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MEMOIRS
      BY NATHAN JSMITH, M.D.
                      • » •


LATE PROFESSOR OF SURGERY AND OF THE THEORY AND PRACTICE

            OF PHYSICK IN YALE COLLEGE.
           EDITED WITH ADDENDA,


     BY NATHAN R. SMITH, M. D.


PROFESSOR OF SURGERY IN THE UNIVERSITY OF MARYLAND.

          *       t-y
        Baltimore:
PRINTED BY WILLIAM A. FRANCIS.
           MDCCCXXXI. 
W8
DISTRICT OF  MARYLAND,  TO WIT:

  BE IT REMEMBERED, That on the twenty-fifth day of January, in the fifty-fifth year
of the Independence of the United States of America, Nathan R. Smith, M. D., of the said
district, has deposited in this office, the title  of a  book, the right whereof he claims ai
proprietor, in the words following, to wit:
  "Medical and Surgical Memoirs, by Nathan Smith, M. D., Professor of Surgery and of
the Theory and Practice of Physick in Yale College. Edited with Addenda, by Nathan R.
Smith, M. D., Professor of Surgery in the University of Maryland."
  In conformity to the Act of the Congress of the United States, entitled "An Act for the
encouragement of learning, by securing the copies of maps, charts, and books, to the authors
and  proprietors of such copies, during the times therein mentioned;" and also to  the act,
entitled "An Act supplementary to the act, entitled "An Act for the encouragement of learn-
ing, by securing the copies of maps, charts, and books, to the authors and proprietors of such
copies during the times therein mentioned;" and extending the benefits thereof to the arts of
designing, engraving, etching historical and other prints."
                                                        PHILIP MOORE,
                                               Clerk of  the District of Maryland. 
ADVERTISEMENT.
   We trust that subscribers to this work will be satis-
 fied that, in its  publication, we  have redeemed every
 pledge given in our prospectus.  The engraved portrait
 is one on which much care and expense have  been be-
 stowed.  We promised between  three and five hun-
 dred pages of letter press;—the work contains 376 ;
 but it will be  observed that we have furnished four
 lithographs and several wood engravings  which were
 not promised.
   In regard to binding we said nothing; we should not
 have been under obligation, therefore, to  furnish the
 books otherwise than in boards; but we ha\e  given  a
substantial and neat cloth  binding, with spring backs.
The paper is much superior to that on which  medical
works are usually printed.
                                N. R.  SMITH.
«*» 
1 
I
                      TO

    GEORGE C. SHATTUCK, M. D.

                  OF BOSTON,

        MY EARLY FRIEND, AND MY FATHER'S FRIEND,

THESE PAGES ARE GRATEFULLY ZNSORZBED.
                            X. R. SMITH.
^—d—■■■■——in—mmm
 
 
PREFACE.
   It had been the  intention of Professor Smith, for
several years previous to his death, to furnish for publi-
cation a volume of Essays on those topics in medicine
and surgery, in relation to which his abundant experi-
ence had furnished him with numerous facts, and quali
fied him to speak with confidence.   An original and
inventive faculty was a characteristic trait of his mind;
and, however familiar he might be with the doctrines
and practices of others in relation to particular subjects,
he never  failed to exercise  his  own judgment, where
the  rationale seemed unsatisfactory, and to resort  to
new expedients, when the means prescribed were ob-
served to fail.
  Of authors, there are two classes, the qualifications
of which  differ  exceedingly, though both render im-
portant services  to the cause of science.   The one, 
vi                    PREFACE.
by extensive research, treasures up the numerous facts
which, from various sources, are contributed to the
common fund of knowledge, and presents them in a
natural  and intelligible  order.   The  other class  is
bent upon the discovery of new truths, and ambitious to
enlarge  the boundaries of knowledge.  For the former
task, Professor Smith was by no means qualified, either
by inclination, or habits of application.   For the latter,
his abundant experience and intellectual propensities
peculiarly fitted him.
  The reader will therefore discover that, in the fol-
lowing essays on medical and surgical subjects, no dis-
play of  learning has been attempted; nor, indeed, has
the writer aimed  to present even  an abstract of all
which has been heretofore written on the topics dis-
cussed.   His remarks are offered as supplementary to
that which we already possess; though sometimes they
are designed to subvert popular errors, and  then the
doctrines and practices of others are discussed, as far
as may  be necessary to contrast them with his own
opinions.
  I have considered it a  sacred obligation to  accom-
plish the publication of this work, because I  thus fulfil
his own design.  I  am encouraged  also in the under-
taking,  by the numerous solicitations which have been
made for its publication in those sections of our country
where  the reputation of the author was  best known. 
                    PREFACE.                  vii
Lastly, I am influenced by the hope, that the posthu-
mous  works of one who, during life, gave his labours
unreservedly to  his fellow  men, may render  some
benefit to  his family.
                        NATHAN R. SMITH. 
 
BIOGRAPHIC  MEMOIR

               OF

       THE AUTHOR.
   There is a class of men whose history should never
be withheld from the public, even although it may not
abound in remarkable incidents.  They are those who
have risen to honourable distinction by surmounting pe-
culiar difficulties.  The lives of such are fraught  with
information, both interesting and instructive.   That in-
dividual must have a dull sense of moral sublimity, who
sees nothing to  admire in the strife which the good and
great are often  compelled to wage against adversity.  If
such a subject be worthy of divine contemplation, cer-
tainly it should  be doubly interesting to those who de-
rive practical instruction from  it.   When we behold
men of great moral intrepidity and fortitude, encoun-
tering and overcoming difficulties of an  uncommon and
formidable character, we are taught to look with con-
tempt on tho trivial embarrassments, of which even the
fortunate  too often complain; and should we, too, en-
counter obstacles of threatening magnitude, the example
of those who have surmounted the same, will rekindle
our zeal, and cheer us with the  accents of hope.
   Had my father begun his professional career under
those auspicious circumstances  which his labours have
bestowed upon  so many others, even had he attained
       2 
10             BIOGRAPHIC MEMOIR.
the degree of reputation which is now awarded to him,
I should have  regarded his history, though interesting
to his friends, as comparatively of little moment to the
world.
  The late venerable President Dwight, who honoured
my father with the warmest friendship, was accustom-
ed, when  instructing the senior class of Yale College,
frequently, in  order  to  awaken their ambition, and to
encourage them in surmounting difficulties, to point out
to them living examples of individuals who had  acquir-
ed distinction under adverse circumstances.  After hav-
ng become  acquainted with  my father he used, every
year, to give a brief sketch of the events of his life.
This circumstance encourages me to believe that these
memoirs may not prove unprofitable.
  In him  the energies  of a vigorous mind, for want of
the quickening influence of early education, were dor-
mant till  comparatively a late period in life,—a period
at which the elastic spring of superior youthful intellect
is ordinarily impaired, if it  has not yet been called into
exercise.  There are certain faculties and propensities
of the mind of which the possessor may be totally un-
conscious, till some genial influence shall quicken then>
into life.  Happy are they  whose  latent genius meets,
with its kindred stimulus "while life is in its spring"—~
while the  ardent zeal and romantic  ambition of youth
impel the  mind to the exercise of all its energies.  But,
the embryo  of his genius never felt a fostering ray till
the period at which the intellectual character of most men
is unalterably fixed. It was at the age of twenty-four that
my father first saw, by mere accident, a surgical operation.
This awakened in  his  mind  a philanthropic ambition, 
              BIOGRAPHIC MEMOIR.               11
which never slumbered to the day of his death,—an ac-
tuating principle that carried him through toils and diffi-
culties which would have  appalled and discouraged an
ordinary mind, till at last it elevated him to distinguished
honour, and extended usefulness.
   When these aspirations were first  awrakened, every
thing was calculated to subdue and defeat  them.   He
had  no  friend to cheer him on his way, for all disap-
proved of his  unseaonable enterprise;—he had no edu-
cation but the common rudiments acquired at a country
school;—he had no pecuniary means  but such as  were
acquired by the  labour of his own hands.  Fortunately
for him (although it would have discouraged  others) the
physician, to who-n he applied as a preceptor, refused
to receive him till his preliminary education should be
more complete.   That gentleman  supposed that this
would be a sufficient repulse, and  his surprise was great
When my father presented himself with  the necessary
qualifications.  He finished his office studies,—toiled on
foot  in a laborious practice, with the  noble avarice of
obtaining means to perfect his education—availed him-
self  of the advantages which the infant schools of  his
own country then furnished—sought the  more approv-
ed sources of  knowledge in foreign parts—returned to
his country, not  alone to  avail himself of it, but to dif-
fuse  it  with untiring zeal.  He was instrumental in
founding colleges of medicine, which now  flourish, as his
noblest monuments, in almost 6very state of  New  Eng-
land,—he extended the boundaries of the science which
he taught—and, at length, he acquired a rank both as
a teacher and a  practitioner of medicine,  which it is no
disparagement to others to gay, wa§ second tb that ef 
12            BIOGRAPHIC MEMOIR.
no individual in New England.  Benevolence was with
him not a less powerful actuating principle than honest
ambition.   Never, when contemplating his eminence
and  usefulness, did he seem to say "what  is all  this
worth?"  The honourable poverty in which he died,
after toiling enough to have accumulated three fortunes,
is the best eulogium upon the  character of his  heart.
He has gone to his grave,  honoured and blessed, and
has thus bequeathed to his family and friends, a legacy
dearer than wealth.
   A plain, unvarnished, and concise narrative of his life,
is all that I desire to give, and I prefer  to give it in the
language of another, who will "nothing extenuate  nor
set down  ought  in  malice."   His  friends ask  not
the language  of panegyric.  There is, indeed, as we be-
lieve, that which will "sooth the dull cold ear of death"
—which will quicken the silent dust, but it is not "flat-
tery," nor is  it "honour's voice," however triumphant
may be the strain.
   The following elogium pronounced  by  Professor J.
Knight, of Yale College, my father's associate and friend,
details, neatly and succinctly, the principal events of his
life, and gives a sketch of his character.  A few sup-
plementary remarks I shall subjoin.

