  your bandages,  draw-
out your pins, cut your ligatures, and take away every thing
like  stricture upon the wound.  These prudent measures may
abate the  rising inflammation, and prevent the total  separation
of the skin.   But should the inflammation rise still higher, and
should you perceive that  a  total separation and turning out of
the wound is inevitable, you must throw all loose, put a large
poultice around the whole, and  forsake, without hesitation, all
hopes of procuring adhesion.  As suppuration will  now come
on, after it is  completely established, and the inflammation has
subsided,  you endeavour again to  bring the edges of  the wound
together, not by stitches,  but by sticking  plaster and  bandage.


                       SECTION  v-iil  ~*  /S.

Description of those wounds where adhesion is not easily ob-
      tained, and of the accidents by which  it  is hindered.

   A wound will probably not adhere where its edges are not

  * Adhefion an-cfts the progrefs of inflammation in contiguous furfaces, as well
as in wounds.  Thus where the pleura becomes  inflamed, adhefion takes place
between it and the part with which it is in contacL; by  which means the further
progrefe of the dileafe is prevented.  For much important information upon the
fubjecT; of Adhefive Inflammation, fee Hunter on the  Blood, p. 377, Burns on
Inflammation, vol. 2. p. 7- 
Of Wounds.
11
completely opposed  to each  other, or where they have been
brought together with difficulty,  and consequently the  parts
put upon the stretch, where there is a necessity for many and
deep stitches, or a tight bandage.   When a wound is deep, it
does not always adhere.   If  there be a foreign body in it, ad-
hesion will  not often take place :  an effusion of any consider-
able quantity of blood has likewise the same effect.   A ragged
and lacerated wound, one made by the crushing of great stones,
of mill-wheels,  or other machinery, the  bite of a horse, dog,
or other animal, can not easily adhere;  because, from the ir-
regular laceration,  the  surfaces  will not  correspond.  The
manner also of uniting a wound, may be so faulty as to prevent
its adhesion ; for if it is left still bleeding at the time it is stitched,
if a piece of the skin be turned inwards when it is sewed, if a
piece of bone,  quite loose and detached  be left in  the wouud,
if the stitches be too frequent, or drawn too tight, inflammation
will  probably take place to so great a degree asto prevent union.
If,  in  addition to  the faults abovemeotioned, a  roller  be
applied too firmly  around the limb, the whole swells the  first
day,  the stitches inflame the  second,  if they be not slackened
or cut, they  burst out on  the third,  and  extensive suppuration
ensues.  But the worst case of all is,  when stitches are impru-
dently made after a  wound has already become inflamed ;  for
then, instead of abating, they will augment the inflammation.
   An unhealthy constitution  is  unfavourable to the healing of
wounds ; but under this head, I by  no  means comprehend a
scrofulous habit of body ; on the contrary we find,  that in such
habits a clean incision heals  with peculiar  ease ; but if a man
be scorbutic, syphilitic, or feverish, ill clothed, exposed to cold
and moisture, if he be laid in a foul hospital, prison-ship or
jail;  if he be a prisoner when wounded, depressed in spirit,'
weakened in body ; if he have lived long in  an unhealthy camp,
or in a warm climate ; any wounds he may have will not quick-
ly unite ; or if they have adhered imperfectly, they inflame and
burst out again the moment these  circumstances affect his ge-
neral health,  or as soon as he  is attacked with fever, dysentery,
or an old intermittent.  It is debility which causes this inflam-
mation and  bursting of wounds ; and it is  debility, either ha-
bitually or suddenly induced,  which  converts wounds into ma-
lignant sores.         (
  This reminds me of telling you in the last place, how impor-
tant it is to  procure  adhesion  in the  very  first moment of a
wound.  A speedy adhesion saves pain and inflammation, pre-
vents suppuration, wasting of flesh,  a wide scar,  and all the
other deformities and distresses of an  ulcerating wound : it pre-
vents more serious ill consequences than pain and deformity, it 
12
Of Wounds.
 prevents that bursting of arteries so apt to happen in an ulcers*
 ting sore, or that oozing of blood which is so much more diffi-
 cult to command than the most impetuous bursting of sound
 arteries, which is always an omen of something still worse ap-
 proaching.  The speedy adhesion of a wound prevents sleepless
 nights, diarrhoea, fever, emaciation, and the  accession of the
 hospital fever or hospital sore.   You do  not know, after a bat-
 tle, how soon your patient may be thrown into some foul hospi-
 tal !  nay,  even in a stationary and well regulated hospital, your
 patient may be seized  with hospital fever, dysentery, or some
 other disease.   If you once get the adhesion thoroughly accom-
plished before any such misfortune  happen, your patient is in
some degree safe ; if you neglect the first moment of the heal-
ing of the sore by adhesion, it may never heal ;  if he lie but a
few days in  an hospital with an open wound, the sore is follow-
ed with diarrhoea, foul tongue,  nausea, and thirst ; the sore de-
generates, he falls into a fever and dies ; his safety and  his life
 often turn upon this single point of procuring  adhesion.
DISCOURSE II.
OF  ILL  CONDITIONED  AND  COMPLICATED
  WOUNDS;  OF  ULCERS,   DRESSINGS,   AND
  BANDAGES.
                        SECTION  I.

          Of ill conditioned and complicated Wounds.

 A HE curing of ill conditioned wounds is a wide and important
department of Surgery ; for under this class we must reckon
almost all wounds which do not immediately adhere; all com-
plicated wounds, in which gunshot wounds are included, and
all others, in which extensive suppurations must necessarily take
place, or the part mortifies.  Whenever,  therefore, from the
nature of the accident, it is impossible to procure adhesion, your
next endeavour should be to bring  on suppuration  ;  for which
purpose you  must have recourse  to warm fomentations and 
          Of ill conditioned and complicated Wounds.         13

poultices frequently renewed.   These must be discontinued as
soon as the suppuration is  established, for after that the relaxa-
tion of parts which they induce, is highly injurious.  After pro-
viding free  outlets for the matter, a circumstance to which very
particular attention is to be paid, dress the wound for a few days
with dry lint only*, taking care to apply moderate, regular pres-
sure, by means of a roller, from one extremity of the number
to the other, if it be one of the limbs which is affected.  Should
the granulations appear pale and flabby;  should  the discharge
of matter continue, some stimulant application will be necessary
in order  to excite the  parts into a more vigorous action,  for
these are the effects of debility.  A poultice  then can be use-
ful in the first days of a wound only,  either where from the  na-
ture of the accident  it is impossible to procure  adhesion, or
where it has been vainly attempted.   Even in the case of a
common  abscess, though  we have  no application so soft and
pleasant, so effectual in relaxing the skin and promoting suppu-
ration, as a poultice,  as  soon as the suppuration is perfected,
and  the abscess is opened, the continuing the poultice (as is  too
often done) relaxes the part and  increases  the discharge.  Even
in this case, the fairest of all for using poultices, we employ them
but  for a time  and for a purpose.   While then an abscess is
forming in  a limb, which has been severely injured by some  ac-
cident, you will watch it  with incessant care;  for an abscess
which might at  first be easily cured, often by being neglected
goes down  to the bone.   At each dressing \ou feel carefully all
parts of the limb, you allow no appearance of redness,  no com-
plaint of pain, no feeling of softness to pass unobserved.   In a
disease like this,  an abscess does not project from the surface
like  a boil,  but  works downward,  among  the muscles,  long  be-
fore the part becomes  red.   This is an abscess  forming in  the
midst of a great mass  of thickening and disease ;  the abscess is
often the flattest part of the limb ; and when you feel one part
sinking below the general  level,  and the integuments becoming
thin ; when your fingers  sink into a softish hollow, which fetrls
empty, with a hard and knotty border surrounding it, you may
be assured the abscess is formed.  Then you must open it, lest
the matter sink  deeper among the parts ; you never make a large
opening, nor cut up the skin, but use, in place  of the  broad
shouldered abscess lancet, a small bleeding lancet.   Strike deep ;

  * Where the difcharge is profufe, preffed fponge is better than lint, as it more
completely abforbs the matter as faft as it is fecreted.  For the proper local reme-
dies, vide fedion on  Ulcers.   Attention muft at the fame time be paid to the ge-
neral  health of the  patient.   Bark, wine and opium,  together with a  nourifhing
diet, unlefs thty be contra-indicated by inflammatory  fymptoms,  muft be prefcri-
bed.  Without attention to the ftate'of tne fyflem, and the exhibition of the pro-
per general remedies, topical applications will be of little avail.   S. 
14-         Of ill conditioned and complicated Wounds.
     open the abscess thoroughly, but with an opening so small, that
     you need  press out the matter diligently every day.   You will
     soon discover whether  your opening be  central, and  whether
     the exit be free ; you introduce your probe, and feel whether
     there be any undermining of the neighbouring parts, any obli-
     quity of the abscess, or whether the abscess be of  such extent
     that a counter  opening  is required; you squeeze out the mat-
     ter gently, but with perseverance; and  having emptied the ab-
     scess, you take advantage of its sides being put together, and
     endeavour to re-unite them ; you fit your compress to the shape
    of the  hollow, you  make it of soft rolled lint, sometimes you
    lay on the  lint in handfuis;  you roll the  part carefully, and with
    such a degree of firmness, as keeps the  sides  of the abscess  in
    contact; though you may not procure adhesion at the first, you
    reduce the size ofthe cavity, lessen the quantity of matter in a
    remarkable degree, and  in the course of time, you find the parts
    grow firm, and the sides of the cavity adhere.
      By this prudent and careful proceeding,  you gain  every ob-
    ject ;  you save the  skin from being further destroyed, and the
    parts within from being further drawn into disease :  but  if you
    neglect  this opening,  the muscles, or even the bones suffer;  if
.   you open the part with an incision*, especially in an hospital,
    the infection comes upon the  sore, and the patient dies ; if you
    open it, and then neglect it, the  openings grow fistulous, and
    new abscesses are formed.   By  opening the  wrist joint, in a
    case of gunshot wound,  with  a small bleeding  lancet, in three
    points, with these precautions, I have saved the joint; whereas
    the slightest incisions, in the same wards of the hospital where
    this man lay, burst out into frightful sores.
      You must learn to vary your practice according to the nature
    ofthe case, and especially according to the parts concerned.  If
    the suppuration be on the outside of the fascia, or strong bind-
    ing  membrane of the arm  or thigh, then your chirf business
    will be to observe the rapidity with which the matter will under-
    mine the skin;  for the fascia, like  the  membranes  of a joint,
    excludes the inflammation,  and  resists it; the skin only is in-
    flamed,  its  cellular substance  is destroyed;  the skin,  by  being

     * I  can by no means agree to the  propriety of the practice here recommended
    by Mr. Bell.   If the opening be not fufftciently extenfive and dependeht to evacu-
    ate the matter, it muft, by being confined, keep the  fides of the abfcefs apart, and
    thereby prevent their union. In a foul hofpital the  practice  may be proper, but
    certainly under do other circumftances.  I do not  mean that an extenfive fup-
    puration fhould be laid open from one end to the other, but I hold no principle
    in Surgery better eftablifhed than that openings fufficiently extenfive  for the
    evacuation of matter fhould be uniformly made. Where matter has formed under
    the fafcia of the thigh, I have feen the baft effecls, even in an hofpital, from an m-
    cifion three or four inches in length.  S. 
Of ill conditioned and complicated Wounds.        15
thus separated from the fascia beneath, » so far deprived of its
nourishing vessels, that it is hardly alive ; it is thin, livid, rea-
dy to burst, and the least accident will make it slough,  and fall
off in gangrene.   If the inflammation be near the haunch,  the
abscess undermining the skin of the thigh, bursts at the knee ;
if in the leg, the matter follows the muscles to the ancle ;  if in
the fore-arm, it bursts out at the wrist ; and some degree of
management is necessary to give a free vent for the matter,  so
as to preserve the skin.
   In gunshot wounds, or in bruises from great splinters in bat-
tles at sea, you will most particularly observe this course of the
matter from above downwards.   It is from this working of the
matter to distant,parts, that the surgeon, after  long searching, is
often disappointed of finding the ball,  and feels for it at the
point most distant from its real place.   If, for example, a matt
is shot with a musket ball in the haunch, the whole thigh will
swell, the integuments will  be separated from the  thigh, the
muscles too (especially if the wound be deep), will be, as  it were,
dissected by the matter ;  the chief abscesses will burst near the
knee, the surgeon will search there in vain for  the foreign body;
the patient  will be exhausted by pain  and  hectic  fever, and
when he dies the ball will be found lying flattened  against th€
haunch  bone, or  sticking  about  the trochanters  of the  thigh
bone: or a ball passing clean through the fore-arm,  the absces-
ses, which begin  to form about the elbow, will extend down to
the wrist; or the elbow being only bruised and slightly  wound-
ed with a splinter, the abscess which forms will cover the whole
of the bellies of the^extensor muscles, and burst at last  near the
hand*.
   Here, then, you may easily perceive, that it  is not  the foreign
body  lodged in the  wound, nor the bruising of the parts, but
the matter  itself following the tract of the muscles  that causes
this extensive  disease: to prevent which,you must attend chief-
ly to these  things ; first,  To open the abscess early, knowing
what destruction the confined matter will make,  if left  soaking
its way downwards through the cellular substance of the skin:
Secondly, If you find  that it has already made great progress,
and that the abscess points  below,  you must introduce your
long probe,  pass  it down to the very lowest point,  and cut  it
out, so as to make a counter opening, by which the abscess will
have from all parts a free discharge: Thirdly, The skin being
thus weakened, being already highly inflamed, unsupported by
vessels on its lower surface, its cellular substance being  entirely
destroyed by the suppuration, there is great danger lest it slough,
  * But this takes place only where the abfeefs form', under the fafcire with whi"h
the limbs  are invefted.  S, 
1.6        Of ill conditioned and complicated Wounds.
 with a total loss and destruction of the integuments of the fort
 arm, for example: injections, even of the most simple kind, are
 in these circumstances so dangerous, that if unfortunately a sti-
 mulant  one  be thrown in under such an extensive  surface
 of diseased skin, it will gangrene and slough; or if, under pre-
 tence of evacuating the matter freely,  this inflamed skin be im-
 prudently cut up with a bistoury, the skin must inflame to the ve-
 ry highest  point, beyond what it  can  bear ; and being unsup-
 ported by its natural vessels, it will die and slough off.   For
 these reasons, then, you never are to use the knife ; you are on-
 ly to make fair counter openings ;  when you push through your
 probe, you may draw after  it a small and fine seton* ; but even
 a small seton is too irritating,  and you are to continue  it only a
 few  days till the opening be thoroughly established ;  whenever
 you are sensible that the course of  the matter is free, you must
 try to lessen the cavity, and  to keep  this great surface of the
 skin  in contact with the parts below by a gentle roller ; but the
 bandage must be rolled very gently and very equally,  and your
compression must be made, not so much with firm bolsters, as
 with a handful of plucked  lint laid over the whole; you thus
press down the skin that is already injured, so as to  make  it
re-unite, and you oppose a  barrier to the further progress ofthe
 suppuration.
  If the inflammation, in place of merely undermining the skin,
 go deep among the muscles,  then the matter finds new cavities
 and hollows to  lodge in, makes new and crooked passages for
itself from  point to point;  one abscess forms after another, the
suppurations become very  irregular and extensive, and this  is
 what surgeons  incorrectly  call a  fistulous  sore.  It is not so,
for while the parts continue inflamed, and the suppuration good,
the disease, however extensive,  is merely an irregular  abscess;
 and  what is chiefly required is  some means of diminishing the
number of  irregular  suppurations,  and as it were concentrating
 the disease ; for the  surgeon seeing matter  confined, the open-
 ings  narrow and irregular, and new  abscesses  forming  from
 day to day, is  uncertain which way  the  matter tends.  He
 knows that it is destroying the muscles, and fears  that it may be
 spoiling the bones ;  therefore he chooses from among the num-
 ber of openings those two  which seem most convenient for his
 purpose,  and introduces a seton from the one to  the  other; or
 from one opening he pushes down his long steel probe  to the
 bottom of some recent suppuration, cuts out the  probe, and so

  * From Mr. Bell's own reafoning I fhould apprehend the feton would be alto-
 gether improper : a piece of lint, introduced between the lips of the wound,
 would produce all the good effects he feems to expedl from a feton, without ma-
 terially increafing the inflammation, already too great.  S. 
Of ill conditioned and complicated Wc unds.         1 f
draws a seton through the most central part of the suppurations.
This seton is  not to be removed when the new  opening  is
established ;  it is to serve a more important  purpose, it is to lead
the pus to those particular openings which the surgeon has cho-
sen, it is to prevent the  matter working deep among the  mus-
cles,  and draw into this single channel the matter of all the col-
lateral abscesses.   The  seton concentrates,  as I may express  it,
the inflammation and suppuration, and brings the disease into
One direct line, so that we know where  to apply  our compress
and roller; we so narrow the passages, and lessen the quantity
of matter, and empty the collateral abscesses, by the operation
of  this seton,  compression, &c. that in the end the seton may
be  withdrawn; but  more commonly a fistula proceeds  from* ~
some  foreign body lodged deep, a ball, a  piece of iron, a rag  of
cloth,  or a spoiled  bone, which  prevents  the  healing of the
wound: and the circumstances and peculiarities of a fistula are
very  easily and naturally deduced from this cause; for where
foreign bodies are lodged in the part, and of course foul matter
is allowed to stagnate, the  part  cannot easily heal; but the pas-
sages where this foreign body is not immediately lodged,  reco-
ver almost  their natural condition, and the only inflammation is
at the bottom of the wouricl, where the foreign body .lies irrita-
ting and supporting the  flux of matter, which must find its way
out.
   Here  our business is  rather to excite inflammation, and pro-
voke the sensibility ofthe parts*.  We use setonsand injections
in this case, with a very different, and much bolder design.  Se-
tons are used rough  and large,  that they may irritate ; they are
used to force the parts into a state of suppuration, and to destroy
the callosity.    They arie, like   bougies,  often loaded with irri-


  * It will be in vain to attempt the cure of thefe fiftulas until the foreign bodies
are removed in a great majority of inftances.  In fome rare cafes  foreign bodies
become enveloped in a fac, which prevents their irritating the parts in which they
are lodged; but this is fo  unufual that it ought  never to be calculated upon, and
never takes place I believe where a piece of dead bone  or cloth is the irritating
fubftance.  Thefe facs moft frequently form around leaden bullets.  After the  fo-
reign fubftance is extracSed, fhould the fiftula not heal, then the plan of treatment
recommended by Mr. Bell may be adopted.  Where thefe extraneous bodies can-
not be removed, all that the furgeon can do is to fupport the ftrength of the pa-
tient, prevent the formation of new abfceffes as  far as is in his power, provide
dependent openings fo that the matter may not lodge, and bandage the  part fv
that it cannot  burrow,  and laftly,  examine from time to time fo as to extract thefa
fubftances as foon as poffible.  The openings may be prevented from clofing  by
introducing preffed  fponge.   When a  bone is fhattered by  an  accident, the
furgeon fhould carefully remove all the  fplinters which are fo nearly detached that
they cannot live, and all other foreign fubftances which he can difcover without
too much probing and examining of the wound.  It is true thefe things may be dis-
charged in the fuppuration which muft enfue, but it is lihewife true that their early
removal will tend very materially to diminifh that fuppuration.  S. 
Is        Of ill conditioned and complicated Wounds.
bating medicines, as red precipitate mixed with basilicon, and'
the cords are drawn through every day.  We also inject a fistu-
la sometimes with barley water, merely to cleanse it;  but often-
er with tincture of myrrh, along with bark decoctions, to correct
a putrid ichor, especially when there are corrupted bones in the
fistula, or where blood has been extravasated through the cel-
lular substance, which produces always very foul and fetid sup-
purations.    Sometimes we  are  really under the necessity of
using escharotics, as injections of aerugo with oil, or strong stim-
ulants, as turpentine diluted into the form of a balsam, with oil,
basilicon ointment, or balsamum arcsei,  which balsams we pour
into the fistulous holes hot, but not too strong; yet for a slightly
stimulant and cleaning injection, perhaps there is not a betteB
than rough red wine.
   Even small incisions are allowed here.    We lay open any
smaller fistula in order  to get a  more  direct passage  for out
seton or injection into the greater fistula, or to enable us to cure
and heal  up some collateral fistula.   We .also use sometimes  a
sponge tent, or piece of gentian, to dilate some particular open-
ing, or to make  way for confined  matter;  and when,  by care,
and various inventions and  practices,  we  have obliterated the*
©ollateral fistulas, made good counter openings, procured a free
yent for the matter, and brought the whole disease into one di-
rect line ; when, lastly, we have brought the tube or inward sur-
face of the great fistula into the  state  of  an  inflamed, active,
and granulated sore, and have converted the thin  ichor into  a
well conditioned pus, we endeavour, with our rollers and com-
presses, tore-unite  the parts, forming, by the manner of rolling,
what the old surgeons called their Uniting and Expulsive Ban-
 dage.
   Wounds  with collections  of matter round a joint, are the
 most afflicting of any; the  matter  is  resisted  by the capsule,
 and makes its way round the joint, among the loose cellular
 substance ; it finds out the weak parts, as the axilla or ham, and
 works towards  them, and often it draws the  acromion process
 ofthe scapula,  or  the olecranon of the ulna, or any other pro-
 jecting bone, into disease.   The joint then  becomes stiffened
 and deformed,  the integuments swell round it; in  some parts
 abscess  forms, in  others the skin is  wonderfully  thickened;
 there is all the  appearance of white swelling, but the  cavity  of
 the joint itself is not affected, though at last,  if neglected, the
 disease  penetrates  into the cavity, and the true white swelling,
 or disease of the joint, is produced.   When  the shoulder  or
 knee is thus massed  by inflammation, hardened, as  it were, in-
 fo a cartilaginous knot, and perforated at all points with fistulous 
Of ill conditioned and complicated Wounds.        19
sores,  the ligaments of the joint are thickened, its motions are
lost, and even the partial cure by a stiff joint, or Anchylosis,  is
hardly to be obtained,  The agonizing pain and want of  rest,
the diarrhoea, and hectic fever, which are inseparable from this
degree of irritation, often destroy the patient, or hurry us on to
amputation.  But while the diarrhoea and pain can be modera-
ted, while the strength lasts, you should try to cure the disease
by varying those practices which I have just mentioned.   You
should be careful not to relax the parts, nor hurt the little vigour
that is left in them, by the  application of poultices ; you should
remember, that the skin covering such a joint is much insulated,
and tends greatly to inflame,  and therefore you should be cau-
tious in  using injections;  you should be well assured that the
parts are really fistulous before you inject, and you should  be
the more anxious and prudent, because the joint itself may  be
affected, and you may be driving a very irritating injection into
the cavity of a diseased joint;* nevertheless, cleansing, or even
stimulant injections, barley water, diluted tinctures, or wine, I
do  not condemn.  You should be careful  to watch abscesses,
and prevent their extension,  by  small  and frequent openings
with the lancet;  perhaps it may be right to use a seton, in order
to procure a free drain for the matter.  You may occasionally
enlarge one fistulous hole, in order to heal up two or three colla-
teral holes  depending on it.   You  should  use  a poultice only
after an incision, when the parts are irritated, and must be ap-
peased ;  a fomentation you will use often, but you should make
it hot and stimulant, and continue it but for a short while ; you
should support the joint with compresses, or rather puffy cush-
ions of lint, and a gentle  roller ;  but be fearful of tents, which
both irritate the parts and confine the matter, rather enlarge the
fistulas with the knife.  If by a shot, or other wound, the bone
be  crushed,  you easily discover it at first,  but not perhaps the
whole extent ofthe injury.   If in a scrophulous boy, the acromion,
or the sternum, or any other bone, be spoiled by suppuration, you
know it by the black and peculiarly fetid discharge ;  you feel it
with the probe through the many fistulous openings which run
along  the ridge of the bone ; a man of experience learns  even
to know by the eye  this state  ofthe sore ;  and, if there be such
a diseased bone,  added to the other disorders, and if the  bone
be  projecting at one end,  you shake it from day to day till you
get it out.   Or if diseased integuments cover the carious  bone,
having fistulous holes from point to point, you take your round
edged scalpel and lay the  openings  all into one,  and take away
the diseased bone.    Far  from  sparing the integuments, you
  * Injections of any kind would be highly improper where there was a poffibility,
,..■>! their getting into the cavity ol the joint.  S. 
20
Of Ulcers.
should open them freely ; you will find them almost insensible,
cartilaginous like the tube of a fistula, not bleeding when cut, but
rather needing an incision to excite them,  and especially need-
ing to be  delivered of the diseased bone, before they can enter
again into a healthy action, and granulate or unite.

                        SECTION II.

                         Of Ulcers.

   When in place of a deep and bruised wound, you have a flat
and superficial wound, it often degenerates into a sore-, and the
methods  by which the cure of such  sore or ulcer is attempted
are very  generally known.    Occasionally,  a sore  may be
wrapped up in a poultice, or soaked in a stimulant fomentation
to cleanse the ulcer, or to abate any pain or inflammation which
our  medicines may have raised ; but  a continued use of com-
mon poultice, of carrot poultice, of stale beer poultice, or any
other, serves rather to relax and hurt the part.  I believe,  that
very generally the cure depends on the prudent use  ol  astrin-
gents, escharotics, and caustics, which must be changed accord-
ing to the condition of the parts, and most especially it depends
on perfect cleanliness and a firm bandage.   If the sore be going
slowly but regularly on,  it requires only such slightly stimulant
ointments as Turner's cerate, or unguentum tutise, or some other
ointment made with zinc.   If it be red  and  fresh granulating, let
it be dressed with dry lint in the basin of the ulcer, and straps of
ointment round the edge.   If the action of the parts flags  at
times, and the sore looks gleety and pale, sharpen the ointment
by adding a little red precipitate to it, or aerugo, or a little dried
alum.   If the edges are quite callous, they must either be touch-
ed with caustic daily, or pared with the knife : for if this be not
done, the edge of the skin being  by this callosity  disengaged
from the soft parts, shrinks and wastes.   If the sore be flabby,
with a profuse discharge, sharpen your ointment by adding  to
it  some spirits of turpentine ; the sore willofter.be so insensible
as to require to be fairly powdered with pure precipitate.   If at
any time these processes for stimulating a  sore have been too
suddenly entered upon,  or too harshly  followed up, so as to ex-
cite inflammation, you must apply a poultice, or rather a warm
fomentation of camomile flowers, with crude sal-ammoniac, till
you restore the ulcer to a quiet and easy condition.
   The most  tedious and persevering ulcers are those  which
arise from habitual debility;  such arescrophulousand constitu-
tional  sores.   The most destructive  a,nd  horrible ulcers are
those which arise from some  poison infused into the system, de- 
Of Ulcers.
21
stroying the temperament and living powers in the parts; such
as the cancerous or venereal poisons*.   The ulcers which are
the most in  danger of becoming gangrenous, are those where
the vis vitse of the whole constitution, or of the particular part,
is destroyed ;  as in dropsy.
  'Of the ulcers produced by local debility, there are  chiefly
two kinds, first, That which may happen to any part of  the bo-
dy where, in consequence of a wound, violent inflammation has
ensued, carrying the excitement to that height,  which the de-
bilitated constitution of the part is  unable to bear.   Then the
parts become flaccid,  and run into ulcer, which is to be cured
by exciting them,  chiefly by those topical applications which I
have just  mentioned :  or,  secondly,  A local ulcer may  arise
from that peculiar weakness of the lower extremities, of  which
we have so many  proofs ; for it is there that leucophlegmatic
swellings,  varices, ulcers, and all the earliest marks of consti-
tutional debility first appear.
   Of these ulcers, that which is in a manner peculiar to the low-
er extremities,  is by far the most frequent.   The cause of this
weakness in the lower extremities, is their dependent posture ;
and  therefore these ulcers are to be cured by keeping the limb in
a horizontal position, on a level with the body.  Uniform pres-
sure, by  means of  straps  of sticking-plaster,  and  bandagef,
must at the same time be applied.   For this purpose alter the
straps are drawn tightly around the  limb, it must be firmly rol-
led <from  the  toes upwards.  In warm weather cold  water
pumped upon  the limb, will be of great advantage in expedit-
ing the curej.
   You will commonly find  the general  fascia or  tendinous
sheath which covers the muscles much concerned in ulcer ; and
I am persuaded that  the unyielding nature of this  part,  more
frequently than, any other cause, protracts  the cure.   An ulcer
seldom penetrates deeper than the  skin, it is seldom able en-
tirely to perforate the fascia;  it is the ill condition of this insen-
sible part that makes a  sore continue throwing off sloughs  for

  * When ulcers are caufed by conflitutional difeafes,  it is evidently vain to at-
tempt their cure until the general diforder is removed.  After this has been effect-
ed they are to be treated as above directed.  S.
  f Vide Dilcourfe on Bandages.
  \ Ulcers of the'lower extremities are fometimes caufed by varicofe veins, and
canndt be cured until the caufe is removed.  The operation is very Ample, dif-
fecl: down and de the vein with two ligatures, and divide it between them, as you
would do an artery when perfaming the operation for Aneurifm.  Trifling as this
operation is in appearance,  death has  been caufed by it in three inftances, one of
which, a patient of Mr. A. Cooper, of London, I examined.  The internal furface
of the vein appeared inflamed, as well as I recolle<5t. 1 have frequently feen ulcers
improved by powdering .them with prepared chalk, powdered rhubarb, &c. and
then  applying the flicking plafter and bandage, as recommended by Mr. Home.
The beft adhefive plafter is that recommended in the note * page 4.        S. 
22
Of Ulcers.
months,  and spreading continually ;, for this tendinous sheath
which lies under the skin being dead, deprives the skin of nou-
rishment, by destroying the intermediate vessels ; the skin can-
not close over a part which  is dead, any  more than flesh can
close over a carious bone ;  nor can it continue  sound at its
edges, since its edges lie over the dead fascia, unconnected with
it, and no longer nourished  by vessels : the skin thus  shrinks
from a part with which it can hold no connection,  and the in-
flammation and the matter working backwards in every direc-
tion, destroy more and  more the1 cellular  substance which lies
betwixt the  fascia and the skin.  This I know is the condition
of most of those sailors' ulcers and hospital sores which I have
seen.  What  can a sprinkling of precipitate, or of  some drug
still more insignificant,  do in such a disease ? The fascia when
once brought into this condition, is like a diseased bone, its con-
nections are strong,  it does not slough off soon, but keeps its
place ; the filthy, yellow, thick, and mucous-like matter of such
an extensive ulcer, is produced by the gradual melting down of
this fascia.  Upon removing this cream-like substance from the
surface of a  deep ulcer, we see the fascia  covering the bottom
like a sheet  of soaked shamoy leather ; with such  a bottom  as
this the ulcer can never heal, the fascia itself is dead, and will
never recover; it sloughs off more slowly than even a diseased
cartilage or bone.  Now I know that this is often  the  impedi-
ment to the  healing of great ulcers ; that the ulcers is perpetuat-
ed only from this diseased and yet unyielding state of the fascia,
and this  has been the occasion of many losing their legs.   The
habit which  first produces such an ulcer is very bad ; the ulcer
itself, Which extends so as to uncover the fascia in this manner,
cannot be easily cured, although the fascia were cut away ; but
while it is left the ulcer cannot heal; you must therefore learn
to pare and  clip the fascia;  and it will be some encouragement
to you to know that  I have  often cut  it up with the knife, then
pared the flaps with scissors, cleared the leg of it in a few days,
and brought the ulcer very suddenly  into a healthy and granu-
lating state.
   When ulcers  are long neglected,  the worms  which breed
in them  give  a dreadful appearance  to the disease.*   These
vermine are  not  the  only  ill  consequences  of uncleanliness,
for  without  any other cause that  we can  perceive,  they
produce  the most extraordinary  ulcers.   I subjoin  M'Gilli-
vray's  case  as  an  example  the best calculated to explain
this position ;  for his wound was extremely small, the ulcer
which followed was very singular, both  in extent and appear.

  * Thefe worms may be killed by wafhing the fore with the juice of the leave*
at green elder.  (Sambucus Nigra of Linn.)  S. 
if Ulcers.
23
anee, and was finally cured,  rather by care and cleanliness than
by surgery. Yet what is surgery in this case but cleanliness and
©are ?
  This man had  been wounded on the Continent,  by a ball
which had entered under the clavicle and passed out behind.
The great blood vessels had escaped,  but he lost a considerable
quantity of blood from the  small  arteries, which were divided
by the ball.   Alter this he  was thrown  into a  French prison,
where he endured every sort of misery for two years and eight
months,  by  which  the  wounded  part was brought into  the
wretched condition in which it was when I saw it.   In winter
he suffered extreme cold; he lived on  bread and water only;
and of the black bread  which he got, his allowance was but  one
pound a-day;  no surgery, no opportunity of cleanliness, no care.
After his health had been injured by cold and hunger, the heat of
summer, in a close wooded country,corrupted the skin, and cover-
ed his  shoulder with this terrible ulcer;  half a year had elapsed
from the time of his being wounded before the surrounding parts
began to degenerate  into this very singular sore.
   The sore never appeared to heal during the heat of summer.
The skin all  around both wounds (and to  great extent),  grew
livid and very dark coloured, then broke out into white pim-
ples ; the pimples afterwards burst, and discharged imperfectly
a white viscid matter; two or three pimples ran together  into
one, and formed a sore;  then a scab covered that sore, confined
the  matter, made the inflammation  spread, and comprehend
other pustules; these, again, were in their turn closed up, the
skin was undermined by successive pustules uniting; from pus-
tules they became abscesses, and from trivial  abscesses, deep
inflamed sores.   During the progress of this ulcer, the fcetor of
the matter was such, that the whole prison was infected with it.
The poor man could indeed get  his  sore  washed with water,
but no diligence could  mend his condition; the fretor was quite
sickening and oppressive to himself; the ulcer spread first round
the  wound in the breast, then  round the back  over  the whole
skin, which covers  the shoulder joint, then over the scapula,
then up the neck, and  down the whole side ; the skin became re-
markably  livid, every where greatly thickened: in  one place,
hard and callous, in  another, soft and boggy, as  if there were
 matter under it,  although there was none  ; in  one place an ab-
scess was  forming,  near that was another abscess entirely ripe,
 and close  to  that another  burst, and discharging yellow, very
 viscid, and mucous-like pus, which undermined and destroyed
 the skin.  These various  abscesses, in all stages of progress
 (like ripe and unripe fruit on one branch), worked, not super-
ficially, but deeply among tho cellular substances, and the whole 
24
Of Ulcers,
 skin was puffed up;  you might have felt the matter in these ab-
 scesses fully a month before they burst; and while  they were
 working under the skin, the veins were eroded,  and the blood
 burst out, sometimes so freely as to bleed like the  vein of the
 arm.   He  frequently bled  to the  amount  of two pounds at
 once, and much of the  blood was, at the same time, driven un-
 der the skin, by which there was mixed with the dark red  of
 this  chronic inflammation  the blackness of echymosis ; and
 along with the hardness and callosity of inflamed  skin, there
 was  from point to point a  pulpy  feeling,  as if of anasarca,
 echymosis, and abscess, united.   There were besides two  or
 three flat, thrombus-like tumours, fully three inches in diameter,
 which when pricked with the lancet emitted only blood.
  This disease being merely a corruption of the skin, arising at
 first from his dirty and miserable situation, and perpetuated by
 one little abscess after another undermining and destroying the
 skin ; the  plan which  I laid down for curing him  was this :  I
 ordered him the warm bath, gave him a purge, and  put him on
 good diet,  with a little wine; I directed the warm bath to be
 repeated three times a week, to support a soft and pleasant state
 of the skin;  and a fomentation of camomile decoction,  crude
 sal-ammoniac, and a little spirits to animate the skin, was  appli-
 ed  to  the  shoulder for one hour every morning and evening.
The chief point was to manage the little abscesses  and throm-
 buses so as to prevent their undermining the skin.   I opened
two or three with the  knife, and taught his dresser how to cut
 each irregular abscess as it  formed,  down to the bottom, with a
 direct incision, till he  reached the sound flesh.   Each abscess
 was accordingly cut before  it was fully formed, with the  knife,
 if large, (as some of them were three inches long), and with
 the lancet, if small.   The incisions were not made in what may
 properly be called an abscess, but through a piece of diseased,
 spongy, and suppurating skin. The matter and blood were thus
 prevented from undermining the  skin;  the  inflammation was
 drawn  away from the  swelled parts towards those occasional
 incisions, which became then, as it were, the centres to their
 own proportion of the disease, and  each scarification was filled
 with a  strong mercurial ointment,  rubbed in very  thoroughly
 with a hair pencil.   The consequence was, that each incision
 being stimulated into a right and healthy suppuration, was made
 to relieve the adjoining skin before it was permitted to heal.
 By these practices, varied according to the circumstances, this
 strange disease was entirely cured;  it had continued two years
 and nine months ; but by persevering in this plan, especially in
 respect of the scarification,  (which  was indeed a daily and se- 
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Of the Hospital Sore or Gangrene.           25
vere operation) he recovered perfectly in six weeks.   Even the
dark colour of the skin almost disappeared, and it became soft,
pliable and clean.

                       SECTION III.

               Of Hospital Sore or Gangrene.

  I do not regard hospital sore as a mere ulcer, to be treated
like other common ulcers, but as a general affection ofthe sys-
tem, a mortal disease ; for when it rages in a great hospital it is
like a plague ; few who are seized with it can escape.
  There is no hospital, however small, airy, or well regulated,
where this epidemic ulcer is not to be found at times ; and then
no operation dare be performed ! every cure stands still!  every
wound becomes a sore, and every sore is apt to run into gan-
grene : but in great hospitals especially, it prevails and is a real
gangrene : in the Hospital Dieu of Paris its ravages continued
for two hundred years, until that hospital was reformed by the
present government of France*.
  Nothing, perhaps, will contribute  so much to your under-
standing this  disease, as a plain description of it  in an indivi-
dual case.
  A boy, by the name of Joiner, belonging to the  Triumph,
whose ulcer I have drawn, received but a very slight and super-
ficial wound, and for some time after the battle he continued in
health, and the wound healed rapidly.   But while it was to all
appearance florid  and healthy, with no threatening of ulceration,
the boy  in full spirits and strength, walking about on crutches,
guilty of no irregularity, it began to look ill ? a sure presage of
some change of health.
  There came on a cough, with symptoms of a common cold,
which he imputed to his  bed being placed near a door,  lately
open and now shut,  but not walled up ; then his health failed,
his  spirits became quite oppressed ; he had occasional attacks
of fever, frequent vomiting, and a continual loathing of food.
With these slight and seemingly unimportant symptoms (but
the tendency of such symptoms when they appear in a foul hos-
pital is easily understood), his sore, which was no bigger than
the palm ofthe hand, became in two days as big as the crown
of a hat.   The whole skin ofthe thigh was destroyed,  the mus-
cles  were stripped of skin and fascia from the hip to  the knee,

  * When I was in Paris I was agreeably furprifed by the cleanlinefs and regula-
rity of this Hofpital, after having heard fo much of its filthy and crowded wards.
S.
                             D 
26            Ofthe Hospital Sore or Gangrene.
 the trochanter was almost laid bare, the hamstring muscles ex-
 posed to a considerable  extent,  and all the muscles of the thigh
 dissected in a manner which no  drawing can express.
   While these ulcers made their dreadful  progress in any of
 the wounded, I could observe  them pass through the several
 stages, first of inflammation, then of insensibility and gangrene,
 and  then of renewed pain  and sensibility.  First, when the
 health is affected, the patient languishes for a few days, and the
 sore inflames ; then come vomitings, diarrhoea, and a distinct
 fever, and the disease seizes plainly upon the wounded part.  In
 its first stage the wound swells,  the skin retracts,  wastes, has a
 dark erysipelatous redness  verging to black, the cellular mem-
 brane is melted down into a fetid mucus, and the fascia is ex-
 posed.  But in the second stage, the  fascia and skin unable to
 bear their inflammation, and deprived of mutual support, be-
 come black, fetid, soft, and fall into perfect gangrene ; yet there
 are no vesicles, and the  mortification is confined within the ca-
 vity of the sore.  This  is  the  stage of insensibility; the parts
 within are covered  and  defended with a  perfect slough, which
 no medicine can penetrate, on which no applications can make
 any impression; and stimulants are used, without pain, of such
 a hot and fiery nature, as none but dead parts could resist: but
 when these sloughs open in the  natural course  of the disease,
 and  the living  parts are exposed,  and the  medicines begin to
 make an impression, it is imagined that these  applications are
restoring life and energy to parts which, before they were  appli-
 ed, seemed entirely dead!  It is under this impression, that sti-
 mulants are continued of a  strength which parts thus inflamed
 cannot bear; the disease is aggravated by them, and the  cries
 from all sides are such as would melt the most rugged nature.
   In the third stage, this  gangrene ceases, the sloughs fall off,
 the muscles become  exposed, the part assumes  once more the
 appearance of a  common sore,  but fearfully enlarged ; a  high
 and glossy red, and a smooth, shining, uninterrupted surface^
 mark the continuance ofthe inflammation and disease ; but if
 the sores are to do  well, it is known by  a  rough, granulating
 surface, somewhat dry, and of a paler colour.
   If the patient is to die, the gangrene or  wasting ofthe cellular
 sheaths proceeds ; the skin first sloughs off; then the fascia is
 destroyed;  those divisions and lamellae ofthe fascia, which dive
 betwixt the muscles  to enclose, protect, and nourish them, are
 next affected; the matter continues slimy and thick, and in pro-
 digious quantities ;  the  muscles are divided  from  each  other
 more and more.  In many who suffered under the disease at
 the same time with Joiner (the boy above  mentioned), you
 could have  laid your hand edgeways betwixt the several  mus- 
Ofthe Hospital"Sore or Gangrene.           27
cles of the  thigh.   Then the vomiting, diarrhoea, and nervous
symptoms increase, the pain is dreadful; the cries of the suffer-
ers are the same  in the night as in the day-time ; they are ex-
hausted in  the  course of a week, and die: or if they survive
and  the ulcers  continue to eat down and disjoin the  muscles
the great vessels are at last  exposed and eroded, and they bleed
to death*.
   These are the  forms which this disease assumes  when it at-
tacks an amputated stump, a broad and open wound,  a laceration
of the skin, or  any surface which is apt to become a flat sore.
But when it attacks a narrow wound, as a bullet wound, a wound
with any pointed instrument, even the prick of a nail in the fin-
ger,  it assumes at once the form of an Erysipelatous Gangrene
(Erysipelas Gangrenosa) ;  and when this disease prevails in the
hospital, you may see even a nurse, from some slight hurt  in
the hand, which at another time could have done no  harm, have
one day a swelling of the Wound, on the next an erysipelas of
the arm, with dreadful pain and low fever;  on the third day the
arm  will become  livid, and covered with vesicles,  and in two
days more fall into gangrene ; the woman  oppressed in the
meanwhile  with hiccup, low delirium, and other symptoms of
approaching death.
   A stump which has not adhered  is a flat wound peculiarly
apt to  be seized with this dreadful  disorder ; and in wards
where  the disease prevails, amputation should not be  performed.
It is almost impossible to heal the stump ; it sloughs, ulcerates,
shrinks, becomes pyramidal; and to the very last moment  of
its healing, and even when the scar seems formed,  or is about
to be formed, the patient is liable to rigors, slight vomiting, a
quick  and irritable pulse ;  and then, in the  course of a few
days, the stump is burst open by inflammation, and spreads  it-
self into a broader surface than even when the limb was cut off.
The danger of this inflammation and ulcer of the stump is ex-
treme ; the least evil that can ensue from it, is a great wasting
of substance, an  exfoliation ofthe bone, and a conical stump :
but we are  often  disappointed even of this imperfect cure, viz.
in the form of a conical stump; for it happens in an ulcerating
stump, as in other sores, that the greater arteries are eroded, and
then the patient almost inevitably dies.  In one day  I saw three
stumps burst open in this manner, each  of which was so nearly


  * The author has defcribed this difeafe as it appeared ameng the Englifh failors
wounded on the nth October, 1798, in an engagement with the Dutch, and after-
wards put into an hofpital at Yarmouth. There were three hundred wounded
Dutch failors in the fame hofpital,  feparated by a wall, among whom there wa?
no appearance of the difeafe.  S. 
28            Ofthe Hospital Sore or Gangrene.
cicatrized, that you could have covered the small spot that was
left unhealed with the tip of the little finger.
   This ulcer and gangrene is in an hospital, what puerperal fe-
ver is  in a lying-in ward; it is an  infection  to  which  all are
equally exposed ; but it is resisted by health and strength, and
favoured by weakness or disease.  Excesses, drunkennesses,
cold,  and every cause of weakness, expose the constitution  to
its attack.   If diarrhoea, fever,  dysentery, or  an old  inter-
mittent, or even a common cold, attack  a wounded man who
lies in an unhealthy hospital, the first febrile symptoms are im-
mediately followed by this terrible disease.  The moment that
a man is struck with it, you may observe him become pale, sal-
low, languid, low-spirited, with a heavy eye, a confused head, a
loathing of food, a fretful pulse, and in short, a universal  disor-
der, which he can neither account for nor describe;  and whether
this disease appear first in the system, or in the part wounded,
its progress is the  same.  When I have  observed in any case
the sore to be first affected, I have noted it as a sure symptom of
the approaching disorder of the whole  system ;  or when  the
system  was first affected, I have marked that as a sure  presage
of the sad change  that was soon to  appear in the sore.   What,
then, is the surgeon to do ?   Is he to try experiments with oint-
ments and plasters, while men are dying around him ? Is he to
seek for washes or dressings to cure  such a disease as this ?  Is
he to expend butts of wine, contending, as it were, against the
elements ?  No !   Let him bear this always  in mind, that  no
dressings have ever been found to stop this ulcer;  that no quan-
tities of wine or bark which a man  can bear, have ever retard-
ed this gangrene ; let him bear in mind, that this  is a  hospital
disease ; that without the circle ofthe infected walls the men
are safe ; let him, therefore,  hurry them out of this house of
death ; let  him change the wards, let him take possession of
some empty house, and so carry his patients into good air;  let
him lay them in a school-room, a church, on a dunghill, or in a
stable.
   Till some change of situation be accomplished, little can  be
done for  men labouring under this plague ; but when the dis-
ease first breaks out and rages, and while you are meditating
some change, or concerting  plans for suppressing the disease,
you will find opium*of infinite service in checking the  diarrhoea
and fever, for these are greatly aggravated by the irritation and
pain; you must try to support the  strength of v;our people  by
wine and cordials, and generous food, administered sparingly;
and be  careful  not to  overload their  stomachs with bark, at a
time  when they are little able to bear any thing but a decoction,
or a small dose of the  powder.  As for external applications, 
Ofthe Hospital Sore or Gangrene.           29
tinctures of myrrh, aloes, and other drugs, still more stimulant
are improperly used in this  case, as they have no effect while
the slough remains, and when it gives way, produce unspeaka-
ble torture.   Of these  I cannot approve ;  keep your tinctures
and balsams for fistulas, and your torturing stimulants for those
local diseases which may be cured by them ;  but this not being
a local disease  cannot be cured by local applications,  and there-
fore the mildest are the best; as, for instance, a solution of sal-
saturni, which is a gentle astringent.
   I think that in this  hospital ulcer I have seen gentle evacu-
ants useful; but I am so undecided with regard to the true prac-
tice in this disease, that I speak with diffidence, and would have
you, if you do venture into this  difficult path, proceed with so
much caution, that you may, as it were, feel your own way ; if
you use evacuations, or a strict diet, it is but for a time, and in
the expectation of renewing your  stimuli gradually, and giving
them a greater power over the system. 
(  30   )
DISCOURSE III.
ON BANDAGES.
                       SECTION I.

              On the various uses of Bandages.

BONDAGES  are useful not only for the  mere tying up of
a wound, but by  them many important operations in  surgery
are performed, more  interesting, though less striking, than the
cures effected  by the knife.  In wounds, in abscess, in fistulas,
in any general disease of a limb, bandaging is the chief opera-
tion of surgery ; what the  knife cures, it partly destroys ; what
the bandage cures, it saves.
   1st.  Although  in recent wounds, it is with plasters and su-
tures that we unite the parts  point to point,  yet it  is with the
bandage that we  support the limb, preserve the parts in conti-
nual and perfect contact with each other, and prevent any strain
upon the sutures with which the parts are  immediately joined,
and we often unite parts by  the bandage alone.  The  Uniting
Bandage has been long known by that name.   But it is particu- 
Of the various uses of Bandages.            31
larly to be observed, that in gunshot wounds, and other bruised
wounds, though it would be imprudent to sew the parts, since it
is impossible that they should altogether unite,, yet the gentle
and general support which we give by a compress and bandage,
prevents them from separating far from each other, unites the
deep parts early, and lessens  the extent of that surface which
must naturally fall into suppuration.
  2dly. Although in  the  hsemorrhagy from amputation,  or in
any regular piece of surgery, we  trust to ligatures alone j in
the hsemorrhagy of wounds, we cannot always  find the artery ;
we dare not always cut the parts, for fear of greater danger;  we
are often alarmed with bleedings  from uncertain vessels, or
from members of vessels,  or  from  veins as well as arteries:
these are haemorrhagies to be  suppressed by  a compress, or
sponge, which is but an instrument of compression, serving to
give the bandage its  perfect effect.  Frequently,  in  bleedings
near the groin, or the arm-pit, in the angle of the jaw,  wherever
the bleeding is rapid, the vessels uncertain, the cavity deep, and
the blood not to be commanded by a tourniquet, and where  the
circumstances forbid a deliberate and  sure operation, we trust
to compress and bandage alone.
   If a compress  be neatly put  upon the bleeding arteries, if
there be a bone to resist the compress, or even if the  soft parts
be firm below, and the bandage be well  rolled, the patient  is al-
most secure*.   But such a roller must be rolled smoothly from
the  very  extremity of the fingers or  toes; the member must
be thoroughly supported in all its  lower  parts,  that it may bear
the pressure above.   It is partial stricture only  that does harm,
creates intolerable pain and anxiety,   or brings on  gangrene.
Haemorrhagv  requires  a  very powerful  compression,  which
must therefore be very general, and must be made very cunning-
ly and skilfully, to be either supportable or safe ; it must not be
made  over the bleeding arteries only, which is all that the sur-
geon thinks of in general, nor  must it be begun  at  that part
where it  is particularly required ; the  bandaging,  for example,
by which a wounded artery at the bending of the fore-arm may
be  cured, must be begun  at the  very tips of the fingers ;  each
individual finger must be rolled; the roller must be continued
over the hand, with the greatest attention to leave  not a single
point  unsupported,  nor subject to  strangulation.   It must be

  • Notwithftanding what is here faid in favour of compreffion, as a remedy for
the fuppreffion of haemorrhage, it ought never to be truiled to  where there is reafon
to apprehend an artery of any coniiJerable fize is wounded ; particularly where
the furgeon is obliged to leave his patient for fome confiderable time,  or refides at
a diftance from him,  Tie the veifels, and then apply  compreffion, and every thing
isfecure. S. 
32             On the various uses of Bandages.
 rolled carefully and firmly upwards  dong the fore-arm; and
 thus the whole of the  limb will be supported against that pres-
 sure which is made, particularly upon the wounded part. When
 thus rightly applied, the  firmer the bandage is,  the less apt it is
 to be attended with pain or danger*.   Gangrene is, you may
 easily  perceive, the  effect, not  of a firm bandage because it is
 firm, but because it is partial, and strangles some single point of
 the limb.
   From these  considerations, we  understand why surgeons
 failed  in the  cure of aneurisms, notwithstanding their curious
 contrivances of plates, and screws, and springs, and cushions;
 they were too curious, all their care was to make the  pressure
 upon some single point of the limb; and all the fault of their
 instruments Was this partial pressure.
   3dly,  In abscesses,  where matter  is working downwards
 along the limb (seeking out, as it were, the weak  parts), under-
 mining the skin and wasting it, insulating and surrounding the
 muscles, and penetrating to the bones,  the bandage  does every
 thing.   The expelling bandage, the  propelling bandage, the de-
 fensive bandage, were among the names which  the older sur-
 geons gave to the roller  when it was applied for these particular
 purposes; and these  are properties  of the roller  which should
 not be forgotten.  It  is obvious, that  of all bandages the sim-
 ple roller is the best fitted for a diseased limbf, but the moment
 you begin to apply this simple bandage, you  will  meet with un-
 expected difficulties ; you will feel the necessity of use and prac-
tice, towards rolling a limb with neatness and perfect effect; you
 will find  yourselves awkward at first, and would almost believe,
 that a simple roller could never be made a perfect support to a
 diseased joint; you will  perceive your  bandages to be irregular
 from the first, and they will be slackened in a few  hours.  Prac-
 tice will  convince you, that the firmness and  neatness of a ban-
 dage depend altogether upon these  two points, first, upon the
 turns succeeding each other in a regular proportion  ; and, se-
 condly, upon making reverses, wherever  you find  ^ny slack-
 ness likely to arise, from the varying form of the  limb.  Thus,
 in rolling from the foot to the  ancle, leg and knee,  you must
 take care first, that the turns, or, as the French call them, Dol-

  • I cannot agree with the author in this reafoning: if you  apply a bandage
 with fufficient firmnefs at the  upper part of the limb to flop the circulation, I do
 not fee how preffure upon the  lower part will prevent gangrene ; and unlefs the
 circulation  is prevented, mortification will not enfue. S.
  f This  rule is not admiffible in the unlimited degree in which it is here laid
 down ; on  many occafions the many tailed bandage is preferable, as in a fuppura-
 ting compound fradure, and in all cafes where moving the limb frequently would
 he injurious.  S. 
              On the various uses of Bandages:            33

loires, of the roller* lie over one another by just one third  of
the breadth of the bandage; and secondly, that at every difficult
part, as over a joint, you turn the roller in your hand, make an
angle, and lay the roller upon the limb with ^e opposite flat side
towards it; you must turn the bandage  so as  to reverse  it)
making what the French call a Renversee of the roller, at the
ancle, at the calf of  the leg, at the kneef; wherever, upon
making a turn of the roller,  you perceive that it will fall slack,
you make a reverse of  the bandage, and at each reverse you
put in a pin to prevent it falling  down ; you must be careful to
roll your bandage from below upwards, and support the whole
limb by a general pressure, that you may be able to support the
diseased part with a particular pressure ; you must lay com-
presses upon the hollows, and upon the bed of each particular
abscess, and change the place of these compresses from time to
time, so  as now to prevent matter sinking into a particular hol-
low, now to press it out from a place where it is already lodged,
and again  to re-unite  the  surface of an  abscess already com-
pletely formed, from  which the matter has been already dis-
charged.
  4thly, In the case of a fistula, or where the abscess has
hardened into a callous tube, while you pare away the callous
edges, or cauterize them; while you open particular mouths of
the fistula with the knife, or  dilate them with sponges (which
vou should prefer if you are afraid of an hospital sore); while

  * The Dolloires are marked in the plate, i, z, 3.
  + Renverfees of the roller are marked in the fame plate, a, b, c.
                            E 
34            On the various uses of Bandages.
you stimulate the internal surfaces with gentle solutions ot cor-
rosive sublimate, spirits, or stimulant balsams, as solutions of
gum, aloes, ckc.  in spirits;  >ou must lay such a train of com-
presses along the co/irse of  the fistula as will bring the sides in-
to contact;  and  when you use a seton, whether it be in fistula,
to excite the tube, or in irregular abscess, to iead the matter, and
concentrate the disease, >ou learn by means ofthe  seton the di-
rection of every irregular passage, and hollow tract in the limb,
and know, of course,  where to lay your train of compresses,
and what form to give them.
   It is in the complicated case of a swelled and diseased limb
that we are sensible of all the uses of a bandage, which is a uni-
versal cure for all its disorders.   By the bandage we dissipate
the leucophlegmatic swelling, abate the inflammation, prevent
the  extension of matter, lessen suppurating cavities, close the
walls of fistulas, procure the re-union of surfaces which have
suppurated.   The  patient is  sensible of an easy and pleasant
firmness from the bandage, and  the limb is actually supported
against accidents, and the further extension of the disease. This
effect of bandage is observable, not merely in this  single case
of an ill bandaged limb, but is equally obvious and interesting
in other cases;  for in  varices, though a  permanent bandage is
usually required, yet sometimes  the parts are  so  strengthened
by a roller that they recover their tone.   It is also  by curing
this low inflammation, restoring  the tone  of the  parts, and
strengthening their  action, that bandage  cures ulcer in the leg.
If  you have seldom seen an ulcer even rendered stationary by a
bandage, much less cured by it, remember how very ignorantly
you  have seen  such rollers applied.  You have  seen  them
drawn round the ulcer, round the shin alone, with the firmness
of a tourniquet; the middle  of the leg bound very tight, the
foot swelled, the ulcer inflamed, the marks of the roller left in
large ridges ; you have seen it recovering in the morning, only to
be tortured into the same condition before night! Instead of this
it should be rolled from the very extremities of the toes, and then
roll it as tight as you will you can do no harm. It should be rolled
in the morning upon rising from bed, in such a manner as to fit
it to bear  the fatigues of the day ; to support  and defend the
ulcer, and keep the swelling all above the sore ; this constitutes
-the true value of the sticking plasters, which have been so suc-
cessfully used by Dr. Bainton : First, The  sore  is thoroughly
cleansed, its edges  smoothed and wrought forwards, and firmly
compressed by the drawing of the plaster: Secondly, The limb
is rolled from the toes to the sore, then over the sore, and some
way upwards, so as to secure the relaxed parts ; the bandage so
rolled, by a skilful hand, is the only certain cure ; neither  oint- 
On the various uses of Bandages.            35
ments nor  mercurial  preparations, nor  sponges, nor  leaden
plates, will cure an ulcer :  it is to be cured only by firm, equa-
ble, and perfect compression, which must be renewed more than
once a day if the bandage becomes loose.   There is  no  inflam-
mation  of the lower extremities  in which I do not experience
the good effects of firm  rolling.   Even mere feel'mg and vul-
gar experience instruct a  man when he has an ancle sprained to
bind it  firm ; and in a diseased bursa (as in a  relaxation of the
knee-joint), that disease, which with but  a little indulgence,  a
very little encouragement of fomentations, poultices, bleedings,
and  low diet, would end  in  white swelling of the knee ; may
be stopped even by so simple a matter as a well rolled bandage.
Stimulants, as calomel, opium, and good diet, will keep the sys-
tem well; and the joint itself may be  excited to a healthy ac-
tion, by  pouring hot mineral waters on it, by animal  oils, cam-
phor, laudanum,  frictions, and most of all by supporting the
action thus excited by a general roller,  well and carefully appli-
ed, and by particular compresses applied upon  each bursa.  By
a compress, merely on each  side of the knee-joint,  when the
great Capsule of the joint itself was swelled,  I have reduced
the size of a  dropsical knee by the quantity of three or  four
ounces in a night's time ;  the fluid being fairly and  unequivo-
cally  absorbed, without any  deception arising from its being
pushed  into the surrounding cellular  substance.  I have fre-
quently in a few days reduced prodigious dropsical swellings of
the knee, relieved  the patient from great pain,  restored the use
of the limb, and made an absolute and permanent cure.  The
common sprain of the ancle also is a slighter disease, a tempo-
rary one of those bursse which accompany the Peronaei tendons.
It seems to be accompanied with very quick and active inflam-
mation ;  if it be but a little  indulged  by long fomentation  in
tepid water, leeches,  poultice,  and  such things as  relax the
parts, it  is rendered a  very tedious disease, and the joint be-
comes swelled and  gummy, lame for months, and  rheumatic
for years, and liable to be easily hurt again by the slightest strain
upon it; but if this swelling be opposed vigorously  by  hot fo-
mentation, continued but for a short time, camphorated  spirits,
a very firm bandage, and long compresses firmly pressed down
behind the ancle, and if after a few days cold  water  be poured
upon the joint,  if it be rubbed, and still firmly bandaged after it
seems well, it will be easily cured, and no remaining weakness
left to remind us of the accident.
  I have reduced all bandages  to those few which  are repre-
sented at the head of this chapter.   They are as follow.
  The Linteum  Scissum, or Split Cloth, marked  No. 1.  is
peculiarly adapted to the  head : it covers the whole scalp, and 
 36           On the various uses of Bandages.

 its legs or split parts tie firmly round the occiput and forehead;
 it may be made with  six or with eight tails, according to the
 parts you wish to compress*.
    The Single Split Cloth, or bandage with four tails, No.
 2.  which is called the  Capistrum or Stirrup, or the Funda or
 Sling, is  the proper and peculiar bandage for the face : in cuts
 of the forehead,  or of the lace, of the nose, of the lips, in frac-
 tures of the jaws, and in every wound which is beyond the cir-
 cle of the hairy scalp,  we use the Sling, or Double-tailed Ban-
 dage.
   The T Bandage,  No 3. which is named from its resem-
 bling the  letter T, is the peculiar bandage of the body.  If the
 breast or belly be wounded, we make  the circular  (a) very
 broad, which serves as the proper bandage of the body, and we
 split the tail-part, (b) and passing one leg over each side of the
 neck, we pin it to the  circular, so that it forms a suspensary for
 the main bandage, which  prevents its slipping down.  But if
 we have a wound, or disease, or operation near the groin or pri-
 vate parts, the tail-part becomes then the most important part
 of the  bandage ;  then  the circular is smaller, and goes round
 the pelvis, while the tail-part is made very broad.   When the
 disease is in the private parts, perineum or anus,  we often split
 the tail according to  circumstances ;  but when the disease is in
 one groin, we generally leave the tail-part of the bandage entire
 and broad.
  The  Roller, No 4. is  the peculiar bandage of the limbs,
 for accomplishing all those objects which I have just explained
 to you ; it serves for the limbs, shoulders, haunches, and occa-
 sionally for the body ;  it is often singularly useful in bandaging
 the head,  where  peculiar firmness is  required, and there always
 you are to use the double-headed rollerf.   You  take one head
 ofthe roller in each hand, and by that which is in your left hand
 you fix down the turns  of that which is in the right, so  that you
 can make your bandage smoothly firm over the whole head, can
 knot it at particular points,  can turn it in every  direction,  and
 fit it to every occasion.  Wherever the roller is to be used as a
 uniting bandage (i. e.) to be applied  round any part, so that the
 legs meet and cross each other over a wound (to draw its. lips
 close together), we make a slit in the roller, see No. 5.  and pass
 one of the rolls through it, and thus we make the decussation
 of the bandage very sure, and give it peculiar effect upon the

  *  Marginal plate at the  beginning of this chapter.
  •j- In all injuries of the head, which render bandaging neceffary, a double-headed
roller is by far the beft : generally a common night-cap will confine the drefiing?
and anfwer the purpofes of a  bandage.  S. 
Of the four-tailed Bandage or single split cloth.      37
wound.  These are  the four bandages which I proceed to de-
scribe, and I believe I shall satisfy you  that you may throw
aside every other.
section II.
Of the four-tailed Bandage or Single Split Cloth.
  The Four-Tailed Bandage, or Single Split Cloth, is the pe-
culiar bandage for the forehead, face, and jaws ; if the forehead
be the part wounded, this simple and very convenient bandage
is applied as in fig. 7.  The bandage is made by  taking a strip
of cloth not quite so broad as the palm  of the hand ; it is to be
torn or split up  at each end, so as  to  leave only  a convenient
length of the bandage entire to be  applied to the wound ;  the
middle or unsplit part (a) is applied to the forehead, one  tail
(b)  is carried  round  the  back head to meet its fellow.  The
other tail (c) is carried, as seems best, either upwards over  the
crown ofthe head, or downwards so as to tie under the chin. 
38      Of the four-tailed Bandage or single split cloth.

  If the top ofthe head or sinciput be the part wounded,  the
bandage may be applied, as in fig.  8, laying the unsht part (a)
upon the wound, making one tail (b) pass down under the chin,
while the  other (c) is long enough to go round the head like a
fillet, so as to secure the bandage  from slipping backwards and
forwards.  It may go round to the occiput only, or  it  may go
round the occiput and return to the forehead, and tie there.
  In cuts of the lip or nose, or both, after putting proper stitch-
es in the nostril, lip, Sec. we apply the funda or sling, as in  fig.
9.;  we  make  one small opening to receive the tip ot the nose,
and we do not forget to make two small holes opposite  the two
nostrils for breathing.  If the nostril or the tip of the nose be much
wounded, or almost cut off, after putting in one or two stitches
with the needle, we wrap lint neatly round the quills to  put into
the nostrils.   The quills serve for breathing through,  and  the
lint dilates and pads up the nostrils, so as to keep the  nose in its
proper shape, and by distending the nostril it keeps the parts in
very nice  and equal contact  ; one tail of this bandage  ties at the
nape ofthe neck,  the other crosses its fellow at the back of  the
head, and then turns round to meet it, and to tie on the fore-
head ; and sometimes the lower part also is brought round to
tie at  the  forehead.  If the upper  lip  be cut, and a bandage
needed  (which seldom is the case), it is almost superfluous to
say that this bandage will serve the purpose.  It serves also in
cuts ofthe lower lip,  though there also we trust rather to hare-
lip pins  than the bandage ;  but this bandage is  particularly use-
ful in supporting the lower jaw  where it is broken.   This ban-
dage, when applied thus to support the lower jaw, is named Ca-
pistrnm or Bridle (as it goes round the jaws somewhat like a
horse's halter).  In some cases the circumstances require us to
support the chin particularly, and then the unslit part of the ban-
dage is  applied upon the chin, with a small hole to receive  the
point; but where  the jaw is broken, we pad up the  jaw-bone
into its  right shape, with compresses pressed in under the jaw,
and secured by this bandage ; where we are in fear of hjemorr-
hagy after any wound  or operation near the angle of the jaw,
we  can  give the  sling a very remarkable degree of firmness.
For this purpose, we tear the band into three tails on  each side,
we stitch the bandage at the bottom of each split, lest it should
give way when firmly drawn, and having laid our sponges first
into the bleeding parts, and then laid compresses above them,
we  make the tails of the bandage depart from  each other, just
over the point where the danger is, as in fig. 10. where two tails
(a) turn round under the occiput, and are tied there ; two others
(b) cross each other a little higher, come round by the temples,
and tie upon the forehead : and the two other tails  (c c) may 
        Of applying the Roller to the Head and Jazvs.       39

either tie upon the top of the head, or return and tie under the
chin.   In those cases, strong and firm pressure being required,
it is not amiss to have two legs of the bandage long enough to
be just twisted at the top ofthe head, and to return and tie un-
der the angle of the jaw with  a  firm knot.   But  for purposes
like these,  viz. of suppressing haemorrhagy after operations, or
supporting a broken jaw,  or  plugging up  a gunshot wound
where there is great haemorrhagy, such as we cannot command
with the needle,  there is a certain  form of the double-headed
roller, which I shall presently recommend in preference to this;
it is named the Knotted Bandage.
                SECTION III.
/
  Of applying the Roller to the Head and Jaxvs.


Fig.ll.           Fiy.rz.             Fig.lS.
  But the Roller is  the universal  bandage; it  supplies occa-
sionally the place of all those which are peculiar to the head or
face ; is applied to the head in the following manner; 1st, As
a uniting bandage.  When the cut  is, for example, on the fore-
head, the two heads ofthe  roller are crossed over the cut, by
passing  the head at one end, through a noose in  the other end ;
and I find it of infinite advantage to touch either the  roller it-
self,  or the skin near the cut, with some adhesive plaster, which
gives the roller a firm  hold upon  the skin,  fig. 11. where the
roller is supposed to cross over a wound.
  2dly, In great lacerations, or in extensive suppurations of the 
40
Of Bandage for the Body.
 scalp, the general pressure which such a case requires,  may be
 made by turning the double-headed  roller  with both hands
 round the head; and while the  right hand surrounds the head
 with circular turns, the left hand crosses the top of the head at
 each turn of the roller, and, when finished, it makes the ban-
 dage  which is drawn, fig. 12.   It is called the Capelline
 Bandage, and is the same with that which was a few years ago
 used for binding up a stump after amputation.
   3dly,  When the jaw  is broken, the double-headed roller
 keeps the parts very firm, and this bandage winds in every di-
 rection which  die exigencies of the case may require; for when-
 ever you wish to turn the bandage to  make it peculiarly firm,
 you have but to cross the  rollers,  and change hands.  But there
 is nothing so peculiar in this'form of bandage, nor so far differ-
 ing from the capistrum, or split cloth,  as to need a drawing.
   4thly, In every case of dangerous  bleeding from about the
jaws, the parotid  gland, the ear, &c.  I prefer that form of the
 double-headed roller which is seen in fig. 13. when at each turn
 
Of Bandage for the Body.                41
you-twist and knot the bandages over the point where the dan-
ger is ;  whence this form of the roller is called particularly  the
Knotted or Twisted Bandage.
                        SECTION  IV.

                  Of Bandage for the Body,

   The best form of bandage for the body is the  very old one,
 represented in fig. 14, named Spica, because, whtn made, it re-
 sembles ->omewhat  an ear of corn.   We  begin the bandage at
 (a), by la\ ing the middle of a double-headed roller in the axilla;
 we carry the two heads first round the body, then obliquely up
 over the breast and back, and make them cross each other over
 the  shoulder, (b); both heads are  then carried round the affect-
 ed arm at (c c), then up again over the same shoulder, and cross
 upon the top of  the shoulder, and then down  again  over the
 breast and back, so as to make  a second turn (d) under the
 sound axilla, and then the roller is returned over the breast and
 back a second time to the affected  shoulder.  This spica ban-
 dage is sufficiently  explained by the drawing ; it is often made
 over both shoulders, and is then called the Double Spica, being
 made with equal crossings on the breast  and back, and equal
 crossings  upon  each shoulder, both over  and under it.  This
 bandage is also used in  approaching the  trunk ofthe body from
 the  thigh :  the bandage is then called Spica Inguinalis,  the Spi-
 ca of the Groin,  and begins with  a turn round the pelvis.
   This spica, in various forms,  sometimes turning more parti-
 cularlv round  the pelvis,  and sometimes turning  chiefly round
 the limb,  according as the trunk or the  limb is most wounded,
.makes a very firm bandage.   In fractures of the clavicle,* in
 wounds about  the upper part of the breast, in haemorrhagies
 from the mammary arteries at the top  of the breast,  in  frac-
 tures near the head of the shoulder-bone,  in  amputations very
 close to the trunk of thr body, we find this bandage, the Spica
 Humeri, very useful.   The  spica inguinis is equally  useful in
 hernias of  the groin, in luxations ofthe thigh bone, in wounds
 of the upper part of the  thigh, or  lower part of the belly, in

   • In applying this bandage  for a fractured clavicle,  it is neceffary to raife that
 part of it attached to the fcapula, until it is put into  complete coaptation with the
 fternal portion. T his is to be effedled by elevating  the humerus, and a few turns
 of the roller, including the body  and arm, will retain it in  its proper pofition.
 For a more effectual but complicated apparatus for fractured clavicles,  vide Def-
 fault's CEuvrc.-; Chirurgicalcs, vol i. p 93.  I<i Boyer's Lectures, on the Diieales of
 Bones, p. 72,  Phil.  edit, there is a more fimple plan  recommended.  The fpica
 bandage will anfwer all purpofes if properly applied.  S.
                               F 
42               Of Bandage for the Body,
supporting aneurisms of the femoral artery, and in a thousand
indescribable cases.
   3dly, When the thorax is wounded or diseased ;  when  the
ribs are much broken ; when the sternum is carious,  with sup-
puration ;  when a schirrous breast has been extirpated ;  when
we perform the operation lor empyema, (that is, when we make
an opening to let out matter confined within the chest); we  use
the Napkin* and  Scapulary, fig. 15.  It is called Napkin  and
Scapulary, because in general it is made by taking a table nap-
kin, folded lengthways  four or  five  times ; which being  put
smoothly  round the  body, and pinned firmly,  is suspended by
the scapulary, so named from its lying flat over the shoulders.
The scapulary  part of the bandage is just a slip of linen split
half its length,  so that its two legs being laid round the neck,
the unsplit part before is pinned to the circular or napkin ;  and
the two legs being made to  cross each other behind, are also
pinned to  the circular, one on one side, the other on the other side.
   The T  bandage, belonging to the groin or private parts, is so
continually used, while almost all other bandages are neglected,
that it would be as superfluous to explain it, as it is useful to
explain the others.

  * A broad roller paffed feveral times firmly around the body, would,  I think,
apfwer better than the napkin.  S.
 
(  43   )
DISCOURSE IV.
ON HAMORRHAGY.
                 Preliminary Observations,


 JL O expire  by successive haemorrhagies is perhaps the least
painful of deaths, and yet it is the most awful.  The repeated
loss of blood so directly intimates approaching dissolution, and
the patient feels his  spirit and strength ebbing so perceptibly at
each return of hajmorrhagy, that he clings to life.   Those of
the most resolute mind are overcome with anxiety which they
cannot conceal, and look round for some one  to delay at least
the fatal moment:  and the surgeon feels himself so responsible,
that with him it is truly an  anxious scene.  If the bleeding be
slow and gradual, from some extensive surface, as from a poly-
pus  of the nostrils, from  the  womb, from the  surface of a
stump, or from some extensive sore, the surgeon  is sent for
from hour to hour ; he is called during  the night; he is made
unhappy for weeks ; and, after repeated uncontrouktble haemorr-
hagies, he  sees his patient expire.  But, if there be a sudden
haemorrhagy from the vessels cut in any operation, or from an
aneurism, or  from some great wound, the arteries of which
cannot be discovered, there is immediate danger of tl?e patient
expiring  even  in the surgeon's hands.—-Let those  who have
witnessed the  agitation of such  scenes judge ofthe importance
of that subject which I  am now to explain to you ; indeed I
may appeal directly to yourselves ! Is not this fear of haemorr-
hagy always  uppermost  in the mind of the young surgeon ?
Were this one danger removed,  he would go forward in his pro-
fession almost without fear.
  Let us then  consider the following points of doctrine, with
the  practical inferences that are- to be drawn from them :  First,
The natural causes  by  which an iuemorrhagy is stopped ; se- 
44          Of the natural Causes of Haemorrhagy.
condly, The artificial means of arresting an haemorrhage ;  and,
thirdly, The condition of an artery when tied with a ligature.
                        SECTION  I.

 Ofthe natural Causes by which an Hamorrhagy is stopped.*

  When  an artery has been tied securely, we are, from that
moment,  free from all uneasiness; but  when it stops merely
by pressure, by astringents,  by  the formation of clots, by the
contraction  ofthe  artery itself, whenever  haemorrhagy  stops
from any  natural cause !  it  is apt to return ; and  w e inquire
anxiously into those natural causes for this reason.  When
haemorrhagy stops  of its own accord, it is neither  from the re-
traction of the artery, nor the constriction of its fibres, nor the
formation of clots, but by the  cellular  substance  which sur-
rounds the artery being injected with blood ;  and to be assured
of this, we have but to observe, what happens in arteries of va-
rious sizes.  First, Let us suppose the wounded artery  to be
so small as just  to spurt  out its blood ; the stream of  blood
gradually lessens, because the artery  is emptied,  and the re-
sistance to the  arterial  action taken away; the stimulus being
gradually lessened, the artery every moment acts less power-
fully : and the blood being no longer solicited or urged on by
the arterial contractions, forsakes the open artery,  and moves
alpng the neighbouring branches.   The surgeon  claps the point
of his finger upon the mouth  of the artery, and  holds it there  ;
the outward bleeding is prevented ; the blood is extravasated
into the cellular substance round  the mouth of the  artery ; the
cellular substance  is slightly injected with  blood ; that blood
coagulates; and  this slight barrier is  sufficient to  restrain the
bleeding of a small artery, till the parts inflame,  and the  artery
is entirely stopped.
   Secondly, Supposing the artery still larger  and more power-
ful, and that it drives its  blood  very  furiously among the cel-
lular substance, it is not this slight injection of the  cellular sub-
stance that will  restrain  the bleeding!  The injected cellular
substance will not support the artery, unless it is itself also sup-
ported.  Suppose then that  the surgeon  first claps his thumb
firmly upon the artery,  and then thrusts down a piece of ?ponge
close to the wounded artery, applies over that a  compress, and
bandages over all to support the sponge and compress in  their
place ; the artery still bleeds^ (though in a restrained way) both

                       * Vide Appendix A. 
Of suppressing Haemorrhage.               45
into the  cellular substance beneath  the sponge, and  into the
sponge itself, till at  last  the  blood  coagulating in the sponge,
and in  the  cellular substance, they  become as one mass, and
often  the  sponge keeps its place till  the parts inflame and sup-
purate,  when, of course, the  wounded  artery heals along with
the other parts.
   Thirdly,  But often it  happens that the blood, which was at
first firmly coagulated,  begins to  lose its consistence ; or that
by some unwary motion, or by a febrile excitement, the  artery
acts  violently;  more  of the  cellular substance is filled with
blood, and the first firm coagulum and the sponge being removed
from  the mouth ol  the artery, the softer cellular substance be-
hind them is filled with fluid blood, and the artery, forcing that
slighter obstacle, bursts out again.
                           SECTION  11.


     Of the artificial Means of suppressing Hemorrhage.


   Styptics, caustics, and cauteries,* aided by compression, were
the  only  means of suppressing haemorrhage, which the older
surgeons possessed.   These have now  been almost entirely su-
perseded by the needle and ligature, for the discovery of which
we  are indebted  to  Ambrose Paree.f   This was a discovery

  "  Mr. Aftley Cooper, of London, mentions in  his- lectures a cafe in which the
adlual cautery was fuccefsfully applied to the artery which paffes through the fora-
men incifivum, when no other application could ftay the hasmorrhage.  Mr.  Hey,
of Leeds, I have been informed, ufes the fame remedy in haemorrhagies from the
tonfils.—S.

  f  Agaric, Bovifta, or Puff-ball, was ftrongly recommended fome years ago as a
fubllitute for the needle and ligature;  but preffed  fponge,  which has been  chief-
ly ufcd by the celebrated Mr. White, is more ufeiul than  the  agaric;  it is like
it in its operation, is really of value in practice, not to take the precedency of the
needle but to affift it.  The fponge can be very thoroughly dried, it can be  com-
preffed into a very  fmall compafs.  it can take any  fhape, and may be thruft down
into cavities and narrow wounds, where the needle cannot go; it can be made fo
hard, and preffed fo firm, by laying compreffes over it, as to have at  once the
effect of a comprefs  and of a fponge; or rather of a comprefs having this curious
property, that at firfl it preffes moderately, but if one drop of blood efcapes, the
comprefs fwells by abforbing that blood, ftill preferves its contact with the bleed-
ing  artery, and fwells more, and preffes harder, exactly in proportion as  fuch
preflure is required.  This is plainly the effect of a fponge, whether it be nitched
in betwixt two bones to comprefs an artery, which the needle cannot reach; or
whether it be laid flat upon an open fore, as after cutting out the breaft; or after
an amputation done  according to the old fafhion, where the furgeon ufed to  drei's
his {lump open, and to heap compreffes, tied with a firm bandage, above each  piece
of agaric or fponge   '1 he agaric, poffelfing a degree of this property, is of ufe;
even our common lint poffefies this quality of absorbing and swelling in a flight
degree.  But  the agaric and sponge are both fo excellent in this refpedl, that even
thole who are the leaft inclined to  ufe them,  muft acknowledge, that though the 
46
Of suppressing Haemorrhage.
 which set  him higher1 in  surgical, than  Harvey is in medical
 science, and it  is altogether his own.    Had this invention been
 well received, it must, in  the course of two long centuries, have
 improved  surgery very   greatly,  and  saved innumerable lives.
 It would  have  rendered many operations practicable, which the
 older surgeons never ventured  upon;  and  have  made those
 operations safe, which were not so till  of late years.
   Paree neglected nothing which could give  effect  to this im-
 portant discovery.  He tried to demonstrate, that even the an-
 cients would have approved ofthe practice.   He also supported
 his reasoning by facts ; by his amputations, and other operations,
 and by his successes in the  most dangerous wounds.    Nor cau
 we observe, without surprise, how perfect his operations were,
 even in the infancy  of this  discovery.
   Paree had three general ways of tying an artery; by passing the
needle round the artery, down on one side, and  up on the other,
 and so tying in along with  it a quantity of flesh; or, by draw-
ing the arteries out from the wound, as from the face  of a stump,
by the artery forceps with a spring handle, which he called Va-


agaric will often fail, it has yet  enabled furgeons to perform the greater amputa-
tions fafely; and the fponge, as h proved by  Mr. White's Pracl:;ce, is the  only
thing that can ftand by the fide of  the ligature to affift it.  I am fenfible, that by
thrufling down a fponge  I have  faved a patient's  life, when I  could not have ex-
tricated myfelf by any nicer operation.  The fponge is often more ufeful than the
needle, and  that, too,  in cafes of the greateft danger.  Wherever the wounded
artery lies deep, and we  cannot cut for it, on account of the nearnefs of fome
great artery or important  nerve,  as, for example, in the axilla, about the neck,
or about the angle  ofthe jaw; wherever the bleeding artery isfo nitched in be-
tween two bones that we cannot draw it out with the tenaculum, nor reach it with
our crooked needle, as, for example, in the fore-arm, or between the bones of the
leg: in fhort, wherever we cannot fee the artery, or cannot  ftrike  it fafely with
the needle ; wherever the bleeding is not fo  much  from a particular  artery as from
a. general furfa;e;  or wherever  the  blood  is thought to flow rather from great
veins than from arteries  (as in  tearing out cancerous glands from the arm-pit)
in all fuch cafes we ufe the fpotige, and we ufe it in the following  manner :  We
keep the fponge dry, and hard compreffed,  and always ready for ufe; and when
it is to be ufed, it is cut into fmall  pieces, fquare or long,  as the incifion requires,
and fmall threads are tied  to the fponges, by which  they may be drawn  away in
due time. In any dangerous haemorrhagy of this kind, we choofe  out a piece of
fponge proportioned to the fize ofthe wound,  thruft it down to the bottom of the
wound, fix it there with  the point of the finger,  either exprefcly upon the mouth
ofthe bleeding artery, or, if that  cannot be diftinctly feen, upon the  place at which
the artery bleeds;  then lay one  comprefs  above the  fponge, a fecond comprefs
above the firft, a third above the fecond ; and taking care to keep the compreffes
always fteady with  one finger, to  prevent the blood foaking into the firft fponge,
and diftending it, we pile one comprefs above the  other, till the whole rifes fo
above the level of the  wound, that our bandage operates well upon the whole
of this  pile, which is called Graduated Comprefs.
  I  advife you, on fuch  occafions, to keep your tourniquet fcrewed during the
whole operation, that  you  may  notJ^troubled with blood; to flacken it flow-
ly, that the dreflings may not be difcWpofed by the too hidden return of blood ;
 and ftill  let  your tourniquet  remain loofe about the  limb, and  ready to  be
 fcrewed, if the artery fhould bleed again. 
Of suppressing Haemorrhage.              4"
let a Patin ;  or by  striking the  needle above the place of the
wound, through the flesh of the  limb, down quite to the bone,
so as to tie in the  great artery of the limb, and along with it
much of the flesh.
  u If there be a bleeding artery,  says Paraeus,  in any wound,
dress the wound  with astringents ; but be careful at  the same
time to lay a firm compress over the wound, and settle it well
with a bandage,  and then lay out the wounded limb in an easy
way.
  " If this do not serve, clap your finger upon the point of the
artery, and wait patiently till a clot be formed.
  " It the artery  continue to bleed, cut up the wound, (if it
have been sewed) and pass a  needle under the  artery; enclos-
ing along with it in the ligature much or little flesh,  according
to the circumstances of the case.
  " If the artery have shrunk up  among the flesh,  cut up the
wound, and tie the artery higher.
  " But should both ends  of the  artery have been still further
retracted,  then continue  your incision, and cut open the skin
freely, still pursuing the artery; but still careful ofthe very artery
that you are pursuing, lest you should cut it a second time.
  " In an  amputated  stump,  draw your arteries  out with the
forceps, tie them neatly with a thread ; but if once you miss the
artery,  or your  first  thread give way, do not use the forceps
any more ; but pass a needle four inches long into  the stump,
so as to tie in the artery, along with  much of the flesh.
   " These ligatures we are careful  not to withdraw too early ;
nor must they ever  be removed  till  the granulations of flesh
have  grown up to protect and strengthen the arcery.
   " If these  operations fail, we  must have recourse to caustics,
vitriols, or the actual cautery, which make eschars and crusts ;
and we must be  careful to prevent these eschars falling off  till
the flesh be formed.
  " Sometimes also the surgeon needs to cut the vessel entire-
ly across, b)  which its ends, shrinking both ways among the
flesh,  the flux stops :  but  always the surest way is to tie the
vessel before cutting it thus across."
   This is a system of instructions which is fairly extracted from
Paraeus's  books,  without mending the text,  and though the sys-
tem be now one hundred and fifty  years old, it is such I believe
as the best surgeon at this day in Europe could hardly improve.
In correctness of practice,  surgeons, from his time,  went back-
wards for  many ages ; and it is only after much experience, and
by very slow degrees, that we have learnt at last, that the draw-
ing out an artery, with the forceps^r tenaculum, and the tying
it fairly with a small ligature, the method which appeared to the 
48              Of suppressing Hemorrhage.
older surgeons to have every  fault, is absolutely the most se-
cure*.

                        SECTION  in.

   Ofthe condition of an Artery when tied with Ligatures.^

   This, far from being an idle speculation, is, I trust, an inqui-
ry which will lead to very important conclusions ; for we natu-
rally inquire, first, How  the artery, (when tied  as in the opera-
tion of aneurism), is affected by the two ligatures which are put
round it? secondly, How the open artery of a stump is affected
by the single ligature with which it is tied ?  and this leads di-
rectly to  a  very interesting inquiry, viz. How the accidental
bursting of arteries is to be prevented, and  from what causes
secondary haemorrhagies arise ?
   An artery is part of the living  system: it has  its vasa  vaso-
rum, its arteries, veins, and lymphatics, for the growth, support,
and  nourishment of its  own coats.  Its circulation  and  nou-
rishment  are according  to the common  laws  of the system ;
and having this apparatus of active vessels, it is  connected with
the surrounding  parts by the common cellular substance, by les-
ser arteries and  veins,  and the division  o)  ,;aat cellular  sub-
stance, or of the  artery itself, is  as much a wound, as an inci-
sion in the skin is !

          Pathology of an Artery  tied with Ligatures.
Retrograde Blood.    adhefion.     dead.     adhefion.    Blood depending.
Ligamentous.                Ligamentous.
  When ligatures are applied round an artery, they operate by
making the several points of the arterial canal pass through the
various degrees of inflammation, from adhesion  in one point,
to gangrene in another.  The space includ' d betwixt the liga-

  *  By this means we avoid including in the ligature the large nerve which ufual-
ly accompanies every large artery :  a circumftance of no fmall importance.  Vide
what is faid on Secondary Hemorrhage.  S.
| Vide Appendix B. 
Effects of Ligatures on Arteries.            49
tures falls into gangrene, the space immediately under the stric-
ture of each ligature adheres;  this adhesion prevents the gan-
grene or the  inflammation passing along the higher parts of the
arterial canal ; but the inflammation affects the arterial tube a
little way upwards and downwards, so as to thicken its walls and
contract its cavity, whence the canal of  the artery is obliterated
a little way beyond the exact place where it is tied.
  The pathology of a tied artery is thus  reduced to common
principles; the obliteration and adhesion of a wounded artery,
is truly compared  with the re-union of any other wound; and
one subject of inquiry alone remains, the  most important per-
haps in surgery,  " What are the causes which prevent the ad-
hesion and obliteration of an artery, and produce ulceration in
its coats?" for the causes which thus produce ulceration and
prevent adhesion of  the artery,  occasion those secondary hae-
morrhages of which so many patients die!  We never leave our
patient bleeding,  yet it often  happens, that in the course of a
i'tw days after an operation for  aneurism or an amputation, the
blood bursts  out  suddenly  and  our  patient bleeds to death!
Direct haemorrhagy from a recent wound is easily suppressed,
for  we see the artery  and can tie it;  but this secondary hae-
morrhagy is peculiarly dangerous, it comes upon us when we
are  least aware of it, the parts are ulcerated, or mortified, and
the bleeding artery can be with  difficulty found.
                        SECTION IV.

Ofthe causes of secondary Haemorrhagy; and, first, of bursting
      . of tiie Artery from the diseased state of its coats.

   The bursting of an artery after it seems securely tied, arises
sometimes from the unfavourable state of the artery, and from
its being incapable of adhesion, but much more frequently does
it happen from that process which should terminate in adhesion
of the artery, proceeding to inflammation,  and ulceration of the
arterial coats.    The diseases of the arterial system have  not
been sufficiently investigated.   There are few people who have
passed their grand  climacteric without having the condition of
the whole arterial system very remarkably  changed.    The  ex-
treme arteries, the active arteries, in all parts of the system,  are
less affected, they preserve their natural pliancy; but the great
arteries which serve but to conduct the blood, and whose con-
traction is less important to the existence of life, are remarkably
affected.  We are sensible towards the decline of life, of chan-
ges in the great arterial trunks,  plainly  unfavourable to  our 
 50       Of the  Causes  of Secondary  Haemorrhagy.

 operations; the cellular substance which joins the  coats of the
 arteries is diseased; the whole tube is but ill disposed to pass
 through those changes which  are familiar to the other soft parts.
 They do  not inflame, adhere, thicken, and obliterate, as sound
 parts do.   In dissecting an aged subject, we always find the ar-
 teries less pliant, sometimes they are contracted, sometimes en-
 larged,  they become white, and their coats thickened and less
 connected with each other, separate like the coats of an onion
 into ten or twelve, or into innumerable lamellae ; they are at the
 same time brittle, and fragile, and have a crisped feel;  they are
 sometimes ossified ; they  break or crack when we attempt to
 bend them ; and the drawing of a ligature round such an artery
 tears it from want of pliancy; our anatomical injections are
 successful only in very young subjects ; while in older subjects
 the arteries burst because they have lost their strength  ; or tear
 under the necessary ligatures because they have lost their plian-
 cy ;  the anatomist knows  by the first touch of the femoral ar-
 tery, for example, whether his subject will bear to be injected,
 and  the surgeon in like manner often foresees by the first touch
 of his finger,  those burstings of the artery and secondary hae-
 morrhages of which so many have died.
   Thus it often happens, that the artery, too hard to bear a li-
 gature, breaks and tears across in the very moment of  drawing
 the ligature;  the artery must  no  doubt have been in this condi-
 tion, which gave the celebrated Petit so much trouble and anxi-
 ety in the case of Mr. Seneuze the bookseller.  Mr. Petit hav-
 ing amputated this gentleman's thigh, found that the femoral ar-
 tery  was nothing  affected,  neither by the tourniquet nor by the
 ligature ; and he was obliged in the end to suppress the haemorr-
 hagy by compresses piled upon the face of the stump, and bra-
 ced down with very firm rollers.   It  must also have  been an
 artery of  this  kind, by the  bursting  of which  Mr. Acrell had
 almost lost his patient;  for the artery did not  stand the ligature
 one moment, but in a manner burst under his fingers! The case
 is as follows :
  " A soldier, of a scorbutic  habit, extremely weak and conva-
lescent,  was stabbed unfortunately with  a pointed  knife in the
 femoral artery, about seven inches below  Poupart's ligament;
and the wound bled so  furiously that he fainted:  a physician,
who  was called, bound it up  so effectually with compress and
bandage, that  he stopped the  bleeding for twelve days ; but the
blood burst out again on the thirteenth day; notwithstanding
which, the outward wound healed, the aneurismal  tumour was
distinctly formed,  and by the  twentieth day it beat very strong-
ly, threatening rupture.  Acrell thinking the aneurism too large
to be cured by compression, proposed  to tie the artery;  he 
Of Ulceration of the Artery.              51
opened the tumour; scooped and washed out the very black and
fetid blood, and exposed the artery, which he found dilated for
about four inches into a large  sac of about three quarters of an
inch in diameter.   He then tied the  artery with one ligature
above, but behold while he was drawing the lower ligature, the
artery suddenly burst above the upper ligature, and threw out its
blood with such force, that in  less than a minute the man had
lost fully four pounds of blood."  This artery tore under the pres-
sure of the ligature ; the tourniquet could not command the hae-
morrhagy ;  the ligature itself was ineffectual.  In these distres-
sing circumstances, Acrell at last suppressed the haemorrhagy
by sponges and compression! with these he "filled up the whole
cavity of the aneurism; and to  ensure a proper compression,
he made a sheath for the thigh, of white  iron,  with a globular
compress upon its internal surface, adapted to the place  of the
wounded artery."   Thus he accomplished the cure, and the
case is a singular example of the artery in that very state which
I have described  breaking under the ligature,  giving way in
the very moment of the operation.

                         SECTION v.

     Of bursting ofthe Artery from ulceration of its Coats.

   Yet it is not to this unhealthy  condition of an artery alone
that I ascribe the death of those who have perished from secon-
dary haemorrhagy.   The diseased state of the arteries never
can explain the difference of danger  in  the two operations of
aneurism and amputation.  In amputation of the thigh we tie
the great femoral artery;  we tie also the profunda, and its mus-
cular branches ; we perform amputation daily,  and we  tie ma-
ny  great  arteries in each amputation;   each  ligature  is  seen
moved and raised up from the face of the stump at every pulse
ofthe artery; the stump  remains open.   These arteries conti-
nue for weeks to bear the whole force of the circulation, unsup-
ported, yet they rarely give way.
   But, in the  operation  for aneurism of the thigh,  the differ-
ence of security  is very great; for this operation is, on the
other hand,  so full of uncertainty and danger, that  hardly any
case can  be mentioned in which the surgeons have not been
alarmed, and the patient in great danger, from  secondary hae-
morrhages :  it is an operation never performed but by surgeons
of the first eminence; and yet  more, perhaps, have died than
have survived it*.   Hunter himself has lost his patients: those
*  The fuccefs attending this operation has been much greater of late.  S. 
52              Of Ulceration of the Artery.
  whom he  did save were endangered by secondary haemorrha-
  ges;  and the celebrated Mr. Pott, from  the ill success of one
  operation, was  forced to amputate the thigh.   It behoves us
  then  to inquire,  What the difference is betwixt tying the femo-
  ral artery in aneurism,  an operation so full  of  difficulty and
  danger, and  tying the same  artery in amputation, an operation
  which is so perfectly safe, that the death of a patient by haemorr-
  hagy after it would be a flagrant disgrace.
    Secondary Haemorrhagy arises from Ulceration ofthe
  Artery more frequently than from  any other cause.  In  am-
  putation,  such ulceration rarely  happens, except when the liga-
  tures, having been firmly tied round the nerves, are prevented
  from slipping off, or when  the whole surface of the stump falls
  into disease, and is eroded;  but in aneurism it is peculiarly fre-
  quent, from  the manner in which a great length of the artery is
  insulated and detached from the surrounding parts.   If the sur-
  geon, forgetting how slight  a force suffices for suppressing the
  pulse of a naked artery, and for laying its sides in  contact, pulls
  his ligature with all the firmness which the artery can bear, al-
  though the artery be not immediately  cut across,  its coats may
  be twisted and weakened; or, though not even weakened, they
. may be so violently compressed that not only the portion of the
  tube intercepted between the two ligatures, but the part imme-
  diately under each ligature  will fall directly into gangrene in
  place of adhering, so that, on the third day,  when the ligature is
  withdrawn, it may bring along with it the end ofthe artery*.
    If  the surgeon, in place of dissecting the artery  fairly, passes
  his needle under it, and  includes much of the muscular sub-
  stance, or other soft parts,  there is little pressure  upon the
  artery, there is no adhesion of it under the ligatures, there  is
  no amputation  of  its  intercepted part, the cellular substance
  and muscular flesh fade and give way on the third or fourth
  day:  But  the artery itself is stiil entire,  and the blood, by  this
  slackening of the ligatures, passes along the canal  of the artery,
  and out at the wounded point; and as the structure ofthe artery
  is but little affected by so slack a ligature, the artery  continues
  entire, the ligature keeps its place round the artery, and, though
  it does not compress the artery, it irritates it, and is never dis-
  engaged till  the artery falls into ulceration and  bursts.
    If  the surgeon should pass  his needle  any considerable dis-
  tance from the  vessel, he will include not  flesh only, but  will

   * From the obfervations of Dr. Jones, it would appear that there is not fo much
  danger to be apprehended from drawing the ligature with a confiderable degree
  of tightnefs as  Mr. Bell feems to fuppofe. The ligature ought to be tied tight
  enough to divide the two internal coats of the vefftl, and the furgeon had better
  ?rr on  that fide,  than incur any riik of having the ligature thrown off.  S. 
Of Ulceration of the Artery.                5 Z
take the nerve into the loop of his ligature ! for every great  ar-
tery has a great nerve of  the limb  accompanying it, the bra-
chial artery has the great  radial nerve,  the femoral artery has
the great anterior crural nerve, the great artery,  nerve, and in-
ternal veins of each limb, lie in a peculiar sheath, and, in order
to tie the artery apart from the vein and nerve, it  is necessary
to dissect this peculiar sheath of cellular substance.   Now, au-
thors  have always talked slightly of tying  the nerve, as if the
tying it related only to the nerve  itself! No! it relates to the
security of the  artery ! an artery,  tied  with  a ligature, is de-
stroyed in a few clays, but a nerve tied with a  ligature is hardly
affected by it: The  nerves  are peculiarly strong, their  coats
hard and firm ; a ligature  tied round a  nerve and  artery  toge-
ther, as  it cannot destroy the nerve, keeps its  hold upon the
artery, till, by the  irritation of the ligature, and other obvious
causes, it ulcerates and bursts ;*  or, if this can be prevented, it
is only by  cutting the ligature timeously  away, which cannot
be done without a degree of difficulty and danger.
   But there are still other causes of the ulceration  of arteries.
If the surgeon, anxious to  insure the obliteration of the artery,
resolves to lay a  considerable length of the sides  of it in con-
tact,  what does he do but  insulate the artery, tear it up  from *
its bed among the  cellular  substance,  separate it from all those
vascular connections  which  kept it  alive I  he exposes it to al-
most inevitable ulceration!   This has been practised upon  the
femoral artery in a great variety of ways, all of them ingenious,
but all in direct opposition to the principles of surgery.  These
contrivances for  insulating  the artery are sure to cause that
ulceration which too many natural causes conspire  to produce;
and it is this ulcerated state of the  artery that makes it neces-
sary to apply successive ligatures, and the same causes make
these  ligatures,  in their turn, give  way.   As  far as  possible
then,  to avoid insulating the vessel,  I would  tie it clear of  the

  * The following experiment, which is extracted from Jones, p. 179, very re-
markably confirms what is ftated in the text.
  " In the month of September, 1756,'' fays Pouteau," I  tied the crural  artery
of a dog of moderate fize with a  ligature, which likewife  included the nerve of
the fame name ; the artery  was not opened, and the animal was left to itfelf.  On
the fourth day there fupervened an haemorrhage, which flopped of its own accord :
on the next day it recurred, and was fo profufe that the animal died.  Upon lay-
ing open the  artery lengthwife, I found it open at its anterior part, immediately
under the thread of the ligature ; there was in its cavity a clot  of a pale red colour,
of a moderate confiftence,  and in  the form of a fpindle : the fuperior extremity of
the coagulum floated in the artery above the ligature ; the  middle portion  was
lightly attached to the pofterior part of the artery under the ligature ; the inferior
portion, which was the mod {lender, floated in the artery below the ligature ; this
coagulum was about four lines in leng;h, and  lefs than a  line in  diameter, at its
thickeft part."  Pouteau Melanges de Chimrgie, p. 8c.—S 
54
Of Aneurisms.
 nerves, which, being indestructible, hold the ligatures too long :'
 I would also have  it clear  of the muscular flesh, which pre-
 vents the ligature from having its full effect upon the artery ;
 and with a ligature smaller than the one  commonly  used, I
 would tie the vessel, with moderate firmness, as near as possi*
 ble to the sound parts.

                        conclusion.

   Thus have I endeavoured to investigate, in  a general way^
 the causes of secondary haemorrhagy: I ascribe the most dan-
 gerous bleedings, both in amputation and in aneurism, to the
 ulceration of the great  artery: some of the causes I hope I
 have explained  to your  satisfaction; and the practical conclu-
 sion, which I would deduce from this doctrine, is of no small
 importance: it has relation more or less directly, to every great
 operation; and therefore reflect, I beseech you, on those facts
 and  principles,  and judge  for  yourselves.  It is  my opinion,
 that a great artery never can be safe while the ligature remains
 about it ;  for, till it comes away, the artery cannot be said to
 have adhered, cannot be buried in granulations, nor supported
 by the surrounding flesh, cannot be out of danger of ulcera-
 tion.  Nor can a great artery ever be safe while it remains in-
 sulated : surgeons seem to take a pleasure in  seeing it lying
 fairly along in the  cavity of an aneurismal sac ;  but they should
 recollect, that if the artery lies more within the reach of an ope-
 ration, it is also surer to need it ; for being thus stripped of its
 Cellular  substance, deprived of its nutritious vessels, the part
 which is included betwixt the two ligatures must gangrene ; the
 parts under the two ligatures often,  in place of adhering, will
ulcerate ; the ulceration,  in place of stopping when the ligatures
fall off,  will continue ; and as the artery is a firm  part, enter-
ing slowly into  disease, it  ulcerates slowly, and bursts only on
the tenth, twelfth, or fifteenth day,*
* Vide Appendix C. 
(  55   )
DISCOURSE  V.
OF  ANEURISMS.
                 Descriptions of Aneurisms.

ANEURISM, when it arises without blow or hurt, steals on
slowly.  A small tumour is  felt, for instance, in the ham; it
is small at first, and firm, and but little affected by the pulsation
of the artery.  It lies deep among the flesh, and must  be felt
for by working in  the fingers  and pressing aside the adjacent
parts.   It is supposed to be a knot or kernel, has little pain,  is
neglected for many weeks,  and might be mistaken,  even by a
surgeon, for a  swelled gland   These tumours begin during
sickness and convalescence,  while  the patient  is in a state of
perfect quiet, and while there is not even the slightest fever to
account for this dilatation of  the artery; but if doubts concern-
ing its nature remain,  we generally find them all resolved by
the dissection of the body.   These aneurisms are found to be
true dilatations ofthe artery ; there is no breach ofthe arterial
coats,  the cellular, the muscular, the villous coats are thickened
as they approach the dilated part, and  may be fairly traced
over the aneurismal tumour* ; it is on the tumour, indeed, that
the several coats  are most distinctly traced.   But strong as this
predisposition is, we are astonished to find these dilatations end
gradually and gently in the  sound artery, which has in the in-
termediate  parts not the slightest mark of disease, the arterial
system being throughout limber, soft, and natural.
   But aneurism arises not only from this inscrutable predispo-
sition, but often  from an actual and manifest disease of the ar-
terial system.  We frequently  find throughout the arterial sys-
tem, the coats  of the arteries  thickened  and brittle, their cellu-
lar substance loose and spongy,  with spots and specks of ossifi-
cation besetting the great arterial trunks.t   We find the great
arteries dilated where they give off their  larger branches, and

                       • Vide Appendix D.
  f Scarpa is of opinion, that fpontaneous aneurifms generally proceed from what
he calls a " flow, morbid, ulcerated, fteatomatous, fungous, fquamous degeneration
of the internal coat of the artery ;" for which he cites numerous authorities. S. 
56
Of Aneurisms.
 the arch of the aorta or beginning of the subclavian arteries in
 an aneurismal state, while the lower part of the  aorta  is small,
 crooked and  irregular.    These are the marks  of a disease
 which prevails towards the decline of life;  it is often observed
 before the fortieth year; but it is singular, that, till the approach
 of that period of life, natural aneurisms are extremely  rare:
 Aneurisms are rare in women: they are frequent in strong and
 hard-working men; but in them also they rarely occur till after
 the thirtieth year, when their arteries begin to acquire-this hard
 and rigid condition.   The defects  of  old  age  come upon the
 arteries sooner than upon the rest ofthe system:  the arteries
 are unequal to those exertions of which the muscular frame is
 still capable:  one part of the system is weakened before  an-
 other, which is the very  essence  of disease, or predisposition
 to disease.
   Yet this predisposition is of such a nature,  that it seldom
 degenerates into aneurism, without some direct violence ; and
 there are  few of those enlargements of the artery which cannot
be distinctly traced to some external injury, some blow, sprain,
 fall, or violent exertion of the limb.   There are few,  indeed,
that do not immediately and perceptibly follow the injury.  Of-
ten,  I am persuaded, the artery is not  merely injured, but ab-
 solutely burst or broken across! Aneurism of the ham is more
frequent,  in consequence of the artery at that part  lying close
under the knee-joint, and bound down by the heads of the gas-
trocnemii muscles, whence it is endangered by every sudden
 motion of the joint, and affected  by every  strain of the limh.
 Aneurism is  frequent also in the  thigh, in consequence of  the
length and great  size  of  the femoral artery, its oblique course
round the thigh,  its passing through the tendon of the triceps,
and from  the  manner also  in which it is braced down by the
muscles.  The operation of these various  causes of laceration
must  next be explained.
  An artery,  such as  I  have just described it, rigid and dis-
eased, an artery which tears under the surgeon's ligature, which
bursts upon injection, which, in dissections,  feels so palpably
hard and brittle, is surely not calculated  to resist violent strains,
or sudden motions of the joint; and accordingly we-sometimes
find an artery perceptibly lacerated by external violence and
sudden bending ofthe joint, just as it might be  broken across
with the finger and thumb in dissection.
  " Three years ago," says Walther, " I had the long wished-
for opportunity of dissecting an aneurismal limb. An old man,
about fifty  years of age, of a constitution naturally hale and vi-
gorous, was  confined  to  his  bed, crooked with rheumatism,
and tortured with pains in his knees; his left  knee especially 
Of Aneurisms.
57
 gave him great distress. This miserable creature being wretch-
 edly poor, instead of sending for better assistance,  applied to
 an old  woman, who,  having  first extended his crooked  knee
 very violently, wrapped it up in  some  of her plasters.   This
 extension of his knee was extremely painful to him, and he soon
 perceived a small tumour upon the popliteal artery;  it pulsated
 very strongly, and, upon  the slightest pressure, produced ex-
 quisite  pain.  This aneurism gradually  increased to an enor-
 mous size ;  and it was only when the poor man became sensi-
 ble of having no other chance for life,  that  he submitted to
 amputation."
   "The limb was  immediately  carried to Walther's  rooms,
 where,  upon  dissection, it was found that the popliteal artery
 was dilated into an aneurismal bag of a heart-like shape, of three
 inches  broad, and four inches long, occupying the main artery
 from a  little below where it gives off its two upper articular ar-
 teries,  to within an inch of that point where it divides into the
 tibial and fibular arteries.  The heads of the gastrocnemii, so-
 laei, and plantar muscles, where they covered the sac, were ex-
 tended  to a remarkable degree of thickness; and the  great vein
 and nerve, raised by  the tumour, were protruded betwixt the
 two heads of the gastrocnemii muscles, so as to be in  close con-
 tact with the skin."
   In the drawing of  this aneurism by Walther, which is in-
 deed very beautiful, we see osseous concretions occupying the
 coats ofthe tibial and  fibular arteries below the aneurism.  We
 have every reason to presume, that in the ham,  and in the up-
 per parts of the  femoral arteries, these  specks  of ossification
 must have been  much broader and more frequent.   These os-
 sifications are the surest marks of this brittle  unyielding  state
 of a great artery.   An artery must like the ligaments and other
 parts, where  the joint continues  for  any length of  time  thus
 crooked and stiff, be proportionably shortened, and in this brit-
 tle state must be unfit to bear sudden extension.  In this in-
 stance,  some  of these brittle  ossifications  had given way, or
 hurt the adjoining parts; the remaining coats of  the artery had
 dilated  into a true aneurism  ;  the artery  certainly had been in-
jured, though not entirely lacerated, for the drawing repre-
 sents a  true aneurism, a sac  entire and continuous with the
 arterial  coats.*
   In natural aneurisms we see the  slow  dilatation of an  arte-
 ry.   But when, as it often happens, a man in the very time of
 falling,  or, in the instance of a blow, or sprain, feels pain in the

   * It is much more probable  that in this cafe the coats of the artery were rup,-
 tured, notwlthftanding the appearance reprefented by the drawing.—S. 
58
Of Aneurisms.
ham,  when he observes that he has from that  moment  consi-
derable pain in  laying his kg across ; when, on  t'.ie  third or
fourth day he feels distinctly the pulsation, pain and lammess,
which are the peculiar signs  of aneurism, what reason can there
be for doubting that the  artery is burst ?  None, surely, but the
slowness with which the aneurism grows.  Thr slow manner,
then,  in which even the greater arteries of the body form their
aneurism, must next be  explained.
  We are naturally inclined  to believe, that an  artery thus bro-
ken or lacerated,  must form its aneurism the moment its coats
give way, and must be able  to overcome  all resistance from the
surrounding parts in a few days. But here we are deceived ; we
must  not  regard the artery as a naked and insulated tube, such
as is represented  in Figure 1st, merely laid along the limb, un-
connected with the surrounding parts, unsupported by cellular
substance.   The  artery has a cellular coat in which it is lodged :
this coat is so peculiar as  to be called the sheath or capsule of
the artery, and is closely  connected with  the  proper  coats  of
the artery by cellular substance and numerous vessels, which
strengthen, support, and nourish it; and  when the proper coats
of an  artery are torn,  the blood is not widely extravasated, but
is confined by this sheath of cellular membrane, which is very
slowly forced, or separated  from  the artery.   Even after the
sheath is separated from the artery, it does not entirely give
way,  but its  cellular substance is kneaded as it were with the
half coagulated blood,  and  rises into a  tumour somewhat re-
sembling the thrombus which rises over  an ill closed vein.
   Fig. 2d represents the true and natural condition of the arte-
ry which is  every where nourished by  its cellular sheath, and
represents a laceration or rupture  of the artery, showing how
the sheath and cellular substance are opposed to the exit of  tin
blood.
   Fig. 3d represents the  aneurism  already beginning to form.
Here is once  more   represented,  the  continued  sheath,
within which the great artery is  enclosed ;  large  branches,
such  as  the profunda  femoris, and smaller muscular  twigs,
are seen going off from the great trunk,  each having its own
peculiar sheath.  For the smallest arteries are as well support-
ed with cellular substance,  and have sheaths as peculiar as the
femoral  or carotid arteries  ; each little  arterv, as it penetrates
among the muscles, is  enclosed along with its corresponding
ve'iu,  and often with a small twig of a nerve, in a peculiar fascia.
Aneurism produced by the bursting or laceration of an artery
dilates slowly, because, ;he continued  canal of the artery is
still open to the blood, the cellular substance yi;!ds  very slowly,
the blood coagulating  in hard and firm clots, walls up  the 
                        Of Aneurisms.                     59

artery, and is so mixed with the first lamellae ofthe cellular sub-
stanc■:,  and is so firmly clotted as to make a strong resistance.
At first, while the blood is confined to its natural course, the
progress of  aneurism is slow.   But when the cavity of the
aneurism is  enlarged,  when the blood begins  to collect there,
and the circulation becomes irregular, these clots give way from
time to time, and by exercise, working, or accidental  excite-
ments, there is  Irom time to  time a new impetus  against the
sides of the sac itself, and it enlarges, the clots which  line the
cellular substance become bigger and firmer; layer is added to
layer, and at  every addition of this kind, the fluid contents of
the aneurism accumulate, the open part of the bag enlarges,  and
the  cellular sheath of the artery, which  in fact corresponds
with the  sheath  in Fig. 2d, is  condensed' into  a  firm aneuris-
mal sac, which gives  the whole tumour  sometimes the appear-
ance of a spontaneous and natural dilatation of the artery itself.
Thus there is formed a great tumour "of clotted blood, surround-
ed with a firm cellular sac, and bounding a cavity which is con-
tinuous with  the artery,  where the circulation of the blood is ir-
regular, and often accompanied with a whizzing noise.

          Sketch explaining the Fascia of an Artery.

    I. The Naked Artery.    2. The Sheathed Artery.    3. False Aneurism*
Artery.                                               Aneurism.
   This hard and firm tumour, rising higher and higher over the
artery,  begins at last to compress the canal of the artery itself;
the clots sometimes loosen, fall  down,  and almost choke  the
current ofthe blood; the limb grows cold and benumbed, from 
60
Of Aneurisms.
  the compression of the great trunk,  and  it swells  and inflames
  from the enlargement of the inosculating arteries.   By the per-
  petual and increasing  pulsation, the pressure and straitness in-
  crease,  the bones are spoiled within, and the integuments are
  almost destroyed without; the limb is safe, for the inosculating
  arteries are enlarged,  yet, when the tumour burts, the patient
  dies from the  bursting of the main artery,  and the immediate

  loss of blood.
     Thus  we perceive that  the  increase of such an aneurism,
  where the  artery is absolutely broken across, is naturally slow ;
  .that the resistance is uniformly  great;  that the artery does not
  lie as in our preparation glasses,  or on the dissecting table,  insu-
  lated and  unconnected,  but  is  surrounded with  cellular  sub-
  stance ; its rupture is walled up  with coagulated blood ;  its ca-
  nal is open to the  circulating fluids, and  there is, for  a long
  while,  a firm  pulse  even in the  artery  which is  desperately
  wounded,  provided it be not entirely cut across*.
     But where the femoral  artery is not  merely wounded, but
  entirely cut, or broken  across,  it  will no doubt form its  aneu-
  rism more rapidly, perhaps  in three weeks, instead of three
  months, as happened  in a case which  occurred to my friend,
  Mr. Harkness.   The  patient was  master of a small trading


                  * Explanation ofthe  Etched Plate.
    Aneurifm proceeding thus, from violence done to the  artery, is very eafily dif-
  tinguiflied from that which proceeds from a natural dilatation of  the tube.   I have
  given this meet of Etchings to explain this piece of Pathology.
    In Figure ill is feen a Femoral Artery where the dilatations are plainly of that
  kind which is called Natural Aneurifmf, the dilatation being fpontaneous and gra-
  dual ; and in  this fketch it will be noticed, that fince the profunda (a) comes  off
  from one ofthe aneurifmal facs, had that fac increafed fo as to become a formida-
  ble aneurifm, had  the operation  been performed, and the ligature been tied above
#■ that aneurifm, the inofculating arteries communicating with the  profunda  would
'  have poured their blood into the fac,  and caufed a  fecondary haemorrhagy if the
  fac was cut open, or fet it a pulfating again, if it was left untouched.
    In Figure ad you have a fketch of that Aneurifm which I have been  juft de-
  fcribing, where the old  woman, by her violent bending of the knee, injured the
  artery, and, I  have very little doubt, broke it acrofs, and left the breach in the arte-
  ry fuftained only by its external coat of common cellular fubftance.
    In figure 3d you have another fketch of an Aneurifm, which.jps operated upon
  by Mr. Hunter.   The man died fome years after, the  artery w||(dlffected out, and
  the following*circumftances deferve particular notice : tft, TKe artery (bb) was
  oflified throughout the whole length ofthe thigh; this does not feem to have been
  the confequence of the operation merely, for the profunda, which was not touched
  by the ligature, was alfo oflified: therefore this man's fyftem of arteries was predif-
  pofed to this rupture of the arterial coats, and his trade, viz. that of a hackney-
  coachman, expofed him to blows, twifts, and  ftrains.  adly,  The aneurifmal  fac
  (c) lay altogether upon the back of the artery ; it was formed all on one fide, as
  if the artery had  given way on  one fide; it lay fo  over the artery, as to prefs
  flrongly upon it.   The aneurifm had, in fome meafure, the appearance of a fe-
  parate bag, it was oblong, a little flattened, and like  a hen's egg, and contained a
  folid coagulum."   3dly, It is indeed very  interefting to  obferve the inofculations,
    f Vide Appendix E. 
*ytw»y
Z /V/ /"/////.j  <>,  ■    / f//t
y
AS/'/// '.1^//-/r'f//'6JV/'>J
***■*■
/''"/#.
 A Hfi/iteaA ,-lnritns/n trAicn Aaa"Seen t^sm/ecS^n
 £r WffunfirvirAerr tAc e/'si/iration /iA'oA Aad/brrttis-
yitted' /AcAstirry/o </i/ntAon is seen at A TAe sma/l
t3*cwsu/a/iit£.ir&rr'es reretriny S/ocafjivm aAere
*w mtztAett' ee. €tn</ t?/tr /arvfe in{>*ct*S&/ts*,j
Arancti tm nJmtfct*? /Ae 73/eaetf* tA* Arterr Ae -
•t*>r ts nvmAectV
_,!_ eliteasevf state gftAe Femo/rtt Artery.
 when- a Ac reyb#ese-nta succe/siofi ty An-
-eunismal  Sacs, d one of tAore Sars oibe*
-nect.ctnde tAe fbcfuneta aretf its AitzncA*
•es veiny tffljrvm t/ietMber-mttst. intra/?
=/ncc( Sac. 

»
»
»
t-
\i 
Of Aneurisms.
61
vessel  belonging to  Borrowstounness ;  a very  stout athletic
man, about forty years  of age.   Six months before, he had
broken his thigh bone ; the fracture was healed,  but had been
set so clumsily, that the lower end of the broken bone project-
ed upwards like a trochanter.   The whole weight of  the  body
rested  very obliquely  upon the  thigh,  which was  manifestly in
danger from future accidents ;  yet, while  the bones continued
united, the leg was strong and serviceable.
   One day, in loading some goods into his vessel,  he slipped
his foot and fell.   Though this limb never actually touched
the ground, the callus had snapped across, the bones passed
one another, and the femoral artery, partly by the angle which
it made over*the prominent end of the broken bone,  and partly
by the  sharpness of the  bone  itself, was torn almost entirely
across.   Even this aneurism did not  increase  very  suddenly,
and never acquired a very great size: it formed for itself a re-
gular sac, and, moreover, when  near bursting, lost its  round
and circumscribed  form,  and became  flat.   It is easy to ima-
gine that an artery  in these circumstances could not be well sup-
ported  by its cellular substance ; for the bones had  been  but
lately re-united by a callus ; they  were now broken again,  and
all the surrounding cellular substance destroyed :  there was al-
ready,  as it were,  a cavity prepared for receiving the blood of
the  artery ; accordingly,  the moment the man's  foot slipped
under him, he felt extreme pain from the various parts  which
were lacerated, and even that night the tumour began to  form.
The next day the tumour was large, and  pulsated very strong-
ly ; and  in a few days its pulsation was so powerful as to raise
the bedclothes.   But from the  time in which the artery  began
to be resisted by the thick muscles and fascia of the thigh (for
the'aneurism lay altogether under the belly of the vastus inter-
ims) it  hardly increased in size :  it  remained quite  stationary
for a fortnight or more : even the pulsation, which had begun to

for we find every mark of great activity among the fmaller arteries of the thigh,
to fupply the want of the trunk.   The femoral artery is indeed obliterated in the
thigh at (b b), but for fome fpace above the aneurifm, as at (d), the canal is again
open, and receives many inofculating arteries (e e t), and is full of blood.  The
popliteal artery, under the aneurifmal bag, is fo obliterated that the lower mouth
of the artery cannot be found.   At (ff)  the popliteal artery becomes once more
pervious, it there alfo receives many inofculations ; by thofe inofculations the blood
probably  came down both from the profunda, along the back of the thigh, and alfo
by fhorter inofculations, joining the pervious part of the artery above the aneu-
rifm, to the continuation of the artery below the tumour; e e e marks the inofcula-
ting arteries, d marks the pervious part of the artery below the tumour, and f the
divifion of the popliteal artery into the tibial and fibular arteries ; g marks a large
and curling  inofculating artery, which manifeftly has borne much of the force of
the circulation, is greatly enlarged, and feems to have taken precedency of all the
other inofculations •, h h h marks the great crural vein, with its branch; s accompa-
nying the artery. 
62
Of Aneurisms.
be very powerful, was in some degree deadened by the accumu-
lation of blood, and the pressure of the surrounding parts,  and
somewhat reduced by the enlargi mtnt of the collateral arteries.
The  limb preserved its natural htat and circulation :  every
thing  was favourable to  the bold attempt of saving a limb at
on^e fractured in its  bones,  deprived of its main artery,  and
loaded with a great aneurism.   This operation was once agreed
to, but a second consultation condemned the limb to be cut off:
it was cut off, and the man died.
  Thus we  perceive, that even the great femoral artery, al-
though entirely  torn across, forms its aneurism but slowly.
The amputation of the limb, in this case, was performed  the
fourth week after the fracture of the bone and bursting of the ar-
tery, and yet the aneurism had attained but to a moderate size:
and the  following  case  shews that even when the aorta  itself
bursts, it forms its aneurism  very slowly, and does not, by any
means, prove immediately fatal.*
  An  officer   of distinction, about  forty  years of  age,  was
wounded in the  battle of Fontenoy ; and from  his long con-
finement to bed he  fell into bad health.  He  was  distressed,
during his confinement, with nephritic  complaints, and, soon
after his recovery, was  seized with vomiting and  spitting  of
blood.   He went to  Bristol  Wells, recovered his health,  and
continued for nearly  ten  years to live a careful and regular life,
attentive  to his  exercise on horseback,  to his diet, and  to  the
quantity of wine he  drank.
  About ten years  after these complaints he seems to have
been  suddenly  seized  with  very  inexplicable distress,  which
soon ended in his death.  He began first to complain  of want
of rest,  tenesmus, gripes, and mucous  stools streaked  with
blood.   These symptoms were appeased by some draughts of
oil, manna, and rhubarb, but the watchfulness continued.   The
patient felt more than usual pain in his belly,  especially  in  the
left side ;  he feared  a return of his gravellish  complaints,  and
about a month after this  first  attack, he consulted Sir John

  *  Except in thofe cafes in which a rupture takes place in that part of the aorta
included in the duplicature ofthe pericardium, in which event death immediately
enfues.  Vide Wifhart's Scarpa, p 8i> for an inftance, and citations of others.—S.
  Another cafe, which is an exception to this rule, is ftated by Mr. B. from War-
ner, who relates it, apparently from memory, in few words, but very decifively ;
the general impreffion ofthe cafe upon his mind feems to have been very ftrong.
" Some years ago the operation for aneurifm was perforated in a fimilar cafe with-
in a few hours of the rupture of the  veffel, the tumour increafing fo faft,  and the
pain proving fo intolerable, that it was neceffary co lofe no time.  '1 lie tibialis
poftica  was burft in the middle of the leg : it was taken up with fome difficulty,
and the patient recovered."
  An immediate operation is the only means of faving the limb, and probably
the life of the patient, under fuch circumftances.—S. 
Of Aneurisms.
63
Pringle.   A hiccup had  come on, the pain was now constant,
sharp, darting to his back, groins, and testicles; it was  especi-
ally severe  when he  turned to his right side, but he never at-
tempted to turn upon  his left.  These were the decisive marks
of some organic disease.   The disorder was quite  unaccount-
able.   His  pulse was quicker, harder, and  fuller than  natural.
He had some degree of thirst, but his head was  clear.    Such
was the degree  of watchfulness,  that for six weeks  he  had not
been  sensible of slumbering half an  hour:  for the last three
weeks of his life  he was hardly sensible of  having even closed
his eyes.    His  feet, he  observed, were  sometimes  benumbed,
which made him call for  more wine than usual; and though he
had no sickness at his stomach,  his  appetite was gone.   He
was bled, but as  he grew  daily weaker, they were afraid  to re-
peat the bleeding; and for his hiccup, he took  musk  and ab-
sorbents, without effect.   Opiates were not omitted; and both
on account of the hiccup, and in order to procure  sleep, lau-
danum was given; at first in smaller doses, but his physicians
were  soon obliged to give it to  the  amount of one hundred
drops during the night, without checking the hiccup, or obtain-
ing sleep;  but it raised a general perspiration.  He  seemed,
after  this, to be relieved : his spirits revived, the pain  ceased;
but this was the  deceitful prelude to death.   On  the day of his
death, he continued all the morning wide awake, sensible and
in good spirits, but  with an incessant hiccup.   About four in
the afternoon he called for drink ; but before the  servant could
warm it, he suddenly expired.
   The dissection of this gentleman's body proves to us a very
unprecedented fact, that the aorta itself sometimes gives  way j
that  the aneurism, which its laceration forms, is hardly more
rapid in its growth than that of a smaller artery ;*  that the sac
which it forms out of  the loose cellular substance,  is firmly at-
tached to  the artery, as  if the aneurism had arisen  from mere
dilatation.   The abdominal viscera were sound;  but there was
a tumour larger  than the fist, of an oblong figure, lying  close  to
the spine, by the side of the aorta descendens, and in the  direc-
tion of that vessel.   It began as high as the emulgent arteries,
descended nearly to the pelvis, and was  of a very firm  consist-
ence.  It was  found to consist of coagulated blood,  condensed
in the cellular  substance, and under the  adjacent  parts of the
periosteum  were some  detached parcels of extravasation.  This

  * The rapidity with which an aneurifmal tumour enlarges, depends  rather up-
on the extent of the  breach in the arterial coats, and the fituation of  the artery
with regard to the furrounding parts.  Thus a popliteal aneurifm muft  neceffari-
ly increafe (lowly from its confined fituation ; whereas an aneurifm  of the external
iliac artery would increafe with much greater rapidity, from the oppofite  caufe.—S. 
64
Of Aneurisms.
 abdominal portion of the aorta,  along with  its  tumour, were
 dissected out of the body, together with a part of  the thoracic
 aorta, and of the common iliac arteries, and the  middle  part of
 the aorta being laid open through its  whole length, there was
 observed, in the space  between the  emulgents and lower me-
 senteric arteries, a complete rupture of all its coats.   The aper-
 ture had lacerated edges ; was big enough to admit the point
 of the dissector's thumb, and led into a tumour, which now ap-
 peared to be a spurious  aneurism  of  the  great  artery;
 that is, a sac formed ofthe cellular membrane, containing blood
 of different degrees of coagulation, which apparently had issued
 at different times  from the aorta.
   The neatness or  this  dissection  prevents  all those  doubts
 which puzzle us  in cases less correctly related  ;  but the case
 is written  by Sir  John Pringle ;  the dissection was performed
 by Hunter:  the tumour was not first mangled, more canino,
 and then the connections and causes of it  stated in  idle conjec-
 tures.   The aorta was  slit  up on that side which was sound.
 The dissectors saw clearly the connection of the  tumour with
 the artery.   The  artery was burst, the laceration  had ragged
 edges,  preventing all  suspicion  of previous dilatation ;  the
 breach was such as to admit  of the dissector's thumb, and was
 proportioned to the size ol the artery.  The sac was formed in
 the cellular substance,  condensed  in  proportion to  the driving
 of the blood,  and  it adhered so to the artery  as  to be cut  out
 along with  it,  and certainly  would have been reported  by less
 dexterous dissectors, as  a natural aneurism which  had  burst.
 The  blood was collected  by  several successive extravasations;
 the artery making (according to the exertions of the body) suc-
 cessive impulses  against the  cellular substance, and against the
 peritoneum, which serves as  the sheath for this vessel.    For
 our entire satisfaction in regard to the nature of this disease,
 we, in another paragraph, learn also  the cause, for " the aorta
 was not dilated above the aperture, but its coats were at that
place  harder than  natural, as if  tending  to ossify,  and  having
lost  their natural elasticity and toughness, were parted asun-
 der."*
   Here  then is the greatest artery  of the body burst; fairly
torn  asunder,  and that without  any strain or blow.'|\   The

  * " Upon the review of the whole, we  conclude that a fmall aperture had at
 firft been made at this weak part of the aorta, fome  confiderable time before the
 death of the patient; that the tumour had been gradually formed of the oozing
 ofthe blood into the cellular membrane furrounding the artery, and which there-
 upon was dilated into that fac mentioned above."  Vid Sir John  Pringle's Me-
 dical Effays and Obfervations of Edinburgh, Vol  III.
  f Mr. Elft obferves, That " the arteries  fometimes become ruptured  without
 any previous dilation.  I have (fays this author) a preparation of the aorta afcen- 
Of Aneurisms.
(U
.greatest artery of the body, not  supported like the femoral ar-
tery by a peculiar sheath, nor bedded in firm cellular substance
of muscles,  but merely covered by the peritoneum, and lodged
in the loose cellular substance of the kidney,  is yet so supported
as to form  its aneurism very slowly.   The blood  is forced in-
to  the cellular substance by successive impulses.   The sac is
fairly circumscribed,  and forms an oblong  tumour not much
bigger than  the fist, though of considerable  length, lying close
to the  side  of the artery, and so connected with it as to be cut
out along with it:  well may such a sac be mistaken for that of
a natural aneurism in bungling dissections.
   Thus have I proved to you, that an artery is sometimes dila-
ted gradually, sometimes  is hurt in  its coats, but very often is
burst,  lacerated, or  entirely broken across*.  That after being
burst, it is supported by its sheath.  That the cellular substance
receives  the blood;  while the breach in the artery thus  walled
up  with  coagula, forms its aneurism  slowly ;  that the greatest
arteries of the body  form their aneurisms slowly,  and have the
cellular substance  and arterial sheath beaten into the form of a
distinct sac  ; and that  an aneurism which truly arises from a la-
ceration of the artery may be mistaken for a natural aneurism or
simple dilatation ofthe tube!
                          SECTION II.

Conclusion.—Containing a description of various anomalous ca-
                        ses of Aneurism.

   To what  practical uses these  speculations may be  applied,
you will next inquire ;  for, unless they have some influence on
practice, your interest in  them should  be but very small.  You
will remark  that no sooner is it proved to  you that an artery
may be  burst by a strain of the  limb,  than you begin  to look
upon certain accidents which are apparently  trivial, in a new
and serious light.   In the case of a direct wound of an artery,

dens, appearing in no place dilated, which exhibits two ruptures, one is fmall, and
fituated about  half an inch diftance from the valves, from which a coagulum was
formed about the fize of a large nutmeg, that was feated between the trunk ofthe
aorta and the trunk of the pulmonary artery. From the white appearance ofthe
coagulum, and the regularity of the edges of the rupture, it feemed to be of long
ftanding. The other rupture is much larger, feated at  the curvature between the
exit of the right and left carotid arteries, the edges of which are torn and irregular,
and formed a tumour, which preffing againft the  lower part of the trachea, and
the branches of the bronchia, deftroyed the patient by fuffocation in  lefs than a
month from its firft rife, and before there was  any appearance of an  external
fwelling.
  * This laft is probably a very rare occurrence.  S. 
66   Description of various anomalous cases of Aneurism.

succeeded by a large tumour, with strong pulsation, and all the
characteristic signs of pure  aneurism, you can be at no loss to
distinguish the nature ofthe disease.  But too often it happens,
that when this disease begins in a sprain, when the pain is great,
the pulsation small, and the whole member swelled to a great
size, the general enlargement conceals the particular swelling of
the aneurism, and the  limb is destroyed  before the surgeon is
aware ofthe nature ofthe disease.  These are the cases which are
so generally called anomalous, or, in other words, cases which
are not understood.  While the surgeon, unwilling  to believe
that an artery is burst by a sprain of the limb, remains ignorant
of the nature of the disease, the artery is actually ruptured, and
is pouring out its blood among the muscles ; the bones are pre-
sently  destroyed, the whole limb is ruined  in its texture, swell-
ed, cold, and lifeiess.   The surgeon cuts it off, and being as lit-
tle expert in anatomy as judicious in surgery,  he, upon finding
bones, blood, and matter mixed in one confused mass, learns by
his dissection nothing  more than  he did by his previous inqui-
ries :  he calls it an anomalous case! but these are  not the  less
aneurisms, because of our  being ignorant  of their nature  and
origin, and of that process by which they come to this last stage
of irregular suppuration.
  This is the general termination of neglected aneurisms ; but
there  are  certain occasions  in which the disease infallibly as-
sumes this form.  First, Wherever the aneurism is produced
by a broken bone, for there the artery is wounded or broken on
the side next the  bone, the  blood is poured out under the bellies
of all the muscles, the resistance  to its  outward extension is
great,  and the inward destruction of parts is proportionably ra-
pid.   Secondly, When the  the aneurism happens in the ham, or
under the bellies  of the gastrocnaemii muscles, for  there the
aneurism is peculiarly straitened, it is pent up betwixt the ham-
string  tendons, it forms slowly, is singularly hard, and frequent-
ly has  neither the pulsation nor other marks of aneurism ; but
the knee-joint being destroyed,  the bones corrupted,  and the
limb enormously swelled, it requires amputation long  before the
tumour threatens to burst!  even amputation is not safe ! Third-
ly, But most of all, the limb is in  danger when the case is not
understood ; when the artery is not wounded, nor gradually di-
lated,  but actually burst; for the surgeon,  little accustomed to
think of this bursting of an artery, never  apprehends  the  true
nature of the  complaint, nor even knows  it to be aneurism  !
After  having amputated the limb, his exculpation  consists in
calling it an anomalous case, intimating that it was unintelligible
and incurable. 
(  67   )
           Of Aneurism from Fracture ofthe Bones.

   Aneurism, from fracture of the bones, is more or less impor-
tant according to the artery that is wounded, and the other cir- .  ^
cumstances ofthe case.  In a fracture near the ankle, the artery $ \
is small,  the. aneurism superficial, the resistance outwardly is
slight, whence the  bones within are  proportionably less endan-
gered.  In such aneurism behind the ankle, in the Fibular Arte-
ry, for example, the tumour should be opened, the artery tied, and
then the bones re-unite, but till you have tied up the artery, you
have in general no re-union of the bones.  We  find that this
aneurism also grows very slowly, insomuch that sometimes it
hardly appears till after the callus is formed, and the patient be-
gins to walk.   There are indeed exceptions to the general rule,
for the  fracture sometimes heals while the aneurism goes on.
" A  surgeon of Guand, being called to set a broken leg, appli-
ed the usual bandages, and in  the usual time  accomplished the
cure.  But when the young man began to walk abroad, a tu-
mour was observed behind the ankle, over the place where  the
bones had been broken ;  the surgeon (now  called again)  being-
ignorant of the nature ofthe disease, applied a caustic, but when
he  opened the eschar, instead  of matter which he expected,
blood gushed out so impetuously, that it was stopped with great
difficulty.  The  young man fainted in  the moment of this hae-
morrhagy, and expired in two days after*."
   When  the artery is of another order, larger  and lying deep
among  the muscular flesh close upon the  bone by  which it has
been lacerated, the case  is more unfortunate, and if neglected,
too frequently terminates in mortification and death.   The tu-
mour caused by such an artery is large and diffused, the coagula
of blood which oppress the limb are very large, and consequent-
ly the pulsation is  not distinct and smart, but heavy and throb-
bing.  Knowing,  as you do, the principles  of Surgery, you
need not  be  informed, that if  the oppression be allowed to|in-
crease, the limb will fall into gangrene, or the skin burst and the
patient bleed to death. ^  And you must be sensible, that if the
skin be left to burst, you  must then  search  for  the artery and
tie it, with but a poor chance of success, the extravasation hav-
ing quite  ruined the texture ofthe limb.   If again the  oppres-


  *  Palfin, page 341.  This is a rare exception to the general rule, that fuch com-
plicated fradture  cannot  heal till after the artery is tied.   In this cafe, probably,
the artery had formed a fmall fac for itfelf, <Mftin<5l from the lacerated cavity form-
cd by the fractured bones.
I 
68         Of Aneurism from fracture of the Bones.
sion be allowed to increase till the limb become generally swell-
ed, cold, lifeless, and in danger of gangrene, you must cut it off,
without perhaps the consolation of saving even the patient's life,
for such & limb is apt to run into gangrene.
   When an  artery, then, is  thus  lacerated, along with frac-
ture ofthe bones, you  have but this  alternative to cut the limb
off at once, if it  be very desperately wounded, or to try to save
it by making incisions (as in simple aneurism), and tying the ar-
tery !  If you call a consultation, it is not to decide so clear a
point,  but  to satisfy the friends and exonerate yourself.  The
fracture is already complicated with aneurism, and  you are un-
der the dangerous necessity of converting this complicated aneu-
rism into a compound fracture !   You apply your tourniquet,
make a long and  deep incision, turn out the  coagula of blood
with your fingers, cleanse  the sac with sponges, search for the
artery  and tie it  up"]*.  You wash out the  blood  from  the sac
with  syringes and sponges, for while it lies betwixt the bones
they cannot unite ; what blood  you are  forced to  leave melts
down into  bad matter and flows off; the deeper parts of the
wound gradually digest, granulate,  and  fill up with soft flesh;
and when the continuity of the parts is thus restored, the new
bone or callus begins to form.   Such is the activity  of a wound-
ed artery in forming its aneurism and destroying the surround-
ing parts, and so complicated is the disorder wht n a wounded
artery is added to a fractured  bone, that unless these operations
are performed early, the limb is inevitably lost.
   But the condition of the periosteum must chiefly be regard-
ed, for being part of the system ofthe broken bone,  it is capable
of generating new bone, and the form of that bone will be regu-
lated by the parts upon which it may be moulded.  The perioste-
um being now expanded into the form of a cyst over the broken
bone and  aneurismal blood,  its  new secretion of bone will
spread over the aneurism.   The outside of the  periosteum is
still connected with the muscles and other soft parts, it is nou-
rished and receives its  vessels from  without,  and lives, and
thickens, and begins a secretion of bone.   The secretion while
it is in this unnatural extended condition  is very powerful, and
the bone which  is formed  by  this dilated or expanded  perios-
teum, is not only firm,  but  broad  like a  scull.  We often  see
the lacerated periosteum and the membranes  of fractured and
luxated joints, or of carious bones,  forming great bony caries or
stalactite like projections.   In gunshot  wounds, with  fracture?
ofthe upper part ofthe thigh-bone, in the scrophulous caries of


   f For more particular directions for taking up wounded arteries, vide chapter cb
 :hat fubjed.  S. 
Of Aneurism from fracture of the Bones.       69
the hip-joint, in luxations of the thigh-bone from the acetabu-
lum, in fractures of the cervix femoris, in compound fractures
and luxations of the wrist, and  in fractures of the shoulder-
bone, bony  cavities are often formed as  big as the head of a
new-born child.  In cases of  aneurism, it is more difficult for
the periosteum to live, or to form those bony cavities, but when
such cavities are formed, they are filled with blood like coffee-
grounds, and constitute a most irregular, or as it has been term-
ed, anomalous disease ; and round the outside of such bony ca-
vities go the enlarged branches of the artery, which preserve the
limb notwithstanding all this  disorder.  It is in such cases that
we are  almost at a  loss to say, whether  aneurism or exostosis
has most share in forming this fatal tumour.
   I shall illustrate this species of mixed aneurism, by relating
a  case which  was communicated to  me two years ago by my
friend Dr. Jeffry, professor of anatomy in Glasgow, whose abi-
lities and zeal are universally known.  Dr. Jeffry had the good-
ness to send me along with the  preparation, the following short
narrative of the case :
   " An old woman of about  fifty years of age,  was rode down
in the streets by a cart, and her arm broken in two places.  One
of those fractures was about  two inches above the elbow, the
other was above the middle of the arm, and the whole bone was
greatly shattered ; yet this poor creature  had no assistance, no
surgeon was  called,  the  arm remained unattended to for six
 weeks, when Mr. Parlane,  a surgeon in Glasgow, visited her
 and found the  arm  greatly swelled, so that he could neither dis-
 tinctly  understand the nature of the injury nor the condition of
 the bone ; it was presumed that there was a fracture, and the
 patient was laid in a  posture favourable to the  re-union of the
 bone."
   " The tumour never subsided but increased, occupied the
 whole arm from the elbow to the top ofthe shoulder; pulsation
 was distinctly felt at the top of the shoulder, but of such a kind
 as might proceed from some artery near the surface, it was
judged to be really so,  the idea of an aneurism certainly had
 never struck the  gentleman who attended her, for he opened the
 tumour which was soft and fluctuating, there was no doubt of
 its containing  a fluid of  some kind or  other ; the lancet was
 struck into  it, but instead of matter, as  was  expected, blood
 flowed in a full stream."
   u This puncture healed  up easily, the tumour  which had
 subsided when it was thus imprudently opened, soon filled  up
 again to its full size, and the hand and fore arm became cede-
 matous and cold.  In this condition the patient survived five
 months, the tumour pulsating manifestly, epecially in its upper 
70       Of Aneurism from fracture of the Bones.
 part; but how this woman died, or after what kind of suffer-
 ings,  is not related in the case."
   *' On opening the  body after death,  eight months and more
 having elapsed from  the time of the fracture, a profusion of
 mixed and putrid blood  like coffee-grounds was discharged.
 Two inches of the lower  part of the bone retained its natural
 form, all the middle  part of the bone was destroyed, the head
 only remained on the upper part of the tumour, but with its
 cancelli quite eroded, nothing being left but the mere shell.
 Through the whole length of the bone, the cancelli were com-
 pletely dissolved, and the outer bony lamina were found adher-
 ing  to the whole inner surface of the sac, many pieces of the
 bone were found in the heart of the tumour, and on the fore
 part and  middle of the tumour was found one  piece  of bone
 two inches and a half long and nearly two broad."
   " Although the humeral artery was injected,  it could not be
 perceived from what  branch of it the tumour  was produced."
   We need but to review in the history of this case a few cir-
 cumstances, in order  to understand the whole  disease in the
 most unequivocal manner.   First, The sudden rising of the
 tumour, the swelling  of the whole arm, the fluctuation, the pul-
 sation in the upper  part of the tumour, prove, that though the
 chief part of the tumour is  found upon dissection to be bony,
 yet aneurism, and not exostosis, formed the basis of the  dis-
 ease.  Secondly, The striking of the lancet into the tumour
 shows that there was blood very early ;  the sudden filling up of
 the tumour to its full size, after having been punctured with
 the lancet, shows that the artery was  open  at that  time,  and
 throwing its blood freely into the sac;  and finally, the bony ca-
 vity being filled at the time of death with nothing but corrupted
 blood, which  always after  long delay assumes the appearance
 of coffee-grounds, proves the tumour to be merely an aneurism ;
 but  it is a complicated aneurism ; it is  combined with  a frac-
 tured bone ;  and the  condition of the periosteum accounts for
 the generation of such extensive plates of bone, equal to a crani-
 um in size, and something like it in the breadth and flatness of
 the  ossifications.  Thirdly, It being proved   that the disease
 was aneurism, it is next to be observed, that there is not belong-
 ing to the humeral artery,  as to the femoral,  a great profunda,
 or collateral branch, as large as the  trunk itself ; there are but
 two  muscular branches in the arm, and those not larger than
 crow quills ;  there is no artery, except the trunk itself, equal to
 the production of such an  aneurism.  The branches which run
 on the inner surface of this tumour,  were all singularly well in-
jected,  which shows that  none of these had  any share in pro-
 ducing the aneurism ;  and surely none of them had terminated 
Of popliteal Aneurism.
71
in the bag; even the  force ofthe  injection had not burst their
most delicate branches; they  were full of the injection, and
the bag empty.   While the entirenessj of these branches proves
that they had no share in forming the aneurism, the enlarge-
ment of the  profunda inferior, to  such a size as to rival the
trunk itself in diameter,  is another proof that the  trunk was
wounded ; for nothing but the wound of the  trunk  could thus
enlarge the profunda.
   This is one of those cases in which, as I have expressed my-
self, one is almost at a loss to  decide, whether aneurism or ex-
ostosis has the greater share in forming the disease.   The con-
fusion ot  the case is almost an apology for any mistake  of the
surgeon;  yet the suddenness of the tumour,  the pulsation, the
blood following the lancet, were signs too conclusive to allow
of any doubt.   There must have been in a certain stage of this
case such oedema, oppression,  coldness of the  limb,  and sup-
pression of  the pulse, as  might have  intimated to the surgeon
that the change in the state of the circulation had taken  place,
on which the fate of such a limb depends.   The  patient  living
with an aneurism certainly proceeding from the rupture  of the
great artery;  living also under such a complicated and oppres-
sive disorder, fracture, exostosis, and extravasated blood, proves
to us that there is hardly  any case  in which  we need despair;
and the enlargement of all the arteries in this limb, is authority
for performing the operation for aneurism, even when the main
artery is ruptured, along with a fracture of the bone.
                         SECTION III.

              Peculiarities of popliteal  Aneurism.

    In  all cases of neglected aneurism, this destruction of the
  soft parts, and caries of the bones, is  the last stage of the dis-
' ease.   But in popliteal aneurism, whether proceeding from spon-
  taneous dilatation ot  the artery, or arising from strains, frac-
  tures or wounds, the  danger is peculiar; for the aneurism  is so
  confined  under the heads  of the gastrocnaemii muscles,  and
  betwixt the tendons of the hamstrings,  that the resistance to its
  extension is very  great, the destruction within is proportiona-
  bly  rapid, and the disease is always attended with severe pain.
    The popliteal artery passes between the condyles of the thigh-
  bone, and behind the knee-joint,  by every motion  of which it

    \ Does not the entirenefsof the trunk a? fully prove that the aneurifm was not
  caufed by a wound of it ?—S. 
72
Of popliteal Aneurism.
 is affected.  It also lies under the gastrocnemii muscles, whence
 it is endangered by every strain of a limb which is very pow-
 erful, and which supports the whole weight of  the  body.   A
 man, for example, has a fall from his horse, and hurts his ham,
 or strains it  in mounting  his horse; or his limb falls in be-
 twixt the  rounds  of a ladder, and is violently and suddenly
 bent; or he receives a blow upon the  ham, or he is seized with
 a sudden cramp in the calf of his leg, and  from that moment
 his pains and  lameness begin.   Whether the  artery be  merely
 stretched and inflamed, or whether it absolutely  gives way un-
 der such accidents, is little to the present purpose ;  but thus it
 is that the disease begins, and is long unsuspected by the sur-
 geon, while the patient walks, or refrains from walking,  by fits,
 as the pain happens to be more or less violent, rubbing the part
 perhaps with camphorated oil.
   Thus all parties continue indifferent to  one of the most fatal
 diseases.   The  ham  is  straitened, whence the tumour, even
 from the  first, is of  stony  hardness.  From  this straitness it
 loses very early the  marks of aneurism,  for the  pulsation often
 ceases, or  is very obscure.   The tumour (even in  natural a-
 neurisms  of the ham) is not always clearly circumscribed,  nor
 to be fairly traced to any connection with the  artery ; and be-
 ing covered, and its pulse suppressed by the great thickness of
 the muscles and skin, the  nature of the disease remains un-
 known.  From  the  same pressure the leg becomes very early
 cold and  edematous ; for the veins, lymphatics and artery, all
 pass in this straitened cavity of the ham, the pressure upon these
 produces a general swelling of the limb, which conceals the par-
 ticular tumour.  From the  elevation  of the bellies  of the gas-
trocnaemii muscles over the  tumour, and from the distention of
 the  hamstring muscles, the limb is  thrown  into  severe and
 painful cramps; and from the nerve  passing over the tumour,
 (pressed sometimes quite flat)  a very distressing numbness is
 always felt, and the lameness and pain are such as the external
 swelling cannot account for.  All these distresses of pain, cramps,
 swelling,  and  general numbness of the limb, increasing every
day, the patient  sometimes dies of locked-jaw,  fever, or long
 suffering and  want of rest, the disease becoming fatal before
that period arrives in which the tumour bursts.
   Although it is very certain that aneurism is often unattend-
ed with pulsation, yet it  is not unlikely that sometimes those
 collections of blood which fill the ham, and hurt the joint, and
end in caries of the bones, proceed from ruptures of the veins ;
for the veins,  more  delicate than the arteries,  are exposed to
the same violences as  the artery, since they accompany it; and
varices of the internal veins are capable of producing  similar 
Natural progress of Aneurisms.              7S
effects with proper aneurisms.   The  destruction of the bones
arises not from the pulsation of aneurism,  nor from any thing
peculiar in the nature of the arterial blood, but merely from the
injection of the cellular substance with the blood, together with
the general pressure, and the internal ulceration, from the pre-
sence of a foreign body.   Perhaps the sudden rising of a tu-
mour from a strain of the limb, a sense of laceration  in the part,
the slow increase ofthe  tumour, and the total absence of pul-
sation through all  its  stages, may be esteemed among  the signs
of a ruptured vein.'j'

                         SECTION  IV.

         Of the Progress of Aneurisms, and their Cure.


1N  the natural progress of every aneurism, there  is a certain
critical point to whic|b|when it arrives, the struggle betwixt the
pulsation and  the resistance must end.   If the pulsation is to
prevail,  the parts become thin, the  tumour bursts, and the pa-
tient expires.   If, on the other hand, the resistance be such as
to oppress the  artery, then the pulsation does not  all at  once
cease, but the collateral arteries enlarge, and begin to  carry off
the blood from the aneurism at the very moment it threatens to
burst.   By this change of circulation, the pulsation of the artery
is weakened, so that the swelling, weight, and resistance of the
surrounding parts, and of the coagula formed within the aneu-
rism, are  able  to resist  the stroke of the artery; its  pulsation
flags, and the collateral arteries  enlarge;  its pulsation at last
ceases, and there is to be observed, betwixt the loss  of one cir-
culation and the establishment ot another, an  interval  of coldness
and deadness in the limb.   The circulation is  thus, for some
time, upon the turn ;  and when  this critical period arrives, the
limb is prepared for the  happiest changes ; and no sooner is the
circulation  in the great arteries stopped, than that of the col-
lateral arteries is substituted in its place.
  This  enlargement of all the smaller arteries implies a condi-

  f In one cafe the diforder was fairly traced to the veins. Mr. Elfe, in hii works
relates a cafe of this kind, in which the limb was amputated on account of the  ca-
ries of the bone.  Upon throwing a wax injection into the arteries,  it was not ex-
travafated in the tumour, but ran freely along the arteries to the foot. Upon ex-
amining the great vein, a rupture was found immediately above one of the valves.
  Any tumour, lying in conta<Sl with  an artery, will receive a pulfatory motion
from it;  therefore,  a tumour from  a ruptured vein might pulfate.  If the tumour
be fufficiently foft, to enable you to prd's out all, or even a very large proportion
of its contents, it is evident that, if it arifes from a ruptured vein it will  not fill with
> ■'- fame rapiditv as from a divided artery.—S.
                              K 
74,
Guattani s Operation.
 tion of an aneurismal limb, which, though hitherto unnoticed,
 is too full of important conclusions to be omitted ;  and the con-
 dition of the aneurismal limb is still the same, whether we per-
 form the cure by tying the artery, or attempt it by compression,
 or  whether we neglect the aneurism till it obstructs the artery,
 and obliterates it by its pressure, or bursts inwardly among the
 cellular substance.
   When the celebrated Guattani succeeded in curing aneurism
 by  long confinement,  with compression and firm bandaging, he
 believed that he had repressed the aneurism, and actually saved
 the  channel  of  the blood, by preserving for it a free course
 through the main artery of the limb.   Were this opinion  cor-
 rect, the tumour should yield at first, then become  flaccid, then
 its  blood should  be  altogether discharged into the artery, and
 the artery  should  be   apt, on  removing the bandage, to inject
 the empty bag and fill it again:  in short,  the  sac  of the aneu-
 rism should be repressed as a preliMte to the cure of the disease.
 Again, suppose  (by some process oTthM»conomy, which I can-
 not foresee, and which surely never dicM^ppen) that  this were
 really the succession of the phenomena in this cure, the artery,
 after such a cure, should carry its blood freely, the pulse should
 be as strong as  ever, and whatever remained of  the tumour,
 though  it were but a thickening of the parts, should receive the
 stroke of the artery,  and this  residuum or remains of the tu-
 mour continuing to  pulsate thus,  the operator never could be
 assured of his cure, and would never lay aside his compress.
   But in truth,  the last stage of the process  is this: The arte-
 ry  being  for some time opposed  by the gradually increasing
tension of the  parts, the blood is thrown upon the collateral
branches; the blood  passing  along the collateral branches, al-
lows the compression to be increased without that intolerable
 sense of numbness and pain, which the compressions ofthe first
 week cause.  At last the compression is supported boldly, firm-
ly, unremittingly.  If the operator stop short of this, the dis-
ease returns; but if he entirely compress the artery, the blood
forsakes it, the  pulsation stops,  the tumour remains  solid and
firm, and does not enlarge, because the  blood no  longer flows
into it, nor  does  it even beat again, because the artery which
lies under  it is  obliterated by  the  pressure.  Thus,  we per-
ceive, that Guattani,  when he cured by  compression, had no
reason to continue his  bandages for years,  nor to fear a return
of the disease..   He performed, in fact, a radical operation ; he
obliterated the artery as fairly as if he had tied it with the four
tapes, which have been so often used in this piece of surgery.
  A grave-digger had an aneurism, which was large,  attended
with pain, fever, a throbbing pulse, and  great swelling of the 
Spontaneous Lure.                   75
limb, but not particularly hard ; you rather seemed to feel in it
a sort of fluctuation.  But the case was well marked ; for " in
the last week of July he  had hurt his limb in a very violent ef-
fort ; it was while he strained very hard in lifting the confes-
sion-desk  from one part of the church to another, that he felt
something give way in  his ham, with a  sudden pain,  but yet
bearable,  so that he  was able for some time to continue his la-
bours.   He was ignorant of the nature of his disease, and had
used only the more harmless applications, till the time of  his
being laid in the Hospital of St.  Peter, under Guattani's  care.
   "  This  man was brought to the  hospital  in the first week of
August.  For the first eight days he  was bled, dieted, confined
to bed,  and reduced so  that the stricture of the bandage might
be safe  and tolerable.   Then the compression was begun,  car-
ried on step by step, and occasionally renewed;  but  on the first
week of November, Guattani found thatthe pulsation ofthe tu-
mour had entirely vanished, and the tumour remained move-
able."   " Yet I failed not (says he) to renew the compression,
and  with such happy success,  that by the middle of January
my patient left the hospital perfectly cured,  excepting a halt in
his  gate, and that* not remarkable."  " Two months  after, I
sent for him to  examine the parts, when I found in the ham
nothing but a small hardness, about the  size  and shape of a
 chestnut, resembling an exostosis."
   There cannot be imagined a more correct history of an arte-
 ry  obliterated by compression.   The  patient was bled,  kept
 upon very low diet, and confined to bed, which relaxed  the
 parts, and the tumour was so compressed, that in the course of
 one month the pulsation disappeared !   The pulsation had dis-
 appeared, though the tumour remained,  which shows that there
 was not pulsation enough in the artery even to affect the tumour.
 He  next performed a work of supererogation, for the artery
 was obliterated, the pulsation gone, the rest should have been
 left  to nature ; but he applied his compress and bandage again,
 and in the two succeeding months did no more than stiffen the
 ham.
   Let us next observe, whether we have  not  the same marks
 of obliteration of the artery,  even in those cases of spontane-
 ous cure, where the surgeon thinks that the canal ofthe great
 artery  is still pervious.   Mr.  Blagden, surgeon at Petworth,
 was consulted by a man of about fifty years  of age,  tall  and
 muscular, who had his  humeral artery wounded in opening the
 basilic vein.  The blood flowed in great quantity •, and, per
 saltum, was stopped by strong compression.   First, an ecchy-
 mosis  extended itself generally from the shoulder to the wrist;
 then the aneurismal tumour formed, and in six months it had 
76
Hunter's Operation.
 increased to the size of a cricket ball.   The arm was oppress-
 ed, cold, shrunk, and, as the  patient expressed  it,  painfully
 lifeless :  he was advised to have the operation performed,  but
 he first thought of consulting Mr. Blagden.
   Mr. Blagden found the aneurism of this great size, hard,
 with a strong pulsation in  it, but the fore-arm below was cold
 and pulseless.   Now the patient had assured Mr. Blagden that
 the  tumour  had been larger;  that  it  was subsiding ; that  the
 pulse  in it was somewhat abated ; and  Mr.  Blagden did  not
 scruple to advise, that he should wait the issue of these changes,
 rub the arm with the flesh-brush, and refrain from exertions.
   In a few weeks the  arm grew a little warmer : in about three
 months he began to be  sensible of a tremulous pulse  at the wrist:
 the tumour gradually diminished, and the strength of the pulse
 at the wrist increased :  in eight or  ten months  the tumour in
 the  bend of the arm was reduced to the  size of a hazel-nut,
 while  the pulse at the  wrist was quite restored,  and the arm as
 full and fleshy, as capable of as powerful exertions, as the sound
 one ;  but he was desired to avoid such exertions.
   The author concludes with this sentence : " It is too evident
 to admit of any doubt, that the circulation is carried on in  its
 usual  course through  the artery, and not through the  lateral
 anastomosing branches of it."
   I am well  assured,  that in this case the blood passed only
 through the  anastomosing branches  ; the profunda and  ramus
 anastomoticus were enlarged,  the  trunk  obliterated,  and the
 circulation along the fore part of the arm gradually subsided in
 proportion as the vessels upon the back part enlarged.
   As, however, spontaneous cures  are  rarely to be expected,
 and  as there are but  few cases in which compression can be
 used,  I should,  in every instance, recommend   the operation
 first disovered,  or at  least  introduced  into practice,  by Mr.
 Hunter.*  This operation  is one of the most  important im-
 provements  in  modern surgery, and one which  only  a great
 surgeon could invent.   In this operation you imitate the natu-
 ral and spontaneous cure : the limb is prepared for that change
 which  you mean to  complete by your operation : the main ar-
 tery is  compressed by  the aneurism : the collaterals are enlarg-
 ing : nature has begun a process, with which it is dangerous to
interfere,  which you are to  complete : you cannot, with pru-
 dence, make an incision into the diseased mass: you would
not choose to cut the parts which are supplied  with blood by
those very inosculations which you wish  to save.   In  Mr.
 Hunter's operation, you tie the artery far above the aneurism
 and thus avoid a part  of the artery, which is frequently dis-
* This operation is practicable in the neck or extremities only.  S. 
Effects of it.
77
eased : you stop  the  blood, and throw the whole  circulation
upon  the inosculating arteries:  you but complete that process
which nature had begun, and leave  the absorption of the tu-
mour to  time.
  You make this  small and  superficial incision (hardly three
inches in length) upon the fore part of the thigh, above the part
ofthe limb affected with aneurism, and of course you have no
thickness of parts to cut through, except what arises from the
general oedema of the limb.  Your first incision is through the
skin ; your next is through the strong fascia of the thigh ; you
encounter no inosculating arteries ; you deprive the limb of no
one blood-vessel, except the great artery, which it is at an)' rate
about to lose, and which is already much compressed ; you
make no disorder in the  limb ; you touch no diseased part;
you have no deep digging for the artery ;  you have no difficul-
ty, no uncertainty in tying it; you  run no risk  of secondary
haemorrhagy,  at least from the articular arteries ;  you make no
incisions among  parts which  are  choked  with extravasation,
where the muscles themselves seem hardly more alive than the
coagulated blood which they contain ; you expose no joint to
ulceration, nor any bones to caries.   Far from increasing those
disorders, which are within the  injured part, you rather  take
away the cause of disorder, by preventing any further effusion
of blood. Your  incision is  small;  your way to the artery is
direct; you feel  your way by the pulse of  the  artery, and  are
assisted by your knowledge  of the  parts ;  if you be  re all v an
anatomist, you must perform this operation in a few  minutes ;
if you be not, and dare  to undertake such an operation, I know
of no punishment  too  severe for such unprincipled  conduct;
no human reproaches can touch a mind which does not feel the
punishment within.*
  Let us now attend to the effects of our ligature, not upon the
artery which it intercepts and cuts across, but upon the tide of
blood which it diverts to the other arteries ofthe limb.  When
we operate with a ligature on an artery, we can mark the very
instant in which it is obstructed : we perceive, after  a  moment-
ary  coldness  and deadness of  the limb, a renewed action of its
vessels and  increased heat.   We find the limb cold  when its
blood is  for a moment obstructed : we find its  heat rising  far
above the natural pitch, while, as yet, there is  no pulse in the
great  arteries of the lower part of the  limb ; for at this time all
the smaller  arteries of the  limb are enlarged and acting very
powerfully.   The smaller arteries perform, for  a certain term,
the  office of transmitting blood;  but when one artery takes the
• For particular directions for performing this operation, vid. Ap. F. 
78             Natural progress of Aneurism.
lead, and acts with  such power as to become the direct trunk
for all the arteries of the lower part of the limb, then the gene-
ral vascular action of the limb subsides ; the blood is drawn in-
to one or two channels; the vessels in general resume a  natu-
ral and quiet action ; and the heat, which had risen 6 or 8 de-
grees above the natural temperature, falls to 96.
   Thus, you will observe, that the aneurismal limb,  which has
suffered the operation, and whose main artery has been tied, is
not deprived of circulation, as has been represented, nor  cold,
nor apt  to fall into direct gangrene ; its circulation is intense :
if disposed to gangrene, it must  be  to  that gangrene which
arises from excessive action.*
DISCOURSE  VI.
ON WOUNDS  OF THE  ARTERIES ; OF THE  A-
  NEURISM WHICH FORMS OVER THE WOUND-
  ED  ARTERY ;  WITH   GENERAL   INSTRUC-
  TIONS  AND  RULES  OF CONDUCT FOR THE
  OPERATIONS ON SUCH ANEURISMS.
SECTION I.
    Of the formation of Aneurism over a wounded Artery.


W HEN a person is wounded  in any great artery, the blood
flows in so full a stream, that in  a moment he faints,  and  it is
then only that the by-standers can command the blood (by  ga-
thering up any cloths that are at hand, and cramming them into
the wound in a confused and  ineffectual way), till  at last  the

  * There are two cafes on record, in which mortification took place in confe-
quence ofthe collateral arteries not enlarging fufficiently to carry on  the circula-
tion. Vid. Appendix to Scarpa on Aneurifm, by Wiihart, p. 481.  S. 
       Formation of Aneurism over a wounded Artery.     79

surgeon comes and  stops it altogether.  When called in good
time to such a wound, he should clap the point of his finger
upon the divided artery,  or make his assistant hold it while he
lays open the wound more freely, obtains a distinct view of the
artery, and draws it out from among the cellular substance if it
be cut across, or if it be only punctured, passes his ligatures un-
der it with the needle, the eyed silver probe, or any instrument
that is most at hand.  Thus may he prevent the aneurism, the
extravasation of  blood, and the destruction of the parts.
  Perhaps there are certain  circumstances, however, in which
this would be improper ; for example, if there be a  wound of
the great arteries in the  back  of the  hip, in the groin, in the
armpit, we cannot command the blood easily ; we are not sure
of clapping our finger down upon the artery,  at the very point
where it is wounded"; we are  afraid lest the patient should die
(even after we have  come to him), with one single gush of blood;
we  therefore close the narrow wound, put its lips together, set-
tle it with a very steady compress and bandage, and try to make
the  lips adhere, and  then we have a fair aneurism, which we can
look upon composedly ;  we can  reflect upon the course of the
wound, and calculate which artery is most probably wounded;
for besides the main trunk there are other arteries in the arm-
pit and the thigh, as the arteries of the scapula or the arteria
profunda, which, when wounded, will form aneurisms as large,
though not so dangerous as those of the axillary or femoral arte-
ries, and to be distinguished from them chiefly by the continu-
ance of the pulsations in the wrist or ankle.
  The advantages to be  derived from an  aneurismal bag being
formed over a wounded  artery,  either before we are called, or
by our own compresses forcing  the wound to heal, are these.
That we are not hurried, all at once and  unprepared, into the
midst of a bloody operation; that we are  somewhat easy about
our patient's immediate safety, there being no danger 0f imme-
diate bleeding, at least for a few days ; that we  have timely
warning of every danger, by the changes on the surface of the
tumour,  which turns livid, inflames,  and gangrenes, before it
bursts.   The wound suppurates, opens, and  discharges a thin
serum, before the actual blood bursts out, whence we have time
to consult,  to calculate which artery is wounded,  and to settle
all the steps of our operation as deliberately as on any ordinary
occasion.
                        SECTION II.

                  The operation described.

  When you are to operate on any great  aneurism high in the 
80           Operation for Aneurism described.

limb, take all the advantage that compression or the tourniquet
can give you ; but do not trust to them ;  do not allow yourselt
to be confounded though the blood rush out upon you ; be pre-
pared to do your operation with an intrepidity which shall make
you  independent of every assistance.  First draw your knife
deliberately  and fairly  over  the tumour, so as the great livid
bag of the aneurism,  surrounded with its strong fascia*, rises
into  view.   Next push your lancet into the sac, and- then do all
that  remains in your operation with great boldness ; run your
bistourv upwards and downwards so as  to slit up the tumour
quickly ; plunge your hand suddenly down towards the bottom ;
turn out the great clots of blood with your hand and fingers, till
having reached the bottom entirely, you begin to feel the warm
jet of blood, and directed by  that,  clap your finger  upon  the
wounded point of the artery! as it is but a point,  your finger
will  cover it  fairly, and your feeling the beating of the artery
will  assure you that all is safe.
   Now the bleeding, confusion and fainting are over in a mo-
ment ;  the operator breathes, and the assistants are composed;
and  all the operation goes on easily  and safely.  The artery is
effectually commanded by  this pressure with the  finger ;  but
the first movement in such an operation, viz. the act of stopping
the blood, of getting at the artery, is all boldness, and nothing
of caution ;  no danger  is to be apprehended, but that of suffer-
ing  your patient to lose blood.
   Being now composed,  you take time  to arrange every thing
for the next step of your operation,  you feel the beating of the
artery with the point of your finger, perhaps you raise the point
of your finger for a moment, to discover whether the pressure
of your assistants,  at the groin  or clavicle, commands the arte-
ry :  if  so, you lift your finger,  and  examine round the artery ;
if not, you keep your finger steady, make the assistants clean the
sac  round the artery ; then, if the artery lies fair and free in the
bottom of  the cavity,  you proceed to tie  it; but if not,  you
 must dissect round the artery,  until you see it free from other
 parts, and have it so insulated that you may put your ligature
 easily  under it, unless, indeed, the recollection of  some great
 trunk being near the wrounded artery (as of the profunda, when
 you are tying the femoral  artery),  should  stop you.  But yet
 the  nearness of any great artery or nerve  is an argument as
 strong against your diving with the  needle to catch the wound-
 ed  artery,  as against your dissecting with the knife.   Since,
 therefore, the dissection is done with your eyes open, and you
  * The fac of futh an aneurifm is always formed by the fafcia covering the limbs
or mufcles. S. 
Operation for Aneurism described.            81
 can see and feel before  the point of your  knife, rather dissect
 or sometimes tear the artery naked with the points of your fin-
 gers, tie its open mouth, if cut across, as fairly as in an ampu-
 tated stump ; or if it be  punctured only with the point of a knife
 or sword,  put two ligatures  round it, one  above and one below
 the wound, and put them neatly and fairly round the artery, and
 then cut the artery across betwixt the two.
    But should it happen  that the parts are so confused by inflam-
 mation, so disordered by the driving ofthe blood in old aneu-
 risms, or perhaps so hurt, as to be almost in a state of gangrene ;
 if the surgeon cannot  by any means get a  fair view of the arte-
 ry, while his patient is  losing  blood,  pouring from some great
 trunk, then he must strike his  needle at  random, in order  to
 come at his object the  nearest  way ; and the only satisfaction
 that he can have, or the  only proof of  his having tied the artery
 at all, will be  the sudden stopping of the blood  when he draws
 his  ligature.  In circumstances like  these,  the greatest surgeons
 (even Mr.  Pott himself,)  have been accused of having missed
 the  artery ; the artery at all events, in  such a case, is irregularly
 and insecurely tied, the  attendants that are appointed must be
 skilful, and must  be interested ; both friends  and surgeons
 should  watch  over the patient's life  most faithfully,  for succes-
 sive bleedings will  happen sometimes  from so slight an  acci-
 dent as a sudden turn, or unwary  motion in his bed during the
 night.
   Of one thing  I am chiefly afraid, namely, that my description
 may seem overcharged;  that I may appear to have exaggerated
 the  difficulties of an operation like this; that it may  be thought
 that an accident requiring all these  precautions,  and this plun-
 ging down of the hand, can hardly occur.   Therefore I sub-
 mit to your consideration  the  following case, and I dare say,
 you will find that it needs no apology.
   u A poor man, who was by trade a leech-catcher, fell as he
 wis stepping out of a boat, and the long and pointed scissors
 which are used in his business being in his pocket, pierced his
hip exactly  over the place of  the sciatic notch, where the great
iliac artery comes out from the  pelvis.   The artery was struck
with the point ofthe scissors, it bled furiously, the patient faint-
ed ;  and in so  narrow and deep a wound, the surgeon, when he
came, found little difficulty in stopping it up, and less difficulty
still in making it heal.   The outward  wound was cured ;  the
great tumour soon formed ; and the  man travelled up from the
north country, where the"  accident had befallen him,  and in six
weeks after  arrived in our hospital here, with a prodigious tu-
mour of the hip,  his thigh rigidly contracted, the ham bended,
                            L 
82
Operation for Aneurism described.
 the whole leg shrunk,  cold  and useless, as if it had been  an
 aneurism rather of the  artery on the fore part of the thigh.
   " The tumour was of a prodigious size, and by that very cir-
 cumstance of its being one of the greatest aneurisms, it had lost
 all the characteristics of aneurism.  There  was no pulsation, no
 retrocession of the blood when the tumour was pressed upon ;
 there was nothing else peculiar in the tumour except this, that
 the great and sudden  distention occasioned  great  pain ; and
 from the continual pain, and lameness,  and from having some
 hopes of a cure, he was ready to submit to any thing, beseeching
 us to operate.
   " There was little doubt of this being a  great aneurism, but
 there was a possibility of its being a vast  abscess ; and  it was
 resolved in consultation that the patient should be carried into
 the operation room ; that a small incision should be made : that
 the skin being cut, the  bag itself should be just touched with the
 point of a lancet; if found to contain matter, it should be fully-
 opened ; but if blood,  then it was to be considered as an aneu-
 rism of so particular a  kind, as to entitle us to call for a full con-
 sultation.
   " I made an  incision  two inches and a half in length; the
 great fascia ofthe hip  appeared blue, and very strong, forming
 the coat of the tumour, and under that were seen the big fibres
 of the great glutaeus muscle.  The knife was struck into it, and
 large clots of very firm black  blood rolled out:  for such was
 the tenseness  of the tumour, that it began to emit the clots in
 this way, the moment  it was punctured.  There was one thing
 further desirable, that before we put the patient to bed, we should
 understand the case so far as to be able to report  to the consul-
 tation, whether the artery was absolutely open, and whether  it
 was the great artery  of the hip.  I continued therefore (know-
 ing that the opening  I had made could be covered with the point
 of the thumb) to pull  out a few more clots, till the  warm and
 florid blood began to  flow ;  I  then pushed in a tent-like com-
 press into the  small wound ofthe tumour (viz. ofthe fascia),
 laid a broad compress over the outward wound, and put the pa-
 tient to bed, with one of the pupils holding the hand upon his
 hip.
   " This was done at one o'clock, and at four the consultation
 met, and the operation was performed.  And in  my notes, I
 find two  steps of the operation chiefly marked :—First, That
upon our  opening the  tumour  fully with an incision of eight
inches long, and turning out the great clots, the blood was thrown
out with a great whizzing noise, and with such impetus, that the
assistants were covered with it, and in a  moment twenty hands
were  about the  tumour, and the bag was  filled with sponges, 
Operation for Aneurism described.            83
and cloths of all kinds, which had no better effect than the cloths
which, in any accident, the friends in great confusion wrap round
a wounded arm ; for though the blood was no longer thrown in
a full stream, nor in jets, it was seen rising through the edges
of  the incision ; it floated by the sides of the  cloths, which were
pressed  down by the hands of  the assistants.   But we knew
also by a more alarming sign that the blood continued to flow,
for the man, who was at first lying not flat, but supporting him-
self oh his elbows, fell down, his arms fell lifeless and without
pulse over the side of the table, his head hung down, his face
was livid, he uttered two or three heavy groans, and we believed
him dead.
  Secondly, Seeing,  in this critical moment, that if he was to
be saved, it was to be only by a sudden stroke, I ran the bistoury
upwards and downwards, and at once rriade my incision two feet
in length : I thrust my hand down to the bottom of the tumour,
turned off the great sponge which was  over the artery, felt the
warm jet of blood, put the point of my finger upon the mouth
of the artery; then I felt distinctly its pulse, and  then only was
I assured that the man was still alive.  The assistants laid aside
the edges of this  prodigious sac, and sought out the several
smaller sponges which had  been thrust in, and the sac being de-
liberately cleaned,  and its edges held aside, I kept the fore-fin-
ger of my left hand steady  upon the artery, passed one of the
largest needles round under my fore-finger, so as to surround
the artery : one of my friends tied  the ligature, and then upon
lifting the point of my finger, it was distinctly seen, that it was
the posterior* iliac artery,  that the artery had been cut fairly
across, and had bled with open mouth ; that it was cut and tied
exactly where it turns over the bone : and although the extremi-
ties were  cold, the face of a leaden colour,  and the  man  had
ceased to groan, and  lay as dead ;  though the faint pulsation
could  not be felt through the skin, in any part of the body ;  we
saw the  artery beating so strongly under my finger, that we
were assured of our patient's safety ; however, he was so low,
that after laying down the sides of the sac, and putting bandages
round his body to keep all firm, we  were obliged to have a bed
brought in, and having given him some cordials, we left  him
to sleep in the  great  operation  room,  attended  by the pupils
and by nurses.   He passed his urine and faeces involuntarily tor
some  days, and was long in recovering his voice.
  He was cured of this great wound in less than seven months,
although  his cure was protracted by the foul suppuration of such
a sac, and by the exfoliation ot the ilium and sacrum, which spoil-
ed,  not so much from their having been laid bare by  the  last
*  Called by Mr. Bell in his anatomy the glutaeal artery.  S. 
84
Operation for Aneurism described.
   sudden stroke of the knife, as by the aneurismal blood having
   passed upon them ; the exfoliations  were very large,  and the
   sacrum especially continued exfoliating  to  the  very  day  on
   which the wound closed.
     I do not know whether this man has  recovered entirely, for
   he left the house lame, from the contractions of the  hip and
   nam, and walking by  the help of a stick;  but,  however,  he
   thought himself fit to  undertake his profession,  and went to
   England with that design.*

                          SECTION III.

                        Rules of Practice.

     In great aneurisms,  then, of the arm or thigh, when the tour-
  niquet can be applied,  do your operation deliberately,  steadily,
  slowly, but do not needlessly prolong your  patient's suffering.
  Cut the skin  nicely, open the sac  freely, dissect your artery
  very clean, and  tie it clear of the nerve, and pass your  ligature
  with a blunt needle  or crooked probe ; for  whenever you are
  reduced to the necessity of using the sharp needles, your pa-
  tient is in danger.   Tie  your  artery with moderate firmness ;
  tie it in two places  (for on several  occasions the  retrograde
  blood has flowed out even in the time of  the operation  ;) clean
  the sac ; look now attentively to your two ligatures, and if you
  see the upper one moving according to the pulsation of the ar-
  tery, all is  right.  Finally, if you  approve  of my reasoning,
  cut the artery across  in the middle betwixt the ligatures. When
  the tourniquet cannot be applied, do not trust to compression.
  Your assistant mav try to compress the artery, but do  not lay
  your account  with performing a cool deliberate  operation ;  ex-
  pect rather a dash of blood at the first stroke you make into the
  sac, and confusion and  alarm  of every kind.   Compose your
  mind for such a scene ; bend up each corporal agent to  this at-
  tempt ; expect safety for your patient from  nothing but your
  own daring operation ;  be resolute, bold, and rapid ;  but let
 this boldness be  the result of serious  deliberation, and earnest
 consultation with your friends.   And in what does this  rapidi-
 ty consist ? Is it a dangerous stroke that you are to make ?  No
 surely : the rapid movement is merely slitting up suddenly the
 half putrid and tendinous sac, and turning out  the clots of blood
 with your fingers, while the artery, nerve, and all  the impor-
 tant parts lie  safe at  the bottom of the tumour.   You  are to

   * Dr. Farquharfon, who fucceeded me in the charge of the hofpital, has juft
"Informed me, of this man having called upon him after his  return from England,
 walking ftoutly,  and in good health. 
Of Wounds of superficial Arteries.            85
trust much to your acquaintance with the parts, therefore make
sure of your knowledge of the artery that is actually wounded;  i
return to  your books, drawings,  and preparations; hold con-
sultations with your friends ;  lose no opportunity of making up
your  mind beforehand;  the  more you  reason upon  the case,
and revolve the possible  dangers, the greater will be your pros-
pect of sustaining yourself with becoming  resolution in the
moment of operation.
DISCOURSE  VII.
OF WOUNDS OF ARTERIES.
                        SECTION I.

                  Preliminary Observations.

 W HEN an artery, like that of the hip or thigh, is wounded,
 it toruis an uncontrollable aneurism.  Such an artery drives eve-
 ry thing before it, forms a large sac, distends more and more, till
 it is in danger of bursting, and if allowed to burst, proves fatal.
   But when smaller arteries, like those of the fore-arm or leg,
 are wounded under the bellies  of the muscles, the aneurism is
 more  irregular, the operation  very difficult, and  the  dangers
 quite of another kind.  The  blood is  injected  slowly  among
 the cellular substance and under the muscles ; no sac is formed ;
 the blood is not  collected, but diffused;  the pulsation is slight,
 or there is none  ; the limb is swelled and hard ;  the  skin black,
 as in a mortification ; the blood bursts out from time  to time.
 It is considered  only as an haemorrhagy, while it is in truth a
 diffused aneurism ; the patient, by repeated loss  of blood, is re-
 duced to extreme weakness, and the  limb gorged with blood,
 and with its parts so insulated and disjoined from each other,
 by the extravasation, often falls into gangrene.   These are the
 usual consequences of such a wound.   If the patient escape,  it
is  after long continued suppurations, foul sinuses, and a great
destruction of the limb. 
86            Of Wounds of superficial Arteries.
  There are also certain parts of  the body where the smallest
artei j cs produce the same consequences.   The  axilla, for ex-
amp e, is a very large  cavity, filled  with the loosest cellular
substance, fit for lodging the vessels and glands.  1 he exter-
nal thoracic or pectoral artery, which, if it lay along the  tem-
ple, and were wounded  there, could not do the smallest harm,
is capable of forcing the cellular substance of the  axilla ; it has
as much effect on the loose cellular substance of the axilla, as the
femoral artery has on the firm  cellular  substance of the thigh;
it has  often filled the axilia completely  with blood,  forming a
very large  and dangerous  aneurism.   These  subjects I pro-
pose now to explain to you.
                        SECTION II.

              Of Wounds of superficial Arteries.

  The radial, ulnar,  and tibial arteries, in the lower parts of
the limbs, lie so superficial, that their bleedings ought to be
easily suppressed ; awkward and imperfect operations are  dis-
astrous only from the successive haemorrhagies, and not from
the important size  of these arteries.
  The  radial artery is one of that order and size which cannot
be restrained  but by  the ligature.   The superficial situation of
this artery, the nakedness of the bone on which it lies, the great
swelling of those naked  and tendinous  parts a few hours after
the artery is wounded,  the  difficulty of finding the artery,  and
the cruelty of the operations which have been performed, make
the case important, both  as  a common piece of surgery, and as
a general example of this kind of wound.
  The Radial  Artery, at the place where we. feel  the  pulse,
lies quite superficial.  We  even see the beating of  the artery
through the  skin, and when we dissect the  wrist, or look to a
preparation, we see nothing but the artery betwixt the skin and
the bone ; yet, when this part is wounded,  we seek in  vain for
this superficial artery ; we  search for  it by cutting  through a
most  unexpected thickness  of parts : this  artery, which  was
felt so readily with the  finger in its natural condition, we can-
not now feel beating, even though the skin be open, and the
wound deep.   We observe the best surgeons at a loss to  find
the artery :  we find them thrusting down sponges, leaving tour-
niquets half screwed about the arm for many weeks ; making
unsuccessful incisions, diving in vain with the needle, and, at
last, striking the needle through the whole thickness ofthe arm,
so as to intercept the artery, with a coarse ligature at the  dis- 
              Of Wounds of superficial Arteries.            8 7

tance of three inches  above  the wound.*   These  difficulties
never can be explained by attending only to the anatomy of the
natural  parts ; here the diseased and sound state of the parts
must be described together, and anatomy and surgery  must go
closely hand in hand.
  The artery  of the wrist lies not immediately under the skin,
but under a thick fascia, which, in its natural state, attracts but
little notice.   The general fascia of the fore-arm,  strengthened
remarkably at the two condyles  of the  humerus, and farther
reinforced by  the tendinous expansion  of the biceps  muscle ;
descends very strong along the fore-arm, enclosing all the flesh ;
the fascia is ve,ry  thick at the wrist, where, though it is a  firm
and continuous* web of tendon, its  glistening fibres are distin-
guished running across the  arm, and binding down the flexor
tendons.   Under  this  fascia the radial artery lies :  this fascia
is connected with  the tendons below by a loose and gliding cel-
lular substance ; and it is moreover  to be remembered, that all
through the body  each artery has its own peculiar  sheath of cel-
lular substance .' even the smallest muscular arteries have  such
a sheath.   This fascia, which is itself but a firmer cellular sub-
stance, is surrounded with a looser tissue of cellular membrane,
both on that  surface which lies upon the muscles, and on that
which is connected with the skin.
   No sooner  is the radial artery wounded, than  the awkward
attempts of the assistants prevent the  blood bursting  out freely ;
the cellular substance  of the  skin is injected with blood; and
the skin,  long before inflammation could come on,  is  inflated,
as  it were, to a great thickness.  The artery shrinks under its
fascia;   the cellular substance of  the  fascia  is  injected  with
blood;  it rises over the mouth of the wounded artery ; it is in-
jected not like the looser cellular substance of the skin.  This
firmer cellular substance of the fascia is so crammed  with blood,
and that  blood is so firmly coagulated,  that the parts are, as it
were, baked together, and the haemorrhagy is rather an oozing
of  blood from a substance resembling the Corpus Cavernosum
Penis.   The  whole bottom  of the  wound is a fine fleshy pla-
centa-like mass; and,  after dissecting with the knife  through
a great  thickness of parts, the artery is not to be found ; or only
by  those who are  perfectly acquainted both with  these changes
and with  the  natural place of the vessel.  This is the  confused
fleshy-like mass,  into which the  surgeon  strikes  his needle.
Here the blood is seen oozing, as through a placenta, at many
places,  but not one of those bleeding points corresponds  with
the mouth of the artery ;  so that when the surgeon strikes his
• Mr. O'Halleran. 
88            Of Wounds of superficial Arteries.
 needle at these bleeding points, he must fail.  The oftener the
 blood bursts out and is suppressed, the more  does the wrist
 thicken ; the farther is the artery removed  from the surgeon,
 and  the more confused the parts become.   It is by this extra-
 vasation into the cellular  substance that the  artery always dis-
 appears,  and the bleeding ceases, before the surgeon is ready
 to take it up  with the needle : the patient loses blood  from day
 to day ; he becomes pale, sickly, and exhausted, till at last the
 blood hardly retains so much colour as to tinge the sheets.*
   But another phenomenon often presents  itself, a natural con-
 sequence of this state ofthe parts.  A  person is brought to us
 a week after the radial artery  is wounded; it  has burst out
 again and again ; perhaps the haemorrhagy has been  suppressed
 by sponges, by compression, or by a rude stroke of the needle ;
 but, upon undoing the dressings,  we  are  surprised  with the
 appearance  of a distinct aneurism  in the  bottom of  an open
 wound ; we  see a   small  distinct pulsating  tumour, regularly
 circumscribed, throbbing  strongly, with thin and almost trans-
 parent coats.   We are at first at a loss to imagine how such tu-
 mours are formed  or supported.  But  though  the  wound  be
 open,  the artery is not  so; the cellular substance is partly in-
jected with blood ;  the first effusion of blood is driven into the
 cellular substance,  mixed  with it, and firmly coagulated ; the
 second effusion has filled more of the cellular substance with
 recent and fluid blood, and raised it in the  form of an aneu-
 rism ; and this aneurism has for its transparent coat the general
 fascia ofthe wrist;   but yet it is so fairly  circumscribed, that one
 would hardly doubt of its  being a dilatation of the artery itself.
   If I do not mistake  the importance of this accident, it is a
 sort of duty to explain  it to  you still further; for  though the
 operation of tying the radial, or ulnar artery, does not range in
 the catalogue of important operations,  along with  trepan and
 amputation, yet,  if I be  not deceived, it is more difficult than
 either, and certainly more frequently required.
  " A shoemaker,  having been at an annual dinner with some
young men of his own trade,  had got merry, but was not in-
toxicated ; and  some of his companions walking home with
him, he swore a hearty oath that they should  not pass his door
without tasting a glass.  Accordingly  they went in along with
him,  and as he  was reaching up to a cupboard for a bottle of
spirits, an unlucky foot encountered his,  and tripped him.   He
fell forward,  and a  nail which stuck out from  the wall ran into
  * Many cafes may be  found in White, O'Halleran, Aitken, &c. where a per-
fon, wounded in the radial artery, has bled for three weeks or a month, till the
blood was little  better than a reddifh ferum.  1 have taken up the  radial artery
after a perfon has been fuffered to lofe blood ten or twelve times during the courfe
of a fortnight. 
              Of Wounds of superficial Arteries.           89

the palm of his hand, and wounded the Palmar Artery.   In-
stantly there was a dreadful bleeding.  He fell down at last in
a faint ;  and so unskilfully was this poor fellow managed, that,
in the course of a fortnight, he had been allowed to bleed no less
than eight times:  The blood  burst out afresh on the slightest
motion, and at intervals of no more than two days,  till he was
reduced to extreme weakness.  He had lost immense quantities
of blood.  It  was only by his shape that I could perceive that
he had been originally a fine athletic and healthy young man.
   " I found him, indeed, in rude hands. The surgeon who had
attended him, and who  was to perform the operation, knew
nothing of the palmar arch,  where it began, or to which of  the
two arteries it belonged, nor whether it lay above or under the
ligament of the palm ;  and so much was he alarmed, and so
ignorant of any but  the rudest means of stemming the torrent
of blood, that he had a coarse bandage twisted round the hand
as firm as a tourniquet! The tourniquet itself was  still round
the arm hard screwed ;  and the hand,  by long continued pres-
sure,  was now  black, not merely from extravasated blood,  but
from actual gangrene ; vesications appeared on it betwixt every
turn of the roller.  The palm of the hand was greatly heaved
up and swelled, with a  puffy kind of swelling.  In seeking for
the artery,  the thick skin of  the palm was first cut through ; it
was very thick, and exceedingly crammed with blood.  The
cellular  substance, belonging to the palmar  aponeurosis  was
crammed also  with blood, was fully  two inches thick,  quite
black  ; it was  all one uniform mass, which  cut like the Corpus
Spongiosum Penis,  and no one part was  to  be distinguished
from another.
   " The artery, with its usual perverseness, (though it had al-
most bled the man to death) would not give one drop of blood
during the operation.  The surgeon unscrewed the tourniquet,
bathed the parts with warm water ;  made the patient swing  his
hand  most  painfully ; made several  rude incisions, but still
could  get no jet of blood from the artery, nor any more than a
general oozing from this spongy  mass.  Without fear of the
palmar nerves, he made many relentless and  unsuccessful at-
tempts with the needle ; at last he  was most unwillingly forced
to make an incision upwards along the arterv : he cut the skin
by the side of the flexor ulnaris muscle, and looked in vain  for
the artery ; was surprised that he could not see an artery which
he felt plainly  with his finger,  not knowing that the artery was
still covcitd with its fascia :  but having at last slit up the fascia,
the artery was forced out by the  tenseness of the fascia; and
from its fullness it assumed a contorted form, and was especially
turgid at each pulsation.   Three inches of the ulnar arterv now
                            M 
90           Of Wounds of superficial Arteries.
lay exposed ; it was seen running over the Pisiform bone into
this spongy mass in the palm ; the artery beat strongly, and was
seen serpentine, and working with a sort of spiral motion, and
a distinct pulsation ;  but  there  was no corresponding jet  of
blood, nothing but a general oozing in the palm.
  u The conclusion of the case is as  extraordinary as  all the
rest of it ;  the surgeon laid a ligature under this part of  the ar-
tery,  but would not draw it ; he  made another desperate dip
with  the needle.  The lad was put to bed, and the bleeding
broke  out  so furiously in the night-time, that had there not been
a pupil watching to tie this occasional ligature,  he surely must
have lost his life."
  This case explains to us what confusion the continual driving
of the blood makes ;  how deep the artery lies  in parts  which
seem to have little cellular substance, and how vain it is to look
for the artery in the midst of such a mass ; the artery will not
bleed till all is quiet again ; and even when it does bleed, it is
not with a fair jet, nor with an open mouth.  To suppress such
bleedings with a styptic, or a compress, seems to be a lenient,
but is,  truly, a cruel practice, and not  without danger.  The
patient's  constitution, if not his life, is often endangered before
the surgeon gets courage to make the  incision ;  and at every
return of haemorrhagy the cellular substance is more and more
injected ; the artery buried deeper ; the incision must of course
be more  extensive, and the operation more difficult.
  The aneurism which  I have described,  as formed under the
fascia, and protruding from the bottom of the wound,  I  choose
rather to exemplify from the writings  of another person, than
from my own case-book.  Mr. Ford, ofthe Westminster Hos-
pital, "• was called  to a butcher who had, about a  fortnight be-
fore, wounded his  wrist, by pushing his hand through  a pane of
glass.  The wound was just below the Carpal ligament, over
the pisiform bone.   It had bied several times since the accident,
and the  haemorrhagy had, with difficulty, been  restrained  by
bandages and common  dressings.   There was a pulsating tu-
mour covered with a thin membrane,  where the  wound had been
received; the pulsation was, with difficulty, checked by a strong
compression on the ulnar artery, but returned again on remov-
ing the compression.
   " I  dilated the wound instantly," says Mr. Ford, " towards
the palm of the hand, and  made an attempt to include the ves-
sel within a ligature, by mrans of the common crooked needle.
This proving ineffectual, I represented to the patient the  neces-
sity of a farther  dilatation of the wound, in order to restrain
the haemorrhage, without injury to the  ligaments and tendons
of  the wrist; but, notwithstanding the most urgent entreaties, 
Of Wounds of superficial Arteries.           91
he could not be prevailed on to submit to any farther operation,
till the ensuing day : he  was  therefore left with a bandage on
the wound, and the tourniquet appii'-d on the  upper arm, with
directions to tighten it, if the haemorrhage should return.
  " I saw him  again  on the next day, in company with Mr.
Lynn, surgeon of the Westminster Hospital, and finding that the
bleeding had  recurred,  it was determined to prosecute the in-
cision farther, and to secure the artery higher up in the arm.
  " I began the incision where the wound had been  received,
carrying  it superficially over the carpal ligament,  in the direc-
tion ofthe ulnar artery, for six inches upwards in the arm.
  "The operation was done with the utmost caution,  to avoid
wounding the tendons and  muscles, which were carefully held
aside with our fingers as they  were exposed  by dissection.
This proceeding was of course tedious, in order to ensure safe-
ty.   The pulsation of the vessel  could not be felt; neither could
the haemorrhagy be provoked  by friction, by putting the arm
in warm water,  or by flannels applied  hot to the part.   At
length, however, the artery was discovered, and a ligature car-
ried round it,  without including  any other  part, about an inch
and  a half above  the wrist.   Some time was then employed
in endeavouring to promote  an haemorrhagy from the lower
branch of the arterv ; but this not taking place, the wound was
carefully  cleaned,  united with strips  of  sticking-plaster, and
rolled up with a flannel roller.
  " The patient was bled, had an opiate administered, and in
every respect was treated in a most antiphlogistic manner.   No
circumstance occurred to render it necessary to open the wound
for six days;  no swelling, tension, inflammation or fever, came
on.  Now, it may be remarked,  that the  circular  ligament  of
the wrist, together with the tendons and muscles contiguous  to
the ulna, had been   laid  bare,  and exposed  to the  air for more
than three quarters of an  hour, during our search for.the artery.
The ligature came away on the  eighth day, and the wound
healed rapidly by the first intention, so that the patient was per-
fectly well on the twenty-eighth ofthe same month."
  I know Mr. Ford, and am sure he  will pardon any obser-
vation that is meant for the improve ment of others.  I believe
it is needless,  in any such case, to cut downwards into the palm
ofthe hand, which is usually so  injected with blood,  that  the
most dexterous anatomist, dissecting deliberately  on the dead
body, would not find it easy to show the open mouth of an ar-
tery; and it were superfluous to repeat to you  how improper it
is to dive with a great needle into the palm ofthe hand : nor is
this necessary ;  for the palmar fascia  and skin are so  swelled,
as to prevent the return of the blood from the lower mouth  of 
92           Of Wounds  of superficial Arteries.
the artery.    I never saw it  necessary to tie the lower end ot
the artery;  and I think it important to mention this,  as an ex-
ception to the rule commonly laid down  of tying  both ends ot
it; it is only  the  direct  impetus of  the  blood from  the upper
part of the  artery that bursts through this injected and spongy
mass ; it is only the upper end ofthe artery that we need to tie.
Irregular and  unsuccessful operations are performed only, from
not having a very decided intention of dissecting for the artery ;
but it comes alwa) s to this in the end; and you should resolve,
the  moment you are called to such a case, to apply the tourni-
quet, to cut backwards along the artery ; to dissect it clean; to
tie it fairly ; to disregard the  bleeding from the lower end of
the artery;  to put a small  piece of  sponge into the place where
the blood oozes  out from this confused mass,  except in  those
very rare cases where he sees  a direct  jet  of blood  from the
lower end of the artery, and then you may use the needle ; but
tha^rarely happens, except in very recent cases, and  before the
palm is much injected with blood.*

                          SECTION  IV.

               Of an Artery wounded by a Lancet.

   It is to ignorant phlebotomists in the country that  we are in-
debted for  the various specimens  of this species  of  aneurism.
They use very blunt lancets ;  and a blunt lancet,  being pushed
rudely onwards, starts through  the skin at last, and strikes deep
into the arm. The aneurism is generally produced by a very large
and rude wound, like that which the  point of a penknife would
make.   I have seen many such aneurisms, and operated on se-
veral.  Once, when  the  operation was  performed by another
gentleman,  I  saw the  artery so wounded, that it was held to-
gether merely by a tag; the cut in it was  indeed  oblique, but

   • Since the firft edition of this work was printed, I  have  met with the following
cafe, which ftrongly proves how dangerous it is to truft to any thing but a ligature
when an artery is wounded ; even although it fhould be one of  fo fmall a fize as
the palmar artery o' a boy.
   A lad of about 13 years of age, fharpening a pen-knife, had the misfortune to
thruft the point of it into the palm of his hand.  The blood gufhed out with fuch
violence as to prove that an artery had been opened, which, from the fituation of
the wound could be no other than the ulnar, where it paffes down  to form the
palmar arch.  The hemorrhage was flopped by compreffion, the wound healed,
and every thing appeared to be doing well for ten days,  when a fmall pulfating
tumour was obferved under the cicatrix.   Little notice was taken of this, but thir-
teen days after the accident, in the middle ofthe night fo violent a haemorrhage
took place that the boy bled almoft to death before it  could be flopped. The next
day  I faw him, and determined  to take up the artery, which  I accordingly did
above the wrift, as the moft convenient place.  No return of the bleeding took
place, and the boy did well. 
Of Aneurismal Varix.
93
so large that it had severed the  artery almost entirely across :*
for the arterial coats are, in their nature,  hard, unyielding, and
callous :\  a wounded artery never heals : a clot is usually in-
terposed betwixt the lips ot the wound ;  the blood runs freely
along the canal of the artery,  ready to flow through the slit up-
on  the slightest exertion of the  arm, or slightest motion of the
clot ;  and there lies a considerable collection of blood betwixt
the  wound of the artery and any compress that we can apply.

                           section  v.

                      Of aneurismal Varix.

   The  aneurismal varix is a disease  produced after bleeding
with the lancet,  by the close  union of  the wound of  the artery
with the wound of the vein, and the blood of the artery rush-
ing into the vein through this  side-passage distends it.  The
blood passes so easily into the vein,  that little  goes downwards
along the artery ; the arm below is impoverished of blood, and
is greatly weakened ; the  dilatation of therein increases al-
most to bursting ;  and as the vein and artefy,f though they run
parallel,  are not in contact with each other, but are separated
by  the sheet of tendon named the Fascia,  the communication
betwixt die  vein and artery comes to be of considerable length ;
by  emptying the dilated  vein,  and pinching with your  fingers
and thumb,  you can distinctly feel the communication betwixt
them.J
   The artery, where it lies within the fascia, is surrounded with
a set of small concomitant veins, which, from their encircling the
arterv, are named Venae Comites, or Sattellites ; these also are
sometimes struck with the lancet ;  and, by  continued pressure,

  *  Should theperfon, who is unfortunate enough to puncture an artery in bleed-
ing, be competent, he had better cut down, and tie the veffel immediately.  For
it fometimes happens that no diftindl  aneurifmal is formed ; but the cellular fub-
ftance of the who.e arm becomes injected, forming what is  called diffufe aneu-
rifm ; in which  cafe, if fomething be not fpeedily done, gangrene will  come on.
As this accident generally happens to ignorant perfons, aneurifm will generally
have formed before a furgeon is confulted.  If there be a diftindl aneurifmal fac,
he may either operate in the middle of the arm, tying the artery juft below the
inner edge of the biceps mufcle, as directed in popliteal aneurifm ; or the fac may
be laid open, as directed in  the text.  Whenever an artery  is tied at the place it
is wounded, which it muft be in every cafe of diffufe aneurifm, the furgeon had
better introduce a probe into the  tube of the wounded veffel,  in order more com-
pletely to feparate it from the contiguous parts.—S.
  f  Scarpa meutions a remarkable cafe of this, in his work on aneurifm, p. 349. S.
  \  Aneurifmal v-arix is likewife diftinguifhed by a  hiffing noife.  Thefe cafes
rarely require any operation. There are inftances on record, in which they have
exifled  for many years,  without producing any inconvenience, the artery above
the tumour becoming fo much enlarged, as to carry a fufficient quantity of blood
to compenfate for that which paffes"directly into the vein.   S. 
94                   Mr. Park's Case.
 the artery, the internal vein, the fascia,  and the external vein,
 are all conglutinated  together with a  considerable degree  of
 confusion and thickening of parts.  But  however confused the
 other appearances may be in such a case,  this circumstance will
 distinctly mark the nature of the  disease ;  that in performing
 the operation (as there are two veins and one artery united  by
 adhesion) the  surgeon will find  two successive sacs of blood,
 one under the other, with a small orifice  of communication be-
 twixt them.  Perhaps the anomalous case related by Mr. Park,
 of Liverpool, was of this nature.
   The young man, whose case  Mr. Park describes, had been
 coarsely bled,  was sensible at  the time of being struck  too
 deep in the arm, and  felt more  than ordinary  pain.   He pre-
 sented himself three times successively at the Liverpool Infirm-
 ary.   Even at  the first,  this was marked as an anomalous dis-
 ease ;  for there was a complication, as if of common aneurism
 with aneurismal varix.  There lay a small hard circumscribed
 tumour, no bigger   than  a walnut,  immediately  over  the
 wounded artery, and receiving its pulsation  ; and there accom-
 panied this smaller tumour a considerable aneurismal dilatation
 of the Basilic vein.  He called a second time at the Hospital,
 and still the aneurismal tumour over the artery held itself dis-
 tinct from the varicose dilatation of the vein.   It  was about a
 year after the disease began, that, having used too great free-
 doms with his arm, he was brought into  the Infirmary a third
 time, with the  arm greatly  swelled, inflamed,  and partly sup-
 purated ; and the tumour having burst during the night follow-
 ing his admission, there was a necessity for performing an ope-
 ration, which, considering the anomalies of the case,  the late
 hour at which  the operation was performed, and the alarming
 loss of blood which made  it necessary, must  have been very
 unsatisfactory to Mr. Park.  But he delivers  this interesting
 case with singular modesty ; and though, in making this ope-
 ration known to the profession, he has, perhaps, done no more
 than his duty, yet he has done it in such a manner as to deserve
 our gratitude. It was remarked by Mr.  Park, that in the time of
 the operation, after opening the first sac, he saw an orifice which
 seemed to him to be the orifice ofthe artery ; but he found, up-
 on introducing  the probe,  that it could not  pass upwards nor
 downwards farther than half an inch.   Upon opening this se-
 cond sac, he found at the back of it a second opening, a small,
 round, circumscribed orifice, which led into the artery.  The
artery, thus discovered, was tied accordingly, and the operation
 finished.
  In this case,  one of two  things must have happened.  The
 artery, the Vena Comes, the fascia, and the outward vein, must
 have all united  together,  being massed and thickened by  in- 
Of oblique Wounds of Arteries.              95
flammation :  the  ready communication of the  Vena Comes
with the outward vein, may have saved the Vena Comes from
dilatation ; and the circumstance of the fascia covering the di-
lated part of  the  internal  vein,  (and adhering to it) may have
given it  peculiar firmness, and may account for  the internal tu-
mour being so small (it was no bigger than a walnut;) and far-
ther, the frequent  valves in this  Vena Comes, or internal vein,
may account  for the  limited dilatation of it, and for the probe
not passing easily upwards or downwards.   Or, on the other
hand, the artery may have begun  to form a proper aneurism
among  the  cellular substance ;  the passage  betwixt the fascia
and  the vein  may have continued  open; the blood may have
made its way from the sac of this incipient aneurism into the
vein ; and, if so, the blood being thus conveyed  away through
the vein, the  force would be taken off from the proper aneu-
rismal sac, the cellular substance would be condensed into the
form of a regular bag, that bag  would  be saved from further
distention by  its free  communication with the  vein, and the
perpetual circulation  of fresh blood, through it, would prevent
the formation of clots, and would also  prevent the tumour as-
suming the proper form of aneurism.

               Mr. Park's Anomalous Aneurism.
I.I. Branches ofthe Median Vein,
2.2. Branches of the Bafdic Vein.
3.3. the Brachial Artery.
4.4. the Vena Comites furrounding
   the Artery.
5. Union ofthe Vena Comites, -with the
  trunk of the Bafdic Vein.
6. the ivounded artery.
7. Dilatation ofthe Vena Comes.
8. Dilatathn of Med. Cephal. Vein.*
SECTION VI.
               Of oblique Wounds of Arteries.

  The point of practice, which I have first of all to represent
to you,  is the difficulty of finding the exact place wThere an ar-
tery has been obliquely wounded by the slanting stab of a knife
or sword, or the course of  a ball.   This difficulty is greater
  *  A cafe very fimilar to this, occurred to Dr. Phyfick.  See Med. Mufcum,
vol. 1, p. 65.  S. 
96              Of oblique Wounds of Arteries.
than it will be easy for you to imagine; for sometimes an ar-
tery, being struck with the point of a knife or sword, is merely
punctured, and not"cut across.  The obliquity of such a wound
acts like a valve upon the artery ; there is but little blood pour-
ed out under the  skin, and  no remarkable tumour  is formed :
Now the  surgeon, satisfied  from  the  sudden and violent gush
of blood that an artery is opened,  feels himself called upon  to
look for the bleeding vessel, and to lay open  the arm or thigh;
but presuming too far upon his own knowledge of the arteries,
he makes a new incision  along the course ofthe artery,  neglect-
ing the  more easy and obvious  wuy of seeking for the wound, in
the  artery, by enlarging the natural wound.*   When, lor ex-
ample,  the artery being wounded from the outside, he ventures
to seek  for it by a new incision- from within ;  he gets to  that
side of  the artery where  no  wound is ; his  attempts to make it
bleed, only press  the slit-like  wound of the artery so much the
more firmly down against the flesh below ;  he cannot see the
wound, nor even believe that there is one ;  he  tries to make it
bleed, but  he fails ; still, he sees the main trunk  of the artery
lying in the bottom of the  wound, beating strongly under his
finger,  apparently entire, and he cannot yet believe that there
is any wound in it.   He continues  his work, but can by no con-
trivance force the artery to bleed ;  he  can never see where the
wound  in the great trunk is,  nor be satisfied whether or not the
blood flows from some smaller artery ; but no  sooner does  he
leave his patient, than it bursts out furiously, and bleeds from
time to time, till the patient  expires.   If I can produce one such
case, it will be at once a lesson and warning to you ; and the
warning will be the more impressive, in proportion to the re-
spectable rank  of the surgeon,  who may have been guilty  of
such a mistake.
  A young man of twenty-five years of age, in parrying a blow,
aimed with a sharp-pointed  knife,  at  his breast,  received  it in
the middle of his arm.   The knife entered  at the outer edge  of
the biceps, and  touched the  Brachial Artery; he staggered for-
wards a few paces, and then, fainting with the loss of blood, fell
down.  Unfortunately there was  no one present but a young

  *  This rule has fome exceptions :  thus, in  thofe cafes in which, if the furgeon
were to attempt to  follow the wound, he would be in danger of dividing fome
important nerve, or have to cut through a great depth of mufcle.  Under fuch
circumftances, let him diffect down  to the artery at the moft convenient place, as
near the wounded part ofthe veffel  as poflible, and tie it firmly : fhould the liga-
ture be above the  wound, of courfe every thing will be  fafe; if below, in con-
fequence  of the obftruction to  the  circulation, the blood will immediately gufh
out, as happened in the cafe mentioned a little below in the text,  and thus  point
out the exact fituation of the wound.  The veffel may then be tied in the  man-
ner directed in the text. 
Of oblique Wounds of Arteries.               97
 pupil in surgery, so ignorant that he bled him in the other arm,
 and tied up the wounded one,  merely laying a compress  upon
 the wound.
    Till the 8th day,  there was no farther alarm, when a very
 slight cough  brought on a  violent bleeding ;  then, fortunately,
 a surgeon was called, who really understood the dangerous na-
' ture of the case, and he, in his twrn, called  Mr. Duschamps,
 upon whom  the care of the patient devolved ;  he found the
 arm enormously swelled, from the arm pit to the  elbow, and
 covered with ecchymosis down to the wrist.
    "  At nine in the morning,"  says Mr Duschamps," I began
 the operation, the patient being seated, and every thing pre-
 pared.   But  behold, when I  introduced my probe into the
 wound, it passed so  far upwards towards the axilla, that I fear-
 ed the wound was very high, perhaps in the Axillary Artery it-
 self;  so that instead  ofthe operation for aneurism, I might find
 myself obliged to amputate at the shoulder joint.   I begged to
 have another surgeon joined in  consultation, and accordingly
 Mr.  Sabbatier met me in the evening at five o'clock.   The ope-
 ration was performed in the following manner :"
   Mr. Duschamps made an incision,  not by enlarging the na-
 tural wound,  but by a new cut along the  inside of the arm, in
 the tract of the humeral artery, full six inches long, extending
 downwards from the tendon of the pectoral  muscle along the
 arm ; and by this incision he penetrated into the aneurismal bag,
 and cleansed it thoroughly of coagulated blood.  Mr. Dus-
 champs and his assistants, then suspending the compression un-
 der the clavicle, hoped to see the wound, or  at least to be di-
 rected  to it by the bleeding;  but though they examined  and
 wrought a full quarter of an hour, and although they saw and
 felt the main trunk of the artery beating under their fingers, they
 could not by any endeavours  make it  discharge one drop of
 blood; so that one of them ventured to say, he thought it could
 not be the main artery that was wounded ; while others agreed,
 that nothing but a wound of the main artery could account for
 the first loss of blood.
   In this state  of uncertainty, it was resolved to lay an occa-
 sional ligature  under the artery, which  at any time might be
 used, if necessary,  while the artery itself should be subdued by
 compression alone, with agaric and dry lint.  Mr. Duschamps,
 first,  enlarged a little the wound of the  knife, and introduced
 his finger into it, pushing it upwards towards the axilla; and by
 this dissection, he applied his occasional ligature half an  inch
 higher than the point of his finger.
   Secondly,  He covered all the course of the artery, within
the wound, with agaric and lint, secured by an eighteen tailed 
98             Of oblique Wounds of Arteries.
bandage ;  but so slightly bound that  it did not suppress the
putse.                                            .
  At four in the morning the blood  burst out, but it stopped
again of its own  accord ; it  burst out  twice the next day, and
in like manner stopped again.  On the third  day  it burst out
yet again ; but the haemorrhage, which came on upon the fourth
morning, was frightful  indeed ; the bed was  soaked  through
and through with blood, which, from the foulness of the dress-
ings,  had contracted a horrible smell.   At ten in  the morning
I reached my patient, says  Mr.  Duschamps, and undid the
bandages.  The agaric and lint were left in the incisions, which
I had made with the knife ;  the lint was drawn out of the ori-
ginal wound ; there was now no bleeding, and the patient was
dressed as  before ; but  again, at mid-day,  the  blood burst
out with amazing force, and again it was stopped by the attend-
ing pupil.  Mr. Duschamps now  undid the dressings entirely,
and cleaned the  parts,  hoping to see the wound ofthe  artery,
or  at least the jet of blood, but not one drop  flowed.  . " With
a patient so exhausted,"  says Mr. Duschamps,   " I durst no
longer trust to compression ; I now resolved to draw the occa-
sional ligature, and the instant that it was drawn, the blood was
thrown out with force, proving very plainly  that  this ligature
was below the place of the  wound.   I applied instantly a  se-
cond ligature above the first ;  the blood was immediately stop-
ped,  and as immediately  did the patient  lose every degree of
heat and of feeling in the  limb."   At this last operation of Mr.
Dusehamps, his patient had lost aboutthree porringers of blood;
halt an hour after, he fainted ; in a few  minutes  he revived a
little, but  a  storm passing over head, at this  critical moment,
with some loud peals of  thunder,  affected him so much, that,
on the third hour alter the operation,  he expired.
    " Upon  opening the body," says  Duschamps, " we found
 the brachial artery wounded from the outside and from behind ;
the wound  was "above the giving off of the  profunda humeri,
 small, punctur-d, made with the  point ofthe  knife, just under
 the border of the  great  pectoral  muscle ; the occasional liga-
 ture surrounded the artery immediately  below the wound, and
that iigature, which had suppressed the bleeding, was half an
 inch above"
    The depth and obliquity of a wound may prevent the bleed-
 ing at first;  and it may not be even suspected that an artery is
 wounded, when suddenly,  on the tenth or twelfth  day, it bursts
 out with such violence, as to endanger the patient's life.  It is
 not in gunshot wounds alone that this happens, where the ar-
 tery is not .ctually open tUl  the slough ialls off on the eighth or
 tenth day, but  in clean wounds with a pike or bayonet; for in 
Of oblique Wounds of Arteries.             99
these only, can the  delay of hsemorrhagy, be attributed to the
obliquity of the wound.  In the practice ofthe older surgeons,
w.  have many examples of this ; for in their days duels were
frequent,  and were always fought with  the sword, and when a
gentleman was wounded in the sword-arm, it often happened,
that although the sword had run obliquely  along from the wrist
to the elbow, and wounded the brachial  artery at the bend of
the  arm,  no bleeding appeared  outwardly, the first issue of
blood was so resisted by  the cellular substance, that it soon co-
agulated,  and filled up the narrow wound, assisted by  the in-
flammation and  swelling of  the parts.  A firm coagulum was
formed, and it was only  on  the tenth  or twelfth day when the
suppuration was free,  and the  clot began to separate, that the
blood burst out.   Le  Dran's  Forty-eighth Observation, con-
tains the case of a gentleman in the regiment of Noailles, who
was thus wounded with a rapier in the sword-arm  ; the slight
bleeding was stopped with small dossils of lint, and the next day
his hand and fore-arm were in good condition. Le Dran, in ex-
amining them, found no symptoms ot a wounded artery, there
was a  little ecchymosis  towards the elbow, and  a moderate
swelling of the whole arm. The dossils  were at last withdrawn,
the cure  went on well,  the pus was formed, the arm was not
swelled, no symptoms of a wounded artery appeared till on the
seventh day in  the afternoon.   B -ing  pressed to go backward,
he went behind his tent with his arm in a sling,  and having, in
adjusting his clothes, either  straightened or twisted his  arm, a
considerable haemorrhagy appeared suddenly.  When the con-
sultation met next day, it was plainly seen  that the artery was
open, the bloody tumour now extended from the elbow to the
arm-pit; Mr. Le Dean advised the opening ofthe  tumour,  or
the amputation of the arm: his advice was neglected ; the army
made a movement ;  this gentleman was sent to Namure ; the
haemorrhagies returned;  the surgeon was long in resolving on
amputating the arm, and when he did  at last perform  it, the
gentleman  was so far  exhausted  by successive hjemorrhagies,
that he died.
  This artery was found, upon dissection, to be wounded above
the condyle, and a hard  clot of blood, which pressed it down
against the bone, prevented the bleeding.
  Thus it  often  happens, through mismanagement, that  the
swelling, the haemorrhagies,  the gangrene,  suddenly terminate
in death ;  but in such wounds, the case.is often protracted to a
greater length, displaying, as it were in detail, all the dangers
of an oblique wound.
  A ball, we shall suppose,  passes along  the fore-arm, rakes
along the two bones, wounds the radial or  ulnar artery in the 
100            Of oblique Wounds of Arteries.
bottom of a deep and narrow wound, and then passes beyond
the elbow, making an opening too small to let out the blood ;
or, we shall suppose the oblique stab of a knife, sword or bayo-
net, touches an artery, lying thus in the heart of the fore-arm,
under all the muscles, and close upon the bone ; then  the  fol-
lowing  consequences  ensue.  The proluse bleeding,  at first,
proves  that some artery is wounded ; the direction of the
wound  ascertains that it is the radial or ulnar artery ; the stop-
ping of the outward bleeding causes an internal aneurism,  dif-
ferent  from the greater aneurisms of the arm or thigh, as it
lies not under a fascia, forming  a fair circumscribed aneuris-
mal bag, but under the bellies of  all the muscles, which are se-
parated from the bones, by a very irregular and a very danger-
ous collection of blood.   The outward bleeding is soon stopped
by  compresses and a bandage;  the friends are less alarmed,
seeing  nothing but a narrow slanting  wound ; but when the
next morning they see the arm  black with the injected  blood,
and swelled to an enormous degree, their fear is like their in-
difference before, quite ignorant, and beyond the true measure;
they btlieve  this to be an  absolute gangrene, and that the pa-
tient is lost ;  while  the surgeon sees in this blackness, not the
signs of gangrene, but the marks of a wounded  artery,  and
foresees a difficult and tedious operation of seeking it out.
   But if again the surgeon have not the skill to perceive  all the
dangers of the case, the apparent gangrene is soon changed in-
to  a real one; the limb becomes cold,  benumbed, and has a
livid redness upon its surface ; the skin  without runs into a low
inflammation ; the blood  within increasing every day in  quan-
tity, corrupts and bursts out; and thus,  as I have hinted be-
fore, it is not merely by the wound of its great artery, and by
losing  the great trunk that nourished it, that a limb is lost;
but in  a case like this, it is lost by the deep driving of the blood
among the flesh and bones.  Either the outward bleeding  is
allowed, and the patient is in danger of immediate death, or
the blood is confined, and the bleeding goes on within : so that
 every  time the artery bursts out, the limb is injected anew, as
 it were, by the arteries.   The matter is bloody, fetid,  corrupt;
 it prevents the re-union of the bones (if any bones be broken ;)
 it makes foul suppurations,  and extensive and fetid sores ;  and
 each new suppuration is succeeded by  a dissolution  of those
 clots which had for a time stopped up the artery,  so that again
 the blood bursts out; till at length, after many months of suffer-
 ing, the patient is  forced  to part with that limb which  he has
 undergone  so many dangers to preserve.  The extensive si-
 nuses,  and foul sores, the disorder of the joints,  and the total
 caries of the bones, make every such case incurable ;  there is. 
Of Wounds ofthe thoracic Artery.           101
even from the very first moment, no  other alternative for the
surgeon, than either to perform immediately a bold  decisive
operation, or to resolve at once  (not keeping the patient in this
lingering and cruel condition) to cut off the limb.   To the pa-
tient himself,  the question may  be honestly proposed  in these
terms : u Will you have this tedious, but necessary operation,
of tying the artery, regularly performed I  Or will  you, to shun
a present pain,  linger  for months in  this miserable condition,
consenting at last  to lose  the limb, when it is perhaps too late
to save your constitution, or even your life !"
   The thoracic artery, though small  and apparently unimpor-
tant,  produces  often the  most  distressing consequences when
wounded, and requires a bold operation.  This arises from the
looseness of  the cellular substance, which surrounds the great
vessels and nerves in  the axilla ; and such is the power  ot this
long and slender artery over the cellular substance, that it drives
its  blood freely under the pectoral  muscle.    The aneurism
which it forms, is  as large sometimes as that of the thigh.   It
often happens,  after a  wound of the thoracic or external mam-
mary artery, that the whole side is blackened with  the suffusion
of blood ; the great cavity of the axilla itself is filled with blood,
(and it is capable  of containing a great quantity) the back and
breast are  black with  the ecchymosis.   The  appearance is  so
formidable that the surgeon suspects  some mortal wound ; the
side  is so loaded  with blood that the patient  is oppressed, and
 he labours  so  in his  breathing,  that  we should  believe him
 wounded in  the thorax, but that there is no cough, nor blood
 coming up from the lungs,  nor emphysema  from air issuing
 by the wound.   From the size of the aneurism in the axilla,
one would, on  the other  hand, be apt to believe the axillary
artery itself wounded,  but that the pulse at the wrist continues
firm.   When the  axilla is thus filled with extravasation, and
the back and breast blackened with ecchymosis, a gangrene  of
the skin must sooner or later ensue ;  the discharged blood will
become foul  and very fetid ; the destruction of cellular sub-
stance, and the irregular abscesses, must extend far and wide ;
the disorder will be several months  in being cured ;  it arises
from ignorant surgeons thrusting their stopples  of lint into that
wound, which is very distant from the place where the wound-
ed artery lies,  which of course continues to bleed within.
   This must  be prevented.   It would no doubt be very wrong
to cut up the axilla, or touch the pectoral muscle  in pursuit of
every trivial artery that may be wounded on the fore part of the
breast;  nor would it be sensible always to make incisions when
the long pectoral  artery itself is wounded; for often the tho-
racic arteries, when wounded with swords or musket shot, bleed 
102           Of Wounds ofthe thoracic Artery.
very smartly,  and yet stop of their own accord, upon applying
merely a piece of lint to  the wound.   Indeed it is not on ac-
count of the actual  wound of the  artery that  we perform any
operation, but to prevent the  destruction of the cellular  sub-
stance and the diffusion  ofthe blood ;  therefore, when you find
that applying a piece of lint with  slight compression stops the
bleeding, without any appearance of extravasation, you remain
satisfied.  But if you be called to your patient  a few hours af-
ter the first dressing, on account of an incipient swelling and
slight,oppression of the  breast, and find that the extravasation
among the loose cellular substance in the armpit is begun, you
must undo your bandages, withdraw your bit of lint, which is
merely a stopple confining the blood, dilate the wound, put in
your finger and advance  it till you feel the jet of warm blood ;
hook out the clots which lie over the mouth of  the artery, and
lay your compress directly  upon  it.   Then  pile qpmpresses
over it on the outside, and apply your  roller; for it is seldom
necessary to cut the wound entirely up, or to use the  needle in
wounds of the thoracic artery.
<£>
DISCOURSE  VIII.
OF  THE ANEURISM FROM ANASTOMOSIS.
 X HAT kind of aneurism which I venture to name Aneurism
from Anastomosis, resembles those bloody tumours which ap-
pear in new-born children, occupying chiefly the lips, cheeks,
eyelids, or hairy scalp, and which grow in process of time to an
important size, bursting at last, and bleeding furiously, so as to
 oblige us to cut them out.
  The disease which I am now about to describe arises, not on-
ly from such natural deformitv, but also  from various and hid-
den causes : it often begins in adults, increasing from a trivial 
Of the Aneurism from Anastomosis.          103
pimple-like speck, to a formidable disease.  This aneurism con-
sists in a mutual enlargement of the smaller arteries and veins.
   I have reason to believe that it sometimes originates from so
slight a cause as a tight  hat or a trifling bruise; it frequently
begins in adults,  in pure, hale, and sound skin, where no spot,
nor  mark,  nor tendency^ to disease, had ever been observed.
The marks which children are born with are  often superficial
stain-like spots, which never change, except that their  colour
becomes occasionally deeper.  But sometimes those spots are
also defects in the substance of the skin,  they are  a species of
aneurism, or they create  a tendency to this disease ; and from
almost imperceptible stain-like  spots, not elevated above the
surface of the  skin, they  grow to dangerous bloody tumours,
which require extirpation.
   In both diseases, viz. of connate aneurisms appearing, when
the child  is born, in  the  form of a small livid  tubercle,  and of
those forming spontaneously or arising from a blow, the process
of their growth and increase is  the same.   When a set of cuta-
neous vessels first enter into this diseased action,  a few of the
extreme arteries in the skin itself are  originally in fault, and
commence  an  increased action, which draws the arteries of all
the adjoining parts into sympathy  with them;  the  arteries be-
hind them convey more  blood  and  push  it on rapidly ; these
larger arteries begin to feed the disease, while the central group
thus supported by the arteries behind, acts powerfully, the tu-
mour begins its  pulsations, and, like a punctum saliens, forms
vessels as it wrre, by enlarging those small branches which were
not visible before.  The  little arteries work powerfully  and are
dilated, the corresponding veins are proportionably enlarged, the
number and activity of those arteries and veins are slowly in-
creased.   This increased circulation solicits more blood towards
the tumour ; and while the central branches impel their blood
with greater rapidity, the trunks they come from, follow up that
action and work so as to  keep them full.
   In women, the phenomena of these tumours are  very re-
markable ;  the haemorrhagy from them usurps the place of men-
struation, the action of their vessels is as regularly periodical as
that of the  arteries of the  womb.   The state of menstruation is
a state of general excitement, and the  particular action may be
turned off towards any set of vessels, as those of the stomach,
nostrils, or lungs.  The excitement of menstruation affects the
breasts, it is felt through the whole system, its effect on every
tumour is remarkable, and I am  daily provoked at  seeing can-
cers, even ofthe breast, (which is always peculiarly affected), and
other tumours which actually rise and  fall with  each menstrua-
tion, extirpated without the smallest regard to the menstrual pe- 
104         Of the Aneurism from Anastomosis.
riod, though the change at such a  time upon  every tumour is
such as the most ignorant observer  might remark.   The disease
which  I am now explaining, this aneurism from  anastomosis,
consists in the increased action of certain arteries ; and the men-
strual excitement, and the local action coinciding, cause periodi-
cal pulsations, periodical enlargements of the tumour, periodi-
cal haemorrhages, and a bursting of the tumour at each menstru-
ation, which alternations 1 have  known continue for many years.
   Having endeavoured to settle  the  character of this singular
species of aneurism, I  shall proceed to relate, in the  first place,
a pure unencumbered case.
   Mr. R—n, a young gentleman of about twenty-five years of
age,  had an aneurismal tumour upon his forehead, which had
been growing for seven years.  It began with a small spot like
a pimple, of the size of a pea, and  was, when he consulted  me,
of the  size of  an egg; there passed along the centre ofthe tu-
mour the scar of an operation which had been performed about
a year before.    Nothing could be more singular than the cir-
cumscribed form, strong pulsation, and various peculiarities of
this aneurism.  Nearly seven years before, he had first observ-
ed a small pimple-like  tubercle rise on his forehead (which had
hitherto  been smooth and sound),  which was seated close upon
the eyebrow, and was so small and so little troublesome, that he
believed it to be a pimple merely, ascribed it to the tightness of
his hat, and disregarded it for some time.   When he  consulted
a  physician of very excellent  abilities, Dr.  Cleghorn of Glas-
gow, that gentleman ordered gentle physic, and other trivial pre-
scriptions, in perfect confidence that it would disappear; for at
this time it was of the same  colour with the rest of the  skin,
had  no  character of aneurism, and was so little troublesome,
that it  was for a long  while  after  entirely  disregarded.    But
when it had attained to the size ot a  sparrow's egg, he thought
he felt pulsation in it at times, he began to be alarmed ;  and
when at last he  resolved to consult a surgeon, the  pulsation/ was
manifest, the surgeon recognized it as an aneurism, and advised
that it should be cut out, but not with  that earnestness which is
necessary to  persuade  a patient, who seldom  has  at first a seri-
ous impression  of the nature or consequences of such a disease.
Mr.  R__n advised, or rather talked, with others, but  in so
careless a way,  that he  began  to  be  himself indifferent about the
tumour was easily  prevailed  upon to believe that if it  increased
at all, it  must be very  slowly; this little tumour seemed at first
to have arisen m-rely from a tight hat, and he  was easily per-
suaded to hope  that it would go away.
   One gentleman directed him  to try compression, and accord-
ingly, a plate of lead was bound firmly down upon the tumour ; 
             Of the Aneurism from Anastomosis.         103

 he suffered the pain of this pressure  with great constancy for
 some days, and for several weeks he continued a less painful
 degree of pressure; but finding the aneurism beating more pow-
 erfully,  foreseeing no good effect, and irritated with the con-
 stant and  ineffectual  trouble  of supporting the pressure, he
 threw away the bandage, and let the aneurism grow as it pleas-
 ed.   This was about seven years ago ; during  five years had
 his tumour continued to grow,  when the nature of  it being no
 longer equivocal, and the consequence of allowing it to increase,
 much to be  feared, k was resolved to perform the operation.
 There is every apology for the theory which the surgeon had
 formed of this  tumour, for its form was very singular.   It was
 seated immediately over the eyebrow, and was about the  size of
 a small  egg; it lay exactly in the course of  the frontal  artery.
 The small orbitary artery was found entering  into the lower end
 of this oval tumour, while a branch of the temporal artery, re-
 markably enlarged and tortuous, went curling along the  temple
 and passed also into  the upper end of the tumour.   No other
 vessels,  neither arteries  nor veins, could be traced to  it, but
 these two arteries,  and the intermediate tumour beat in  con-
 cert ; the arteries beat much more powerfully than in their na-
 tural  state, and the tumour had a very  powerful  throbbing.
 This  tumour,  which became turgid whenever  the pulses beat
 strong, seemed to be merely an enlargement of the frontal arte-
 ry, (vid. fig. 1. p. 108.) and under this  apprehension was the
 operation arranged as follows : The surgeon first made an inci-
 sion in the lower part of the tumour,  and passed a ligature un-
 der the orbitary or frontal artery ;  but when he had tied this ar-
 tery the  pulse of the  aneurism was nothing  abated.  He next
 made an incision along the temporal branch, where it ran into
 the upper part of the tumour, and tied  it also with a ligature, but
 in vain ;  the pulsation  of the tumour  was still  unaffected.   It
 was then necessary to  operate upon the tumour itself ;  it was
 opened its whole length, and bled very profusely ; one ligature
 only was used,  that ligature was struck with the needle into the
 centre of the tumour, where  there was  one artery larger  than
 the rest ; but from all  the  surface besides there was one  con-
 tinual gush of  blood ;  the htemorrhagy was repressed, and the
 wound bound up with a compress and bandage.  The tumour in
short  was  thoroughly  cut open, but  it was. not cut out.   It
healed slowly,  the ligature came away with  difficulty ;  after  a
 fortnight the patient was left to dress the wound himself; he felt
distinctly, before the wound was healed, that the pulsation had
begun  again; the pulsation became very strong,  and the tu-
 mour, by the time the wound was  actually healed, had attained
                            O 
106
Of the Aneurism from Anastomosis.
  the  full size it had before the operation ; it was indeed rather
  larger than before.
    But it might easily have been perceived, that this could not
  be a mere dilatation of  the frontal artery,  for the  tumour was
  some thousand times the diameter of that  artery.   The press-
  ing the point of the finger upon both arteries  stopped their pul-
  sation, but did not in the slightest degree affect the tumour ;
  and since the striking a needle and ligature under each artery,
  did not affect the pulse of the aneurism, it was plain  that the
  tumour was  of such a  nature, as to  draw its blood  from a
  variety of sources,  and that it was necessary,  not to cut it open,
  but to  cut it out.
    For nine months longer the tumour was suffered to grow un-
  molested.  When Mr. R----first desired my advice,  the cha-
  racter of the  tumour was very strongly marked.
    It was very protuberant from the forehead, of a regular oval
 form, about the size of a small hen's egg.   The scar of the for-
 mer operation, about three inches long, ran  across the centre of
 the tumour.   The tumour was not  purple on its surface, like
 the flesh spots of children, it was covered with a  firm and sound
 skin ; the scar was white, the rest of the  skin was of a deep
 red, from inflammation,  and  not  from  the  blood appearing
 through it ; its throbbing was exceedingly strong, and of late it
 had become very painful, so that  he was in fear of the bursting
 of the tumour, or the corruption of the bone ; it was from the
 pain, which had of late been considerable, that he was inclined
 to ask advice, or to submit to  a  second incision.   The notes
 taken at this  period, in  relation  to the appearance, size,  and
 pulsation of the tumour,  are as follows :
   The  lower  artery, the ocular,  which comes from within the
 orbit, is very large, and is felt entering into the lower corner of
 the tumour; the temporal branch  is very greatly enlarged, is re-
 markably tortuous, pulsates with  great force, so that I am sur-
 prised it has not wrought out other aneurisms near this first one.
 He wears his  hat quite off his face ; when his hat presses upon
 the tumour, it increases in size; when he runs, when he is heat-
 ed, when he stoops, when he breathes hard, it increases in size,
 and its  pulsations are  very strong : when he drinks spirits or
 wine, it  swells, pulsates, assumes a deeper tinge, and  every per-
 son at table am perceive the change ; and when I handle it rude-
 ly, it swells up, and when he chooses to retain his breath,  it is
inflated  like the gills of a turkey cock.   It is only for ten days
that the  throbbing pain has been remarkable, but that pain  increa-
ses, and as it runs backwards along the course of the artery, it
is, by compressing the artery, in some slight degree  relieved.
  Were this aneurism a mere dilatation of one artery, it  should 
Ofthe Aneurism from Anastomosis.          \07
 be emptied at once  by compression,  and the  continuing of that
 pressure,  should prevent its being  filled again.   But when it is
 compressed firmly, it yields very  gradually, as it the veins re-
 ceived its  blood ; the -compressing  ot its two  great  arteries,
 does not prevent its filling again ;  you are able to suppress their
 pulsation, but the aneurism still pulsates, it throbs from the bot-
 tom,  it rises very gradually  when you cease  from pressing, and
 soon fills to its full size ;  it seems to receive its blood from one
 knows not what sources, from small arteries which cannot be
 perceived.   The sudden inflation  of this tumour, like  the gills
 of a turkey cock, its various fulness, according to the season of
 the year,  its falling in autumn when the blood is low, and  its
 rising in the spring when the circulation is rapid, the variations
 of it in respect of fulness,  and its colour varying according to
 the degree of turgescence, its sudden puffing up upon taking wine
 or using exercise, its slow subsiding, and yielding in some slight
 degree by pressure, and its being so little affected by compress-
 ing the great artery which feeds it, are sufficient indications of
 its nature.   All this proves, that it is a tissue of small arteries
 and veins, it fills not like a varix, slowly; there is, indeed, no
 dilated vein to be seen near it; its filling is by distinct throbs,
 it is filled by its  small and numerous arteries, and its swelling is
 (like the erection of the penis) produced by the pulsations of the
 arteries, stroke after stroke, pouring out their blood into the cells.
    With this view of its nature, I was sure that it was a kind of
 tumour which was not to be cut open, but to  be cut out.   Dr.
 Jeffrey, and Mr. Cooper, surgeon in Glasgow, had the goodness
 to assist me.  I tied this rampant temporal artery before touch-
 ing the tumour, that it might be once more  ascertained  how
 little this interruption of any one artery7 could affect such a tu-
 mour.  The pulsation of the tumour was nothing affected; I
 knew by this what sort of an enemy I had to deal with ; I knew,
 that if I cut within the active circle of this tumour,  I  should
 have innumerable branchings of the artery to tie up; but that if
 I cut  wide where the arteries were  undivided, and before they
had formed their anastomoses, I should have  to deal with but
one or two.   I disregarded the bleeding,  I knew that I had no
means of saving blood but by making the operation rapid.   I
made an oval incision which comprehended about a fourth part
of  the surface of the tumour; dissected  the skin of  each side
down from it rapidly ;  I went down to the root of the tumour,
and turned it out from the bone.   The tumour was a perfect
cellular mass, like a  piece of sponge soaked  in blood;  it  was
tolerably solid, and  dissected out very clean, in the form of a
regular tumour; it bled furiously during the operation  (that I
had resolved to disregard), but the moment  the tumour  was 
108         Ofthe Aneurism from Anastomosis.
turned out, there was not one drop of blood, the surface was
clean,  the  pericranium quite bloodless,  the lower artery  stood
wagging out of its hole in the orbit,  and  I held it with the hook
while Dr. Jeffrey tied it.  The upper tortuous artery was also
tied; the  eyebrow, which was  divided exactly in the middle,
was  brought nicely  together, the incision healed in ten  days;
the wound has been now two years healed, and the scar is  small,
reddish, and very little perceptible,  and the two extremities of
the eyebrow, which were two inches distant  at the time  of the
operation, are perfectly close.

           Plans ofthe Aneurism ofthe Forehead.
  But there are varieties of this disease, which nothing but
a variety of cases  can explain ;  and one consideration  should
give us a particular interest in investigating its nature ; that if ne-
glected, it becomes incurable, and when it is incurable,  I think
it cannot fail to be in time fatal.   It becomes  incurable, when
having  been operated upon  with a partial incision, instead of
being extirpated,  it is but irritated, and grows till it spreads its
roots  among the adjacent parts.   It becomes incurable when it
occupies a great extent of skin :  It is an incurable disease when
it effects any ofthe viscera.   One phenomenon of this disease,
I think, is very remarkable ; often, in the course of it, vari-
ous sacs are formed,  which receive sometimes serum and some-
times blood, according to the state of  the  tumour, so that tu-
mours of this kind sometimes burst like a ganglion, or great
salivary tumour, discharging a thin serum like saliva.
  This  kind of aneurism sometimes grows in the limbs,  and to
a very remarkable size:   bleeds profusely, and reduces the per-
son to extreme  weakness, and yet is easily cured ; for the rule
which I have laid down, gives you a perfect command of the dis-
ease.  You  must not cut into the tumour but cut it out.  If you
merely cut into it,  the haemorrhagy is terrible, and the cure im-
pu'f-ct • if you cut round it, and at a l'ttlc  distance from  its 
Ofthe Aneurism from Anastomosis.          109
root, in place of the profuse haemorrhagy, from numberless ar-
teries,  you have but a slight bleeding from one or two, which
are extremely small.
   A tumour of this kind, which had grown to  a remarkable
size, and done  infinite injury to the constitution of the patient,
was extirpated by my friend  Mr. Harkness.   The history of it
is  as follows :
   " Jean Smith, a house-servant, about thirty-nine years of
age, had a tumour upon her arm of a very singular appearance.
It was  seated exactly over the middle of  the triceps muscle, on
the back part of the arm ; but the disease belonged merely to
the skin.  The  tumour had a very firm fleshy basis, and a sort
of dead and throbbing pulsation through the whole thickness of
it.   The tumour had something of the appearance of a s crotum,
with an enlarged  testicle : It was about eight or nine inches
long; the walls of the tumour were very thick and fleshy ; there
seemed to be a sac, or rather many  sacculi within the tumour,
but quite flaccid.  The  tumour hung down flabby  and pendu-
lous ; it was of a livid  colour, as if it contained  blood, or the
remains of blood; where it was  not  blue, like a vein, it was
mottled of a deep red, or lakey colour.  This tumour had burst
often, and poured out prodigious quantities of blood, and at the
place where it had burst, and especially at one point, where the
blood had  always of late been poured out,  the surface of the
tumour was covered with thick white scabs,  as if the bleeding
orifices had been plastered up.
   The  history  of the tumour was singular.   It was about eigh-
teen months before, that there  had appeared a small purple
spot upon the back of the arm, which soon grew into a tumour.
The tumour enlarged slowly,  and had,  in the course of  five
months, attained to the  size of a hen's egg;  then, for the first
time, it burst, and discharged a  great quantity of blood.   The
blood was red and florid, and thrown out with great impetus ;
but  it  stopped  of its own accord.   It increased  in  size from
this time forward very rapidly, and in  four days more it was
thought necessary, by the surgeon  in the country, to open the
tumour.  This  was  done by  incision ;  there had  been  a sac
formed, even at this time ;  a great quantity of coagulated blood
was taken out, the  haemorrhage was very profuse,  from the
whole surface,  but no particular artery was seen.  No vessel,
great or small, was taken up;  the hajmorrhagy was stopped
with flour, firm compresses, and bandage.   The wound was
healed, the tumour grew, and, from the size of  a hen's egg, it
increased in a few  months to its present dimensions, of eight or
nine inches in length, and six or seven in breadth.
   But this incision never healed entirely ; a succession of scabs 
110           Of Aneurism from Anastomosis.
 formed upon that part of the tumour, and from time to time
 the  blood burst out from it on the slightest accident or injury,
 and most infallibly the haemorrhagy returned at every menstru-
 ation.
   Her menses continued regular;  at every menstrual period
 she  was  sensible of a heat,  pulsation, and swelling  in the tu-
 mour ; at each menstruation,  blood  burst out afresh from  the
 central opening ; she  lost immense quantities of blood,  but still
 the menses held on their regular  course, and flowed in due
 quantity.
   About three weeks before she came under the care  of Mr.
 Harkness, she had her menses, the blood again flowed in  the
 usual quantity from the tumour in her arm.   The blood  burst
 out again from her arm  just two days before this second ope-
 ration was performed.   The  bandages which had been kept
 firm from the time ofthe last haemorrhagy, chanced to be loosen-
 ed and thrown aside; the blood, on  the  day of menstruation,
 and  just two days  before the operation, burst out impetuously,
 and  she lost no less than four pounds of blood.
   Operation.—This haemorrhagy was so dangerous,  and im-
 plied also something  so peculiar in the nature of the tumour,
 that  Mr.  Harkness very prudently called together a full con-
 sultation,  especially of  the  older surgeons.  The tourniquet
 was applied, the foul  cloths  and tight bandages were taken a-
 way  from the tumour.   It hung like a thick and massy bag half
empty.  Mr.  Harkness did not set about the operation  without
•a degree of apprehension, nor  were the gentlemen, who were
 convened to see the operation,  without fear of a  very  trouble-
 some haemorrhage.   Mr. Harkness went round the base of  the
tumour with two strokes of his knife ; he separated the  tumour
 very rapidly ; when  the tourniquet was  slackened, there was
not the smallest haemorrhage ; the place where  the tumour had
 been, remained  almost  clean of blood ; one small artery bled
 smartly, and was taken up with the  tenaculum.  Those who
had seen the alarming hyemorrhagy of the preceding day,  were
 astonished, while those who  saw the tumour  for the first  time,
 and had been  called together as to an important case, were al-
 most offended to find themselves so formally summoned to at-
 tend on an occasion of so little danger.*
   When such tumour is seated among the viscera, or in any
 inaccessible part, it must be an incurable, and, in the end, a
 fatal disease.   It is  likewise  incurable in those cases when,  al-
 though occupying an external surface,  it is of such extent that

  * Upon diffecting this tumour, I  find it like a placenta, ftringy, cellular, con-
 fifting of a confufed tiffue of fmall arteries, veins, and cellular fubftance, Tike the
 fubftance of th&placenta, or ofthe womb. 
Of the formation of Callus.
Ill
no operation can be  performed.  But in all cases in which  an
operation is practicable, the rule is,  " not to cut into them, but
cut them out."
DISCOURSE  IX.
ON FRACTURES OF THE LIMBS.
                         SECTION  I.

                  Ofthe Formation of Callus.


 J\. BONE is a well organized part ofthe living body; that
 matter,  which keeps its earthy parts together, is  of a gelati-
 nous nature; the earth  of bone,  to which it owes its hardness,
 strength, and all its useful properties, is deposited in the  inter-
 stices of this gluten, undergoing  a  continual change and reno-
 vation ;  it is incessantly taken up by the absorbents, and secret-
 ed again by the  arteries.   It is  this continual  absorption and
 deposition of earthy matter which forms the bone  at first, and
 enables  it  to grow with the growth of the body ;  it is this un-
 ceasing activity ofthe vessels of a bone, which enables it to re-
 new itself when it is broken or diseased ;  it is, in short, by va-
 rious forms of one secreting process that bone is formed at first,
 is supported during health,  and is renewed on all necessary oc-
 casions.   Callus is thus  a regeneration of bone, organized by
 the same action with that by which the original bone is formed.
 The callus  begins to be formed after a fracture, as soon as the
 continuity of vessels is re-established,  and their healthy action
 renewed.*   It is not a concrete juice, deposited merely for the
 occasion of filling up the interstice betwixt fractured bones,  but
 a fair regeneration  of new and perfect bone, with its needful
 apparatus of arteries and  veins, and of absorbents, by which its
 earthy matter is continually changed like that  of the contiguous
 bone.   Callus, indeed,  could hold no connexion with the con-

  * Of courfe, the length of time which intervenes between the accident and the
 formation of the callus varies ;  where the inflammation is inconfiderable it proba-
 bly commences in a  few days ; but where that is violent, even though no matter
is formed, this procefcis delayed until the inflammatory action fubfides—S. 
112               Ofthe Formation of Callus.
tiguous bone, were it that inorganic concrete which was once
 supposed.
   It results from  this doctrine, that callus is established in a
renewed continuity of vessels ;  that a soft, flexible, and  vascu-
lar substance is interposed betwixt the ends ofthe broken bones;
that a sort of temporary gland is  organized for the generation
of bone, or, to  speak not figuratively, but  philosophically, it
seems as if, by this re-union of all the adjoining parts, the ori-
ginal constitution  and  proper  organization ot a bone  were re-
stored.   But  for  some time the  secretion of earthy matter is
imperfect; it is infant  bone, soft,  flexible,  of an  organization
perfect for all the purposes of bone, but as yet delicate and un-
confirmed ; not a  mere concrete, like a crystallization  of salt,
which, if interrupted  in the  moment of forming, will never
form ; not liable to be discomposed by a slight accident,  nor to
be destroyed entirely even by  a  rude shock.  In its organiza-
tion so far  perfect, that when it is hurt,  or  the bony secretion
interrupted, the breach soon  heals like the adhesion of soft
parts, and  so the  callus becomes again entire, and the process
is immediately renewed.
   But as this is a theory which is to have  some  influence on
your practice, it must not be slightly treated  ; but must be sup-
ported with something more  substantial that hypothetical rea.
soning.  I  shall proceed, therefore, to state facts.
   Towards the end of the cure of a frtfctured limb, the patient
becomes careless and confident, and often by his playing tricks
with his crutches, or by the crutches slipping or breaking through
his negligence,  he loses his balance, throws  all the  weight of
the body suddenly on the weak limb, and  thus breaks it a se-
cond time.   And here a phenomenon presents  itself,  which
very strongly  confirms  our doctrine.  It is, indeed, contrary
to the vulgar opinion, but yet  it is certainly true, that when a
limb is broken a second time, it re-unites more easily than  at
the first, and when broken a third and a fourth time, heals still
faster and faster.   A little girl, a daughter of Mr. Y. had her
arm three  times broken, and at each time I  found it  unite  in
a shorter period than the preceding.   A young man, a servant
with Mr. G. having broken his leg,  it bent and broke  under
him three successive times, and at each successive fracture it
healed more and more easily.
   " An officer, whose  leg had  been reduced by a French sur-
geon,  and who was  recovered so as to  walk abroad, fell and
broke it a second time,  about the  fiftieth day  ofthe cure.   The
limb being  reduced  and laid again in splints, was so well ossi-
fied in twelve days,  that the surgeon took off the  splints, the
patient was able to lift his leg;  it  bore its own weight quite ea- 
Of the Formation of Callus.             113
 sily, and by the twentieth day it bore the weight  of the  body;
 he walked abroad, used all manner of freedom, and  was cured
 a second time,  and by the twenty fourth  day, he was  able to
 walk without any other help than  a  cane.   But this ill-fated leg
 was destined to be  broken  a third time; for, this  gentleman
 having mounted his horse, in order to go and join his troop, the
 first step  of his journey was a  disastrous one.    His horse
 plunged in among some clay; he  fell; and the  horse, in kicking
 to clear himself, broke both the boot and the rider's leg.*  This
 third fracture was still more easily re-united than the second ;
 for in less than six weeks, he went to his regiment with the leg
 strong and firmly joined, and so accurately, that it was not easy
 to distinguish the broken leg from the sound one."
    In all these cases the limb yields ;  it bends under  the weight
 ofthe body;  it is broken so  that  it can no longer support the
 body, but without any  snapping or sharp splintering of the bone,
 and,  in general, without any overshooting of the  bones,  and
 without crepitation.   It is chiefly by the change of shape in the
 limb, by its bending somewhat, that you know it to  be  broken.
   Every accident of such a case is perfectly consistent with the
 doctrine which  I have laid  down, and proves  it very strongly.
 Callus is really more vascular than bone ; and of this we are as-
 sured by various proofs.   Having cut off the limb of a soldier,
 whose leg had  been broken in America twelve years before,  I
 found, upon injecting the bone, that while the  bone itself re-
 ceived the red colour of the   injection pretty  freely,  the  callus,
 which goes in a zig-zag form, joining together the several ends
 and points of a very oblique  fracture, was  very singularly red.
 The  callus, then, is more vascular than the bone which it  be-
 longs to, even at the distance of twelve years from  its forma-
 tion.   This callus, unconfirmed at the time that it is  broken, is
 soft,  and very highly vascular.   When the  callus breaks, many
 of its vessels are ruptured, but some are only elongated,  and it
 rarely happens that its  whole substance  is torn.   You may ea-
 sily imagine how much more  readily the continuity  of vessels
 will be renewed within the substance ofthe  limb, when the bone
 or callus is  surrounded by vascular parts  ready to  swell and
 close up the breach, than in any external wound.   When  we
 consider the perfect vascularity  of a  callus,  the  excitement
 which must follow this  partial rupture, and the  full  and vigo-
 rous circulation  in vessels accustomed to the secretion of bone,

  " The meaning of the horfe breaking the  boot, as well as the leg, will not be
undcrftood by thofe who are not acquainted with the peculiar manner of accouter-
ing a bidet or hack-horfe in France.  It has two large fixed wooden  boots, flung
on each fide of the faddle, and when the rider mounts, he thrufts his leg, boot and
all, into thefe wooden boots.
                             P 
114             Ofthe Formation of Callus.
we understand why a fractured callus is more speedily re-united
than a broken bone, where nothing is prepared for the genera-
tion of new bone.
   I think  I cannot illustrate the condition of a  callus, at the
time that it is broken, better, than by comparing it with the con-
dition of a bone,  where, by the perpetual restlessness ofthe pa-
tient, a proper callus has been prevented, where the bones have
covered themselves with a son of cartilage, and an unnatural joint
has been formed; where the surgeon makes  an incision, turns
out the ends of the bone, pares off the callus from each end of
the bone,  returns  the  pared ends of the bone again into their
place, and lays them among the flesh, opposite to each other, and
sews up the wound; then adhesion takes place, the communion
of vessels, from bone to bone, and also the  continuity of all the
surrounding soft parts, is  restored;  then  all the surrounding
vessels are drawn into action, a mass of parts, active and in high
circulation, is formed round the broken bone, the blood and hu-
mours are worked towards it, and the vessels of the bone itself
being thus supported in their new action, the ossific process is
renewed with great energy.  This is the result of an experi-
ment, or rather of an operation,  which has  been several times
performed, and particularly by Mr. Park, of Liverpool,"!" and,is
a fine analogy for explaining the condition of a fractured  callus;
for in proportion  as the organization is advanced,  and the parts
full of blood and in high excitement, the second fracture is more
rapidly re-united than the  first.
   This accident, of breaking the leg a second time, is in no
case so grievous a misfortune as might be imagined;  in a very
ill-redueed fracture, I should rather  esteem it fortunate.   It
was the practice  of surgeons in all ages, to  snap the limb across
their knee whenever  they were ill-pleased with the shape of it  ;
and although, in the present day, such a practice  would be es-
teemed a mark of the grossest ignorance, it is but one example
out of ten  thousand, where opinions which now pass only among
the vulgar, may  be traced to the highest and most respectable
authorities.
   That the ancients had very generally engaged in this practice,
I  could easily prove by direct authority : and men of the  first
eminence in our profession, the very best surgeons in the world,
have been in the practice of performing this operation.  " I was

  f This operation has fo frequently failed, that it is, 1 believe, never now per-
formed.   But to Dr. Phyfick, of Philadelphia, we are indebted for the difcovery
of another, much more eafily performed, and likewife much more fuccefsful.  He
advifes a feton to be paffed between the fractured ends of the bones,  and to be re-
tained there until a confiderable and fufficient degree of inflammation is excited,
when it may be withdrawn, and the limb treated as in a cafe of recent fracture. S. 
Of the Formation of Callus.
115
called," says La Motte, " to a young man of sixteen years of age,
who had the thigh-bone broken seven or eight weeks beforehand
it  was so re-united that  he could not walk;  the broken thigh-
bone was shorter by  halt a foot than  the sound  one, and he
called me, in order to learn whether some sort  of  shoe might
not be invented, by which  the leg might  be raised so as to en-
able him to walk.
   1  found the bone broken about the middle  of the thigh; the
bones  were so awkwardly joined, that they absolutely crossed
each other.   There was  a great elbow looking outwards, and
a  proportioned hollow  within; but the lad  being young and
healthy, and the callus as yet  soft,  I formed  the resolution of
setting the thigh-bone again, in its right shape, by extension and
counter-extension ; for I knew that the attempt  could do the boy
no harm, and I remembered from the accidental breaking of
the callus, that the callus was long of obtaining its  perfect con-
sistence.   So, having made his bed, and prepared bandages and
splints, I made a powerful extension by die help of my young
men,  and pushed in  this elbow with the flat  palm of one  hand,
and resisted with the  other.   I succeeded perfectly to my mind,
so that, without one cry from the lad, I reduced this angle, and
made  his fractured thigh  as  straight and as long  as the other.
In a month he was freed from his splints, and walked without
pain or halting, while his thigh was as straight as an arrow."*
   From this  history, I  draw no  rash conclusions.   I do not
propose to break limbs when  they are almost healed,  that they
may heal faster; nor to take even a crooked and unserviceable
limb and lay it across the  knee, like La Motte; but I do, with
perfect  confidence, advise you,  to leave off bandages,  which
you see were originally designed for no other use than to mould
and fashion the callus; to reject those  long  compresses,  which
were bound so firmly round the limb for the same purpose ; to
use such splints only, as  when laid along the  whole limb, may
serve to maintain  its posture, and preserve it steady, and to tie

   *  The following cafe, which occurred to myfelf, is fomewhat  analogous to that
of La Motte.
   Upon my return to this country from Europe, I found in the family ot one ot
 my relations, a little girl  about ten years of age, whofe  thigh had been fractured
 about a month before, by a fall from a cherry-tree.   The limb had been fo badly
 fet, that the fradtured ends of the bones over-lapped each other about an inch and
 art. half, and the limb on that fide was- confequently that  much fhorter than the
 found extremity.  As the  effect of this would have  been lamenefs for the reft of
 the child's life, I propofed breaking the extremity, as from the age of the patient
 I had no doubt of its re-uniting.  As there was an  appearance of cruelty in the
 propolul, the family would not agree to it.  Upon this,  I recommended  that the
 patient fhould have a pair  of crutches, and be allowed to walk about. Thu was
 accordingly done, and in  a few hours 1 was  informed, (he had flipped down and
 that her thigh w^s again broken.  l"now treated the fradure, and fhe got well m
 •_he ufual time ; and no difference is now perceptible  between the limbs, b. 
116            Of the Formation of Callus.
those splints slightly with  tapes; to lay out a  broken thigh
(since  it cannot be  commanded by splints) smoothly upon a
pillow, and to venture, without fear of hurting the callus, to ex-
tend the limb anew, and lay  it straight when it is disordered and
shortened.    In  a simple fracture of the leg, it  is almost suffi-
cient to  lay it on  a pillow  ; and you have  done  every thing
when you have laid  it lightly and easily in a smooth splint of
pasteboard; then the  patient himself is almost able to keep it
right.   In fractures  of the arm, the part hangs naturally in  the
best posture, and  requires  but  two splints of thin pasteboard,
rolled gently with a linen roller; and in fractures of the fore-
arm also, the limb preserves its natural length and natural form ;
it requires merely to be laid upon a long splint  of pasteboard,
with a smaller splint above,  the  two splints secured with slight
tapes or ribbons, and the arm slung round the neck.
  Dismiss,  then,  those anxieties about the manner of rolling,
and the express degree of  firmness which the bandages should
have; look no longer thus anxiously at the points of the  fingers
or toes, to see whether the  bandage  presses  properly, so as to
make those parts swell; you are not to draw  the roller, so as to
straiten the  limb up to the very point of producing gangrene,
nor to use any bandages that are formidable from their strait-
ness, nor any that are even firm, except in children, in  drunken
people, in maniacs, or in those who are  delirious  with  fever or
pain.

                        SECTION II.

                  Definition of Fractures.

  Having corrected  some prejudices, and initiated you into the
history and theories of this interesting subject, I propose next
to lay before you the various characters and distinctions of frac-
tures.
  First, Simple fracture is that in which the bones, though bro-
ken, do not protrude.   The soft parts, though  inwardly torn,
are but little injured.   The periosteum is not separated in any
remarkable degree from the bone ; but the periosteum clings to
the bone, the tendons and  muscles to the periosteum, and  the
surrounding soft parts are so compressed  around the  fracture,
in consequence ofthe limb being entire, that adhesion soon takes
place among them.   The interstices  are filled with a gelatinous
effusion, which soon becomes organic, and the continuity of ves-
sels is immediately restored.  Even in a comminuted  fracture,
each little piece of bone retains its connexion with the soft parts,
and lives, and is nourished, and re-united with the bone to which
it belongs, so that when we dissect a fractured bone in the first
days, we find the  periosteum thickened like  soaked shammoy 
Definition of Fractures.
117
leather, the soft parts glued together by inflammation, and the
secretion  of bone beginning in  separate points ; and when we
dissect an old fracture, we  find little pieces and  splinters  per-
fectly consolidated  into the callus, which had been entirely se-
parated from the bone.  This case,  then, requires nothing but
ease and quiet, and a favourable  posture of the part.  The cure
may be resembled to the adhesion of an open wound, where
there is immediate re-union of vessels, no suppuration, no waste
ot parts, no remaining mark of injury, there is  a spontaneous
and perfect cure.   The cure is spontaneous, the work of nature
alone; the surgeon has nothing  to care for but the form of the
limb ; to lay it even at first,  and to redress its posture when it
happens to be disordered.
   Secondly, Compound fracture is that where the  fracture  is
accompanied with  an  outward  wound, and it is called  Great
Compound  Fracture when  the  bone protrudes.   And in this
case the flesh is often  cruelly mangled, and the bone shattered
into many pieces, and yet the parts retain (though not  always)
their life and vigour. The protrusion of the bone makes a rude
and lacerated cut ;  the soft  parts,  as the  periosteum,  muscles
and skin,  are all cruelly mangled,  but they are not destroyed ;
the periosteum  still clings to the  bone, the muscles  to the peri-
osteum, and the skin to the  muscles ; there is a very shocking
outward injury, but there is happily no proportionate  disorder
ot the  inward parts.   The inward parts  are  lacerated and
wounded by the protruding bone ; they are hurt by the  violence
(as the crushing of a chariot wheel) which caused  that protru-
sion ; but they  are still alive, still adhere to each other,  and give
mutual support ;  no part is so entirely killed, as by its  death to
draw on the death of the whole.   But then these parts, though
not killed, nor separated from each other, are  so  torn that they
seldom re-unite; they run into  inflammation, and  the cellular
substance is so filled with extravasated fluids,  and the bones so
crushed, and re-unite with so much difficulty, that the suppura-
tion is very  profuse.
   The case, then, which is here  defined, is a compound of frac-
ture, with a great suppurating wound, not void of danger.  The
gorged  vessels are soon unloaded by a free  and timely suppu-
ration :  after the first swelling subsides,  the parts become flac-
cid,  the matter profuse, the patient is in  clanger of being ex-
hausted with pain and  fever, and the dangers of the  case are
chiefly those of a great suppurating wound.   If we are forced
at any  time to amputate such  a limb,  it is  only for  want of
strength in the  patient to support the pain, fever, and profuse
discharge; for through time and care the lax swelling subsides;
the suppuration lessens in quantity ; the loose bones  are  dis- 
118
Definition of Fractures.
charged: the living bones (whose periosteum still adheres to
them) though broken in a way seemingly destructive of all orga-
nization, recover their connexion with the fractured bone,  in a
manner which has long been admired.  Of the bruised parts,
those which lie deep come to be pressed into contact with each
other ; the vacant spaces within,  and the  external wound, are
filled with granulations, and then the continuity of vessels is re-
stored, and the callus is completed.  This continuity of the ves-
sels is essential to the regeneration of the bone ;  and we see the
reason of a phenomenon which has excited the surprise, not only
of Dr. Hunter, but all surgical writers from time immemorial,
viz.  that during the suppuration, and while the wound continues
open, no callus, or at least no complete callus, ever forms.
   Thirdly,  In  compound fracture and luxation, where,
along with the  protrusion of  the bones, there is a laceration of
ligaments, tendons, and capsule of some great joint, the case is
peculiarly dangerous.  When, for example, the ankle-joint is
burst up, the astragalus broken to pieces, or turned out through
the wound,  the lower end of the  tibia shattered and protruded,
and the fibula also broken, the disorder is such as to defy the
powers of nature, and art can do but little.   This is of all cases
the most perplex ng  to the judgment, and distressing to the
feelings of  the  surgeon, who often wavers in fear and anxiety,
for some days  desirous of saving the limb, and yet fearful of
losing the patient's life, till at last the fatal gangrene appears,
and he feels most poignantly  the fault he has committed, if, in-
deed, the surgeon can be said to have committed a fault, who
has attempted to save a man's limb, though at the risk of his
life.  Yet the surgeon, though he has acted deliberately,  con-
scientiously, sensibly and humanely; though he has been sup-
ported by the countenance of his fellow-surgeons ;  still, when
misfortune comes, must feel himself unhappy.
   The French surgeons, with one accord, declared amputation
to be, in such cases,  the only chance of saving the life.  Palfin
says, " In luxations of the ankle, there is seldom any thing to
be done but amputation."  The same is laid down  by Duver-
ney,  as an express, unconditional rule of practice.   We do
not comply with any  such barbarous rule;  we take it only as a
denunciation ofthe danger which is observed to attend this par-
ticular case ; we keep our minds free and unbiassed, so that we
mav be able to decide this question according to the circum-
stances.  We know that nature  will do wonders, but they are
wonders, and we never enter upon the attempt of preserving a
limb thus desperately fractured, without awful hesitation, and
when we do venture to dilate the wound, and push  back  the
bones, we feel all the responsibility of what wejhave just done. 
Definition of Callus.
119
 We watch the appearance  of mortification for some days  and
 wait with inexpressible anxiety the natural issue ofthe case life
 or death.*
   Thus the simple fracture terminates  in adhesion of the parts
 inwardly bruised and injured ; compound fracture ends  some-
 times in adhesion, but more frequently in suppuration of parts
 too much bruised to adhere ;  but the fracture of a great joint,
 as of the ankle,  is attended with  lacerations too terrible to ad-
 here,  or even to suppurate easily ;  this  is the case which, while
 it sometimes suppurates, is most apt to terminate in gangrene
 and death.
   Fourthly,  Gunshot fracture has  many dangers peculiar to it-
 self ;  and of all those circumstances  by  which, in other frac-
 tures, the soft parts  recover  their healthy condition,  and the
 splinters regain  their natural connexion with the bone, not one
 can take place in gunshot-wound  :  for here there is infinite loss
 of substance; the bone  is  not merely broken, it  is destroyed,
 contused, and deadened by the blow,  and condemned to the ab-
 solute exfoliation of every individual  particle and  splinter that
 has been shaken by the ball.
   From the moment in which the  bone is struck by a ball,  k
 loses its life and circulation, and all  its connexions with  the soft
 parts.    The bone is deadened to some  extent by the  force of
 the blow;  it is splintered into  many pieces ; the periosteum too
 is killed by the shot, so that, of the  injured or splintered pieces,
 not one  can  recover  its life,  or resume its connexion with the
 living system.
   Nor is the bone only killed, but all the surrounding parts also j
 for the bone is the resisting body which, by receiving the force
 ofthe ball, reverberates it upon the adjacent parts;  so that that
 portion ofthe flesh which most immediately surrounds the bone,
is particularly affected, is deadened, and afterwards thrown off
 in the form of sloughs.
   These are the  accidents of this species of fracture, which dis-
tinguish it from all others j for the death of all the internal parts
insulates the broken bone.   There can  be no adhesion among
parts which are actually dead; the continuity of contused vessels
can in no shape be restored: instead of a knotting of the soft
parts into a vascular mass, full of life  and action, supported by
a continuity of vessels, and fitted for the generation  of callus,
there  is a cavity full of fetid matter,  dead  and sloughing flesh,

  * 1 would recommend, in every cafe of compound luxation and fracture of the
 ankle-joint, to endeavour to fave the limb, not only becaufe many have been pre-
ierved, but becaufe 1  believe the patient is more apt to die where the leg is taken
                                                liicatioi
                                                lablifhe
                                                ceffary. 
120
Definition of Fractures.
and insulated fragments of bone;  a narrow opening, a deep and
ill-conditioned wound,  and a profusion of foul and putrid ichor
flowing from the narrow openings, or bursting through various
fistulas from time to time.
   Thus a gunshot-wound, with a  great fracture, resembles  in
many points the worst kind of caries.  The detached bones are
discharged with difficulty ; the dead parts which have sloughed
off, are very slowly replaced; it is long before the wound be-
gins to heal from the bottom, or, in other terms, before the con-
tinuity of vessels is restored, or the mass of vascular substance
prepared, in  which the callus  is to be formed.   In short, the
parts are with difficulty regenerated; they are slow to heal; apt
to run into ulcers, fistulas, and collections of matter; while the
patient is exhausted by pain, fever, and profuse discharge.
   Having thus  explained to you the general nature of  a gunshot
fracture, I  believe you  can be at no loss to imagine the peculiar
difficulties of each case;  for where the limb that is wounded  is
small, there is  less destruction of parts; the sloughing is not
great, the suppuration is slight, and the bones being near the sur-
face, the shattered fragments are easily discharged.   Thus it is
in wounds  of the radius and ulna,  and of the os humeri.
   But where the bone  is greater, the mass of soft  parts more
buiky, the  wound of course deep,  and  the destruction of parts
proportionably  great, the matter is apt to insinuate itself among
the muscles, to insulate the bones, and to  make, in the end,
crooked and fistulous passages, and  an almost incurable  sore.
Such  are often  the consequences when the bones of the leg are
broken, especially where the  joints of the ankle or knee are
concerned.
   But where the bone is the largest in the body, and covered
with a great  thickness of flesh, as in the thigh, there is a very
extensive destruction of parts, the mass of disease is very great,
and if the patient escape gangrene  in the first days ofthe wound,
he generally perishes afterwards from the lever,  the incessant
suffering, and profuse discharge.   From  a gunshot-wound in
the haunch-bone, or in the femur, near its neck, about the tro-
chanters, or any where high in the bone, not one  of twenty es-
capes.  The sufferings of such a person may  be easily imagined,
since he lives, or rather, one  might say, continues dying for
five years, and while he lies on this bed of torture, with matter
running in profusion from  various fistulas every  where sur-
rounding the joint, irregular callus shoots out in fantastic forms
round the bone, so as to unite the bones in that crooked form in
which he lies;  yet, even while the callus is  thus  forming, the
fistulas being incurable, and the discharge profuse,  amputation
is impossible, and the patient expires. 
(  121  )
DISCOURSE  X.
RULES  FOR  THE MANAGEMENT OF  SIMPLE,
   COMPOUND AND GUN-SHOT FRACTURES.
 OYSTEM-WRITERS  still retain the old  descriptions and
terms of art, of which there is not one that does not  imply an
absurdity.   Of these the  most  conspicuous  are, extension,
counter-extension, coaptation and diligation.  These
terms were descriptive of operations which were actually per-
formed  by the glossocomas of the ancients, and by the block and
tackle of the modern surgeons.
   Extension was the fixing of lacs and bandages  upon the low-
er part  of the fractured limb, to which  were applied ropes and
pulleys, by  which the assistants pulled.  Counter-extension was
the resistance which other assistants made by tablecloths, girths
and bandages, put round the pelvis and upper part ofthe thigh.
Coaptation was the thumbing and working the smaller fragments
and  the broken ends of the  bone into  nice contact with each
other ;  but diligation was a process which it would take hours to
describe, as  it took hours to perform ! of compresses applied
round the broken ends of the bone, pads and cushions laid along
the sides of the limb, splints above  these compresses and cush-
ions, with distinct rollers for each several stage ofthe operation.
   But I will describe the real operation in plain words, in which
there is  no occasion for any such terms as extension, counter-
extension, diligation, rope, pulley, compress or bandage !  That
is  indeed rampant surgery !  Were it possible for a limb to re-
quire such extension, it never could be maintained.  When a
limb, the leg, for example, is broken, you need no nice and cri-
tical diagnostic signs to distinguish the fracture by; the broken
limb yields under the weight of the body, the patient hears and
feels the snapping ofthe bone at first, and is sensible, when the
limb is moved,  of that grating of the broken ends of the bone
against each other, which was in the old vocabulary termed Cre-
pitation  ; and the  surgeon, when he begins to handle the limb,
                            Q 
i 22      Of simple, compound and gun-shot Fractures.
is sensible of the same grating, he perceives by the bending of
the limb that it is broken, and there is indeed so little difficulty
in distinguishing a fracture, that I have never seen a patient who
was not sensible of his condition, nor heard of a surgeon setting
a sound limb,  except by design.  In setting this broken  limb,
there is no extension required but such as common sense would
direct you to use if you were  not a surgeon.   You lay the  pa-
tient in bed, and lay the limb on a pillow, or if you design to use
splints, you have  two long troughs or pieces of pasteboard bent
into a hollow form, lined, or rather cushioned, with two or three
plies of flannel, and with tapes or ribands, four or five in  num-
ber, attached to the outside of one of the splints, by which both
splints may, after all is over, be gently tied together with bow-
knots, to be slackened or tightened according to the swelling of
the limb ; you also soak and soften the pasteboard a little,  that
it may take a shape suitable to that of the  limb.
   A long splint of this kind being laid flat upon  the bed by the
side of the fractured leg, you desire one of your assistants to ap-
ply his hands broad round the upper part of the limb, and grasp
it gently and steadily ; you take the foot and ankle in the same
manner in your own hand ; you slip, perhaps, your left hand un-
der the broken part of the limb, and thus  you and your assis-
tant carrying, or rather sliding the limb gently along, lay it upon
its  pillow (which should  not  be a common one,  but rather like
a mattress or settee pillow flat and firm), or upon its splint.
   Then you begin to lay the limb smooth ; your assistant grasps
it again by spreading his hands upon the thigh, or below the
knee,  with the design of extending along with you, not by lift-
ing the leg  from the pillow, but rather by spreading his  hands
over it, pressing it down to the  splint or pillow, and steadying
and holding it by the pressure, while you, with both hands, lift
the foot and ankle,  grasp  them  gently but very  firmly, raise
them a very little from  the pillow or splint, and draw gently,
steadily,  and  smoothly,  and when you have extended and
smoothed the  broken leg in a manner which you  almost suppose
agreeable rather than painful to the patient, you press it down
upon the  splint, you and your assistant both keeping the limb
steadily and gently pressed down.  You keep it flat and press-
ed with all your hands till it  gets a  sort of seat  and bed in the
pillow ; or if splints are to be applied, the limb  is  now pressed
against the lower splint; the upper splint is then laid above it
by a third assistant; you now grasp the limb with your hands
on the outside  of the soft and moistened splints;  you grasp and
model them a little, and when the whole has taken a form, you'
tie the several tapes one after another, and after having tied them
 in a general way, you go over them again one by one  a second 
         Of simple, compound and gun-shot Fractures.      123

 time, and tie them a little closer, so as to keep the limb agreea-
 bly firm.
   There is in this description, you perceive,  no mention  of
 those high-sounding terms which were so peculiarly descriptive
 ofthe grand surgery ofthe old masters; if we must retain them
 in our modem nomenclature, there should be associated with
 them no ideas of lacs, and pulleys, and  assistants  pulling at a
 fractured limb.   Extension means, the surgeon gently drawing
 out the fractured member ; counter-extension means no  more
 than some friend or assistant holding it firm above ; coaptation
 means only the  smoothing ofthe limb and grasping the fractur-
 ed parts in the  hands, and pressing it so down  upon its pillow
 or splint as to give it a sort of seat; while the  diligation is  a
 thing to be quite forgotten.   There is much virtue in a word ;
 many a lameness, and not a few gangrenes, may be imputed  to
 this term diligation.*
   Yet these directions, though plain, simple, and  manifestly con-
sistent with common sense and the best principles of pathology,
will give you little confidence unless you  be satisfied that they
can be safely applied to each  individual case, and that no other
rules can be applied with good effect.
                         section  i.

           Rules for the setting of Simple Fractures.

   It is manifest that a fractured limb needs only to be laid even
and moderately  steady, to be perfectly re-united without our
help; but  if a person  were  drunk, delirious, or maniacal, it
would need to be bandaged :  for the same reason, if a fractured
bone be in danger of being moved by the unavoidable motions
of the body, or by the natural functions, as respiration, it surely
must be bandaged.
   1st, In fracture ofthe humerus or arm  bone, the patient
is not to be  confined, he is not to lose his health on account of
this trivial accident;  and since he is to walk about, the motions
of the body and swinging of the arm would necessarily discom-
pose the  bones,  and absolutely  prevent their re-union.  The
fracture ofthe arm-bone then is  to be set with two small flat
splints of pasteboard, lined with flannel and rolled with a roller

  * I here am careful to defcribe the common operation, and thst only : there are
certain cafes afterwards to be mentioned, efpecially of compound fracture, with
protrufion of the bone, where a more powerful extenfion is neceffary, but ftill nei-
ther pulleys nor ligatures are ufed, only, the furgeon fometimes twifts a hand tow-
el round the ankle to give him a Headier hold. 
124         Fractures of the Arm and Fore Arm.
gently,  but not carelessly applied, because the common  splints
merely tied with tapes would slip off, and because the arm hangs
naturally away from the body, so that it is easily rolled.
  n. B.  When  the fracture is near the lower  end of the hu-
merus, near the condyles, or in what is improperly  called the
neck, viz. near the head ofthe bone, it is apt to be more oblique,
and then firmer splints, a steadier bandage, and more careful pos-
ture of the arm are necessary ;  and when it  happens that  the
shaft of  the humerus  is  separated from its  head,  the axilla
should be filled  with a compress  to keep the bone out and in its
right direction.
  2d, When the fore  arm is fractured, although one bone on-
ly be broken, it is easily  distinguished, because the slightest
turning ofthe hand produces rotation ofthe radius, and con-
sequent crepitation, the radius being fractured ;  whereas, when
the ulna alone is  fractured,  the change of shape  is almost as
great as if both  bones were broken.   When one bone  is bro-
ken, the arm manifestly cannot  be  shortened,  and even when
both bones are  broken,  the general  surface formed by the two
bones and their interosseous membrane is so broad, that they are
fairly opposed  to each other, and soon re-unite.  The fracture
of the fore arm requires two flat splints which are to be laid one
on the inside, the  other on the outside of the  arm, and in place
of rolling the fore arm with a roller, I usually tie the splints with
three or four  broad  tapes or  ribands, each  about a  foot in
length,  not connected with the  splints, but laid upon the table
under the lower splint when the arm is  about to be laid upon it.
   n. B.   In the  fore arm I have remarked two things, first, That
the hand must not be turned in any degree, i. e. it must neither
be  in what anatomists call a state  of pronation, nor a state of
supination, but the thumb even with the line of the Radius, and
the little finger with that of the Ulna ;  and to preserve it in that
position,  the splint that lies on  the inside of the arm must be
long enough to reach to the palm of the hand, so as to keep the
wrist steady, and prevent  rolling of the radius ; and this splint,
where it is lodged in  the palm of the hand, must be a little pad-
ded and a little bent, so as to let the fingers bend easily over it.
   Observe also, that  the representation I have given of the ad-
hesion and  massing of parts about  a fractured bone, is so  far
true, that the callus is formed, not by the particular ends of each
individual bone, but by the whole mass of bone, inflamed peri-
osteum, and cellular substance ; whence it often happens, espe-
cially in  compound fractures, where the mass of parts engaged
in the process is great, or in gun-shot fractures, where the arm,
from the tediousness of the sore lies very long extended upon
 its  splint, that the ends of the bones  are united in one  mass of 
Fracture of the Arm and Fore Arm.         125
callus, by which the motion of the radius is hindered, and  of
course the turning motion of the hand is lost.   This produces
a more awkward and distressing kind of lameness  than you
would easily imagine, the patient cannot carry any  thing  to his
mouth without turning the arm at the shoulder,  the effect is the
same precisely with that ot an anchylosis  of the elbow  joint.
I saw several examples of this at Yarmouth in the Dutch hos-
pital, where men shot through the fore arm had been permitted to
remain in their cradles all the time ofthe cure, their arms lying all
the while flat and unmoved, till at last they became immovable.
   3d,  In fracture  of the clavicle, or collar-bonl*,  the
weight of the arm pulls down the scapula, lor in fact the  clavi-
cle is the only connexion the  scapula has with the trunk; the
scapula itselt only glides upon the ribs, without being connected
with  them, large muscles lie  betwixt the lower flat surface of
the scapula  and the thorax.  The accident is easily distinguish-
ed, as the bone can  be felt in its whole length; perhaps  there
never was a patient sober enough to know any thing of his own
situation, who was not conscious of the  nature of the accident
that had befallen  him when the collar-bone was broken.
   This particular fracture is both reduced and retained, by first
pulling both shoulders strongly backwards, and then turning a
firm linen roller round the shoulders, crossing upon the back, so
as to leave the place of the breast where the fracture is, exposed
and open; for this no more requires splints nor compress than
any other fractures, it is only in consequence of the weight of
the arm that the  fractured clavicle requires firm bandaging.
   N.  B.  This particular fracture is rarely accompanied  with a
wound, nor is  there any difficulty in reducing or retaining the
clavicle in its right place; but sometimes it may be useful to fill
the axilla with a large  compress, in order to support the  shoul-
der and to keep  it off from the thorax, so as to extend  (if  we
may use such an expression) the broken clavicle to its full length.
When the arm is big and heavy, when the patient has to com-
plete  his journey  in  a carriage, &c.  it is proper to add to the fi-
gure of  8 bandage round the shoulders,  another bandage sup-
porting the fore arm and confining it close to the body.   This
second bandage is indeed necessary in every case, to prevent the
swinging ofthe arm and the unavoidable rolling ofthe collar-bone.
   In respect of the fracture  of the acromion process of the sca-
pula, it may be sufficient just to remark, that it also is known by
a falling forwards of the shoulder, and the place of  the fracture
is easily distinguished as the bone is superficial.?  This fracture
requires chiefly that the shoulder should be pushed upwards, by
   * See what is faid on this fubject, in chapter on Bandages, page 41.  S.
   f The finger muft be paffed along the fpine  of the fcapula, in order  to  afcertain
 when this accident has happened.  S. 
126             Fracture of the breast Bone.
 which the head of the shoulder-bone, pressed upwards against
 the fractured process of the scapula, raises it to its right place.
 In this fracture, the shoulder must be firmly bound, and the
 fore-arm particularly well supported.*
   4th, In fracture of the  sternum, the broken  bone is  moved,
 not by the motion of the trunk or body, but by respiration: at
 every motion of the thorax, the patient is  sensible of the grat-
 ing or crepitation of the  bones;  the surgeon feels it with his
 hand, and hears it by approaching his ear to  the breast.   The
motion of the broken sternum soon inflames the mediastinum
 under it, and by  degrees the inflammation  extends along the
pleura and whole  of the thorax.    There  comes on a frequent
cough, and  during  every paroxysm of coughing, the crushing
 of the fractured sternum is dreadful.
   This fracture admits neither  compress  nor splints, and yet
 it  must be kept perfectly steady; to do this, nothing is required
but a simple swathe or bandage round the chest, but it must be
so firm as to prevent the respiration  being  in any degree per-
formed by the motion of the thorax; the motions ofthe thorax
must be entirely suppressed by  the bandage, and respiration
 performed by the diaphragm alone.
   N.  B.   In this fracture, the motions  of the thorax being in-
cessant, the re-union of the fracture, without bandage, is impos-
sible :  if you fail to  apply the  bandage, the motion of the bones
will raise the inflammation to  that height, that the patient  will
be suffocated by the general affection  of the lungs, or  by the
effusion of matter round the broken bone; and the least mis-
fortune that can  happen,  is  tedious suppurations under  and
around the broken parts of the sternum,  and caries of the bone
 itself, so that it becomes necessary sometimes to apply the  tre-
pan.   The bandage  which we have directed, though drawn ve-
 ry firm, is far from oppressive, the patient feels it to be rather a
relief; before the  bandage is  applied,* the  grating of the bones,
the inflammation,  high breathing,  and terrible cough,  are  in-
creasing every moment; but no sooner  is the  bandage drawn
firm, than the crepitation ceases, the pain is relieved, the cough
and high breathing,  begin to abate ; and  by  plentiful bleedings
 and opiates, all comes right again, and the patient is saved.
   5th.  Fractures ofthe ribs  are like those ofthe limbs, simple
 or compound, with or without injury of  the surrounding flesh  ;
and when there  is injury of the adjacent parts, it is by the ribs

  * There is an accident  to which the fhoulder-joint is liable, which  Mr. Bell
 has not noticed ; that is, a fracture of the cervix fcapuk*.  This fracture may be
 always afcertained by preffing with the finger upon the coracoid procefs, and ro-
 tating the arm, when the crepitus may be felt. The treatment is fimple ; the arm
 muft be fupported and bound to the body, fo as to prevent its motion.  S. 
Fracture of the Ribs.
127
being driven inwards, so as to wound the  lungs  without any
outward wound, such as make the inflammation dangerous.
  If the fracture be simple, of one  or more ribs, it is distin-
guished, and hardly distinguished,  by a slight crepitation, the
broken  ribs being wrought backwards and forwards under the
fingers, by the patient being sensible of the  grating of the bro-
ken bones, and by the sharpness of  the  pain.  There  is little
crepitation,  because  the ribs are so connected with each other
by' the intercostal ligaments and muscles, that they  cannot be
displaced ; each rib  serves as a splint to preserve  the direction
of the adjoining ribs.  There is no occasion  for setting the bro-
ken rib  for any compress, nor for any particular bandage ; but
to prevent  motion, the  heavings of the thorax are  to be sup-
pressed by applying a table-napkin firmly round the breast, as
in figure 14, which, the  firmer it is applied, gives the more per-
fect  relief.  This  is all that is usually done ; labourers  and
country men, with whom the accident is frequent, do no more,
and seldom require advice.
  When the rib has punctured the lungs, the air is effused, an
emphysematous tumour is formed, crackling like a bladder half
full of air.   There is no possibility of mistaking the nature of
the accident:  it may in general be disregarded, for inflamma-
tion round the broken bone soon closes the  opening in the tho-
rax,  inflammation in the wounded part  of  the lungs  prevents
the farther effusion of air, the air already effused is  absorbed,
and the tumour disappears.  But if the effusion of air continue,
the whole body will be inflated, the air passing along in the cel-
lular  substance will inflate  the scalp and eyes, and extend
downwards to the thighs and private  parts,  till, by its accumu-
lation about the throat,  it almost suffocates the patient.  Small
scarifications with the  point of a bleeding-lancet,  are required
to discharge the air, through which  it must be pressed ; they
may be made occasionally in various parts  ;  they heal imme-
diately.  After the cellular substance is emptied of the air, the
point where the broken rib is, should be pressed with a firm
compress, to assist the adhesion of the lacerated parts surround-
ing the  fracture.
  6th. In fractures of the spine, there is nothing that belongs
to the surgeon's department;  the spinal marrow is affected by
the compression of  the fractured bones,  or  injured by the  con-
cussion, just as the brain is affected by a blow on the head ; but
it is a kind of injury much less accessible to the surgeon's hand.
The spinal  marrow  is plainly compressed, the patient loses in-
stantly the power of his lower extremities, which  are cold, and
without feeling, the  bladder and rectum are paralytic ;  the sur-
geon needs to order glysters daily, and to introduce the cathe- 
128
Fracture of the Leg.
ter.  The parts on  which the patient  lies ulcerate first, and
then, in spite of all possible care, fall into gangrene.   Such are
the symptoms, and such frequently the manner ot our patient's
death ;  and notwithstanding the bloody operations described in
books, of making  incisions, finding the fractured or luxated
bone, and drawing it out by the spines or splinters, there is no-
thing practicable ; and those very ignorant directions, given up-
on  the  highest authorities, are  dangerous  to  none  but boys.
The cutting into the fractured vertebra is a dream.
  7th. In fractures of the lower extre?nities,  there is no occa-
sion for bandages ;* for the patient lying in bed, the part is in no
danger of  being moved.   Unless you could invent a machine,
which could enable a patient to walk or stand upon his leg, you
need none.  In all fractures of the leg,  then,  simple as well as
compound, you merely lay the limb out upon its pillow or splint;
nothing but convulsions,  delirium, or mania, can endanger the
fracture, or require bandaging. In laying a fractured leg, where
but one bone is broken,  you need be at no pains about the pos-
ture ;  if the  leg  lie  easy, and the  patient  complain  of no
pain, all must be right ;  but when both bones are broken, you
must be  at pains to trace the sharp line of the tibia  with your
finger; for that regulates the posture of the leg.  This you can-
not do at first,  because the general sweUing hides the  bone, but
you have no fear of altering the posture of the limb, and you
know that the subsiding of the swelling marks the proper period
for ascertaining the posture of the  limb.
  N B.   In fracture of  the leg, and especially in  compound
fracture, you must be careful to preserve the right posture ; for
the limb is exceedingly apt to change its form from day to day,
according to the place that the patient  takes in  his bed, and the
posture of the limb with regard to that of the body. Two points
you wiil especially attend to ; first, The heel slipping over the
end or side of the pillow, or, making by its prominence more
impression upon the bed or pillow, falls downwards ;  and when
the bones  are re-united, it is found that there is a slight devi-
ation of  the tibia from the straight  line ; the bone appears a lit-
tle prominent on the inside of the leg, while the foot is  a little
turned outwards, in a lame, or at least a.weakly posture ; yet
this degree of obliquity, though it causes a slight awkwardness,
never causes a great  deformity.   Secondly, The strong mus-
cles  lying all on the back part of the leg, the fractured part  is
more apt to be bent in the opposite direction, so that the bones

  •  Notwithftanding what is here faid, I would recommend a many-tailed band-
age over the limb, which may be kept wet the firft few days with  afolution of
acetate of lead.  Tapes ought to be paffed under the pillows, and tied with mode-
rate firmnefs over the leg, to prevent involuntary ftarts and other accidents.  S. 
Fracture ofthe Thigh-Bone.              129
unite with  an angle at  the  shin.  This causes a grievous de-
formity, and worse  than that,  produces  a  shortening of die
limb, and a halt in the gait,  almost as remarkable as that which
arises from fracture ofthe neck ofthe thigh-bone, and the point
or angle where the tibia  projects, is apt to become a sore, for it
is very  easily fretted and ulcerated.   This is especially to be
guarded against, and is  particularly apt to happen in compound
fracture, where the limb, being laid in  a great case, is plastered
and poulticed, so that the surgeon hardly allows himself to see
how the bones lie,  and has given such a formidable appearance
to the disordered limb, that he is afraid to look at his own work,
or to  move  the leg.  Two directions then may be useful :  first,
Always to pad up the heel and foot properly, so as  not to allow
the heel to  sink, or the  foot to  fall to one side.  Secondly, To
be  careful always to prevent the leg taking an arched form, with
an angle at  the middle ofthe tibia ;  it is impossible to keep the
foot too far forwards, or, in  other words, an angle in which the
middle ofthe tibia was depressed, was never known to happen.*
   8th.   But in fracture of the thigh, there is no possibility of
having any  relief, but by that slight change  of posture which
can be accomplished by  moving the body, while the thigh itself
is kept as steady as possible  upon its pillow.
  First, When the  neck ofthe  thigh-bone is broken near its tro-
chanter, you would not  leave the cure entirely  to Nature ; you
would not willingly believe  that you can do absolutely nothing
for your patient  or friend.   When you extend the limb, and
find that you have so far replaced  the broken bone,  that you
begin to feel the crepitation, you cannot  but wish to retain  it
in that place, and you lay large and firm compresses upon the
trochanter,  the  rising of which marks the shortening of  the
limb,  and the fixing of  which would prevent  that shortening.
These compresses should be pressed very firm  by a spica band-
age rolled round the hip, as it is in page  41 round the shoul-
der.  A long splint must next be prepared, of sufficient length
to reach some way up the side, made  of firm deal board,  de-
clining gradually in  size, in proportion as the member natu-
rally diminishes in size,  covered well with  flannel, that the pa-
tient may feel no hardness.  There must be put round the pel-
vis a very firm bandage  like the topband of a pair of buckskin

  *  Whether fplints ought to be applied in the firft inftance, or not, to a fractur-
ed leg, there can be no doubt  of the neceffity of ufing them when the inflamma-
tion has fubfided. Martin's whalebone-fplints are the beft, though the common
wooden ones will anfwer.  They fhould be applied with fufficient firmnefs, to pre-
vent all danger of the fractured bones being deranged  by any ordinary accident;
the roller will require re-applying about twice a week,  during the progrefsof the
cure ; at each time of doing this, the furgeon fhould afcertain chat the bones are h*
their proper pofition. S. 
130             Fracture ofthe Thigh-Bone.
breeches ; and into a slit in this bandage must be fitted the top of
the splint.   The resistance which is to elongate the limb, is to be
accomplished by the pressure of the  top of the splint against this
circular, and therefore the circular must be prevented from being
pushed upwards by a strap going round under the pelvis, like
that of T bandage ; or why should we not actually take the top-
band of a pair of buckskin breeches, keeping also a  part of the
thigh ofthe breeches to make  the pressure more general, with
a pocket something like the fob or side-pocket inverted, to slip
the top of the splint into,  as an ensign lodges the colour-staff in
his side-pocket ?   I need not  relate to you how, after the chief
resistance is established,  the limb may be extended and secured
by lacs round the knee  and  ankle ;  as to the permanent  exten-
sion, if you will attempt it, it must  be easier with the assistance
of this splint: after fixing your lacs or bandages round the an-
kle, you may  bring one of them round the lower end or point
of the splint, and extend  it occasionally, without any ill-looking
apparatus, any apparent cruelty, or real  violence.*
   Secondly, When the fracture,  in place of being in the neck, is
below the trochanters in the shaft of the bone, where fewer mus-
cles are implanted, the  retraction is  less  powerful, but still there
is retraction, and the shortening of the limb must be resisted by
the long splint of Duverney alone  ; it  is not a torturing ma-
chine ;  does not  grasp the limb at particular points, but  lodges
the whole limb, and gives friction and resistance at every point.
   Thirdly, When the thigh-bone is fractured in the middle, there
is no  reason,  even in  the  most muscular man, to  fear retrac-
tion,  and the thigh may, with all possible propriety and safety,
be laid smoothly out upon a pillow,  being careful of the posture
of the body, that it be not higher than the thigh, so as to gravi-
tate downwards upon it;  the thigh  should be laid  on one side ;
should be laid a little out from the body, and a little higher, (in-
deed  the body naturally  sinks into the bed) and the surgeon
should also be careful of the posture of the heel and foot; for
the leg is apt, by its weight and wrong  inclination, to turn  the
thigh upon  its axis.
   Fourthly,  In fracture of the  very lowest part ofthe thigh-
bone,  in the part adjoining to  the condyle*, or lower head ofthe
bone,  the fracture  is apt to be  vers oblique ; and  sometimes it
happens that the bone is  fractured  so very  obliquely, that the
effect is  the same as if one of the condyles only were broken a-
way.   In this oblique  fracture there is indeed no forcible re-

 • * Boyer'sfous-cuijfe might certainly be added with advantage to this apparatus,
whether the furgeon attempted permanent extenfion or not ; nor muft he by any
means omit keeping the thigh wet, as long as there is any danger of inflammation,
with a folution of acetate of lead.  S. 
Fracture of the Thigh-Bone.             131
traction of the bone, but a continual tendency to obliquity.  Ve-
ry often I have seen such a fracture so ill cured, that there has
been a shortening and weakness in consequence of the in-kneed
posture of the limb, which was both very distressing, and a ve-
ry great deformity.   Then, although there is  no occasion in
this  fracture for any powerful  machine,  there is a necessity for
the perpetual resistance of a very strong splint.   The leg turns
outwards  ; the splint of firm fir board, c*c. is therefore to be ap-
plied (with proper compresses to prevent pain) upon the inside
of the knee-joint, and bound very firm with circulars above and
below the knee.  You cannot bend the  leg too much inwards ;
it always inclines to turn out.
  n. b. In fracture of the thigh-bone, we foresee a very uneasy
confinement of six weeks to the  most irksome postures, and the
ease and  comfort of our  patient are  principally to  be studied.
He should be  laid on a hair mattress, which  is cool and  firm,
rather than on a bed, in which  he is  apt to sink down ; and it
will be of  infinite advantage to him to have a fine flat and thin
hair mattress cut into four or six pieces, and the cut parts sew-
ed again and  covered with pieces  of sheet ;  then  first lay ing
boards in place of the canvass  across the frame of the bed, then
laying an  entire mattress for the bottom of the bed, and then
laying the several pieces of the  cut mattress according  to your
pleasure,  you can raise or depress any part of the body to any
degree, and alter your patient's  posture with the least possible
motion.   If any other pillows be required, they should be the
firm and flat hair-cushions, like those of a couch, and indeed the
best bed is a couch, which friends and attendants can go round
about in all directions, which  can be wheeled to the  window, or
towards the fire, without discomposing the fracture, and which
should be placed in some public room, where the  patient will
have  as little as possible of the feelings of  a sick bed.
  You must have a hand-rope for the patient to raise and move
himself by, without any strain  ofthe limbs  or body,  urinals and
bed-pans for his  conveniency, and he must have occasionally
anodynes to abate the irritation of his confinement and distress-
ing posture, and laxatives of castor  oil, cream of tartar, lenitive
electuary,  sulphur, or whatever  suits his constitution,  to pre-
vent the constipation which proceeds from  opiates and confine-
ment.
  9th. In  compound luxation of the  tibia  and fibula, in  that
where the bones are broken, the joint burst up, the heads ofthe
bones turned out through the  wound ; the  astragalus and heads
of the tibia, or of the fibula, almost separated, there is such de-
struction  and laceration of parts, that we are doubtful whether
to attempt preserving the  foot ;  we can do little more than lay 
132               Fracture of the Patella.
 the limb on the sound side, and keep the foot as nearly as pos-
 sible in its natural and proper  direction.   I have sometimes
 seen the ankle-joint wonderfully distorted, from being fractured
 and dislocated, even without  that laceration of the skin which
 constitutes  the case of a compound fracture ; and by drawing
 upon the foot vers gradually,  but powerfully, and working and
 modelling the disordered joint in the hand, I have restored  it
 to its right  shape,  have set it with a firm splint well  covered
 with flannel, &c. and bound pretty firm with a figure of 8 roller
 round the foot and ankle.
   n. b.  In this fracture still the tendency of the foot is to turn
 outwards, and you have to  lay your splint  along the inner side
 of  the ankle-joint,  making a small window or opening in your
 splint to receive the projection of the inner ankle.   By the re-
 sistance of  this  splint you draw the foot,  which  is inclined to
 turn  outwards in  a splay-foot posture, inwards into a natural
 one.   It is the process of the fibula that guards the ankle on the
 outside, and keeps the foot right;  and it is the fracture of the
 fibula, and  the yielding of the outer ankle, that makes  the foot
 fail oft towards that side.
   I mention this luxation here, because it is the  only luxation
 where the head of the bone  being replaced does not remain ; it
 is the only luxation that needs to be bandaged as a fracture.
   10th.  In fracture of the patella,  the chief difficulty is to pre-
 serve  the bones  in perfect contact with each other,  insomuch
 that Dr. Hunter, unable to  account for the difficulty of  accom-
 plishing a perfect cure,  imagined that the  failing of the usual
 process in this particular instance, could be owing to nothing
 else than some part of the  membranes  surrounding the  joint
 falling in betwixt the two bones, so as to prevent them coming
 into proper contact.
  In this particular fracture the leg must be kept extended to
 the utmost ; the upper piece of the fractured patella, which is
 retracted to a great distance above the knee, must be smoothed
 and thumbed  downwards, and put in as close contact as possi-
 ble  with the lower fragments.   To put it in  close contact is the
 difficulty : it seems to be in close contact  at the time of your
operation, and you  are only convinced that the pieces have not
 been in contact  when the cure should be complete;  for when
 the swelling has subsided, when the patient begins to walk, a
hollow is seen betwixt the  two  ends of the bone, and a ligament
 of some length is felt uniting them.   The patient losing the
pulley-like projection of the patella or rotula (and  the extensor
muscle being shortened) is never able to stand on one leg, ne-
 ver able to bear up the body on that limb, never able to mount
 a stair without carrying  that  leg before, and is never  out of 
Fracture of the Patella.
133
 danger of forgetting  himself, trusting the weight of the body
 upon that limb, falling backwards,  and so  breaking the  other
 patella, or snapping the same one a second time, as I have seen
 happen vers  often.
   To preserve the  bones in absolute contact, and prevent this
 imperfection in the  cure, is  almost impossible.   The swelling,
 before you are called, is so great, that in many cases bandage
 cannot be applied for six or eight days.   When the swelling is
 gone, the pieces of the bone cannot be made to approach each
 other, nor can the bandage,  from the remains of the  general
 puffy swelling, be applied close to  the bones.   The bandaging
 has been  attempted  in various ways.   The common bandage is
 a belt of leather split like the common leather retractors, with a
 small opening in the middle of  the slit, for receiving the  pa-
 tella ; each of the sides or semicircles of this opening is padded
 up with leather, so as to make a pretty firm compress of a cir-
 cular form ;  and when the bandage is buckled  round the knee,
 and drawn firm, the two  sides  of  the slit are  of course drawn
 so close together,  as to  press the  two pieces of the patella be-
 twixt them.j"
  n.  b. Before applying these rollers, they should  be all soaked
 and wetted (best in spirits) to make  them stick  closer  to  the
 flesh, and if (having applied them) you are  perfectly satisfied
 with  their operation, you may easily convert them into a firm
 case, by taking a glue-pot and soaking them  with  glue, so that
 each turn of your roller would stick to another, and the whole to
 the flesh, the knee  being thus enclosed in a very  perfect case.
 Both during the cure and for some time after the patient begins
 to walk about, 1  find it convenient and safe to stiffen the joint,
 by laying a strong splint behind the ham, lest the patient should
 make a false step, and the knee yield before the ligament joining
 the bones svere become strong.
  n.  b. Though I prefer simple and moist rollers, which stick
 thus close to the  parts, yet  there  is  no doubt that the clumsy
 compress-like roller contorted round the knee  in  the  form  of
 figure of 8,  has  sometimes succeeded remarkably well.  In
 proof of this, remember what Meibomius reports of a cow-herd,
 who  having broken his knee  pan, made a very perfect cure by
 twisting round it a firm straw-rope.
  11th, In fracture of the Olecranon (which is another excep-
tion to the general rule of keeping a fractured  limb gently and
                            *
  t A fimilar roller paffed firmly from one extremity of the thigh to the other, fo
 as to prevent the contraction of the extenfor mufcles of the leg, will be  of great
 fervice. I have, within this day  or two, feen a perfou whofe right patella has been
 broken, and is re-unittd by a hgament, who fays that leg is as frong as the other.
 The fpace between the fractured portions is about half an inch.  S. 
134              Fracture of the Olecranon.
 pleasantly bent), you must keep the arm completely extended,*
 for the triceps muscle pulls up the olecranon to an incredible de-
 gree,  it mounts absolutely half way up the arm, and although
 you thumb it down again, yet if you keep the fore arm in any
 degree bent, the interstice betwixt the end of the ulna and its
 broken process will be filled up with bone, and  the  fore arm be
 so far anchylosed,  that the patient will never be able to  extend
 it, for this filling up of the interstice will be just equivalent to
 the lengthening of the ulna.
   In setting this fracture, you force down the retracted olecra-
 non, which is broken away from the end of the ulna, and you
 completely extend the fore arm so as to make the end of the ul-
 na meet its broken process, you cover the broken process with a
 compress, and fix it with a double-headed roller, turned in form
 of figure of 8 (as in bleeding), making occasionally turns purely
 circular round the broken part, and you make all sure by laying
 a stiff splint in the  bend of the arm, and fixing it with a  second
 roller in order to prevent the arm being thoughtlessly bended;
 indeed, nothing in  such cases should be trusted to the discretion
 of the patient.
   n. b.   In this fracture there is abundance of callus :  there is
 no danger of  that imperfect and ligamentous union which  takes
 place in the broken patella, nor is there any danger of that  pro-
 fusion of callus, running like molten lead, into the cavity of the
 elbow joint, which was supposed to happen, and to occasion an-
 chylosis.   When this fracture has been neglected or ill set, the
 fore arm kept at right angles with the arm, and the person lamed
 perhaps in his right arm, it has been proposed to make incision
 to  cut oat the intermediate callus, with the design of setting the
 bones properly with the arm  extended;  an  operation which is
 surely not impracticable.
   12th,  The  rupture ofthe Tendo-Achillis, or great back tendon
 of the  leg, more justly  ranks with fractures than  with  lacera-
 tions ;  for while it  was considered as a laceration of a soft part,
 it was actually the practice of surgeons to sew the ends  of the
 tendon together with great embowelling needles ; but now be-
ing ranked with fractures of the bones, it is set like a  broken
bone, like the fracture of the patella, for example, and the sur-
geon has no  care but merely  to smooth  down  the muscle, to
prevent the retraction of the tendon, to preserve the ruptured
parts as nearly as possible in contact with each other.

  * It is neceffary in this accident to ufe great care to prevent  the  joint from be-
 coming ftiff from want of ufe.   In the firft place the fore-arm ought not to be ex-
tended farther than is neceffary to allow the fractured ends to be placed in contact.
 adly, Moderate flexion and extenfion ought to be ufed as early as the third  week,
 and repeated every day or two to as great an extent as can be fafely done, S. 
Rupture ofthe Tendo-Achillis.            135
  The  tendo-achillis is broken as the patella is,  not  by a blow
or fall, but by a sudden and violent exertion  of its own mus-
cles, in consequence of making a false step, the patient being in-
stinctively incited to make an exertion too sudden and violent for
the tendon to withstand it; an exertion which sometimes,  in
place of tearing the tendon, breaks the heel bone.   When the
tendon  is broken,  the  patient, from its insensibility, feels no
pain, he feels as if he had been struck a smart blow with a stick;
it commonlv  happens, in dancing, or in making a  false  step,  as
in slipping, though not unfrequently it happens when  walking
apparently  securely on even ground ; the patient instantly alls
down lame,  the shortening of the bellies of the gastronemii
muscles, the  retraction of the tendon, and the interstice between
the two ends of it  are  perceptible, and the patient  himself is
conscious he  has broken the tendon.
   For setting this  ruptured tendon, various machines have been
invented, and especially various shoes with straps and buckles
behind to draw up the  heel, while the upper part of the tendon,
on the  other  hand, is pressed downwards.  According  to my
experience, this extension of the toe and drawing  up of  the heel
are unnecessary* ;  the  foot may be safely left in its natural pos-
ture ; it is  chiefly important to prevent the slightest contraction
ofthe gastrocnemii muscles; for this purpose, the calf of the
leg should be  smoothed downwards with the hands, the whole
of the calf of the leg from  the ham downwards must be rolled
with a firm roller, proceeding from above, but the bandage should
not pass the biggest part of the calf, nor at all approach  the rup-
tured part, nor even the inflammation and swelling which sur-
rounds it.
  n. b.  The  chief  danger  in  rolling the leg in rupture of the
Tendo-Achillis, consists in approaching the part actually frac-
tured.   I was once called to a  gentleman whose whole leg from
ham to  heel  was firmly bandaged with a  roller, the turns  of
which made deep impressions on the swelled ankle; and at the
point where the tendon was actually ruptured,  the turns of the
roller (so firmly was it  drawn) had sunk down very deep indeed
betwixt the ends of the tendon, they were thus separated to a
great distance from each other, there was no possibility of their
uniting, and had they been left so, the old gentleman must have
continued perfectly lame.   It was on  the fourth  day after the
accident that  I was called and undid this bandage, yet the cure
was in the  end tolerably perfect.  The muscle should be well
rubbed and smoothed down, and neatly rolled, the  ankle and cel-
lular substance surrounding the ruptured part should be left per-

  *  The extenfion of the foot may be of fervice, and can do no injury.  S. 
136                General Observations.
fectly  free, the foot should be steadied, but kept quite  on the
level,  the toe neither pointed downwards nor upwards,  but the
foot kept at right  angles with the leg.   Mr. Robbard, surgeon
(I believe) at Ipswich, was so bold and so honest,  as to make
the experiment first on his own person, of just tying down the
gastrocnemii firmly, but still continuing to walk about all the
while the tendon was re-uniting. This I dare no more approve
of than the firm bandaging of the ruptured parts.
   The tendon is generally a little knotty, especially when first
united ; sometimes it adheres so to the surrounding parts, as to
make the joint stiff; and always the tendon is a  little lengthen-
ed, and the muscles of the calf somewhat contracted, so that the
calf of the leg seems to have shrunk upwards towards the ham.

                        SECTION  II.

                        Conclusion.

   In this section, consisting altogether of rules, which should be
perfectly minute, I fear there must be many omissions which I
shall hardly be able to  compensate for in the following general
observations.
   First, It is uncomfortable for the  young surgeon not to know
at what period he may  venture to undo the apparatus in any par-
ticular fracture ; for this reason, though there can be no  specific
nor absolute rule, yet surgeons have been at pains to mark the
period in which they  suppose each individual  fracture to  be
healed.  Without  warranting the propriety of these rules, allow
me to mention, that authors say, the smaller bones, as the Cla-
vicle, the  Ribs, the Fibula, are curable  in twenty days ; the
bones  of the Cubitus  or Fore Arm, the Radius or Ulna,
are curable  in  thirty days ; the fractures of the humerus  or
Thigh Bone require fifty days to re-unite;  though, to be perfec-
ly re-united and strong, the fractured Thigh Bone requires seven-
ty days.   But  rules so specific as  thtse,  mentioning the  very
day on which a fracture may be supposed to be  cured,  cannot
be useful  without being understood.   Allow me  then  to ob-
serve, that as it appears to me the process is either slower and
more imperfect in  children, or  at least, in children  the  bone is
more apt  to be broken again, we cannot indeed  wonder at cal-
lus being slowly formed, since the bones themselves are  still in-
complete and growing for two-and-twenty years:  in  fractures
then happening in children, you keep the  roller and pasteboard
splint longer applied.   Nor is it from the slow formation of cal-
lus that the cure is delayed in fractures of  the great bones ; the
process is  not slow in  proportion to the greater mass of bone 
General Observations.
13T
that is to be formed, perhaps a callus will form as rapidly round
the bone of an ox as round that of a boy, and be as speedily
completed in fracture of the thighbone, as in fracture of the ra-
dius, for every part has vessels proportioned to the mass of cal-
lus that is  to be formed; but the cure is slow in proportion to
the size of the bone, from the larger bone having to bupport a
greater weight; or rather the mass of callus is slow in acquiring
firmness proportioned to its size, or to the weight it has to bear.
It is for this reason that we are cautious of trusting the weight
of the body too early on a broken limb ; in fracture of the hu-
merus,  as  the arm hangs and  does not necessarily carry any
weight, the patient may leave off his splints in six weeks ; but
in fracture  ofthe thigh bone, which has to bear the whole weight
of the body, we dare not expose the unconfirmed callus under
such pressure, till fully three months have elapsed.
   Allow me also to observe, that on  particular occasions,  parti-
cular precautions must be taken ;  that while a  man  is in his
sound health and reason, no  bandage nor splint is required in
fractures of the lower extremity; but that  when a man is mani-
acal or delirious, besides the ordinary precautions of splints, the
limb, after being set, must be laid betwixt two pillows, tied to
them, and the pillows in their turn  fastened to the bed ; that
when a man has to be carried far with a fractured limb, besides
being regularly bandaged with splints, there should be laid along
the sides of the limb, above the splints, long and firm  pieces of
wood bandaged like the splints,  and extending beyond the heel
to prevent  accidents.   And finally,  that in the sea service, and
in the army, when either an army is to retreat, or an hospital to
be moved, or when a storm  is expected at sea, the surgeon
should be as carefully advertised of the approaching storm, or of
the approaching movement of the army, as any higher officer,
for he has many precautions to take for the safety and comfort
of his men.
   The surgeon  when he wishes to make any part or bandage
particularly secure, has it in his power to convert his rollers into
a firm case, either by soaking the bandages in whites of eggs,
which soon hardens in a very firm varnish ; or with the whites
of eggs may be mixed a little flour and sugar to make it into a
paste, or he may apply any common varnish over his bandages,
as white spirit varnish,  but that is slow of fixing, and is very
thin,  or he may strew a little powdered rosin on his bandages
before they are applied, and then by soaking the bandages with
spirits of wine, the rosin is dissolved, and the whole adheres to
the limb with very singular firmness ; or finally, the bandages
may be soaked with fine and well made glue,  which makes a
very firm case, and is very far from  being offensive. 
138            Rules for Compound Fracture.
  These methods  are all of them more cleanly, less cumber-
some,  and indeed  L think more  effectual than the old Arabian
method of bedding a fractured limb in stucco or Paris plaster.
  Lastly, I would observe, that though in a fracture of the leg
or thigh bone, or of the patella, splints are quite unnecessary
during the cure*, yet when the patient rises from bed, rests the
weight of the body on the fractured bone,  and begins to be ex-
posed to accidents, light, but firm splints, should be laid along-
side of the limb ; while he wears those splints he is in a man-
ner under your control,  will walk with restraint,  and be careful
of using dangerous freedoms  with the limb, and thus he may
be saved from a second confinement more terrible than the first,
as it is incurred by precipitation and rashness.

                       SECTION III.

               Rules for Compound Fracture.

  The moment you arrive at the place where your patient lies,
if called to the spdt at which the accident happened, you must
proceed to extend the foot, while your assistants hold the limb,
and by pulling firmly, steadily, and, remember,  very strongly,
(for in this case a  good deal of extension is required) you get
the bone to go back within the integuments, and though perhaps
you do not get the bone and the edges of the wound arranged
exactly to your  mind, you  get the foot restored to a right
direction with regard to the leg, the bone tolerably covered  by
the integuments, the patient relieved in some degree from the
pain of this protrusion, and the whole  member put in  such a
posture that vou can lay it on a  splint  as  a safeguard.   There
are two forms in which the compound fracture usually presents
itself; first, when the patient having leaped or fallen  from a
height, the bone is merely broken, and  protruded perhaps  to
the length of some inches,  then the foot being extended and the
bone  reduced, you, after  laying scraped  lint upon the  wound,
(which presently cakes with the blood) lay it upon a stiff splint,
made of fir board, properly covered and padded with cloths, to
which the limb being fixed by broad circulars of any  common
ribbon gently tied, and with proper folded compresses,  put for
softness under each of those circulars, the whole becomes pretty
firm, and can be carried with  safety.
   Perhaps you have at first only turned down the  stocking,  or
cut the breeches ; but the patient being now brought to  his own
home, you proceed to perform your operations more regularly.
* See note, page cap.  S. 
Rules for Compound Fracture.            139
 You have  had your  patient conveyed along  with all possible
 tenderness ;  but you  nosv proceed to operations which require
 a degree of harshness, and even of apparent cruelty.
   First.   You prepare  the bed, by lifting the mattress and
 clothes, and in place of the laced canvass-bottom, you lay boards
 across the bed-frame, which make the bed hard, and  keep it
 perfectly level and true during  the cure.   You next, in place of
 the feather-bed, lay only a mattress above the boards;  for a
 feather-bed permitting the patient to sink down, the body gra-
 vitates towards the fractured leg, so as often to make the bones
 overshoot each other,  with a dangerous shortening of the  limb.
 You next cut another mattress  into four  pieces, and round each
 piece you sew a piece of sheet; these are laid over the first mat-
 tress, and shifted under the patient from time to time.  You then
 lay a pillow for receiving the limb; and having laid your patient
 on this bed or couch, you proceed to cut off the breeches, stock-
 ings,  &c.
  The first and most  important point of practice  I have to  teach
 you is, how to reduce the bone; and to instruct you, I must be
 careful to represent the several possible conditions of the parts.
 Let us first suppose then, that the tibia protrudes through a very  *
narrow opening, the  foot turned entirely  over  to one side  ; the
bone, as if strangled by the flesh, under these-circumstances,  it
 is  difficult to extend  the  limb  so as to get the bone to go back
 again through the skin ; but it is possible, and  you try it in the
 following manner: You lay the whole limb quite flat; you make
 two strong assistants,  with both their hands, grasp the leg  very
 firmly below  the knee; you then grasp the foot firmly over the
 tarsus, and behind the heel, with both your hands, and begin to
 pull gently, steadily, and very powerfully, turning the root a little
 from side to  side ; you also twist a hand-towel round the ankle,
and take the assistance of it to give you a firmer hold on the foot,
and to make  you  pull more steadily and equally.   But if the
 bone  will not go back, you must give the foot to another sur-
geon or assistant, and  clasp your own hands round the  broken
part, and with your thumbs, without much reserve or  affecta-
tion ot delicacy,  endeavour to force in the bone, which though
 it needs this  force to reduce it, yet lies easy when it is reduced.
  Should it be impossible to reduce the bone, on account of the
 narrowness of the wound,  and  its swelling and  strangulation,
 you proceed to dilate  the wound; you try to push in your fore-
 finger, or your little finger, to condu t the bistoury,  or, if ne-
 cessary, you  push in the bistoury, which makes way for itself;
 it is the straight probe-pointed bistoury  you use.   You  have
 onlyone danger to avoid, that is, the cutting of the tibial  artery ;
 and to avoid  that, you keep to the inner side ofthe leg, and op- 
140            Rules for Compound Fracture.
posite to the highest ridge ofthe tibia (not to the outside of the
tibia, for the artery lies in the middle, betwixt the tibia and fi-
bula ;) you run your bistoury forward, and carry it pretty deep,
till \ our finger, which follows behind the bistoury, passes in
easily, and till you feel the stricture quite relieved*.   But if you
find the bone splintered  with  points and  spicule, which  (if it
were reduced) would run into the flesh, instead of reducing the
bone in  this dangerous condition, you cut off the sharper points
with the cutting forceps of an  amputation-case;  and having
smoothed the bone, you may then, after dilating the wound, re-
duce it safely.
   If you find, at the same time, the bone strangled by the nar-
rowness of the wound, and pointed at its extremity, so that it
would be dangerous to return it  among the  soft  parts ; if you
are sensible that the bone is broken so obliquely, that though
reduced, it would  not keep its place, but allow the other bone
to shoot over it, and at the same time sO sharp-pointed that the
spiculse would run into the flesh, you have  then to make your
election betwixt the two operations  of dilating the  wound and
of cutting the  bone; and as you prefer cutting the bone, you
proceed not merely to smooth it  with the cutting forceps of the
amputation-case, but to amputate  it in the following manner:
Your assistant takes a flat iron spathula to defend the soft parts
with from the teeth of the saw, lays it flat  under the bone be-
twixt it and the flesh, he holds it steady by one or two fingers
on each side of the bone, and presses or draws it up edgeways
betwixt the bone and the flesh, and the spathula being thus fixed,
you proceed to saw the  bone, as close as possible to the wound,
with the  small spring-saw, commonly put  into the amputation-
case for the purpose (though never used) of sawing the  finger-
bones.
   Let us next suppose that the bone does not protrude, but that
a loaded  wagon has passed over the limb, and  that the bones
have been so crushed, that  through one  great wound a large
piece of the tibia has been squeezed out;  that  the separated
piece of the tibia projects, and is easily pulled away; that upon
introducing the finger through this lacerated wound,  you feel
the bones all  shattered,  the splinters loose  and  moveable, the
tibia destroyed to a great  extent,  of three  or four inches, ac-
cording to the broadness of the wheel, and that upon insinuat-
ing your finger, you hardly distinguish the lacerated flesh from
 the bruised bone.   In dressing a limb thus shattered, you take
 away the pieces which are entirely loose, because they are plain-

   • In making this incifion you  muft keep the knife  very clofe to the hone.
 for fear  of wounding  the pofterior tibial artery.  S. 
Rules for Compound Fracture.             141
ly destroyed, and must produce suppuration ; you are at pains
to get away the sharper splinters, though not so entirely detach-
ed, because they excite spasms by their immediate irritation, and
cause abscess after abscess till they are discharged ; you use the
finger more than forceps ;  you would spare no present pain in or-
der to put the parts in a good condition for laying easy, and reco-
vering their healthy state ; and although you would take away
whatever splinters might cause abscess, you  would  not  work
too long with  your finger, nor pick with your forceps too curi-
ously,  lest you  should cause more suppuration by your own
imprudence.   But I might give you a volume of directions, and
still be obliged to conclude at  last, that  I must leave much to
your discretion and good sense.
  Let us next suppose  that the  crushing of the bones is ac-
companied  with a bursting  or laceration of the  arteries ; the
blood always streams from the limb, and cakes about the wound
soon after;  often small arteries bleed smartly at first, but shrink
before you can attend to them,  and close entirely by putting a
little bit of lint to the wound ;  but when the tibial artery,  as of-
ten  happens,  is wounded, it  bleeds so as to require attention.
Sometimes you  have occasion tor the needle, but very rarely;
for  such  is the effect of the laceration, whether by opening the
cellular  substance so as to receive the extravasated blood, (or
in what other way it is immaterial to determine) that even the
tibial artery stops  by merely applying to it a pellet of lint*.   If
the artery continues to bleed, you must  take a piece of sponge,
well dried, apply it as close as possible to the  mouth of the ar-
tery, and make one of your young men hold it down for some
time with the point of the finger.
  But there is another kind of haemorrhagy still more perplex-
ing: the arteries  are sometimes wounded from  within by the
sharp bones, the blood  is extravasated, you open a large ecchy-
mosis with the lancet,  in order to prevent extensive  suppura-
tion ;  the extravasated blood flows out, the skin falls down again,
no more blood collects in that place, and you  think all is right,
and have no  apprehension of any large  artery being wounded,
when suddenly,  and at the distance of two or three days, a con-
siderable artery begins to bleed from the bottom ofthe sac, and
after bleeding outwardly, it threatens (when prevented bleeding
openly) to inject the whole limb with blood.
  Wherever an artery thus threatens to produce successive and
dangerous extravasations  into the cellular substance, you must
cut up the skin and muscles to the place where the bleeding ar-
tery is, and although sometimes you may have occasion  to use
* Never truft a wounded tibial artery to any thing but a ligature.  S. 
142            Rules for Compound Fractures.
the needle, generally (even in this kind  of haemorrhagy) you
have but to apply a piece of sponge.
   Let us next suppose, that in place of the leg, the thigh itself
is fractured.   There is, in this case, less laceration than when
two bones, as the Tibia and  Fibula, are broken ; there is in ge-
neral one simple wound, and one pointed and projecting bone,
but the strangulation round the bone is great, the reduction of it
by extending the limb is almost impracticable ; the finger is not
allowed to pass into the wound, and when, by a little  dilatation
with the bistoury, the finger  is admitted,  the surgeon  feels sen-
sibly strong bridles of the muscular flesh, and considerable  re-
sistance from the tendinous firmness of the Fascia-lata.   This is
the case where (whatever we may determine as to the pinching
off of splinters, or reducing the bone to a right shape) we choose
to dilate the wound,  both because of its natural narrowness, and
because there  would  be unquestionably great danger of stricture,
were the Fascia-lata left  entire ; for when the whole thigh is
swelled, the tension  of the fascia makes that inflammation run
into gangrene, which might otherwise  have  passed on to an  ea-
sy suppuration, or might almost have admitted of adhesion.
   In the thigh, then, so fleshy and muscular, and covered with
this  firm  Fascia, the blunt  bistoury should be carried pretty
boldly forwards, and the wound very freely dilated.


                   Of Dressing the Wound.

   When, after a fracture, the patient,  by falling forwards upon
the broken limb, has forced the tibia or thigh bone through the
skin, the wound is not large, the flesh is cut, and not much lace-
rated ; it is not only  possible to make it adhere, but  perfectly
proper (after reducing the bone), to bring the lips as close as pos-
sible,  and stitch them together, as you  would  do the integu-
ments after the great operations of Hernia or Trepan.   When,
after a more terrible accident, the limb being torn by machinery,
or by carriages passing over  it, the laceration is great, you may
be able, with the help of the  needle, to bring two  points of the
wound together ;  but the sides can seldom be  made to meet
fairly, stitches are seldom useful, the  sides of the wound are to
be generally  supported, by laying small and thin pieces of lint
on each side of the wound ;  these pledgits of lint are soon soak-
ed with blood, which cakes  and adheres to the open part of the
wound.   By  making small rolls and compresses  of  linen and
soft lint, which you lay upon the edges of the wound (at those
particular points where you  apprehend a gaping of the lips, or
where you apprehend that suppuration and  cavities will form). 
Rules for Compound Fracture.            143
 you keep the parts very close.  You then lay up the tails ofthe
 eighteen-tailed bandage about the limb,  and though you cannot
 use  a roller (because that would require the lifting of the  limb
 from its pillow at every turn), you give as much firmness as pos-
 sible with the eighteen-tailed bandage.   The steady firmness
 with which you support the parts  helps the adhesion, prevents
 suppurations, and hinders an afflux of blood  to the limb ;  over
 all, you may pour a little of some spirituous balsam, as the Bal-
 samum Traumaticum.
   When the limb is thus dressed, the wound which, while the
 bone protruded, seemed so very formidable, is  very small, the
 pain is relieved, the very firmness of the limb is agreeable to the
 patient; you then apply the outside splints close to the limb, tie
 them moderately firm with their ribands, and having, perhaps,
 bled your patient, you give him an anodyne and  compose him to
 sleep; it is  now that a situation which seemed very desperate
 is changed into a state of hope and expectation.

                Of the stage of Suppuration.

   Though you expect to  procure adhesion,  or at least to make
 some part of the wound adhere, you  are  often disappointed ;
 you  are sensible, from the violence  of the fever and  the swell-
 ing of the limb,  that mischief is  going on  within.   The  dry
 skin, the parched mouth, the thumping pulse, the  restlessness and
 delirium, continue for some days, and there  is a  blackness round
 tbe  wound  threatening gangrene.   But this fever by degrees
 becomes less violent,  the  livor,  which  proceeded partly from
 ecchymosis, partly from the dark colour of the inflammation,
 gradually changes to green, the great wound begins  to suppu-
 rate  and open very wide, the  whole limb swells  to an  enormous
 degree, the skin and cellular substance are soft and relaxed, and
 bear the impression of the finger, the redness extends over all
 the limb, and from the particular hollowness and softness of cer-
 tain  points, you are sensible that great suppurations are forming
 within.
   Suppose you are called  to recover a limb in this ruined con-
 dition, you first lay it in a large tin case which opens and  shuts;
or upon a large splint lined with sheet-lead.  You next wash
the limb with soap and water, clean it from its filth, lay pieces of
 fine spongy lint upon the wound and upon the  various  openings.
 You then make the whole  thoroughly dry, and moisten the sur-
face  a little with a sponge  dipped in vinegar and spirits.   You
next apply adhesive plasters  to the sound  parts  of the limb,
which  support it, and defend it from the moisture.  You  lay
small cushions of folded lint to  support  the hollow parts,  and 
144            Rules for Compound Fracture.
lay scraped lint or small sponges to absorb the moisture; and
having one or two small pasteboard splints covered with leather
(or covered  rather from day to day  with clean  linen),  you lay
them along-side of the limb, and by  tying  two or three  such
splints on each  side of the limb, pretty firm, with separate tapes
or ribands, (which should lie always under the limb) you give
a due support to the hollow and suppurating parts, and a com-
fortable  and general support to the whole.   The  limb lies out
meanwhile upon the broad  and general  splint, which being of
tin, or lined with sheet-lead, allows  the water with which you
occasionally  clean the limb, to run off.
  You are careful to dress the limb every  morning, and per-
haps to clean it also  a little in the evening.   By regular washing
and wiping with the moist sponge, you prevent  those smells
which depress the patient's spirits,  and injure his health ; and
by laying clean*  lint to the wounds twice a-day,  you  soak up
the foul  matter; by the occasional use of spirituous tinctures,
you stimulate the skin, and keep it in good condition ; by wash-
ing the excoriated parts with salt water, you relieve the itching.
You examine the hollow and yielding parts of the limb careful-
ly, and after each fit of inflammation,  you feel anxiously with
the point of  the  finger for any abscess it may have occasioned.
You find  new suppurations produced,  sometimes by the extra-
vasations  of blood,  sometimes by the pricking of splinters, or
sometimes from  matter lodging in  hollow places; you  open
such abscesses with the point of the  lancet, soak up the matter
with  scraped lint,  and lay small compresses upon the hollow
places, by which  you  heal them, and  make the internal parts
unite.
  The importance  of attending to the general health, and even
to the most trivial circumstances connected  with  the ease and
comfort of the patient, is very great; you  should be careful to
have the windows open and the room ventilated, to change the
linens, to  make your patient wash his face and hands with cool
vinegar and  water, and when the matter is very profuse, to have
the room fumigated with vinegar.   You give nourishing food
in small quantities,  wine according to the  constitution and ha-
bits of the patient,  anodynes according to  the degree  of pain,
fever, or  restlessness, and laxatives  when they are required.
You give  astringents and anodynes when the diarrhoea is vio-
lent;  you give  sometimes  gentle emetics  upon the attack of
nausea and fever; and as for bark, I believe, in place of remind-
ing you to give it when the suppuration is great, I must rather
(so common is this prescription) advise you against overloading

* Preffed fponge is much better, as it abforbs a much greater quantity of matter. S. 
Rules for Compound Fracture.             145
your patient's stomach  with  this heavy drug! three or four
drachms of bark is enough to sicken the appetite of  a man in
health,  much more of a man confined for six months to lie on
his back.
   How  much is due to care and cleanliness, you  may judge
from this,  that in  the case of a gentleman who  lies in his own
house, we often venture to save a limb, which, had the accident
befallen a poor man lying in a crowded hospital, must have been
cut off.
   Often it happens,  from the destruction of parts, or the un-
happy circumstances of the patient, that all your cares are una-
vailing.  Every time you examine the limb, you make discove-
ries of more extensive destruction,  you find the  whole limb
swelling every day more and more, you find the  matter running
profusely from the openings, the openings increasing in number,
and the suppurations extending from  the ham to the heel, with
intolerable fetor, the muscles all undermined, and the bones ca-
rious.   You find that you are no longer able  to support the pa-
tient's health, that  repeated attacks of diarrhoea  and fever have
reduced him to extreme weakness, and the wan visage, the pale
and flabby flesh, the hollow eyes and prominent cheek bones, the
long bony fingers and crooked nails,  the quick, short breathing,
and small piping voice,  declare the last stage of hectic and de-
bility.   The natural powers are then sunk so low,  the appetite
for food, and even the desire of  life so entirely gone, that we
would believe the patient past all help, did we not know by ex-
perience that it is never almost too late to amputate the limb.
   Now, it is come to that crisis  when our patient  must die or
part with the limb  he has suffered so much to save ; but he is
wearied out with suffering, and consents easily to whatever we
advise  ;  and whatever the difference of opinion on the first con-
sultation, when the limb was first  laid on its  pillow  all bleeding
and shattered, with its bones projecting and its arteries torn,
there is none now that it is thus undermined  with suppurations,
with universal caries of the bones ; the first  was a state of ex-
pectation, the  second is a condition where  we must despair.
When  we  are thus sensible  that  further attempts  to save the
limb are incompatible with the life ofthe patient; when we per-
ceive plainly that the limb thus mangled, shortened, and imper-
fectly cured, would be rather a load to the patient, and a perpe-
tual reproach to the surgeon,  we perform amputation.  There
can be  no difference  of opinion now, because the  experiment
of trying to save the limb  has been tried, and has failed.
T 
(  146  )
                   Of Gun-Shot Fracture.

  Gun-shot fracture is the one which,  though by far the most
formidable,  appears at first the Wast dangerous ;  it is a small
circular wound which admits the finger, has little sensibility, is
often bloodless, and when the patient is struck, he feels rather
surprise than pain ;  but when the bones are fractured,  the pain
is sometimes very exquisite, and always the wound degenerates
in consequence of the destruction of the bone into a fetid sore,
with fistulas, foul matter, and a discharge of carious bones.
  When a wounded man is brought to you, you find,  perhaps,
one single wound in the thigh, the limb bending, the bone bro-
ken, perhaps some large  branch of the profunda bleeding pro-
fusely, and the man faint and sick.   You immediately lay him
in the floor of the cock-pit, or when brought to your tent in the
field of action, you lay him upon a bed, or upon the bare ground.
You lay a large splint (or any coarse  board, any spar ot  wood)
under the limb, to prevent it bending and being more  injured :
if the blood flows profusely, you thrust a piece of lint into the
wound, and hold it  steady with your finger  ; you call your
assistants, and one  gives  him a cordial, another cuts off the
breeches,  while you, by pressing with your finger, prevent loss
of blood.  The wound being in the thigh, where strangulation
from tension of the fascia is to be feared, you are more willing
to dilate the wound; and the bone being shattered, and a large
artery bleeding, (for in a gun-shot wound no  small artery ever
bleeds) make  the  dilating of the wound a matter of absolute
necessity.  Your finger then being kept steady upon the wound,
is to conduct your bistoury ; you lift your finger,  draw out the
bit of lint, pass your finger into the opening, push in your probe-
pointed bistoury upon the  finger, and  as you open the wound,
you push your finger deeper,  until \ou feel distinctly the jet of
warm blood; then fixing the point ot your finger fairly  upon the
mouth of the artery, you lay it open, and, according to its size,
either tie it with the needle, or suppress the bleeding  by press-
ing a morsel of dry sponge down upon it.
  Your assistants now extend the limb, and hold it very steady;
while  you push your finger deeper into the  wound, you hook
out the splinters of the bone, then you feel a piece of cloth, or a
button of the breeches, and with the help of a probe,  or lever,
or dressing-forceps,  you  hook it out ; you  find  a piece of the
ball, and also pick it away, but you are sensible that the rest of
the ball, or that one of two balls, with which your patient was
shot, lies very deep ; you find the wound extending beyond the
reach of your finger; you find that it has passed almost through 
Of Gun-Shot Fracture.
147
the thigh,  and having reason to believe that the ball is near the
skin on the opposite side, you make an incision there, (called a
counter-incision) and extract the ball, together  with whatever
splinters of bone are driven to that side.
   The shot having passed through the thigh-bone, you get out
the ball, pieces of bones, cloth, buttons, keys, sword, belt, and
other foreign bodies in this way, with the finger : when the shot
has passed through the fore-arm, or tibia  and fibula, or through
a group of bones, as the carpus or tarsus, it is sometimes useful
to draw a slip of dry linen through the wound with your long
iron probe.
   The wound being thus cleared, you proceed to  dress it, not
with any expectation of  procuring adhesion : that in gun-shot
wounds is  impossible : you never pretend to stitch a gun-shot
wound.  You put adhesive plasters  round  the  limb,  because
you  know  that  it must lie  long soaking in suppuration ; you
bring the wound close together with compresses  upon the sides
of it, a piece of fine lint over the mouth of the wound, and you
bind it with a strip of fine linen.  You lay the member on a firm
splint, or case of tin, to prevent any bending of it, and you dress it
always perfectly dry ; you pour sometimes a little  spirits upon
it, using no poultice, nor any thing but compresses of dry lint,
padded splints, and circulars of ribbon to  tie them with, and
to support the limb.  You should never forget this circum-
stance, that the rangers in the woods, who never are within a
house, who are continually exposed to fresh air, in constant mo-
tion, and living from necessity on a  spare diet  of the coarsest
kind, who merely bind up their wounds with a piece of lint and
a slip of linen, recover to a miracle ! while those who are nearer
what is called help, who are thrown  into a  foul  hospital, and
who, if they are able to walk, loiter about in idleness and nasti-
ness, or who, if wounded in their lower extremities, lie  with
oils, poultices, and rancid ointments, applied to their limbs, in-
fallibly sicken and die.
   In the progress of such a wound, the sloughs will come away
spontaneously ; the suppuration need be encouraged in no other
way than by supporting the  general health;  the  carious bones
will usually be discharged of their own accord ;  perpetual care
is required in  keeping the wound clean, close and dry.   The
way of curing the fistulous sores that remain after gun-shot
wounds, has been already explained.

Of Compound Fracture and Luxation, when the Joint is distort-
    ed, the Bones fractured,  and the Integuments lacerated.

   It is in  the lower extremity only, which bears the whole 
148         Of Compound Fracture and Luxation.

weight of the body,  that we are to look for such complication
of injury as is described in these words; and however a com-
pound fracture of the arm, or fore-arm,  may destroy the part
itself, life is  actually in danger only in great fractures of the
lower  extremity, which forms  so great  a proportion  of the
whole body.  Whether the Tibia only is protruded, or the as-
tragalus displaced, or both,  you perform the same operations ;
and whatever may be the decision of a Consultation afterwards,
your duty  is immediately  to replace  the foot, and  close  the
wound.  Always, you proceed in the first instance as if you had
no doubt of saving the limb.
  In  general it happens, that the Astragalus or Tibia  having
burst through the integuments, the bones are so strangled in a
small slit or opening, that no degree of force will reduce them ;
3Tou do not, in this case, cutoff a bone so necessary to the joint
as the inner process of the tibia ; you never, unless  it be already
entirely separated, cut away the astragalus; you first extend the
foot very powerfully, and press in the astragalus, and try to re-
duce the bones ;  but failing in this,  you make a free incision,
taking care to avoid the tibial arteries ; extend the foot, replace
the astragalus betwixt the  processes of the  Tibia and Fibula,
and having closed the wound, you lay a  piece of lint upon the
lips of the laceration.   You then place the limb on a  large and
stiff splint, in a  manner which surely I need not  explain, and
with such pillows, compresses, and bandages, as you find neces-
sary for keeping the  foot in its right position, with regard to the
leg.
  The limb being  thus laid, you are not to promise yourself
absolute success, but the surgeons whom you have sent for be-
ing arrived, you consult together upon the probable event of the
case ;  and so very favourable is the aspect that matters assume
after those operations have been nicely performed, that the con-
sultation will very rarely order the limb to be cut off; they soon
leave you to your own prudence, and advise in general terms
that every thing should be done to preserve the limb.   You are
now afloat, and  must abide the chance of time  and circum-
stances, for after a day's delay the limb is  inflamed,  and you
never call a second consultation; it is too late (whatever changes
come upon the limb) to perform amputation with success; nor,
indeed,  must you be alarmed at  the  appearance  of gangrene,
even in this case, where gangrene is so often the cause of death,
for the force with which the parts are twisted, or the bones dri-
ven through the skin, occasions an extensive ecchymosis, which
reaches along the leg, and up the thigh itself,so that the whole limb
is almost black.  Nay, you must not be alarmed even though this
blackness turn into  a true gangrene,  though vesicles  rise,  the 
Of Compound Fracture and Luxation.         149
part lose all feeling, and the patient lie in a degree of stupor;
for such gangrene  is often but superficial ; it is confined to  the
skin ; it is limited even to a small portion of the skin, and in
eight or ten days small sloughs are thrown off, the suppuration
is established,  and the patient revives.   Such laceration  sel-
dom  or never adheres immediately,  yet is often cured by sup-
puration ; and sometimes, when pieces ot the tibia and  fibula
have been separated and  thrown off, when  the astragalus  has
been  fractured,  and one half of it cut out by the surgeon,  the
joint has healed ; nay, it has even  happened that the astragalus
has been so entirely twisted out of its place, that it has morti-
fied and been removed by the  surgeon,  and yet the  gangrene
has ceased, the suppuration has been established,  granulations
have filled up the great hollow, the outward wound has closed, and
(though it is  difficult to believe so surprising a fact)  the bone
has been so far regenerated, that the patient has walked firmly
on that foot, and  with a free motion of the ankle, a new joint
having been formed.   Yet you should be aware, that such cures
are never  perfect; after even the least of those  accidents  the
joint  continues long weakly, always rheumatic, apt to swell
with the slightest fatigue,  and requires to be firmly supported
by a well-padded buskin laced  firmly round the joint: I have
seen some patients, indeed, who did not absolutely need this,
but few who did not acknowledge the comfort,  security,  and
strength it gave them. 
(  i^o   )
DISCOURSE  XI.
ON THE  ACCIDENTS  AND  DISEASES OF THE
                      HIP-JOINT.
SECTION I.
   Diagnosis of the various accidents and diseases ofthe Hip
                           Joint.