Friends and Fellow Citizens.
   The occasion which has brought us together  is  one
of solemn and mournful interest.  We are assembled
to pay the last tribute of respect to the remains of one,
in no ordinary degree, useful and beloved.   Why one
so beloved, so respected, and  so useful, should be re-
moved, when, to all human view, in the midst  of his 
               BIOGRAPHIC MEMOIR.             13
usefulness, is one of those mysterious dispensations of a
wise providence, which short-sighted man can neither
fathom nor explain.   It becomes us  to be thankful to
the Giver of all  good, that he raises up wise and good
men among us; that he suffers them to remain, until by
their example they excite,  and by their instructions,
they prepare others to walk in their steps: and when
He sees fit to remove them, to say with humble submis-
sion, Thy will, O God be done.
  When a man, who  has been widely  known and be-
loved; who has exerted an extensive and beneficial influ-
ence over the interests of an important  profession; who
by the exertion of  skill, assiduity and benevolence, has
acquired the affections of a large and enligtened  com-
munity, is removed by death,  public opinion requires,
and inclination  dictates, that some testimonial  of his
worth should be brought forward, by those who, having
been associated w ith  him, are supposed to know him
best.  This  duty, with respect  to our deceased friend,
has been assigned to me.   For the imperfections of its
performance, the circumstances in which it is under-
taken will be a sufficient apology.
  The subject of these remarks was the son of respec-
table  parents, in moderate  pecuniary  circumstances,
who at the time of his birth resided in Rehoboth, Mass.
He was born on the 30th  Sept. 1762.  While he was
yet young,  the  family removed to Chester, Windsor
Co. Vermont, where his  parents  remained until  their
death.   Of  his early life little has reached us, except
that his time  was spent, in  acquiring  the elements of
education at the ordinary country schools, and in agri-
cultural pursuits on his father's farm. 
 14            BIOQRAPHIC MEMOIR.
   Before he arrived at the period of manhood, in some
 of the latter years of the revolutionary war, he joined a
 body of the Vermont militia, which was stationed  on
 the frontiers of that state, to repel the incursions of the
 Indian tribes of the neighborhood, and to keep them ill
 check.   How long he continued in this service  is not
 known.  He frequently alluded  to  the hardships and
 privations which he endured, while encamped in what
 was then a wilderness, with few of the necessaries, and
 none of the conveniences of life.   While on this  expe-
 dition  he was shot at, and narrowly missed, by  an
 Indian lying in ambush.  These privations and dangers,
 were not however peculiar to him, but were  endured
 in common with many thousands of others of the hardy
 and enterprising inhabitants of our frontier settlements,
 during that perilous period,  when property  and life
 were exposed  to all the dangers of  savage warfare.—
 While residing at his father's, a portion of his time was
 occupied with what was then almost a necessary em-
ployment; securing the game, and destroying the beasts
of prey of  the neighboring forests.  In these pursuits,
small  parties  of  young men were  often absent from
home for many days.   On one  of  these excursions,  he
was left by his companions, in mid winter, at a distance
from home, with a slender stock of provisions.  While
waiting for their return, his supplies  were exhausted,
and what was  more unfortunate, a sudden thaw  came
on, which softening the surface of the snow, then many
feet in depth, rendered  travelling  impracticable.  Here
he was detained several days, subsisting entirely on the
unsalted flesh of some game which he had taken.  By
the time the impediments to travelling were removed,, 
               BIOGRAPHIC MEMOIR.             15
he found himself afflicted, in consequence of exposure
and  improper  food, with a severe and distressing dis-
ease.   With difficulty he reached the nearest house,
where,  and at his father's, he was, for many months,
confined by sickness.  Thus his life passed on, in  a
course of laborious industry, and of hardy enterprize,
until he arrived at the age of twenty-four years.  WThat
his mental acquirements  at this period were, we have
no means of judging.  And, although from the  limited
means of instruction which he enjoyed, we cannot rate
them high,  yet, from the  fact that he was engaged
during  some  of  the winter months, as teacher of  a
school in the vicinity, we are warranted in the belief,
that they were more than were ordinarily obtained by
the young men of  the period, in that country.
   At this time an event occurred, which gave a new
direction to his thoughts and his life.  This event, tri-
vial  in its nature, and apparently casual, led him to the
study, and finally to the practice, of a profession, which
for more than forty years, he adorned and improved.—
The events  to  be  stated, add one  more to the many
well  known cases, which  shew, by how small an ap-
parently inoperative means, a  wise overruling Provi-
dence, controls and directs  the affairs both of individr
uals and of  nations.  Mr. Smith  was present, almost
without design on his part, at a surgical operation per-
formed  by  Dr. Josiah  Goodhue, then, and for years
afterwards,  the most celebrated surgeon in that region.
By witnessing this operation, his attention was directed
to the structure of the human  body,  and his curiosity
excited to learn more of a subject at once so novel and
interesting.   Shortly after, he mentioned to Dr. Gflod? 
 16             BIOGRAPHIC MEMOIR.
 hue his desire to engage in the study of medicine, and
 requested permission  to enter his office as a student.—
 The Doctor  judiciously inquired of him, for they were
 almost strangers to each other, what had been his pre-
 vious course  of life, and what  were his acquirements.
 The reply was,  until last night, I have  labored with
 my hands during my life.  Dr. Goodhue told him kindly,
 that he was not in the habit of receiving young men as
 students, who had not received  some preparatory edu-
 cation:  giving him as the reason for this, that the pro-
 fession of medicine was  in a low  state in that  part of
 the country, and thaUo elevate it in reality and in public
 estimation, young  men properly qualified only, should
 be encouraged to engage in it.   In  conclusion, he stated
 to Mr. Smith, that if he would place himself under the
 tuition of some person capable of  instructing him, and
 acquire so much  literary information, as would enable
 him to  enter the freshmann class of Harvard College,
 he would  then receive him as a student.   This  judi-
 cious advice  was  happily followed.   He selected the
 Rev. Mr. Whiting of  Rockingham, Vt. as his instruc-
 tor.   With him he remained until the required condi-
tion was fulfilled.   For three  years after this he was a
 pupil of Dr.  Goodhue, then residing in Putney, Vt.—
The assiduity and success with  which he pursued his
prefessional studies, are fully attested by his instructor,
who always regarded  him, with  that esteem and affec-
tion, which can be excited in the mind of an instructor,
only by diligence and good conduct on the part of the
pupil.   These kind feelings were fully reciprocated by
Dr. Smith.  He always spoke of this, his early friend,
in the warmest terms of esteem and gratitude, as well 
                BIOGRAPHIC MEMOIR.             17
 for his early advice, as for his  subsequent instruction,
 and for his countenance and support after he engaged
 in  the practice  of his  profession.   That respectable
 gentleman still  lives, and will mourn at the  tidings of
 the death of a favorite pupil and devoted friend.
  Dr. Smith commenced the active duties of his profession
 at Cornish in N. H.  After practising, with what reputa-
 tion or success we are not fully informed, for two or three
 years, he visited Harvard University, for the purpose of
 availing himself of the advantages which that celebra-
 ted institution afforded.  Here, he attended the several
 courses of Lectures on Medicine and Surgery, as well
 as those on Natural Philosophy, and  other means of in-
 struction, to which persons, not members of the acade-
 mical department could gain admission.  At  the close
 of the term at Cambridge, he read an inaugural disser-
 tation on 'The circulation of the blood,'  which was re-
 ceived with high approbation, and, at the request of the
 faculty was published.  Having received the degree of
 Bachelor of Medicine from this University, he returned
 to Cornish, and engaged anew, with  increased informa-
 tion and enlarged  means of usefulness, in the practice
 of his profession.
  At this period the medical profession, in that vicinity,
 was at a low ebb.  The country itself, was  to a great
 extent a wilderness, throughout which, were  intersper-
 sed flourishing towns and  villages.   This  state  of the
 country was a type of the medical  profession.   The
 large  majority of the physicians were uneducated and
 unskilful.   This was true  with respect  to all of New
Hampshire, except Portsmouth and its vicinity, as well
 as the neighboring state  of Vermont.   There  were
       3 
18             BIOGRAPHIC MEMOIR.
Physicians and  Surgeons, respectable for their talents
and  attainments, scattered  over  this region; but they
were few when  compared with the whole number.
This state of his favorite profession was painful to the
benevolent and enterprising mind  of Dr. Smith.  In-
stead of merely taking advantage of it, to elevate him-
self by the ignorance of others, he early engaged, with
his usual vigor, to correct it.  The most obvious and
effectual means to remedy this evil, was to furnish those
who were about to enter upon the profession, with an
opportunity of obtaining a  correct professional educa-
tion.  To accomplish this object, he projected the  plan
of a Medical Institution in  connexion with Dartmouth
College, located at Hanover in New Hampshire.   The
plan was soon completed, and Dr. Smith was appointed
professor of medicine.   For several years the business
of instruction in the various branches of Medicine and
Surgery, as well as the auxiliary sciences, was perform-
ed by him alone.  To qualify himself more thoroughly
for this employment, which he probably foresaw was to
occupy a large portion  of his future life, he determined
to derive  larger stores of knowledge from  what had
been long considered as the fountain of medical science;
the school of Edinburgh.   He accordingly left a prac-
tice  which had then become lucrative, and again be-
came a pupil, seeking instruction from those who were
well qualified to  give  it.   He spent about  a year  in
Great Britain, partly, in  attending a full course of the
Medical Lectures in  Edinburgh,  where the elder Mon-
ro and Dr. Black were then active teachers; and part-
ly, in witnessing the practice of the hospitals in London.
That this  visit was full of interest and improvement to 
               BIOGRAPHIC MEMOIR.              19
him cannot be douted.  He was perhaps in the best
state to be improved by it.   He was of mature years?
had studied and practised enough to know, not only in
general what every physician should learn, but what in
particular was necessary for him; and  he was ardent
and zealous in the cause of his profession.  His course,
after his return to his native  country, was one of almost
unrivalled success.   The medical school, which he was
the  means of establishing, flourished in a high degree,
under his auspices, and those of the able professors who
were, in the course of a few years, associated with him.
The number of pupils, which for several years after the
establishment of the  school, wTas about twenty, gradual-
ly increased, so that for many of the last years of his
connexion with it, the average number was not far from
sixty.   These, upon the completion of their education,
were scattered  over  the  neighboring  parts  of  New
Hampshire and Vermont, and other more distant pla-
ces  in New England.  They gradually occupied the
stations, rendered vacant by the death of the older mem-
bers of the profession, and by the loss of business of
those who were  incompetent.  Thus, that  portion of
the  country became filled with a  race of young, enter-
prising, intelligent physicians, who all justly looked up
to Dr.  Smith as their friend and professional father.
This, together with his deservedly high and continually
increasing reputation, as a  kind, attentive, and skillful
Physician and  Surgeon, necessarily drew upon him a
vast amount of business.   Every Physician, especially
all who had been his pupils, desired him as their coun-
sellor:  the sick and the friends of the sick,  looked to
him as their last resort in all cases of difficulty. 
 20             BIOGRAPHIC MEMOIR.
   The labor which he endured in traversing, for the
 most part on horseback,  such an extensive country,
 then, in part, almost a wilderness, over mountainous re-
 gions, and roads which were often nearly impassible, at
 every season, and in  every vicissitude of weather; the
.good which he accomplished, in affording advice and
 instruction, and by imparting a portion of his own vigor
 and energy to the younger members  of the profession,
 as well as the more direct  benefit which he afforded to
 the sick and distressed, can scarcely be estimated.
   Thus he continued his laborious and successful exer-
 tions in the business of instruction at Hanover, and in
 the practice of his profession, in that vicinity, until the
 autumn of 1813.   At this  time, he accepted the invita-
 tion, which had  been previously given him, to occupy
 the chair of a  Professor, in the Medical Institution of
 Yale College, then just established in this city.  From
 that time to the  present, he has delivered an annual
 course of lectures, on  the Theory and Practice of Phy-
 sic and Surgery, to the class of Medical Students in this
 Institution.   Since that period, he has also  delivered a
 course of lectures on the same branches, at Dartmouth
 College; one at the Vermont  University in Burlington;
 and two at the recently established and flourishing Me-
 dical  Institution  of Brunswick College in Maine.   To
 trace the career  of Dr. Smith, as an  instructor, and as
 a practitioner of Physic and Surgery, since his removal