J.N distinguishing the various affections of  the  hip-joint,  we
can trust nothing to the opinions of the  older surgeons, so en-
tirely unacquainted with the scrophulous disease, and so inac-
curate in their distinctions of all the other affections ofthe joint.
Nor is it indeed by authority  and the facts of others that  we
should be guided in the practice of our  profession,  hut rather
by reason, by our knowledge of the structure of the parts, and
in the  present case, by observing the various  distortions and
shortenings of the limb;  for it will be found, that from the pe-
culiar structure of the hip-joint, certain accidents will produce
invariable appearances, and luxation, fracture, or  injury of the
acetabulum, wiil give infallible  signs of distinction by the pecu-
liar distortions of the limb.   I well know how difficult it is to
remember correctly the forms  of any internal part, and how
much more difficult it is  to apply such anatomy to the peculiar
circumstances of each case ; how impossible  it is  to  reason up-
on luxations and fractures as abstract subjects,  without some sen-
sible representation of the facts j it is for  this reason that I think 
Of the accidents and diseases ofthe Hip-Joint.     151
it advisable  to accompany each  difficult  point of the diagnosis
with a simple plan.
  The first plan that I lay before you, is such a scheme of the
hip-joint as will explain decidedly the effects of blows or falls in
various directions,   (a)  Marks the deepest part ofthe socket
which  entirely receives the round head of the thigh-bone, and
upon this point the whole weight of the body  rests,   (b)  Next
marks  the head of the thigh-bone raised and turned a very little
out of its acetabulum, in order to show the hollow  ofthe ace-
tabulum and  the root of the round ligament,  (c) Marks the
round ligament which arises rather from the  lower  margin of
the socket, and which prevents the head from starting out of the
socket, or being luxated upwards till this ligament is burst; and
indeed it would seem as if the weight ofthe body were  in some
degree supported by this strong ligament, though the weight is
chiefly  balanced upon  the head of the  thigh-bone,   (d) Marks
that deep part of  the socket where the mucous ducts and fatty
fimbria? lie, and  where the inside lining of the capsule is most
peculiarly delicate ; and since the body hangs  by the upper part
of the socket on the top ofthe thigh-bone,  this delicate appara-
tus, lurking in a small dimple at the lower part of the socket,
escapes all dangerous pressure,  and is but gently moved as  the
central ligament moves.
   With  the plan  of the joint thus before us, nothing is more 
 152    Ofthe accidents and diseases ofthe Thigh-Bone.

 easy than to judge, with almost  mathematical precision, of the
 effects of each particular  blow or twist.   1st. In the perpendi-
 cular posture of the body, when the pelvis rests fairly on the
 head  ofthe  thigh-bone, the neck ofthe thigh-bone bears its full
 share of the weight ;  and in falling from a height upon the feet,
 or  in dropping from  a window, or in falling with force  upon
 one knee, or in  taking a high and dangerous leap, the whole
 weight ofthe body strikes upon the head of the thigh-bone in a
 direction transverse to that of the neck.  The resistance of the
 ligament from below, and  the deepness of the socket above,
 prevent  luxation upwards, and the neck  of the bone breaks
 across.  The direction of such  a shock is  indicated by the dot-
 ted line  (l.)  A blow in this direction, then,  may fracture the
 neck  of the  thigh-bone, or may so bruise the  socket,  as to pro-
 duce  disease,  but can never  hurt  the lubricating apparatus,
 which is safely lodged at (d), where there  would in that case be
 no pressure.
   2d. A fall in which the foot slips inwards,  the limb is twist-
 ed, and  the  body falls on one side : in short, when the thigh
 is  distorted  in the direction marked by the dotted line  (2), the
 head of the  bone is more  frequently twisted  out of its socket,
 and luxated upwards ; the great capsule of the  joint is burst;
 the central ligament is torn up by its  roots ; and the  head of
 the femur is lodged on the back  of the haunch-bone, or in the
 sciatic notch.
   3d. But when the person slips his foot,  so  that the inside of
 the ankle slides along the ground, and that the limb is  twisted
 outwards ; or when having a heavy burden on his back,  he falls,
 so  that the inside of the knee  strikes the ground ; or when, as
 in laying a sack  of corn from his back upon a cart, he makes one
 step away from the cart, and the sack falls upon his extended
 leg, so as to twist the limb outwards ; then the thigh-bone comes
 into the  direction denoted by the dotted line  (3), the  head of
 the thigh-bone is turned downwards towards the  lower part of
 the socket, and  is easily luxated in that direction, because there
 the socket is  imperfect, its border is low, and guarded only by
 a ligament (the ligamentum labri cartaliginei)  while the central
 ligament prevents only luxation upwards, because its root arises
 near this lower border of the acetabulum.
  4th. It is very obvious, that when the thigh-bone is struck in
the direction  ofthe dotted line (4) by a fall  upon the trochanter,
its head is beaten down into that part of the socket where  the
mucous ducts lie, and  these  soft parts are bruised,  whence
comes immediate and  dreadful pain, high  inflammation in the
joint, and sometimes suppuration, and carries off the acetabu-
lum, followed by anchylosis. 
        Ofthe accidents and diseases ofthe Thigh-Bone.    153

   5th.  When the great trochanter is struck obliquely from a-
 bove downwards in the direction ot the dotted line (5),  any of
 all those accidents may ensue, for the head of the bone is struck
 so downwards into the socket, that very frequently  the mucous
 ducts are injured;  or being struck thus obliquely,  the head of
 the bone may be luxated downwards, by being driven over  the
 border of the acetabulum at its shallowest part; or,  finally, by
 being struck thus obliquely, the neck itself may be broken.
   In enumerating these consequences,  it is to be observed,  that
 the effect of no particular blow is absolutely limited, while yet
 it may in general terms be affirmed,  that luxation  is produced
 by a  twist of the limb; fracture of the neck of the  thigh-bone
 by a  desperate leap or fall from a  height; while falls in  which
 the trochanter strikes the  ground, though  they do  sometimes
 luxate or fracture  the  thigh-bone, more commonly injure  the
 acetabulum  and its  lubricating apparatus.    It must be matter
 of wonder, indeed, how, since the  soft parts within  the socket
 are so easily injured, they ever escape disease  in  any of the
 common accidents of the  joint: but it is to be observed, first,
 That  the bone is luxated or fractured by blows or twists, which
 tend  rather to  turn  the head out of the acetabulum, than to
 drive  it down into  the cavity.  Secondly, That the mere lace-
 ration of an internal part,  as of the central ligament,  heals very
 easily;  for  in every case  of  luxation it must be torn, and  yet
 no disease  ensues.   Thirdly, The actual fracture or luxation
 produces no disease, because that peculiarity of constitution is
 wanting, which produces  in boys the most dismal consequences
 from  the slightest accidents, not in this joint only, but in all the
joints.  And, lastly, We  find, that even when, in  consequence
 of inflammation arising from mere local  injury, the bones do
 inflame and throw  out callus, it is a healthy  inflammation,  like
that of a  granulating  wound, and stops spontaneously as soon
 as the callus is  formed, and  the re-union of the neck of the
thigh-bone, or the formation ofthe new socket, completed. The
actual condition of the  limb may be  ascertained by the follow-
ing marks:
   1st. The  limb being sound, or but slightly hurt, is moveable,
but not loose ;  the joint moves easily and smoothly ; you can
turn the thigh-bone  in  every direction, though not without a
degree of pain proportioned to the injury ;  and this  is princi-
pally to  be noticed, that the point of the haunch-bone, the knee
and the great toe, are all in one direct line;  or, in other words,
the leg, thigh and body, all lie  in the natural  direction, with re-
gard to  each other; and the limb being measured with its  fel-
low, is of the same length, and answers knee to knee, ankle to
ankle, and toe to toe : for  though the patient will naturallv  dis-
                             V 
 154    Ofthe accidents and diseases ofthe Thigh-Bone.

 tort the leg to give himself ease in the bruised part, yet the sur-
 geon can, by a little force, make the limbs even.   Figure 1st.
   2d.  When the thigh-bone is luxated, the limb is always im-
 movably fixed bv the entireness  of  the neck  of the bone, and
 the awkward posture in which the head lies against the pelvis;
 and when the thigh-bone is luxated upwards, we have the fol-
 lowing decisive marks of its condition:   The  head and neck of
 the thigh-bone are firmly braced down against the back of the
 pelvis by the surrounding muscles, whence the limb, which lies
 in a very awkward posture, is absolutely immovable.   The
 head of the bone having started fairly over its socket, and lying
 even as high as the sciatic  notch, that is, at the distance of three,
 or rather four inches from its natural situation, the limb is  very
 remarkably shortened,  the heel of the luxated limb touching the
 sound one a little higher than the ankle.    Next the neck of the
 thigh-bone being entire, and the head of the bone looking back-
 wards  towards the sciatic notch,  the whole limb is  singularly
 distorted, the toe is turned inwards, or rather backwards, and
 the knee of the luxated limb falls in behind  the  thigh of the
 sound  one,  and  in this awkward posture the limb  is so im-
 movably fixed, that  when you attempt to  turn the thigh-bone,
 you give great pain; in the  moment of the attempt, you are sen-
 sible of insuperable resistance; indeed, if you could turn the
 thigh-bone, you would  reduce it.
   Now, when the limb is thus luxated upwards, if you lay your
patient on his belly, you will find  the leg  half bent, and stand-
 ing up  at right  angles with the thigh; and taking the leg in
 your left hand, and working it like a rudder, backwards and
 forwards, laying your other hand at the same  time flat over the
 haunch, vou will be sensible, every time the thigh-bone is turn-
 ed, of the ball or head of it turning under your hand ;  and when
 you persist in turning it very largely and  rapidly, you  will be
 very sensible of the head and neck of the bone clucking against
 the haunch-bone.   But of all the marks, none is more  particu-
 lar than this, that the great trochanter rises very high, the pro-
 minence which we call the haunch, seems to be transferred  ve-
 ry high up upon  the hip, the thigh is remarkably shortened and
 flattened,  and when you first begin  to roll the thigh-bone, and
 to feel the joint, you would be apt to mistake the trochanter for
 the head of the bone, and the clucking noise of the luxated bone
 for the grating of a fractured one.   Figure 2d.
   3d.  When the thighbone is luxated  downwards, the bursal
 and central ligaments are lacerated, the obturator muscle which
 fills the thyroid hole, is in part torn up from its origin, and the
 head ofthe bone  is lodged in its pl?ce ; the turning or rotation
 of the thigh-bone is in this luxation also  entirely  prevented by 
/*.  M4:
Fit/ 'A. -Z. uxattd  upwards.
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        Ofthe accidents and diseases ofthe Thigh-Bone.     155

 the  awkward posture of the  neck; the head of the bone looks
 forwards, or rather upwards, and the limb is as much fixed as
 when luxated upwards.
   All the peculiarities of the distortion first described,  are re-
 versed in this luxation ;  the head of the bone is now lodged in
 the  thyroid hole, a part of the pelvis so much  lower than its na-
 tural socket, that the leg is lengthened fully three inches.   The
 head ofthe bone in this luxation looks forwards and upwards,
 so that  the toe,  which was turned inwards in the luxation  last
 described, is turned outwards in this; and the head being now
 turned forwards, the knee, which in the upward  luxation  lies
 under the  sound knee, is in this turned remarkably outwards,
 while the whole limb is kept in a very remarkable manner strad-
 dling away from the body.   In the luxation upwards, the head
 of the  bone is less  distinctly felt, because the trochanter is apt
 to be mistaken for it, the head  and neck lying deep under the
 glutaei muscles ; whereas in this luxation,  the head of the bone
 is felt rolling very distinctly and superficially in the groin, very
 nearly in the place of  the venereal bubo, for at this point  the
joint of the hip is not covered with large muscles, such as the
 Glutaei, but with one  thin and flat muscle, the  Pectineus, and
 the joint is so near the surface here, that the suppuration in the
 hip-joint disease usually bursts first in the groin.  Figure 3d.
  4th.  The peculiar signs of fracture of the neck of the thigh-
 bone, are not less decisive.   The moment the neck of the thigh-
 bone is broken,  the bone is retracted by the power of its mus-
 cles  ; it is turned somewhat round by the rotaton  muscles (the
 Obtur.  Internus. quad. Femoris, &c.)  operating upon the shaft
 of the bone ; and while the head and neck ot the bone remain
 in the socket,  the broken part of the bone at the root of the tro-
 chanters mounts upwards.  The following signs then must fol-
 low  those peculiarities in the posture of the bone.  First,  the
 moment the neck of the thigh-bone is  broken, the shaft of the
 bone is so retracted by the power of its muscles, that you would
 imagine the bone to be luxated upwards ; secondly, observing
 next the posture of the leg, you find that the  toe is not turned
 inwards, nor the knee of the hurt limb bent in under that ofthe
 sound one, it is turned outwards, but not in that fixed, awkward,
 and  straddling posture,  which indicates luxation downwards.
 Thirdly, you next begin to turn the limb  and  to  hearken for
 crepitation ; but you will remember that this fracture is distinct
 from all others,  in having no crepitation,  for the  ends  of the
 broken  bone are not opposed to each other  (as where a bone is
 broken  across its middle) but the broken  neck of the bone re-
 mains in the  acetabulum, while the part  (i. e. the root of the
 trochanters) where the neck of the bone was broken away from 
156     Ofthe accidents and diseases ofthe Thigh-Bone.
the shaft is so retracted, that the fractured parts are never op-
posed to each other, unless indeed in the moment ot extending
the limb with the design of setting the fracture, tor then the
limb being drawn out nearly to its natural length, the  fractured
parts come to be opposite to each other, and the  crepitation is
distinguished.  Fourthly, It is to be observed, that  the  limb
cannot be fixed and embarrassed by the neck of the thigh-bone,
as in luxation ; the connexion  betwixt the head and shaft of the
bone is destroyed; the limb is not only free, but absolutely loose ;
the natural thigh-bone moves easily,  but  the broken thigh-bone
turns loosely, as far as a bone  can turn loosely which is encum-
bered with such a mass of muscles lying about it.
   This also is very particular ; it turns vertically like  a spindle.
If you take in your hand a sound limb with the design of turn-
ing it,  and lay the palm of your hand over the  trochanter, you
will be sensible  that the  bone moves slowly and steadily, be-
cause is is connected with its neck.  The head oi the bone  is
the centre  of the  motion,  the trochanter is at the distance of
three inches  from that centre, and moves in large circles, of
which  the
thigh-bone
dius ;  but
shaft is bro-
from   the
shaft of the
self the cen-
tion,    the
of  course
cally in its
out making
it  merely
its axis.
   The frac-
neck of the
easily distinguished from luxation,  by the ease with  which the
limb is turned,  by the thigh-bone  turning vertically upon its
axis, by the leg being  much shortened, easily lengthened by ex-
tending  it, but  very difficultly retained.  But though I  affirm
that the thigh-bone is  easily turned and moved  in various di-
rections, I mean so  only in reference to the mechanical resist-
ance, for it  is not moved  without  dreadful  pain ; the ragged
trochanters, and broken part of the bone, are lodged among the
soft parts, and every time you try to draw the  leg outwards, the
patient suffers dreadful  pain  from the pressure  of the broken
part of the femur against the lacerated parts  which  lie on the
back of the haunch-bone; thence it is,  that the patient  is no
neck of the
is  the  ra-
when   the
ken   away
neck,   the
bone  is  it-
tre of mo-
trochanter
turns verti-
place with-
any circle,
turns    on

ture ofthe
bone thenis 
       Of the accidents and diseases ofthe Thigh-Bone.    157

sooner laid in bed than he inclines the knee inwards, and dis-
torts the limb, in order to raise the broken end of the bone, and
prevent it pressing against the lacerated flesh.
  This last observation reminds me ot the necessity of explain-
ing two doubtful points in the diagnosis;  first, it is not certain
that the toe  is always turned outwards; secondly, it is not cer-
tain that the limb is always immediately shortened.   You may
have observed that Paraeus describes the toe as turned inwards,
" the limb  shortened, and the foot  turned inwards."   Petit
also, in  his Maladies  des Os,  mentions,  that being  called
to a patient  under the care of a surgeon who  had not read
Paraeus,  and  who mistook  the  nature  of the injury, " he
found,  upon  undoing  the bandages,  the  great   trochanter
four inches higher than  its natural situation, and  the toe and
the knee turned inwards."   But it  should  be  remembered,
that the  ease with which the thigh-bone turns vertically, or in
other words, the ease with which we turn the toe outwards or
inwards at pleasure, is among the  most decisive marks of this
kind of fracture ; that though  the  toe is  naturally  turned out-
wards by the action of the rotatory muscles,  yet we can  easily
turn it in ;  this implies that the patient himself can turn it in.
He often does turn it  in that he may lie with greater ease ; and
accordingly  you will  often  find the patient lying with the  toe
turned in, and the knee of  the hurt limb turned under the knee
of the sound one, for in  this posture  the  fractured  part ot  the
bone is lifed  up from the lacerated flesh.   In short, there  are
two postures of  the limb :  first, That which it takes while the
parts are insensible immediately after the accident; secondly,
That which it is instinctively put into for ease after the patient
is laid in bed.   But though the posture of the limb  comes thus
to be nearly that of a luxated thigh, viz. the limb shortened, the
toe turned in, the one knee falling under the other, yet still frac-
ture is easily distinguished from luxation by the mobility of the
limb.
  Secondly, There is one point more in  which there is a  de-
gree of uncertainty, for the most  decisive symptom of all is
sometimes wanting,  I mean  the shortening of the limb : The
shortening of the limb in fracture ofthe neck of the  thigh-bone,
is not, as in luxation, the unavoidable effect of the posture of the
bone ;  it is an accidental consequence of the contraction of  the
muscles, and sometimes  these are so benumbed by the injury,
or so inactive from some other cause, that they do not pull up
the thigh-bone.  Even though we were less able to explain the
fact, we are not less constrained to receive it, it stands upon
record.  Sabattier has, in consultation with Louis, Foubert, and
Goursoud, seen on several occasions the neck of the thigh-bone 
158             The Diagnosis Recapitulated.
 hroken, the limb remaining of its usual length, and the retrac-
 tion happening suddenly, from the patient being turned rather
 rudely in bed by the helper of the hospital.  Sometimes this
 retraction has taken place on the fourth or fifth, sometimes not
 till the twenty-third day after the accident.*
   The causes then of luxation and of fracture, are as different as
 the causes  of hydrocele and aneurism  ; fracture always, or
 almost always, arising  from a fall, a blow,  or a violent strain
of the muscles ;  while  luxation as certainly arises from a sud-
den twist of the joint, when the weight of the body, in some
awkward posture, is thrown entirely upon the joint, and  the
limb is so far out of its natural direction, as to be entirely be-
yond the power of its own muscles.
                         SECTION II.

                        Of Luxation,

   In what degree the ligaments of the joint will extend when
they are gradually dilated by a collection of serum within, we
need not at present dispute.   Unquestionably they are capable
of distention, of almost incredible distention ; but that the head
of the thigh-bone should be all at once  displaced  by a twist,
forced clear out of its socket over the back of the haunch bone,
and lodg-d in  an instant at the distance of four inches from its
natural place, without laceration of its ligaments, with its liga-
ments merely dilated,  is impossible.  There is, indeed, no fact
of which we are better assured than this, that when the head of
the bone is twisted out of its  socket, there is no dilatation of the
capsule, there is no subluxation, as it is called ; the head of the
bone never stands upon the edge of the socket, for then it would
immediately fall back  into its place; but the capsular ligament
is burst, the central ligament is torn up from its root, the mus-
cles which lie in the thyroid hole, or on the back of the haunch
bone, are displaced, to  make way for the head of the thigh-bone,
which  lies betwixt the naked haunch bone and those lacerated
muscles, and there it remains, undergoing changes which are of
the  most interesting nature.

           Of Luxation of the Femur downwards.

  1st,  While the head of the bone lies thus among the lacera-

  *  When the fracture  takes place  within the capfular ligament, if this is not
Lorn, its ftrength prevents this effect from immediately taking place.   S 
           Of Luxation of the Femur downwards.       159

ted parts, the slightest motion occasions excruciating pain, and
as the slightest motion prevents adhesion, the head  of the bone
continues long reducible.  When the bone is first driven out of
its socket, the patient hears the crash of the lacerating ligaments,
and when a recent luxation  is reduced, the head of the bone
being distorted in respect to its posture, and very firmly braced
down by the contorted muscles, goes home into its place with a
violence proportioned to the tension of the muscles with a loud
snap; but when an old luxation is  reduced, the  reduction, which
is opposed by the strong adhesions, requires  a force  equal  to
that by  which the bone was luxated, if not greater; and in the
instant in which the adhesions give way to that force, the patient
and the surgeon both feel the same crash  of  laceration which
accompanied the first displacement ofthe bone ; it often sounds
as if the neck of the bone were broken by the violence.   This
is the  sign of  the luxation  being reduced,  and the  surgeon
should be aware of it; for I have often been sensible of this
crashing and laceration among the ligaments,  which announces
the yielding  ofthe dislocated bone ;  but as the  head of the bone
does not, in  such old luxations, go home with a sudden nor dis-
tinct snap, the extension has, to my certain knowledge, been of-
ten continued, even after the bone has  been reduced, and that
with a degree of violence  almost sufficient to tear the limb from
the body.    Observe this in  your  future practice, and you will
find that I am not incorrect; and if  what I  have alleged  be
true,  the vis percussionis (far from being a subject for thought-
less jokes)  is perhaps absolutely necessary to the reduction of
old and confirmed luxations.
  2d, Though the capsule so entirely surrounds the joint, that
it can in no case  escape sudden laceration when the head is dri-
ven from its socket, yet the  muscles,  which  are  small, which
turn round  the joint with  small tendons, and are implanted
about the roots of the trochanters, and are but  slightly connect-
ed with the capsule  are, very seldom torn.   The head of the
bone bursts  through the capsule, and tears it in a very irregular
Way;  but it passes out  betwixt  the  tendons  of the  muscles,
without tearing them ; therefore it happens, that as soon as the
bone is reduced, as soon as the head of the thigh-bone  is drawn
out from among the  lacerated parts,  and  again  lodged  in  its
proper socket, all  pain ceases, the  patient exclaims that he is re-
lieved ;  and  as the muscles preserve their attachments to the
bone, and are now restored to their offices, he moves the joint
as easily, and walks upon  it as firmly as before,  and returns to
his business  or pleasures sometimes without one day's interrup-
tion ; and though the capsule is completely lacerated, yet as it is
connected on its external surface with  the surrounding parts, 
160        Of Luxation of the Femur downwards.
and these also are injured, they swell, and the surrounding parts
being close, the edges of the lacerated capsule are regularly op-
posed to each other,  and the entireness of the capsule  is soon
and easily restored :  rest is not necessary to these adhesions.
  3d, When the head of the bone remains unreduced, new and
important changes take place on the head of the bone itself, and
on the part against which it rests.    When the thigh-bone  is
luxated  downwards, it  displaces in some degree the obturator
muscle,  and rests in the hollow of the thyroid hole covered by
the lacerated muscle, and pressing against the bone,  and there
it lies braced down by the distortion  of the other muscles.
The surgeon cannot turn it in examining the parts,  except in a
very slight degree, so firmly is it embraced by the muscles ; and
besides,  the patient is careful to prevent even the slightest mo-
tion, for motion  is productive of excruciating pain.   He lies
immovable  for  some weeks! the hollow in which  the head of
the thigh-bone lies, is lacerated and raw; the parts surrounding
the neck  of the thigh-bone are  also lacerated,  which  parts mu-
tually adhere so  as  to form a new and  perfect capsule.   The
head of the bone resting in  the  thyroid  hole,  as in a  socket,
comes at last to move in it with a degree of ease; and the pel-
vis, resting thus fairly upon the head of the thigh-bone, is stea-
dily supported ; and  though the  leg is much lengthened in this
luxation, so as to make the patient halt towards the sound side,
yet the limb thus luxated downwards bears up the body firmly.
  This  is one striking peculiarity of the luxation  downwards
into the thyroid hole.  But still farther changes take place, very
slowly indeed, for the changes I mean now to speak of affect the
bones themselves.  It seems to be after the thigh-bone is fixed
in its new situation, and after the continuity of vessels is restor-
ed, that the bones begin to change their form.    The soft parts
connected with this surface of the pelvis are all  swelled, vascu-
lar,  inflamed, and  in the condition of the periosteum and soft
parts surrounding a fractured bone.   This  mass of active ves-
sels connected directly with the vessels of the bone itself, draws
them also into an active state.  A secretion of bony matter be-
gins, the new bone is deposited in the now inflamed capsule in
the surrounding cellular  substance, and  among the lamellae of
the obturator ligament, against which the head ofthe bone rests,
and which  is of course irritated and inflamed.  The thyroid
hole comes in time to be filled up with ossification, so as to
make a  bottom for the new socket.   The edges of the thyroid
hole sprout out so as to form lips or edges for the socket; and
these edges sometimes are so deep as  to  surround entirely  the
neck of the thigh-bone, and to form a complete  box of bone, in
which the head of the thigh-bone is so enclosed, that though 
Luxation of the Thigh-Bone upwards.          161
perfectly moveable,  the head cannot be disengaged from its new
socket.
   Nor does even the thigh-bone itself always retain its original
shape ; while excitement enlarges a bone, pressure, on the con-
trary, prevents its growing in a young person, or even  lessens it
when full grown.  The  thigh-bone, when thus  luxated,  bears
the weight of  the body in a new direction,  the obliquity of the
neck  is lost, the head of the bone now receives the pressure in
one direction only, whence the head of the  bone  is  flattened,
and the neck is in time depressed, loses all its obliquity, is short-
ened, and stands out at right angles from the shaft of the bone ;
and as the  shoulders  and neck of the bone now press against the
lower part ofthe empty socket, that part yields to the pressure,
tlie lower edge of  the socket is depressed inwards, and the ge-
  1 have given in this drawing one of the nioft extraordinary facts in this depart-
ment of pathology.  I have reprefented here a thigh-bone which was luxated
downwards and backwards into the fciatic notch, and there formed for itfelf a new
:ocket, where, though entirely enclofed in the bo.-?, as the French academicians have
chofen to call it, ic was  ftill moveable.  One thing is very  curious, that in this
;icw focket there is a certain opening feparated from the reft by a thin partition ot
bor. -, through which the veffel* enter whidi fupply the joint. 
162         Luxation ofthe Thigh-Bone upwards.
neral cavity of the socket, now forsaken by the head of the
bone, is almost filled up.
            Luxation ofthe Thigh-Bone upwards.
  4. When the thigh-bone is luxated upwards and remains un-
reduced, the new joint and all its apparatus is less perfect, and
the patient continues very lame.  The  head of the thigh-bone
being now lodg- d on the back of the haunch bone,  upon a flat
and gliding surface, obtains a  fixed place with great difficulty ;
there is no hollow  like the thyroid hole to receive it ;  there is
not here, as in the luxation downwards,  a variety of surface and
great extent of bone  wrought  upon by  the head of the femur ;
the generation  of  bone is very sparing; an  accidental  socket
is  indeed  formed, but shallow,- smooth,  irregular, not  deep,
not sufficient to receive  or lodge the head of the thigh-bone ;
it is rather a dimple than a solid socket,  and looks merely  as
if the  haunch bone being softened had been slightly impressed
by  the head of the  thigh-bone.  How does the patient walk
then in this case ?   Very miserably ; his thigh-bone rather lies
upon the side of the haunch bone than under it, so as to sup-
port the weight of the body; the weight of the body is sus-
pended upon  the head  of the thigh-bone  by the strong liga-
ments that are  generated  out of the lacerated  capsule,  aided
by  that cellular substance which connects  the lower surface  of
the glutei muscles with the bone.  The dislocated leg is remark-
ably shortened, and when the patient rises on the sound limb to
make a new step,  the luxated bone hangs in air ; and when the
dislocated limb is  in its turn put to the ground, the whole weight
of the body falls heavily upon those thickened ligaments ; at eve-
ry  step the patient twists the body, and  turns the pelvis so as to
throw the haunch  bone flat upon the  head of the  thigh-bone,
and this inclination of the trunk, together with the shortness of
the limb,  distorts  the whole body ; and in this case the weight
falls so heavily upon the neck ofthe thigh-bone, that it gives way
under  it.   The head of the thigh-bone  is flattened, the neck is
shortened, it is also bent downwards, as if it had given way, as
if it had slided a little lower along the shaft of the bone.  When
we  look at the thigh-bone which has been long luxated, we
should at first believe that it  had been actually fractured, and
the neck shortened ; but upon examining the neck,  we find  no
mark of fracture, while we easily distinguish many marks of the
long continued pressure,  for the whole of the upper part of the
thigh-bone, even to the trochanters, is  extenuated,  the neck is
somewhat extenuated and bent down,  the  head also is smaller
than that of the sound thigh-bone, and on the top of the globu- 
Luxation of the Thigh-Bone upwards.         163
lar head of the thigh-bone is a depression or flatness, indicating
the place where the back  of the haunch bone rested upon it.
  In  such a luxation remaining unreduced, the weight of the
trunk is ill supported, the motions of the joint very imperfect,
the limb  remarkably shortened, and wasted  in some  degree,
while the whole  person is distorted  and bent  towards the lame
side.   Though such luxation happen during infancy, the person
never  recovers,  but continues lame, pained,  unable to ride on
horseback, easily fatigued, equally unfit for  business or pleasure,
and reminded of his misfortune every moment of his life.

                        SECTION  III.

Pathology of the diseased Acetabulum,  or  Affection ofthe soft
                 parts within the Hip-Joint.

  The disease I  am now to describe proceeds from a  fall up-
on the haunch (as when the foot  slips upon ice, &c.) in which
the trochanter being directly struck,  the head of the thigh-bone
is beaten down into  the socket, the  round ligament, which oc-
cupies the bottom, and the mucous fringes, which are  contain-
ed rather in the  lower part of the socket, are  violently bruised,
whence arises immediate and very terrible pain, continuing for
many months.  The torture is excruciating, the patient cannot
be turned, nor even moved, in  the most gentle manner  in bed ;
after, perhaps, a year's suffering,  he begins to move about up-
on crutches, entirely lame.*
   This accident  is clearly distinguished from fracture,  because
there is neither crepitation  nor shortening of the  limb ; from
luxation, because the limb turns easily ; and from those and all
other affections by this, that though  it turns easily, and  there is
no mechanical obstruction to motion, the  patient  cannot suffer
it to be turned,  every motion ofthe head  of the bone rolling a-
gainst the injured parts of the socket producing delirious and
frantic outcries.   Sometimes this  inflammation ofthe joint sub-
sides,  and after long  confinement  and  torture, perhaps after
using warm  baths, frequenting watering-places, fomenting and
gradually  exercising the joint, the patient recovers the use of
his limb;  but much  more frequently he continues lame.
   It is not difficult to imagine, and  indeed to prove by dissec-
tion,  various changes by which  the joint is  destroyed.  The
first effect of such inflammation and  insufferable pain is, to pro-
duce a trembling solicitude on the part of the  patient to prevent

  * It does not always happen that thefe fymptoms fupervene immediately after
the accident.  I have  feverai times feen fome days elapfe  before the patient com-
plained of pain, or was perceptibly lame.  S. 
164              Affection ofthe Hip-Joint.
the slightest metion of the limb.  The patient lies in all the
filthiness of a sick bed, will not permit a pillow to be changed,
or a sheet to be rolled  under him; even the trembling of the
floor, when people walk  rudely,  increases his irritability, if not
his actual torture.  This is almost like  a provision of Nature,
for motion actually does harm, excites inflammation, brings the
inflammation forward to abscess of the joint and caries  of the
bones, and prevents anchylosis, which is often the only possible
cure :  the presumptuous interference of quacks with the pro-
cess of Nature, their daring to twist and turn such a limb, under
the pretext of reducing luxation,  has actually proved fatal.
   The stillness of the patient, and the uniform posture for ma-
ny months, favours all  those  changes which are apt to take
place  in a joint thus highly inflamed.   Sometimes the  inflam-
mation stops short of ulceration, the capsule, tendons and mem-
branes surrounding the joint, are merely thickened by  the  in-
flammation,  and the joint remains stiff, rheumatic, but move-
able,  and, as far as  pain will allow, useful.   Sometimes, and
especially in younger  people, the inflammation  runs high, ab-
scess  forms, and after repeated paroxysms of inflammation and
most  excruciating torture,  the matter bursts out  at the  haunch
or in  the groin, with proportioned relief of  pain.  Often, you
may suppose, before the matter thus bursts out, the bones them-
selves are ulcerated, the capsule is destroyed, the head of the
bone  is  extruded from the acetabulum, and retracted  by the
force  of  its muscles  upon the back of  the haunch-bone ; then
the leg is shortened ; and this is what the ancients called Sub-
luxation, the French, Luxation Consecutif, and  which has been
by almost all surgeons acknowledged as a  luxation under the
title of Luxation  from an Internal Cause.   Often the  bones,
thus  eroded, become carious, and  not unfrequently hectic en-
sues,  and the patient dies.
   If, escaping all  those dangers, the patient live, and the bones
granulate, they unite with each other; for the persevering pos-
ture of the patient prevents the process of ossification being dis-
turbed,  more effectually than  our  most  severe and  curious
bandages could do ;  the bones unite with each  other often in
the most awkward direction, the thigh-bone being fixed and
united with the pelvis at right angles in respect to the body.

                        SECTION IV.

Ofthe scrophuhus Disease of Boys, or the Disease ofthe Bones
                which compose the Hip-Joint.

   The scrophulous disease of this joint is peculiarly frequent in 
Affection of the Hip-Joint.             165
ooys from five to eighteen or twenty years of age, and is of that
insidious nature, that its approach is hardly observed ;  the dis-
ease is established before its symptoms are noticed,  even by the
most affectionate and attentive parents, and it ends in total ca-
ries of the joint, with anchylosis or  cohesion of the diseased
bones, though often, from the suppurations and dreadful pain,
hectic and death prevent this imperfect cure.  The bones, and
not the soft parts, are the seat of the disease, therefore its pro-
gress is very slow ; the pain  is so dull,  that the boy walks and
runs about for months after the disease is formed. The parents
first  observe an awkwardness and trailing of the affected limb,
as if it were weakly ; the boy complains little, except of weari-
ness after play, and of that numbness and stupor, with dull and
heavy  pain, which the parents mistake for growing pains, so
frequent in boys.
   The boy now begins to stand always on the sound limb, and
in such a posture, that the parents  chide him for awkward ha-
bits.   After sitting a little while, his joint stiffens ; when he re-
turns to play, he begins to feel pain ; when  he  is warmed by
exercise, the joint moves more easily, and he runs his race with
his play-fellows ; but when his bout of exercise is over, he falls
again into a state of languor.   The limb seems weakly, and be-
gins  to waste, the  boy  loses his health  and complexion, from
day to day he complains more and more of pain, till at last he
is confined,  and a puffy swelling appears about the joint.
   During all this stage of the disease, the bone is swelling and
becoming more vascular, the lining of the acetabulum,  and the
periosteum covering the head of the thigh-bone, are thickened
in common with the  bones themselves, which are  now swelled.
The head of the thigh-bone is protruded in some  degree from
its socket, just as a diseased tooth  is  protruded from its socket
by a bag of suppuration forming under its fangs.   Still  the dis-
ease is limited to the bones ;  there is not, as in the disease aris-
ing from bruises of  the  acetabulum,  excruciating  acute pain ;
although the  leg be remarkably elongated, so as to straddle a-
way  from the  body,  though it be so elongated that when  the
boy stands on the diseased leg, the toes only of  the sound one
touch the ground, yet he is almost without pain, and walks with
a degree of  ease :  exercise, or the common degree of  motion,
during this stage,  is not so difficult on account of  pain, as im-
prudent, from its increasing that  affection  of the bones which
unhappily is too late  of  declaring itself by acute pain.
   But at last the stage  of acute pain does  come ; the boy be-
comes unable to move;  the pain becomes very acute ;  the  soft
parts which connect the bones begin to partake of the inflamma-
tion ; there is redness now, as well as swelling, round the haunch. 
166              Affection of the Hip-Joint.
 The pain is often, though not always, excruciating ; abscesses
 form round the joint ;  the matter bursts out, first at the groin,
 then at the hip ; as the abscesses give vent to the matter, the
 torture is in some degree relieved,  as one sinus or ulcer dries
 or closes up,  another  runs more plentifully, or new abscesses
 form.  Then the cartilages are ulcerated, the matter which had
 distended the capsule is evacuated, and the sweUing of the parts
 within the acetabulum, which had in some degree extruded the
 head of the bone from its socket, subsides, the head of the bone
 falls down again within its acetabulum; the limb, remarkably
 elongated  at first, is shortened  in  this second or suppurative
 stage of the disease.
   The cure of the disease is now  to be looked for, or the pa-
. tient's death.   The patient, wasted with suppuration,  and tor-
 tured night and day with excruciating pain, becomes greatly ex-
 tenuated ; he is reduced to skin and bone ; he is pale,  and ca-
 daverous in the face, the nose is pinched, the eyes starting from
 their sockets, and the face altogether shrunk and shrivelled up
 with discontent and pain. Often,  the  suppuration and caries
 extending along the bones, the whole pelvis is affected, the dis-
 charge is profuse,  and the child dies of hectic ;  but sometimes
 the  matter ceases to flow, the high inflammation subsides, the
 bones begin to granulate within,  like soft parts, (as they indeed
 are  in the boy  extremely vascular)  and by perseverance in one
 uniform posture, the bones unite, a proper anchylosis is formed,
 smaller suppurations are occasionally observed and opened, till
 at last the bones, after successive fits of inflammation, are en-
 tirely united with each other.  The thigh-bone is generally united
 with the haunch-bone at  an angle more or less acute, according
 to the posture  which the child had found  the most easy ; fre-
 quently it is found, when the  boy begins to walk with his crutch,
 that the thigh protrudes forwards ; sometimes it is in the natu-
 ral direction of the body; but even then the limb hangs in air,
 it is extenuated by want of exercise and by disease ; the dis-
 eased limb has been stationary in its growth for eighteen months
 or two years, while the other limb, and the rest  of the body,
 has been growing; thence the affected limb is always shortened,
 and often useless.
   This is plainly a disease, and a slow disease of the bones ; it
 is a disease of boys, because in them the bones are but form-
 ing ; it is a disease of scrophulous boys, because in that  state
 of the system ossification is a slow and imperfect process ; it is
 a disease most frequent in the bones with great joints, because
 they are large,  and are, till the twentieth year, very imperfectly
 formed.
    In this disease the pains are dull, because the bone is insensi- 
Affection of the Hip-Joint.              167
ble; slow, because the firm system of a bone  does not easily
enter into disease ;  the elongation of the joint is  a  sure  sign
that the disease is established,  and the head  of the  bone, the
socket and the soft  parts  beginning  to  swell, the excruciating
pain demonstrates that the soft parts are fully inflamed  and ul-
cerated,  and that to the original disease of the bone is now  add-
ed a disease of the surfaces, such as takes place after the bruise
of the acetabulum ;  and finally, the shortening of the  limb  inti-
mates  to us that the bones are wasting, which is often confirmed
by small fragments and scales of bone coming away along  with
the matter.   Finally, When the matter ceases to flow, the fistu-
las to close, the limb to shorten still more, and the pains to  sub-
side, then the bones come into actual contact, granulate, unite,
and anchylose firmly in due time, for the hectic ceases, the ap-
petite returns, and the cure goes on well, if only the patient can
survive the degree of debility already incurred.
   This final destruction of the joint is the ordinary issue ofthe
disease, for where the bones are once thoroughly diseased,  they
are in general carious, or in other terms, dead, or (as we should
say of soft parts) gangrenous to some  extent.  The carious part
then must be separated; the bones which enter so slowly into dis-
ease, must of course recover slowly;  but besides the extent of
surface, the disease  is  attended in its  first stage with so  little
pain, the patient walks so long while the disease is forming, and
the joint bears so entirely the  whole weight of the body, that
being once  diseased  it cannot  easily recover ; it is indeed en-
tirely ruined in its structure almost  before the disease is ob-
served.
   The cure in the bruise of the acetabulum is to be effected by
leeches,  fomentations, blisters, general bleeding, and perfect
quiet;  but in this scrophulous disease of boys, the cure is  best
conducted by cold bathing, generous food,  wine, and whatever
will contribute to the restoration ofthe health and strength.  The
immediate progress  of the disease is best antagonized by the
counter irritation of blisters, or rather  of deep and large issues
upon the hip, or by the application of cauteries (the oldest and
perhaps the best method of cure) along with prudent  openings,
and careful, but unofficious surgery.   But the  object  of chief
importance in  promoting the anchylosis, is to  prevent  motion,
for even the weight of the limb is very painful, the very turning
in bed inflames the part and interrupts the process; and quacks,
by turning and twisting joints during  this process (the patient
being in a fair way of being cured) have caused death.
   When the period  of ulceration, granulation, and  healing of
the bones arrives,  a remarkable, but very gradual, shortening
of the limb takes place, because the bones  must first be ulcerat- 
168               Affection of the Hip-Joint.
ed, then fall into closer contact, then granulate, and then adhere,
before the anchylosis is complete.    During the whole of this
process the parts are wasting, coming closer and uniting : at least
it most generally is so.   I  observe in  anchylosis,  even of the
knee-joint, where the bones are flat, and the cartilages remark-
ably thin, that there is a very remarkable shortening of the limb.
   When such a  suppuration and caries, beginning in the bones
themselves, does happen, not  in  boys,  but in  adults, not from
any constitutional disease,  but from a  blow, the blow is  in  a
very particular direction, and affects only the bone;  for it is not
a blow upon the trochanter striking the head ofthe bone down-
wards, so  as to bruise the soft parts at the bottom of the ace-
tabulum; but  it  is by a person  making a desperate leap and
lighting fair upon the feet, for the head of the thigh-bone is then
struck  upwards  against the deepest part of  the  acetabulum,
where the Os Innominatum is particularly large  and firm; the
bone only  is  bruised, there is no immediate pain,  the lameness
comes on slowly,  the disease usually makes that slow progress
which is described in the case related in the  foot note from the
Posthumous  Works of Justamond.*


  * A woman about eight and twenty years of age, laden with a bafket full of
bottles,  having jumped down  a fe-w fairs  in  going into a cellar, prferved the
centre of gravity of the upper parts upon the left  thigh and leg fo  well,  that fie
kept herfe/f from falling; but fhe experienced, in the infide of the joint of the hip, a
•violent food, which was. however, attended only -with a very bearable degree of pain,
fince fhe was able to continue her ordinary work for more than a fortnight, •without
complaining.  But fhe  ftill felt, in  walking, a pain  whjch gradually  increafed, from
the continual exercife fhe was obliged to ufe in her capacity of fervant: the diffi-
culty of motion increafed with the pain; and both the one and the other, three
months after the accident, were grown fo much worfe, that the woman was no lon-
ger able to fupport herfelf upon that limb.  At this period fhe came into the hof-
pital where 1 attended; different  embrocations were ufed to the upper part ofthe
thigh, but without any effect; refolutive, anodyne, and  maturating cataplafms,
were then applied, becaufe a tumour manifefted  itfelf at the upper  pofterior, and
external part of the thigh, which feemed tending to fuppuration.   A fever came
on; and when the abfcefs became evident, all the openings and counter openings
were made, which the finufes the pus had formed, required ; the matter which
came out, had no kind of offenfive fmell: it brought away along with it fome
fmall  bony particles,  and an oleaginous  fluid floated on the furface;  the inci-
fions were lengthened as much as it was thought neceffary, fetohs were  paffed,
and during the courfe of the treatment, vulnerary and deterfive injections were
tried, fuch as were imagined to be beft fuited to the ftate of the parts. At differ-
ent intervals fmall portions of bone came away, feparated either from the head of
the thigh-bone, or from the cavity of the joint, into which feveral of the finufes
penetrated. A flow fever and a marafmus, which is its ufual attendant, deftroyed
the patient between three and four months after her admiffion into the hofpital.
Upon examining the feat of the difeafe, I found the capfular ligament almoft de-
ftroyed, the round ligament totally confumed, the head of the thigh-bone carious in all
its furface, and even to a confiderable depth  in its centre; the cavity of the joint ixjas
alfo attacked -with caries throughout its whole extent;  and laftly,  its  cartilaginous bor-
der was completely defrayed. 
The Diagnosis Recapitulated.            169
                        CONCLUSION.

   A slight and easy pathology of these various accidents, and
an accurate diagnosis, is all that I have  aimed at in this dis-
course ; nor do I know of any subject in surgery which so well
merits a  careful recapitulation.   The disorders which need to
be distinguished from each other are, fracture, luxation, bruise
ofthe acetabulum, and the scrophulous disease  of  boys, seated
unquestionably in  the bones ;  and the chief signs are, the length
of the limb, the direction of the toe, the place of the trochanter,
the  elongation or shortening  of the limb, and the manner in
which  it turns, when moved by the surgeon.
   First, We are assured that the  thigh-bone is luxated down-
wards, when the  accident has been a twist of the limb, or a
blow upon the very top ofthe great trochanter; when the thigh is
elongated three inches or more ; the toe turned outwards, in a
splay-foot posture, and kept straddling away from the body with
great pain.  This  luxation is accompanied with a proportioned
displacement of the great trochanter ; the hip  is flattened,  and
in lean people you can distinguish  the head of the bone rolling
in the groin, though not in fat subjects, nor in women whose
pelvis is broad and flat.
   Secondly,  We distinguish luxation upwards  by the remark-
able shortening of the limb, by the ham being crooked, the knee
of the luxated side turned close  in under the thigh of the sound
side, and the toe  turned  inwards, or almost backwards.  The
great trochanter rises very high, and the  thigh is flattened  in
this  case, as much as the  hip is in the last mentioned.  The pa-
tient lies on his sound side, almost on his face, and when you
take hold on the leg which stands up, and begin to turn it, you,
by laying  your hand over the  most tumid part of the  haunch,
feel  first (because it is the most  prominent point) the rolling of
the trochanter, and then by carefully examining and turning the
thigh-bone, you at last distinguish the head of the bone.
   Thirdly, When the neck  of the thigh-bone is fractured, the
limb is remarkably shortened, the  trochanter is higher than its
natural place, the thigh is flattened, the pain is exquisite, and
the general appearance is  that of a thigh-bone luxated upwards ;
but the moment you take the limb in your hand, you distinguish
this  from all other accidents ; for while the limb is so remarka-
bly shortened as to leave no doubt of some very essential injury
having happened, it yet turns so easily as to prove  that it is not
luxated, and indeed it turns so loosely as to prove that the limb
has not that degree of steadiness  which the natural connexion of
the shaft of the thigh-bone, with its head and neck, should give.
                             Y 
170             The Diagnosis Recapitulated.
The limb is shortened, but is easily lengthened ;  the toe is turn-
ed out, but is easily turned in again ;  in short, the manner in
which it moves will satisfy you at once that the shaft is separa-
ted from the head of the bone.   If crepitation be not among the
immediate signs of this fracture, it is because the bones are not,
as in other fractures,  opposed to each  other ; if crepitation be
felt afterwards, it is only  when the  limb is extended, and the
bone set,  or in other terms, the  broken parts regularly opposed
to each other.
  Fourthly, When the patient  has fallen upon the trochanter,
or received a blow, when the head ofthe  bone has been  struck
down into the socket with violent pain,  when the patient be-
comes instantly lame,  and  lies in a  crooked posture,  with the
knee of the injured limb bent in under that of the sound, (in or-
der to  raise up the head, as much as possible, from the inflamed
socket where  its pressure  occasions  pain) when, along with
these  appearances, we are perfectly sensible  that the  limb,
though crooked, is not shortened, when we find, that though
when moving  it occasions dreadful pain, yet it does move easily
and  steadily,  we may be assured that the fall has occasioned
merely a bruise  in the acetabulum.   In this case the patient lies
crooked in bed,  the pain  is exquisite, he cannot  bear to have
the joint  touched, or the limb moved,  the  slightest motion is
terrible to him,  to  stretch out  the  limb is excruciating.   The
surgeon has not leave to handle  the limb freely, or is prevented
by his own timidity, and by the shrieks of the patient; he mis-
takes the nature  of the injury, makes cruel attempts  to reduce
a bone which  is  neither fractured nor luxated, and does  essen-
tial injury to a joint already much injured ; perhaps he   never
doubts of the limb  being  luxated or fractured, till,  after some
months ofthe severest misery, the  pain remits,  the patient be-
gins to walk, and recovers at last the use of his limb.
   This  mere bruise of the acetabulum is  unquestionably the
disease which Petit describes, where he says  that he has often
prevented it coming to any height by applying  astringent so-
lutions, and defensives made  of alum,  and whites  of eggs,
with  spirits of wine.   Rest is of chief service,  but rest need
hardly be recommended to one in such exquisite torture, whose
pains are aggravated by the slightest motion.
   Fifthly, When a scrophulous boy,  under eighteen  years  of
age, has  laboured  long under a disease  of this joint,  where
th re is  great lameness, little pain,  a puffy swelling,  an elonga-
tion of the limb, if there come at  last acute pain, hectic fever,
symptoms of internal suppuration, and at last an abscess upon
the hip or groin, you  know that it is a constitutional disease,
that it is seated in the bones, that it is analogous to the white 
Of Lithotomy.
171
swelling of the knee, or curvature of the spine;  but unlike the
disease  of the knee-joint, this ot the hip  cannot be amputated,
and the boy must go through the  fiery ordeal, and often dies
from fever and irritation, great profusion of matter, and caries
of the bones.   If he survive, it is usually with a limb emaciat-
ed, crooked, hanging in air, and fixed by the anchylosis of the
femur with the haunch-bone.  The chief cause of such disease
is the scrophulous  condition of the system, the imperfect ossi-
fication  of the bones,  the great extent of diseased surface, and
from the occasional shocks which this  great joint suffers, in con-
sequence of its supporting continually the whole weight of the
body.   The chief danger of the disease is the boy feeling but
too little pain  to make himself or his parents sensible of the
danger  ; if it be not chiefly  in consequence of the pressure and
motion  that such disease goes on to the last stage of caries, yet
certain  it is, that under the pressure of the whole weight of the
body such  a disease  cannot be cured ; the only chance,  then,
of recovery, is from wine, generous diet, cold bathing,  caustics,
issues, and absolute rest.
DISCOURSE  XII.
                    OF LITHOTOMY.

                 Preliminary Observations.

\JF all the operations of surgery, lithotomy is that in which the
true principles of the  operation  may be most safely deduced
from the anatomy of the parts.   To conjecture a priori, which
form of incision would be attended with fewest dangers, would
not be difficult;  but  now that we have before us  such a suit of
experiments, performed in  various countries by the greatest
masters  in surgery,  and accompanied with such authentic re-
cords of their various successes, we are able,  from experience
as well as theory, to resolve that important problem; " How
we may, with least danger, open our way into the bladder, for
the extraction of the stone."   And the universal adoption of
the lateral operation  invented by Chesselden, sufficiently attests
its superiority to all others.
   Accustomed with teaching, I have had occasion to observe
that the mind of the surgeon is ill at ease, who has to perform
an operation for which he has no theory ; he must operate with
litde decision who merely imitates the motions of others.
   I have also  observed that, to perform an operation like this 
172                    Of Lithotomy.
with an intrepid spirit and steady hand,  the mind of the young
surgeon must be composed; he must have an entire and perfect
confidence in his own knowledge; he must be familiar with the
structure of the parts; he must see them exposed in every variety
of posture, and must have their relations to each other explain-
ed ;  he must dissect them often, to make this knowledge fami-
liar, and to acquire  dexterity and address, for no operation in
surgery can be so properly defined a dissection performed 6n
the living body as this.  While the young surgeon studies the
connections  and relations of these  parts, he  must also be  in-
structed in all the accidents which may occur; he must be
taught to foresee every  possible difficulty, that he may not in the
midst  of  an operation  be overcome with the sudden  apprehen-
sion of some interruption which he  does not understand.  The
teacher who is to describe so eventful an operation as this of
lithotomy, must first explain  in detail,  circumstantially and  se-
parately, each important movement ofthe hand or instruments,
and every precaution with which each  is to be accomplished;
and then close his lesson with such a rapid enumeration and de-
scription of the successive acts,  as will leave a vivid impression
on the mind of the young surgeon of the manner in which he is
to proceed.   This last description should serve him as a dra-
matic picture of what he is to perform, which he may look up-
on anew every time  he has to operate.
   Before I proceed to describe the several stages of the opera-
tion  of lithotomy, there are some preliminary points to be ex-
plained) which relate not to the dress ofthe patient, northe height
of the  table,  but to the main design of the operation, and es-
pecially to the posture of those very moveable parts, the  rec-
tum and bladder, with regard to each other, and  the manner
in which the surgeon should feel and ascertain  every thing that
is interesting to him.  The kind and degree of distress which
your patient suffers, will enable you to guess at the state of the
parts ; in a bov who cannot have passed many years in this  con-
dition, whose parents,  from observing his  pulling out the penis
and pressing the thighs, and crying when passing the urine, can
ascertain both the duration of his complaints, and the  degree in
which  his health is affected, you are sure of every thing favour-
able for your  operation ; for boys  are naturally healthy ;  the
stone has not with them time to acquire any uncommon size,
it usually is small like  a gall-nut, and very  rough and irregular
on its surface ; the bladch r is not contracted nor ulcerated ; you
can feel the  stone with the  fingers, in the rectum,  and  press
it forward so as to make  it prominent  in the   perinaeum;  in a
healthy boy, with a small stone recently formed, you undertake
the operation with confidence.   In  an adult, who retains much 
Of Lithotomy.
173
 urine, who, though the symptoms  of stone are decisive, yet
 passes long intervals with little pain, in whose urine there is not
 great sediment of mucus, and seldom any blood, with  whom
 the paroxysms of the disease, i. e. the temporary inflamed and
 irritated state of the bladder, is not frequent; the bladder is pro-
 bably capacious, the stone small, and the state of the parts most
 favourable  for operating.   But the scene is sadly reversed when
 the patient, shrinking from the pains of the operation, has long
 endured the tortures of the stone : when he has endured this
 disorder for many years,  he is pale,  languid, and emaciated ;
 the parts are unfavourable  to the operation, and  his constitu-
 tion  to recovery : he can retain but one or two ounces of urine:
 the bladder is, by its frequent contractions, thickened in its coats,
 and,  its  inner and most delicate surface being in almost continual
 contact  with the stone, he feels excruciating pains in the glans
 penis every time he passes his urine :  when he walks, he has a
 gravitating  and dragging feeling, accompanied with tenesmus or
 diarrhoea, from the increasing size  of  the stone, by  which his
 paroxysms  of particular distress  are frequently renewed ; his
 urine is  so  mixed with mucus, that, of the quantity which he
 passes into  a glass for our inspection, the urine being poured
 off, one  half remains a pure white mucus,  and each paroxysm
 of pain,  especially if it arise from walking, is accompanied with
 a discharge of blood :  the day he passes in almost unremitting
 torture,  and, during the night,  he is every half hour  on his
 knees, straining to pass his urine  with dreadful pain.  In such
 a patient the bladder is small, contracted, subject to inflamma-
 tion ; from  frequent paroxysms of the stone, the parts are in a
 state  sometimes peculiarly  disposed to inflammation, and never
 favourable to the operation, while the strength and constitution
 are exhausted by suffering and want of  rest.
   It  is only when your patient is free from pain, when  he has
 had a long  interval after a paroxysm of pain, when  he  is free
 from  irritation and fever, and in no danger from the infection
 of any reigning epidemic, that you can venture to perform the
 operation.   You wait for the more favourable seasons of spring
 or autumn : you nourish  and strengthen  your patient,  if ex-
 hausted, and prepare him so by opiates and the warm bath, as
 to ensure a  favourable state of the skin and bowels.   The sea-
 son of any  epidemic  disease is much to be avoided.  I have
 frequently,  during the prevalence of influenza, or of dysenteric
 diseases, been cruelly disappointed in the adhesion of wounds,
 after  common operations, in cases of the most simple incisions,
 as in  the extirpation of a cancerous  breast ; but the inflamma-
 tion,  which merely prevents adhesion and retards the cure in
 common operations, produces  in this,  where the wound is so
near the  viscera, abdominal inflammation and death. 
174
Of Lithotomy.
   And let me advise the surgeon to be  slow in pronouncing
his opinion, to be careful to ascertain the existence ot the stone,
by sounding, and to feel it also by introducing the fingers into
the rectum, and to  establish and authenticate  his  own opinion
by a regular consultation, before he  presumes to operate.   He
should almost live with his patient for some days, for, unless he
inquire carefully into his history, he  cannot proceed with confi-
dence, or his  confidence may draw  him  into dreadful errors.
The patient may have no stone, but an ulcerated and thickened
bladder ; he may have a stone, but too small to require, so dread-
ful an operation, one which the patient might be able to engage
in the urethra, and  pass naturally by drinking floods of diluents,
and passing the urine upon his knees; a small stone, being im-
pelled by  the force of the urine  into the urethra, sometimes
forms  there a sac  for itself, and  the sound grating along this
small calculus, in passing along the urethra, persuades the sur-
geon of  the existence of a stone  in the bladder:  a patient has
been unfortunately  cut for a  stone so small,  that it  has been
swept  out along the channel of the  gorget with the flood of
urine,  and none been found to  seize  with  the forceps ; at  other
times a small  calculus,  of a cherry-stone  size, has been found
in the hinge of the  forceps, and such accidents have been  men-
tioned with as much indifference as if the surgeon were not re-
sponsible for the cruelty and folly of thrusting a gorget into the
bladder of a patient whose stone  was so  small  as to be passed
by  the urethra.   In short, these  are accidents which  nothing
but uncommon precaution, and a  most faithful attention to the
complaints, feelings,  and whole history of the patient,  can de-
tect or prevent.
   However distinctly the sound may plump upon the stone, and
satisfy every one of its existence,  the surgeon never is to omit
introducing one or  two fingers into the rectum; from this mode
of  inquiry, various circumstances may be discovered,  and in-
estimable advantages arise to the surgeon, who, in place of imi-
tating the motions of other operators, proceeds with intelligence
and design.   I  hold this mode of examination to be little less
important  to  the operator who cuts  with the knife or  gorget,
than to him who cuts on the gripe:  By introducing two fingers
into the rectum  he  feels the staff distinctly, upon which  he is to
perform the most delicate part of his incision : he feels the po-
sition of the rectum,  which he is to keep out of the way of his
instruments :  he distinguishes, through the walls of the rectum,
the membranous part of the  urethra, which is to be his aim if
he cut  with the gorget, and  the  prostrate gland, which he is
to divide,  if he cuts  with the knife :  he feels the manner in
which the stone lies in  the bladder,  which, after  his incisions, 
Of Lithotomy.
175
he is to grasp with the forceps: if the stone be small, he may not
feel  it very distinctly ; but if it be large, it falls low towards the
neck of the bladder, is easily felt, its very form may almost be
distinguished, the staff being plainly  felt  passing  under  the
stone, when large, and holding it in its bend or curvature.  The
surgeon,  by occasional  examinations,  may almost estimate its
size, and, if he do not expressly proportion his incision to its
size, may at least avoid the  error of making a great incision for
a small stone, or the still greater danger of making a small in-
cision when the stone is very large ;  and when the stone is so
large as to require to be broken by strong  forceps, he  may al-
ways be aware  of the nature of  the operation he is to perform.
I remember to have been called to a consultation, in which the
gentleman, who invited the  consulting  surgeons, wrote in these
terms :  " To consult upon the case of a patient who has a stone
in the urethra,  and another in the  bladder."   The patient, in
fact, Had laboured long under the disease, the stone had  increas-
ed to an enormous size ; upon passing the sound, it encountered
the stone almost before  it had entered the bladder, so low was
the stone depressed by its own weight, and the patient's strain-
ing dilating  in  some degree the neck  of the bladder and pro-
jecting into it.   Upon examining by the rectum, I felt a stone
nearly the size of the fist,  and intreated the surgeon  to have
strong forceps  in readiness to break it  in case of difficulty.
When we were met for the operation, I used the freedom of
asking,  " Whether forceps  were at hand to break the  stone ?"
He said, " No ; that he had sent for forceps, such as I wished,
but could not easily procure them."  Then I said, "Sir, if you
value your own reputation,  or your patient's life, refrain from
operating till you are better provided,  which you may easily be
to-morrow morning; to perform this operation in the ordinary
way, will be murder."   He turned about  and  proceeded with
his operation :  the scene  which ensued was dreadful;  two or
three forceps were  successively twisted, or broken;  all present
were in the  most distressing perplexity.  Mr. Wood bethought
himself of a pair of large and strong forceps, which had lain as
lumber  among his apparatus ; these were sent for to his house,
and  with them the stone  was extracted;  but the operator had
never one moment refrained from labouring with one  instru-
ment or another; the patient had struggled under his hands  a
full hour, in the most dreadful agonies ; I need hardly say, that
in two days he  died.
   Not to break  the stone, when of so uncommon a size, is cruel
and dangerous, and no one accustomed with this operation will
scruple to do so for fear of fragments ofthe stone remaining in
the  bladder, for he must be conscious that he seldom  operates 
176
Of Lithotomy.
  without the forceps chipping off small fragments of the stone,
  which are more  dangerous than the fragments of a stone de-
  signedly broken, as they are less observed.
    The condition of the rectum and bladder should be an object
  of particular attention. The bowels must be emptied by a purge
  two days before operating, for fulness and irritation of the bow-
  els,  will  dispose to abdominal inflammation.  The rectum must
  be emptied by a  clyster on  the morning of the operation, lest
  the fulness of the gut should expose it to be wounded :  This,
  if not a fatal,  is yet a blundering wound, of which the surgeon
  should be much ashamed:  although we  have the best authori-
  ty for affirming that the intestine may be wounded by the most
  dextrous operator.   Chesselden  acknowledged to Mr.  Mo-
  rand, that he had  twice, in operating, wounded the rectum.  As
 it is chiefly important to prevent  the cutting edge of the gorget
 injuring the back  part  of the bladder, it is of the  first import-
 ance, in operating with the  gorget, to have  the bladder  full;
 the fulness of the bladder allows the staff to be  turned easily to
 every side of the bladder, in feeling for the stone ; it allows the
 surgeon to set the staff before cutting, in the  precise direction
 he wishes to have it.   The  fulness of the bladder presents the
 fore part  of its body, viz. that where the prostate surrounds it,
 fairly to the cutting edge of the gorget, and gives the bladder a
 steadiness to resist the push.    This fulness of the bladder pre-
 vents the  cutting gorget being driven through the fundus among
 the bowels, and the quantity of urine running off freely  along
 the channel or hollow of  the gorget indicates to the operator,
 that this,  the most dangerous movement in the operation, is pro-
 perly performed.   The patient  for  this end must retain his
 urine four or five hours in the morning of operation ; in  boys,
 and even  in men, a linen rag must be tied round  the  penis to
 prevent the urine flowing off.  The string must not be undone
 upon introducing the staff for operation, for the body of the pe-
 nis is so compressible, that the staff passes as easily when the
 string is left, as when it is taken away.  I have often been pro-
 voked to see the string taken  off,  the staff introduced,  and the
 whole of the urine allowed to run off by the groove of the staff,
 in the very moment in which the surgeon  is about to drive his
 gorget into the  bladder.
   As one  great purpose of many things which the surgeon does
immediately previous to the operation, is to ascertain the re-
lative posture of the parts,  and revive  his own recollections of
the several points,  he  should never fail to introduce the staff
himself, though often this is committed to the  assistant.   May
 not an unskilful assistant drive the point of the staff through
 the membranous part of the urethra,  and lodge it between the 
Of Lithotomy.
177
rectum and bladder where, of course, the gorget when driven
along will follow the groove ?  Is it not a satisfaction to the sur-
geon to pass the staff himself, that he may do it gently without
irritating the parts ;  that he may  feel and distinguish  any rub
from any small calculus, sticking in the urethra ; that he  may
lodge fairly in the bladder that grooved directory,  which  is to
guide  the  most important  stroke  of his knife ; that he may
plump his staff against the stone, and feel it distinctly before he
operates; that he may, after introducing the staff, pass his finger
into the rectum, feel how  the staff lies, incline the  handle  ot it
to the right groin, and so protrude  the  heel  in the perinaeum
where he is to cut ?  Will not the  introducing  and  setting the
staff and feeling its curvature, both in the perinaeum and from
within, give the operator more decision, and a more  distinct
recollection of what he has next  to perform ? To deliver the
staff to the assistant, that he may introduce it, is a slovenly, a
timid, or an evasive practice ; I have seen this often done, but
it always seemed-to  me that the man who dared to undertake
the operation of lithotomy, was doubtful whether he could  in-
troduce a staff;  or that he was so jealous of his reputation as a
rapid operator, that he would not allow the more ignorant of
the attendants to calculate the operation as begun, when he was
only introducing the  staff; or perhaps he feared lest his hand
should be unsteadied  by some slight opposition to the introduc-
tion of the staff; a part of the operation which should, in fact,
by  reminding him of all the important relations of  the parts  in-
spire him with steadiness  and manly resolution.
  There is a gradation in the length and  curvature of the  in-
struments which are on various occasions to be introduced  in-
to the bladder.   The catheter, as  it needs  not  enter far into
the neck of the bladder, though  it should always be as big #s
the urethra will  easily admit, should not be long, and should
have a very gentle and simple curve  : the  sound,  with which
we  feel for the stone, must be round, smooth, longer, and more
curved ; but it must not be very long, nor much curved, lest it
do not turn easily from side to side in the bladder; and it should
be introduced when the bladder is  moderately  full,  that it may
be  turned  easily in   various  directions in search of the stone,
which, if it be not found when the bladder is full, or  the patient
seated, or lying on the ground, may perhaps be felt after he has
been permitted to empty the bladder, or allowed to  stand  up.
The staff along which the  surgeon  designs  to  run  the gorget,
should have a prominent heel, that  it  may be easily felt through
the  membranous part of the urethra ; it should have a wide
groove, but should not be  protracted  into a beak, lest it  should

                             Z 
178
Of Lithotomy.
hold the knob ofthe gorget too long engaged in the groove, and
carry it so deep as to endanger the fundus of the bladder.
  The posture in which the patient is bound, is horrible, most
oppressive, but yet it is essential to the performing of an opera-
tion,  where the slipping of one instrument, or the  misgiving
of one stroke of the knife,  makes the difference,—of safety or
death.  He must be made to grasp his feet with his hands, and
secured in that posture by strong garters, encircling the  wrists
and ankles, and thus, bended into  a curve, he rests almost up-
on one point of the spine, and is brought so near to the edge of
the table, that he is almost suspended in air, by the  two lateral
assistants, who support each a foot and an arm.  Unless the pa-
tient is brought thus far over the edge of the  table, supported
by the assistants, and his breech bolstered  up by a pillow ; un-
less his breech project over the edge of the table ;  unless the
perinaeum be turned almost directly upwards,  and the surgeon
seated low, and rather under his patient,  he cannot pursue his
incision so far beyond the tuber ischii as he should do, in order
to cut the transverse muscle, for the  incision  should pass the
curvature of the hip.
   The patient should be brought out for operation,  dressed  in
a loose gown, stockings, and  slippers : his neck-cloth   should
be loosened,  or a light silk handkerchief put about in place  of
it:  Three medical assistants should support him, one on each
side should hold, each, a leg and wrist, supporting the  sole of
the foot in the hollow of one hand ;  the third assistant  should
support his head and shoulders, and  keep him forward accord-
ing to the operator's directions.   The table should be big, firm,
and steady, covered with a folded  blanket, with one or two small
pillows  placed for the head to rest  upon, and one longer ahd
bigger to support the breech, or rather the loins; a  little  sand
should be strewed under the lower end of the  table.   A friend
should stand by to speak  to him, to encourage and support him,
and to give him occasionally a little wine and  water; and, as no
unseemly confusion should "be  allowed, every thing on the ta-
ble of instruments should be fairly arranged,  and every  atten-
dant steady, silent, and observing.  One only should hand the
instruments  ; while the assistant-surgeon, taking his  place be-
hind the young man who supports  the  right  foot, waits there
till the surgeon, having introduced the staff, and felt and placed
it, lays it down towards the right groin, and gives it to him in
charge ; when he is -to grasp  it firmly and hold it steady  with
his right hand, but without pressing hard, supporting the testi-
 cles and scrotum with the flat palm of his left hand, and pulling
 slightly upon them so as to stretch the perinaeum, and make  it
 tense for the incision. 
Of the External Incision.              179
   Upon the table are placed, a decanter of wine, another of
cold water, and a large glass of cool wine and water, which may
be poured into a  small tea-pot, as more convenient for the pa-
tient in the awkward posture in which he lies ;  a basin of warm
water,  with  the forceps and scoops  in it;  and in this basin of
water the  surgeon heats the staff with which he chooses to ope-
rate.   The  staff he chooses, and the gorget suited to the size
of the patient, and well and smoothly fitted to the groove of the
staff, and the  knife with which he is to cut, are laid on a plate
upon a  fine cloth or towel.  These instruments lie on the plate j
the staffs and forceps  and scoops are placed in the basin  of  ho t
water;  the sponge, for wiping the wound, in another basin of
warm water: the needles, the lint, the dry sponges,  or agaric,
to be used in cases of  unusual haemorrhagy, together with the
canula, round which the sponge or lint is to be wrapped in case
it should be necessary  to thrust a canula into the wound, lie be-
hind the basins and apart; and along with these is to be laid, in
another basin of warm water, a strong syringe, or a large glyster
bag and pipe, for washing out any small calculi or fragments of a
broken stone.   When the surgeon, advancing to the table, thus
arranged, warms the  gorget, and then sticks it  in his girdle or
apron string; warms the staff and oils it, with the purpose of
introducing it; twists a towel into his girdle, for it is impossible
to perform the several parts of an  operation neatly, with soiled
Jiands ;  and leaves upon the plate only the incision-knife, which
his assistant  hands him, upon  receiving the sign ; and  some-
times also the gorget is  left to be handed by the assistant.
   The  operation of lithotomy, as performed with the  gorget,
may  be divided into  these stages: 1st, The external incision,'
by which we divide the skin and the transverse  muscle  of the
perinaeum : 2dly, The internal dissection, by which we divide
the tat and  cellular substance, and  the fibres of the  levator ani
muscle, and open the urethra: 3dly, The settling ofthe gorget
in the groove of the staff,  and pushing it onwards through the
prostate gland : 4thly, The introducing the forceps, withdraw-
ing the gorget, and grasping and extracting the stone.
                       SECTION  II.

                  Of the External Incision.

  The general belief and the common description stands thus :
14 That you are to  make your staff protrude in the perinaeum,
and  to perform  your  external  incision, by  cutting upon the
staff." 
180               Ofthe External Incision.
   Nothing is more untrue*; we cut far from the staff: and
 this unfortunate  description occasions infinite perplexity to the
 young surgeon, who, in setting his staff, cannot cause it to be
 felt in that place where he must perform his incision,  and who,
 having made his incision, and penetrated to a considerable depth
 without feeling the staff, continues in confusion and dismay.
   The external incision  relates  not at all to the neck  of the
 bladder, nor is it made upon the curve ofthe staff; it relates to
 the great hollow betwixt the rectum and tuber ischii;  it is de-
 signed merely to open the way into  this hollow, through which
 the stone is to be extracted;  and the  surgeon's chief care must
 be, after cutting  through the skin and fat, to divide the transver-
 salis perinaei muscle, and all the ligamentous fibres, which would,
 if left undivided, oppose the extraction of the stone.    The in-
 cision begins  at that point, an inch below the scrotum, where
 the heel of the staff is felt, and, departing  from that  point and
 leaving the direction of the staff, it passes over the great hollow
 in a line betwixt the anus and tuber  ischii;  the incision is  per-
 formed in  the following manner:—The surgeon seats himself on
 a low  stool; the assistant draws the testicles upwards, to make
 the perinaeum tense, and gives a slight pressure to  the staff;  the
Operator then lays his left hand flat over the right buttock of the
 patient, so that the palm of the hand lies upon the tuber ischii;
 spreads out his fingers upon the perinaeum, as in the posture of
 displaying a ring ;  by pressing first two or three times with the
 point of the tore-finger at the root of the scrotum, he  feels the
 heel ofthe staff; and then, by drawing the skin of the perinseum
 towards the left  side with the  points  of the fingers,  he makes
 the lurk betwixt  the perinaeum and the hip, even.   Then, taking
 the knife (which sometimes, while stretching the perinaeum, the
 surgeon holds in his mouth) in his right hand, he holds it light-
 ly like a writing-pen,  with the points of the thumb and three
 fingers; begins the incision about an inch (in a big man) behind
 the scrotum, and carries it downwards,  declining  regularly to-
 wards the  hip,  till  it terminates apparently upon the  hip, for
 though the incision is carried regularly in the middle betwixt the
 anus and tuber ischii,  yet, the skin being tenser to the side ofthe
 tuber  ischii,  the wound  seems to decline towards  that side.
 The extent of the wound being ascertained and marked out by
 this first stroke of the  knife, three inches and  a half in length,
 more or less, according to the bulk ofthe patient, or the size of
 the stone ;  this incision beginning behind the scrotum, proceed-
 ing obliquely towards the hip, running in  the middle betwixt

  * Moft furgeons whom I have feen operate, make the incifion in this manner,
 cutting  confequently through the corpus fpongiofum penis, nor have I feen any
 ill conferences from it. S. 
Of Cutting the Urethra.
181
the anus and tuber ischii, or holding off but a little from the anus
for fear of wounding the rectum, will be found to have its cen-
tre nearly opposite to the anus ;  and if the whole length of the
incision  be three inches and a half, two inches of its length will
lie before the anus, and one inch and a half behind.   The fin-
gers of the left hand, which at first kept the skin tense, are now
withdrawn for a better use.  The fore-finger now guides  the
knife, and the operator proceeds to dissect through fat and cel-
lular  substance, and muscular and ligamentous fibres, till  the
wound is free and open, till all sense ot stricture is gone ;  for it
is only by feeling opposition and stricture  that we recognize the
transverse muscle.  When  this hollow is fairly laid open, the
external incision, which relates  merely to the free extraction of
the stone, is completed; and  the  operator begins to leel for the
staff.

                       SECTION III.

                  Of Cutting the Urethra.

   The incision thus made is into the hollow of the pelvis below
the place of the staff, which is to be felt only in the upper angle
of the wound.   If it were  his design to operate only with the
knife, the  surgeon would  now push his  fingers  deep into the
wound, and, by the help of the fore-finger, dissect from the ure-»
thra along the body of the  gland, till he distinguished its  thick-
ness and solidity,  and reached the back part ot the gland ; then
plunging his knife through the back ofthe gland, and settling it
in the groove of the staff,  he would draw it firmly and steadily
towards  him, pressing the knife steadily  into  the groove of the
staff, and then, the free discharge ofthe urine assuring him that
the gland  and cervix vesicae  were divided,  he would lay aside
his knife, pass the left fore-finger into the bladder, withdraw
the staff, and introduce the forceps.
   But in operating with the gorget, the next business after the
outward  incision, is to seek  out, not the  body of the prostate
gland, but the membranous part of the urethra ; to find it, the
operator turns his fore-finger  towards the upper angle of the
wound ;  feels for the  staff close  under the pubis, where  it lies
close upon the bone, hardly to be distinguished from it; and as
the operator recognizes the transvtrsalis muscle only by the
feeling of resistance, he recognizes the membranous part  of the
urethra only by  the nakedness  of the staff.   But it is safest to
be very  clear, to dissect fairly to the staff, to  teel not merely '^
the membranous part of the urethra,  but the body of the gland.  -*
In this stage ofthe dissection you can do no  harm  ; a fair dis- 
182               Of introducing the Gorget.
 section may save you the disgrace and danger of making three
 or four unsuccessful cuts at the urethra; you therefore keep
 pressing down the rectum, with the  mid-finger a little crooked ;
 with the fore-finger pointed  nearly upwards, you  guide the
 knife in dissecting along the naked part ofthe staff, and the body
 of the gland ; and when all is fair, and you are prepared to strike
 into the urethra,  you place your  fore-finger upon the apex or
 point of the prostate gland ;  and turning the edge of your scal-
 pel upwards, you strike it firmly through  the urethra into the
 groove of the  staff, and draw it  towards you, steadily, along
 the groove, till you have  made an opening such as you cahnot
 miss, about half an  inch in length,  into which you fix the nail
 of your left fore-finger, or of  your  thumb,  and prepare to in-
 troduce the gorget.*

                         SECTION IV.

                  Of introducing  the Gorget.

   Keeping his thumb-nail firmly fixed in the groove, the  sur-
 geon gives away the  knife, and lifts  the gorget;  poises it,  and
 then holds it firmly in his hand.   He then passes the gorget in-
 to the wound,  where it enters pretty deep before it reaches the
 staff; then, pointing  the beak of the gorget to the groove ofthe
 staff, he lodges it fairly in the  groove, and running it once or
 twice  backwards and  forwards to be sure that  all is  fair,  and
 holding the gorget steady with the right hand, and reaching the
 left hand over the pubis to receive the staff from his assistant,
 he  lays hold of the  handle of the staff, holds it steady for  a
 moment,  then, moving the gorget with the right hand, feels by
 the left whether the beak runs fairly and smoothly in the groofpfe;
 then, the two hands  acting in concert with each other, the ope-
rator balances  the staff and gorget, and by making the  two
hands  feel  each other, prepares them for co-operating in the
most critical moment of driving in the gorget; and when all  is
prepared for driving  home the gorget into the bladder, the  sur-
geon depresses the handle of the staff,  so as  to carry thepoint
of it deep  into the cavity of the bladder; his staff stands, at
this moment, at  right angles  with the patient's body ; he rises
from his seat, stands over the patient, for  an instant of time,
balancing the  staff and gorget  once more,  and, feeling once
  • I intreat thofe who are not perfectly confident, to make their incifion of the
urethra more than half an inch in length; an incifion of half an inch in length is juft
fufficient to be diftinctly felt, and to allow the beak of the gorget to be lairly intro-
duced ; but it is an incifion which a furgeon unaccuftomed^with operation might
lofe and fall into confufion.  I advife him rather to flit up nearly the whole length
of the membranous part of the urethra, when his incifion will be nearly an inch
in length. 
Of extracting the Stone.               1&3
 more that the beak is fairly in the groove,  he runs  it home in-
 to  the bladder, pointing it rather upwards, than directly back-
 wards :  then the  urine  gushes out ; the  beak  of the gorget
 goes off from  the point of the staff with an audible cluck,  and
 the operator withdraws the staff with the It ft hand, as the con-
 clusion  of that movement with which he  drives in the gorget
 with the right.

                   Of extracting the Stone.

   The moment the gorget is driven home, as it always is,  up
 to the hilt, (the thumb of the operator, which lies upon  the
 gorge  of the instrument,  being  actually  within the  wound,)
 the fundus of  the bladder is in danger,—for the  horrid and un-
 natural feeling of being thus  impaled excites the patient to press
 downwards,  as in passing  the faeces and urine ;  the bowels are
 forced down upon the bladder ; the fundus of the bladder is for-
 ced, by this pressure from above, and  its  own natural contrac-
 tions, upon the edge of the instrument ; matters  stand now in a
 very dangerous condition,  and the  best means of preventing
 harm,  is to introduce the forceps quickly ! no time should  be
 lost in  the foolish ceremony  of introducing the fore-finger to
 feel for the stone! Those who use only the  knife, use the finger
 as a conductor for the forceps ; but those who use the gorget as
 a conductor for the  forceps cannot feel the stone with the finger,
 for it Vies under the gorget, and the gorget exceeds the length
 of two fingers.
  The moment the  gorget is thrust home, the  operator with-
 draws the staff, and gives it away ; takes the handle of the gor-
 get with the left hand,  and  the forceps  in the right; the chops
 of tto; forceps being close, he passes them  along the channel of
 the  gTOrcet, and the moment the right hand has introduced the
 forceps »the left hand withdraws the gorget.   Then the opera-
 tor,  taking the handles of  the  forceps, one in each hand,  be-
 gins to feel for the stone ; the forceps must, by passing along
the  gorget, inevitably pass  over the stone ; let him, therefore,
taking ^ie two handles  of the forceps, one  in each hand, stand'
high above his patient, point his  forceps downwards towards
the  bottom of the pelvis,  to  that sac or bulging of the bladder,
in which the stone  usually lies, and there he,  in nine of  ten
cases, will encounter the stone ; if he feels it with the forceps
 and canuot seize  it, it is  because he has passed over it, and
touches it only with the lower side of one of the chops. When
he teels that,  he presses the stone with the point of the forceps,
he then opens the blades with both  hands, grasps the stone,#ries
the  hold  he has of it in a way which it is impossible to describe. 
 184      Of the causes ofthe Slipping of the Gorget.

 then, by grasping very firmly with  the right hand at the extre-
 mity of the handles, he holds the stone firm,  and by laying the
 left hand on the forceps,  and holding with it also, he assists the
 right, confirms the hold, and prevents  at  the  same time (by
 slipping his left  fore-finger into the hinge) any undue pressure,
 such as a soft stone will not easily bear.  Having thus fixed his
 hands, he begins to pull; and if the stone be small and the inci-
 sion free, it comes easily and smoothly along.  But I have ob-
 served that the young  surgeon, when he feels the slightest op-
 position,  expects to succeed by  turning, twisting,  and  every
 kind of unmeaning  violence, and  has no  absolute  rule  for a
 stage of the operation, which should yet be performed with an
 intention and manner as  determined  as any other.   If  the sur-
 geon holds firmly and pulls in one uniform direction, though he
 had the strength of a Cyclops, he could not succeed; if he turns
 and twists his forceps from side to side, " this way and that way,
 ca-et-la," as if he were dilating, not extracting, according to the
 directions of Paraeus, since he is pulling without any design, he
 still has but little chance  to succeed.  If he will but reflect on
 the operation of the forceps, that the forceps are two levers with
 which he is to  act alternately, depressing first one side of the
 stone, then the other, he will not scruple to  adopt that decisive
 manner in extracting, which, though it seems harsh, is really
 easy, and relieves  his  patient the most speedily, and with the
 least violence.  Let him, after having seized the stone fairly,
 press the handles of his forceps first down, then raise them up,
 then depress them  again,  with a wide and free motion, and he
 will be sensible,  that by this slow  and equable motion, the parts
 are little  bruised by the cheeks of the forceps, and the  stone
 will be, in a few strokes,  brought to the mouth of the  wound,
 and turned out, by one  wide but  gentle movement, into the
 left hand of the surgeon,  which is held with the palm upwards
 ready to receive it.*
                         section v.

          Of the causes of the Slipping of the  Gorget.

  It will be  easily perceived that the  critical movement on
which the fate of the patient  depends, is, the cutting the ure-
thra, the lodging the beak  of the gorget in the groove of the
staff, and the  driving  home the gorget.   In  attending opera-
tions, I have observed, in this moment,  such a degree of hesi-


  •  If the ftonc be large, it will be obftructed by  the  arch of the pubis, un-
lefs the operator prefs downwards towards the rectum:  this muft be particu-
larly attended to in women.  S. 
Of the causes ofthe Slipping of the Gorget.     185
tation and evident alarm on the part of the operator, as convin-
ces me  that  it is a most important duty to explain  the  va-
rious causes  of  the  gorget  slipping  off from the groove of
the staff:  he will best guard this accident,  who  is, aware of
every possible cause:  it proceeds, lite every important  error,
from want of knowledge in anatomy : since   we often  see  the
surgeon seeking  the femoral  artery for an hour, to tie it in a
sound thigh,  (the aneurism  being in the ham,) we need  not
wonder if such an executioner mangle the urethra  in attempt-
ing to perform lithotomy, and conclude with thrusting his gor-
get betwixt the bladder and the rectum.
   1st,  It sometimes happens, that the surgeon, deceived by the
common description, and  expecting to cut his  incisions fairly
upon the  bend of the  staff,  goes deep into  the hollow of the
pelvis,  and yet,  after much dissection,  feels  no staff; falling
then into confusion, and anxious to be relieved from this  dis-
tressing scene, he begins to believe that he must somehow have
cut the urethra, and, believing this, he at a  venture thrusts in
his gorget: sometimes the surgeon, having  felt the staff,  and
distinguished the  membranous part of the urethra, and turned
up the knife, cuts  into the groove with so tremulous a hand  that
he hardly wounds it; and having failed to dissect the urethra
naked, before making this incision, the fibres of the levator-ani
muscle  close upon the small slit which he had  made in it,  and
thus, after feeling distinctly the  groove of the staff, he loses it
again,  and his gorget passes betwixt the  bladder and  the  rec-
tum.
   2dly, Confusion and alarm, in the simple business of cutting
the urethra, is a  sure indication that the  surgeon is in danger
of doing something very  terrible.  Often you  will observe the
surgeon, in place of turning up his knife at  once,  and striking
it steadily and firmly into the  groove of the staff, lay down
the  knife, and lift it alternately several times ;  first he be-
lieves that he has cut the  urethra,  and then again becomes
sensible, either that he has  not  cut it,  or that he has lost the
small slit that he  had made.   I have seen  the operator  give
away the knife, receive the  gorget from the assistant, point it
at the groove of  the staff, and  try to introduce it, resume the
knife, and make  new incisions in the  urethra, five  or  six  suc-
cessive times. I have seen  the  gorget driven twice,  not  into
the  bladder,  but deep  among the bowels,  for although there
was a stone, the  surgeon never reached the bladder, never one
drop of urine flowed, the stone was not extracted,  and the boy
died;  this last mistake is mere butchery ; the first is little sHiort
of it, for if every time that the surgeon  resumes the knife, he
has lost his  first incision  and makes a new opening in the  ure-*
                            2 A 
186      Ofthe causes ofthe Slipping ofthe Gorget.
thra, if every time that he  loses one incision, the urethra  has
turned in some slight degree upon the staff, before he  makes
another, the successive  incisions will almost  entirely separate
the urethra from the  bladder, and the slightest push ofthe gor-
get will drive off the  glanrjNrom the urethra.
   3diy, There is much too in the direction in which the gorget
is driven forward, for though the urethra be fairly cut, yet  the
angle at which the staff is held,  or manner  in  which the beak
of the gorget is laid to the  groove of the staff, may disappoint
the surgeon  of his purpose,  and make the gorget shoot past the
bladder or push off the gland from the urethra.  If the handle
of the staff be too much depressed, so as to turn its point high
up towards the fundus of the bladder, while the gorget is point-
ed too low towards the rectum, the gorget, in place of  enter-
ing smoothly, will start off from the  staff:  or  if, on the other
hand, the handle of  the staff be held too high, is too near the
groin, too much in its first position, and  the gorget pointed
much upwards, the directions of the groove and the beak ofthe
gorget wiil not correspond ;  the cutting edge of the gorget will
not be so directed as to cut its way forward ; the beak will hitch
against the point  of  the gland,  and may, especially if the ure-
thra be  mangled, force off the neck of the bladder and prostate
from the urethra.
   4thly, The surgeon, in place  of moving the  gorget along the
groove of the staff, sometimes   allows both gorget and staff to
go together  deeper into the  bladder,  till they touch its fundus ;
sometimes  the operator,  by an awkwardness  in the posture of
the gorget,  needs to use such  force,  that the  gorget, when it
starts through the first obstruction at the neck  ot the bladder,
may, (especially  in a contracted bladder) wound  the  fundus.
Even the forceps, blunt as  they are, may,  by  rudeness and ig-
norance,  be driven  through the fundus of the bladder,  the
stone escaping by the rent, where the  forceps cannot  follow it,
into the cavity of the abdomen.  Those  who prefer the gorget,
and  regard it as the  ultimate improvement of this operation,
avow these facts.   u I have more than once (says Earle) known
a gorget,  though  passed in a right direction, pushed on  so  far
and  with such violence, as to go through the opposite side ofthe
bladder."
   5thly, If  the staff be short and the assistant  unskilful  in  the
management of it, he may,  after the surgeon has cut  the ure-
thra, allow the stiff to recede from the bladder, and in thrusting
it back, push its point not home again into the bladder,  but  out
through  the wound  in  the urethra!   The  staff being thus
lodged betwixt the rectum and bladder, the gorget must follow
it; the surgeon feels the groove of the staff quite  naked, fixes 
         Of the causes ofthe Slipping of the Gorget.       187

the beak of his gorget, and drives it home in the true direction,
but no urine  flows !  upon introducing the forceps, he feels no
stone !  he is  in the end, after much violence, obliged to put his
patient to bed to die.  Such an accident is recorded  by  Mr.
Earle, it proves the dangers  of this  particular operation  with
the gorget, and the superiority of  that with  the knife ; the
plunge of the gorget, to those who know how to operate only with
the gorget is irremediable, but a surgeon perfectly acquainted
with the  parts,  and skilled in dissection, would, in such a case,
introduce his finger, feel for the prostate, strike his knife into
it, and, putting in his finger,  guide the forceps into the bladder,
and at least extract the stone, if not save the patient.  Chessel-
den  once  performed this, when another operator had failed,
and pushed his instruments betwixt the bladder and  rectum.
   6thly,"Though the gorget has passed right, the forceps may
be  directed wrong,  for after a first attempt at extraction, and
when the forceps have slipped, the scoop  or finger  are  intro-
duced,  and the forceps re-entered ; but, the opening  which the
gorget makes, does not very easily admit the forceps even when
the gorget lies in the wound, to guide them; after the gorget is
withdrawn, the  forceps enter with greater difficulty, they slip
more easily in among the loose cellular substance of the rectum.
The  operator  opens  the forceps, and feels in  vain for the
stone ;  he at last has an  indistinct  perception (A  the stone,
closes them upon it, grasps it, and begins to pull; but the for-
ceps slip ; the  bladder is  betwixt  the stone and  the  forceps.
These are the true sacculated stones,* but the sac is the bladder
and  the  cavity is that which is made among the cellular sub-
stance of the rectum,  by  the  turning ofthe  forceps in search of
the stone, and the opening their blades violently to grasp it.  In
one unfortunate case, the surgeon groping thus upon the outside
of the bladder, actually grasped  with the  point of his forceps,
and  twisted awray the great  part of  the prostate gland, which,
when he had thrown it down among his feet,  was  picked  up
by a professor of anatomy who assisted at the operation, and,
when the gentleman died, the parts were dissected out, and are
preserved.
   It is  unquestionable that the gorget is   often  thus plunged
among the viscera,  and perhaps it is to be lamented that ever
cutting for the stone ceased to be a distinct profession, or that
the operation was brought to that  kind of perfection which in-
duced ignorant men to venture upon  an operation,  which, even
 thus  simplified, requires  consummate  skill and knowledge.
 Whatever may be the apparent facility of this common operation
 with the gorget, that with the knife  is alone secure, it is indeed
   * There are  inftances of ftones contained in facs : I have feen a preparation of
 one : the circumftance is probably rare.  S. 
188             Of the Operation of Lithotomy.
   to the  last degree  simple,  as simple as that of cutting on the
   gripe; for it is cutting with the  knife  upon the staff, which is
   more easily  held, fixed, and directed, than  the  stone.   But
   since the  operation with the gorget  has been approved, and
   will continue to be performed, I have  taught it faithfully  ; no-
   thing can, in my opinion,  so well prepare the young surgeons
   against this fatal accident, the slipping of the gorget, as knowing
   perfectly the causes from which it may arise.   And I will now
   fulfil my purpose of describing the several acts and stages of
   the operation  in  that rapid succession in which they should be
   performed.*

                           section  VI.

                   Of the Operation of Lithotomy.

     An operation so mechanical as  this,  regulated in its  most
   critical  movement by a  grooved  staff, should, though  there
   must be no unbecoming haste,  proceed rapidly without a pause,
   the several acts being connected in idea,  and continuous in  ex-
   ecution.  The surgeon should never, to  catch the vain applause
   of the ill-judging spectators, proceed in  haste and  trepidation ;
   but he who can perform the operation  at all, will perform it best
   to his feeling,  and, for the safety of the  patient, rapidly  ; for,
   having  the purpose of the operation full  in his mind, its several
   stages areas parts of one continued action, on which his mind is
   so intent, his judgment so clear and   unperplexed, his hand so
   steady and resolved, that he moves, by  a sort of  instinct, with-
   out pauses, without fear.  In truth, dexterous and rapid execution
   are synonymous words; it is not policy, but feeling and self-confi-
   dence, that carries the  surgeon boldly  on ; this rapid energetic
   manner is natural and not assumed ;  it is even in  some degree
   essential  to the patient's safety, that the several acts should suc-
   ceed each other without stop or pause,—that, the gorget should
   be introduced as soon as the urethra is cut,—and,  the  forceps
   instantly  after the thrusting in of the gorget.
      The surgeon should be  prepared for this, and,  in place  of
   receiving and returning every  instrument from  his assistants,
   should  draw each instrument from  his girdle  when he is to use

     * When  this accident happens, which may be always known from not  hearing
   the click which is produced by the flipping of the beak of the gorget from the end
   of the groove of the ftaff, and from no urine flowing upon the introduction of the
   gorget, if the furgeon has not withdrawn the ftaff, which he never fhould do un-
   til he is certain the gorget is in the bladder; he fhould withdraw the inftrument
* -and make another attempt  to introduce it; but fhould he have withdrawn the
   ftaff, the pat itnt muft be unbound, put to bed, and the wound fuffered to heal before
   any thing further is attempted.  S. 
Of the Operation of Lithotomy.   -            189
it.  Every thing being prepared, he ties an apron about him,
which being firmly girt, he  twists a towel through the apron-
string,  fixes the gorget also  in the string like a dagger in the
girdle,  and the forceps he puts in the fore-pocket of his apron.
Then  advancing to the patient, who is tied and placed for ope-
ration, though his  posture is not yet adjusted, he  dips the staff
in oil  and passes it gently and softly ; he  then  dips the finger
in oil, and insinuates into the  rectum, to feel that all  is right
and  fair;  he then wipes the  fingers that are soiled with  urine
or faeces, or lubricated with oil, and seats himself before his
patient, on a low stool, pulling the breech towards him,  till  it
projects  fairly over the edge of the table, and pressing in the
doubling of the blanket under the breech, till he has raised it  to
a proper angle; he then commits the patient's feet  to the lateral
assistants,  who are to keep the breech in this suspended posture:
then  reaching his right  hand  over  the patient's breech,  he
takes a firm  hold on the handle  of the staff;  presses its heel
against the perinaeum; feels for it immediately behind the scro-
tum  with the fore-finger,  or with the edge ofthe  thumb; lays
down the handle of the staff to the right groin, and gives it  to
the assistant-surgeon  to keep it steady.
  He now  wipes the  perinaeum with his towel,*  lays  the left
hand over the hip and anus, and spreads  his  fingers so  as  to
stretch the perinaeum ;  then fixing the point of the knife just
below the point where he feels the heel of the  staff, (i. e.  about
an inch behind the scrotum) and pressing with  the point of the
knife to mark the beginning of the incision, he  draws it with a
firm and steady motion, obliquely downwards, till  he passes the
anus about an inch and a half, the middle and  deepest  part  of
the incision being thus opposite to the anus, but inclining some-
what towards the tuber ischii to  avoid the rectum.   The first
stroke of the knife passes through the  skin and fat; a second
stroke,  guided by the fore-finger,  passes deep into the hollow
of the pelvis, through fat tendinous fascia, and  the transverse
muscle, and,  in short,  through every obstruction,  till the  open-
ing is quite  free.   A third dissection, in which the fore-finger
is turned upwards to the pubis, while the  ring and mid-fingers,
a little crooked, repress the  rectum, lays the staff  almost  bare;
and then, the edge of the  knife also turned upwards, as well  as
the finger which guides it, is struck into the groove of the staff,
through the membranous  part of  the urethra;  and the knife,
being then drawn  steadily forwards, slits it up  from the  point


  * The rectum generally protrudes in a child, from crying and ungoverned
{training,  and  needs  to be wiped and held afide  by a bit of linen  cloth laid
upon it. 
290           Ofthe Operation of Lithotomy.
ofthe prostate gland  nearly to the  bulb of the  urethra, i. e.
through almost the whole length of the part that feels naked.
   The edge of the thumb-nail being fixed steadily in the groove
of the staff, the beak of the gorget  is lodged in the groove; the
surgeon,  first  moving the  gorget  backwards  and forwards,
reaches his left hand over to  grasp the staff,  takes  a firm hold
of it, rises from his seat, balances with the two hands tor a lew
instants, and feeling that the  instruments correspond,  that the
hands feel each other, and re-act mutually, and that the btak of
the gorget glides  smoothly and equably in  the groove  ot the
staff, he holds the staff steady,  clenched  in a dagger-like man-
ner, in his left hand, and pushes the  gorget  steadily, strongly,
but slowly, forward with his right.   The moment that he feels
the resistance over, and the  urine flow, he begins to give that
turn to the staff (viz. depressing the handle  ot  it to the belly of
the patient) by which  the gorget is  disengaged,  and  the staff
withdrawn ; he slips the staff into his pouch, or  lays it down,
seizes the handle of the gorget with  the  left hand, draws out
his forceps  with  the right, lays the chops of them gently in the
broad channel  of the  gorget,  pushes them gently onwards into
the bladder, and  when  he  feels  them in the  open cavity, he
withdraws the gorget, withdrawing it carefully  in  the  direction
in which it was  pushed in, that its edge may  make no second
wound.
   The staff is withdrawn as  a part ofthe same motion by which
the gorget is introduced ; the gorget is withdrawn as a part (the
concluding part)  of the same motion  with which the forceps are
introduced ; the  gorget is next slipped  into the pocket  ot the
apron, and both  hands applied to the forceps, one to each han-
dle ; and the operator, conscious that the forceps now look di-
 rectly upwards towards the  fundus ofthe  bladder, where the
 stone cannot be,  and that the gorget has carried them  over the
 stone, raises  the handles  high, and while he opens the  blades
 gently, points them downwards to the sac behind the prostate,
 and near the  neck ot  the bladder where the stone  lies; and he
 withdraws them at the same time a little, that they may have
 the stone before  them:  he then pushes  the stone before him,
 and thus excites the bladder to contract, and press it  close to
 the chops of the  forceps ; he closes them, and presses once  or
 twice in directions slightly varied, according to feelings  which
 cannot be described,  before he thinks himself sure ot his hold ;
 but when he  is sure, he grasps firmly, very  firmly, because, if
 the stone be so large as to endanger its breaking, he is more will-
 ing that it should break into a  hundred  pieces than injure the
' parts by dilatation; and he now depresses the handles quite low,
 because the direction in which he is to extract the stone, is en- 
*
                Ofthe Operation of Lithotomy.            191

 tirely opposite to that  in  which he catches it.  The forceps,
 holding the stone, now point  directly upwards, as at first: he
 holds firm, and pulls almost directly downwards, that the pres-
 sure  may  be  not against the pelvis,  but against the dilatable
 parts in the lower angle ofthe wound ; and moving his forceps
 gently, slowly,  steadily, from side to side,  with a  very wide
 motion, he depressts, first,  the upper side ofthe stone,  then the
 lower side, and so alternately, till the widest parts ofthe chops
 stretch  the wound: the stone begins to appear ; he holds the
 palm of the left  hand, which had hitherto held firm the hinge
 of the forceps, so as  to receive  the stone; and with one wide
 motion ot the forceps moving the handles largely downwards,
 he turns it out.
   If  the  perinaeal artery, which is unavoidably wounded,  is
 large, and bleeds profusely,  it is usually  tied with  the needle
 after  the  external  incision, and  before  the urethra is  cut.   If
 the haemorrhagy  be  neglected till the operation is finished, the
 arteries are then  so bruised,  and  so retracted among the cellu-
 lar  substance, that they never bleed again; if there be any in-
 ternal haemorrhagy from arteries larger than common, coursing
 round the prostate gland, and cut with the gorget,  it is disco-
 vered only some  hours after  the patient is laid in  bed; it  is
 known by the  desire to pass urine, the sense of load at the low-
 er part of the  abdomen, and restlessness and pain ;  and it is re-
 lieved by pushing in the finger, «nd breaking down the coagula,
 which are then*discharged  as from  the  uterus in an abortion,
 and  then, if fresh blood continues to flow, farther danger is pre-
 vented by thrusting a  wide canula into the wound, surrounded
 with a piece of dried sponge, the canula being passed through
 a hole in the centre of the sponge.*
  The  stone  being extracted, the*urgeon,  having examined
 and assured himself that there is no second stone, lays  a piece
 of oiled lint within the lips of  the  wound; unbinds the patient,
 and lays his thighs together,  the knees being bended,  and, an
assistant holding his hand flat  over the wound ;  and the  patient
 is conveyed to bed, and laid  on  his right side.   An opiate is
 given with a glass of warm wine and water;  the curtains are
 drawn, the windows closed, and  a medical attendant being left
 by him to watch  any accession of haemorrhagy, or abdominal
 pain,  he is  composed to rest ; the urine which flows  freely-
through the wound is received upon a thick folded cloth.   The

  * If the internal pudic artery be divided, which it fometimes is, particularly
 when Mr. Cline's fingle-edged gorget is ufed, it may be reftrained; for I have
 feen it done, by introducing, after the  operation is concluded, a large doffil of lint,
 and prefling it firmly for fome minutes againft the artery, fhould  however this
 not anfwcr, the veffel may be tied.  S. 
192             Of introducing the Catheter.

warm bath, clysters, bleeding, if he be an athletic man, and em-
brocating the lower part of the belly with spirituous applications,
are the chief means for preventing abdominal inflammation.
   I hope that, in preparing my reader  for understanding this
description,  I have with proper seriousness inculcated the im-
portance of study, and the fatal consequence of imitating, with-
out intelligence  or design, the motions of other operators ; that
I have not, by any presumption on my part, incited the young
surgeon  to anv rash or unpremeditated attempt or new exploit,
but have described perspicuously, simply,  and with a sincere
sense of duty,  the  most important and eventful operation in
surgery.
         — 4!» —I


DISCOURSE  XIII.
OF OBSTRUCTION OF URINE.
                        SECTION I.

                Of introducing the Catheter.


 X HE operation of introducing the catheter,  if it do not re-
quire intrepidity and courage, requires at  least  peculiar deli-
cacy, a perfect knowledge of the  parts, and, above all, a humane
and steady temper; for when the surgeon is at  any time con-
scious that he is  in danger of committing  violence, he must
submit to the imputation of having failed, even at the risk of
his reputation.  The obstacles and difficulties to the introduction
ofthe catheter are besides of so  peculiar a kind,  that while all
our diligence to learn  this art  is necessary,  our utmost dili-
gence is sometimes unavailing, for the most unskilful surgeons
have  succeeded, by a sort of chance, even after the most dex-
terous have faili d.
  There are no c rcumstances in which the patient is more per-
fectly grateful,  than for the relief which the skilful introductioa 
              /  Of Introducing the Catheter.             193

 of the catheter procures;  for  it is-.a sudden and entire relief,
 from anguish more excruciating than any description of pain.
 Often the valuobf  our assistance is'enhanced by the unsuccess-
 ful attempts of others less fortunate or less skilful.  To feel this
 uneasiness and intense desire to pass  the urine, to submit to a
 dreaded operation, and yet to be disappointed of  relief;  to see
 the blood streaming from the penis,- and still to continue in ago-
 ny ; to lie tossing  with fever and pain,  aggravated by dismal
 recollections of many  having died of obstruction  of urine  ; and
 then in the  midst of these sufferings, to receive sudden relief,
 from the hands of a skilful man, must  be accompanied with a
 deep  sense of gratitude.   Such reflections as these, my reader
 will not think  unnatural.   I  would condescend to suggest even
 selfish motives, to the few who are born to feel no others,  as in-
 ducements to study those diseases 6i which I am now to offer a
 short practical sketch ; I should be inclined to blame the sur-
 geon very much, who was not equally  prepared  to use the ca-
 theter as to use the lancet.
   The introduction ofthe catheter is an operation which a good-
 surgeon, who is able to perform with ease, would be apt to de-
 scribe with little care or minuteness ;  and there is unfortunately
 in this,, if any part of surgery,  a kind of address which is to be
 attained only by  practice.   Yet this  experience  and acquired
 dexterity Ss founded on previous knowledge of  the  parts.    I
 shall give, as the first  and  most sample lesson in this depart-
 ment of surgery^ that of introducing the catheter, in cases where
 the urine is retained, not from  any resistance arising from tu-
 mour or other obstruction in  the urinary canal, but from  para-
 lysis or mere want of power  in the bladder itself.
   When, from remaining  too long in ceremonious companies,
 in assemblies, in processions, or in^oourts of justice ; when,
 from travelling in public carriages, orfrom any cause of delica-
 cy or restraint, a man  resists too long the calls  of nature, the
 bladder being over-distended, loses its contractile power, and
 when he would pass his. urine he makes vain and painful efforts
 to discharge it:  a spasm about the neck of the  bladder then  a-
 rises, and resistance is  added to want of contractile power; eve-
 ry repeated effort increases the difficulty, and pain succeeds to
 the simple desire of emptying the bladder.  It  is this pain and
 spasm alone that prevents the catheter passing with perfect ease,
 and makes all the opposition  we experience  in performing that
operation on the living body, which is so easily performed on
 the dead ; for, the  introducing the catheter in a corpse,  is not
 a lesson of that importance which has usually been supposed.
   The catheter passes  with perfect ease, when  the retention of
urine proceeds from a paralytic affection  of the bladder,  as in
                            2 B 
194             Of Introducing the Catheter.
fractures of the spine, in palsy or apoplexy, in confluent small-
pox, in the end of low fevers.   Even in cases when strangury
and pain, accompanied with intense desire, have followed the
simple retention of  urine ; in cases when the canal is generally
inflamed, as  in gonorrhoea, the surgeon should still  be able to
pass the catheter with tolerable ease.   But in cases of stricture,
or other disease in the urethra,  the catheter is seldom useful ;
and where  the prostate gland is diseased, it passes with the ut-
most difficulty, if, indeed, it can be made to pass by any means.
You proceed in the following manner :
  You place  your  patient with his back resting firmly against
the wall, striding, but not very  wide, his feet being projected
before him a very little; and you place yourself on his left side,
kneeling on your right knee ? you may lay him across  the bed,
his feet resting on the floor,  his buttocks touching the edge of
the bed, and his head and shoulders supported with the  pillows;
or he may seat himself upon a chair, resting with his hands up-
on the seat, the perinaeum  projecting a little over the edge of
the chair, and one  of his  friends standing behind  to support
him.   In whatever posture you place your patient, you find the
posture of  kneeling on the right knee the most convenient to
yourself; it gives you perfect steadiness ; and, by placing your-
self low with regard to the patient,  you obtain a perfect com-
mand of your catheter,, which, while you are introducing it,  is
to move in a circle.
  You lift  the point of the penis betwixt the fore  and mid-fin-
gers,  securing  the  posture of the penis  by pressing the  glans
with your thumb : then taking the catheter, which  is previously
warmed, and smeared with oil, white of eggs, or butter, in your
right hand, you hold it firmly by the ears, betwixt the thumb
and fore-finger ; and while you hold by the wings with the fin-
ger and thumb, you lay the middle,  ring, and little fingers, flat,
across the shaft, just as you would a pipe.   You then apply the
point ofthe catheter to  the opening ofthe urethra, and glide it
down steadily andrather rapidly along the urethra, drawing the
penis with the left hand, pressing the catheter onwards with the
right, and guiding it with a semicircular sweep round the pubis,
in proportion as the catheter passes along the urethra.   The two
hands, thus re-acting, the catheter glides onwards without ob-
struction, till it has turned round the pubis, and you become
sensible by  the turn, by the length it  has passed, and by the de-
gree of resistance, that it  has approached the  neck of the blad-
der, and is just about to enter it.
  This is the critical moment, in which may be  seen whether a
surgeon can or cannot pass the catheter;  for  if  he knows how
to pass it, he suddenly, but not violently, changes its direction- 
                Of Introducing the Catheter.             195

He depresses the handle with a particular kind of address,  and
raises the point, which, as if it had suddenly surmounted some
obstacle, starts into the neck of the bladder, and the urine bursts
out in a jet from the mouth of the catheter.
   Those who are unskilful, press the tube forward, and persist,
as they had begun,  in drawing up the penis, pulling it out to an
immoderate length, imagining, as indeed they are plainly  told,
that by stretching the penis, they lengthen the urethra, and make
it  straight, whereas, they elongate only that part of the  urethra
along which the catheter has already passed.
   In  truth, the elongation ot the penis does not at all affect  that
part of the urethra at which the catheter is interrupted, the  part
which lies in the perinaeum, and which is fixed by various con-
nections  : a dexterous surgeon indeed generally passes the cathe-
ter with  one  continuous motion uninterrupted, and without let-
ting go the penis;  but when he  does feel that he is obstructed
he lets go the penis, as of no further assistance ; he, (while his
assistant  holds up the scrotum,) lays two fingers along the peri-
naeum, on each side of the urethra, and draws the fingers along
the perinaeum towards the scrotum, soothing the parts,  and re-
laxing the spasm, by the  pressure and motion, and acting  as if
the design were to work the urethra along the catheter, as he
would put the bait on a hook.   If this fail,  he kneeling before
the patient, oils the left fore-finger and passes it into the anus,
the effect of which,  is, I am persuaded, neither the elongation of
the urethra, nor the unfolding any inequalities, of the canal, but
merely lifting up the point of the catheter,  by  the  pressure of
the finger, and with a degree of force and effect which  the sur-
geon  has not the confidence to use in the proper way of bending
down the handle of the staff.
   From the  moment in which the catheter begins to pass along -
the perinaeum, the point should be pressed strongly against the
upper side of the urethra which lies under the pubis ; the cathe-
ter must be all along carried so close to the arch of the pubis, as
never to lose the feeling of pressing hard against the bone, and*
when it approaches the neck of the bladder the  point  must he
turned quick under the arch of the pubis, as if it were  the sur-
geon's intention to keep it pressed close to the inner surface of
the  pubis.   While  the  surgeon  makes  the  point run  thus
along the bone,  as if to avoid  the angle at the lower part of the
urethra,  he must guide the catheter steadily along, holding it
firm and with an action something like that of pulling, as  if it
were his design to hook the pubis.   He  must turn down the
handle and raise the point of the catheter, I will not  say  sud-
denly, or strongly, but  with  quickness  and address, as  if it
were his design to  catch at some orifice, distinct from the canal 
196             Of Introducing the Catheter.
 in which the instrument is passing, and to catch it with addres?
 and quickness, as if it were an opening which might otherwise
 escape.
    If these manoeuvres do not succeed, the surgeon changes his
 catheter, choosing one bigger or more slender, with a  greater
 or lesser curve,  according to what observations he  may have
 made  in his first  attempt;  but if  the  catheter has been of a
 good form and commodious size, yet has not passed easily, he
 should, instead of choosing a rigid  catheter of  another  size or
 form,  take one  that is flexible tor his second attempt.  The
 flexible catheter is  generally slender and  of sufficient  length,
 and its shape may be accommodated  to all occasions, and to all
 forms  of the urethra ; for, having a stiff wire, we can give that
 wire (either  before or after it is passed into the catheter) what-
 ever shape we please ;  and,  what is of still greater importance,
 we can introduce  the instrument without or with the  wire as
 circumstances may direct; or what I find far more advantageous,
 we can introduce the wire partially  so as not quite to reach the
 point  of the catheter, but within twro inches or a little more of
 the point, by  which contrivance the point, if previously  warm-
 ed and wrought  in  the hand, has  so much elasticity that it fol-
 lows the precise curve of the urethra, and has yet sufficient rigi-
 dity to surmount any slight resistance.  If this too fail,  and es-
 pecially if there be the slightest reason to suspect that the resist-
 ance is not merely spasmodic, but arises from stricture near the
 neck of the bladder in the young, or  sweUing of the prostate in
 the aged, we take a small bougie, turn up the extremity of it
 with the finger and thumb, so that  the hooked point may look
 towards the pubis,  oil it lightly and rapidly,  and allowing no
 time  for the softening of the wax, pass it into  the urethra, run
*• it down nimbly  to the place of the  obstruction, turn it  with a
 vertical or twisting motion, and stick it fast in the  constricted
 part;  and having left the bougie thus fixed for ten minutes or a
 quarter of an hour, we usually find upon  withdrawing  it, (es-
 pecially if, in withdrawing, we feel a pull as if it would invert
 the urethra,) that either the urine will begin to  flow, or at least
 that the catheter will now pass.
    But when we are unsuccessful in these operations, just as
 when  we fail in our attempts to reduce a hernia, we resort to
 other  means of  relieving the stricture of the parts,  before ma-
 king a second attempt; first  we bleed, bleed repeatedly, which,
 at once prevents the most fatal of all symptoms, inflammation
 of the abdomen,  and serves as an anodyne, and never can be
 superfluous where the future dangers  of the  case,  and  in some
 degree the  present obstruction,  proceed from inflammation;
 when  we observe the condition of our patient, his flushed face, 
Of Introducing the Catheter.              197
parched tongue, and rapid pulse, we can feel no reluctance in
bleeding.   We immerse the patient in a warm bath, and rub
the perinaeum and lower part of the abdomen with  stimulant
embrocations, as spirituous and camphorated balsams or oint-
ments ; we lay hot and stimulant applications to the pubis, co-
ver all the parts with a thick made  poultice,  impregnated with
camphire or  onions,  and, above all, give opiate injections very
strong, tor we find this the most effectual means of alleviating
the pain and  desire, or in other words,  the spasmodic action of
the parts :  it is spasm merely that  intercepts the catheter; tor
were  the path nt dead, no such opposition would be  experien-
ced ;  innumerable  dissections have  proved  that the catheter,
which was not admitted in the living, passes easily into the dead
body.  If after a  few hours of these applications, the  pain is
relieved, and the patient, by the force of the opium, is inclined to
rest,  we are then able to pass the catheter with ease;  and when
we have relieved such a patient, we must continue our attentions
to  him unremittingly; we give him prudent advice lest the
same  continued life of thoughtlessness and dissipation  confirm
the complaint; we charge ourselves with drawing off the urine
thrice a day,  till the parts recover their tone ; and we  never dis-
miss such a patient without acquainting him,  that on the slight-
est excess or imprudence, he will relapse into this painful condi-
tion ; for the bladder once distended is  apt to be again distend-
ed, without  creating any sensible  effort, and, being over-dis-
tended, it loses altogether its muscular power.
   The period at which a  patient  will recover the  contractile
power of his bladder must depend  much on  the conduct of the
surgeon, who will be able to restore its tone  by being careful in
his attendance, and preventing the bladder  being at any time
filled ; by  directing the patient to make occasional efforts to
discharge his urine, even although not incited by any desire ; by
applying stimulant embrocations to  the pelvis;  by giving stimu-
lant and purgative injections, or, by giving,  if necessary, a few
drops of tincture of cantharides ;  and finally by applying blisters
from time to time to the sacrum,  which I hold to be the most
powerful means of restoring the contractility ofthe bladder :
along with these means the walking barefooted on a stone floor,
or having  cold water dashed or sprinkled about the pelvis, is
 very effectual in seconding the efforts of the patient.
   If in introducing the catheter, you find your instrument stop
 early in a lower part  of the urethra, and have reason, from the
 history of the case, to believe that the obstruction arises from
 stricture, you must  not persist  in pressing on  your instru- 
198             Of Introducing the Catheter.
ment, but withdraw it,  and pass a small bougie, or use a caus-
tic*
   If,  in passing the catheter, you encounter a stone, which you
know  by  the catheter grating against it, be not rash to drive it
back into the bladder, but press your finger upon the perinaeum
behind the stone, lest it should be driven back,—withdraw your
catheter, and stop to consider of the case, and the means ot giving
safe and permanent relief.
   But if from the age  of your patient and the history of his
complaint, you suspect  the  prostate  gland to be diseased, and
especially if, from introducing your finger into the anus, you
are assured that the complaint is of that  dismal  nature, you
may, after having failed in  the common way, turn the concavity
of your  catheter towards  the perinaeum, and turn it at that
point of your progress in which you are sensible of the opposi-
tion from the diseased  gland and would pass your instrument
through it.   I have sometimes imagined  that  this method  of
operating contributed to open the cleft or valve-like mouth of
the tumid prostate.
   I am next, I confess, anxious to make the due impression on
my reader's mind, when I come to explain a prejudice which has
indeed almost ceased to appear in this odious light, from being
avowed by  men of high reputation and supported by facts.  It
has been asserted, that,  though upon introducing the  catheter,
blood flows  from the urethra in a full stream, tt No  harm  is
done; such haemorrhage is rather useful, and  facilitates every
future attempt  to pass  the instrument.'*  I will freely acknow-
ledge that often, from a slight injury a great profusion  of  blood
will flow; this is an inevitable consequence ofthe peculiar struc-
ture of the parts,  and no great harm  ensues; but that  such a
discharge of blood  is entirely harmless, is a sign of dexterity,
or of any thing but awkwardness, violence,  and a breach of the
cellular substance, I cannot allow.

  * In this cafe, as well as the foregoing, the patient will be in general relieved
by bleeding, anodyne injections, &c.  For even where ftrictures exift, fpafm is
frequently  the  immediate caufe of the retention of urine.  S. 
<   199  )
DISCOURSE  XIV.
OF THE  VARIOUS  CAUSES OF  OBSTRUCTION
  OF  URINE; STRICTURE, STONE, INJURY OF
  THE  PARTS  FROM BLOWS, &c.
SECTION  I.
                       Of Stricture.

 JL HE stream of urine small and tortuous, even in the  sound
state of the parts, impresses us naturally with an erroneous
conception of the size of the urinary canal.  Mr. Home, having
injected it with wax, was surprised to find the roll which repre-
sented the  urethra so large ; and  I myself, when I made a
drawing of  the   urethra,  could hardly  believe  my  draw-
ing at all correct or faithful; for the urethra  though corru-
gated in the  living, is, when  expanded  in  the dead and dis-
sected  parts, full  half  an  inch broad.  This  canal,  made
for dilatation, is full of rugae ; and  the bigness  ofthe stones
which  pass along the  canal, and the size of the catheter which
it receives with ease,  intimate to  us its natural dimensions and
peculiar conformation, which is  such  as to enable  it to  dilate
into a large sac, wherever the passage  is obstructed by a stone
or stricture, and the urethra is forced by the  propulsive power
of the bladder.
   It is to no peculiarity of organization, that I would ascribe
the disease  we call a stricture of the urethra : I ascribe it nei-
ther to the rugous  form of  the internal membrane, nor to  the
muscular and contractile power with which the whole canal is
supposed to be endowed ; though the fact of an occasional  or
spasmodic stricture, ending in permanent disease, setms to ar-
gue this very strongly.  As the tumour, which  is a  wart on the
skin,  is a pile when growing near the anus, or a polypus  when
in the passages of the nose or throat ;  so that vascular action
and thickening of parts, which externally would form a tumour, 
20G                    Of Stricture.

forms a stricture in any hollow tube ; and the stricture is still
the same, whether it form in the throat, rectum, urethra, or pre-
puce.  Stricture is tumour, and, as a tumour must perpetually
increase while the circulation  survives in the part,  unless a to-
tal adhesion of the canal, by obliterating the cavity, put an end
to the  action.   " When in a small degree, (says Mr.  Home)
this  contraction appears, upon examination after death, to  be
simply a narrowing ofthe canal at that part; but, when the con-
traction is increased, it becomes a  ridge, projecting into the ca-
nal."  Page 21.
  Those  who have been troubled  with an  occasional or spas-
modic stricture of the urethra, have  every  reason to fear that
it will become permanent: yet I have often observed stricture
to be merely spasmodic, and  I think I have found it often a
sort of febrile  disease.   The stricture  I speak of is more fre-
quent  in winter, arises from  cold,  is attended with fever,  and
is more easily cured by any thing than the  bougie, which but
aggravates  the  complaint.  This  febrile stricture I have fre-
quently cured in men of the  most chaste and exemplary lives,
free from  the slightest  pollution, married,  and of intelligence
much above any kind of secrecy, where  they were  once pleased
to give their confidence, men  who never  were diseased.  The
fit of obstruction is  preceded by head-ach, languor, and listless-
ness, while the obstruction continues: and the accession of the
hot stage,  which comes on in the evening,  and especially the
paroxysm of perspiration, which comes on  during the night, is
generally a forerunner of relief.  I have seen the obstruction  so
complete that not one drop of urine has passed, though accom-
panied with a  degree of desire which Urged the patient to place
himself in the posture every quarter of an hour, and with such
violent straining as produced a partial erection of the penis,
whence always the  obstruction became complete, though not  so
before : the bougie being at the same time resisted at  a single
point as  fairly as if the stricture were permanent  and organic.
I have gone to such a patient at midnight, with catheters and
bougies, resolving  to relieve  him  from  the distention of the
bladder : yet  feeling a degree of reluctance at using harsher
means, I have,  by  ordering a sharp emetic,  followed  up by a
strong dose of laudanum with hot wine and water ; by rubbing
the  perinaeum very hard at  the  same time with  camphorated
mercurial ointment;  and by  fomenting the  lower part of the
belly,  if necessary, with a hot stimulant fomentation,  or wrap-
ping the parts in  a large poultice, been saved from doing any
thing painful, and have been rewarded for my patience and pru-
dence, by  seeing the urine discharged freely next  day, and con:
tinue to flow in a full and easy stream. 
Of Stricture.                     201
   I  have, after a  scene  of this  nature  was  over, found  the
 bougie pass with perfect  ease  into the bladder, and have  the
 pleasure of knowing that many who have been alarmed with
 these symptoms have  continued for years free from  organic
 disease, though thus affected from spasm.
   The  sudden and total obstruction, which I have just describ-
 ed, is often seen in  the conclusion, but rarely in the commence-
 ment, of proper stricture, which usually betrays itself by little
 accidents, and symptoms not  at all distressing.  The  patient,
 who has a real stricture, whether from venereal complaints, from
 excess committed  in warm  climates, or from any accidental
 cause, is far gone  in this malady before he is. conscious of it.
 He  is first thoroughly alarmed by a sudden interruption of  his
 urine, when, having remained at table with his friends, he has al-
 lowed the bladder to fill beyond its natural and easy condition ;
 for that straining which accompanies over-fulness of  the bladder,
 causes a state  of half erection  of the penis, the  cellular sub-
 stance thus filled with blood,  compresses the canal of the ure-
 thra,  and aggravates any latent  stricture, till the urine  is actu-
 ally  interrupted.  The patient,  the  more  he strains, feels the
 difficulty the more  ; he but increases it by straining, and now
 observes, in  a particular manner, the smallness and the spiral
 form  of the stream of  urine:  from this unfortunate hour his
 situation  attracts  his  attention, and his disease increases;  he
 recollects that at times, especially after coition, he has had such
 a degree of running for three  or four days as has inclined him
 to believe  himself infected with gonorrhoea ; he  has felt occa-
 sionally  slight  pain  in the urethra, accompanied with very fre-
 quent  desire to pass urine, which he is  in  the custom of dis-
 charging every  three or four hours.  He now remembers that
 for some time he has been  forced to rise, according to the quan-
 tity he drinks at supper, three or four times during the night;
 and all this  he would willingly ascribe  to spasm,  because or-
 ganic stricture is indeed  always  accompanied with spasm; the
difficulty of making urine, far from being permanent, returns  in
 paroxysms, is aggravated by cold, increases in  winter,  and in
 summer almost disappears, is easy while the patient is in a warm
chamber,  is  absent almost  entirely  when he perspires, returns
upon exposing himself to the air, and those paroxysms,  which
last three or  four days, proceed usually from  changes of habit,
so slight, that he > can hardly mark  the  cause.   But this run-
ning like a gleet, returning, upon using venery, accompanied
with irritation, but never  arriving at the virulence of a clap ; this
occasional difficulty of passing urine, and the frequency ot the de-
sire to pass it, are among the most certain signs of incipient stric-
ture, which  ends at last, sometimes in the  course of a few 
202
Of Stricture.
months,  (though often it is delayed for years) in unequivocal
disease.
  This scene of suffering once begun,  is renewed from time to
time.  The running, and the desire to pass his water, increase
every time he attempts coition, and he is threatened with abso-
lute and total obstruction every time he drinks hard, or  rides a
hunting, or travels  post,  exposes  himself to cold, is seduced
into debaucheries, or any way interrupts the quiet tenor of his
life ; and when  stricture is thus confirmed, it is accompanied
with new and unequivocal sensations, for along with urine the
semen is  obstructed, coition is attended, in the moment ot emis-
sion, with a spasmodic action  of the accelerator muscle,  cre-
ating a sharp  and thrilling pain ;  though the sense of emission
is complete, the point of the  penis continues dry ; the semen
recedes into the bladder,  and sometimes  is observed to  flow a-
long with the urine: in  this state of things  barrenness is one
consequence ofthe obstruction, though it be in  such a degree
only as retards, without entirely  preventing, the rapid ejection
ofthe  semen.
   Betwixt that obstruction in which the urine is forced off drop
by drop,  with violent straining, and that in which the bladder is
entirely obstructed, the limits are extremely narrow, the slight-
est  imprudence, the being unavoidably  exposed to  cold and
moisture, will suddenly  bring such a patient (like one labouring
under hernia) into  extreme peril; for after the obstruction has
passed a certain point,  no straining will  force off one drop of
urine ; nothing  but the introduction  of  the catheter can  give
relief, and it is not in every village that  assistance can  be  pro-
cured.   If the surgeon  arrives but a little too late,  the  bladder
is distended to its utmost pitch, and far beyond its natural size,
the tossing and uneasiness are very great,  the abdomen begins to
be  inflamed, the pulse  is quick,  the  tongue parched,  the lips
black, the eyes inflamed, the visage pale and ghastly ;  and the
 patient, after twenty-four hours  of insensibility, or of low and
 muttering delirium,  expires.  Thus,  in villages and parts re-
 mote from help, many valuable lives have been lost; and  when
 in this doubtful state, not apparently  ill, yet bordering on the
 greatest dangers, no officer can go to  sea, no soldier can go in-
 to service, no country gentleman can retire to his estate,  with-
 out extreme hazard.
    Without most culpable imprudence the disease is rarely fatal,
 but the patient, by the natural course  of things,  falls, if neglect-
 ed, into a most miserable and loathsome condition ; for, from
 the moment that the obstruction is nearly complete, the portion
 ofthe urethra, which lies behind  the stricture, is exposed to the
 whole force  of the bladder and  abdominal muscles, it is  soon 
Of Stricture.
203
affected, as an artery is in natural aneurism, (i. e.) it is first di-
lated, then inflames, then bursts, then the urine spreading (as
yet not  widely) among the cellular substance, causes indurations
of a singular hardness, as if they were rather knots of callus,
gathering round a fractured bone,  than inflamed cellular sub-
stance surrounding  a breach  in  this thin and  delicate  tube.
Such thickening, excited by the urine, forms but a slight and
temporal) barrier to the ruptured part of the urethra ;  the knot
extends and grows,  it becomes red on  the surface and softens,
it suppurates  with  little pain, and bursts slowly ; but when it
bursts, the urine issues through the opening, the abscess spreads
in various directions ; the surrounding parts are all affected; the
pacient often loses,  from  mere irritation, the  power ot retain-
ing his urine, the ulcers and fistulas become foul and  sloughy,
the linens and the  bed are incessantly moistened with urine.
The patient is exhausted with fits of incessant vomiting, and is
shaken by paroxysms of fever, apparently peculiar to this dis-
ease,  such as  make his teeth  chatter and the  bed shake under
him during .the cold stage,  and when the  sweating comes on,
the  sheets and bed-clothes,  the bed, and even  the mattress, are
soaked with  perspirations, and the smell  of  his room resem-
bles that of a  Russian bath.    If in this condition he be neglect-
ed but a few weeks,  or unskilfully treated,  if that fever is com-
bated with bark and emetics, which ceases only when proper
surgical incisions are  performed, if the obstruction is left un-
touched, and  the sinuses unopened,  and the  matter permitted
to work its way deeper among the cellular substance of the pel-
vis, the patient  sinks gradually lower and lower, loses all de-
sire for food, has  a cadaverous and jaundiced aspect,  faints
when raised in bed,  and at last dies.
  Stricture is a tumour or growth,  and the striking a firm bou-
gie into the ring, and wedging it there, can do nothing but ex-
cite the action, by which the stricture is produced.   I have seen
the patient under the old regimen, endure much torture,  and
with  wonderful  fortitude.   The wedging the  bougie  into  a
stricture,  recalls all the feeling to that part, and excites an in-
expressible desire to pass the water, to retain the bougie half
an hour at first using it,  is  impossible ;  the irritation does not
cease when the bougie is withdrawn ;  after the passages are in-
flamed the mucous  flux  is increased, the desire to pass urine
becomes extremely  urgent, if the urine  passes more easily at
first,  the relief is but  momentary ; never can the patient  feel
relief till ;\fter he has learnt  to endure the bougie for hours, and
continued to wear it for  months.  To live thus for months or
years, is but protracted misery ;  and to see the stream of urine
gradually lessen at every intermission of torture, and to be sen- 
204
Of Stricture.
sible that the disease, never cured, tends incessantly to return,
make the patient desperate, and he feels  that life is not worth
holding on such terms.   It is this state of protracted torture
and disappointment that affects so visibly, the physiognomy,
temper,  and general health of a patient who has stricture ; it is
this that produces  the  chagrined  countenance, sallow  com-
plexion, and wasted habit; and often it happened, while bougies
were used, that false routes were  produced  by the  irregular
pressure of the point of the bougie, cavities were formed by
the sides of the canal, and the canal itself well-nigh obliterated
by this new cause of compression ; the bougie passing thus in-
to the cellular  substance by the  side of the stricture, the ure-
thra behind the stricture, dilated under the force of the bladder,
and the parts fell into a  complicated state  of disease.
   With this long  suffering and ill success, let us  contrast the
effects both  immediate  and ultimate  of the  caustic  bougie.
When the caustic is pressed against the ring of a stricture, none
of  those ill consequences predicted by theorists, ever are pro-
duced ; there  comes over the patient a  confusion and a sort of
alarm  arising from the  novelty of the sensation, which makes
the most vigorous and hardy man tremble like an hysterical girl,
and shiver for ten minutes with the pale and contracted visage
of one in terror.   Yet the patient is not in a state of suffering ;
he talks all the while freely, and feels neither any deep sense of
burning, or any other description of pain.*  Nor  is  there any
thing of that immediate  inflammation and swelling  which it was
so  natural for the theorist to predict,  which it was  supposed
would infallibly close the canal,  and entirely suppress the flow
of  urine, at least  for a time.  There is  indeed very often, a
haemorrhagy,  but it is of that kind which has  been thought so
slightly of, when it flows from introducing the catheter ;  and in
the present case alone is such haemorrhagy  desirable; for, as it is
a sign ofthe caustic having penetrated to the cavernous body of
the urethra, it is a sign of  success.   Neither does  the effect of
the caustic extend along  the canal, nor  operate, except on that
point against  which  it  is  pressed ;  the swelling   even  of the
burnt part is   not perceptible ; the mere  act of touching the
stricture with  the caustic,  instantly gives a degree of relief; for
the caustic kills what it touches ; there is no intermediate state
of inflammation ; the part shrinks, and the opening, though

  • Notwithftanding what Mr. Bell here fays, patients fometimes  evince  by
their actions that they  fuffer  the moft excruciating agony upon the introduction
of the cauftic, as I have often feen; and wherever  the common bougie would
anfwer, (and that it frequently will, I can aver) I fhould prefer it.  S. 
Of Stricture.
205
affected but in a trivial degree, is actually  and instantly enlar-
ged; in short, the name only of caustic is alarming.*
   The bulb of the urethra is a natural  dilatation  of the canal,
fit for receiving the semen, which is poured into  it during coi-
tion, and ejected from it by the smart action of the accelerator
muscle, in the moment of emission.   Immediately behind this
dilatation or  sac  of the bulb, the urethra, where  it enters the
bulb  is naturally narrow, and joins  the  bulb with something
like a ring, or natural stricture ; and  it is here, at this point na-
turally straight, that the stricture is formed ; a second stricture is
often found a little beyond this point, about half an inch nearer
the  neck of  the bladder :  and whether there be one or more
strictures, they lie so far down in the urethra, that one, unac-
customed to introduce  the bougie,  would believe that he had
passed it along  the  whole  canal,  and that  it had entered the
bladder ;  and when he feels resistance, he would suppose it to
arise from the natural straightness ofthe prostate gland : if there
be other strictures than those near the neck of the  bladder, they
are usually in the penis, often about the middle, very commonly
in that part of it from which  the scrotum hangs.-f-
   It is the number of successive strictures that makes the most
formidable resistance  to  the passage of the  urine, and a person
unacquainted with this  department of practice, having applied
his caustic and  at last plumped his bougie unpremeditatedly
and suddenly through a complete  stricture, would be apt  to
triumph,  but the urine flows  not a whit the more easily ; and
upon introducing a bougie as  a probe,  the  second stricture  is
distinctly felt.
   There  is no  other evidence of the  existence  of permanent
stricture but  the bougie, nor is it even a very absolute test:  I
have found  the bougie stick  firm, as if engaged in a stricture,
which, after  the spasm which stopped  it had  subsided, has
passed with perfect  ease.   I  have often seen the bougie  intro-
duced by the patient,  and so  fixed,  either by its  point hitching
within one of the lacunae, or by some  other accident, that no de-
gree of force could  have driven  it onwards, whereas, upon
withdrawing it a little, and passing it on in  a true direction,  or


  * For a very  ludicrous denunciation of dangers to be apprehended from cauftic,
by  half a dozen of grave and learned Doctors and Proieffors, fee in Mr. Home's
book on Strictures, page 5.
   t" Strictures occur moft commonly," fays Mr. Home, " juft behind the bulb
of the urethra, the diftance from the external orifice being fix and a half or feven
inches; the fituation next in order of frequency, is about four and a half inches
from the orifice ol the glans ; they do occur at three and a half inches, and fome-
times almoft clofe to the external orifice.''  Home on Strictures, 2d Edit. pp. 27,
28.  S. 
206                     Of Stricture.
withdrawing it altogether out, and using a fresh and firm one a
little larger, it has gone on easily to the bladder.
  When your own or your patient's suspicions of stricture have
gone so far that you meet with him to decide the question, you
first make him pass his water before you, that you may remark
the size and form of the stream: you next  take a bougie of a
respectable size, by no means a small one; and,  having oiled
and bended it somewhat in  the form of a catheter, you intro-
duce  it before it softens;  and always, in passing the bougie,
whether simple or caustic, you  are quick and dexterous in run-
ning it up to  the constricted part, before  it begins  to soften,
which it does very suddenly, when affected by the heat of the
urethra.   You proceed thus : you raise the point of the penis
with  the  left hand, you then introduce the bougie with the
right, and run it on suddenly, till having passed the scrotum and
reached the perinaeum, you change your left hand from the pe-
nis to the perinaeum, you press in  the points of the fingers of
your left hand behind the scrotum, and run  them back along
the perinaeum, accompanying, as it  were, the progress of the
bougie; and  while you  push the  bougie smartly on with the
right hand, you press in the perinaeum with the fingers of your
left hand, directing the  points of your fingers so as to turn the
point of the bougie directly  upwards, before the  anus, at the
place where you expect to feel the stricture.   You feel the re-
sistance  and assure yourself of the stricture.    You  satisfy
yourself that the bougie, in  place of  going  onwards, is curling
up under the force of the pressure, you then withdraw the bou-
gie and find it curled like a pig's tail, but with a point not at all
ruffled, because it was  never admitted within the ring of the
stricture, so as to receive any impression from it.   Either now
or at some future occasion, you measure the stricture, by using
a bougie small enough to enter into it; you take a small pointed
and stiff bougie, give  it the bend,  introduce it after the same
manner, but instead of stopping, for fear of giving  pain,  you
press it on and wedge it firmly into the stricture, where, if it be
pressed but a very little, it takes a hold and is withdrawn again
with difficulty, and with a sort of feeling as if the urethra were
inverted by it.  Upon being altogether withdrawn,  the wax is
found ruffled on the point ofthe bougie, a sort of ring marks the
part embraced by the stricture, and the progress which the coni-
cal point of the  bougie had made in the stricture, denotes the
size ofthe ring.
   The application of the caustic really  and effectually to the
stricture thus discovered, "is no easy matter.  The most dexte-
rous apply it sometimes twenty or thirty times without success,
while it happens not unfrequently, that the armed bougie plumps 
Of Stricture.                    207
through the stricture at the third or fourth experiment.  Those
bougies which are made in London, are certainly the best, for
they have a long caustic  securely lodged,  and sufficiently  expo-
sed ;  yet I  make  armed bougies perfectly satisfactory  to my-
self, by cutting the pencils of caustic  nicely, introducing the
point of a sharp pen knife into the  point of the bougie, and turn-
ing it vertically, till the  centre rolls of cloth, of which the bou-
gie is composed, are scooped out and the outer circle only left;
then the caustic being lodged in the hollow and the edges ofthe
cloth, of which the bougie is composed, folded over  it, a small
round knob of the  caustic is left exposed, and the bougie which
had softened under the  modelling  of the  fingers, is  laid by to
harden ; the edges of the plaster having then taken a firm hold
upon the caustic.
   When the caustic bougie is to be introduced, I like to pass a
common bougie before it, liberally besmeared with oil, not to as-
certain the place of the contraction so much, as to lubricate the
passage, and make the caustic  glide quickly to the destined
point.  Then placing the patient, and bending the bougie as just
directed, you (having oiled the point of the urethra, and spread
its lips, that the caustic may not,  as  often happens, touch the
point) glide the bougie down nimbly and quickly down the ure-
thra till it is resisted by the stricture ; you then change the fingers
of your left hand quickly from the penis to  the  perinaeum,  and
there by pressing them in succession, you  direct and work on
the bougie with the left hand,  and prevent it bending, while you
force it into the stricture with the  right; and all  this  must be
smartly, nimbly,  and dexterously  done, for the bougie soon sof-
tens and bends, and you have  no longer  any  power over it: ha-
ving struck the bougie firm into the stricture, you keep it pres-
sed home against  it for a few  minutes: the patient at first feels
very little indeed,  only the slight pain of pressure, which, howe-
ver together with  the novelty  of the sensation  and the  alarm,
makes him blanch and almost  faint,  or at least be seized with  a
cold and trembling fit, shaking  as  if in  an ague.    The pain is
nothing compared with  the patient's imaginings ;  though the
name ofthe caustic sounds alarming, the sense of burning which
it occasions is very slight, the bougie,  after  a few minutes, is
withdrawn, and the slight irritation occasioned by it subsides.
   There  sometimes accompanies the application ofthe  caustic,
a slight tinge of blood, a degree of ardor urine,  an increased
desire to pass the urine, but indeed the pain and irritation are so
 slight, that the patient is contented and easy  in  his mind, and
 his urine  flows more freely than  before ;  he is at all  events
 freed from that apprehension which he could not but feel when
 he thought of having a caustic bougie passed into the yard. But 
208
Of Stricture.
the stream of urine which was a little enlarged by the first ap-
plication, becomes smaller again, the caustic is again applied, and
on the fourth or fifth, or perhaps the eighteenth or twentieth ap-
plication, sooner or later, it passes through the stricture, and the
urine, if there be no second stricture, flows with perfect ease.
   The young surgeon, in the course of his practice, will observe
and be  perhaps alarmed with several  unexpected circumstan-
ces.   First, he will sometimes be alarmed with  the apprehen-
sion of  the caustic having dropped from the end of the bougie,
and it often does  actually  excoriate a great length of the canal,
but the worst consequences produced even by this accident, are
an unusual degree of irritation in the course ofthe canal, a run-
ning, as in a smart gonorrhoea, of thin  and • bloody  serum,  a
heat of urine, slight pain in the perinaeum, and sometimes slight
pain in  the testicle.  I have seen large flakes of the lining mem-
brane of the urethra discharged* along  with the bloody serum ;
but the  worst of these  symptoms  subside, and in a  few days
the caustic can be applied again.  Secondly he will be  surprised
to find, when he chooses the largest caustic bougie in order to
make sure  of the effects  of  his caustic, that it has actually no
effect, for though a large bougie exposes a  greater  surface of
the caustic, that surface does not come  in contact with the stric-
ture ;  a  smaller bougie is more fairly admitted into the ring ofthe
stricture, and has, according to my observation, a much happier
effect.  Thirdly, he will be  surprised with the rude and unu-
sual sensation the bougie conveys to his  finger when  passing
through the stricture ; for at that particular application in which
it passes through, there is no determined interruption ! but in
the moment when the bougie approaches the  neck of the  blad-
der and is passing through the cauterized ring, it is felt to grate
along as if it were passing through a shot hole in a rough  deal
board.  Fourthly,  he will sometimes be alarmed  even by the
happiest presages;  for often there comes on  so profuse a  ha>
morrhagv, that, instead of urine, nothing but blood  seems to
run from the urethra, in a full stream,  as freely as from a vein
in the arm, hanging in coagula from the point ofthe yard.  Yet
such haemorrhagies imply nothing but success, for they arise
from the sloughs having destroyed the stricture, and penetrated
into the cavernous body of the urethra :  a profuse haemorrhagy,
while it is actually harmless, is a prognostic of a speedy cure.
   The  horror and shivering which the patient, though suffering
neither  fear nor pain, cannot suppress;  a shivering so violent as
to make the teeth chatter audibly, is no  sign, as  far  as 1  can
distinguish,  either of safety or danger, of success or failure ; but

  * Probably flakes of coagulable lymph thrown out by the inflamed mem-
brane.  S. 
                   Of the Causes of Fistula;.               209

 if any thing, it intimates the successful application and action
 of the caustic, for in the  same patient I do not find the same
 paleness or trembling upon introducing the common bougie.  I
 have sometimes on the evening after applying the caustic, found
 my  patient vomiting from  the  nervous affection,  and  some-
 times I have seen him, after a long fit of shivering, slightly de-
 lirious, without any perceptible  fever.  The sickness and deli-
 rium, resemble those from intoxication.   The sickness is of so
 unusual a  kind, that the patient has not time to stretch out his
 hand for the basin, and the delirium or confusion of the head,
 accompanied like that of drunkenness, with particular stupor.
 Fifthly, the young surgeon will be often surprised to find, while
 he is despairing of success, that his patient informs him of his
 cure, of having passed his urine freely and in copious  streams,
 and especially he will be surprised when informed, that the flood
 of urine has pushed on  before it a stone of considerable  size.
 But,  in truth, stones are often formed behind a stricture,  from
 small particles of gravel sticking  there and accumulating; and
 when the stricture is destroyed, the stone passes and drops into
the water-pot the first time the urine is freely discharged.   The
surgeon and patient are alarmed  at the first, by every  unusual
symptom, are soon reconciled to the use  of the caustic,  then
become familiar,  and are at last doubtful of any effects, bad or
good, from this application ;  but a surgeon experienced in the
use of it is not dismayed, although  he perceive no effect after
many  applications..  The  bougie  often  starts unexpectedly
 through the stricture,  the  fifteenth or twentieth time it is ap-
plied ; it has been applied forty times, by the most skilful, with-
out effect, and has at last succeeded.  To mention thus the oc-
casional circumstances which accompany the cure, is  perhaps
the surest  way of preventing alarm, and ensuring success.
                        SECTION II.

           OfFistulce in the Perinaeum and Urethra.

  From these simple obstructions I proceed to describe more,
complicated scenes of distress, arising not solely from stricture,
but from any cause  obstructing the urinary canal: for whether
a stone sticks in the urethra, or  by  a blow on  the  perinaeum
swelling  and inflammation are produced, whatever cause pre-
vents the urine from passing freely exposes the urethra behind
the obstruction, to be dilated, inflamed, ulcerated, or even burst
by the force of the bladder.
   It is not  to be told what difficult and perplexing forms this
                            2 D 
210               Ofthe Causes of Fistula:.
complaint assumes, how  anxious, careful and curious, the sur-
geon's inquiries must be before he can understand the extent,
form, and other circumstances of any particular fistulae ;  I shall
therefore  be at pains, both  by my arrangements and descrip-
tions, to give the young surgeon clear conceptions of this dis-
ease.
   There are three  general cases which demand especial atten-
tion :
   First The  obstruction of urine proceeding from some vio-
lence  to the perinaeum,  from a blow, a fall, or other  accident
by which, though the skin remains entire, the urethra itself is
lacerated, and the urine, obstructed in its natural passage, bursts,
along with the extravasated  blood, into the cellular substance
of the scrotum and perinaeum, and makes external openings by
causing a gangrene of the parts.
   Secondly, The canal obstructed by the sudden  impaction of
a stone in it.   The case ill understood, and the urethra expos-
ed to the  force ofthe bladder, by which it is dilated into a sac,
in which  the  original  stone  is gradually augmented in size,
while other stones are often generated.
   Thirdly, The fistula arising sometimes from stricture; some-
times from venereal or scrophulous ulceration, which, in  its
progress,  is accompanied with a succession of abscesses, various
openings through which the urine is  discharged, and extensive
indurations of the surrounding cellular substance ;  till  at last,
the perineum and scrotum,  perforated ajmvarious points,  and
discharging urine,  pus, and  flatus  froirTthe  putrid  cellular
substance,  resemble in  lividness  and  hardness the  integu-
ments covering a diseased  bone, while  the patient is  wasted
with successive paroxysms of fever and pain ;  by  want of rest,
and by the uncleanliness and offensive smell.   Let these slight
definitions serve to indicate the chief subjects of the following
discourse.
   The membrane ofthe urethra is delicate and easily ruptured,
and the cellular substance surrounding  it is like a vein  full of
blood continually circulating in it.    The urethra  itself, or the
cellular substance of the  urethra, is often burst by  a blow or fall
upon  the perinaeum, as in trying to leap across forms or chairs,
or slipping a foot in crossing a stile ; or by masons, miners, or
sailors, failing from a height  and alighting among loose stones,
or upon projecting  beams, or upon the breech of  a gun, or the
fluke  of an anchor.  The urethra, or cellular substance of the
urethra,  being burst by a blow, the blood either flows from  the
penis, or is extravasated in the perinaeum according to  the de-
gree of injury.
   When  the lining membrane of the urethra alone  is burst by 
Ofthe Causes ofFistulce.
211
the fall, the blood runs from the penis in a full  stream to the
great terror of the patient, who apprehends  the  most horrible
consequences;  but it is  like that haemorrhagy which follows
the  rude  introduction of the  catheter, harmless:  the  blood
flows indeed as freely as from a vein, but it coagulates, and the
haemorrhagy stops  of its own accord: it is indeed renewed by
the passing of the urine, the clots which are in the urethra be-
ing forced off  in  long strings, or bolted out in small knotty co-
agula ; but  it  stops again :  and though I have often seen such
h emorrhagy  proceeding  from a  venereal ulcer in the urethra
bleed thus for three days, and though I have at last been obliged
to lay a compress upon the penis, and lay it down upon the belly
with a bandage to stop the haemorrhagy, I never yet saw the
patient injured  by the loss of blood.
   I have  had  patients run into my room with their pantaloons
filled with blood,  but I have seldom  been obliged to use  pres-
sure, to which  the  whole canal of the urethra,  and especially
the bulb, is so fairly  exposed,  that no harm can  ever happen.
When  blood flowing along with the urine comes thus from the cells
of the  urethra it flows in a stream ; and when coagula are form-
ed  they  are  long,  slender, and stringy ; but when the blood
flows,  as  I have seen it, from the kidney into the  bladder, or
from the  ulcerated surface of the prostate  (a part which is sur-
rounded with a plexus of veins) the clots are very condensed,
round, and firm ;  they obstruct the urethra and neck of the  blad-
der so that the  foro^required for their expulsion is  very great;
the patient, every time he passes his  urine, stalks about his room
in all  the agonies that those feel who have actually the stone;
and when, after many efforts, the clots are propelled through the
urethra, they bolt out to a great distance.
   When  the blow is very violent, the bulb of the urethra  is
completely burst, blood flows from the penis in great  profu-
sion, and a tumour is observed in the perinaeum arising  from
the same extravasation of blood.   The extravasated blood, like
that ot an aneurism, makes a rapid  progress among  the  loose
cellular substance of the scrotum, which  swells  sometimes  to
the size of a child's head.   The blood is pushed forward also
under  the skin  of the penis,  till the swelling of the prepuce en-
tirely  hides the  glands; and the blackness extends upwards
over the belly and down the thighs.   A surgeon  well acquaint-
ed with  the structure  of the parts, even though not skilled  in
this department of practice,  will easily perceive that the  urethra
is burst, and will  no sooner see blood effused and an extending
ecchymosis, which is comparatively harmless, than  he will ap-
prehend,  next  an effusion of urine into the cellular substance,
which is full of danger; and, the moment he sees an  effusion 
212              Of the Causes of Fistula.
of urine,  he will make no delay,  but  perform those incisions
which are necessary to save the parts,  especially the skin of the
perinaeum and  scrotum from destruction.   When the patient
feels the sense of passing urine so distinctly  that he cannot be
persuaded that  it is not passing, but by seeing the  point of the
penis dry; when the scrotum and perinaeum, which  were at first
swelled and livid, become puffed up suddenly; when the swell-
ing,  which was  at first firm and  resisting, becomes soft, and
gives a crepitating feeling, and especially when no urine passes,
and  yet the patient feels  the usual relief, the surgeon may be
assured that the urine  is  passing  into the cellular substance;
that the parts will soon fall into gangrene ; that the testicles, and
perhaps the penis, will, by the sloughing of the skin, be left
naked and exposed, and the skin of the perinaeum partly or en-
tirely  destroyed.   These are most dangerous circumstances,
and the fate of the patient depends  directly and plainly on  the
talents and  discernment of his surgeon:  and there are two
modes of  proceeding,  one of which leads to safety, and  con-
verts  a dangerous accident into  a very simple case in surgery;
the other,  of which there  are  unhappily too  many  precedents,
leads to destruction.
  If, when the  surgeon arrives, he is  not aware of all the  con-
sequences of the accident:  if he do not reflect more upon  the
effusion of urine soon to  take place, than upon the present diffi-
culty  of introducing the  catheter; if  he calls a consultation  of
surgeons chiefly to assist him in the introducing of  the catheter,
or in  consulting about tapping the bladder: if one  or two  days
are lost in vain attempts to  introduce  the catheter,  and in  the
unmeaning and trivial occupation of applying fomentations, em-
brocations, and poultices to the parts; the parts fall inevitably
into gangrene ; and it has  actually happened  that, while a grave
consultation has been deliberating on the means of drawing off
the urine, it has been escaping into the cellular substance and
causing gangrene ;  and after  gangrene has actually taken place,
they have, in a fit of despair, and to accomplish they knew  not
what,  tapped the bladder from the rectum ;  and yet,  after all
this destruction by  surgery and disease has been consummated,
the parts have healed in so kindly a manner  as to  prove  that
nothing was required but a few superficial incisions to keep the
patient in safety.
  The stricmre ofthe parts and usual consequences then of this
accident being  considered, the surgeon cannot easily  mistake
what is to be done.
  First, no  doubt he is to introduce the catheter; it is the most
obvious and easy means of preventing effusion of urine, and
restraining the  extravasation of blood :  and,  if the  flexible ca- 
Of the Causes of Fistula.               213
theter can be introduced and left in the bladder, it will ensure
an easy cure.   But generally  the surgeon will find a degree of
obstruction at the ruptured part, which he dares not overcome,
and be sensible of  the point of his catheter lodging in a sort of
sac.   When he is conscious that he cannot  pass the catheter,
he will not think of perforating the bladder ; if he is to perforate
at all, he will  perforate the perinaeum, where  already the urine
begins to he effused, and where  his knife will uncover,  and his
medicines reach, the ruptured part of the canal.   He will treat
this case of effusion of urine into  the scrotum and perinaeum
according to the analogy of air effused trom the lungs or trachea;
i. e. he will take care to provide an exit  for the urine which is
already effused ; and he will be careful to support a free outlet
for that which may continue to  be discharged till the  natural
passage for the urine be restored by nature or art.   With these
views he will  make small incisions  proportioned to the bulk of
the tumour;  he will place one incision in particular so over the
ruptured part of the urethra (which he  can mark  by the stop-
ping of  the catheter there) as to  provide in  future  free egress
tor the urine.   Having relieved the parts thus,  he  will expect
the swelling to subside so tar as  to allow him soon  to pass the
flexible  catheter along the canal of the urethra.   In the mean-
while all is safe, and, when he is able to introduce the flexible
catheter into the bladder and  leave it there,  the breach of the
urtthra heals over it, or will indeed heal without the catheter,
if the external wound be not tortuous,   nor  fistulous, but free
and open.   No poultice nor fomentation should be applied to
parts  in this condition: they must be moistened from time to
time with vinegar and spirits : they must be kept dry and clean,
and wiped at every time they are soiled  with urine  : the com-
presses dipt in spirits should be supported with gentle pressure :
the wounds,  especially  that which  is opposite to the urethra,
should not be  crammed with lint or other dressings, but dressed
lightly with gentle escharotics, as  red  precipitate  mixed in a
small proportion with any ointment.  The  sloughing parts (if
there has been a great destruction of parts)  must be touched
lightly with turpentine, not burnt up by  a perpetual  application
of it; and any edges that become particularly callous, may  be
touched with  lunar caustic.  It is so essential  to prevent ill con-
sequences, that the parts endangered by  the effusion of urine be
freely exposed, that I am  earnest in recommending the practice
to my reader on all occasions of this kind.
   Yet these are not cases of fistula : there is no long continued
disease, no callosity, no irregular passages through  which  the
urine flows with-difficulty ;  but direct and clean incisions, which
should easily  heal:  nor do  I account those sores to be properly 
214               Of the Causes of Fistula:.
fistulous which proceed from stones  arrested in their passage
along the urethra : yet, when a stone stops in the urethra, and
the urethra is dilated behind it in form of a sac, it is a mere di-
latation ofthe lubricated canal, and the surface of the sac, when
at last it does burst or  is opened, is  very little disposed to gra-
nulate or heal. The surgeon, who is thoroughly acquainted with
the structure ofthe parts, has this unquestionable advantage, that,
in any given accident, in any complicated case, when some par-
ticular cause is producing disorder and exciting disease, he rea-
sons correctly on its consequences, foresees all that may happen,
and anticipates whatever symptoms it is possible to prevent: in
the case, for example,  of stone either dropping down from the
kidney, or formed in the bladder, and  driven on by the stream
of urine along the urethra,  he will easily anticipate the conse-
quences, or at least understand them when they do present.
   A stone, while  within the urethra, is pushed on by the stream
of urine, but the moment it  is delivered  from the urethra, and
lodges in the prepuce, the urine no longer urges it forwards ;
and if the prepuce be narrow, the  stone remains there, and es-
pecially in boys, who are unconscious of the cause of their pain,
and do not seek relief, it remains  till  it acquires an  extraordi-
nary size.   When a small stone is thus lodged under a narrow
prepuce, the stream of urine being from time to time particu-
larly strong, the stone presents itself at the narrow opening  of
the prepuce, the prepuce then sustains the whole force  of the
bladder, and is dilated, and, by successive dilatations and fits of
inflammation,  it  is made to thicken,  and grow into a sac  of
considerable size.   In a little boy the prepuce has been thus en-
larged to the size of a French apple,  the size of the  bag, and
the narrowness or stricture of its point, increasing in  equal pro-
portion, and the stone  moving within the sac, like the pea  in  a
cat-call, often presenting so as to obstruct the urine, and pushed
back by the mother with a pin or bodkin, so as to give the boy-
relief by emptying the prepuce.   The stone has been allowed,
from the timidity of parents, to  remain for  years till it has in-
creased from the size of a pea to that of a nut,  and in men grown
in years, a succession of such stones have been formed under
the prepuce,  one being generated  as another was discharged.
The inconvenience of pushing such a  stone back to make way
for the urine, has been endured for years rather than endure the
simple operation for the phimosis, viz. cutting up the foreskin.
   Stones passing along the urethra are often  interrupted by that
narrowness of the canal, which is observable immediately be-
fore the bulb whence they are  fixed in the perinaeum : often
again they are interrupted at the  very point ot the  glans, the
 orifice being encircled by a sort  of membranous  ring, which 
Of the Causes of Fistula.              215
girds it and makes it narrower than any lower part of the canal.
The canal is, in all its length betwixt those two points, so equa-
ble in its diameter, so lubricated, and so dilatable, and the blad-
der is so powerful in its contraction, that the stone  seldom
stops at any intermediate point, or never longer than  a day ; du-
ring which time the urine passes in such quantities by the  side
of  the stone as to relieve the bladder, while the bladder  dilates
the urethra, so  that the stone makes its progress  slowly, insen-
sibly, in respect of its descent, but with great pain.   I never
knew a stone stop at any other point than either  the  perinaeum,
or the very opening of the glands.  I never have  found it ne-
cessary to cut the urethra, nor  even to  use those  means,  as
blowing into the urethra, or dilating it in any other way, which
have been spoken of ever since the days  of Prosper Alpinus :
in ninety-nine of a hundred cases, stones once  engaged in the
urethra, pass along without the help of art; but if they are de-
layed it is in the perinaeum,  and it is necessary here to tell the
consequences.
  When a stone actually stops in the  urethra,  it is  usually  at
the turning of the urethra, under the  pubis, at  that narrower
part where stricture usually occurs.  On the first day there is
a total obstruction, with intolerable pain, from which the  pa-
tient has no relief; on the second day, the force of the bladder
overcomes, in some  degree, the resistance  of the  urethra, and
urine begins to pass by the sides  of the stone.   But while  the
urethra is suffering this pressure, it is in some degree dilated;
and if the stone be immovably fixed  in  the  urethra,  the dila-
tation increases till such a sac is formed as is capable of receiv-
ing the stone.   Then it rolls back into the sac and lies there,
out ofthe course of the urine, which passes at times, freely, but
at times is interrupted, the stone  being,  by the contraction of
the parts, placed opposite to the urethra :  and thus  it  happens
that the urethrals exposed,  from time to time, to the  force of
the bladder, the preternatural sac is dilated more and more, and
being enlarged  much beyond  the size of the original stone, is
capable of containing a small  quantity of urine.   This lateral
sac of the urethra resembles a second bladder, and other stones
are formed in it:  now the parts are thickened, the bulk is very
perceptible in the  perinaeum :  the patient sits uneasily, and sel-
dom passes urine without interruption and pain :  the swelling
either is in the back part of the scrotum  originally,  or extends
that way.  The patient, from long habit of observing  his situ-
ation, can recollect that often  while  the  urine flows  in a  full
stream, he is sensible of some going into the tumour ;  and after
having passed his urine, he can, by squeezing  the swelled part
of the  scrotum  or perineum,  press out a small  quantity of 
216              Of the Causes of Fistula;.
 urine extremely fetid, from being retained in the sac :  often,
 while the urine is flowing in a full stream, he finds it stop sud-
 denly, from the presenting of one or other of the little stones in
 the proper course of the canal;  and that there are such stones,
 he can feel distinctly, for as the stones are formed  in the  sac,
 and  not the sac moulded upon the   stones, the sac is large
 enough to let them rattle so against each other, that the patient
 feels them within the tumour, like those in the crop of a bird.
   When such a sac is opened by an incision, stones are  found
 in some cases to the number of  sixty or eighty, and  the  fistula
 is nearly, though seldom entirely, cured :  why such a sac is not
 easily cured  is obvious, for the  formation of so  many stones
 implies a long continued disease and callosity of  the parts ; the
 sac is generated by pressure, distention, and successive inflam-
 mations ; there is a remarkable thickening and massing together
 of the parts, and when the tumour is opened the surgeon feels,
 by introducing his finger, that the sac is so  smooth, so lubricat-
 ed, and so perfectly analogous with  the inner membrane of the
 urethra, that it is probably a simple aneurism-like dilatation of
 that canal, supported by a thickening of the cellular substance ;
 and the sac formed  out of such a  lubricous  membrane is not
 likely to inflame and heal.
   Perhaps it may  not  be irrelevant to mention  here, among
 the diseases of the urethra, an accident which is shockingly fre-
 quent : little boys who in their dreams wet the bed, have often,
 to avoid the  shame  and  the punishment  of  such a fault,  tied
 tapes about the penis, and, unable to undo the knot in the morn-
 ing,  have concealed  their situation  ; and I have known parents
 so fool-hardy as to do  this, and have seen the  penis cut half
 across.   It is always the lower side of the  penis, or that on
 which the urethra lies, which suffers; and the only remark which
 Thave to  suggest is this, that I have never seen any good done
by attempts  to  re-unite the parts  at the  time  of the injury.
That the applications of cantharides, red precipitate, and other
irritating applications, in place of assisting the re-union, or pro-
curing granulation, have invariably  widened the breach.  I ad-
vise that the parts be suffered to heal;  that if  any thing  be in-
troduced into the urethra, it be only a leaden  probe  ; and  that
all attempts at healing the breach, be deferred  till the  parts are
skinned over, the inflammation   entirely gone, the orifice  cal-
lous ; and  then by paring and scarifying the edges, retracting the
skin  of the penis, securing it by adhesive  plasters,  and  intro-
ducing a flexible catheter, it may be  readily cured.
  These are accidents comparatively rare;  to omit the mention
of them would indeed be wrong, but to represent  them as  fre-
quent causes of fistulae,  would be to deceive my reader:  let us
turn then to matters of daily practice* 
Of the Causes of Fistulas.               217
   That inflamed,  indurated, and confused state of the parts,
 where the urine having ceased to flow through the natural canal,
 has burst through  the perinaeum in various irregular openings,
 is the work  of time, and proceeds from the slow operation of
 some continued resistance to the passage ofthe urine : stricture,
 and venereal disorders of the urethra, are the only causes which
 we recognize in common practice.  If the interruption  of a
 stone  passing  along the urethra, or a blow bursting the canal,
 produce a fistula, it is to be regarded rather as an accident, and
 indeed  the disease is more easily  cured.   Strictures  are,  in
 ninety-nine of a hundred cases, the causes of fistulae ;  for irrita-
 tion and frequent desire  to pass urine  are inseparable  from a
 stricture, which is  continually felt as a foreign body : the fre-
 quent contractions of the bladder lessen  its dimensions, thicken
 its coats, and increase its mascular power; and thus, while the
 bladder is acquiring daily increase of power, and its contractions
 are becoming every hour more frequent, the urethra is no longer
able to  bear the pressure.  I do not mean to say that the ttre-
thra is burst,  as where a stone  impacted in the urethra totally
shuts the canal,  but it is dilated by the  continual force of the
bladder,  it inflames, the surrounding parts are soon affected,
and thence begins the disease of the perinaeum.
  The penis, and all the surrounding cellular substance, are so
dull and obtuse in their sensations,  that  though the former is
the seat of a peculiar kind of sensibility, its diseases make great
progress with little  pain,  and though strictures in the urethra,
and abscesses of the perinaeum,  are diseases of no slight impor-
tance,  yet the fact is, that they steal upon the patient by such
slow and insensible  degrees, that he is hardly aware either that
he is labouring  under the one disease, or  in danger ofthe other,
before he falls into the most calamitous circumstances.
  When a fistula first  threatened in the perinaeum, you may
feel the callosity firm, knotty, and perfectly moveable, and you
can move the urethra sideways,  with the finger and thumb, as
if the bulb were injected with wax ; the pressure of vour thumb
squeezes out matter, which passes into the canal ofthe urethra,
and issues from the  penis  ; and such a tumour I  have seen for
many alternate  days, almost vanish, then return  again,  and at
last disappear ; whence  I  am inclined to conclude, that such a
small abscess or blind fistula, opening not outwardly, but only
into the urethra, varies in size according  to the quantity of mat-
ter contained in it,  and sometimes is cured and obliterated.
   From the time that urine begins to issue through openings in
the perinaeum,  the disorder becomes every  moment more com-
plicated, and the  condition  of the  patient more loathsome.
When  the urethra is  obstructed anew,  and the  perinaeum in-
                            2  E 
218              Of the Causes of Fistulce.
flames, when either the old fistulae are about to burst out, or
new ones are forming, the patient has distinct rigours and fever,
and clouds do not more certainly portend  a storm, than rigour
and a feverish paroxysm, the generation ot some new fistula.
It is not  a  slight rigour that the  patient is assailed with,  but a
cold fit like  that of a quartan : the patient feels a sickishness,
languor,  and giddiness ; his face  grows  pale, and the circle
round his eyes livid ; and when the fit comes on, the  bed shakes
under him, and his teeth  chatter audibly.   He vomits a pro-
fusion of bile ;  his  urine is sparing and high coloured ; his tem-
ples throb, and  the  hot stage which succeeds is very violent, and
is followed by a sweating stage, very long and exhausting.   He
is bathed in sweat, shirt after shirt is changed,  and is actually-
wrung out before it is thrown into the closet.   The bed-clothes
are thoroughly soaked. The fetor of the urine passing through
the fistulous sores and wetting the linens,  and the extreme fre-
quency of  passing  water, and  the imperfect manner in which it
passes, the patient  having  hardly any degree of retention, make
his condition most  miserable.   His frequent rising to take the
water-pot  during  the night, while under  this sweating-stage,
gives him  cold and aggravates every symptom.  The patient,
after  each  paroxysm, looks wan and meagre ; he could not, in
the space of several weeks, entirely recover from the shock, but
weeks are not allowed him, for one paroxysm  succeeds another
at intervals of  but  a few days, bilious vomiting or diarrhoea of-
ten occupies the intermediate  time, and the surgeon,  with all
his care  to preserve his patient from fever, is hardly able to find
two days  free from  fever, during which he  may perform his
operations.  This  is an intermitting fever so purely  sympto-
matic, that bark or wine,  or antimonial medicines,  are of little
use ; the  patient very generally  cannot  use  laudanum,  which
only increases his sickness; nothing can give relief but destroy-
ing the  stricture and opening the fistulae.
   The catheter, if it can  be passed or retained at such a time,
 is of use,  by preventing the impression of the urine upon  the
 parts ;  and extreme cleanliness, air, and exercise in a carriage,
 and the warm bath, with  opiate clysters,  palliate the distress
till a fit time comes for attempting the cure.
    When a patient  commits himself to your care, look well to
 his condition, reflect maturely on every circumstance of his case,
 and weigh all  the  probabilities before you promise, or seem to
 promise,  a cure;  although he has been  long labouring under
 disease, and the  parts  are in  great disorder,  though the peri-
  naeum be  perforated with  irregular openings,  and abscesses ex-
  tend from the urethra  to the scrotum and hip, vou will not de-
  spair ;  because, these points are accessible.   But when the eel- 
Of the Cure of Fistulce.
219
lular substance of the  pelvis is deeply  affected,  when  flatus
bursts through the several openings, demonstrating that they pe-
netrate to the rectum, though you will never abandon the per-
son  who puts his confidence in  you,  you will be cautious how
you express your hopes of saving him, to his friends.
   This is  so entirely a surgical disease, and the parts are so
irregularly affected, that natural ingenuity and a spirit of enter-
prise are of infinite use, and a nice and careful hand in adapt-
ing  instruments to the condition of the parts, and laying dress-
ings, so as to keep the sores dry and clean, sometimes perform
wonders,   fhe surgeon sits down to reflect deliberately on the
causes of the fistulae, and  of their various directions and com-
munications,  he passes  first the  catheter or  bougie into the u-
rethra, to feel for the obstruction, he probes each fistulous open-
ing,  to discover its depth and direction,  and  its communication
with, other openings,  and to observe whether the probe,  when
passed through the  fistulous openings, and the catheter where it
is stopped in the urethra, can be made to meet.
   He examines carefully into all the circumstances of his pa-
tient's case,  that he may know in what succession the several
openings burst out, and in what degree the parts  have suffered.
He  then tries to get the staff, if possible, into the bladder, in-
troducing his finger at the same  time into the anus,  that he may
be assured whether there is any disease within the pelvis, and
beyond the reach of his knife.   On the clearness of his concep-
tions and reasoning, does the fate of his patient entirely depend;
the stricture is to be relieved, the fistulae laid open, the  canal
made direct and clear,  and the incisions healed by escharotic
applications  : and, while  no diseased part is to  be spared, no
part, either ofthe urinary canal, or surrounding integuments, is
to be wantonly destroyed.  In  short, care and cleanliness, in-
genuity and  industry, a perfect knowledge  ot the anatomy of
the parts, and a mechanical genius for contriving various means
of restoring  the passage of the urine, and healing the openings,
are of inestimable  value ; they are talents which may be improv-
ed and cultivated,  and will eventually save the lives of patients,
who, if laid  in a foul bed,  and macerated in  relaxing poultices,
would die.
   Fortunately there is no  doubt nor delicacy concerning these
operations on the perinaeum, which seem so cruel, and which
are indeed  so often unsuccessful ; the natural  force of the  urine
never could overcome a  stricture in the  urethra,  and the peri-
naeum  being perforated, even that ineffectual force is taken off,
the parts are  running every moment into greater disorder ;  the
most vigorous health (and that is not to be  expected) can never
cure those sores, while the obstruction in the urethra remains ; 
220               Of the Cure of Fistula:.
  the suppurations are continually spreading, and  the  fever in-
  creasing, so that something  must be done, and since that part
  of the urethra which lies betwixt the stricture and the point of
  the penis is now of no use, we may proceed to remove the stric-
  ture, and since the urine has a free issue by the perinaeum,  we
  are not interrupted in our work.
     These general theories of the disease and of its cure, are of
  use to give the surgeon clear conception ofthe difficulties he has
  to encounter ;  but that he may learn how to encounter  them, I
  shall proceed to lay  down rules for his conduct in somewhat of
  an aphoristical form.
     1st, It is not here as in the case  formerly described, (viz. a
  sudden bursting of the urethra,) the first duty of  the surgeon to
  make free  openings in the perinaeum ;  for the  walls of  a fistula
  are so condensed by inflammation, that the urine is not injected
  into  the cellular substance,  but flows through  one or many
  openings, whose walls are firm  and  tube-like, as  the name
  fistula implies.  The  first care then of the  surgeon, in every
  case of fistula,  whether old or recent, is to clear the canal, and
  that is best done by passing a caustic bougie down the  urethra,
  If there be plainly a stricture in  the urethra,  if the  bulb or
  lower parts are just beginning to give way, and the perinaeum
  to inflame,  let the  caustic  bougie be applied immediately ; or
  let the common bougie be forced into the stricture, to procure
  a momentary  relief, by freeing the passage  and relieving the
  perinaeum  from its immediate pressure ;  while leeches  and
  saturnine solutions are applied to  the perinaeum, and the part
   supported  with gentle pressure.   Sometimes in proportion  as
  the passage is cleared by the caustic,  the pain and swelling of
   the perinaeum subside, and  the patient is saved from a breach in
   the urethra.
     2d. When  the  disease  has proceeded a  point farther, and
   there is not only an inflammation in the perinaeum, and a threat-
   ening of danger, but an actual abscess ; the surgeon  should
'   make no delay, but open it: there is  indeed  no danger of  the
   urine being diffused widely under the skin,  but  there is danger
   of the abscess extending itself, of more cellular substance being
   destroyed by suppuration,  and of the urine being admitted into
   a larger sac; in short, the  abscess in perinaeo  will always  be
   more or less extensive, in  proportion as  it is more or less pru-
   dently managed ;  and it  is  a point of prudence to open it early.
   If  it could be  prevented  from suppurating, that  would be a
   great point; but, when it has already suppurated, and  points to
   a head, when you distinctly feel the matter,  and suspect, from
   circumstances, that the urine has access to the abscess, you open
   it without loss of  time,  with the point of a lancet ; and  at the
   same time, take every measure for freeing the natural  passage. 
Of the Cure of Fistula:.
221
  3dly,  In cases of irregular and  complicated fistula;  which
have continued long, when little urine passes by the urethra, and
much  through fistulous openings,  become  callous  by time;
where there is no threatened disease which  may be prevented
by timely incisons; where either the surgeon feels plainly one
long and lormidable stricture, or  suspects various openings  in
distinct parts of the  canal, he will first give his whole attention
to the clearing of the natural passage, that he may afterwards
deal more successfully with the fistulae.
  His means of overcoming such strictures, must be adapted
to the circumstances  of each.    If  he has  reason  to  believe
that there  is but one small and  solitary  stricture, he will  per-
haps hope to give a temporary relief, by forcing the point of a
bougie  into  it, and thus, for a moment, taking off the force
from the perinaeum, he may gain time for the  use of the caustic,
and be able in a more deliberate way, to destroy the stricture
altogether, and restore the free  stream of urine.   If, from the
history of the complaints,  and a distinct account  of what has
been done  by  lormer surgeons, if  from the entire obstruction
of the urine,  from  the  extensive  fistulae  and long continued
disease in the perinaeum,  he has reason to believe that the stric-
ture is very complete ; but especially if upon feeling the urethra,
he  is sensible that the obstruction  arises, not from a single
stricture, hard and round like a pea, at one point of the urethra,
but from several contiguous strictures occupying a considerable
length of the urethra  ; if, to speak more  accurately, he .feels
with the finger and thumb, a space of the urethra,  nearly half
an inch in length, small and hard, like  a big thread, at which
the bougie or  catheter stops,  he has reason to fear, that not a
hundred applications of caustic wouid destroy such a stricture,
and is sensible that he must have recourse to rougher methods.
He introduces the stalk of a silver catheter, the bend being cut
smoothly off, and using it as a  canula, he plants the point of it
upon the stricture,  and passing down a trocar or piercer, either
squared or lancet-pointed, and  grasping the urethra firm in his
left hand,  and holding the piercer  firmly  with  his right,  he
bores it along, (a thing  which  cannot be done without much
force and  exquisite pain  to the patient)  and makes his  way-
through the stricture, indifferent whether it  passes through the
body of the stricture or by  the side of it, if only it meet the
open part of the urethra.    This operation I hold to be chiefly
practicable in strictures manifestly of considerable  length, and
occupying the middle  parts of the urethra, especially that which
lies within the scrotum; and I have found the operation  greatly
facilitated, by  feeling  very  carefully from the point where the
catheter stops, so as to  ascertain  the extent of the stricture, 
222                Of the Cure of Fistula.
 making the patient in the meanwhile press his urine,  so that I
 would feel the  urethra  dilated into a  sort of sac, behind the
 stricture.   This sound and  dilated part  of the urethra is that
 which is to be aimed at with the trocar: I have found it neces-
 sary to hold  the urethra and penis particularly  firm, for it re-
 quires great force to drive the piercer on:  and in this operation
 of working the urethra  along the piercer, as you would  put the
 bait on a fishing-hook,  I have, I  confess, found  the greatest
 difficulty in hitting precisely  the  free and dilated  part of the
 urethra behind the obstruction.  The  lancet-pointed trocar,  is,
 I am certain, from experience, preferable to the round or square
 pointed trocar, and  I think it necessary to mention, that gene-
 rally and almost necessarily,  the  trocar must enter the side of
 the sound part of the urethra,  whence there will be  a  degree
 of crookedness in the  new canal;  and if there be any collateral
 abscess to distort the urethra, the irregularity will be very great,
 and  the catheter will pass this point with a degree of difficulty,
 and not without some address on the part of the surgeon, who
 must learn,  by practice, towards which side the obliquity  lies.
 To prevent or lessen  this, to  preserve as far as possible,  a di-
 rect channel,  a large leaden probe  as big as the catheter  should
 be worn during  the cure,  and the  caustic occasionally used:
 this  operation of perforating  is,  I acknowledge, difficult and
 delicate, but we  speak now of cases where bougies are merely a
 torment, and the caustic ineffectual.
   This stricture  in the middle of  the penis, is usually accom-
 panied with strictures  equally formidable near the  bulb, the
 immediate cause  of the fistula.   These are to be  cut with the
 knife, rather  than cauterised, for the fistulae  of the perineum
 lead directly to those lower  strictures, the probe  or  directory
 passed to the bottomof the fistula, touches this point; and when
 the fistula is to be laid open, though it would  be wrong where
 there were no breach,  to approach  the urethra, it is good prac-
 tice,  when  there is  an opening in the urethra, and  that callous,
 to make that opening a part of the incision;  to pass  the  staff
 down till it is  stopped  by this lower stricture; to pass the direc-
 tory along the fistula, till it almost  touch the staff;  to observe
 well the direction of each, and to cut along the directory till the
 staff is laid bare.
   4th, To  attempt any  surgical  operation on  the  perinaeum,
before the  free course of the  urine is restored, would  be but
loss of labour, and a wanton destruction  of parts ;  and the mo-
ment that the  canal is free, the  urine, no longer disordering the
parts, they shew a tendency  to heal, while  the bladder itself
seems to recover  its  powers.   I h ive seen a patient, whose in-
 continence of urine was such as to wet the bed incessantly, and
» 
Ofthe Cure of Fistula.
223
led me to suspect that the body of the bladder itself was  per-
forated,  so relieved,  by cauterising or perforating the stricture,
that he has retained his urine  from night to morning, and from
morning  till  night,  passing two  pounds at once.  When the
operation of the caustic is complete, the  stricture  perforated,
or the free course of the urine, by any art restored, the surgeon
addresses himself to the new and arduous  duty of healing the
sores, he performs now on the fistula in perinaeo, the same
radical operation that he would  on the fistula in ano, i. e.  he
lays it completely open.   He places the patient as for the opera-
tion of  lithotomy ; examines all the openings once  more with
the probe, and sounds their depth,  and remarks  their relation
to the urethra.   He then introduces the staff down to the stric-
ture  in the perinaeum, and gives it to an assistant to hold;  he
next  passes the grooved directory,  perhaps a little bent, along
the main channel of the fistula, till it  reach the stricture, and
almost touch the staff; he  then  either runs his sharp or probe-
pointed bistoury, as he thinks best,  along the directory,  or  he
cuts with a common scalpell, till he at once lays open the fistula
and cuts the  stricture, making it the  last  part of the  incision
and nicking it fairly.   He has now laid some length of the staff
naked, but, to be  assured that the stricture  is completely un-
done, he pushes the point  of the staff through the incision of
the  perinaeum  and then  passes it into the bladder.   He then
withdraws the staff, and introducing the  flexible catheter, or a
leaden staff,  dresses up the incisions lightly, and perhaps orders
a warm stimulant fomentation of chamomile decoction sharpen-
ed with sal ammoniac  to  be laid over the parts and repeated
from day to  day  to  keep  them clean  and in a pleasant state ;
and  though  the circumstances of the case should have forced
him to lay open a considerable length of  the  staff, he need  not
be dismayed, for we frequently see several inches of the urethra
 (I have seen full three inches of it) regenerated, or rather re-
 placed, from the  growth of the surrounding parts.
   In the future dressing,  though I do not altogether forbid  the
 occasional use  of poultices, I do not approve  of  their being
 continually applied,  the warm bath  or stimulant fomentations
 are much  to be preferred,  while the parts  will always be found
 most healthy when  kept dry and clean.   The sponge and  lint
 are the best dressings.    The callous parts  may  be touched
 with caustic ; and when the granulating process languishes, the
 parts may be animated with red  precipitate mixed with basili-
 con ; spirit  of turpentine, when not applied  too widely  so as
 to parch the parts, but touched on with a hair pencil, is often re-
 markably useful;  and, the  alternating these stimulant applica-
 tions with poultices, is particularly useful, for the occasional 
224               Of Paracentesis Vesica:.
use  of a  poultice which, if continued, relaxes  and indisposes
the parts,  swells them, increases their sensibility, and exposes
them to the operation of the turpentine or precipitate.  Never
let such sores be  crammed even with  lint, far less with stimu-
lant dressings, but let the dressings be laid  on lightly  and re-
tained with a (T) bandage.  The flexible catheter, if it can be
retained,  promotes the cure greatly by saving  the parts  from
the excoriation of the urine ;  but it is  not to be imagined that
the lodging of the catheter within the bladder prevents alto-
gether the urine tainting the parts, for every time the  bladder
acts  (and it acts more  frequently  and more irresistibly when
stimulated by the  catheter) the canal of the urethra dilates so,
that  while much  of the urine flows through the catheter, some
passes by the side of it and issues at the perinaeum.
   The bathing the parts with salt-water contributes to prevent
the itching and preserves them cleanly  and granulating,  and the
use  of sea-bathing and exercise often  contributes to the  final
cure of sores which seem altogether callous ; but it is not to be
concealed that often, after the  cure of the  great fistula, and
when the perinaeum seems entirely restored to a healthy state and
the urethra to be free  of obstruction, one small point  continues
perversely open, and  can by no means be healed : and  the cir-
cumstance of the patient being now restored  from the  most
melancholy to a comfortable situation  discourages the surgeon
from making any new attempt.
DISCOURSE  XV.
OF TOTAL OBSTRUCTION OF URINE, ANDTHE
    OPERATION OF PARACENTESIS VESICAE.

                         SECTION I.

                 Preliminary Observations.

1  SHALL conclude  this subject  with the description  of a
desperate operation,  which is yet our sole resource in the last
stage of misery.  The operation of paracentesis is less frequent-
ly  resorted to  as the  means of saving the lives of young and im- 
Of Paracentesis Vesica:.
225
 prudent people ; it is more commonly resorted to as a means of
 prolonging the years of the aged and infirm.  When in a voung
 and otherwise healthy man  it happens, that by a blow  or tall,
 the perinaeum is injured ; or when, from  a neglected stricture
 and a  sudden  suppression  of urine with fever, it is  necessary
 to perform the operation of paracentesis vesicae, the scene is ve-
 ry distressing; but  when in a man far  advanced in  years,  the
 prostate gland  has been long diseased and has  occasioned fre-
 quent obstruction ;  when, at last, the bougie gives no relief, and
 the catheter cannot, even with any degree offorce or  rudeness,
 be driven into the bladder, the scene is not  less affecting,  for
 this swelling ofthe prostate  is a disease almost peculiar to learn-
 ed and sedentary men; and the  patient's age,  infirmities, and
 present sufferings; the dignity with which he supports them;
 the presence of his family depending perhaps on the survivancy
 of his  offices,  and the melancholy dispersion  of  his  family,
 which must follow his death,  create a  strong sympathy.   His
 genius  and  literary talents give us a particular interest in  his
 fate ; the operation is, it must be acknowledged, but a tempora-
 ry resource, yet such a man can bear to linger on a little longer,
 and, with his family around him, think it happiness.
   It is not  possible to  reirain  from alluding to a melancholy
 scene,  which returns too often not to leave  serious impressions,
 and it  is most natural to feel some degree of anxiety in trying
 to resolve  many doubts concerning the proper  conduct  of the
 surgeon in circumstances naturally perplexing;  where the  chief
 masters in surgery deny us the benefit of their advice and counsel.
 "  I must own," says one of the first surgeons of our own coun-
 try, " that I have not seen cases enough to enable me to give
 all the varieties that occasionally happen, and, of course, ail the
 advantages and disadvantages of each method."  But are those
 who presume to teach, entitled thus to decline giving their best
 advice because every such case is full of difficulty and danger ?
 Is it fair thus to devolve the most difficult questions in our art
 upon the individual surgeon perplexed at once by the delicacy
 of his situation and the selfish reserve of authors, whose pro-
 vince it is to lay down  the  plain  line of his duty ?   Whatever
 presumption there may appear in offering  to explain a subject
 which has been declined by so great a master in surgery as Hun-
ter, I cannot  but reflect that  this is an  operation which  may
 eventually tall to the lot of every surgeon to perform : that no-
 thing could be more ungracious on the part  of a  teacher than to
 devolve on every young man the difficult task of going unassist-
 ed through a long process of  reasoning  upon the choice of in-
 struments or methods, attended with the imminent risk of think-
                            2 F 
226                Of Paracentesis Vesica:.

ing too long, or of acting too rashly:  I cannot but recollect that
the  young surgeon coming unprepared to  such an  operation,
may make his incisions in the perinaeum deep and wide, and yet
miss the bladder, and find no better way of retrieving his error
than by performing a second operation by incision  above the
pubis:  I have  seen this, and,  to  my utter amazement, have
seen a patient so mangled, survive.
                         SECTION I.

          Of Distention and Rupture of the Bladder.

   When we speak of the over-distention, and of the bursting
of the urinary  bladder, as cause and effect,  we are guilty of a
palpable solecism ; nothing, I believe, can be more easily proved,
than that the bladder never is so distended, as from mere exten-
sion, to give way ; it is not burst by dilatation, but is inflamed,
becomes gangrenous in one spot, and then yields.*  If the
bladder can be  so distended, without rupture, as to contain ten
pounds of urine, if it be so distended as to compress  the intes-
tines,  fill the whole abdomen,  and rise to the scrobiculus cor-
dis, without rupture; if it be thus distended by the third day of
the suppression, and yet continues entire to the eighth or  tenth
day ; if the urine begin to be slowly  discharged from the  third
day, so as to prevent any farther accumulation, how  can  it be
that  it gives way from mere extension ?   The expression over-
distention and the bursting of the urinary bladder, is so  com-
mon, and yet so deceitful,  that I hold it right to say a few words
on the dangers of distended bladder,  which will at once explain
the difficulty.
   The urinary bladder, which naturally holds a pound and a
half of urine, is no sooner dilated so as to contain two pounds,
than uneasy  sensations are experienced : the desire of passing
the water is  very  strong, and  if the desire  be not  gratified,  if
the bladder be  suffered to be dilated beyond its natural state, it
loses all  power, and becomes paralytic.  The  desire indeed
continues, and the efforts are  renewed in painful  paroxysms,
with impatience and violence,  but the power is gone, and the
bladder continues distending more and more.
   When it becomes so enlarged as to fill the whole abdomen;

  * Either the neck of the  bladder, or the beginning of the urethra,  certainly
ruptures in fome inftances; in confequence of which, the urine becomes extrava-
fated in the perineum.  The impreflion  on my mind is very ftrong that  1 have
feen bladders evidently lacerated from over  diftention. S. 
Of Paracentesis Vesica.
227
when it reaches the scrobiculus cordis, and can rise no higher ;
when the distention is at its extreme, and neither the bladder nor
the space in the abdomen can receive more, the general pressure
acts like an expulsatory power, and one of these things must hap-
pen : either the bladder must give  way and lacerate,  which  it
never does, so equally is  it supported by the pressure of the sur-
rounding parts ;  or its orifice must dilate, and the urine begin to
flow.  The urine actually begins to flow from the third day of
the suppression, and whatever urine descends from the kidnies
is evacuated in small quantities from time to time.
  Now this gradual and dribbling evacuation of urine,  which
empties the bladder, which begins  with the full distention of it
and continues till the eighth or  tenth day,  or till the bladder
yields, has been long  understood   by good surgeons, and has
been especially named by the French writers, <k Urine par re-
gorgement."  This evacuation of  urine, proceeding from over-
distention, is most dangerous and deceitful.   The friends feli-
citate themselves that the urine begins to  flow;  they commu-
nicate their information to the physician, which he is too apt  to
believe; basins and cloths  wet with urine  are easily produced,
but the patient lies unrelieved ; and the continued distention of
the bladder is followed by universal inflammation of the abdo-
men : the insensibility and low delirium of incipient gangrene,
are mistaken for that relief  which was expected  from  the  flow
of  urine, till either hiccup comes on, and the patient dies of fe-
ver and inflammation;  or the urinary bladder actually give9
way, and the acrid urine is poured out into the cavity  of the
abdomen.  Cases innumerable of this description are to be found
in the writings ofthe older surgeons ;  the quautity of urine cor-
responds so well with  the quantity of drink,  that the  physician
is apt to be deceived ;  and Colot tells of many cases  in  which,
while they believed this overjloxv of urine to be an incontinence,
they actually mistook the distended bladder for  an abdominal
abscess, and made appointments to open it by incision.
   Let no surgeon then trust to the reports of nurses or friends,
nor partake of their inconsiderate joy, but lay his hand upon the
abdomen and tap with the finger, that he  may distinguish the
distended  bladder and the fluctuation of the urine.
   Since then the bladder suffers no farther distention  from the
third day, why should it burst ? Not from laceration, for it is
 supported by the uniform pressure of the  surrounding viscera,
 and the general tension  of  the abdomen:  not by yielding sud-
 denly,  for it is distended to its utmost on the third day of sup-
 pression, and yet seldom gives way  before  the  tenth:  not by
 attenuation, as a substance merely elastic gives way  fibre  after
 fibre, or bursts suddenly,  for the  bladder, even more than  the 
228
Of Paracentesis Vesica.
   womb, increases in thickness in proportion as  it is distended.
   The term laceration never was more unfortunately applied than
   to the bladder;  for when there is a bnach in it,  we find upon
   dissecting it to be a small round hole, such as might be covered
   with the point of the finger; it is round  like a shot hole, with
   a rough and ragged margin, in short the  rupture is at a single
   spot,  not longitudinal, but circular ; the  bladder,  and all the
   adjacent viscera, are red and inflamed, while this single point is
   black  and mortified.*
     The signs of death are not merely similar to those of pro-
   tracted labour or strangulated hernia, but are essentially the
   same,  as proceeding from the same cause.  While  the bladder
   is distending, the abdomen feels hard and firm, and the tumour
   is circumscribed in the hypogastric region:  when the bladder
   reaches the scrobiculus cordis, the symptomatic vomiting comes
   on, the pulse becomes rapid, the belly becomes extremely sensi-
   ble, and the patient cannot endure the gentlest touch :  and soon,
   the particular swelling of the bladder is concealed, because the
   abdomen in  general becomes tumid and elastic,  like  a drum,
   while  the pulse becomes  frequent  and  irregular,  the mouth  is
*   parched, the face  ghastlv, and the extremities  cold; and when
   after a period of insensibility or low and  muttering delirium,
   the- patient expires, we find,  upon  dissection,  the  bladder deep
   coloured, of a dusky red, thick and fibrous, or  fleshy : often
   the bjadder has formed adhesions  with  the surrounding parts,
   •and the viscera of the abdomen are very generally inflamed before
   actual gangrene comes on, or the  bladder gives way, and  the
   patient usually expires thus, not of rupture of the bladder, but of
   fever,  irritation and suppressed discharge.  But when the blad-
   der has actually yielded, its rupture is accompanied with a sense
   of something giving wav within,  and we find that the  opening
   is in the centre of the fundus, in  one round gangrenous spot.
     To  those who imagine  that the extension of parts in the living
   body, is like that of the dead, an attenuation or mere dilatation!
   who expect to find the bladder, upon dissection, thin and  trans-
   parent !  its  real condition must appear very  surprising.   The
   bladder has not indeed time to grow by any actual  deposition
   of parts, but it is thickened by the fulness and turgescence of its
  vessels,  ind bv extravasation into its cellular substance.   I find
  always the veins extremely turgid,  the muscular  fasciculi big,
  fleshy-hke, apparently injected with blood, (as in a preparation
  where the bladder is injected with s;ze, till the size  is extrava-
  sated among the coats). And while much blood  is extravasated

    * Thefe appearances may no doubt be fomctimes met with on diflection, but  it
  is certain that the bladder is occafionaily fairly ruptured. S. 
Of Paracentesis  Vesica.              229
 into the cellular substance of the coats ofthe bladder, some ex-
 udes into its cavity, thence the urine is always deep  coloured,
 obviously tinged with blood, and the last pound of urine drawn
 off either by the catheter or trocar, from a  distended bladder,
 is as thick and as deep coloured as coffee grounds, tinges the in-
 struments black, and is extremely  fetid.  The slow and gradual
 distention of any living part is invariably accompanied with ac-
 tual growth or a secretion of new  parts ; sudden extension is ac-
 companied only with a turgescence of vessels, a fulness of blood
 in the part, and  an extravasation into the cellular substance : in-
 flamed  viscera,  have always from  this extravasation, a livid ap-
 pearance :  a strangulated  intestine, and a distended, and conse-
 quently inflamed bladder, resemble each other in this respect,.
 and though such parts seem gangrenous, yet,  upon macerating
 them in water, the blood being washed out,  they  resume  their
 natural  complexion.
   That these several stages of dilatation ofthe bladder may be
 exemplified,  I shall briefly recapitulate the circumstances of such
 a case :  A woman having fallen in labour on Saturday morning,
the head of the child descended into the pelvis, the pressure on
the urethra prevented any urine  being discharged,  the  head
descended lower and lower, till the scalp appeared, on Monday,
protruding through the orifice of the vagina    In  this state of
suffering the woman was permitted to remain till Tuesday even-
ing, when she was delivered.    During four complete days the
pelvis had been so occupied by the  head of the child, that the
urine could not be discharged.
   The catheter  was never introduced, nor did the medical at-
tendants make even the slightest inquiry into the state of the ab-
domen : the  nurse,  when changing her linens, after delivery,
was sensible of an unusual degree  of fulness,  and the  patient
expressed her desire to  pass her urine, but she lay down, the de-
sire returned  again at the distance of two hours,  and then she
passed about  a pint of urine, next day she  suffered much  from
pain in the abdomen, with frequent desire to make water, which
she discharged in tea-cup-fulls. On  Saturday, (the eighth day of
her distress) the  physician who attended her was again  called :
her belly was  now greatlv distended, with great torments,  diffi-
culty of breathing,  and oppression, an  intense thirst which she
durst not indulge, fever, furred'  tongue,  and very frequent
pulse : about an  hour before his visit, she felt  something zvith-
in, at the navel cracky with great pain.  For  thirty hours  pre-
ceding this she had made  no urine,  nor did she pass one drop
 from that time forward.  A few ounces of very fetid and dark-
coloured urine were now drawn off by  the catheter, and on the
second day after, she died delirious.  The abdomen was found, 
230
Of Paracentesis Vesica.
upon dissection, universally inflamed : the bladder had  given
way, and the opening was found to be in the centre of the fun-
dus, of a circular form, and with a black and gangrenous mar-
gin.
   Obstructed urine, hernia,  and  lingering labour, resemble
each other so entirely,  that in each case the same signs indicate
the same danger.  In the common fate ofthe patient those three
cases unhappily agree but too well;  delay  is the greatest
danger,* and perhaps I have  not,  in  this book, announced a
maxim of  more importance than this !  I  entreat the young sur-
geon to beware of delay.   In  suppression  of urine it is  most
painful to see  that the needful  operation  is usually performed
too late, that the  patient's resignation  avails him nothing, and
that the dexterous operator has no reward for his skill and  dex-
terity.   In these three  cases it requires talents,  experience, and
a spirit of observation,  to conduct the  patient safely : to give a
fair chance of relief from the powers ofthe constitution, without
exposing the patient to  danger, by delay: to decide whether in
cases of retention of urine, the abdomen  be still uninflamed, so
as to allow time for the good effects of fomentations, poultices,
with a variety of trials, to force the passage ? or whether the
danger be not pressing, requiring the bladder to  be  relieved at
every  risk, either by  forcing the  catheter violently  through
every obstruction, or by piercing it with the trocar ?  This I am
well assured of, that there is no  mode of operating, no kind of
danger equal to that of delay.   It were better that the surgeon
cut into the bladder by any cruel method !  better  that  he cut
above the pubis, or make his way by incisions in the perinaeum,
after the manner of the lateral lithotomy, than to delay the ope-
ration one  hour beyond that in which the signs of inflamed ab-
domen  manifest themselves ;  for,  after  the rudest operations,
the patient sometimes survives, but from delay thousands have
been lost.   It is,  I believe, the opinion of all good writers, the
maxim respected  in all eras  of our science, the fair deduction
from all the fatal or prosperous cases on record, that we should,
in retention of urine, as in hernia, operate early.
   But while I speak thus the language of conviction, and repeat
the injunctions ofthe most experienced of our profession, I can-
not be without some anxiety, lest the young surgeon should be
led into  rash measures.  I know it to be true that few have

  • This maxim is undoubtedly correct where the operation is or will be neceffa-
ry ; but this is fo feldom the cafe that in ten years Default performed it but once,
in the Hotel-Dieu, of Paris;  and even in that inftance, he afterwards thought it
might have been avoided.  Mr. Abernethy is of opinion that the operation is
rarely if ever neceffary, that the remedies above mentioned will, in almoft every
cafe, procure a difchatge of the urine.  S. 
Of Paracentesis Vesica.
231
suffered by precipitation, such is the natural aversion to opera-
tions, and the reluctance of friends ! while in my own  limited
practice I have seen many victims to timid measures and ope-
rations performed too late ; yet I am inclined to trespass with
one observation more, which may  serve to qualify the opinion
I have laid down.
   Although  the greatest danger is to be apprehended from in-
flammation of the abdomen, yet the whole aspect of the case is not
to be ascribed to this cause:  the low delirium, trembling pulse,
or even hiccup,  do not  portend death in distention of the blad-
der so absolutely as in a gangrened limb: these  are not always
signs of internal gangrene,  often they  manifest  themselves
while the parts continue sound: nor does every degree of swell-
ing ofthe belly, vomiting, and faintness, infallibly indicate abdo-
minal inflammation : many of the  worst signs proceed, in some
degree, from mere irritation, and  the patient's exhausted state.
In retention of urine, the fulness  of the bladder and suppres-
sion of the natural discharge, the tossing and misery of the pa-
tient, from desire to pass urine, and the ineffectual endeavours
to introduce the  catheter, exhaust him, and he seems in the
last stage of the suppression,  to lie almost in a comatose state.
In short I have, in the course of my practice, observed that in
all these cases delirium comes on very early, in consequence of
the pain, fever,  and want of rest, for  many days and nights.
The inference then is plain: that though in such cases  nothing
but operating can save the patient's life,  we never must so far
prejudge the  question, as to  say he is beyond the reach of art!
Every surgeon of experience must have observed, that in dan-
gerous distentions of the bladder, the  abdominal pain ceases,
the pulse subsides,  the tossing  of  the patient, and all the signs
of indescribable  uneasiness, vanish as  soon as the catheter  or
trocar is forced into the bladder : after those several operations,
the delirium goes off, the senses become clear, the fever abates,
and the natural sleep is restored.
   In short, the worst signs are  no  sure proofs of gangrene;  the
patient is  perhaps exhausted with  sickness, irritation and pain;
we never must prejudge the  question, saying,  " It is  surely
too late to operate."  In the most hopeless cases, let the
PATIENT  HAVE HIS CHANCE  FOR LIFE.
   And now that I  am to  analyse the  several operations, and
teach that which is fittest in the several  circumstances to be per-
formed,  I shall say a few words on a subject of  some delicacy.
The talent of operating is not merely useful,  as enabling the
surgeon  to perform safely, a  dissection  which  is not without
danger, but still more  in giving him perfect possession of his
own mind.   The degree of skill we have or suppose ourselves 
232             Of Puncturing  the Bladder.

to have, in operating, enters, I fear, too much into our feelings,
when considering what is best to  be done ; for,  in ddn> ult cir-
cumstances, a man timid and unskilful in operation will be apt
to linger and  hesitate ; a man bold and conscious of operating
well,  especially if not familiar with practice,  will be apt to hur-
ry on with  precipitation,  to the most decided measures;  but a
man who is familiar  with scenes  of this  nature,  and has both
performed  many operations, and has studied well the prognos-
tics  of danger or safety,  will, if  he be at the same time a tear-
less operator,  proceed at once with resolution and caution, will
neither hurry, nor delay too long, the measures which he thinks
necessary for the patient's safety ; and though  no modest nor
ingenuous man will ever, upon a retrospect, be  entirely  satis-
fied with his own conduct, even  when most successful,  yet one
thus qualified  at once to reflect deliberately, and  act intrepidly,
will, upon the  severest scrutiny into his past conduct, find little
reason for  self-reproach.   I do  regard  skill in operating as of
the utmost importance in giving the surgeon perfect self-pos-
session :  a  bad operator will hesitate,  in  the most simple cases,
while a good and dexterous  operator, like a man skilful in the
use of weapons, will not  enter rashly  into difficulties, but be-
ing engaged from conviction, will bfing  himself through with
courage.   Let every young man then endeavour to become a
dexterous operator,  for that  will help to make him  a judi-
cious SURGEON.

                        SECTION III.

      Of the several Methods of puncturing  the Bladder.

   If we are entirely in any case to join pathology with surgery, to
reason from the constitution and nature of the parts, and from the
acknowledged dangers  of operation,  to any practical  conclu-
sions,  it must be in  the  present  case,  where  innumerable dis-
sections instruct us in the causes  of death.   Having established
the fact, that in cases of retention of urine the patient dies from
no other cause than  inflammation of the abdomen,  let us  see
what assistance this theory will give in deciding the  main ques-
tion, " Which is the  least dangerous method  of tapping  the
bladder?"   First,  If we  make our incision above  the pubis,
and strike the  trocar from that point into the bladder, we cut
parts  contiguous to  the  peritonaeum  already inflamed.   Se-
condly, If we cut from the perinaeum,  with incisions resembling
those of lithotomy, we  make deep, unnecessary   wounds in a
part  of the bladder which, though lodged in  the  pelvis,  some-
times extends  its inflammation, as in  Chesselden's first  experi- 
Of Puncturing the Bladder.             233
 ments, to the cavity  of the abdomen.  Thirdly,  If we strike
 the trocar skilfully  into the same part into the perinaeum, with-
 out such preliminary incisions, the  risk of inflammation is
 greatly lessened; and if we pass the trocar from the rectum in-
 to the bladder, we carry it through no thickness of parts, but
 transfix only two membranes: it is " like  a  stroke in the  wa-
 ter:"   and  the danger of inflammation  is exceedingly small.
 This slight index of the principles, according to which I mean
 to  reason, will enable my reader to accompany me in the fol-
 lowing critical review  of the several methods  of operating:
 perhaps it will enable him to anticipate many of my conclu-
 sions ;  it will surely incline him to adopt a mode of puncturing
 the bladder very different from that in common use.

                       FIRST  METHOD.

   The most common operation, because the most obvious, is
 to penetrate  from above the  pubis.   Every  ignorant tyro,
 though  unable to strike the bladder from any other part,  is able
 to plunge the trocar into it, at a point where he feels the fluctu-
 ation so  plainly:  that superficial objection  of  the danger of
 wounding the peritonaeum, so often urged against this method,
 is indeed of no importance; there is no  danger of wounding
 the peritonaeum, for the bladder, when greatly distended, reaches
 high above the navel, carries the peritonaeum, of course, belore
 it, and  exposes a space of several inches, in which we may per-
 form our incisions without incurring this kind of danger.   But
 the abdomen is inflamed;  the preliminary incisions, which pre-
 pare for the introduction of the trocar, pass, in a gross old man,
 through several inches of fat  and  cellular substance:  the  inci-
 sions must be wide in proportion to their depth : the canula is
 no sooner lodged here than it is  displaced, in some degree, by
 the contraction ofthe  bladder,  which, when  emptied, subsides
 under the pubis: the  canula stands so obliquely that the urine
 never flows with ease but by running out upon the  wound, and
 by being injected among the cellular substance, it causes the if
 wound to inflame,  the wound, by its proximity to the inflamed
 peritonaeum, soon mortifies, and  thus, notwithstanding the tem-
 porary relief produced by the emptying of the bladder, the  pa-.
 tient dies  on the third or fourth day.
  Those who have been forced by fatal experience to condemn
 the  puncture above the pubis, have entered into no investiga-
 tion, and have n.it always been able to assign a  cause for their
 ill success ; but it  is well known that the wound is apt to gan-
grene, the operation is so easy  that nothing  but  experience of
its ill conseouences could prevent its being universally prefer-
                           2 C, 
234             Of Puncturing  the  Bladder.
 red :  but the unfavourable issue of the operation is now so uni-
 versally  acknowledged,  that even the difficulty and  deep  inci-
 sions in the perineum are preferred.*


                       SECOND  METHOD.

    To perforate the bladder with a trocar, from the perinaeum,after
 making incisions, like those of lithotomy, is the sole method now
 mentioned in systems of surgery, a harsh, cruel, and dangei ous o-
 peration.  For when the surgeon is to make ^ incision in theperi-
 naun, an inch and a half in length,  at the commencement of the
 membranous part of trie urethra, and continuing it toward* the anus
 in a line parallel xvitfi,  but at least half an inch distant from the
 raphe,  perinai /" he has to operate  according to precepts so in-
 consistent with the actual relations ot the parts, so unintelligible
 to one who is an anatomist,  and so nugatory to one who is not,
 that he must cut at random : having made deep incisions in the
 perinaeum, he no sooner begins  " to search for the bladder with
 his finger in  the bottom  of the wound," than he directly en-
 counters the enlarged body of the prostate : If he  understands
 what he  feels,  and dissects  backwards till he distinguishes the
 bladder itself, he actually reaches that part of the bladder which
 lies upon the return ;  (viz. the space betwixt  the visculae) he
 arrives exactly at the same point which he touches in perfora-
 ting from the  rectum, and no one will deny that he might per-
 forate with more security and less pain from the rectum, through
 its thin walls, than from the perinaeum by  these incisions:  But,
 having made his way to  the gland, he points  his trocar (which
 is usually too short for  any purpose, and not at all appropriated
 for this) directly  upon the  gland,  drives it deep  into its sub-
 stance, and no urine flows, or flows  only when both  trocar and
 canula  are  withdrawn.—How this happens  it is  not difficult
 to conceive: " An old man who, for  the last twelve or fourteen
 years of his life, was subject  to occasional difficulty, was at last
 affected with  entire retention,  so that for five days preced-
 ing the operation,  he had not passed one drop of urine:  all at-
 tempts  to introduce the catheter, or  give relief by passing bou-
 gies, were in vain,  the  tumid bladder was felt above  the  navel,
 he had  continual straining to avoid   his  urine, with sickness,
 thirst, and a feverish pulse.   But in his disease, nor in his pres-
 ent distress, there was nothing peculiar or worthy  of notice.
 A voung surgeon periormed  the operation of puncture in peri-
 naeo by  all the usually prescribed rules.    After dissecting into

  * Mr Abernethy has performed, this operation feveral times with fuccefs, and
prefers it to ?.uy other for relieving the bladder under thefe circumftances. S. 
Of Puncturing the Bladder.              235
 the hollow  of the pelvis, he struck his trocar  deep,  but upon
 withdrawing the stillet,  no urine  flowed, it was only when he
 was withdrawing the trocar also,  that a little  urine  ran out;
 nothing intimidated by this ill success, he struck his trocar once
 more, now the urine flowed freely; the canula was  left in its
 place, the urine continued to be discharged, but the  abdomen
 inflamed and the man died."
   44 Upon dissecting the body,  the first thing that could be ob-
 served was the fundus of the bladder hanging flaccid  upon the
 point of the canula, which projected some inches into its cavity ;
 upon opening the  bladder, the canula was seen in its place ;
 upon withdrawing the canula and cutting out the parts from the
 pelvis, laying them on the dissecting board, and investigating
 the inner surface of the bladder, not the slightest mark of punc-
 ture was to be found; so that had not the trocar been seen  in
 its place, upon opening the abdomen, no one could have believ-
 ed that it had penetrated !"
   This case 1 noted down as  peculiarly instructive ;  an opera-
 tion essentially bad was  performed  in a manner so  rude and
 barbarous, that a coroner's inquest might  have taken cogni-
 zance ot the affair: 1 his culpable  homicide  was a consequence
 ot the same ignorance ot anatomy, which makes many an ope-
 ration for the stone miscarry :  There is no wonder it a surgeon
 who would, il he were cutting tor the stone, nick the  urethra
 several times  before he  was sure  ol having divided it, strikes
 his trocar twice be tore he  punctures the biuUdti : This gentle-
 man directly encountered the diseased prostate without knowing
 it! He not onh plunged into its substani e,  but that transverse-
 ly, so as to transfix the gland; for  the point  ol this canula being
 buried in the farther sidt of the gland,  no  urine  flowed  when
 he first withdrew the stillet! but while he was withdrawing the
 canula, after he haci drawn its  point irom the  Uirther  lobe of
 the gland, and before it was withdrawn  altogtthi r, it  received,
 in passing from side to side, a lew drops of urine which flow-
 ed out:  The second time he  struck  in his trocar,  it  neither
 passed deep behind the gland,  u hich is the  proper intention in
 this method, nor into the substance  of  the gland, and through
 its thickness into the cavity of the  bladder, as usually  happens,
 but directly onwards  in  the  line of the  natural canal, first
 thiough the urethra, and then through the centre  ot the gland.
 Thus it  happened, that,  alter death, no wound  of the trocar
 could any where be found : as  for the death ofthe patient there
 cannot be a matter ol wonder.
   1 here is no more heinous fault than that of practising surgery
without a knowledge o! anatomy, unless  ii be that of  studying
anatomy  iiiocpeiid'.nily  of pathology, and applying the descrip- 
236
Of Puncturing the Bladder.
tions  of parts in the sound body, to the same parts in a state of
disease.   The effect  of the enlargement of the prostate gland,
upon our operations, has  (as I know by fatal examples)  been
but little studied.  The plan  1st, of enlarged prostate is very
simple, I have represented in a true drawing the enlarged  pros-
tate which in truth fills all the  lower part of the pelvis, and pre-
sents itself to the surgeon, so  that without a perfect conception
of its form, and actually feeling it with the finger, he can per-
form no operation without blundering.  The* extent of the en-
larged gland is designated by the figures  (a a a) ; the contracted
bladder  (for  it thickens  and  corrugates in proportion as the
gland grows) is  marked (b b) ; the membranous part| of the
urethra is marked (c) ; while the  original and natural size of
the prostate is marked in dotted lines ; and let it be observed
that as the gland enlarges, the space  (d) betwixt the ureters and
vesiculae seminales of the  two sides,  is increased ; by being re-
moved from  each other,  they leave a wider space open to the
puncture of the trocar, so that they cannot  be wounded, and
though it were not so, the wounding  of the vesiculee, though it
has been represented  as a  mighty objection to the puncture from
the rectum, is none: the vesiculse would heal as easily as any
other part, and the vasa deferentia would re-unite (unless indeed
they were  cut across), as easily  as the bladder re-unites, but
this is a question of no importance, the operation is performed
in people advanced in years and ruined in constitution, and the
question is not about  saving the organs of procreation from any
slight injury, but about saving life.   The plan 2d, presents the
same parts in a vertical section.  The staff is stopped at (a), in
the membranous part of the urethra, by a stricture.   The gland
(bb)  is represented as enlarged, filling the lower and fore-part
ofthe pelvis, and compressing, in some degree, the  rectum.
   That the  surgeon  can  hardly perforate behind the diseased
gland through the body of the bladder itself, except by a  very
deep and dangerous  dissection, is what I have always conjec-
tured,  when observing the size of the diseased gland ;  every
operation  I have since witnessed  has contributed to strengthen
a suspicion, which has been absolutely confirmed by a miscar-
riage more extraordinary and less pardonable than that which  I
have just mentioned; for though it is unpardonable to begin the
operation by  incisions in the perinaeum, without  introducing
the finger in ano, to feel the  condition and size of the  gland,
yet nothing can exceed the folly,  in  actually  perforating from
the rectum, of having the finger introduced for the purpose too
of guiding the trocar, without estimating the  extent  of the
gland, or choosing a  trocar sufficiently long.
   A gentleman being resolved to practise the newest piece  of 
P/.uil. of Enlarged.  sM%'^:"'f^^s  ''
Prostate. Jhijc  '   '. -'"^        P>% "
'    ./B^V7- A/.*
F.K^ny\Vc 
 
Of Puncturing the Bladder.              237
surgery ; viz.  puncturing  from the rectum ; used, in spite  of
every remonstrance on my part, a common trocar, hardly more
than three inches long!  a common trocar tor  tapping the belly
in ascites !  The consequence  was most lamentable, for  the in-
strument being buried in  the substance of the enlarged  gland,
not one drop of urine flowed ;  the trocar and canula were both
withdrawn, and the  operation of puncturing above the pubis
performed.

                      THIRD METHOD.

   In tapping the bladder from the perinaeum without previous
incisions, the puncture is performed on the broadest part of the
bladder,  where it  lies under the arch ofthe pubis; the point  of
the trocar  enters about the level of the urethra, where there JSgflfr
little of the  diseased gland ;  to hit the bladder,  not from be-
lli nd the  gland, but from  its fore part thus,  is as easy as  to
plunge into its fundus from above the pubis: no tyro could miss
the stroke;  if the  surgeon keep close to the arch of the  pubis,
without actually encountering the bone with his trocar, he can-
not fail to strike the bladder fair.
   For this operation the patient is to be laid as for lithotomy,
on the side of his  bed, on his  back, the knees raised and separ
rated by  assistants, and the heels placed firm upon the bed, near
the buttocks, or held by the assistants  on  each side ; a  skilful
assistant is to compress the ahdomen with both hands,  so as to
depress the bladder and keep it steady.
   The  surgeon is to imagine a line  drawn in the direction  of
the transverse muscle; i. e. from the  anus to  the  tuber  ischii, ^%
and the centre of the triangle which that line forms with the arch
of the pubis,  or a  little  higher than the centre, is the point  at
which the trocar is to enter.
   The catheter is to be introduced as  far as it will pass,   to pre-
vent any harm to the urethra, and to direct the trocar; the fore-
finger of  the left hand is  to be passed deep into the rectum,  to
feel the  bladder or the swelled gland, and to enable the sur-
geon both to  judge ofthe relation of parts,  and to  keep them  in
some degree  steady ; the trocar, which must  be long, slender
and a  little curved, must  have a big, round  handle, and the
surgeon taking  the handle  in the palm of his right hand, and
laying the fore-finger along the canula to steady it, is to enter
it, at first, directly into the part inclining a  very little  upwards
and to  carry  it  on  slowly,  steadily, and without fear, until he
feel it in the open cavity of the bladder, when,  bv withdrawing
the trocar, the  urine will flow out.
   " The operation of paracentesis, though  it be no more (says 
238              Of Puncturing the Bladder.
Dionis) than a simple puncture, requires on the part of the sur-
geon, a perfect knowledge of anatomy, and  ot the relation of
parts, both to conduct his instrument directly  into the bladder,
and to avoid encountering any  important  parts ; it  is indeed
alarming to a surgeon little versed in anatomy, though extreme-
ly easy to  those  who are."   To this opinion we very willingly
subscribe ; if the  operation be at all  perplexing, it must be to
those only who are ignorant of anatomv, but I have gone a step
farther in  protesting that it can be difficult to no one who  has
discretion and  courage  ; and that it is as easy to strike  the
broad anterior surfae of the  bladder  under the arch of the pu-
bis, as to  plunge into it from  above.

                     FOURTH METHOD.

  When the catheter is obstructed and can by no means be  for-
ced into the  bladder, what  is the difficulty ?  some  stricture,
amounting almost to obliteration of the  membranous part of the
urethra, or  more frequently an  induration  of  the  prostate.
Where is  the catheter arrested i always near the  point ot the
prostate gland ; it stops just  where  the point of  the catheter
passes the finger laid on  the perinaeum,  and at that place where
it is felt upon introducing the same finger into  the  rectum.   If
the catheter could be thrust through this obstruction and driven
into the bladder,  even at the expense  of some violence,  and
much blood, would such rudeness be  fatal ?  by no means, such
an operation would, on the contrary,  give present relief.
  If either by thus  pushing  on the catheter with  some lacera-
tion of parts within,  or if, by a small incision in the perinaeum,
the course of the  urethra could be  recovered, and a probe  pas-
sed along  it, or  the common grooved  directory, or any such
instrument introduced, would such injuries be at all equal to
those I have enumerated ? or would the danger of inflamma-
tion, when  the neck  and natural opening of the bladder were
thus forced, be  at all comparable with these dangers, which
must accompany  a wound of  its body, whether from above the
pubis,  or  from  behind the prostate gland ? surely not.   Ifsur-
gtons  would but condescend to make  themselves correctly
masters  of this  piece  of anatomy  ;  if,  having passed  the
male catheter as  far as  it could  go, they would then, with a
small incision, seek out the obstructed part of the urethra, they
wouid be  able either to  help  on the catheter with the probe, or
to dilate the urethra, or to force the prostate gland, by passinga
female catheter straight on from the point where the male cath-
eter stops ; and a wound so bloodless, so far from  the pelvis or
abdomen, so nearly resembling the thrusting on of the catheter, 
Of Puncturing the Bladder.              239
 affecting merely the neck  of the bladder, might be resorted to
 early, and many precious  lives be saved.

                       FIFTH  METHOD.

    If there be a method which may be put in competition with
 this, it is that of puncturing from the rectum.  I am not indeed
 ignorant that this  way of reaching the bladder lies under the
 formal protest of some writers, but they are of those who have
 written about surgery by conjecture, whose authority stands on
 no other grounds than reasoning ;  and what reasoning can dis-
 cover any thing sup.rior in the common and rude operation of
 making incisions in the perinaeum,  when compared with this of
 puncturing from the bladder?  The surgeon  must have  little
 confidence  in either his  reasoning or experience, who says,
 " we shall  therefore dismiss  this method (viz. the puncture
 " from the  rectum) without farther consideration."   Yet this is
 wisely said, for the question  will  bear no reasoning;  first an
 operation is described,  in  which, after incisions long and deep
 in the perinaeum, a trocar is plunged into the bladder,  some-
 times through  the diseased prostate, but more frequtnth  be-
 hind that gland, if the design of the operation be truly fulfilled;
 and next, the puncture from the rectum is protested against be-
 cause the trocar miy wound, forsooth, the vesiculae seminales,
 when in  fact the operation by  incisions in the perineum brings
 the trocar to that very point, where, if struck from the rectum
 it must enter.
   The project of puncturing the bladder from the rectum, ori-
 ginated,  like many  valuable inventions, in accident.  The sur-
 geon introducing the finger into the  rectum,  felt the bladder
 distinctly; and  to use  the expression of one gentleman, (who
 however  unfortunately neglected the hint,) u the bladder  was
 felt so distinctly, and the fluctuation  of urine was  so obvious,
 that the surgeon was conscious he  could  have struck a lancet
 into it as easily as into a vein."  Others  more confident did
 actually strike the trocar into the bladder, through the walls of
 the rectum,  and draw  off the  urine very easily, and had the
 happiness to find that the  canula could be  retained,  and  that
 when, by accident it slipped out,  the perforation still continued
 open, so as  to permit the urine  to pass, and yet the contraction
 of the levator-ani muscle shut the opening like a sphincter, so
 that the urine never  flowed except when the bladder was suffi-
 ciently full to excite desire, and when the natural course of the
 urine was restored,  the opening betwixt the bladder and rectum
spontaneously healed.  With such advantages,  with no import-
ant parts endangered in the operation, this method is unfortu- 
240              Of Puncturing the Bladder.
nately limited !  it was  once practised very happily in a child,
whose urine  was obstructed by a stone sticking near the glans
penis ; it has been practised also with the best effects in young
men, who have had the urethra burst,  by falls upon the peri-
naeum ;  but it is  to be preferred chiefly in cases where the ob-
struction is temporary, and when we have reason to hope  that
the natural course  of the  urine will be soon restored  ; but in
the most frequent and most distressing of all cases, the disease
of the prostate, this method I fear cannot be of use.*

       SIXTH  METHOD OF FORCING THE CATHETER.

   The disease of the prostate gland, which embitters so often
the last  stage of life, of which Dr. Fothergill, and many men
eminent  in literature and science,  have died, is that chiefly in
which the operation of paracentesis is required, a wretched
resource which only prolongs life.
   The surgeon is aware of his patient's condition, for he has at-
tended him  for years,  and witnessed  the slow but unceasing
progress of this malady ;  he has frequently been called to attend
him in slighter obstructions of the urine, and has remarked the
flattened form  which the faeces take, he has heard the feelings
of the patient often described, who, along with a continual sense
of pressure  and fulness in  the pelvis, has an unceasing desire
to  pass his urine ;  when attempting to give him relief by the
bougie,  he has remarked the point of it turned backwards, and
when next he has betaken himself to the catheter,  and forced it
through  the  passage, he has felt with the finger in ano, that the
prostate  gland filled the pelvis, and compressed the rectum ; he
has witnessed the frequent  returns of  these paroxysms of parti-
cular difficulty, and lived in the continual fear that the obstruc-
tion would in  the  end be  final and insurmountable.   At  last,
from some unfortunate fulness of the bladder, from some acci-
dental cold,  from piles affecting the rectum, and producing irri-
tation and irregular spasms  in these parts,  the urine is retained ;
all attempts to introduce the bougie, or to insinuate the flexible,
or  force in  the rigid  catheter, are  vain ; fomentations, poul-
tices, and stimulant embrocations, produce no relief ; the blad-
der, contracted by  long diseases, bears the distention  very dif-
ficultly ;  though it is but slightly distended, the anguish is intol-
erable, the abdomen inflames, and fever comes on, with parched
tongue and  rapid pulse, and thirst which cannot be indulged.

  * Mr. Home relates four cafes in which he performed this operation ; in one
inflance fome inconvenience enfued from the paffage of the urine through tht
rectum. See" Home on Stri&ures," vol. %. c. 7. p. 3Z<).  S. 
                  Of Puncturing the Bladder.             241

 Then the surgeon is  sorely tempted to do a thing which will
 give  instant relief, but which  is  yet attended with unequivocal
 danger ! he feels that he could drive  the catheter forward into
 the bladder, but not perhaps in the  regular canal,  nor without
 tearing through the membranous part ot the urethra, and plung-
 ing through the substance of the diseased prostate.   Authorities
 for such a practice we have none, or next to none ;  unless it be
 an authority for this desperate plunge, that the case is desperate,
 and very desperate the operations to which we  must  next re-
 sort.
   Mr. Ware,  in dissecting a patient who had died of this dis-
 ease,  having begun his dissection by drawing off the urine, found
 that his catheter had,  with no great force, been driven  through
 the membranous  part of the urethra, into the cellular substance
 of the rectum, and thence into the  bladder, through  the sub-
 stance ofthe prostate gland;  and he naturally and justly infers,
 that had the same force been used in the living body,  the vio-
 lence   would not  have been fatal, the relief would have  been
 perfect.   The celebrated  Dr.  Hunter  being  occupied  along
 with a surgeon, in trying to introduce the catheter, was entire-
 ly foiled, and the  surgeon had gone home for a trocar to punc-
 ture the bladder;  but  the doctor meanwhile trying the catheter,
 and using perhaps unjustifiable force, it started suddenly into
 the bladder : the  patient was for the time relieved, but the ab-
 domen being inflamed, he died on the  third day ; and it was
 plain, upon dissection, that the catheter had burst into the blad-
 der, through the substance of the gland.   Dr.  Hunter affects
 to say, that this was his design :  but since  the surgeon was ac-
 tually gone  for the trocar, we  have reason to believe  that the
 doctor did not design to perform so important an operation, so
 unprecedented, and so adventurous, in the absence ofthe surgeon,
 but gave a post  facto  reason  for  what happened merely by
 chance, by what might have been named, in a less eminent per-
 son, imprudence and rashness.
   Dease, a man  intrepid and fearless, and who had not (to  a
 surgeon perhaps it is no reproach) all the  delicacy and gentle-
 ness of nature,  which were so justly admired in Dr.  Hunter,
 and which,  in  his own peculiar department, had so conspicu-
 ous an influence on his practice, was in the habit (and I can assure
 the profession of  this  curious fact) of driving his catheter right
 onwards into the bladder,  when at any time, gentle means  and
 art, or  cunning,  failed:  he allowed no degree of  difficulty to
 frighten  him from his purpose: he assured me of his success :
 and upon leaving  me, presented me, as a token of remembrance,
 with two flexible catheters of uncommon size, bent at the heel,
into a  very  acute angle, and furnished  with very strong iron
                           2H 
242             Of Puncturing the Bladder.
wires, assuring me that he had often used them thus success-
fully, and soliciting me to make that bold use of them, which,
thank God, I have never had occasion to think of.   I  would
not willingly  acquaint a tyro in surgery, with an expedient so
full of danger; if the catheter, ever is to be forced thus, let it
be done by a man of judgment and skill, one who  has experi-
ence  to distinguish, when it is  allowable  to have recourse to
such an expedient,  and who has so much address as to be  in
no danger of using force,  merely by being foiled for want of art.
Whether it is from conversation or books,  that  I have some re-
collection of  a catheter, with a concealed canula, I do not dis-
tinctly remember.  But if so rash a thing has been done, I pro-
test against it, u as a sword put into the hands of a fool.'' Such
an  instrument (a trocar-pointed catheter) would soon be in the
hands of every young man, and would prove, in surgery, what
the crotchet  is in midwifery, a merciless resource:  in cases real-
ly simple it would be used, by  y oung surgeons, with little  dis-
cretion.   The catheter is, I am  persuaded, sufficient, if skil-
fully  used, to make its way through almost any  obstacle.
   The operation of paracentesis  vesicae is one which the sur-
geon must perfectly understand, since the  occasions are  sudden
and imperious ; and  while  he is  balancing amidst imaginary
difficulties, or comparing a variety of expedients, (none of them
 without danger) his patient  may be lost.  It is  an operation
 which it is most important to scheme and study, for various ex-
 pedients may suit the circumstances  of particular cases. Of all
 the operations which I have reviewed, any one must seem pre-
 ferable to that in common use j and  that perhaps is best which
 the surgeon can best perform. 
(  243   )
DISCOURSE  XVI.
PRELIMINARY DISCOURSE ON THE ANATOMY
   OF THE  CRANIUM,  AND THE  RULES OF
         PRACTICE  DEDUCED FROM  IT.
                        SECTION  I.

                 Introductory Observations.


IN injuries of the head, the chief object of your studies must be
to learn the signs and causes of danger, and to judge wisely ofthe
motives which should induce you to operate.  For in the  ope-
ration of trepaning, as far as the operator is concerned, there is
nothing formidable, nor any thing which the most unskilful can-
not easily, I  fear too easily, perform.
  But such is the uncertainty of these signs: so often does our
patient fall suddenly into slight paralysis, and faints and expires
while we apprehend no harm ; so often does he revive from
that stupor which seems to arise from  extravasated  blood op-
pressing the  brain; that the  diligent investigation of the  true
signs of danger, of the causes of oppression, or ulceration of
the brain, (a severe and complicated study) should be the chief
occupation of the surgeon.  But it has not been so ;  operations
have been more studied than the means of avoiding them.
  Those who, on the revival of learning,  assumed the  weary
task of  explaining the first writers on medicine,  were not  men
of practical skill, but philologists, commentators, men of mere
learning ;  and they commented best, most learnedly, and in-
deed most suitably to  the text, who  shewed themselves  most
ingenious in multiplying the distinctions of fractures ; as those
were thought to operate best,  who found means of applying the
greatest number of trepans to one scull.   But of  all the  lessons
of the old school, the one most dangerous to the young sur-
geon is that which teaches how to  distinguish fissures from su-
tures; forth? rules  for  distinguishing  fissures clearly imply, 
244            Ofthe Anatomy ofthe Cranium.
that wherever such fissure is proved to exist, it is allowable, it
is necessary to trepan the patient; and thence a fracture ot  the
scull,  and the necessity of trepaning the injured part, are so
inseparably connected  in  the  surgeon's  mind, as to form  the
most essential rule in his practice.
   In surgical systems, I do  not know any two arrangements
more irrational, or more exceptionable, than these two :  First,
That in treating of amputation, the subject is always opened
with a dissertation on  gangrene, as if the fear of gangrene, or
its actual existence, were the sole motive,  or  at least the most
frequent,  for amputating  a limb.  Secondly,  That  in  explain-
ing the operation of trepan,  the  subject is invariably introduced
with remarks on the sutures,  the cancelli, the variable thickness
of the  cranial bones, and the many scholastic distinctions of ca-
pillary fissure,  fractures, depressions, and  depressed fractures
ofthe  scull, as if such fracture or fissure  were  the sole motive,
or the most prevailing one, for applying the trepan.   This is not
the meaning of our operation  ;  we often perforate with the  tre-
pan, to give vent  to the purulent matter,  often to give  vent to
extravasated blood, sometimes on account  of  a depression of
the bone, sometimes to cut away sharp points  which may hurt
the  brain or membranes, or  to take away  balls or  foreign bo-
dies nitched into the substance of the bone, but never on ac-
count of mere fracture of the scull.*
   First,  You are desired to remark the  constitution  of these
flat bones, " that they  are composed  of two tables or plates of
solid bone, with  intermediate  cancelli,  (or cellular substance,
such as is natural  to bone,  full  of  bloodvessels) which bleed
when with your trepan you  have sawed through the outer table,
occasioning at the same time a change of sound."  This, though
occasionally  modified, y ou are  taught to regard as a rule of
practice;  and, to  every elementary book,  \ou find it  to be a
most important subject of debate, whether, in perforating  the
scud, you should  use th  trephine,  which saws rapidly, or  the
trepan, which, from making  onlv  half circles, cuts more slowly;
or, whether you should first use the trephine,  till you  have cut
down to the cancelli, and finish  the more delicate part,  the saw-
ing off the inner table With  the  trepan   Never, perhaps,  was
any remark more unfortunate  than this,  which refers the sur-
geon to the bleeding a»id the change of sound, as signs of hav-
ing cut through the out' r table, and teaches him to be proud of
sawing rapidly.  Of all  operations,  this is the  one where pre-
cipitancy and hurry have the fewest apologies,  since the patient
usually lies insensible,  since the sawing of a bone occasions  no

  * All the directions  therefore, which the older phyficians, from Hippocrates
downwards, have given for the difcovery of fra&ures and fiffures, are now ufe-
lefs.  S. 
Of the Anatomy of the Cranium.           245
pain, since the trepan is an operation where haste may occasion
the most dismal consequences, trom wounding the dura mater,
which, when left  uninjured,  supports  the  brain  (after the re-
moving of a piece ofthe cranium) like a second scull.
   Secondly,  But this first suggestion is inconsistent with a rule
much  more worthy ot notice; viz. u that in all circumstances
the surgeon should saw cautiously, on account of  the incalcula-
ble irregularities in the  thickness  in the cranium, which is uni-
versally  thin  in  boys and very aged people,  and is, during all
the  middle stages  of life, extremely irregular, generally thick,
but at  certain points  extremely thin,  or excavated by the deep
impressions of tortuous veins." I approve of sawing the cranium,
in all circumstances, with prudence and deliberation ;  but yet I
discover, in all these rules, intrinsic marks of their having been
invented by mere speculators in surgery,  not  by surgeons; for
in truth we almost never operate in a mere fracture of the scull;
we almost  never operate where the bone is sound, and the dura
mater closely  attached to the bone ; even in cases of extensive
fracture, we rarely  operate except  on account  of some affection
of the brain.
   Thirdly, The artery of the dura mater  is described with a
particular reference to the operation of trepan.   " As an artery
of  considerable  size, the chief artery ot the dura mater, run-
ning along the inner surface of the parietal  bone, marking the
anterior  corner of the bone with its  trunk,  and the upper  part
with the impression of its branches, and  making  a  groove so
deep, that  the bone cannot be entirely cut through by the trepan,
without  the artery  being divided.   For these reasons it is ad-
vised, that the surgeon  should avoid the  whole tract of this ar-
tery,  and  especially that he should not trepan the lower corner
of the parietal bone."    That  the surgeon should, except in ca-
ses of the  most absolute  necessity, avoid  even the shadow of
danger,  is a precept from which I will not allow myself to  dis-
sent.   But in this, as in all these notable  observations on the
cranium, there are strong intrinsic marks ofthe reflection com-
ing from one little acquainted with practical surgery ;  for in all
circumstances, and on all points of the scull, have  I seen the
trepan applied without  much skill, or any thing of  this fore-
sight,  but  never have  I seen  or  heard of a haemorrhagy from
the artery of the dura mater*.

  * Mr. A. Cooper mentions in his Lectures, an inftance in which this artery was
divided  by the trepan,  the hamorrhagy was at fitft confiderable, but eafily fup-
prefled by  a piece of lint preffed upon it for a fhort time.  That this artery  muft
be inevitably wounded in removing the anterior and inferior corner of the parietal
bone, in a great majority of cafes, is moft certain, of which any perfon will be
futisfied upon examination.  S. 
246           Of the Anatomy of the Cranium.
   Fourthly, You are warned of the danger of wounding another
important vessel,—the Longitudinal Sinus. You are told, "that
the longitudinal sinus is the greatest vein  of the brain, named
longitudinal from its running along the whole length ofthe scull,
and  changing its name at the occiput, where it forks into the
branches which terminate  in  the  great jugular veins,  and are
called the lateral sinuses ;" and it was set  down as a very abso-
lute rule, " that the scull  should  never be trepaned in the line
of the sagittal  suture, under which this sinus lies."—You are
told that such a wound is  fatal.
   This is none of the surgeon's  rules, who, if he  had at  all
mentioned the longitudinal sinus, would probably have observed
how sluggishly the blood  moves along in the great  sinus ; that
it is  more properly a reservoir than  a  vein; that  there  sure-
ly  could be  little  danger in wounding it;  that often when we
find it necessary to operate in the  direct course of this canal, we
feel it turgid under the finger, that in such a case the temptation
is  too strong, not to be yielded to, of striking the bleeding lan-
cet into it, with the hopes  of  relieving the patient from the
lethargy in which he lies.   Warner and  Pott have both seen the
longitudinal sinus punctured by fragments of bone, and the blood
flowing from it  profusely, which was yet more easily stopped
than that flowing from a vein, merely by applying to it a  piece
of dry  lint.  Pott  and  Warner  have both, without  scruple,
opened the sinus with a lancet, and bled the patient from it.*.
   Calisen, the celebrated Dmish surgeon,  having  trepaned a
sailor who  was knocked  down by a block falling from above,
felt the sinus lying turgid  under the finger, and seeing no pros-
pect of the  oppression in which his patient lay being relieved,
bled him from the  sinus with as little concern as he would have
done from the jugular.
   Fifthly, I am now to speak of a rule more purely hypothe-
tical than any I have yet commented upon.   The dura  mater
was  supposed by  the  ancients to pass through the scull by the
indentations of the sutures, not merely to connect itself with the
pericranium, but to form that membrane, and from thence was
supposed to be derived all the membranes of the body.
   The name of Crassa Meninx, or Dura Mater, was derived
from this imaginary office of  forming all the other membranes,
and the surgeons were advised not to scrape the sutures with
the rugine, nor trepan near  them, lest  he should injure this
most important connection.
   The surgeon is  called upon to remark the peculiar firmness
with which the dura mater adheres to the sutures, and  coun-

  * Vide Warner's Cafes, p. 10.  Pott's Surgical Works, vol. I. p. 196. 
Of the Anatomy of the Cranium.           247
selled not to apply the trepan  exactly upon a suture, when the
dura mater adheres  so, but on each side of the suture  so as
to be thus sure of finding the extravasation.  But I  no more
find  this adhesion capable of limiting  extravasation,  than the
sutures capable of stopping fractures.   I find the extravasation
always extending beyond the place of the sutures, and  covering
very generally one entire hemisphere ofthe brain.   I never saw
any occasion for applying the trepan, first on the one side,  then
on the other side of the suture, though much has been written
on this  subject.  I find in no book a proof of extravasation hav-
ing been limited and interrupted by intervention of a suture, nor
one case  unequivocally  stated, where the surgeon, having
applied his  trepan on one side of a suture,  was obliged to repeat
his operation on  the other side.
   Sixthly,  In  describing  the  frontal bone, its internal  spine
or ridge running longitudinally along.its inner surface,  is, point-
ed out  as particularly  interesting to the surgeon, as being an
absolute bar to the perforating of that part of the bone.   The
observation seems important, the difficulty seems demonstrable;
but this, though  it be a difficulty which must naturally present
itself to the  imagination  of the speculative anatomist, is one
which can have but a slight influence over the resolution of the
practical surgeon.  He recollects, that in most of his operations,
even upon the most level and equable parts of the cranium, he
seldom dares to cut both tables of the cranium entirely through,
but leaves part ofthe circle uncut, and begins with his elevator
to poise out the sawed piece of bone, before it is entirely insu-
lated ; the part that is uncut usually breaks  and splinters  with
an audible noise, and he smooths the ragged edges of the trepan
circle, with the instrument named Lenticular.  Though a well-
instructed surgeon will not fail to recollect this internal ridge of
the os frontis, he will nevertheless perforate here when the ope-
ration is required at  this  point, with this sole precaution, that
he will  saw  more circumspectly,  will cut through  all  that he
safely can of the circle, burst up" the rest, and smooth the  rag-
ged edges of the hole.   It is only in one single point, at the
very root of the nose, at a point considerably lower  than we
ever need to perforate, it is only in the very middle betwixt the
brows,  and in  a  space no bigger than one  crown of the trepan
will cover, that this  spine can at all prove an interruption.  I
know no mischance, by which the most ignorant person could
be induced to apply the trepan so low, and  believe that there is
more danger of  a thoughtless operator doing harm when tre-
paning  upon the ridges  of the  occipital bone ; but in neither
the one place  or  the other is  the trepan required ; of an  hun-
dred cases in which  this  operation is required, the  instrument 
248            Of the Anatomy of the Cranium.
is placed in ninety-nine cases upon the upper parts of the scull,
upon the parietal or frontal bones.
   The rules which I deprecate, often incline the young surgeon
to deviate from the plain way of common sense, and, by avoid-
ing imaginary, he runs into  real dangers.   To understand the
case I am now going to relate, you must assent to one principle,
which I shall afterwards prove in the most unequivocal terms ;
and it is this : " That  mere depression of  the  scull, which was
once believed to be the most perilous of all accidents, has really
but a very slight effect in compressing the brain."* The line of
a depressed bone deviates but in a very slight  degree from the
natural convexity of the scull ; the depression, as such, produ-
ces no compression, for  the  patient  walks  about  unaffected,  or
but very slightly ; and if he falls into  a dangerous state, it is
indicated by tremblings of the hands and knees, a sort of imbe-
cility, slight shiverings and nausea, which are signs, not of com-
pression, but ulceration of the brain or its membranes.   The
bone itself is sometimes deadened  by  the blow, or its spiculae
and fractured edges stick in the membranes,  and occasion sup-
puration ; while the integuments continue  entire  over a fractu-
red bone,  the interstices  often are filled with extravasated blood
and gluten,  and soon  become vascular, so that the bone re-
unites, as  in the fracture of a limb,  and the brain  and its mem-
branes remain sound ; but if the integuments be much injured,
and the depressed and fractured bone exposed, ulceration is apt
to ensue.
   "  W_______L-------, a chimney sweep,  fell from  the third
story of a house, upon  a street paved with very coarse round
stones ; though he had  sustained a very  dreadful fracture of
the scull,  he was very little  affected, and  not brought into our
hospital till  eight days  after the fall.   The  clerk or surgeon, far
from expressing an alarm either at the nature of the accident, or
the peculiarity of the symptoms, described the case thus in the
books : " He  has, on "the lower part  of the frontal  bone, a
fracture in the form of the letter V, about an inch in length, and
with a spot of the cranium, which  you could  cover  with the
point of your  finger,  bare,  but without any mark  of depres-
sion." By marks of depression was  meant, perhaps, " signs of
oppressed brain:" for, though  he had  no such signs, the de-
pression  was great,  and was easily  distinguished by the finger
or the probe.   When  I first  saw  this man, he was sitting up in
bed, submitting to the operations ofthe dresser, talking ration-
ally^ and apparently little injured ; and I was told that I might,

  • That mere depreffion of the fcull, and that to no great degree, will frequently
produce anthefymptomsof oppreffed brain, is clearly  proved by the relief which
enfues immediately the depre.ffed bone is elevated or removed.  S>. 
Of the Anatomy ofthe Cranium.           249
 it I pleased,  feel a fracture pr tty  distinctly, but without  de-
 pression, and that the patient was in no danger.
   I formed a different conclusion from every circumstance of
 this case. The height from which the patient fell was very great;
 he had fallen perpendicularly upon the  forehead, else it could not
 have been fractured, and he had not broken, nor even sprained,
 a wrist or ancle, so that there was no intermediate shock to break
 his fall.  He was incl.x-d sitting on the side ot his bed, but  ex-
 tremely meagre, sickly,  pale,  languid, and dejected ;  his  eye
 was sunk, his cheek hollow,  and his face somewhat  distorted
 with spasmodic twitches.   Upon opening the  lips of this trian-
 gular wound, which was now suppurating, and puffy,  I found
 that the fracture seated exactly in the middle  of  the forehead,
 was very wide, and that the bone at the  lower part of  the frac-
 ture, and immediately over the eye-brow, was much depressed;
 and,  worse than all, I found the bone  so  comphtelv discolour-
 ed, that though the depression did  not affect the  brain, the  ca-
 ries, I was sure, would, in process of time, affect its mem-
 branes, and cause suppuration.  That  the fatal symptoms were
 begun, I was convinced, by a more deliberate examination of
 his nurse and attending friends ; for, though he sat on his bed,
 bore the perpendicular posture, and suffered the operations of the
 dresser; though  he answered pertinently to all our  questions ;
 his articulation was slow, his motions languid and listless,  his
 eye  oppressed,  his breathing anxious, and accompanied with
 sighing.  There was a sort of sardonic grin, or  distortion of
 face,  and a silliness or fatuity of look.   His  pulse was quick
 and irritable, his tongue parched ;  he had a  hectic  flush  upon
 his cheek.   Though he made no complaint, he was sickly,  his
 hands trembled,  he vomited  frequently during the night.  He
 was always slightly delirious  during the  night, before  he was
 thoroughly roused ; and during the day, he walked round  his
 bed, fumbled about the  clothes, seemed to wish  to  do some-
 thing, yet had no purpose.   In short, he was in  a state of  in-
 describable disorder, never soundly asleep,  nor entirely awake ;
and,though  his sickly condition conveyed no intimation  of ap-
proaching danger to his ignorant  friends, it could not  but  be
observed by his medical attendants ;  for these are  the signs^
slight as they appear, which announce  suppuration  within the
 cranium, and approaching palsy.
   A  consultation having  advised  that the patient should  be
trepaned,  the operation was performed with  such circumstan-
ces of misconduct, as I think very impressive and instructive.
                            2  I 
250           Of the Anatomy of the Cranium.
There was a large transverse fracture  across  the  lower part of
the frontal bone, with one limb extending into the orbit.  The
lower part ofthe bone above the frontal sinus was depressed the
full thickness of the  bone, and the depressed portion ofthe bone
was plainly carious,  black, and  dead.   Unhappily the rules of
surgery, which the operator but too well remembered,  and ap-
plied too accurately, were in every thing opposite to the dictates
of good sense.  The rule says, " apply your trepan upon  the
sound  bone, which can best bear it, that  you may  be able to
press your levator under the depressed bone through the trepan-
hole."   But common sense directs no man to cut away a sound
and living portion of the cranium, to save by elevation a  part
which  is depressed, and perhaps dead.  The rules  of surgery
say, " You  shall not trepan on or near the  frontal sinus ;" while
common sense requires the surgeon to perforate wherever any
cause of danger exists.   The  rules of surgery would  impress
us with the  belief, that " of all the accidents of fracture, depres-
sion of the skull is the most fatal cause of compressed brain, and
the one which most immediately  requires the operation of  tre-
pan ;"  while this very case, combined with  a thousand  colla-
teral proofs, shows  how slightly the greatest depression of  the
cranium affects the  functions of  the brain, for fifteen days  had
elapsed before it was distinctly known that the bone  was depres-
sed, or the  man in danger.
   Though the depression of the scull was, in this case, the cir-
cumstance which should chiefly have attracted the attention of
a tyro, thinking only about the anatomy of the scull, and ima-
gining nothing more correct or absolute  than these  mechanical
rules ; the carious or dead part of the bone  affecting the dura
mater as a foreign body, would alone have appeared important
to one who reasoned on the affections of  the  brain, and knew
them by their signs.  The one would have thought only of ele-
vating the depressed portion of bone, the other of cutting away
whatever was* dead.  The one would have  applied the trepan
upon the sound bone, the other would have applied  it upon  the
injured part.
   Resolved to perforate as far as possible  from this formidable
sinus,  the frontal  sinus, the operator, instead of elongating the
triangular wound of the integuments downwards,  prolonged  it
by  incisions upwards, and applied the crown of his trepan upon
the sound and undepressed bone above the fracture.   The os
frontis was  extremely thick, like that of a rachitic person; in
avoiding the   frontal sinus, he  encountered the  frontal spine,
and was, though  it may  seem incredible, fully an  hour  in ac-
complishing the perforation, the patient all the while crying out, 
                Oftrepan'mg the Frontal Sinus.            251

struggling, and taunting him with expressions which I thought
he very well deserved.   But, after having sacrificed this sound
part of the scull in favour of a  part carious and irrecoverable,
he found the depressed  portion  not only well able to bear the
working of the trepan, but so exceedingly firm, that no force of
levers could enable him to raise it.   The  operator, conscious
that he had by this perforation done  nothing effectual for the
relief of a patient who'had endured so much, was now willing,
after an intermediate consultation, to attempt what should have
been done at first.   The incision of the integuments was car-
ried downwards through the eye-brow, to the root ofthe nose;
the whole extent of the  depression, and-of the deadened por-
tion ofthe bone, was now displayed.   The fracture was  seen
running down  into the orbit;  the operator would have now ap-
plied his trepan  upon the depressed portion, which should have
been first cut away ;  but, after operations and consultations last-
ing an hour and a half,  the patient, exhausted by his cries, re-
sistance, and  loss of blood, the manifest inhumanity,  too, of con-
tinuing such  unavailing cruelties, induced the surgeon to com-
mit  his patient  to bed,  where his rest was  long  and  sound.
What he suffered afterwards, I had not the courage to inquire,
but he died.
SECTION II.
               Oftrepan'mg the Frontal Sinus.

   The alarm  about wounds ofthe frontal sinus has been uni-
versal ; the injunctions not to approach it with the trepan have
been transcribed from book to book,  in the same unvarying lan-
guage.
   But never having been accustomed to indulge these irrational
fears,  I trepaned  this sinus* in a case of general  convulsion,
singular in all its circumstances,, and not uninstructive, but es-
pecially in this respect, that it was plainly connected with a dis-
ease of the frontal sinus.
   " A very tall, well-made, and handsome lad, about twenty-
tour years of age, a house-carpenter in Appleby, while assisting
his fellow-workmen in laying a heavy beam upon the  frame of
a saw-pit, slipped a foot,  and falling  forwards,  had  his head

  * Although  the frontal finus  may undoubtedly be trepaned,  it is certainly
rarely, if ever,  neceffary to do it, fo as to expofe the brain, which is the reafon
why the furgeon is directed to avoid it.  As to merely opening the  finus itfelf,
flieri- can be neither difficulty nor danger in the operation.  S. 
252
Oftrepan'mg the Frontal Sinus.
  immovably wedged betwixt the beam which they were lifting,
  and th.t which had just been laid upon the frame ; and so hea-
  vy was this log, that his companions were obliged to take their
  hand-spikes and poise it up.   He tried out during the time his
  head was wedged between the logs, and when released was able
  to rise ;  though giddy, he was not insensible ;  nor did the blood
  burst from his  nose and ears, as m ght  have been expected af-
  ter such  an injury.
    " Though his head suffered this pressure en the sides, being
  compressed irom temple to temple, there is every reason to be-
  lieve that the forehead had suffered, and the frontal sinus been
  injured ; for he walked home under the agony ot an acute head-
  ach, which  soon, however, subsided into a heavy, dull, and
  continued pain, aggravated at times, but never entirely absent.
  His head was confused ; he gradually lost his hearing,  and by
  the third week from the time of the injury, was entirely  deaf:
  he returned to work,  but his headach,  giddiness, and deafness,
  were unremitting, and he  had occasion to remark, that " he
  never, from the moment of that bruise, had  a good head  lor
  standing  or working in difficult places."
   "  The  sudden manner in  which he regained his hearing, and
  the  profuse flow of matter from  the ears and nostrils, which
 opened the  passages, are very remarkable.  It happened about
 a fortnight after  losing his hearing, that while he was  working
 in the fields, upon blowing his nose, there rushed out from one
 ear a great  quantity ot matter, with a painful  noise.   He fell
 down by  the wall in a sort of fit, lay for some time insensible,
 and when his senses returned, he was as much surprised at hear-
 ing the barking of dogs, and the voices of the people  in the
 neighbouring village,  as  if he had been born deaf.  He now
 found that matter was flowing from the nostrils, as well as from
 the ear, with a smell so offensive, that at first he imagined that
 his hat in his fall must hive lain in some foul place.  He smelt
 his hat first, and looked to  it, out found it not soiled, nor foul,
 and upon  blowing his nose,  there run out mto his handkerchief
 a profusion of foul and  very  fetid matter, mixed with blood.
   "  When he had fully recovered his senses, he found thatrthe
 discharge  of blood  and matter from the nost was accompanied
 with agomzng pains in his head ; he retired to the shelter of an
 unfinished house,  where his companions had  been working
 and threw himself down on a bed-frame, and lay there alone till
 evening, with his head hanging over the bed-frame, a black, fe-
 tid, and bloody  matter distilling profusely from his right nos-
 tril, while an acute and confuted pain ran through his forehead.
 He got up, after some  hours, and walked to his father's house,
about a mile distant, in great pain and confusion of head. 
Of trepaning the Frontal Sinus.           253
   " From this time the pain in  his forehead was unremitting
and severe, and when heated at  work, it was particularly vio-
lent. '-  This  pain, at the root of the forehead, was aggravated
at times to violent paroxysms ;  it affected the ey e,  puffed up
the eye-lid, swelled the whole side ol the face  and forehead.
The discharge from the nose continued very profuse, and this
local disease,  accompanied with general headachs, afflicted him
for five years, and a permanent bony swelling, marked by a  ve-
ry conspicuous protuberance of the right eye-brow, at the place
of  the frontal sinus, was formed.
   " But his  complaint  underwent a  sad revolution in  conse-
quence of  a second fall, which happened  thus :  After mowing
hay in weather which was  oppressively hot, he retired with the
other labourers at mid-day, to rest in the  hay-loft;  being over-
come with labour, and having fallen into  a perturbed sleep, he
by successive restless motions got so near the edge of the loft,
that he at last shpt over.   One of  his fellow labourers chanced
at that moment to observe  him sliding, and ran to catch him by
the feet, but too late, for he  fell from the loft headlong, upon
a rugged pavement of big  round stones,  and alighted exactly
upon that part of the forehead which had been long the seat of
disease ; lor I find the scar  ofthe  wound which he then received,
just over the bulging of  the right frontal sinus.   He  lay insen-
sible during a  quarter of an hour, and when he revived he ielt
sick, faint, and languid ;  and his companions being gathered
about him, he waved his hand as for room, and a freer breath-
ing-space.   They carried him into the open air, where  he in-
stantly  fell into  an epileptic fit, which epilepsy has  continued
ever since.
  u The epileptic paroxysms returned frequently, at least every
night and morning, from the time of this fall.  He was weakly,
almost paralytic, walked  only with the help of stilts, and trailed
his limbs along.   In about five weeks he  had so  far recovered,
as to think  himself strong enough for work, and the paroxysms,
which had  at  first recurred three or four times a-day, became
less frequent,  ceased at last, and  were  absent  entirely for a
week.   Thus  encouraged, he returned to  his daily labours, and
by the violence of his labours the fits came on again.  He had
been now six months labouring under this disease, is reduced,
weakened,  and dispirited ; is distorted with these fits of spasm
or convulsion twice a-day at least, and tormented  from hour to
hour with severe threatenings.  Fits so peculiar, and proceeding
from so unusual a cause, I think it right to describe with par-
ticular care.
  •  He recovered, about a fortnight after this, the hearing of his other ear, by a
like difcharge of matter, which alio happened fuudenly upon blowing his r.ofe. 
254            Of trepaning the Frontal Sinus.
  " The convulsion is distinctly connected with the disease of
the forehead.  The  approach of each paroxysm is announced
by pain of the forehead,  with a sense of fulness ; first his jaw
begins to shake with a trembling, and convulsive motion, and
the tongue, too,  trembles, and is  retracted into  the  mouth.
This is the  warning or first  alarm of the approaching parox-
ysm,  which sometimes, as  he imagines,  he prevents by
clenching the jaws, and holding them firmly.   Being once at-
tacked when reading, he, in  hopes of stopping the convulsion,
thrust the book into his  mouth, the convulsion increased, and
was  as usual propagated along the neck, arm, and side ; the
book was so fixed by the  convulsion of the jaw, that he had no
power to withdraw it, and the suffering was so dreadtul, that
he remembers having howled with agony.
   " But the convulsion only begins in the jaws, then trembling
and  convulsive  motions run downwards along the neck : his
head is turned to the right side, while his neck is tortured with
the spasm ;  the  convulsion descends from  the  heck down the
arm, and to the hand, which  is clenched and contracted, till the
whole of the right side is affected with it.
   "Besides frequent threatenings, and incessant fear, he has
three or four regular paroxysms during the day.  He is warned
of its  approach, like those who have the  aura epileptica, by
slight distortions of the  parts, and a confused sensation in  the
forehead ; he immediately clings to a bed-post, a chest of drawers,
a door, or some firm body, continues sensible, and feels all the
horror of its slow  approach, and all the pains of the convulsion;
and the perpetual fear of this attack has given his countenance an
anxious, subdued, and melancholy cast. First in orderly succes-
sion, comes the  pain and fulness of the forehead,  then  the
tremblings of the jaw and tongue, then the sore contractions of
the neck, which draw his head over the right shoulder, and then
successive cramps and convulsions of all the right side of the
body, till it is bent down; and in this state of agony he continues
four or five  minutes, when the muscles of the side, of the arm
and of the neck gradually and successively tremble, and fall into
a quiescent state, and the  convulsions of the neck and arm having
remitted, the spasm of the jaw, and trembling and retraction of
the tongue also cease, and then he returns slowly to his  seal.  He
is always in great confusion, but never insensible, during the fits,
unless it be during the night; for it would appear, that during
sleep he is seized with fits more nearly approaching to the nature
of true  epilepsy.   He passes his faeces and urine involuntarily
during the night.  His disease has, if not the express form, at
least the effects of epilepsy ;  for his  faculties begin to fail, his
memory is  injured, certain words  he is unable to pronounce, 
Of trepaning the Frontal Sinus.            255
 or pronounces them with  a painful and convulsive hesitation.
 Although he does not actually fall  down, his confusion during
 a paroxysm amounts almost to insensibility, and each paroxysm
 is followed by drowsiness  and  a degree of oppression, so that
 very commonly he falls asleep, his right eye is turned obliquely.
 inwards, the swelling of the frontal sinus over it is very promi-
 nent, and gives .an  obliquity to  the whole  countenance;  the
 matter which runs from the right nostril only, is in great profu-
 sion, it  is partly  glairy, partly purulent,  amounts  to two  or
 three ounces in the day, and sometimes entirely fills a  bleeding
 palate*.   His speech^  especially after a paroxysm, is slow, dif-
 ficult, hesitating, and interrupted.   When pain of the forehead
 comes, and is not followed  by convulsions,  he has a general
 feeling of weakness,  as if all his joints were loosened ; he trem-
 bles,  and his knees  shake under him, and he has a trembling
 and paralytic feeling in the arm."
   This is  the  whole state and  condition of this young man,
 who, from uncommon  health, and bodily strength, is reduced to
 great weakness and  despondency; and since the first signs  of
 the paroxysm are distinctly referable to the frontal  sinus, and
 since  the convulsion  affects the same side of  the body with  the
 injured part of the head, all suspicions of its arising from any
 disorder  of  the brain are removed.  I have resolved, (encour-
 aged and supported by the unanimous voice of the consulting sur-
 geons), to trepan the sinus, hoping, by  curing this ulcer, to re-
 move a possible cause of disorder: The dism  1 situation, and
 earnest intreaties ofthe patient, are arguments too powerful to be
 resisted ; and the operation, though unusual,  is no rash enter-
 prise, but on the contrary, entirely void  of danger.
   I laid  open the diseased and  much  enlarged sinus  with an
 incision  of  little more than an inch  long, and perforated  the
 bone, which was of  such thickness, that the  assistants believed
 that I had mistaken the case, and pierced not the outer plate of
 the sinus, but the whole thickness of the scull; and they plainly
 said, that the membrane now exposed was  not the lining of  the
, sinus, but the dura mater.  But it was merely the lining of the
 sinus ; the injections  passed from this small trepan-hole, into the
 throat and nostrils,  and the  patient could at pleasure draw it
 back again through the trepan-hole.   By a little skill and practice,
 and  by inclining the head of the patient properly,  the  dresser
 soon learnt to direct  his injection,  so that the whole of it flowed
 out by the right nostril.   The lad continued  under my care for
 three months, and  I injected the sore first with barley-water,
 then with solutions of vinegar and honey, then with tinctures of
• Containing from four to five ounces. 
25G            Of the Connections of the Scull.
bark and myrrh, and finally with tinctures of corrosive sublimate
and-crude  sal ammoniac ; but (as I must confess) without the
slightest alteration  on the matter, (which  ran profusely from
the  nostril), or the slightest improvement of his health : Des-
pairing of doing good, and wishing that he  should leave  the
precincts of an hospital not always healthy, and enjoy his native
air and better food,  I sent him home,  having  first withdrawn
the tent, and healed the fistula, which closed solidly  in two
days, and had always been inclined to  close.   So untrue are all
these idle tales about the danger of wounds, and the rashness of
trepaning this part.
DISCOURSE  XVII.
OF THE PATHOLOGY OF THE INTEGUMENTS,
           SCULL, AND DURA MATER.
                        SECTION I.

         On the Vitality and Connections ofthe Scull.

jf\-S you are now aware  ofthe important truth,  that the rules
of our art are not to be deduced from the external forms ofthe
scull, I shall  now begin to unfold the true  theory  of injuries of
the brain, by explaining, not the outward form of the cranium
and the anatomy of its several bones, but the internal organiza-
tion,  ^he living powers, the susceptibility of injury, and  the
sympathy of the pericranium,  the scull, and dura mater with
each other :—these are the integuments of the brain, and from
the slightest injury ofthe most remote of these, there often en-
sues,  slowly,  imperceptibly, and  at a distant and unsuspected
period,  suppuration  of the brain itself.   Life is endangered
more frequently by a laceration of the integuments, or by  a
mere contusion of the scull, or by an imperceptible  separation
of the dura mater, than by the widest fractures.   Now,  the
proofs of this consist in facts,  which even  in their simple  de-
tail, though not connected by theory, nor recommended  by  any
ingenious explanation, would be of themselves useful; but the
mutual dependence of the scalp, the scull, and the dura mater 
Ofthe Connections of the Scull.            257
is so clearly made out by innumerable practical examples:  the
progress of disease, from a slight puffy tumour ofthe scalp*,  to a
fatal suppuration of the dura  mater,  is so  plainly traced;  the
slow but undeviating progress of fatal signs, from the first nau-
sea, and slight tremblings of the hands and tongue, to the fatal
convulsions,  is so easily traced, and forms so interesting a sub-
ject for judicious prognostics, and sensible and manly practice,
that I know not in the circle of our profession a piece of pathol-
ogy more intelligible, nor a subject  of inquiry  more easily pro-
secuted, to sure and interesting conclusions.   And we have
this encouragement to consider the  pathology in place of the
anatomy of the scull, as the rule of our prognostics, that while
anatomy, and the enumeration and  classification of fractures,
has led to an undue propensity  to  operation,  the study  of the
living powers, and mutual dependence of these parts, leads to
a reserved, modest, and rational practice,—to a just confidence
in the powers of nature,—to a careful and solicitous attention to
all the insidious symptoms of suppurating brain.
  The  integuments or scalp, i. e. the successive  layers of the
skin, occipito-frontalis muscle, cellular substance, and  pericra-
nium, are closely connected with each other, and with the scull,
by one continued tissue of vessels.   When these integuments
arc separated from the scull, even in  the dissection of the dead
body, the  scull sweats out drops of blood from every point of
its surface.  The outer table of the scull is so plainly alive, that
the surgeon can perfectly judge of its death : when alive, it  is
moist, clear, and bleeds upon being  perforated; it is by its dry-
ness and faded colour, and its bloodless appearance, (and when
trepaned,) by  the dryness of the dust  turned out in sawing,
that the surgeon is able to pronounce  it carious  and dead.   The
scull is nourished, yet not altogether dependent for its circula-
tion on its periosteum and scalp: a piece of scalp may not on-
ly be raised by  a clean cut of the sabre, and laid down again so
as  to adhere to the bone, as  to any  soft part, but being cut off,
it is replaced, in part at least, by granulations from the scull.
The integuments not cut, but lacerated, detached from the scull,
flapped down  over  the face  and ears,  soiled with earth  and
mud, will, upon  being  cleaned,  and laid in their place, adhere
to the scull.
  The scull re-unites thus easily with the integuments, from hav-
ing every essential provision for life and circulation within itself.
It is by means of the same provision that when large and broad
pieces of the  scull  are  apparently insulated by  fractures  sur-
rounding the piece of bone on all sides, with the dura mater  as
completely detached from the internal,  as the pericranium is,
by  laceration, or  by scraping, from the external surface of the
                             2K 
858            Of the Connections of the Scull.
scull, and after being depressed by violence, are as  violently
raised by working with the  levator, that ithey live and are re-
united, and granulate and heal.
   The circulation thus maintained by  the pericranium from
without, so vigorous in the structure of the bone itself, is like-
wise well supported from within ;  for,  indeed, if we were to
assign the nourishment of the scull to any one source, it would
be to the dura mater, which is more properly the internal peri-
osteum of the scull, than a membrane belonging to the brain ;
with the brain it has no vascular connection, but is separated by
a halitus or secretion similar to that of other cavities, as those of
the pericardium or peritonaeum: with the scull it is so connect-
ed, that the scull-cap is in dissection torn up with the greatest
force,  and every point is covered  with  the ruptured mouths of
delicate and bleeding vessels.
   The dura mater is very firmly attached to  the whole internal
surface of the scull; it is hard, firm, grates like a cartilage when
cut with scissors, and has a glistening surface, like the capsule
of a joint: it  has  no appearance of delicacy  or sensibility, for
indeed it has none,  since acids, caustics, and even  the actual
cautery, have been applied  to it, and it has been cut and torn in
experiments on living animals, without exciting pain.   It enters
very slowly into diseased action,  and has as little appearance of
vascularity as of sensibility ; often it is inflamed, and even sup-
purated, without changing colour,  and  is  little affected by our
most subtile  injections.    But the  injection, which does not
change the colour of the dura mater, colours the bone, passes
through its vessels,  and runs out from innumerable minute ori-
fices, when the dura mater is torn away: it appears from every
circumstance,  that the vascularity ofthe  dura  mater is destined
for the nourishment of the scull, and may be truly named its
Internal Periosteum: and  the great arteries and veins (as they
are called) of the dura mater, might be more justly described as
the Nutritious  Vessels of the scull.   Were  we first  to  observe
this vascular connection, and then  glance  our eye hastily over
the facts relating to it,  we should be apt to pronounce the scull
entirely dependent for its nourishment on the dura mater;  and
that its connection cannot be dissolved by disease, without cor-
ruption ofthe bone, and suppuration  ofthe brain, nor detached
by violence, without  effusion of  blood.   Yet  this  important
source of nourishment, the scull  can also dispense with, and
live;  for, in cases of the most extensive effusions of blood un-
der the scull, and where this membrane is divided from  it by
a thick and solid cake of coagulated blood, we  find, that the
scull bleeds in trepaning, and  granulates during  the cure ;
and although it may seem a fact difficult to ascertain, I  shall 
Of Injuries ofthe Scalp.              259
prove to your conviction, that the dura mater may by a shock be
detached  from the scull, and adhere again to it without harm,
leaving unequivocal marks  by which, in dissection,  it can be
known that it had been separated and re-united.
  I take a pleasure in submitting to your review these facts, so
opposite to the doctrines, and so inimical to the practice of  the
older surgeons ; for they will teach you, if you dwell upon them,
to have a perfect confidence in the powers of nature.   With so
many sources of circulation, the life of the scull is very secure:
the scalp, the scull, and the dura mater, are the successive in-
teguments of the brain, they mutually support  each other, so
that they cannot be individually injured j and we have reason to
believe, that when the dura mater suppurates, and the brain is
endangered, the whole system of this vascular connection  has
suffered a fatal shock, or the bone, the centre of that circulation,
has been deadened by the blow.   I fear that those general con-
clusions, which by a sort of anticipation I have  laid before you,
may seem more allied with speculation  than practice, yet are
they the true and genuine source of your prognostics.

                        SECTION  II.

                  Of injuries ofthe Scalp.

   However extensive the laceration, if the scull be uninjured,
the scalp not irrecoverably  bruised, the patient in health,  and
not exposed to contagion or fever, it may (with only slight  and
partial interruptions) be made to adhere again to the bone.  Of
such  recoveries,  every  practical surgeon has  seen  examples,
and many interesting cases, made remarkable  by the circum-
stances of the accident, are recorded.
  The following case is related by Mr. Hill: " A drunken coun-
try-man, aged about sixty-six years, riding furiously along the
street, was flung  with  such force against the sharp  edge of a
door-post, that about the length and breadth of a hand was strip-
ped off the right side of his head, and laid down on the cheek.
  " Some people,  in the dark,  took his wig out of the kennel,
and, not knowing what had happened to his head,  put it on full
of mud,  and squeezed his hat over it.  He did not complain
of his head, but complained greatly of his neck and shoulders.
   " The dirt was rubbed into the Tunica Cellulosa in  such
a manner, that it was impossible to clean it fully out.  I there-
fore pulled up the loose piece of the scalp, and, after washing
and stuffing it with soft liniments, put four stitches into the up-
 per part, but so loosely, as to allow the matter a free passage.
   " The  wound digested so well, that in five  days, all danger- 
260               Of Injuries ofthe Scalp.
ous symptoms were over, and his friends carried  him home
without acquainting me.   Having no proper person to take care
of him, the stitches gave way, one  after another, and it healed,
leaving near two fingers-breadth of  the scull bare, the teguments
lying in folds on the Os Petrosum.   This circumstance might
easily have been prevented by renewing the stitches.   He,
however, lived and enjoyed good health above twenty years."
   Yet a laceration of the scalp is a state of danger and uncer-
tainty.  We never can be assured  that the bone is not too much
injured to  admit  of its re-uniting with the scalp, or that the
constitution is not too weakly, or the season or the air  unfa-
vourable ;  we never can be assured, even when the prospect at
first is most flattering, that a laceration ofthe  scalp will not  be
followed by a suppuration of the brain.
   "Thomas  Sharpe was an itinerant dancing-master,  a tidier,
a performer in a military band ; he died trumpeter to the Dura-
frieshire militia,  and had attained  to all the perfection of liber-
tinism, and dissolute  behaviour, that such occupations natural-
ly entail upon those who practice them. ,„One morning,  reel-
ing out of a low tavern, he, after scrambling up the stairs of it,
staggered forwards into the unguarded area of a house that was
building, and, without any other apparent injury, had his  scalp
torn down over his face.  The scalp was ragged in its edges,
and mangled every where, with  several penetrating wounds;
it was separated from the whole upper part of the  head, from
the lambdoid suture nearly  to the  eye-brow,  and from the ver-
tex to the right ear ;  much of the scull, and especially of the os
frontis of that side of the head was laid bare : nor was the op-
posite side without bruises, and lesser wounds, for  it seemed to
have been jammed in among the loose stones.
   " The scalp  was sponged, cleaned, and dried, and smoothly
applied again  to  the scull; and  as the edges  of the laceration
were irregular, and bruised, and in no fit condition to be nicely
joined with stitches, they were held by plasters only, they  were
united in a few days with each other, and even seemed re-united
on the lower surface with the surface of the scull; whatever
inflammation there was, seemed a  very natural consequence of
the general bruises, and lesser  wounds ofthe scalp; and we
were confirmed in this good expectation, from the  man's hav-
ing recovered from his intoxication, and continuing in apparent
health.  He felt his bruises, and complained ofthe pain,  slept
well, had neither delirium, sickness, nor fever, and was  bled
only on account of the fulness of the pulse.
  u On the fifth  day, the little discharge, which  issued  from
the irregular openings,  and smaller wounds, was good ; -the ad-
hesion continued apparently sound; on the sixth, the discharge 
Of Injuries of the Scalp.              261
from under  the  scalp  was more  copious, and  compresses
were nicely applied  to keep the scalp and the  scull in contact
with each other.   On the eleventh day it  became necessary,
from fluctuation and softness in all the  lower part of the de-
tached scalp, to make an opening over the ear for the discharge
of matter, which flowed so profusely, and was accompanied
with such fits of rigour,  that I abandoned all hopes ot any firm
or general  re-union, and began to fear that  the brain was in a
state of suppuration. Upon pushing the probe through the soft
and downy granulations which united  the edges  of the scalp
with the scull,  I was persuaded,  that all below  the mere  edge
was disengaged, that the whole extent of the parietal bone was
rough and  naked.   The probe,  in its progress between the scull
and integuments, encountered what all my assistants conceived
to be a fracture of the scull;  yet  still the patient retained his
senses, and suffered little in his health.
   " The symptoms of suppurated brain are, as I  know  from
much experience, far from alarming  when  they first  appear.
The detached state of the scalp, the roughness of the bone, the
profusion of matter which flowed through all the openings, and
the slight rigours,  dejected looks, and tremblings of  the hand
and tongue, though they are such as alarm  the  surgeon,  can
hardly vindicate him in taking any decisive  step.   I was per-
suaded that the bone was dead,  and the  brain in a state of sup-
puration :  I saw no prospect of interposing  with success  at so
late a period as the sixteenth day from the injury : I was  sup-
ported by the consulting surgeons  in the  preliminary  step of
opening the scalp, and exposing the  diseased bone; but they
seemed to suffer a disappointment, when that rough line, which
was so curiously traced with the probe, was found not to  be  a
fracture, and, as there was no fracture,  I  was,  fortunately for
my reputation,  prevented from applying the  trepan ; for though
there was every motive for operating, the patient died next day
of a disease, inevitably fatal, connected indeed with the  acci-
dent, but having no relation to the state  of the brain.
   " Let me now, then, proceed to give you an account of the
condition of this man before the  operation, of the manner of
his death, and of the appearance on dissecting the body.   Be-
fore the  operation of cutting up  the scalp, there  were  no deci-
sive signs,  nor  fatal prognostic ; for of all the fatal affections of
the brain, this of suppuration of  the dura mater is the most in-
sidious in its progress;  and our patient, before we apprehend
him to  be in danger,  is in  general beyond  the reach of help.
This man,  though he had the cranium naked, the scalp in  full
suppuration, and a profusion of thin matter pouring out from
various openings, had no other symptoms than slight rigours, 
262
Of Injuries of the Scalp.
and no more violent rigours, indeed, than often accompany the
slight fever of a lacerated scalp.  It was towards the sixteenth
day, perhaps about the fourteenth, that  these rigoars were fol-
lowed with a sweating stage, that they  became sensibly more
frequent and violent, and that they  were accompanied during
the day with unusual languor, and in the night with a slight de-
lirium, which disappeared only when he was thoroughly roused
from sleep.  Yet, at this most critical period, I could not make
him say that he had any corded feeling over the brow, any head-
ach, any  thing which  might indicate  to his own apprehension
a disorder within.   I could not perceive the slightest wavering
in his intellect;  I could not find, in the irritable state of his
pulse,  the foulness of his tongue, the dulness of his eye, in his
perturbed  sleep,  and  alarming  dreams, any thing more than
the feverish disorder naturally accompanying so extensive a la-
ceration of the scalp;  and yet at that moment was the suppura-
tion of  the  dura mater fairly established,  and the biain itself
deeply tainted.
  " An  increased drowsiness, with rigours more violent than
usual, a degree of headach, and  a sensibility to light induced
us, upon the sixteenth  day, to cut up the slight adhesion of this
great flap of suppurated scalp, which immediately fell over the
ear, and left the whole parietal bone exposed, in a condition
perfectly decisive, in my opinion, of the state  of the brain, and
indeed of the patient's fate.  There was a portion of the parie-
tal bone broad as the palm of my hand, of a square form, appa-
rently  insulated  from the rest, black, carious and  elevated,
above the level of the  surrounding bone, and circumscribed  by
a line as decisive  as if  it were a fracture. This part, which was
the centre  of the parietal  bone, was  rough, dry, and promi-
nent,  of a dark yellow colour, engrained with black spots like
a toad's back.  The pores of the bone, or,  in other terms, the
minute and almost invisible holes by which the blood-vessels
enter it, seemed wide, and not red as when  blood is circulating,
but black.   In the margin immediately surrounding this, where
the bone was still alive, and  in  a state of ulceration, the bone
was wasted, so that the  carious part was left prominent, with a
line so fairly circumscribed, that, when felt  with the probe,  it
might be mistaken for  fracture ; this is indeed, uniformly the
condition of a dead and exfoliating piece of the  scull.   Beyond
this ulcerating circle, where the integuments and  muscles ad-
hered, they adhered with particular firmness,being crammed with
extravasated blood, and hardened by  inflammation. Though the
certainty of the brain being in a state  of suppuration, inclined
me to perforate the cranium, the certainty now of there being
no fracture inclined my assistants, and the consulting surgeons. 
Of Injuries of the Scalp.
268
 to refuse their consent to that operation, which alone could save
 our patient :  thus I was destined to escape the opprobrium of
 having shortened the life of a man, whose death, from a very
 different cause,  was inevitable.
   " He was perfectly sensible during this preliminary operation,
 and would most willingly have consented to any measure we
 might judge  expedient.  But, when he was conveyed to bed,
 he  seemed weak, his breathing was low and difficult, his pulse,
 which had beat 124 in the afternoon, was this evening extremely
 feeble and slow, and  he broke out into a very  profuse sweat.
 His features  were shrunk, and his face pale  and ghastly.  A-
 bout four in the  morning he was  seized  with sickness and se-
 vere vomiting, and  with a rigour, which lasted fully twenty
 minutes, and at eleven in the morning his breathing was ex-
 tremely oppressed ;  it  was  painful to  witness his struggles for
 bn ath, and the anxiety and cold sweats which it brought upon
 him :  in half an hour after  his most violent struggle for breath,
 he was seized with a profuse haemorrhage from the lungs,
 brought up, with coughing  and struggling, fully a pound of flo-
 rid blood, and expired.  Thus, in the very moment in which
 he came into  manifest danger from suppuration of brain, he
 died from the bursting of  a blood-vessel in the  lungs.   What
 bruises, besides the wounds of the  head, he may have received
 unconsciously in his state of intoxication, we do not know ; but
 nothing is more likely,  than that in the fall which thus hurt  his
 head, the lungs had also  suffered materialinjury ; it is perhaps
 from such injuries  passing unnoticed, that suppuration of the
 liver so frequently accompanies fractures of the  scull ;  indeed,
 I know not how a man can fall from a height, without so heavy
 a viscus as the liver suffering by the shock, independent of any
 direct blow.
  " The appearances on dissection were as follow :  The ap-
 pearance of the brain implied danger ; but it was the  dissection
 of the lungs that explained his sudden death.   Upon raising
 the  cranium,  all that surface of dura mater which  lay un-
der the  diseased bone was in full suppuration,  covered with
 white and mature matter, and, in  many  points, perforated with
 ulceration.    The pia mater, in contact  with the diseased dura
 mater, was not yet ulcerated, for the brain cut sound and firm
 up to the very surface; yet the whole mass of the brain was in
some degree  affected, an increased action of its vessels had
unquestionably taken place,  for all the ventricles were enlarged,
 and full of serum, but  not obviously inflamed.   Thus our pa-
 tient was in that state of danger from suppuration of the brain,
from which so few are recovered even by the most timely ope-
rations ; but the sudden bursting of a great vessel in the lungs 
264
Of Injuries of the Scalp.
was the immediate cause of the death; for, upon opening the
right  side of the  thorax, there was found  in the lungs of the
right side a great effusion of blood, and a small superficial ulcer
on the largest lobe of this part of the lungs."
  Whether is* it to the mere laceration of the scalp that we are
to refer all this disorder ? Was  the scalp  so  mangled by the
sharp and irregular stones among which this man had fallen ;
was it perforated  in so many places by these irregular wounds
I have mentioned, as to destroy  its texture, and  make it no
longer capable of maintaining its connection with the scull ? Or,
was the bone itself so much injured in its internal structure and
circulation as to be incapable of pushing out granulations to meet
those of the scalp ? Does not the  practice here  pursued,  of
holding the scalp in its place, of supporting partial adhesions,
and endeavouring to extend them by using compresses, and
confining the inflamed scalp in contact with the diseased bone,
tend rather to increase that inflammation, and  indeed to widen
the separation ? Were  not those  symptoms of shiverings and
languor which (slight though they be) indicate suppuration  of
the brain, too long neglected ? Should  I not in place of making
successive openings,  when new  abcesses were  generated, have
thrown down the scalp to examine the bone ?  Should I  not,
according to the  strict  rules of good sense and  good  surgery,
have proceeded to trepan a scull, carious to such extent,  unequiv-
ocally dead, quite incapable of maintaining any connection with
the dura mater, sure, on the  contrary, to operate  upon it as a
foreign body,  and to produce suppuration ? For this was not
one of those circumscribed and  superficial exfoliations, which
can be thrown off without danger to the brain.   Finally, since
this patient survived so horrible an injury for three weeks, and
died  by a  sort of accident, is not the long delay of this  fatal
suppuration a sort of proof, that it happened not from primary
separation of the dura mater detached by  the shock,  nor by a
secondary separation depending on slow  disease of the  bone,
but from this  destruction  of the scalp, followed in succession
by death of the  scull,  and suppuration of the dura mater, the
internal periosteum of  the scull ?
   Though I regard every  fatal case as an occasion of reflection,
and almost of self-reproach, yet I am sensible that this case was
too complex not to admit of many apologies : There are in such
cases  of lacerated scalp certain  irregularities and anomalies
which incline me at all times  to proceed with caution.  There
are conditions ofthe individual systems, and varieties of climate,
or air,  which, without any local cause, without the scalp or the
 scull being essentially ruined in their texture,  prevent their re-
 union, and even occasion death.  The air of particular  countries 
Of Injuries of the Scalp.               265
 has been remarked through ages  as peculiarly noxious to those
 wounded in the head.   Lusitani ha^ celebrated  " the noxious
 air of  Florence and Bologna, while the air of  Ragusa,  seated
 upon a rock,  is so extremely favourable,  that even where the
 cranial bones  are  fractured and  destroyed, hardly any patient
 dies, but all recover."
   The ill air  of an hospital is more fatal to the  re-union of the
 scalp, than either the bruising of the  scalp, or  the injury or
 contusion of  the  bone.    The air  ot the  hospital, the Hotel-
 Dieu, in Paris, is more noxious than the  climate ot Cremona,
 Florence,  or  Mantua,  and has  been a matter of regret in all
 ages.   The good old surgeon, Saviard, shows us what danger
 there is in making even the slightest incisions,  by a  case in-
 structive in many  respects.
   " Nurse  Bernard of the Hotel-Dieu, no more than twenty-
 three years of age,  was  struck on the back of the head by the
 falling of a pole, set up for drying clothes, and fell senseless to
 the ground.   Upon giving her a  little eaii  de vie, she revived,
 when there was observed upon the injured  part  a small  bump
 only, of the size of a nut, and without any wound.
   " The same evening she vomited, and was oppressed at in-
 tervals  with a degree of stupor,  which having continued four
 days, we became  anxious,  (says  Saviard),  and resolved to
 open the tumour, which was full of coagulated blood, the  peri-
 cranium adhering soundly to the scull beneath.   From this time
 forward she had irregular shiverings, which lasted at each return
 four hours uninterruptedly;  and during the seventeen days in
 which they continued, we reckoned twentv-five returns. Bleed-
 ing we were so  little sparing of, that in the first days of her ill-
 ness we bled her no less than fourteen times in the arm, and once
 in the ankle ;  her vomiting continued incessantly, accompanied
 with pungent  pain in the region of the liver.
   " Alter the  seventeenth day, gangrene came upon the wound,
 which forced  us to make  repeated  incisions ;  bad symptoms
 continued, notwithstanding,  for  forty days,  and  two  months
 and a fortnight had expired before the wound closed.   Nor
 did her sickness end here,  for shortly after the  closing of the
 wound,  her face was puffed up  with an (Edematous swelling,
 much serum running continually by  the ears and nostrils for
 fifteen days ; deafness supervened, with lancing pains,  and con-
 tinued disorder of the head ;  more than a pint of reddish mat-
 ter flowed from the nose, and  a  rheum inundated the chest,
 and threatened suffocation to such a degree, that ("or a long while
 we looked for  nothing but sudden death.   It were impossible
to  enumerate  (besides  the twenty-six  bleedings) the various
medicines she used; it was by the frequent use  of ass's  milk
                            2L 
266               Of Injuries ofthe Scalp.
that her health was at last restored.   Her pains in the head
continued for two years,  with beating of the temples which in-
creased with every change  of the weather."
  Without having the misfortune to have served in any hospital,
where, to use the  language  of  Saviard, " I  saw innumerable
victims," or, being driven to absolute despair, like  Dessault,*
and abandoning  all hopes of being useful in wounds ofthe head,
I have yet learnt a degree of caution, with which I would fain
impress you in your first conceptions -, for  of all the abuses ot
practice, the most grievous to one who reflects soberly and mo-
destly on  what  art  can  do, is the confident and presumptuous
hope  which young men  are  too apt to indulge, of re-uniting
every piece of lacerated scalp by the main force of sutures, and
relieving every symptom of oppression, or  slight delirium,  or
temporary  fever, by trepaning the  scull.   I  have often ob-
served, that though the season  seemed  favourable, the heat
moderate, and the air of an hospital untainted; while other pa-
tients, and less  important wounds, were recovering a-pace, and
no  sign of infection could be perceived,  those wounded in the
scalp  became, after a few days  confinement, languid, feverish,
and oppressed,  and had  every usual symptom of an oppressed
brain.   Not to specify innumerable cases, from which  my ge-
neral observation is deduced, I  have seen a boy whose  scalp
was lacerated so very largely, as  to  shew the scull naked, but
uninjured, continue  well, and  free from  fever or delirium se-
veral days, then seized with  vomiting, like  that of oppressed
brain, with rigours and foul tongue, and rapid pulse, and deliri-
um.   I  have seen a boy  lying in this doubtful and dangerous
 state for fifteen  days, the suppuration ofthe  wound being inter-
rupted, and  its complexion as  much affected as  the  general
health, exhausted  by successive  paroxysms of fever, and  yet
i  n  no imminent danger.   I have seen three  soldiers hurt, in
 the confusion  of a  fire, from  bricks or beams falling on them,
 all the three wounded in the head, all seized at once with the
 same temporary fever and delirium, and  yet not one of them
 in  any kind of danger.   I have  often seen,  in an aged person,
 where the scull was laid bare by a blow, the integuments slough
 entirely  away,  and fall off in cakes as black  (to use the expres-
 sion  of nurses) as the soot on the pot, and,  after an interval of
 imminent danger, in which even the outer plate of the scull has
 exfoliated, I have seen with admiration the scull push forth its
 granulations  with such  vigour  in extreme old age, (at seventy-
 five  years of age)  as to replace the scalp with a broad and firm

   • Deffault was fo unfuccefsful, that at laft he renounced all thoughts of ope-
 rating in fractures of the fcull, and with a few ordinary precautions and remedies,
  abandoned every fuck cafe to nature. 
Of Injuries ofthe Scalp.
267
cicatrix.  These accidents of fractured scull, or lacerated scalp,
are frequent only in an hospital; and you will often  observe
your  patient, whatever  his age or constitution, attacked with
sickness or fever, which seems to imply danger, but which is
to be cured by antimonials, opiates, and the warm bath.   " Ne-
ver permit  yourselves to be alarmed  too much  at these first
symptoms of fever, nor hurried into any precipitate step, for
many have narrowly escaped the knife and the saw, the scalping
process, and the useless perforation of the scull, to whom, du-
ring the continuance of such a temporary fever, the slightest of
these operations would surely prove fatal."
   That aphorism of Hippocrates, which  relates to  the fever
of intoxication, may  be transferred, without reserve, to that ac-
companying wounds of the head.  u If a man be so intoxicated,
as to lie speechless, and he be seized  with fever, he is  in no dan-
ger;  but if not seized with fever, he dies the third day."  We
may,  with much greater truth, pronounce the patient safe, who,
having a wound  ofthe head, has his delirium and vomiting ex-
plained  by concomitant fever;  while he  who has the slightest
shiverings, a less perceptible oppression, and  no concomitant
fever,- is in a doubtful state.
  But that  a wound of the integuments, naturally slight, and
void of danger, may, by misconduct, cause not merely  caries
of the bone, but suppuration of the brain, the following incident
will prove  to you.   u A young man of seventeen years of age,
was struck in play, by one of his companions, with a small stone
on the left side of the head, over the parietal  bone.  He put
himself into the  hands of a sort of surgeon, who dressed this
slight wound with a heavy  hand, cramming it so with  rough
lint,  that the sore rankled and  inflamed, with  a daily  wasting
ofthe integuments.   Yet the boy was well in all other respects,
went daily to market, and served his master with his usual ala-
crity.   I saw this slight cutaneous wound at the time of his first
committing himself  to the hands of the barber, with whom I
at the time remonstrated concerninghis coarse manner of dress-
ing the wound ;  but he replied,  '* That it was the duty of a sur-
geon to be cruel, and not  faint hearted."  It was because the
wound seemed  so very slight, that I gave up attending the lad,
but on the eighteenth day, he came to me of his own accord,
desiring  me to see how  things went on.  I found all the sur-
rounding  integuments fistulous, down to the bone, and there
was  one great abscess,  full of putrid matter, which  could not
be emptied but In--pressure of the hand.  I,  of course, advised
rhat  this abscess should be opened at its lower  part,  which the
surgeon promised to  do.
  tl At this time I had no fixed quarters, but  was obliged to 
268               Of Injuries of the Scalp.
follow the royal army,  so that I was prevented from seeing the
patient for some  time; but, about the twenty -filth day, 1 was
called to him, and his  friends mentioned to me, that the fever  /
which I found him in, had continued tour days.   His eyes were
heavy and swelled ; he was in a sort of stupor, and was reduced
to extreme weakness.   The sinus was still unopened,  and con-
tained very fetid  pus ;  for this blockhead of a barber had, either
through pride or fear, altogether neglected what I advised.
   " I had now no reason to doubt that  the brain  was affected,
and proposed that the integuments should be laid open, and the
bone  perforated, thinking a doubtful remedy preferable to cer-
tain death.   But the  presumptuous fool,  when he heard that
I had proposed  to perforate the scull, protested, " That it  it
were not for  the  fever,  or if the fever should cease,  he could
make the cure of the wound a very easy matter.
   " On the  twenty-sixth day, this young man expired :  I re-
quested  that his body might be opened-, and the  empyric con-
sented with all possible alacrity,  assured in imagination that his
patient's death proceeded merely  from fever, not from any in-
jury ofthe head; and  in this presumption he was  hardened by
recollecting, that from the first there was  no  sign nor appear-
ance of any injurv to the bone.
   " Upon opening the head, the cranium was, indeed, found
free from fracture; but there was found betwixt  the scull and
dura mater  a considerable quantity of matter,  the brain  being
at that place  suppurated, and melted into pus."*
   Thus  are  we assured, that the mere detachment of the scalp
(if it continue detached) will destroy the  scull, and endanger
the brain ; for, though it has (in the dura mater, and in its own
structure)  various sources of nourishment, though it is little
injured by a temporary or partial privation of blood, yet the
permanent separation  of the  pericranium  manifestly  kills, de-
stroys at least, the outer portion ot it, and sometimes  its whole
thickness.    In the older times, when the doctrine  of exfoliation
prevailed, when they were in the practice of cutting off the  scalp,
so as to occasion the death of the scull, when the  separation of
the dead part was mistaken for an essential process in the  cure,
it was reckoned  the duty of the surgeon to procure exfoliation
in rvery wound of the  scalp ;  and he attained his end by remov-
ing the scalp, and by scraping and cauterising the bone.
    In modern surgery, nothing is to be  seen at all correspond-
 ing with this; the scalp  is never, bv any accident, kept separate
 from the scull, unless  it be by an effusion of blood.
    These effusions happen in rambling school-boys, and are  of
* Botallus, p. 736. 
Of Injuries of the Scalp.
269
  such a description as might tempt the inexperienced surgeon
  to open them.   Whether irom opening such  tumours  any ill
9 consequences might result, I shall not venture to predict,  and
  do not by experience know.   But  of this I am assured, that if
  left alone  they  are  generally safe  ; that  it the young surgeon
  were to yield to the suggestions of his own fear, whenever in
  those cases he imagined he felt a depression, and were upon this
  presumption to  cut open the integuments, and trepan the scull,
  the issue of his adventure would be very often fatal.  The de-
  ception proceeds irom  this peculiarity, that where  the  vessels
  ruptured by the fall have made the  greatest effusion, the blood
  continues long fluid ;  but, towards the  margin of  this  cavity,
  where the cellular substance is not entirely detached from the
  pericranium,  the blood is so injected into the cellular substance,
  and mixed with its  fibres, that the basis and margin of the tu-
  mour are uncommonly firm,  and  the hardness  such as actually
  to resemble that of  bone.   From this hard circumference, the
  surface apparently declines towards that part where the cranium
  is more distinctly felt through the fluid blood ; and the declivity
  is so distinct, and the  hardness  of the  margin so  entirely re-
  sembles that of the centre, where the scull is felt unequivocally,
  that the surgeon has not the slightest doubt that he feels a wide
  and deep depression of the scull; and when along with this the
  boy lies oppressed, and vomiting, he  can hardly refrain from
  opening the tumour, or think himself vindicated in leaving the
  boy without help.
    I know no deception which experience so effectually corrects
  as this, of an apparent depression felt through a bloody tumour
  of the scalp ; nor can any thing but experience correct it ; tor
  to the sense of touch, the depression is so  palpable, and the
  boy's danger  so very obvious, that even an experienced surgeon,
  on any new occasion of examining such a tumour,  is contused
  with the very peculiar feeling of that deception, which he is al-
  ready aware  of.  Many times  I have been called to rambling
  boys, who had fallen in climbing walls, or in playing about saw-
  pits, and unfinished buildings ; and have often  found them with
  great effusions  of blood over the parietal bone,  and apparent
  depression ;  the face ghastly,  and the  extremities  cold, in a
  state of insensibility,  with the eyes  not closed, but turned up-
  wards,  as in  the convulsions  of children.   But, fortunately for
  me, the case of the  boy that I first saw lying in this stupor, in
  the earliest part of  my practice, was so perfectly decisive,  that
  I have never since been in danger of any precipitate step ; for
  this boy, who had fallen from a garden-wall,  lay in a  state of
  absolute stupor, and with a degree of convulsion,  during  four
  days.   He vomited incessantly, and his extremities were  cold 
270               Of Injuries of the Scalp.
and  his face  ghastly.   The appearance of depression was so
striking and singular, that I made not the slightest doubt, that
if he did recover without any operation,  manifest marks of de-
pression must remain.   But he recovered in  a lew days perfect
health and  spirits,  and the appearance of  depression vanished,
as the  blood was absorbed.*
   I  know not whether any specific  and unalterable rule can be
proposed lor  the  treatment of  cases so various  in  their forms,
their causes, and probable effects, but something I teel inclined
to say on this subject.   When the tumour assumes  the proper
form of aneurism,—when  there  is a large and circumscribed
tumour, fluid blood in the centre,—a hard basis  and margin,—a
distinct pulsation through the  whole tumour,  and its size in-
creasing from day  to day, there is great  danger  to the scull :
the tumour should be laid open without delay, and dressed with
lint  ; and it will, after two  or three  days of suppuration,  (in
which the  matter  will  be fetid, from  being tainted with  the
blood), heal  kindly ; for the arteries  of the scalp, when thus
bruised, and pouring out blood, have sufficient force to maintain,
or even to enlarge,  the effusion of  blood which  cannot be
absorbed,  in  opposition to  such a cause*  Yet, when  opened,
such arteries  do not bleed much, the htemorrhagy is suppressed
merely by applying a bit of lint ; they rarely need to be tied.f
Lastly, Effusions of blood,  though unaccompanied with pulsa-
tion, if  they  continue fluid, and do not  gradually subside from
the period of the sixth or seventh day, must not be regarded as
of a slight or  indifferent nature, and, before the  tenth or twelfth
day, should be opened.  From all the experience I have had,
these rules of conduct will be useful to you ; and while I warn
you to refrain in general  from opening such  tumours,  it is also
my duty to state unequivocally and plainly, that  there are others
which occasion caries of the scull, where a little imprudence,  a
little delay, endangers the patient's life.
   " Mr. Harrold,  partner to Mr. Wilmer,  had a boy brought
to him, of fourteen years of age, with a tumour  on the crown of

  * Though the author's practice, in  this cafe,  was  fuccefsful, I fhould not be
difpofed to imitate it. It is certainly exceedingly difficult, in  thefe cafes, to afcer-
tain by  the feel alone whether the bone is deprefftd  or not, a  poiut of the greateft
confequencc to afcertain ; and as I know by experience that no injury refults from
laying open  fuch tumours, even though the  bone  fhould not  be injured, 1
fhould recommend it in every cafe where the tumour was confiderable, or from
circumftances attending the accident, there was reafon to apprehend an affection
of the fcull.  S.
  f  The haemorrhages may be reftrained by a comprefs, and the bandage recom-
mended for the head, (fee Difcourfe on Bandages  p. 39—40.) provided the artery
be completely divided, which alone will be in moft cafes fufficient.  This Bandage
is particularly adapted to thofe cafes, in which the fcalp has  been feparated from
the cranium.   S. 
Of Injuries ofthe Scalp.               271
the head,  the size of a hen's egg.  It was seated on  the middle
Of the sagittal suture :  it was occasioned, as his father  related,
by a blow, the boy having been struck over  the head  with the
arm of a  broken chair: the swelling ensued immediately  after
the blow.   The father had flattered himself  with  hopes of  its
dissolving by time, and the simple remedies recommended  by
his neighbours; but about two months after the blow, he brought
the boy to Mr. Harrold,  the  tumour undiminished, and  con-
taining, according to Mr. Harrold's  apprehension, nothing but
blood.  As a measure of precaution only, and without appre-
hending the disorder  which  had already  been produced,  he
opened the tumour with a long incision, and discharged a quan-
tity of blood, yet fluid, and not in the slightest degree grumous
nor  blackened ; and  as the artery from which it  had flowed
was still  open, and a considerable haemorrhagy  ensued,  he
dressed the cavity hastily with dry lint.
   " On the  second day, he removed the external dressing; but,
not chusing  to risk a second haemorrhagy, he left the lint which
adhered more immediately (and very strongly) to the surfaces,
untouched :  when this also was removed at next dressing, much
ichorous and putrid matter was  discharged, and, upon looking into
the bottom ot the cavity, was surprised to perceive distinctly the
pulsations of the brain, and that the  bone was entirely wanting
in all that part which corresponded with the basis ofthe tumour,
a space of two inches in diameter."  The danger  ot  this boy,
then, was most conspicuous and imminent; fortunately the dura
mater granulated, and the opening healed kindly.
   Such are the dangers proceeding Irom  delay,  those arising
from misconduct are no less to be feared.
   " A school-boy, having his hair severely pulled in a quarrel,
there rose a small bloody tumour ofthe scalp which he concealed
for three weeks, till it had extended from the size of a pea to that
of a large tumour  seven inches long, and four inches  broad,
rising very high in its centre, and covering much of the parietal
and  frontal bone.  This was an aneurism too large to be void
of danger, and required decision in the opening ot it, and deli-
cate dressing to prevent ill consequences, and bring it to a right
suppuration.   Mr. Hill of Dumfries was desirous of having it
opened with caustic.   The gentleman who had him under his
care preferred the lancet.   Upon  puncturing the tumour,  four
ounces of pure and florid blood flowed from it, and the  peri-
cranium appeared entire.   Mr. Hill now proposed a loose ban-
dage,  till  the parts should have  time to contract; but again,
says he, " I  was overruled, and  a  thick compress  was bound
down over the tumour, and a dossil put into the orifice.   Next
day, the integuments had adhered closely to the pericranium, 
272               Of Injuries of the Scalp.
 and a full sac was formed at each end ; and to discharge these,
 the gentleman tore up the scalp, by  thrusting a  probe  under
 it,  and then renewed  the  compress.   On  the third day,  the
 sacs were again filled,  the  parts  adhering so firmly, that  the
 probe could  not be introduced, though he tried it  several ways,
 and with so  much force, that the  bone was  laid  bare in three
 places.
   " Then followed an  oedema over all the scalp.  The gentle-
 man to whose care the case was'committed  being out of town,
 the  sore was neglected  for three days ; the swellings increased ;
 there was much pain, fever, sickness, and a degree of delirium
 and raving.   On the tourth, two caustics, notwithstanding  the
 inflamed  state of the scalp, were applied ; and on the fifth,  the
 bloody and purulent matter being discharged, and a fomentation
 applied all over the head, the delirium subsided, and the swell-
 ing  soon vanished.   There were  now three  openings, each of
 which continued  to run for many weeks, till the  bones  which
 had been laid bare exfoliated."
   Before I forsake this subject of injuries external to the cran-
 ium, I shall  represent  to you one which is  attended with  no
 danger of caries,  but relates to the scalp only, a nervous and
 most singular disease ; resembling  that which arises from some
 injury in  bleeding in the arm, attended with little danger, but
 marked by convulsive motions, nervous affections  of the most
 undefinable nature, and sometimes with agonizing and period-
 ical  pain ; pain varying according  to  the  state ot  the weather,
 or the patient's health.
   "  The  man whose case I am going to relate to you, was about
 thirty-two years of  age, sallow, sickly, and,  I  fear, dissolute.
 He had lost his health,  his industry, and his morals, by an un-
 fortunate  blow on the head,  which had deprived him of reason
 for many  months ; and, after a second blow on the head,  he
 suffered, in consequence of  the sewing of the temporal artery,
 a very singular nervous  affection.
  ^  First, about three years  ago,  he was  attacked  by  some
drunken companions of  his own, who, knowing he had in  his
pocket thirty  shillings of wages, and he refusing to treat them,
way-laid him  in a dark passage, and knocked  him down  in re-
venge.  He fell backwards into a  cellar-stair, struck the back
of his head against the stones, and was carried to the hospital
senseless; where, notwithstanding  every  care of the surgeons,
he lost his reason, continued many  months insane, left it at last
in a weakly and languid state, ill able to return to  his hard  la-
bour, that of press-man in a printing office.  From that time he
wrought  little, and irregularly, became a miserable vagabond,
subsisting  chiefly  on charity, and living among  his friends. 
Of Injuries of the Scalp.
273
   ** About three months ago, as he was coming down an open
 stair,  which had no hand-ran, and was so dangerous as to have
 betn the occasion of frequent complaints to the landlord, he fell
 over the stair, and  alighted among sharp stones, and his fore-
 head was laid open with a ragged wound, about four inches in
 length, extending from the forehead to the temple.
   " The stair was notoriously dangerous,  and the  night dark,
 but he confesses that he was a little tipsy. Nothing so surely in-
 dicates a vagabond and idle life, as indifference to cleanliness and
 health; he did not  return to his old  asylum, the hospital,  but,
 with a penny worth of  Wade's balsam, and some filthy appara-
 tus of rags, made a fashion of dressing his wound,  till, by "filth
 and neglect, it ulcerated ; the temporal artery was eroded ; the
 blood sprung briskly from the corner  of his sore, and thus he
 was brought to the infirmary.
   " The house-surgeon sewed the artery ; he was laid in bed,
 and enjoined not to stir, lest it should  burst out again.  He was
 very timid by nature, and the students took a pleasure in alarm-
 ing him from time to time, with saying, that it would surely
 burst out again.  About a fortnight after, the ulceration still  ex-
 tending, the artery was again eroded ; and at night, betwixt ten
 and eleven  o'clock, when turning gently in bed, he felt his fore-
 head moist:  and, upon  putting up  his hand, found it wet with
 blood.   The artery soon began to  bleed per salium ;  and  the
 house-surgton being called^ the artery was again secured, by
 striking a needle and ligature under iu
   """Alter the first sewing of the artery, he felt nothing unusual;
 but after this second stroke ofthe needle, he found, next morn-
 ing, his mouth pursed up and contracted, his jaws so  clenched
 that he could not speak,  while spasmodic contractions extended
 along the neck and throat.   His cheeks were flattened, and his
 mouth pursed up, and at the same time protruded as in a ludi-
 crous simper, or  like one attempting to whistle, and prevented
 by an inclination  to laugh. The form of the face was re markabiy
 changed ; the sphincter oris  pursed up the  mouth,  while  the
 zygomatic and  triangular muscles retracted the corners  of it,
 and made the dimple natural to that part very deep ;  the cheeks
 were flattened, the mouth protruded; when he  attempted to
 speak,  which he  did imperfectly, the whole face was agitated,
 and his tongue got entangled between  the upper  and  lower ran-
 ges of teeth,  so that he imagined, if he persisted, he  might bite
 it across ; and the throat and the whole neck was obviously con-
tracted in a spasmodic state, accompanied with remarkable pain ;
 and he could not open his jaws to receive the smallest particle
 of food, but lived on spoon-meat."
                          2M 
274
Of Separation ofthe Dura Mater.
  Having pointed out with deliberation, and, I hope, with pre-
cision and clearness, the various injuries of the scalp, I hasten
now to a subject more interesting in an infinite degree ; I mean,
the consequences resulting from a separation of the dura mater
from the internal surface of the scull.

                        SECTION  III.

              Of Separation of the Dura Mater.

  The blow which detaches the dura mater, may at the same
time injure the integuments, or affect the scull; hence nothing
seems more difficult than to ascertain  the simple consequences
of  separation of the dura mater, unallied with injury of the in-
teguments or cranium.   Yet I hope I shall  be able, by a suite
of  facts, to prove, that the dura mater may be separated  even
by  a shock, without any direct injury to the  scalp, or scull, and
to explain to you all the varieties of this accident, and all its re-
mote and unforeseen consequences.
  " A little boy, of five years of age, fell from the  first story
of  a stair, but alighted on his feet, and walked up stairs again,
saying that  he was not hurt;  no importunities, questions, or
threats on the part of his parents,  could ever extort from  him
any other answer, than that he was  not hurt; indeed, they had
little reason for their anxiety,  the boy appearing  to enjoy, for
three months, the most perfect health.  But at the end of the
third month, he was seized with a violent  headach,  accompa-
nied with a puffing up ofthe eye-lids, and fits of vomiting:  and
when the surgeon was called, he found the face suffused with a
purple colour, and the boy deprived of speech, and able only to
point with his hand to the place of the pain.   He was bled in
the arm without loss of time;  he grew worse, and  was, a few
hours  after, bled  in the leg, but almost immediately,  and before
the orifice was closed, he expired.
  " Mr. Casaubon being called to open the  body, found with-
out the cranium nothing particular, except a slight puffiness of
the integuments ;  but, on opening the scull, he found an exten-
sive abscess betwixt the dura mater and the  inner surface of the
right parietal  bone; but neither within the scull,  nor in any
other part of the body, was any thing remarkable observed."
  Here we have presented for our  consideration,  in a short,
plain narrative, a suite of most important facts.  First, A  boy
falls from a great height upon his feet, as it would appear, in
the presence of his parents, but certainly upon his feet;  and the
dura matter is detached, not by a blow, which might at once in-
jure the cranium, and shake the dura mater  ; it is detached by 
Of Separation ofthe Dura Mater.           275
the shock merely, without any concomitant injury of the scull.
Secondly, The integuments being sound, the cranium unhurt,
the parts not disposed to run quickly into disease, the child con-
tinues in perfect health,  and when he is suddenly seized  with
the fatal signs, there is still no conspicuous swelling of the in-
teguments ; and,  when he dies, the cranium is  found in its na-
tural state.   Ihirdly,  It is remarkable,  that here, as in almost
every instance, the suppuration of this membrane is slow and
insidious in its progress; for this boy had continued three months
in apparent health ;  no symptoms betrayed the danger: the pa-
rents had dismissed their first anxieties and fears ;  yet all the
while this fatal suppuration was ripening.   The boy, the mo-
ment he is seized with the stupor,  is gone, past remedy.   The
trepan could not then have saved him ;  the cause of this sudden
and fatal convulsion was discovered only after death.   Fourthly,
Though the suppuration was of considerable extent,  (un absces
considerable)  it had plainly arisen from the mere  separation of
the dura mater ; for the  dura mater alone was affected;  long
as it had been  divorced from the cranium, neither was the cra-
nium affected  by this separation, nor the  brain by the disease of
the membrane which immediately surrounds it ; the separated
surface was alone  purulent.*
   In one of the following states and conditions, the dura  ma-
ter always must be after  a violent  separation from the internal
surface of the. scull: First, Either, the bone being hurt, (as ge-
nerally happens in cases where it is shaken by a blow) the du-
ra mater cannot re-unite, its surface will suppurate, and the pa-
tient die, with shiverings, stupor,  and palsy ; or, secondly the
dura mater may continue separate, and yet its surface heal, but
with a disposition to form fungi, which betray its unhealthy condi-
tion ; for the  cranium,  by pressure on its lower surface, be-
comes carious, part of it is absorbed, the fungus begins  to pro-
trude through a  small circular opening, and the fatal sign of
pulsation in the tumour,  is felt, which pulsation is,  indeed, the
motion of the brain: then the opening enlarges,  the  fungus in-
creases,  the brain is at  the same time diseased, and  sometimes
suppurates, and the  patient,  seized with stupor, with epilepsy,
sometimes with howlings, and the most horrible convulsions,
expires.
   In the German Ephimerides, is to be found  a case farther
confirming this singular fact of the  separation of the dura mater
by a general shock; and  that  the  surface which remains de-

  * This cafe proves  how flow and infidious fuppurations of the dura mater are,
but by no means that this membrane can be feparated by a fhock: the contrary I take
to be the more probable inference ; for had it been feparated by the accident, and
had not re-united, fuppuration muft, I think, have immediately taken place.  S. 
276           Of Separation ofthe Dura Mater.
 tached, forms fungi,  and destroys the scull.   "This man was
 about fifty-one years ol age, fell from his horse, and was sensi-
 ble of a violent  concussion of the head;  a distressing pain en-
 sued,  but it  soon vanished,  and the patient  thought no longer
 of his fall, nor of this pain.  About  four years alter,  he be-
 came conscious of a loss ot memory ; and this malady increased
 so, from day to day,  that he at last forgot what he had said or
 done the moment before.   Then came cruel and incessant fits
 of epilepsy.   Those  paroxysms seemed  for  six months  to  be
 appe/ased by  the medicines he took ;  but there followed next
 pains of the head, excruciating, unremitting,  and  continual,
 which no remedy could alleviate,  and which,  in six months
 more, proved fatal ;  and so dreadful  were these pains which
 aff jcted the left side  of his head, in the form ot  megrim, that
 the left eye was convulsively turned in its socket, by  the excess
 of pain.
  " On opening the scull, the middle and fore part of the right
 parietal bone was carious, and destroyed in a space equal  to the
 size  of a half-crown.  Lesser spots of caries were observed  in
 various parts of the scull-cap, while the  left parietal was corrupt-
 ed by a fungous excrescence from the  dura  mater, which ex-
 tended towards the orbit, and had destroyed also the  cribriform
 plate of the cethmoid bone."
  Here we see again  the sudden shock separating the dura ma-
 ter, perhaps to a great extent from the scull.  The bone dying,
 and  falling into general disease,  by the loss  of its nourishing
 membrane ; and that  fungus (which it seems the peculiar dis-
 position of the dura mater to produce, when  healed apart from
 the cranium) destroying the  parietal  bone,  making its way
 through the thin plate of the cethmoid  bone, and causing death
 before it had growth sufficient to produce an external tumour.
  In speaking of tumours proceeding  from within the scull,  I
 have been  insensibly  led on to this subject, by considering the
 various consequences  of this separation of the dura mater: and
 my object has  been to impress you with just and serious fears
 of entering upon any surgical enterprise, where such tumours
 arise from within the  scull.   The cases which I have already
 detailed, are not merely destined to adorn the works of a learned
 society, or to be a matter of stupid wonder, but to serve as use-
ful  warnings ;  they are forms of disease, horrible,  indeed, in
their  conclusion, but in  their beginnings, hardly to be  distin-
guished from  the most trivial  tumours: and that surgeon is in
great danger who does not, from reason and reflection, (for ex-
perience few can have in such rare cases)  lorm a decided opi-
nion the moment such a tumour is exposed, who does not re-
 solve,  with a steadiness not to be shaken, " not to touch it for 
Of Separation ofthe Dura Mater.           277
 the world."  The good  that can be done is problematical, the
 danger dreadful; and the surgeon who but allows himself to con-
 sult upon such a case, or to hearken to the intreaties of a patient
 weary of existence, is in danger of robbing him  of life.    The
 disease, it  must be acknowledged, is fatal in the  course of na-
 ture ; yet,  wherever  an operation  has been attempted, it  has
 uniformly accelerated the death of the patient.
   Let  these facts, then, stand to you in place of experience.
 Examine, with a scrupulous and jealous precision, into the his-
 tory of all tumours seated on  the head.  Regard, as suspicious,
 those which are connected with venereal affections, with blows,
 or falls, or concussions ofthe head.   Regard, as peculiarly dan-
 gerous,  all tumours ot slow growth, of  deep pulsation, reced-
 ing within the cranium, covered with puffy scalp, and  causing,
 upon being repressed, not pain, but sickness, confusion of head,
 convulsions, and tremblings of the limbs.   When the scull is
 first destroyed, and the brain, or the internal tumour protrudes,
 a temporary relief sometimes ensues.   Occasional ease is some-
times procured  by gentle pressure, and equable support,  but
the event is inevitably fatal ; and  frequent swoonings, insensi-
 bility, coma, or quivering of the limbs, an involuntary discharge
of urine and faeces, delirium, and  convulsion, close the scene.
Touch no such tumour, at the peril of your reputation ; for, it
is either a caries of the cranium,  through which the brain pro-
trudes,  or  an aneurism from without, or a fungus from  within,
 which has destroyed the bone.
   Let us now return to reflect on one indisputable fact, and it
is this :  Within  the proper structure of the scull, the circula-
 tion is so vigorous,  and its sources of blood so varied, that the
 bone by no means depends on any one set of vessels for nourish-
 ment, nor  even  on that which seems the most  essential to its
 health, the  dura  mater.   Almost the whole of the dura mater
 may be  separated from the  internal surface of the scull, and yet
 the union be restored.   We often,- upon applying the  trepan,
 perceive that the oppression of the vital powers  proceeds from
 an effusion of blood  under the scull, compressing the brain.
 The blood is hooked out  with probes, washed away with mild
 injections ;  diluted by the natural secretions, and by the puru-
lent discharge from the suppurating surfaces of the dura mater
and scull; and  the  clotted blood being thus dissolved and dis-
 charged, the surfaces unite again.   We are often persuaded, by
 the quantity of the extravasated blood,  that it  must  have co-
 vered the whole hemisphere  of the brain, up to the sagittal su-
 ture.  We sometimes feel the extent  of the separation, by in-
 troducing the probe ;  but we seldom have so clear a conviction,
 as in the following case of the whole extent of the dura mater, 
 278           Of Separation ofthe Dura Mater.

 of the whole internal periosteum of the scull  being detached,
 "A  young man, of about thirty years of age, was struck re-
 peatedly on the head witn a crab-stick, and with a loaded whip.
 Next morning, he was  found lying in a state of profound le-
 thargy, and with his right side paralysed, but without the slight-
 est appearance of  fracture, or  depression of the scull.   The
marks of the blows being chiefly on the right side,  that side
 (contrary to a well-established rule) was first trepaned, and the
 dura mater was found  disengaged to such an extent, as to con-
 tain, at least, six or seven ounces  of blood, betwixt it and the
 scull.
   " This first perforation gave him some respite, but his friends
 resisted  all further attempts to relieve him, till four days had
 elapsed, when there appeared no longer any hopes of life,  and
 he was left to die among the surgeon's hands.    Then the left
 parietal  bone was trepaned.    The whole  hemisphere of the
 brain was seen to  be surprisingly compressed by a thick black
 cake of coagulated  blood, of the consistence and colour of cur-
rant-jelly.  The cake of blood extended actually from the falx,
or sagittal suture, to the bottom of the os petrosum ;  in short,
from the vertex to the base of the  scull;  and seemed to con-
sist of the same  quantity that was discharged from the other
side,  amounting, of course, to six or seven ounces of blood.
Although it was not thought prudent to bring away at once the
whole mass, yet, so much was discharged, that,  upon speaking
to the patient, he instantly looked up, like one awakened from
sleep, named  every one,  and raised the arm, which had been
paralytic, over his head; and much of the coagulum being re-
moved,  he recovered  apace, so as to  be able, by the fifteenth,
to walk into an adjoining room ; but by the accidental bursting
out of an artery in  the scalp, he was weakened, the confusion
of head, and even the paralysis, in  some degree, returned.
  "Some  days after  this, his friends, despairing  of his life,
laid  him on a  litter,  and, without acquainting  his surgeons,
(Mr.  Hill, and Dr. Gilchrist, of Dumfries,) carried him home,
a journey of eight miles.  The left side of the brain suppurated
five or six times, each paroxysm of inflammation being accom-
panied with fever, stupor, and difficult deglutition, and relieved
by an eruption of matter; and it was remarked, that when such
suppuration formed towards the fore part of  the brain, the
candle appeared to the patient double;  but when the suppura-
tion was backwards, the light appeared to have a halos,  or
circle, round it; and after each eruption of matter,  the candle
appeared single and distinct.  Notwithstanding these occasional
interruptions,  he was,  in three months, completely cured ; be-
came the  father  of a family,  and lived long in perfect health, 
Of Separation ofthe Dura Mater.           279
excepting a  slight  defect  of memory,  and slight convulsive
twitches,  to which he continued subject."
  In this  most interesting case, related by Mr. Hill,  he had
taken every pains to ascertain the extent of the separation.  He
found no  apology for introducing his probe  under the  scull, on
the right side, because the blood flowed freely out ; but, on the
left side,  his probe, while hooking out the  coagulated blood,
passed from the trepan-hole,  in the centre of the parietal, down-
wards, along the temporal bone,  till it was stopped by the  cur-
vature ofthe os petrosum, and upwards again by the lambdoidal
suture,  all along the sagittal suture, and over the orbit, along the
frontal bone; " and it is my persuasion," (says Mr. Hill, " that
the separation of the dura mater was not less extensive over the
right side."
   What,  then, are we  to infer from these  phenomena ?  Surely
this : That,  as lacerated scalp adheres readily with the external
surface, the dura mater has an equal aptitude to  re-unite with
the internal surface of the scull : and these phenomena  present
themselves daily to the observation of the practical surgeon.  He
presumes, from the sudden oppression of his patient's  senses,
and the palsy of his limbs, that the dura mater is separated, by a
shock, or blow, not slightly, so as merely to endanger suppuration,
but to such extent as to cause a great effusion of blood from all its
vessels.   He trepans the scull, and by the general pressure, and
rising of the brain, the blood is, (as I have generally observed
it)  spued up in grumous clots, through fhe trepan hole.   He
puts in his  finger,—turns it round,—feels no solid resistance,
and is conscious that the dura mater is much depressed, and the
effusion of great extent.  Sometimes he finds a cake of solid and
firm coagulum, which bears the pressure of the finger.   At each
dressing,  he introduces his probe, binds it, and turns it in every
direction ; by injections of tepid  water,—by the the help ofthe
probe,—by the purulent secretion from the surface ofthe scull,
and dura  mater, the blood is gradually discharged, and by every
mark it is certain, that the extravasation has  exuded under the
whole of  one parietal  bone,  from the forehead to the  occiput,
and sometimes from ear to ear.   Yet, by the secretion of pus,
and by the heaving of the brain, the blood is entirely discharged,
and purged away.  The scull and dura mater are in a state  of
suppuration  by the time  they are allowed to approach each
other.  The  dura  mater  is covered with a velvet-like pile  of
granulation.   The margins ofthe trepan-hole, and (by inference)
 the internal  surface of the scull, is covered with a similar pile
of granulating flesh.   The dura mater is, by the pressure of the
 brain, supported in close contact with the  scull,  and the surfa-
 ces are united, and the trepan-hole closed by a process of nature, 
280                 OfContusio Cranii.
visible to the surgeon, in every stage, and expressly resembling
the re-union of soft parts.

                        SECTION  IV.

                     OfContusio Cranii.

  As it is my wish that you should on this, as on all questions
of practice,  draw your  own conclusions from fair descriptions
and plain facts, instead of defining the essential change produ-
ced in the injured part of the cranium by a blow or contusion, I
shall proceed to shew their effects.
  " A man (says Dessault) of five and thirty years of age, was
struck with a  bludgeon over the head, a blow which  stunned
him for a few minutes,  but did not knock him down.  He had
himself bled in the foot,  drank of  a  vulnerary potion,  believed
himself cured,  and continued well for a month.   Then he sick-
ened, lost his appetite, his tongue took on a yellow  scurf, shiv-
erings came on, he fell into coma, and died on the sixth day.
  " On dissection,  (says Dessault)  we found not the  slightest
outward mark of injury ;  the scalp was  sound, the  external  ta-
ble  of the scull had its natural colour, but the internal table was
blackened through the whole extent  of the parietal bone.  The
dura mater lining this part of the scull was of a colour still dark-
er ; yet it adhered  as firmly  to this surface, as to that  of  the
uninjured part of the scull, while all the lower surface  of  the
dura mater was coated with an ash-coloured viscid pus, which
not only covered the  surface,  and entered among the  convolu-
tions of the brain, but tainted its substance to the depth of seve-
ral lines.  The rest of the brain was sound and natural."
   There cannot be imagined a more perfect example,  or short-
er description of contusion, pure and uncomplicated.  The  in-
teguments  still entire, without even the  slightest tumour, so
that the bone had not suffered by any disease from without;  the
dura  mater still adhering, so  that, unless the bone had been
deadened by the blow,  it  might have preserved its circulation
from within ;  the bone alone had  been injured by the blow, so
as to  affect, in its turn, the dura mater, which alone was infla-
med and purulent,  in consequence of the death of those parts.
But yet an accidental description of Le Dran pleases me still
more.   " A man, who had been wounded with a sword, conti-
nued well, and walking about in the hall of the hospital, till  the
seventeenth day, in the evening of which day he was  suddenly
seized  with delirium and fever, and soon after died.   The first
table of the scull was divided by the sword, the second was only-
 contused ;  betwixt the pericranium  and scull was a coat of a
 sort of purulent mucilage; the same purulent mucus was lodged 
Of Contusio Cranii.
281
betwixt the cranium and dura mater, and also betwixt the dura
mater and pia mater.
   " When I examined the cranium,  (says Le Dran) I  disco-
vered the cause of this disorder.   There was no fracture ; but
a contusion, about the bigness of a crown, was visible  in the di-
ploe, discoverable by a large black spot,  which was of an ellip-
tical figure, in  a line with the cut in the external table, and sur-
rounded by several black rays.   I  have  preserved that piece of
bone : and, although it is dry,  and I have had it for some time,
the black spot still appears upon the internal table, and not upon
the external; but it is more conspicuous against  the light."
   But of all the examples of contusio cranii, that produced by
the  grazing of an oblique ball,  or the obtuse blow of  a ball,
whose force is spent, seems to  me the  most simple ;  no other
kind of violence so effectually deadens a bone, nor so certainly
draws after it fatal consequences.  " A Lieutenant of the regi-
ment of Haynault,  (says Mr. Martiniere) was wounded with
a spent ball a little above the right frontal sinus.  The surgeon
who first saw him thought it right  to make  a crucial incision,
to display the state of the bone, which he found free from frac-
ture or fissure.   The  ball had  somewhat stunned the patient,
but bleeding had relieved this symptom ; and there seemed to
be nothing to do but take care  of  the wound. But at the  end
of three weeks, the  patient fell into a lethargy, with a hard and
oppressed pulse.   When  Mess.  Petit  and Martiniere were
called, they found his case desperate;  y et  they felt it to be
their duty to apply the trepan.   The perforation  gave vent to
a great profusion of pus ; but, by being late performed, it was of
no avail."
   I need not seek to impose upon you the authority of respect?
eel names, to  confirm a theory  which 1 have  proved ; but re-
mark it rather as a proof of the ing nuity and good  sense of
Botallus, that he understood so well  the invariable effect of a
ball, in deadening the bone.  He regards every gun-shot wound
ot the head, (that where there is merely  a bruise, as well as that
where there  is  a fracture), as an accident requiring the trepan.
He represents the slightest touch of a ball as a kind of  contu-
sion,  never to be neglected.   He directs, that  the  piece  so
struck should be cutout with the trepan.   He savs, finally, that
having seen some die, from such slight grazing of a ball ne-
glected, he  has, invariably, found pus  collected under the dura
mater, directly  under the injured part of the scull.
   The soldier who is struck obliquely  by a  musket-ball, whirls
round, and falls.  He lies as in a swoon.   When he revives,
he is cold, pale, with a haggard countenance, and wild and con-
                           2  N 
282                 Of Contusio Cranii.
fused air ;  but he is soon able to get upon his feet.   He is car-
ried to a safe place ; there is found no external wound ; the  in-
teguments are livid, yet no  inexperienced person would appre-
hend any danger ; but he continues pale, dispirited, and  lan-
guid ;  in a few days, the part is  puffed up, and slightly swell-
ed.  He has then sickness, swimming in the head, cold shiver-
ings, and nervous tremours ; and, upon making  an incision into
the part, the bone is found bare, and often discoloured ; and if,
upon the exacerbation of these symptoms, the trepan is applied,
pus  issues through  the  trepan-hole, and the patient  is thus
saved.
   We cannot then but  be struck with all the phenomena of con-
tusion, and take an interest in them, for  they are far from being
rare;  and  especially,  we  must  be struck with the apparent
slightness of the injury,  a  superficial wound, unattended, du-
ring many days, with either pain or sickness, or any  sign of
danger.   We cannot but reflect seriously on the critical condi-
tion of such a patients, the slight variations which mark  the
change from health to the most dangerous condition ; and above
all, on the limited period in which it is permitted us to inter-
pose successfully ; how precious the moments of reflection and
consultation should appear ; how  vigilantly the  surgeon should
watch over his patient,  and mark  those changes of the  counte-
nance, that expression  of the eye, that mixed state of irritation
and languor, those  alternations of delirium  and reason,  those
perturbed nights and alarming dreams, which no nurse nor hired
attendant is qualified to report: and it is worthy of notice, that
the matter of a suppurated dura  mater  is peculiarly ripe, i. e.
yellow, viscid,  and tenacious, (which is to be  ascribed, not to
the peculiar nature of  those surfaces, but to the  compressed
state of those parts, and to the continual absorption of the humid
fluids), from the moment in which such abscess is begun.  And
let us not forget, that it is but the uncertainty of the signs that
suspends our resolutions, for  this  is an abscess which cannot
like any other, burst outwardly ; which, when once begun, pene-
trates rapidly to the brain,  the most susceptible, and the most
important organ ;  so that there is but a moment in which the pa-
tient can be saved.
   To  watch the patient,  and distinguish the signs,  so  as  to in-
terpose with decision, void of rashness,  and seize the short in-
terval that is allowed us,  is  the mark of professional skill.* The

  • Undoubtedly a carious bone may, in any part  ofthe body, remain infulated,
fntrounded by a fiftulous and callous fore, but no where is this condition attended
with much imminent peril and danger, as in the caries of the fcull.  That a contu-
fed and deadened part of, the  fcull fhould remain thus unoffending, and unaccom-
panied with fymptojns, is nothing  but what our philofophy can eafily explain; it 
OfContusio Cranii.                 283
true and lively manner in which Fallopius describes the mark for
discovering contusion, and claims it as his own, will strike you
very much.   " Since," says he, " the contusion of the bone  is
very dangerous, how, say the commentators, shall it be known?
not  by the senses,  not immediately after  the fall, not till the
third or fourth day."  It is to be known, (says Vidius), by mak-
ing an incision,—by the blackness of the bone.  God have mer-
cy on those, whose physicians think  fit to wait the blackening of
the bone.  Why, bones the most cruelly mangled and depres-
sed, contused, as they certainly  must be,  do  not  blacken,  if
treated with prudence and care ; often, indeed, in  wounds, the
bone blackens, but that is through  length of time;  how,  then,
shall we presently know, when a bone  is contused ?  I have not
heard nor read in any writer the secret marks  of contusion ; but
they are as follow:
  "  Look to your nails ; remark their fresh and lively  colour,
white, tempered with red, but spotted with specks of a  deader
white.   Those spots have been named  by the Greeks nebula?, by
us mendacia; and exactly such spots  appear  in contused bone,
red at first, but afterwards of this  dead white; for the  bone
changes colour in its various states of life, death, and putridity.
The  colour of a living bone is white, delicately tinged with red;
that  of a dead bone, unmixed white ; that of a putrid or carious
bone, livid or black.   This is the  cause why, when you first lay
open a bone, you find it of a reddish  white colour; white, be-
cause its earth is of the purest; and mixed  with red, because  it
contains the finer part of the blood, a  sort of sanguineous vapour,
which, as it is from the blood,  is red.    And-this is my  proof,
and  you may  witness it, that when I scrape  the cranium, I have
scarcely penetrated the  surface,  when blood begins to flow; and
so it is, indeed, in  every bone.
  "  This being established, it follows, that during the first stage,
i. e.  during the two first days of a contusion,  that part which  is
marked with these specks of blood is still alive.  But the blood
exhales  by the third day ;  for then the contused parts are di-
vorced,  though without any visible  separation from the  living
bone.   They no longer hold a  living connection with it, nor are
nourished by  a circulation of humours ;  hence the redness cea-
ses,  and the spots and specks become white, which  is truly the
colour of a dead bone.   Thus do I recognize contusion by the
change of colour;  I recognize it also by its blackness ;  but this

implies no more than that the dura  mater, if it efcape the firft fhock, may feccdc
fo fiowly from the deadened bone, as to lefftn  the danger ; in fhort, that a contu-
fion of  the fcull  may terminate in mere caries.  But this is no reafon why we
fhould depart from' that jult and important rule ofthe ancients, that we fhould in
all cafes of confufion, operate early. 
284
Of Contusio Cranii.
is a mark too decisive, and  too certainlv fatal, to be waited
for."
  But as yet, I have related no fact, nor advanced any  thing,
which might lead you to conceive the notion of an injury affect-
ing a part only  of the system of a bone, of a caries of one only
of the tables, and of an abscess of the diploe which lies betwixt
them.  It was what I myself never suspected ; so that the oc-
casion in which I first  observed it was extremely  interesting.
  "A young man, in the prime of life and health, fell from his
cart,  and the  wheel,  passing  obliquely  over  his head,  slided
upon his scull as  upon a stone.  The integuments were torn
down to a great extent.  There were three large and triangular
flaps  of scalp so  ingrained with mud and sand, that the blood,
hair, integuments,  and scull,  seemed caked into one mass of
filth.   The man was profoundly drunk ;  upon cleaning the flaps
of the scalp, with the design of replacing  them, the marks ofthe
cart-wheel upon the scull, which was rough and scratched, were
so visible, as to preclude all rational hopes of re-union;  yet the
flaps  were nicely cleaned, replaced,  and held together with
slight stitches.
  " That integuments so lacerated,  and a scull  so  plainly inju-
red, should recover, was not  to be looked for ;  but the injured
bone might exfoliate, as a mere caries, and the violence, besides,
was of a peculiar kind, there  was no fracture ;  the patient  had
received no blow by which the  bone might be contused through-
out ;  the injury was apparent on the surface only,  and was pro-
bably limited to the external  table of the scull.    The  external
table might exfoliate,  but it was infinitely more probable, that
the caries should penetrate and  affect the  dura mater; and it was
our duty to watch for signs of danger; and yet to trust to nature
s$ long, as the  injury stemed local,  so long as it was possible
that it might exfoliate  superficially,  and as a mere caries.
  "The man, more astonished than hurt, was  no sooner resto-
red from his brutal state of intoxication, than he appt ared to be
in  perfect  health ; there were  no shiverings, no fever, no con-
fusion of head  during the day,  nor  delirium during the  night;
much as we were persuaded of his danger, it was only danger to
be apprehended,  no symp'om as yet announced it.   The sup-
puration from the integuments  in such a case is profuse and
foul; and, while such a lacerated wound, so ingrained with filth,
is cleansing and granulating,  it  visibly  mends,   and the surgeon
js too apt to indulge hopes, which are never to be realized.   In
this case, the integuments first  thickened, as they always do, by
inflammation;  were next wasted  by suppuration, and remain-
ing still insulated, the edges became  livid, and  sloughed off,
while the scull blackened more  extensively ; a  slight fever was 
Of Contusio Cranii.
285
inseparable from such  a  state ; his face was  full, and his eye
heavy and languid ; yet that was not much to alarm us ; but he
sickened ; on the thirteenth,  he was reported delirious during
the night.  We could  no longer be responsible for delay, and
he was trepaned ; and  circumstances of the most singular na-
ture,  which I wrote down, (as always  I have done by the bed-
side of my patient), persuaded me on the instant that this was as
truly an abscess in the  substance,  in the cancellated part ot the
bone, as ever a boil was  an abscess of  the cellular substance of
the skin."
        Remarks in the time of operation,  and after it.


  " The integuments,  by retraction, by suppuration, and most
of all, by the gangrene or sloughing of the edges and angles of
the several flaps, were so wasted as to have left an extent of na-
ked bone, as broad almost as the palm of the hand.  The bone
dry, and scabrous, was black in two places.   The perforation
was made near the centre of the parietal bone, on a point of
bone black as a coal.  In perforating the outer table of the scull,
not the  slightest tint of blood appeared ; it seemed dry through
all its substance; the saw-dust was black at first, and became
white in the progress of sawing, and as dry as hair-powder ; it
was easily blown away, and the working ofthe saw was like the
cutting  of  button-moulds from a piece of horn.  The whole
scull was extremely thick; the sawing, which was deliberately
performed,  was of course extr mely slow ; at last  thick  and
viscid  pus spouted  up round  the instrument, and  I had no
doubt, (although I had before affirmed the dura mater and brain
to be still unaffected), that there was an abscess ;  that the opera-
tion was fortunate, and might eventually save the patient's life.
But the most accurate probing of the circle with the point of a
quill did not discover to us even a single point in which the per-
foration was complete.  The  inner table, to our utter amaze-
ment,  was perfectly entire : and there appeared, for a moment,
no other rational explanation of this phenomenon, than that the
inner table  must  have  been fractured, permitting the  pus to
exude through some oblique passage,  from an abscess ot the
dura mater, to the cancelli betwixt the tables of tjje scull.
   " The crown of the trepan was again applied, and,  under the
 impression of there being an abscess betwixt the scull and dura
 mater, it was turned boldly and freely, without fear of wounding
 that membrane, \^hen suddenly there issued through the trepan-
 hole much blood ; and it was feared, that some ill accident had 
286                 Of Contusio Cranii.
happened, in short,  that the dura mater was wounded.    But,
upon probing  with  the  quill, the inner table  was found still
entire ; there was every reason for sawing slowly and cautiously;
and it was, accordingly, very long in cutting through.  During
all this  stage of the opi ration, the blood flowed profusely  ; and,
when the  circle  of  bone was at last taken out, the  blood and
matter  ceased to flow.   The dura  mater was seen white and
clean, firmly attached to the edges of the bony circle, and  no
where suppurated ; and every circumstance of the operation  in-
clined me  to examine the trepaned circle with  particular  ac-
curacy.
   " The circle of bone sawed out with the trephine was, except
one,  the thickest I had ever seen.   The external surfacp^was
perfectly  black ; the hole where the centre-tooth  of  the trepan
pierced this carious  table, and all the sides of the same table,
were of a dead, white, or ash colour ; the cancelli were gaping
and irregular, yet without any very particular appearance.** But
the inner table was red in its substance, and bloody in its edges.
   " The state of the dura mater was, during  the cure, the sub-
ject of  my most careful investigation.  There was, I am well
assured, no abscess  ; its surface changed,  and it went through
the process of granulating without more matter than that which
that process implies, and  such as the  exposed surface  alone
might produce.   These descriptions, taken carefully from my
casebook, require no comment.  This  at least is sure, that the
inner table may remain sound, and full of blood, while the exter-
nal table and cancelli are contused and dead ; and  I have  no
doubt,  that this  man was saved from most imminent danger.
Every  such  caries should be trepaned  ; very  slight indeed is
the chance of such an injury being partial at the first, or conti-
nuing so ; still less likely is it, that after penetrating just to the
dura  mater, it should be separated by an effort of nature."
   The  following interesting case, communicated to me by my
able and much-esteemed friend,  Professor Jeffrey, and related
by his nephew Mr. M'Dougall, who attended the patient in her
last moments, will, I believe, be highly gratifying to you.
   " A  young  woman,  living then  in London, about six and
twenty years of age, was struck down by a smoothing-iron fal-
ling from a height, where it had been carelessly hung, perpendi-
cularly upon her head.  It struck her on the top of the head,  on
the upper parj of the left parietal bone.   She was conveyed to
an hospital in a state of insensibility, and continued  delirious
for some time.   She was bled, the head shaved, the wound in
the scalp enlarged ;  and when  she  recovered her senses, she
complained of  a sense of giddiness,, accompanied  with pain  of
the head, which continued for many weeks.   Of the state  of 
                     OfContusio Cranii.                  287

the bone she had never been distinctly informed, but could ]per-
ceive at the end of some months, that the surgeon, or his ass ist-
ant, at each dressing, attempted to extract a large piece of dead
bone, which was moveable, and which they shook and pulled in
various directions.   During these  attempts, the sore was dres-
sed with lint, and a poultice was occasionally applied.
  " She  remained  very long in  the hospital, (eight  or nine
months), where her health having suffered greatly, the phy sician   v
suggested to her the propriety ot removing to the country.  She
complied with this advice ;  and after three  or four months spent
with her friends, she returned to  the hospital much recruited.
Many and various  attempts  were now  made to disengage the
insulated piece of bone.   Her health began again to decline, her
appetite failed, she vVas greatly reduced by fever, fits, and  pro-
fuse perspirations.   The discharge from the carious ulcer,  pro-
fuse as it  had  always been, was now greatly increased, becom-
ing more profuse and extremely fetid,  as she became weaker.
Nourishing diet and cordials  were not spared.  She  felt  that
her health could not improve in the air of an hospital in London,
and resolved to return to  Scotland,  to  live or die among her
friends ;  weak as she was,  she  actually performed this journey
of 400 miles in a mail-coach.
  " When leaving  London, the  gentlemen under whose  care
she had been,  charged her never to permit any operation for the
removing of the carious part of the scull.  They remarked, that
the bone,  which was slowly decaying, would be at  last disenga-
ged by the ulceration and erosion destroying those parts by which
it was surrounded ; that to this alone should she trust; the pro-
cess of nature, they said,  was safe, and sure to happen, it she
could but regain her health ;  the expedient which would proba-
bly be proposed to her,  of applying the trepan, extremely  dan-
gerous.
   " On her arriving in  Glasgow, and applying to Mr.  Ander-
son, an eminent surgeon in that city, his opinion  was so entirely
opposite to this, he was so  persuaded ofthe propriety of remov-
ing this  insulated bone,  (now entirely uncovered, and of great
extent),  that he remonstrated with the patient, argued with her
friends, and assured all  who had an interest in her,  that the pain,
irritation, diarrhoea, and fever, the want of appetite,  and pro-
fuse discharg, could not fail to  bring  her soon to the grave:
But still  his advice was neglected, till at last her health manifest-
ly declining, and her situation being in  all respects hopeless, the
operation was assented to.
   " With  the design of afterwards bursting up the corrupted
part  of the bone, he applied the crown of a very large trepan
nearly on the  centre of this extensive caries; an operation which 
288                 OfContusio Cranii.

wasnot accomplished easily, nor at once ; for such was the per-
verse and fretful temper of the patient,  fatigued with pain and
suffering, that she submitted very ill to the operation ; such, in-
deed, was her real weakness,  that in place of completing the
perforation at once, Mr. Anderson thought it prudent to allow
two! days to elapse betwixt the first  and second application of
the trepan.
   " By this central perforation, the insulated bone  was convert-  *
ed into a broad ring;  it was of the form of a quoit; and a se-
cond perforation, with a smaller crown of a trepan, would have
divided the ring, have reduced it in the form of a crescent, and
have enabled the operator to  break  up  and extract the caries,
without endangering the dura mater.  But he was not permitted
to complete his operation ; if there was  either danger or pain in
the operation, he had done all the harm, but was  permitted to
do none of the  good that might have been  expected.  Though
prevented from fulfilling his  more  important duties, he conti-
nued his charitable visits to  the patient.  He still hoped, in
some period of pain, or from a deliberate conviction of  her dan-
ger, that she would allow him to complete his operation ; but,
wearied with opposition, and  finding himself really useless, he
at last withdrew.
  " It was from charitable motives only, to  sooth  and alleviate
her distress, without the  slightest hope or design of offering any
more important assistance, that Mr. M'Dougall  now agreed
to attend her, and assist her friends in  applying the dressings,
and keeping her sore  in the best condition.   The  state of mat-
ter at this period is excellently well represented in the following
report by Mr.  M'Dougall.
  " On  removing the bandage and dressings, I had now an op-
portunity of seeing the  extent and appearance of the disease.
The scalp had ulcerated and sloughed off to the extent of five or
six inches in diameter, exposing almost  all the upper part of the
scull.  The insulated piece consisted ofthe upper and back part
ofthe right and left parietal bones.  It extended from the lamb-
doid suture behind, to within two inches  of the coronal suture
before.   The sagittal suture was seen to run along the middle of
this caries, wheh measured transversely five  inches, and lon-
gitudinally three inches and a  half.   A great part of the exter-
nal table of the loose  bone had mouldered  away, and the dura
mater was seen through the trepan-hole, and through many ul-
cerations in the scull,  covered with pale  unhealthy granulations.
The edges ofthe scalp were swollen, livid,  and painful, and the
discharge of pus was  profuse, of a dark colour, and very fetid.
The insulated piece of bone whs immersed in matter, blatk< ned
on its surface, and incrusted with the discharge.  I could easily 
Of Contusio Cranii.
289
 move this piece of bone a little way upwards or downwards, or
 to either side, the thin edges of it passing at each movement un-
 der the edge,  or between the tables of the surrounding bones.
 It could even  be depressed a few degrees, though the resistance
 to this  was  very  considerable;  nor  did the patient com-
 plain of any  uneasiness.   It was this resistance that enabled
 Mr. Anderson  to apply the trepan on the insulated piece of
 bone itself.
    "  Compresses had been applied to prevent  the matter from
 descending betwixt the cranium and scalp, but without success.
 The matter had worked its way downwards, forwards and back-
 wards, had destroyed the cartilaginous tube of the external ear,
 giving a free exit to the discharge through the external meatus,
 and had separated the scalp from the squamous  portion of the
 temporal,  from  almost the whole of the left parietal, and from
 a great part of the occipital bone.  The matter had descended
 to the neck, and formed a  large collection there,  which poin-
 ted ;  but the  patient would  not allow  of a counter-opening.
 The application of compresses, to prevent its accumulation, was
 now out ofthe  question, for the scalp covering the left and back
 part ofthe cranium had become livid,  and extremely painful to
 the touch, and as thin as paper.   A bent probe, when introdu-
 ced under the scalp directly backwards, could be passed down
 to the neck, and  made to turn round the convexity of the scull,
 till it was withdrawn opposite to the ear.   The bone felt rough,
 and denuded of pericranium throughout this whole circuit. The
 matter exuded  also from  under the bones of the cranium, and
 had detached the dura mater from them to a considerable extent
 laterally, and downwards to the  base of the scull.
   " The ulcerated scalp was dressed morning  and evening
 with a pledget of lint,  covered with soft ointment.   Tow was
 applied above  the lint, to absorb the matter,  and the  whole
 was retained by a bandage loosely applied.   At each dressing,
 about an English pint of a dark-coloured fetid  matter, very
 much resembling coffee-grounds,  could, with gentle pressure,
 be forced up from the neck, and from betwixt the cranium and
 scalp  on the left  side, and discharged at the large opening above.
 The scalp bled on the slightest touch, but the blood was almost
 without colour.
   " The patient  had at this time survived the accident twenty-
 three  months.  She lived about a month longer, her debility
 daily increasing till she died.*

   ' '*  I need not,  Sir, fend you a copy of my notes of the diffec"tion; as nothing
 very remarkable prefented  itfclf.  I may remark, that the dura mater  adhered
very firmly, where it was connecte'd with the parietal bones anteriorly,  and was
in  general  much thickened in  its fubftance.      " Petkr M'Doug all."
                            20 
290             Of Suppuration of the Brain.

   It is my opinion, that the carious bone of a member may be
left, till it be discharged or loosened by  nature ;  but th a when
a vital organ, as the brain, is endangered by slow extoliutum,
the bone  should  be removed  as soon as it begins  to shake ;
that  life  being at stake, nature, when she  makes  the effort,
should be assisted, but always  modestly and delicately.  There
are circumstances, in which  it is plainly our  duty, not  only  by
shaking  and moving the deciduous piece, but by cutting and
trepaning the scull, to remove it; for, when  the  integuments
have sloughed off; when much, or the whole ofthe cranium
is bare; when the dura  mater is ulcerated over almost all  its
surface ;  when one separated  piece of bone  supports an ulce-
ration and caries over a  great extent of the scull ;  I  should  (in
hopes of removing  that  insulated  piece of bone)  procetd to
the most dangerous and  fatiguing (for these  are not  painful)
operations,  as freely as I should pull a thorn out of the flesh.
                        section v.

Of Suppuration ofthe Brain, from xvhatsoever cause it proceeds•,.
   whether from Laceration of the Integuments,  Separation  of
   the Dura Mater,  or Contusion of the Scull;  of the Signs of
   Danger, and the proper Time for Operating.