 to this city, would be  only to repeat the account which
 has been given of him, while residing in Hanover.   To
 this place have resorted for many  years past, from se-
 venty to ninety young men; and it is  no injustice to Dr.
 Smith's associates to say, that a  principal object has 
                BIOGRAPHIC MEMOIR.             21
been to learn from his wisdom and experience, the prac-
tical parts of their profession.  Here, the sick and un-
fortunate, from every part of the country, have collect-
ed, to receive the benefit of his skill.  In addition to his
practice in the immediate vicinity, he has  been called
to visit, professionally, every county, and almost every
town in this state, as well as many more distant places
in the  neighboring states.  Thus his life has been one
continued scene of active, laborious and useful exertion.
   Such as he has been for many years past, so useful,
so honored and  so beloved, we  fondly hoped he  might
continue to be,  for many succeeding years.  But alas!
our hopes  are blasted.   The last dread summons has
reached him; his spirit has ascended to him who  gave
it, and his body must return to the dust from which it
sprung.   By this melancholy event, a bereaved family
is called to  mourn the loss of  a kind and affectionate
husband, a  tender, indulgent and well beloved parent;
the institution  with which he was connected, a chief
pillar  and support; the medical profession, a father and
a friend; the poor, the sick and the distressed, a means
of consolation and relief, and the community at large, a
distinguished benefactor.
   The story of his sickness and death will be brief.
About the middle of July last, he was seized with a se-
vere illness, which after a short continuance, left him^
but in a very  debilitated state.   From this state  his
friends perceived with alarm that he did not entirely re-
cover.  He continued to be weak, with occasional  at-
tacks  of illness, through the remainder of the  summer
 and autumnal months.   Though enfeebled in body, his
 mind  retained its usual vigor and  activity, and  unwil- 
 22             BIOGRAPHIC MEMOIR.
 ling to yield  to what he probably considered  a trivial
 complaint, he continued, with the exception of a few
 days, his laborious employments.  No considerable al-
 teration in the state of his health appeared, until about
 four weeks since, when he was attacked with a severe
 influenza.  This was  accompanied and followed, by a
 painful and  vertiginous affection of the head.   By the
 use of remedies  these symptoms were  alleviated.  On
 the evening of Tuesday, the 13th inst. he first perceived
 a slight numbness of the left hand, with a trifling indis-
 tinctness in his articulation.  These symptoms of para-
lysis gradually increased, until the morning of the 26th
 inst. when the powers of life became exhausted, and at
 6 o'clock, in the  67th year of his age, he slept the sleep
 of death.
   That our deceased friend was no ordinary man, the
brief story of his life  already told, most  conclusively
 proves.   In early life he was a poor boy, in a compara-
tively obscure village, with a limited education, and still
 more limited  means of advancing it.  Thus he remain-
 ed, until  past the period when most men are fixed in
their situation for life.   At  this time his mind received
 a new impulse.  He resolved to render himself useful
 and  distinguished.   Having chosen his profession, he
entered at once, with  the decision which marked his
character through life, upon the work of preparing him-
self for it.   The  means of acquiring an education were
furnished  almost entirely by his  own  exertions.   He
appears for many years, to have labored to acquire pro-
perty, only to expend it in advancing his knowledge of
literature  and medicine.  Following this purpose  with
untiring zeal, he  obtained a medical education, such as 
              BIOGRAPHIC MEMOIR.               23
was then almost unknown in New England.   With the
same  zeal, activity and intelligence, he  entered  upon
the practice of his profession, and subsequently upon the
business  of instruction.   By  pursuing  this  course,
his reputation gradually  increased, until he became
more   extensively  known, than  any other  medical
man in New England.   Indeed it  is doubted whether
any other man in New England, of any profession, pos-
sessed so large a number of personal acquaintances and
friends.
   His acquaintance was  not only extensive, but reach-
ed to  every rank in  society.   The poor knew him as
their benefactor; the  sick, as their skilful, attentive phy-
sician; the rich, were honored  by his society; and  the
wise  and the good, received him  as their friend and
companion.
   At the same time  his  influence over medical litera-
ture was equally extensive.  This influence was exert-
ed, through his large acquaintance among medical men,
by his advice and example, as well  as  more directly
through the medium of  the  various medical schools,
which were favored  with his instructions.  By means
of his influence thus exerted, he effected, over a large
extent of country, a  great and  salutary  change  in  the
medical profession.  The assertion, that he has done
more for the  improvement of Physic and  Surgery in
New  England, than  any other man, will, by no one, be
deemed invidious.   If the accomplishment of objects so
important; with means so limited;  the raising and sus-
taining so  high and extensive a reputation, from so
humble an origin; the advancing in such a degree,  one
of the liberal  professions, over  so large a country, be 
24              BIOGRAPHIC MEMOIR.
not marks of strong native talent, fostered by industry ?
I know not where  indications of such  talent can be
found.
  To form  a  correct opinion of the character of Dr.
Smith, it will be proper to view him in the various re-
lations which he sustained.
  As a physician and surgeon, he early attained a high
rank: a rank which he held through life.   The present
is neither the place, nor the occasion to inquire into his
opinions upon medical and surgical subjects, nor upon
his  mode of practice.  It  may however  be proper, as
illustrative of his character,  to  investigate those  qua-
lities of his mind and habits of life, which raised him to
this elevated station.
  The first faculty of his mind which I mention, was a
keen discriminating inquisitiveness into every thing sub-
mitted to his  inspection.   Nothing passed before him
unseen or unheeded.  This  quality, which in a weak
mind is mere inquisitiveness, exercised to gratify an idle
curiosity, is in a strong mind, a principle of rational en-
quiry, seeking in every direction, for information to be
applied to  some valuable purpose.  By the continual
exercise of this quality, ripened  into a habit of steady,
fixed observation, he collected in his mirfd, not only the
outlines of the diseases with which man is afflicted, but
all the minute circumstances, relative to their causes,
rise, progress and  termination; and the effect of reme-
dies upon them in  their various stages.
  Another faculty of his mind was a memory highly re-
tentive.  This is so nearly allied to the habit of obser-
vation just mentioned, and  so certain is it that what-
ever we observe minutely, is long remembered, that we 
                BIOGRAPHIC MEMOIR.             25
are not surprised to find them so often associated in the
same person.  With him every fact which he observed,
every truth which he heard stated, appeared to be im-
pressed indelibly upon his mind.   In the last years of
his life, he would relate with wonderful accuracy, not
only the great, but also the minute events which he had
witnessed.  Especially,  he remembered the diseases
which he had seen, in all their varieties; the surgical
operations which he had performed, and the causes re-
quiring their  performance, with all the attendant cir-
cumstances of person, time and place.   By the aid of
this faculty, his  mind became a store-house, well  filled
with facts suited to his necessities.   From it he could,
at will, draw  forth materials to guide him in his  prac-
tice; to confirm  and to illustrate his opinions.
   Another faculty, which contributed more than either
of the foregoing to his eminence, was the power of re-
ducing all the knowledge, which he acquired, whether
from reading or observation, to some useful practical
purpose.  This is opposed to mere speculation.  It does
not enquire into  matters which have no practical  bear-
ing upon the happiness of man; but it observes all things
as they now exist, in the present age, and in this coun-
try.  It looks upon the evils now to be remedied, and
the blessings now to be enjoyed.  It leads the physician,
to  view  diseases  and  accidents,  as  they present
themselves to his  own eyes;  and to summon together
all the information and every fact which he possesses,
to bear upon the case immediately before him.   This
faculty is familiarly called plain common sense.  It was
possessed in a high degree by Dr. Smith, in relation to
all subjects connected with his profession.  The  same
       4 
26              BIOGRAPHIC MEMOIR.
faculty was illustriously displayed, in the lives of Wash-
ington, Franklin, Sherman, Dwight and Whitney.
  Another faculty possessed by the deceased, and which
aided him much in  his successful career, was an  un-
daunted  moral courage.  The physician often feels it
to be his duty to apply a powerful remedy, and the sur-
geon to perform a  painful and hazardous operation, in
cases where he can give no positive assurances of their
success.   The timid man  shrinks from  such high re-
sponsibility, and suffers his patient to be destroyed by
disease.   Such was  not Dr. Smith.  Having satisfied
himself what course wras best for his patient, he honest-
ly advised, and fearlessly pursued it;  regardless of the
censure which might follow, should it prove unsuccess-
ful.   With  him there was no hesitation, no wavering
between duty and expediency; between the welfare of
his patient and  his own reputation.  This conduct, in
one who valued reputation so highly, is the strongest
proof of the existence of that courage of the mind, so
much more  noble, and so much more  rarely found, than
mere physical valor.
   To these intellectual qualities,  were added others of
a moral  nature, which facilitated his progress, and ren-
dered it more successful.   I allude to the kindness, as-
siduity, and delicacy with which he treated his patients.
In  him kindness was a natural feeling, springing out di-
rectly from the benevolence of his disposition.   This
feeling,  he doubtless cultivated  from a knowledge of
 the effects which its expression produces, in alleviating
 the distress, as  well of the body as the mind.   In all his
 intercourse  with  the sick, the kindness of his heart
 beamed upon his  countenance, and flowed fourth from 
                BIOGRAPHIC MEMOIR.             27
his lips.  Their faces brightened, and their spirits were
roused at his approach, not more by the relief which
they expected, than by the kindness with wrhich it was
afforded.
   The assiduity of his attention to patients dangerously
sick, was unremitted.  He watched at their bedside by
day and by night, administering to all their wants, and
performing the offices of a kind friend, as well as of a
skilful physician.
   The esteem and respect which he entertained for the
virtuous female character, and the purity and delicacy
of  his conduct towards those who possessed it, render-
ed him highly acceptable to all such as their physician.
The continual exercise of these feelings gained for him
at once their confidence and esteem.
   As an  instructor, the reputation of Dr. Smith was
high, from the time he began the business of instruction.
Of the method which he adopted in relation to this sub-
ject, in the earlier part of his life, I have little informa-
tion.  The facts however, that for many years, he gave
instruction upon  all the branches of Medical and Sur-
gical Science; that this instruction  was acceptable to
classes of intelligent  young men; and that many who
were thus  instructed, have become eminent in their
profession, prove not  only versatility of talent, but  va-
riety and extent of information, with a happy method of
communicating it.   His mode of  communicating  in-
struction, since his connexion with the institution in this
place,  has been simple, natural and unaffected.  He
sought no aid from an artificial style, but merely pour-
ed fourth, in the plain language of  enlightened conver-
sation, the treasures of his wisdom and experience.  He 
28             BIOGRAPHIC MEMOIR.
occupied but little time with the theories and opinions
of other men, referring to books, only  for the facts
which they contain; nor did he  often indulge in theo-
retic speculations of  his own;  but gave principally the
results of his practice and experience.  His object was
to instil into the minds of his pupils the leading princi-
ples of their profession; not entering fully into the de-
tails of the  practice, but leaving it for them  to  apply
these principles to individual cases as they should pre-
sent themselves.  These principles he would illustrate,
by appropriate cases, furnished by a long course of prac-
tice; related always in an impressive, and often in a
playful manner, so as at once to gain the attention, and
impress the truth illustrated, upon the mind.   He often
urged upon them the necessity of correct moral deport-
ment, of industrious  habits, and especially of forming a
judgment for  themselves, concerning the cases which
were presented to them.
  He endeavored to inspire them, both by precept and
example, with a love of their profession, with activity
in the practice of it,  and a  zeal for the promotion of its
best interests.
  At the same time that he communicated to his pupils
instruction, he gained their affection by the suavity of
his manners, and by  a course of conduct towards  them,
by which they were  satisfied  that he ardently desired
their best interests.   Of all who have been instructed
by him, the number  is small of those who were not his
personal friends.
   The various relations of life  were sustained by Dr.
Smith in an exemplary manner.   As a citizen, the
same spirit which prompted him to enlist in the service 
               BIOGRAPHIC MEMOIR.             29
of his country, when engaged in war, led him to sup.
port, by his influence, her  free  institutions in  time of
peace:  as a lover of good order, he rejoiced in the en-
action and the execution of wholesome laws and regu-
lations;  and as a friend of morality, he discountenanced
vice in every form.  The purity of his life, it is believ-
ed, arose not so much from the restraints of society, as
from a purity of mind, which remained unsullied.  So
far as personal observation enables me to speak, he re-
garded the institutions and the ministers of religion, with
the highest reverence.  With regard  to subjects of this
nature, it is believed, that his  last days were his best
days.
   In his relations to  his fellow men, there are particu-
lar traits of his character,  which ought not to pass un-
noticed.   He possessed strong social feelings and  hab-
its.  Accustomed from early life to the society of men
in every station, he entered readily into free and unre-
served intercourse with all.  In companies of  every
kind, learned or  unlearned, polished  or otherwise, his
free conversation, his fund of anecdote, and the acute-
ness of his remarks upon all subjects, whether relating
to the common affairs of life, or the more important con-
cerns of morals and literature, rendered him a welcome
guest.   His manners, which were free, yet unpresum-
ing, and unshackled by the forms of ceremonial obser-
vances, were such  as to impose  no  inconvenient re-
straints upon others or upon himself.  No  one delight-
ed more in social intercourse with his friends, and in a
free interchange  of  feelings  and opinions  with them.
This was  one of the pleasures of his life,  and this en •
deared him to those with whom he associated. 
30              BIOGRAPHIC MEMOIR.
  Dr. Smith was eminently a benevolent man.  He re-
garded man as his brother, and  when  in distress, as a
brother he afforded him relief.   No one, it is presumed,
ever heard him say to the destitute, Be ye warmed and
be ye clothed, without at the same time furnishing the
means of relieving' their necessities.  That his  charity
was always discriminating is not probably true. It was
the chanty of the heart, and not of calculation; and often
his  most  valuable benefactions were  rendered in the
course of professional exertion.
  The mere distribution of a portion of his property to
those who  were in need, was indeed, the least part of
his  beneficence.  It is no difficult matter for those who
receive, as a compensation for their labor, an abundant
supply of  all  they need, unless their  hearts  are fast
bound by the chains of  avarice, to distribute  a  small
portion of their substance  to  those who are in  want.
Indeed the selfish man often does this to rid himself of
troublesome importunity.  These merely, of their abun-
dance, cast into the treasury.   It is a far nobler  chari-
ty,  to relieve distress by personal exertions and sacrifi-
ces.  The man, who to alleviate or remove the misery
of his fellow men, exposes himself to cold, hunger, and
fatigue, in visiting the abodes of wretchedness, penury,
and even of guilt; who, when there, listens with sympa-
thizing attention to  the story of sickness, told  by its
miserable inmates; relieves by personal attentions their
immediate sufferings, and cheers their  hearts  with as-
surances of future assistance, exhibits the fairest speci-
men of human benevolence.   Surely, upon  the head of
 such a  man,  the  blessing of  many ready to perish,
 will fall. 
               BIOGRAPHIC MEMOIR.            31
  The sketch, thus feebly  drawn, exhibits one feature
in the character of our deceased friend.   To him, the
sick and suffering, whether rich or poor, were equally
objects  of attention and compassion.  He regarded all
alike, the rich, the poor,  the beggar and  the outcast,
when his services were required to  relieve their  dis-
tresses.   This with him was a matter of feeling, rather
than  the result of meditation.   He  did  not serve the
poor, that  he might gain  the favor of the rich, but to
fulfil  the desires  of his own benevolent  heart.   He
acted in accordance with an opinion which I have more
than once heard him express, that the great object of
the intercourse of man with his fellow men, should be
to do them good.
   Nor  was his benevolence confined in its  exercise, to
the sick and the poor.   It led him to rejoice in, and to
promote by his influence  and exertions, all plans, cal-
culated, in his view, to promote the best interests of his
fellow  men.   The  interests of literature and  sound
morality, received his cordial and unvaried support. In
regard to objects of this kind he indulged in no narrow,
local prejudices;  but looked abroad with  an enlarged
view, to the  welfare of all, both of the present  and
future generations.
   From the preceding statment, it cannot be  doubted
that Dr. Smith performed with fidelity the various rela-
tions of domestic  lire.   That benevolence which was so
active and so expansive, could not but shed its brightest
and warmest rays, upon those who were the nearest
and dearest to his heart.  Why should I speak of  him
as a kind, affectionate husband, or as a tender, indul-
gent  and judicious parent, who bore good will to all 
32             BIOGRAPHIC MEMOIR.
mankind?  Those towards whom  he sustained these
endearing relations,  are  witnesses of the manner  in
which he fulfilled the duties which  they require.   The
affection and respect which they  manifested towards
him while living, and the mourning and tears which ac-
company his departure, bear testimony, that as he was
abroad, so  he was at home, the kind  companion, in-
structor and friend.
  The  life  of a  man  so illustrious as  our deceased
friend, imperfectly portrayed as it  has  been, is  full of
instruction.  It teaches the young who are just entering
upon the busy scenes of life, especially you,  my young
friends, who are preparing to engage in the same ardu-
ous profession, the value of enterprise, industry, and
benevolence.  By the exercise of these, he rose from
obscurity to eminence.   What hinders that you, by the
judicious use of the same means, should not accomplish
the same end.  All cannot be  equally eminent, but all
may render themselves highly useful and respected.
  It teaches  all the folly of selfishness.  He  sought
nothing for himself, but the reputation of doing good.
This  he obtained, as all others may, by deserving it;
and with it, received all that he desired of this world's
goods, the esteem, respect, and affection of a large and
enlightened community; the approbation of the  wise
and the good, wherever he was known; and the assu-
rance that his memory will remain a noble inheritance
to his posterity.
  If his life is  instructive, not less so is his  death.  It
adds one more lesson to the millions which have pre-
ceded  it, teaching us the slight tenure  by  which we
hold our mortal existence; and the necessity of prepar- 
               BIOGRAPHIC MEMOIR.             33
ing for that  event, which  happeneth unto all.  The
wise,  the great, the good, and the useful, are removed
in rapid succession, and why are we suffered to remain?
Why! but  through the  good pleasure  of him who
waiteth to be gracious.
  Although it would have  been obviously improper to
euter, in the body of  this discourse, upon a considera-
tion of the medical opinions and the modes of practice
of Dr. Smith, a few remarks upon them, may not, in
this place  be unacceptable.  Upon  these subjects, I
have  no means of information at hand, previous to  his
removal to this city.  The  few remarks which are
made, must therefore  be  considered as confined to the
last thirteen years of his life.
  All who have witnessed the practice of Dr. Smith,
must have remarked the rapidity and decision,  and, at
the same  time, the general accuracy, with which he
formed  an opinion on  the cases of disease submitted to
him.  He appeared to strip diseases of all their adven-
titious attendants,  and to seize, at once, upon  their
important and essential phenomena.   This process was
often  so rapid, as to resemble more the effect of intui-
tion, than  the regular deduction from a train of reason-
ing.
  With the same rapidity,  he saw, as it were with a
glance, the course proper to be pursued, and with equaF
promptness, applied the  appropriate remedies.   This
course of  practice, can by no means be held out as an
example to the young  and inexperienced; nor is it per-
haps the best mode to be pursued by any one.  It is
justifiable only in those, whose habits of observation
and  discrimination, have been  matured, by  a long
      5 
 34               BIOGRAPHIC MEMOIR.
 course of enlightened  experience.  Even such would
 escape occasional errors, by more careful deliberation.
  . The practice of Dr.  Smith in the treatment of acute
 diseases was essentially the same, as that of the other
 respectable physicians of  New England;  varied some-
 what perhaps, by his notions of the nature of  typhus,
 the prevailing fever of the country.  What these notions
 were, and what his practice founded  upon them was,
 he has fully explained, in his treatise upon typhous fever,
 published a few years since.   If he had any peculiari-
 ties in the treatment of  other acute diseases, than pure
 typhus, they consisted, in discarding the use of remedies
 comparatively inert,  and in employing those which are
 more powerful and  effective.   He often asserted that
 the use of medicines, which, in common language,  if
 they do no good, will do no harm,  is usually the resort
 of timidity or ignorance;  and that  the  physician who
 knows not when and how, to apply or  to withhold the
 more powerful articles of the materia medica, was unfit
 for his profession.
  In the treatment of chronic diseases, energetic reme-
 dies,  especially  such as  acted powerfully upon the
 stomach and the other organs of digestion, wrere more
 especially resorted to by him.   To this course, he ap-
pears to have been led, partly by  his  own  reflections
upon  the nature and causes of most chronic diseases,
and partly, by the situation in which he was placed, with
respect to patients of this class.
  Many  of them consulted him after they had employ-
ed all the ordinary means of medication.   Others still
consulted him from such a distance, as precluded him
from  watching  over the  tardy effects of  ordinary 
                BIOGRAPHIC MEMOIR.             35
remedies.  Both these circumstances, combined, led
him to the administration of full doses of the more effec-
tive medicines, with the view of producing speedy and
great changes in the organs diseased.
  For the duties of a practical surgeon, Dr. Smith was
eminently qualified, and upon the manner in which he
performed these duties, his reputation must, in a great
measure, ultimately rest.   To these, he brought a mind
enterprising, but not rash; anxious,  yet calm, in delibe-
ration; bold, yet cautious, in operation.   His first object
was, to save his patients, if possible, from the necessity
of an operation;  and when  this could be no longer
avoided, to enter upon its  performance, without reluc-
tance or hesitation.   In his operations, he  was calm,
collected and cautious.
   He manifested no  desire to gain the reputation of a
rapid operator: a reputation, so ardently, and it is to be
feared, so unfortunately sought for, by many  surgeons
of the present day.  He who commences an important
operation, with his eye upon  the  minute hand of a
watch, starts in a race against time, in which the life
of his patient is the stake, and often the forfeit.   The
true rule for  the surgeon is, sat, cito si sat bene. Neither
did  he make any display, in  the course of his opera-
tions, to gain the applause of bystanders.  Hence there
was no formidable array of instruments; no ostentatious
preparation, so well calculated to excite the wonder of
the ignorant, and to strike a dread  into the mind of the
patient.  Every thing necessary was prepared,  while
all useless parade was avoided.   When engaged in an
operation, his whole  mind was bent upon its proper
performance.   Every  step was  carefully  examined, 
36              BIOGRAPHIC MEMOIR.
every occurrence narrowly watched;  and if any thing
unusual appeared, he would ask the  advice of those
present, in whom he had confidence.  In such  cases,
his promptness and decision, joined to what Chesselden
calls "a mind that was never ruffled nor disconcerted,"
were of singular utility.   By the aid of these, he could
look, with  a steady eye, upon the varying  features of
the case, as they rose to his view, and adapt his mea-
sures, at once, to every emergency.   By this cautious
mode of proceeding, calculated to gain, not the applause
of those who were present on a single occasion, but the
enduring reputation of a judicious, skilful Surgeon, he
performed with great success, the most important ope-
rations.  That his  success  was great  is fully attested
by the  facts, that of  about thirty cases of  Lithotomy,
only three proved fatal; and that in the  course of his
practice, he lost  no patient of  hemorrhage, in  conse-
quence of an operation, either direct or secondary."
  In the practice of Surgery,Professor Smith displayed
an original and inventive mind.   His friends claim for
him the establishment  of scientific principles,  and the
invention of resources in practice, which will stand as
lasting monuments of a mind fertile  in expedient  and
unshackled by the dogmas of the schools.   It is believed
that he was the first in this country to perform  the bold
operation  of extirpating the ovarian tumour.  With
him, the operation was altogether original, for although
it had then been once or twice performed in Germany,
he was, at that time, unacquainted with the fact.   He
was also the first to perform, in this country, the opera- 
               BIOGRAPHIC MEMOIR.             37
tion of staphyloraphy.  Important scientific principles
were developed by him in relation to the pathology  of
necrosis, on which is founded a new and successful
mode of practice.   He also devised  and  introduced a
mode of amputating the thigh, which, although resem-
bling methods for some time in use, is sufficiently origi-
nal to bear his name.
   The apparatus which he invented for the treatment
of fractures, is  altogether new, and has been adopted
by some of the best surgeons in every part of our coun-
try as decidedly preferable to any in use.  His mode
of reducing dislocations of the hip is new, philosophical,
and ingenious.
                                        N. R. S. 
 