   You now perceive, that contusions of the cranium lead natu-
rally to one of two forms of disease ; either to a mere exfoli-
ation, a disease limited to the bone, and  long  protracted, yet
in no period void of danger ; or a present affection ot  the dura
mater penetrating in a few days to the brain itself, and follow-
ed by very sudden death.  If, in demonstrating to you the va-
rious affections of the lacerated scalp, separated dura mater, and
contused bone,  I have treated individually and distinctly of af-
fections which are oftener combined, it is with the purpose, first,
of proving  that they do  happen  independently of one another ;
and, secondly, of accustoming you to reason correctly on the
individual facts ; and teaching you to distinguish the  peculiar
constitutions and affections of" each part, so as to be able to fore-
tell the dangers resulting from each particular injury.  But these
parts having one common  circulation, and a mutual sympathy
and dependence, the blow which affects the bone, by  contusion,
must necessarily, in most cases, shake the dura mater, and dead-
en the integuments, and produce,  by this complicated injury,
symptoms  different  in  complexion (and more immediate in
their consequences) from any  I  have yet described.   I have
now to describe that form of contusion where  the  symptoms 
Of Suppuration of the Brain.              291
 immediately follow the injury; where,  though there is no ex-
 ternal wound, nor apparent bruise, to intimate the patient's dan-
 ger, there rises, after a few days of shiverings, and indescriba-
 ble confusion of head, a puffy tumour, the surest mark of dan-
 ger, and where in a few days more the brain is deeply affected,
 and the patient dies.   I ,am  now to  explain to you the princi-
 ples on which this case is to be resolved, the rules and data, ac-
 cording to which a consultation, the most solemn and  interest-
 ing in our profession, is to be conducted.  The confusion of
 head, shivering, and fever,  are all too  slight to alarm the patient
 or his friends, and his surgeon only can justly estimate  his si-
 tuation.  The symptoms are too slight to allow the mention of
 an operation,  esteemed the most hazardous in surgery, which
 yet must be  immediately performed, else the man is lost without
 redemption.   Not  one among you, perhaps, is destined ever
 once to perform lithotomy,  but there is not one of you who will
 not probably be  called upon,  in future practice, to decide upon
 the most difficult of all questions respecting injuries ofthe head;
 to  deliver before a jury a sentence on life or death ; to proclaim
 the motives  and principles of vour practice, your  reputation
 being involved in the fate both of your patient, and  ofthe cri-
 minal accused of his death.   The phenomena which I have hi-
 therto described, are chiefly those of  caries, affecting only the
 bone, sometimes protracted for months or years;  but the train
 ot  symptoms I am now to describe, are  those from which dan-
 ger is inseparable.
   A man, in a quarrel, or in a riot, is knocked down with a
brickbat, or bludgeon.  He is, perhaps, only stunned by the
blow, and does not fall down :  he is sickened,  faint, cold, and
pale,  but in a few minutes he  feels quite recovered : often a
blow  apparently more terrible, is harmless: but whatever may
be  the force, there is unhappily no criterion of the effect of such
a blow.  Though a  patient thus hurt is apparently well, and
goes about his usual occupations,  he  feels a depression of spi-
rits, and a confusion of head,  a want of  appetite, and  loathing
of  food : he  is in a faint, languid, and nervous  condition: his
hands tremble, and his head swims upon being  hurried  in ex-
ercise, or disturbed with any unusual  emotion,  and  he passes
the night in unquiet sleep, and terrifying dreams, from which
he wakes in indescribable confusion, from time to time.   In a
few days, the part injured,  though  at  first it was hardly  livid,
rises into a puffy tumour, round, soft,  regular,  circumscribed ;
important, only  as it is connected with these signs of danger,
and as it implies a detachment of the dura mater, and contusion
of  the bone.
  In a few days,  the fever is more conspicuous, (though per- 
292             Of Suppuration of the Brain.
haps the tumour is flattened) with slight horrors and shiverings;
the confusion is more distressing, attended  with pain, and a
sense of girding in the head ; he can no longer endure the light;
the eyes are red,  swollen and  gummy; the pulse is  quick and
Weak ; the tongue foul; the skin parched ;  the visage pale and
ghastly, with a  hectic flush  upon the cheek ; the urine pale, and
sparing in quantity ; the hands, and the tongue, when he puts it
out, tremble.   He knows not  what ails him, but  is,  night and
day, in a state  of indescribable confusion.   During the night,
roving, grinding the teeth,  and slightly delirious ; and   during
the day,  desponding, oppressed and sick.
   If  the surgeon be fully aware of the import of these  slight,
but alarming signs,  he opens this puffy tumour with the scalpel,
and finds  the  bone dry,  and whitish,  or  inclining to yellow.
He knows by the aspect ofthe pores, which are the holes by which
the arteries entered it,  that it is dead.   He applies the  trepan,
and upon taking out the piece, finds that there is a slight coating
of cream-coloured  pus upon the dura mater, and congratulates
himself,  not without reason, on having anticipated the  danger,
and saved his patient's life ; for usually the symptoms  subside
after  perforation, the dura  mater reddens, granulates, and heals
along with the  scalp, with  which it unites  in one common ci-
catrix.*
   But, if the patient be regardless of these symptoms,  uncon-
scious of his  situation, or indifferent to the intreaties of his
surgeon; if any how this happy interval be neglected, the ulcer,
which was in  this  stage confined to the dura mater,  extends
to the brain.   The confusion of head, and fever increase : the
patient becomes  stupid, and drowsy,  and awakes from sleep in
great confusion  and  alarm.    He has  longer shiverings,  and
more continual sickness ; his knees totter under him, his hands
tremble, and his face is often slightly distorted with spasms ;
 and his limbs, especially  of one  side, are often slightly con-
vulsed ; and growing gradually weaker, he sometimes becomes
 paralytic of one side, but usually becomes only more stupid,
 and oppressed, and suffers slight convulsive paroxysms before
 he dies.   During the first eight or ten days, he is in this state
 of languor and sickness ;  from the tenth to the twentieth, he is
 in manifest danger ; and usually before the twentieth or twertty-
 fifth day, he expires.
    The nature of this puffy tumour,  and the sad presages to be
 drawn from it, are now plain to you.  The blow which contu-

   * Although the operation fhould certainly be performed under thefe circum-
 ftances, as giving the only chance for life, the  furgeon fhould not be too fanguinc
 as to the event.  S. 
Of Suppuration ofthe Brain.              293
ses the bone, deadens the scalp, and that surface which is next
the cranium, is chiefly affected, in consequence of the hard resis-
tance of the bone:  the surface of the  scalp,  in contact with
the contused scull, is gangrenous,  and thence the tumour is em-
physematous,  soft,  uninflamed: the  deadened part being lim-
ited, gives a circular form to the tumour ; by the extravasation
of blood, and inflammatory thickening ofthe surrounding parts,
it is circumscribed;  and by its relation to the contusion of the
bone, and   the probable  separation of the  dura mater, such
tumour becomes the most infallible sign of danger.  Nor is it to
be doubted, that such puffy  tumour arises from the contusion of
the bone,  and the bruising of the scalp ;  for the separation of
the dura mater will  not cause it.   Often  have I seen the pa-
tient, who had great  effusions of blood betwixt  the  scull and
dura mater, lie  for  days or weeks oppressed-  and  unassisted;
but never have I seen such  separation of the dura mater marked
with puffy tumour.
  " T. a  big  gross  man,  of about  thirty years of age, was
(upon I know not what quarrel, but I believe in defending a little
boy who had been abused) knocked  down with a brick bat.
The fellow who had abused the boy, and then revenged himself
upon the innocent man who interposed, was notorious for his
savage dispositions,  and for such uncommon bodily strength,
as to leave  no  apology for his lifting any thing like a weapon.
He lifted half a brick, and, standing on a stair  to which he had
retreated, threw the  brick  with all his force, and hit T. on the
head a blow which felled him to the ground. He lay very long
insensible, for the space of a day and a night, in his own house,
so  that had we seen  him at this period, we might have appre-
hended some bursting  of blood-vessels,  and extravasation
within ; but he revived, recovered his senses  entirely, found
the cut on his head very trivial, and would have returned to his
trade,  but for that indescribable  sickness and languor  which
hung about him, without any remarkable symptoms, to the hour
of his death.
   " Deep as the  ulcer had penetrated into the brain, and early
as the  symptoms began in  this man,  they were all along very
slight.   He had hardly recovered from  the insensibility,  when
the shiverings  commenced.  On the 3d day he had frequent
fits of shivering, ot a quarter of an hour's duration, followed by
heat and thirst.   A  purge (which I prescribed on the 4th) of
jalap, and submuriate of mercury, operated smartly,  and re-
lieved the pains in his h«ad.  Next morning, I found the ver-
tigo, head-achs, and tinnitus aurium,  almost gone, and  he felt
nothing but a degree of weakness, and  languor, and disturbed
sleep.   On  the 6th  day,  I found this giddiness, languor, and 
294             Of Suppuration ofthe Brain.
 pain,  increased,  but again relieved on the 7th, by the operation
 of a second purge : and, on the 8th, he mentioned but slightly
 the pain ofthe head, and  seemed  chiefly distressed by the de-
 bility  and languor.  In this state did I watch him carefully, the
 headachs  being relieved, but the  languor increasing, till the
 10th day, when, besides the oppression and languor,  he felt
 sickness,—an increase of the headachs,—long-continued chillness
 and  horrors,—a degree of confusion during the  night ;  and he
 awakened, not as from a refreshing  sleep, but oppressed in an
 unusual degree, with a hot skin, and fretful pulse ; and he had
 that degree of constipation which I know not whether to ascribe
 in such cases, to sudden confinement after a state of health, or
 to an incipient state of paralysis, which affects always, I observe,
 the viscera, before it sensibly affects the limbs.  By a repetition
 of the  purge,  his confusion  of head,  and sickly feelings, were
 again  abated,  and  something of cheerfulness and content was
 visible in  his  countenance.   He remonstrated strongly against
 the cutting of his  hair, under pretext ofthe ill tfftcts which he
 had always experienced  from cutting his hair, which infallibly,
 h<t said, produced headachs ; but  really, I believe, for fear of
 this being but a prelude (as  it was indeed designed)  to some
 operation.
  " The small wound  was now puffy and livid; the  adjacent
 skin began to be undermined, and the probe, when introduced,
 ran along some extent of naked bone.  The pulse had risen be-
 yond a hundred,  the tongue was white, the belly still costive,
 and the night of the 14th he passed in  a sleepless perturbed
 state,  succeeded  in  the  morning with headach, a permanent
 sense of coldness, sensibility to light, and that character, in his
 features, and in all his motions, of oppression and  extreme Ian-
 guor,  which is inseparable from a  suppurating brain.   An un-
informed person would expect suppuration of the brain  to be
marked by convulsions or delirium, while one at all acquainted
with such scenes knows, that it is distinguished only by extreme
weakness, not by  the violence, but by the total absence of symp-
toms.  The man knows  not what  ails him ; the  surgeon per-
ceives  his condition, but the patient hardly complains, unless it
be of sighing,  oppression, slight confusion of head, shivering,
with a  feeling  of coldness at the accession of each  febrile parox-
ysm, and trembling of the hands,  and tottering  of the knees,
when either his mind is alarmed, or he endeavours to  exert his
strength.
  " This man  I had destined for the knife, conscious that ho
 earthly power  could save him, if that suppuration was  allowed
to come to maturity, which  was  plainly begun.    But he was
 reserved for a different fate;  for the natural course of rotation 
Of Suppuration of the Brain.             295
of the hospital having delivered  him into other hands, I  met
him wandering in the cold stairs of the hospital, his eyes indeed
open, but his senses gone, at the moment he should have been
under the operation of trepan.  On the 13th day an incision had
been  made, so  as  to prolong the cut on his head, and expose
the naked part of the scull, which was nearly on the top of the
head, close by the sagittal suture.  The bone was bare, and was
known to be so tor many days ;  but it  was not supposed dead.
The incision healed, or seemed  at least in a healing condition ;
and for his sickness, effervescing draughts were prescribed. He
continued, with slight variations of pulse, countenance, and in-
tellect, in the same ailing condition,  Irom  the  13th to the 17th
day ; but his vomiting was now severe ; his rigours lasted some-
times half an hour;  his complexion was  wan; his features con-
tracted and pinched  ; his eye heavy and  melancholy ; his fever
increased, and his  pulse beating 112; and though generally
feeble, it was sometimes very strong:  even in the hour of visit,
his vomiting was so incessant,  his shiverings  so  violent, and
his pulse at  the same moment so weak  and trembling, that it
could not be felt.  On  the  18th, the  confusion of head, the
ringing of the ears, the fever and shiverings, and all the marks
of disorder, were so  much increased, that the operation could be
no longer delayed,  but unhappily, the  man was, by  eighteen
days  of suffering,  reduced so very low, that the chance of his
being saved by it was indeed very slight.   Upon perforating
the scull, a profusion of ripe pus flowed from the trepan-hole ;
and he was committed to bed,  where he passed an indifferent
night.   In the morning, though  no shiverings  were reported, he
was chill;  and, in place of the  oppressed and dejected counte-
nance which he had before operation, his looks were wild, and
his pulse extremely rapid.
   " On the second  day7  after  the operation,  the dura mater
looked black and sloughy, the  discharge  fetid, the matter  con-
tinued to flow profusely from the trepan-hole; yet his looks had
changed again  from wild  and  distracted  to  oppressed and
anxious ; the shiverings, he said,  had  ceased, because  he had
refrained from cold drinks,  but  his  head was sadly confused.
On the 3d day he fell lower; his  senses were perfect,  but  his
looks expressed unspeakable distress :  the matter was brown,
thin,  and fetid,  the  wound  dry  and  glazed, the skin  hot, and
the pulse feeble and quick, and the breathing oppressed :  with-
out  having shiverings,  he had frequent  dullness; with less
feeling of pain in the head, he has a  miserable feeling in eve-
ry part of his body.  . By the 4th day, he had  fallen extremely
low ;  the universal  uneasiness  seemed  very  distressing ;  his
pulse extremely weak ; his voice feeble ;  his features shrunk; 
296             Of Suppuration ofthe Brain.
 he never  slept,  but  moaned and tossed continually.  On the
 evening of the 5th day, after a  severe shivering,  he sweated
 profusely ;  his features  shrunk  perceptibly,  his  pulse was ex-
 tremely quick, his extremities cold; the night was passed in
 great disorder; he struggled to  get out of  bed, and towards
 morning fell low, and expired."
   The affidavit  which I presented on this occasion to the ma-
 gistrates,  I have unfortunately lost.   But in this case, I have
 given a faithful picture of a condition of the system which  I
 have often observed and watched, from the  slightest glimmer-
 ings of danger, to the last fatal struggle of delirium or convul-
 sive tremors.  By this instructive case, you  are taught at once
 the slightness of the symptoms,—the danger inseparable from
 these phenomena of shiverings and puffy tumour combined,—
 the deadly suppuration that infallibly lurks  under a dry and dis-
 coloured piece of cranium,—the folly of delaying, till deadened
 bone  degenerates  actually into  black caries! and you are now
 conscious,  that though the fate  of the patient is terrible, the
 symptoms  are not so :  that the most deadly and decisive are,
 debility, anxiety, shiverings, and slight confusion of head : that
 to wait for sy mptoms is  to wait for death,  for the  first  slight
 convulsion, or decided delirium, is the immediate forerunner of
 death.
   The  case I am now about to  lay before you, is of a very dif-
 ferent complexion.   " Elizabeth  Barrow, a woman ofthe most
 dissolute life and manners, about thirty years of age, was knock-
 ed down in the dark, in a drunken tumult,  with  a  candlestick,
 poker,  or  some  such weapon, but immediately  recovered her
 senses, and continued in health.
   " The blow she had received was near the  vertex, upon the
 corner of the parietal  bone, and not far from the sagittal suture ;
 and there rose over the contused part a circular tumour, not ex-
 actly a puffy tumour, but rather aneurismal,  containing blood.
 For  six weeks the  tumour  was stationary, and the woman,
 though  weakly, and having pains in the head, was without any
 formal complaint.   Perhaps there is no greater mark of a dis-
 solute life,  and vicious dispositions, than a disregard of health ;
and this woman  ran her usual course of vice and wickedness,
undisturbed with any  thoughts concerning her health, till febrile
paroxysms and pains of the head forced her to apply to  a sur-
 geon, who opened the tumour, which was then of the size of a
hen's egg, with the point of a lancet, and it discharged chiefly
 blood.   But the puncture soon closed, matter gradually collect-
 ed, and the  tumour was soon of its original size.   In a month
 more, it was again opened, and  discharged  blood mixed with
 matter, healed again, and again formed. 
Of Suppuration of the Brain.            297
   " The  tumour  was pointed,  and about half the size  of a
tennis-ball, soft, puffy, and little elastic.  The centre soft and
fluctuating,  the  circumference hard, firm,  and bulging ; the
bottom solid,  and  giving  that very peculiar feeling, bv which
we are apt to be deceived, in recent extravasations of blood ; it
felt as if the  tumour covered a very remarkable  depression  of
the scull.   Upon laying it open with free incisions,  the matter
which flowed was thick and purulent,  much mixed with blood;
one of the arteries of the  scalp  bled profusely ;  the bone was
felt rough and scabrous to a great extent, and from p irt of  its
surface a loose fungous growth, so loose that you  could push
the point of your finger through it, protruded into the cavity
of the abscess. In  these circumstances, how to proceed was in-
deed a question of delicacy.   In a recent contusion, with even
the slightest of these symptoms, where there was,  with occasion-
al shiverings, a naked bone at the bottom of a puffy abscess, the
rule  would have been express.   But this woman was in appa-
rent health ; much time had elapsed without any  signs  of dan-
ger ; the bone might be carious merely on its external surface,
and might exfoliate, or  might granulate, (as indeed it  did  in
the end granulate)  : There could be  no apology  for precipitate
operation ;  there seemed to be time for reflection ; the perfo-
ration of the cranium was accordingly deferred.
  " But she had been induced  to present  herself to the  sur-
geons, from having headachs, sometimes severe, with confusion
of head, dullness, and fever-fits, which were very distressing ;
she was at the same time so nervous and alarmed, and her suf-
ferings  altogether  so great,  that she  received  with  pleasure
the first proposal of an operation.   The catamenia, which had
disappeared after the blow,  were now flowing,  but were  sud-
denly  stopped with an increase of headach, a costive belly, a
hot skin, and a febrile pulse,  counting always above i00.  On
the 4th day  of putting herself under our  care, the incisions
being already very free, the operation of trepan was performed
by Mr. Lawson, who made his perforation near the sagittal su-
ture, and on the anterior part of the caries, through a very un-
usual thickness  of bone : but the bone was in  part  alive ; a
great profusion of blood flowed from the cancelli; and the mo-
ment the inner table was divided, and before the  perforation
was complete, mutter spouted up in great profusion by the sides
ofthe saw.
  " The night following the operation, the patient was restless
and feverish,  for, upon opening an abscess within the scull,  as
in opening one in any part of the body, the fever and nervous
symptoms, hardly perceptible before, became very conspicuous.
Though the wound looked well, the head was in confusion, and
                            2P 
298             Of Suppuration of the Brain.
she became extremely sensible to noise or light.  The succeed-
ing night was calm ;  and the headach, which was violent the
first day, was relieved by rest and quietness on the second. The
flow of matter from the surface of the dura mater was good and
copious, and its surface began to granulate.
   " Even on the 5th, I found her complaining of great depres-
sion of spirits, nausea, and sickness, and great pain of the head;
but, by the prudent use of clysters, of opiates,  and a little wine
dashed with water, the sickness abated in two days, the wound
contracted apace,  the pus was thick and well-formed, the sur-
face of the dura  renter  was florid and  granulating.  By the
8th day, the margins of the trepan-hole were red and  fleshy,
and the whole  surface of the diseased scull was covered with
a rich pile of granulations.  In about  twenty days more, the
wound was contracted ;  the cicatrix of the scull, scalp, and du-
ra  mater^,  consolidated ; and the woman perfectly cured in six
weeks."*
   Without any suggestion  on my part,  you will reap every ad-
vantage from the contrasting of this with the preceding case,
and learn by experience the duty of watching with extreme so-
licitude the slightest  changes of the eye, countenance, or pulse ;
the  slightest shiverings, oppression,  or sickness, in those  who
have this contusion of the scull.
   In cases of fracture, there may, indeed, be doubts as to the
propriety of operating: the danger  is  eventual, the operation
merely preventive,  Fracture may cause  a suppuration of the
brain and  membranes at some future period ;  but contusion is
the  disease itself, it  is the actual suppuration of the brain, an-
nounced by infallible signs.  Of all the cases in surgery, this is
the  least equivocal.  Of  those who have fractures of the scull,
many even in the most alarming  circumstances survive unas-
sisted ; but  in  contusion,  followed by suppuration, unless the
scull be perforated, unless the abscess be opened,  all must die.
   O'Halloran  says  a thing at once untrue and discouraging ;
untrue at  least as a general aphorism, and discouraging, since
it tends to make us  indifferent to the most interesting question
in practice, and to the condition of many who might be saved :
"  In the course"  (says O'Halloran)  " of many years practice
and careful observation, I  cannot  give  myself credit for a sin-
gle cure I ever performed in this way, (by  trepaning) when
the symptoms of deposit  were formed; for whether the patient

  * This woman, who made no fecret of her vicious life, or fyphilitic taints, had
a new fuppuration  over the trepaned part of the fcull nine months after the ope-
ration •  the abfeefs  was opened; a fcale  of bone exfoliated; and fhe had a mer-
curial 'courfe  adminifttred to her  for the cure of very fufpicious pains, accom-
panied with flight nodes on the clavicle and fternum. 
Of Suppuration of the Brain.             299
was or  was not trepaned, the scene closed with death."  This
does but prove the culpable  delays, even of this good practical
surgeon, forewarned  as he  was ofthe dangers of  matter being
loaned;  and demonstrates to us,  that  those who die are  lost
by temporising and timid counsel.*
   Pott, our celebrated surgeon,  whose opinions  and writings
are so justly esteemed,  was engaged in that tumult of practice,
which left him little time  to frame general  laws ;  yet he could
not fail to act with good sense and skill in each bd.vidual case:
he was sure to practise right,  but in danger of teaching wrong,
or at least imperfectly:  his opinions want but one short expla-
nation, for they are such as will never be disputed, where they
are understood.
   " lor  my own part,  (says Pott)  I have no doubt, that, al-
though by  establishing it as a general  rule to perforate  in all
cases, some few  would now and  theh be subjected to the ope-
ration,  who might have done very well wiu.out it; yet, by the
same practice,  many a valuable life would be preserved, which
must be inevitably lost without it,  there being no degree ot com-
parison between the good lobe derived from it, when vised ear-
ly as a preventive ; and what may be expected, it it be defer-
red till an inflammation of the dura mater,  and a symptomatic
fever, make it necessary."
   A preventive !  How could the operation of trepan prevent
inflammation  of the dura mater? Could perforating  the  scull
with  a saw, tearing  up the vessels  which naturally connect  it
with  the dura mater, and  exposing  that  nembrane to rude
dressings, and the touch of instruments,  prevent inflammation ?
Yes, surely : it could  prevent  ail  the dangerous  consequences
of inflammation :  it  could  prevent matter accumulating,  and
inflammation   spreading :   it  could prevent  ulceration  pene-
trating  to the brain:  it  could convert  an  extending and most
dangerous abscess into an open sore : it could enable  the dura
mater to granulate and unite with the integuments.   There is no
good purpose that a timely operation  might not serve ; and if

  * The opinion of Archigenes, as cited by Mr. Bell, is probably correct :—
" When the dura mater is inflamed, then come fhiverings, and fever, and flufhings
of the face auite difproportioned to the degree of fever ; difturbed fleep, eyes hea-
vy and fwelied, a fore flabby and foul  with ilKdigefted pus; fometimes puftules
cover the tongue.  Thofe -who are fpeedily ajjifed have fome chance offafety; but-when
help is but a little delayed, they almost always die.''  Whenever fymptoms of inflam-
mation of the brain, or its membranes, take  place, if there be a puffy tumour,
and no wound of the integuments, they fhould be immediately laid open down to
the bone.  The head fhould be fhaved, and a blifter applied over  the whole  of it,
except immediately upon the wound.  Bleeding and purging muft likewife be ve-
ry copioufly ufed, and the ftricteft abftinence obferved, in order, if poflible,  to
prevent the formation of  matter, for  fhould this happen, no fubfequent treat-
ment will probably fave the patient.  S. 
300             Of Suppuration ofthe Brain.
the trepan be used only when it should,  there can be no vessels
torn ; nor will the dura mater be exposed, for the dura mater
is previously in a state of suppuration, and separated from the
inner surface  of the  scull.   We find, by his examples,  that
Pott meant, by prevention, the anticipation of worse sy mptoms,
the preventing of death ;  that he regarded the operation as pre-
ventive, when it was used so early,  that though the dura ma-
ter had previously suppurated, the suppuration  was but slight;
when, by the timely opening of such abscess, it was prevented
reaching the b»-ain, when the dura  mater granulated easily, and
healed naturally.   Unless we were to take an ungenerous ad-
vantage of a slight inaccuracy  of language, and dispute the words
of this author, while  we  understand his sense,  we must acqui-
esce in the principles he  has laid down,  and give him honour
and praise, for the comprehensive and judicious views he has
taken of what he saw  going on around him, for the honest and
manly boldness with  which he has declared his  principles,  so
different from those transmitted to  us by the writers  of the pre-
ceding age, and for the generous manner in which he has taken
upon himself a responsibility of the most critical nature, resist-
ing alone all that torrent of reproach which was likely for a time,
and especially in his  own day, to be attached to what may  be
termed Hospital Practice, harsh and cruel surgery.  But study
his  cases, arid you will perceive, that whenever Pott trepaned,
the patient was in danger, the  bone bare, the tumour puffy, or
the wound (il thi re  was one) fetid, the pulse  quickened, the
face flushed, the head in  confusion, and  the fatal shiverings be-
gun ; and these are marks, not of future danger, but of actual
suppuration.   It is fortunate  for mankind, when new doctrines
are not extravagant ; when  those  who enjoy the public favour,
have won it,  not by  the capricious and  captivating effusions  of
genius, but by the lasting attraction of sober inquiry and sterling
sense ; when a popular work contains principles  which, being
founded  on experience, will stand  the test of time. 
(  301   )
DISCOURSE XVIII.
OF FRACTURES  OF THE  SCULL.
SECTION I.
                 Preliminary Observations.


 ± HE old surgeons allowed not the slightest chink, fissure,  or
rima, as they  called it, to escape investigation ; the slightest
fissure, or the  bare  suspicion of one,  was the  signal  for apply-
ing the trepan, and there was nothing so gratify ing to  them as
a fracture  so circumstanced, or an extravasation so extensive as
to require, or at least to vindicate, the application ot  the trepan
ten or twelve times.  It was not that the crown of their instru-
ment was  small, and thence its application, necessarily frequent,
to make  even  a moderate opening; they scrupled not,  after
making numerous  perforations, to cut up all the intermediate
pieces  of  bone with the saw,  and clear  away a whole parietal
bone, or  half the scull.  This was the pomp and pride of sur-
gery in former times, which you are  called upon to imitate, by
the approbation with which such facts are now  commemorated,
and by the very form of instruments put into your hands, which
are by  no means calculated to make  very  moderate  openings:
the making very large  openings, either by large trepans or fre-
quent perforations,  is   a practice highly commended in every
book, and  the extent of the fracture is usually reckoned the sole
limits of the opening.
  " In excessive fractures  (says Dionis) we should not  hesi-
tate to make two, three, or four perforations,  if required.  A
young girl, of eleven or twelve years of age, having, by  a fall
down stairs,  fractured  the whole of the parietal with a part of
the temporal bone, Mr.  Marechal  trepaned her   next day
in two places: he  made his son trepan her a  third time; he 
302               Of Fractures ofthe Scull.
 allowed my son, who was present, to trepan her a fourth time:
 the next day, applied the trepan twice more, and in the end had
 actually perforated twelve times, and cured her completely.  So
 precious an example shows how little reason we have to be sur-
 prised at the frequent application  of the  trepan."   Here is a
 doctrine laid down, which,  I fear,  there  is little occasion to
 enforce ;  and I cannot but persist in being surprised and shock-
 ed, at the frequent and  large perforations  which I have both
 read of and seen, and cannot but think of these veterans in sur-
 gery in no very amiable light, when I see them indulging their
 boys  in the novelty of operating, probably  on very slight com-
 pulsion.
   These reports, and especially the last  clause  of this para-
 graph,  viz. " that we should not be surprised at the number of
 trepans," have  plainly a reference to the ever memorable ope-
 ration performed  in the time of King William's  wars, on Philip
 Count of Nassau, by He.-.ry Chadborn,  chirurgeon.   Godifre-
 dus, chief surgeon to the States of Holland, mentions with par-
 ticular exultation this operation performed by his friend, who
 trepaned  the cranium of the Count  of Nassau  twenty-seven
 times, and ascertained the fact by the most indisputable autho-
 rity, for he made the said Duke of Nassau, after he was reco-
 vered, on the  12th day of August,  1664,  write the following
 curious certificate.   " I the  under  written  Philip Count Nas-
 sau, hereby declare  and testify that Mr. Henry Chadborn did
 trepan me in the scull twenty-seven  times,  and  after that  did
 cure me well and soundly."
   Mr. Pott, a surgeon of unrivalled excellence, whose influence
 was fairly acquired, (but 'et those who have  influence with their
 profession use  it diecrtetiy aad wisely, let them ponder well the
 maxims they announce) fell into a system of practice so bloody
 and enterprising, that, in the *ew years which have elapsed from
 his death, it has fallen into utter discredit, and he delivered his
 maxims in a style so  decisive and imperative as to impose even
 now upon the younger part ofthe profession, while, by all who
judge for themselves,  his practice is abandoned :* no wonder
 it is abandoned, being, in every point, except one, repugnant
 to good principles.  He, in every case, whether slight  or dan-
 gerous, cuts off the whole puffy tumour, scalping the part with

  * In the accounts which we have of the former practice in France, it is related
 that furgeons made numerous perforations along the whole track of a fradture of
 the  cranium ; and, as far as I am able to judge, without any very clear defign.
 Mr. Pott alfo advifes fuch an operation, with a view to prevent the inflammation
 and'fuppuration ofthe dura mater, which he fo much apprehended.  But many
 cafes have occurred  of late, where, even in fra&ures with depreffion, the patients
 have done well without an operation.  Abernethy't MJfays. 
                 Of Fractures of the Scull.              303

 a circular incision: he, in every suppuration of the dura mater,
 and in every case of extravasated blood, applies the largest tre-
 pan, though he has no other purpose than to give vent to such
 matter  or blood :  dissatisfied (as he had reason  to be) with the
 small trepans in common use, he ordered them to be forged
 for him of  an unusual size,  and did not spare their liberal ap-
 plication.   After perforating the scull once, in place of  provid-
 ing  by other means for the  free  evacuation of  the matter, he
 applied his  trepan again and again,  till all the suppurated sur-
 face of the dura mater was displayed, declaring  it to be his in-
 tention to cut away all that part of the scull, however extensive,
 under which the suppuration existed.                    ,
   " When  the operation, says Mr. Pott, has  been performed,
 not  as  a preventive,  but to give  discharge  to  matter, the
 only chance of relief is from laying bare a large portion of the
 dura mater, that the  discharge may7  be as free, and the confine-
 ment as little as possible, as nothing but this can do good." And
 again he says, " Yet perforation is absolutely necessary, in seven
 cases out often of simple undepressed fracture ofthe scull." He
 does by no means  deliver  these rules with temperance or mo-
 desty,  but says,  " I am as well satisfied of this as of any truth
 which repeated experience may have taught me."
   Such bold words lose all power when we begin to find how
 ill experience may te?.ch a  man,  and how  unreflectingly such
 language is used.   At first, the reader would naturally say wjth-
 in himself,  "Surely  Mr. Pott,  before he could use such confix
 dent language, must have seen repeated and afflicting proofs  of
 the necessity of using the trepan:" but to  his utter confusion,
 he finds  the very  words repeated in commending the now ob-
 solete operation of scalping, and, indeed, on every occasion
 trivial or important, for  it is with this author, a  manner, and no
 more:  He  says, "The way of doing this, (viz.  of scalping) has
 formerly been the occasion of much difference of opinion; but
 there  can be no doubt about the greater propriety of remov-
 ing  a piece  of scalp for this purpose, by an incision in a circular
form.'"   Even when Mr. Pott applied the  trepan, not on ac-
 count of any present, but of some eventual, perhaps imaginary
 danger, he set no limits to the number of perforations,  but the
 extent of the fracture.   He say-s, " If the trepan be applied in
 a preventive sense  merely, the  length  of the fracture must de-
 termine the number!  one or  two  only  may  be  made at first."
 In short, all his  precepts, most of his cases,  and  even the very
 form and size of  his instruments, contributed to renew and
 strengthen that passion for frequent  perforations and large open-
 ings ofthe cranium, which the decline of false learning and the
 progress of plain good sense had almost allayed: and I will ven- 
304              Of Fractures of the Scull.
ture to say, that  whoever has studied his writings, or imbibed
his principles, must imagine that, in the work of trepaning,  he
can never do too much, and is only blamable where he has left
any possible thing undone.   But a few men ot  strong  natural
sense, among whom Platner is one, have had the sense and cou-
rage to protest against such frequent applications of the  trepan.
" There is by no  means any necessity (says Platner) to have
recourse, in all cases of fissure or fracture of the scull, to  in-
struments to cut them  out with:  where there are no evil signs,
the trepan is not required:" but unhappily the most extravagant
and foolish things are best remembered, and  oftenest repeated,
while these  solid remarks  of a man of skill and judgment are
but too easily forgotten.
   We find that it had been the practice of the older surgeons
not only to apply their trepans the whole length of a longitudi-
nal fracture, but along each of the radii of a  star-like fracture,
and in short, to repeat the expression of Platner, * to cut it out.'
The testimonies  of the  most sensible writers  are against the
operation, and most unfavourable to the men who have indulged
it, for it  has been ascribed  not to reason, but to pride.  " If
the opening (says Wiseman) in  the fractured scull be not suf-
ficient, make  one  in  the most  declining part, and  raise up the
bones, and free the membrane of whatever may offend it, but
do not take out any more bone than needs must, like some of those
surgeons I  have  met  carrying  them about in their pockets,
BOASTING IN THAT WHICH  WAS  THEIR  SHAME."  Never is
the apology wanting to those who are proud ot making nume-
rous perforations :  if they do not find a conspicuous depression,
or a great length  of fracture, they affect to be seeking for pus,
or that they are anxious  to  let out  extravasated blood.   They
dare not forsooth, after making   the necessary opening, allow
the pus to ooze out gradually, or the  blood to melt down and
be resolved  into serum.    They affirm, V that it  is infinitely
more dangerous to wait the dissolution of the coagulated blood
than to make numerous  perforations for the evacuation  of such
pernicious  juices,  for  not only  such  openings as that we have
just mentioned of 12 trepans, but openings much more exten-
sive,  close easilv."    " I have  seen  surgeons,  says Ravaton,
so infatuated, sp desperately bent cm discovering abscess on the
dura mater, that, after applying six crowns ot the trepan, they
would,  I verily believe,  have pulled away all the remaining
bones of the cranium,  had not their patients been delivered by
death from such operations."   In  short,  their doctrines  and
practice outraged common sense : every thing  was  to be done
by the surgeon, nothing left to nature : every depression was to
be  elevated; the whole matter to be evacuated ; the whole  ex- 
Of Fractures of the Scull.              305
 tent of the extravasation to be covered by trepan-holes, and the
 limbs and  whole extent of a radiated fracture  were to be cut
 away.   There were no limits assigned for these openings, but
 the extent  of the extravasation or fracture,  and they were well
 contented to find that 40 crowns of the trepan might upon ne-
 cessity be applied to the human scull.
    But there is a scene of practice very different from this, where
 men, engaged in the actual duties of the profession, in peace or
 in war,  in cities  or in the field, learn to look coolly on wounds
 of every description, and know from experience  what nature
 will do,  and how impertinent and vain those operations are. It
 often happens to  grooms or farriers, trimming horses feet with
 too little precaution, that the horse striking out,  they receive
 the kick full in the forehead : the scalp is torn up, the scull ma-
 nifestly  injured,  or  not a  little depressed ;  these men live  a
 coarse irregular life, and yet such fractures heal easily, but, were
 the trepan applied on every such occasion, we should have many
 dismal scenes.  It often happens that boys playing with horses,
 plucking hairs from a colt's tail, for example, are  knocked down
 by a kick in the forehead ;  often the bone is  deeply depressed,
 very often the marks of the heels or caukers of the  shoe are
 impressed upon the os frontis ; sometimes a piece of the bone is
 actually turned upwards along with the scalp; but the scalp being
 re-applied to the scull, the splinters ofthe bone picked away, and
 the ragged integuments smoothed and secured with stitches, the
 boy, without one hour  of  sickness, recovers as if his wound
 were only of the skin.  But were such pieces of depressed or
 shattered bone cut out; were  openings made at all proportioned
 to the depressions, or to the  extent of the fractures ;  were the
 delicate dura mater of a boy left exposed to that  force of circu-
 lation, which dilates the brain, and fretted  by every stroke of
 the arteries against the margins of  the opening, the dura mater
 would slough, perhaps, the brain protrude and suppurate, and
 the boy expire howling and convulsed.   Examples of such im-
 prudence and such consequence I shall presently relate,  for I
 know, that when  my business is to impress you with any prac-
 tical truth, the best way of confirming the maxim, and  making
 you feel the force of it,  is plainly to represent the scene.
   Often  the recovery, where  the scull is very deeply wounded,
 is  so rapid, as to surprise those even  who are the most resolute
 in refraining from the use of  the trepan, and the best prepared
to expect a happy  issue.   The faith and credit of Pareus stand
unimpeached; and the case he relates, of a cure performed  with
his own hand, is the most remarkable of any yet recorded; since
even the  segment  of the scull  itself in a  clean sabre-wound, ad-
hered again  in common  with  the  wounded scalp.    " I advise
                            2Q 
306              Of Fractures of the Scull.
(says Pareus) wherever there remains a portion of the skin still
connected with the wounded scalp, that neither that skin, nor
the divided  portion of bone be cut away, but the bone sewed
up along with the skin.  What Celsus commends (says Pareus)
I performed  in the case of Captain Hydron,  who was a short
while ago wounded in this city with a sword through the centre
of the os frontis, the  bone being cut down the length of three
inches, so that it hung over his face, connected with the scull
only by its pericranium,  and about three inches of the fleshy
scalp.   At first  sight, I questioned whether or not  I should
complete the separation of this piece of skin with its adhering
bone,  but remembering Hippocrates's maxim never to uncover
the brain, I cleansed  the blood, which was upon the dura ma-
ter,  laid up  the separated piece, and, for the better retention
thereof, made three points ofthe needle in the upper part, and
put in three small dossils in the sides of the wound, the whole
being so nicely replaced, that, by God's grace, it healed perfect-
ly, though the gentleman was otherwise much wounded on the
face,  in the thigh, and in the right breast.   I finally beseech
you (says Pareus) never to amputate neither skin nor bone, lest
the brain should be left bare."
   In  the work of Berengarius, De Fracturis Cranii,  so much
and justly praised, you have no instructions for discovering, nor
any  warrant for trepaning fissures.  He seems to  have been
taught a very different practice by his father in his earliest years.
They seem, in these times, always to have felt a sort of trepi-
dation when they sewed the scalp; and Berengarius gives many
anxious directions about undoing the stitches  upon the slightest
appearance of fever or abscess ; but still he directs that the scalp
be sewed.
   Especially when the bone was wounded, they feared to sew
the integuments ; yet Berengarius,  while he complies with the
rule, relates  an  exception highly worthy of notice.  He re-
minds his reader that  he had advised the suture of the scalp on-
ly when the bone was unhurt and the pericranium entire ;  " for
a suture (says Berengarius) being drawn close over a diseased
bone, the patient dies, wherefore, such wound must be dilated
and opened, not  sewed and closed :  Yet,  I call God to witness
the truth ofthe following narrative, so unprecedented that I dare
hardly tell what  I saw.  While I was a young man, a soldier
wounded his  fellow with a weapon, and cut down the os frontis
from its upper  part to the superciliary ridge, so  that the os
frontis, with its integuments, hung over his eyes, divided from
above and at  the sides, and connected only below.   My father
went first to his  assistance, and removed  the bone from the in-
teguments ;  the bone  was the whole length of the os frontis; 
Of Fractures ofthe Scull.
307
 the dura mater was untouched.   The skin of the forehead  was
 replaced and stitched without that opening at the lower part of
 the wound which  surgeons are  accustomed to leave as a drain
 for the  matter; being closed with white of eggs,  and dressed
 daily,  it was in ten clays completely re-united, and ever after
 the systole and diastole of the arteries was distinctly seen where
 the bone was wanting.   This I have put down, says Berenga-
 rius, to  make  medical men keen  and courageous in curing
 wounds."
   Besides  these instances, in domestic life, it is  remarked, to
 the dishonour of our trade,  that in  times of war  and trouble,
 when men are not allowed to take care of their wounds, those
 who are least cared for are soonest cured ; and a man, who is
 forced to wrap a clout about his head  and ride for his life, is
 safer than  one who is chambered up, dieted, and dressed, per-
 haps  trepaned  by the  surgeon.   The great  rebellion  was full
 ot such  adventures and hair-breadth escapes,  many of which
 are related by Wiseman : among others, that of " a gentleman
 who, a day or two  before  the battle of Worcester, attending the
 Earl of Derby in his retreat thither, received a large wound be-
 tween the sagittal  and  coronal sutures by a sword,  which went
 through the cranium to the dura mater, is  exceedingly remark-
 able :  the membrane was  covered with small shivers of bones  :
he had only a  thin linen cap over it, his haste not permitting
 him to be dressed,  and it may be it  was the better for him,  for
 if dossils had been hastily  crowded upon  the bones, severe
 symptoms  would  have followed;  whereas the shivers lying
 lightly  upon the membrane,  he was free ; and  being  ignorant
 of his danger,  rid a great journey :  I after took them out, and
 dressed the membrane  with digestives,  the short time  we  were
 together."  It was upon such proofs that Wiseman came to be
 persuaded of this general truth,  that "  recent fractures or
 THE CRANIUM DO FRLOJJENTLY  UNITE  LIKE THOSE IN OTHER
 parts, if  the  matter hath liberty to discharge from within.
 Therefore having raised up the  bones that are loose, dress the
 others dry."*
   " During the war," (says Wiseman)  " I was  frequently em-
 ployed in the dressing of some one person or other, wherein I
 have seen all or most of the several  sorts of fractures.   I  have
 dressed many that  have been cut through the scull, the shivers
of the bone lying pashed with the flesh and the hair,  upon the
dura mater ; yet the patient hath had  no symptom of such a
 wound."   Here, in a few sterling words, are descriptions which
 will better  satisfy all your doubts than the most learned argu-
 ments.
•  Wifeman, page 113. vol. ii. 
308              Of Fractures of the Scull.
   So much for open wounds, when the clean incision of a wea-
pon seems  to have done the business of the trepan.  But, even
in cases where the bone is fractured with a wide and portentous
fracture, or when it is actually depressed in a way which might
vindicate the  application of the trepan ;  in cases where it re-
quires some  courage to refrain from operating, the patient is
cured v. i.h  surprising ease.  I can be at no loss in proving this
in a  thousand  various forms ;  if I could feel any difficulty, it
must be only  in selecting the cases which best represent the va-
riety of circumstances.  In Mr. O'Haloran's paper in the Irish
Transactions, we  find, among other cases, that of Edward Pow-
er, " who received  a desperate wound of a back-sword, extend-
ing from the  top of the coronal bone to the orbit of the left side,
forming an extended and frightful chasm, in which were includ-
ed the bone,  membranes, and brain.   It  bled considerably,  as
may be well supposed.  He remained exposed to the air for
near three  hours after, and had not so much as a bit of rag to
cover it: fever and inflammation of the brain might reasonably
be apprehended ; yet,  by a couple of bleedings, and some other
antiphlogistics, the  man was completely cured in five weeks,
without exfoliation  or  the smallest operation."
   On one  point you may naturally  feel some hesitation:  You
see that clean wounds, as when a trooper is cut to the scull with
a sabre, are not,  (even when the scull is fractured, or  part of it
sliced away) attended with that danger  which was once sup-
posed ; but fracture of the scull produced by a heavy blow, where
the bones are broken,  perhaps depressed, may be, nay,  must be,
 an injury of quite a different nature.  You  are not only to  re-
frain from trepaning fissures, in the absence of dangerous symp-
 toms, but, if I may advise you, even fractures very wide and
 gaping.  " John Smith," (says Mr. Hill in his Book of Cases)
 " when forty years of age, had several inches of the scalp torn
 off by the  kick of a horse, and some of the hair was beaten in-
 wards through a long  fracture of the scull, which was so wide
 that there was no occasion for the trepan.  He recovered in a
 few weeks, and  is well."   Why does Mr. Hill announce  this
 fact  in such abrupt familiar terms, but  because he well knew
 that this  was no unusual accident, that he had often seen such
 fractures ofthe scull spontaneously cured ?
   Even deep depressions and very irregular fractures heal, and,
 what is more rarely  to be found, are  permitted sometimes  to
 heal, undisturbed.  The case of James  M'Cartney,  a boy  of
 between five and six years of age, is of this nature : " He had
 a large piece of the parietal  bone driven deep in by  a stone.
 A few days  after he was stupid, dosing, starting, and vomiting :
 there was a large tumour and obscure fluctuation on the depres- 
Of Fractures of the Scu 11.               309
sion, owing to some ounces of blood below  the pericranium ;
on piercing of which, it sprung out to about a foot's distance.
The incision was continued across the depression and fissures :
to prevent  such exfoliations as olten  happen, the scalp was in-
stantly laid close aown again, with soft dossils  only in the wound
to keep it open.   As no bad symptoms intervened, the fissures
being wide enough to allow a passage from within the scull, no-
thing farther was done but lessening the dossils gradually,  till it
healed,  which happened in a  short  time,  without exfoliation.
The hollow is considerable, and will continue for life."*  He
is in good health, and at sea.
  You will naturally say, What then should we infer from these
cases ?  Are we to do nothing in fractures of the scull? Are the
instruments hitherto appropriated to fractures of the scull to be
thrown aside ? The trepan  is not the instrument  appropriated
to fractures of the scull, but that with which we perforate the
bone, when either fracture or any other kind  of occasion re-
quires such opening ; and of all the motives for using it, that of
fracture of  the scull is the least frequent : you perforate the
scull to let  out extravasated blood, which oppresses the brain,
to open abscesses which could never force its  way through such
resistance,  to raise depression, if you will, but never on account
merely  of  fracture.  Allow yourselves but to consider in what
fracture of the scull differs from that of any  other bone :  not in
 want of circulation in the scull, you have every proof that its
 circulation is lively and perfect, since  the dura mater is detach-
 ed, the pericranium scraped off, the bone itself bent from its
 right direction,  sometimes raised up, sometimes  depressed,*
 and vet it does not die : you see the integuments coarsely torn
 off with a stone or a carriage-wheel; you see the scull rough,
 yellow, and apparently void of circulation ; you see every threat-
 ening appearance of caries, and would believe it  dead  : often
 the wound seems as if a part  or the whole would exfoliate, yet
 in a few days all the naked part of the bone begins  to look red ;
 a fine velvet-like down of vivid granulations begins to appear in
 spots and  clouds upon the bone ; sometimes these granulations
 are, out of mere  wantonness and ignorance,  scraped off, but
 they instantly sprout out again :  what becomes of the rima fis-
 sure, or fracture, is never observed ; it is  covered  in  by this
 pile of granulation spreading slowly over the bone, and uniting
 it with the integuments.   This process I have seen with admi-
 ration, where I could least expect it to take place ; in old crea-
 tures of ninety years of age, very poor and miserable,  and in
  whom, along with fracture, the integuments had  been so man-
• Hill's Cafes, p. 117. 
310              Of Fractures of the Scull.
 gled as to slough off in flakes.  It is just such a delicate pile of
 granulations that covers the surface of the dura mater, when it
 appears after the operation through the trepan hole, uniting the
 dura mater with the  integuments and  with the margins of the
 perforation.   Those  who affirm that there is no danger in tre-
 pan, affirm of course that there is none in fracture of the scull,
 for the perforation and the fracture heal by  one process,  and
 with an equal pace.  If this, which I have observed many times,
 be the regular  and natural process of healing both in the trepan-
 ed and in the fractured  scull, what apology have we for per-
 forating the  scull, and tearing with levers  all those parts we
 think suspicious, or perceive to be depressed?
   The motives assigned for  making large and  frequent open-
 ings are,  in case of simple fracture, to prevent danger ; in case
 of depressed fracture, to raise up the depression ; in case of
 extravasation or abscess,  to let out the blood and matter freely.
 But, are  not the  smallest openings we can make sufficient to
 give vent to any suppuration,  as the smallest puncture is suffi-
 cient for the cure of the largest abscess in any other part ?  Is it
 possible, would it be prudent in any case to lay open all that part
 of the scull under  which blood is effused ? Though you were to
 work with your trepan as industriously and unconcernedly as a
 button-maker,  or to trepan as this Henry Chadborn did twenty-
 seven times, you still would never get to the end of your opera-
 tion, if the extent ofthe extravasation were its only limits; I have
 rarely seen a case  of extravasation where the cake of blood did
 not extend over one entire hemisphere  ! under a whole parietal
 bone, and generally down to the basis of the scull, nor an abscess,
 but  where much  of  the surface of the dura mater was coated
 with pus :  I have never had the good fortune to perform or as-
 sist at any operation  in which it was possible, had we  been so
 extravagant as  to design it, to expose the whole coagulum of
 blood by perforations : in short, what I  have observed, is this :
 that, where,  in the case of abscess, we are fortunate enough to
 be alarmed early,  one perforation gives vent to the pus as well,
to my  apprehension,  as  fifty :  the  matter bubbles out at each
 systaltic motion or heaving of the brain ; nothing prevents it but
 that fungus or  protrusion of the brain, which so frequently hap-
pens when the  openings are large.   That I may almost assure
 you that, where the openings are made large, they never conti-
nue long free, but are  plugged up by protrusion of the brain. In
 the case of extravasation, which has  no certain limits, I have
 always been sensible of the folly of  trying to lay it all open, for
then the limits  of our operation could only be limits of the scull:
but after one  perforation, when, by the heaving of the brain,
the clots have rolled out of the trepan-hole, as thick and black 
Of Fractures of  the Scull.              311
as pitch, there succeeds a more fluid  blood, the patient often
finds instant relief, moves his paralytic side, raises his eyes, and
though,  without being able to speak, knows his friends ; from
day to day, the blood by the natural process of  its dissolution,
and by a sort of secretion from the surface ofthe dura mater, is
diluted and flows out.  The introduction of the probe,  often to
the extent of six inches in every direction, proves how vain it
were to attempt laying open the whole extravasation : the deep
introduction of the probe has probably suggested  that  practice,
which is mentioned in books, of making a second and  far  dis-
tant perforation as a counter-opening,  but which  I  cannot ap-
prove because I have never seen  it  necessary:  the probe bent
and surrounded with a little lint,  or a long hair pencil, is very
useful in hooking out the clots, and an injection of tepid milk
washes them away.    While the coagulum is thus resolving, the
dura mater is suppurating and cleansing on its surface ;  it is at
last seen through the trepan hole of a lively red, granulating and
bleeding upon the slightest  touch : then  it comes into close  con-
tact with the lower surface  of the scull, protrudes  with gentle
convexity through the trepan hole: the granulations of the inte-
guments, scull, and dura mater gradually  adhere, till the whole
becomes one  undistinguished  granulated surface, where bone
cannot be distinguished from flesh.  This is the state of mat-
ters, (with occasional interruptions and variations) in the third
week, and thus the opening closes and heals.   I have often
found it necessary,  from the strong protrusion of the dura ma-
ter into the trepan circle, if not through it, to repress the dura
mater at each dressing with the probe wrapt in lint, in order to
give exit to the matter or blood.*
   This I can most safely affirm,  that wherever I have seen ca-
ses of fracture, whether simple or depressed, committed not in-
judiciously nor  carelessly   to  nature,  they  have  done well.
Wherever I have found the surgeon impatient to perforate, in-
tent on raising every depressed part of the scull, careful to in-
clude in the circle of his saw every suspected piece of bone, and
anxious to secure a free evacuation of matter by  large openings;
I have seen such tearing up of the scull, especially in boys,  as I
could not witness without pain, uniformly followed by protru-
sions of the brain, and death.  In no other part ofthe body do
you open  abscess,  or discharge extravasated  blood by large
openings ; is the brain the only part to  be thus roughly  treated

   • In the circumftances here defcribed,  fome phyficians have ordered counter-
openings, others have ufed leaden canulas, grooved  or guttered probes, &c. to
conduct the matter or blood from under the cranium: F have never found thefe
neceffary. 
312               Of Fractures of the Scull.
and exposed to the air, to dressings, and to every thing that is
supposed to injure it ?
   Are we then to do nothing in fracture of the scull?—Nothing
I believe  which you should not do in fracture of any other bone
of  the body.   Pick away the fragments of bone,  lay the edges
ofthe lacerated scalp quietly and smoothly together, stitch them
that they  may lie in that nice contact which is necessary to pro-
cure adhesion, but not tight lest they inflame :* lay all smooth,
nice, and close, dressing the wound" daily and  lightly that it
may adhere, which often it  does to a miracle,  the dura mater,
trepaned  circle, and crushed bones and integuments, all conso-
lidating in one  firm scar: preserve the  patient carefully  from
every irregularity or excess that  might  cause inflammation;
keeping him quiet, cool, low in diet, and without  wine.  Be as-
sured that the experience of a Wiseman, and the good sense of
Platner  are not  to  be  despised;  remember  what   Platner
affirms, " if there are no bad symptoms,  there is no occasion
for the trepan." Adhere to this general maxim announced from
such high authority,  and it shall  be my care to  explain every
exception so fully as  to prevent you,  while you avoid the fault
of hurry  and impatience, running into any fatal error from ne-
glect.   You see with what perfect confidence  these celebrated
men dressed up a fracture,  and committed the case to nature,
while men of less experience or knowledge would have been bu-
sily occupied in scraping every limb of the fracture, and in ap-
plying the trepan to each.  But they were emboldened by  the
best of all teachers, experience, to act thus : and  whatever pre-
judices in favour of operating you may carry  with you  from
school,  to this opinion must you return at last.   I  can safely
declare  along  with  O'Haloran  that,  " in cases of  fractures
of  the scull, long experience  has convinced  me  that many of
them require no operation."  If there be any exceptions to this
rule it must be  when the fracture is accompanied with  depres-
sion.

                        SECTION II.

          Of Fractures of the Scull with Depression.

  I must seem then to have admitted that " depression of the
scull oppresses the brain, and requires to be raised up with le-

  *  In fuch cafes I would not attempt completely to re unite the integuments.,
becaufe, fhould they adhere, it will be frequently neceffary to open them to let
out matter.  Interpofe a fmall piece of lint between the edges of  the fcalp, fo as to
prevent a complete re-union, and as foon as all danger of bad fymptoms is vamfhed,
it can be healed in a few days.  S.              < 
          Of Fractures of the Scull with Depression.        313

ver, or cut out with the trephine :"   Yet there is no  general
conclusion I should more unwillingly allow :  I should be inclin-
ed rather to reject the general rule than to qualify  it  with so
many perplexing exceptions as it would in my judgment reqiure:
There  are  many depressions so  fixed that no force of instru-
ments could raise them ; so extensive, that to cut them out, or
loosen and pull away each fragment of bone, would  be to open
half the  cranium and expose the brain to protrusion, on ac-
count  of imaginary  dangers.  Depressions  seem many times
so alarming to the  surgeon, that to raise them, or cut them
out, he will use  the most  unjustifiable  violence ; yet,  though
he fails,  and the depression remains,  the patient, notwithstand-
ing this additional violence,  survives: and many times the de-
pression, which has been the subject of such unjustifiable  vio-
lence,  though very conspicuous while the surgeon is labouring
to raise it, is really so slight as to be invisible before  the wound
is closed.
  The striving to elevate depressions  of the scull,  while the
patient, far from having any oppression of the brain, is  crying
with torture, struggling and resisting, though it  has  been long
esteemed the most meritorious work  in surgery, is  extremely
censurable, and has, to my certain conviction, brought many a
patient to an untimely grave.   " I shall now (says O'Haloran)
remark on such fractures as necessarily require the operation in
the first instance : these are fractures accompanied with de-
pression, with  dr without wounds : for not to  advert to the
restraint such pressure must necessarily cause to the brain, suf-
ficient  in itself to produce fatal effects, &c."  This is affirm-
ing, in its utmost latitude, that very  mistake on  which  all the
bloody doings of past and present ages are to be attributed. "If
a single operation (says Warner) be insufficient,  (as I have of-
ten known it to be) to effect the elevation ofthe depressed bone,
a second and a third must be performed, that the surgeon  may
be  enabled to  raise up every part ofthe depressed bone ; which
rule must be strictly  observed, otherwise  the operation cannot
be expected to be attended with success, as the bad effects ofthe
oppressed brain must remain." In every elementary  book  you
read the same language, and from every lecturer hear the same
general conclusion; for, in  describing the scull, he assigns de-
pression of it and its fractured part intruding upon the brain, as
the principal occasion for using the trepan.
  This passion for leaving nothing undone will naturally glide
into your minds ; for the prejudice of every profession is in fa-
vour of what its art can accomplish, and in ours,  this bias is pe-
culiarly strong : trepaning  fractures, raising depressions,  and
making ample  openings for blood or matter,- are the surgeon's,
                            2 R 
314       Of Fractures of the Scull with Depression.
 chief pride.   But I cannot help recollecting the droll expres-
 sion of Permanmus, who says, or his translator for him,  " there
 are many persons who fondly imagine that boring a hole  in the
 scull is an easy matter, and to be  done at any time, whereas it
 requires mature consideration, a very able head, ana. a skilful
 hand to undertake it.
   Aware ofthe deceptions to which you are exposed, I should
 feel myself much  to blame did I neglect to warn you of them.
 You will say within yourselves, " though it is plainly our duty,
 and is most natural, to leave a mere incision or wound, although
 it affect the scull itself, untouched  and but lightly dressed, since
 we  know that wounded bone will re-unite with  the  soft scalp ;
 though it be equally natural and right to treat a compound frac-
 ture  of the cranium,  eveu  where  it is much shattered,  like a
 compound fracture of a limb, by picking away the loose bones,
 cleansing the wound, composing  the soft parts, and laying all
 smooth and close  ; is it equally natural or proper to leave unre-
 duced a  depressed portion of the  cranium, which  cannot but
 press upon the brain ?"  " Surely, (you would  say), the visi-
 ble  depression of a piece  ofthe scull must be an oppression to
 the sensorium,  of the worst and  most  dangerous nature, be-
 cause it is  sudden or  rather instantaneous, and because it is
 produced by a firm and solid body: blood and matter  being
 fluid, may  be absorbed, and thus time may lessen  that kind of
 pressure ; but what can remove the compression of a firm and
 solid bone ?  Are we to remain, you would be inclined to ask,
 unconcerned spectators, whilst our patient labours under a visi-
 ble depression  of the  cranium ?"—These are real  difficulties,
 and must  be answered;  and facts will  hardly  persuade you
 when balanced against -such  strong probabilities : but the whole
 question shall be fairly laid before you ;  it is one  of those which
 I stand pledged to discuss with soberness  and deliberation ; it
 is one in which you must learn to decide on sure principles,
 since you are about to  enter  on that scene where responsibility
 rests on each of you, where  you must trust to your natural rea-
 son, not to the  dogmas of any teacher,  and  suit your practice
 to the various exigencies of each case.
   There is a wide difference, in theory and in fact, betwixt the
 oppression  proceeding from extravasated blood,  and that from
 depressed bone.   It is because bone  is  firm  and  immovable
that its depression does no harm !  for the pressure it causes is
permanent, not progressive ; it is fixed  and complete at once :
if the patient be not struck insensible the moment  the bone is
beaten below its level, he  never can  become  so; and you will
find, by a singular  variety  of proofs, which I am  now to lay be-
fore you, that he seldom becomes insensible.   The brain is ca- 
 
P. SIS.



    • »
Fig-.i.   6
r,o',:v
Fin, -I-
Jj!r'\d£
FJiatr»y.J C. 
          Of Fractures of the Scull with Depression*      315

pable of accommodating itself to any  degree of pressure which
is fixed and stationary, and that  arising from a depression  of
the scull is  so slight  that it can  hardly be estimated; for the
depressed portion is a very small segment of a large circle : the
broadest depression  possible  is not  equal  to one-tenth of the
whole convexity ofthe cranium.   The smallest deviation from
a circle seems very great, and that depression which is very vi-
sible  outwardly,  makes an inconsiderable impression within:
the depressed portion of the cranium is so little off its level, that
it merely exposes a rough and rising edge never exceeding the
whole thickness of the bone :  the fractured and depressed por-
tion dips only at the line of fracture, and declines very gradual-
ly from the line where it is level with the scull to the line of its
greatest depression:  a depression even of three inches long, of
the parietal bone, for  example, (Vide (a)  figure 1. of fractured
sculls) declining gradually for two inches,  and  terminating  in
a depression of the depth of a fifth  of an  inch, (i. e.  the full
thickness ofthe most  substantial scull,) must produce an abridge-
ment of its cavity inconceivably small, as is marked and demon-
strated by the dotted line (c: fig. 1.)
  The slight effect  that  could, in the worst depressions,  be
produced by intrusion of the bone, would be to exclude from
the regular circulation within  the  head a very trivial proportion
of blood.*   But when blood is poured out, the effusion is not
instantaneous but slow ; every time the brain subsides, i. e. at
each respiration, more blood exudes from the ruptured vessels;
it  is injected betwixt the scull and  dura mater by the force of
the circulation:  this  internal haemorrhagy is probably not com-
plete at first, but is renewed in paroxysms ; it  is not  limited to
one spot, but is diffused over the whole hemisphere of the brain:
the extravasated blood has, by accumulating and coagulating, all
the effect of a solid body: nay more,  as it increases in quantity,
in proportion as  the  brain yields, it acts  with  the  force of a
wedge, which presses harder the deeper it is driven.   Such  is
the difference betwixt the injection of soft blood within the firm
cranium, and depression of the scull.
  But these are only arguments, which you dare  not trust to ;
you must have proofs more relevant  than these; and the facts*
I have to  display are  really singular.   It having once  become
an acknowledged maxim, that the surgeon should trepan  every
fracture, and elevate every slight depression, no one having any
opportunity of  seeing a pure case of depression where the sur-
geon had not been busy, it might eventually have  been very

  •  Is  preflure upon the dura  mater nothing, or there is no chance  of that
reflure caufing iiiflammatici of  the  membranes of the brain? S. 
316
Of Fractures of the Scull with Depression.
difficult to prove that it is safe to leave such fracture untouched.
But a thousand  favourable accidents have  betrayed the  im-
propriety of this  rash  practice,  and proved, in various ways,
that the surgeon has been usually  occupied,  and often with ex-
treme violence, in elevating fractures which had been better left
alone.  Sometimes, in the  hurry and confusion of such a bloody
scene, a remarkable depression of  the scull has escaped investi-
gation, the  patient has escaped the violence and dangers of an
operation, and the surgeon  has been sensible of the deep de-
pression only by feeling it through the scalp when the man  was
well: Sometimes  relations  and friends have interposed and  pre-
vented the well-intended operations of  the  surgeon, who has
protested against leaving  a  great depression unreduced,  and
prognosticated death,  yet  the  patient has recovered:  Some-
times, the surgeon having leave  to do his  work, having made
his perforations and pushed in his levers, has found the depres-
sion too deep  and too firm to be raised ;  after every justifiable
and every unjustifiable violence, he has been  unable to raise the
depression,  and has not dared to cut it out;  he has left the pa-
tient in this desperate state, and  yet seen  him recover after such
violence, added to the deep depression : Sometimes when, from
the foul air of hospitals, or  the prevalence of  epidemic diseases,
the surgeon has been deterred from his favourite work,  he  has
discovered, with equal pleasure and surprise, that " more reco-
ver (to use  the words of  Perusinus) by medicines than by the
knife and the  saw."  Indeed, the  conclusion against the  pro-
fession  and its general propensity to operate, in mere injuries
of the scull, is stronger than I believe you are aware.  I know
that if you had seen with me the precipitation and violence with
which depressions  of the  scull are torn up, and the miserable
consequences  arising from  large  openings, both your reason and
your feelings would revolt against the practice.
   " I chanced once  (says Platner) to be  called to the  assistance
of one who had fallen from the third story  of a house, and lay
quite torpid and oppressed, as in a deep sleep.  The. surgeon,
having  shaved his head, found there a very  deep and wide de-
pression ofthe scull.   While we were wondering how the scull
could be thus deeply impressed by the fall, the integuments be-
ing but slightly ruffled, the  man recovered his senses in a for-
tunate hour;  alarmed at  the proposal of an operation, he  told
us that the impression  we had observed  was  of no importance ;
he had it from his childhood; and yet had lived in perfect health :
he recovered without assistance."  We are at a loss to conceive
how, even where the integuments remain  entire, so wide a frac-
ture, and  so much  depression, can be consolidated without any-
ill symptoms;  but several cases, which I have  myself witnessed, 
Of Fractures of the Scull with Depression.       317
make the process quite familiar to me :  and one related by Bo-
tallus I think particularly worthy of your notice :  " Some" (says
Botallus) " will very readily acknowledge that bones, fractured
without an external  wound, are easily cured in other  parts of
the body, while they deny the bones of the scull to be thus cured:
I will relate plainly  what 1 have myself seen.   Wliile I prac-
tised surgery, a  boy, as  I guess about  seven years of age, fell
from a gallery twelve feet high, and pitched directly upon his
head ; the  parietal and part of the frontal  bones were so frac-
tured that you could feel distinctly the several fractured pieces,
yet the skin  (he  having  fallen upon a flat pavement) was  not
wounded, nor even the hair ruffled.   When called, 1 was alto-
gether confounded at finding such a fracture, the boy speaking,
and  in his perfect senses, with only a slight acceleration of pulse,
(he  was however insensible at first,  and had  vomited up his
dinner along with some bile) a thousand thoughts passed across
my mind, while  those I  had sent  to the apothecary's were re-
turning with some medicines.  I was for some time irresolute
whether to make  an  incision and pick away the fractured bones,
or to leave the parts entire:  at last I resolved on this more lenient
plan.  In place of making an incision, I covered the whole  head
with Armenian Bole, Myrtle  Berries, and Rose Leaves,mixed
with vinegar and  white of eggs ; and this astringent application
I used during tour days.   The boy perfectly recovered without
incision ; he lived many years ; and, though I do not  recollect
his name, I have reason to believe he is still alive."*   This in-
genuous avowal ot Botallus, that he was altogether confounded
at feeling such a  fracture, and that a thousand thoughts had  fleet-
ed across his mind,  makes the case highly  interesting  : we are
conscious, from the conclusion of the case, how dangerous these
thoughts were to the patient, and must feel that when they pre-
sent themselves to our imagination, they should be resisted.
   Parents have often, with seeming perverseness,  refused as-
sistance  in the last extremity, and even the earnestness  with
which it is offered,  is a motive for refusing it ; despair makes
them unwilling to disturb the last moments of their child, which,
being left undisturbed, recovers ; what the  fate of such a child
might be if trepaned, must ever remain doubtful.
   I was called once to a child, whose circumstances  seemed so
very desperate that I urged the parents to allow of an operation,
which fortunately they refused.  " This little girl, about twelve
years  of age,  was playing with her school  companions on the

   * I cannot agree with Mr. Bell in the propriety of the practice here commend-
ed, although the patient recovered. Though the general argument is correct, that
it  is not neceffary to trepan ev.ry depreffion, the doctrine muft not be pufhed too
fo.  S. 
318       Of Fractures ofthe Scull with Depression.
 very steep declivity of the Earthen Mound : two of them were
 running, hand in, hand when  this little girl, losing the hand of
 her play-fellow, rolled from top to bottom of the Mound, with
 continually  increasing velocity, till at last she pitched with her
 head full against a low wall,  at some distance beyond the bot-
 tom.  She  was carried home  in a chair, stiff and motionless,
 perfectly  pale,  and without pulse ; she  hardly breathed ; and
 we had no evidence  of her being alive but  a  slight degree of
 warmth, which, after cutting off her clothes, (for she was stiff as
 well as motionless) was difficultly increased to a natural warmth.
   " From this  time  she lay in a deadly stupor, with a blemish
 on one temple ; there was no tumour,  but flat integuments,
 through which   I imagined  I  could feel  a fracture and depres-
 sion of the parietal  bone, while the signs of accompanying ex-
 travasation seemed very unequivocal: her limbs were stiffened ;
 her whole frame in  a sort of tonic or permanent convulsion:
 her jaws firmly and immovably locked ;  her extremities  cold,
 and her pulse oppressed and  intermitting.  In this state she
 lay for four or five days immovable ; hardly was a tea-spoonful
 of wine and water admitted betwixt her teeth, which were firm-
 ly and immovably closed.   I  was then persuaded, and remain
 so, though she  happily recovered, that there was extravasation
 under the parietal bone ;  and my persuasion was so great that,
 on the fourth and fifth days, I  solicited her  parents to allow of
 an incision,  and even spoke to the clergyman, who was called
 to them at this dismal time, to persuade  them to consent.  On
 the sixth  day she yawned widely, and from that moment her
jaws were loosened :  we could now put  in  a few spoonfuls of
 wine and water, and give purgative medicines:  but she lay still
 and dead, in the most profound stupor I  ever witnessed.  She
 began in the second  week to  stir the limbs  of one side a little,
 and in two days more she stirred  sometimes  an arm, some-
 times a leg, ofthe opposite side : then her eyes opened at times,
 and she began to mutter and speak ; but it was the fifteenth day
 before this low muttering came on;  and then, and till the twen-
 tieth, though her eyes were open,  we had unquestionable evi-
 dence  that she could not see ;  a candle approached to  the eye
 gave no sensation, the eye did not  follow it,  nor were the eye-
 lids closed as expressive of impatience of light, and the pupil
 was as much dilated  as if she had lain in a dark place.
   " She now became restless, the struggling of the limbs of both
 sides increased, she put out  her hands and stretched her limbs
 with a sort of trembling,  and   muttered  perpetually.   On the
 fourth week, she came to  swallow more easily, to take the drink
 which  had hitherto been poured into her mouth, and to speak
 rationally.   She next sat up in bed,  was raised into a chair, and 
          Of Fractures ofthe Scull with Depression.        319

 gradually recovered her senses and her strength. She was then
 able to be led about the room, but two months elapsed before
 she could be said to walk :  even then she was never left alone,
 nor walked unsupported.   She  was led about the  whole sum-
 mer in this weakly condition ;  but is now a strong and healthy
 girl."*
   But  the  practice of those who believe it to be their duty to
 scrape every fissure, and raise  every depression, who are ever
 ready to go to xvork with their instruments,  affords the com-
 pletest proof of the improvidence of such practice ;  and we find
 practical errors narrrated, by the best modern surgeons, with a
 non chalance, and want of consciousness, altogether astonishing.
 " I cured a boy, (says Marchetti) of seven  years of age, who,
 from the kick of a horse in the forehead, had a very remarka-
 ble depression, which neither tripod nor lever could any way
 elevate  ; but there being a fissure in one part, I betook myself
 to the rugin, dilated the fissure, so that the  serous humour had
leave to exude, while the medicines had leave on the other hand
to penetrate to the dura mater,  so that in the course  of forty
days, flesh being regenerated in the fracture, the wound was
safely and soundly cured."   But,  had the celebrated Marchetti
been permitted (as it was a wonder his authority did not pre-
vail) to trepan this  little boy, to  tear up the scull with his tri-
pods and levators, it is possible at least, that even after such vi-
olence, he might have survived, and then the operation and the
operator would have been applauded for saving the patient's lifej
and had the elevation of the bone been accomplished, though
with every circumstance of violence and rudeness, the operation
would have  become memorable.  Such a case is that recorded
by Mr. O'Haloran,  in which every principle of sound surgery
was violated.   He  found a child with a depression  of the scull
with the integuments entire, and the senses quite composed and
perfect, when,  without any motive but his own fears,  he cut
open the scalp ; and that depression, which had hitherto done
no harm to the child, he elevated in the rudest and most shock-
ing manner, making no fewer than four  perforations in the scull
of the child, thrusting into each hole a levator,  and to his four
levators he had two  surgeons, who  seem to  have had as little
tenderness  as  himself, for they pulled  with  might and main,
till the depressed bone rose with a sudden spring.   But here is
his own narrative.
  " A girl,  about seven years ofag* received a severe fracture,
xvith profound depression, on the left parietal bone ; the integu-
ments were entire, the girl quite comfwta and sensible, but the

 ' This cafe fhews what may happen, but would  Mr. Bell himfelf prognofticate
 a fimilar iffue,  under fimilar circumftances ? S. 
320       Of Fractures ofthe Scull with Depression.
depression was so deep that it could  contain a very small egg.
Such was her situation when brought to me half an hour  after
the injury.  Seeing that it would require three  or four crowns
of the trephine to raise  this extended fracture,  I requested of
Mr. Wallace, a  military surgeon, and  Mr.  Pierce, to  assist
me in this charitable work.  I removed all the integuments, wi-
ped  away the  blood, and whilst these gentlemen with their fin-
gers  made compression  over  the  bleeding vessels,  I began to
operate on the inferior parts ofthe bone.  I then commenced a
second on the upper part, and in a line with this; but two eleva-
tors, though acting at the same time, had no effect on the de-
pression.  Two  more crowns were then applied to the sides of
the bone, and parallel to each other.   Four levers acting in con-
junction, it astonished me to see with xvhat a sudden spring the
depressed parts resumed  their former station.   Notwithstanding
the great extension of this fracture, the loss of covering, and of
the bone itself, by four crowns of the trephine, this girl never
after had the smallest untoward symptom."
   Is it by such narratives and such proceedings that the good re-
pute of surgery is to be preserved ? by no means: we should at
first sight be  inclined, both from the violence  used in raising
this depression, and from the  success of the  operation, to as-
cribe the patient's safety to the intrepidity of the surgeon  ; but
what should we  have said of  Mr. O'Haloran's practice had he
miscarried, and been  unable, with his military assistants, his
pair of surgeons  and double pair of levators, to raise  the depres-
sion, and yet  the patient, after all kinds of violence being added
to the depression, had lived ?  There is not in the  narrative of
this case any  shadow of proof that the patient was saved by this
mode of operation; the child was composed and sensible, had
no bad  symptoms, and  would {might) have  had none to the
very end of the cure, had she been left alone : it proves merely
what is but too  surely true, that often the patient survives the
most imprudent  things the surgeon can do.
   I will  now produce you evidence that I put no  worse con-
struction upon this case than it should bear ; it will  prove to
you,  that, even where the depression is broad and deep, where
convulsions have ensued, where  the surgeon, alarmed at these
signs of danger, has made his incisions and his perforations,
and tried ineffectually to raise the depression,  the patient has
survived both the depression and  the ineffectual  operation,
which must ever be a violent one.  Mr. Hill undertook,  in an
unfortunate hour, the following  operation   "  A  boy of the
name of Carson,  between five and six years of age, by the kick
of a horse, had a long piece of the os frontis beat  in fat : he
slept sound, as the people termed it, about two hours, and then 
Of Fractures ofthe Scull with Depression.       321
 fell into strong convulsions.   The extravasation was so great
 externally, that the precise quantity of the bone depressed could
 not be determined, till the blood was discharged by a horizon-
 tal incision along the depression, by which  I discovered it to
 be of an ellipticulform, extending above two inches across the
forehead, and above the right sinus frontalis,  with  a fissure  all
 round it.  The external discharge not relieving him,  showed
 that the  perforation would be necessary ;  and, therefore, after
 allowing the first incision  to bleed some ounces, it was stopped
 by dry dossils.  Being determined,  for the  reasons formerly
 given, not to touch the depressed part, unless some symptoms
 should afterwards make it necessary,  I continued the incision
 till there was room for perforating a quarter of an inch from the
 fissure, at the right end of the depression.    The bleeding was
 troublesome ; but no arteries required to be stitched,  but were
 stopped  by dossils dipt in ardent spirits, and  applied for half an
 hour.  After which just as much of the pericranium was remo-
 ved as was necessary7 to admit the smallest head of the trepan.
 The connecting blood vessels betwixt the dura mater and scull
 were broken  through  the whole extent of the depression, being
at least two inches ; for so far I introduced the levator, without
opposition, and attempted, with a good deal of force, to raise
it; but in vain.—After the extravasated blood was discharged,
three intersected  stitches  were put into the first incision above
the depression, and it united in a few  days ; and the rest of the
skin healed in four weeks, without the intervention of any bad
symptom.—He is well, 1771;  and the depression,  owing  to
his youth, is so expanded  by natural growth  and callus,  as not
to be much perceived."
   If any thing could repress the presumption of a man of an
adventurous temper, this  must: to propose an operation under
protest, that it was the only possible means to save the patient's
life ; to attempt that operation ;  to  see the patient survive the
depression which had been declared fatal, unhurt by  the addi-
tional violence of  incisions,  trepans and levers ! Surely these
facts should lead the surgeon, who had been in the habit of ele-
vating inexorably every slight depression, into a new  train of
thought.
   The prominent points ot  this case of  Mr. Hill's,  stand, in
common  sense and plain argument, thus: First, the depression,
while it continues, does no harm, the boy  being in his entire
senses : Second, the surgeon is so alarmed at the very appear-
ance of depression, that he labours with every degree of vio-
lence to raise it, his own  reputation,  as  well as the patient's
                             aS 
322      Of Fractures of the Scull xvith Depression.
health, seeming to be at stake : Thirdly, abandoning the opera-
tion, and leaving the depression as he found it, he puts three
stitches  in  the  wound, and so the integuments unite over the
depression in a few days : Fourthly  the patient  is no sooner
recovered, and the wound healed, than  the depression, which
appeared so formidable to the surgeon when seen and felt at the
bottom of a bloody wound,  the depression, to raise which  he
willingly risked every thing, disappears spontaneously,* so little
is it off the level.t
   I will now relate the  circumstances of an operation  in which
I was a party ;  where although  I was  obliged to  be a witness
and unwilling assistant  in much mangling, I saved  the man a
great deal more.   There was, along  with a wide fracture ofthe
parietal bone, through  which the extravasated blood was seen,
a slight depression of it at one corner ofthe fracture : the trepan
was applied : the extravasated blood rolled  out: the duty  of
the surgeon  was, according to  my  apprehension, completely
fulfilled; but he was urged by others who were present to raise
this depression, with a  degree of earnestness which left him en-
tirely  responsible for the consequences.    I most  unwillingly
witnessed, but would not  consent to assist  in this  part of the
operation.   After extreme violence (for always the violence is
extreme where the surgeon works till he is foiled)  it was found
altogether impossible to elevate the depressed bone.  The ope-
rator was now called upon, under  the  same  responsibility,  to
make  one, or, if necessary,  two perforations, on  the  sides of
the  depressed portion,  to raise it.   I saw  plainly that, if the
operation, noyv  protracted for  an hour, should continue still

  * Thefe are not folitary, nor even rare cafes.  Read the following from Mr.
Hill.  " February 24, 17$&■   Mr- Robert Rae, when a young  man, fell  back-
ward from  his horfe on a rock, about twelve miles from Dumfries.    By his foot
flicking in the ftirrup, he was dragged fome way, till the girth broke, and  left
him with* his head betwixt two ftones in  a rill of water, where  he would foon
have been fuffocated had not a fhepherd boy drawn him out.—A large  piece of the
left parietal bone was driven  in backward to the lambdoid future,  with a fiffure in
the right parietal forward, being like a fhepherd's crook : notwiihftanding the lar-
ger depreifion, there was no extravafation ; nor -would the bones rife, though a very
great force ivas employed; but they exfoliated like the former, and  the aperture be-
ing wider, the protrufion was  greater. The cicatrix continued foft for three years,
when it offified  completely.
  f Mr. Bell's criticifms on Mr. Hill's operation,  if the cafe is entirely related,
do not appear to be altogether correct.  He fays" the boy was in his entire fenfes,"
when Mr. Hill lays " he was in ftrong convulfions."  Although the depreffed bone
was not elevated, yet the extravafated blood was difcharged ; a circumftance of no
flight importance.  Mr. Hill fays, that " owing to  natural growth and callus,"
which implies confiderable length of time, " the depreffion was not much perceived,"
and not that it  difappeared when the boy recovered.  S. 
Of Fractures ofthe Scull with Depression.       323
 another hour, the man  would be carried off delirious ; that  if
 the scull was widely opened by  two perforations,  and  by the
 tearing away the  depressed bone, his chance for life was very
 slight.   I said  across to the surgeon, that if he would permit
 me, I should most willingly take the responsibility upon myself.
 On his consent, I put aside the busy fingers that were  search-
 ing for  depressions, clapped a piece of lint on the dura mater,
 and conveyed him to  bed, where he  mended daily and became
 a  very stout and healthy man.
   The  bloody decrees of the surgeon against all who have de-
 pression of  the scull are never so absolutely suspended, as where
 the ill constitution ofthe air in a great hospital is known, by the
 experience of  centuries, to destroy  all those  who suffer opera-
 tions on the head.  Under this imperious necessity was Des-
 sault,  surgeon  of the Hotel Dieu, who,  during his adminis-
 tration, declined,  even  m  the most urgent circumstances, to
 perform the operation of trepan.
   Dessault's clinical  practice, when he merely allowed the pa-
 tients to lie undisturbed and quiet,  with a  poultice to the frac-
 tured and depressed scull, and a dose of calomel to move the
 bowels, exhibits  a splendid series of examples of what nature,
 undisturbed by  partial operations, will do ;  and taught  Des-
 sault himself,  and proved to the profession, how great a pro-
 portion  of those who are trepaned would live without the help
 of surgery  : for many recovered after lying long in a state of
 stupor, accompanied with symptoms every way alarming, such
 as would,  in any other circumstances,  have induced Dessault
 or any surgeon  to have trepaned.
   But  Dessault, who was too much inured to bloody scenes to
 fear operating, and too indifferent to the reputation of being an
 operator to feel  any thing of the passion  for cutting and trepan-
 ing, tried,  for the first time, the great  and important experi-
 ment of leaving his patients having fractures and depressions
 of the cranium, at  quiet  in  their beds. Among others, one Jo-
 seph Gautier's condition was in every  sense interesting, but es-
 pecially in the slow absorption of that general suffusion of blood,
 which we  must presume to have taken place in the brain after so
 violent  a  concussion as he seems to have suffered, and the gra-
 dual recovery of  his senses, proportioned in all likelihood to
 that absorption,  and accompanying  it step by step.  "Joseph
 Gautier, a hale young man,  twenty-three years of age, was
 found in the morning under a window, which he  was accustom-
ed to scale when late abroad, lying in a state of stupor, and ba-
thed in his blood, which  streamed from his mouth and nostrils,
and from  his left ear.  When he was brought from his village,
 a few miles distant from Paris, into  the  Hotel Dieu,  he was 
324       Of Fractures ofthe Scull with Depression.
still  bleeding from the mouth and nostrils, and insensible ; the
body cold, the face deadly pale, and the pulse small and con-
tracted.   On  his head were many  marks of contusion ; and
one over the  lower and fore part of the parietal bone, was ac-
companied with a depression, deep in the centre, and rising to-
wards each side.  The clavicle, which was also fractured, be-
ing set and bandaged, the  head was wrapped in a  large poul-
tice : next day he was better ;  the poultice was continued, and
he was bled in the foot ;  and in the evening his  senses in some
degree returned.   On the sixth, he began to articulate, but in-
distinctly.  By the seventh his  senses were restored ;  his taste,
smell,  and touch were perfect,  but his vision somewhat impair-
ed :  he heard also imperfectly ; and, in respect to his intellect,
the faculty of memory seemed much weakened ; he could by no
means recollect whence he came.  He had no pain : it  was on
the tenth day that he first  rose  and  walked :  on the fourteenth,
he walked abroad upon  the bridge, and took his airing there
dailv,  till the twentieth,  when, the  fractured clavicle being re-
united, the bandages were undone.   His memory mended dai-
ly ;  his hearing became more acute ; his eyes gained strength,
but still the pupils remained  dilated somewhat wider than in the
natural state, and the scull remained manifestly depressed.  On
the twenty-seventh, he was carried into the hall  at lecture,  and
shewn to the  pupils: this  was before he was dismissed.  At
the end of three weeks, he returned to show himself, his sen-  *
ses being entirely restored, and his memory perfect: the pupils
of his  eyes had recovered nearly their natural smallness,  except
that the pupil of the left eye continued a little wider."*
   In this case, when about the third day,  the  bumpy swelling
and ecchymosis began to subside, they felt the fracture  and de-
pression very  distinctly, the fracture being of a circular form,
about  two inches and a half in diameter, with one edge more
raised than the other; and  after his recovery it  was still more
plainly felt.
   " The invariably fatal consequences of using the trepan  in
the Hotel Dieu, deterred Mr.  Dessault from  using it on this
occasion ; nor had he any reason  to repent of his resolution."
Even  when the depression seems to produce the worst signs ;
when the patient bleeds from the nose and ears, and lies insen-
sible ; when his senses were not merely stunned and shocked,
but so materially injured that they recover slowly,  it is  safe  to
leave  the depression untouched ; to trepan where  there are no
such signs would be destruction.   Mr. Abernethy " had a man
brought  to St. Bartholomew's, who was  hit on the forehead
' Deffault's Chirurgical Journal, Vol. i. p. 17. 
Of Fractures of the Scull with Depression.       325
with a brick: the frontal bone was fractured half an inch above
the orbit;  the fracture measured two inches in length, and the
upper portion of the brow was depressed about the eighth of an
inch.    He was not even stunned by  the blow, and walked to the
Hospital without assistance, complaining only of soreness in the
wounded  integuments.    He  was bled;  was  confined,  much
against his inclination,  to a scanty and liquid diet, and was pur-
ged every  second  day.   This patient did not experience any  ill-
ness, and the wound soon  healed."   But had   Mr.  Abernethy
been a surgeon of the complexion I have sometimes ventured
to  describe ; had  the patient been confined, much against his
inclination, to an operation-table,  and  trepaned,  there  is  little
doubt, I think, how  it would have fared with him.
   But this is the difference betwixt the proceedings of a man of
sense and  experience, and a man of  theory.   There has  been
too much  of surgery!   A master in surgery can look,  calmly
and composedly, on that depression  upon which a novice would
instantly fasten his levers ; he  can see the scalp  whirled off from
both sides  of the scull ;* the parietal bones laid bare ;  the tem-

  * " A lad, feventeen years of age, had his head preffed between a cart wheel
and a poft ; by which accident the fcalp on both fides was turned downwards, fo as
to expofe the  lower half of the paiietal bones,  the fquamous part of the temporal,
and alfo part  of the frontal and occipital bones; about a quarter of the cranium be-
ing thus denuded of its coverings.  'I he periofteum was in feveral places ftript off
from the fcull, the fcalp much bruifed, and the  pojierior  and inferior angle of the left
parietal bone  -was beaten in.  The deprtffed portion, which was vifible, -was an
inch in length, and more  than the eighth of an inch below the level of the cranium ; but
the fracture  extended  along the fquamous part of the temporal bone, towards the
bafis of the fcull. it could not, however, be traced, as the temporal mufcle had not
been removed from that part by the injury.  The fcalp being cleanfid, was repla-
ced, retained  in its fituation by flips of fticking-plafter, and a flight preffure by ban-
dage, was applied.  The boy was perfectly fenjible, his pulfe regular, and not quickened.
He had bled  considerably  from the temporal artery, which had been divided by the
accident: eight ounces of blood  were, however, taken from his arm ;  and fome
purging medicine was adminiftered next  morning, which procured three or four
ftooh. The next day, (Friday) his pulfe beat nearly no in  a minute ; his fkin
was hot and  dry ; and he  complained  of pain in his forehead.   Twelve ounces of
blood were taken away, and four grains of pulvis antimonialis ordered to be given
three times a day.  On Saturday, the former  fymptoms ftill continued,  and were
rather increafed.  The  antimonial powder made him fick, or at leaft increafed his
difpofition to be fo.  Fourteen ounces more of blood were taken from him ; the
vibratory feel of his pulfe not  being altered until that quantity was taken away :
 the blood, on ftanding, appeared very buffy.  His fkin,  notvvithftanding all this,
 ftill remained extremely  dry ; fome antimonial wine was given, which produced
 vomiting.  On Sunday, his pulfe was evidently lowered by the evacuations he had
 undergone,  but it was  ftill quick and fufficiently ftrong.  The pain of his  head
 remained as  before.  Having a fufficient number  of ftools, and the ficknefs ftill
 continuing,  the antimonial powder was omitted.   He was bled, however, in the
 vena faphena, and his feet and legs afterwards immerfed in warm  water ; during
 which, he, for the firft time, perfpired copioufly.   A blifter was alfo applied to hie
 neck.—The  fcalp united, with only a trifling fuppuration over the fraciured part
  of the bone; and to this ready union, the lowering plan, by preventing inflamma-
 tion, fee.ns very materially to have contributed.  The  matter collected over the
  fracture was difcharged by a puncture, and the boy got well."—Abcrr.ahy, 
326      Of Fractures of the Scull with Depression.
  poral and frontal bones also denuded; part of one of the  bones
  beaten in, for an inch in length, and more than the eighth of an
  inch in depth, and a fracture extending downwards to the basis
  of the scull,—and  yet refrain from trepaning.   He can see a
  fracture similar  to  this, with a part of  the bone depressed even
  a quarter of an inch below its natural level, without thinking of
  making an effort to  raise it;  and can even see the boy sicken on
  the third day,  with  headach  and  disturbed sleep,  with dozing
  and a  slight  convulsion, without being moved to do any thing
  rash  or unbecoming.*  While the tyro, just sent out from the
  schools, makes diligent inquisition into all the circumstances  of
  a fracture, will allow  not even a  capillary fissure to escape his
 jealous search; and,  where there is hardly any  visible fissure
  imagines such internal damages as may entitle him  to  " set to
  work with his instruments," and perform  that great  operation,
  which is  to be the pride of his future years, " boasting of that
  which is  his shame."
    It  is not honourable to our profession  to have it thus proved,
  that while the opinion is almost universal that depression of the
 scull must oppress the brain, the  fact  is  entirely the reverse:
 that wherever by chance  such depression  has  passed unob-
 served, or the friends have refused all surgical help; wherever,
 by the deepness and firmness of the depression, it has been im-
 possible to raise it;  wherever the danger  of infection  has de-
 terred the surgeon from operating, or he has resisted the temp-
 tation, and,  by an effort of good sense, has ventured, at  the
 risk of his reputation, to disregard the established  maxim, the
 patient has done well.  This is enough  to throw a doubt upon
 all that has  been doing for centuries; and makes it a duty to tell
 you plainly, and without reserve, that the desire of leaving, in
 a dangerous  operation, nothing undone, is not wise, and leads
 to nothing but rashuess and violence : it  is a prejudice  so  na-

  * A  boy, about twelve years old, received a kick from a horfe in Smithfield,
 which ftunned him ; and he was immediately brought to the hofpital.   The in-
 teguments of the forehead were divided by the injury, and the fuperciliary ridge
 of the frontal bone depreffed at least a quarter of an inch beloiv its original level; the
 depreffed portion meafuring about an inch and a half in  length.
  It is obvious that the bone could not be thus depreffed, without a fracture of
 fome part of the bafis of the fcull occurring at the lame time, on which account
 the cafe might be confidered as more dangerous.  In lefs than two  hours he had reco-
 vered from the immediate cffeft of the blow, being at that time perfcBly fenftblc.  Four-
 teen ounces of blood were taken from his arm; his bowels were  emptied by a
 purge, and faline medicines, with antimonials, were directed to be given.   He
 went on tolerably well for  two days, at the end of which time, evident fymptoms
of confiderable irritation of the brain took place.  He  now complained of pain in
his head; flept little;  and, when dozing, often ftarted, or was convulfed in a
flight degree.  To remove thefe fymptoms, he was bled twice, took opening medi-
cines occafionally, was kept quiet, and without light, and was allowed only a fpare
diet.  By continuing this plan for about three weeks, he perfectly recovered. 
Of Exceptions to the general Rule.           327
tural  that it should be resisted ;  it is  a manner of reasoning,
which is worse applied to this operation than to any in surgery.
To leave a Second  Stone in  the Bladder, while performing
the operation  of Lithotomy,  is to do nothing : to leave dis-
eased glands in the Axilla, when extirpating a cancerous breast,
is to do worse  than nothing : but to leave a slight Depression
of the scull,  even  when the patient is stunned and sickened,
or any depression where there are no bad symptoms, where the
integuments are entire, when  the patient is young, is to make
a just and modest sacrifice of  our wishes and prejudices to the
safety of our patient.
                       SECTION IV.

Exceptions to the general Rule of leaving Depressions to Nature;
  or Definitions of those  Cases which actually require the use
  of the Trepan and Lever.

  I know not whether I have persuaded you, but I have my-
self, to the most  entire conviction, that of all the  injuries of
the scull that which is the  most dreaded, viz. depression, is the
least hurtful.  I have seen such  happy recoveries, where the
depression was left undisturbed, such melancholy scenes when
depression was raised at the expense of large perforations,  and
extensive openings of the scull,  that I confess myself very in-
different to this kind of danger, and very doubtful of the pro-
priety of such operations : the  practice which I think so very
hurtful, it is my duty to oppose ; and I shall now endeavour to
keep my promise with you,  of explaining, first, the general
rule, so as to give you confidence, viz, " That you are  not to
trepan,  nor elevate every depression  : and,  next, " the excep-
tions, so fully as  to prevent you, while you avoid  the fault of
hurry and impatience, running into  any fatal  error from  ne-
glect."   You will find that I  have considered these exceptions
seriously, and that I retrace my opinions on this point to obser-
vation and experience.
  First, The general  principle which  I  have laid  down is
illustrated, and, I  believe, proved,  by this figure,  (Fig. 1.)
where  (a)  represents the point from which a fracture of
the parietal bone is bent down ;  (b)  the  natural level of the
scull ;  (c) the extent of the depression, deep and formidable
when seen and touched outwardly ; but the  space betwixt (b &
c) demonstrates  how  very little the depressed bone  is  off its
level, how partial and trifling the pressure  must be, how slight
nn intrusion this is upon the  convexity of the scull ; and the 
328           Of Exceptions to the general Rule.
 truth which this plan  demonstrates as probable,  is proved be-  *
 yond a  doubt, since, under the most  extensive depressions of
 the scull,  the patient  preserves his  senses.   Nothing is  more
 essential than  that you should have clear conceptions of the mo-
 tives for applying the  trepan :  it  is one  great point gained, to
 say with confidence, that " this of depression is not among the
 number."  I never saw depression  occasion stupor, nor the  ele-
 vation of it  bring relief;  but many times when the  surgeons
 have been busy, in a mob, struggling and elevating depressions,
 in a manner almost as rude as that of O'Haloran with his four
 levers, the boy or man has been  struggling, remonstrating,  and
 making  every kind of resistance :* nay, it is most singular, and
 not to be found in any equal number of  injuries of the head of
 any  other  complexion, that, in all  the  instances of deep  and
 wide depression which  I  have just  quoted,  or  have  yet to
 quote, the patient was sensible, f
    Secondly, Though this general principle  cannot but  be  ac-
 knowledged, it remains to be circumscribed by certain definite
 rules : as we  should take different  measures in  a clean  cut of
 the integuments, and a rude and  mangled  wound, where  the
 parts were bruised,  lacerated,  and unfit  for adhesion,  we must
 take various measures  in fracture  of the scull,  according to its
 peculiar circumstances ;  and as there  are circumstances which
 are found  to prevent the adhesion of  wounded integuments or
 wounded scalp, there are many  which wilt prevent the healing

   * There are, in my recollection, no cafes, and I find in my readings very few,
 in which the depreffion feems to have occafioned ftupor, or the elevation of it gi-
 ven relief.  The following obfervation from La Motte, is perhaps worth your no-
 tice as much as any.
   " A boy" (fays  La Motte) " was rode over by a young prancing horfe, which
 pranced upon him.  There was a great wound, and much bone naked ;  and be-
 fides there was a confiderable depreffion, apparently made by the cauker or heel
 of the fhoe.  This boy I found lying on his back, crying out continually  that he
 was falling, that he was falling  down !  I trepaned, introduced  the levator,  and
 raifed the depreffed bone.  This boy, while the  bone continued depreffed,  had
 continually the feeling of a drunken perfon, of the room running round with him:
 but the moment the bone was raifed, and the extravafated blood evacuated, he reco-
 vered his fenfes.''  P. 320.
  f A cafe is related by Mr. Chne, in  his Lectures, of a feaman on board an
 Englifh fhip in the Mediterranam, being knocked  down by fomething failing
from aloft.  He was rendered infenfible by the blow,  and in this ftate was carried
to Gibraltar, where nothing was done for him, and thence to London, to St. Tho-
mas' Hofpital, ftill in a ftate of infenlibility.  Thofe who were with him knew
when he wanted to eat or drink, by certain  motions which he  made. He had
likewife a catching of the fingers of one of his hands.  His head being fhavcd a
dep-eflioh (of one of the  parietal bones, I think)  was difcovered, for  which Mi.
Cline operated.  That very evening  the motions of his fingers  ceafed, and in a
few days his fenfes were entirely reftored. What is very remarkable, when he firft
became rational he thought himfelf ftill cruifingin the Mediterranean, having no
idea of the  lapfe of time, or change of fituation, which had taken place.  I do not
recollect how  long he remained in that infenfible ftate, but it muft  have been
feveral months. S. 
Of Exceptions to the general Rule.          329
of a fractured scull, and cause it to inflame the bone, and affect
the dura mater :  These are the exceptions, and  they must be
defined, and I will now describe that kind of depression which I
judge to be safe.    It is not by present pressure that fracture is
dangerous ; therefore, when it runs in a right line, when there
is a general depression, but no particular point forced in upon
the brain ; where  the  declination of the  depressed  from the
sound part of the scull is gradual and uniform ; when the whole
line of fracture is generally depressed, and the central point sinks
rather deeper only ; though you can feel the hollow with your fin-
ger, and can see it (not without apprehension) when the coagu-
lated blood is discharged; yet as the centre does not intrude ma-
terially upon the brain,  as this point does not dip so as to present
points or spiculae to the dura mater; as there is  no rough edge
presented on the  inward surface, nor any rude shock, like that of
a ball, to deprive the bone of life, and prevent its healing;  as it
is broken by such a force as  fractures other bones,  and is sur-
rounded (as marked at d, fig. 1.) with a mass of  cellular  sub-
stance, thickened by inflammation, and by the injection of blood
into it,  such as re-unites other fractures, the scull,  pericranium,
and dura mater,  all mutually  adhere, and the effects of such
depression are never felt.
   Upon every principle, and every precedent, taking care, how-
ever, to watch the  slightest  appearance  of fever, rigour,  puffi-
ness ofthe scalp, flabbiness, or gleety discharge from the wound
we are bound to  commit such a case to nature : it daily happens
that boys have the  forehead thus flattened by the kick of ahorse;
sometimes dangerous spiculae, as where the caulkers of the  shoe
have pierced the bone, are cutaway, and very properly, with the
trepan : sometimes, too, the  bone is elevated; but very often it
is left untouched, the wound lightly stitched, and  dressed dry,
and the parts re-unite and heal as in any other wound, a visible,
but harmless, depression remaining.   While the integuments
are entire, the  inducement to leave them so  is particularly
strong ;*  when left entire, the  consolidation of the parts, and
the absorption of the blood, is certain, or almost so :  to  open
it,  is to convert a simple into a compound fracture, with  every
danger of its not healing favourably. :' I remember to have put
in my finger, through a wound in the scalp, and felt, in a very

  * If you follow this'advice, how  can you know whether or not there are any
fpiculse  of bone  driven in upon the dura mater ? I have been, after the example
of Mr. Birch of St. Thomas' Hofpital, in the invariable habit of laying open fuch
tumours, never with any injury to the patient that I could perceive, and often with
manifeft advantage.  When all danger of bad fymptoms vsnifhes, the inafion may
■^ bailed in a few days  S.
2T 
330
Of Exceptions to the general Rule.
  old woman, near 70 years of age, a depression of the parietal
  bone of two inches of extent, the fracture wide, the edges rough,
  and the depressed bone apparently driven far below the  unhurt
  part of the scull; and the only notes  I have taken of the case
  are, that she never passed one sleepless night, nor had one hour
  of sickness ;  her appetite never declined ;  that she sat up to be
  dressed, and kept her bed a few days only, through precaution
  rather than for  want of spirits  or strength, and recovered as
  from the most ordinary wound.   In those  less advanced in life
  there is less danger ; and we have the best  authority (the au-
  thority of those whose general practice is to use the trepan) for
  affirming,  that in such cases, not only the present depression
  does  no harm,  but the fracture  unites, and the wound  closes ;
  the patient may even be seized  with  shiverings, and the part
  with suppuration, (strong reason for suspecting a carious bone)
  yet such abscess, being punctured, will discharge  " a consider-
  able quantity of  matter," and the patient be in no danger: nay,
  we are assured, on the same impartial  testimony,  that a bone
  loose, and somewhat depressed,  will fix again.*   But in boys
  especially, where depressed bone  has in general no sharp edges ;
  where the scull  rather  bends than breaks;  where the bone is
 vascular and growing,  and the circulation in it and in the inte-
 guments sound and vigorous,  the chance of a fracture's healing
 is so great that I would not presume to touch  it, unless in most
 peculiar circumstances ; especially as in boys the dura mater is
 too tender  to serve as a second scull to sustain the pressure of
 the circulation within  the brain : wherever  it is necessary to
 make large openings in the cranium of boys,  protrusion  of the
 brain and death  ensue.
   It is not then the present,  but the remote consequences of
 depression  we have to dread;  a depressed fracture is more apt
 to become carious than one that is direct or linear; and it is
 as a fractured Rib or Sternum inflames  the Pleura or Pericar-
 dium, that depressed fracture of  the scull by  becoming carious
 inflames -the brain.   This is an accident which mav happen
 in any form of fracture, where the bone is but  laid bare, or
 scratched, or punctured, as well as where it  is depressed ;  it is
 one  for which the surgeon, who  has endeavoured  to re-unite
 the fracture, can be  no more blamed than he could be blamed

  *  " Samuel Hafte received a wound on the upper part of  the right parietal
 bone, of two inches long,  -with a loofe bone and fracture.   '1 hough  the fracture
 could not admit of a doubt,yet there feemed to  be but little depreffion, and the
fides of it were firm to the touch.   I faw no reafon for the operation at prefent,
but carefully attended to the fymptoms.  In the fpace of four weeks the bone be-
came  covered,  the wound healed, and he  has fince enjoyed perfect  health."—
 0'Haloran. 
Of Exceptions to the general Rule>          331
for an extensive suppuration ofthe scalp, where, having stitched
the hps  of  the wound  lightly and  nicely  together, and taken
every pains to prevent suppuration,  it had yet suppurated ; but
it is an accident so frequent, and indeed so much  depending on
peculiar  forms  of fracture, as  to  occasion a variety of excep-
tions to the  general rule.
   1 hirdly,  The first exception  which I would explain to you,
is not of this nature, but depends on other concomitant circum-
stances.   A fracture, with or  without depression, may be of
such extent  as to indicate great violence, the concomitant symp-
toms announcing extravasation : the fracture traversing the chan-
nel wherein the great branches of the arteries of the dura mater
are lodged,  they are often lacerated, and pour out much blood,
which  may be actually   seen oozing through the chinks of the
fracture, and in  such circumstances it is our duty to operate :
but then our sole motive for  operating is  to  relieve the  brain
from the blood  which oppresses it, not on  account of the frac-
ture, which only  marks the place  of the chief violence.  Fi-
gure 2.  may represent  such a fracture ; where (a) marks  a
wide fracture  (through  which the  black blood is seen) running
down  into the orbit,  perhaps into  the basis of the scull; (b)
two other limbs of this wide and gaping fracture, running down
along the temple, and  backwards  through the parietal bone ;
(cj  represents a  large  corner  of bone depressed, apparently
loose, and so surrounded and insulated by the the various chinks
of the fissure, that you   would  believe, first, that it  would be
easily removed if that were reckoned  prudent ; secondly, that
it must be perfectly easy to elevate the slight  depression of a
bone so insulated; thirdly, you would be naturally inclined to
fear  that such a bone could not have sufficient  circulation to
live :  but all this is deception, a very common deception ; for
such a  bone is steady,  immovable,  cannot by any  force ofthe
levator be elevated, and lives, and  granulates :  (d) marks the
trepan circle which should  be made in these circumstances, and
the piece  of bone being  sawed through and picked away, the
half-coagulated blood rolls  out as black  as pitch, and the patient
is relieved, and finally saved.
  This represents in truth the head of a very stout sailor lad,
who, in  going out upon the main-yard, to get in the studding-
sail boom, fell clear from the height of the main-yard : no stay
nor tackle broke his fall; he had not a  wrist, nor any part pain-
ed or bruised ;  he lighted full on his forehead, which bore the
whole force of the fall,  and, by  hitting a cat-head, (a solid pro-
jecting clump of timber, round which the tackles  are secured)
his scull was fractured with deep and wide rents, running down
towards the basis, in every direction.  This happened on Sun- 
332
Of Exceptions to the general Rule.
day evening;  he was immediately carried down to the cabin,
and  lay  long  insensible, and when  he revived, found himself
cold, giddy, sick  and powerless, and  continued to vomit tor
some hours.
   On  Monday', when I saw him, there  was no delirium  nor
confusion of intellect, night nor day; no faultering of the tongue ;
no dilatation  of the pupil;  no sign nor degree  of palsy  in  the
left side, and the  vomiting had ceased :  he complained of no-
thing but of indescribable  suffering in his head, and a sort of
oppression and misery during the night;  yet his condition was
very decidedly marked by a sign, which I have seldom found
deceive  me, a slowness  and marked intermission of the pulse,
which, throbbing slowly and heavily,  pauses at every fifth or
sixth beat.  The  wound in  his forehead was  right-lined, of
small extent,  about an inch and a half; not mangled  nor lace-
rated ; the lips not puffed up by extravasation, but simple, as it
had  been made with  the  blow of a poker ; and through this
wound the probe, passing obliquely, discovered  a slight depres-
sion, a rough edge  of bone, and wide fractures,  through  which
the buttoned point ofthe probe might have passed.  His condi-
tion  was  singular: he was a big and fleshy lad ;  and, from  the
Steadiness of his posture, the  sluggishness of his motions,  the
manner in  which his limbs were folded, and the slow  and  op-
pressed  way  with which he  spoke, from the slowness of his
breathing,  together with various indescribable  circumstances,
one felt, while standing  over him and rousing  him to answer
questions, as  if conscious that he lay heavy on his bed.*  His
answers, even to  the most  curious questions, were circumstan-
tial and correct; but they were extorted by urging him to reply :
his answers to each question were delivered slowly, after draw-
ing  a long breath, and with an oppressed  sigh.   He seemed to
feel gre:>t oppression at the scrobiculus cordis : his head always
dropped  upon his breast; and his hands, when you raised them,
dropped  heavily by his side.   You were conscious ofthe pain it
gave him to renew a conversation, by the  slowness and sighing
with which he began his replies :  he  lay still, oppressed, breath-
ing slowly, with deep inspirations, and he had a correspond-
ing  pulse, for it throbbed slow and .heavy, beat  just 50 in  the
minute, and at every fifth or sixth throb, it paused distinctly the
space of  one slow pulsation.
   His suffering during the night, he  said,  was inexpressibly
great, but it was such as he could iu no shape  describe.  He was
told  how doubtful his condition was, and how likely that  we

  * I do not fcruple to copy  expreffions of this  inaccurate  kind from my cafe-
book, when I find them, however incorrect, to be fuited to convey thofe lively im-
preflions which one has only in the moment of looking upon a  patiert 
Of Exceptions to the general Rule.            333
should advise him to submit to an  operation.   After passing
one  night more  in this oppressed condition, he allowed us to
elongate the incision, making at the same time a crucial one, by
which these terrible fractures (fig. 2.) were  displayed; but  the
inner surface of the flaps of skin was so exquisitely sensible, and
he was so far from feeling  all his misery, that he insisted upon
being carried to bed.
  But, two  nights more of that  indescribable suffering,  which
he had tried  to express to  us, quite subdued  him :  he said,
" whatever we  pleased  to do with him, was now welcome."
The flaps of scalp were  now, on Thursday,  in a state of suppu-
ration;  the  hlack  blood was, at  the time  of incision,  distin-
guished through the fissures; and upon the circular  piece of
bone {d) being  cut with  the  trepan, rolled out in large clots.  I
could feel a great hollow betwixt  the scull and dura  mater,
which was depressed by the extravasated blood,  and the  probe
passed along unobstructed  for several inches,  in  every  direc-
tion, from the trepan hole.    To  talk of repeating the perfora-
tions till  an extravasation of this extent were uncovered, would
be to%think like a school-boy': the process was in this case sim-
ple and uninterrupted.  The patient's anxieties and  oppression
were gradually  relieved.  He was trepaned  on  Thursday : on
Friday he felt quite relieved ; on  Saturday, his slow, throbbing,
and intermitting pulse, had  risen from fifty to eighty in the  mi-
nute ; and at each dressing the blood diluted with a sort of se-
rous exudation from the surfaces  melted and flowed out.   At
the first dressings,  1 made way for its flowing out more  freely,
by introducing the probe, wrapped in oiled lint, and moving it
gently round betwixt the scull and dura mater;  and as the  du-
ra mater rose, which it  did  visibly from day to day it assu-
med a vermeil colour :  the  scalp, bone, and dura mater were,
in course of a fortnight, one undistinguished mass of red gra-
nulations ; the  process  of healing was rapid and uninterrupted,
not even  interrupted by the loosening of a small piece of bone,
which was partly cut by the trepan and partly insulated  by  the
fracture, and which  I picked away, without the help of forceps,
with  the  probe.   I  find that, on  the Sunday following,  I had
been obliged to turn out large  clots of blood with  the  probe,
which presented at the  trepan hole, and extended  far under the
scull; and that, on the following days, I was occasionally obliged
to use the syringe,  with tepid milk to wash  out clots.
   Fourthly,  Yet you must perceive, that it  is not in such cases,
that the gaping fracture, or even  the excessive depression, that
is an object of concern,  but that the extravasated blood is at once
the cause ofthe danger and of those signs which denote its exist-
ence ; and those signs  of extravasation may be so decisive, es- 
334           Of Exceptions to the general Rule.
pecially when conjoined with fracture and depression, as to in-
duce  you  to cut  open  the integuments and perforate the
scull.    This was proved  by   the following  case  of a fine
sailor boy, about fourteen years of age,  spirited.,  active, and
very thoughtless.   While the vessel was unloading, he trip-
ped in skipping about the deck, pitched headlong  into the hold
among casks, and was carried up into the air in  a state  of stu-
por,  bleeding from  the nostrils and vomiting.   There was  no
external wound,  but a universal  extravasation of  blood into the
cellular substance of the scalp, especially over the right eyebrow,
by which the eye was almost closed.   It was some time before
he was removed from the ship in the roads ; and when I first
saw him, it was  easy,  through the integuments,  swelled as they
were, to  distinguish fractured edges, and a depressed bone ; but
the extent or form of these could not be ascertained, and indeed
they never should have been with me a motive for making in-
cision  into  the  swelled  scalp, but that he lay still in a state of
stupor, vomiting, and  bleeding from the nostrils: his stupor
was not the deadly  snoring of the apoplectic  state ; it had  the
peculiar  character which! have just attempted to delineate :  he
could be roused, was  sensible and rational when excited, but
still he was in a state of stupor, injo which he instantly relapsed.
Generally the removing the patient to an operation-table, and
almost always the first incisions, excite the patient, though  de-
lirious, he becomes rational, though torpid, he  is  roused;  yet
still, even  when thus roused, his actions, bear the character of
stupor or delirium.  This boy, when carried to the operation-
table was   roused  to a  perfect consciousness  of every  thing
around him ; and, when the operation was done, said, "I  think
I have borne it with spirit."
   This  boy then was perhaps a  fit subject for the experiment of
trying how  far the powers of nature might prevail, in  at once
supporting the system under oppression, healing wide fractures,
and absorbing much extravasated  blood; for while there was
such extravasation  outwardly, along with  conspicuous  fracture
of the scull, there was great probability,  almost a certainty, of
extravasation within.  It was an experiment I did by no means
feel myself entitled to make ; because the stupor, the vomiting,
the hamorrhagy from  the nostrils continued :  I  therefore  made
an incision  into  the tumour, a long incision, which, directed
by what I felt without, uncovered a long fracture.  The  lower
part of  the forehead was more swelled with suggilation;  the
eye  was more  closed;  the edges of the incision, when laid
aside, were  more  choaked with coagulated  blood than  could
be well  represented in a drawing: the coagulated blood was 
Of Exceptions to the general Rule.           33,5
  also injected so  into the cellular substance about the pericrani-
  um, that the fractures could be better felt than seen: but, one great
  fracture running down the forehead, passed into the  orbit,  and
  was so very wide that it easily admitted the handle of my scal-
  pel : another limb of the fracture ran round in the direction ofthe
  coronal suture ;  a whole piece and corner was deeply depressed,
  and so far locked under an edge ofthe sound bone, that it was ne-
  cessary to make  two perforations, and to cutoff a small project-
  ing corner with the finger-saw, before we could think of using the
  lever.  The blood rolled out through the first perforation.  The
  depression of the dura mater by the blood  was as great as in
 the former case ;  the circle in which,  I  could with  the probe
 feel it  detached,  was as wide :  the rising of the pulse, which
 had been oppressed; the recovery  from  the  stupor; the gra-
 nulation of the dura  mater, and the closing of  the wound; and
 the  daily issue  of clotted blood,  make this, in all respects, a
 just parallel with the case I have just related.    The  extent of
 the wound was such, that the boy was not  dismissed till the 9th
 of January, the 7th of September being the day of his fall: but
 what surprised and gratified me was this,—the piece of bone,
 which had been  depressed and elevated, actually  moved with
 each pulse of the brain,  so loose did it lie  upon the  dura mater.
 I feared, when I  saw the dhra mater through  the trepan holes,
 red and granulating ; when on the 20th day from  that  of  the
 operation, I found also all the exposed part of the scull covered
 with a fine and florid pile of granulations, this triangular piece
 of bone excepted, (which  continued  yellow,  quite bare, and
 still  moveable), that it must become entirely carious, and exfo-
 liate ;  and that this, by protracting  the cure, or, by its exposing
 the brain, might bring the boy into  new danger : I  had this im-
 pression on the 30ih of November, and marked it  in my daily
 report; but by the 6th of December, the same pile of florid gra-
 nulations had crept along over the whole surface of  this portion
 ofthe scull, and by the i4th the  whole wound was cicatrized.
   Such wide and  gaping fractures, then, imply a very heavy
 blow, or a fall from a great height: I find them often  accom-
 panied with  deep apopletic  stupor,  with palsy of one side, di-
 lated pupils, and involuntary stools ; with groaning and sighing,
 an uneasy tossing from  side to side in bed, as if from oppres-
 sion, and a frequent raising of the hand to the  affected  side of
 the head.
  Fifthly, There is a kind of danger inseparable from certain
 forms of depressed fracture, which no experienced surgeon will
despise.   A flat and even fracture,  having no particular point
depressed, causing no stupor, and attended with no 111  signs,
's by  no means  a  fit  subject for  operation :  but, where  (as 
336          Of Exceptions to the general Rule.
  in fig.  3.)  the  fracture is  radiated and pointed,  where the
  bones  do not " lie pashed or loose upon the dura mater,"  and
  yet are much shivered : where not a long flat edge is  driven un-
  der the sound bone,  but  particular  points are  depressed, pre-
  senting probably on their  inner  surface  spiculae and irregular
  and jagged edges, there  is imminent danger, not irom the de-
  pressed bone lying heavy upon the brain, but from its points
  pricking the dura  mater, whence on the eighth or tenth day,
  inflammation extends from the  membrane to the brain, shiver-
  ings and tremors come on, and the patient dies.  Not the long
  and wide fracture (a a, fig. 3,)  nor  the general depression pro-
  duced by the yielding of. the three triangular portions (6, c, d,~)
  are the cause of danger, but the dipping in a more perpendicular
  direction of the point (d), which, being central, has  received a
  great proportion of the force, and which by being driven deeper
  than the lateral parts (b and t),  is likely to carry down splinters
  from the inner table of one or both these portions : it is because
  the scull consists of two tables, and not by the peculiar fragility
  (though it is more fragile) of the inner table,  that points, and
  spiculae of it are so apt to be driven into  the brain : when the
  pointed portion (d) is driven below the level of the  contiguous
  parts (b and c), it leaves  behind it  the  outer table  of each  of
  these portions,  but it passes the inner table, and, as it is driven
  inwards, every inequality,  or angle of the fracture, makes a re-
  sistance  by which  splinters are not only  carried  before the
  point (tf), but driven vertically, like pins or  sharp wedges,
  through the dura mater.  The experienced surgeon distinguish-
  es at a glance the forms  of fracture in which there is danger of
  this  kind:  and, in a fracture of the form here described, radia-
  ted, pointed, and depressed, an there is no room betwixt fragments
  lapped over each other,  like fingers when plaited and squeez-
  ed together,  to  admit a  lever,  I think it right to apply the tre-
  pan at the angle (e)  (as usually there is such an angle in every
  fracture of this species),  through which the lever, being intro-
  duced under the depressed points, raises them,  and the  probe,
  being turned round within the scull,  will ascertain whether any-
  rough edges still present, or  whether any spiculae or dangerous
  points  stick in the membrane.
*   Sixthly, Fractures of  this form may  prove dangerous, but
  depressions of the kind which lam next to describe must be so.
  The form of depression which  happens when a man is  thrown
  from a stumbling horse,  and  pitches with his head  directly  a-
  gainst a stone;  or when he falls from a  yard-arm for example,
  and pitches upon the  deck ; or  when a  block and tackle,  or a
  corner-stone from a building, falls directly upon his head. This
  fracture is described  by the ancients under the title of Camera- 
Of Exceptions to the general Rule.          337
tio, the camerated fracture, as resembling the inverted  tiles of
a house ;  that centre is depressed in a direct line, the sides de-
cline towards that centre,  like  the forrh which  the  two hands
make when laid together edgeways.  The form ot this peculiar
fracture has been  but too minutely described ;  while  its charac-
ter has been less an object of attention, though, from its very
form, these inferences are  plain :- First, that in consequence of
its great extent, both lengthways and from side to side, the op-
pression of  the brain,  if such an effect could be produced  by
depression ofthe  scull, should be most manifest ;. yet I affirm,
from experience, that such  effect is rarely felt, and shall prove,
at the least,  that oppression of the brain is not inseparable from
this  kind  of depression :  Secondly, it follows  that from the
depth to which the central line, or direct fracture, is depressed,
there must invariably be  presented  two rough and very  dange-
rous edges, which, by irritating the dura mater, will  cause sup-
puration : Thirdly, that though the patient should escape this
danger, the circular fracture or crack  which  surrounds the
whole, and which must invariably accompany depression of this
form, (without which indeed the bone, in an adult at least, could
not yield), must almost always insulate the  depressed  pieces,
they must in nine of ten cases become carious,  and  to prevent
these manifest dangers, I imagine  it to be  clearly the duty of
the surgeon to elevate and pick  them  away, by pressing in
his lever betwixt  the edges of  fissures usually  very wide; or
this being either  impracticable, on account of the wedge-like
impaction  of the depressed portions, or dangerous from the
dipping of one end of  so long and broad a fracture, while the
other is rising, he should apply the crowns  of the trepan suc-
cessively, till the bone can be  raised  without being turned in
upon the brain.
   The case which I have selected for illustrating this principle,
is that of  an old  man, of  the name of Thompson, who might
have been saved by a timely operation, but who was  lost by de-
lay.   He  had fallen headlong down a  precipice, (the Calton),
fractured his scull,  had a double depression in the very course*
of the great longitudinal sinus, and of the  falx, which, if any
thing could oppress the brain and disorder its circulation, should
have produced that effect: but so slightly was he affected, that
nineteen days elapsed without himself feeling, or his friends
suggesting,  the propriety of procuring assistance.  At the end
of twenty days, this  was  his condition: the depression was
manifest to the  touch and to the eye ; the whole extent of the
bone was black and bare, and a pale granulated fungus surround-
ed it: he had never, from  the moment of the accident, had one
                           2 V 
358          Of Exceptions to the general Rule.

hour of sickness, or vertigo, or any considerable pain, but, on
the twentieth, began to lose his appetite,  became drowsy when
undisturbed, and languid when forced to speak or move ; his
pulse was rapid and small, his nights were passed in confusion.
On the  twenty-second day7, he complained  of more than usual
pain, of slight  vertigo,  and of nausea ;  and these  symptoms
succeeding a night of confusion and delirium, in which he strug-
gled often to get out of  bed,  made it necessary to  perform
straightway an operation so obviously necessary,  which had in-
deed been resolved on, and delayed only by necessary arrange-
ments. The crown ofthe trepan was applied twice, and through
each perforation the lever was introduced, and the bone poised
up, but could not be safely moved till the third perforation set
it quite free,  when all the blackened bone was taken away.
   But long before the operation  was performed, the fatal in-
flammation had begun ;  so it appeared from the depth and ex-
tent of the fatal abscess, which had indeed destroyed one entire
hemisphere of the brain.  Hitherto his state  might rather be
described by the term drowsiness than stupor: but the delirium
of the night preceding the operation was a decisive and fatal
sign.   This delirium never ceased : in the present, as in all ca-
ses that I have watched,  the symptoms were aggravated during
the night: in suppuration of the brain, every long slumber is fol-
lowed by a degree of delirium, and the fate of a patient, whose
condition cannot be suspected from  any symptoms occurring
during the day, may be prognosticated from  the confusion  in
which he passes the night.   Through the night following the
operation, our  patient  started up frequently, struggled to get
out of bed, talked incoherently, but the return of light restored
his senses, and during the day he was rational and composed,
but still he slumbered.  This was  his condition during the nine
days that he survived the operation : his pulse was a hundred
and twelve, weak and variable ; he was restless and confused
during the'day, especially after slumbering, and was delirious
during the night:  from  the opening in the scull, there was  a
considerable oozing of blood and of bloody serum.   The third
and fourth nights after the operation, were less perturbed : du-
ring the fifth and sixth,  he was extremely restless and agitated,
speaking much, and struggling to get out of bed: the dura mater
appeared now black and sloughing, with a fetid, thin, and bloody
discharge. On the seventh, he became comatose; his cheek had
a circumscribed and hectic flush ; his pulse beat 120, there was
no more delirium,  he lay insensible, and passed his urine and
feces unconsciously; on the sixth, seventh,  and eighth days, the
coma became deeper; he lay still,  and muttering ; and,  after
flight convulsive rigours, expired, on the ninth day after the
\ 
Of Exceptions to the general Rule.           339
 operation, the twenty-eighth from the time of his fall.  In de-
 scribing deep suppuration of the brain, to speak of the laxavities
 and draughts that are administered,  or of their  effects, were a
 very trivial detail.
   Upon dissection, the whole of the  right  hemisphere of the
 brain was found in a state of suppuration; the basis of the ab-
 scess was very large ;  the opening through the dura mater, was
 like  that made by  a  large abscess lancet,  into  the sac of any
 great tumour:  the  medullary  substance of the brain was soft
 and gelatinous; the part  immediately surrounding the abscess
 was  gangrenous,  marked by  a black or leaden colour, extend-
 ing an inch or more round  every part of the abscess, and ter-
 minating in a disk or halos of a deep green colour :  the left he-
 misphere  was also, in a degree, tainted with the same colours,
 and slightly ulcerated  on its surfaces.
   Seventhly.   Punctured fracture is that form of wound  in the
bone  which  has  the same relation  to these wide fractures and
broad depressions, that the stab of a bayonet has to the cut of a
sabre:  plainly and indisputably requires  the trepan,  for in no
case can we divine how deep the point may have  gone ; how
far the ball, weapon, or point,  may have sunk  into the brain ;
in what degree or form the bone, especially its inner table, may
be  fractured : blood  is often  extravasated, and often spiculae
stick in the dura mater, or in the  sinuses : the present injuries
are  sufficient motives  for applying the trepan, and caries is,  in
this form of fracture, almost inevitable.  I hold it to be the du-
ty of the surgeon in all such fractures to use the trepan ; to place
the  centre-pin  of his  instrument as close by the centre of the
fracture as its irregularities  will allow ; and to  operate with a
crown so large  as  to cover all the  fracture, and cut  it out  at
once.
   Such cases remind me of  the necessity of establishing this  as
a rule " that all punctured  fractures should be  trepaned," and
of enumerating the general accidents by which they are produ-
ced.*   When  a man falls backwards against the sharp coiner
  • The melancholy confequences of fuch a fracture, are admirably depicted in
the following Angular cafe,  where the fracture  was fo minute that,  had the in-
 teguments been fully opened, it might  have efcaped  inveftigation ;  and  yet the
cutting out of fuch punctured piece of bone early, could alone have faved the boy's
life.
------Brand, aged  about 14, was ftruck  on the temple by a pair of fciffors
flung at him, the point of which ftuck  a little above the external canthus of his
eye, till it was pulled out.  A bit of fugar tied on the wound by his mother flop-
ped the blood.  He complained little for two or three days ; but the pain gradual-
ly increafed every day after.   However, he went about till the eighth day, when
he fell into convulfions,  and I was fent for.—There was a hard tumour under the
pericranium and crotaphite mufcle, fo tenfe, that a fluctuation in it could with dif-
ficulty be perceived. The tumour lay fo exactly under the artery, that it could
not be hid fully open without wounding the artery.  To prevent an haemorrhage, 
340
Of Exceptions to the general Rule.
of a stove or grate ; when, by the bursting of a fowling-piece,
either the fragments of the gun-barrel, or  the breech-pin enter
into the forehead; when, by  a blow from a hammer, from the
keys of a crane swinging  and  hitting the  head; when,  by the
blow of a sharp-pointed stone,  making a radiated wound  of the
scull, depressed in the centre ; when a splinter  from a carro-
nade, or bolts, nails, or other fragments of iron have, in a sea
engagement,penetrated the scull;  when  a musket-ball,  a  dag-
ger's point, or  the  point  of a pike or bayonet, sticks in it—the
fractured bone, and the fragment  of the weapon or the ball,
must be  cut out with the trepan, else,  slightly as  the  patient
feels the  wound, he will,  by  the inflaming of the bone and the
suppuration of the dura mater, be irrecoverably lost,  before the
symptoms indicate danger.    These  are  almost the  only  frac-
tures in which I think the largest sized trepan should be used.
   Shocking as the accident was,  which  I am now going to re-
late, I hardly ever saw a punctured fracture that I would so wil-
lingly have left to nature as that which happened to Billy Came-
ron, a  boy of about twelve years of age.    He was occupied  a
whole morning with his little play-fellows,in swinging upon ana-
rea door : the staple was loose: the insecurity of the door made a
part of the pleasure they had in swinging upon it.  When it  came
round to this  little boy's  turn, the stone in which the staple was
socketed, gave way ; the gate  of cast iron, the corner-stone, and
the boy, tumbled all at once into the area ; a good woman ran
out instantly to lift  the boy, and found him lying  with his head
pinned to the ground,  betwixt two iron spikes, one of which
had grazed and wounded the left side of  the head, while ano-
ther had pierced the scull, and was sticking in the parietal bone,
the weight of the gate and  the stone lying  above him.   She
carried him in  her arms into her house, where he lay without a
sigh or a struggle, cold, pale, and death-like,  for ten  minutes:
 he then began to draw long breaths, to groan, and  to  open his

 therefore, I cut the artery and all through to  the bone with a biftoury.  About
 half an ounce of well- conditioned pus rufhed out, by which he was greatly relie-
 ved — When I thought enough of blood had been dilcharged, it was eafily flopped
 by a dry dollil ahd a halfpenny in the comprefs___Next day he was brought to
 town ; and Dr. Gilchrift ordered fuch internal medicines as were judged proper for
 him, and he continued eafier for two or three days.   After which the violent head-
 ach and vomiting returned and lafted two or three days more, when  a large
 quantity of matter burft out from  within the fcull,  which again gave fome
 eafe.—But, though the  orifice in the integuments was enlarged, no further dif-
 charge could be procured.  He died in a day or two  after, being the fixteenth
 day after the* accident.—On opening his head, half a pound of pus was found
 in the brain, and the hole in the fcull made by the fciffors  would  not admit
 the point of a pin.—His friends abfolutely refufed the trepan,* by" which he pro-
 bably might have been faved.  His death,  however, was of ufe  to others, who
 more readily luDmitted to the operation, upon feeing the fatal confequences *'■
 meglc&ing it in his cafe. 
Of Exceptions to the general Rule.           341
eyes ; when his elder brother passing, and hearing ofthe nature
of the accident, went into the house irom a common impulse of
humanity, and found his little brother in this mangled condi-
tion.  He called a sedan chair, and placing him on his knee on
piilows, brought him to  the Infirmary.
  By the  time his father and mother had arrived, he was quite
collected, and in his senses, he was sitting up, while his head
was shaved, his mother took him upon her knee and soothed
him ; he laid down his  head upon her bosom, and cried : but
he wiped away the blood carefully and nicely with his handker-
chief; was perfectly collected and obedient,  and neither cried
nor  struggled.   The wounds were, one upon the left side,
slight and superficial,  from the  grazing of one  of the  spikes ;
another in the right temple,  or rather about the  centre  ot  the
parietal bone, very deep.  The  punctured wound of the integu-
ments admitted a probe, which, passing obliquely backwards,
encountered the edge  of a deep depressed fracture:  the iron
point had not directly pierced the scull,  but crushed and burst
through the bone obliquely, and, by a lateral pressure, it had so
bent down a piece ot the scull, that the fracture was long and the
depression broad; but the integuments were only slightly wound-
ed, they were punctured,  and not torn. -  The boy was in his
perfect senses, without even that tremor or agitation which such
an accident might occasion ; no weakness of one side ; no stu-
por ; no vomiting ; no dilatation of the  pupil ; no slowness nor
 pausing of  the pulse, such as usually accompanies tffusion  of
 blood.   I was averse from the proposal of opening the integu-
 ments, and ventured to prognosticate the worst consequences if
 a fracture, already so extensive, was trepaned,  and the bones
 torn away : but the boy,  though there  was  not the shadow of
 an  ill  symptom, was  trepaned ; a long incision was made :
 two pieces  of bone, each half an inch broad  and  an inch long,
 were twisted and pulled away ; two smaller fragments were loo-
 sened  and  pulled away by  the help of  the levator and forceps:
 all, in short, that was depressed, was disengaged and separated ;
 and the boy, whose condition was  after the accident doubtful,
 lay now  in a most perilous state: The integuments cut up to the
  extent of three inches; the scull opened to  the same extent ;
  the dura mater left to sustain alone the force of the arterial pul-
  sations, and the brain already protruding, even while the dura
  mater was still entire.   I never, in boys, find the dura mater ca-
  pable of supporting itself; wherever the openings  are thus wide,
  it inflames, sloughs, gives  way at  one  or more points, and the
  proper substance of the   brain, previously suppurated,
  and ready  to form a fungus, protrudes: so it was in this case.
    " Upon examination,  after  death, it was  found  that the 
342          Of Exceptions to the general Rule.
 chief disorder lay in the right hemisphere of the brain, though
 it  was in part communicated to the left.  The left ventricle
 was  somewhat enlarged, its  surface irregular and soft, with
 suppuration,  while a dirty  greenish-coloured pus lined the
 walls :  the  inflammation, thus  communicated to the left side,
 was universally diffused : the substance of the brain, in its an-
 terior part,  remained natural; the cortical and medullary parts
 were distinguished by the usual  colours and forms, but the sub-
 stance  of the brain, where it approaches either inflamed sur-
 face, viz. that of the ventricle, or of the hemisphere, assumes
 a dirty olive green colour,  which muddy and dusky green is
 the prevailing colour of the inflamed or half-gangrened  parts.
 Immediately opposite  to the wide opening of the scull, all dis-
 tinction of the medullary and cineritious substance ceases; the
 brain has degenerated into a confused mass, which  may  be re-
 presented, in a drawing or a model,  by a ground of olive  green
 touched with spots  of vermilion, like extravasated blood.   The
 dura  mater  covering the  right hemisphere of the  brain, was
 much thickened, and leathery-like ; its  vessels  conspicuous,
 red, and turgid, and coated with a tenacious coat of pus, great-
 ly resembling, and  in some degree partaking of the nature  of
 coagulable lymph;  but there was much unequivocal pus spread
 over all the  hemisphere, reaching even to the basis of the  scull.
 The dura mater  was  perforated, but  not round  the margin
 of the circle made by the trepan, as if wounded by the teeth of
 the instrument; the openings were round and centrical  in re-
 gard to the naked part of the membrane, and were filled by the
 protruding parts of a fungus. The most  difficult and interesting
 part ofthe anatomical inquiry was that which related to the state
 and origin of this fungus: it proceeded apparently  from  the
 membranes of the brain, from the pia mater ; it was elongated
 from the surface ofthe  brain in the form of threads, the remains,
 I presume,  of vessels which gave consistence  and strength to
 what  in other respects resembled mucus."
  Eighthly.  One principle, relating  occasionally to every form
of fracture;  to the depressed ;  the angular and fractured wound
of the scull; the mere  rimaor fissure ; nay, even to the slight-
est bruise of a bone, is this—that every such fracture may be-
come carious.   When, by carelessness or design, a fracture
has been quite neglected, or imprudently treated;  when,  along
with a fracture or fissure, the scull has been grinded and  brui-
sed by a carriage-wheel, or grazed and deadened by  a musket-
ball ;  when the wound and the exposed bone has been much ne-
 glected  or much tormented, by the ignorant surgeon, the frac-
 tured part becomes carious;  when the wound becomes pale and
 flabby, the bone still seeming to the touch of the probe bare and 
        Of Concussion and Compression ofthe Brain.      343

rough, or in part exposed, yellow, duskish, or inclined to black-
ness ; when the patient sickens and becomes  languid, with a
furred tongue,  a  hot skin,  and a febrile pulse,  and  a chorded
feeling within the head—let the surgeon no longer show his hu-
manity or skill, by watching his patient, but make haste to per-
forate the scull;  if he perforate early,  he  will find but  a little
cream-coloured pus upon the dura mater, which will  granulate
and re-unite with the inner surface ofthe scull; but if he wait
but three days,  the ulceration will affect the brain.
   Let this, qualified with such exceptions as  your own good
sense and experience may suggest, be your rule of practice.   It
is not by neglecting depression, which  never is in itself hurtful,
but by disregarding a carious bone, and the slight but mortal
signs of internal suppuration, that many patients are lost.
DISCOURSE XIX.
ON  THE  STATES  OF CONCUSSION  AND COM-
  PRESSION OF THE BRAIN ;  WITH EXAMPLES
  NARRATIVE AND DESCRIPTIVE.
SECTION  I.
                 Preliminary Observations.


 J. O treat  fractures, wounds, and other open and manifest
injuries of the scull, prudently and skilfully, may  be thought
difficult; but how to reason concerning those  internal injuries
which are hidden from the senses, and marked only by variable
and uncertain signs, must ever be perplexing.   Perhaps there
is nothing more generally desired by the profession  than some
decisive  marks, denoting the particular nature of that stupor in
which a  patient  lies oppressed after a  fall or a heavy obtuse
blow.  But  there is no such sign ; we are doomed to proceed in
our profession always with  a degree  of  uncertainty, and to re- 
344              Of Concussion ofthe Brain.

gulate our conduct by a perpetual and attentive exercise of our
judgment and senses.  It is  only by a deliberate and calm re-
view of the  circumstances attending concussion, that we can
arrive at any thing like a conclusion.
   To reason upon the cause  of every phenomenon in the liv-
ing  body, is natural and unavoidable,  and does by no means
contribute either to multiply or confirm whatever prejudices we
may have : it is only from refusing to reason that our worst pre-
judices have  arisen : and prejudices of ignorance are infinitely
more dangerous than the prejudices of those who, being willing
to reason, are of course open to conviction, and inclined to en-
ter into the  discussion of whatever new views or  unobserved
phenomena are brought to light.  Nothing perhaps can be  more
unmeaning than the  word Concussion, which is not,  in the com-
mon acceptation,  accompanied with any  conviction of the
structure  of the brain being disordered by the shock, the  term
implies a belief that  the affection is ofthe nature usually  deno-
minated  Nervous.'  that it is inscrutable in its nature ! that, as
we know  nothing ofthe immediate cause, we can do nothing to
recover our patient! that whatever phenomena we observe, are
such as are usually designated signs of debility ; and from this
persuasion,  and an  indistinct and  confused analogy, (as Mr.
Abernethy observes) betwixt fainting and concussion, stimulants
and wine, the  most dangerous of  all medicines, are poured
down.
   If concussion be indeed this inscrutable nervous affection, un-
attended  with physical disorder, we must become mere specta-
tors ; there is an end of reasoning, and  in such uncertainty it
were better  to refrain from practice.   But, the comparing the
 brain with other parts and organs of the body, will bring to our
 recollection  many consolatory circumstances,  which will encou-
 rage you to believe, that here also our profession may be useful.
 What does  a  bruise, a shock, and  a  general injury, do to  a
limb ?   Does  it produce any sort of disorder in a limb, which
 it may not produce  in the more delicate  substance of the brain ?
 When a man is hurt by the oblique blow of a cannon-ball, or has
 his thigh bruised by riding  furiously against  a carriage, by  a
fall,  or by a log of wood, a  block of stone, or any  heavy body-
falling  upon him, what does he feel ?  nothing but numbness :
 the part is torpid  ; he hardly  knows how much he is hurt; he is
lame ;  and we can hardly believe that any internal  or physical
 disorder  has taken place so suddenly!  yet before  he is  reco-
 vered from  his confusion,  or is able to mount his horse, the
 limb is stiff and swelled; the swelling increases every moment;
 the suffusion of blood,  under the transparent skin, shows, by
 the speedy discolouring of the  part,  that the swelling, (too sud- 
          Of Concussion and Compression ofthe Brain.      345

 den to proceed from  increased vascular action)  proceeds truly
 from blood extravasated by the ruptured vessels, and  there  is
 no reason to doubt that the swelling in the deeper parts is from
 the same cause : the vessels ofthe limb have given way in many
 parts ; its cellular substance is choaked  with blood  : if the suf-
 fusion be so universal and so great as to suffocate the arterial
 action, the limb never recovers, all living action  stops, it gan-
 grenes and dies :  if the blood be injected in such a degree as to
 create only pain and disorder,  the arterial action  is rather excit-
 ed, and heat, pain, redness, and suppurative inflammation, take
 place : if the blood be less generally injected into the limb, it is
 more easily absorbed,  and the  swelling is resolved without red-
 ness or pain.  Of this suite of  phenomena I must needs remind
you,  before proceeding, to observe in  what degree these  ap-
 pearances take  place in  shocks or blows upon the head, and in
what degree they are likely to affect the functions of the brain.
                         SECTION II.

                        Of Concussion.

   The patient who has fallen from a great height,  and lies in-
 sensible  from the shock, has sustained the principal injury  in
 that system of vessels  which, from all  that I have related  to
 you, is the most  delicate, and the  most susceptible of extra-
 vasation.   Nor  is there  any  mark wanting  of extravasation,
 slighter or greater, general or  local, having taken place in the
 brain :  nervous affection  (if we are still to use this unmeaning
 term)  might, for a moment, confound the functions of the brain,
 as a man  is not only stunned, but  sickened by a blow ofthe fist;
 but the patient, who has suffered a concussion, lies  insensible
 snoring, and with his senses oppressed, and is in a state resem-
 bling that of apoplexy or intoxication ;  his forehead is  swelled,
 his eyes often  closed, and his features  deformed with  extrava-
 sated blood ; blood gushes at once from his nostrils, mouth, and
 eyes ;  his pulse is slow and pausing ; his limbs and joints loose
 and relaxed ; the pupils of his eyes dilated; his breathing slow ;
 his whole body cold ; you hardly know that he is alive, but by
 his groans.   If blood has  thus burst from  every  part of this
 system of vessels, is it likely that  the  brain has escaped ?   If
 the blood-vessels of the nostrils, of the  throat, ofthe ears, have
 burst from the  shock, and blood is also  effused under the  skin,
 is it likely  that the delicate substance  of the  brain should es-
 cape the same degree of suffusion ? It is indeed true that, when
the patient dies, and  his brain is  dissected  in that coarse  and
                           2X 
346      Of Concussion and Compression ofthe Brain.
slovenly manner, which it but too common, and by boys who
hardly know its natural colour and forms, it seems as if nothing
had happened to account for the sudden death of the patient;
and it is confidently reported so, because there is no fracture of
the scull, nor any conspicuous effusion  of blood: but when a
brain thus deranged is dissected  by a master who, by judging
what is likely to happen, knows  what to look for ; the pheno-
mena, though little perceptible to  an ignorant man, must be in-
teresting to a thinking observer.
   " A  man" (says Mr. Abernethy)  " having fallen from  the
 roof of a brew-house, a.height of at least eighty feet, had  his
fall broken by touching the ground first  with his wrist, which
was dislocated and  mangled ; his forehead  next  struck the
ground, and his face was bruised, but his  cranium was unin-
jured : he lay  at first almost inanimate, cold, and with a feeble
pulse:  when he became warm, he had  stertorous breathing, a
dilated pupil, and a profuse perspiration  ; his pulse rose to 140,
he recovered a degree of sensibility,. his pupil contracted, and
his eye-brows were drawn into a frown;  but his pulse again sub-
 sided ; the animal functions gradually failed ;  he died the fol-
lowing day;"  and  his head was dissected by Mr.  Abernethy,
 who reports the state of the brain in these words : " On  dissec-
 tion, there appeared every mark denoting violent inflammation
 of the  brain and pia mater, of short duration.   The minute ar-
 teries of the pia mater were turgid with blood :  in many places
 THERE WAS THE  APPEARANCE  CALLED BLOOD-SHOT,  which
 was also to  be seen  in the lining of the ventricles.   Dark-co-
 loured, and in some places bloody  coagulable lymph, filled all
 the recesses  between the  tunica arachnoidca and pia mater.
 On dividing the substance of the brain, all its vessels  ap-
 peared AS IF INJECTED WITH BLOOD.'''*
    Every word of this report,  (more impartial than  any  I could
 relate  on my own authority,) conveys  the idea of turgescence
 of vessels, and general cellular effusion, throughout the whole
 substance ofthe brain, and makes good the parallel betwixt  that
 state designated by the term Concussion of the Brain, and  the
 benumbed  and torpid condition  of  a limb whose arteries  are
 burst and cellular substance suffused by a blow : it is not possi-
 ble to  imagine circumstances  more suited to support the paral-
 lel than that suite of phenomena which takes place in concussion.
 The patient who  has  fallen from a great height, or otherwise
 suffered that shock which so deeply affects the functions of the
 brain, is found, when lifted from the ground, cold,  pale,  mo-

    * There is a preparation in the mufeum of St. Thomas' Hospital of a brain with
  a laceration in one of its hemifpheres from a fall, which the fubject, from whom
  it was taken, received.  S. 
         Of Concussion and Compression ofthe Brain.      347

 tionless  without pulse,  without  sense, and  is as in a fainting
 fit;  if he continues cold, and passes his urine and faeces invo-
 luntarily, he dies.  The first  signs of returning life are deep
 and oppressed groans,  the cold sweat breaking on his temples,
 and a  fluttering motion in the pulses  : when laid in bed,  when
 warmed and restored to life, the groans become more frequent,
 he seems deeply oppressed, he tosses  his limbs from  time to
 time ;  his face is flushed, his nostrils  dilated, his breathing la-
 borious and noisy,  his  pulse slow  and heavy, and has all the
 symptoms of deep apoplexy : by the  second day his pulse has
 risen to 120;  his lips are parched, his skin dry,  his  eye more
 open ; he stares widely, but is insensible ; and being roused, he,
 after a short  and  confused  struggle, and  muttering, as in low
 delirium, falls down again  into a heavy slumber, from which,
 if bled and purged profusely, and his head bathed with cold vi-
 negar, the surgeon having the good sense to refrain from giv-
 ing opium or  wine, he gradually  recovers.  It would appear,
 from this series of  symptoms,  that whatever general effusion
 takes place in the moment of the shock, is slowly absorbed ; and
 that the febrile inflammatory action,  which such a state of the
 sensorium excites, in the days immediately succeeding the fall,
 is harmless: yet not unfrequently  there is a true Typhomania;
 the pulse rises higher,  and  throbs powerfully;  and the patient,
 after long  tossing  and oppression, starts from his bed, strikes
 and  struggles with  his  attendants, and subsides again  into a
 state of torpor ; but by profuse evacuations, and bold prescrip-
 tions, escapes the  danger of an  inflamed brain,  though the ac-
 tion sometimes terminates in continued insanity, followed  by
 imbecility.
  These  successive states, first of coldness and stillness  in all
 the vital actions, with oppressed brain, and next ofhigh arterial
 action, accompanied with delirium, have always struck me, as
 intimating strongly the parallel  (so natural in every other  point
 of view) betwixt a contusion  of a limb,  or of any other organ of
 the body, and concussion of  the brain:  nor am I over anxious,
when I find my patient quite insensible,  lying in a state of stu-
por, resembling intoxication,  if that first stupor be followed  by
arterial action and the  signs of inflammation, for then I know
the  oppression  is from no local cause: nor am I alarmed when
he becomes delirious, for that is a state little more than febrile,
which  I  have  usually observed to be a sure forerunner of  reco-
very ;  there is  in such case nothing essentially to oppress the
vital functions, or to cause death. 
(  348   )
                        SECTION III.

                       Of Compression.

   When, in place of general  suffusion  and disordered circu-
lation, some greater  vessel has given way, and either under
the dura mater, or in the substance of the brain, there is a par-
ticular effusion of blood, the scene is very different from that
now described:  the patient, oppressed by an effusion of blood,
is never insensible,  (unless he is about to expire) and rarely de-
lirious ; his pulse never rises,  but is slow, heavy, and pausing
at every fifth stroke; his pupil is sometimes dilated ; one  side
usually paralysed, or at least still  and motionless, while the
other often shakes with a sort  of  tremulous convulsion, which
returns at regular  intervals, and is attended with a  quivering
and irregular pulse,  cold  extremities,  and insensible  evacua-
tions,  when he is about to expire.
   Extravasation more frequently arises from a blow or fall up-
on a hard body, and is more  connected with fracture  of the
scull than concussion, which arises rather from a shock than a
blow : extravasation is more ofthe nature of a local injury : the
patient, when raised up, is cold, pale, and motionless, but to this
no usual heat ensues ; he tosses as under some oppressive feel-
ing, and often  lifts his  hand  towards the  injured side ofthe
head ; he  lies with his eyes shut, groans as from oppression,
but is always  sensible ; stares at you when roused ; answers
whatever questions you ask rationally, but in monosyllables; he
seems impatient when teazed with questions ; his answers are
pronounced with a sigh or a groan ;  he is correct in  answering
to the circumstances of  his fall, even to the nature  of the op-
pression he suffers,  and to the part of his head that is  pained,
towards which he moves his hand, though irregularly,  when-
ever he is desired : in his tossing he sometimes rises upon his
elbow; when requested to rise, he sits up, and takes the drink
which he  calls for, but soon sinks down again into a slumber,
more like sleep than apoplexy, and tosses and groans more as his
sleep becomes deeper :  the oppression and tossing are insepara-
ble from this condition of the sensorium, and the pulse is slow,
pausing, beating no  more than fifty in a minute, and interrupted
at every fifth or sixth stroke, especially  while the patient is ly-
ing in deeper slumber, or when in particular danger.   I believe
I have rarely seen a patient, to whom an operation or any kind of
assistance could be useful, quite insensible from  mere oppres-
sion of extravasated blood ; and of this I am very sure,  that I
have innumerable  times seen the patient whose extravasation 
Of Compression.
349
 was-so great as to prove fatal, such  as was found upon dissec-
 tion to cover one entire hemisphere of the brain, retain his per-
 fect senses, and recollect minutely the circumstances of his tall,
 with a consciousness all along ot  every thing that was said or
 done about him.
   I have just described a condition which, I would fain flatter
 myself, can hardly be  mistaken, which at least is not likely to
 be  confounded with the total stupor of concussion.   In the
 first degree of extravasation, the  person lying oppress-
 ed  with extravasated blood, is  not insensible, but tosses  and
 groans from oppression, replies when spoken to, feels giddy,
 and, when able to express his  feelings, says that every thing
 seems to turn round ;  he pukes from time  to time, and has a
 slow, heavy, and pausing pulse : if you add to these signs, that,
 in his tossing, you  perceive  that one leg or arm still moves,
 while the opposite arm and leg lie  almost still and  motionless,
 you will  seldom  be deceived ; and finding these  symptoms to
 continue for days, the oppression to become deeper, the vomit-
 ing to cease,  and the  pulse to  decline in strength, becoming
 slower as it becomes feeble,  it is your duty to apply the trepan,
 and often you are successful.  These are the signs of slighter
 extravasation, which yet, without the assistance of the surgeon,
 becomes desperate :  for,in a few days, the side opposite to that
 which  received the blow becomes  manifestly paralytic ; and as
 the extravasation and oppression  ot the  sensorium  increase,
 the palsy is followed by convulsion ; while the one side becomes
 paralytic,  the  other  is  seized  with  slight tremors, and soon
 after the pulse becomes weaker, though it can hardly become
 slower, the natural heat declines, the patient expires  : wherever
 such convulsion accompanies  the palsy, it is too late to operate.
  In the second degree of extravasation, when the pa-
 tient is paralytic, or completely oppressed,  from the first mo-
 ment,  and there is no  perceptible interval betwixt the paralysis
 of one side and declining of the vital powers ;  when he lies op-
 pressed and moaning,  raises his hand  frequently towards his
 head,  but is not deeply insensible, nor  has the pupil much di-
 lated ; if he speaks, when teazed, though slowly  and difficultly,
 and then in a particular manner raises his hand to his head, the
 evidence of extravasation is complete, the patient is  in the ut-
 most danger, the operation should immediately be had recourse
 to, and perforating with a large trepan,  and giving  vent to the
 coagulated  blood, which rolls out thick and black,  sometimes
relieves the palsy, restores the senses, and finally saves the pa-
 tient's  life.
  But there is a third degrf.e of  extravasation, invari-
ably fatal;  and I believe the symptoms I am now to  describe 
350                   Of Compression.
indicate in general, that extravasation which either  expands it-
self over the lower parts of the brain, or extends from the up-
per parts to the basis of the scull, raising the nerves from their
origins, and distending them betwixt the basis of the brain and
the foramina through which they pass out.   The condition  I
have here to describe  is that of total insensibility  and grinning
convulsion ; an insensibility unaccompanied by stertor or snor-
ing, but, on the contrary,  with a pale face,  cold extremities,
and a fluttering pulse; a convulsion agitating not one side, but
chiefly affecting the features ofthe face, jerking the head back,
and stiffening the neck: the convulsion  resembles  that of the
locked jaw ; and it is very distracting to look upon such a pa-
tient, for  the  symptom brings  an absolute conviction  to the
mind of the spectator that the disorder is fatal.
   The patient's condition may be thus characterised; he is taken
up cold, insensible, with a dilated pupil, and hardly any signs
of life, and recovers  heat very  slowly and imperfectly :  after
lying oppressed, groaning, deadly pale, with  a  dilated  pupil,
the extremities cold,  and the eye-lid remaining raised  as you
open it, unless you lay it down again, he begins on the second
day to be affected  with convulsive  twitches ;  the cheek is par-
ticularly distorted, the whole  body is still  and cold ;  the con-
vulsion increases in violence,  and returns with a degree of re-
gularity every ten  minutes or quarter of an hour: at each return
of  the convulsion he  continues, while you can count two hun-
dred or more, to have the cheek  and corner of the mouth raised,
the eye-brow and  all the  features of that side violently distort-
ed, with spasmodic twitches,  the neck  rigid,  the head jerked
violently round and bent backwards upon the neck, with inter-
rupted strokes;  and each convulsive twitch is accompanied with
a catch of the respiration, a distortion of the  mouth,  and with
a noise of hick ! hick !  repeated at each twitch, while the con-
vulsion lasts.  It seldom continues long: on the third or fourth
day the  convulsions grow  weaker ; the  extremities  and the
whole body become cold  ; the pulse, which is not at all  to be
felt during the convulsion, trembles during the intervals, and
the patient expires.
   These  two states of concussion and compression bear a
strong analogy with the  relative states of apoplexy and pal-
sy.   Concussion, there is every reason to believe, is not a mere
nervous affection,  else it  could not be permanent,  but a suffu-
sion into the substance of the brain, resembling the ecchymosis
or bloody suffusion of a bruised limb, attended with symptoms
resembling apoplexy, and terminating usually in a gradual ab-
sorption and slow recovery ;  sometimes in high inflammatory
action and sudden delirium, in  Typhomania, or rather that al- 
Of Compression.
351
ternation of Delirium and Coma, which is almost inseparable
from such  a state of the sensorium : while compression, pro-
ceeding from extravasation of blood is plainly palsy;  begin-
ning in stupor, without insensibility, and ending in Hemiplegia
and convulsions ;  but, with this special distinction, that  Palsy,
proceeding from rupture of vessels overcharged by the apoplec-
tic arterial action, is a disease of the brain itself, is attended
with destruction of the cerebel  substance  and is thence  incu-
rable ; while the paralytic state, proceeding  from a shock or
blow, consists in extravasation, foreign to the substance  of the
brain, external even  to the dura mater ; is merely a local com-
pression, not directly injurious  to the cerebel substance, and
thence is curable : the  moment the extravasation is let out, the
patient  raises his eyes, knows his friends,  and  moves the af-
fected side.  The truth or  probability of these  parallels will
best appear from narratives of such accidents  as  you are likely
to meet with in practice.
  Being called to Hamilton, to visit a gentleman, an officer in
the 7th Dragoons, who was supposed to have a fracture  of the
scull;  I found that in riding a wild  horse in  a  court-yard of
the barracks, unaccustomed to the heavy bit of the cavalry equi-
page, he had checked his horse in rearing, and pulled him back,
and  the  horse falling upon him,  he was knocked down and
struck to the ground  with great violence, his occiput encoun-
tering the hard beaten gravel: he lay pale, pulseless, and insen-
sible, was  restored to heat very slowly, and  continued in a pro-
found stupor, snoring  and motionless.  I arrived the following
day, and found  him still insensible ;  his  pupil not dilated, his
tongue furred, his hand hot and dry  ; his pulse high, his face
flushed ; his looks,  when roused, wild and distracted ;  he in-
stantly, after being disturbed,  fell  down again into  a state of
stupor,  and nothing could  rouse him to any recollection of his
situation, nor enable  him to  articulate even a  monosyllable.
Upon consulting  with Mr.x Taylor, the regimental  surgeon,
formerly  of Mercer's Hospital, a man ofthe best education,
and of strong  good sense, we agreed,  however unpromising his
condition might appear to his friends, to report to Colonel Heul,
that he was in no danger; that we should make no incisions ;
that,  by profuse  evacuations, this  fever might be prevented
from rising to delirium; that, after slumbering a  few days, he
would gradually recover his senses.   Presuming, from this in-
fallible mark of quick pulse accompanying the stupor, that the
stupor was void of danger, I left him with confidence ; and, by
letters from Mr. Taylor,  had the comfort to learn that, after
slighter dawnings of sense and reason, he was, by bleeding and
strong  purges of calomel  and jalap,  perfectly restored, before
the week had elapsed. 
352
Of Compression.
   Concussion, in a greater or less degree, is almost insepara-
 ble trom that kind of shock to which the head is exposed when
 a man is thrown from on horseback ; sometimes it is accompa-
 nied with fracture  or  extravasation, and thence questions of
 great delicacy and difficulty often arise.   The first head I ever
 dissected, after an accident of this  nature, was that of a young
 gentleman,  who having rode  on a pleasure-party to Roslin, ex-
 ceeded in wine,  was ill able to manage his horse, was thrown,
 and died on the fourth day :  but in his scull was found not the
 slightest trace of fracture, nor within, the  slightest extravasa-
 tion ; nor could any peculiar appearances  be remarked in  ex-
 amining the substance ofthe brain itself, except general  red-
 ness of the  pia  mater,  vessels  extremely turgid, and many
 bloody points.   Whence  we  perceive how narrowly those  es-
 cape who have violent  concussion ; they invariably die, if the
 pulse continues low, or is at any time intermitting.
   Another young gentleman, on  his return from a like excur-
 sion, was  thrown from  his horse, lay in a death-like stupor  for
 ten  days, during which  period  the blood, which  had at first
 gushed from his nose, mouth, and ears, continued to flow  un-
 remittingly from his right ear.  The shock, which thus bursts
 the vessels on these delicate surfaces, cannot but have a like  ef-
 fect on  the delicate  cerebel substance  within:  the  senses  and
 intellect suffer from this suffused  state of the brain,  but the hae-
 morrhagy from these vessels probably  saves the internal part of
 the  system from any extreme  violence ; at all events, it is cer-
 tainly  observed, that such issue of blood from  the  mouth and
 nostrils, though  a  sign of great violence,  is favourable to  the
 patient's recovery ;  and if any such haemorrhagy is dangerous,
 it is that from the ear, for there is little doubt that it must come
 from those  internal vessels which traverse  the ear :  yet  this
 young gentleman entirely recovered.
  In such cases, wine and  the  heat of exercise,  youth, and
 health  and strength, prepare  the vascular system but too well
 to assume  an inflammatory action, and to re-act powerfully ;
 thence it often  happens that, in place of lying like these young
 men, torpid and oppressed, the patient bursts out of bed, strug-
gles with  the attendants  with maniacal strength, and is  very
 difficultly  subdued, and in great danger of ultimate  violence to
 the structure of the brain from such high and continued vas-
cular action.   This I saw  conspicuously exemplified, in a young
 man, uncommonly  athletic, accustomed to  violent exercises,
who, being thrown from his horse when riding extremely hard,
not brutally intoxicated, but furious with wine, lay for five days
 in a state of profound stupor, from which he, after staring,
 struggling, and muttering, wakened to such a  phrenzy that 
Of Compression.
353
 four stout men with difficulty held him down in bed, and yet he
 recovered, and reformed, and now lives in perfect health.
    These  familiar examples, such as you will daily meet with
 in practice, cannot perhaps be more happily closed than with a
 short case from Jacotius; it stands recorded in his commentary
 on the third aphorism of the first book of  Hippocrates.  " We
 have observed" (says this author) " ot those who have the brain
 injired, some, dying suddenly, others lying oppressed and snor-
 ing, while others have  blood issuing from the nose, ears,  and
 mouth, and yet  live :  one patient of mine having lain speech-
 less a long  while, and apparently  dying in convulsions, started
 suddenly from his bed, in the middle of the night, fell upon the
 attendants with maniacal fury, and felled every mother's son of
 the m to the ground, except a Franciscan monk, a  lusty able fel-
 low, against whom he maintained a long battle, with feet,  and
 hands, and  talons: the  monk called loudly for  help to those
 who were already felled, but in vain ; they lay strewed on the
 ground, while he struggled alone with the furious patient,  who
 seized alternately  clubs, fire-irons, piss-pots, whatever he could
 lay hands on;  and laying hold at last of an iron stanchel,he tore
 it from-the window with incredible strength: he had  now near-
 ly levelled  the monk with his fellow-watchers, and  would have
 beaten out his brains with a stone of forty pounds weight, which
 he lifted and aimed to throw at his head, when the monk, breath-
 less and exhausted, but desperate, collected all his strength into
 one last effort, and gave him a kick on the cods, which brought
 him to the ground.  This  man,  says Jacotius, I entirely  cu-
 red."   This example of horrible phrenetic delirium, I quote in
 proof of what I have constantly remarked, that delirium  is  the
 least unfavourable symptom and the most curable.
   Th_*  more fatal accident of extravasation  is attended with
 symptoms less terrible,  and with a comparatively slight affec-
 tion of the "intellect and senses :  I  have been confounded often
 to see the patient recollected and sensible,  under a compression
 so decisive as to cause paralysis of one side : somnolency,  not
 stupor, is truly the mark of this«tate.
   John  Hutchison, a sailor lad, of twenty  years of age,  fell
 down stairs, and lay in a state singularly characteristic of com-
 pression of the  brain :  his condition was described to me by a
 good  woman, who was  very careful of him from the moment
of his fall, for he  was the companion  of her son,  who had  fol-
 lowed him to sea ; when  the one boy was gone abroad, the o-
ther would not stay at home.  This lad, on a visit to his father,
 perfectly sober, going negligently up an outside stair, fell,  but
 whether three steps, as a workman reports,  or the whole*flight,
 as this woman's husband believes, we could  never certainly
                            2 Y 
354
Of Compression.
learn :  this good woman, who lived  in the house under his fa-
ther, was abroad at the time, but her husband heard the fall, so
violent was the shock, and running  out, carried him up stairs
with the assistance of a mason  who was working in the close.
When she came home, she went up to  him,  and found him ly-
ing oppressed, as in a deep sleep ; she  asked him often  what
happened, and how he was, which he answered always in  two
or three words, passionately and impatiently  pronounced, " that
he was better," " that he would soon be well,"  " that he would
lie and sleep a little," still he begged that they might let him lie
still and sleep.  His tongue sometimes faltered; he answered best
when most roused ;  there  was a cold sweat all over him ;  his
face was exceedingly pale, he yawned perpetually, and always
when offered drink, &c. cried, " let me lie and sleep:" he vo-
mited frequently during the two first hours after the  fall:  his
left side, his left arm at least, was plainly powerless, he never
moved  it in concert with the right: he lay in a slumbering con-
dition, groaning and  tossing as if oppressed ; muttering,  out al-
ways conscious of his condition ; complaining of his head, and
able to  answer:  when this good woman sat him up in bed,  or
when he raised himself to pass his urine, he  complained often
of his breast, and sometimes of his belly, but continually ot his
head:  while  quiet he had no snoring, and slept like a child, till
after being bled by the surgeon of his ship, from which time he
enjoyed no more of  that placid sleep.  On the  third day, this
woman brought him up a basin of warm milk, and he seemed
to like it;  she raised him in bed, he sat up and took  the basin
in his own hand, and when she gave it him, saying, take it my
good lad, he  answered, " I will, I will,  but do not trust to my
hand only ;" yet, with her help, he  heid it to his head, and
drank it off.   He complained continually of his head ; and in
whatever way roused or disturbed, he begged  they would let
him sleep ; " if they would let him sleep a little longer, he said
he would go down to Leith and go on board."
   This good woman went up  to see him at seven in the morn-
ing of the fourth  day ; she found him still slubbering, and con-
tinually complaining of his head ;  suddenly he  was seized with
a strong convulsion, raised himself a little in bed, and thumped
incessantly with his  hand upon the side ofthe bed, striking with
the paralytic  arm as  well as with the  sound, and all the while he
kicked  and struggled with his  feet; at last his left hand was sud-
denly seized with a violent spasm, the wrist was  strongly bent
down towards the fore-arm, the fingers  stood out rigid at right
angles with the hand, and Horn that  moment he  never moved
 that arm more, his hand continuing rigid in this distorted io/m.
 But the convulsion did not then cease ;  it continued from seven 
Of Compression.
355
in the morning till eight:  notwithstanding  these  terrible con-
vulsions,  and this spasmodic palsy of the left hand, he retained
his  senses,  spoke sensibly when roused, supported himself in
some degree in bed, complained sometimes of his belly and of his
head ;  and when asked about the state of his  bowels from the
time of his fall, answered collectedly and correctly.   This was
on Thursday, the fourth day from the fall: on Friday morning,
I saw him, for  the first time ; and in the evening by six o'clock
he was dead.
  " In the last day of his existence, he still retained his senses ;
he lay in a perpetual slumber, but had no puking ; his tossing
and anxieties were very distressing to see ; his face was deadly
pale, his right  eye  stood  immovable when opened, the pupil
being widely dilated ; while  his left (though his left side  was
paralvsed) remained irritable and moveable, the pupil of it was
contracted, and it turned  quickly from the light;  his pulse was
small, quick, and fluttering,  like that of  a sick child ; and the
vital motions so affected, that it appeared manifestly that they
could not go on ;  his extremities were  cold, and I judged him
dying : but nothing surprised me more than to find, upon lifting
his eye-lid, that I could rouse him to speak ; when  I bade him
put out  his tongue, he did so, and when I  spake loud and im-
pressively, and asked where  his pain was,  he  raised  his right
hand, though in an irregular way, and laid it upon his head."
  " This very stout voung man expired  about six  o'clock on
Friday evening ;  and the following evening we found, upon dis-
secting his head,  no tumour, nor even a  bloody effusion in the
integuments, but  in the cranium a large and wide fracture, tra-
versing the parietal bone, and running through its whole length :
unconnected  with that, on the vertex, was  a  small  fissure, pe-
netrating only through the first table : under the  centre of the
parietal bone lay  a  very large  coagulum of blood; it was  as
large as the whole hand," bating the points of the fore and mid-
fingers, and thicker than the fleshy part of the palm ; it was ve-
ry firmly congealed, and came off in one cake like the placenta
of a foetus,  leaving a very deep depression in the brain, into
which you might have  laid the back of your hand."
  It is not my intention  to accumulate authorities for what  I
know to be a plain tact, but will go on to represent to you the
condition  of the  patient while  labouring under  symptoms un-
doubtedly mortal.
  u A very old man was carried into the  hospital, who, after  a
fall, lay insensible and convulsed : no relations accompanied him
to tell what had  happened: two sons, who afterwards came,
were at once brutal and perverse, seemingly  indifferent to his
sufferings, and yet sternly and  impudently  refusing to allow  us 
356
Of Compression.
to proceed in the way that prudence and the  necessities of the
case required.   He was a very old man, with bald temples,  a
naked scalp, and not the slightest appearance of injury  on the
head: he lay in a deep stupor, immovable, except when  agi-
tated with a convulsion, which returned every ten minutes,and
became more frequent as his strength declined ; his eyes, which
were closed during the interval of stupor, opened when the con-
vulsion approached, and stood staring wide,  with a much di-
lated pupil: first the cheek and features on the right side of the
face were drawn up into a ludicrous grin ; then the neck stiffen-
ed, the head was jerked backwards, and the jaws worked back-
wards and forwards with a violent spasm ; the tongue and throat
were also affected, and the lips made  that  kind ot noise  that
follows when we draw the  breath through the closed  teeth, to
prevent the saliva escaping  by the angle  ot the mouth :  alter
continuing two  minutes or  more, the convulsion terminated,
with deep groans, in a  state of stupor.   His unnatural  sons
would not suffer us to touch one hair of his head ;  and  on the
evening of the second day, when he died,  they came with a
mob of vagabonds at their heels,  and  carried away the body,
with a degree of precipitation which inclined us  to believe that
there was something particular in the manner of this blow which
they were afraid dissection might reveal."
   Not a moment should be lost  when such  symptoms appear :
the extravasation may be in the ventricles, on the basis, or with-
in  the substance of the brain ; and if so, the man is gone be-
yond redemption ; but if it be only on the surface, and there is
a possibility of  saving his life, it can be only by immediate ope-
ration : when the symptoms of extravasation are accompanied
with fracture running downwards towards the basis of the scull,
we may despair of doing good.*
   " A big and  strong man, a common labourer, fell down  three
steps of a stair;  but  there  is every reason  to believe he had
struck his head  on the edge of a bucket, hitting that part wh  re
a  projecting  iron hinge joins  the iron  handle with the tub:
when raised up, he was pale, cold, and pulseless ; cordials  were
given him, he was restored to heat, and then blood was observ-
ed to distil from his nostrils and right ear.   Being  carried  into
his own house,  he passed a disturbed and restless night, till to-
wards morning  that he enjoyed a calm sleep.  He lay still and
motionless  the second day ; his eyes seemed dead and glazed,
  * Whenever there is a fracture at the anterior and inferior angle of the parietal
bone accompanied  with fymptoms of compreffion,  nothing but an immediate
operation can probably fave the  life of the patient; becaufe fhould the princi-
pal meningeal artery be torn, as it frequently is under fuch circumftances,  it
pours out its blood with fuch force as  to prove very quickly fatal: of this I have
lately feen three inftances.   S. 
Of Compression.                    357
 the pupils of both were dilated, contracting only with the very
 strongest light; his jaws seemeo clenched, his teeth closely
 shut,  his lips retracted and turned backwards,  uncovering the
 teeth as in grinning ; he breathed slow and heavily through his
 nostrils ; he  was paralytic  of his left side, had involuntary
 stools, and passed his urine  in the bed.
   " Yet, upon  being stirred  and roused, he  looked up wild
 and bewildered, and had frequently, during the night, attempt-
 ed to get out  of bed ; his pulse was  weak and fluttering, and
 his body  cold ;  he  was not so insensible but  that a purge ope-
 rated  briskly, though then and always his stools passed uncon-
 sciously : his face was pale  and shrunk ;  he lay but a few mi-
 nutes in one posture ;  he then turned and struggled, and a  sort
 of foum issued  from betwixt his  closed teeth, while his lips
 were retracted into a grin ; his cheek was distorted, and his
jaws worked perpetually, so that you  heard his teeth grinding.
 He was permitted to lie too long in this desperate state unassist-
 ed.   When my  brother and 1 saw  him  together on the third
 day, the paleness of the face and coldness of the body had  in-
 creased, the stools were involuntary,  the  pulse extremely  fee-
 ble, almost imperceptible; we called immediately a consultation,
 rather to witness what was to be done,  than to give advice in a
 case so plainly desperate: perceiving, though there was not the
 slightest swelling, a  degree of livor on the temple, my brother
 made an incision, and, turning down a large angular flap of scalp
 and temporal muscle, uncovered the temporal bone down to the
 zy goma, and  in  doing so  felt his knife grate  against a  rough
 and wide fracture ; the flesh of the muscle being cleared awav,
 a very  rude fracture was seen to  run  horizontally through the
 parietal and temporal bones, its  branches passed down  under
 the zygoma to the basis of the scull, blood oozed through the
 chinks of it, and a large trepan being applied directly above the
 zygoma, very black grumous blood rolled out.   He died in
 about fourteen hours."
   Your own good sense will suggest to you that, besides those
 decisive conditions ofthe intellect  and bodily functions which I
 have endeavoured to characterize, there must be many interme-
 diate states, extremely perplexing and difficult  to resolve into
 any simple principle; in all things I wish to leave you to your
 own discretion ;  in many, I am sorry  to say, you can have  no
precise rul< s from any teacher, but must trust to your own pe-
netration and  judgment : experience, or,  in other words, the
ha'>it ot reasoning, so  as to infer from  external signs the kind
 and degree of internal injury, will enable you to resolve the most
anomalous symptoms ; but that condition ofthe brain in  which
general suffusion of blood is followed by inflammation, delirium, 
358
Of Compression.
and death, that condition which is marked by convulsions and
spasms resembling those of Hydrocephalus, and  with a pulse
indicating nothing of oppression,  is of all the anomalous states
of the organ the most frequent.   I cannot remember that I was
ever more perplexed how to act than in the following case.
   "  A poor boy, of thirteen years of age, in scrambling with
his play-fellows,  on a  Sunday afternoon, about the ruins of a
house which workmen were pulling down,  fell from one of the
windows, a height of fourteen feet,  and struck  his forehead
against a beam.   There appeared  upon the forehead, close to
the root of the nose, a soft elastic tumour, and a general suggil-
lation of blood, which  entirely closed the  eyes; he was stunned,
and lay in a death-like  stupor for a quarter of an hour,  but en-
tirely recovered : he had been universally bruised, for he vo-
mited blood, which also flowed in a full stream from his nose ;
his pupil was contracted ; his pulse regular and strong,  beating
90 in a minute.   Next day the vomiting continued ; his pulse
was still full and strong :  upon being bled, the vomiting ceased,
and the pulse  subsided both in strength and frequency : the
night he passed tolerably, though restless, feverish, and in pain ;
he often  carried his hand to  his  forehead, complained of the
pain, and sometimes talked wildly through his sleep.   The se-
cond night he passed  in  great confusion, with much delirium,
and when most rational he complained grievously of his head,
while a thin and bloody serum distilled from his right ear, with
great pain behind the ear, where it would appear he had sus-
tained a degree of injury, which might well happen in a fall so
irregular among stones and beams.   On the third day, the tu-
mour of the forehead  subsided,  and the eye-lids opened : on
pressing the tumid part of the forehead, he complained of intol-
erable pain ;  his pulse continued high  and rapid ;  the bleeding,
purges, leeches, and other sedatives, were renewed; his sleep
during the night of the third was  more composed and natural,
and he had no unfavourable change, till ten o'clock in the morn-
ing of the fourth day ; when  he became very hot, feverish, and
restless ; vomited much; the vomiting was excited by repeat-
ing the cathartic, and even by taking the acidulated drinks which
were ordered him; at four in the  afternoon he was seized with
extraordinary contortions, and strong  spasms of the abdominal
muscles, with violent tremors of the whole body, and grinding
of the teeth : his breathing was affected by the violence of the
spasms in the abdominal muscles ;  it  was noisy and laborious,
but not slow nor oppressed, and the pulse beat 120 in the mi-
nute :  towards afternoon all  parts  of the body were at times
convulsed ; he howled as if  distracted with pain of  the head,
and  his eyes squinted  horribly ; he grinded his teeth continu- 
Of Compression.                   359
ally, his features were distorted, his arms and fingers stiffened
and crooked with cramps and spasms : his condition this day and
evening reminded me of the condition of boys in the worst stage
of acute hydrocephalus or inflamed brain.   At ten at night, he
had, after suffering thus violently  all day, subsided into a sort
of stupor, without  vomiting, but with a rapid pulse.
  " The night of the fourth was restless and  miserable, but
much of it he passed in a state of  stupor : on the  fifth day the
swelling of the forehead had entirely flattened ; that of the eye-
lids was gone ; nothing remained to  denote the place of injury,
but the  general suggillation of blood with which the  forehead
and eye-lids were discoloured : at five this evening I found him
quite sensible, complaining of excruciating pain  in the head,
screaming with the torture, and his eyes horribly  distorted, es-
pecially the right one,  which was turned downwards  and  in-
wards till the iris was almost hidden under the  inner angle of
the eye. This night he had much delirium, and while conscious
complained of pain of the head, especially behind the ear;  for
though he felt pain  of  the forehead when  pressed, he felt pain
behind the ear and through the  head at all times : he   howled
much this night from eleven o'clock, and his thighs were rigid
and  his toes crooked with the spasms.
  "  On the sixth I found him dead ; he had raved  the whole
night long, had cried  continually  with the pain  of his ear  and
forehead, was seized betwixt two and three in the morning with
such universal spasm,  squinting,  and howling as he had on  the
afternoon of the third, and at six in the morning  he expired."
  Here was no symptom of extravasation nor of compression ;
none but of inflammation ; and  against inflammation what could
I have done by tearing the scull with the trepan ?   It was not
for want of those marks which are usually thought  a vindication
by those who are impatient to apply the trepan, that I refrained
from using it,  for  I distinctly  felt a fracture  in the forehead,
accompanied with a degree of  depression in the  place of  the
frontal sinus :  but from a perfect consciousness that my opera-
tion could do nothing but increase  the inflammation, and from a
persuasion that the fracture was a concomitant merely of a more
fatal disease ; I  reflected seriously, and found myself  assured,
from the symptoms, that inflammation was the principal  dis-
ease ; that fracture at this point could be attended  with no  re-
markable  depression;  that if  it  was extensive,  it  must run
through the basis of the scull;  and I had the satisfaction,  me-
lancholy though it was, of discovering, on dissecting  the boy's
head, not the slightest  extravasation upon the dura mater,  but
the surface  of the brain universally reddened,  and its vessels
 turgid, and there  was a  wide fracture, beginning at the  orbi- 
360             Ofthe Operation of Trepan.
tary plate of the frontal  bone, and running quite across the oc-
cipital bone into the foramen magnum ; but without any remark-
able  appearance either  under the bruised part of the forthead
or behind the ear.
   I will no longer detain you, but hasten, after a short section on
the mechanical part of your dutv, on the operation of trepan, to
lay down rules for your general conduct, not without a confi-
dence that, among  the variety of delineations of  the  disordered
conditions of  the brain, narrative or descriptive,  which I have
laid before you, you will be able to find rational  parallels  for a
great proportion of the accidents which may overtake  y ou in
your future practice.
SECTION IV.
                 Ofthe Operation of Trepan.

  At the head of this little chapter, of instructions how to use
the surgical instruments, I have placed those used by the mo- 
Of the Operation of Trepan.              361
 dern surgeon:* if you conceive, as I  trust you do, the essen-
 tial purposes of the operation,  I have  no fear of your using
 them with sufficient dexterity and address ; and my instructions
 on this head shall be few, plain, and simple.
    The simple form ofthe modern instrument marked (A) turn-
 ing in half circles with the hand, is found to perforate  quick
 enough, and to be extremely manageable, since the saw is ea-
 sily inclined so as to continue its semicircular incision  on that
 segment or side of the  perforation which is least cut.  The for-
 ceps (B) take out the piece  of bone, either by their circular lips
 (C) corresponding with the  circle of the crown, being introdu-
 ced into  the  circular cut to seize the sawed piece, or by the
 points (D) being introduced to poise it out.   The lever (E) is
 sometimes useful in poising  out the piece separated by the saw,
 but the point of it is  too blunt and round to be very serviceable,
 in  any but its proper office, which is to poise and raise up what-
 ever depression of  the  scull  requires to be elevated; and the le-
 vator and the forceps are equally  used in twisting or poising out
 loose pieces of the  scull.   These  are the simple  instruments
 now laid in the operating case; along with which you are usual-
 ly provided with a brush to clean  the teeth of your saw ;  a se-
 cond head or  crown, of the same diameter with the first, that
 while the one is blunted, or when it is unscrewed for  the pur-
 pose of being cleaned, the other mav be used;  a knife is also
 laid in the case, for dividing and raising up the scalp,  and of-
 ten a rugine or triangular instrument, like a caulker's iron, for
 scraping away the pericranium, which I never do, for I find it
 unnecessary, and do  not think it right or safe.
   1. For the disposition of your Instruments and Dressings—
 They are to be laid in  two small plates, within a  double table-
 napkin, the napkin being pinned so over the bottom of the plate
 that it may not shift, nor any awkward accident happen : on the
 fust plate is deposited,  within the folds of the  napkin,  the tre-
 phine, the centre-pin of the  crown, the key to unscrew it  with,
 the lever,the forceps, a tooth-pick, and a brush; on  the outside
 of the cloth is laid a  knife and  sponge, soaked  and squeezed,
 so as to be ready for use.  Or. the  plate of dressings are to be
 laid, lint nicely folded into smaller and  greater compresses, ve-
 ry soft; a little square  piece of oiled lint; a broad compress of
 four or six folds of old linen ; a double-headed roller, three ells

  * I have added to Mr. Bell's figures, a representation of a faw, recommended
 !>y Mr. Hey, of Leeds.  With this  inftrument, any particular point of bone may
 be cut out, and it has this very great advantage, that it enables you to remove
no more of the bone than is abfoiutely neceffary. It is ufeiul on many other occa-
 !• m for the removal of difeafed bone  : (it is here rrprefented half its proper fize.) S, 
362             Of the Operation of Trepan.
long, pinned at each end, so that when lifted, however hastily,
it may not run down ;  and in the cloth that covers the plate
should be stuck one or two needles of the smaller size, threaded
with a double thread waxed.
  2. For the Posture of your Patient—If composed and sensi-
ble,  and capable of sitting erect, you should place him on the
ground, as a dentist places his patient: the assistant, who is to
hold him, should have  a board laid across his thighs, the pa-
tient's shoulders  fixed  between  his knees,  and the patient re-
clining his head upon a pillow laid upon the board; the assist-
ant should lay his hands gently over  the head so as to steady it,
and in such a  manner  as to  use, without  change 'of posture,
greater exertions, if required: where the patient lies insensible,
he should be moved towards the side, or towards the head of
the bed;  his head laid  on a pillow, steadied by a board under
it;  unless the couch on which the patient chances to be laid, is
sufficiently firm :  a bed never is.
  3. In  cutting the Integuments—The first step  of your opera-
tion, you lift  from the  outer cover  the knife and  the sponge ;
the sponge, small and  compressible, you hoid in the palm of
your left  hand, under the ring and  little  fingers; you  lay the
mid-finger, fore-finger,  and thumb of the left hand broad upon
the scalp ; you feel with the point of the left fore-finger, and by
it guide your knife through  all parts of the incision.   First,
If the scalp, having been once detached to a great extent, is re-
united but over a carious bone and suppurating brain,  the hol-
low integuments admitting the probe to turn to  a great extent
over the diseased scull, you take, in place of the round edged
scalpel, a blunt pointed bistoury, and running it along, you at
one stroke disengage the flap of diseased integuments, and  turn-
ing it down see the whole extent of  the dry, yellow, and black-
ened bone : your perforation should  be central in respect to
such caries.  Second, The scalp  having risen in form of a  puffy
tumour over a contused part of the cranium, you make, with
the round edged scalpel, not a crucial incision, for that makes
four small angles in the  scalp, the raising  up  one  or more of
which displays but little of the diseased bone, but an incision in
a tripod-like "form ; then the three points being dissected away
from the scull, make a very large opening, and even two only of
the points being raised, they make, as being two thirds of a circle,
a very free opening : here too the state  of  the scull marks the
danger to the brain ; but in  place of  being yellow, rough, or
blackened, it is usually only dry, not shining,  nor brilliantly-
white, not attached to  the periosteum  or  integuments ; some-
times it is spotted or tinged with yellow, and devoid of circu-
lation, and does not bleed when  scraped with the  point ot the 
Of the Operation of Trepan.             363
 knife.   Third, When,  after a dreadful fall, the scull is cruelly
 fractured, pieces beaten in, and  the fissures wide, circumspec-
 tion is so natural, and you can so  distinctly feel with the point
 of the left  fore-finger those asperities  and openings, through
 which your knife might plunge into the  dura mater, that I need
 but to intimate the danger.   But, fourthly, When from a des-
 perate fall upon the steps of a stone stair-case for example, the
 patient lies in a deadly stupor, cold, pulseless, moaning, the in-
 teguments never rise into a tumour, nor become ecchymosid,
 except very slightly; they remain entirely flat for days, because
 the man is almost dead; the hemiplegia alone, with some slight
 blemish on the scalp, directs you on which side to operate, viz.
 the side opposite to  that which is palsied, and from the  con-
 vulsed or dying state of  the  patient you  must do so quickly.
 The surgeon  in  such case,  operating without a certain know-
 ledge of the state of the scull, is in danger of plunging his knife
 unawares through a wide fracture.  I have witnessed this  dis-
 aster ; let such incisions then be done carefully.
   Allow me to add to these particulars a few general instruc-
 tions.   Do not seek to pursue the several limbs of a fracture,
 for to  these your operation does in no shape  relate  ; but seek
 the central point only, where the  weapon or  sharp stone has
 penetrated,  or where the depressed angle  is kept down by the
firm and sound bone.   Do  not seek to scrape the  bone,  that
you may  trepan easily; I never,  in amputation or  in  trepan,
found the soft parts  entangle the  teeth of the saw :  in  trepan-
ing, I  only cut away that cellular substance into which the ex-
travasated blood is  strongly injected, sometimes solidly impact-
 ed, and no farther  than to procure a distinct view of the  frac-
 tured pieces.   Do not lay pieces  of  lint on the integuments,
 entrusting them to awkward assistants to hold them back while
you perforate ; for it is the sensibility  of the integuments  that
makes the patient cry, resist, and struggle,  which at once  im-
 presses the  spectators with  horror, and brings the reproach of
 cruelty on the surgeon, who  must complete his operation in the
 midst of such cries: if you would avoid this  unseemly scene,
use spathulas  or flat plates of iron, such as Mr. Croker King
calls defenders, to hold aside the  integuments, and  the perfo-
ration, which should be slowly and deliberately performed, will
 not seem tedious nor cruel.*
   In perforating the Scull—Ascertain  first the place most fit
for perforation, viz.  on the angle of depression,  and in the line

  * If you remove the pericranium with the rougine in the firft  inflance, and"
have the integuments held back, your patient experiencing no pain, will give you*
no trouble.  S. 
364             Ofthe Operation of Trepan.
ofthe fissure where the fissure is wide and gaping:  on the bro-
ken bone, if it be firm, on the sound, if it be so .unsteady as not
to bear  the pressure of the  centre-pin, or the  working  of the
saw; in the middle of the  carious portion, when there is caries
without fracture ; and any where on  the side opposite to that
paralysed,  but  especially a little below and to one  side of the
centre of the parietal bone,  when there is reason to  believe the
brain oppressed by extravasation, without any visible injury to
mark the place.
   Lift first the crown of the trepan you mean  to apply;  press
it firm to the bone, and make one or two turns in order to mark
the centre  of the circle, by penetrating with  the centre-pin a lit-
tle way: next dismount the  trepan  head;   take the  triangular
perforator, and having fixed  it in the shaft, bore with it a cen-
tral hole, for the centre-pin, deep enough to hold it securely while
you perforate:  then  mounting the  crown of the trepan  again,
place the centre-pin of it in that hole, and begin to saw :  in cut-
ting with the trephine, which turns in half circles, observe well
the way in which the teeth are  set, for they are set obliquely ;
you may be turning and twisting it, and that very  vigorously,
as I have seen some surgeons do, without cutting more than a
right-handed person  would pierce a cork by turning a left-hand-
ed cork-screw :  as  your trephine turns but half circles, you
must inevitably  cut  deeper  on that  side of the circle towards
which the  hand  turns ; you must  therefore probe frequently
 (especially when there is  much bleeding, or when you are sen-
 sible of having cut  deep) with the tooth-pick; and when you
 feel that you have penetrated* on one side, change your pos-
 ture,  turn half round the patient, which, by giving your hand
 a new inclination, sets it right for cutting what remains, which,
 in such delicate circumstances, and having so nearly completed
 the perforation, must be cautiously done and slowly.
   In the course of perforating, while you probe with the quill,
 you give  the crown of the trepan to  your  assistant  to be brush-
 ed, or to  be  altogether changed; and when you are satisfied of
 th' depth of your perforation, he, in returning it to you, wipes
 away the  saw-dust with the same brush.
    I seldom have completed the perforation, never have got  out
 the trepan circle  sticking in the crown of the  trepan, but have
  sometimes poised it out with the handle of the  scalpel,  or  the

   * I would advife the furgeon to change hispofture feveral times when lie thinks
  he is nearlv through, fo as to endeavour not to have the fcull thick in one  place
  and perforated in tnother, but try to cut fo uniformly as not to let the inftrument
  ~et through at ail; but when the whole is thin, break  up the piece with the ele-
  vator   For where the dura mater adheres clofely to the bone, he  will be very apt
  to wound it if he fuffers his inftrument to cut through.  S. 
Of the Operation of Trepan.              365
pointed extremity of the forceps marked (D).  While sawing,
whether in trepaning or in amputation,  never think to over-
come difficulty or resistance by pressure, but when you feel op-
position, cut lightly, and turn the saw nimbly, lighten your hand
when  it threatens to stop ; never in sawing a long bone expect
to loosen the saw  by pushing and wriggling, but by withdraw-
ing  it,  nor in trepaning  by pressing onwards, but by turning
the trephine half round backwards.  Choose trepan crowns with
the sides grooved and sharpened, as  well as the points of the
teeth,  for that  kind of saw cuts wider  as it goes deeper,  and
works the whole circle of the bone large  and free for the trepan
to move in.
   5. In respect to the Object of the Perforation—You will find
that extravasated blood rolls out spontaneously, in black and
firm clots, through the trepan hole ; and from dressing to dress-
ing is  easily hooked out, with an armed probe, or washed out
with tepid water, the dura mater coming gradually into closer
contact with the scull: pus flows out still more easily, and mul-
tiplied operations for either purpose (of letting out blood or pus)
are extremely imprudent; to repeat the perforation  is  some-
 times necessary, on account of a great depression attended with
 manifest danger, where the edges of the depressed portion are
 fast locked under projecting  corners of the firm scull, and the
 lever being introduced first into one, then into the other perfo-
 ration, the depression  is raised, but never without great force,
 usually  a loud noise, and sometimes,  as I have argued,  with
 unjustifiable violence, insomuch that on many occasions, espe-
 cially  where the depression it flat, extensive, and having proba-
 bly no offending  points, I would rather  leave  it unreduced:
 unless in depressions of a singular and dangerous form, punc-
 tured fractures,  and  those  where, from  their peculiar form,
 there is strong reason to suspect spiculae, I am  not curious a-
 bout depressions, nor over-anxious in raising every point.
   6.  In respect of Dressings—I would intreat you to consult
 your  own good sense, rather  than hearken to the common igno-
 rant advice of laying merely a piece of oiled lint on the wound,
 and over that a poultice.  The old practice of cutting a circular
 piece of cloth as a syndon, and cramming it under the scull to
 support the brain,  and leave  room for matter and blood flowing
 out, I entirely disapprove of, but neither can I approve of leav-
 ing it quite unsupported ; in short, 1  dress the trepaned  scull,
 as I do every other wound, nicely and carefully : first, I lay the
 edges of the'scalp  smoothly together, sometimes  stitching it
 with  one or two points of the needle ;  then I lay upon it a small
  pledget of oiled lint ;  next a small and rather firm compress of
 lint;  next a general compress over the whole of that side of the 
366
Rules of Practice.
head; and finally, I roll the head gently, but steadily and some-
what firmly, with a broad roller, and put over that a thin linen
cap, lightly tied under the chin.
   I allow no poulticing, except what is necessary to bring off the
first dressings;  and no washing  nor curious cleansing of the
wound, which I  wipe slightly, and dress with very little  oint-
ment,  almost dry: when blood still exudes, that makes an ex-
ception, being a special case ; and when a fungus threatens to
protrude,  and even where only the sound, but granulating dura
mater projects through the trepan hole, I find it necessary some-
times to depress the dura mater, or push aside the fungus, to
let the matter, confined  from dressing to dressing, flow out;
then, contrary  to my usual  practice, I think it right  to dress
morning and evening.
  When,  in the course of the cure, fungus protrudes and fills
the opening, and the confinement of matter causes stupor and
hemiplegia, and the inflammation of the brain, cries and con-
vulsions,  I reckon my patient lost: but I  am  proportionably
more diligent in my methods of procuring a free efflux of the
matter, and I think it better to shave off the protruding fungus
than to apply escharotics, which I have usually found hurtful.
  It is invariably found that noise, heat, wine, passion, and other
exciting causes, are fatal to those who have suffered the opera-
tion of trepan : the confusion of a storm, after a battle at  sea ;
the renewal of the engagement; the hour of firing the batteries
in a besieged city ; the intrusion of unwelcome visitors in the
chamber of a private person; quarrels, intemperance, or venery,
have in many instances brought on inflammation  of the  brain,
such as has proved fatal to those far advanced  in their recovery
after this dangerous operation ;  therefore let them be kept low,
still, quiet, with a loose belly, a perspirable skin,  little light, and
few visitors, and no conversation but such as is composing and
cheerful.

                        SECTION v.

Aphorisms,  or  Rules of Practice, deduced from the foregoing
                        Discourses.

  We have examined in detail every point of practice,  and are
now arrived at the conclusion of these discourses, in which  it
is natural to recapitulate whatever is important, and ascertain
whatever rules should particularly dwell upon your memory.
This task, could  I entirely acquit myself of prolixness  in these
discourses, might be spared; yet it will be useful,  I doubt  not,
to explain in short aphoristic  rules what an experienced surgeon
would naturally do in any given case. 
Rules of Practice.
367
  1. Above all things I counsel you to beware of precipitation ;
the  only fault which can incline the surgeon to conceal the cir-
cumstances of his private practice, or leave upon his mind any
lasting unhappiness : I entreat you on every new  occurrence, to
think deliberately, judge soberly,  and act gently, however ur-
gent a  case may seem, be in no haste  to operate, take time  to
consult, and rest assured that nature will often perform a cure
while you are deliberating upon an operation ; be also assured
that you can never  fail, in  the worst cases, to foresee the pa-
tient's  death, by his coldness, paleness, convulsive motions, and
involuntary stools :  if these signs have not yet appeared, you
have time for a  few hours deliberate  reflection,  it they are al-
ready  begun, you have  then, least of  all  any motive for preci-
pitate measures, you are surely too late, the patient must die.
  2. Fractures  and injuries of the head are more frequent in
public  hospitals, where the friends of the patient, or  the spec-
tators of any unfortunate accident,  leave him all most inanimate,
perhaps with only  some slight apparent injury of  the head,
while  there is some serious damage to the brain, the nature of
which you are ill able to develop, without knowing how the
patient was struck,  or  where  he  fell : let your first step  be to
collect  the  friends or spectators,  and  inquire into the circum-
stances of the fall or blow.  Let it be an especial rule  with you,
never,  in these cases, to do  any thing precipitate or rash.
  3. Every man of prudence  and  discretion, while  he exam-
ines the wound,  and  reasons on  the symptoms, inquires into
the  circumstances in which  the patient was hurt: whether  by
a fall or by a blow,  whether when he fell he  was drunk or so-
ber, helpless, and pitching headlong,  or in his senses, aware of
his  danger, and by  extending his arms breaking the force of the
fall: whether he pitched headlong over a rail, or  tumbled  down
stairs,  touching each step ;  whether he fell on  plain ground,  or
on a declivity, and if he received a blow, whether he was struck
by accident or by design ; at arms  length  or close ; with a hea-
vy weapon or with a sharp one ; by a feeble man or  a strong ;
by a drunken man without aim or force or by an angry man,
in the  height of rage and with full effect.
  4. There are certain kinds of accidents which import danger,
each according to its peculiar nature; as a concussion, a con-
tusion, A  WOUND WITH  A  SHARP  WEAPON, A  PUNCTURED
wound.  Writers  on jurisprudence  have  long distinguished
these kinds of wounds,  of which the  danger  is in some imme-
diate,  while  in others  it is deferred  till  the fortieth or till the
hundredth day,  and have  been accustomed  to  affirm that the
more the scull  is fractured the less the danger, the breaking of
the  scull deadening the  force of the blow.   Of all the quaint 
368                  Rules of Practice.
reasons which authors have given, not one is true ; but yet it is
a fact, that the man who has an extensive fracture of the scull
escapes, while he who has no fracture dies.   It is not because
the yielding of the bone lessens the  force of the blow upon the
organ which that bone protects, but because concussion is a more
dangerous injury than fracture, even though accompanied with
deep depression of the scull: there  is  great danger in the case
of concussion, though there be no fracture! there is little com-
parative danger in  fracture when there is no  concussion! when,
from the nature of the fall, the concussion is great, no degree
of fracture can lessen the danger, for the danger lies in  the con-
cussion or injury of the brain which  is produced by a fall, not in
fracture, which affects  only the scull, and is occasioned by  the
blow.  If a mason fall from the tiles of a house, or a sailor from
the yards or rigging of a ship, and fracture his scull,  the great-
ness of the fall lessens in no degree the violence of the concus-
sion; the  extent of the fracture marks rather  a probable  con-
cussion, of whidyif it be great, the patient dies: but if the tiles
fall upon  the  masorfy or the sailor is knocked down  by the fall-
ing of a block  and  tackle,  a great fracture  does not cause an
equal degree of injury, much less if he is knocked down with
an handspike, and still less, if his  scull be  cut with a  cutlass;
the fracture may be m such cases great, and the concussion and
consequent danger slight: in short, the scull is most fractured
by those blows which are least injurious, and least  injured by
those general  shocks  which cause  the  most dangerous concus-
sions and extravasations in  the brain.
  5.  As a bruise is worse  than a wound, and  a sprain or lux-
ation of a limb more distressing in its consequences than a  frac-
ture, so is concussion of the brain more dangerous than wounds
or fractures of the  scull: to the distinctions  I have hinted at,  I
should wish to remind you of one which I have remarked:. if
by a  fall your patient lie in a  state of stupor, it may  be from
Concussion: if,  after a  smart blow with a bludgeon,  not heavy
nor depriving the patient instantly of his senses,  it must be from
extravasation.
  6.  It is not  with every kind or degree of stupor that an ex-
perienced surgeon  is alarmed, he is accustomed to  distinguish
many kinds, as well as d? grees, of that affection:  the stupor
may  be that of intoxication,  which, by the smell and the vo-
miting,  he is often able to distinguish, and  never is afraid  to
leave the  head  of  the patient untouched till the longest period
of intoxication (if it be intoxication) and all its consequences
have expired ; or it may be that of slight concussion, which, be-
ing attended  with no oppression of pulse,  nor  suspension  of
breathing,  is soon resolved bv the natural force ot the circula- 
Rules of Practice.
369
 tion : or it may be that stupor which, in old age,  generally fol-
 lows a blow or fall, without indicating, as far as I have observ-
 ed,  any permanent injury:  but if the stupor, though slight, is
 accompanied with vomiting, and a slow intermitting pulse, there
 is reason to apprehend the most imminent danger.
   7. Nor does every  degree  or kind of delirium alarm him :
 delirium, arising after stupor, is a favourable sign  : a wound of
 the. scalp is often followed by erysipelatous sweUing, and a short
 and harmless delirium : a patient thrown into an hospital with
 wound of  the scalp, is  often seized  with sudden  rigours, vo-
 miting, high fever,  and delirium, but these are the symptoms
 of hospital fever merely, and might as well be superinduced af-
 ter a wound of the finger, as  after a wound of the scalp: one
 who has formerly suffered much from fevers, or  who has been
 insane,  is more apt,  as  I have known in several  instances,  to
 awaken in a state  of phrenzy, after lying some time  under the
 stupor of a blow : these are not dangerous cases  of delirium ;
 and though stupor, insensibility, rigours, and other  marks  of
 suppuration or of effusion of blood, may be motives for apply-
 ing the  trepan, delirium, as far as  I can recollect or imagine,
 never is.
  8. I believe the danger to be prognosticated is very nearly  in
 this gradation : Stupor, though  deep, and to the tyro seemingly
 very dangerous, is not a cause of immediate alarm to the expe-
 rienced surgeon : Delirium, succeeding such  stupor, shows that
 the vascular action  is begun, and  the oppression at an  end.
 Slighter somnolency, free from stupor,  in  which the patient has
 his senses,  (though inclined to  sleep) but with a heavy, op-
 pressed, and intermitting pulse, is extremely alarming, and re-
 quires the trepan :  Stupor, accompanied with dilated pupil, and
palsy of one side,  indicates the most imminent danger, yet such
 as is often relieved by the trepan.  Stupor, in which the^ac*? is
pale, the extremities cold, the pulse not heavy and labouring, but
 quick and f uttering, especially if attended with palsy ojioneside,
 or slight convulsions agitating the features or the limbs, is a state
 altogether to be despaired of:  yet perhaps it is even here our
 duty to operate, but without hope.
  9. The prognostics from tumours, I  must remind vou are
 still more interesting;  for any peculiarity in  the tumour  indi-
 cating the death of the  bone below, more certainly foretels dan-
 ger to  the  brain than  the most formidable  fracture :  First,
 Where the scalp merely is wounded, perhaps punctured, but no
 tumour ensues,  the patient is often affected with spasms in the
 face, and the most ludicrous  contortions of the mouth ; this is
 a symptom much resembling that contraction  which follows the
 wounding of a nerve in bleeding, and, like it, requires an inci- 
370
Rules of Practice.
sion.  I have at this moment, under my  care, a  little boy, of
ten years old, who, having fallen over a stair-case in swarming
the baluster, was taken up  apparently dead, has  lain for  two
day s in a state of deep stupor, is now entirely recovered from
it; he has his mouth turned more entirely to one  side  than I
ever saw it in a paralytic, and though able to run  about among
his play-fellows, does not expose himself among them ; this, I
have promised confidently,  (because I have often  seen it)  will
go off.__Secondly,  Erysipelas often seizes the scalp after slight
wounds, extends over the face and  ears,  closes the  eye-lids, is
attended with smart inflammatory fever and delirium,  but  sub-
sides in a few days.—Thirdly, A bloody effusion, if the blood
be in great quantity and the effusion permanent, is  sometimes
dangerous to the scull;  but I must remind you of a danger of
another nature, viz. of a feeling as if of depression of the scull,
so particular that even the  experienced are apt to be deceived:
but an experienced surgeon is in no haste to make incisions into
such tumour, even though  the  patient is vomiting, and  in a
state of stupor ; these usually are but the first consequences of
the injury, and, like the tumour, vanish.   I have seen extrava-
sation so extensive as to fluctuate from ear to ear, and yielding
so as to admit the finger to feel depression of the bone, yet the
whole  has  been absorbed.—Fourthly,  The most  portentous
tumour is the least formidable in appearance ; for it is one which
proceeds neither from  extravasation nor inflammation;  it is
neither red, inflamed,  fluctuating,  nor  extensive, but arising
from the death of the cellular substance next the bone, and from
the impossibility of the dead surfaces renewing their adhesion,
thence it is Emphysematous,puffy, small, circumscribed, not pain-
ful : is accompanied with rigours or febrile shiverings, and start-
ing or nervous tremblings ;  confusion of head,  and feebleness
of body and mind : it is the most desperate disorder with the
slightest symptoms :  suppuration of the dura  mater is  begun,
and  if, upon the slightest intimation  of this kind of danger, the
patient be not trepaned, he dies.
   10.  As your  preceptor, I am much more jealous of your be-
ing found wanting in judgment than in skill: your operations,
I doubt not, will be performed  with address, but  I am truly
anxious that your address should be reserved  for  occasions of
real  danger, and that the powers of  nature should never  be an-
ticipated nor interrupted, by any rashness of  yours.—First,
be not too confident in promising  a  speedy recovery;  even in
slight and cutaneous wounds, for the bone,  though not wound-
ed, may be deadened by the blow; but lay the edges together,
and  stitch them  lightly'  and gently  to procure re-union: dress
the wound dry  with lint,   court-plaster, and  a sprinkling of 
Rules of Practice.
371
hair-powder, which, by caking with the blood, keeps the edges
of the wound in close and nice contact : and watch your pa-
tient's condition constantly, especially  where the wound  has
been made with  a  bludgeon,  a stone, or any blunt and heavy
body.—Second,  be  not afraid  of an open  though apparently a
desperate wound, even when the scull is cut or fractured, even
" where the splinters of it lie pashed upon the dura mater :"
there is in such a  case undeniable danger,  since the bone is
wounded and  all the parts inflamed  which defend and lie in
contact with the brain ; but such open wound, though wide, is
often less dangerous than  a slight contusion ;  it is but  a com-
pound fracture of the scull, and you have  no warrant for doing
any thing which you would not do in a compound fracture of any
other part.  I spoke of Paree's operation on Captain Hydron,
and of bone re-uniting with bone, I  meant but to illustrate a
general doctrine, not to announce a rule of practice : I advise
you, to pick away carefully every fragment of the scull, to  dis-
sect away whatever little  fragments you may find adhering to
the scalp, and to lay down soft and  sound  integuments  only
upon the wounded  scull and  exposed dura mater.— Ihird, be
not careless of  cleansing  the scalp  and  laying it  nicely  and
smoothly down,  because of my having proved to you that rag-
ged integuments or scalp having even its inner surface ingrain-
ed with mud and dirt, has adhered,  for such proofs were but
meant to illustrate a general  principle,  to show how tenacious
both the scull and integuments are, of life and circulation  : to
lay them down ragged or foul were the. height of presumption,
and  a most  culpable carelessness ; pick  the surfaces,  cleanse
them with the sponge, do  every thing to entitle you to success;
when you stitch the lacerated  parts  together, do it lightly,  and
dress the edges  dry ; do  not, in your anxiety to cleanse them
from sand or mud, wrap  the head in a poultice, expecting to
unite the parts after suppuration is begun, for after suppuration
they curl backwards and  retract;  they never, as far as I have
seen, can be laid together again, but heal with a gap equivalent
to an actual loss of substance : having stitched the integuments,
watch the state of the wound diligently, and the instant you ob-
serve the stitches overstrained by the swelling of the scalp, or
can  perceive  that matter is  confined, the bone bare, and the
probe admitted under the diseased  scalp, lay the wound open,
and  then use a  poultice,  and wait patiently the granulation of
the naked bone,  or the  signs of internal suppuration, to direct
your future steps.—Fourth, be upon  your guard against the ir-
retrievable fault of  making incisions into the integuments when
they  are entire, however distinctly y ou feel a fracture or de-
pression through them, for it is wronderful how happily the  hurt 
372                  Rules of Practice.
parts heal and the extravasation of blood is resolved when the
parts are kept entire ; the making an incision in such a case is
converting a simple into a compound fracture, with all the dan-
gers of it; nothing can vindicate you in taking such a step but
the most unequivocal proofs of a concomitant extravasation of
blood ;  viz.  oppression, somnolency, a  heavy pausing  pulse,
a dilated pupil, and palsy of one side :  make such incision (the
integuments I mean being uninjured) only after great delibera-
tion in adults, and in boys never, or almost never.*—Fifth, be
not too  rash in entering upon an operation, merely because the
patient lies in a state of stupor or breaks out into delirium ;
these are  the cases which least frequently require the trepan:
and when you are entered upon an operation, be not too parti-
cular in raising every point or piece of bone that  either seems
or is really depressed : but above all, be not too late in opera-
ting when there is reason to.suspect a suppuration of the dura
mater ;  make it a principle, whatever the occasion may  be tor
using the knife or saw, to be  sparing of the integuments,  for
the loss of them affects the scull, to be still more sparing of the
scull, for it supports the dura mater, and to think with the ut-
most reluctance  of puncturing the dura mater strong as the sus-
picions  may  be of blood being extravasated under it,  for, like
a second  scull,  this firm and  strong membrane  supports the
brain after perforation, and when it is punctured the brain is
deprived of all support,  and I have never failed to see it pro-
trude :  I will not disguise from you that this operation of punc-
turing the dura mater is sometimes successful, that it is report-
ed so by creditable authors, but it is my  duty to inform you
that I have always found it  fatal.                      #
   11  In respect to the medical treatment of your patient, 1
must remind you, that the first moment of  stupor, coldness,
and paleness, requires cordials ;  but the  reaction  that follows,
requires that the powers ofthe  circulation should be repressed :
and I must also remind you, that  such accidents happen chiefly
to workmen, vigorous, strong, and healthy, full of blood  and
often in the prime of life, that though there are many who bold-
ly  deny the  use of bleeding,  they speak  from  theory,  while
none dare neglect it who are  acquainted with practice : many
times  the patient lifts  his eyes and moves his hmos while the
blood is yet  flowing from the vein, and many are thus recover-
ed who otherwise would never move them again : bleeding is
useful in all contusions, falls, and blows,  to arrest the progress
of extravasation; but  where  extravasation  has already taken
place,  and one side is palsied,  blood should not be too profuse-
* See note, page 329. 
Of Tumours.
373
ly drawn  away, lest the strength suddenly sink :  the  brain be-
ing already compressed and the vital powers low,  it is peculiar-
ly dangerous to draw away much blood.   In concussion, which
is an apoplectic state of the brain, consisting at once  in fulness
of vessels and general exudation, bleeding relieves the oppres-
sion and promotes absorption : in stupor, with a heavy pulse,
throbbing gradually stronger and stronger, and increasing at the
same time in velocity, bleeding must  be used to prevent the
reaction rising to delirium ; and when delirium actually rages,
and the patient starts from his bed, and strikes and struggles, it
is most eminently required to save the organization of the brain
from  the  intense action of its  own vascular system : frequent
bleedings,  drastic purges of calomel,  and cold applications, and
cool air, are useful; blisters* and opium, doubtful in their op-
eration : and all other stimulants, as wine, volatile alkali, &.c.
quite improper.
@>
DISCOURSE  XX.
ON TUMOURS.
                        SECTION I.

                  Preliminary Observations.

IT is,  I am persuaded, my first duty to display the importance
of this department of our science, and to interest your sympa-
thy and reason in behalf of tlmse who are afflicted with tumours ;
of which, though some are  narmless,  far the greater number,
by their cancerous or malignant nature, by  oppressing  the or-
gans of breathing and  swallowing, by destroying the bones, or
even affecting (when seated on the head or in the nostrils) the

  * Bliftcrs are ftrongly, and I think juftly recommended by Mr. Abernethy.  S. 
374
Of Tumours.
functions of the brain itself, bring the patient, and that  too in
the vigour and.prime of  life, to an untimely grave.  In each
subdivision of our subject I  shall have occasion to lay before
you examples of neglected and fatal tumours, of dismal scenes
which the surgeon did not dare to prevent; of operations rash-
ly begun,  and abandoned in the  very moment of execution ;
we need not seek for sad and  persuasive examples of such dan-
ger to impress the importance of the subject upon our minds,
nor strive to recollect minutely the long-continued sufferings of
those who  have  died of  tumours.  The scenes  we have wit-
nessed in Hospitals, or in private practice,  return to the ima-
gination from  time to time, accompanied with all their tragical
circumstances ; we recollect the sufferings of our patients, and
we also remember that the most loathsome, painful, and, in the
end, fatal tumours, were once trivial; we also know that thou-
sands, at  this present time, are verging towards that hopeless
desperate state from which even the most intrepid surgeon will
not attempt their rescue,  at the peril of his reputation and eter-
nal peace of mind.
   Tumours are the most  frequent of all surgical diseases  ; eve-
ry surgeon must find the treatment of tumours, a part  of his
daily  practice: a tumour, in whatever part  of the body it is
seated, requires an  intimate acquaintance with the structure  of
that part,  and a clear recollection  of all the precedents or rules
which may serve either to direct the judgment, or to guide the
hand.  The surgeon should know how to resolve a tumour, or
to excite it to suppuration; how to evacuate the matter, and ob-
literate the sac;  when to suffer the mild and harmless to grow,
and how to extirpate  at every risk that which is prone to ulce-
ration or cancer.   Every tumour is a subject of new and  anx-
ious consultation,  and every  operation of this irregular nature,
demands  a knowledge of blood-vessels and nerves not easily
remembered, and  perhaps no where truly described.
   Need I remind you what torture a skilful surgeon  may pre-
vent,  what misfortunes ignorance may cause ?  Do we not see
surgeons mistaking tumours, malignant in their nature, for indo-
lent  and harmless  swellings  of  the glands ?   By tormenting a
simple tumour it  may become  malignant,—by  neglecting a
moveable tumour it may become fixed,—by allowing a small and
seemingly harmless tumour to grow, it may wax to so great a
size,  and acquire such intimate connections with  the more im-
portant vessels and nerves as to defy all kind of surgery.
   Look well, then, to the nature and probable consequences  of
every tumour ; for a tumour,  though void of any character  of
peculiar malignity, will, if seated in the passages of the  nose
or the throat, on a bone,  or in connection with great vessels or 
Of Tumours.
375
nerves, have all the ill effects of a malignant tumour without
being so, by bringing caries upon the bones, causing disease and
ulceration in the nostrils, compressing  the throat, and weaving
in its roots with the great vessels and nerves, and from this uni-
versal fact results this incontrovertible  rule of practice, " That
no suspicious tumour, seated in a dangerous part,  should be
permitted to grow."   Secondly, That almost every tumour,
though seemingly indolent in its nature, has its period of ulcera-
tion.   A  tumour of mere fat,  a tumour in which the adipose
membrane is alone diseased,  a steatomatous, or an ulcerous tu-
mour in which is collected an increased secretion, partly fluid
and partly solid, or purely of fat, is indeed harmless, unless by
its bulk and  weight, and when it suppurates it suppurates  mild-
ly : but wherever any part ofthe body, except the cellular fat
or muscular flesh is engaged  in the disease, wherever the eye,
the breast, the testicle, a bone or a joint; wherever, in short, any
part, having a complicated structure, is  affected, however long it
may have held the character of a mere overgrowth  or simple
tumour, it is ever to be feared, that sooner or later, its structure
will  undergo unfavourable changes, from long distention, from
occasional excitement, from  blows or  other injuries, and from
changes seemingly internal and spontaneous ; or, in other words,
from physical causes which our patient has not remarked,  and
which  we cannot trace.   Thence results another rule equally
established  in  my mind, that no tumour of a doubtful nature
should be permitted to grow, even through that period in  which
it seems indolent; for when  it inflames or  compresses the  sur-
rounding parts, when it is likely to suffocate our  patient, or to
end  in a malignant and fetid sore, it is so fixed as to defy ail
surgery.
   I  have  perhaps reason to suspect the opinion I have concei-
ved  of the importance  of a subject, which, from  long contem-
plating it  in its various  relations, has made an impression on
my mind which gains  strength while  I endeavour to infuse  it
into yours; to  ah author,  his  favourite theme,  his present
theme, seems ever important.  The surgeon, no doubt, when
he proclaims the importance  of a favourite  subject, is bound in
a peculiar manner to prove  it in detail,—to  prove it by  facts :
yet  I know  not why he should be debarred the common privi-
 lege of explaining without a  pointed reference to facts, whence
 the  general  impressions he has received have taken their rise: he
 most  of all may be pardoned an  overweening love of his  pro-
 fession, who sees it daily a source of relief from pain, from dan-
 ger, and from death inevitable, but for his interposition  : he
 may be acquitted of any affectation  of extraordinary sympathy
and feeling, who has been called at all hours and seasons, from 
376         Of the parts most subject to Tumours.

his bed,  his table, his family, to witness the agonies of a friend
suffocating from the bulk of a tumour,—alarmed with haemorr-
hagies which threaten life, or wasting under the cruel pains of
cancer.  Can  the  surgeon be  accused of affected  sensibility,
who describes with interest scenes in which he has so great a
share, so far different  from that even of the nearest friend, so
much  the  more responsible ?  He  alone sees all the variety of
misery, the least part  of which, if witnessed by common spec-
tators, is related in affecting terms ;  he alone knows the trivial
beginnings and sad conclusions of diseases, and can form a true
estimate  of their  importance.   The surgeon, in representing
the interest which particular diseases should excite, deals not in
the fantastic horrors  which the moralist conjures  up when he
declaims against the vices of a  declining age, or  the politician,
when the iniquity  of public measures is his theme, and he pre-
dicts the ruin of his  country : the  surgeon's mind is occupied
with distinct, impressive recollections of what individuals  have
suffered s though steeped in the colour of his trade, inured to
blood, he may be allowed to feel every degree of sympathy with
scenes of distress, presented to his imagination in such  various
and afflicting forms.
  Believe me, Gentlemen,  I use  no art to  engage  you in this
department of study,  and do not seek by exaggeration to en-
hance its importance :  what I think and feel, I must, in justice
to you, speak freely, and without restraint; and surely  no  way
can be so faultless as to lay before  you a slight and  preliminary
sketch of the  various parts subject to tumours, and the  various
consequences  of  their growth, as  they affect the  skin, the
glands, the bones, the eye, the  breast* the testicle, the  throat,
the rectum, or other  hollow passages of the body,  ruining by
pressure  and ulceration, the structure of the affected, and the
adjacent  parts.
                       SECTION II.

            Ofthe parts most subject to Tumours.

  The Skin is the part of the body perhaps the most vascular
and delicate, and is often by injuries,  as by the pulling off the
hair, or  the pinching or bruising of its vessels  so excited,  that
its vessels taking on a lively action, its arteries and veins are in
process of time dilated,  and form  aneurisms, or bleeding tu-
mours ; or they are merely by such excitement so quickened in
their ordinary function of nutrition, that the whole  web  of in- 
Of the parts most subject to Tumours.        3 71
  teguments becomes a tumour, retains its natural form and sub-
  stance, with only some slight enlargement of its pores and pa-
  pillae, but becomes so voluminous as to be wrapped round  the
  body, forming thus the most extraordinary tumours, which are
  still nothing but skin.
    The Bones, as vascular as the softer parts, and perhaps more
  regularly and  unceasingly absorbed and replaced, form, when
  they are injured, the most bulky,  and, from their solid texture,
  the most permanent tumours, which, when they turn to ulcera-
  tion and caries, are the most incurable and fatal.  We very fre-
  quently observe a tumour of a bone to follow a blow, and, when
  the blow and the swelling take place near a joint, when the knee,
  the wrist, the shoulder, or the ankle are involved in the tumour,
 its growth is extremely rapid. Often I have seen the radius, when
  the wrist has been fractured and  ill re-united,  form an  enor-
  mous bony  tumour ;  or the  heads of the tibia and fibula swell
  out  in  consequence of a bruise into a tumour cavernous and
 gristly, partly occupied with matter and partly formed of a solid
 increase  of  bone, till the thigh almost equalled  the body in
 thickness.   Very often such  tumours bursting pour out the
  most fetid matter; and large bony cavities, or numerous honey-
 comb-like cells are formed.   Often  too without external vio-
 lence, without any conspicuous marks  of a scrophulous  habit,
 without any possible relation  to venereal  diseases ;  the  bones
 universally are disposed to form tumours, by which sometimes
 the hands are deformed, the wrists swelled, the  fingers crooked
 like birds' talons, and sometimes the long bones, as the thigh-
 bones, shoulder-bones, ribs or scapulas, are studded  with large
 knobs or grow out in tumours.  These are diseases  still more
 dismal, quite irremediable.
   The  Glands, when  their  vessels are excited by  blows, by
 cold, by  the absorption of foul and  virulent matter, are enlarged
 beyond all credible limits, and draw the adjacent parts into dis-
 ease, insomuch that the tumour which originally was a simple
 gland has, in the end,  a  very  anomalous  aspect, and conveys
 such confused impressions to the feel, that we know not how to
 pronounce upon its nature, which the history only ofthe tumour
 can in any degree elucidate.   These are the tumours which,
 when seated either within the mouth, or at the angle ofthe jaw,
 repress the tongue, displace the trachea, or obstruct the free pas-
 sage of the  food and  air,  and connect themselves so with the
 branches of the  carotid arteries, that the hand of the most in-
 trepid surgeon can no longer avail, and wise and prudent men,
 met in consultation, shrink from those dud«-s which the patient's
 manifest danger plainly  imposes, lest  they- should bring, not
themselves only, but their profession into disgrace.
                          3  B 
378         Of the parts most subject to Tumours'.

   The Eye, a part at once exquisitely sensible, and exquisitely
vascular, and consisting of humours which are in a state of con-
tinual circulation,  being continually secreted and re-absorbed,
grows by the slightest excess of vascular action into a tumour.
Sometimes the secretion of aqueous humour, not changed, but
merely augmented, distends the globe of the eye into a tumour
continually increasing, till first vision is deranged, (not destroy-
ed) next head-achs  ensue, and, finally, the coats of the eye
give way.   On other occasions the adnata, or loose and vascular'
coat of the eye, arising  from the inner surface of the eyelids
and connecting them with the skin, is so swelled by inflammation,
that its cellular substance being of a spongy nature, the tumour
of it covers and involves the  whole eye, conceals the  eye-ball,
protrudes far beyond the eyelids red, flesh-like, and often ulce-
rated, so as to seem  in the hasty opinion of ignorant surgeons
a cancer ofthe eye:  even for such a disease, so little connected
with the globe of the eye, or allied with cancer, have  I known
the whole eye-ball extirpated.  Sometimes the deeper parts of
the eye are  so  inflamed as  to terminate in suppuration of the
globe, after delirium  and dreadful pains ; then the  central parts
having suppurated, the firm coats of the eye at last ulcerate, the
globe bursts,  the  eye subsides  into its socket, and the eyelids
close upon what remains of its coats:  but these, thickened by
continual inflammation, harden and grow  into a new and more
formidable tumour ;  and the  eye protrudes again from its sock-
et, of a  scirrhous  hardness, with a painful and burning ulcera-
tion.   Sometimes from  a suppuration less deep or extensive,
where not the vitreous humour or whole body  of the  eye, but
only the cornea and  the iris are diseased, the eye becomes can-
cerous ; for when, after a partial suppuration and ulceration of
the eye, the iris very often throws out a fungus, bearing the true
character of cancer,  even  from the first, or becoming so by the
excoriation of the  tears,  and the  friction of the eyelids.   The
lachrymal gland seated within the socket is often, as I shall have
occasion to explain  by examples, a cause  of incurable disease,
and  the  small glands or lacunae of the tarsus, or cartilaginous
borders of the eyelids, form tumours extremely firm and unal-
terable in their nature, sometimes indeed stationary, but never
resolving under any  course of treatment, and often causing such
pain and inflammation of the eye as to require extirpation.  All
the parts, in  short  of this delicate organ,  whether proper or
merely adjacent, are  subject to tumours more frequently cancer-
ous than. mild.
   The Breast is a gland destined to perform a secretion more
profuse and rapid, in proportion to its size, than even that ofthe
salivary glands, and  more elaborate.   It is subject to great pe- 
Of the parts most subject to Tumours.         379
 riodical excitements ;  at each menstrual period it swells slight-
 ly, is greatly enlarged by pregnancy and  suckling, and in warm
 climates, or diseased constitutions, in all countries, it is the part
 first and most conspicuously  enlarged.   The period of life at
 which menstruation ceases  is so critical for this  gland, that it
 then falls into scrophulous and cancerous diseases, having every
 variety of aspect.  Sometimes  the  whole breast is indurated
 and enlarged, with a sweUing so truly scrophulous,  that I have
'seen the  breast suppurate, burst out like other scrophulous
 glands,  heal at one point and ulcerate in  another,  become indu-
 rated to an extreme degree,  and pour out from various openings
 a limpid serum in profusion, proportioned to the natural secre-
 tion of the gland.  Often there  takes place,both in women who
 give milk and in those more advanced in  years,  a  voluminous
 abscess, which is both formed so slowly, and lies involved in so
 thick a mass of indurated gland, and so void of pain, that it  is
 distinctly marked as a scrophulous disease.   In both the  affec-
 tions ofthe  mamma  here described, though as far removed
 from schirrus, as scrophulous swelling of the testicle from can-
 cer of that part, I have seen the breast amputated with circum-
 stances of particular cruelty.  From scrophulous inflammation,
 blows,  milk-fever,  or, in  consequence   of  that indescribable
 change  which take  place at the  ceasing of menstruation, the
 gland ofthe breast is hardened,  either in one mass or in  sepa-
 rate kernels, which, however long they may remain indolent,
 become sooner or later inflamed, and then the proper gland of
 the breast, the lymphatic glands connected with it, the skin, and
 cellular substance, even the pectoral muscle itself, are apt to be
 massed together into one hard globular  and ponderous tumour,
 with separate glandular tumours interspersed in the surrounding
 cellular  substance.    When  this mass  ulcerates,  the  axillary
 glands,  previously indurated, also inflame ; the skin of the axil-
 la reddens, as that of the breast ulcerates; the whole armpit
 swells,  the arm becomes (edematous, and liesi powerless ; and
 the patient dies in a most loathsome  state, w ith  roul  and very
 fetid matter running from the sore in great profusion, so as  to
 make the last offices of friends difficult to perform.  Sometimes
 this disease begins like a kernel in the centre ofthe gland, some-
 times like an excoriation  of the  nipple,  sometimes like a mere
 contraction and induration of the skin, not beginning invariably
 round the nipple, but  extending, as I have several times remark-
 ed, from the axilla downwards, so as to affect the breast.  Thus
 a careful observer sees in the course of practice a sad variety of
 disease in this part, according with the various structure of those
 parts in which the disease begins, or the species of the  malady, 
380         Of the parts most subject to Tumours.
whether varicose, scrophulous,  or cancerous ;  varieties which,
simple as the part seems to be, are as widely different from each
other, as  venereal, scrophulous, or simple inflammatory affec-
tions of the eye  are from one another, or affections of the cor-
nea from those of the humours.
   The Testicle is apart subject,  like the eye and breast,  to
cancerous affections, often commencing in venereal inflamma-
tion, affecting the structure of the gland, or arising from blows
or falls, complicated almost always with a watery tumour of the
tunica vaginalis,  and indurations of the spermatic chord.  These
diseases, too often concealed even from  the  surgeon, arrive  at
their last stage   undivulged :  but the scene is  dreadful indeed
when either before operation the testicle bursts out into  open
ulcer,  or,  after  an  operation performed too late, the chord, be-
ing diseased, protrudes from the upper angle ofthe wound in the
form of  a fungus or cauliflower-like tumour, which  it is in  vain
to extirpate with either ligature or knife, for it  shoots out again
in a day, bleeds, and discharges the  most  fetid sanies, accom-
panied with cruel pains of which the patient dies.
   The Membranes lining  the Nostrils are  of  so vascular
and glandular a  nature, so continually txposed to the  air, and
yet so delicate and sensitive, that tumours arise even from the
very slightest irritation.  These tumours, mild perhaps in their
own nature, are dreadful in their  consequences, from being
seated in narrow passages, limited not by dilatable membranes,
but by unyielding  bones, which suffer  every  kind  of disorder
when the passages begin to be filled with  even the softest of
these tumours, while the cavities of the antrum highmorianum,
and other cells far out  of the  reach of instruments, are often oc-
cupied by tumours  of a more malignant nature.  So destructive
are the consequences of even the mildest tumour, growing and
distending these passages,  that we  know not  how to admit  or
refuse that definition of tumour so  often mentioned in  books,
" The  Cancerous Polypus ; for no cancer can be more des-
tructive than even the most simple polypus. Little does the patient
apprehend the fate that awaits him, when a small tumour which
he can just touch with the  point of the finger, soft, pendulous,
void of  pain, and attended with no worse disorder than sneez-
ing and  watering of the eyes, first appears :  it is not that slight
sense of suffocation which first alarms  him, increasing to  a to-
tal obstruction, that occasions his death; but the narrowness and
crookedness ofthe  passages ofthe nostrils and throat, and the
vicinity  of those parts  to the  brain, separated indeed only  by
the thin  plate of the ethmoid bone that occasions death.    The
bones first become  soft and carious, and discharge  a  fetid and
acrid matter, which distils in such profusion as to excoriate the 
Of the parts most subject to Tumours.         381
lip, and  to cause diarrhoea by  running down the nostrils and
throat.  The blood bursts impetuously from the corroded ves-
sels irom time to time:  the  hearing is entirely  interrupted by
the pressure of the tumour on the mouths of the Eustachian
tubes: the teeth fall  out from the sockets, in consequence of
the caries of the alveolar processes : the  head  seems rending
asunder with distracting  and  continual pains: usually the patient
is exhausted by long suffering,  and  frequent loss  of blood;
sometimes he lives till caries ot the ethmoid bone admits the ul-
ceration to the brain, and he dies lethargic.
   The Gums, when they fall  into a diseased condition,  hard
as tht y are,  (and  their hardness approaches more nearly to the
consistence ot  the  teeth and jaw-bones, which they connect to-
gether, than  to that ot flesh,)  throw out  tumours so luxuriant,
so truly fungous, so profusely supplied  with blood, that the hae-
morrhagies from them are, even from  the fit st,  alarming,  and
are in the end fatal; and the tumours, when extirpated with the
scalpel, or torn away with ruder instruments, often sprout up,
(after the very bones have been  laid  naked,) in the space of
twenty-four  hours,  and  effloresce in  the course of a few  days
into cauliflower-like txcrescences. and still grow so rapidly, ac-
companied with dislocation of the teeth and caries  of the  jaw,
that the patient expires  of haemorrhagy,  diarrhoea, and cance-
rous pain. There is no form of tumour I so greatly dread, none
so rapid  in its  growth,  as those  proceeding from these callous
gums,  nor any disease in consequence  of which I have suffered
such severe,  unlooked-for disappointments, or seen such unsuc-
cessful operations and horrible deaths.   Sometimes the extirpa-
tion is  successful, and, I  think, I can often predict when it will
be so;  but, when it fails,  no cauterizing, nor the most cruel pro-
cesses of surgery, will repress the alter growth ; it is  truly can-
cerous, and invariably fatal.
  Tumours  of the  Throat, whether external to the jaws, or
visible  only within, give  no alarm but by the effect they produce
on the  breathing and swallowing ; and yet they are, beyond all
comparison, the most dangerous tumours, fatal if neglected, and
yet so connected with great vessels and nerves, that to extirpate
them is almost impracticable.
  Suppurations  within the throat  of a  scrophulous nature  are
frequent;  and I shall have occasion to  lay before you  examples
of these bursting by  multiplied openings into the larynx and
oesophagus occasioning suffocation by the matter falling into the
trachea, or inanition and  death by the contraction oi the oesopha-
gus,  in consequence of long ulceration.    Other tumours again,
which, at first sight, the surgeon is disposed to imagine are sacs
of purulent or serous matter, and  which  I confess  myself  to 
382         Of the parts most subject to Tumours.

have mistaken for such, are sacs of blood formed by dilatation
of the extreme  arteries  and veins;—aneurisms of that kind,
which I have formerly described under the name of aneurisms
by anastomosis, but lying too  deep under the skin and the pla-
tysma  myoides  muscle,  and too near to the great carotid arte-
ries  and  its accompanying  nerves,  to admit of extirpation.
Sometimes I have found tumours, especially occupying the fore-
part ofthe neck,  in the place of the thyroid gland, to be sacs of
blood, but of a structure widely different from that of those an-
eurisms, and perfectly curable, distinguishable from those ca-
ses of  aneurism by anastomosis, in having no pulsation, and a
thicker sac.  The tumour is stationary in respect of size, and
not becoming more turgid upon retaining the breath, nor flatter
when the blood  is repressed  by the hand:  there is  no conge-
ries of active vessels opening into  them, and  supplying  them
with blood.  The blood, I find, has all the characters of having
remained long in the sac, and the sac itself is  of a firm consis-
tence,  difficultly brought to  suppuration, infinitely  more diffi-
cult to obliterate than those sacs which contain matter or serum,
and  leaving behind them  a  permanent thicking of the throat.
Aneurisms of the carotid arteries are not frequent,  but I have
seen a pure and simple dilatation of this vessel under the  angle
ofthe jaw, of the size of a fist, intruding upon the throat rather
than projecting outwards, little  conspicuous as a tumour, but
having  an  awful throbbing  pulse, when the palm  of the hand
was laid over it.  One would  fear nothing in such aneurism
but the bursting, and the loss of life by haemorrhagy; but long
before the sac inflames or ulcerates, the fever  with which it is
accompanied, and the difficulty of swallowing, arising  simply
from its pressure upon the  pharynx, occasion death.*
   The  Salivary and Lymphatic Glands, lying under the
tongue, and about the angles  of the jaw, are frequently diseased,
and form tumours  varying  greatly in  their form  and nature,
and growing sometimes to  an enormous size; usually they con-
tain a gelatinous matter, thick, ropy, sacculated, and  mixed
with  solid bodies like grains of millet or mustard-seed,  some-
times a pultaceous matter: often these tumours are so far fluid,
as to give  hopes when first the sac is opened, that the tumour
 will entirely subside, and the sac  be easily obliterated;  but so
 far solid as to mock these  expectations, for, while  the matter
 runs  out, the base is indurated, so that before  the opening of
the sac is closed, the base has become a tumour, firm, glandu-
lar and visibly increasing.  Sometimes these glandular tumours
 especially such as are seated  under the jaws, though of a stony
 hardness, are  moveable, subject to no pain nor occasional m-
   * The carotid artery has been fuccefifully tied by Mr. Aftley Cooper when af-
 fected with aneurism.  S. 
Of the Tumours ofthe Bones.            383
flammation, not adhering to the  skin nor subjacent parts, but
indolent and harmless.   Always in children and boys, some-
times too in adults, such indurated glands are harmless, but of
firm and knobuluted tumours, especially of those seated in the
cheek, covered with a coarse, porous, and puckered skin, and
connecting themselves strongly with the surrounding parts, livid
on their more prominent points, and aching with every change
ot weather or season, I have never seen a happy issue.  There
is no safety for the patient who is endangered by such a tumour,
except in extirpation ; nor can we assure him that such an ope-
ration (not always void of danger,) will eradicate the disease.
  These preliminary sketches and characters of tumours, shall
serve as a slight index of the subjects I have to explain in de-
tail : the varieties of suffering will be but too truly confirmed by
facts: the distress the patient suffers who dies of any form of tu-
mour, whether suffocating, carious, or cancerous, exceeds what-
ever the most eloquent writer on  professional subjects  could
represent, or the warmest imagination conceive.  Believe  me,
it is the sufferings of individuals that have given me such deep
impressions, and you shall feel, before I have finished  the nar-
ratives of the cases corresponding  with these characters, how
little I am inclined, how little I need to exaggerate,  the impor-
tance of this subject.
DISCOURSE XXI.
          OF TUMOURS OF  THE  BONES.


 IN this discourse, vyhich is devoted to the diseases of the bones,
 I shall first sketch out to you my conception of those changes
 which happen in the structure of bone,  before it swells  into a
 tumour; and shall next lay before  you the facts in detail, from
 which those conceptions, true or false, have arisen.
   Every tumour must derive its peculiar form from the structure
 of that part of the body from which it arises ; for it is not seated
on the part as a new and accidental existence,but is engendered
by us vessels,  and is of its actual  substance.   Manv things
conspire to give the tumour proceeding from a bone a peculiar 
384            Of the Tumours of the Bones.
 aspect; it is always irregular and anomalous, never simple.   I
 have rarely seen a single bony  protuberance arising Irom  the
 head or the shaft of a single bone.   When a bone falls into dis-
 ease, a large  proportion  of tendinous and muscular parts, of
 bursse,  and of cellular substance, partake of the morbid action.
 The bone lies in the centre  of the limb connected by its larger
 head with the joint, and by its  periosteum with the tendons,
 bursa?, and muscles ; and all this mass of parts is sooner  or la-
 ter affected; and since every deposition from vessels  appointed
 for the secretion of bone is solid, and every increase  ot >mch  a
 tumour permanent, it soon attains a great size ;  it is ponderous
 and massive from the proportion of  bony  secretion,  and  from
 the various structure of these several parts, it has every irregu-
 larity of form and substance.
   When  the tumour of a bone has attained a considerable size,
 much of  the original structure is destroyed,  and a new irregu-
 lar mass of gelatinous and bony matter is substituted for it.  The
 bony tumour is firm, bulky and ponderous, but not solid ;  feel-
 ing it from without, we can conjecture of  What substance it is
 composed within ; we are sensible that the tumour is covered by
 a shell, bony in most part of its circumference, cartilaginous  in
 Some parts, and  throughout the whole yielding and elastic ;  we
 are sensible also, that within,  there are  irregular  points or
 spiculae traversing the cavities or cells of  the hollow tumour;
 that these are mixed with the cartilaginous substance, and with
 irregular  collections of matter, partly purulent, but chiefly ge-
 latinous ;  and we find at last, by pain  and partial  ulcerations,
 and by the increase of fluctuation and redness at particular points,
 that ulceration, the last stage of the disease,  approaches ; then
 the limb is effectually ruined, and the patient must submit to am-
 putation, or die hectic.
   When  such tumour is dissected, we find  our suspicions of its
 internal structure confirmed ; we see that foul matter flow out,
 when we open into the centre of  the tumour, which we felt but
indistinctly through its walls ; the parts of  which appeared the
most solid, are hollowed out by ulceration, and full of foul and
putrid sanies ; while the bone has been declining into disease,
the cancelli and marrow have been  degenerating into a sort of
fatty mass, with which much of  the cavity  of the tumour is fil-
led, and thence such disease has been very generally described
under the  name osteosteatoma.   This fatty  secretion, occupying
the diseased cavity, is the  part, which, when the tumour bursts
into open  ulcer,  throws out such prolific fungus,  growing appa-
rently from the substance  of the bone, and sprouting up when
amputated, in the fourse of a few hours. The solid  bone, whe-
ther radius or thigh-bone,  is annihilated, and a  mere shell of 
Of the Tumours of the Bones.            385
osseous matter substituted in its place, and that in a manner so
peculiar, that it must seem to the unintelligent observer, as if
the small and solid bone  had been expanded into an extensive
and  flat plate  of osseous substance,  whereas the process is in
truth very simple and very intelligible.  The bone dies piece-
meal of ulceration, or what, in technical language is termed ca-
ries,  and is conveyed away by absorption ; but the bone being
dead, the  surrounding membranes,  viz. the periosteum  and
tendinous expansions,  which once formed a  part of its system
of circulation, continue still alive, and  ready  to secrete new
bone  ; and  thus it happens that while a carious abscess preserves
a large cavity full of foul matter, the surrounding membranes
continue secreting bone, which, like a shell, thin and expanded,
covers this cavity, and forms the walls of the tumour, of which
some part  is  composed of thin expanded bone, resembling a
cranium, some of cartilage, some of  thickened membrane ; and
this shell is formed in proportion  as  the original  fabric of the
bone  is destroyed.
  Bone is  destroyed by this  internal ulceration, just as it is by
open  caries, piecemeal ; the  process  would  not be ulceration,
if, while one part were perishing the other were not active and
secreting new matter ; so vigorous still is the general life of the
bone, that  while the  internal parts are thus suffering, while one
side is wasting with ulcer, the other side is often secreting bone
irregularly  and profusely,  and shooting out into fantastic forms
among the  membranes and surrounding parts, whence the cen-
tre of the tumour is cavernous and cellular, and the walls often
rough with spinous  and projecting points.   So merelyT  local is
the action of arteries in a  tumour, whether osseous or soft, that
one side, or  part, or bump  of a  tumour, grows visibly,  and
protrudes,  the features and external form of the  tumour, gra-
dually changing, without any sensible  cause ;  and so peculiar is
the secretion of each species of vascular structure, according to
the original destination of  the part, that in one part of a tumour
is generated bone,  in another gristle, in another gelatinous effu-
sion ;  while in another part, the vascular action is violent and
destructive,  and the  solid  bone, marrow,  and  surrounding
membranes,  are all resolved  into a foul and  fetid suppuration.
From the periosteum is secreted bone ; from the  marrow,  this
steatomatous and solid fat, with which much of the tumour is
filled  ; to the tendinous and aponeurotic parts we can distinctly
trace  the cartilaginous secretion ; and the  gelatinous effusions
we can perceive, even during life, are thicker  or thinner accord-
ing to the degree of inflammation.
  These are the external  characters,  and internal conditions of
                            3 C 
386             Of the Tumours of the Bones.
a tumour,  occupying any of the bones.   Such  tumour arises
often from a bruise or fracture ; sometimes from a less obvious
cause,  or from internal  disease.   The radius, for example, is
fractured at the wrist, re-unites, and heals, but heals clumsily  ;
the thickening never subsides, the pain never ceases, and though
not great,  is greater than what is natural to  a  fracture ; at
length a sensible tumour arises;—at first it is firm,  but in pro-
portion as  it increases in size, it becomes somewhat soft and
elastic : the thin plate of bone of which it is composed yielding
to the distention from within.—From time to time the  tumour
changes its form, still increasing in bulk ; on the side of the ra-
dius it is firm and solid ; it bends and yields  at the  parts most
distant from it; it is plainly bony at its basis,  and as obviously
cartilaginous in the extreme part of its circle ;  it plainly contains
matter in those  softer parts, where it yields to the  impression
ofthe finger;  cartilaginous  knobs arise, and sometimes are red-
dened on the surface ; and  at certain  points the fluctuation is of
such a kind as to imply,  that the  effusion is in part of a gelati-
nous nature.  Thus the tumour grows and  extends, with vari-
ous irregularities  in form  and consistence ;  it overhangs the
dwindled hand, the use ofthe joint is lost, and the patient, who
would gladly be delivered of it at an earlier  stage, has in the
end no choice left;  for when once it bursts into carious ulcera-
tion it never heals,  the  fetor is inconceivably overcoming, at-
tended with hectic.  You are also to remark, that  when such
disease takes place in the hand itself, the joints of each of the
fingers grow out into tumours, at  first of a heart-like form, cor-
 responding with the articulations ofthe finger-bones ; but in pro-
 cess of time,  they grow to globular, irregular, and almost trans-
 parent  tumours, still firm, or  at least of a cartilaginous firm-
 ness.   The whole hand degenerates into a deformed mass, dis-
 coloured,  ulcerated, and  fetid  ; from the  individual knobs of
 this deformed mass, the points of the respective fingers project
 like griffi:i's claws,  with crooked  nails of enormous length.
    You will conceive, I trust, from these general descriptions,
 an idea, not far from perfect, of  the irregular forms, and inter-
 nal disorder accompanying this disease: you  may imagine how
 ill th- surgeon is qualified for practice, who is  not aware of these
 changes in the internal structure  ; he feels fluctuation, and re-
 gardless of the history of the tumour, of its firmness,  or of its
 connection with a bone, plunges  his abscess  lancet into it, and
 it pours out, if he strike deep enough, a  profusion of thick mat-
 ter ; he then believes that it will heal, but it will never heal. Or,
 knowing it to belong to the bone, he  imagines, perhaps, that it is
 a firm  and solid tumour, but believes that the tumour is move-
 able, because the  radius  moves  along  with it, allowing it  to 
Ofthe Tumours ofthe Bones.            387
 turn ;  he projects an operation for cuttingoff this tumour ofthe
 bone,  but, after  a slow and  painful dissection, he finds it not
 solid but cavernous, and full  of tatty or fetid mater ;  he finds
 the  bone to which  he imagined the tumour  attached,  entirely
 gone,  and the joint to which that bone belonged entirely open ;
 he finds the smooth cartilaginous heads of the wrist-bones ex-
 posed in the cavity of the ulcer; and is forced, after the patient
 has  lost  much blood, and manfully endured a slow excruciating
 operation, to cut off the hand.  Such are the lessons  which ex-
 perience  teaches, and I have known instances where the case
 and  all its probabilities have been maturely considered, by men
 of great  skill and judgment;  where a Lynn, surrounded by his
 approved and skilful friends, has reckoned the probability of
 success,  such as to vindicate  an operation ; the tumour small,
 firmly attached to the radius,  turning easily along with it, not
 yet  distorting the tendons, not yet interrupting  the use of the
 hand,  I  have known the operation, performed even by such  an
 operator, fail.  Now, in such cases,  the tumoup does not cease
 to grow,  the incisions heal up, the part of the radius  cut out by
 saws grows again, the tumour continues to increase, till it de-
 stroys  the wrist, the  hand  dwindles, the fingers grow long,
 sh ipeless, and powerless, from want of use,  and amputation is,
 in the end, the only resource.
   The forms ot this disgusting disease, which never fails to de-
 stroy the limb,  are infinitely various.   I have seen the ankle of
 a woman, from a very slight accident, fall  into this disease ; the
 tibia and fibula grew into a  common tumour;  the bones seemed
 to me annihilated, and a large shell of bone substituted in their
 place.  The leg,  in the course of the disease, twisted round in
 a singular manner, and the limb enlarged to the size of the pil-
 low of a  settee.   This woman died of hectic, from the open ca-
 ries  ofthe tumour.  The wrist, more exposed than any other
 part  to  sprains and fractures is,  very liable to  be thus de-
 formed and ruined;  but  the hand itself is still  more liable, the
 original injury is some slight  blow or sprain;—one finger  is
 first  deformed, joint after  joint enlarges, one finger becomes
 crooked  alter another, the nails project unpaired like talons, and
 force their way into  the very  flesh  of the swelled and ulcerated
 hand, which  they sometimes  actually  penetrate  through and
 through ;  the hand degenerates into an unwieldy  and irregular
 mass,  studded  with  knobs and bony tumours.   From a ne-
glected fracture ofthe collar-bone, I saw once in  a  stout young
 man, (who, living a  most dissolute life, left the fractured  part
no rest to heal and unite,) a tumour formed, partly bony, partly
cartilaginous, rising  to the height  of six inches,  round, insula-
ted,  moving when the arm wa^ moved, too large and too criti- 
388            Of the Tumours of the Bones.
cally seated over the axillary artery, to admit of  extirpation,
and which, I doubt not, has by this time become carious, and
occasioned his death.
  The stage and period of growth at which such a tumour may
be extirpated, if  ever such operation be practicable, I profess
not to know: the circumstances must be very favourable  in-
deed, to  incline  me to undertake such an achievement; it is
often indeed  a matter of doubty. whether it would be advisable
even to amputate the diseased limb, for occasionally  we see
both hands thus diseased, and often the tendency to form such
tumours seems to  prevail through all the osseous system.   If
the disease proceed from a fracture or bruise, we cannot ven-
ture to extirpate the tumour, for the joint is diseased, and  we
have no resource  but amputation: if the  tumour is spontaneous,
and without any violence or manifest cause, we have reason to
fear it is a constitutional, and not a local disease ;  and dare  not
propose amputation with confidence ; it is only in the rare  oc-
currence of  a bony  tumour  being altogether limited  in its
growth, insulated in its form, solid  and firm, and unaccompa-
nied with disease ofthe surrounding parts; seated on the shaft
ofthe bone, not connected with the joint, and yet growing to a
great size, and threatening destruction, that we should think of
any such  operation.   Such, perhaps, is a  case  recorded by
Heister, of a great bony tumour rising from the middle of the
sternum,  equal in size to a child's  head, which was successfully
extirpated.
  The general description of this disease, and the chief practi-
cal lessons, will be as fully illustrated by the  following case, as
by a hundred such, for it includes all the principal features of
the disease, and all the practical difficulties, which the surgeon
may have to encounter.
   " A labouring  man, about 40 years of age, sallow, lean, and
meagre, presented himself with a tumour of an enormous size,
and of an anomalous character, partly solid/partly cartilaginous,
occupying two thirds of the fore arm,  from the wrist upwards :
the hand  was sound,  and all its joints limber, the wrist bended,
and the fingers  moved easily; it was from  pain  only, and
weakness, and the  incumbrance of so great a tumour, that  he
could no longer work :  the tumour seemed also to move freely,
whence it seemed possible to dissect it away, and save the joint;
and the surgeon,  a man whom I respect as a man of learning,
skill, and consummate  prudence, was induced to begin a par-
tial operation, a dissection of the tumour, from a sincere desire
to preserve the right hand of a poor labourer.
   " But here you are to take notice,  (and I should put no value
on a case which did not convey some practical lesson) how  un- 
Of the Tumours of the Bones.            389
 expectedly we are sometimes involved in great perplexities from
 reflecting too slightly on the nature of a tumour: a tumour of
 this singular complexion, any tumour indeed which requires an
 operation, should be so particularly examined, as to enable the
 surgeon to  prognosticate every thing that could occur, and to
 describe the disease before amputation, as precisely as if it lay
 already dissected before him: much  of what will be found on
 dissection may, in almost every case, be anticipated, and every
 such anticipation will be happy for the patient, and creditable
 for the surgeon.   The  surgeon should, at least, ascertain the
 general character of the tumour, yet, I question whether, in this
 case, it was absolutely known, that the tumour was at all attach-
 ed to the bone ; that it was merely a tumour ofthe radius, as-
 suredly not.
   " Little is to be learnt, even  after much inquiry,  from those
 ofthe lower orders concerning the early stages of their diseases.
 This, perhaps, was  of a  nature originally malignant, but cer-
 tainly irritated by neglect at first, and, in the end, by imprudent
 advice and rash  applications: the  man had,  about six or eight
 months before applying for assistance, first observed the disease,
 in the form of a circumscribed swelling, rising upon his wrist,
 gradually increasing, and becoming daily more painful: he ima-
 gined it right to apply poultices, and, after  some time, brought
 it happily, as he imagined to a  suppuration: but,  as it did not
 heal, a mischievous old woman undertook the cure, cramming
 it with tents, and acrid and corrosive  powders, and  making so
 very free with the lancet, that he narrowly escaped  dying  of a
 haemorrhagy, caused probably  by the erosion, or wounding of
 one of the veins above the wrist.   The tumour was, at the time
 of the operation, enormously large;  it was  at the  lower  and
 bigger part of a dusky brown, but at  its upper and  smaller  end
 of  a fresher colour, with a wide and  open ulcer,  bleeding at
 times, and disposed to throw out a luxuriant fungus, to suppress
 the growth of which was, perhaps, part of the old woman's in-
 tention, in applying the  escharotics, if intention of any kind can
 be imputed to so ignorant a creature.   The  veins,  as  is usual
 in bony tumours, were far from being conspicuous even in  this
 part.
   " This poor man, having willingly assented to any operation,
 however lingering or painful, which  might save his hand, the
 dissection was carried all round the tumour and into its central
 parts, before the surgeons  present were  undeceived.  As the
 radius turns vertically like a spoke or spindle, it turns  without
 any apparent motion, except in the parts connected with its low-
er end; the  hand turns freely along with the radius, so that we
never suspect till we become  acquainted with anatomy, that it 
390            Ofthe  Tumours of the Bones.
is by the spoke-like motions of the radius that the hand moves;
it seems moveable in itself  by  its own immediate joints.  This
tumour, in like manner, moved easily, could be turned upwards
and downwards,  so that the surgeon never once suspected that
the motion was in the radius, or that the tumour was fixed, and
made a part of that bone ; it seemed moveable, and he began to
extirpate it,  by drawing a  long incision round its root, on the
side  of the  ulna : but,  finding it difficult, with this limited in-
cision, to dissect the tumour,  he prolonged the incision, con-
tinuing it over the back of the hand to the knuckles, in  the di-
rection of the  extensbr tendons.  He then dissected more free-
ly, and continued separating the skin from the tumour,  till  he
came  to a thick and solid sac,  which seemed to consist of mus-
cular  and ligamentous fibres.
  u He continued this dissection, separating this  thick and solid
sac from the interosseous ligament, till he could go no farther;
finding that  it terminated then in a solid and osseous  basis, he
now plunged intrepidly into the heart of the  tumour.  In doing
this he found that he had opened a very large sac, not firm only,
but osseous  ;  but still as he was penetrating into the tumour at
one side, viz. at the  side  nearer the ulna, with which the tu-
mour was manifestly unconnected, and at the greatest possible
distance from the radius, from which the tumour in fact arose,
he continued still  unsuspicious, and persevered in dissecting
away  what he imagined to be a common tendinous  sac, ossified
only at certain points: he made thus a large opening into the
tumour, felt its cavity full of loose and fatty bodies, pushed his
finger under the  extensor tendons into the  deepest part of the
sac, began to hook out the fatty tubercles with his  fingers, and,
at last, baling it out with his hand, (for the cavity was large
enough to admit  his hand) hooking with his finger  and catching
the fatty masses in  his palm, he  so far emptied the cavity as to
be able to search with his fingers in every direction, and then he
found, to his  utter  confusion, the ball of the carpus, (formed by
the schphoid and  lunated  bones) at the bottom of the cavity,
bare :  he was now for the first time, undeceived, and knew what
sort of disease he had to contend with ;  he was now conscious,
that the radius was diseased, the joint ruined, the original bone
ulcerated and destroyed ;  he felt distinctly that the ball  of the
carpal bones, originally  opposed to the lower end of the  radius,
was now, by the destruction ofthe radius, left naked ; and, in
fine, that the wrist-joint was irrecoverably ruined.   There  was
no going on with this operation, and no stopping here ; he there-
fore explained to the patient, who had  borne this severe  and
long protracted dissection with great  composure, the necessity
of amputating his  hand,  which he  submitted  to  with equal
resignation." 
Of the Tumours ofthe Bones.             391
  The reflections naturally arising  out of this case are obvious
and impressive ; we must be conscious how suddenly a surgeon
may, in a moment of thoughtless security, be plunged  into cir-
cumstances extremely  perplexing.   How btcoming it is to in-
vestigate and examine with care, the history of every disease
before operating, and to ascertain the soft or solid, the fixed or
moveable state of a  tumour, its probable connections and even-
tual dangers : we should be aware of attempting (which is indeed
equivalent to promising) to extirpate a tumour, which, though
apparently moveable,  is only seated  on a moveable bone  : we
should be  careful not  to promise a  cure where, perhaps, the
joint is destroyed : not to enter upon a painful and exhausting
operation,  in  a  case where  nothing but amputation can avail.
In a case such as I have just described,  it should  be recollect-
ed, that  the metacarpal bones lie very deep in the  hand, have
a considerable latitude of motion, and may communicate  that
motion to the tumour ; the circumstances of this tumour and its
history were such as  might deceive the  most  circumspect, the
 turning  of the  radius conveyed an  idea of the tumour being
moveable ; the elastic and cartilaginous feeling, that it had no-
thing extraordinary in  its  nature ;  the sac, when  the surgeon
had dissected  down to its root, was such as gave him reason to
believe it was but in part ossified ; the fat which he scooped out
from its  cavity, that it  was  merely a steatome ; it was not till he
felt with his finger the ball of carpal bones naked, that he  knew
the joint to be diseased ; he had every apology for his mistake,
for, in a disorder of no more than six months duration, he had
no  reason to believe  there could exist such universal destruction
of  the joint and of the radius.
   But a charitable endeavour to save  the hand of a poor and
 labouring  man, even when it involves us in a severe and  fruit-
less operation, is not the worst error ; the surgeon, alarmed by
 the  uncouth appearance of a hand  deformed  by such disease,
and not  calculating with due deliberation the  individual bones
that are affected, might rashly  amputate the whole  hand, where
 an useful part of it might be preserved.   Among  the cases  of
 this nature that stand recorded, is one by Severinus, short, in-
 deed, but  not the less interesting :  "  Hyeronimus  Damianus,
 a youth about twenty-two years of age, crooked and scraggy,
 and of a puny habit of body, had his right hand so enlarged  as
 to  be  a burden too great for him to bear : in lying, he iaid  it
 above his head, walking, he carried it with difficulty on his other
 hand  : it was  diseased, chitfly by  the enlargement of the pha-
 langes of four of the fingers ; the individual tumours you would
 have likened, in respect of size, to lemons, in respect of colour,
 to  rotten apples, being large, globular,  and livid:  these knobs. 
392            Ofthe Tumours ofthe Bones.
  or enlargements, were plaited over each other, and the points of
  the nails projected like claws from the extremities of the seve-
  ral tumours."  Men of ordinary genius and resources no sooner
  stumble upon a difficulty than they are alarmed, and fear mag-
  nifies every  danger that is likely to affect their  reputation  or
  practice.   Many surgeons, in a case like  this, fearful lest, after
  a  partial operation, the  disease  should  return, would have
*  straightway chopped off the hand.   Severinus acted quite other-
  wise :  cutting off each finger by the last joint, by which it is
  united with the carpus, he burnt the roots, and brought the parts
  to a sound and healthy cure: he thus preserved the hand, i. e.
  the carpus and the thumb,  the form, and something of  the use
  of the part, for such a stump antagonising the other hand, and
  assisting it, would be very precious.   Enormous as this tumour
  was, Severinus had the skill  and courage  to save  at least the
  patient's thumb :  and we have the consolation to learn, from the
  case of this unhealthy and  crooked creature, plainly disposed
  to diseases of the bones, in whom the spine was deformed, and
  the tumour of the hand  spontaneous, that it is  possible  even
  where our incisions can hardly carry us beyond the immediate
 limits ofthe disease, to accomplish a cure.
   In the sketch of this hand, you will remark, that the bones
  are alone diseased, that the several knobs or tubercles represent
drawings erom severinus. 
Of the Tumours of the Bones.             393
 the several phalanges or joints of the fingers ;  that the hand and
 wrist (a) are dwindled, while the tumours (c. d. e. ) represent
 the several joints ofthe ring-finger, which had far exceeded the
 rest in size, forming the chief bulk  of the tumour : the elonga-
 tion of the whole hand, demonstrates the  growth of the bones
 in every direction.
   But extension such as this, especially when proceeding from
 the high action of vessels, must end in ulceration, which is the
 natural conclusion of the disease.  The ulcer is fetid and ca-
 rious,  affecting at once the  bone and the flesh, and so ruinous
 to the health that amputation cannot be delayed.  Such, for ex-
 example, is the case communicated to Severinus by Larch^eus,
 accompanied with a drawing : it seems to have been a tumour
 of enormous size indeed, involving all  the  carpal and finger-
 bones, very massive and tuberculous, the hand weighing no
 less than seven pounds ; the bones  were  thoroughly diseased.
 This irregular mass  breaking out in its centre (in  the  middle
 of the carpus) into ulceration, destroying not only the fleshy
 parts, but the bones,  there ensued a hectic fever, when the man
 betook himself to the hospital of St. James for incurables, and
 solicited to have his hand amputated, which otherwise he would
 not have parted  with, for he was a pauper, and  lived by ex-
 posing this monstrous mass  of disease.
   So desperate do I  account this kind of tumour, when accom-
 panied with any general disease of the bones, and so loathsome
 are the carious ulcers,  which  sooner or later  ensue, that I al-
 ways think it a consolation when the disease is in  any degree
 local, even though it admit  not of saving the hand by any par-
 tial operation ;  if it allow of our saving the patient's life by am-
 putation, I think it a special piece of good fortune.   How little
 it was in  our power  to save the patient whose wrist is drawn
 on the same page with  this of Severinus,  you will perceive
 from the following notes  of his case :  " His wrist is  deformed
 and loaded with a tumour,  or rather  a congeries  of tumours,
 surrounding the joint,  knobby, hard,  immovable, of a rocky
 firmness, and  plainly proceeding from the bones,  both radius
 and ulna : the arm is weakened by the tumour, the wrist al-
 most powerless, the  hand dwindled from  want of use.  The
 man is about twenty-six years of age, a weaver by trade, born
 with this disease,  and now in a condition which hardly admits
of any  alleviation.  This  tumour of the wrist was observed
even at his birth ; it was then very small, and waxed slowly and
 gradually  to its present size : from year to year the  tendency
of disease became more and  more  conspicuous, tumours sue-
 tessively formed on  various parts of his body.  The bones of
 his fingers, ribs, legs,  are deformed with tumours  ofthe same
                            :? D 
394              Ofthe Tumours ofthe Bones.
rocky firmness ; one of these arising from one of the ribs, is of
a most singular form, projecting from the flat rib like the han-
dle of some instrument, and sticking directly out.   These va-
rious bony tumours,  which have appeared in  regular succes-
sion, and grown slowly, have been hitherto  void of pain,  and
have never yet prevented his daily labour ; but  during the in-
clement weather of last winter, and taking mercury for a slight
venereal affection,  the tumours on the left leg, whether from
the imprudent administration of the remedy, or some lurking
taint of the disease,  became so extremely  painful, that he  was
disabled from  work, confined  to  bed, and  is now in the infir-
mary.  The papillae, or prominent parts represented in the  draw-
ing, are the apices of those rocky and firm tumours, which are
somewhat  pointed;  and each  prominent point is discoloured,
so as to assume the  form of a  common pimple, but  very fiery
and red.  The painful tumours of the left leg, are  in like man-
ner reddened; the whole skin  investing them, is inflamed; the
complexion in short of these tumours  is such, as demonstrates
the  approach  of that ulceration, which is to convert each tu-
mour into a loathsome, fetid and carious  sore."
   Though I have upon my recollection many proofs of tumours
of this nature, being altogether void of pain; yet, I have a pre-
possession, that wherever there are acute pains in  the bones,
there is actually a tendency to  such tumours; the close connec-
tion of  pains and tumours in venereal cases, vindicates my sus-
picion, and I believe, that when  a  patient speaks of rheuma-
tism in his bones, and feels it  deep-seated with oppressive pain
affecting the whole limb,  the  disease is actually seated in the
centre ofthe limb, and substance ofthe bone :  of one very sin-
gular case of this nature,  I find I have taken short, but accurate
notes:  "John M'Donald went early in life an apprentice to
the  West-Indies; he was then a stout  young man,  and in his
profession, as stone-mason, had a  gang of workmen  under his
charge ; and during  a period  of ten years,  which he spent in
that climate, had suffered  no less than ten  successive and se-
vere attacks of ague and fever, and had suffered much from
dysentery.  He is married, and has been so many years; he is
a sober and respectable man, apparently fifty years of age ;  ne-
ver  had venereal  complaints,  never had general rheumatism,
nor  indeed any other pains in his bones, but that which I am
now about to describe.
   " He had suffered very violent pains about his shoulders
and arms, but especially in the left  humerus, for the space of
a year; those  pains had in some degree ceased, and the pain
in the left arm had been little distressing for three months, when
'-one  day, at a quarterly meeting for the regulation of a common 
Fig.i
Fig.-2
-/"S^  ^  "5T'

J£r«, tltlf
yJcWny,./?' 
 
Ofthe Tumours ofthe Bones.             395
subscription fund, or society subscription for the relief of dis-
tressed  members, a little girl of five years old,  being in the
room, he lifted her over one ofthe benches, and in the moment
of doing so, felt a pain so sudden and acute, that he could not
be persuaded but that some one had hit him a smart blow from
behind, across the arm;  he spoke, he says,  very testily, and
could not help crying out, that by that silly trick they had raised
his old  pain, which instantly became more violent  than  ever.
From that moment he  was incapable of raising his  arm to his
head ; his pain, upon every occasion, of coughing, laughing, or
moving hastily, is excessive : but when at  perfect rest, he has
no pain.  From this period a swelling began to arise, occupy-
ing gradually the upper and middle parts of the humerus, sur-
rounding it like the  lump  of  clay and straw which  is wrap-
ped  round a grafted tree."  In  this very singular case, I have
little doubt,  that the fibres at the origin of the triceps, and in-
sertion of the deltoid muscles had given way, in consequence
of the diseased state of the periosteum, and tendons,  where
they are implanted into the humerus and that from  such injury
the tumour had arisen ;—the bone, I doubt not, is carious with-
in, supported only by this shell or new secretion; I could bend
the arm gently, and could perceive that the  sac of bony secre-
tion, which at first seemed perfect and firm bone, is in part car-
tilaginous,  and yields ; the arm bends at  this thickened part
with a sort of elasticity:  having  one day committed his arm
for examination to a  very  brutal  surgeon,  and turned to go
away while he was thus  employed, he called me  back, with
great exultation, to shew me, that he had been able  to bend my
patient's arm to an obtuse angle, so as to put the  fact of the se-
paration of the bones,  and the flexile and elastic nature of the
tumour, beyond dispute ;  a favour, which  I acknowledged,  I
fear, in a very ungracious manner.
   I have given,  along with the drawing of the wrist of the
man  whose whole osseous system was diseased, one Irom Mr.
Mery, of the hand of a youth of sixteen, which had attained to
a prodigious size  and monstrous form ; it weighed, after am-
putation, from six to seven  pounds ; it was one deformed mass
consisting of three  protuberances of various magnitude ; the
largest,  (a figure  1.)  belonging to the  ring-finger,  appeared
chiefly on the back ofthe hand, and  was seven inches in diame-
ter ; the tumour next in  size (b),  proceeding from  the  mid-
finger, was six inches in diameter; that proceeding from the lit-
tle finger, was four inches in diameter, and is seen only  in the
second drawing, viz. in the skeleton of the  hand at (c).  The
skin, wherever it  lay over these  tumours, was coarse, with
deeper ridges:—the surface was deformed with deep  ulcers, 
3.96            Ofthe Tumours ofthe Bones.
 affecting not the soft parts only, but the bones: though from the
 unsightly appearance of the whole mass, it was by many pro-
 nounced cancerous, yet these  sores were in truth red, granu-
 lating, and healthy ; even the deepest of them were void of pain,
 and the veins ofthe hand, usually swelled in cancerous tumours,
 were flat.  Through the skin, which was thin from extension,
 the tumours felt very firm and osseous  ; the lad assigned, as
 the cause of this monstrous deformity, the hand being bruised
 at the early age of six years :  he was entirely well of this hurt
 before the  hand began to grow, but it began soon after the ulce-
 ration healed to increase in size, and continued to enlarge for
 ten years.  The hand, he had remarked, during the two latter
 years, had grown more than in all the eight preceding.  Upon
 dissecting  the amputated hand, the tumour was found to lie ex-
 clusively in the bones ;  the greatest  tubercles were merely en-
 largements of  the  first and second phalanges of the three last
 fingers ; those joints of the fore-finger and  thumb being sound.
 The joints, in this instance, at the same time that they were
 enlarged, were motionless from being anchylosed ; but their ar-
 ticulations with the metacarpal bones were fixed, by the rigid
 state only  in which the tendons were, from  motion being so
 many years suspended.  The shell of these tumours  was thin,
 the internal  parts  crossed by bony fibres,  cellular, and caver-
 nous, were filled with a juice resembling the  jelly of  meat in
 colour and consistence ; and it is  singular, that the carpal and
 metacarpal bones being but slightly affected,  and the extreme
 phalanges  on which the nails are implanted, entirely sound, the
 intermediate  bones were  enlarged to this prodigious  degree.
 One only ofthe metacarpal bones, that, viz. which supports the
 mid-finger, was diseased, and so far enlarged as to be  an  inch
 and a half in diameter, studded with  some small tubercles, and
 exposed in part by carious ulcers.  The carpal bones were per-
 fectly SOUND.
   There is no case from which some lesson, more or  less im-
 portant,  may not be deduced :  all this description is interesting.
 The two drawings represent, 1st. the deformed and fetid mass,
 the enormous tumours,  the roughened  skin, and the ulcers pe-
 netrating into the cavities of these tumours. 2d. The skeleton
 of the hand, exhibiting the respective tumours of the middle,
 ring, and little fingers, and the heart-shaped  enlargement  (t)
 of the metacarpal bone of the middle finger, is also singularly-
 interesting, demonstrating  that the whole tumour is bone, per-
manent, and firm, and not  an expansion  of the phalanges, but
 a new secretion.  The bone of the  fore-finger was not so much
diseased as deformed, dwindled in  size, and bent into an arch,
under the pressure of this tumour:  the thin shells of  bone, the 
                Ofthe Tumours ofthe Bones.             397

cancellated texture of the tumours, and the  carious  openings,
are also well represented.
   From this description we learn, that it is not during the pe-
riod ofhigh and violent action that tumour is generated.   Mat-
ter is added to matter in the animal body by a slow process;
whereas high action terminates in  suppuration, gangrene, or
some violent crisis.   The state  of vascular action, which  is
slower, more nearly approaching to  that of health, resembling
the slow accession of disease, or the remains of high action not
yet subsided, is more favourable to the generation of tumour ;
for such moderated action  does not injure the  structure  of the
part, does not interrupt nutrition,  allows  the secretion of new
parts to proceed,  and, in so far as it is accelerated beyond the
natural state, augments it.   You will take notice that it was not
while this hand was inflamed and suppurating,  (for it seems to
have  been not merely bruised  but wounded, il avoit ete gueri
parfaitement de sa blessure mais  peu de temps apres sa gueri-
son,)  but after the cure was so  far complete, and the increased
action not yet subsided, that his hand began to  swell.
   This  case  brings  an  important practical  question to  a very
short issue,  for these drawings prove the local nature  of the
disease,  viz. that it is merely in the bones, always in the heads
or softer parts, that the disease is seated:  that  the phalanges of
the fingers, which are peculiarly spongy, and  the lower heads
of the radius and ulna are most  liable to disease.   Mery con-
fesses (without being conscious how far in that  case  he was to
blame) that one half of the hand was apparently sound ; and that
upon  dissection, the finger and thumb were found in their sound
and natural state.*  How then can  we acquit  him of rashness
in smiting off the  hand of  a boy of eighteen years of age, with
youth and health on his side,  and  all the world before him,
when, by a less painful operation,  he might  have saved his
thumb, fore-finger, and wrist ?   Surely we may pronounce him
wrong, if there be one word of truth  in the case  of Severinus, in
which the thumb and carpus were  saved.
   Of the various questions which cases of this nature suggest
there is one which I am almost afraid to investigate.   When in
an adult such tumours appear, we have reason to hope that they
may be local, and that,  by cutting out the bone, we may extir-
pate the disease.    Even  when  such  tumours grow at once
on various  parts, we may, by circumstances, be induced  to ex-
tirpate the individual tumours, and cauterize  their roots ; but
what  shall we do when, in childhood, the  disease manifests it-

  * Cepcndant la moitie ou environ, en paroiffoit faine exterieurement, et le Pouce
et l'lndex dans leur et at naturel. 
S98             Ofthe Tumours of the Bones.
 self in various parts of the osseous system ? when all  parts  of
 the bones seem (like the cellular fat of some diseased people)
 disposed to excrescences ?  When tumour after tumour appears
 in quick succession ? and the fingers, the hands,  the wrist, the
 elbows,  the toes, the tibia, become affected ? when both hands
 are crooked alike, griffin's claws in every finger ; and when the
 arms and feet begin to be deformed ?   Shall we  remain specta-
 tors ofthe ruin of joint after joint, in a fine healthy boy ?  shall
 we calmly look on till each tumour has acquired its utmost mag-
 nitude, suppurated, and burst  into that state of loathsome ca-
 ries which must close the  scene ?  or  anticipate  this  inevitable
 termination, amputate and cauterize those tumours, and even-
 tually subject our art to  discredit, and ourselves to the personal
 reproach of trying rash, severe,  and yet lingering operations ?
 Although,  in a situation so hopeless we must be sorely tempt-
 ed, yet duty and charity, I fear, compel us to refrain.
  The rapid manner in which bone is secreted and accumulated
 to an astonishing bulk, is one of the most singular phenomena
 that occurs in the living body.   The  instance I  am now going
 to relate  will, I am sure, appear surprising, but it is selected
 for a far better purpose,  to serve as an example of the difficulty
 we sometimes find, in saving the patient's life, even where the
 the disease is local, and  growth of the bone sensible and rapid.
 I fear too it is one of a thousand examples, of a man lost in the
 prime of life, and dying a most loathsome and miserable death,
 from the reluctance of  the surgeon to charge himself with the
 fate of such a patient, or to  predict the future consequences of
 a tumour while it is yet  small.—It is the case of a young man,
 " committed to my humanity and  skill," by Dr. Forbes,  of
 Inverness.
  Alexander  Macdonald,  a Highlander  from  Fort  Au-
 gustus, a tall and handsome lad, exceeding six feet  in height,
 and uncommonly athletic, was put to the Perth Academy for
 his  education in writing,  book-keeping, and such other parts of
learning as might qualify him for a counting-house, as it was in-
tended to send him to  America a clerk in  the North-West
 Company in the fur trade.  In running violently  at tennis, on
the  academy green, he fell, and hurt his shoulder  : it was such
 a bruise  as  often  happens from a fall,  without  entailing  the
 slightest ill consequence, beyond the first pain and swelling: the
 skin was blackened by the bruise, and the joint was sprained ;
 he had excessive pain along the whole  arm  for twenty-four
hours, but it vanished gradually:—He  imagined himself well;
he had recovered  every thing but the strength of his arm ; but
 after  the violence of the pain, (which  lasted no  more  than
 aventy-four  hours,) was  gene, such weakness remained,  that 
Of the Tumours of the Bones.
399
   though, from his great strength, he  could  lift perpendicularly
   such weights as others could not move, yet he could never
   raise his arm to his head.
     I was at pains  to question his father, a respectable old man,
   concerning the part which received the injury ; and he  clearlv
.  and decidedly affirmed, that it was not the shoulder-joint, but
   the  middle of the  bone of the arm  that  received the shock, it
   was along  the whole of the arm that he felt the pain, and could
   distinguish the marks of the bruise.    The  pain  had, after its
   first violence, totally ceased, as if the part had sustained no per-
   manent injury, and he believed himself well; it was exactly at
   the  end of a month,  that  the pain  returned, and fixed in the
  joint, with a  very distressing sense of weakness, so that he could
   not raise his  arm at all; if he  meant to put on  his hat with  it,
   he had to raise it with the other hand, and when thus raised, if
   he lowered it again without support,  the moment it fell unsup-
   ported below the level, it descended like lead.   Still he could
   lift perpendicularly a very great weight: but  from  this second
   period of pain we must date the disease.  The whole arm swel-
   led,  but especially about the  shoulder; his  cries and shrieks
   were wild and melancholy ; living in a remote part of the High-
   lands, it is natural for the father to express himself in the fol-
   lowing words, which he invariably uses when I question him  in
  regard to the degree of pain, " Sir, there was  no hour of the
  night nor day in which you could not hear his wild cries miles
  off."  He represented the particular pain, by saying, " it seem-
  ed as if he had been bored with hot irons; and his cries  were
  so unceasing, as  well as so piercing, that though they lived in a
  very long house, they had no sleep from this time forward."
    That such  had been his condition no one could doubt, who
  saw  him before his death; for the sweUing kept equal pace with
  these dreadful sufferings;  at first the arm seemed chiefly to
  swell from  the shoulder-joint; gradually the yvhole arm swelled,
  and the fore-arm and hand dwindled.   His  body, before lusty,
  and strong, was  wasted with the agony and want of rest.  Yet
  even at this time, when the arm was monstrously  swelled, and
  before it was entirely oppressed, or  the fore-arm wasted, he
  could lift as heavy  a weight with the left  arm as with the right;
  and even to the last stage, that in  which  I saw him, his hand
  was strong to grasp.   In the first four months, the upper part
  of the arm had so increased in size, that the  prominent part ex-
  ceeded the  size of his head, but now, at the end of nine months,
  it greatly exceeds in size his emaciated body7.
    When I  went to receive this  poor  lad, I  found  him  lying
  deep in the hold of a small sloop,  in which he had been trans-
  ported from Inverness, laid on a coarse mattress, and bolstered 
400            Of the Tumours of the Bones.
up against the shelving side of the vessel; and when the clothee
were  lifted, I solemnly declare, that I hardly knew, at first.
what it was that I saw, which was the tumour, and which his
body, or how to connect in imagination the one with the other.
He lay in an inclined and  irregular  posture, extremely languid,
and hardly able to articulate; his head inclining to one side, the
tumour,  when first exposed by lifting  the  clothes, might be
mistaken for his body; in respect of size,  it was of a suitable
bulk,  and when  the lean, yellow, and emaciated  thorax was
next exposed, the tumour  seemed so much to exceed it in size,
with a shining surface and brilliant colour, that at first I was
more  confounded than shocked, so  impossible was it, in the
first moments, to consider of it as  a tumour, or to see its rela-
tion to the arm.   The  fore-arm was dwindled and shrunk, and
projected from the tumour at a  strange and unnatural distance
from the shoulder: the veins were swelled, like those of a horse's
belly :  large fungous tumours, as big as oranges, projected in a
group  from the outside  of the arm,  at the place where, about
two months before, a  large abscess had burst; and such  was
the fetor of the matter running from under these fungi, and
the languor of this poor emaciated creature, that I had no thought
for the present,  but how to get him  conveyed alive to town.
After a few days, when he was somewhat recovered from the
fatigues of his voyage, I proceeded to write down the history,
and examine the actual state of this  tumour.
  It consisted chiefly of bone, was little cartilaginous ; hardly
in any part elastic or yielding, and discharging matter, not from
any superficial abscess, but apparently  from the centre of this
enormous mass.   I had every reason to believe, that the bone
and the  joint, which  certainly were neither broken nor dislo-
cated,  had been generally injured,  not  merely by the shock,
but by the  bruise: that the parts nearest the bone, and con-
nected with it by  the periosteum,  had been bruised and in-
flamed :  that the extreme pain for  the first twenty-four hours,
indicated only the  violence of the  immediate  injury, but  the
slow vascular action which succeeded,  at the distance  of  a
month, proved how deeply the circulation of  the  bone was af-
fected, and caused that osseous secretion which generated this
prodigious shell of bone;  while  the shaft  of the humerus,
from  the periosteum  of  which  this callus had been secreted,
was in part destroyed by an ulcerating process within : that the
ulceration, deep seated, not only  in the bone, but in the joint,
occasioned those excruciating tortures  which  were  announced
by wild and desperate  cries,  night  and  day:  that the matter
bursting at last  through  every obstacle,  had made  its  way
through that ulcerated part ofthe surface, which is studded with
fungous excrescences. 
Of the Tumours of the Bones.             401
    This bursting out ofthe matter brought relief from the pain;
  he now lay in a state of extreme languor, moaning and slum-
  bering ; you found it painful even to question him,  he was so
  feeble ; he fell,  after a few broken answers,  into a slumber of
  mere debility,  and closed his eyes as exhausted;  and while I
  took a sketch  of his posture, and of the proportions of this
  prodigious tumour, he slumbered continually.  His extreme
  weakness  precluded every practical  experiment, and  left  for
  our discussion the speculative question only ; u In a  case so
  deplorable and  hopeless, what should we have done at an ear-
  lier stage,  when the patient's strength  was more entire,  and
  youth and  vigour (for he was but twenty-one years of age) on
 his side ?"
    Here, for the first time, I felt  that a bony tumour might,  by
 advancing to the trunk of the body, preclude amputation as en-
 tirely as aneurism of the subclavian artery !  That the question
 here to be resolved was not, whether we  might dare to ampu-
 tate at the shoulder-joint,  the question was of amputating  the
 scapula also,  and along with  it a tumour, exceeding in  size
 even the trunk  of the body !  and the accident mentioned by
 Cheselden,  (an  accident  which has  often happened since)  of
 Wood, the  miller, whose arm, scapula and all, was rudely and
 suddenly torn from his body, could not but come into our recol-
 lection.  There was  hardly left us even a choice to exercise
 our discretion and skill upon ;  for, from the state  of the veins,
 large,  tortuous, and already ulcerating, and so numerous as to
 give a livid colour to almost all the surface of the tumour ; it
 was plain, that  he was in daily peril of hsemorrhagv,  and that
 this was at no remote period, certainly within  a few weeks,  to
 put a period to  his life !  Could there then be  a question, whe-
 ther to wait in fear of that hsemorrhagv, which was assuredly
 to end in death, or to risk  by operating, that  hamorrhagy by
 which he might be saved  alive ?   For my part I had  not the
 shadow of a doubt :  what  should determine us in  any despe-
 rate case, to do desperate things \  Surely the possibility of safe-
 ty through operation, the certainty of death !  I saw it  possible,   +
 by  trying first the subclavian artery, the root of all the circum-
 flex arteries of the shoulder and scapula, to prevent any alarm-
 ing degree of  haemorrhagy ; by sawing across  the outer end of
 the clavicle  to get command of the scapula, and  turn  it back,
 as easily as  the  H'ip  from an ordinary  stump  ; to tie  when  it
 was cut, the arteria transversa!'^ scapulae,  and certainly to sepa-
 rate the whole,  without immediate deith.  But had this been
 an enterprise as  certainly  fatal as  the Caesarian section itself,
still it gave some chance'for liiV.   Confident in the justness of
this reasoning, moral and physical, I  should have urged him 
402            Of the Tumours of the Bones.
to this awful trial,  and devoted myself to the task ; but he wa.*
sunk too low for any trial, and to be regarded only as  an object
of charitable care.  He died in the Royal Infirmary, of haemorr-
hagy, about three weeks after his admission, and these are the
notes of the dissection.

             DISSECTION, July 13th,  1806.

   " Having divided the integuments, which were extremely
thin, we found,  on attempting to cleanse the tumour from one
extremity to the other, that it was of  a substance much resem-
bling callus ; in  many places it was so firm and solid,  that af-
ter trying in vain to divide it with a strong knife, we were o-
liged to betake ourselves to the common amputation-saw.
   " The cells of this bony tumour were every where filled with
a matter resembling thick cheese ; the tumour itself, from it's
great size, and the entire appearance of the os humeri, seemed
only to be attached to that bone ; but upon a more minute ex-
amination, was plainly a production from its substance.  The
humerus could  be traced through the whole  tumour ; but en-
larged,  spongy,  and ulcerated.   The upper part of the scapu-
la,  the  acromion process, and  the outer end of the  clavicle,
could,  during life, be plainly  distinguished to be enlarged, and
to form part ofthe tumour; and upon dissection, all  the bones
forming the shoulder-joint were  found to be deeply  diseased.
The upper and most bulky part of the tumour,  seemed to pro-
ceed as much from these, as from the  os humeri, and the  joint
was completely anchylosed."
   There is a period in every such case, when the tumour being
still of moderate  size,  and yet requiring an operation of the
most desperate  and unprecedented nature, viz.  the amputation
even ofthe scapula itself; the question must be ofthe most per-
plexing and agitating nature.   The surgeon must be conscious,
that the patient is to die a loathsome and  miserable death ; yet
it is a consciousness which he  never can bring home to the mind
of the  patient or  his friends, and if he take upon himself to
urge an operation so desperate, and  the patient  should die,
the slight impressions his representations have made  vanish,
the danger,  which was distant and problematical, has been ac-
celerated by his misconduct; by his ill success he is condemned,
and never can it be put out of the minds  of the relations, that
the patient might  have  lived, or that  even the tumour might
have burst and resolved into matter. But a precedent like this,
and I have witnessed and could relate many, solves all scruples,
and he  who knows the constitution of such a tumour,  its inevi- 
Of the Tumours ofthe Bones.            403
 table increase, and the loathsome end of the sufferer will not
 I believe, shrink from his duty.  This case is highly interest-
 ing, as it is the direct consequence of a very ordinary mischance,
 of a slight fall, and a bruise importing nothing  : it is not mere-
 ly a prodigy to be gazed on, but an important precedent.
   Allow me, before I forsake this interesting subject, to  give
 you  one document in practice, from the universal ignorance
 or wilful neglect of which, I  see every day the most dismal con-
 sequences.  A bone, both in itself, and in its surrounding vas-
 cular apparatus, is as susceptible  of inflammation, and while it
 is inflamed, or in danger of  being inflamed, should be as deli-
 cately treated as the soft  parts.  How  often, how continually
 you have seen this  injunction reversed,  I need hardly remind
 you:  every bruised  bone, and sprained joint,  is rubbed and di-
 ligently  moved.  With an ignorant and stupid fear, of the joint
 losing its motion, it is wrought backwards and forwards in eve-
 ry direction ! and whatever inflammation is begun, is never per-
 mitted to subside ! Thus a military gentleman, whose humerus
 was  diseased,  with, I doubt  not, an  internal caries, (for I
 have dissected such cases, and kept in preparation very long, a
 shoulder-joint thus diseased  internally, which  betrayed no  out-
 ward appearance of disease)  and who had excruciating pains, a
 total lameness, a singular emaciation ofthe whole member, and
 who  though he could mount his horse,  could  not endure the
 motion  of it, even  at a foot pace, was ordered by the  physi-
 cians he last consulted, along  with various other prescriptions, to
 have his arm  turned and wrought backwards and forwards by
 his servant with all his strength.   He fainted  more than once,
 under this discipline, and fortunately was not able longer to en-
 dure what must have killed him in the end ; by completing that
 caries of the joint which was at that moment just remediable.
 He came from Ireland, and put himself under  my care, and by
 a course of stimulant fomentations, by bandaging his arm to his
 side with rollers, as closely as if it had been fractured, and by
 renewing caustic issues all  round the  acromion process, and
 head ofthe shoulder, and keeping them running for six months,
 he is now almost entirely cured.   His arm, notwithstanding the
 stricture of the bandages, has recovered its flesh and firmness ;
 he can raise it now  without  pain, and  find that he could use
 it with confidence :  but, I think it right  for a limited term to
 keep him safe,  with the  arm slung, and without  motion, till
 every  tendency to disease is gone.
   A young lady7, whose arm I have been obliged to amputate,
 fell, at the age of fifteen, from a table, and sprained her elbow7-
 joint.   The immediate pain  was just such as is usual on such
flight  accidents; it  subsided, and  there remained only  that 
404             Of the Tumours ofthe Bones.
dead and heavy pain,  and stiffness of the joint, which indicates
that the ligaments and periosteum are not yet relieved from  the
inflammation, and which requires stimulant fomentations:  per-
haps a  caustic issue, and  perfect  rest: what was  directed?
Why, that she should carry all day long a heavy dressing-iron
in her hand, to straighten the joint by the continual extension,
and that she should, by frequent exertions of swinging this load
backwards and forwards, with the help of a servant to twist and
turn the joint, try  to recover  the free motion of it.   This im-
prudence has almost  cost her  her life :  the internal inflamma-
tion was never permitted  to subside; the  joint swelled, burst
out in fetid ulceration;  the bones and the joint became com-
pletely carious; paroxysms of  inflammation, new suppurations,
and weeks of excruciating pain before the bursting of each  ab-
scess, reduced her to  the lowest extremity  of weakness :  she
had haemoptysis and every appearance of confirmed hectic, and
approaching death, when a consultation dictated the amputation
of the arm as the only  possible means of saving  her.   Since
the operation, and even  before the adhesion  of the stump was
complete, she had, by  pleasant sleep, and the return of appetite,
recovered her strength and freshness of complexion,  and  is
now in perfect health.
   Such errors are so  commonly and thoughtlessly committed,
that they are  as it were  contagious; we do  what we see daily
done  before us,  without thought or re flection,  which makes a
document of this nature, on an ordinary occasion, of no slight
importance to the young surgeon. 
( 405 )
DISCOURSE XXII.
ON TUMOURS OF THE NOSTRILS,  GUMS, AND
                        THROAT.


 X  HOUGH polypus is one of the most loathsome and  fatal
diseases, it is described in terms little suited to  convey this
idea to the young  surgeon ; who,  while he reads  a systematic
author, or hears a lecturer talk in slight and familiar terms  of
the disease, and its cure, little suspects the dismal scenes which
are  passing in the chambers of the sick, and puts his hand with,
little forethought or prudence, to operations the most difficult
for  a man  of experience, the most impossible for  an unskilful
person to perform.
  How this levity of manner should be explained,  I have  been
at times doubtful, and am now perhaps uncharitable; but I
could  not  avoid observing, that in  the  works of systematic
writers, this  appears so simple, so trivial, so harmless a dis-
ease ; it is represented as so mild in its ordinary, and so incu-
rable in its more malignant form, that the chief  care of the
surgeon should be, to make a just prognostic, and act with re-
serve and prudence.  But  those who have transmitted to us the
most  faithful records  of their cases, represent a  far different
scene.   Polypus appears, in  their juster pictures, to be one  of
the most horrible,  the most incurable diseases.  In writings of
systematic authors, all  seems simple and  harmless,  and the
methods of cure are trifling and temporizing.   In  the works of
original authors,  the methods are rude, violent, and unrelent-
ing : rather than  not unroot the tumour,  they would burst up
the cells of the face, and destroy all the  bones ; and they de-
liberately debate  these questions, whether we should not split
up the nostrils? trepan the  antrum of Highmorianum ?  and dig
away the spongy bones ? rather than fail to reach  the  roots  of
the tumour.   Whether  it  be not allowable  to perform bron-
chotomy, and by opening the trachea procure free breathing for
the patient, while these more cruel operations  are performing ?
This is a text, these are discrepancies, on which it  becomes  us
to comment.   Those who  have heard and repeated the  saying,
that polypus is in general a mild disease, have of course be- 
406    On Tumours ofthe Nostrils, Gums, and Throat.

lieved that these are cases of peculiar malignity ; that there are,
certain polypi which  the surgeon need not disturb, and should
not tamper with, and others which  he assuredly cannot  cure.
But were this conviction  ever brought home to the mind of the
surgeon, then should his good offices be at an end;  surely we
must  not in any case pretend to meddle  with a disease, which,
if mild  in its species, we should  not irritate;  which, if malig-
nant,  we cannot cure ?  But I have some experience in this line
of practice, and some judgment in this department of reading;
and have strong  suspicions of something wrong, if not unfaith-
ful, in these opposite  representations.  Polypus is never  mild,
nor ever malignant; time, and the natural growth of  the tu-
mour, and the pressure  it occasions within the soft  and  bony
cells of the nostrils and jaws, must bring every polypus to one
invariable form, in its last and fatal stage.  Those who  are em-
ployed in recording cases on unquestionable facts, give us the
true and only picture of diseases, they  speak of none which
they have not seen; but systematic authors, obliged  to explain
each  disease in its order,  give descriptions of diseases widely
distant  from truth, describing what manifestly they have not
seen, and explaining, without the slightest remission of their
wonted  confidence, what  they have not learned and cannot
know.  .Whatever you  might learn, (yet that would be  in an
irregular and dangerous way) from books of cases, be  assured
you  might  read  those  systematic  authors,   (which I might
name, I  hope, without  envy, and  which I allude to  without
malice,) from  sun-set until sun-rise, without conceiving the
very slightest notion of the disease of which I am now to speak.
   Polypus is indeed a dreadful disease;  but like every  other, it
becomes so by a slow progression, and advances by  gradations
easily characterised, and which you will do well to mark.   It is
described as a small and pendulous tumour, projecting in the
nostril, void of pain,  attended with  no worse symptoms than
 watering of the eyes, and  sneezing, sometimes soft, some-
 times firm in its texture, and moving backwards  and forwards
 with the breath.   You  would imagine nothing  more simple
 than to noose such a tumour with a thread, or  pull it away with
 forceps.                          .  .      ,               ,,
    And so indeed is every polypus in its early stages,  a small,
 tio-ht, and moveable tumour, attended with sneezing, watering
 ofthe  eyes, sweUing  in moist weather, descending with the
 breath,  but easily repressed  with the point of the finger, void
 of pain, and in no shape  alarming ; and it is easily extracted
 too,  so as for a time to clear the passage for the breathing ! Yet
 this  little tumour, simple  as it may appear,  is the germ of a
 very Ltal and loathsome disease  ; and this easy extraction, th« 
       On Tumours ofthe Nostrils, Gums, and Throat.    407

very cause, often, of its appearing in its most malignant form :
the more easily it is extracted, the more easily does it return ;
and  whether carelessly extracted, or  altogether neglected  it
soon returns ; and when  it  does return, it has not  in  truth
changed its nature, it has not ceased to be in itself mild ; it is
then to be feared, not from  its malignity, but from its pressure
among the delicate cells and membranes of the  nose : it soon
fills the nostrils, and obstructs  the  breathing, and causes in-
describable anxieties :  the   patient  lies all  night  with open
mouth ;  during sleep he is harassed  with fearful dreams ; and
when he  wakes his mouth and throat are parched  and dry.
The tears are obstructed, and the eyes become  watery from the
pressure on the lachrymal sac ; the hearing is in like manner in-
jured, by the pressure of  the tumour against the mouths of the
Eustachian tubes; the voice is changed, and its resonance and
tone entirely lost, by the sound  no longer  passing through the
cells of the nose and face ;  the  swallowing is in some  degree
affected  by the tumour depressing the soft palate ; the pains
arising from such slow and  irresistible pressure are unceasing ;
from the same pressure the bones become carious, and the cells
of the face and nose are burst up by its slow growth.
   The tumour, in no long  period, begins  to project from the
nostril before,  and at the arch of the  palate  behind; one nostril
grows wide and thick, the nose  is turned towards  the opposite
side,  and the whole  face, in consequence of a rising of the
cheek-bones, becomes oblique :  the  root of the nose, where
it is  set  off from the  forehead, swells  and  becomes  puffy ;
the features tumid  and flabby,  the face  yellow, and the parts
round the eye, livid: the patient is affected with headachs which
seem to rend the bones asunder, and with perpetual stupor and
dozing : the bones  and  membranes now  plainly ulcerate ;  a
foul and fetid  matter, blackened with blood,  distils  from the
nostrils, and excoriates them, and by passing  partly down the
throat, occasions diarrhoea : the blood-vessels next give w7ay,
and sudden impetuous haemorrhages weaken  the  patient; the
teeth fall from  the sockets, and through the empty sockets a
foul and fetid matter issues  from the antrum.
   Now the disease verges towards its conclusion.  The patient,
conscious that  the tumour,  lately so mild and moveable, has
degenerated into a mortal disease, is resigned to his fate ;  and
no flatteries of his friends,  nor  soothing words from his physi-
cians,  can longer deceive him :  in the night he starts from his
sleep,  in horrible dreams, and with a sense of suffocation ;  and
frequent hemorrhages bursting out from time to time, reduce
him to such extremity of weakness, that for several days he is
not able to crawl from his bed ; and when he rises from it, he 
408     On Tumours ofthe Nostrils, Gums, and Throat.

hangs over the fire, cold from loss of blood, pale as a spectre,
his lips colourless, and his face like wax, yellow and  transpa-
rent : he hangs his head forwards,  resting it on his hand, and
moving it incessantly from  side  to side,  from the intolerable
pain,  the saliva distilling from his mouth, and the  foul matter
dropping from the nose  : in this state he survives a few weeks,
desolate and hopeless.   During the  last days of his illness, he
lies in a state of perpetual stupor, and dies lethargic.
   Never can you thoroughly know this part of your profession,
nor arrive at a just sense of the danger of this disease, till you
have seen your patients thus suffering and dying; nor have you,
from systematic books of surgery, the very slightest intimation,
that scenes like these are passing in the chambers of the sick.
Perhaps, it will be said, (1  wish  it could  be justly said)  these
are very exaggerated pictures ! they are, on  the contrary, so
very faithful and true,  that I,  who have witnessed them many
times,  know not how they can be exaggerated ;  I have traced,
as simply  as I could describe, with any  regard  to  truth, the
phenomena of this disease, from the stage repuied  harmless
and mild, to that reputed malignant.  If,  indeed, horrid symp-
toms could establish the fact of malignity, that there is not to be
found in all nosology a  more  malignant disease than this: but
aneurism, though it destroys  the thigh-bone,  the sternum, or
the cranium,  is not  accounted malignant ; neither is polypus
malignant,  though it destroys the cells of the face, and pene-
trates even through the ethmoid bone, to  the brain.
   I shall demonstrably  prove  to you that polypus is a tumour
in itself indolent  and harmless ; that it is no farther malignant
than as it does, by universal and irresistible pressure in the lat-
ter stages, destroy the bones :  that circumstances determine the
growth, and the  more  or less rapid growth, determines the
fate of the  patient: and I shall, I  doubt not, prove to your con-
viction, that it is  far better to  suffer the salutary  pains of ope-
ration  and  caustic, than the unavoidable  tortures^of a disease,
which,  as soon as it becomes  painful, is  incurable. ^ You are,
by every law,  moral and professional, bound to continue your
good  offices 'to your  patient,  while he consents  to suffer, or
there remains  the slightest hope of success.   While  the doc-
trine of benignity and malignity (and these terms are repeated
in every page of Pott and other writers) is acknowledged, while
the surgeon pronounces every incipient polypus mild only, be-
cause his  small,  and as yet harmless ; and every polypus ma-
lignant  which has attained a conspicuous size and  more solid
texture, and begins to affect the  bones :  while he neglects the
beginning,  and shuns all concern in the lamentable conclusion ol
the disease, no patient's life is safe. 
        Of Tumours ofthe Nostrils, Gums, and Throat.     409

   Yet with all these distinctions of mild from malignant polypi,
and endless injunctions not  to tamper with the disease, no au-
thor  can refrain from praising that operation, whether 8y liga-
ture,  forceps or  caustic, to  which he is most favourably inclin-
ed ; and in such  familiar  terms are  the several stratagems for
reaching the roots of the tumour described, that I know not
how  the young  surgeon can escape  a deception so naturally
suited to the complexion of an ardent and inexperienced mind.
It is impossible to read the  boundless commendations lavished
by each author on  his own  peculiar  operation, without being
persuaded  of its  efficacy, and  imagining besides a thousand
other ways, the least perfect  of which will equally succeed :
but there is a sad disappointment when we put those inventions
to the test of  actual practice.   Instruments  and methods  of
cure have been imagined in the closet, by men who have not
even  introduced a  finger into the nostril, much  less felt the in-
finite difficulty  of casting a noose round a polypus ; and the re-
sult is, that, while these methods are very seemingly perfect,
declared by their inventors to be infallible, and allowed by all
to be  ingenious, they are altogether unavailing when put to the
test.  The young surgeon finds  these practices so described  in
books, that he thinks of nothing  but the  admirable ingenious-
ness of the invention, nor can he  admit a  doubt, that he can in-
troduce his probes, his tubes, and his  catgut or wires, so as  to
noose the tumour : but when he goes to grapple with the actual
disease, and while he is struggling to apply his wires, the nose
is streaming with blood, the patient staring and  struggling as if
in the act of suffocation, the  tubes and forceps are thrust  perse-
veringly into the  nostrils and throat, the forceps are next dri-
ven deeper into the nostrils, the blood streams again, and the
pendulous parts of the polypi, which are more  prominent in the
nostrils, are bruised and mangled, while their  roots are left en-
tire, and only fragments of the tumour mixed with the clots of
blood, are found  upon the clothes.  The patient terrified, sick-
ened, and spent with haemorrhagy, prays for some suspense of
his suffering, at the  moment when the surgeon begins  to be
abashed  at his  ill success ; he desists, for awhile,  from farther
violence, but the same unsuccessful  operations  are repeated
from time to time, and if but  the slightest  breath of air  pass
through the nostril, he takes advantage of that  seeming success,
and introducing bougies, or a thick roll  of lint, persuades his
patient that his  condition will improve daily.  But the patient,
after a season spent in vain  and  miserable endeavours  to pre-
serve the nostril  free, returns to town  with carious bones, de-
formed features, a projecting polypus, a frame  exhausted  with
suffering, and especially exhausted by suffocation  and  want ot 
410    Of Tumours ofthe Nostrils, Gums, and Throat.

sleep:  his life is threatened every moment by impetuous  hae-
morrhagies, and he  is plainly beyond the help of better surgery.
  God  forbid that I should impute such  negligence to a de-
sire of gain,  or contempt  of duty, to  a haste to succeed,  or a
vain desire  to appear  successful.  These are the consequences
merely of a deception, which no one who takes his ideas from
books can well escape.  The operation of noosing a nasal poly-
pus, which I shall prove to  be  altogether futile;  or that of ex-
tracting it with forceps alone,  which I know by experience ne-
ver can be perfect or successful, are yet represented as perfectly
effectual.  The operation of noosing a polypus is  one which the
young surgeon is taught to perform with all the ceremonies and
circumstances of an operation; and if it is but  so performed,
that the wire or ligature does not immediately drop away, all
the  instructions he has ever read or heard of, seem to be ful-
filled, though the tumour begins to project  again in a few days.
He believes the  cure of polypus to be an  operation  to  be ac-
complished at once,  by a coup de main,  while  in truth it is a
cure to be  accomplished by various and persevering methods.
The  operation of noosing  or extracting a polypus is far from
being a splendid piece of surgery, fit to be exhibited in an ope-
ration room. I have never known  an operator put on his
sleeves, and address himself to the work with those mistaken
notions ; and in  the hopes of visibly unrooting the tumour with
the forceps, or entangling it in a noose, who did not retire from
the scene with confusion and dismay.  The horrid scene which
ensues, the quick re-production of the tumour,  and the caries
of  the  bones, is not the effect of tampering with a  malignant
disease, but  the  natural progress of a  tumour uninterrupted by
operations so imperfect and mal-adroit.   Let no man attempt
the  cure of  this disease whose sole purpose is to shine as an
operator; who has not perseverance and  diligence enough to
try, successively, every method, and humility  enough to be
contented  with  the happiness  of saving  his patient  by any
means.
   I verily believe, that none are more innocent than those who
deceive us by commending such trivial operations, for they first
impose upon themselves.   They invent an instrument or me-
thod indisputably ingenious, and with all the simplicity in the
world imagine,  because it is ingenious, that it must be  useful.
I believe the very reverse of this might be proved by all past
experience, in respect to surgical inventions ; for the most cu-
rious and ingenious have invariably proved the most inefficient;
and,  if passing over the first inventor and his eulogiums, you
inquire of the next  who tried the instrument, you find it quite
useless ; or,  if one have performed the operation, and it be left 
Of Tumours ofthe Nostrils, Gums, and Throat.    411
to another to report its success, the reverse is sudden and mor-
tifying.   Speaking on this subject,  I cannot help laying before
you one example of this,  to me the more striking,  as I remem-
ber how much I was delighted when  a boy, with the piece of
mechanical  ingenuity which  I  am  now going to explain :  so
much was I delighted, that in my  admiration of the author's
genius I contrived to forget his ill  success.   The operation is
related in  the third volume  of the Edinburgh Essays,  Physical
and Literary.   " A man ofthe name of Davison, very far ad-
vanced in years, was admitted into  the Royal Infirmary, with
a voluminous  polypus, which had its root near the epiglottis,
lay within the oesophagus,  and was occasionally  vomited up,
when he was excited by emetics, or by thrusting the finger into
the fauces.  The polypus then occupied the mouth, extended
to the fore-teeth, and appeared to consist of four distinct lobes,
arising from one root or neck.   But the polypus, while it thus
occupied the mouth, prevented the breathing of the patient, by
covering the opening of the  trachea ; wherefore, having just
shewn it to his surgeons,  by vomiting it up into the mouth,  he
was obliged presently to swallow it down again for want of
breath.   His speech, his swallowing, and his breathing, were
all so'affected by this very voluminous tumour, that it became a
very interesting question  how to extirpate the tumour :  and it
was proposed, that while  the operation of  bronchotomy was
performed to give him breath, the noose, by the help of some
very  ingenious  useless machines should  be cast over the tu-
mour, which latter part of the scheme was  fulfilled in the fol-
lowing manner :  a ring, mounted on a stalk, and having the
thread designed for ligature conceded within the  c; xle  of the
ring,  was pushed down into the fauces : the pushing down of
the ring excited the patient to vomit,  and the ring so occupied
the fauces, that when the tumour was vomited up it was driven
through the ring ; the ring was then pushed harder down to-
wards the root of the  tumour ; the ligature was then  drawn
tight ; other instruments with wheels  and  pulleys  for passing a
double ligature (the single one not succeeding)  were "next  in-
vented ; and finally, the  purpose was so effectually accomplish-
ed, that the polypus was strangled :  he passed, by stool, lumps
which he  mistook for clots of blood ; but he passed also along
with  those, the ioop of the  ligature  with which the polypus
was noosed."  It is, in short,  insinuated in the surgeon's nar-
rative, that the  patient had  passed the bulk of the  polypus by
stool ; and  it is directly affirmed, (by Mr.  Dallas, the operator)
that " having, at the end ofthe month,  sent for the  patient and
examined his throat, and  made him vomit, nothing preterna-
tural  appeared ; and that, having presented  himself at the dis- 
412    Of Tumours ofthe Nostrils, Gums, and Throat.

tance of eight months at the infirmary, on account of a  com-
mon cold with which he had been lately seized, he,  upon  being
examined, seemed to be entirely free from any ailments of the
polypous kind."
   Such, and so circumstantial is the narrative of this ingenious
invention, and of its success ; and it  is supported by all  the
usual apparatus of names, dates, consulting surgeons, opera-
tion-room, students, &c.   Hear now how a plain tale puts this
down ;  hearken   to the fate of a poor soul (in  the month ol
April, 1765) who was declared thus entirely free in  April 1764
" of all ailments  of the polypous kind?  u I was  informed,"
says Dr. Monro, " that James Davison had died in the Royal
Infirmary, to which he had returned a few weeks before that,
very feeble and emaciated, as for several months past he had not
been able to swallow any solid food, and even swallowed  fluids
with much difficulty ;  the polypus  had not however been seen
by the surgeons who had examined  his throat.
   u On  dissecting his body, the oesophagus was found  to be
greatly  dilated, by a very large  fleshy  excrescence or polypus,
which grew out from its fore-part, by a single root,  about three
inches lower  than the glottis, but was split at its under part into
several lobes, the largest and longest of which reached down to
the  upper orifice of the stomach."  So untrue is the tale told
by a man who never  designed to  deceive! Judge, then, how
dangerous it is to believe, where there is no other evidence than
that of the inventor, and where the cunning of the mechanism
is so apt to pass  for a  demonstration that it must be successful.
Believe me it is safer to doubt ; it  will be found by all past ex-
perience, that the most ingenious and complicated schemes are
apt to fail in exact proportion to  the seeming ingenuity  of the
invention.  I can venture, on my own   authority, to assure
you, that the ring of Hildanus,  the tubes of Levret, the probes
and other instruments by  which,  as later authors assure you, it
is so easy to apply the noose,  and slip it up to the very root or
 pedicle by which the polypus hangs ; the  very instruments and
 methods which you have taken most delight in practising, will
 fail you.
   I am now to  enter upon the anatomical  investigation of  this
 subject, and to speak of  the origin, form, and effects of poly-
 pus ; a subject which will admit of no conjecture ; of the man-
 ner in  which the tumour presents  itself in the passages of the
 nostrils and  throat; and how it may be successfully grappled
 with, a subject surely ofthe highest importance to the practical
 surgeon.
    I affect not to purge the science of every prejudice, but those
 which have a direct relation to our  subject in any practica- 
Of Tumours of the Nostrils, Gums, and Throat.     413
sense, I like to treat  of freely.  That a small  and apparently
trivial tumour of the nostril should be ascribed to the common
and unseemly practice of picking the nose, is far from being
particular ; and were this reported merely to frighten boys from
unseemly  practices, I  should feel  little disposed to refute it.
But there is a most dangerous  prejudice connected with this er-
ror, viz. that the  polypus is not only tangible, but its  root ac-
cessible to the finger, since caused by the intrusion of it.   The
most impatient finger  could never reach that part of the nostril
where polypus has its  seat, for that is  deep and high in the nos-
trils, towards the throat, and near the openings ofthe Eustachian
tubes.  The finger can be admitted no  deeper than the cartila-
ginous wing  of the nose extends, and can hardly touch the
anterior point of  the  lower spongy bone.  The  anterior and
posterior chambers of the nostril are separated from each other
by a narrow slit,  which the finger can never pass ; this opening
is somewhat  of the  carved form  of the  slit in  the sounding
board of a violin,  and the intrusion ofthe  anterior point ofthe
spongy bone,  which is the point that encounters the finger when
thrust into the nostril, gives it this peculiar shape.   There is a
little opening above, and another below this projecting point of
the spongy bone ; through these the heads of the polypus pro-
ject;  one  generally fills  the  opening  above the spongy bone,
another polypus usually fills the space below; there they  hang
pendulous, and are forced  sometimes through this opening by
the breath pushing them down very low ; at other times they
are retracted  by drawing in the breath ;  but how very  distant
this tangible  part of the polypus is from its root, and how  long
the tumour usually is,  I shall  next  prove to you.  The  very
proof  of  this is  dissection ; and if what I have  described be
true, you  will find it obvious in the drawings, to  which I next
appeal: in these   you  will observe,  that all the polypi  are  long
and pendulous, and only bulbous at the extremity where they
are felt with the finger.   You will  observe, that  in consequence
of their great  length, the roots are at a great distance from the
pedicle or stalk from  which they grow, that their bulbous ex-
tremity cannot be felt at all times, their roots never, for they
are in the  highest and narrowest part of the nostril.   You will
observe, that polypi, which, were they produced by picking the
nose,  or any local injury, would be solitary, are, on  the  con-
trary,  numerous beyond any conception you can  have formed*.

   * It is by no means a matter of flight importance to afcertain this point.  We
know by diffection, and by much fad experience, that  polypi are rarely folitary ;
chat the whole membrane is diseased, that both  noftrils are frequently affected ;
that the cells as well as the paffages of the nose and throat are lcudded with polypi
 of various fizes.  The melancholy cafe which 1 am now to tranfcribe.or rather to 
414     Of Tumours ofthe Nostrils, Gums, and Throat.

   Polypi hang forwards in the nose, in a direction so unfavour-
able to  their being noosed, that  I see it, from the preparation,
plan no.  1.
cpitomife, from one of the most celebrated writers on  this  difordcr, is a proof
how rarely it is local, how impoflible that it fhould be produced by  picking the
nofe, or any fuch injury, how univerfally the membrane is difeafed.
  " A vcunsr man," fays  Manne, " of twenty-feven years of age,  disd at La
Chark/.  Three years after having the fmall pox, from which period he ruJ 
       Of Tumours of the Nostrils, Gums, and Throat.    415


as improbable, as I have felt it  in practice impossible  for the
young  surgeon to  succeed in noosing them; and a practical
fact is the point to which I shall particularly call your attention ;
yet let  me acknowledge, that it  is by experience alone that  I
have learned  how difficult  it  is to noose that lesser  polypus
which hangs forward in the nose.   Had I sat down,  like many
of my  betters, in the closet, to contrive ways of noosing such
a  tumour, I could have  imagined nothing more likely to suc-
ceed than the common process.  I no more doubted than others,
that the method which I found so ingenious, when  described in
books, could fail me  in the act.    Allow me to explain,  first the
Plan No. 1, from  which you  will learn  the  actual  circum-
stances of these kind of tumours.   Secondly, The plan, No. 2,
which will illustrate this indescribable  and unforeseen difficulty
of noosing them.    In this  plan  1, fig. 1, you cannot but  remark,
that the three polypi, with  which the-nostril is filled,  the largest
marked (a), the next in size, (b), and  the  third,  (c), hang
from a point  very high in the nostril, and very far back, that
their roots must be in the  posterior  end  of the  upper  spongy
bone, under the socket of the eye, and not far from the open-
ing ofthe Eustachian tube.   Of this you will  be satisfied by
looking to  Fig. 2,  taken from  the same  preparation,  hanging
still by  the  same  thread, only turned round, so as to shew the

been afflicted with polypi in the nofe ; a whole hot-bed of them (fays the author),
if I may be permitted to ufe the term, appeared.  He had in the paffages of the
throat and nofe, in the antrum maxillure  of each fide,  and in the frontal finufes
seven polypi in all.  His face was fhockingly deformed; he had a great bulging
at the root of the nofe;  his eyes were removed from each other,  by the fwelling,
to three times their natural diftance, and feemed burfting from their fockets; the
noftrils were expanded, and the  nofe flattened and  extended; while  the cheek
bones were raifed to the level of the nofe,  and the face and head fwelled to  an
enormous fize.  The ears were obftructed on either fide ; the tears flowed over the
excoriated cheeks, and fometimes fetid pus burft out from the fiftula lachrymalis on
either fide.
  " While his  head and face were thus externally deformed, the palate of this
miferable creature was fo depreffed that it lay upon the tongue, and bulged fo, that
the lower jaw was depreffed; the mouth kept perpetually gaping, fo that the faliva
diftilled continually from his jaws, while the noftrils were diftended by the bulbous
extremities of two larger polypi.
  '• In diffecting his head  thefe polypi were found to have occafioned great de-
vaftation ; the cheek was laid open by a crucial incifion, and the upper maxillary
bone feemingly annihilated, nothing being left, of the walls of the antrum but a
thin fcale like the peeling of an onion : on opening the oppofite cheek  they found
the antrum burft open in a ftar-like form, and on dividing the delicate  membrane
which clofed this breach in the  antrum, a thin and bloody ferum exuded, and
there projected from the cavity a fmall portion of a very firm and elaftic polypus
of a red colour ; and when, by cutting and tearing away the reft of the bone, the
tumour was found very large and quite infulated, except at its neck, which wr.s
of fuch dimenfiops as  to be eafily embraced in  the circle ofthe fore-finger and
 thumb.   It refembled a turnip in  refpect of fhape; its lower end vias bulbous and
large; but its  pedicle, or immediate attachment, was so exceedingly delicate that
it feemed difficult to imagine how fo great a tumour could grow, or even be nou-
rifhed, when formed,  by fo fmall a root.   It was no more than one line (the 
416     Of Tumours ofthe Nostrils, Gums, and Throat.
 back of the nostrils; and here the  same iron probe (d) is left
 in the nostril.   You may see how this nostril (the right one) is
 dilated by the polypi.  The septum or partition  of the nostril
 (~ej  is inclined, by the pressure, towards the left.   The poste-
 rior opening of that nostril into tht throat, marked (f), is great-
 ly dilated;  nor must you wonder at this, for  the tumour was
 once large and bulky.   Tumours which, in the dead body,  are
 flat, long, and corrugated,  by  long  immersion in spirits, may
 not only  have filled, but distended the  nostril,  and  dilated it
 permanently :  (g) marks the  centre of the  septum  greatly in-
 clined to the left, and (h) marks the mouth or opening of the
 Eustachian tube ;  the tumours taking their origin betwixt  this
 and the  nostril, marks the point of their  origin to be the upper
 spongy bone ; and the patient  suffering deafness from the pres-
 sure of the  polypus  against this  opening, shows, that slender
 as the tumour appears in  this  preparation, they had, when the
 patient was active, and the blood in full circulation,  been suffi-
 ciently bulbous to occupy  the whole circle of the opening, fi) :
 (kk) marks the whole length of that slit-like opening, betwixt
 the septum and spongy bones,  which the  finger can never pass,
 and which,  from  its  narrowness,  occasions the chief difficulty
 in managing instruments of any kind, and especially those tubes

 twelfth of an inch) in diameter, and of the fame  length.  The coat of the tu-
 mour was fmooth, delicate, not irregular nor warty ;  its fubftance was lardy, and
 the bottom of the cavity in which it was lodged formed one half of that concavity
 of the palate which preffed upon the tongue.  On opening the antrum of the op-
 pofite fide, they found it occupied with a tumour exprefsly fimilar in all points
 and circumftances, in fize, form, confiftence, and colour, and in its effect upon the
 adjacent parts.  Upon opening the two frontal finufes there was found on each of
 them a tumour of half the fize of thofe which diftended the antrum.  Thefe alfo
 had each its delicate pedicle, which grew  from the margin of that little hole by
 which  the frontal finus of each fide communicates with  the nofe ; the partition
 betwixt the finufes was  deftroytd,  thence they formed but  one general cavity;
 from this cavity, as from the antra Highmoriana, a little  of a yellowifh ferum if-
 fued, upon their being opened;  and  here, as in the antrum,  the pituitary or
 Schneiderian membrane was much thickened.  Thefe tumours were fpherical,
 but the mutual preflure of the tumours had flatttened each upon  that fide when it
 encountered its fellow.  To have a more perfect view of the effects of this pref-
 fure on the adjacent parts, they were obliged to diffect out the eyes,  and then it
 was feen that the eyes were difplaced by the preflure of thefe tumours which had
 made the inner fide of each orbit bulge outwards; and  upon opening the fcull
 they found  that a thin protuberance had actually compreffed the brain, for the
 two hollows of the os  frontis were convex and preffed fo inwards, that betwixt
 them the crifta galli was entirely concealed.  Upon opening the throat behind the
 palate,  three tumours, feemingly arifing from  one pedicle, were feen projecting
 into the fauces.
  " This may ferve as a general  analyfis of this unhappy  cafe, and muft fuggeft
 a doubt whether it may not, in circumftances, be allowable  and laudable to at-
 tempt the defperate, yet harmlefs operation of trepaning, or rather cutting open,
with a ftrong fcalpel, the frontal or maxillary finufes, diftended, foftened,  and be-
 come carious by the long preflure  of fuch enormous tumours.  It is  lamentable to
 obferve  how  unavailing every kind of operation muft  be  where the tumour*
 are thus numerous, and in how  fhort a period it runs its fatal courfe." 
        Of Tumours ofthe Nostrils, Gums, and Throat.     417

and probes which I am next to describe.  But while I am mak-
ing these observations on the drawing, you cannot but remark
the proof of those  peculiarities I have already taken notice of
viz. that polypus  is not solitary ; on the  contrary, that the pre-
disposition  is  so  strong, that three or  four  polypi are often
crowded in one nostril, a circumstance extremely unfavourable
to the operation of the ligature, which, though in itself effectual
would, in a case like this, fail; for it would, in such  a case, re-
quire to be applied three successive times;  after each operation
the breathing would be again interrupted ; a tumour lying deep-
er would re-place that which was extirpated, which would thence
seem to grow again in a few days ; for one  tumour only is seen
at once ; a second presents itself as soon as the nostril is cleared
ofthe first ; tumour after tumour presents  in succession, and the
operations seem endless and quite ineffectual. Besides, while the
polypi are numerous in one nostril, it rarely happens that others
are not formed or forming in the  other,  which are also nume-
rous.  Polypi are usually found at the same moment fit for ope-
ration in both the nostrils, as appears in the right nostril of this
preparation, where  (k  k) represents  a  polypus long and flat,
resembling one of the nymphae in shape,  and hanging from the
upper spongy bone(7) ,•  for in this preparation (mj marks the
roof or upper part  ofthe antrum High morianum opened, that
part which forms the floor for the eye ;  the alveolar process and
teeth of  the upper jaw are cut away,  and of course the lower
spongy bone is gone, and only the superior one (IJ left.  In
this drawing, then, the length of the polypi,  their slender stalks
and  bulbous heads,  their peculiar direction, viz. hanging for-
ward in  the nostril,  the straightened condition of the neck of
the tumour, and especially the number of  long stringy  polypi
occupying both  nostrils, are circumstances, I doubt not, alto-
gether new and unexpected.  Now, you  will judge, without
any help of mine, how unlikely it is that picking the nose should
ever cause  this disease.   The  most  impatient finger (I have
said) can never (in  picking the nose) reach that point  whence
these tumours have their origin, nor the most dexterous opera-
tor push his finger so deep as to reach these roots.  You will
also judge how impossible it is that operations should be suc-
cessfully performed only on that  bulbous part of the polypus
which can be touched with the point of the finger ; how difficult
to apply a noose to the root of the tumour which lies so  far be-
yond the narrow slit of the internal nostril.  Remember, that
in all your operations, and especially in the  application ot caus-
tic to the roots of polvpi extirpated by other means, your aim
must be  to reach a point nearly under the socket ot the eye, in
the deepest and highest part ofthe arch  ofthe nostrils, where 
418     Of Tumours ofthe Nostrils, Gums, and Throat.

the  nostril  opens  backward into the throat.   Remember the
length of i polvpus, (a circumstance which shall be demonstrat-
ed by  other drawings) and that however  low  the bulbous part
mav  descend,  or  be felt by the finger,  it is  only by pushing
your instruments deep, beyond the narrow cleft formed by the
projection ofthe spongy  bone, that you can do good.

                        PLAN NO. 2.
  Let me next represent to you, in explaining  the plan No. 2.
what I conceive to be the chief  difficulty in applying the  noose
to such tumours:  the tube Fig.  (1), was invented by Mr. Lev-
ret, for the purpose of passing a silver wire as a noose, and of
tightening the noose after being thus applied ; and in the appli-
cation of the  ligature, which was new, and peculiar to Levret,
he had no motive so much at heart as the guarding against hae-
morrhagy.  This was a vain fear, for though I have seen dread-
ful haemorrhagies in the last stage of polypus, I have never, in
twitching away polvpi  with the forceps, seen a haemorrhagy
worth regarding , I have always kept a ligature in the nostrils,
and a plug in the mouth, ready to be drawn up, by the help of 
        Of Tumours ofthe Nostrils, Gums, and Throat.    419

 that ligature, into the posterior opening ofthe nostrils, but have
 not found occasion actually to draw up the plug more than three
 or four times in  my life; and then rather from fear than dan-
 ger.    The tube of Levret  is thus used, the loop of the wire
 (bj is passed over the lower end or bulbous head of  the poly-
 pus, and hitched higher,  towards the  root  of the tumour, by
 pushing the tube deeper and higher into the nostrils, or others
 (1 know not who, for such probes are drawn in every book) ad-
 vise us, after laying a noose of wire or cat-gut loosely about the
 tumour, to  hitch it up to the root, where the tumour rises from
 the bone, by pushing it higher, first on one side, then on the
 other,  by the help of the forked probe. Fig. 2.  But when you
 look to the scheme or imaginary plan of such an operation, fi-
 gure 3, you will foresee much difficulty in accomplishing it;
 lor the tumour, long and slender as it always is, hangs in the
 direction in which you are to push the ligature;  the ligature or
 noose, you never entertain a doubt, is  to run as  clean and easi-
 ly along the polypus as  a ring slips upon the finger, or as the
 ring ot a window-curtain slides along the cord ! but the truth
 is, that either from  the poly pus being forced backwards into the
 nostril  along the  ligature, or  by the hitching of some part of
 the noose against the inequalities of the polypus, or by the nar-
 rowness of the nasal cleft catching the  wire,  it certainly is not
 merely difficult to  apply  it, but impossible.   I have seen such
 an operation attempted fifty times, by  men of various degrees
 of skill, and ingenuity, some extremely awkward, some perfectly
 dexterous, but never have I seen this method succeed :  if even
 the ligature hung two days by the polypus, still the extirpation
 was but partial; usually  the  ligature gets no hold on long and
 slender polypi, which hang thus forwards in the  nostril.   No-
 thing, gentlemen, could tempt me, in a question where I am to
 deliver, not  an opinion, but a plain fact,  to  prevaricate  or  dis-
 guise the truth, however unfavourable to myself; I have no
 curious nor cunning operation to substitute in  place of that
 which  I condemn;  but I solemnly and impartially declare, that
 with my best and  most sincere endeavours to succeed, I have
 alwavs  miscarried  in attempting to catch a nasal polypus in a
noose of wire or cat-gut;  I have planned my little operations
 so cunningly, that I have imagined it impossible I should fail,
yet, in  my best concerted schemes  I have  been  foiled as com-
pletely  as  the most awkward  person I  ever saw  attempt the
operation.   I shall  ever therefore retain a suspicion, that the
method itself, rather than any want of address on my part, is to
 blame.                                          v    .    .
  If I  am correct in ascribing this difficulty to the direction in
 which  the nasal polypus  hangs, being  the fame with  that in 
420     Of Tumours ofthe Nostrils, Gums, and Throat.

which the ligature must be drawn, my reasoning  will  be con-
firmed, by the converse ofthe proposition being true, viz.  that
guttural polypi,  those which, in place of occupying the nostrils,
pass backwards  into the  throat, are easily noosed.   This is an
operation to the  happy success  of which I can speak with  con-
fidence as perfect, as  my conviction is, that the operation just
described never  can succeed, or very rarely.   When the poly-
pus is single, or  when one polypus has arrived at such  a size, as
to render whatever others  may be behind it trivial; when the
tumour, after having long  filled the  nostril, projects from  the
posterior opening of the nostril into  the  fauces, depresses the
palate,  hinders the swallowing as well as the breathing, and is
both  seen, upon depressing the  tongue, and felt upon passing
the fingers deep into the throat, firm, hard, and  bulky: at this
stage of its  growth, when the surgeon  most fears to grapple
with  such a tumour, it is in truth the  most manageable, it may
be extracted  with safety ; its root may be cut across by passing
a curved knife along the  nostril, yet not without difficulty; and
if there be an internal tumour which  admits  of extirpation  by
ligature, this is it.   It is the only case in which I can  with per-
fect confidence promise  to apply  the  noose, and where the tu-
mour is thus visible in the fauces, the ligature must be passed
through the corresponding nostril, hooked out from the fauces
with a hook, or catched with the  forceps, brought through the
mouth beyond the teeth and lips, spread out upon the fingers,
and by the  help of the  fingers (pushed  deep into  the  throat)
passed over the bulbous part of  the tumour,  and then the wire
 being pulled back through the nostril, it slides up to  the  root of
 the polypus, or near it, or may  be placed pretty correctly by a
 little help.   Now  when thus drawn, the  course of the ligature
 is transverse to  the direction  of the  tumour, and  is perfectly
 effectual in  its  operation; for the good effects of a ligature,
 thus applied, I  would willingly  be  responsible, having so very
 often performed it with  unvaried  success.  The plan No. 3.
 represents such a guttural polypus (a), small in  its neck, very
 bulbous in its extremity, bulky and solid,  so  as to  depress the
 palate, and so wedged in the upper part of the  fauces, betwixt
 the fore-part of the vertebrae, and the bones of the  face, as to
 cause  almost total deafness,  by pressing the mouths of the
 Eustachian tubes, and so exposed to the operation  of ligature,
 that having passed it, you  might, in place of gradually twisting
 and tightening the wire, by  the  help of the tube (b), twitch out
 the polypus by  the roots, by mere force.
   Experience,  if  ever you should be so unfortunate as to havet
 experience in this  disease, will best refute the prejudice so long
 indulged, so often mentioned as  an apology for ill success, viz. 
Of Tumour^ of the Nostrils, Gums, and Throat.     421
the malignant nature of some  polypi!  If haemorrhagies, pains,Jj
or a fetid ichor distilling from the  nostril, are to be accounted1!
tokens  of malignity,  every polypus must  be malignant in its
latter stage, for its first ill symptoms begin  from the pressure of
the tumour against all the cells and spongy  bones, and especially
the walls  of the antrum Highmorianum;  and its fatal conclu-
sion proceeds from a total caries of the face.  In all the prepa-
rations  from which these drawings are taken, the proximity of
the tumour to the antrum  Highmorianum, or great cavity in the
upper jaw-bone, is  observable.   In the drawing  of  polypus,
No. 2.- where the incipient polypus is seen hanging flap-like over
an  edge of bone, that edge is distinguished to be the partition
or thin plate  of bone, which separates the antrum from the nos-\w
tril.  In the  drawing of polypus,  No. 4. where the small inci-
pient polypi  (a a) are  seen  one in each  nostril, the posterior
openings of the nostrils (b b) are already almost filled with these
tumours,  small as they  are.  The great cavity of the antrum is
marked on the left side (e) ; there it is cut entirely open.   On
the right side, though the  bone is  cut away, it  happens  by
chance, that the very delicate membrane, or periosteum, which
lines  this cavity,  is still  almost entire, and  you see into the
antrum  only by two small irregular breaches,  (f g)  in this deli-
cate membrane.   Thus explained,  this little preparation seems
to me of the highest importance to you, as giving you a clear
and  perfect conception of the original  condition and final con- 
422    Of. Tumours ofthe Nostrils, Gums, and Throat.

sequences  of tumours so  situated; where  the most simple,
destroy ing the bones by their pressure, must in the end seem ma-
lignant ; for  the bony parts and cells, as they stand related  to
such tumours, may be reckoned thus f*first the septum narium(h),
or partition which  divides the nostrils  all the way from their
op. nings before to that point where each communicates at (b b)
with  the back of the  throat.  Secondly, the sides  of  the nos-
trils (h h),  which though seemingly very firm and solid in this
drawing, because the jaws in this preparation are cut  far back,
are really very  thin, especially in the middle of the nostrils,  at
that part where the  lower spongy bone lies upon the side of the
nose :  this  plate of bone, as you perceive, divides the  cavity of
the antrum Highmorianum  (e fg) of each side from the cavity
ofthe  coiresponding nostril; it is in short the partition of the
antrum, dividing that  cavity from  the  nostril; it is a plate  of
bone, actually as delicate as the os unguis ; covered with deli-
cate membranes, and  very  easily destroyed by pressure; and
it is here that the caries, which proves fatal, begins.   But it is
further to  be remarked, that the sella turcica  lies immediately
above the cleft of the nostrils, and the two anterior- lobes  of the

     PLAN  NO. 4.
 
Of Tumours ofthe Nostrils, Gums, and Throat.
 brain lie in hollows by the sides ql the sella turcica; you have
 here then all the essential relations of these  bony  cells to the
 polypus, arjd must perceive, that as soon as the  tumours (a a)
 fill the whole cavities (b b), distend them,  and in the end press
 upon them,  they  will  produce  caries by such pressure  as
 speedily as an aneurismal tumour: thatsuch caries wilt be  long
 of affecting the septum,  because it is massy, and yet can  give
 way and be inclined to one side»  but will affect more immedi-
 ately the thin partition betwixt the nostril and the antrum,  ami
 lay them into one cavity.   The cribriform  plate of the ethmoid
 bone, which lies immediately before the sella turcica, and above
 the nostrils, will be next affected ; and  indeed one of the ear-
 liest signs of polypus is a degree of stupor from pressure on the
 brain; and one of the most frequent and  fatal  conclusions of
 the disease is a continued coma, for several days preceding d< ath.
 But more frequently the upper jaw-bone is destroyed ;  the tu-
 mour makes its way into the antrum ; the whole upper jaw-bone
 becomes carious ; the teeth drop  from their places ; and a fetid
 matter distils from their sockets  ; and the  patient dies, wasted
 by pain and haemorrhagy.
    Such is the condition  of these long  and  pendulous polypi,
 which should, from their consequences,  have been  pronounced
 peculiarly malignant:  in the tumours themselves there  is no
 tok§n of malignity ;  in the state of the bones,  there appears
' destruction enough to account for the fetor, the pains, the pro-
 fusion of matter, and all the worst symptoms of the disease,
 during life ; and for the miserable manner of the patient's death.
    Polypus has sometimes, independent of any innate malignity,
 and rarely from its peculiar situation, a verv peculiar aspect^'
 and runs its course more rapidly.  I  am confident, 1 have ob*
 served that when polypus,  which in  its early  stage, is  usually
 attended with no worse signs than sneezing and running of thd-
 head, is attended  with rheumatic, and toothachy pains ; wherf •
 the side of the face swells, before the natural growth of the tu-
 mour should produce this alarming change, and the  cheek-bone
 particularly  rises, and is covered with inflamed  and puffy in-
 teguments ;  when the incessant and acute pain is limited to  one
 side ofthe face ; when the teeth  loosen, drop out successively
 from  their sockets, and are followed by a sanious  and fetid  dis-
 charge, we may be assured of  the polypus  having one kind of
 malignity, viz. that it is  confined within a  narrow cavity,  that
 it is seated in the antrum, that  the cheek and jaw-bones will be-
 come early carious, while the destructive pressure is opi/rat'nc
 also in every other direction ; and that the polypus being within
• 3fc 
424    Of Tumours ofthe Nostrils, Gums, and Throat.

the antrum, the operation of noosing is not practicable,  and no
ordinary operation, nor common degree of violence is likely to
be successful in eradicating the disease.  Thus far is early pain
a sign of greater  malignity, or,  in other  terms, of that  de-
structive pressure, which in the end causes caries, haemorrhagy,
and death.
   One thing more I beg leave to  observe: it seems to  me that
the predisposition to disease is universal in the Schneiderian
membrane ; that the earliest appearance of the disease is, in
general,  sweUing,  especially of  that  part of  the membrane,
which involves the  spongy bones  ; that  almost universally  the
disease is produced by cold; that many of those who have been
under my care, having got wet  in riding,  running,  or other
exercise, have had a sudden and sensible cold, attended with
violent paroxysms of sneezing, which has never for a moment
ceased, till the polypus was perfectly formed, the breathing ob-
structed ; the  particular character  of  the tumour, viz. that of
moving backwards and forwards with the breath becomes per-
ceptible, and  the  polypus, in short,  tangible  with the finger.
Where the polypi  are  incipient only,  they are  flat  and broad,
have  no  pedicle, do not  hang pendulous,  but seem merely  a
general swelling of the membrane; in some  cases while  the
complete polypi in one nostril  are long, slender, and pendulous,
the incipient polypus in the other  is flat, membranous,  resemb-
ling one  of the nymphae in form, without a pedicle, and to all ap-
pearance a general swelling ofthe membrane : but I hold it un-
questionable, that such an  enlargement would in no longtime be-
come a conical polypus, for it seems to me that the neck or pedicle
is formed by time, and the pendulous posture ofthe tumour: but
a conclusion far more important, not certain indeed but probable,
and not  unworthy of consideration, follows, viz. that since the
disease often is formed instantly,  and sensibly,  after a violent
and sudden rheum or cold, and as it consists at first in a mere
relaxation of the membrane, there is a stage in which  it is  per-
haps  curable by astringent solution, and  the use of caustic.
   From the conceptions which now open upon you  of the  na-
ture of this disease, you must naturally suppose,  that in place^
of  arranging polypi according to  the imaginary  characters of
soft,  and hard, mild, and  malignant, I should rather define the
several stages and  periods of its growth,  and describe the opera-
tions corresponding with each  stage.   It  is not  by books nor
conversation,  that you will ever be able to decide which mode
of extirpating a polypus is  to be preferred: you will  learn only,
that some  have used ligature, some caustic, some forceps, some
'the cautery, some heated irons, some  long needles,  with which 
Of Tumours ofthe Nostrils, Gums, and Throat.    425
  they have bored and transfixed the polypus! That old surgeons
  have been  in the practice of cleaving the palate most unrelent-
  ingly,  to get at those polypi which  hang  in the  throat; while
  others have most audaciously proposed, to  cut open the nostrils
  and cheek-bones!  Each  praises his own method as invariably
  successful; and  the imagination of the young surgeon being
  left, distracted among such a chaos of inventions, though he  is
  at a loss to choose, never doubts,  that with such a variety of
  means before him, and the privilege of trying one after another,
  he  cannot  entirely fail.  Many an  operation,  good and  bad,
 successful and  unsuccessful, have  I witnessed;  and  certain
 practical conclusions, which I  neither  sought nor  imagined,
 have come to be established in  my mind ; but especially these :
 That the surgeon who attempts to noose a polypus of the nos-
 tril, invariably  miscarries ; yet this is  the kind of polypus,
 which being easily seen  and felt, is supposed to be most easily
 noosed.  That the big and bulbous polypus, which descends by
 the back of the nostrils towards the throat, and depresses  the
 soft palate,  though usually shunned as too bulky to be grappled
 with, is truly  the most  favourable  for this operation ;  this is
 indeed  the only period of its growth, in which the polypus can
 be effectually noosed.  That the polypus  which has its root
 within  the antrum maxillare, is characterised by early and per-
 manent pain, the caries of the jaw-bone,  and the  dropping out
 of the  teeth, and that it is not to be reached  with the silver
 tubes  of Levret,  nor  to be noosed,  nor extracted by ordinary
 methods, is too obvious to require illustration :  it is equally ob-
 vious, that the  polypus which has already  burst up the cells, and
 produced a  general caries among the spongy bones, is past all
 surgery:  That  the extraction of the  polypus in such disastrous
 circumstances,  only hurries on the catastrophe,  as I shall prove
 by sad  memorials.  After  being long perplexed,  as  every one
 must be who takes his first ideas from books,  concerning the
 preferable modes  of practice, I learnt from experience, what I
 regard as a  discovery more precious and useful than that of the
 most curious instruments,  viz. that each stage of the disease
 requires an appropriate operation ; so that each method, in its
 turn, becomes  valuable ; and that with judicious distinctions,
 and moderate skill, every polypus has its appropriate mode of
 cure, except in  its last and fatal stage.
   I am now to define the several stages in the growth of poly-
 pus, which  require appropriate  operations; but do not  flatter
 yourselves,  that, because all seems clear and simple in descrip-
 tion, every thing will be so in practice :  I am, indeed, an en-
 thusiast, but not in this degree ; for though I hope and  mean
to make the subject very simple, yet you are in your turn  to 
426     Of Tumours of the Nostrils, Gums, and Throat.

have your disappointments and uncertainties.   You are neither
to judge by your eye, feel with your fingers, nor act with your
instruments so perfectly, nor so dexterously as you might expect.
  1. In its early  stage polypus  has invariably that character
which  is  usually denominated mild:  it is  small, moveable,
pale, colourless, and has not as yet begun to affect the adjacent
parts by the pressure;  there is a watering ofthe eyes, sneezing,
altered voice, and interrupted breathing, but as yet  no  pain, nor
any fetid ichor distilling from the nose: from the smallness and
pendulous direction of such polypus, to noose  it is difficult; and
from  the numbers of smaller polypi which  usually lurk  one
behind another, the perfect extirpation of all of them by apply-
ing the noose is nearly impossible.   The  happiest and most suc-
cessful process is to extract the body or bulky part of such polypi
with forceps, and to destroy their roots with caustic.
  2. In its next stage, the polypus grows to  a great  bulk, not
only fills the nostril, but is visible in the  throat, the voice is en-
tirely changed, for not a breath of  air reaches the bony cells,
nor passes through the nostrils : the hearing is greatly affected ;
if you introduce your  fingers  deep into the  throat, you feel a
tumour so bulky,  as  at once to depress the soft  palate,   and
compress entirely the mouth of one or both Eustachian  tubes :
the face is swelled and unsightly, the nose inclined to one  side,
blood begins occasionally to flow, and the matter distilling from
the nostrils and throat begins to be  fetid ; the pressure  is now
universal, and begins  to affect the bones,  and the disease   bor-
ders on that stage which is, I fear, incurable.
 ; This bulky and seemingly dangerous polypus,  terrifies the
young surgeon:  he reads in elementary  books only of trivial
tumours appearing in the  nostril, and  is alarmed when he sees
a polypus of this enormous size : he has read in books of cases,
of polypi thus oppressing the patient and descending into the
throat, but he recollects that the surgeons, in these  desperate
circumstances, committed every kind of devastation,  they of-
ten cleft the palate to reach  the tumour, and were  willing  even
to perforate  the trachea:  yet  this  case,  or this stage  rather of
the disease, is not desperate ; it is indeed on the verge  of that
period in which the polypus is incurable, but from its very  bulk
it is easily and effectually  noosed.   I find not the slightest  diffi-
culty in this case; passing  a  silver wire through the nostril,
bringing it out through the mouth, and with the points of the fin-
gers (thrust deep into the throat) raising it over the bulbous and
most dependent part of the tumour, I draw it back into the  nos-
tril,  and,  as  it appears to me, quite to the neck of the tumour,
for I have often succeeded thus, and never found reason to  seek
the roots of the polypus, or apply caustic. 
        Of Tumours ofthe Nostrils, Gums, and Throat.    427

   3. In its third and last stage, when the passages of the nos-
 trils and throat  have been long obstructed, and the face much
 deformed; when the patient has long endured the rending head-
 achs, and pains proceeding from the distention ;  when the sur-
 geon can distinguish, by pressing with his fingers, that the cheek-
 bones are softened, and the nasal bones become moveable, and
 fetor and haemorrhagies  intimate the caries within ; when the
 integuments of the face are puffy,  the skin reddened, or livid,
 over the root of the nose, and the teeth loosened ; when the stu-
por from pressure on the  brain, and the chilliness from want of
 nourishment and loss of blood are great  and continual, the dis-
 ease is declining into its last stage, which we can hardly palliate,
 and cannot cure.  This is the stage of the disease reputed can-
 cerous,  and operations undertaken in these circumstances,  and
performed, as I have seen them with rudeness, inflame the brain,
so that the patient presently sinks into absolute stupor, and dies.
  For  every practical purpose, the  definition of these three
stages is, as I judge, altogether sufficient.
DISCOURSE XXIII.
OF  THE  VARIOUS OPERATIONS  PRACTICA-
  BLE  IN  THE  SEVERAL  STAGES OF POLY-
  PI.
     Of the first Stage; or, of small and incipient Polypi.