PRACTICAL ESSAY
ON
i<m
        BY XATHAX SMITH, M. D.

Professor of the Theory and Practice of Physic and
             Surgery in Yale College. 
 
PREFACE.
   The following Essay on Typhus, first published in
 1824, by no means claims to be considered a complete
 treatise  on this extensive topic, or a digest of what
 has been written upon it.  It was submitted to the pro-
 fession rather as a  report of facts ascertained by  the
 author's own extensive observation and experience, and
 as a supplement to  that  which we already possess on
 this subject.  While his incessant professional labors
 rendered it impossible for him to execute the former
 task, they were calculated  to  qualify  him thoroughly
 for the latter.   This was executed, as  he informs us in
 his preface to the first edition, "under the constant pres-
 sure of professional business, and during a more limited
 period than I was desirous of devoting to  it.   This is
 the reason, if not apology, for any carelessness of style,
 or inattention to arrangement, which may be  observed
 in it.   Should I find sufficient leisure, I hope, at some
future period, to enlarge the work and add more facts
in illustration of its  principles."
  As the period of  leisure, for which  he hoped, never
occurred, mine will be the melancholy duty of subjoin-
ing to the present edition such observations as I have
heard him make in  relation to this subject, since its first
       6 
42                   PREFACE.
publication, and also an occasional note in defence of
the opinions which he adopted.
  I trust that it will be borne in mind by all  readers,
that the author treats of Typhus as  it presented itself
to him, and not as he  had studied it in  books.   His
sketch is from nature, and if it occasionally differs from
those  which have been executed by other hands, it is
because the aspect of the  original is often modified by
circumstances.   The climate and soil of New England
are peculiar, and we look for  corresponding modifica-
tions  of disease.  It was the duty of the author, there-
fore, to present a faithful delineation from the thing it-
self.   If he has omitted to describe certain symptoms
described by others, it is because they did not present
themselves to him.  If he has omitted  to mention
remedies recommended by others, it  is because he did
not witness their effects.
                                         N. R.  S. 
TYPHOUS FEVER.
            HISTORY OF TYPHUS.