                        section  i.


 J. HE first stage of polypus I no longer characterize by symp-
toms, the enumeration of these,  I hope, I am entitled to omit
in future.   I am now to speak of the extirpation, of the means
of eradicating, not apparently,  but effectually, that  smaller po-
lypus,  which hangs forwards in the nose, and only obstructs the
nostrils.   Of the  operation of ligatures  I have spoken  with
little restraint, I  know too well what is usually done, what can
be done by Levret's tubes, to mention that method with respect. 
428            Of small and incipient Polypi.
On this subject I will use but  one plain blunt expression, and  .
take notice that I say no worse of the attempts of others than  I
do of my own, (for I have many  times attempted this method.)
That the  disappointment of those who confidently expect and
promise to noose such small tumours, is so frequent and so lu-
dicrous, that I should be loath to quote examples : many  are
the times  I have seen the surgeon thrust his tubes and wires
into the nostrils,  and withdraw  them again, leaving the nose
streaming with blood : the attempt  is, on such occasions, re-
peated without delicacy or mercy, and if he but so fix his tube
that it can hang without dropping  away by its own weight, he
willingly leaves it there,  and trusts his reputation to this first
appearance of success.   But it drops away on the second day,
the breathing, the voice, the hearing, are still affected as they
were before ; even were  there but one polypus, (and you know
by these drawings, and I  assure you from experience, that there
are usually many) a second would immediately descend, and
occupy the place of the  first.  But  where  a ligature is thus
slightly applied,  the point only,  the  mere bulb alone,  of the
polypus, is cut off; the nostril is so far closed,  that the breath-
ing is for a moment more free, but the long neck and root, from
which the disease germinates again, remain untouched, and the
individual  tumour,  which is the  subject  of the operation,
sprouts again with renovated vigour in a few days.  This then
is a harmless, but it is as  certainly an useless  operation ; I knew
not how very trifling it was, till I had often  failed :  be assured
that, however much you may  be captivated  with  these  ingeni-
ous tubes  of Levret,  for applying ligatures, and though you
may be still more captivated with" your own inventions, (for eve-
ry  one invents  instruments for  extracting polypi) be assured
that a grievous disappointment awaits you,  which I now warn
you of.  As Richter observes, there are  but two methods of
extirpating  polypus, viz. by ligature, or by forceps, and ever
since the time of Levret, who, from a horror at haemorrhagy,
and the fear of tearing away the  spongy bones, invented  instru-
ments for passing the ligature, surgeons have uniformly  prefer-
red the ligature  to forceps.
   I will not allow myself to protract my  discourse by any but
occasional  hints  of the irregular and inefficient practices ot  the
early surgeons, nor defer what must be interesting to you,  the
simple account of what experience has taught me : I was early
aware of the little advantage to be derived from the ligature in
smaller polypi, and learnt to use the forceps,  the knife, and the
caustic with particular freedom.   I fear I teli you no more than
the truth, when   I say that, in my mind,  every operation for
polypus, must be one way or other, rude and cruel,  to be at all 
Of small and incipient Polypi.              429
successful; and that these nice and curious methods  must be
unavailing.
  The forceps, knife,  and caustic, are the means I have  found
most suitable  to the smaller polypi ; and, according to the con-
ceptions I form of each particular  tumour, according to the pe-
riod of its  growth,  the symptoms and  effects of its pressure,
and by searching  with the probe, or fingers, I use those  instru-
ments variously, and pursue them according to the progress and
effect of the  operations.  I begin with  the  forceps, and con-
clude with the caustic, and  I find the extirpation of a polypus,
and  the killing of its roots, not  an operation to be performed
with  such a show of  dexterity as  to captivate the pupils who
assist or are present;  I find it to be a work at  once slow and
difficult, and often, I  fear, it is imperfectly accomplished.
  It is  assuredly  neither the root,  nor even the body of a po-
lypus, that you are able to seize with the forceps ; but the bul-
bous point only ; for you will observe in  all these drawings, that
the neck of the  polypus, and  all that hangs  in the passage, is
slender  and delicate,  that it forms a bulb only where  it hangs
below the narrowed  slit of the internal nostril, or  behind the
palate ;  that it is of this bulb  only, that  I can catch a slippery
and insecure hold, so that you may  sometimes,  in consequence
of the slenderness of the neck, and by a sort of accident, twitch
it off from its narrowest part, and close  to  the  spongy bone.
The pedicle sometimes gives  way  spontaneously, the tumour,
dropping into the  fauces : and it will often, by a happy chance,
break off from the root in extracting.*   In such operation no
man need affect  unusual address : if the bulb retires before the
instruments when  pushed into the nostril, he has then a better
chance of catching the neck:  the bleeding  so much  dreaded,
and made an argument, almost the  sole one  by Levret, for a-
dopting his method by ligature, is indeed  extremely  slight:
from  much experience I can assure you, that  such haemorrhagy
will  never  weaken  the patient, nor require  a plug, which yet
should always be  in readiness ; but it is not  so in  extirpating
the roots of the  tumour with  the knife,  then the haemorrhage
is great.   Both nostrils  are usually diseased, and, on the first
day, I  extract whatever polypi  present in either nostril; but,
far from imagining that I have done all my duty to the patient,
I proceed at the next visit, and  indeed at every following visit, to

  * The forceps, as they. are now formed, feldom  catch  a fecure hold.  Thofe
commonly ufed, and belt known by the name of Polypus Forceps, are entirely
ufelefs; are bigger than the  finger and give no hold.  Their blades are too broad.
Thofe which I prefer and ufe are fmall, long, delicate, and their ftrength is put
upon the thicknefs, not upon  the breadth ofthe blade  ; they  enter eafily, and catch
well. 
430              Of small and incipient Polypi.
search for polypi, or their remains.   Some polypi, I find, come
out entire, as I judge by their form ; others, manifestly short
of their full dimensions, and mangled*   The anterior nostril
being cleared,  I see down  into the nasal slit, and feel deeper
with my finger:  often, upon  looking into the  nostril,  I  see,
even at a late stage of my operations^ the remains of a polypus,
or feel  it with the extremity  of my finger, and still more  fre-
quently I am sensible of eradicating, by  various methods,  po-
lypi which are too  deep to be visible ;  for behind the narrow
slit which the finger cannot pass, the nostril is enlarged-, and  in
that wider part, usually the vomer is pressed to one side, there
is left a hollow in which the  polypi hang.  It is only by con-
tinual examination, and the most earnest attention, and a care-
ful calculation  of points and  distances,  that such  remains of
polypi are discovered:  first, by a rattling noise, when the breath
is  driven  through the nostril,  which, though  tolerably free,  is
so only«t times,  and in particular postures : secondly, by feel-
ing with the  probe,  or with a bigger instrument, when we  per-
ceive that the back  passage is not clear, the point of the instru-
ment (I often use the Sound)  encountering a  resistance  when
  • No. 7. a polypus of full fize, root and all.  No. 8,9, 10, II, polypi fhort of
their natural dimenfions. or extracted in fragments. 
              Of small and incipient Polypi.            432

it should descend to the back of the nostril, so as to touch the
Ydum ; the  resistance we  are sensible  is not solid, such as
would proceed from the probe encountering one of the spongy
bones, but soft and yielding, such as. we  are sensible we could
overcome by' dashing the instrument down into the throat:
thirdly, vyhen the patient, in consequence of our first operations*
inhales his breath freely, but cannot breathe out with equal f reel
dom, we are sure that a polypus, or the remains of one,  is still
hanging in the back part of the nostrils, nearer the  palate; act-
ing like a valve, it recedes when the patient draws in his breath,
but, when he qreathes out, it falls flat upon the back of the nos-
tril and  prevents the exit  of the air.   Now, although  I  am
pleased when I see the stupor lessen, the  breathing more free,
and the hearing restored, I am conscious that all is not safe, and
that there must be added other essential  signs  of  the passage
being free.   It is in this  stage that  the patient  is usually dis-
missed, and  most inhumanly, with  some trivial directions of
introducing  bougies,  or  drawing astringent  solutions up  the
nostril, to return in a few months with an  incurable  and carious
disease of all the bones.   When I find  that,  though the  pa-
tient breathes easily, the  head reclining backwards, he cannot -'
breathe in the natural and perpendicular posture; when  I fiffi|.:'
that though he inhales* the  breath easily, he  finds it suddenly
and^ vehemently stopped,  however strongly and perseveripgly
he presses it; when I find (suspecting from  those signs some-
thing wrong) that though the anterior nostril is free,  some  co-
loured body appears within the nasal slit, is fejt with the finger
though  indistinctly, and  is  directly  encountered by the Sound,
or big probe, passed from the nostril towards the throat; when
I find that his breathing (even after  having become free)  after
he is able to dash out by vehement efforts, the prodigious quan-
tity of thickened  mucus, which the inflamed state ofthe nostril
generates, is yet accompanied with a rattling and snorting noise;
when that peculiar noise continues after the nostril is cleansed by
snorting, and by wiping it within with the probe  covered with
lint, I am sure there are some dangerous remains ofthe disease.
Often I see  this, after I have begun to  apply the caustic,  and
discover the remains ofthe polypus, rounded by ulceration, of
a brilliant colour and bud-like ; but never, after this stage, do I
expect good from the forceps : I proceed to rougher and more
decisive methods.
  When I find  the whole of the posterior nostril  closed by a
spongy polypus, which I  either have not  reached, or have ex-
tirpated imperfectly, I have recourse to the knife: when I first
ordered knives to be forged for me of the form  represented in
No. 6. I little imagined I had the least authority for  proceed- 
432            Of small and incipient Polypi.

ing in this enterprising way ; yet I find that, far from having
neglected those passages of ancient authors, where  the use ot
the knife, and the spathula, which was a sort of knife, was men-
tioned by Celsus, and by the Arabians, I  had made accurate
notes of their methods,  which  I  had yet so entirely forgotten,
as to proceed in cutting out polypi, with all the timidity of one
who was attempting a thing, at once unprecedented and danger-
ous.  I recollected no precedents, and reasoned only on the ne-
cessity, on the simplicity  of the operation, and by  analogy in-
ferred, that if we might extirpate a tumour of the cheek, or lip,
of the palate, or  tonsil, with the knife,  much more should we
adventure  to extirpate  that of the nostril, since, by drawing up
plugs into the nostril from behind,  we could entirely  suppress
whatever haemorrhagy any operation  produced ; we  could ap-
prehend nothing from the  wounding of the spongy  bones, and
the operation of incision, in place of  the rude  method of tear-
ing and  mangling  with forceps, seemed more delicate in rela-
tion to the membrane, and more  effectual  in respect to the tu-
mour.    I have never since that period (now many  years past)
spared the knife in operations of this nature: often I have used
it in the first  operations, and in place of pulling away the more
bulky polypi with the forceps, have  slipped in the knite into the
nostril, and carrying it flat and vertical, till  I  reached, accord-
ing to my apprehension, the root  of the  tumour,  have  then
turned the edge towards it, and with some mangling, and not
without both difficulty and fear, have cut it off.  But when the
nostril is already  in some degree clear, when  the anterior nos-
tril is free in so far as to admit the  knives easily, but  the pos-
terior nostril still encumbered with  tumours, or the  remains of
tumours,  I find it particularly advantageous, to pass the  knife
deep through the nostril, till  it lies in the posterior  opening of
the nostril over the palate; then turning the knife,  and striking
a stroke alternately to right and  left, or cutting with premedi-
tation in that direction,  in  which from  the probe, or the cir-
cumstances of the breathing, I suspect the tumour  to hang,  I
free the nostril of this last obstruction.  I do not know a greater
happiness for the patient, or a greater victory en the part of the
surgeon, than that of clearing the nostrils of this very danger-
ous disease : in whichsoever  relation  I  stood, of patient or of
surgeon,  I would set no limits to  the sacrifices I would make
for such a purpose : I have ever remarked, that the period of
suffering on the part ofthe patient, or of necessary cruelty on
the part of the surgeon, though seemingly long, is really  tran-
sient, and, when the end is  accomplished, on the return of health
and pleasure, when freedom  of breathing,  and of hearing is
restored, is entirely forgotten.   Therefore, I intreat you in 
Of small and incipient Polypi.            433
all  such cases to persevere :  there is but  one immediate dan-
ger, viz. that of haemorrhagy , and I leave you to judge, whe-
ther any incision these knives can make, although it were di-
rectly into tne membrane and among the spongy bones  much
less such as is made into the slender neck or body of  a tumour
so small as to be contained  within the nostril, could be danger-
ous !   Confident that it could not, I have ulvvays used the knife
freely, and,  though I have had the plugs  for suppressing hae-
morrhagy ready, and have usually indeed had the ligature  rea-
dy passed from the nostril to  the throat, prepared  to draw up
the plug, I have not more than twice or three times at the ut-
most had occasion to draw it, and then only to save the strength,
and lessen the alarm of the patient,  not to save his life.
  Let me now  represent to you, after  these general descripti-
ons, the particular acts of these successive operations.
   1st, For the extraction, you must be conscious, that with the
best imagined forceps, you can grasp  only the  bulb or most
pendulous point of the polypus ; that if you  are successful in
twitching out tne polypus by its root,  it must be by your good
fortune in having to deal with a polypus whose root is natural-
ly delicate;  that your forceps are to be used  with any degree
of success, they must be so formed  as to operate with their
blades vertical, viz. one towards the forehead, the  other towards
the  chin of the patient ; or, in other  words,  according to  the
length of the nasal slit.
  2d,  Whether to amputate entire polypi, or to eradicate those
which have been partly extracted, you will do better to use a
knife sharp on its convex edge.  Those fashioned  like the one in
plan No. 6, which Ihave hitherto used, will be found occasionally
very convenient, especially in cutting at the roots of polypi ly-
ing far back in the nostril, or in the arches of the  palate,  and
where you are to make your cut by hooking the crooked knife
beyond the root of the  tumour, and drawing it  towards you.
But I am conscious that I could manage the form, No. 5, with
perfect safety, and it is manifest that I could cut more decided-
ly with it; for the  polypi hang down from the' upper spongy
bones, in tne form I have represented in all the drawings,  and
especially in the drawings, No. 1, and 3, but which I have more
correctly  represented in the plan No. 6,  which I drew in the
time of operating, and for the correctness of which I can be re-
sponsible.   Alter long reflection and many partial operations
on  this patient,  I sketched this plan the moment  after my fin-
ger  and instruments were out of the nostrils.  As soon as  the
gentleman, being freed from pain, could  sit  composedly  and
without suffering, he seated himself before me,  while I made
the plan, with every recollection and feeling fresh and lively. 
434             Of small and incipient Polypi.
In this plan are represented  the features  in profile ; the  cavity
or hollow formed by the bending  aside ot the vomer or parti-
tion of the nose; the roots  of one  poly pus already extirpated,
the remaining root being still sufficiently long to  appear move-
able upon looking into the nostril, and exposed,  of  course, to
the stroke ofthe knife, and requiring it; another polypus entire,
and deeper  seated, obstructed the back of the nostril, allow ing
the patient to draw his  breath,  but falling down valve-like, so
                        plan no. 5.
plan no. 6.
as to prevent the breath being driven out:  (a) a semicircular
dotted line marks the place where the cirtitag'mous wing of the
nose terminates, and the opening of the nostril is narrowed by 
Of small and incipient Polypi.             435
 •he arch of the nasal bone : (b b) the hollow produced by the
 receding of the  vomer towards  the left, being pressed by the
 bulk of the polypus :  (c) marks the upper spongy bone, where
 the polypi had their roots : (d) the remains of a large polypus
 which  had  originally filled the  whole opening ofthe nostril, and
 Of which only the root (d) is left, but was left of such a length
 as to  require a stroke of the knife :  (e) the direction of the
 lower  spongy bone represented  in a  dotted line.  This lower
 spongy bone,  hanging on the edge  of the antrum  under the
 cheek-bones, and the antrum being cut away, it can be repre-
 sented  only by this  imaginary line,   (fj marks a longer and
 more entire polypus, which so obstructed the  back opening of
 the nostril, (viz. that towards the throat,) that neither the big-
 headed probe, nor even the common probe  or director could
 pass freely : (g) demonstrates the direction of the knife, when
 passed  down the nostril, towards the  throat,  so as to cut the
 poly pus, in withdrawing it, by very slightly  turning its edge.
 But it  is obvious,  that had 1  used knives cutting on the back,
 though I could not have been sure  to conduct them so harm-
 lessly  through the nostril, I should  have been sure of using
 them more  effectually ; for a knife so  formed,  scythe-like, and
 cutting on its convex edge, could not have failed to cut off, and
 that probably very near its root,  whatever polypus hung down
 from the upper spongy bone.
   3d.  For the suppressing of the haemorrhagy, it is  necessary
 that you be made acquainted with the introduction ofthe noose,
 which is a method at once simple and effectual, of drawing up
 a plug from behind the palate  to the  posterior opening of the
 nostril, so  as to  have it in your power to close at once both
 openings, to restrain the blood.   You are-to take, not  a piece of
 catgut,  for  that is liable to twist very provokingly, and to be so
 softened with  the moisture of the fauces as to lose its shape ;
 but a piece of delicate silver wire, or  occasionally, I have used
 a harpsichord wire, and doubling it, you make the patient gape,
 introduce the loop ofthe wire through the nostril, and watch its
 appearance  in the throat; the splendour of the silver wire shows
 it at once ;  if you  find the patient not at all excited  to cough,
 you may be assured the wire has  not yet reached  the fauces ; if
 he is in danger of suffocating,  you may be assured that the
 loop of the wire actually touches the epiglottis ; then you will
 retract it a little, and the irritation will  cease.  The way to suc-
 ceed is  to carry all  quietly and  softly, to  insinuate  the wire
 along the nostril very gently, to watch for it in the throat care-
 fully, to mark its appearance instantly, when it begins  to pass
 behind  the velum, to push it no farther, for then  it touches the
irritable parts, to be readv with the crooked probe, or the dress- 
436             Of small and incipient Polypi.
ing forceps, or a blunt hook, to catch it the instant it appears,
and draw it out by the mouth.  Then, in the loop of  the wire,
you  fix, with a piece of thread,  a small pad of charpie,  and
make ready to draw it back  through the mouth,  and up behind
the soft palate, into the back of the nostrils.  You  prepare for
tlis act by twining the  wire round the fingers of your  left hand,
near the nostril, and by holding the plug upon the point of the
fingers of your right hand ; you then draw back the wire through
the nostrils,  and push the plug  into the  mouth by correspond-
ing motions of your two  hands, and when you have got the plug
to the back of the palate, and just sticking in the fauces,  you
must not leave it a moment  there, but by a sudden jerk with the
left hand, pushing boldly at the same moment with the fingers
of the right,  you bolt it up into the  posterior  opening of the
nostrils, above the  back  of  the palate, and fix it at once in the
cleft at the back of the nostrils.   This being finished by plug-
ging, at the same time,  the opening of the corresponding  nos-
tril,  there  is  no longer a possibility of the blood escaping.  I
have  several times  needed to use this method in cases of epis-
taxis,  and three or four times  after extirpating polypus, but
especially after using the knife.
   4th.  When all is done that knife or forceps can do, I proceed
to use the  caustic,  and with this conviction, that I should be
very  indifferent indeed, whether I destroy the polypus only, or
the spongy bone, or much of the membrane, if but the  polypus
be destroyed.  However confident I am of having extirpated
the tumours by my  preliminary operations,  I  never think it
superfluous to burn the roots, but apply the caustic  the more
boldly, when, by the frequency of my operations, I am sure of
being able to mark the points of  the nostril at which I  have to
expect the roots of the polypi.   To apply the caustic effectual-
ly, you must apply it  boldly; and if you consider the important
object to be attained,  you will be careless although it should af-
fect the spongy bones  ; or rather, you will be fearless of every
thing, but the error of hot applying it effectually.  I find much
address necessary in this, which  I confess I have learnt slowly.
   I alter my method occasionally,  in the course of a  cure, and
according to the circumstances of each case.   First, I am care-
ful to have  the nostril entirely cleared of  mucus, which, in the
inflamed state of the  fauces, and especially after the  operation
of the caustic is begun,  is secreted in such profusion  as almost
to suffocate the patient:  he draws much back into the throat, he
drives much outward  by blowing the  nose, and  I clear out the
nostril effectually with the probe rolled in lint, and then the  nos-
tril,  raw and red with the violence it has sustained, is so clearly
seen that I have often  perceived,  upon looking into it, a%bud or 
Of small and incipient Polypi.             437
germ of the polypus still remaining, though very deep in the
nostril, and very small.   But independent  of this process of
clearing and  inspecting  the nostril,  we  are  able, merely  from
calculating the depth  and distance of the upper spongy bones,
and recollecting  the circumstances of the operation, to apply
the  caustic to the  roots of the tumour with much confidence ;
no  dismal consequences  have I ever witnessed, nor  even the
slightest inconveniences from its being misapplied.
   I never  have  used  a pencil caustic*  in a port-crayon ; that,
I know, would be, extremely dangerous, but spread the caustic
Fig. 13.
upon lint;  (I at first spread
it upon leather) as I would
for making a common caus-
tic issue.  First,  I fold a
piece ot lint twice  or thrice,
and   give it  a triangular
form, (fig. 13)  and  after
pounding  the  caustic,  I
mix  it with water into a
paste, and spread it  in the
form  and dimensions (a)
upon  the  lint, and then bend the lint over the point of a probe, or
of a  directory rather, the big obtuse point of which carries it, and '
deposits upon  the precise point you wish, fairly and without get-  '
ting entangled in it. In passing so big a caustic  along the nostril, *
the parts would be cruelly excoriated, were we not careful to guard %
the canal,  which  I do, by cutting a stripe of sheep's leather, and
conveying it high into the  nostril with  the probe, and laying it
flat  and smooth  along the surface to be cauterised.  I leave it
there, and turning the caustic towards it, I run it up to the point
I  design to burn.  Upon the slightest sense of disappointment
I withdraw both, and begin anew ; but being conscious that I
have succeeded,  I withdraw  the sheath of leather at the same
moment that  I push  up the caustic to the  part, and I impress
the caustic very firmly upon the part; for, the instant it touches
the  naked surface, the eyes fill  with tears,  the patient draws a
long breath, and  sneezes tremendously, and instantly displaces
  * I find, in looking  over my notes of cafes, that this is not quite correct ;
that when I firft began  to ufe the cauftic, I ufed it by foaking a large piece of
camel's hair pencil in it, conveying the brufh  along a canula made of a playing-
card ; but finding fuch application quite ineffectual, and having also thought of
ufing a port-crayon, perhaps 1 may have tried it, but  I even, in this firft cafe, re-
newed the ufe of it,  and betook myfelf to the  fcraped cauftic, which being laid
thick, is equivalent to a folid cauftic, and yet absolutely fafe. 
438            Of small and incipient Polypi.
 it: but if you press firmly,  this irritation  goes off ; if you have
 passed it far beyound the strait of the nostril, and up to that point
 where always  I conceive the roots of the tumour to lie,  it sel-
 dom is driven away by  any future paroxysm of sneezing.   It
 does sometimes happen, that the  profuse secretion of mucus
 carries it down, and the operation being performed at ten o'clock,
 for example, the caustic  is discharged by two or three o'clock ;
 but of.en I have found  the caustic in both nostrils next day  at
 dressing.  It will add to your assurance and confidence  when
 I tell you, that deep as you may appear to yourself to have in-
 troduced the caustic rather beyond the nostril  as  you would
 imagine, and on the very verge of its  posterior opening, just
 over the palate, it never falls backwards  into  the throat, nor
 ever is swallowed  ; of the many hundred times I have used the
 caustic, no such thing has ever happened.*
   There is one thing perhaps contributes to its coming always
 forward, viz. that the  moment the caustic is  placed, and the
 sneezng is over, I instantly cram the nostril full of little  dossils
 of lint, which are lying ready prepared and are quickly handed
 to me  ; if this be not done first, the  nostril and upper  lip are
 severely  excoriated  and deeply corroded with the caustic ; se-
 condly, the caustic piece  of charpie, if not  supported by others
 from behind, is apt to be displaced ; the nostril being enlarged
 by the polypus, requires  a great deal of lint  to fill it;  and  to
 prevent any  drop of melted caustic  or mucus  descending this
 way, I  ram  the lint hard  into the  nostril at each dressing.   I
 find the lower dossils of lint discharged, (those I mean, which
 fill the  cartilarginous mouth of the nostril) the caustic ones of-
 ten are returned (they occupying the deeper, straiter,  and bo-
 ny part of the  nostril,  beyond the narrow slit  formed by the
 nasal and spongy bones.)   The dossils and muscus are hooked
 out, the mucus picked away and  sometimes the  nostril washed
 with barley-water or oxymel  at each  dressing.   The caustic I
 apply every second  or third  day ; I often continue this  severe
 process during a whole month, with occasional intermissions :
and I confess the whole cure to be so difficult, that whether  from
the presenting of polypi already existing, or from the quick re-
 generation of those  already extirpated, I have had occasion,
 even while using the caustic, to repeat  my incisions  with the
 knife: and while I  am making incisions  upon the remains of


  * It was long before I was entirely void of anxiety on this  fubject ; I find in
 my notes, a cafe of a young lady of 19 years of age, who is now in perfect health
 that in place of ufing fimply this pledget of charpie, coated with cauftic, I mount-
 ed the lint upon aconeofftiff paper, or card, the conical form of it, the apex
looking forwards would, I expected, prevent the cauftic from  paffing backwards.
into the fauces.  I did not then  know how fuperfluous fuch precaution was. 
Of large and guttural Polypi.
the polypi, or consuming their roots with caustic,  I find it  ad-
vantageous to clear the  nostril, especially  in its back parts, by
methods almost approaching to rudeness, by  wrapping a'big
iron  probe, of a  curved  form, round with lint, or mounting it
with  a sponge, and running it thus guarded  down  the  nostril:
I make  it so large as not only to fill the nostril,  but  to  pass
through it with  great difficulty, and by forcing it through the
slit ot the nostrils, quite  back  to  the palate, I often force off
these remains of polypi, which are already half  consumed, or
imperfectly cut.*  These,  gentlemen,  are the  methods which,
used  with perseverence and courage, have seldom failed  me'
of many patients whom I have  treated, there  are  very few, I
declare  solemnly, who have returned to put themselves  under
my  care:  of the entire  recovery of such as  I  have not seen
again, it would be presumption to speak confidently, but from
many I  have had the happiest assurances of their continuing in
perfect  health.   Such is  my process with the softer,  smaller,
and incipient polypi, which occupy  only  the nostrils,  and are
pronounced mild and benign :f the hard and  bulky polypi, pass-
ing down  into  the throat, require other operations ; and  to ex-
plain  these, demands a more methodical enumeration of the
various  inventions, and, I may say, cruelties, of  the  older sur-
geons.

                          SECTION II.

                    Second Stage of Polypus.

   The  fears of the surgeon increase in proportion to the  size
of the polypus, and there is no task from which he revolts so
much,  as  that of grappling with a  polypus which already de-
presses  the  palate,  and  begins to  fill the  fauces and throat.

  * I fee  occafionally  the half-confumed polypus, or rather the root  of it, of a
very florid red colour, and touching it with the probe,  I feel it hard and granu-
lated :  fometimes the opening of the noftril is fo exulcerated as to require inter-
miffion of the procefs, and the anointing of the  excoriated parts with oil or oint-
ments.
  f I  fhould be forry to omit mentioning an operation, which has been approved
and commended by the greateft practitioners, and has held its place from the ear-
lieft times; it was invented, I believe, by the Arabians; is defcribed by Albu-
cafis, and was ufed fuccefsfully by La Faye, in the Hotel Dieu.   It is the paffing
a large feton or cord from the mouth through the noftrils,  knotted, at intervals
of an inch or more ; the knots are meant to prefs upon the roots of the polypus,
and made larger, and  drawn up  tighter, in proportion as the  tumour yields, or
the paffage dilates.  1'he mechanifm of this invention is eafily undcrft';od by thofe
general terms, and I am not entitled to be particular, as no occafion has prefented
itfelf, in which I thought of ufing this method; but it is  furely worthy of being
mentioned, and 1 can imagine a variety of circumftances in which it may be vfc-
% 
440             Of large and guttural Polypi.
Such a tumour left to itself, is indeed full of danger; the nos-
trils and throat are filled with its  bulk, the  bones sorely  com-
pressed, as the pain and stupor  sufficiently evince;  the  voice
affected ; the hearing injured ; the breathing and swallowing in-
terrupted ; the patient is thence  in the utmost jeopardy, and
that stage fast approaching  which  is so incurable.   But this
bulk, which  threatens destruction  to the bones, facilitates all
the surgeon's operations, and is a probable sign of the tumour
being single.
   Surgery was at one period rude and cruel in all its operations,
but those used for the extirpation  of polypus, were so in a  pecu-
liar degree.   The larger  polypi, depressing the palate and ex-
tending towards  the throat, seemed to the ancient surgeons to
vindicate every degree of violence.   They attempted the  extir-
pation, sometimes by the most  cruel cauteries, oftener by main
force.   They,  if the polypus was long and pendulous, tugged at
it with merciless rudeness;  if beyond their grasp, they consumed
it with heated irons.*
   But  of all the examples of successful violence upon record,
none is so well calculated to shew what the parts will suffer, to
banish all fears of endangering the brain  bv violence  done  to
the spongy bones, while  extracting polypi  with forceps,  as that
which I am now  to lay before you.   It will at once suggest ma-
ny practical reflections, and teach you much of what you ought
to know familiarly, concerning the relation ofthe tumour  to the
passages of the nose  and throat.
   Mr.  Manne, a respectable surgeon of Avignon, was the ope-
rator,  and he related the case in  a small  volume, published at
Avignon,  anno  1747: not  contented with the ordinary means
of extracting the polypus,  finding even  the  strongest crow-bill
forceps unavailing, he transfixed  a large   and cartilaginous  tu-
mour with many ligatures,  each of which successively he  twist-
ed round the body of it, and with the help  of these, used like
a halter, and by  pulling  upon the  projecting part of the tumour,
and pushing at  the same  time  that part of it which he could
reach by introducing the fingers into the throat, he delivered
the patient  of an enormous massy polypus, which, in bolting
through the nostril, made a noise like that of uncorking a bot-
tle.   The  patient,  from  confusion, pain, and loss of blood,
fainted; while the numerous assistants were left in a degree of

   * This method of deftroying polypi by cauteries, little ufed by modern fur-
 geons, was univerfally employed in thofe times when fire fuperfeded blifters, frtons,
 iffues,'incifions! and  nothing but fire was ufed for headachs, white fwelhngs, hx.-
 morrhagies, rheumatifms, tumours !  Whatever, in fhort, was to be done, which
 could not be done by incifion, was (to ufe the words of Hippocrates) " to be
 done by fire." 
Of large and guttural Polypi.       >     441
astonishment, from which they did not soon recover: butthtse,
with  many other points, you  will best It am from the narrative
of  Mr  Manne, which is very perspicuous,
   " Etienne  Ducres, a villager of the Duke de Gadagne, se-
venteen years of age,  born in the village of Saint Saturnine, in
the Comptat, was attacked, in the  year 1745, with a violent
haemorrhagy  of the  nose  and  throat,  occasioned  bv extreme
heat,  from the direct  ravs of the sun  striking upon his head
during the labours  of  the  harvest.   During months the  hae-
morrhagy returned from time to  time.  The rheum, and stop-
page of the passage, which followed this,  shewed the thicken-
ing of the membranes and glands, and soon after the patient
began to snivel through the nose  : the passage  was daily more
and more obstructed ;  he was no  longer able to breathe through
the left nostril, which  proved  the existence of a tumour.
   u He now  betook himself to Avignon,  and there consulted
a surgeon, who, though he  found  an  incipient polypus  in the
nostril,  found nothing, at that time, wrong  in the throat:  he
pronounced the heats of the autumnal  season, to be very unfa-
vourable to any operation,   This unhappy  delay gave occasion
to such  a growth of  the polypus,  that in  the  space  of  a  few
months, it had not only filled the cavity ofthe nose, but protrud-
ed backwards into the throat, and forwards through the nostril.
   4' The  patient, alarmed by  this  sudden growth, had  once
more recourse to his surgeon, who now attempted the  op .-ra-
tion ; and holding  the mouth open with  a speculum oris,  he
tried  to twist and tear away the  polypus from the  throat, with
crow-bill forceps,  and  pincers of  various forms ; but succeeded
so ill  as to tear away only one morsel, the size of a peach-stone.
   u Wearied with this fruitless  labour, he was willing to try,
whether he could not obtain a better hold on the polypus hang-
ing out df the nostril ; but at the first pressure of his forceps,
there came on a haemorrhagy so alarming,  both to  the surgeon,
and to all who assisted at the operation,  that  their work was
instantly suspended  : yet they made four more attempts of the
same kind, within the eight succeeding days, and at each time
were alarmed  with  the same haemorrhagy, and obliged  to de-
sist.  From  the time  in which these  fruitless operations were
altogether abandoned,  the patient  suffered periodical haemorr-
hagies ; sometimes from the throat, (issuing from  the lacerated
endof the polypus) sometimes from  the nose, (where also  it had
been  torn and mangled with the forceps) and often  he bled from
both  nose and throat,  the polypus growing incessantly, so as to
burst up the bones of  the  nose.
   " After the attempts just  mentioned, there came a violent
.inflammation and abscess of one  side of the face :  the skin sup-
                             3 K 
442            ' Of large and guttural Polypi.
purated ; the cartilage of the wing of the  nose was ulcerated
and  opened ;  the  suppuration,  and all  its consequences, in-
creased daily for two months, and at last ceased ; and then the
patient fell again into  his old disorder of periodical haemorr-
hagies, the blood  issuing chiefly from the  nostril, by the side
of the polypus, and through a fistulous  opening on the cheek
near the nose.
  " In this desperate and most deplorable situation,  the  pa-
tient  addressed himself once more to his surgeon, requesting
his  help.  But this gentleman,  unwilling to risk his reputation
further in so hopeless a case, contented himself with prescrib-
ing some cathartic powders.   The patient knew well that this
was but an apology for leaving him to his  fate, was anxious to
find some one resolute enough  to do him good, and  lighted
happily on Mr. Manne.
  " When this patient came to me, (says Mr. Manne) I con-
versed with him,  consoled him, supported his hopes, and his
courage; and  after some restoratives, and general  remedies,
undertook the operation in my own house, on the 25th of Oc-
tober, 1747, two years after the commencement of the  disease,
in presence of fifty gentlemen  of the profession.   I did  not
choose to have so particular a case reported only on my own
testimony, or on that of a few partial friends.
  " In the presence then of  this respectable company,  I began
my operations, without having recourse to the gag,  or  the spe-
culum oris,  used in the former operations : I placed the pa-
tient opposite to a window; and reclining his head a little back-
wards, I intreated him to open his mouth  wide, which he did
very courageously ;  I then took a crooked bistoury, passed it
betwixt the velum pendulum and the tumour,  and  slit up the
velum from the side of the uvula to the palate bones, and pro-
ceeded then to the  tumour itself, which was  wedged in the
throat. It was so firm, that it resisted the knife, as the attend-
ants will testify,  who cannot but remember the quantities of
blood that flowed after each incision.  The moment I began an
incision, the flood of blood suffocating the patient forced  me to
desist ; when  it ceased I renewed my attempt, only to be inter-
rupted by a new haemorrhagy :  till at last, at each incision, in
consequence ofthe hsemorrhagy that ensued, the patient  fainted,
so that we were obliged to allow long intervals after each stroke
of the bistoury, lest the patient should actually expire.
  " The assistants were careful during all this  time to  support
the patient with  spirituous  liquor, and occasionally spoonfuls
of nourishing soups ; and thus from incision to incision, from
haemorrhagy to hsemorrhagy, after many  paroxysms of faint-
ings,  did I, at last, partly by the  knife,  partly by tearing, se- 
Of large and guttural Polypi.            443
parate completely this mass of tumour, which lay in the throat,
and which  I immediately  delivered  to the bye-standers that
they might examine its extreme firmness and semi-cartilaginous
nature.  The patient, restored as it were from death to life had
still sufficient strength to walk from my house to the suburbs
where he lodged, when he was presently put to bed, and proper
diet and regimen prescribed.
   " It was not fit that we should comply with the spirited and
resolute request of this young man, who besought us to finish our
operations,  and deliver  him at once,  of whatever remained of
the tumour.   I thought it prudent to allow at  least a few days
of rest and nourishment, to repair this loss of blood.
   " After three days the slight fever excited by the operation hav-
ing subsided, and his strength seemingly recruited, I resolved to
begin my operations anew.   This was in  October,  1747:  I
placed the patient with his back resting firm,  and  his head re-
clined and fixed;  I  knew too well the firm  and cartilaginous
nature of this tumour, to think of extracting  it with  forceps,
which would but tear it into morsels, leaving perhaps, after the
laceration of the nasal portion, and of that  which  hung back-
wards in the throat an intermediate part, which would still ob-
struct the nostrils, and occasion  endless operations.   I saw the
nostril besides, too completely filled with this  polypus, to ad-
mit my forceps,  and the polypus itself too firm to be grasped in
them : I  had experience sufficient  moreover of the partial and
imperfect success of the forceps, in the case of Jaques Grenau;
I therefore resolved upon a more decisive, and more direct me-
thod of unrooting the whole at one pull.
   " With this design, taking in my hand a needle  remarkably
curved, threaded with a strong waxed ligature, I transfixed the
polypus as far back in the  nostril as possible: I then cut the nee-
dle away from the ligature, and (the J,igature  being double)  \
took first the two lower  ends,  and tied  them  firm round the
lower part of the tumour,  and the  two  upper ends I  tied in like
manner round its upper part,  and then taking  one end of each,
viz. of the upper and lower  ligature,  I  twisted them on one
side, I tied and twisted the two other ends  of the opposite side,
and thus having transfixed the centre of the polypus, and twist-
ed these numerous ligatures round the sides  of it, I had got a
hold which could not slip : I grasped the four ligatures, twisted
them into one, and pulling by this hold, I  brought the polypus
so low, that not merely the part thus transfixed with the crook-
ed needle, but half an inch more of the  polypus appeared with-
out the nostril.  I took now a second crooked needle, trans-
fixed the polypus with a second double 11 gature, like the first,
tied and knotted it in like  manner, and having thus got a firmer 
444             Of large and guttural Polypi.
purchase, I twisted the  four  ends of this ligature along win.
the first, round the tumour ; and now shaking the whole mass
ofthe poly pus from side to side,  then moving it with a rotatory
motion,  then pulling from right to left, and next reversing that
motion,  by moving the mass  from  kft to right; in short, by
moving and shaking the polypus in every possible  direction,  I
sought to disengage it from its connections, pulling towards me
always with such strength, as to make the tumour follow every
lateral  motion, and yet with such a measured force, as to pre-
vent the ligatures breaking; for had that unfortunate ly happened,
the tumour itself would have receded into  the  nostril, while  a
fragment only would have remained in my hand.
   " By successive and regulated efforts,  I  so far succeeded, as
to elongate the tumour still more ; an  inch more of its length
appeared without the nostril; I struck a third double ligature
through the polypus, which I twisted  as formerly, and  added
to the others; and with this new purchase, I pulled so success-
fully as to elongate the tumour still more  ; and transfixing it
again with  a fourth ligature, as. deep as possible  within the nos-
tril,  I obtained, by pulling with the whole sixteen ligatures, in-
conceivable power and purchase.
   u I was  now on the point of extracting the  polypus by the
roots;  and by the happiest chance observed  a trifling circum-
stance (for the most trivial circumstances are, in  the critical mo-
ment of an operation, of the very last  importance) which con-
tributed greatly to my success : having introduced two of the
fingers of my left hand crooked,  into the  throat, to  feel whe-
ther the hold I had upon  the twsal branch of the polypus af-
fected that within the fauces, and whether the  guttural part of
the polypus was of such a form  as to pass easily back again
through the opening from the  throat to the  nostrils, so as to
follow the nasal br.mch wjhen it was  extracts d, I felt distinctly,
that by pulling the ligature which  surrounded the nasal branch
ofthe polypus, I not only  moved at each pull, the branch which
hung down into the throat, but also was sensible  that this lower
branch (the branch which I had formerly cut  with the bistoury)
consisted of two tubercles or heads, greatly exceeding  in size
the posterior opening of the nostrils.   With my fingers of the
right hand, twisted among the ligatures surrounding the nasal
branch, I pulled upon it  ; while  with  the fingers, of my left
hand, thrust into the throat, I pushed  back towards the  poste-
rior opening of the nostril,  the tubercle which  was nearest to
it; then by a second effort of the same kind,  I forced the  se-
cond tubercle to follow the first;  and being sensible  that both
were fairly entered into the passage of the nostril, I continued
to thrust with the fingers of the  one  hand  against the guttural 
Of large and guttural Polypi.             445
part ofthe polypus, pulled with the other upon the nasal branch,
and  redoubling my efforts, and increasing the force,  in propor-
tion to the progress of the polypus, it, after much struggling,
and  many repeated endeavours, bolted (after one final effort)
so suddenly  out of the nostril,  that the  noise was  like that of
uncorking a bottle.
   *' The  moment the polypus was torn away, you would have
thought the patient would have expired, the blood bursting out
in a full flood from nose and mouth ; but as the blood  burst
out  thus suddenly, it ceased  instantaneously ; tor it proceed-
ed chiefly from the  vessels  of  the  polypus distended by the
compression, which were no sooner emptied than they ceased
to bleed.
  "■  The spectators did not soon  recover the amazement with
which they were struck at seeing so enormous a mass of tumour
issue from so narrow a passage.   This polypus was covered
with a membrane, very white,  smooth and polished, with an
infinity of small vessels circling  upon its surface ; and its sur-
face  was  dotted with  an infinite number of bloody points, red
with drops of blood, denoting the  manner  in which it had ad-
hered to the  pituitary membrane.
  "  No sooner was the lad delivered of the polypus, than he
straightway  breathed  through that  nostril freely,  and was as
suddenly  relieved of an insupportable head-ach,  with which he
had been night  and day tormented for more than a year,  He
recovered his sense of smelling; but what is more singular,  he
recovered at the same time the sense of tasting, which he had
entirely  lost.  After this second  operation we washed out the
passages with detersive and vulnerary  injections,  to which spi-
rituous  tinctures  were necessarily added, to correct the  putri-
dity of the foul and very fetid  sanies, which, by its horrible
fetor, declared the disorder of the parts produced by this  tedi-
ous disease, and the recent violence done to them.
   "  Yet the patient was in perfect health, weakness  excepted :
he was free from  fever: he slept  as if he would never awake;
and  when he  rose  it was with the  appetite  of a famished crea-
ture, ravenous for food.   But the  attendants were inexorable,
and  never permitted him to exceed the diet prescribed for him.
   "Two  days, and no more, had passed, when the patient, all
at once observed,  that he had no longer  that perfect freedom
in swallowing and breathing,  which  the operation had restored
him to so suddenly.   He  was sensible of a new obstruction  in
the throat, little differing  from that which  he had so long en-
dured :  I visited him on occasion of these new symptoms, and
I will ingenuously confess, that  if I was astonished at the size
and  nature ofthe first polypus, my surprise was inexpressible, 
446             Of large and guttural Polypi.
 when I found the throat choaked anew, with a polypus of such
 enormous size, that it seemed as if not a particle of the first
 had been  actually  destroyed.  I, without loss of time, con-
 voked the physicians and surgeons who had  witnessed the first
 operation.   They were, I believe, not a little astonished to see,
 apparently,  the individual polypus which they themselves had
 assisted  to  extract,  re-occupying its proper  place.   Curiosity
 led us to examine how this could be, and no conjecture seemed
 more probable than  that this new polypus had fallen down from
 the upper and back part  of the nostrils, where it had been
 squeezed up by the former polypus, and nitched in the narrow
 cavity: the extirpation of  the  former, it would appear, had
 made way for this  falling down.
   " I did not long hesitate  how to act, but waited only the re-
 turn of my  patient's strength,  to cut off this polypus also: for
 I was afraid, in his present weakness, of the haemorrhagies in-
 separable from such operations.  I allowed however only six
 days to pass over, when convoking the  same surgeons who had
 assisted  me at the  former operation,  I, in their presence, on
the third of November, cut out from the throat, a portion or
knob of the new polypus, represented  in the drawing, which I
accomplished now with much less pain, because it hung by two
pedicles, and was softer than the former : the haemorrhagy was
moderate, and nothing to be compared with that of the former
 operations.
   " The patient instantly felt the benefit even of this partial ex-
 tirpation, for  the throat was entirely freed, and he even began
 to breathe through the nose :  but this quiet state he did not long
 enjoy, for before morning a new lobe of the polypus had de-
 scended, occupied the place of that just amputated, and all his
 difficulties and distresses returned with the tumour.   Nothing
 remained for me, but to  relieve the patient, by  cutting off all
 the heads of this Hydra, or abandoning altogether an operation,
 in which I had already atchieved so much,  which had cost my-
 self such anxieties, and my patient so much pain and  suffering.
 My spirit was so raised,  and the patient himself so full of con-
 fidence and  courage, so well resolved to submit himself to what-
 ever I thought fit to do, that it was  determined to cut this poly-
 pous mass once more, and to the quick.  But I had found such
 advantages in  allowing an interval betwixt each  operation, that
 I imagined I could not, on the present exigency, act more pru-
 dently than to allow  the patient a short respite.
   " But while I was meditating this new operation, the singu-
 lar nature ofthe case drew together all those,  who had hitherto
 in compliment to me, or  through charity towards the patient,
 watched the course  of his  disease, and, by perpetually thrust- 
Of large and guttural Polypi.            447
ing in their fingers, touching the polypus, torturing the nostril,
searching in various ways, some to ascertain its size, others to
feel for its root, others with the hopes of reaching  its pedicle,
and disengaging the tumour, without  having  further recourse
to the knife, the roots were finally so torn and lacerated, and the
body of the tumour itself was so compressed and bruised, that
in a  few days it began to shrink and shrivel, fell into suppura-
tion, became rotten  and fetid, and dropt away  piecemeal in
small portions,  one of which however was as long and as large
as a thumb : by this wasting of the  tumour the  patient  was
freed of it in  a few days, without the help  of the knife or
cautery,  nor did I  choose to meddle  with the roots of the  tu-
mour,  both because I thought  that where nature had done so
much, it was wrong to interfere ; and because I could perceive
that the root or basis of the tumour was melting away slowly of
its own accord."
   Mr. Manne has added in his book, in testimonial of these
facts, the affidavit of nine of the Gentlemen who attended the
operation, and  of Francois Payen, in whose house the patient
lived.
   " This," says Mr. Manne, in concluding the narrative,  " is
a deadly blow to the opinion of those who believe in the plurali-
ty of polypi :"—by no means : it is as I have said, in the words
of the fable, one  looking on the side of the statute which is
white, while another looks on that which is sable.   Polypi of
this magnitude are usually, but not necessarily, solitary.
   A narrative  so  very interesting as this,  should not be  dis-
missed slightly ;  it suggests various  useful remarks ; it opens
up to us much  of  the rude practice which prevailed even in the
last century, of slitting up the palate, pulling with great  iron
forceps, bolting out the tumour at the same time, by pressing be-
hind the palate with the  fingers  ; extracting by  main force of
pulling, with the help not unfrequently of a great crooked knife.
We are led by this narrative to doubt the prognostic handed
down  from the times of Fabricius, or indeed  of Celsus, of  the
soft polypus being mild,  the  firm and hard cancerous ! Every
polypus is soft in its commencement,  firm in its perfect growth :
 I never have grappled with a polypus of this size, or any thing
 approaching to it, which was not semi-cartilaginous and  of  a
 stony  hardness; such at least were those of a young man ofthe
 name  of Reid, and of one Gow, which I extirpated  with liga-
 tures ; their cases I shall presently mention, for other purposes
 than to prove this fact.  But surely, if ever a long and firm poly-
 pus should by nature,  and by irritating  causes,  have become
 cancerous,  this might have been so;  nay, I doubt not, that in
 examining  the  records  of our profession, you will find those 
448             Of large and guttural Polypi.
 cartilaginous polypi the most frequently and effectually cured ;
 and I shall  presently  state to you my reasons, why I would
 rather grapple with a big polypus, than a small one ;  rather with
 a tumour that reached the throat, and depressed the soft plate,
 than with one  which  was but indistinctly felt in  the nostril.
 The latter is small, delicate, and yields to the forceps ; the body
 is crusted so as  to give no hold, while the neck and root remain
 untouched ;  the latter, in proportion as it grows firmer in its
 body,  grows smaller  in its neck, or pedicle, its  root cannot
 much  enlarge,  while its body does;  the disproportion betwixt
 the tumour and its  pedicle is daily increasing, and becoming
 more favourable to all kinds of operation,  whether rude or skil-
 ful.   The polypus, by this process, has been known, I  have
 known it myself, drop away in process of time, as ripe  fruit
drops from the tree.
   The merit of the operator, in this singular case, is least of all
to be passed  in silence.   The enterprise was  bold, manfully
 conducted, and  attended with  success every way  gratifying.—
Never perhaps was there  a more  desperate situation than that
of the patient ;  the face deformed, the cheek in a state of sup-
puration,  the gristle of the nose perforated, the polypus protru-
ding through the opening of the nostril, filling the cavity ofthe
nose, and extending to the throat : the disease neglected for
two years: the patient  tortured with pain and confusion of head,
dying of hamorrhagy, and soliciting  the  surgeon  to  perform
any desperate operation that might promise relief. The polypus
of that firm and cartilaginous texture, which all  writers  have
agreed, denotes a cancerous disposition.   Even such a tumour
was torn, mangled, cut, one way or other extirpated, and finally
cured ! From this  what should we infer? First, that  if there
seem something of good fortune  in  that perpetual laceration,
with the  fingers  of inquisitive visitors, by which the patient was
ultimately delivered by ulceration of the polypus, or its remains;
still it was that sort of good fortune which the bold and skilful
deserve ;  and next it  leads us to indulge the belief that it is
among the first  moral  duties of our profession, to attach  our-
selves  more  faithfully  to our patient, in  proportion to his  dan-
ger,  not  to shrink with heartless policy from the ugliest opera-
tion  his condition may  require.   It is not because we are un-
certain of atchieving a  cure, acquitting ourselves with honour,
that we are to abandon our patient:  where nicer and more de-
licate operations  fail, we must,  at his request, betake ourselves
to the  more  rude and desperate.  It is  not the barbarous or
cruel manner of our operation, that we have to consider, but its
tendency to preserve life :  it is not by our feelings, but our rea-
son,  that  we are to be guided ;  else all great  and  important 
                Of large and guttural Polypi.            449

operations should be  abandoned ; surgeons would decline ope-
rating for the stone or even trepanning ; for these also manifestly
endanger life, and are attended, even in the most skilful hands,
with  circumstances of  particular cruelty.  You know now by
experience, in this one case at least, that operations for the cure
of polypi, to be successful must be  in some degree  cruel: ope-
rations within the  narrow passages  of the  nose"and throat, like
those of midwifery, where we are forced  to introduce the hand
and instruments, require perseverance, even violence and de-
termined  courage,  more than skill or delicacy ; and in both
kinds of operations, these natural passages bear, without essen-
tially  suffering, a degree of violence, which those  unaccustomed
with practice would be  afraid to use.   Haemorrhages from the
womb,  or from the nostrils, and  the  violence necessary in ex-
tracting a polypus, or delivering a woman, are such as would
terrify a  timid man, and prevent him  from performing his
most necessary duties ; whereas  to the man of experience and
courage, these  considerations are but an  incitement  to  do  his
work resolutely and speedily.  From this feeling it is that the
fear  of a patient suffocating or bleeding to  death, incites the
operator ;  like personal danger,  he feels that the present fate
of his patient is in his  hands, he acts by an impulse like instinct,
he is  unconscious of the efforts  he makes, and  accomplishes
things during such a struggle, which, in cold blood he could
not do.   This is the kind of merit that the operator had in this
singular case.
   Often  the methods of the  older surgeons are  so incorrectly,
or at least so indistinctly related, that we learn little more than
this,  that wherever the polypus was sufficiently large to pro-
ject,' they could never resist the desire of extracting it by main
force :  they seldom  used the knife,  or even  cauterized the
roots of a polypus.   But Purmannus appears to have  approach-
ed to a  better manner than any of  his  predecessors : for while
his assistant or apprentice, pulled  upon a great polypus, which
hung pendulous from the nose, as large as a Muscadel pear, he
introduced the  forceps towards the  root of the tumour, and
pinched it off;  and indeed it  has  often  occurred to me, that
should  I ever  fail of  extirpating by  the ligature, those great
polypi which  tend backwards  to the  throat,  and  depress the
palate, I should operate, not as these gentlemen have done, by
slitting: the palate, by  cutting across the tumour,  when  it ap-
pears behind the palate, or  pull with great forceps introduced
by the mouth ; but in examining the disease I should, by feel-
ing  with a bent probe, or various shaped hooks  search the
nostril for the root;  if I could  then  hook  the neck  ot  the tu-
mour, so as visibly to move the  body where it appears m the 
450            Of large and guttural Polypi.
throat,  I should be sure of my stroke, and proceed with cor.
fidence  ; if fixing a sharp hook into the tumour behind the pal-
ate, and passing a blunt one into the nose, I could move the
tumour alternately upwards and downwards,  I should then be
able, either by pinching with the forceps, to pinch off the root,
as  Purmannus seems to have done; or  rather,  following my
usual method, I should pass one ofthe knives, small and bistoury-
shaped, such as I have hitherto used,  deep  into the nostril,
and cut the root there :  and take notice,  that the surgeon who,
in handling a great  guttural polypus, reaches its root by the
nose, is  sure of cutting it in the narrowest part of its neck, close
by the spongy bone.—This  operation, if dexterously perform-
ed, would be speedy, almost painless, and as  effectual as if the
tumour were  cutaneous ; and the haemorrhagy would be very
slight indeed, and easily suppressed by the plugs.  I have con-
stantly observed, that the haemorrhagy which is  dangerous or
fatal, is that only which proceeds from the universal ulceration,
and an extensive surface ; not that  it proceeds from the small
root of a polypus,  or the stroke of the knife.
  There is yet, among the practices of the older surgeons, one
which,  though the most obsolete, deserves, I think, the atten-
tion of a practical surgeon in an especial manner;  because it re-
lates to   many  of  his operations, and may, I think,  suggest
occasional methods very useful; it is an operation not very dis-
tinctly defined, otherwise than by its name, which  expresses
the purpose of it, viz. The Compunctio Polypi, or, as I think I
have somewhere read it, Comminutio Polypi: it was a lacerating
or  transfixing of the root so  as to kill the body ; and though it
seems to have been performed according  to no very regular nor
established plan, is yet commemorated by various authors.—
Heister mentions it in very brief terms, " There are yet several
methods (says he) of removing polypi; those which are recent
will sometimes shrink and  disappear, by  repeated  punctura-
tions  or scarifications with  a  scalpel or lancet,  as  Severinus
asserts  he has experienced."   Hildanus  gives  the  title  De
Compunctione  Polypi to his ninth chapter, and speaks respect-
fully of  this operation of Severinus.   He describes it as an ope-
ration performed by itinerants rather, whose method was not
expressly known, than by regular physicians,  and says, " 1 he
report goes, that they tie together three long needles, and pla-
cing  the  head  of the  patient  in a favourable  posture, they
scarify  the tumour with the  points.  They  then  anoint the
punctured  part  with  oil.   No ill consequences are found  to
ensue ,  the process is repeated from day to day, and the polypi
shrink  and waste till the patient is in a little while restored  to
perfect  health.  Such," says Hildanus,  " is the  method  sug- 
Of large and guttural Polypi.            451
gested by H;erocles, a celebrated writer in  the  veterinary art.
Nor do I see why an operation so gentle should not be transfer-
red to ours.?"  Nor can I imagine a reason against a practice so
likely to  prove successful^  so generally believed among the
older surgeons to be profitable  in the small spongy and blood-
less polypi,  whii h occupy the nostril alone.
   It is  reported, that the method of killing a polypus by a liga-
ture,  drawn  high round its roots, and tightened from day to
day, is of ancient date.   But though I willingly commend, and
as willingly borrow from the works ofthe old surgeons, I  find
nothing to praise in their manner of applying  the ligature, nor
indeed  any thing but their boldness and courage, in grappling
willingly (sometimes, it must  be  confessed, after having bar-
gained for their thirty or fifty crowns,) with the most bulky and
formidable polypi.   Ligatures, no doubt, they did apply ; but
assuredly they had no  other design,  than to save that blood,
which the patient could not but lose when they cut them off with
their bistouries.  The design of pushing up the ligature to the
basis of the tumour, never  entered so far into their system of
operating, as to lead them to think even of pushing the loop up
to the root with a forked  probe.   Glandorpius passed  a thread
of strong silk round  the polypus, drew  it tight, secured it  with
a knot, and then cut off the tumour close to the ligature.  " But
to perform this operation successfully," says Heister, " it will
he necessary to extract the polypus as far as you can out of the
nose  by pliers.  This too must be done gradually  and gently,
lest you  break off the tumour  before you have  made  the liga-
ture ; it must be left upon the part after your abscission, till it
is spontaneously  digested  off ;  and thus you cure the disorder
xvithout  running the risk of a profuse hamorrhagy,  which  is
sometimes such as to kill thepatient, especially when the poly-
pus is removed by avulsion."  Such  were the purposes of the
ligatures, used  by the older surgeons:  it  was a tourniquet,
merely intended to prevent the loss of blood in their rude ampu-
tation of the tumour.   Heister seems to have had a conscious-
ness of the imperfection of this  method, and to have sought a
more effectual manner of fixing the ligature.   In the case of an
old lady,  afflicted with polypus, he struck his ligature  through
the body of  the tumour within the nostril, but far from the
root.
   But all these methods were violent and rude.  Seldom  did
the older surgeons affect gentle means: never  indeed, that I
recollect, except in this solitary instance, when they stood in the
point blank danger of disgrace from haemorrhagy, when cutting
with their crooked knives.
   They  scrupled not to slit up the nostrils; and the  cleaving 
452             Of large and guttural Polypi.
 the palate, with the first stroke of their bistoury, from the uvula
 to the bone, was no uncommon way of making room for cut-
 ting the polypus itself at the  second stroke.  u Before I con-
 clude,"  says Garengeot, " I must mention to you, that often
 polypi so entirely obstruct the  nostril, as to prevent  the possi-
 bility of introducing  instruments to grasp the tumour ; and in
 such circumstances the surgeon has no choice, but must dilate
 the nostril with a cutting instrument.  The sole difficulty is to
 know at  what point,  or in  what direction."  These are  polite
 terms, " dilating the nostril with  a cutting instrument," for
 slitting it up with a bistoury ; and where the only difficulty was,
 about the direction,  that would not stand  long  in  way of a
 surgeon of this complexion.
   Such was the horror  of surgeons at this disease, or rather at
 this stage of it, that they seem to have thought no way excepr
 tionable, that afforded the  slightest  chance of destroying the
 tumour.  Petit, Garengeot, Dionis, Le Dran, Heister, Levret,
 and Tulpius,  all the  best authors, mention every possible me-
 thod with equal commendation, as if the surgeon had no choice
 nor limits in  his operation, but were to twist, tear, burn, pull,
 and destroy, by whatever methods he best could, a part at least
 ofthe polypus,  if he could not unroot the whole.  They  were,
 you will find at all times, as ready to slit the nostril, as to com-
 mit any less remarkable atrocity ; and no operation, was so uni-
 versally applauded, as that of slitting the palate. " We cannot,"
 says La Faye,  " extirpate by the nostril, polypi which descend
 backwards and  depress the  palate ;  for what we  see of such
 polypi iiythe nostril, is but a small portion, which easily follows
 the body of the tumour, when it is extracted by the mouth; and
 to extract  it by  the  mouth, we must imitate the manner of
 Petit, viz. first,  divide the fleshy palate  xvith a  bistourq, and
 then catch the polypus with  crooked  pincers on the fingers."
   This operation of cleaving the palate they never shrunk  from,
 because  it is neither bloody nor dangerous,  and it facilitated
 their main design ; the consequences they  never  reflected on,
 which, though in some degree distant, are not less melancholy.
 For, whatever the patient, thus treated, does not swallow with
 great precaution, rather by letting it  glide over his throat, than
forcing it by the usual effort, rushes  upwards into his nose ;
and his voice resembles that  of  one who had lost his palate by
the venereal disease.
   To these rude and  cruel methods, the best of us may  need
to have recourse ; 'and it is a merit to bend up our mind to such
cruelties, for our patient's safety: but when the  polypus has
attained  this size, and fills the nose, and depresses the palate,
its bulk is peculiarly favourable  to the operation of the ligature ; 
Of large and guttural Polypi.            453
 and as it has not yet destroyed the bones, the operation is al-
 most always successful.  I like to be diffuse in my descriptions
 and character of diseases :  in my directions for operating,  I  at
 least wish to be perspicuous and/Concise.   You would imagine
 the apparatus for applying the noose round a polypus to be mul-
 tifarious and complicated; you would at least imagine the tubes
 and other instruments of Levret, to be essentially necessary,
 and cannot perhaps at  this  moment imagine  that any contri-
 vances but what were extremely ingenious, could be at all suc-
 cessful : it is quite otherwise :  I have often  tried those much
 reputed instruments, with perfect  confidence in them,  and uni-
 formly, I concluded with my fingers, the operation which I had
 tried in vain to perform with this apparatus.  The operation I
 am going to describe requires address and courage,  but no in-
 strument great or small: indeed  the instruments are so descri-
 bed,  that  I  am persuaded those  who write in  praise 'of  them
 never use them.   I require nothing but a piece of fine silver-
 wire, and my fingers:  I  have frequently used cat-gut, but al-
 ways found it soften, untwist, and become altogether unmanage-
 able.   Ligatures of wetted thread are quite flaccid, and difficult
 to  apply:  a silver-wire, of  the size of a common harpsichord
 wire, passes easily through the nostril, preserves its looped form
 in the throat, is easily cast round the polypus, and easily twisted,
 in a gentle degree, so as to kill without cutting it.
   First.   How to pass the wire through  the nostril to the
 throat.   You have already  felt the tumour depressing the pal-
 ate, and estimated its size :  you have repeatedly placed the pa-
 tient before you, and made him open his throat, and depressed
 his tongue, so as to occasion straining and retching, which un-
 folds all the parts, and shews you their size  and  relations:  you
 now place  him before you opposite to a light, supported by as-
 sistants, resolute to bear whatever you do,  and reconciled to it
 by seeing that you have only a piece of silver-wire in your hand.
 You take  the piece of  wire, about  three feet long,  double  it
 and smooth  and arrange the  doubled  part, by  pressing and
 modelling  it  in your fingers into a neat noose, a little open  and
 ready to expand when it gets into the throat, but small enough
 to pass through the nostril;  and taking this loop betwixt your
 fore-finger and thumb, you enter it into the  nostril, and push  it
 gently along.   However big the polypus, you find that the loop
of silver-wire glides easily and smoothly along; find  it some-
times stopped, and then it bends and resists, but withdraw it  a
little, and  then push it, and it will go on.    I have never found
occasion to use any instrument for conveying  the  loop  to  the
throat,  except  when the  bones  were  destroyed ;  a case in
which  I can hardly counsel you to attempt the cure.  I have 
454             Of large and guttural Polypi.
thus imagined, that the wire was turned aside into the antrum
Highmorianum, and have used a catheter, cut or  open at the
point as a canula, for passing the wire, and then pushed on the
wire till it could be  seen and catched in the throat, and  then
withdrawn the catheter.
   Second.  How to hook out the wire from the throat.  You
cannot be one moment at a loss to know, when the wire reaches
the throat; for while it passes along the nostril, it excites not
even sneezing or watering of the eye ; but the moment it passes
the uvula, or touches either on one side the tonsils or the  back
of the pharynx it excites a sense of suffocation, and a desire to
cough, with sneezing, which the patient cannot a  moment re-
strain.   Upon  looking down into the throat, the loop of the
wire is seen, it is easily hooked out by a blunt hook, or catched
with  common  dressing forceps,  or a bended probe.   Then
quickly push the wire onwards through the nostril  with  the fin-
ger and thumb of the left hand, hook it forward  through the
mouth with the crooked fore-fingers of the right hand,  and as
soon as you have got the loop without the lips, all is quiet
again; yet in all cases the hooking it thus is a painful struggle,
though in the hands of a dexterous surgeon, a momentary one.
Often you will find the loop of your wire passing actually down
into the glottis ;  the  patient instantly  cries, coughs, and strains
violently, while the face becomes turgid, and the eyes stand in
tears:  instantly, knowing what kind of an accident  has  hap-
pened, you withdraw the wire a little towards the nostril; by
this motion you retract it from within the glottis, and you keep
it carefully there till the straining ceases;  then  you  push it
gently on again, keeping the mouth open, and catching the wire
the moment it appears behind the tonsils.   In this part of the
operation,  there is much address and some practice requisite ;
first,  in  stealing the wire on so gently that the patient scarcely
feels  it;  secondly, in  diving  keenly and resolutely with the
finger into the fauces, the moment the wire begins to excite the
throat, or  becomes  visible  behind the  velum :  and lastly, in
quieting and composing the patient for the next part of the  ope-
ration, viz. that of casting the noose.
   Third.   Of spreading the loop ofthe wire, and casting the
loop over the polypus.    You now draw out the loop of wire en-
tirely from the mouth,  and spread it wide; you  prepare to re-
act with the right hand, in  favour of the left; you take the two
ends  of the wire, which project from the nostril, firmly in the
left hand, twisting it round the  fingers  for a surer hold ;  you
gather the  fingers of the right hand together with the thumb, so
as to form a cone, and  taking the  loop of the wire upon the co-
aical fingers, you, by drawing the wire up towards the nostril? 
Of large amd guttural Polypi.             * 55
tighten the loop so upon the  fingers, that it is not  easily dis-
placed in  the next step ofthe operation :  you now prepare for
that effort, by which you are to carry the  loop over the biggest,
and most  pendulous part of the tumour;  and in this effort you
are to succeed at once, or to fail;  it can last but for a moment:
the patient, while you make this effort, cannot breathe, he feels
the severe pressure of your fingers in his  throat, he  is suffocat-
ing, struggling at once for  breath, and striving to vomit; his
eyes are staring,  and his visage  inflated: you dare not keep
him one  moment in  this condition ; you must act  resolutely
and dexterously.   Your purpose is  to push  the ligature home
over the bulk and body ofthe tumour with the right hand, while
with the left you  draw the ligature backwards towards the nose:
you first allow the patient time to take breath, and be  composed;
you let him fairly understand what you design to do, and how:
you prepare yourself by making the wire tense, by pulling with
the left hand, and fix the loop by spreading  and distending a
little the conical fingers of the right: you  then, in one moment,
retract the ligature  steadily, but speedily with the left hand,
while you plunge the loop into the mouth, and  carry it quite
to the back of the throat with the right.   The tumour, which
in your  previous examinations  you were able to  touch with
the points of  your fingers, you are now, in the moment of ope-
ration, using  every degree of violence,  and pushing your hand
boldly and deeper into the throat, able to  grapple with, and by
hooking and grappling with the points of your fingers, you get
it in some degree within your grasp;  and pulling  the bulk  of
the tumour towards  you, with the crooked points of your fin-
gers, and  slipping off the ligature from the points of your fin-
gers by bending them still  more, you at  once turn  it over the
lower part of the tumour with the right hand, and pull the
noose up  towards the root of the tumour  with  the left.
   Fourth.   Hoxv to hitch up  the  ligature  close to  the root.
With every operator this must be a matter of great anxiety, for
he has no sign nor mark by which to know, th it the loop is car-
ried to the highest possible point, nor any sure means of doing
so.  Do not  let me  deceive  you, by representing  the simple
methods I am going to speak of as  infallible ;  so much the re-
verse, that though they seem to me at once the best and the most
simple, though I  have always entered  upon  this part of the
operation with confidence,  I  have never  finished without a de-
gree of diffidence and uncertainty.
   I  have often  found, especially in firm and smooth polypi,
that I have by that quick and forcible retraction ofthe lig.it'.re,
by which  I draw it up behind the polypus hitched it at once  so
high, that no after-operation was either necessar  or useful. 
456             Of large and guttural Polypi.
But the attempt to hitch the ligature high, and place it correctly
round the neck of the tumour,  can  never be superfluous: the
instrument I most frequently use is a boy's catheter, or one of
the smallest size, cut across about the middle, or  somewhat
short ofthe middle of its curve.  Taking one of the ends of the
wire as  it hangs out ofthe nostril, I pass it through the tube of
the catheter, and then holding both ends of the wire or noose
firm,  I pass the catheter deep into the nostril, along the wire,
till I imagine  the point of the  catheter touches  the tumour ;
then, by tightening both ends of the wire, and  turning the point
ofthe catheter  upwards, I try to raise that side of the wire or
ligature as high as possible ; I then withdraw the catheter, pass
the opposite side of the wire through it; I hold all tight again,
and try to raise that side of the noose as high as possible ; I
then pass both wires through the tube  of the  catheter at once,
push the catheter along till it touches the tumour, pull both ends
of the ligature so  as to tighten it round the neck or smaller part
of the polypus,  and,  twisting the wire  fast round the handle of
the catheter, I  leave it there.   More frequently I  use for  this
latter  purpose a shorter tube, or very small section of a  cathe-
ter, a  little bended, which, when fixed, projects no  more than
an  inch, or an inch and a half beyond the  nostril, and is  less
apt to be discomposed by accidents during the day, or change
of  posture while the patient lies asleep.   Sometimes I have
run along the line of the  ligature to hitch  it higher,  a probe
with the point bent.  Sometimes, giving the loop a twist in its
middle, I have, before introducing it  through the nostril  into
the throat, tied a ligature of waxed  thread, or cat-gut, to the
loop of the wire, the twist of which keeps the regulating liga-
ture in the centre, so as to raise the proper  ligature  and adjust
its  place.  When a loop of wire is  thus mounted and in-
troduced into the  nose, and the loop caught  in the throat,  and
retracted through the mouth, this  assistant-ligature is fixed on
the centre of it; the noose of wire is then carried into the throat
upon the conical fingers of the  right hand, and  cast over the
tumour,  and retracted behind it, as  I have already explained,
and of the three ends hanging out of the nostril, you raise, first
this supplementary ligature, by running the catheter along it,
and thus you make sure of hitching  the  centre of the loop of
silver wire higher, after  which  you carry  each of the sides
higher,  by running the tube along them, and  if you know the
windings of the passages, and have formed a true conception
ofthe form ofthe polypus you have to deal with, your  chance
is tolerable of placing the ligature very true.   If there be a se-
cond  polypus, one in the nostril as well as  one in the  throat,
this method enables you  to carry the same  ligature  at once 
Of large and guttural Polypi.             457
 found both.  I have occasionally done this with the common-
 eyed probe, but the eyed-end of the probe, though from its flat-
 ness it glides pretty well along the sides of the tumour, is too
 big to turn easily,  and too sharp  in  its point ;  but a surgeon in
 the country may, by  clipping off the point with scissors, and
 hammering and rounding it upon a  stone, fit it for this use.   I
 have occasionally used for this purpose a piece of stiffer wire
 twisted into a loop, for conducting the ligature down into  the
 throat, or placing  it correctly, and hitching it high  upon the
 neck of the polypus.   In performing this operation then I take
 only a catheter nicely7 cut and smoothed, a few waxed ligatures
 and cat-guts of various dimensions, small and flexible wire, for
 forming the noose, and thicker and firmer brass wire to use for
 this purpose, with  cutting pliers,  and common  pincers, to  turn
 and twist the wires into whatever shapes best suit the occasion,
 or  the accidents ofthe case.
   Fifthly,  Ofthe effects ofthe ligature on the tumour, and of
 the time of its separation.   When you first draw the noose,  the
 stricture is followed with extreme pain, the  eyes fill with water,
 the patient cries out and  retracts  his head, and  violent sneezing
 follows ; during the whole of the first and second day, the pain
 is like that of severe tooth-ach, and, upon tapping with the fin-
 ger upon the catheter or probe, you find it firm.   On the third
 day7, a  thin and bloody  serum begins to distil from the noose,
 and continues to flow in great profusion, the probe or catheter is
 blackened by the putrid taint of this serum, the polypus,  if any
 part of it project so as to be felt,  is perceived to be  flaccid,  the
 breath begins to pass through the  nostril, and the patient, who
 had felt his fauces choaked with the polypus, and was deaf from
 its pressure, now swallows easily, and hears very acutely, because
 the tumour begins  to shrink.
  These are the first auspicious signs of the fading of the poly-
 pus :  the fetor  of the matter increases on the fourth and fifth
 days, the probes and silver wire  are still  more blackened, the
 wire manifestly has become looser from the shrinking of the tu-
 mour, the  catheter now shakes from side to  side, and, that it
 may  completely destroy the polypus, you find it necessary to
 draw it a little closer in proportion as the tumour yields.   Not
 unfrequently it happens,  that at this time the probe or catheter
 comes easily away ; but if the ligature continue to retain its hold,
 it is but for a day, or at the utmost two days longer; and though
 the pain is not renewed, the polypus, being now less sensible,
 the parts are still more blackened, the  discharge is  extremely
 fetid, thin, and copious; some blood usually flows at this time,
the swallowing  improves, and the hearing grows too acute, ir-
regular, and confused; the tube falls away on the sixth, seventh. 
458             Of large and guttural Polypi.
or eighth day, and often it happens, that the tumour melts away
so entirely, and  is  resolved into this gangrenous ichor, that no
perceptible portion of it  falls  away:   sometimes, continuing
more entire, it drops into the throat, and the patient rejects it;
often when it drops into the oesophagus it is  swallowed, and  is
passed undigested by stool;  sometimes the patient is conscious
of having swallowed the tumour, but more usually it passes over
the throat insensibly, and during sleep.   I have known it hap-
pen, especially in the hands of ignorant people, that, after the
polypus has dropped  off, and actually been passed by stool, the
tube and wire have kept their place, without the reason being  at
all suspected : it is  this, that  the loop  of the ligature  is larger
than that narrow  slit of the nostril, through which it  should pass,
and thus it hangs suspended, and I have  known  it hang so a
month, but loose, moveable, and  easily  taken away.   1 do not
know  that the  loop  of wire  ever needs be left, even in the
most bulky and cartilaginous polypus, beyond the eighth day.
   These are, I  believe, the most material rules and directions
I have to give you; but there  are some of them, perhaps,  that
I ought to explain or to  impress.  The operation which use
has made easy, or frequent success has inclined us to  prefer  to
all others, we are apt to praise too much;  but I am conscious,
that it is a serious duty to represent this not favourably, but tru-
ly.   The  operation  of noosing a polypus, is not suited, in any
degree, to these  small  and soft polypi,  which occupy  only the
nose, but to  those big and solid ones, which depress the palate,
and are felt in the throat.   It is most natural for the young sur-
geon to believe a polypus the more formidable, the  greater  its
size ; but indeed  it" is impossible to grapple with  those which
are not large ; those are most easily grappled with the points of
the fingers, and noosed with the loop or ligature, which are very
 conspicuously large.
    Some apparatus you will assuredly require ; you would ima-
 gine many  and curious instruments necessary;  you must  have
 small catheters,  or other tubes, you must have a blunt hook for
 hooking the  noose forwards, as soon as it appears in the throat,
 a pair of common dressing forceps, which indeed  I  find  best,
 silver wire of various thickness, and pliers for twisting, and cut-
 ting forceps, or strong scissors, for dividing it; but having had
 much experience in such operations, and seen every variety of
 the disease,  I protest I know  of no circumstances in which I
 would not prefer a bit of silver wire managed with my fingers,
 and passed down into  the  throat, without a tube, drawn out
 with dressing forceps from the throat, formed into a loop, and
 thrust over  the tumour  with my three first fingers ofthe right 
Of large and guttural Polypi..             458
 hand, in a conical form, to the most ingenious instruments that
 ever were devised.
   An operation so effectual and radical, and yet so little alarm-
 ing,  I do not know ;  for the  surgeon presents  himself without
 instruments, with only a bit of silver wire in his hand, and with
 the  professed intention too,  not  of cutting, tearing or cauteriz-
 ing, but merely ot casting a noose round the tumour, as  round
 a wart on  the surface ot the skin.   Nor are the efforts made
 in applying that noose, though  violent, at all dangerous; they
 are  not latal, like those of an unskillul  surgeon groping in the
 lacerated bladder for a stone; there is  here no incision, and
 the surgeon is  grappling for a hold of an uninflamed tumour,
 in natural passages, which, though they be inflamed by his un-
 skilfulness or rudeness, (and  1 have seen them inflamed so that
 the whole throat has swelled  exceedingly) yet such  inflamma-
 tion does no material  harm.
   But, though harmless, the  efforts necessary for noosing the
 polypus makes  it a moment of great agitation and  anxiety for
 the surgeon :  his  patient strains, and  suffocates, during his at-
 tempt ; however long it lasts, breathing is suspended ; the eyes
 are filled with  water, the blood gushes from  the  mouth and
 nostrils, the fingers, or rather the hand of the operator, is dri-
 ven deep into the throat; and the patient is held staring, and
 struggling, at once terrified by a sense of suffocation, excited to
 vomit, and  alarmed and pained by the pushing of the opt rator,
 who is obliged to push his finger deep, before he even feels the
 turn mr, behind  the palate, who grapples  hard before he gets the
 lower part of it  within the grasp of the fingers,  and  pushes still
 more violently7, and struggles  much, before he can pass the loop
 of the wire beyond and over it: it is  a painful, and to the spec-
 tators an apparently desperate  and unavailing struggle ; it is dif-
 ficult to perform in the living  subject, for in one moment of vi-
 olent struggling a thing is to  be accomplished, which you have
 no opportunity of try ing previously in the dead body : it is also
to be  accomplished at once, for if the operator suffers himself to
 be once foiled, he may be so fifty times, and never succeed :
 never, therefore, attempt this  operation in the presence of stu-
 dents, nor think of it as an  exhibition  of skill, but privately,
 with one or two chosen friends, when having no concern about
 your  own reputation, or shame  or  fear of being foiled, your
 whole thoughts  are occupied with  your patient.
   Like the  operations of midwifery,  such as turning the  child,
or dilating the  womb in  floodings, this requires a degree of
strength, and a  sort of cruel violence, which the inexperienced
surgeon cannot  allow  himself to  use ; insomuch,  that one who
has often performed it, forgets that there is any skill required, 
460              Of large and guttural Polypi.
and knows not how  to describe the art he does use.  So great
is the force, that I long imagined that nothing but courage was
necessary; I was not aware, that in  a matter so simple, there
was  occasion for particular address ;  and among many, whom
I have seen try in vain to noose a polypus, I represented to one
gentleman, that  he had but to push  his fingers more courage-
ously into the throat, and  he could  not fail to  distinguish  the
polypus, and after a short  struggle to noose it; this  was the
only point of my instructions in which he did not fail.   More
desperate struggles, I confess, I never witnessed; and when,
after twenty  attempts, I perceived  that it was impossible  he
should succeed, I  found it  as difficult  to disengage him from
the patient as a  mastiff from his  hold, he seemed furiously re-
solved not to be defeated in what was esteemed easy, and ne-
cessary for the patient, nor disgraced before a whole theatre of
students.
   The  surgeon  must, in performing this part of his operation,
be prepared to use great force ; he first draws out the loop from
the throat, then spreads it,  then passes the three first fingers of
his right hand in a conical form into the loop, then retracts the
wire in the nostrils with the left hand, so as  to  straiten  the
loop upon the fingers of the right  hand, that it may not shift,
then  pulling back the wire with the left hand,  he  gradually in-
troduces the  right hand into the  mouth, conducting  the loop
upon the points of his fingers.   He next prepares  for  the final
exertion, by pulling the ligature  smartly  with the left hand,
thrusting the right hand forwards into the throat, distending the
mouth more and more, and pushing the hand deeper, till he  not
only feels the tumour, but passes beyond it with the points of his
fingers, hooks it towards him with the  crooked finger-points, as
in the motion of  tickling,  pushing the  ligatures  up with  the
backs of the fingers at  the  same moment, and pulling it very
strongly back into the nose ; the throat all the while re-acts and
assists  him.  This, as  far as I am conscious, is the manner in
which I have successfully  noosed  the polypus, and  in  no in-
stance have  I yet failed wherever L conceived it to be of suffi-
cient size for such an operation.*

   * It is eafy to imagine the manner, and ftill eafier to underftand the effect of
thefe manoeuvres, but to execute them is extremely difficult, as  I am now  per-
fuaded; for I have feen  furgeons, by no means awkward or ignorant, mifcarry
moft inexplicably in this fimple operation of applying the noofe. 
Of large and guttural Polypi.            461
                HISTORY  OF THE DISEASE.

  " The case of A. Gow is one, I believe, particularly suited
to convey clear impressions of this second stage of the disease,
in which the tumour is bulky, fit for the application of the noose
and not yet accompanied with  any caries of the bones.   Gow
is a hard-working young man of twenty-one years of age, ap-
prentice to a mill-wrightin Blair Athol;  his polypus is big, and
of a stony  hardness ; it choakes the fauces, as if a fist with its
knuckles downwards1 were  thrust into the throat; the chief bulk
of the tumour descending from the back of the nostrils, pushes
out the soft palate into a great convexity, so that it presses the
root of the tongue ; two  large knuckle-like tubercles of the po-
lypus project below the curtain or moveable palate, and on the
centre of the convexity  formed by the protruded soft palate,
are two long gashes of incision,  made apparently with the ex-
pectation of letting out matter by his country surgeon, and now
in suppuration. There is no part of the polypus projecting from
the nostril, the  bulk of the tumour is in the fauces, yet the face
is deformed, the nose being inclined to one side, as if a branch
of the polypus  were lodged there.   There have been frequent
and very profuse haemorrhages ; the  parts within the nose are
greatly endangered  by the pressure,  which  is  attended  with
considerable pain; but as yet, no matter distils from the nos-
trils or throat,  there have  been  no intense pains in  the cheek,
the maxillary and nasal bones seem firm and sound, the disease
is advanced to  the farthest verge of the  second stage, and be-
ginning ofthe third, in which the bones and Schneiderian mem-
brane fall into  incurable  ulceration : nothing has saved the pa-
tient from such caries, but that the tumour,  though very bulky,
is but of recent growth ; it is of such a size as to be extremely
favourable for  operation, before applying the noose, I take the
following notes of its progress.
  " The lower order of people are  coarse  and hardy, very-
little attentive to their health ; it is not a slight alteration of the
voice, slight obstruction of the nose, or occasional haemorrhages,
that can alarm them ; thence  it happens, that  the date  they
assign for  such a  tumour,  is not the beginning  of its growth,
but that  stage  of  its progress in which  it occasions particular
distress.   It is no more than six months since Gow suspected
any thing to be wrong in his  throat or nostril ; he had tooth-
ach, and had a tooth pulled, without any possible relation to
his present ailment, the first sensible sign of which was haemorr-
hagy  from the nose :  during eight or ten days, he seldom rose
in the morning without violent hsemorrhagy,  which sometimes 
\j>2             Of large and guttural Polypi.
 recurred during the day,  or in the evening, but it ceased spon-
 taneously.
   " About a month after this first attack, the occasional haemorr-
 hagy returned in all its violence ;  he bled profusely  from the
 nose, not only in the morning, but at all hours of the day and
 night ;  all  the usual methods of restraining it now failed, he fell
 into extreme weakness ; and, to use his own homely expression,
 "• seemed to have bled out all  the blood of his body."
   " One day when he was out in the duke's woods,  with his
 master,  the mill-wright, cutting  wood for their  work, he  ob-
 served, in  blowing his  nose,  that he could not blow  with his
 right nostril ;  he felt, at the same time, something uneasy in
 his throat,  and directed by this feeling, pushed his finger as far
 back as it could go, and then he plainly felt a soft lump, obstruct-
 ing his  throat,  and hindering his free breathing ;  and  being
 greatly alarmed, he begged his master to look into his throat,
 who saw the  lump  very plainly.   Thus  you perceive  in this
 coarse country lad, little in the habit  of observing his own feel-
 ings,  and not easily discomposed by  trifling uneasiness or dis-
eases,  which in a more delicate person, and in a higher rank in
 life, would have caused great alarm.  The polypus was not ob-
served, till after it had  occasioned very profuse  haemorrhages,
 and had grown to a very remarkable  size.
   " The tumour  increased rapidly ; it was the difficulty  of
 breathing, and uneasy feeling  in the throat, that first led him to
 the discovery ; and  being sensible  that the lump in his throat
 was still growing, and feeling  his right nostril particularly stuff-
 ed, he introduced his finger there, Irom time to time, and was
 sensible also of a smaller lump obstructing his nose.
   " At this period when  he  had difficulty of breathing, with a
 total obstruction  of the right  nostril, difficulty of swallowing,
 with a d. gree of deafness  in the right ear, he had no distinct
 tooth-ach, but a general uneasiness, sense of pressure, and  con-
 fused pain  in the head:  but he had no returns of the  haemorr-
 hage, and  only a  thick, white, and  starch-like mucus, a mere
 increase of the natural secretion distilled from the nose.
   u In this stage of the disease it was, that he first applied to a
 surgeon, a very ignorant one,  who performed a singular opera-
 tion ; the incisions which he made are still in a state of suppu-
 ration.   The lad went to this  surgeon to complain of  difficulty
 of breathing, and a lump growing in the throat, which he  could
 easily see  and feel.  The surgeon having heard of swellings
 of the tonsils, and obstructions of the throat,  and read perhaps
 of the operation of scarifying the tonsils, to let out the matter,
 knowing nothing of diseases, and apprehending that the tumour
 he saw could be nothing but the swelled tonsils, he proceeded to 
Of large and guttural Polypi.
463
make two long and deep incisions.   This bulky and firm poly-
pus, having pushed down the velum, had depressed it to a right
angle with the bony palate: and the soft velum, with its uvula, was
thus protruded forwards in the mouth, in the form of a tumour
so far, that you could easily touch it with the finger.   He per-
haps imagined it some great abscess ot the tonsil:  he made, with
what instrument I know not, two long incisions,  each more
than an  inch long, parallel with each other, down through the
very centre of the velum,  and the  same pressure  which thus
extended the velum continuing and  increasing,  has so dilated
the  two incisions, as to prevent them healing : they are to this
day in a state of  suppuration, with red and hardened edges,
though it is full two  months since they were made.
  <*■ Fhe surgeon  said he would  come back and  complete this
operation ;  what he designed next to do  it is difficult to conjec-
ture ; but fortunately for Alexander  Gow,  the operator, while
meditating  upon  the operation,  died, probably from  solacing
himself after hard rides with too strong a cup; and soon after
his  death, Gow came to town  to  have some operation per-
formed."

        NOTES OF  THE OPINION IN THIS CASE OF  GOW.

  " The tumour is big,  distinctly felt behind the velum pendu-
lum, easily grappled with and noosed : the stage of  the disease
is  urgent,  the  pain, deafness, stupor,  and affection  of the
voice, shew the pressure to  be such that  we cannot for one mo-
ment reckon  upon the part continuing  sound, the operation
should be immediately performed."
  The annexed figure is a true drawing of this polypus which  I
found of this size, exceedingly hard and cartilaginous, and so firm,
that a delicate knife might be broken on it, before  it could be di-
vided.  Such is the tumour, which would in former times have
been cut  out, or torn imperfectly away, after cleaving the palate
not partially, as was  done by the Dunkeld surgeon, but entirely.
I extirpated this polypus with a  noose of silver wire,  after the
usual severe  struggle in  passing  and  adjusting the noose ;
whether the point  (a) be that small projection  which was felt
deep within the nostril, I do not know;  but the broad surface
(b), which either implied that this polypus  had not a narrow
pedicle, or  that the  ligature had not been fortunately placed,
alarmed  me.  I was  long without  tidings of this young man,
and  feared lest he had been cut off by a  return ofthe disease ;
but just now, at the distance  of eight years from this operation,
I have recognised him a waiter in a tavern, and in strong health,
and  grown a stout and athletic man. 
464             Of large and guttural Polypi.
   In another case of a boy of fourteen years of age I applied the
ligature with the usual painful struggle, but he bore it well : the
tube for tightening the ligature stood very firm :  he was, on the
4th day, relieved of the tube and ligature, which dropt  away ;
and at the same time, of his deafness and stupor, recovering
with all his natural voice.  But, though I have noosed many
polypi successfully, in  this  I  certainly  failed ;  I imagined I
had noosed both polypi effectually, for both dropt away, and he
was conscious one night of swallowing that one which choaked
the fauces ; but either the polypus projecting forwards into the
nostril, had in part escaped ; or, from the ligature embracing
both, they had been imperfectly  compressed : or there had
lurked behind them a third polypus, which indeed I conceive to
be the most likely conjecture ; but the disease actually returned,
in a  few  months he came  back to me with a  voice as much
affected, and the guttural part of the polypus as bulky as at first.
Though mortified, I was not discouraged by my ill success, but
addressed  myself again  to the business,  and noosed this new
tumour,  taking every precaution to carry the ligature quite up
to the root, and I am confident  this boy  was, by this second
operation,  perfectly cured, I saw him grow a fine stout yroung
man,  and I must have been his sole resource had the disease
returned a third time, for the operation was bloodless, not at all
alarming,  and  little painful, and his relief perfect.  When I
operated on this polypus I supposed there was but one root to
both  tumours, but I have since changed my opinion on this sub- 
Of large and guttural Polypi.             465
ject, and  am  persuaded that, wherever there are two or more
polypi, they are distinct in their roots, as in their bodies.  This
was just Gow's polypus in embryo, and I  speak of it to you as
an example of two polypi; and a warning  of  the unlooked-for
disappointments you will have to brook, if you are engaged in
this line of practice.
                        SECTION III.

            Ofthe third and last stage of Polypus.

  The last and fatal stage of this disorder you  will know even
at sight by strong and characteristic marks ;  by  the humid half-
closed eye, moving slowly and half drowned in water ; by the
snuffling voice, the total deafness, the stupor and  languor, ap-
proaching  to apoplectic, the distorted  nose, and  pallid trans
parent  wax-like face ;  while the loose  nasal bones, and puffy-
cheek, denote the incurable stage of the disease  ; the puffy inte-
guments and«softened bones, and fetid matter running from the
nose,  prove  that all you have in your power to do by an ope-
ration is to save the patient for a little while from dying of hae-
morrhagy.
  " When first I visited Mr. Cameron, his whole form and
countenance and  state of suffering  struck me: he was a fine
young man, about 25 years of age,  tall, athletic, and had been
noted  for  his strength  in all kinds  of exercise and  feats  of
strength.   His form was emaciated, his face deadly pale,  with
a ghastly transparency of skin, which gave his countenance the
appearance of modelled wax, this proceeded from  the frequent
loss of blood.   There  was a remarkable torpor and heaviness
in the  eyes, which  were  half closed ; for haemorrhagy brings
on a languor  and sleepiness which,  in a case  like this, is in-
creased by an actual disorder of the brain.   His nose was in-
clined much  to one side, and his  face greatly deformed, not
merely  by the rising of the cheek-bone, and the  dilatation of the
nostril, but from the swelling of the whole of the right side of
the head, which seemed universally enlarged.   The right eye
was turned obliquely  in its socket,  and almost closed ; a large
andvmassive branch of polypus projected from the right nostril;
and looking into the  throat, I saw the soft palate pressed for-
wards by a second polypus as big as  the fist; from continual
pain of the caries, the  tears  streamed unceasingly down his
cheek, so that he saw confusedly ; the saliva flowed continually
from his mouth, and involuntarily, while a foul, black,  and cor-
roding  sanies, distilled from trie nostril, and  excoriated and 
466             Of large and guttural Polypi.
swelled the upper lip.   He  said his head was  continually tor-
tured, as if squeezed from temple to temple in  an iron vice.—
He sat pale as a spectre, hanging over  the  fire,  though in the
hottest season of the year, his knees almost touching the grate,
resting his head upon his hand, and waving it  to and fro with
continual  agony,  moaning and complaining.   His visage was
pale, his  lips bloodless, and  every thing about  him  denoted
despair,  and  the most  perfect  indifference about life.   He
was so  deaf  as to  be  nearly  insensible to  noise ; you could
scarcely make him understand you, even when  you halloed
in his ear ; he was unconscious when any one entered the
room,  or shut the  door; his teeth were loose on the affected
side, and some had  dropped from their sockets; he was able to
swallow liquids only,  and,  partly  from this cause, but rather
from  despair, he  refused all sustenance, drank  only  water to
slake his  thirst, and to every  kind or  encouraging expression
he always replied, "Heknew he could not be cured, he wished
he could die."
  " At the distance of two  years from  the commencement of
his complaint, this poor man requested my assistance in circum-
stances altogether desperate, when little could be  done, even to
prolong life, where to save it nothing but a miracle could avail.
I was induced by his earnest and  imploring manner to do what-
ever was in my power, and, encouraged by this reflection, that,
in such desperate circumstances, every  partial success, though
it seems simply to  prolong  life,  is followed  by an interval of
tranquillity and hope; and by  this  rule and feeling I shall
always be guided,  doing as I would be done  by, persevering
always even after all hope is over, if conscious  that I am doing
no direct injury.   I have told you how he was  exhausted by-
suffering, how distracted with pain, how overcome with stupor,
except in the moment  of violent suffering, and  when I tell you
that, upon the slightest intimation, that  the prospect of saving
him was very small by an operation, he refused food, I repre-
sent in one word his despair.   The haemorrhage was particu-
larly terrifying ; and he obtained a promise  ot me, that,  upon
the first return of it, I should  introduce the plugs to arrest it:
from this moment I  was entirely embarked in a desperate
cause;  when the  haemorrhagy  returned, which it  did with
violence, and at midnight,  I  passed a ligature  and drew  up
plugs from the throat to the back of the nostril,  and  thus pre-
vented him actually expiring,  for he was now too far exhausted
to bear loss of blood.
   " I now called a full consultation,  and was not merely per-
mitted but advised, at  his request, to try every  method: I pro-
ceeded by passing a wire through the nostril, and  drawing it 
Of large and guttural Polypi.            467
from the throat  into  the  mouth, to noose  the  main tumour,
which was bulky, depressed the palate to right angles, was very
visible in the throat, and felt,  while I "grappled with it, as bulky
as the  fist.   The tube which I used lor tightening this noose,
stood out from his nostril very stiff,  having a very firm hold:  I
had also been careful to include a polypus which hung down in
the nostril, and thence  expected after the operation of the liga-
ture,  that the passages should be  tolerably clear.   The tube
continued rigid and very firm for five days;  he had in the very
moment of tightening the wire, and for several days,  a poignant
excruciating pain, in all that side of the head, but especially in
the teeth and ear;  the matter flowed, blacker, and more fetid,
discolouring the wire  and the tube.   On the fourth  day the
wire slackened, and the tube could be  moved a little from side
to side, I therefore drew the  wire tighter:  on the fdth he was
suddenly  restored to  his hearing, he was  sensible of swallowing
the tumour, the wire dropped off, his pains vanished, he swal-
lowed  easily,  and he  was so elated with hope and confidence,
that he ate heartily, drank his wine, took exercise abroad, and
felt assured  of what no prudent man  could promise, an abso-
lute cure.
   " This was the period,  in  which having made way into the
nostrils so as to operate freely, I should  have searched  boldly
with my  finger,  introduced my knives,  forceps, and  caustics,
and resolutely extirpated the  branches, and roots ofthe polypi;
if I was  guilty  of any dereliction  of duty, it was from no sel-
fish nor trivial motive ; this was a case so desperate in all res-
pects, with a stupor so manifestly implying an affection  of the
brain, that I was afraid of causing inflammation and sudden
death ; if at my next operation I was more resolu'-e, it was from
despair, joined to the earnest entreaties of the patient.   In less
than a fortnight I felt the tumour from the nose  rising again ;
at this  time, restored to strength,  and spirits, and  the  nostril
open,  he  could blow through it so freely, as to dash out the foul
matter and blood with  great  force, and  my  fingers  could pass
deep into it.    There  was no sensinle tumour in  the throat, but
in a little while the nostril was much obstructed ; in  a little lon-
ger, the tumour could be felt  also  in the throat; the haemorr-
hages returned,  so that he  was in danger of sudden death —
His entreaties were renewed,  and  Dr. Monro, Messrs. Wood,
and Harkness, and the other Gentlemen,  met again  in consul-
tation, added to the patient's  wish  of having these attempts re-
newed, and  were  assembled  again the day following, to assist
in the  operation,  but  I could not noose the polypus as at first,
not because of its lesser size, but because when I grappled with
the tumour in the throat,  it recoiled into the nostril; when I 
468             Of large and guttural Polypi.
 resisted this by plunging a finger deep into the dilated nostril,
 and met and resisted the tumour there,  it seemed to recede in-
 to the antrum Highmorianum,  and when I  pursued the now
 moveable  tumour,  with the  finger among the cells, I found,
 to my inexpressible horror, that every bone and bony cavity
 was entirely carious:  the  partition  which divides the  antrum
 from the cavity of the nose was  quite destroyed :  the polypus
 occupied the cavity of the antrum:  the edge of the vomer
 rough, carious, and disengaged from  its cartilage,  met the
 finger,  and  the nasal  branch of the upper maxillary bone was
 rotten: the  polypi felt soft and mucous, and the whole seemed
 to be one mass of corruption.
   " Since our operation was begun, though  it  could, in these
 circumstances, be  nothing but unavailing, still the patient's en-
 treaties, together with  our natural  desire to give  him every
 chance of life prevailed.  To  prepare for this severe operation
 I  passed a ligature by the nostril to the mouth, fixed a plug of
 lint to it, kept it ready to be drawn up into the back  nostril, in
 case of haemorrhagy, which our patient could ill bear, introdu-
 ced then the forceps, and catched at whatever branches of po-
 lypus were within my reach ; turned the instruments in every
 direction,  and  cleared  the  nostril by  every means, however
 rude, and  indeed so cleared it that he could blow freely, and
 dash out a clot of blood, mixed  with fragments of mangled po-
 lypus, to a great distance, and without permitting him to lose
 even one ounce of blood, which indeed he could not  have en-
 dured ;  I  drew up the plug, and made all close.  In three days
 the plugs were removed,* the nostril  was in full suppuration,
 and the passages seemingly clear.
   "But the same,  or another polypus, soon appeared, small
 in the nostril, more considerable in the throat; the  deafness,
 the pains, the loss of voice, and the difficulty of breathing soon
 returned;  and the patient, who, during a short respite,in which
 he had eat,  and drank cheerfully, and recruited his  strength,
 fell again into a state of despair ; and above  all, this fear was
 most distracting to him, that we  should sooner or later abandon
 him to  his  fate.   The polypus had now  attained such a  size,
 that  it was again possible  to noose  it;  and the hcemorrhages
 were  such that he felt distinctly that if nothing was  done for

  * In removing the plug, you firft undo the knot that fecures the anterior plug
 in the noftril; you then flacken the firing, that the pofterior plug may fall down
 towards the throat; if it  do not fall down fpomaneoufly, you pufh againft it by
 pafling a probe through the noftril, holding the firing at the fame time, that the
plug may not  go quite into the fauces: you put in your drefling forceps, catch it
at  the back of the palate, pull it forwards from behind the velum, and having
brought it out of the mouth, you cut the firing in the  noftril, you  thus ex-
trad it. 
Of large and guttural Polypi.            469
 him, he had not many days to live.  The ligature was again
 passed, and the noose  cast over the tumour, and in four or five
 days, when its operation was complete, the  nostril was so clean
 and  at the  same time  so dilated, that I passed the finger, and
 turned  it in every direction with  ease, almost to the throat.__
 But  I may say, my finger was hardly out of the nostril, ere the
 tumour began again to protrude;  and on the 12th or 14th day-
 he had a dreadful hsemorrhagy.
   "  There was now no alternative but death, or the most reso-
 lute  operations :  I had not then learned to use the caustic so
 freely as I now do, and considered the  partial application of the
 caustic as disproportioned to the size and rapid growth of these
 polypi.   I resolved to  burn, with the actual cautery, whatever
 remained  of these polypi; and to give access  freely to their
 roots, I noosed the polypus, the polypus which  presented, and
 cleared the nostril a third time, and had a large cautery, with
 a proper canula,  forged for the occasion.   But it was  now the
 height of summer;  the weather  towards the end of  July  in-
 tensely hot; the  foul and pestilent ichor which excoriated the
 lips outwardly7, passed in such quantities into the throat, that he
 was seized with diarrhoea; shiverings, and fever ensued : then
 a state of stupor and  extreme coldness succeeded ; in five days
 he became  quite insensible,  and after lying three days more in
 a state of complete stupor, accompanied with  slight delirium,
 he expired."
   From this narrative  you will learn how  much more terrible
 this disease is than lues or cancer : for, with all that is loath-
 some or painful, in those diseases, it is  attended with haemorr-
 hages, stupor, a confusion  of head, and affection of  the brain,
 which I  have always  observed, is more than hectic or haemorr-
 hagy, the immediate cause of death.
  Since  I have represented almost every other  form and stage
 of the disease, let me  represent this also,  of delirium and in-
 flamed brain, brought on by a rash and ill-timed working with
 forceps.
   I have often found the polypus  advanced to its last  stage of
 caries, and external abscess, even in the sixth month after it
 was first observed;  if not  actually in the  sixth month of its
 growth,  and fatal within  the  year.   So it was in the good
 woman,  whose death I  am now going to describe : in her case
 indeed it would have  been so, although no such rude  operation,
 as that I am now going to speak of, had been performed.
  " G. T. a good woman of forty-five years  of age, was afflict-
 ed with polypus,  which had long obstructed her breathing : for
half a year or more, the right nostril had been impervious ; dur-
ing the three succeeding months she had been deaf, and torpid : 
470             Of large and guttural Polypi.
the tears flowed continually over her cheek, and the tooth-achy
and rending pains of the face  and head, became at times dis-
tracting.   The right nostril was filled  manifestly, with a soft
and mucous polypus, the eye watery and inflamed ; the cheek
suppurated and burst, near the canthus  of the eye; the whole
side ofthe head was pained, the cheek  and jaws  swelled,  soft,
inelastic, and  doughy; a  purulent and thick  matter flowed
from  the suppurated  parts, at  the inner canthus ot  the eye ;
while a thin and fetid matter distilled from the nostril, and ex-
coriated the Up-  Her general head-ach was  aggravated by a
more pungent,  and tooth-achy pain  in  the nose  and jaw :  yet
she seemed hale, and vigorous;  and there appeared no reason
to fear such a sudden or dreadful catastrophe from any opera-
tion, however rude ; let this case then, be a warning to you.
   " A  consultation decided that an operation  was advisable,
and it was performed by the forceps.   To my apprehension, no
polypus was extracted: little rags,  of a soft  and mucous  mat-
ter, seemed to be squeezed by the forceps into a  mere jelly: the
forceps were used for twenty minutes,  with no great delicacy ;
a small piece of bone was found among these  rags of the poly-
pus ; there was not even  any remarkable haemorrhagy : when
invited by one of the attendents to look into the  largest portion
of the  polypus, I found it no other than a roll  of lint' soaked
with blood.  She was  reported to  breathe more easily through
the nostrils, but for that slight and momentary relief she paid a
dear forfeit.
   " On the day following  the operation, her pulse rose ; there
were manifest signs of an increasing pain ; the pain shot through
 all her head ;  she was hot, and thirsty, with  a small and rapid
 pulse ; her anodyne draught produced no pleasant nor refresh-
 ing sleep.                        _
   " On the second day, the  nostril, the face,  and eyes, were
 extremely painful, and the shooting pains and confusion of head
 increased ; but all  this inflammation was.internal, (not the less
 dang  rous for being so,) the eye and cheek were little apparent-
 ly am cte d.
    " On the third day, the heat, thirst, rapid pulse, and general
 disorder within the head, were alarmingly increased.  The sa-
 line draughts,  the shaving of the head, and the poultice in which
 the whole face was involved, availed nothing.
    " On the fourth day, at nine in the morning,  she was found
 insensible, and remained so ;  the pupils of the eyes dilated,  the
 breathing slow, and  stertorous, and the bladder paraly tic,  so
 that the urine  needed to be drawn  off with a catheter.
    " On the fifth day, she  lay in a  deep apoplectic stupor, had
 no stool, passed no urine, was visibly sinking; a blbter applied 
Of large and guttural Polypi.            471
to the head had its effect;  the sinapisms also inflamed the soles
of the feet, but she could not swallow.
   " On the sixth day she continued comatose, sunk  gradually
during the night, and expired before morning : and upon dissect-
ing the  head,  the polypus was found  a mere  pulp  of  putrid
flesh: the  ethmoid bone destroyed on the right side, and the
vessels of the brain were  found turgid with blood ;  its  upper
surfaces suffused with water, and its lower surface in a state of
suppuration.  Here are the terms in which the appearances, on
dissection, were noted down."

                       DISSECTION.

   " Upon removing the scull-cap,  the sinuses and arteries of
the dura mater  seemed  to be unusually turgid with  blood :
when the dura  mater was cut and turned aside, those of the
brain were found to be extremely turgid with blood: over the
right hemisphere of the brain, there was an effusion of coagu-
lable lymph ; on the left side the effusion was merely of serum ;
the ventricles were much distended with water : the same effu-
sions of serum, and coagulable lymph were found upon the lower
surface also ofthe brain, and there the dura mater was manifest-
ly inflamed.   The cribriform plate  of the ethmoid  bone was
gone, being entirely destroyed  by caries.  The bon^s   of the
right side of  the nose seemed all loose and carious ;  but all be-
low the ethmoid bone within the nose, was an indistinct mass of
putrid and mucous flesh and bone."

   Having thus set before you many lessons, and some  exam-
ples, and proved what I have  described, by true drawings, and
illustrated the operations I recommend to you by'plans ;  I leave
you to your  own discretion, sense,  and judgment, reminding
you only, that this like every tumour, should be resisted at an
early  period of its growth : that these are not maladies to be cur-
ed by gentle  and trivial.practices. 
( 472 )
DISCOURSE  XXIV.
      On Tumours ofthe Gums, Lips, Cheeks, and Throat.

r-tr%
 1 HIS is, in every sense, an arduous subject;  ^specially if it
was my design, to reconcile every appearance of disease in those
parts, with their complicated  and curious structure :  parts in
perpetual motion,  parts  performing a variety of functions,  as
chewing,  swallowing,  speaking,  breathing : parts provided
with various  glands, salivary,  and lymphatic:  and secreting
even from their surfaces, fluids  of various properties.   Surely
such complicated structure must be a  source of various disor-
ders ; for always in the animal body, as in less perfect machines
of human invention, no  part is  so formed as to  serve various
purposes, and to perform many functions perfectly.  Reasoning
from the complicated and intricate functions  and structure  of
these parts, you would find cause to believe, that their diseases
must be very anomalous; observing, on  the  other hand, the
strange  tumours,  obstructions,  and unnatural communications
of one part with another, you would be inclined, as every one
unacquainted with our  science is accustomed  indeed to infer,
that the complex structure ofthe  parts about the throat and jaws,
is the  source of much danger and misery.
  This  confused impression of  complex  structure, and propor-
tioned danger, was all that struck me when first I  entered on
my more mature and serious studies ; without a  hope of ever
arriving at any satisfactory knowledge  of subjects  so  slightly-
mentioned in books.  But time and diligende have enabled me
to do something for myself, and sometb/ng for you.   If you
find in this Discourse no pleasing and delusive speculation, you
will, I trust,  find  many useful precedents,  and  such  accurate
dissections,  and summary histories of diseases,  as  will induce
you to be studious, and help to make you superiorly useful.
  When we can distinctly perceive, that it is from something
peculiar in the structure of a part that diseases are frequent and
complicated, precedents are very precious ;  for we are irresisti-
bly inclined to reason on  the cause of such organic disease : and
it is  only under the correction  of plain  facts and dissections,
that we can reason safely.
   I  must acknowledge,  while I can no way explain the fact,
that the gums, lips, and inner surface of the cheeks, parts seem-
ingly  insensible and indolent,  give rise to tumours which are 
On  Tumours ofthe Gums, £sfc.           47 Z
 indeed slow,  firm, indolent,  and void of pain in their early sta-
 ges, but in their latter stages, of unparalleled malignity, assu-
 ming usually  a  fungous form; and, when the firm and indolent
 tumour thus bursts out into a fungous efflorescence, its growth
 is so rapid,  that I know nothing to equal it, not even the fun-
 gus  of the brain ! you almost see it grow, and, when extirpated
 partially, it sprouts up again before  the blood of such imprudent
 incisions is dried up.   The tumours of the gums are spongy,
 luxuriant, haemorrhagic, and truly cancerous :  those  lodged
 within the substance ofthe cheek, knotty, indolent, slow, malig-
 nant, and, however long they are  of showing their malignant
 nature, they terminate, if  neglected, (and much it is to be la-
 mented, that, from the patient's fears, and the  surgeon's timi-
 dity, they often are so,) in  the  most incurable and desperate
 maladies.
   The gums  are subject to such an  infinite variety of slighter
swellings, to  boils, to little  indolent tumours resembling the
hordeoli,  or tumours of the eye-lid, and  to harmless  indura-
tions, that those which are the  germs of the most horrible dis-
eases, are too  little suspicious, too slightly characterised by any
peculiarity of  form or aspect  to attract attention, till too late.—=
A small, firm, seed-like tumour is perceived, but hardly noticed,
for months ; it is seated between two of the fore teeth,  begins
to separate,  displace and loosen them ; it grows imperceptibly
and  slowly : the teeth are raised from  their sockets;  they be-
come loose  and vaccinating ; they have no longer any hold of
the jaw, but  are merely  hanging  in the tumour ; the tumour
retains its original gristly hardness  at its basis, becomes rugged
and irregular  in its upper part,  with a cock's-comb-like edge :
though little painful,  it bleeds from  time to  time ; it extends
itself to the  gums ot other teeth, whieh are successively displa-
ced from their sockets and  loosened, and one side ofthe mouth
is occupied with it. Next the hard  basis ofthe tumour extends
into  the cheek ;  the tongue begins to be pushed aside,  horrible
 fetor of the mouth ensues, with  frequent  haemorrhages ; the
tumour now protrudes and keeps the mouth open  ; the disease
becomes now  terrible  and painful, the patient survives for a few
weeks,  with the mouth and lower part of the face wrapped up
 in handkerchiefs, in a miserable and  loathsome  condition ; the
putrid and  blackened  blood distilling  with the  acrid saliva
through the fihhv clothes, till wasted by suffering he  dies in
inexpressible  pain.   Such  is the kind of death, from which,  I
sincerely believe I have saved many by a slight incision.
   "  A young Gentleman,  Mr.  H----,  about 25  years of age,
of an athletic form and healthy constitution, and  without the
slightest taint of disease, hereditary or acquired, had,  from no 
474              On Tumours of the Gums,
perceptible cause,  a tumour firm,  cartilaginous, and  elastic,
seated so fairly in the  centre of the  gums, as to raise the two
centre teeth of the lower jaw from their sockets far above the
general  range of the teeth, and separate the two that lay adja-
cent.  Gradually, but yet in a short  period, in a little more
than  three months, it had separated  those two central teeth,
projected from betwixt them, and increased to a very remarka-
ble size  ; and, though it had begun from the inside gum, the
greater portion seemed to be before the gum, just over the chin,
projecting the nether lip.
   " This tumour was about the size of a walnut, irregularly glo-
bular, knobby, and shining; when moved by pressing it with the
thumbs,  backwards and forwards,  it  seemed firm, fixed, and
actually a tumour of the jaw-bone ; yet I knew it by its  smooth
rounded form and its  elasticity to be a tumour of the gum.  It
felt,  when pressed between  the finger and thumb, so elastic,
that  a tyro must have  believed it to  contain a fluid, while I
knew it to be in truth a solid tumour, neither suppurated, nor
capable of suppuration.  Its general aspect was that of a  tumour
so indolent, that nothing need be dreaded  from it, and so much
had it the form of one that might contain matter, than an unskil-
ful surgeon might have  been induced to  strike  his lancet into
it; but I was well aware, that not a drop of matter would follow
any puncture made into it, that the tumour inflaming, would
turn out its edges, spread into a fungus, and,  in a few months,
cause a horrible and melancholy death.
   " Dr. Munro, Mr. Allen, and myself, having consulted on
the nature of  this tumour ; judging by the analogy of former
cases, declared it to be of a most  dangerous nature ; it had
already  displaced the teeth, probably  injured the alveolar pro-
cess of  the jaw-bone, attained to an alarming size, and threat-
ened, in no long period  of time, to assume the most malignant
possible form :  we explained to our patient, that it  contained
no matter, was incapable of suppuration, was of a size that for-
bid all hopes of  resolution, was sure to become cancerous, ad-
mitted of no delay, and we explained, that we dared not, even
in its  first and  least alarming stage, do  less  than extirpate  it
from  the very root: we represented,  the operation was harsh
but not tedious,  void of danger, even of haemorrhagy.  That
nothing was to be feared but the not cutting it completely out.
   " In preparing for such an operation, it is right to have ready
the apparatus of a dentist, especially forceps to twist  out the
teeth, strong pincers to cut  the solid gums, engravers' knives
to cut away whatever is  corrupted of the jaw-bone, and pieces
of dry and solid sponge, to thrust  down into the void left by
extirpating the tumour,  in order to  prevent haemorrhagy ; and 
Lips, Cheeks and Throat.
415
 two things the surgeon  must be  prepared to encounter, great
 difficulty in cutting the tumour, and  such confusion from the
 mouth filling, like a cup, with blood, that, after the first stroke,
 he can see nothing of what he does, but must proceed by feel-
 ing.   The surgeon has much reason to fear that,  in an opera-
 tion where his  view of the incisions is so  obscured, he will be
 guilty of much  unseemly mangling and tearing;  yet the pain
 of such an operation, however  rudely performed, is nothing
 to  be compared with that of pulling  out a rotten stump, and
 the motives infinitely more persuasive than a tooth-ach.
   " In performing this  operation, I held the jaw-bone  firm
 with the  fingers and thumb  of  my left hand, while my assist-
 ant  inverted the  lower  lip,  and^ with  a scalpel of  special
 strength, broad-backed like a cartilage knife,  I made the in-
 cision in such a form as to resemble the letter V, or the Greek
 delta.   The knife was carried by the  side of each of the dis-
 placed teeth; all my  strength of hand  was requisite to carry
 the knife down  to the angle ; blood instantly filled the  mouth,
 so that, after the first stroke of the knife, every thing was done
 by feeling ; but  I cut with such decision, with such level lines,
 and made them so fairly  meet each other  in the angle, that, by
 pressing my  two thumbs, one within  side of the  tumour, the
 other without, and pushing alternately with my  thumbs, and
 poising with the flat handle of  the scalpel, I  pushed the tu-
 mour out, clean and unmangled, leaving a very wide opening
 bounded by the  fangs of the  adjacent  teeth ; and,  after allow-
 ing the  part to  bleed till it stopped, I laid a piece  of sponge in
 the deep triangular cleft made by the operation,  and closing the
 upper  range  of teeth upon the sponge, their pressure kept it in
 its  place.  This sponge was removed  the second day ;  simple
 dressings of dry lint rolled in the  shape of a pellet was substi-
 tuted for the sponge ; during eight or ten days our patient ate
 cautiously, and, in little  more than ten days, the  incision  was
 completely healed.
  " I  was greatly interested in knowing the internal state ofthe
 tumour in this stage ;  for I regarded this small tumour as the
 germ  of that terrible disease, which I knew so well by experi-
 ence, for which  I had operated  sometimes successfully, some-
 times at  so late a period as only  to witness, perhaps to accele-
 rate, its fatal Catastrophe.   There had, upon making the incision
by the side of one of the teeth, appeared a  little matter, but so
very little as hardly to be perceptible  in the time of a bloody
incision, and not at all  to diminish the size of the tumour;  but
whether there was any fluid, purulent or gelatinous in the cen-
tre was still doubtful.   In the central parts  were small cavities,
and, when they were cut vertically,  a gelatinous substance 
476              On Tumours of the Gums.
oozed  out.  The internal surfaces were studded  with small
grains like millet seed: the thickness and cartilaginous texture
ofthe coat of this tumour formed by the gums,  shews that the
matter would have been long in making its way through them ;
its gelatinous nature proves that the cavity would not have clos-
ed ;  the irregular surface studded with small grains of a glan-
dular nature, explains to us how such a  tumour, after bursting,
turns inside out,  and degenerates  into a  granulated  mass  of
fungus, sprouting in  berry-like knobs,  and little masses of vas-
cular granulation. Whatever cavity there is in a tumour of this
solid consistence, seems to me like a calix ready to burst, and
turn out its  inner surface, with a new  and luxuriant growth  of
fungus.  The dissection of such a tumour, having fleshy walls
and  granulated internal surfaces, always reminds me of the im-
prudence of partial incisions, in consequence of which a part
of the walls of the tumour being left, the worst part ol  the dis-
ease is  left: a fungus sprouting  up  from the bottom of the
wound, is  the first  intimation of the  disease being imperfect-
ly extirpated, a rapid growth, hatmorrbagy, pain,  and, in one
word,  cancer ensues :  and these  are  as invariably  the conse-
quences of striking a lancet  into such a tumour, as of imperfect
and  ill-concerted operations.
   " This gentleman is perfectly cured, the gums and  adjacent
teeth firm  and sound,  and I confess I could not reflect on the
structure of this small  tumour, without saying  within  myself,
what would  have  been  the state of  this tumour  in  three
months i What would have  been his condition in six or eight ?
In its second  stage, in little more than three  months, it must
have filled the mouth with a fetid bleeding fungus!  In  eight or
ten  months it must have assumed the  perfect character of incu-
rable, loathsome cancer."
   It appears to me  that, in  many  cases which I have been in-
volved in,  the disease appeared in a more  insidious form, no
circumscribed tumour, no formal disease awakening the attention
of the patient, preceded the fungus; no suppurated cavity  open-
ed,  and turned its diseased surface out, in form of fungus ; but
the  mere  separation of the  gums from  the teeth, and  alveolar
process ofthe jaw, had the same effect, for this is the description
of what I have frequently seen, and it  is exemplified in  the fol-
lowing case of a young woman who, I fear, never recovered.—
 In this girl, not more than  twenty years of age,  the gums of
 one or more teeth became sp< ngy and rose in jagged points, se-
parating from the teeth : the  roots of these diseased parts ofthe
gum became  hard and  tumid, in  proportion as their jagged
 points  became more soft and luxuriant; the  disease spread
 from gum to  gum, till it extended along the whole range of 
Lips, Cheeks and Throat.               477
the jaw; the whole substance ofthe gums became thus spongy,
thick, and fleshy, rising into the form of  a tumour, of  a deep
red or liver-colour, with a hard and scfnrrous basis, a bleeding
surface,  and cock's-comb-like  edges ; haemorrhages burst fre-
quently from the general tumour, while a viscid and extremely
fetid matter  issued from about  the  roots of the  teeth.  '\ his
tumour was so vascular, that the teeth, though poised  from the
sockets,  and universally loose and  vaccillating,  were  almost
buried in it, and strong bridles of flesh extended across, from
that which was external to that which was  internal, in  regard to
the range of teeth, through their interstices.   To look into the
mouth, you would imagine you saw it  occupied  totally with a
very solid tumour; when you pressed it  with the fingers,  you
found it spongy and soft ; when you  tried  it with the probe you,
found it a mere tissue of vessels, through which you could push
the blunt point of it in  every direction; when  you  felt for the
alveolar  process with the probe, you were conscious  that  the
bone was carious.  By the general aspect of such a tumour  you
would be deceived, for  you would imagine it, especially in its
early stage,  to be nothing worse than a spongy  intumescence of
the gums, which you might successfully clear away  with a scal-
pel, or  almost scrape off  with a spoon, while  it  is, in truth, a
tumour so  malignant, that I have myself performed,  and seen
others perform, very painful and very unsuccessful  operations.
It is one of  a character so peculiar, that I  know nothing but  a
careful and  early extirpation of it that will prevent  mischief in
its latter stage, nor any  thing but a fair, open, and candid prog-
nosis can protect the surgeon from obloquy:  be assured, that
when far advanced, it is unsubduable by the knife, cauteries, or
caustic ; I have seen it, after long continued and  cruel cauteri-
zing, grow for three months, the patient being  permitted to re-
tire from this torturing process to the country, only when hope-
less and desperate, there to die unobserved.
   The case which I am now to relate to you, is  one which
was confided to my care too late to serve any other end, than as
a melancholy example of the  consequences of leaving such  a
disease to run  its natural course ;  a timely operation might
have preserved this worthy man in health to his family.
   " Mr. Keil, of Monargan,  c/me to town to consult me late in
the month  of  August,  1802, after  a regular  correspondence
with his attending surgeons Dr. Stewart and  Mr.  Nimmo---
Though past the prime of life, he was a stout and  lusty man,
healthy, laborious, and active.   His whole mouth was filled
with a fungous tumour of the  worst complexion, wanting no
character of cancer, but that it was void  of pain ; from imper-
ceptible beginnings, and by very slow degrees, it had increased 
 478              On Tumours ofthe Gums.

to such a size as to fill the whole  mouth, press the tongue en-
tirely to one side : his speech  was  embarrassed, and his swal-
lowing difficult and painful, for he could  no longer close his
mouth  correctly, the tumour  beginning to protrude.   The tu-
mour was of a deep red colour, irregular, and  ragged on its
 surface, luxuriant, and of such  rapid growth,  that,  in  a few
 months, it had attained this horrible  form: it projected from
his mouth, kept his teeth separate, raised  those  of the  lower
jaw from their sockets, so that they  (all those at least of the
right side of the mouth) stood high above the range of the ad-
joining teeth, and entirely loose, so loose that  they could be
picked  out with the fingers, and some of them were picked
away with the fingers before the  incisions were  begun.   The
 tumour was void of stinging or lancinating pains, no rude pres-
 sure of the fingers excited any but the ordinary sensation ;  it
was soft,  spongy, and bleeding in  its extremities, or cock's-
comb-like  edges, solid and fleshy in its middle parts, and bul-
ging and firm as  bone itself where it rose from  the jaw-bone:
it was neither on account of pain, dangerous haemorrhagy, nor
fetid ulceration, that  the patient was now thoroughly alarmed,
but by the rapid growth and horrible form of the tumour; and,
from the increasing obstruction in speaking and swallowing, he
was conscious that he  could not live, and desirous of any ope-
 ration  that might give him even a chance of  surviving, ft>r he
 was satisfied, there being no blood-vessels, nor other dangerous
 parts in the vicinity of this tumour, that the operation, though
 painful, could not be dangerous."

              Opinion on  Mr. Keil's  Case.

   " Mr. Keil cannot have witnessed the doubts  and difficulties
 of his attending surgeons, without being aware  of that imminent
 danger, which it falls  to my lot to  announce  to him:  and my
 duty and conscience  equally incline me, to declare it  without
 loss of time, and  without reserve.   A tumour  so  unusually
 rapid in its growth, cannot cease to  grow,  but  must continue to
 extend the disease by increasing the caries of the jaw-bone, and
 propagating  the morbid action among the surrounding parts:
 the hardened basis ofthe fungus will soon spread  into the cheek;
 abscess, and indurations  of the  lymphatic glands will ensue,
 each ulcer will throw out its fungous efflorescence, and the dis-
 ease will burst out  upon the face and angle of the jaw, with all
 the  virulence, and more than  the deformity of real cancer ;
 this resembles in its  form that fatal fungus which sometimes
 sprouts from   the  axilla, after amputation of a  cancerous
 breast, or that which still more frequently proceeds from the 
Lips, Cheeks, and Throat.              479
spermatic chord, after extirpation of the schirrous testicle, and
which no methods,  even the most severe and rude in surgery7,
have ever been known to subdue.
  " I am of opinion that, though not accompanied  with pain,
nor as yet with much fetor, nor with profuse bleeding, nor bear-
ing the precise character of cancer, this tumour is equally incura-
ble except by the knife, and sure to prove fatal if neglected, (as
I fear it has already been neglected,) too long.  When I speak
in favour of an operation, I must do so with a degree of reserve:
I wish I might  propose  it as a sure resource, but the difficul-
ties, and the  chances of success are so equally balanced, that
he would, in my mind,  be  an inconsiderate and presumptuous
man, who would, in  these  circumstances, confidently promise
a cure ; but he would, on the other,  hand be inhuman and  sel-
fish in the extreme, who, for  fear of any reproach that might
attach to his own reputation,  would refuse our patient the only
remaining chance  of life and health.   The terrible stage of
ulceration, protrusion, and haemorrhagy, and probably of pain,
which is soon to ensue ;  the loathsome and miserable condition,
which is inevitably approaching,  would  be more grievous to his
friends, if, from  any  want of  constancy, we should decline  our
help; and they will  feel, at  some future period, a degree of
self-reproach for any present loss of time.   But I am beginning
to reason on moral  feelings and duties,  which belong to  others,
when I am expected, perhaps, to deliver only my opinion oa
the medical import ofthe case.   I have, in the previous part of
this letter, explained the grounds of this opinion,  with unaffect-
ed deference to the judgment of these professional gentlemen,
who, having seen the beginnings, and  watched the progress of
this disease, have had time to  reflect seriously on its nature and
consequences.   I advise the operation, and, should this be your
opinion also,  and the wish of our patient and his friends, shall
be ready to perform it,—the best proof I can give of the sincer-
ity of my opinion."
   This Gentleman, conscious of his impending fate, advised by
his surgeons, that this  was  the only  chance  he had for  life,
without concealing that it was but a slender chance, gave his
consent, and became  every moment more anxious that it should
be done quickly ;  but so critical was his  situation, that before
the necessary arrangements were completed, a gland at  the an-
gle of the jaw had swelled, an abscess there was distinctly per-
ceived, the  hard basis of the tumour  had run deep into  the
cheek,  and, at  this  most inauspicious moment, when  every-
thing  had assumed the most unfavourable aspect possible, the
importunity of the  patient, and his friends, became very  great, 
480               On Tumours ofthe Gums.
 and I received repeated notes from Mr. Nimmo requesting and
 urging me to come.
   Nothing can be more unpleasant to a surgeon, who has any
 pretensions to skill,  than  an operation necessary,  mangling,
 cruel, and savage in appearance, performed within the mouth,
 beyond the sight of the assistants, and  where even the long in-
 cisions must be guided by the finger, where the dissection must
 be irregular, and  the whole must  be done blindfold,  from the
 blood with which the mouth  is filled ;  where the best surgeon
 can hardly say he is sure of what he has  done, nor confidently
 think he has  cut away the whole disease.  The operation  in
 this case consisted, first, in picking away some of the  loose
 teeth which lay in the way of the dissection : secondly, in a te-
 dious and painful dissection, by which the tail, as I  may ex-
 press it, or a  prolonged and firm part of  the tumour, which
 connected itself with  the cheek,  was separated from  its  inner
 surface, near the  angle of the jaw, and dissected down nearly
 to the chin ; the cheek being reduced in all  this  extent to ex-
 treme thinness :  thirdly, in a long and direct incision guided by
 the finger,  which  separated  the firmest part or basis  of the tu-
 mour,  from the  whole length of the jaw-bone, from the  angle
 all round past the  chin, and nearly to the canine teeth of the left
 side, where alone the  gum remained sound.   Fourthly,  in
 carrying a like incision, more dangerous  by far in point of hae-
 morrhagy, round  the opposite or inner surface  of the jaw-bone :
fifthly,  in dissecting away the tumour from the jaw-bone, from
 the side of the tongue, and from the whole circle of the mouth,
 a work  not accomplished without frequent interruptions  from
 haemorrhagy, irregular, and  which was performed by  incisions
 rude and mangling :  and, finally, all the teeth of the  right side
 of the lower jaw  were twisted away  with the tumour, and the
 bone scraped clear of all remains of the fungus, down to .that
 decided line, of incision, by which the root ot the tumour was
 separated.
   I need not  say how careful I  was to make the extirpation
 complete ;  or how much I risked in dissecting the cheek,  so  as
 to leave  merely the thickness of the skin, not without a  thou-
 sand anxieties and fears, lest it should slough off.  I left this
 gentleman, on the third day,  under the care of Dr. Stewart and
 Mr Nimmo,  and am  sure that never were assistants more care-
 ful of their patient, nor more sincerly interested in the success
 of another; his pastor, Mr.  Smith, took upon him,  with the
 most charitable  disposition,  every  little arrangement, nursed
 him, and watched him.  The part exhibited a promising appear-
 ance at one period, but a dismal, though  not unexpected re- 
Lips, Cheeks, and Throat.              481
 verse followed, after  a few days of retirement in the country,
 he died in a painful and loathsome condition, with this  terrible
 and fetid fungus, protruding both from the mouth, and through
 the opening of  the gland which had suppurated at the angle of
 the jaw.   Far from being any argument against the early extir-
 pation of tumour, the whole scene struck me as a most melan-
 choly instance of the danger of delay.
   Perhaps it is the peculiar structure ofthe gums, perhaps the
 proximity of the bone, that gives this m llignant complexion to
 these  tumours; for I have  had many occasions of remarking a
 singular contrast betwixt the malignity of these, and th^ir sud-
 den growth, after an imperfect operation; and the indolent na-
 ture of those of the rectum, though  very awkwardly and imper-
 fectly extirpated.   Sometimes, though rarely, I'have found
 long turn mrs,  like polypi, depending from the walls ofthe rec-
 tum, protruding every  time the patient went to stool:  and cre-
 ating inconceivable irksomeness and unnatural pain.    Very of-
 ten I find the folds of the integuments, where they are gather-
 ed and plaited at the opening of the gut, and  the  glands with
 which the rectum is surrounded, growing into ragged tumours;
 sometimes of  a prodigious size,  fungous and  loose  in their
 texture, swelling like a  turkey's gills,  when the  patient strain-
 ed at stool, usually concealed within the rectum, but sometimes
 protruding partially.   But these  tumours, formidable as they
 may  appear,  I have always found of a mild character, void of
 pain, attended only with irritation and  a sense  ot gravitation ;
 but never ulcerating, seldom haemorrhagic, and  bearing to be
 treated by every rough method,  to be tied with ligatures, or
 extirpated with the  knife, or destroyed  by  caustic,  without
 returning.
   The history of such  a disease has so little interesting, so lit-
 tle variety  of circumstances, that even in  the case of a  friend,
 for whom  I had a particular regard, I found, after many an anx-
 ious conversation, nothing to mark but  what I have  found in
 every  case, viz. a tumour slowly forming, indistinctly  perceiv-
 ed at first,  long conceived to be merely  an irritation, unwilling-
 ly recognized as  a tumour,  growing very slowly  to that size
 which requires operation:  protruding at each time of going to
 stool;  but  easily repressed with the finger, like  a mere pro-
lapsus  ofthe rectum, and occasioning, through many years, in
which  the patient was sensible of its existence, no worse  symp-
tom than irritation, and a sense of gravitation.
   " M. D.  a young gentleman of about twenty-five years of
age, had, if not from infancy, at least from the earliest of his
recollection, a  tumour  in  the  rectum, which, every  time  he
went to stool descended, so as to leave a long continued tcries<
                            3P 
t  482               On Tumours ofthe Gums.
mus, with irksome squeezings of the sphincter, and frequent
squirts of urine :  but it was easily repressed with  the  fingers,
after which the strainings ceased.   The tumour was not pain-
ful, but haemorrhages frequently burst from it, though never to
a great excess : it was  manifestly of great length.   The head
or bulky  and dependent part of the tumour is extremely firm,
and  bolts out before the faeces at each time of going to stool;
the stalk or pedicle, is  four inches long, not that  its origin is
that far from the  opening of  the rectum ; for the neck is lax
and  fleshy, and lies, after being pushed back within the gut, in
somewhat of a coiled or convoluted form : when the finger, be-
ing  passed into  the rectum,  is laid along the tumour, a large
nutritious artery  is  felt, distinctly running the whole length of
the tumour, and  beating along the whole  length of the finger,
just as the artery of the testicle is felt running along the sper-
matic chord;  a circumstance, which makes it, if not necessary,
at least desirable, to kill the tumour, by a ligature applied at its
root, and close as  may be to the walls of the rectum.
   " I know no disappointment so provoking, no sense of awk-
wardness  so irritating,  as that of miscarrying in an operation
seemingly so simple as this: yet I confess my sense of awkward-
ness, and want of adroitness, was very unpleasant  to me.  I
confidently expected to apply a noose, with Levret's tube, or
what is  equivalent, the  eyed-probe which I  sometimes use
in tying a polypus ; and it is my duty to make  this  confession
to you, that I endeavoured in vain to apply the ligature, by this
simple operation, to the root of the polypus, and kept my young
friend long under an irritating operation, in a painful posture.
But on these occasions, I have by  me wires, probes, and eyed-
needles of all shapes:  I abandoned the intention of slipping the
noose thus over the pedicle of the tumour : I threaded a long-
eyed needle, mounted on  a  stalk,  with a ligature  of  waxed
thread; I passed into the rectum  a lithotomy  conductor, or
blunt gorget, filled with cork in  its  concavity,  and introducing
the needle, and striking it through the root of the tumour, very
close to the walls of the rectum, I with a  common hook run
along the  face of the cork, picked out the ligature from the eye
of the hook, (a hook like that  is used in aneurism  of the thigh
or ham,) drew it  down, and brought  it out by  the  anus, and
turning it  over the knob, or bulky lower part of the  tumour, re-
tracted it so as to make the loop  strangle the tumour, which
dropt off  in a few days."
   But watery and yet very bulky and protuberant tumours,  en-
circling the whole  verge of the anus,  corresponding in their
form, viz. three, four or  five  tubercles,  with  the  great lurks
or folds in skin, are infinitely more frequent than  tumours with- 
Lips, Cheeks, and Throat.
483
 in  the gut.  Those tumours of the verge of the anus,  though
 bearing  the  most formidable aspect,  rarely  degenerate into
 cancer of the rectum, except in extreme old age, and when irri-
 tated, neglected, or disregarded.   But if any thing can incline
 the disease to cancer, or make it alarming, it is the imperfect
 extirpation of it, or an ungainly attempt  to kill it with ligature.
 Among  other varieties of this tumour, the following instance is
 one which, after being imperfectly  extirpated, grew again in a
 few months to twice its original size ; after this second growth,
 the surgeon, more anxious and more timid from his ill success,
 applied ligatures, by which, far from having strangled or killed,
 he  irritated and inflamed them :  they had suddenly increased
 in size, and he was not a little alarmed,  and doubtful  whether
 to draw  the ligatures firmer, or to extirpate the whole with the
 knife.  The subject was a very hale and vigorous  young man,
 in the prime of  life ;  though the  basis of  the tumour was very
 hard, and the tumours themselves towered to a great height, I
 found all the verge of the anus, down  to  the very circle from
 whence they arose, soft, limber,  and natural, as if no such dis-
ease were even  in its vicinity.   With three or  four strokes of
 the bistoury I extirpated the whole, and cleared the verge of
 the anus entirely of disease, or the seeds of it, so that the young
 man continues now in perfect health ;  but to do  this, I spared
nothing;  I pulled each tumour out with all the strength of  my
 finger and thumb, and cut out along with it that part  of  the
 verge of the anus that belonged to it, muscular as well as cuta-
 neous : to whatever depth the hardness extended I cut, introdu-
 cing the  bistoury quite within the circle of the anus.  Conscious
 that if the operation  should prove  again  unsuccessful,  the lad
 could not escape a miserable death,  I cut away the whole circle
of the anus, and have so often cut away the  whole, or much of
 the circle, without the slightest  ill consequence, that I cannot
 but admire the story related in Keill's Anatomy, which, when I
was a boy struck me with so much  horror;  where, in speaking
 ofthe verge ofthe anus, the case  is  related of one, who having
the whole circle of the anus extirpated for piles, I believe, had
the anus  so constricted,  that he could never after pass  harden-
ed foeces, nor go to stool without a glyster.
  Wherever it becomes necessary to extirpate the whole circle
of the anus,  I have  found  it safe: the  necessity of the case
would vindicate us;  but  experience of the little .inconvenience
it  produces entirely reconciles us.   In another case a tumour
of prodigious  volume, rolled out  lump after lump, every time
 the patient chose to squeeze it down, and  still left great rolls
within the rectum, which could be hooked out with the fingers,
as you would  hook out a poney's  tongue from its mouth, when 
  484-             On Tumours ofthe Gums,

  preparing to  give it a drench.  From such a voluminous tu-
  mour, you may imagine the distress this poor creature suffered.
  He was by natural growth, a big, strong,  and clownish fellow :
  by continual  feeling of sickness  and disease, he was  become
-  sallow,  and  meagre ;  and by  frequent, 1  may  say  incessant,
  diarrhoea, he was greatly reduced in strength    The sense of
  pressure was inseparable from this enormous tumour, whether
  reduced or protuberant; and this tenesmus and straining so in-
  cessant, that twenty times in a day, a  pressure, which he could
  not restrain,  pushed it out: you may easily imagine,  what un-
  ceasing feelings he must have suffered, when so voluminous a
  tumour was  repressed within the gut.
     Yet the character of the tumour was  singular, in  being at-
  tended with not the slightest pain, not a speck of ulceration, and
  little  haemorrhagy ; it  was soft, woolly, lubricous, and  of  a
  shining red like velvet, and  as  smooth, except  in its extreme
  edges, which were toothed, and scolloped, like a cock's comb.
  The whole mass of tumour might measure about thirty inches
  in circumference ;  it belonged to the circle of the verge ofthe
  anus in such a manner, that  that circle was the root ot the dis-
  ease, and the tumour could not be extirpated without the whole
  circle being cut out: and it was so compressible, that when you
  thrust the fore and mid fingers through the centre of the mass,
  into  the  rectum, your knuckles, and almost your  hand, were
  buried in the tumour ;  the tumour receding on each side, and
  allowing you to penetrate as deep with your fingers, as if there
  had been no such disease, and you had the consolation to feel
  from within, that the verge ofthe anus, a very little way  with-
  in the circle was entirely free.   This tumour, by far the largest
  ofthe kind I have ever seen, was extirpated by  ligatures, driven
  through the  verge of the rectum, with a common emboweffing
   needle,  passing it alternately from within outwards,  and  tying
   each stitch,  or  round, as firmly as  the biggest waxed ligature
   could bear to be drawn.  The whole operation was completed
   at once ; the whole of the tumour faded and died at once ; the
   patient was entirely and perfectly delivered of his disease  ; and
   the circle of the anus was entirely extirpated, the patient  never
   complained, nor even  suspected the slightest inconvenience.
     You  remember that I do  not profess to follow any  perfect
   order ; yet, if I did, I know none more natural than to arrange
   with tumours of the gums those of the cheek ; or  to compare
   the diseases of  adjacent  parts, especially  where their constitu-
   tion, form,  surface, and internal texture, their glands,  exha-
   lents, and other  apparatus of secretion,  in short, their  entire
   structure is similar; and where  by a very  allowable inference,
   »-heir diseases may be expected to be allied.  So it is, I believe, 
Lips, Cheeks, and Throat.
485
 with the cheeks and the gums, where the schirrous indurations
 of the early, and the  cancerous excrescences and fungi of the
 latter stages, are so extremely similar, and where there are but
 a few special differences, which are easily described.
   The cheek is a part where no conspicuous gland, (the parotid
 and the socia parotidis excepted,) are known to exist ; and yet
 the tumours I am now to describe, are plainly not  diseases of
 cellular substance, nor of the secreting surface, but assume very
 early,  and always before they arrive at ulceration, a  knobulated
 and glandular  form ; where,  the  first knot or kernel is plainly
 glandular, and where the tumour, when it becomes irregular,
 and threatens  cancer,  plainly is so, being irregular, by the
 spreading of the disease from  gland to gland.  I know no dis-
 ease which I stand more in awe of, and chiefly I fear it from
 these considerations,  that it is rarely  mild or stationary, almost
 always  progressive towards something more alarming ; and
 either the tumour is seated so much in the centre of the cheek,
 and so adheres to the inside membrane, as to make it difficult
 to extirpate it,  for fear of making a large opening there ; or by
 being seated further back, is so entangled with  important ves-
 sels and nerves, as to make the extirpation a matter  too critical
 to be attempted lightly.   This is a disease of the most insidious
 nature, so slow in its growth  that we are, from  its  long dura-
 tion, diverted from any sense of danger ; I have known it ex-
 ist for twenty years, and even from infancy, without assuming
 a threatening  aspect; when all at once, without any sensible
 cause, it has shown  its malignant nature.   While you are en-
 couraging your friend or patient with hopes,  that the  tumour,
 which  he  cannot but think  of at  times  with apprehension, is
 mild in its nature, it grows  suddenly  hard,  reddens, ulcerates,
 and becomes cancerous.  Or  when you have extirpated the tu-
 mour,  and dismissed your patient, confident in his sound condi-
 tion, and  self-contented  in respect to  what you have  done,
 when you have long  forgotten the operation, and the patient,
 and can hardly prevail with yourself to believe that a disease so
 extirpated can return, letters come, announcing  to you that it
 has grown again.  Various inexpressible circumstances, of con-
 sistence, colour,  and form,  intimate to the surgeon the lurking
 danger.  The tumours which I most dread, are those seated
 in the centre of the cheek, deep within its substance, connected
 at once with the inside membrane, and with the skin, not move-
 able, firm,  glandular,  hard in their general substance, and irre-
 gular in their form, knobulated,  and having, as a  sort of centre,
some one or more globular masses, also very  firm, but which,
in place of being hard, have a  sort of  elasticity which gives the
conception of their having cartilaginous walls of extreme thick- 
486
On Tumours ofthe Gums,
ness, containing a small proportion of gelatinous matter.  And
in truth it is so ;  these central globes are found usually to con-
tain a gelatinous fluid : but sometimes, nay frequently, a thick
and gelatinous  blood,  partly  clotted, partly fluid.  Such a tu-
mour is extremely slow in its growth,  but is still growing ; lit-
tle painful, but vet communicating a general sense of tooth-achy
pain, or shooting ; sensibly  aggravated in moist weather,  or
east winds ;  and  it is usually covered with a coarse and granu-
lated skin, very thick and porous, like that of a lemon,  firmly
attached, in a considerable extent, to the surface of the  tumour,
and incorporated, as it were,  with the substance of it;  this ad-
hesion of  the skin is ever a sign of  danger.
  Of such tumours, I shall lay before you various examples,
not uninstructive, with operations sometimes  fortunate,  some-
times unsuccessful : nor shall I be so unmanly  as to conceal
from you the cases in which I have  been unfortunate, especially
where  the ill success may be imputed to  any want of skill or
conduct, for every such avowal must be  invaluable to you.—
No man  can be always  wise, nor  always fortunate ;  he who
pretends to  unvaried success, is either a  knave  or a  fool.   I
take  especially pleasure in laying before you'a case where this
species of tumour was strongly characterized ; where it existed
perhaps from birth,  certainly from early childhood ; where the
operations were such as I could not enter  upon without  reluc-
tance, nor perform without encountering various  difficulties.—
In the first,  I fear, a slight fault on my part proved the  occasion
of great pain, and danger to my patient,  of a weary journey,
and  a second  operation; the  recollection of which, though
painful  to me,  may be useful  to you ; and this  I feel  to  be
the surest way of restoring myself to placid and approving
thoughts.
  " Mr. Taylor, a tall and slender, but strong and active man,
not exceeding thirty years of  age, was afflicted with a  tumour,
which had indeed existed from  his earliest years, but had in-
creased lately with alarming rapidity ; assuming,  at the same
time, so  malignant an aspect, that all those whom he consulted
declared it dangerous, wished that  it might be extirpated, but
declined performing an  operation attended with  so many dif-
ficulties.  In this disturbed and agitated state  of mind, he tra-
velled from  a remote part of Ireland to commit himself  to my
care.  The  indolence of this tumour  from childhood upwards,
its sudden increase of growth, from imprudent and violent ex-
ertions, its hard irregular form, the coarse and porous skin with
which it was covered, the firmness with  which it adhered to
either  surface,  viz. to the skin  of the cheek,  and to the  mem-
brane of the mouth ; the redness it contracted, and the  shooting 
Lips, Cheeks, and Throat.              487
pains which began, towards the latter stage of the disease ; the
manner also in  which  it was consolidated into one substance
with the whole cheek, and the apparent impossibility of extir-
pating it without cutting actually the  cheek itself away, were
circumstances particularly worthy of attention.  This  tumour
he was well assured, had existed, if not from his birth, at  least
from his early infancy, in the  form of a small, firm, kernelly tu-
bercle, seated within the substance of the cheek,  not far  from
the angle of the  nose ; nor can he recollect, during all the peri-
od of his youth, or manhood, any circumstance, either of pain,
swelling, or change of colour,  which called his attention to this
tumour, much less alarmed him.   He had arrived at his  thir-
tieth year,  when suddenly, in  consequence,  of violent exercise,
in very sultry weather, and in the  open air, he observed,  first,
slight  and  transitory  pains in  the  tumour ; but such as never
would have alarmed him, had he not been  wakened from  this
supine and unreflecting state of mind, by a manifest and sudden
increase  of size.  Then  he thought of rubbing the part with
mercurial ointment, and applied to his brother, who is of our
profession, for  his advice.  Then, for the first time, he began
to feel all  the  unhappiness of a man in danger of cancer, and
doubtful whether even the severest operation could afford  him
relief ; and with all  the  agitation  of  one occupied with  such
dismal reflections,  he consulted every one  who was accessible
to him, and still as he passed through the country sought  new
counsel, and every where he had the  unhappiness to find, that
his disease was regarded as desperate,  and the operation as bare-
ly practicable.
   " Six months had now elapsed, from the  time of this con-
spicuous  increase of size; the tumour had attained to  more
than twice  its original bulk: there had been an accretion of many-
lesser lumps to  the main body of the tumour; in little more in-
deed than  three weeks, the tumour had increased to four times
its original size, the pains were become more pointed and fre-
quent, he was obliged to be careful of it,  and preserve it like a
part affected with  tooth-ach  or rheumatism, from cold, and
the  vicissitudes of  the  air ;  and  in damp weather or severe
cold, he was tortured with pungent heat and shooting pains, the
heat  and shooting pains being peculiarly felt in that part of the
tumour which was most conspicuously increasing in size.
   " But if those shooting pains, and this sudden increase of
size were  ominous, the  change which next ensued was more
perplexing, and alarming ; for on  its  internal surface,  it began
to connect itself not only with  the inside surface of the cheek,
but with the substance of the gums :  an  irregular excrescence 
488              On Tumours ofthe Gums.
 projected into  his mouth,  which he  compared with a claw or
 horn, and of such length and bulk, that, being checked by the
 teeth during sleep, it was torn away  with a considerable  effu-
 sion of black and fetid blood.   On the  external surface ofthe
 cheek, the skin  thickened, became porous and coarse, adhered
 to almost the whole extent of the tumour, was puckered and
 pursed up, at the place where the lesser glandular lumps were
 grouped and knotted round the chief body ofthe tumour, which
 was very nearly  in the centre ofthe cheek.
   " Alarmed by such decisive changes  in the character of the
 tumour, he called upon a Dr. Henry, who had  promised to per-
 form  the operation,  but he now  expressed his reluctance on
 account  of certain blood vessels, especially   of the infra-orbi-
tarv nerve and artery,  which he feared would retire into their
hole under the cheek bone, before the artery  could  be secured
This discouraging suggestion,  and an express  declaration that
the tumour was  of a schirrous nature, induced Mr. Taylor to
apply to a number of gentlemen who told him of the danger of
the disease, of the difficulty of the operation, and the prudence
of coming directly to this city.
   " My patient was of a pale complexion and melancholy tem-
perament, and, after a journey  so cheerless and  inauspicious,
where he was told at every step the danger of this disease, and
the difficulty of that operation  from which alone he  could ex-
pect relief, he was too  unhappy and  dejected to receive any
consolation from my  assurances.   The tumour was  not of that
size to be esteemed monstrous in any glandular or fleshy part,
but it was great in proportion to the part  in which it was seated,
it was of a stony hardness, firmly  connected with the substance
of the cheek, of a globular form, and surrounded by  small sub-
sidiary tumours, seemingly of a glandular nature, firmly con-
densed and mixed in their substance with the main tumour and
with the substance of the cheek. The skin was thick, with gaping
pores, a coarse  granulated texture, and a very firm adhesion to
all the tumour,  except its very apex ;  and, in the centre of this
granulated skin  were livid tubercles, about the size of a boy's
marble, extremely hard  in their substance, and of a very  omi-
nous appearance ; and where these projected a little below the
centre of the cheek, the  skin was  puckered and  drawn in.—
While the external surface was thus connected  with the skin of
the cheek, so as  to draw the angle  of the  mouth obliquely  up-
wards, the internal surface was very dangerously attached, not
only to the inner surface of the cheek, but to the gums : the
inner surface of the cheek felt, upon introducing the  finger, tu-
berculous, and rugged, and extremely hard ; and the tumours,
 when felt from withiny'^npeared distinctly  to be the same indu- 
Lips, Cheeks, and Throat.
489
rated  schirrous substance which projected from the external
substance.  Upon  inverting  the cheek,  these  tubercles were
seen knotty, irregular, and rugged like piles, or like those vene-
real warts ofthe anus, which  are termed  fici.   Where this dis-
eased substance approached the angle  of the  nose, it adhered
very firmly to similar tubercles springing from the gu.ns, and
the shooting pains, now severe and  constant, together with the
dejected appearance, and  sallow complexion  of Mr.  Taylor,
joined to the  united opinion of many  of our profession, could
not fail to impress me with a confirmed apprehension of its ma-
lignity ; but that only inspired me with a greater desire  to give
him the only  chance of life.
   " In  respect to the  projected operation no  circumstances
could  be more discouraging than those I have just described :
I  was  conscious that, in attempting to save  him,  I must not
merely extirpate a tumour by nice dissection, but cut  through
the cheek and dissect away almost all its substance ;  that I must
divide the facial artery below, and the  transversalis faciei com-
ing from the temple, and  the labial  artery returning from the
lip ; that I must not merely  wound, but cut away the salivary
duct, and lay  the whole side  of the  face open, making a breach
larger than the mouth : it could not but seem  problematical,
whether, after such an operation, the saliva, or food, could ever
be retained again, whether the attempt  would not involve me in
disgrace, whether I should not be blamed deeply for adventu-
ring on that operation  which so many had declined.   But I was
emboldened  by this recollection, that, often by a grape-shot, or
by a  splinter in battle at sea, the whole  cheek is carried away,
and sloughing succeeds to immediate loss of substance ; that I
had every reason to believe, though much of the substance ofthe
cheek must be cut away, I should be able to bring together the
remaining skin of the  cheek ; I most of all considered  that this
gentleman  had travelled from a distant  country, and, leaving
behind many skilful and dexterous  surgeons, came to commit
himself with  resignation and confidence  into  my hands, that I
owed him some sacrifices  in return, and  that,  unless I  attempt-
ed to save him, he must, at no remote period, die of cancer ; I,
therefore, prepared myself for the operation."
   The hooks, knives, and forceps necessary for such a dissec-
tion  being  properly   disposed, with  needles  for   tying  the
arteries, I  proceeded  with an  operation which could  not fail
to be extremely slow, since  its principal purpose  was to dis-
sect  out the  whole disease,  and save as much as  possible the
sound parts.
   I drew  -nv knife in the direction of that line  of feature which
                             3  Q 
490               On Tumours ofthe Gums,
marks the levator anguli oris, and  surrounded the tumour with
a second incision, like the first ; but, approaching  very closely
the angle of the mouth, I proceeded to dissect awav the tumour
from it, and from the jaw-bone,  and thought it singular, that the
labial artery  where it approaches the lip, and  the facial artery
where  it turns over  the  angle  of the jaw, were so elongated
without being divided, that I slipt a ligature under each of them
with the  needle, without pricking even the cellular  substance,
and tied them before cutting them across.
   Having turned the  tumour upwards, I cut through the inside
membrane of the  mouth,  cut clean away the tuberculous promi-
nences ofthe gum, dissected upwards towards the eye ;  and,
when much of the tumour  was detached, regarding  the infra-
orbitary nerve as the most  important  and painful  part ofthe
dissection, I  reserved this as the'last stroke, and while I dissect-
ed this  part, and especially  when I cut the  nerve across, the
suffered  an intensity  of pain which  made him  quite  savage, it
was then only that he stamped with his  feet  and cried  out  in

agony.*

   * I have always obferved thatthe  cutting acrofs a nerve produces an inconceiva-
ble fhock and of  this nerve  efpecially a dreadful  pain, which is on no occafion fo
manifeft, as when the operation of cutting acrofs the  nerve for the cure ofthe tic-
douleureux is performed ; for then the cutting acrofs the nerve is complicated with
no other incifions to  confound the  fenfation, which  is at  once fo peculiar and fo
alarming, that the patient  feels as if fhot, and ftarts up in agony inexpreffible ;
and this firft fenfation is inftantly followed by a pleafing calm and a happy, and
perfect relief from pain.   Thofe whom  J have feen labouring under this lingular
nervous difeafe,  have  had the affected fide ofthe face reddened, the cheek con-
vulfed, the  lip quivering,  and the eyes filled with tears  from the intenfity of
pain.  One old man about 70 years  of age, who was cured in an inftant of a dif-
eafe of many years duration, by my worthy and much refpected friend, Mr. Har-
rifon, of Ulverfton.had this  convulsion, and trembling of every feature, in a An-
gular < e^ree. Another  old gentleman, Capt. G. of R----, in Ivernefhire, had
this inceffant  trembling of every feature, as if each mufcular fibre of the face had
been ftruggling  in an  indetermined condition, betwixt convulfion and paralyfis;
and this convulfion was  accompanied with fuch agonifing pains, and wild and
piercing cries, as aclually alarmed  the ftreet  in which he lived : but I fhall de-
fcribe his  condition in his own words, as dictated to my  affiftant  Mr. Allan :
Capt. G. was, at the  period of the operation, about 75 years of age.
   " One afternoon, about  eleven years ago, while fitting  at dinner,  I was fudden
ly and f'everely  attacked with fharp and thrilling pains.beginning at the root of
the wing of the  nofe, extending all over the right fide ofthe face, centering in the
cheek, but mooting in a particular manner upwards by the corner of the eye into
the temple . the fit was  momentary, but the  cheek, the lips, and eye-lids quiver
ed, and were convulfed.
   " From this time I have been always fubject to this torturing difeafe, which has
been  the occafion of various journies to town, and innumerable confultations: my
fufferings fometimes intermitted for weeks, during which I was almoft  entirely
free from pain, and often again Ifuffered fix or fever, severe paroxyms of convul-
fion and pain, in one  day,  and as many during the night • I was for two years
contented  with the  advice  of my furgeons in the country, who prefcribed bhfters
and many other applications both fevere and trivial, but  with fo little good effect
that they afcribedmy  diforder  to worms in the cavity of  the upper  jaw.   About
fwo years after  the  firft  attack, my difeafe affumed  a more determined form and 
                      Lips, Cheeks, and Throat.                  491


   The tumour being removed, the  gap which was made  seem-
ed horrible, even to me.    The side of  the face was open, the

returned in paroxyfms with a degree of regularity :  after a lapfe of two or three
months, it would return for an equal period,  and continue to torture me, fo that
my appetite and fleep left me, my memory even feemed affected, and my general
health fuffered.
  " About four years ago I came  to Edinburgh, and put myfelf under the care  of
a furgeon of diftinguifhed reputation,  confulting, at the fame time, Dr. Gregory
Grant; and, by their conjoined advice, i had the gums of my upper jaw fcari-
fied, and three or four  of my grinders extracted;  and, after  remaining fome
weeks under their care, I returned home  feemingly well, and felt nothing of my
difeafe till about the third month, after the fcarifying, and the extraction  of my
teeth,  when fuddenly it returned in all its violence, and continued to diffract me
for two years more.
  " At the end of two years I was again driven to town by  this diffracting mala-
dy, and, having put myfelf under the care of the fame  gentleman,  and.  having
called Dr. Monro into confultation, he. directed that the only remaining grinder
on  that fide  of the upper jaw  fhould  be  pulled, and I was then fent home,  but
without the flighteft alleviation  of my diforder, which 1 endured for two years
longer.
  " About three weeks ago I  arrived in town a third time, and, after a very formal
and numerous  confultation, it  was refolved, to try the experiment ot  cutting
acrofs that nerve which paffes under the eye to the face: my agonies were now
fo dreadful, and unremitting, that, often I was obliged to ftart up from table,  and
could not refrain from  cries  and howling, fuch as were but too  diftmctly heard
in the ftreets.  The operation was accordingly performed by one of thofe gentle-
men, who made the incifion you fee  beneath the eye: for fome  time I flattered
myfelf I had derived all the  benefit  that  was promifed mc, and even when  my
pains returned,  I was over-perfuaded that  thofe were the  flight remains of a
defperate difeafe, and would be tranfient.   In this perfuafion  I  had, I may fay, be-
gun my journey ; 1  had got into the poft-chaife which  was to  convey me from
town, when 1 was  i'eized with  a paroxyfm  fo agonizing, fo very dreadful, that I
was carried back into the  inn, and have now refumed my  place in lodgings, to
 commit myfelf to your care.
   «April, 1804."                                    .            ...   ,   ...
   I doubt  not the reafon ofthe tic  doleureux returning,  is often like the ill
 mccefs of vaccine inoculation, to be afcribed to  the manner in which the opera-
 tion  is performed.*    The   performing  of  this nice and  delicate ftroke of the
 knife was probably confided, in this cafe, to a  gentleman  whofe firft and only
 diffection of nerves had  been in the living fuijeel;  his .11 fuccefs was fufficient
 warrant for this conclufion ; it  was impoflible  for an anatomift to  look  at  he
 fear of his incifion, without  an inftant  conviction,  that it did not at all crofs the
 courfe of the infra-orbitary  nerve;  deceived by the baggy eye  of a man advan-
 ced in years, and feeling only for  the margin of the  focket, he had carried a
 long incifion in the direction ofthe natural  lurk of the 1km,  and certainly could
 touch only  the rim of the focket; it is far below this,  that the nerve lies in a deep
 hollow: my education and my experience, put me,. I believe, far above the pue-
 rile vanity/and, I   hope, above the fufpicion of  magnifying beyond the truth,
 this trivial  fuccefs; 1 could not but know  the infra-orbitary nerve a little better
 than my predeceffor, and could not fail to cut it.  I feated  my patient in a chair,
 and  prefling the point of my fore finger  deep into  the  hollow where the nerve
 Iks'cut    acrofs, by linking in a fmall fharp-pointed knife, making no length of
 omward incifion/and, hooking the point of the crooked b Itoury behind the nerve ;
 in  the very inftant  of the ftroke by  which it was divided,  Capt. w—- ltartt 1
 !^m hilfeat, ran forwards in great confuCon, exclaiming, " Good God!  what s

   * The tic doleureux has returned after the operation has beer, performed by the
      ««c ui. uuicuiv.             r   1   ,    !v uas f..TiiMmes been cun.d by  the
 .urft furgeons both in France and ling.J-nu.   it rras 11 .n-w
  -onioined ufe of calomel and opium.  ^ 
492                On Tumours ofthe Gums,

range of teeth in both, jaws quite exposed, in  spitting out the
blood it issued through the cheek, and the tongue, when he turn-
ed it that way,  passed through  the opening,  not  through the
mouth, but through the under opening of the cheek, so that my
assistant found it right, to prevent the alarm of the patient, and
decent  in regard to the  spectators, to  purse the parts together,
and cover them with his hand: in short, it was such an appear-
ance as you would  willingly hide from  yourself.
   But it was a pleasure to see how nicely the parts fell together,
when smoothed down with  the  palm  of the  hand, and how
little they were pursed when sewed.   I make  it  a rule in all
my operations, to let even the oozing of blood cease before I lay
the parts together; having allowed some time  to elapse, I pro-
ceded  thus: first,  taking the edge ofthe  buccinator muscle,
much of which I had saved in the dissection, I raised it towards
the cheek-bone, sewed the edge of the  muscle, to the rags of
the inside membrane  of  the mouth, and  to the strong cellular
and muscular substance,  under the most prominent part of the
cheek-bone, and carrying the  thread inwards and tying it on the
inside  of the mouth, I there  cut it quite short,  resolving never
to look after it, but leave  it to suppurate out.   Next, I passed a
deep stitch through the upper part  of the incision, where force
was  required to bring the parts in contact or to hold them so
there;  in the hollow, I meant to lay a  soft and large compress.
But the lower and  central parts of the  incision, where the flaps
of skin were  more easily approximated,  I  joined, by passing
three delicate sewing needles, as hare-lip pins,  through several
points  ofthe wound :  the intermediate points I drew nicely to-
gether with  plasters; I  was  careful to use the least possible
force ;  to make no strain by the sutures ; to lay my compresses
light and soft in the hollows; and  to roll my bandage round the
jaws very equally,  and  gently,  for the teguments were most
alarmingly  thin, the slightest inflammation would  have caused
the whole cheek to slough, so as to leave the parts in a dreadful,
irremediable condition, with the saliva  continually flowing over
the cheek, the speech imperfect, probably unintelligible, and the
patient would  have  found no way of  being nourished, but by
pouring the food down the  throat, in  place of masticating or

that ?" he fat down inftantly  in perfect compofure, free from pain, unconfeious
of the operation being perlormed, and expecting it : when  qucftioned about the
fenfation which made him ftart  up, he faid, he felt nothing but as it he had been
fhot in the head, followed by a momentary confufion, and a total relief from pain.
He faid  he did nof imagine the operation done,  becaufe the firft operation had
been a deliberate diffeciion ; he felt  now  perfectly confident that he was cured,
and returned home in two days,  fince which time,  he has lived in perfect health, is
happily married, and continues well at this moment.
   Jannary, 1807. 
Lips, Cheeks and Throat.
493
 swallowing it.   Happily the  skin adhered in a few days, the
 needles were withdrawn, in a fortnight he was cured.
   But  the slightest speck or  spot  of imperfection in such  a
 work is followed by severe self-reproach.  I am  not sure that
 I observed my fault during the operation, but certainly after the
 cure, I took an alarm, far from  groundless.  I observed a small
 glandular-like knob towards the lower part of the cheek, which
 I ingeniously warned him  might be  the source of future dis-
 tress, as the small tumour,  indolent  during  his  infancy and
 youth, had been suddenly the cause of this mischief; I took his
 promise that he should be  observant of it.
   This error, so opposite to my experience and conviction, so
 unlike my general maxims and conduct, I sorely repented.  It
 was at the  distance of three years from the period of this ope-
 ration, that  I received a succession of letters from my patient,
 announcing the return of the disease, and asking permission to
 come once more to this country, to put himself under my care.
 The small glandular knob, which I required him to watch, had
 increased in size,  and the gums also had begun again to shoot
 out small tubercles;  that the  new swelling, and the  return of
 this disease had ^ begun in  this small glandular  knot, no bigger
 than a pea.   I  remember, only from his conversation, not from
 his letters:  from  the complexion of these, one should rather
have concluded, that the new growth was only  in the gum, be-
ginning  in  the angle  betwixt the gum and cheek, and  in the
centre ofthe cheek ; a  part ofthe tumour, in the extirpation
 of which, I surely had  not to accuse myself of any fault; and
 from the slightest and most  imperceptible beginnings,  viz. a
 small longitudinal thickening  along the scar  of the wound, a
 small pea-like hardening near the lower part of  that scar,  and a
 similar hardening  betwixt the  cheek  and gum ;  it grew  with
 such rapidity, that from week to week its increase was manifest,
 and  in less than two years, it  had  attained fully  its original
size ; accompanied with pains, more distinctly lancinating, more
poignant, and frequent, than in its first stage.  Again he travel-
 led from Tyrone to this city, and after  many  perplexities and
 fears, submitted again to the operation.   I, on  my  part, had no
 slight motives for  anxiety,  for  now  actually  the whole cheek,
 the skin excepted, was to be  cut away ;  the buccinator muscle,   >
 and the living  membrane of  the mouth, were both to be cut
 out;  and I was shocked to think, how possible it was, how far
from  improbable,  that the whole cheek, even from  the slightest
overstraining of the  suture, or the slightest accidental  fever,
 might gangrene and slough, and leave a horrible chasm.
  The tumour  was almost us large as at first:  the great  glan-
dular-looking substar.ee. rounder and  more uniform ; the livid 
494
On Tumours ofthe Gums,
part of the surface of greater extent, and a stage nearer ulcera-
tion, and the scar of the  former operation binding the tumour
firmly along its whole length ; and, except in the very apex of
the most bulky and prominent part, where indeed it was more
elastic, the whole was of  a stony  hardness, accompanied  with
perpetual pain, by which, together with his fatigues, and  fears,
in this  wearisome journey, he was greatly cast  down.  It now
also approached so close to the angle of the mouth, that  I saw
no  way of extirpating the  tumour, and leaving  more than a
quarter of an inch,  hardly  so much, entire,  betwixt the gap
made by the extirpation ofthe tumour and the mouth.
   I proceeded to make first, a long incision, bending a little,  so
as to include all the tumour  that was below the  cicatrix, and
which, in bending  round the tumour almost touched the angle
of the mouth next,  a similar incision bending upwards, in such
a direction, as to include the scar of the former operation, the
puckered and adhering skin, and a part of the tumour, all that
part to which  the skin inseparably adhered.  Those two inci-
sions included that  part of the adhering skin, which required to
be extirpated,  in  the same manner,  that we usually include
within  an oval incision, the nipple of a much indurated mamma.
Thirdly, I made  a tranverse incision,  from  the temple, i. e.
from the tip of the ear over the zygoma,  directly across the
face, which meeting the first oval  incision made two flaps. The
tumour I found now more regular in its form than I expected,
sacculated, and very dark and bloody ;  I, after raising the an-
gles of the skin from the  cheek and face, and saving all ofthe
skin that  I could save, dissected all round the tumour, and re-
served those parts of the  dissection for the last, in which  I had
to divide  arteries.   I then dissected out the  tumour from the
angle of the mouth, and  tied the  labial artery ;  then dissecting
down through the lowest  part of the incision, into the cavity of
the mouth, I tied there the trunk ofthe fascial artery ; and finally
dissecting out the tumour from under the cheeJk-bone,and tearing
it from the zygoma, a  most difficult and painful dissection, 1
tied a large branch from the  transversalis faciei.  The   veins
spouted out blood profusely  when cut, but shrunk  instantly :
the arteries thus successively  tied  bled none.   I  never indeed
performed so unseemly, and  at the same time  so bloodless an
operation.
   Now observe, that in all these points, and to the full extent
of the tumour, I was obliged to go fairly through the cheek,
and cut every thing completely away, for it  was  all tumour.
The tumour looked formidable when it presented itself, in time
of dissection, high above  the separated  flaps  of the skin, and
the chasm was horrible when it was cut away; the flaps consist- 
Lips, Cheeks, and Throat.
495
 jng of skin  only, were so thin,  that  I was in despair when I
 laid them together;  I solemnly declare, that nothing ever asto-
 nished me more, than the speedy cure, which was such as must
 give me  courage on all occasions that may  in future occur.
 First, my assistant,  Mr. Allan, brought the edges nicely to-
 gether, and passing a needle through the three points of the in-
 cisions, I  brought them altogether  in one  star-like centre, ex-
 actly in the middle ofthe cheek.   But one ligature, though  it
 approaches two points nicely, cannot go under a third, and bring
 it into contact with the other two, without turning  over  and pass-
 ing from  within  outwards;  in consequence of  this awkward-
 ness, for  which  I was  provoked with  myself,  I had almost
 balked/the great purpose of re-union, and that  too at  the very
 centre ot all the sutures, and therefore endangering each of them,
 and of course in the  centre of the  cheek, so  that the whole
 cheek was endangered;  but  fortunately the suppuration, in this
 central  point, was very slight: yet, however slight, it grieved
 me, as  it  plainly proceeded from  my  awkwardness.  I then
 took the most delicate sewing needles, mounted on small wooden
 shafts, like pencil sticks, and passing two  needles from side to
 side across each long incision,  I  brought the sides ofthe three
 radiated incisions, into the nicest contact imaginable, careful al-
 ways  not to twist  my threads round the needles  too tight; and
 I passed one  very delicate  needle  close to the angle of the
 mouth, to secure that point.
   This I do on all occasions, and always very deliberately, and
 at some distance of time after the operation, and  when  there is
 no  longer any bleeding to discompose  me ; and  every  thing
 sponged, clean, nice, and dry, I take narrow strips of linen, and
 dipping them in warm glue,  lay them across the  incisions, and
 these being well dried, and hardened, and the needles kept clear
 ofthe glue, I can, without risk,  on  the end ofthe second day.
 or on the third, before there  can  be the slightest  risk of suppu-
 ration, slip out my needles one  by one.
   So I did in this case ; the less necessary  needles I withdrew
 on the second day; those on which more depended, I left  till
 the third and fourth days;  and the needle  nearest the centre  I
 left longest.  I draw  each needle with nice forceps, turning it
 first a little vertically,  that there may  be no tugging.   I often
pass a thread into the eye of the needle, that I may pull quite
vertically, and  often pass a flat stick betwixt the ends of this
thread,  and,  twisting the ends round the stick, turn the needle
vertically, and so loosen it with  so  true a motion, that there is
not the slightest  sensible  violence,  nor the smallest  drop of
blood ;  and,  before I  attempt to  move a needle,  I take a hair
 pencil,  and, by washing and  cleaning  the point,  and oiling it, 
496
On  Tumours ofthe Gums,
prepare it for passing easily.  This method I have long U9ed in
all delicate sutures,  especially in extirpating  small tumours of
the face and jaws, and in hare-lips.   It was in this  manner I
re-united, a second time (the operation  having been Very mal-
adroitly performed upon  him when a boy,) the hare-lip of Mr.
Whirter, surgeon, of Newcastle, with a  scar hardly visible, and
with an evenness of lip which enables him to blow the flute very
delicately.  He  was conscious of the necessity of this second
operation, and gratified with the success of it.
  I have another remark to make to you, that, though a needle
is withdrawn, its twisted suture remains upon the surface, cak-
ed with blood, and is a security to  the wound;  and always,  up-
on  withdrawing  each needle,  I heat the  glue-pot again, and
dipping a hair-pencil in it, I wash the remaining ligature, or
twisted thread with glue,  so that the needles being removed on
the second,  third, and fourth days,  there are substituted to them
various strips  of fine  linen,  with  glue, and  the pencil  being
carried over all parts of the incision, the whole is held firmly, yet
gently together, by a cake  or  plaster of glue,  which  need  not
once  be  troubled till you find it safe to wash off the  whole at
once.
  This, compared with the common adhesive plaster of wax,
is a nice and cleanly manner of performing those operations in
which so much depends upon delicacy, and the niceand curious
contact of all the edges ;  for any one point left open endangers
the whole line of suture ; and this method had, in the present
instance, such perfect success, that, in ten days Mr. Taylor  be-
gan his journey to Ireland perfectly cured, and with less mark
of incision, and a more perfect evenness of cheek than  at first.*
In an hospital, an unhealthy season, or an unsound constitution,
the whole of such incisions must have sloughed off, a  dreadful
and an irremediable calamity! but in this healthy and  vigorous
young man, the parts united most happily.
  In  operating on this tumour, I  was surprised  to find a very-
singular connection betwixt the veins and the central and more
conspicuous tubercles, which were indeed firm but elastic sacs,
of pure and coagulated blood, inclosed  in very thick  and solid
walls'; and, upon dissecting the tumour after it was laid upon
the table, the great tubercle being  cut open, and the hard and
clotted blood turned out, it  was manifest and visible, distinctly