   Typhus is a word of Greek derivation, which signi-
fies smothered fire, or stupor.   As applied to disease, it
is doubtful whether it was originally meant to indicate
internal heat, or whether it was used to denote a fever
particularly affecting the  mind, and producing stupor
and coma.
   With regard to the  history of this disease, we have
no account of its first appearance; on  the contrary, it
is always spoken of by the older writers as an affection
well known.   And from the additional circumstance of
its having received its name from the Greek physicians,
it is probable that it has occasionally afflicted mankind
from time immemorial.
   From  the   descriptions given  of it  by European
writers, there  cannot be a doubt that the disease called
Typhous Fever in Europe, and especially in England,
is similar to the one  known by the same name here.
   I have  not  been able to  ascertain  with much cer-
tainty, at what period  it  made is appearance among
the Europeans, who  first emigrated  to America.   For
an hundred and fifty  years after their earliest establish- 
44             HISTORY OF TYPHUS.
ment, there were few if any books on medical science
published  in  this  country, and  no medical  journals
made their appearance till a still later date.   Of course,
all we know of the diseases of that early period has been
collected from historical records, which casually mention
times of sickness, but give us no descriptions, or at most
imperfect ones, of their appearances and symptoms.
  We have reason to believe, however, from these im-
perfect  and broken accounts, and from oral tradition,
that it was not long after the first settlement of the
country, before the inhabitants were afflicted with what
is now called  Typhus, but which was then known by
the various names of long fever, slow fever, nervous fe-
ver, putrid fever, &c.
  Whether the Typhous Fever was originally a disease
of this country, I have not been able to ascertain.  Al-
though I have made particular inquiries in various parts
of the countiy, and especially near the borders of the
Indian possessions, I have never found an instance of an
aboriginal inhabitant having suffered from  this disease.
  I have  likewise consulted several physicians, who
have lived many years in the vicinity of Indian tribes,
and who have often visited them  in sickness; they have
all informed me, that they have never seen a native at-
tacked with Typhous Fever.
  I do not think, however, that my inquiries have been
sufficiently extensive,  positively to warrant the conclu-
sion, however probable it may seem, that  Typhus has
never made its appearance among them.
  Whether this disease is of universal occurrence, or
is confined to any particular  climate or latitude, as has
sometimes been suggested, is a question  which I am 
               HISTORY OF TYPHUS.             45
not prepared to decide; but I have every reason to be-
lieve that it has prevailed  in every part of the United
States.
   A late writer in one of our periodical journals, has
advanced the opinion, that Typhus  does not prevail in
the warm season of temperate climates.  This conjec-
ture is unfounded, as I have seen it attended with all its
characteristic marks in every month, and, I believe I
may say with truth, in every day of the year.  This
fact might be attested by the whole medical faculty of
New-England.
   With regard to the liability of the two sexes, I am
disposed to think there  is not much difference in the
number of each attacked, but more females are cut  off
by it than males, in consequence  of  its appearance
during  pregnancy and soon after parturition.
   As to age, I have never seen a child nursed at the
breast affected with it, but other physicians have; and
those in whom I could  place confidence have assured
me that they have met with infants suffering under this
disease; and if so, it may be said to attack both sexes
and all ages, from the cradle to the  grave.
   Notwithstanding its general occurrence throughout
the  country,  long periods of time have  elapsed, in
which it  has not existed in particular sections of coun-
try of considerable extent.
   When I commenced the practice of physic in 1787,
in Cornish, N. H., a town situated on the banks of the
Connecticut  river, I was  informed by physicians, as
well  as the inhabitants who had resided many years in
that part of the country, that about twenty years pre-
vious, a fever, which they had called nervous, had pre- 
46             HISTORY OF TYPHI'S.
vailed  in  that vicinity,—had soon  after disappeared,
and, for the twenty years next succeeding, had not re-
turned in a solitary instance.  It was eight years after,
during which time I  visited the sick pretty extensively
in that and the adjacent towns,  before  I saw or heard
of a single case of Typhous Fever.  I  was then called
into a family, one member of which  had died of this
disease, and another then lay sick of it.  Soon after, I
left this portion of country, and was absent  for about
eighteen months,  and  was in consequence  unable to
trace the  course  of  the disease; but in 1798, a year
after my return, it made its appearance  in  the village
surrounding Dartmouth College, twenty  miles  distant
from Cornish, and in several neighbouring towns simul-
taneously.  From that time to  the present, a lapse of
more than twenty-five  years, I have never  so far lost
sight of the disease, as to be unable to follow its changes
from  one place  to another, and to  tell where  it was
prevailing.
  During this same period,  it has appeared in all the
New-England states, and as far west as my knowledge
extends.  Indeed it  seems to possess  a  migratory
character, and travels  from place to place, and,  after
remaining in one village for a longer  or  shorter time,
as,  from one year to two or three, it ceases and appears
in another.
  I have not observed that situation has any influence
either in  producing  or preventing this disease.   It
affects alike persons  living on mountains and in valleys,
on  plains and the  banks of rivers, and on the borders
of  lakes and stagnant ponds.
  And I have not perceived that occupation or habits 
           CONTAGIOUSNESS OF TYPHUS.         47
of life make any difference in their liability to receive
this disease, nor has it in this country been confined to
the poor and filthy; but affects  nearly  alike the rich,
the poor and middle classes.

             Contagiousness of Typhus.

   That the Typhous Fever is contagious,*  is a fact so
evident to  those who  have seen much of the  disease,
and who  have paid attention to the subject,  that  I
should have spared myself the  trouble  of saying any
thing with regard to it, did I not know that there are
some physicians in this  country, who  still dispute the
point; one, which I think can be as fully demonstrated,
as that the measles, small-pox, and other diseases uni-
versally allowed to be contagious, are so.
   The arguments usually  brought against this opinion
are, that in certain cases, we cannot trace the contagion
to its source, and that many persons exposed to it,  do
not contract the  disease.   These  objections might be
advanced with equal truth against the  contagiousness
of  all diseases; as it frequently happens, that one or
more  individuals  in a family  will escape an  attack,
though equally exposed as those who suffer from it.
   A  few instances,  which have fallen under my own
observation, would alone be sufficient to determine the
question.
   A  young man, a pupil of mine, was attacked with
the Typhous Fever, from which  he recovered  with

  * Without going into a discussion upon contagion and infection,
I would observe, that by a contagious disease, I mean simply, one
that can be communicated from one individual to another. 
48         CONTAGIOUSNESS OF TYPHUS.
difficulty.   Some of his family,  who lived about forty
miles distant,  came and  took care of him during his
sickness.  Upon his recovery, they returned home in
good health, but soon after  sickened  with the same
disease, and communicated it to others, who had  not
been exposed  in the first instance.  From  this, it
spread  to numerous  other families in the vicinity, who
had been exposed to the contagion.  In the whole town
where  this  occurred, there had been no case of  Ty-
phous Fever for many years, till  brought  there by the
circumstances  above related.
  During  the  prevalence  of the Typhous Fever in
Thetford, (Vt.) a woman  went  there from Chelsea,
about  ten miles distant,  to  visit and administer to  a
sister sick of this disease.   Upon her return, she  was
herself attacked by it and soon after died.  Others of
her  family contracted it  of her;  and in about four
weeks, there were  thirty  persons taken  down with
Typhus, all of whom had been  exposed to the con-
tagion.
  A young man belonging to Plainfield, (N. H) who
had  left his friends, and  resided for some time in the
western part  of the  state  of New York, returned to
his  father,  who  had a numerous family.    He  found
himself unwell before he  reached home—was  imme-
diately confined with Typhus, and soon sunk under the
disease.  In about  four w^eeks after, I was called  into
the family, and found nine members of it sick of the
same fever.
  With a knowledge of these facts,  and many more,
equally to the  point, it is impossible for me not to be-
lieve this fever contagious, though it may not perhaps 
                 ORIGIN OF TYPHUS.                49

be so Certainly and readily communicated as some other
contagious diseases.*

                   Origin of Typhus.

   Some physicians admit that Typhous  Fever is often
communicated from one person to another, who never-
theless suppose that it is frequently produced without
any contagion or specific cause; that is, that  it arises in
many cases  from errors in diet or exercise, from the
effects of  temperature,  or what  Sydenham  would call
an epidemic  state of the  atmosphere, from marsh mias-
mata, or confinement in  close crowded  apartments.—
This is  a  difficult subject, and it is  not easy  to demon-
strate that it is never produced by some or all of these

   * Professor Smith's belief in the contagiousness  of Typhus has
not escaped  the censure of reviewers.  Since the non-contagious-
ness of Yellow Fever has been so satisfactorily determined, the con-
tagiousness of  all fevers has become an unpopular doctrine.  The
reader will observe that Dr. S. by no means asserts that Typhus is
uniformly, and  necessarily contagious, but  only that it is so under
peculiar circumstances.  Such being the question, it appears to me
that it is  far easier to ascertain the affirmative, if it be  true, by posi-
tive testimony, than it would be to determine the negative, if that
were true.  If three credible persons were to declare to me that they
had seen, in this City, yesterday, an acquaintance of mine, and a
hundred  others should declare that they had not seen him, I should
certainly believe the former, theirs being  positive testimony, and
that of the latter negative.  When, therefore, as is the case, a few
individuals present such unequivocal facts  as those detailed by Dr.
S. we cannot withhold  our credence, even although  hundreds  of
others have never witnessed the same.   They appear to me necessa-
rily to lead to the conclusion that Typhus is sometimes contagious.
This opinionis mentioned by some of the best authorities of the pre-
sent day, among whom is the distinguished  name of Hildebrand. 
50             ORIGIN OF TYPHUS.
causes, and  perhaps the circumstance of analogy is all
that can be adduced against the assumption.
  However, the fact already noticed, of the absence of
the Typhus in a large section of country, for an interval
of more than twenty years, would lead us to doubt the
possibility of its being produced by any of the accidental
causes above enumerated; for in such an extent, and
among so many people, it is impossible but that some of
these  circumstances should  have  occurred—and the
disease of course be produced.   Besides, if it can be
communicated from one person to another, it has a spe-
cific  cause,  and I know no disease that arises from a
specific cause, that can be produced without the agency
of that cause.
  It  has been  suggested that  Typhus occasionally
arises from  marsh  miasmata* the  same which, under
certain circumstances, produce intermitting and remit-
ting  fevers.   A  fact,  which  I  shall  here  adduce, is
strongly opposed to this hypothesis.   On the Connecti-
cut river, from  Northampton, in Massachusetts, to its
source, a distance of more than two hundred  miles
from north to south, and on all its tributary streams, on
both sides,  for  an hundred miles  in width, there has
been no instance of any person's having contracted the
intermitting  fever, from  the  first settlement  of the
country to   the present time; and yet the Typhous
Fever  has  prevailed  more or less in every township
within that tract of country.
  The Typhous Fever, as far as my experience, which
has been considerable, enables me to judge, is a disease
*Good, Study of Medicine, vol. ii.p. 188. 
               LIABILITY TO TYPHUS.             51
sui generis, exhibiting as little variety in the  different
individuals affected by it, as some of the diseases which
are acknowledged always to arise from contagion.   If
its duration is not so uniform as some of the contagious
diseases, it is less irregular than  others, which spring
from specific causes,  as for instance the  intermitting
fever.

                 Liability to Typhus.

   There is another marked point of analogy between
Typhus  and  the common  contagious maladies, which
is, that  it rarely affects the same  individual  twice.—
Those, however, who do not consider it a distinct dis-
ease, but only a state of fever, will probably differ from
me in  opinion on this point.   For  it is evident, that if
we make the name of the disease depend on the pre-
sence of one or two symptoms, or on that indefinite
thing or  state called debility, we shall be liable to mis-
name it, and  that this is actually done, and in very many
instances, there can be no doubt.   Indeed,  within  the
last year, I have been consulted in several cases of dis-
ordered secretions of the digestive organs* which were
called  low nervous  or low typhous fever, merely on ac-
count of the presence of a furred tongue, loss of appe-
tite, and some  degree of thirst.  Several  of  these
patients  told  me, that they  had had one of these "low
fevers" every year} for several years in succession.   It
is obvious that those physicians  who have such vague
and indefinite notions of fever, as to call a stomach af-

  * "Acute disorder of the digestive organs" of Hall—On Diag-
nosis, part 2, p. 102. 
 52            LIABILITY TO TYPHUS.
 fection, Typhus, would be equally liable to call other
 febrile complaints by the same  name, and may imagine
 they detect its  existence in the same individual many
 times.
   My  own personal experience is strongly in favour of
 the opinion I have advanced of the non-liability of the
 same  individual,  to a second attack of Typhus; for
 during the twenty-five years since I first attended pa-
 tients in this disease, and in that time I have visited
 many  hundreds, and  have witnessed its  prevalence
 several times in the same village, I have never known
 nor heard of its recurrence in the same person.
   I once attended a numerous family, every member of
 which  was sick of Typhus, except two, who escaped at
 that time; but two years afterwards, when the disease
 again appeared in that  neighbourhood, those two indi-
 viduals of the family, and those alone, were attacked.
   In another family, which I  attended,  consisting of
 eight persons, five of the eight had the disease  during
 the autumn, and early part of the winter, and recover-
 ed. The next summer, the remaining three and another
 person, who had been added  to the family after  the
 former sickness, were attacked by it, while all those pre-
 viously affected escaped.
   The experience above spoken of, in addition to these
cases, and numerous others equally in point, forms  a
strong  presumptive proof, that in this respect, there is
 an analogy between Typhus and the common conta-
gious diseases. 
     CHANGES AND COMBINATIONS OF TYPHUS.   53
                 Changes of Typhus.