  *  The part was not covered with lint or  comprefs for fear of diforder ing the
needles, or concealing any accidental inflammation,  but  to prevent any ill confc-
quer.cesfrom the extreme ho'llownefs of cheek, a nice fitted plumper, or comprefs
of foft rolled lint, was introduced into the mouth, and the jaws bandaged to pre-
vent motion during fleep, and he was hardly permitted to lie down in bed for fear
ef fome mifchance. 
Lips, Cheeks, and Throat.
49r
 visible, that these cellular cavities had communications with the
 greater veins.
   Many distressing, and some fortunate cases of this nature
 have been under my care ; tumours  of a less malignant nature,
 and easily  extirpated, present themselves daily, and excite no
 perturbation ; but I would endeavour,  by relating less favour-
 able or fortunate cases, to enure you to difficulties, and disap-
 pointments.
   u Mr. S----, a venerable  old man  of 60 years of age, re-
 markably strong, active, and athletic, for his time of life, had
 been long subject to a very dangerous  swelling of the parotid
 gland, which now  manifestly declined to a state  of cancer.—
 The tumour began  early in life, and was extirpated twenty years
 ago by Mr.  Dunlop, a celebrated surgeon in Glasgow : but a
 gland in which the  trunk of the carotid artery is so entirely im-
 bedded, can never  be entirely extirpated, thence  it  has grown
 again slowly.   Mr. Dunlop  declining himself to perform the
 operation, and yet  desirous that Mr. S----should  have every
 possible chance  for life, has requested me to receive him under
 my care.
   " The tumour is  divided in the middle by the scar ofthe for-
 mer operation;  along that line it is irregularly straightened and
 bound down ; it rises on  each side of the scar, in knobs or api-
 ces of a stony hardness,  reddened of late on the  surface, with
 a coarse granulated and adhering skin.  The whole  surface of
 the tumour is of a  dusky red, and its extent very great, for it
 covers all the flat part of the cheek ; a flattened part rises over
 the zygoma, towards the temple, to which it adheres  very firm-
 ly ; one glandular and almost separate lump, lies far forwards
 upon the cheek, and seems to me a tumour  of the socia paroti-
 dis, while the rest is a tumour assuredly of the parotid itself.—
 The tumour is so large  as to be flat though bulky ; the  most
 salient point is that which lies immediately  before the ear, the
 lap of which is turned back by it ; another branch, I may call it,
 of the tumour,  lies under the lap of the ear, and presses it up-
 wards ; the  chief mass of the tumour lies upon the cheek, but
 a very bulky part lies deeply  imbedded behind the angle of the
 lower jaw-bone  ; its appearance was unpropitious, for it was of
 a deep red colour, sensibly inflamed, the inflammation increas-
 ing every dav, with a deep and stunning pain, while all the  basis
 ofthe tumour was as hard as stone.
   " Nothing can be more unpropitious than the state of this
 gland ; first, it is a  disease returning long after its growth had
 been interrupted by amputation : secondly,  it is very firm, of a
stony hardness, very  irregular and  knobby ; that part which
lies out upon  the cheek is bound down firm, and flat, by the
                            3 R 
498              On Tumours ofthe Gums,

fascia, or tendinous membrane that descends from the zygoma,
and by the platysma  myoidcs muscle: thirdly,  it is growing
sensibly and rapidly, and  its surface has begun to take a deep
and livid colour, while very poignant and torturing pains shoot
through the tumour, prevent his sleep, and distract him while
awake.  This st hirrus has every character of approaching can-
cer, it is most likely too late to attempt the operation, yet what
would not one do or suffer to preserve life ? The operation too
is full of danger ; this gland  cannot be extirpated but  by deep
incisions,  and a very severe and slow dissection ; at the best, it
Cannot be separated  from the angle of the jaw, without cutting
the portio dura ofthe auditory nerve, and paralyzing the cheek;
nor without  dividing the temporal, facial, and other arteries :
perhaps it may not be possible to extirpate it totally, for fear of
wounding the very trunk of the carotid artery, and that opera-
tion which  is begun with  the knife, it  may be necessary to
finish less perfectly with the ligature.   This is the first time  I
have  been obliged to think of such a resource : the latter part of
the operation must be performed by poising out the gland from
the deep hollow under the zygoma, and behind the angle ofthe
jaw,  and  then it may be necessary to strangle with the ligature,.
what assuredly we dare not amputate with the knife.
   " I came to this decided conclusion in my own mind, that,
though a  case the most unpromising  I had ever witnessed,  it
was  my duty, in compliance with Mr.  Dunlop's and his pa-
tient's wishes, and with Dr.  Monro's advice, to perform the
operation, difficult as it seemed, and it was plainly such as ad-
mitted of no previous plan, but required  that I should be guid-
ed by circumstances, and my past  experience, for I had often
[partially'] extirpated the diseased parotid.
   " I can hardly enter too much into the detail of such an opera-
tion, seeing especially that it had an unfavourable issue ;  I en-
tered upon  it with more than usual composure, with more than
I thought  natural to the  occasion, but, 1 believe,  it was the
very  difficulty of the case that reconciled  me to my task,  for I
was conscious, in such difficult circumstances, I was entitled to
stop, that it was my duty to stop, the  moment I approached
any dangerous point, that  I was no way responsible  for extirpa-
ting the whole tumour, nor for doing all with the knife.  The
peculiar complexion  ofthe tumour, for it was now inflamed al-
most to ulceration, and accompanied with lancinating pains, was
unfavourable to our hopes ;  its growth, after being once extir-
pated, confirmed the suspicion of its being, of a  cancerous na-
ture ; and the parotid has  the temporal and maxillary arteries
imbedded in it, while the  ponio dura, or middle nerve of the
face, that great nerve which runs across  the cheek, and goes to 
Lips, Cheeks, and Throat.
499
all the side of the face,  passing through it  in  many branches,
so that it  absolutely  cannot be cut away  from its root, which
sinks deep behind the branch of  the  lower  jawbone,  without
cutting the carotid artery ;  and it cannot be torn away,  the firm
nerve being entwined with  its substance; even the casting a lig-
ature about the root of the gland is accompanied with excrucia-
ting and maddening pain, the nature of which may be imagined
from the agony which a tooth-ach or a rheumatic affection of
the temple causes.   The act of tying a nerve,  I am conscious,
produces a kind of injury,  accompanied with terrible inflamma-
tion : this injury is permanent, and the  inflammation becomes
habitual.   It often happens,  for example, that the  nerves ot an
amputated stump are so engaged in the cicatrix,  that their ex-
tremities being  superficial, and covered only with  a delicate
and thin cicatrix, the slightest accident irritates  and inflames
them ; and I have seen a stump exposed by this to paroxysms
of  inflammation, in  which  the stump swelled to the size almost
ofthe patient's body,  attended with ftver, and such convulsive
startings of the stump as  usually occur immediately after am-
putation.  The cutting of  the portio dura, or nerve of the face,
occasions the m ist excruciating p »in, as I have already explain-
ed  in the case of Cap. G----,(vid. foot note to page 490) and
I have reason to believe,  that the pain  proceeding  from the
truncated extremity  of this nerve being unavoidably engaged in
the cicatrix after an  operation such as this,  causes the return of
the swelling,  revives the  disease  in whatever remains of the
gland, and is the cause of its cancerous nature.
   " My incisions were made in a tripod-like form ; not straight
but bending, so as  by their prolongation over the cheek, ear,
and temple, to make a triangle, in direct lines with three corn-
ers, which  being dissected  away, exposed the convex part of
the tumour.   By giving these three incisions a circular form in
the centre,  I left the adhering part of the skin, attached to the
most diseased part of the gland, and this centre of knobular and
stony glandular substance, with thickened  and adhering skin,
connected firmlv by the scar of the  former operation, I left
untouched, and'cut up three flaps of thin and sound  skin.
    " After  dissecting back  the  flaps exposing the surface  of
the tumour, I dissected away that part  of the tumour which
approached the mouth, and lay upon the masseter muscle, with
which it was so connected that I chose to cut away large pieces
 of the muscle, hardened and identified  with the tumour, leav-
ing the jaw-bone bare near its angle, rather than leave any part
of the disease.   Next, I turned the tumour down  from the
 ear ;  but  do not imagine this was accomplished easily  as in
 ordinary tumours bedded in loose cellular substance ; this tu- 
500              On  Tumours of the Gums,
 mour was so firmly embraced by the fascia, and adhered so firm-
 ly to the zygoma, to the thick fascia which  descends from it,
 and to the  tendinous pasts of the temporal muscle, that 1 was
 cutting through  a firm,  mixed, cartilaginous substance, and
 couid not distinguish where I had got through the gland, or its
 adhesions, but by distinguishing that I was cutting  muscular
 flesh, or encountering a  naked bone.   The third  part ot the
 dissection was at once cruel and full of danger ;  it was the dis-
 secting away the tumour from the cartilaginous tube ot the ear,
 which was vet done so effectually, as to detach the tumour from
 the whole length of that tube, down to the temporal bone ;  but
 there, a big and  firm root seemed  so fixed, that I  durst go no
 further with the  knife ;  I had dissected the tumour backwards
 from the cheek,  and upwards from behind the jaw-bone, and
 insulated it up to that point where the temporal artery transfixes
 the gla"nd just before the ear ;  there, it will be recollected, the
 great internal maxillary artery divides from the temporal arte-
 ries ; I could go no further, the next stroke of the knife would,
 in severing the gland from  its root, have cut the common root
 of the maxillary and temporal arteries ; would,  in  short, have
 truncated the carotid artery ; what  remained of the operation
 could therefore be done only by ligature.
   *' In this dissection I  experienced all the difficulties peculiar
 to a second operation ;  for  a gland  which grows again after be-
 ing cut, is so bound down to every subjacent part, by the scar
 of the skin, and  by7 new and strong adhesions, that its connec-
 tions are of an unusual and cartilaginous firmness : and I had,
 in this case to encounter  the additional danger of a tumour far
 advanced in its progress towards the last stage of schirrus, and
 ready to degenerate into cancer ; and it appears to me that that
 unfavourable change which is marked by shooting pains, consists
 in inflammation, is accompanied  with adhesions, or,  to speak
 more truly, with a consolidation of the diseased gland, with
 surrounding bones and muscles, just as the schirrous breast is
 united  solidly and in substance, with the pectoral muscles, and
 the  ribs :  in the present case, the fascia,  descending from the
 zygoma over the surface of the tumour,  was identified with its
 substance, and,  when cut,  was like a  cartilaginous  ligament,
 hard, and  thick.  The dissection of the part ol the tumour which
 lay over the jaw, and masseter muscle, was equally rude, and
 imperfect;  for the tumour was equally identified with the sub-
 stance of this muscle, which was,  in its own substance,  of a
 gristly hardness.   The tumour, in short, adhered to the fascia
 ofthe temple, to the zygoma, to the masseter, to the jaw-bone,
 and to the cartilaginous tube ofthe ear; from all of which,  it
• was more or less rudely7 or delicately dissected ;  but with  such 
Lips, Cheeks, and Throat.
501
 excruciating pain that Mr. S----, though a man of the most
 perfect  composure, courage, and constancy, grew deadly pale,
 hiccuped, fainted, would have fallen fr.om the chair, had he not
 been supported, and that so early in the operation, that even his
 neckcloth was not yet stained, at least not wet, with blood.
   " We were obliged to lay him  down, to  lave cold water on
 his face, to suspend  the dissection for a whole quarter of an
 hour ;  this was in the beginning of the operation, which lasted
 ten minutes after it was  resumed.
   u The  first artery which sprung was the transversalis faciei,
 but  it was too small  to  be heeded, and it was to be cut again,
 wherefore I disregarded it, and  it shrunk: the next artery, in
 dissecting the lower part ofthe  tumour, was the labial or facial,
 where it  turns round the  angle of the jaw ;  in  this, as in all
 other dissections of the like nature, it stood out from its cellular
 substance so insulated, to the extent of half an inch, that I found
 it easy, without the needle or tenaculum, to casta ligature round
 it, by laying the loop of the ligature over its mouth, and draw-
 ing it:  the third artery was the great temporal artery ; the man-
 ner in which it presented was not pleasant, for, first, in dissect-
 ing downwards that part of the tumour which covered the zygo-
 ma, the  artery was  necessarily opened; but  knowing that  I
 had not approached any dangerous point, I clapped the point of
 my left fore-finger on the mouth of the artery, while grasping
 the body of the  tumour in the  hand, I  continued to dissect it
downwards from the temple, and to dig it away from the carti-
 laginous tube of the ear;  then, lifting the point of my fore-fin-
ger, the mouth of the artery appeared in the very centre of the
tumour, throwing out its blood, and was tied.   By dissecting
 the gland down from the zygoma,  and from behind the angle
of the jaw, I had  almost touched the point where  the carotid
forks into the  internal maxillary  and temporal arteries ; to have
gone  further, would have been rash and  unpardonable ;  the
next stroke ofthe knife would have truncated  the  carotid arte-
ry and left no possible chance of saving the patient, but instant
compression of the artery at  that point with the thumb, and a
desperate dive with the  crooked needle at that part behind  the
angle of the jaw, where the trunk forks into the external and in-
ternal carotid arteries.
   " I  wrought  so successfully  with my fingers, as to insulate
the gland all but a trivial  root; I then pushed the flat handle of
the scalpel round  and round, so as to lessen that root  still more  :
I next with the fingers alone passed  a big and thick ligature
round the root of the tumour, and tied it in a general way, and
by the hold  of  this ligature was enabled to  turn  the tumour
round like a button upon its stalk, and by  compressing it, was 
502               On Tumours ofthe Gums,
enabled to feel more distinctly to the root of this slender neck.
I believed, but I was mistaken, that I could drive the eyed end
of my needle through this ;  it was of far too firm a substance
for any such  attempt; but resolved any way to get at its root
I turned at last the ^bint of the needle to this pedicle? struck it
through behind the general ligature, and having thus carried  a
very thick waxed ligature through  the root, I cut the  l'guure at
the eye  of the needle, tied two of the ends round one side  of
the tumour, the two others round the other side of the tumour,
then crossing them, and bringing the  respective  ends  round the
opposite sides of the  tumour, I  tied them again ; and as this
was the point necessarily including the portio dura, or great nerve
of the side of the face, the drawing of the ligatures proved the
most cruel part of the operation, was  accompanied with an
outcry of intolerable suffering; the cheek fell paralytic, and be-
came instantly oblique, and I was impressed also  with the con-
viction,  that I had so pulled out the gland by the help of the
general ligature from its deepest seat, betwixt the jaw and tem-
poral bone, that I had, in tying the root of the  schirrous gland
and the portio dura, tied also the carotid."
  " The gland was cut off, and only a button'left with those lig-
atures about it ;  the whole operation  was bloodless : at the first
dressing, at the  distance of four  days, the whole surface was
found in a state of kindly suppuration,  but the ligatures, espe-
cially that which encircled the lower part of the tumour, needed
to be drawn firm,  which  occasioned once more  excruciating
pain, which continued through the whole night,  during which
our patient was feverish andjtjestless.  On the second dressing,
at the distance of seven days from the operati&n, I  found  the
gland, or the remains of it, not killed by the ligature, but adhering
round all its edges, to the surrounding parts ; and especially I
found it adhering firmly to the flap  of the ear. I  disengaged  the
adhesions with the probe, and examined the ligatures and found
them loose ; but having fixed them  with running knots at the last
dressing,  I now finding it impossible  to draw them tighter, took
another method,viz. passing the ends ofthe upper ligature through
the eye of a large crooked needle, and carrying it, eye foremost;
round the gland, I carried the same  ligature a second time round
the neck of the tumour, and tied and drew it again with consider-
able pain. The button-like head and neck  were now so hard and
brittle,that I might safely have snipped them across, but I thought
it best, since the  ligature still occasioned pain, to leave it  to kill
the part completely.  At a third dressing I found still the gland
not killed, but adhering to the ear,  and bleeding when touched,
so  that  Dr. Monro could not be persuaded that the ligature
actually surrounded the tumour.   I drew the ligature  now a 
                   Lips, Cheeks, and Throat.              509

 fourth time with great pain; I  waited for its sloughing, as this
 root ol the gland seemed to delay the  cure, which was  other-
 wise far advanced , but at the next dressing 1 found the tumour'
 hard, brittle, entirely blackened, and turning in every direction
 upon  its Harrow neck, which I  twisted  ofjpwith a  very slight
 twitch, merely by  turning it round and  round.   The surfaces
 suppurated fairly, and  granulated;  and the cheek healed even-
 ly and well:  but the  pains never  entirely ceased ;  our patient
 had rheumatic feelings in all that side of the  head,  always re-
 ferable to  the diseased part: they were increased in moist wea-
 ther, o|when the east wind blew.   He retired to a delightful
 climate  near the mouth of the Clyde, and while there the thick-
 ening ofthe parts daily lessened, and I flattered myself he would
(-entirely recover;  but after receiving from our patient a suc-
 cession ot very afflicting letters, he returned to/m* in the  month
 of January, in a very  calamitous situation, with  the  tumour al-
 most as big as in the month of July, when the operation was per-
 formed, and having all the aspect of a part ready to burst out into
 cancer. T,he surface and the cicatrix, and all that belonged to the
 skin, seemed to be  particularly diseased, and  prone to ulcera-
 tion.  Three points stood particularly prominent like knuckles,
 from the centre of  the sore : these  were the three corner points
 of the skin  formed by the triangular incision ;  they were of a
 dull red colour, extremely painful, with an indistinct sense of
 fluctuation, or rather of boggyness,  (soft and hard mixed,) and
 resembled in short the livid skin of a schirrous breast, when the
 operation  having been unsuccessful, the part is about  to burst
 into open  cancer.    The pain whuih had for some months been
 moderate  and 'tempered with intermissions, was now unremit-
 ting,  extremely "severe, shot across the cheek during the day
 with stunning violence, and at night was so fierce and intolera-
 ble, like the burning of live coals, that  he wished for ice tApply
 it to to the side of his head; and even with large doses of opium-,
 which he had learned  to use, he  passed much ofthe night with-
 out closing his eyes.  With Dr. Monro's  consent, the  ,usual,
 the hopeless, prescriptions of hyosciamus and mercury7 were giv-
 en him,  and  he  returned to the care of his surgeon at  home,
 whose letters announced  to us only a succession of sufferings
 daily  more and more, and  were terminating at  last in a fatal
 cancer :  he  survived but a few months."
   Those  more ordinary  operations  on tumours rolling under
 the skin,  insulated, easily extirpated, and which we know it to
 be our duty  to dissect out, as a measure of precaution, I  need
 not describe to you ; but those in which there is any thing either
 singular in the place of the tumour, or critical in the dissection
 required,  I hold it my duty to represent; and I  am permitted 
504
On Tumours of the Gums,
by Mr. Dunlop, surgeon in Glasgow,  to  explain  to you some
things very singular in the operation which he found it prudent
to submit to in his own person.
  Mr. Dunlop, surgeon, after deliberate and frequent  consulta-
tion with his fatherSresolved to rid himself of a continual anxi-
ety in regard to a glandular sweUing, deep seated, lying imme-
diately under the lobe of the ear, and which had been increasing,
though slovvlv, for  five years.   No well  instructed  surgeon
could be indifferent to the  consequences of such a tumour in
his  own  person.   Had the gland been a mere scrophulous
swelling, he might have waited the event patiently, of) it sup-
purating, shrinking, or remaining stationary ;  but a gland, hard
as a stone, gradually  increasing in size, deep seated, extending
its adhesions, and connecting itself with the carotid  artery and^
portio dura, was not to be long disregarded.   Much as I have
been in the habit of comparing external with the corresponding
internal parts,  and planning operations, there  were many things
in this dissection altogether unexpected, and for which I was in
no shape prepared.    I felt (more than even  in  those cases  in
which I had been correct in  my conjectures,) the necessity  of
thinking long before lifting the knife :  I was  sensible of some-
thing  very unconfirion and anomalous in this tumour, for though
it did not seem to Adhere, it  lay  very deep,  though moveable,
its form coul^bt be distinguished, though extremely  hard and
globular, itseemed to be covered with coats of an extraordinary
and unaccountable thickness;  and, if I  can pretend to remember
any conjecture I made, it was a very mistaken one,  viz. that
the fascia, fat, and cellular substance had thickened jto a singular
degree over it.   But Mr. Dunlop, passionately desirous ot be-
ing rid ofthe tumour, required that I should perform the opera-
tion without delay.
  The usual apparatus of knives and needles, a fork to transfix
android the tumour with, tenacala and dissecting forceps, to-
gether with sponge, and a long bandage being  prepared, I began
my operation  by an  incision carried over the centre of the tu-
mour of three inches long, running behind the line of the jaw-
bone, and parallel with it from the tip of the ear downwards;
the edges of the skin  being  then drawn strongly  to either side,
I proceeded to dissect the tumour,  but after I had dissected off
the fascia, the tumour seemed still soft and shapelesss; nothing
like a firm gland or circumscribed tumour appeared  ; what pre-
sented under  my knife was flat and fleshy, and undefined ; and
when this fleshy mass was pinched up betwixt  the finger and
thumb, the hard tumour was distinguished under it: I now re-
collected that I was cutting  directly over that part of  the paro-
tid gland which lies behind the  angle of the jaw, and as instant- 
 
P. 6>08>  .
-N9.17
JBiti, Mr-,
T.Keamy' tfc, 
Lips, Cheeks, and Throat.
505
 ly distinguished, that the surface I had laid bare, was no other
 than the flat white granulated substance  of the  gland.  I per-
 ceived that the tumour, the object of my operation, lay under
 the parotid:  I  first dissected round this  lobe of the parotid on
 each side, then turned off the lap of the parotid, or that lobe
 which lies behind and under the ear, and then saw the indurated
 gland lying beneath it.
   This was assuredly a  delicate  piece of dissection; for first
 the lobe of the parotid was turned back and carried behind the
 angle of the jaw, at that point where the division of the external
 carotid enters into its substance.  Under the gland lay the trunk
 ot the carotid, and the space was far from being free for making
 so dangerous a dissection confidently: there  was no want of
 courage on the  part of my  patient, but it was somewhat of an
 obstreperous and boisterous kind ; for having imagined  the tu-
 mour a simple and moveable one,  to be cut or dug, or torn out
 easily and quickly ;  he was provoked at my tedious way  of dis-
 secting, and  called  for a mirror to inspect, if not to direct my
 incisions.   The gland itself was now laid bare with its glistening
 bluish capsule of  cellular substance, and  while  the lobe ofthe
 parotid was held up by my assistant, I dissected  cautiously and
 slowly into the  angle, to  separate the tumour from its connec-
 tions.  In the accompanying  sketch, No. 17, made  instantly
 after the dissection, the sides ofthe incision are  marked (a aj
 the parotid gland held upwards  by a hook struck through the
 fascia is marked (b),  the tumour lurking under  it, and entirely
 enveloped in it, (for it is flat and cushion-like,) is marked (c).
 The operation lasted long, and was not a very tranquil one: but
 it was safe, and  by making the  incision  merely longitudinal,
 without any cross incision, and immediately under the whisker,
 and by pinning it  nicely and delicately  with fine sewing needles,
 and laying slips of court  plaster curiously  betwixt each needle,
 the adhesion was  accomplished in  a few days, with only  a very
 slight leaking of pure  saliva from the  wounded surface  of the
 gland which lasted but two days,  and in eight days  my  friend
 was well  and had returned home: it is by his express permis-
 sion,  I lay this slight sketch of the dissection before you.
   Slight as these  difficulties may  appear in this narrative, it  is
 fit you be aware of them ; for the young surgeon, in the moment
 of seeing something altogether unexpected, a flat  and shapeless
 mass, in place  of a firm circumscribed  gland, is in danger of
 losing courage, and falling into confusion.   I hope I need not
 remind you how unpleasant an accident it would have proved,
 had a young and  thoughtless  operator in  these  circumstances
 proceeded  rashly, and cut across the  parotid, mistaking it for
the tumour, or cut at a venture, down into the angle where the 
506               On Tumours of the Gu?ns,
Carotid and Portio Dura lie.*  It is just such a tumour as this,
that by adhesion and induration affects all the surrounding parts,
becomes too formidably  connected to be extirpated, and at last,
by causing cancer and destruction ofthe bones, and by its enor-
mous size, lays the patient's head upon the  pillow from  which
it is never to be raised again.  I have  once seen, just from so
slight a beginning,  a boy with an osteo-sarcomatous  tumour of
the head, where bones, muscles, and glands, were all massed
in one common tumour, big as the original head, of a  weight
too great for the  neck  to  raise,  and  which, when it was to be
moved, was moved with the help of both hands ;  the  lad died
of stupor and apoplexy,  from suppuration ot the brain.
   It has often struck me that the things  a  surgeon ventures to
do in  the moment of operation, resemble in one respect those
which a soldier  does in mounting a breach: what is past looks
like a dream, and upon returning to the scene,  and considering
the danger that is  over, he  shudders at his hair-breadth escapes,
and is conscious of having done, what he can never venture to do
again.   This  has been  especially my feeling every time  that I
have,  in turning  over  my case books, glanced my eye on the
following case of Jane Sharp.

               Jane Sharp, aged 27.
                          January 15th          M. J. Bell.
   "About 12  years ago,  without any evident  cause, she ob-
served a small very painful tumour forming immediately  un-
der the  right ear, which  gradually  increased for  four years,
 until it had arrived at the size of a large goose's egg,  rising up
anterior to the  ear.   At this time  she had it  cut out; during
 the operation she  lost a  considerable quantity of blood, and suf-
 fered great pain;  since  which  she has been unable to move the
 muscles of that side of the face, which are paralysed, in conse-
 quence of the division of the  Portio Dura,  or  fascial nerve.
 About a year after, the  tumour began again to form,  accompa-

   * The fketch of this diffection  explains the difficulty and delicacy of it.  The
 lobe of the ear is marked (a) ; it was from the hollow betwixt the ear,  the angle
 of the jaw, and the vertebrae, that hollow where the  carotid arteries lie, th^t the
 tumour was diffected.   In order to avoid deformity, 1 had made the incifion lon-
 gitudinal only, and not  very lopg, no more than three  inches; '(b) marks the
 lower lobe of the parotid gland, which in its natural fituation extends  almoft to
 the angle of the jaw, and which in this cafe entirely involved the fchirrous gland ;
 but at (6)  the parotid was diffected from the  furface of the gland, turned up-
 wards and held afide by the hook, till the gland (c) was diffected out from be-
 neath it. The whole appearance of the parts was in this  cafe like that of a dif-
 fected hernia, the fafcia of the gland (</) refemhled in fome degree that  of the
 herniary fac; the parotid refembled a thickened omentum, which being tamed
 afide expofed the gland,  as the laying afide of the omentum in operating tor her-
 nia fhows the turn of the'incarcerated inteftine. 
Lips, Cheeks, and Throat.
507
nied occasionally by lancing pains ;  since which time it has in-
creased  gradually.  It is  at  present about the size of a large
hen's egg, hard, unequal  on its surface,  quite  colourless, and
at times accompanied by stinging pains.  It extends considera-
bly behind the jaw, and on the anterior part of it  is  seen  the
cicatrix from the former operation."
                           17th.
  A tolerable night's rest, no  haemorrhagy, but she complains
ofpain in the throat and difficult deglutition.
                           18th.
  She complains to-day of difficulty of breathing, the pain of
the throat continues, the  bandage being slackened, there is im-
mediate  relief to  both, she sleep's ill,  opium is substituted for
the draught.
                           19th.
  The sponges adhere firmly to the surface ofthe wound, there
is little t nsion or inflammation of the parts, but she still com-
plains ofthe pain in the throat, chiefly on deglutition.
                           20th.
  Two of  the sponges were  removed with little difficulty  or
pain, no haemorrhagy.   The wound is filled up with lint.
                           22d.
  All the sponge is removed.
                           25 th.
  The discharge is copious.
                       February 4th.
  The cavity fills up rapidly.
                           15th.
  She continues to do well.
                          25th.
  She was dismissed nearly well.

     Report of the Operation  by Mr. Bell,  January 16.
  " The one  half of the parotid gland,  that which lies behind
the angle ofthe jaw, had been  left :  the scar of the former ope-
ration was on the fore  part of the tumour  : the tumour lay be-
hind and under the ear, pressing deep betwixt the mastoid  pro-
cess,  and the  rising branch of the jaw-bone.  It seemed  out-
wardly a small tumour, but it had shot  down very deep, ad-
hering to the pteregoid process and to the back of the pharynx.
The dangers of the operation were these ;  the portio dura, and
the 9th pair of nerves passed through the tumour : immediately
under it lay the  trunk ofthe carotid.   The external carotid be-
hind the lower jaw,  but  chiefly the large jugular vein, was in
danger,  for the  tumour lay so  entirely under the mastoid mus-
cle  that part of the muscle is taken away with the gland.   The 
508              On Tumours ofthe Gums,
gland being dissected free in its lower part, where it lay near
the carotid artery,  was torn up from  the roots where it ad-
hered to the back of the fauces.   The  internal  maxillary arte-
ry bled  very  profusely ;  a small piece of sponge, the size of
the thumb, and supported by other pieces of sponge filling up
all the hollow, was  pressed- upon the artery at the back  of the
nostril.   The swelling of this piece of sponge caused a difficul-
ty of deglutition,  which ceased when the sponge was removed.
After the operation I put my finger into the hollow whence the
gland was extracted,  which I felt to be two inches and a half
deep ; at its lower angle,  (i. e.) behind the corner of the jaw-
bone, the carotid lay bare, beating strongly, not dilated; the
upper part of the wound was deep,  so that the finger touched
the pteregoid process forwards, and the apophysis cuneiformis
ofthe occiput backwards ;  and  when she swallowed, the mor-
sel,  in passing down  the pharynx,  pressed  upon the point  of
the finger."
   When it happens that a glandular swelling, small in its first
stage, and but too  little formidable  to excite alarm, grows  in
its second stage to such magnitude as  plainly to require extir-
pation,  which the  surgeon, even after  he has begun the opera-
tion, dares not complete ; when the same unhappy person pre-
sents himself again, claims the assistance of the surgeon, will-
ingly offers to subject himself to any operation,  however severe
or cruel, but is by a formal consultation rejected and  bereaved
of all hope  of relief, is not the doctrine explained  in my pre-
liminary observations, but too certainly proved ?  In this sense
I venture to call your attention in a particular  manner to  the
case which I am now to relate, and to  the reflections which oc-
curred to me on this consultation.
   " Jenny Brown was a poor solitary thing, who worked la-
boriously to maintain her aged mother, her father  being some
years dead :  she slaved at all  kinds of work as an out-servant
in a farm-yard. After churning milk, being exceedingly heated,
she went out  with her cap loose,  and jaws exposed, and by
carrying bundles  of wet grass for the cows, upon her head, had
a severe toothach, for which a tooth was pulled, and still con-
tinuing the same labour, she got  cold ; thence arose a kernel-
like swelling of a gland under  the lower jaw near the gum of
the corrupted tooth.  Her face was swelled, so that her eyes
were closed; the lump grew as big as a hen's egg, with severe
pain ; the swelling of  the face subsided, the pain ceased, but
the glandular tumour remained.
   Whenever an  operation  is ill-concerted; when  the surgeon
proceeds to  extirpate a tumour with  this vulgar notion in his
head. " we shall trv to take it away,"  he is almost sure to fail : 
Lips, Cheeks, and Throat.              sof
 accidents, no doubt, will  prevent the most dexterous surgeon
 from  accomplishing all his purpose, and a zealous  man will
 sometimes attempt what he dare hardly perform ;  but a sur-
 geon  really acquainted with the uncertainties  and difficulties
 01  his profession,  will, even in  the least dangerous circum-
 stances, reflect long and  much on the nature  of the tumour
 which he is to extirpate, and the anatomy of the adjacent parts ;
 whether it consists of various smaller glands,  or of one only ;
 whether it has its arteries from one  point or stem, so that it
 could  be dissected  round and insulated,  this point being left to
 the last entire, or from various sources,  so as to make a slow
 and bloody operation  necessary ;  whether these  arteries must
 be cat near to their going off from  some  large trunk,  as  the
 carotid ; whether a large vessel itself,  or its immediate branches,
 may not be entangled in the roots of  the tumour.  Such calcu-
 lations I will venture to say never entered into the mind of the
 operator, who first adventured to extirpate this tumour :  he en-
 tered  upon it with little premeditation, and stopped short at the
 first slight appearance of danger.
   To  extirpate any tumour safely, you must keep to its sur-
 face ;  dissect cellular substance only ; never touch, if possible,
 its system   of vessels; if  once you plunge into its centre, you
 are inundated with blood,  (unless it be merely a steatoma) and
 your future dissection is irregular and imperfect.   A very long
 incision being made, the operator seemed to me to plunge into
 the very heart of the tumour, several arteries (not, it is mani-
 fest, of very dangerous size, for he had never even approached
 the roots of the tumour)  threw out blood, all the  assistants
 thrust  in their  fingers to stem the blood,  and the operator  tak-
 ing advantage of this consternation, little confident in himself,
 and having calculated no circumstance beforehand, obtained an
 easy and unanimous vote,  that the incision should be sewed up.
 This was to me manifestly the result of an imperfect know-
 ledge of the route and size of the several arteries,  of the error
 of cutting towards the centre of a tumour, and of the worst of
 all faults and weaknesses,  that of  turning  round with  fear and
 trepidation, in the midst  of occasional  difficulties, to consult
 those,  who from the moment an operation is begun, should be
 no more than spectators.   It proceeds from a paltry desire, to
 make the attendant surgeons parties,  not to the  general opera-
 tion, for which they  have given their voice,  but to each step of
 it.   Let the surgeon act from himself according to the best of
 his  judgment,  cut slowly when  he is conscious  of approaching
 too near the great  vessels,  and  stop when alarmed  by  that
 immediate   sense of danger, of which he  must  be  the  sole
judge, or at least the most competent. 
510
On Tumours ofthe Gums,
   One advantage this poor  creature derived from this unsuc-
cessful operation, viz. the relief from pain, tor she was relieved
by the loss of blood, insomuch that she recovered her  health,
and, in some degree,  her strength,  and returned to  work  tor
the support of her old mother ; at least she could spin.  *or
a long while she has been unequal to this ; she has lingered and
wasted in a very helpless  condition, and is now in a state ot ex-
treme weakness for want of food :  she walks but a  few paces
without  stopping for want of breath ; her swallowing is  dim-
cult ; she has great pain night and day Irom the mere  distention
and size  (I am persuaded) of the  tumour, which is not  red-
dened in the very slightest degree :  the weight ot the tumour
is intolerable, and it appears to me that, m  not many weeks,
at the utmost in a few months, she must be released from her
sufferings.   She has saved one  shilling to enable her to travel
to town,  from the village she lives in, (Falkirk) which is about
20 miles distant; and  now,  from  the  first and unsuccessful
operation,  she presents  herself, after no great  lapse ot time,
with a tumour so enormous, as to make the  question of  ope-
rating  difficult to resolve,  but in  a condition  which  admits
no delay, she  is sure  to  die, and  willing to  suffer  any thing
which may tend  to save  her life : there is one inducement  to
comply with her request,  viz. that she must surely die, though
from no  other cause than the bulk of the tumour: the tumour
not being  cancerous,  leaves us nothing  to  dread  alter the
operation.                                   .
   A  consultation  has decided that  no  operation  can be per-
formed.   I imagine there are very many safe and easy ways
by which this  tumour,  great as it is, may be extirpated, or de-
stroyed ; and, reflecting upon the possible success ot  such  an
attempt,  I  think I have  estimated  the dangers fairly, and  as
impartially as if the operation were my own appointed task.
   This poor creature's difficulty of breathing seems to me to
proceed as much from the weight of the tumour,  as from the
hold it has upon the parts ;  from the immense mass resting up-
on the trachea and oppressing even the  breast.   The tumour
has every character of what is usually called a wen ;  the whole
rriass incredibly  hard in proportion to its bulk, so that she sup-
ports it continually with a sling round the head and neck ; it is
extremely  firm,  not very vascular  throughout  its  substance,
but receiving  its arteries'at particular points ; it has no great
veins running over its  surface, whence  it may be  presumed
that it has no  very irritated circulation, nor any thing of a can-
cerous nature.  The  whole surface  of the skin  is healthy and
free from redness or any blemish,  except where the scar of the
former operation passes  obliquely over it : it is plainly glandu- 
Lips, Cheeks and Throat.
511
lar, the  most  prominent parts indeed consisting of  individual
glands:  two  large distinct prominences  lying one before, and
another behind the ear, form the chief bulk of the tumour at
that part, and  are plainly separate glands, moveable both in re-
lation to each  other and to the main  tumour.  The extirpation
of that  part which lies  under the chin could give us no con-
cern ;  there  we  could  cut  no arteries  but the   facial,  which
would be divided in separating the tumour from  the line of the
lower jaw; its own weight seems to have lengthened  its root,
and drawn it down  from under the ear, and from the  angle of
the jaw: it hangs  so that I can push the points  of my fingers
deep behind it, without  feeling any  strong adhesion,  and, I am
confident, it has  no dangerous connection  with  the carotid at
that critical point, where it forks behind the jaw-bone into the
external and internal carotids.   I am confident that the carotid
and great jugular vein lie together safe  in their sheath, while
the tumour, lying external  to  the sheath,  might be dissected
away from it: from the mastoid muscle, and Irom  the vessels
beneath  quite safely, as we often find immense tumours ofthe
thigh (equal almost in size to the patient's body) are dissected
from under the Sartorious muscle, without injury to the femo-
ral artery.   The  worst effect of the tumour, and the most dan-
gerous adhesions of it are to  the side of the throat, to  the os
hyoides and its muscles ; there, by pulling down the os hyoides,
it makes the swallowing difficult,  and oppresses  the breathing
by its weight; and at that point there might be infinite trouble
from arteries  proceeding into the body ofthe tumour from those
ofthe thyroid gland. But the tumour is, by its weight, dragged
so  away from the  jaw, and admits the points of all  the fingers
ranged in a line, so deep on all sides, that, though I foresee much
 difficulty, I find no absolute danger in the attempt.  Yet it must
be done by one who goes not to work with  the general  and con-
fused notion, of extirpating the tumour u as circumstances will
admit," and, proceeding according to the best of his judgment.
His judgment must be decided and designs matured before he
begins; he must calculate  at what points the  arteries enterj
what the probable  size of those that come from under the chin,
from the lingual arteries ;  what the size of these derived to  it
 from the facial, where it crosses the angle of the jaw ;  what the
 size and probable direction  of those coming to  it from the oc-
cipital, or temporal branches of the carotid ;  or those deep ones
 coming from  thyroid arteries ;  he must resolve  in  what  suc-
 cession to  cut them, and with what precautions.   The surgeon,
who  sees an artery throw out blood furiously,  and in  the neck
too, not knowing from what root it comes,  must instantly fall
jr.to great  coufusion : but if  he has calculated  every probable 
512
On Tumours ofthe Gums,
danger, he  is prepared, and his  patient comparatively  safe.
In the present case, the incision should be made, not over the
centre of the tumour ; the purpose or saving all the skin which
invests it, is  absurd, and the conception of dissecting into its
substance, extremely ignorant.  The oval incisions should be
made to  encircle its'upper and lower parts ; there are points in
which it should be opened freely, as there the chief dissections
are to be performed.  The great and  dangerous  dissection
would be in  the line  of the lower jaw,  about three inches  from
it, and extending from behind the ear to  the throat: the skin
being laid back, this dissection would follow the convex of the
tumour ; the tumour falling by its weight would widen the in-
cision and expose the parts,  the  left hand laid  upon it would
press it down, while the assistant retracted the skin :  the  fore-
finger of the left hand would guide the dissection; the  point
of it, fixed upon each lesser artery successively as it bled, would
stop it till it shrunk : the  form ofthe tumour, the line of inci-
sion, and the direction of the jaw-bone, would keep the relation
of parts distinct:  the operator would certainly  know when he
approached  any dangerous point;  in drawing down the tumour,
and dissecting it  from under the .chin, he would cut branches
of the  lingual arteries :  pressing the tumour next down  from
the angle of the jaw, he would cut the facial artery ;  and would
go no  further in that direction ;  having tied the facial artery,
he would next, in tearing away the  tumour from under the ear,
divide branches of the occipital and temporal arteries : it  is the
seeing those arteries bleed furiously in succession, without fore-
sight,  without knowing from what trunks, in what directions
they come,  or knowing what may next  happen, that makes an
operation seem bloody and dangerous.
   In next dissecting deep into the  angle  or  cavity  below the
jaw there must be  danger; every incision must be  made with
caution, the point of the fore-finger must go before to feel for
the beating of the carotid  artery; and  much  should be done
now by  laceration,  the tumour being inclined first from  the
chin backwards, then from  the  occiput  forwards,  and pulled
so as to give a distinct feeling of the parts with which it is con-
nected, whether, for example, pulling upon the tumour moves
the os hyoides fairly along  with it, whether the tumour sends
down roots, involving the  carotid  and  internal jugular  vein:
this deliberate and daring proceeding would,  I doubt not,  en-
able the surgeon to approach by dissection, or laceration, quite
close to the only dangerous point, viz. that where  the carotid
lies under the angle of the jaw: if, having reached  that point,
he found a  clear and distinct cellular substance,  to lead him in
his dissection,  he would, pressing aside the dangerous parts 
Lips, Cheeks and Throat.
51p
 with his finger, continue it with equal deliberation through its
 next stage ;  if he found inextricable adhesion, and increasing
 hsemorrhagy  he would  stop ;  but, having so far insulated the
 tumour, he could, if forced to stop,  tie its root, even though
 several inches thick, and strangle it, if not with a surgical li-
 gature, at least with a garter or coarser string.
   I should not, in  the slightest  degree, shrink from such an
 operation, and would dissect so very large a tumour with less
 reluctance, than  many a smaller one I have dealt  with.  I
 have even a  persuasion, that  this second stage of growth may
 be accompanied with circumstances  favourable to the opera-
 tion, the  weight of the tumour elongating its roots, weakening
 its adhesions, and  concentrating its arteries.   I beg leave to
 remind you of another  circumstance in such  an  operation,
 which you will do well to attend to.   Do not  dissect in haste
 and in a hurry,  for by  time and circumspection, you can ac-
 complish things which  seem  impossible, and I would explain
 my  opinion  and my practice more fully thus :  *k Would there
 be much danger had you to deal at once with one only of all
 the arteries which  are  cut in extirpating a  tumour?"  None
 assuredly.—" Would there be much additional  danger were
 the pain of this  dissection extended from a quarter of an hour
 to an hour ?"  None.  Let us apply this reasoning to  the  case
 before  us  : I have uniformly  found, that permitting the blood
 to stop  entirely, and the incisions to become dry before bind-
 ing up a wound, contributes to  its speedy adhesion;  in all  ope-
 rations  I wait long: this is with  me one universal rule in ope-
 rating.   I  have  as uniformly found, that, when a dissection be-
 came perplexed and confused,  the taking up of the large ves-
 sels,  and  allowing the bleeding from lesser ones to cease, and
 waiting till the surfaces get that raw look, which betokens the
 drying up of the blood,  explains  every thing, and restores that
 clear conception which I had at first of the relation of parts, of
 the arteries I  have actually cut  and  tied, and of those  which
 are still endangered : and this  I regard as a  rule in all difficult
 operations.   In  dissecting  this tumour, or such a one, I am
 convinced that the danger might be  brought within very nar-
 row limits, and am confident that, in the present instance, even
the lower lobe of the parotid gland, as well as the sheath, con-
 taining  the carotid artery  and internal jugular vein, lie  under
and behind the  tumour; in short, that the gland lies betwixt
 the tumour and  the artery, and defends it.
   But are  there not various ways,  independent of direct inci-
 sion, for working out, or  weakening the roots and adhesions
 of rhis, or even of a more formidable  tumour ?  May not a
greater  enterprise than this be atchieved by partial incisions, 
514
On Tumours ofthe Gums,
 by ligatures, or  by both combined ?  The  two  great globular
 knots which form  the upper part of the tumour, and project
 before and  behind the ear, are, I am persuaded, so insulated,
 that they might be dissected away  by one operation,  reserving
* the great mass ofthe tumour  for a second :  or the  operator
 might go as far as he safely  could *by direct incision, and  then
 striking a long needle, like those with  which 1 have been ac-
 customed to transfix large strumous sacs, pass a ligature through
 the tumour  to be tied  on either side of it  ; or  the tumour, I
 am persuaded, might  be so  pulled  away from the throat, and
 the  long and crooked  needle  I speak  of passed so cunningly
 round and under the tumour, as  to  pass the ligature round it
 without any preparatory  incision.   It is possible to  penetrate
 so into the body ot the tumour with  caustic, as to pass a  liga-
 ture  through  its centre, and after extirpating the chief mass by-
 stricture,  to destroy  the root  by   a  continual use of  the caus-
 tic.   It is possible without penetrating  into its  centre,  to dis-
 sect  up one side, or to pass the long needle obliquely through
 one side, so as to give a hold to the ligature, make it embrace
 the neck of  the  tumour,  and  by  twisting it with a tourniquet
  (made by twisting  a stitch in the ligature,   and slipping a piece
 of pasteboard under the knot) from day to day, mortify  und
 extirpate the whole mass.*
    But there is no need for  subterfuges in  a plain  and  simple
 piece of dissection, which, though not without danger,  is  vin-
 dicated by the  suffocating condition of the  patient, and by the
 inevitable nature of that death which awaits him, an operation
 which, though not absolutely safe, is so, in  the hands of a  dex-
  teio.us surgeon,  witness the  following most  interesting  case.
 The most considerable tumour,  seated  in so dangerous a part
 as the neck, which I have ever in my life extirpated, (says M.
 Petit) occupied all the side of the face, neck, and Jaws ;  it  was
 almost entirely  circular,  extended from around  the  ear,  both
 before and behind, upwards  to the angle of  the eye, forew aids
 to the corner ofthe mouth, and downwards  over the jaw, along
 the  neck, to the articulation ofthe clavicle with the  acromion
 process.   It was seemingly eight inches in diameter, and the
   * My reader, unlefs he be a practical furgeon will  not readily feel the reafon
 of my enumerating thus the many refources  which will present thtmfelves, nor
 the fad neceffity of having recourfe to fo many means.   What dangers in the way
 of operation, what continued tortures by any  flower and lefs dangerous method,
 will not a  man undergo to fave life ?  This poor creature probably died,  as
 thoufands have died, in a ftate of protracted fufftring;  and the furgeon who has
 witneffed fuch  a fcene, who has felt compunction at having lightly difmiffed a
 patient in the early ftage of a tumour, which has afterwards proved fatal.or who
 has felt  the difficulty of deciding when a tumour was plainly to prove fetal, hut
 yet too deeply connected to allow of extirpation, will think over all the poffibk
 i-.cfouvces with  fiacerc intcreft.                             - 
Lips, Cheeks, and Throat.               Slh
patient, about 50 years of age, had carried it twenty years ;  foi-
st was of slow growth, its first beginning being a glandular in-
duration,  seated about two inches under the ear, and lying on
the mastoid muscle.                            *  .
   When  this tumour was  no bigger than  the  fist, I advi.pd ■**'
him, and often repeated the'advice, that he  should have it ex-
tirpated.   When he refused, I prescribed such discutient re-
medies as I imagined might have some effect;  and every time
I repeated my advice, he rejected  it entirely, because he could
still conceal the tumour under a voluminous peruke, such as
was then in fashion: but the tumour  increasing in  bulk, so as
no longer to be  concealed, and growing so painful as to excite
alarm, he convoked a number of surgeons to have their  advice.
I alone, of all the gentlemen consulted,  advised the extirpation
ot this tumour ;  each of us, as the consultation  was not  held in
the presence of  the patient, spoke his mind freely; and when
it came to my turn, I explained myself thus : *<• Of all the rea-
sons, gentlemen, which you have advanced against the opera-
tion, one only affects me, and that is the fear of hsemorrhagy
from the  numerous arteries of this tumour, which not having
one root or  pedicle, would bleed at once  from all points, and
from the number  of its arteries, some most likely of consider-
able size, the patient might lose  much  blood, perhaps his life.
These, said I, are the dangers, but have I not skilful assistants
willing to stand by me? What then should I fear? I shall cut
away the  skin along with the tumour which it  covers, because
they adhere, I shall first dissuct away the part that lies over the
cheek, and  some  one of you appointed for that  duty, shall be
ready  to clap a  finger on the  first artery I cut; and  as I pro-
ceed in my dissection, he will have a finger ready  for each ar-
tery that springs.   Thus  shall  I pursue  my operation, and
whatever number of arteries are cut^ so many fingers will there
be ready to compress them ; and the whole being accomplished,
finger  after finger being raised, first from the greater arteries,
and next from the smaller, each in succession  will be secured
with the needle and ligature.   The scheme was acceptable to
ail of  them.  It was deferred  only till  the following day, and
never was a  project better fulfilled, for never perhaps had  a
young surgeon  so many of his masters in surgery to support
him.   Arnould,  Tribauld,  and the elder Le Dran, held their
fingers on the arteries.   The smaller ones of the eye-lids,  lips,
&■:. were considerably dilated, but those which occasioned the
most trouble were the  anterior and posterior branches of the
temporal artery,  and the  facial where  it turns round the lower
iaw.   Kach ligature hdd its place : at the first dressing not  a 
516              On  'Tumours ofthe Gums,

drop of blood flowed  ; in two months, or little more, the wound
was cicatrized."*
   You will observe that M. Petit's confidence in undertaking
an operation so formidable,  arose from a conviction of the tu-
mour  being superficial; not under  the mastoid  muscle,  but
above it;  not  connected with the carotid artery, but endanger-
ing only  the temporal, and  facial branches.   But the  question
is a very awful and serious one, when the tumour is seated be-
neath the  mastoid  muscle, projecting from  under it in conse-
quence of its great size, and probably connected at its root with
the sheath which includes the carotid artery and great jugular
vein : such a tumour, if  firm, glandular, growing rapidly, and
pressed inwards by the perpetual bracing of the mastoid muscle,
will connect itself so  with the parts  beneath by  adhesion as to
make  its  extirpation  dangerous  in the last  degree, and  it will
at the  same time press so upon the throat  as to make the at-
tempt an act of necessity and duty.   Often I have had  occasion
to consider the anatomy of thispart ofthe  neck, and especial-
ly of the  vessels and  nerves lying in the angle under the jaw-
bone, but never  more anxiously, than  when preparing for the
following operation.   The subject of it was a  gentleman about
35  years  of age, of the best,  and most grateful  dispositions,
and the  stoutest heart.  He confidently required me, on my
allegiance and duty, to perform the operation if I found it at all
consistent with safety, although  it had  been  forbid in ma-
ny former consultations with other surgeons:  his courage was
not in  words only.  While I performed a very painful and slow
dissection,  he sat  like a monument.  The tumour projected
from under the ear, of a stony hardness, and of such a bulk as
to  fill up all the angle betwixt the ear, jaw-bone and neck :  it
extended  backwards  behind the ear three inches, forwards to
the chin^ and downwards along half the neck ; it already dis-
placed the larvnx and  throat, pressing  them over  towards the
left side ; and made the swallowing difficult, and the breathing
so laborious, that  he  could no longer sleep at night, but started
out  of bed, partly from suffocation,  partly from fear ; it in-
creased withal very rapidly  in size.   The  sum  of the opinion
which I delivered to him in writing  was this : u that a tumour
so situated could  not cease to grow, and could not fail to pro-
duce, at  no very distant period,  the  most  distressing conse-
quences:  that upon comparing the  tumour with the great ves-
sels and nerves ofthe neck, it  was my persuasion, that though
it lav upon the great  carotid artery and jugular vein, it had tie
essential  connection  with  them, and that  the only  arteries
*■ Ouvrage Pofthume de J. L. Petit. 
Lips, Cheeks and Throat.
517
 which would be unavoidably cut were the temporal, occipital,
 and facial arteries:  that the carotid, with its accompanying vein
 and nerve,  were involved in  their own peculiar sheath ; that
 the angle where the great carotid branches into the thvroid, fa-
 cial, occipital, and temporal branches, was protected by the mas-
 toid muscle, and by their sheaths of  cellular substance: that I
 thence inferred, that, though no  such operation can  be  void of
 danger, there was in the present case, nothing to deter the sur-
 geon  from attempting so needful a dutv : that  I  should with
 pleasure assist at this operation, or  with equal alacrity perform
 it;  but, that I conceived it a  necessary privilege that  the
 surgeon who made  himself responsible  for the life of a patient,
 should be  entitled, in  all irregular  operations,  especially  in
 one so full of danger as this, to stop at the first apprehension of
 danger."
   The history of every tumour must  be alike: and  I found in
 the history of this particular tumour nothing interesting.   Were
 I inclined to draw any inference, from what mv patient told me
 of the origin and growth of this tumour, or from the severe and
 dangerous operation he was forced to submit to, it would  be that
 so strongly enforced in my Preliminary Discourse: viz. That
 no tumour,  when it passes the usual  limits of a swelled gland,
 and begins  to adhere  to the surrounding parts, should be per-
 mitted to grow ; for this  too, like that of Jenny Brown, was
 but  a swelled gland.  The description of every-  dangerous  tu-
 mour is delivered by  the patient in the same phrase, u It be-
 gan like  a little knot or kernel, and  grew slowly :" it is  there-
 fore unnecessary to detain you with insipid and  trivial  details
 of its growth.
   My first  desire, on  all occasions  of danger, is to  make just
 conjectures in regard to the internal relations, and probable ad-
 hesions of the tumour ; and on these to found a true prognosis,
 to be delivered to the  patient, or his friends, and  a rational
 scheme of the  several  parts and steps of my  intended  opera-
 tion.   First, I found  the tumour of  very  formidable dim-n-
 sions, projecting to the perpendicular height of four inchfs,
 and terminating in an apex, which stood as prominent from un-
 der the ear,  as the  chin from  the  face  and throat; and this
 pointed apex was the  smallest part of the  tumour,   which  in-
 creased in bigness  towards its base,  and  there, especially  in
 the part lying under the mastoid muscle,  though it was move-
 able,  because the muscular parts of the  neck are moveable, it
seemed solidly connected with  the parts  beneath it.   Secondly, -
though that never could be regarded  as  a superficial tumour,
 which  lay, in its  biggest  part, und  r the belly of the mastoid
muscle :  yet  I found no motive for clespa.r, for 1 was. by eve- 
518             On Tumours ofthe Gums,

ry  calculation, persuaded it had no  very intimate  relation
to the more important vessels, but stood thus connected:  it lay-
so close upon the carotid artery, that it entirely  covered that
verv dangerous point behind the angle of  the jaw, where  the
carotid forks into  the great branches  destined to the thyroid
gland, tongue, face, and temple : that it lay  closer still upon the
root ofthe occipital artery,  and covered the whole length ot
the facial artery, but, though deep in  respect of the mastoid
muscle, and firmly compressed by it, it was superficial in respect
of the carotid artery, for the angle where it forks  into its great
branches is covered  by the styloid process,  and the muscles
arising from it; and is even bound down and protected by them.
The great carotid, the jugular vein, and the eighth pair, were
not only thus  protected by  the styloid process,  and muscles,
but are  farther involved in  their peculiar sheath of fascia.  It
thus seemed to me less dangerous to extirpate  even this great
tumour, than the smaller one of Jean  Sharp,  seated as it  was
deep behind the ear, were  the carotid artery lies ; yet the de-
gree of security, arising from this  interposition of the styloid
process, betwixt the angle of the carotid, and the body of the
tumour, only rendered the  Operation possible, not safe : there
were other manifest dangers to be  encountered, the tumour
passed under the mastoid muscle, and was so connected with
its inner surface as to require that muscle to be turned entirely
backwards in dissecting the tumour from  beneath it; the tu=
mour could not, without a degree of danger, be detached from
 the side of the throat, where, as it seemed to me, the carotid,
the temporal, and occipital  arteries, could  hardly escape,  and
where the inosculations of the external jugular vein, with the
great internal jugular, would not fail to be cut across, so as to
cause, if not, a dangerous, at least, a very  perplexing hasmorr-
hagy.
   With these conceptions I formed that plan for the operation
which succeeded so far, as to carry me to the very roots of the
tumour, and save my patient from  very imminent darger.
First, I resolved to have  full  room  for such  a dissection, and
to carry the external incision  obliquely across the neck, in the
direction of its natural  wrinkle, following,  in some  degree, the
edge of the mastoid  muscle, beginning the incision on  the oc-
ciput three inches  above  and behind the ear, and ending  four
inches below the chin:  Secondly, to dissect up the skin large-
ly and widely, and, turning it back, proceed to dissect up the
 mastoid muscle from the tumour:  Thirdly, to  dissect away
the tumour from the lower  and lesser  point, where it projected
from under the mastoid muscle backwards, but not far ; and to
 dissect it next down" from the ear and from  the  chin, towards 
Lips, Cheeks, and Threat.               519
the place ofthe carotid artery :   Fourthly, the tumour and the
mastoid muscle being  moveable  in  respect of each other, in
place of merely  raising up the tumour gently from under  the
mastoid, with  the design of dissecting, resolved to poise it up
strongly, in the intention of tearing it away  from its adhesion,
and gouging it out with my fingers.  I perceived that using
my knife here,  though it might not much endanger the carotid,
would  wound its branches close to the trunk.  I considered la-
ceration as the  true principle of our proceeding in all such dan-
gerous points, and the thrusting in a piece of sponge, as the best
means of  suppressing  any  occasional  hsemorrhagy.   I have
gouged out tumours with the fingers u more laniano,"  which I
should never have dared to attempt with the knife.
   From this plan of operation, I confidently expected that there
would be no other haemorrhagy than from  the  general wound,
viz. blood oozing out slowly, from the cut-surfaces, as menstru-
ation does from the surface of the womb ; unless it were that
sudden gush of blood which flows from the jugular veins when
cut across, but  which will cease  instantly,  and will be distin-
guished by its black colour and by the want of pulsation, so as
not to create even a momentary alarm.
   This plan I put in execution with  great success, and it rests
upon my  own  mind as a conspicuous instance of an operation
performed in very inauspicious circumstances, without spilling,
I may say, one  drop of blood, where it seemed difficult to es-
cape wounding even the greatest arteries; his shirt  was hardly
moistened, and I had no other cause of alarm, than feeling with
the point of my finger the great arteries beating.  First, the out-
ward incision of fully eight inches long, being carried round the
neck, and over the apex of the tumour, the mastoid muscle was
dissected  away from the body of it, and so entirely insulated,
that my assistant taking it on his fingers, turned it before or be-
hind the tumour, according to the part that I meant to  dissect;
and thus I dissected sometimes before, and sometimes behind the
mastoid muscle.  In this dissection the platysma myoides mus-
cle and strong fascia of the neck were dissected back along with
the  skin.   Secondly, in dissecting down the tumour from the
occiput, and from the chin, no conspicuous artery bled, and my
assistant, while  I dissected along the line of the jaw, followed
my knife with his finger-points of both hands, go arranged  in a
line, and following the  incisions  in its whole length so correct-
ly, that, by holding down the surface from which I was dissect-
ing away the tumour, he saved the arteries which might other-
wise have been cut,  and was  ready, had  an  art€ry  bled, to
cover it instantly, and make its place by clapping the point of a
Snger upon it;  and thus he followed the dissection over the an- 
j20              On Tumours ofthe Gums,
gle,  and  along the whole  length of the jaw-bone, repressed
the throat where the lingual arteries and nerves run along, and,
by  pressing down the carotid artery and its sheath, enabled me
to carry my dissection down  very low, I dissecting and pull-
ing the tumour away from th'J jaws,. while he repressed the
parts, at one  time with the line of his fingers, at another period
of the dissection with a long flat piece of sponge,  cut  for the
purpose.  Thirdly, turning  the mastoid muscle now  off from
the tumour,  I began to  tear  upwards and  dissect the lower
part, that which projected, according to the natural relation of
the parts,  from under the mastoid muscle at  its  back part:  and
here, for the first  time, I  found reason to  hesitate;  for  this
part of  the tumour was connected actually  with the spine,  it
seemed to shoot down strong thick mots, or fangs, betwixt the
transverse processes; the external branches of the nerves which
proceed from betwixt the  cervical  vertebrae,  I  had no scruple
nor fear of dividing across,  but I  was come now almost to the
flat fence of the vertebra?.    I was going deep behind the pha-
rynx and the  sheath of the carotid, and was sensible that the di-
viding the phrenic nerve, (for the principal part you recollect of
the third cervical nerve is destined for the  diaphragm,) would
probably prove fatal.   The harm I might do was terrible, the
good  problematical; very  little of the tumour remained, it was
such as  even  my assistant could hardly  perceive, much less a
spectator, but I found myself not entitled to venture farther, I
therefore cut these roots across, and, having  thus delivered the
patient  from this tumour,  I felt the great chasm left by  it —
Now, Gentlemen,  I  am  explaining these  matters  for your in-
struction, and  the good of humanity,  and  with thoughts far
above any politic regard for my own reputation,  such as might
tempt me to conceal or palliate  any fact:  the  little portion -that
was left of this tumour I could  hardly feel:  I  had no  misgiv-
ing in my own mind beyond  that vague, indefinable  anxiety,
which an upright man should feel after an  operation, however
promising, and which I have never failed to  suffer  from,  even
where most  successful, for I  am ever apt  to imagine, that I
might have performed the operation better,  and this was all I
felt at the time, it was only by future consequences that I was
struck with  regret for not  venturing a  little deeper *   The
chasm left by the extirpation of the  tumour I next examined ;
the dissected mastoid muscle lay  loose  and flapping, and we
turned it occasionally over, from one side to the other, to look
for bleeding vessels, but there  were  none, there was  nothing

  * The tumour, in little more than a year, began to grow again; and it is now3
■•>■: the diftance of two years, as large as at the time of the operation. 
Of Salivary Tumours.
521
but the very slightest general oozing, the surfaces were dressed
with lint,  with a  very gentle compression :  the wound suppu-
rated favourably, and healed within the month : but the tumour
has grown again  to a great size.   Such are the difficulfand
distracting circumstances to which those are reduced who, from
their own timid dispositions, or the ignorance of their medical
friends, have allowed an indurated gland to grow and fasten
itself by adhesions, to  the surrounding  parts, and to push its
roots deep into the neck, or axilla.
DISCOURSE  XXV.
                   Of Salivary Tumours.


JjUT it is not the discussing of interesting doubts, and ques-
tions of life and death, nor the  performing operations within
the extreme limits of  possible success or possible safety, that
constitutes  the chief occupation  of one engaged in  practice—
The more homely talent of distinguishing the various aspects
and characters of tumours, and treating them judiciously, is far
more  desirable  to acquire ; and, indeed, there  is a very per-
plexing variety ol tumours  within the mouth, and round the
jaws,  which one learns to  distinguish, only by referring their
various aspects  to corresponding  peculiarities in the structure
of the  parts.  The tumours which I have just described are of
a very malignant character, and, I confess I know not whether
to refer them  to  the salivary or the lymphatic glands ; to the
latter,  rather,  I believe.  This, for example, of Mr. M-----,
though it looks like a tumour of the sub-maxillary, I know to
be a tumour ofthe lymphatic glands: had it been a tumour of the
sub-maxillary gland, which holds imbedded, I may say, in its sub-
stance, the facial artery, it could not have been extirpated without
dividing that artery : the sub-maxillary  gland is divided into two
masses, and the trunk of this artery is received into the recess 
522
Of Salivary Tumours.
 or cleft, the artery seems to twist round the gland, and I have,
 both in extirpating the sub-maxillary  gland, and in assisting at
 such operations, recognized it by this mark.
    The following case, if not full of interesting particulars, is,
 at least, accompanied with useful rules ; and  I transcribe it
 from  my case-book,  with those reflections which arose in  my
 mind, when forming my opinion and preparing for the opera-
 tion, as I have ever done with  a scrupulous and conscientious
 desire, to foresee every eventual danger, and recollect  every
 circumstance, anatomical or pathological, which might  contri-
 bute to my patient's good : the reflections, you will perceive,
 bear a mutual relation to the instruction of my pupils, and  my
 own improvement. It is the case of a young Lady who came
 from a very great distance,  urged by her own fears, and the
 persuasions of her surgeon, whose letter I shall transcribe.

                                 Shetland, Aug. 14,  1802.
     " Sir,
   " Though I have  not the honour of being personally ac-
 quainted with you, yet from the eminent and justly distinguish-
 ed character which you hold in the world, and  from my own
 observation  of your superior skill and abilities,  I beg you will
 receive Miss N-----, a particular  friend of mine, under your
 professional  care.  She  has for  more than three years had an
 enlargement of one of the glands under the jaw, which gave her
 not the slightest uneasiness, till of late that she has begun to feel,
 occasionally, some pain from it, which has induced her to take
 this journey, in order to have the real nature and tendency of
 the tumour determined ; and to submit to  any thing you may
 judge  most proper.   In the full confidence  of your affording
 her every attention in your power, I remain, with esteem, your
 most obedient.
                              " John  Barclay, Surgeon."

                      OBSERVATIONS.

   Every new operation, I perceive,  will afford for  my pupils
 some new rule of surgery, and prove to  myself a source of in-
 struction ; and  the various lessons which we derive  thus from
 experience,  are such as no conjecture nor previous study of  the
 parts will enable us to anticipate  ; nothing but a long  continued
 and faithful attention to practice can make a surgeon  skilful,  or
 enable him to give lessons to others.
   1st.  I observe in this lady's  case,  that  the gland affected
seems to be the very gland, which after  an unsuccessful opera-
tion, grew to so  immense a size in  the  case of Jenny Brown ; 
Of Salivary Tumours.
523
and  in her, though the tumour arose from  the  slightest and
most accidental cause, without any cancerous  diathesis  or other
mahgnant  tendency,  it proved  fatal by  suffocation, the most
miserable kind  of death.  What  might  have become of this
lady it is easy  to  foresee, had  she not been warned  by her
surgeon, and alarmed by the recent accession of pain for her
own safety.
  2d.  When we are consulted what is to  be done, in any par-
ticular case, we are in other terms called on to  prognosticate
what will  be the patient's condition at the distance of one  or
two years :  in the  present case the gland is very large and of a
stony hardness, it never can suppurate, it is even  threatened
with  a cancerous  inflammation, it is  indeed incapable of any
other ;  the pain requires that something should be resolved on,
and  our prognostic may be safely grounded on  this  unques-
tionable assumption, that  such  a tumour will not fail to grow,
and  that in one or two years the deformity and bulk, will .of it-
self be a motive, while the  suffocating condition  of the patient
will be an absolute reason for  operating,  however dangerous
the operation  may be rendered by such  unwise delay.  It  is
moreover to be observed, that the gland is the  sub-maxillary
gland, which  has  the facial artery nitched in betwixt  its two
lobes,  not so  inextricably indeed  as   the parotid is connected
with the carotid artery, but in a degree to give alarm and trou-
ble to the  surgeon, and accompanied  with a degree of danger
(in the case of operation)  which is well worth calculating.
  3d.  We are  to regard the actual circumstances of every  pa-
tient, as a part of his case, and the danger to this  lady, if  re-
manded to her own country, so far distant, and  so difficult of
access,  is but too  palpable.  Should we speak to her  the usual
temporising language, and say,  " it will perhaps  get well, a
slight course of mercury or cicuta  may be useful,  and time may
do much,  and perhaps it  may be  well to wait."   It may hap-
pen that the gland may become stationary in its growth, a mer-
curial course may  be of use,  but I fear that this is in the truest
sense  tampering with a tumour, and that time can do  nothing
but increase the danger.  It seems to me but too possible, that
this  lady,  before she can  take  a second resolution,  and accom-
plish a second journey, will be suffocating,  and  in immediate
danger of life : then we shall not  venture  to do that operation,
which is now comparatively  easy  ; for this gland being seated
in the  angle betwixt the trunk ofthe carotid artery and one of its
great branches,  the maxillary or facial, wdll  distend that angle,
and  both  the trunk and its branch will  be  too  closely united
with the tumour  to admit of an  operation: or will make  the
operation most dangerous and critical.   n 
524
Of Salivary Tumours.
  4th. Though  there is no imminent  danger in the proposed
operation, the circumstances are sufficiently forbidding to make
it far from being a matter of choice,   My assistant was unwil-
ling that it  should be performed without the advice of Dr.
Munro, and his assent  seemed rather reluctant.  The tumour
is  of very  considerable size, it is plainly  the sub-maxillary
gland, as  may be inferred from its shape, size, and peculiar
hardness ; not  a lymphatic gland, for then most likely more
than one would be enlarged.  We must be resolved to deal
with this artery in one of two ways ; either to dissect it so from
the tumour, as to insulate the artery, and turn the tumour from
under it;  or should this attempt threaten to embarrass our ope-
ration, to  cut it across where it lies over the middle of the tu-
mour, tying before dividing it,  lest it should  shrink back to-
wards its  trunk.   No one  circumstance is so favourable  to the
operation, as that  extreme  hardness of the  tumour,  which
makes the operation necessary ; for that shews  it to be circum-
scribed, and to  be little connected by inflammation, with the
cellular substance.

                NOTES OF THE OPERATION.

   We had agreed either to dissect so as to lay the artery to one
side, while employed  jn extirpating the gland;  or to tie  and
cut across, and  so proceed with greater freedom, in the more
dangerous part  of the dissection; but, after the first incision
which I made, according to the length of the jaw-bone,  the in-
cision being long and more free, the several parts  appeared in
so  advantageous a state, as to leave no  doubt or difficulty  in
the rest of our proceedings.   The artery presented itself arch-
ing over  the diseased  gland, much elongated and  serpentine ;
so that, in place of embarrassing the  operation  with any need-
less delicacy, or endangering the shrinking up of such an arte-
ry towards its trunk, we passed two ligatures of single  thread
under it, cut betwixt the ligatures, and then proceeded more con-
fidently in extirpating the  gland : there we found no such  ad-
hesion of it to the trunk, or rather to the sheath of the carotid,
as we had reason  to apprehend ;  the tumour was of such a sto-
ny hardness, the cellular substance so loose, the arteries so dis-
engaged  from it, that, without the help of the  knife, with only
the swallow-tailed end of  its handle,  which I used as a  scalpel,
 I  turned  out the tumour in a few  seconds,  and the  tumour
 carrying its cellulur substance along with it, the styloid muscles
 were left as clean, distinct,  and bare, as after  a neat dissection
 in the dead subject.
    In regard to operations where blood-vessels of great size are 
Of Salivary Tumours.
525
endangered,  or actually wounded, I think I may safely  pro-
pose  those simple  rules to  my pupils for their general con-
duct.
   1st. To consider well the anatomy of the natural  parts, and
the probable connections of the tumour, so as not to plunge un-
advisedly into difficulties, which may unnerve his hand in the
most critical  moment; never  to endanger  any unexpected
bursting out  of  blood, such as might  cause  alarm :  for,  to
wound an important artery, without having foreseen the possi-
bility of so doing, or to encounter any danger of this nature,
without  having approached it by slow and delicate  dissection,
and provided  against the sudden eruption of blood, by concert-
ing with his assistant, what is to be done in each  possible case,
would be an indelible disgrace to the surgeon.
   2nd.  The surgeon, while he approaches a dangerous point with
all possible circumspection, and with  precaution amounting al-
most to timidity, and tries to avoid any  important artery, or is
careful as he approaches it,  to distinguish it by its place, to feel
it with his finger, to dissect so as to avoid,  or to tie it, should,
the moment the artery  he fears, or any artery is wounded, and
blood bursts out,  dismiss all fear, then let courage and rapid  ex-
ecution take  place of fear,  or circumspection: let  him plunge
his finger down  to stop, or to  catch the artery, or dive with
his needle to surround it.  If there be nerves, important nerves,
as in the axilla, which are endangered by this stroke  of the nee-
dle, he must be prepared to  decide instantly how far the danger
authorises such a plunge.   If the long course  ofthe wounded
artery gives him  room  to seek  it at another point, he must be
prepared instantly to run his knife  backwards along  its  course,
or to cut with his  scalpel, or plunge  with  the needle, into  the
hollow where  it lies, without a  moment's delay ; a man who
is not prepared for this by his knowledge of the  blood-vessels,
and able for it by his courage and  presence of mind, is no sur-
geon.
   Thus, circumspection  and daring  have each  their peculiar
point of time  ; neither  is to be regarded  as forming a promin-
ent feature in  the temper of the surgeon ;  but that knowledge of
parts, and firmness of  mind, which prescribes  circumspection
and caution in approaching a dangerous point, will ensure con-
fident and rapid execution, when danger is actually present.
   3d. The surgeon, when  he speaks of courage, must always
distinguish the discreet  and deliberate  boldness which belong
to his  professional character, from  the personal bravery,  or
fool-hardy contempt of danger, which he  is entitled to indulge
in his own individual case ; it may to  himself seem heroic, or
gallant, to endanger, or to throw away life ; but, when  respon- 
526               Of Salivary Tumours.
            •
sible for that of a fellow-creature, he has no such latitude of
sentiment or action, and must be guided, not by feeling, but
reason.  So strictly is he bound to avoid danger, that he is ac-
tually  bound to afflict his patient with prot acted and  severe
pain,  to ensure his safety ;  and to endure the  unmerited re-
proaches of whatever ignorant or ill-judging person may  choose
to report his operations  as awkward or slow.  Dispatch and a
show of dexterity will ever be a poor apology for endangering
life ;—and pain,  a bad reason for hurry or perturbation,  where
loss of blood may be the forfeit; the pain of pulling the stump
of a corrupted tooth is more severe and often more protracted
than that of the most important operations ;  the pain of simple
incisions is never deadly.
   4th.  Protracted pain is attended with danger, only in those
operations where, from such torturing,  inflammation  of some
internal part, or  great cavity, as the  knee-joint, the thorax, the
abdomen, may ensue.
   There is  another  species of tumour, of a complexion the
most opposite possible to this ; a vesicular transparent tumour,
seated  on the tongue :  as the hydatid of the testicle, brain, li-
ver, &c. was long supposed to be a mere enlargement of a lym-
phatic  vessel, this clear vesicular tumour on the tongue has been
supposed to be a mere distention of the sublingual ducts, which
are indeed delicate and transparent, and lie in this direction be-
neath the tongue.  One instance of this disease occurred in an
infant on  the breast;  the  tumours  had continued for  several
months, had been punctured three times, but returned  inces-
santly, and had grown to such a size as to  prevent the child
sucking, by turning the tip of the tongue away from the nip-
ple : there were three vesicles, two of  which lay in  that place
and direction which correspond with  the situation ofthe saliva-
ry duct, but the third affecting more the tip of the tongue, de-
monstrated  how  futile this  common idea  is, for  this third
vesicle was situated  altogether out of the. course of the ducts.
These  vesicles are merely accidental;  they  are  stationary,
which  they would not be, if they were  dilatations of the duct;
they pour out no more  fluid, than what the vesicle itself con-
tains, which would not be so if they were connected with the
salivary gland ; upon being punctured they rise again in  a week
to their original size:  this had been so punctured, and had re-
turned three  successive times.  A more singular appearance
cannot be seen than such a pure and pellucid vesicle, projecting
from the red and moist surface of the tongue ; it  is harmless,
and seldom in child or adult arrives to any considerable size ; it
is stationary, for I have seen it continue in children, or in young 
Of Salivary  Tumours.               527
 people, for years, without harm ; when slit open, it leaves no
 sore, nor even a discernible mark, but in a week it is just what
 it was before : I have  found no way of ridding the patient of
 this, which, in a child, is but an inconveniency, but in an infant
 prevents sucking, but to tranfix the vesicle with a little hook and
 cut it freely out with scissors.
   A proper tumour of a salivary- gland is more frequent in the
 adult, and is truly a formidable disease ;  for the salivary glands
 are  inclosed by the muscles of the throat and tongue,  the sub-
 lingual gland especially, which lies under the tongue, is cover-
 ed by the genio-glossi and hyo-glossi muscles, it is thence so in-
 rested with thick masses  of flesh, and  so compressed,  that,
 when it falls into disease, the collected fluid, unless it should be
 pus, cannot make its way through  so  great a  thickness of
 parts;  it continues for  years, and, if idly punctured, without
 any care being taken to obliterate the sac, or  distended  part of
 the  gland, repeated distention of it, accompanied with inflamma-
 tion, so  thickens the root or vascular part of the gland, that it
 grows into a solid tumour, sometimes fatal, by compressing the
 throat and  tongue.   Misconduct in not distinguishing such tu-
 mours, in not obliterating very carefully  the cavity of all saccu-
 lated tumours of the neck, and in not preventing the formation
 of firm and indissoluble roots, or bases, is an error so very fre-
 quent that I think I cannot do you a greater kindness, than to lay
 before  you a few examples as documents.
   " Margaret  Murray, a woman about fifty years of age, had
 crawled from one of the miserable Edinburgh closes into  the
 Infirmary,  asthmatic and suffocating, with one of the most for-
 midable and bulky tumours I had ever seen;  it resembled that
 of Jenny Brown in  siuation and nearly in size, but its nature
 was altogether different.   Her's was throughout of  a stony-
 hardness ; this, though  of  a degree  of hardness resembling a
 cartilage, was hard only  on its surface, while  there was within
 an obscure  fluctuation, which determined myT opinion both of
 its nature, and of what should be done.   The tumour  was  as
 big as the patient's head, it stuck close  under the jaw,  and so
 compressed the throat that the  poor  creature lay gasping for
 breath ; the  least necessary motion in putting out her hands, cr
 struggling to raise herself, threatened suffocation:  her eyes
 were staring, her nostrils widely dilated, and her hands grasping
 every thing near her as if for help; her friends supported her
 perpetually  in the recumbent posture;  her face was livid, and
 the lips purple  with stagnant blood ; the tumour itself was uni-
 versally lurid, or of a deep purple cast,  as if  verging  towards
gangrene;"and indeed I doubt  not  if it had been possible for
 the woman  to have survived in this condition, it must have fall- 
528
Of Salivary Tumours.
 en into gangrene ; it seemed so solid withal, that  the  surgeon
 was doubtful what should be done, and refused to puncture it.
 My importunate representations at length prevailed, and, at an
 irregular hour, and in no very regular way, it  was punctured ;
 a trocar too small for such a purpose, was plunged into the tu-
 mour ;  the matter which  flowed  was thick  and ropy, like  that
 which is most frequently discharged from a diseased ovarium ;
 it resembled sago  made  with port  wine;  about two   pounds
 flowed without any sensible diminution of the tumour.   It  was
 expected, that this  first discharge, and the thinner gluten which
 afterwards flowed, would  give relief; but those who indulged
 such an expectation did  not recollect, that to produce a secre-
 tion so  profuse, a great mass of vascular substance is required ;
 and the consequence of  permitting a gelatinous collection of
 matter to attain to such a  size is,  that the vessels by which  it is
 secreted, not being, as in a case of suppuration, ulcerated or
 destroyed, the stool or basis, consisting of those vessels,  is con-
 solidated  into a tumour; there is a sac indeed, which may be
 emptied,  but  there is  also a stool or nucleus to that sac which
 cannot be discussed, which  indurates more  and more, and ac-
 tually increases in size as soon as the sac  is emptied, and the
 surface  exposed to ulceration: thus the stool of a fluid tumour
 becomes itself a solid one ;  and I have seen the imprudent
 treatment of such a sac establish a solid tumour, so large as to
 impede  the motions of the jaw, and threaten suffocation, yet
 too intimately connected with the great vessels and nerves to be
 extirpated.  So it was in this poor woman;  there was no di-
 minution  of the tumour, not even a temporary relief from the
 suffocation, though the  matter continued, while she survived, to
 run from the opening, thin and pellucid like  saliva.   She lay re-
 clined,  always  struggling for breath, and  sometimes attacked
 with violent asthmatic paroxysms ;  the  jaws  almost  entirely
 closed;  the mouth  continually open: the nostrils dilated;  and
 the stupor, which such difficulty of breathing causes, increasing
every moment, and her swallowing being equally difficult with
her breathing, she expired in the fourth week."
  Timid and irresolute sentiments on the part  of  the surgeon,
often bring the patient into those desperate circumstances: one
surgeon confidently and sensibly advises that a tumour should
be unrelentingly opened; affirms that an incision, since it is in-
stantaneously performed,  cannot  be much more painful than a
puncture which is but a momentary pain, and protests that, by
incision  is the only  way in  which the sac  can be obliterated,
and a tumour, more formidable by  being more solid than  the
first, prevented from growing :  another surgeon contends, that,
in a sac  containing  merely a fluid, a puncture will suffice ; this 
Of Salivary Tumours.                52%
 ♦pinion is too flattering to the little fears of a patient, not to be
 received  ; the puncture is made,  and the patient becomes the
 more  credulous, since the tumour  disappears ;  but it returns
 again,  and is  again punctured, till,  in the  course of a few
 months of expectation, and,  after various trivial operations of
 this nature,  the basis,  probably the  body of the gland itself,  is
 hardened into a solid tumour, and then not even that operation,
 which  would have succeeded  at first, not even the slitting it
 open and ulcerating with escharotics,  whatever surface still re-
 mains, will prevent its continued  growth.
   Though I find salivary tumours usually filled with a pellucid,
 gelatinous fluid, I have found them not unfrequently  filled
 with a mixed matter, resembling honey, or rather resembling
 mustard, and consisting of a tenacious, gelatinous matter, mix-
 ed with grains and lumps of a bright yellow colour, and an in-
 tolerable  smell.  I have taken notes of one case  of this  nature
 in a young woman from Berwick, whose native  peculiarity of
 accent, had  got a singular aggravation, by such an uncouth
 obliquity  and imperfect motion of the tongue,  as conveyed the
 notion of her attempting to chew, and turn  each vocable with
 her tongue before  she proceeded  to swallow it, in place  of ut-
 tering it.   This was produced by  a  tumour of very great size,
 and of a character so peculiar as plainly to denote its nature : it
 consisted in a vast collection of matter in the sub-lingual gland,
 and as that gland is covered by the  whole thickness of the tongue
 within, and by the mylo-hyoidei muscles without, and bound-
 ed by the line  of  the jaw-bone, it had the following singulari-
 ties  of character :  it could not be distinguished as a tumour,
 but had rather the appearance of a general swelling of the lower
 part of the face, jaw, and neck, such  as often accompanies se-
 vere tooth-ach  or mumps :  upon  laying the hand upon the
 outside of the neck, below the lower jaw-bone, the whole hand
 was filled with a swelling, apparently solid, but so little convex
 or circumscribed, as to resemble  in  no degree the tumour of
 any  particular gland ; and yet so limited and so firm, as not at
 all to resemble  the general  tumefaction proceeding from tooth-
 ach.   Upon  introducing the finger  into the mouth, you found
 the tongue raised, turned edge-uppermost, and pressed entire-
 ly towards the left side of the mouth, the external  tumour being
 in the  right side ; upon pressing the fingers very firmly down
 by the  side of  the tongue, and re-acting from  without, you
 could sensibly perceive, not  so properly a fluctuation as an elas-
 ticity,  which implied the presence  of a fluid ; the tumour seem-
 ed elastic, lik^  a foot-ball,  but with a degree of tension which
 made it seem almost solid.  It was by comparing a variety of
circumstances,  especially the original place and slow growth of
                            3 X 
53©                Of Salivary Tumours.
this  tumour, that I confidently referred it  to the sublingual
gland ; m this I had the advantage of the surgeon under uhose
particular care she was, but I did  him the justice to send her
back to him again and again, expressing my opinion, and my
wish at the  same time, that he should do whatever he might
imagine right.   B> good  fortune she  called upon me  the day
she was to return home, nothing being as yet done to the tu-
mour, but supplied with  abundance of blisters and plasters  to
apply at a fit opportunity to her throat:  I felt now  that pro-
fessional ceremonies should give way to essential charities :  I
placed her in a  chair,  and almost without her consciousness, at
least before she was aware, struck a  fine bleeding lancet deep
into the tumour by the side  of the frsenulum linguae,  where,
from the firm compression of the surrounding parts, the matter,
though too  gross to pass  freely through  such an opening was
spewed out  from the orifice in  a manner expressly resembling
that,  in which  yellow  paint is  squeezed out from the bladder
upon a painter's palette.   It was of a deep saffron colour, thick-
er than mustard, mixed like gruel with seed like  particles, and
extremclv fetid.   I knew that the tumour was not  emptied,
though the outward  swelling  was almost  gone ; but  I also
knew, that,  even though I should not enlarge the opening, the
second secretion from  the surface of the sac, which is in all ca-
ses thin, would dilute and wash out whatever viscid matter re-
mained ;  and,  when she saw how suddenly  my prognostic was
fulfilled, she expressed a  perfect confidence in whatever 1 pre-
dicted, and a perfect  willingness to submit cheeriully to what-
ever I proposed to do.  Next day I introduced the point of the
probe-bistourv  into the orifice made by the lancet, and knowing
that the lingual artery  lies on a lower level, imbedded among
the muscles, and  running along  the lower  surface of this tu-
mour, while I  had over the  point and blade  of mv  bistoury
nothing but the inside membrane of  the mouth much thicken-
ed,  I ran it fearlessly, and at one stroke,  as the iess  painful
wav, along the whole length ofthe tumour, when the thickest  of
the  yellow  mucus flowed  freely,  or was raked out with the
points of the fingers,  and the handle  of the  bistoury  ;  and the
tongue descending now to its  natural level,  was in a capacity
once more  of delivering the peculiar  dialect of  her native city
in all its purity.
   So tense and apparently solid was this tumour, in  conse-
 quence of the  compression of so many surrounding muscles,
that her surgeon mistook  it for a solid  and strumous swelling.
 I reckoned that in this, as in  all  cases of  sacculated  tumour,
 the  second secretion, which is thinner, would  wash out the
 thicker mucus, and I was not deceived, but she left  me  too 
Of Salivary  Tumours.
531
early for me to witness the obliteration of this sac.   I find it in
all such cases  a matter of some importance, especially in a girl
to anticipate the outward suppuration of any sacculated tumour
by puncturing  it,  though to a great depth  within  the  mouth,
and under the tongue, and equally necessary, to be at pains in
preserving the  opening, and obliterating the  sac ; a slight mis-
conduct in this respect, occasions nuich distress to the patient
and  much superfluous labour to the surgeon; among  the ex-
amples of this  which I have had occasion to remark,  the fol-
lowing is  the most instructive,
  " Peggy Hall was affected with  a tumour which,  in all its
stages, and for  a course of three years, was ill understood,  and
worse treated: it was of a great size, sacculated, and its con-
tents  were fluid.   She was a stout and lusty girl  about twenty-
two years of age;  the tumour occupied all the left side ot the
neck,  irom the lobe of the  ear  and angle of the jaw, quite to
the sternum, displacing  the mastoid  muscle.   This, like the
tumour of Jenny  Brown, arose from  that slight inflammation,
which follows the  extraction of a tooth.  More than  two years
ago, after being distracted with tooth-ach,  she  had two  cor-
rupted teeth  pulled  from the lower jaw, and she distinctly  re-
members, that, two  days after the extraction  of the  second
tooth, she was sensible, upon   undoing the  flannels  in which
her"swoln and  inflamed face had been  for some  time wrapped
up, that there was  a little  lump,  about the size of a small
plumb ; it lay under the  angle of the jaw, and has never ceased
to grow, and^as now, without  the  slightest pain or change of
colour, attained it  present size.
  "In the month of April,  1799, she was directed to apply
some kind of plaster ; in the  month of May, she was advised
by Dr. Munro to  have it opened;  in a few weeks after, this
was attempted  by the surgeon of the village in which  she lives*
who made a large incision, but being soon alarmed, he laid
aside the  knife and lancet, and prosecuted his  work  rather by
bormg than by cutting ; he tried with probes and directories
to make good his  way  into the sac, but, having pushed them
very deep, and toiled half an hour in  vain,  he abandoned  his
purpose :  the  scar of this ill-concerted operation, remains  on
the face ofthe  tumour.   The certain conviction that a respecta-
ble surgeon did, three months before we saw it, dig to a  consid-
erable, depth, without finding matter; the manifest proof of his
good  will to reach it in this huge scar lett after his operation,
and the firm ad lesions under it ofthe skin to the  mastoid mus-
cle ;  the difficulty too,  of distinguishing fluctuation in  a very
tense s ic,  mad - more tense b\  the general construction of the
platy sma  myoides, and the strong pressure  of the great mas- 
do2
Of Salivary Tumours.
 toid muscle, was enough to disconcert us,  and impress a be-
 lief that this tumour could not be of a fluid nature, and indeed
 these considerations induced almost every  surgeon who had a
 share in the consultation to pronounce, that the tumour contain-
 ed no  matter, and should not  be punctured.   But to decide
 thus  is to  forfeit the natural advantages of our own skill, and
 indeed  is little better than  yielding our own deliberate judg-
 ment in favour ofthe opinion of a man plainly ignorant and awk-
 ward : so far from trusting any thing to his judgment, or believ-
 ing that he miscarried, only because the tumour was solid and
 not fluid,  I think it no  difficult matter to demonstrate the kind
 of awkwardness,  which made him miscarry in his operations.
   " The tumour is, distinctly, to my apprehension, a great sac
 of fluid  secretion: there is nothing doubtful in the case : this.
 sac lies  under the platysma-myoides, and under and before the
 mastoid muscle  ; the belly of  the  mastoid,  being raised upon
 the bag or tumour, feels soft and flaccid, and might have seem-
 ed to an unskilful surgeon,  to form a part of the tumour ;  by
 making his incisions Over the belly of the muscle, he could not
 penetrate  to the  sac otherwise  than through the body of the
 mastoid muscle ; having,cut to a considerable depth among so-
 lid and quivering  flesh,  he became alarmed ; willing  still  to
 penetrate farther, and yet without danger, he  bored with his fin-
 ger, cut a little obliquely with his knife, and bored a little more
 with his directory, till  having  buried it apparently  in .the  tu-
 mour to the depth of three or four inches, he believed, and  to
 the ignorant relations and patient, seemed  to prove, that there
 was no fluid in the tumour,  while there was nothing singular in
 all this but his own  awkwardness : he had penetrated entirely
 under  the belly  of the mastoid muscle, pushing  his  probes
 obliquely betwixt it and the sac ; to avoid  the great vessels  of
 the neck, he wrought obliquely backwards: by cutting oblique-
 ly backwards, he made good  his  way  under the belly  ofthe
 mastoid muscle.   The  young woman  endured the disappoint-
 ment,  and  suffered  the tumour  still to extend, not  without
 great inconvenience and deformity for  seven  or eight months:
 the operation being then performed more correctly and  confi-
 dently, every circumstance tended to confirm the notions I had
 formed  of this awkward  proceeding :  the surgeon who now
 operated was timid in his  manner ot performing the operation
 and careless in conducting  the cure.  The  incision through the
skin only was freely made  ;  the incisions through the platysma-
 myoides were made timidly, the  flesh of  its fibres retracting
and quivering as  they were  cut : the  sac then burst from be-
twixt the divided fibres  of the muscle, white and transparent.
 I could almost distinguish the  fluid through it;  and this by- 
Of Salivary  Tumours.                533
irocele-like sac being cut, several pounds of thin serous  fluid
gushed out: then  the long iron probe  was  passed across the
cavity of the tumour, and its  point  cut upon  at the  anterior
edge of the mastoid  muscle; in  short,  near the  place of the
former incisions:  whereas,  to  lie across the tumour, the point
should have been cut out behind the belly of the mastoid,  and
then the seton or cord would have more effectually inflamed the
sac, and obliterated the cavity.
   If these sacculated and solid tumours of the neck and jaws
are interesting from their trequency, there are others still more
so  from  their danger: they are carefully  to be distinguished
from other tumours, especially  from those of an  aneurismal
and varicose nature; and  I especially request you  to  remem-
ber, that, of the  tumours  which occupy the  fore-part of the
trachea, and are connected with the vascular system of  the thy-
roid  gland, a great proportion are venous:  aneurism of the
carotid artery is indeed so rare a disease, that it is not certainly
known whether such a disease exists, it absolutely is not under-
stood how or from what causes  the patient dies.*
   The  profuse plexus of inosculating veins about the  angle of
the jaw, and the corresponding  branches  of the maxillary  and
facial arteries, are frequently thus diseased, and  still more  fre-
quently the veins  and arteries of the  thyroid gland, whose
trunks, as they run down the fore-part of the neck, are dilated,
and form a conspicuous part of the tumour.  Jean  Bryce has
a tumour of this nature, growing from her early years, which,
like those occurring in the skin, the lip, the eye-lids,  the  rec-
tum, &c.  began in a very small tumour, having nothing pecu-
liar in its form:  it began when she was  a  little girl, has  been
Waxing gradually  larger  for these thirteen  years, and seems to
me almost purely an enlargement of the vessels and cellular
substance  of the  thyroid gland,   it  is  difficult, in describing
such a tumour, to  distinguish the sensations conveyed by the
touch and by the eye, from  those conjectures  which imagina-
tion presents to us in handling the tumour.   The marks I have

  • I faw a young woman, not 24 years of age, die of this difeafe, in the fixtla
Vtreek after the dilatation of the artery began.   She had a cough and  quickened
pulfe, and her diforder was miftaken for a cold :  fhe had great difficulty of fwal-
lowing, and it was miftaken for the effect of  fore throat and fwelling of the
glands: fhe had a conftant ftupor,  and  it  was afcribed to fever :  but the  com-
preffion of fo  large a tumour,  lodged clofe upon the trachea, and braced down
upon it by all the ftrong mufcles ofthe throat, and compreffed too by the jaw-
bone, could not fail to excite at once  difficult deglutition, dyfpncea, and ftupor, and
thefe were the fymptoms of which fhe died.-t-
  ■f- There is now at leaft no doubt of the exiftenee of this difeafe : Mr. Aftley
Cooper has operated twice for it, once with complete fuccefs, in the other cafe the
oatient died, but not from the operation. S. 
534                 Of Salivary Tumours.
taken in my case-book are of a mixed  nature ; they are these ;
the tumour was in its early stage small, knuckle-like, but sott,
round,  moveable, and  without  pulsation : whatever its nature
may have been at the first, the structure of the part is now en-
tirely changed;  the tumour is now large, soft,  spongy, and
spreads equally on each  side  of the throat, filling the whole
neck, and occupying expressly the place of the thyroid gland :
though soft, it rolls  loose under the skin, is  moveable  also  in
respect to the muscles  and  internal  parts, and may, on  each
side, be worked backwards under the mastoid  muscle,  especi-
ally  towards  the  right side of the neck,  where  the  tumour
seems more condensed: it suffers ^general subsultus, or shock,
from  each stroke ofthe carotid arteries, but it has also a particu-
lar and distinct pulsation within itself, which, though never in.
termitted,  is  yet more sensibly felt when the blood contained
within it is repressed through  the veins into the general course
of the circulation ; for,  whih the cells of the tumour fill again,
the blood seems, at  first, to ooze  or pour insensibly  into the tu-
mour, but, when it is a little filled,  the  stroke  of the  arteries
which are filling it begins to be felt, and, as it fills, the pulsation
strengthens still,  being completely injected and become tense,
there is a deep and strong throbbing  in every part  of the mass:
in this particular case, tliere is much accumulation  of solid mat-
ter, i.  e.  of  thickened  vessels  and cellular substance, besides
the mass of circulating blood : the  proportion of both  can  be
distinctly perceived, for,  by handling, and squeezing the tu-
mour, and repressing the  blood, it can  be so  much ot it re-
pressed into the veins,  as to diminish its  size  by two thirds;
but no  force can repress it entirely, as in  smaller  tumours,  or
in varicose aneurisms.   When the blood is rr pressed, the  loose
doughy  feeling of  cellular substance and dilated veins  is more
sensibly felt, and is  perceived to form  the  chief mass, and es-
pecially the  basis of the tumour: when  the blo< d is  thus re-
pressed, you  can  distinguish, by pinching strongly, a thick and
solid sac within the skin, and quite unconnected  with  it.  Be-
sides the other intimations of its connection with the  thyroid
gland,  and the whole vessels and substance of the throat, I can
plainly  distinguish  the thyroid arteries running long and tortu-
ous over the sides of the tumour* as if they descended  from
under the  chin, and then  spread over the sac, (so far are these
arteri  s displaced from their natural course)  they divide,  upon
the surface of the  tumour, into  lesser, yet very  perceptible
twigs, then dive  into its substance, and iose themselves : while

   * The thyroid arteries were) even in their leffer branches, dilated to  the fize <r
the temporal arteries. 
Of Salivary Tumours.
535
the external jugular veins,  dilated both  in their trunks and
branches,  run tortuous  over its  surface, especially down  the
middle of the neck.
   The whole tumour, when voided of blood by continued pres-
sure,  has the puffy feeling of varicose and dilated veins ;  when
distended by  the  reflux of blood, it has the  firm elasticity ot a
sac full of some  fluid,  dense as the  blood  is,  and having firm
and fleshy walls.
   These are the characters of a tumour which is to be avoided
any where, but in the  neck most of all:  which  might indeed
have  been extirpated in its early growth when circumscribed,
small, soft, and not pulsating, by laying  open this part of  the
neck  fairly, by dissecting cautiously round the  tumour,  and
tying its  root; but now the disease has, by cam ing the dila-
tation of veins, arteries, and cellular substance,  deep into  the
substance of the neck, become too formidable  to be dissected
out.   The lay ing  open the neck for the extirpation ot so slender
a tumour in a  little girl  o) ten years of age,  must have seemed
harsh to parents, had it  been proposed ; but how just the prog-
nostic ot the  surgeon is, when he  advises  such  an operation,
never is known till years have elapsed, and the case is despe-
rate.   This girl, after enjoying a respite, not without frequent
alarms, is doomed,  in  a few years  hence, to feel the conse-
quences of neglecting  such a tumour in  its  early stage :  the
disease tends, according to my apprehension,  to  spread  in-
wardly, and the first haemorrhages  will be into the trachea or
throat.*
   In  another case the form of the  tumour was  still more  cir-
cumscribed, and  corresponded  more perfectly  with  the  de-
scription formerly given of this disease ; it is  similar  to  the
preceding case in  having begun from  the  girl's early years,  and
increased till now  that she seems about  28 years of age ; in
having a  lively and strong pulsation ;  in having a thick  i;nd
spongy basis,  seated on the jaw bone, extending  into  the sub-
stance ofthe cheek, and  over the chin into the  substance  of the
neck  and throat;  in having this  stool or  basis less compressi-
ble, yet  plainly filled with circulating  blood, while the  central
parts  of the  tumour are more distinctly  sacculated, consisting
ot  a  wider  spongy  substance of  large cells, or  of something-
like a proper sac, from which the blood can be entirely  squeez-
ed out by pressure.  But it differs in being superficial, in  be-

   * The thyroid gland has been fuccefsfully extirpated by Default.   In  doing it
which  is exceedingly difficult,  and fhould not be attempted, except by a moft ac-
curate  anatomift, and dexterous and intrepid operator, the four thyroideal arteries
muft be tied before they are cut, and the principal  part of  the diffefton muf:
b; done wich the handle ofthe fcalpel. S. 
>36
Of Salivary  Tumours.
 ing cutaneous, or almost  so, in having thin  walls,  and a red
 colour, deepening into a purple at those points from which the
 blood  bursts out:  large dilated veins, two or three especially
 like venous trunks, descended from  the  central parts of the
 tumour, into the  veins of the neck, while the thick and fleshy
 basis of this tumour so encircles the jaw-bone, enters so deeply
 into the substance of  the cheek, and joins so solidly  the neck
 to the jaw-bone, that,  though this girl's life were the most va-
 luable, (she is like many I have observed who  have these im-
 perfections, an idiot)  and her  circumstances the most despe-
 rate, I hardly know how it could be extirpated,  since  there  is
 no way of  effectually  extirpating such tumours  but by  leaving
 not the slightest part ofthe diseased substance behind.
  But pulsation is not an essential, nor inseparable character-
 istic of such tumours, and it is my duty both to give  you no-
 tice  of this fact, and to acknowledge,  with that  generous tem-
 per which becomes one discoursing on matters of life and death,
 whatever errors or mistakes I recollect in my own opinions or
 practice.    I was consulted for a tumour of this kind in  a young
 woman (also an idiot)  about 24 years of age,  big, lusty, and
 otherwise in perfect  health;  but being  accompanied by  no
 friends, I could learn nothing of the history of her  disease.
 Her neck was  fleshy and fat,  her cheek  round and full, her
features large and masculine, and, behind the angle of the jaw,
 was  seated a tumour of this singular character: the skin was
 thick and  sound, and  altogether unconnected with the tumour ;
 the tumour was  conical,  and  occupied exactly  the triangular
 hollow behind the corner of the jaw, but it was a tumour which
 we  could not say it was either very soft, or very elastic, reced-
 ed like a loose, puffy, and unconstricted hernia, upon the slightest
 pressure :  when it receded, you could  pinch  up a distinct and
 thick sac,   which held not the slightest communion with  the
 skin, or its  system of vessels:  the contents  of  this sac could
 be almost dissipated by pressure, and no solid nor spongy  basis
 could be felt at the deepest part of this  sac, nor could the slight-
 est  degree  of pulsation, or whizzing noise be perceived, when
 the fluid returned into the  sac.  The case so entirely resembled
 that  of P. ggy Hall, viz.  a seemingly  thin and  serous matter,
 contained within a large and flaccid sac, that I entirely believed
 so.   Although the characteristic of the almost total  receding of
 the fluid was too marked, and particular,  not to have  excited
 strong suspicions;  yet, in  opposition to Mr.  Russel, and seve-
 ral respectable and judicious surgeons, I believed that  it  con-
tained  matter, and was confident, at all events,  that there was
 no shadow  of danger in making the experiment of puncturing
 the tumour; in opposition to their better  judgment, I made a 
Of Salivary Tumours.
537
slight incision through the skin, and, with the point of a bleed-
ing-lancet, punctured the sac, and found that it contained actu-
ally blood,  which seemed to ooze out into the sac, from  innu-
merable small vessels, had no arterial pulsation, and no dis-
tinct character by colour or otherwise of being venous or arte-
rial blood ;  it had so little impulse, as to make not the slightest
sugillation of the neck,  at the place where the  puncture was
made, and  healed  like  a vein opened in bleeding.  I take  a
pleasure in mentioning this,  both as it ascertains  that often the
sac is of great extent, and the transit  of the blood  from the
arteries to  the veins through the cells  very slow ;  that the tu-
mour may be  large, and truly an aneurism from anastomosis,
without being characterized by pulsation ; and also as this lit-
tle narrative may prove  a warning to you, for the blood might
have been difficult to restrain, and the wound difficult to heal.
  As I always reckon a case  more useful in proportion  as  it
approaches  the more ordinary occurrences  of  practice, and
sacculated  tumours on the throat containing blood are so fre-
quent, and require such careful treatment, that  I will occupy
a small portion of your time in laying an example before you.
  Miss A----came from a distant part of the country,  with
a tumour encircling the  whole throat,  from ear to ear almost,
and extending from the  chin to the sternum.  This tumour,
the  growth of several years, could  not  be a suppuration of the
thyroid gland,  for there  had been from the first no induration
nor  inflammation, but a sac  containing a secreted  fluid, in-
creasing slowly in  quantity,  till the tumour  covered all the
trachea.   This, like every other great sac, was far from being
tense, it could be pinched up with  the finger and  thumb,  so as
to make the uncommon thickness of the sac very sensible to
the feeling, and the fluid so distinctly fluctuated,  and so easily
from side to side of the tumour, as to convey the impression
of its being like that of  Peggy Hall, of a thin and serous na-
ture ; nor was there any  other reason, except the peculiar seat
of the tumour, to doubt of its being serum,  or  to apprehend
that  a tumour so  old, and forming so slowly,  could contain
blood.
  In the choice of means for obliterating so large a sac,  occu-
pying in a young lady the whole circle of the throat, it is  most
natural  to incline to those methods, which, if successful, are
least liable to produce either a scar, or unsightly thickening, or
any other deformity : but, in the present case, I  could not but
prefer the most decisive method of proceeding, to those which
seemed milder, for the  following  reasons.  The flaccid  state
of the tumour was  such as permitted  me easily to  pinch up
the  sac,  and feel most sensibly that its walls were peculiarly 
538
Of Salivary Tumours.
thick and fleshy : I foresaw that if such means only were re-
sorted to as tend to obliterate the sac slowly, and by successive
paroxysms of inflammation, the muscular fascia of the  neck,
the platysma-myoides,  would  be united by  adhesion to this
thick and fleshy sac :  I  feared that if the walls thus constituted
were kept  long in an  inflamed state, irritated, and thickening,
the thyroid gland would not entirely escape, but become in-
flamed and hard, so as  to form a solid basis for the  tumour ;
and I could not but recollect how much more apt the thyroid
gland is to swell in the  female  sex : for these and various rea-
sons,  especially from my patient's intention of returning home,
I proposed that method which, though it  may be blamed as the
most cruel, is often in truth the most lenient, by being the most
effectual;  I mean the passing a seton or syndon  across the sac:
but, from that timidity  which carries with it such strong apolo-
gies, the method I proposed was  unfortunately declined, and
that of a simple puncture preferred.
   Having called Dr.  Monro into consultation, the propriety of
opening the sac was decided on, from these motives ; first, the
certainty of the sac continually  increasing in size, deforming
the neck more  and more, and, perhaps  in  the end, corrupting
the cartilages of the larynx, and making its way into the tra-
chea, and forming there such irregular suppurations,  and incu-
rable  fistulas, as often  prove fatal.  Secondly, that there is no
kind of  motive for refraining from this  very necessary  act of
duty, since the fluctuation  is  distinct, the sac  circumscribed,
the fluid not repressible ; no varicose veins occupying its sur-
face,  no pulsation felt from within  its substance, to  make us
fear its being supplied by any remarkable arteries.
   It appeared  to us that, if there was blood in the tumour, or
hsemorrhagy in the operation, it could  be only such as  might
distil gradually from the surface of so firm a sac, not such ac-
tive hsemorrhagy as might endanger life, or prevent the suppu-
ration of the cavity.*
   Upon  making an incision through the skin and fascia of the
lower part of the neck, and striking the lancet directly into the
tumour, a thin bloody  serum ran out, or rather pure blood, for
it coagulated  in the  saucers,  even before  it could be turned
from  them into the basin  : it expressly resembled  that thin
bloody  secretion,  which I  have so often  seen run  out   upon
making  openings round the knee-joint, or in swellings  when,
in consequence of a shock or rude blow,  blood of this  dilute


   * The opinion and defcriptions are extracted from my cafe-boot; the other cir-
cumftances of the cafe are not from recolleclion, which I never truft to, but from
letters and memorandums. 
Of Salivary Tumours.
539
and serous nature is effused, as from the shock of riding against
the pole of a carriage, &c. or in consequence of high and sud-
den inflammation ; even after strains of the  muscles without
any external injury, I have seen such effusions of blood,  and
shall have occasion to relate some fatal cases of this nature.
   In the evening when the plug was withdrawn, the same thin
bloody serum, instantaneously coagulating, flowedfrom the sac ;
and at each dressing, during the first four days, the fluid which
was discharged seemed little different from pure blood; it was
plainly a  sort of secretion from the thick walls of the tumour,
it gradually became less coagulable, then very thin and whitish,
and ripened before the tenth day into pure and well conditioned
pus, importing, that the internal surfac,  oi the sac  was in a
state of suppuration, and inclined to b  ■ ',.
   Now the time of mv patient'< d< p >.' :.,ue approached, and the
seton or long skein of cotton by u inch the sac was to be kept
inflamed till obliterated, and Uie sponge with which the opening
was to be preserved, had been long used, and those who were
in future  to manage them  made familiar with their use.  The
former was lodged deep, and within the sac by the long probe ;
and the latter had  been gradually enlarged so as rather to dilate
the opening in proportion as the cavity ofthe sac lessened ; the
Gentleman who was to  be intrusted with this part of the pro-
cess was  a party at each dressing, and  I had no fear that all
would go  well : but my first letter from the country announced
that the matter was  foul,  bloody, and fetid ; the flow of it ob-
structed by fungus, almost, closing the orifice ; that the intro-
duction of the sponge was become  difficult, or almost impossi-
ble ; and  that advice was  expected of me, which really could
be ot no avail without either my personal presence, or my pa-
tient returning to town.   I was sensible  that now the means I
recommended  must be resorted to,  for, (although it was not
included in the description of all that was wrong,) I was sensi-
ble that there must be a great thickening ofthe neck and throat,
from the induration of the sac: I found that much pressure and
thumbing of the  parts was necessary to discharge the matter,
and that she  had suffered  from attacks of fever,  accompanied
with pain  and swelling of the tumour.
   By good fortune I was called into that part of the country,
and found when I visited this lady, the whole tumour condens-
ed into a thick  spongy mass, inflamed over the whole surface,
and spongy in its substance, in consequence of continual tortur-
ing and squeezing,  while  pieces of the sponge tent were  sus-
pected to  lie  buried in it :  I actually encountered these lost pie-
ces of sponge with the probe, and  hooked them out :  enlarged
the lower opening, passed the  long iron probe  obliquely across 
540
Of Salivary  Tumours.
 the throat to the upper part of the tumour, and examined how
 I might best cut it out: but this I found a more  difficult  and
 delicate operation than I had imagined, for the  upper part of
 the sac lay under the left lobe of the thyroid gland, entirely un-
 der it, so  that a considerable  thickness  of parts was interposed
 betwixt the probe and the skin, and it seemed impossible  to cut
 out the probe without wounding the thyroid gland and some of
 its arteries.   The best I could hope was by circumspection not
 to cut a large  one, I  therefore felt long and circumspectly
 round the point  of the probe,  made an incision  through the
 skin only, such as  admitted  the point of my finger, and with
 that feeling the mass  of the  thyroid gland, and being sensible
 that no large  artery  was under my finger, I  dissected  through
 it.   The  bleeding was  so violent and alarming that my assist-
 ant,  a medical Gentleman  inured for forty years to all variety
 of practice, fainted, and forsook me.   I  could not go on to open
 the sac, for  that  would have left  me without  any surface to
 press against, or  cut upon, if I should need to open the skin
 more widely, and take up an artery ; and had I  opened the sac,
 the blood would have been admitted to  its cavity : laying
 therefore a piece  of sponge  into the incision, and pressing it
 down with the thumb, I allowed some time to elapse,  and the
 hsemorrhagy ceased, so that I was enabled,  in half an hour, to
 proceed and cut out the probe : having passed it 1 drew a coarse
 big seton across the sac, and left it there with careful instruc-
 tions how to use it,  viz. by carefully shifting and replacing the
 cord ;  by  applying poultices outwardly, and slightly astringent
 injections  inwardly, according  to the state  of the parts : thus
 from a  mistaken  lenity the  cruelty was still  to do,  and  the
 thickening and deformity fixed and irremediable.
   Recollect then in  your future practice, that a tumour hard at
 first,  and gradually softening into fluctuation, must contain mat-
 ter more or less mature; but that a tumour soft, even when ve-
 ry small, gradually enlarging, and having no stool, or basis, may
 contain blood : that a  tumour of this last description, seated on
 the fore-part of the  neck, often does contain blood, though it
 is neither  varicose,  nor pulsating :  beware then  to make  no
 rash opening without  making this prognostic,  that  the tumour
 may contain blood not matter.
   Believe  me, gentlemen,  I  am incapable of magnifying by
 the manner of my narrative any such trivial difficulties, as this
 of the thyroid gland and its system of vessels, being interposed
 betwixt the knife and  the probe ; I mention these occurrences
 as  lessons concerning  little  points of practice,  which,  without
 experience, you could  never learn, and  which  indeed without
 careful notes of the trivial  perplexities of the  hour  of  visit, I
should not  have remembered to  teach vou. 
Of Salivary  Tumours.
541
  But to return to subjects still more interesting: you will have
observed that I speak of erosion and caries of the cartilages of
the larynx, as producing very dismal consequences, and as far
from being unfrequent, and that I  allude to the possibility of
blood or matter penetrating through the  walls of a suppurating
or  sacculated tumour into the throat; and when this happens,
the  complicated functions of the throat, in breathing, swallow-
ing, and speaking, produce a strange variety of suffering.  I
have remarked in practice several  stages of  danger and suffer-
ing, which I think it  desirable you should be acquainted with :
first, the suppuration which I am now going to describe, seems
to me of a scrophulous nature ; it begins without any sensible
inflammation, it ripens insensibly, and extends, and displaces the
trachea, and  (esophagus, without  pain  or  any other disorder,
except difficulty of deglutition ;  it  grows  so very  slowly,  that
the patient is  no way alarmed, and the surgeon is not at first
conscious of all the dangers  of his situation.   When first the
surgeon's attention is called to  the tumour, it has very general-
ly attained to a great size, at once  compressing the throat,  and
bulging out  the neck : a diffused tumour is  observed towards
the iower part of  the neck, below  the place  of  the larynx, ap-
proaching nearer to the clavicle than  the throat, occupying the
interstices of the muscles, and capable, like a hernia, of  being
repressed behind the mastoid: the fluctuation of the matter is
obscure, when the surgeon feels for it it in the neck only ;  but
when he looks into the throat, he  distinctly  perceives a  soft,
uniform tumour, pressing the tonsil and root of the tongue to-
wards  the opposite side, intruding upon the  throat, obstructing
the breathing much, but still more  the deglutition:  he is  sensi-
ble  that this  is  the  upper part of that sac, which protrudes
in the  neck  below ; by pushing his  fingers into  that side of the
throat, he  feels the softness and fluctuation  of the matter con-
tained within  a large and  flaccid sac; and  by  tapping below,
and feeling or  looking at the same time into the thront, he is
sensible that it is one great abscess  occupying all the neck, lying
deep under  the muscles, in the direction of the  oesophagus, and
what is more dangerous still, of the trachea;  and, it he  is as
conscious as he should be of this danger, and as clear as these
signs should make him of the extent and place of the abscess,
he with his scalpel cuts through the skin in the  lower part of
the neck, dissects till  he feels distinctly the sac and the  fluctua-
tion, and then plunging his knife or lancet into  it,  prevents the
sad consequences  of  its bursting into the throat, by this timely
opening in a dependent point;  by  the pressure  of  the muscles,
which, every time they turn the neck, or move the throat, press
the sides of the sac in contact, it is obliterated  though slowly, 
542
Of Salivary Tumours.
  and the judicious use of injections and of syndons contributes
  greatly to  the cure.  I have more than once seen the throat
  surrounded on every side with these baggy abscesses, occupy-
  ing the space under the angle of the jaw, and the two sides of
  the neck irregularly, so as to require incisions  which it yet is
  always unpleasant to make:  nor should the surgeon ever allow
  himself to  make such incisions without that declaration, which
  may be so necessary to his own good repute, viz. that it is not
  impossible the tumour may already  have  communication with
  the trachea, or that air may issue along with the matter ; for of-
 ten the abscess bursts in the throat with an opening so small,
 and of so valvular a form,  that the abscess imperfectly dischar-
 ged of its  contents, maintains its original form and size, while
 the slow  issue of the matter from it only  excites'a slight and
 occasional cough.
    Secondly—I have said the patient feels no pain, and the sur-
 geon is unconscious of danger, when an abscess thus occupying
 the neck threatens to burst into the  throat: the danger  indeed
 is of a nature, which practice only, and not theory, could enable
 you to predict.  While the disorder has not reached the throat,
 its effects cannot be imagined, so entirely is the simple abscess
 free from harm, or the appearance of harm, the displacement of
 the trachea, the uneasy bulkiness of the throat, and the difficulty
 of breathing and  swallowing excepted: nor is it  upon its first
 bursting into the phary nx that the ill effects of it are  perceived;
 I remember one coarse country-fellow, in whom two large scro-
 phulous abscesses of this complexion had burst into the  pharynx,
 but except a hoarse  uncouth voice, and difficulty of swallowing,
 he had as yet no symptom which was not rather ludicrous than
 dangerous; for you distinguished the connexion  of these ab-
 scesses with the throat, not by seeing any openings internally,
 or knowing by any  mark that matter was  discharged into the
 throat; but by the fellow blowing  up the  two bags  at will, till
 they resembled the alforges of a baboon, and  really when this
 resemblance struck you, you could  hardly, on looking at his
 ill shaved, grinning muzzle, think them at  all misplaced.  By
 making free openings on each side,  and washing  and cleaning
 the sacs, they were consolidated.
   But when such  abscess lies deep behind the  throat, betwixt
 the vertebrae and the pharynx ; when it is not sensible, nor can
 be' opened outwardly, and ulcerates and bursts within, a sac is
 formed, accompanied with a  ruinous disorder of the structure
 and function of the part.   Even before the  abscess bursts into
 the throat,  the larynx, or cartilaginous and  only solid part of
the throat, is pressed  strongly over to the  opposite  side ; the
arches of  the palate betwixt which (i. e. betwixt  the  anterior 
Of Salivary Tumours.
543
 and posterior  arch)  the tonsil of each  side is lodged, are so
 pressed together as to adhere ; the secreting surface of the ton-
 sil is thus sealed up, and covered over by the adhesion, as it it
 had never been, and the  membrane of the throat becomes flat
 and shining, its natural  plies are obliterated, and the whole is
 smoothed into one level surface, till new constrictions and diseas-
 ed folds and ridges are formed.
   Thus,  by the very first adhesions, the throat is straitened •
 often  the arches of the  palate are so fixed down by  adhesions
 that the whole opening from the throat  towards the nostrils is
 closed up, or is almost closed leaving a small slit-like opening,
 like the slit in a poors'-box.  Now there is a perpetual regurgi-
 tation of  the food and drink, suffocation, so that the eyes stare
 in the head,  accompanying every attempt to swallow  : the air is
 admitted into the abscess, and the matter into the trachea : the
 tickling cough is incessant, the expectoration endless, the fits of
 real asthma very frequent.   The admission of  the air and lood
 into the abscess mixing with  the pus, gives a pestilent fcetor to
 the breath ;  and those functions of speaking,  breathing, swal-
 lowing, which go on  in the  natural  state ot the parts without
 consciousness, or any sensible efforts, are now a  perpetual strug-
 gle, and if the patient can at all survive, it is by  being careful to
 swallow little drops of fluid, and  little morsels  of nourishment,
 with that caution which is absolutely necessary to prevent suffo-
 cation, which yet often fails, and then severe struggles and suf-
 focation come on.
   During the progress  of the disease, the thin matter of the
 abscess is  streaming  into the trachea, while the coughing and
 straining  supports a  perpetual state  of  ulceration :  the whole
 inside membrane of the throat is thickened ; that glandular sur-
 face surrounding the  root of the epiglottis, and named, from its
 natural aspect,  caro. glandulosa, is thickened and exulcerated ;
 the mouth of the  glottis has its lips so thickened, that it is no
 longer flexible  nor patent ; and the back  of the pharynx, if it
 be not hidden by the adhesion of the arches of the palate, is
 ulcerated, grows fibrous and stringy, like the chordae tendineae
 of the heart  ; the strings which cross it in every direction are
 red, and ulcerated ; and  the reticulated interstices, filled  with
 pus, which you see sometimes oozing out  from larger ulcera-
 tions and cavities.  These are changes of structure, which oc-
casion a very protracted  scene of suffering ; the patient walks
 with his chin resting on his breast to relax the ulcerated throat ;
 his usual  breathing is slow and difficult, accompanied with a
 lifting of the chest and  shoulders, a raising  of the eye-lids,
 an  anxious  contraction  of the  features, and  a hissing and
stridulous  noise ;  he is perpetually clearing, or attempting to 
544                Of Salivary Tumours.
 clear the thickened  and encumbered trachea coated with mu-
 cus, and this action  is so incessant, that it seems necessary to
 his breathing at all.  The voice is whispering, and when forced
 degenerates  into a sort of screech :  the  arches  of the  palate,
 while they contract and close over the tonsils, adhere also to the
 Eustachian tubes, so that the hearing is almost lost, whence the
 patient,  in conversing with you,  always turns his head and lays
 his ear to hear you.  His breathing is habitually difficult, so that
 the blood is driven into the head, and he passes much of the day
 and all  the  night in  a lethargic stupor,  each fit  of  anxious
 breathing being followed by oppressive head-ach, and increa-
 sing stupor.   He rises during  the night  in  asthmatic  parox-
 ysms,  and exposing himself to an  open  window, finds a slight
 relief,  and, returning again to bed, falls into an apoplectic stu-
 por, from which,  even at mid-day, he is roused with difficulty.
 At last,  becoming truly apoplectic, he, in some unusual parox-
 ysm of asthma, runs to the window, throws open his neck and
 breast, grasps at something for support, and, no  longer able to
 sustain the struggle,  he falls into a fit of stupor, his head drops
 forward,  his limbs relax, and  he falls down and is found dead.
 This is  the dreadful conclusion  of the  scene where the slow
 thickening of the  internal membrane of the throat, and espe-
 cially the induration" of the glottis,  is the cause of his death.
   Thirdly.—I  know not whether this labouring and dreadful
 condition, much as I have sympathized with those who have
 died so, is the worst, for often the disorder is more complicated
 by big and capacious  sacs of  matter bursting into the throat;
 and the death of the patient, though less  lingering, is more ter-
 rible.  When a great abscess is permitted to undermine all the
 cellular substance  of the throat, and  surround the oesophagus,
there are no limits to the number of openings : it bursts at va-
rious points into both oesophagus and larynx: the openings into
the tube are as various and perplexing as  those around adiseas-
 ed urethra, and it is  as difficult  to find the true passage, so,as
to convey nourishment to the patient.   The openings are large,
oblique, and valve-like, and often surrounded with strings of in-
durated fibres, resembling the openings in the auricles of the
heart:  these mouths of the abscess are as large  and open,  to
receive whatever  fluid or solid the patient tries to swallow ;
the food  and drink pass sometimes into the trachea, sometimes
into the sacs, sometimes they regurgitate with great violence by
the nostrils, going, in short, in  every direction but down the
natural passage, which being fleshy collapses, while the  slits in
the solid  larynx, or  cartilaginous part of the  throat, present
themselves to receive the morsel, or a part of it;  and the bag,
when distended by food, or drink, or  air thus pressed into it by 
Of Salivary  Tumours.
545
the action of the throat, compresses the oesophagus.   Where
there is less of general ulceration and thickening  of the mem-
brane, and the sac compressing the oesophagus is large, the pa-
tient is rather starved than suffocated ; he retains  all his facul-
ties, makes every effort to receive food, he falls into fits of suf-
focation only when he tries to drink, and  actually dies of fa-
mine.   His condition gives a greedy eager expression to his
features,  and a wild and hurried manner to  all his actions  ; he
wishes  lor food, yet knows he cannot swallow ;  he has an irre-
sistible desire for drink, but, when he  endeavours to pour it
down, it is rejected by his nostrils:  the struggle  for breath  con-
tinues long after each  attempt to swallow, and  shrinks up his
features into a rigid grinning form ; his  shoulders are raised,
his lean and skinny hands sprawling and extended, his  visage is
pale, and  meagre, his nostrils dilated, his  forehead wrinkled,
high, his eye-balls staring from their hollow sockets, the angles
of his mouth retracted,  and the viscid saliva, which  he has not
power to swallow, distils in  strings  from his mouth.   Such is
the dreadful condition to which a patient is reduced  by that ig-
norance and indifference to slighter signs of disorder, which are
so common with the vulgar, or by the surgeon allowing, for fear
of danger, any deep-seated abscess to burst thus  into  the throat.
   Even after the tumour has burst into the throat; it is not too
late to cure the abscess ;  it seems to me that a dependent opening
will, by emptying the sac, prevent  those disorders which  only
long continued ulceration and complicated openings  occasion.*
   " James Ogilvy, a man of middle age, has a deep scrophulous
abscess occupying the right side ofthe neck, displacing the tra-
chea, and pointing in the throat: how long it may have existed
he does not know, but  six  months ago it became very promi-
nent, especially towards the lower part of the neck, affecting his
breathing and swallowing, yet that very slightly, and accompa-
nied with no sense of uneasiness nor pain : but soon after, how-
ever, the tumour appeared in the lower part  of the neck, it be-
came painful, and, about four months ago,  the swelling began
to be felt in the mouth;  this scage of the  distention was accom-
panied with violent pain.   Since  then the swelling has increa-
sed continually, though slowly ; the  swelling in the  lower  part
of the neck is diffused, soft, and  colourless; within the throat,
in the fauces, it appears large, soft, fluctuating, equably, convex,
and  apparently  filling the whole  of the  pharynx; the pain is
gone, but the respiration is affected,  deglutition extremely diffi-

  * Should  the tumour burft into the trachea by  a large opening,  fuffocation
would probably immediately take place.  Should the matter make its way into the
pharynx the  patient might recover, but if it  was difcharged into the larynx he
would moft probably die.  S. 
546
Of Salivary Tumours,
cult, and the abscess is so tumid, that you would expect it to
burst immediately, and widely,  into  the  pharynx ; indeed, al-
though the abscess thus preserves its convexity, I cannot but be
persuaded, that  there is  already a partial opening betwixt the
horns of the os hyoides, and those  of the thyroid cartilage, at a
point where we cannot see the ulcer.    I  am persuaded ot this
from the incessant cough  and perpetual discharge of matter:  he
has a hectic visage,  and  a fretful  pulse, and the circumstances
of the abscess admit of no delay.
   "On the 25th  of July this great abscess was opened by an
incision in the lower part  ofthe  neck, and nearly three pounds of
thick yellow pus were discharged.   The neck flattened, the re-
spiration and deglutition became easy, and the internal swelling,
viz. that which  appeared  within the  throat, disappeared: the
abscess was carefully washed out with injections, and every care
taken to keep the cavity of this enormous sac clean, and to sup-
port the patient's strength and prevent fever.
   " But it  rarely happens that  so  great  an  abscess is opened
without hectic:  the discharge was very  profuse and  thin, his
pulse rose from  80 to 112, he  complained of great weakness,
and had night-sweats, while  his skin was burning hot, and his
tongue white : the fever continued with little abatement for ten
days, for eight days more  it continued  increasing, so that his
life  seemed endangered, but as yet we were not conscious of
any other cause  than the great extent of this abscess and the
profuse secretion of pus,  when suddenly the abscess within the
throat, which seemed to be emptied through the incision below,
but had only  subsided,  burst  into the pharynx; then his ano-
dynes procured  him rest, the bark  sat pleasantly on his stomach,
his food nourished him, his appetite and  strength  increased
every day, the  discharge which now became very moderate,
sometimes almost ceased at the external  opening, and then to-
tally ceased from the abscess ofthe throat:  at last, at the  end
of six weeks, he was permitted  to  retire  to  the  country to live
on milk and take gentle exercise, with every prospect of a per-
fect cure."
   The condition  of  the  poor creature, whose case I am now
to describe, was wretched in the last degree.   The only open-
ing left betwixt the nostrils  and the mouth, or top of the pha-
rynx, is slit-like, and no bigger than to permit a farthing to
pass into it edge-ways; the arches ofthe palate,  and the velum
palati, or soft  and moveable palate, have both  adhered so to
the back of the pharynx as to  seal down the tonsils, and the
face of both  tonsils  is  so  covered by this  adhesion, that even
the place where  the tonsils should be , is  not to  be perceived ;
and the adhesion of the  arches of the palate is so  complete, as 
Of Salivary Tumours.                547
to leave only this slit-like opening.  This slit-like Opening only
was visible during life ; for the  ulcerated openings from the
abscess into the pharynx, lay opposite to the  glottis, and so far
below the root of the tongue,, as not to be seen, or even sus-
pected in any other way,  than by the  catheter (when we at-
tempted to pass it into the  oesophagus) slipping into them : the
mechanism of the throat was entirely ruined, and  the  larynx,
irritable even in its healthy state, was kept in a perpetual irri-
tation and struggle,  in  a state  of asthmatic  constriction at all
times, and in a state of absolute strangulation upon the slightest
attempt to swallow.  The  effects ot every attempt to take down
food or drink may be easily imagined, from  the relation of the
parts ; for, first,  the glottis  and epiglottis, the parts which should
be in perpetual motion to prevent accidents in swallowing, were
stiffened by ulceration  and  thickening :  secondly,  the opening
of the pharynx  into the oesophagus by which  the food should
descend into the stomach,  was distorted and obstructed, both
by the pressure of the  abscess behind, and by the cartilaginous
part of  the trachea,  the larynx being drawn  continually back-
wards by the stylo-hyoidei  muscles, in the incessant spasms of
the whole throat: thirdly, the valve-like openings of the abscess
or abscesses, (for abscesses appeared during life to occupy both
sides  of the jaws  and  throat) presented themselves more di-
rectly than the openings ofthe oesophagus, receiving every mor-
sel of food or  drop of fluid.   The  mechanism of the throat
was so changed, that the more violently the  efforts to  swallow
food  or nourishment were excited,  the more effectually was
the purpose defeated, for,  when  the whole force of the throat,
tongue, and muscles of deglutition was  exerted to force down
the morsel, the  oesophagus received not a  particle of what was
destined for the stomach, the whole force therefore of the mus-
cles of  deglutition was spent in injecting the  sac of the abscess
with the  food or drink.   The sac, large  and  capacious as it
was,  soon filled  ; and no sooner  filled,  than  it effectually com-
pressed the oesophagus ; the food or drink  ran over into the
trachea, and, by the effort which this instantly excited, the con-
tents of the bag, along with the last mouthful ofthe fluid, were
rejected through the nose.   It was in this condition, in this last
stage of his  malady, that I saw this wretched man : he  was
meagre and staring with famine, his belly clung to his back, his
skin  to his bones, his face was squalid, lean,  and  yellow, his
voice hollow  and rattling, his  gray eyes sunk in their sockets,
the eye-lids and skin of the forehead raised and wrinkled in
deep furrows :  whenever he moved he was in danger of suffo-
cation : the slightest attempt to swallow was accompanied with
a struggle, which he seemed hardlv capable  of surviving : his 
548
Of Salivary Tumours.
skinny hands and sprawling lean fingers, were perpetually ex-
tended before him, as if ready to catch at something for sup-
port,  when  the strangulation came upon him : he had neither
strength  nor voice,  to tell me the date nor the cause of his suf-
ferings,  and, though the abscesses on  each side of  his jaws,
extending along the neck, varying in their state of fulness, and
bulging  upon every attempt to swallow, explained his condi-
tion in part,  yet in honest truth I mistook, at first, the slit-like
opening above mentioned for the way into the oesophagus, till
I found that, in place  of admitting the lithotomy  staff which I
used as a probe, to pass downwards into the pharynx, it only
entered when turned with the point  upwards towards the nos-
tril.  Satisfied and  instructed in this  point, and  knowing part
of the disorder, viz.  that the arches  of the palate had closed
and adhered, I sought  the  passage  downwards, and  having
passed the flexible catheter into the oesophagus, I poured down
by  the syringe a basin of warm beef-tea, the first meal he had
enjoyed  for a long while, and which he acknowledged to be
very grateful.  But neither this first operation, nor any subse-
quent one, was easy ;  I  knew nothing precisely concerning the
ulcerated openings leading into the sac ; often when the cathe-
ter  seemed to pass into the oesophagus, it plumped into the Vac,
its  point was resisted, and it  was only by its stopping  short
thus, that I was aware of the tube having missed the  pharynx ;
upon such occasions  I withdrew  it to  try again for the  true
passage : the catheter was always passed two or three times,
before it actually entered the oesophagus ;  it was only when it
passed easily and quite down into the throat,  that I durst ven-
ture to pour in the soup ; sometimes it went into the opening
of  the larynx, and, though  instantly withdrawn, excited such a
suffocation as was very alarming.   I fear that the pupil to whom
I entrusted the passing of the catheter,  and the nourishment of
the patient, had actually failed,  and concealed his own awk-
wardness from me : I cannot but  reflect with self-reproach on  ./
my own  remissness in not  passing the catheter regularly my-
self : but, I believe, this complicated disorder was quite incu-
rable ; the poor man grew  more  ghastly  in the visage,  and"
weaker every hour, and, wdiile we were engaged in contriving
how the sac  might be opened, or what should be  done, he ex-
pired on  the fourth day."*
  I have now narrated much of what 1 have seen or done, in
tumours  of  the head and throat, diseases always dangerous in


  *  Where the catheter is to be paffed into the cefophagus for the purpofe of
conveying food  into the ftomach, it had better be introduced through one  of the
noftrils, as pra&ifed by Default.  S. 
Of Salavary Tumours.
549
their tendency, by affecting respiration and deglutition, and in
which we must often decline  operating, from their roots being
entangled with the  great  arteries  ancl nerves.   Often when I
have seen a patient dying in  a miserable and lingering manner
I have wondered that no other means of extirpation has ever
been proposed, than that which the knife affords,  nor any de-
sign invented,  by which tumours might be forced to suppurate.
To express such a thought implies  that a scheme of this nature
has presented itself  to  my imagination, such as, I think, may
be  successful : it is so,but being yet untried I am bound to sub-
mit the following suggestion to you  with diffidence, and to men-
tion it without much detail, and with becoming modesty and
reserve.
  Tumours refuse to suppurate when their  substance is pecu-
liarly solid, disease having obliterated the cellular substance of
the part: tumours also  are difficult to extirpate ; and often, in
consequence of a hurried, bloody, and imperfect dissection, much
of the disease is left behind,  because successive  inflammations
have  hardened or filled  up the cellular substance which  sur-
rounds the gland, and consolidated it as it were  into one mass
with the surrounding skin and flesh : but could we venture, to
inject the more solid tumours, so as to restore by moderate vio-
lence the cellular interstices, among its integral parts  ; or could
we  surround and insulate an apparantly immovable  tumour
from its manifold adhesions,  by an injection which would pur-
sue whatever remained ofthe tela cellulosa from cell to cell, we
should perhaps attain this desirable end, of forcing the one spe-
cies of tumour into a state of suppuration, and  disengaging the
other from the surrounding parts.
  What is it peculiar in the  texture  of a tumour that prevents
suppuration ? what is the character  which implies that it is ca-
pable of being resolved ? a stony hardness , and extreme specific
gravity, indicating that  the cellular substance is quite oblitera-
ted, that there is  no  interstitial substance to receive those secre-
tions, which are by time matured into pus :  thence it is that in
glands  indurated to this degree, schirrous as they are  named,
vascular action being excited by a  blow or fall,  and accompa-
nied or relieved by no secretion , occasions only pain, ulceration,
partial  gangrene  in each bursting part, and a  thin and watery-
ichor, which is itself an animal poison.  The blow-pipe forced
into any tumour  would, by successive  attemps,  form those in-
terstices, and injecting  the part with oily and camphorated  so-
lutions, would force suppuration in the diseases ofthe salivary,
or  thyroid, or lymphatic glands, where no opperation could be
attempted ; and, in tumours even of the mamma, it  might be
advantageous to disengage the part  by such injections, as would 
550               Of Salivary  Tumours.
throw  all the  surrounding cellular substance into suppuration,
the part itself,  incapable of suppuration,  would thus be  insu-
lated  and might  be turned out like  a  kernel from its husk.
Such   spontaneous  suppurations  of  the surrounding  cellular
substance,  and  such happy  deliveries  from a desperate dis-
ease, we have witnessed many times; and  what I  have now
proposed, though  not  without  many  difficulties and objec-
tions, is too strong in analogies not to  be worthy of some de-
gree of  notice.   I know not how any tumour could resist this
practice:  what dangerous  consequences could  ensue?  none
worse than such suppuration.   Gangrene, or sloughing, as it is
called, when thus  local,  would be limited to the cellular sub-
stance  and  skin, and the operations  of inflating or injecting a
tumour for the purpose of suppurating or of unrooting it,  could
be conducted with such prudence, and, being ofthe nature of an
experiment, would be attempted by  such gentle degrees,  as
would  save us from self-reproach, or the misery of doing harm
where  we intended  good.
   I have read somewhere of an expression, which often re-
turns upon my  ear, "Examples  are  eloquent;" I  have ever
found them the most precious  lessons, and been at pains through
all my  life to record them with care and  precision:  our reason-
ing on  every professional question, and our proceedings in every
new case, must be regulated by precedents,  and I have  laid be-
fore you such examples, and deduced from them such  lessons,
as you will not despise, for they  are  the fruits of experience.
Of all  professional questions, that concerning the nature, ten-
dency, and future  consequences of a tumour, seems to me the
most solemn:  the  physician  or surgeon may but too easily rid
themselves of the importunity of a patient afflicted with a dan-
gerous tumour, for if they will but pronounce any projected ope-
ration  fatal, the patient will retire from public view, mourn over
his helpless and miserable state in solitude, and  die  a  willing
martyr to their opinion, and to  the too natural abhorrence of
pain, and the fear of expiring at once from loss of blood. 
APPENDIX.
                              A


T
 JL HE following explanation of the process employed by nature  in
arresting the hxmorrhage from divided arteries, appears to me to be
much more satisfactory than Mr. Bell's.   For the experiments and
facts, which prove it, the reader is referred to the work from which
it is extracted, " Jones on Hxmorrhage."
  " The results of the experiments related in the last section will not
allow us to give so concise and  simple an account of the process,  as
has hitherto been done ;  but  they afford  us one more  satisfactory,
because it accords better with the operations of the animal ceconomy,
in which we are accustomed to observe the  most important changes
gradually produced  by  the  co-operation of several means, rather
than by the sole influence of any one in particular
   " They accordingly shew, that the blood, the action and even the
structure of arteries, their sheath, and the cellular substance connec-
ting them with it—in  short, that all the parts concerned in or affect-
ed by hxmorrhage, contribute to arrest its fatal progress, by operating,
in  the case of a divided  artety of moderate size, in the following
manner.
   " An impetuous flow of blood, a sudden and  forcible retraction  of
the artery within its sheath, and a slight contraction of its extremity,
are the immediate and almost simultaneous effects of its division.
The natural impulse, however, with which the blood  is driven on,
in some measure counteracts the retraction, and resists the contrac-
tion ofthe  artery.  The blood is  effused into the cellular substance
between the artery and its sheath, and passing through that canal  of
the sheath which had been formed by the retraction of the artery,
flows freely externally, or is extravasated into the surrounding cellu-
lar membrane, in proportion to the open or confined state ofthe ex-
ternal wound.  The retracting artery leaves the internal surface of
the sheath uneven by  lacerating or stretching the cellular fibres that
connected them.   These fibres entangle the blood as it flows, and 
552
Appendix.
thus the foundation is laid-for the formation of a coagulum  at the
mouth ofthe artery, and which appears to be completed by the blood,
as it passes through this canal ofthe sheath, gradually adhering and
coagulating around its internal surface, till  it completely fills it up
from the circumference to the centre.
  " A certain degree of obstruction to the hxmorrhage,  which re-
sults from the effusion of blood into the  surrounding cellular mem-
brane, and between the artery and its sheath, but particularly the
diminished force and velocity of the circulation,  occasioned by the
hxmorrhage, and  the speedy coagulation of the blood, which is a
well known consequence of such diminished action of the vascular
system, most essentially  contribute to the accomplishment of this
important and desirable effect.
  " A coagulum then, formed at the mouth of the artery, and with-
in its sheath,  and which I have distinguished in  the experiments by
the name of the external coagulum, presents the first complete bar-
rier to the effusion of blood.  This coagulum, viewed  externally,
appears like a continuation of the artery, but on cutting open the
artery, its termination can be distinctly seen with the coagulum com-
pletely shutting up its mouth, and inclosed in its sheath.
  " The  mouth ofthe artery being no longer pervious, nor a colla-
teral branch  very near it, the blood just  within it is at rest, coagu-
lates, and forms,  in general, a  slender conical coagulum, which
neither fills up the canal of the artery, nor adheres to its  sides, ex-
cept by a small portion of the  circumference of its base, which lies
near the  extremity of the vessel.  This coagulum is distinct from
the former, and I have called it the internal coagulum.
  " In the mean time the cut extremity of the artery inflames, and
the vasa vasorum pour out lymph, which  is prevented from escaping
by the external cQagulum.  This lymph  fills up the extremity of the
artery, is situated between  the  internal and  external  coagula  of
blood, is somewhat intermingled with  them, or  adheres to them,
and is firmly united all round to the internal coat of the artery.
  " The permanent suppression  ofthe hxmorrhage chiefly depends
on this coagulum of lymph ; but  while it is forming within, the ex-
tremity of the  artery  is farther secured by a gradual contraction
which it undergoes, and by an effusion of lymph between  its tunics,
and into  the cellular membrane surrounding it;  in consequence  of
which these parts become thickened, and so completely incorporated
with each other, that it  is impossible to distinguish one from the
other : thus, not only is the  canal of the artery  obliterated, but its
extremity also is completely effaced, and blended with the surround-
ing- parts.
  " From this view ofthe subject we can no longer consider the sup-
pression of hemorrhage as a simple or mere mechanical effect, but
as a process performed by the concurrent and successive operation
of many  causes:  these may briefly be stated to consist  in the  re-
traction  and contraction ofthe artery ; the formation of a coagulum 
Apptndix.
553
at its mouth ; the inflammation and consolidation of its extremity by
an effusion of coagulating lymph within its canal, between its tunics
and in  the cellular substance surounding it."


                             B

  To Dr. Jones,  likewise, we are indebted for a more complete ex-
planation ofthe effect of ligaures upon arteries, than that given by
Mr. Bell.  The following account is extracted from p. 153—4 of his
work.
  "1.  To cut through  the internal and middle coats of the artery ;
and to bring the wounded surfaces into perfect opposition.
  " 2.   To occasion  a determination of blood on  the  collateral
branches.
  " 3. To allow of the formation of a coagulum of blood just with-
in the  artery, provided  a collateral branch is not very near  the liga-
ture.
  V 4. To excite  inflammation on  the internal and middle coats of
the artery by having cut them through, and  consequently, to give
rise to an effusion of lymph, by which the wounded  surfaces  are
united, and thecanai is rendered impervious : to produce a simulta-
neous inflammation on the corresponding external surface ofthe ar-
tery, by which it becomes very much thickened with effused lymph ;
and at the same time from the exposure and inevitable wounding of
the surrounding parts,  to occasion inflammut'yan in them, and an
effusion  of lymph, which covers the artery, and forms the surface
of the wound.
  " 5. To produce ulceration in the part ofthe artery round which
the ligature is immediately applied, viz. its external coat.
  " 6. To produce indirectly a complete obliteration, not only ofthe
canal of the artery, but even of the r.rtery itself to the collateral
branches on both sides of the part which has been  tied.
  " 7.  To give rise to an enlargement of the collateral benches.
  " In the account which I have now given ofthe effects ofthe liga-
ture on the artery, I have had in view only those instances, in which
the ligature has been applied on the extremity of a divided artery, or
those in which two ligatures  have been applied on an   artery, at a
small  distance from each other, and the intermediate portion divid-
ed.   But, from observation on the human subject, it appears, that  the
effects are different, or at least their accomplishment is  much more
likely to be interrupted, when one or two ligatures are applied on an
artery  without any subsequent division of it."


                              c

  Dr.  Jones has fully  proved that there is not so much danger to
be apprehended from drawing the ligature upon the artery with con-
siderable firmness ; if, however, the surgeon should be afraid ofthe
                               4  A 
5 54
Appendix.
ligature's being thrown off by  the force of  the circulation,  he may
absolutely prevent it by passing the needle through the coats of the
artery, between its mouth and the former ligature and tying another
knot.  After doing this, the ligature  cannot be pulled away without
great force is used.
   In addition to what Mr. Bell has said upon the subject of seconda-
ry hxmorrhage, the following observations  are extracted  Irom  Dr.
Jones's work p, 18 1, and seq.
   " There is yet another cause of secondary  hxmorrhage, which,'
although I have hinted at it once or twice in the preceding parts of
this treatise, I have  not yet represented it in the important point of
view which it ought to be.   I allude to the sudden separation or la-
ceration ofthe  recently united parts of an artery by  premature  and
extraordinary exertions of the patient.
   " That newly cicatrized wounds may easily be torn asunder, for a
certain time after their union, a sufficient number of proofs might be
adduced, if any were required, from the operation for the hare lip ;
but in  these, and other instances of disunited wounds in fleshy parts,
the united surfaces  had been  more or less broad,  and,  of course,
their adhesion  proportionably strong; whtreas in the  case of a re-
cently united artery,  the cicatrized part is  a mere line, and, conse-
quently, weak, and  easily  torn through:  it is, therefore, of the ut-
most importance to keep the limb, a large artery of  which has been
tied, in  a state of the most perfect rest, and to prohibit and guard,
as  much as possible,  against  the  patient's making any  sudden or
great exertion.   In the case of amputation  which gave rise to Pctit's
invention for compressing divided arteries, secondary hxmorrhage
was brought on, on the twenty first day after the operation, by the
patient's raising himself suddenly and sitting up in bed.   On this
subject Petit makes the following observation : a But in  every  case
it  is absolutely necessary that the  patient and the  wounded part
should remain in a complete state of  rest :"*  in which, however, he
seems rather to have  had in view ihe  perfect formation of the clot,
for he afterwards adds : " because the formation of the clot is dis-
 turbed by a change of position."!  But the remark is not the less
 valuable and worthy  of attention : nor does this allusion to the clot
 prove that he was ignorant of the stale ot the extiemily of the artery ;
 for in a former memoir, after describing how he conceived the par-
 ticular figure of the  ciot, formed in  an artery that had  been tied,
 would prevent hxmorrhage, even  though the extremity ofthe artery
 should  ulcerate; he  adds: ik It is not thp same  thing when  some
 convulsion or some other violent motion on the part of  the patient
 causes a separation of the ligature ;  because this separation happens
 before the  vessel is perfectly closed, and moreover, the coagulum,
 notwithstanding its figure, is pushed with   such violence that  it not
 only escapes, but in its passage destroys whatever re-union may have

   * Petit, Memoires de 1' Acad. &c.  de l'anr.ee 1732.
    f Ibid. ibid. 
Appendix.
5 55
taken place, and the mouth of the vessel as large as ever, discharges
 the blood as m the first clay of Us division."\
   Scarpa,  in  his  ireatise on aneurism, lays great stress on keeping
 the patient in  a state of icst, and recomnieuus moderating the force
 of uie circulation, by bleeding in the hist  instance, if a snould be ne-
 cessary, and afterwards keeping the patient on very low diet for some
 tunc,  tic mentions several cases in vvnich secondary haemorrhage
 took place several  weeks after tying a large artery,  appaiciitly and
 in all probability, from some exertion on the part of the patient,

                                D

   In describing the manner in which aneurisms are found, Mr. Bell
 states what was universally  admitted to be correct at tne time he
 wrote.   Since that tne celebrated Scarpa has published a work upon
aneurisms, in wfncii he has proved,  that, in a vast majority ot instan-
ces at least, aneurism is the effect of a  rupture in the coals ul the ar-
 tery, the consequence of violence or disease.  Scarpa, inneed, con-
tends for the universality of this  breach in the coals of the vessel, but
in tins he is pcinaps  not  altogether correct.  1 have certainly  seen
an incipient aneurism winch ajipcared to be the effect of dilaialio.i,
 though i confess 1 did not examine  it so  minutely  as I might have
done, as at that lime no doubis weiecniertained on this subject,  i lie
truth now  appears to me to be this, that  sometimes in  the incipient
stage of aneurism, the internal coat ofthe artery, at least, is dilated,
but  when  the  tumour becomes increased in size, ttiis  too  gives
way.
   The following extract  from Scarpa,!  contains his opinions upon
this subject, from vvnich a coirtct idea  of  the truth  or fallacy  of his
doctrine may be formed.
  " The internal coat of an artery being ulcerated or lacerated from
a slow internal cause in some point  of  its circumference, (uhich he
supposed always happens in spontaneous aneurism,) tne blood  im-
pelled by the heart begins immediately  to ooze through the connec-
tions ofthe fibres of tlic muscular coat, and gradually to be effused
into the interstices of the ctilular covering, which supplies the  place
of a sheath to the injured artery, and forms for a certain space, a kind
of ecchymosis, or extravasation of blood, slightly elevated upon the arte-
ry.  Afterwards, the points of contact between the fibres of the muscu-
lar coat being insensibly separated, the arterial blood penetrating be-
tween them, tills and elevates, in a remarkable mannei, the cellular
covering ofthe artery, and raises it after the manner of an incipient
tumour?  Thus, the fibres  and  la>ers of the muscular coat  being
wasted or lacerated, or simply separated from each other, the arterial
blood is carried  with greater force, and in greater quantity than be-
fore, into the cellular sheath ofthe a.tery,  which it iorces more out-


  |  Petit, Mem. de l'Acad. &c. de l'anree 1781.
  f See Wifhart, p. 73 & lecl- 
656
Appendix.
wards :  and, finally, the divisions between the interstices of the cel-
lular coat being ruptured, converts it into a sac, which is filled with
polypous concretions, and with fluid blood, and at last forms, properly
speaking,  the aneurismal sac;  the  internal texture of which,  al-
though  apparently composed  of  membranes placed one over the
other, is, in fact, very different from that of the proper coats of the
artery, notwithstanding the injured artery, both  in the thorax and in
the abdomen, as well as the aneurismal sac,  is covered externally,
and enclosed within a common smooth membrane.
  " In the very considerable number of aneurisms of the arch, and
ofthe thoracic and ventral trunk of the aorta, commonly regarded by
medical men as true or encysted, or as formed bya dilatation of the
proper coats ofthe great artery, which I have had an opportunity of
examining,  I have not found a single one,  in  which  the rupture of
the proper coats ofthe  artery was not evident, and in which, conse-
quently, the aneurismal sac was produced by a substance completely
different from the internal or muscular coat of the injured artery.
To ascertain the truth,  and confirm the constancy of this fact, it is
not necessary that one  should be  possessed of uncommon knowledge
in the art of dissection, but^Mily that he be disposed to see things as
they really exist,  and that he undertake to examine the aneurism in
the situation in which  it is  found, and without removing the parts
which  surround  it, er at least that he do  this with clue circumspec-
tion.  For,  as  I  have asserted above, very often the  examination
which is made by medical  men,  of internal aneurisms in the dead
subject, consists  of Utile more than a simple division of the fundus
ofthe tumour, without paying attention to  the cellular sheath which
surrounds the artery, above  and  below  the place of the aneurism,
and  without examining  the disposition and particular characters of
the proper coats of the aneurismatic artery, and comparing it with
the substance which  forms the parietes of the aneurismal sac ; and
what is still worse, the aneurism is examined by some, after being
removed from the body, and filled with some substance, or dried; in
which preparations, there is nothing to be  seen but confusion and
obscurity, in every thing which  relates t© the true nature and struc-
ture ofthe parts by which the tumour is formed.
   "  A circumstance  very important  to be known relative to this
subject, has been hinted  at above ; viz.  that  the  aneurismal sac
never comprehends the whole circumference of the injured artery,
but only a portion ofthe arterial  tube, to which  the tumour is united
on the one or the other side.   At this place, the aneuiismal sac pre-
sents, as it  were, a species  of constriction, or  neck, beyond  which
the sac of the aneurism is more or less enlarged, or expanded, and
sometimes to an enormous degree.  This circumstance would never
accompany aneurism, or rather  quite the contrary would be found,
if the aneurismal sac were produced by an equable distention of the
tube and of the proper membranes of the aneurismatic artery.  I  or,
in incipient  aneurisms, at least, the greatest effect ofthe distention
acting upon the tube of the artery, the  greatest  size ofthe tumour
ought to be  in the artery itself, or in the beginning or root of tie  tu- 
Appendix.
557
mour,  and the  least at  its fundus.   But observation demonstrates,
that, whether the aneurism be recent and small, or of long standing
and large, the  passage from the artery is always narrow, and the
fundus of the aneurism, the farther it is  removed from  the artery,
the more it is enlarged.  Another circumstance worthy of attention
on this head, which  I have likewise  pointed out above, is, that the
aneurismal sac  is always covered by  the same soft tlistendible cellu-
lar substance, which in the sound state surrounded the  artery, and
united it  to the adjacent parts ;  which soft cellular substance, sup-
posing it to be  an aneurism of the arch,  or of the thoracic irunk of
the aorta,  is covered by the pleura, and if the aneurism  is in the ab-
domen, by  the peritoneum ;  which membranes include the  aneu-
rismal sac, together with  the ruptured artery, and  present  exter-
nally,  a continued, smooth, shining surface, as if  the artery alone
was in that way dilated.
  " But if, instead of dividing, as is commonly done,  the  fundus
of the aneurismal sac, the aorta be divided lengthwise on the other
side, and opposite to the constriction or neck of the tumour, the
place of the ulceration, or of the rupture of the proper  coats of the
artery, immediately appears within the artery, on the side  opposite
to that where the incision  was made, and the fissure which has taken
place is immediately discovered, the  edge of which is  sometimes
fringed, often callous and  hard, like that of a fistula ;  through which
fissure the arterial blood had formed itself a passage into the cellu-
lar sheath of the artery, afterwards converted into an aneurismal sac.
If, as  sometimes happens in the arch of the  aorta in the vicinity of
the heart, the  artery,  before being ruptured,  has suffered some de-
gree of enlargement beyond its  usual diameter,  it appears at first
sight that there are two  aneurisms ; but the constriction or neck
which the  aneurismal sac next to  the artery presents externally,
points out exactly the limits, beyond which  the internal and muscu-
lar coat of the aorta had not been able to resist the distention, and
have therefore been torn  by it, and shows clearly the difference ex-
isting between an aneurism and a simple enlargement in diameter of
the tube of the aorta in the vicinity of* the heart.
   " The rupture in the artery is  always  small  in proportion to
the large size of the aneurismal tumour ; so  that  when the arch of
the aorta has suffered some degree of dilatation before bursting, as
sometimes happens near  its passage out of  the heart, on making an
incision on one side into the aneurismal sac, and on the other into
the tube  of the artery lengthwise, two sacs present themselves, se-
 parated from each other by means of a partition or diaphragm lace-
 rated  in its middle ; which partition is formed of nothing else than
 the remains ofthe internal and  muscular coats of the ruptured arte-
 ry.   And as the limits of the proper coats of the aorta,  and the be-
 ginning  of the cellular aneurismal sac, ate marked externally by
 that kind of constriction or neck which the tumour presents in the
 vicinity of the artery ; in the  same manner, internally, this partition, 
S58
Appendix.
 torn in its middle, determines the precise point of the rupture of the
 proper coats of the artery occupied by aneurism.
   " All  this  acquires a  degree of demonstration and  certainty,
 to which nothing can be opposed, by carefully dissecting the proper
 coals ofthe ruptured aorta in its situation, and comparing them at
 the same lime with the cellular substance forming the aneurismal
 sac ;  for, in the incision made in the direction of the axis of the aor-
 ta, and in its side opposite to that where the rupture has taken place,
 its proper coats are found either perfectly sound, or a little weaken-
 ed and intermixed with earthy points,  but still capable  of being se-
 parated distinctly into layers from one another ;  when,"on the  con-
 trary,  in the opposite side ofthe aorta,  wnere the ulceration or lace-
 ration exists, ns proper coats are met  with unusual.y thin, blended
 together, and with  difficulty, or in no  way capable ot being separat-
 ed from each other, intermixed very often with heterogeneous  sub-
 stances,  which render  them brittle like the shell  of an  egg;  and,
 lastly, disorganized and torn at the place where they form mat  spe-
 cies of partition, which marks the limits between the ruptured artery
 and  the entrance of the aneurismal sac.   Continuing to  separate
 these coats from within outwards, we  come to the cellular sheath
 which surrounds the aorta externally.   Then,  on removing the cel-
 lular pulpy sheath of the aorta, it is found smooth externally,  like
 the  artery, villous, ceilular, and irregular  internally,  extending
 from the circumference of the tube of  tne artery  over the neck and
 fundus of the aneurismal  sac.   This external covering or sheath of
 the artery actually  appears, to those who are not sufficienify skilled
 in such dissections,  as if the artery were dilated under it  to such a
 degree as to form the aneurism  ;  and it has still more  thai appear-
 ance if the aneurism is very large and of long standing, since m  this
 case the  cellular sneath of the artery becomes unusually  thick and
 pulpy, and because u adheres very firmly  to the subjacent, muscular
coat of the artery at the stricture or neck of the aneurismal sac—
 But even in these cases, as well  as in those of  recent and small  an-
 eurisms of the aorta, by employing care, we may at least succeed in
 separating, without laceration, this cellular sheath  from the tube of
 the artery, above and below  the injury, and successively from  the
 subjacent muscular  coat, as fur as the neck or root of the aneurism.
 It is then clearly perceived that  the muscular coat of the aorta does
 not pass  beyond the partition which divides its  tube  from the en-
 trance of the aneurismal sac ; and it is  distinctly observed,  that the
 fibres and layers of  the muscular coat aie not prolonged over the an-
 eurismal sac, but terminate like a fringe, or in obtuse points, at  the
 edge of the rupture of the artery.  On which account,  nothing  can
 be more  evident than that  the aneurismal sac does not belong at all
 to the artery, and  that, properly speaking, it  is only  the  cellular
 sheaih,  which in the sound state covered and connected the artery
to the neighbouring parts which being elevated by the effused blood,
at first in the manner of an ecchymosis, then distended and compress-
ed,  has acquired that degree of  density, and of additional  haidness 
Appendix.
559
and thickness, as if it had been formed by the proper coats ofthe ar-
tery,  prodigiously rela ed, distended, and  thickened.   These  ap-
pearances ihe more  readily lead to error, as both the injured artery
and the aneurismal sac, as has been frequently  mentioned,  are  co-
vered by a common smooth membrane externally, such as the pleura
in the thorax, and the peritoneum in the abdomen.
   " From all that has been hitherto said  with regard  to aneurism
in general, and more particularly of that ofthe aorta,  it appears to
me, that we may with certainty  conclude,  1st, That this disease is
invariably formed by the rupture of the proper coats of ihe artery.
2dly, That the aneurismal sac is never formed by a dilatation  of the
proper  coats of the artery, but undoubtedly by the cellular sheath
which the artery receives in common with the parts contiguous to it;
over which cellular sheath the pleura is placed in the thorax, and the
peritoneum in the abdomen.   3dly, That if the aorta  immediately
above the heart  appears sometimes increased beyond its natural di-
ameter, this is not common to all the rest of the artery ; and when
the aorta in the vicinity of the heart yields to a dilatation greater
than  natural, this dilatation does not constitute, properly  speaking,
the essence of aneurism.  4thly, That there are none of those marks
regarded by  medical men as characteristic  of aneurism  from  dila'a-
tion, which may not be met with in aneurism from rupture, including
even  the circumscribed  figure of  the tumour.  5thly,  That the dis-
 tinction of aneurism into true and spurious,  adopted in the schools, is
only the production  of a false theory ;  since observation  shows,  that
there is only one form of this disease, or that caused by a rupture of
 the proper coats of the artery, and an effusion of arterial blood  into
 the cellular sheath which surrounds the ruptured artery."


                               E

   This figure, I am satisfied from the description, although the au-
 thor is not cited, refers to a supposed case of dilatation of the coats
 of an artery by Dr.  Donald Monro.  The following is an account of
 a dissection of that  case by Monro the lather.   The account is given
 in a letter to the son who had  sent the parts to Edinburgh to be dis-
 sected.
   "  The aneurismal sacs ycu sent to Edinburgh were  dissected by
 your brother, in my presence ;  the appearances were the following.
 The external loose cellular, and the cellulo-menibranous coats being
 dissected  away carefully, the circular fibrous, commonly called the
 muscular coat, was evidently continued on  all the three small sacs,
 in every part of them,  bin was thicker  there than  in the sound part
 ofthe  artery," andtvliat  is worthy of the greatest  attention, " in  the
 most  enlarged part of the sacs, an extraneous substance, resembling
 a soft  steatomatous matter was intermixed with the muscular fibres.
 The cellular substance being  the  inside of the muscular coat, was
 considerably thicker than natural, and had much the appearance of 
560                      ,  Appendix.
an extraneous substance filling its cells.   The internal membrane of
the artery adhered so firmly to these cells,  that it could not be  se-
parated, but seemed thicker than in a sound Btate."
   Trom the foregoing account we are at a loss to determine whether
the artery was dilated  at these enlargements.  Scarpa says it cer-
tainly was not.


                              F

 DIRECTIONS FOR PERFORMING THE OPERATION FOR  POPLITEAL
                          ANEURISM.

   Having prepared the patient, if he be  at all plethoric, by low diet
and the administration of purgative medicines,  you provide yourself
with the following apparatus ; a common convex edged bistoury, an
eyed probe, two ofthe  smallest sized needles, each  armed with a
waxed ligature of moderate thickness, a tenaculum with a few ordin-
ary ligatures some straps of sticking  plaster, a little lint and a six-
tailed  bandage.   Tye the two ligatures together which are provi-
ded  with needles, then pass the knot through the eye of the probe
and secure il there in such a manner that the ligatures will be of
equal length, and cannot slip.
   The patient is  to be placed upon a table  near its edge, with his
head  somewhat  elevated, and  the leg  and thigh  of the affected
side in a state of semiflexion and supported on a pillow.   The surgeon
should ascertain  the  course  of the artery by feeling its pulsation as
it passes  from under the crural arch down on the inner side ofthe
thigh.  The incision which is to be about three  inches  in  length,
is to be made along  the inner edge of the sartorius muscle in  such
a manner that the inferior angle  of the  wound will just reach the
apex, of;;-the triangle  formed  by the convergence ofthe adductor
bresfis and vastus internus of the thigh.  The first  incision should
be of sufficient depth  to expose the fascia lata of  the thigh, the
next stroke of the knife will lay open this and expose the  fibres of
the sartorius muscle which covers the artery in some degree, which
is  therefore  to be drawn outward: this immediately exposes the
tendinous sheath  which incloses the artery, vein, and anterior cru-
ral nerve.   This sheath is to be very cautiously opened for about an
inch, and  then the artery is  to be completely separated from the
vein and  nerve with  the nail, or handle of the scalpel so as to avoid
wounding the coats of the vessel.   The probe  being gently  curved
is  now passed under  the artery, and ihe  two ligatures are thus car-
ried under the vessel which  must now be separated from the probe
and from each other.   One ligature is to be carried as high as pos-
sible on the artery, and the other as low dov/n, and then the surgeon
having satisfied himself that the  ligatures include  nothing but the
naked vessel, he proceeds to  tye  the upper one with considerable
firmness and an ordinary knot.  Should he apprehend  the ligature's 
Appendix.
561
being thrown off, let him pass the needle through the  coats of the
artery and tie another knot which will effectually prevent it.   The
lower ligature is now to be  tied in the same  manner, and then the
vessel is to be divided and suffered to retract.   The ligatures are to
be left of a moderate length hanging out from each angle of the
wound which is  to be  drawn  together with straps of sticking-plaster,
and the whole secured  by the six-tailed  bandage.  A small dose of
opium may  be  administered after  the  patient  is carried  to  bed,
where he is to be kept in a state of rest, and upon low diet for some
time.   The limb is to be kept in the easiest position with a  tourni-
quet around it, in case of accident, and covered with flannel.   Should
it become very cold, bladders filled with warm water are to be ap-
plied.
   Immediately after the first ligature is tied,  all pulsation ceases in
the aneurism, which  after some days,  begins to diminish and is ul-
timately absorbed.
   This is the  method of securing every artery where it is tied at a
distance from the aneurism ;  when it is necessary to  open the aneu-
rismal sac, a different plan is  to be pursued.


                               G

   When the thigh-bone is luxated, and the  head  of it is  lodged
either upon the os pubis, or in the foramen  thyroideum, it may be
reduced in the following manner.
   The patient is to be extended, upon his back, upon a firm  table, a
broad bandage is then to be passed around the pelvis,  the two ends of
which are to be made  fast to a pillar, or some other firm object on the
side  of the patient, opposite to the luxated  extremity.  Another
bandage is to be passed  around the dislocated  thigh as high as possi-
ble,  that is in contact with  the perinxum which is to be secured in
the same manner as the other, but. on the opposite side   The ban-
dages should be  made of such  materials and drawn so  tighly as not
to yield, when the  attempt  to  reduce the luxation is made    This
is to be  done by extending  the leg upon the thigh and  then using
the Whole limb as a lever, in which the resistance is at one end, the
power at the other,  and the fulcrum, which is the bandage around the
luxated  limb, in  the  middle, which is done by  foicing the luxated
limb suddenly  and smartly across the other.   In this  way, if the ban-
dages are properly  fixed and of sufficient strength, any  requisite de-
gree of force may be applied.   This method of reduction I have seen
practised by Mr.  Astley Cooper with success.
   But when the head ofthe  thighbone  is lodged in : the ischiatic
notch or upon the dorsum ofthe ileum, then recourse  must be had to
other and more effectual means.  The first thing to be attended to is
the fixing of the pelvis.   If this is attempted with bandages only, the
table on which the patient is placed must be  very heavy and strong,
and the bandaces must be sufficiently long to fasten him securelv to it.
                              4 B 
562
Atijiendix.
A better plan has, I think, been recommended,  of making the pa-
tient sit astride a beam wrapped round with cloths  sufficient to pre-
vent injury to the  perinxum.  The extension, which must be very-
powerful and long continued, and more depends upon the length ot
time than the degree of force, is to be made  downwards and out-
wards, in the latter direction first, to detach the bone from its  unna-
tural position, and enable it when the force acting downwards is ap-
plied, to slip over the edge of the acetabulum into the socket.   In
order to diminish the resistance from the muscles, various remedies
have been used, of these, bleeding to as great an extent as the patient
can conveniently bear, is by far the best.  Fainting should be brought
on  if practicable, without too  great a loss of  blood.   1 obacco  in-
jections have proved fatal and  ought therefore, I think, never to be
used.
 
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fources, and judgment in difcriminating  between real and pretended difcoveries.
 In thefe refpeds, we think the author of the prefent work has not been deficient.
 It is a compendium of the exifting dodrines and pradice of medicine."
                                         Medical and Chirurgical Rcvieii'. 
 
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