   Some late writers, have described a fever beginning
 inflammatory, and ending Typhus, and vice versa. Upon
 this point, I would observe, that in many  if  not  all
 acute diseases, there is a marked difference  in  appear-
 ance between the rise and decline of the same disease,
 whether it terminates in death or recovery,  and gene-
 rally, the early part of all febrile affections is attended
 with more symptoms of inflammation than the latter.
 This is undoubtedly the case with Typhus; but  such
 difference of symptoms in its  different stages, should
 not induce us to give the disease different names.
   As I consider Typhous Fever as arising from  a speci-
 fic cause, if it  begins  Typhus, or arises  from  such
 specific cause, I believe it to continue Typhus  through
 its whole course.   Variations, in severity or mildness,
 can  make no specific difference in the disease.

              Combinations of Typhus.

   With  regard to the  combination of Typhous Fever
 with other  diseases, the opinion  has been often,  and
 confidently  advanced, that two diseases arising  from
 specific causes  could not exist in the same individual,
 at the  same time.  But however dogmatically it has
 been stated, it is nevertheless without foundation, since
 I have myself seen the Hooping-Cough, and the  most
 malignant dysentery co-existing in the same person.* It

  * Extract of a letter from Daniel Sheldon, M. D., of Litchfield,
 Conn.
  "In the course of the year 1807, the mumps, hooping-cough and
measles were all prevalent in this town, at the same time.  The 
54          COMBINATIONS OF TYPHUS.
has been stated by Mr. Harryf, that Dysentery  and
Typhous  Fever often combine, and I  can  add my
testimony to the same fact, for  I have often seen a pa-
tient  taken sick with all  the  characteristic marks of
Dysentery,  and after some time the dysenteric  symp-
toms have wholly subsided, while those of Typhus have
continued  for  many  days, so strongly marked as to
leave no doubt on my mind of the truth of Mr. Harty's
position.
  I have  likewise often seen this  disease attack  per-
sons under the influence of epidemic catarrh,  and the
symptoms  of both diseases continue  perfectly evident
for some time.
  From the view of  this subject above taken, and the
facts there stated, I consider Typhous Fever a disease
sui generis, arising from a specific cause, and that cause
contagion, and seldom  affecting  the same  person more
than once.
  The diseases with which it is liable to be confounded,
and for which it is often mistaken, are pure, unmixed

children of the Rev.  Dan. Huntington, then a resident here, were
subject to these complaints.  One of them had the mumps, hoop-
ing-cough and measles at the  same time-, another, the measles and
one of the other  complaints, which, I do not now accurately re-
member.  In each child, the peculiar symptoms and appearances of
each disease were exhibited and strongly marked; and, so far as I
observed, progressed together, without  any mitigation or suspension
of either.  Each of the children, after the abatement of their disor-
ders, had an inflammatory swelling about the neck, of considerable
size, which suppurated and was opened."
  ^Observations  on  Dysentery and its combinations, by William
Harty, M. B. London, p. 57, et. seq. 
            COMBINATIONS OF TYPHUS.          55
catarrhal fever, the acute stomach complaints above re-
ferred to, and those bilious affections, which take place in
the latter part of summer, and  the commencement of
autumn.*
  I have seen many cases of all these affections, which
have been considered and treated  as Typhus, by those
who consider it  as a mere state of fever, and  not as a
distinct disease, dependant on a specific cause.
  It will be observed, that simple  inflammatory fever
is not mentioned as one  of the  diseases with which  it
may be confounded.  The reason is, that no such  dis-
ease has ever fallen under my observation.
  Although I have practised  physic  and surgery for
thirth-five  years pretty extensively in all  the New
England states, except Rhode-Island, and have lived in
New-Hampshire, Vermont, Connecticut and Maine, I
have never witnessed a single case of continued fever,
except Typhus, which was not either the effect of con-
tagion, as the small pox, measles, &c. or evidently con-
nected with local inflammation, and dependant upon it.
  I do not mean to assert that  Typhus is  never con-
nected with local inflammation; indeed I know that the
reverse of this has been the opinion of some men of
great observation, and that there are many phenomena,
which serve to corroborate it; but  if so, it differs essen-
tially from that kind of sympathetic fever, attendant on

  * It is a fact, favourable to the correctness of the author's opinions
on this topic, that he has not neglected  to notice, in relation  to
Typhus, that state of the mucous lining of the stomach and intes-
tines, which the French pathologists regard as  its cause.   The fre-
quent occurrence of gastric fevers, but of a character essentially dif-
yerent from Typhus, was familiar to him.            N. R. S. 
56              CAUSES OF TYPHUS.
phlegmonic inflammation, and on attentive examination,
this difference will be sufficiently obvious.
  Typhus, like  the  other contagious  diseases, has a
natural termination, and if it does not end fatally when
uninterfered with, it gradually exhausts itself and dis-
appears; at the came time, unlike those diseases,  it is
not restricted in its duration to so narrowr limits.
  So far as I  have observed, it has rarely terminated
under fourteen days from its commencement, and sel-
dom exceeds sixty.   In a few  rare  instances, it may
have terminated earlier or continued  later.  In one case
which I visited, the patient had been confined an hundred
days, and  the  symptoms still resembled  Typhus, hut
the specific character had probably been changed, and
these symptoms were rather the effect of  the disease,
than an evidence of its then actual existence.

                 Causes of  Typhus.

  With regard to the remote and proximate causes of
this fever, which have been  so often and  diffusely de-
scribed by the learned, if the  remark made above be
correct, contagion may be considered as the antecedent
to all which follows its application, and that without it,
no  effect  would   be  produced.   But  how this cause
operates upon  the system, or on what part  it makes its
first impression,  or how this first impression produces
the ultimate effects, wre  are wholly  ignorant.  As  for
the proximate  cause,  I know not how to separate it from
the disease itself.   Since the disease is known only by
the phenomena it exhibits, these phenomena may be
considered as  constitutingthe disease, or all we  know
of it. 
             CAUSES OF TYPHUS.                 57
  According to our late nosological arrangements, the
Pyrexia, or febrile diseases, affect principally the circu-
latory system; if so, the affections of the other functions,
are the consequence of the change first induced in this
system.  But as all the different parts of this system,
are destined to perform different functions, it may hap-
pen that a disease may primarily affect one part only,
and the change produced in the rest of that system, may
be the consequence of a change produced primarily in
another part.
  In the sanguiferous system, the proper function of the
heart seems to be nothing more than  to receive the
blood from the veins, and throw it  into the arteries,
which may be considered as living  canals, intended to
convey the blood from the  heart to the system of capil-
laries.   Here all the functions belonging to this  system
are performed, such as nutrition, reparation of the body,
absorption, secretion and the production of animal heat.
Of course, the functions of the heart and great arteries
must be considered wholly subservient  to those of the
capillaries, which in reality, perform all the  great and
essential offices of the circulating system.
  As  this fever  is  supposed to  make considerable
change in the action of  the  circulating  system,  the
question presents itself, what part is first affected? does
the increased action of the heart  and great arteries,
cause the increased action in the  capillaries, or vice
versa?
  In cases of local inflammation, which produce symp-
tomatic  fever, it appears very evident that the capilla-
ries are first affected; the action of the heart and great
arteries is not changed till symptomatic fever is produ-
        S 
58             CAUSES OF TYPHUS.
ced; and that  this symptomatic fever, seems to com-
mence in the capillaries, is evinced by the paleness of
the skin, and the chills with which its first appearance
is accompanied.
  The  analogy between the inflammatory and  febrile
action is so great, that we may with confidence rely on
the similarity of cause.
  The  paleness of the skin, and the  sense  of cold
spoken of above, which attend inflammation, and pre-
cede the attack of fever, or the developement of those
phenomena  to which we usually apply the name, and
which is followed by an increase  of the action  of the
heart and arteries, I explain in the following manner.
Before the diseased action can  take possession  of the
capillary vessels,  the  natural  and healthy one  must
cease, unless disease be a mere increase of the healthy
action, which we have abundant reason to believe is not
the case.  It is during this interim, that is, between the
interruption of the natural healthy  action, and the com-
plete establishment of the diseased  one, that the patient
feels the chill.
   Something of this kind is observed in cases of local
inflammation, which still continues to extend itself.  A
few lines  beyond the discoloured  part of the skin, be-
tween that and the portion which still retains its natural
tint, there is a pale circle, evidently showing that the
action of the capillaries in that part is suspended.
   When local  inflammation  proceeds so far as to pro-
duce symptomatic fever, a degree of paleness  accom-
panied  by chills, precedes the increase of heat.
   Upon the whole,  wdiether we consider Typhous
Fever as dependant on local  inflammation or not,  it is 
              SYMPTOMS OF TYPHUS.            59
probable,  nay, it is very certain, that like  all other
febrile diseases, the morbid action commences and con-
tinues principally in  the capillary system, and  that the
change  which we perceive  in the action of the heart
and great arteries, is symptomatic of the disease exist-
ing in that system.
  The  most violent affections of the heart and large
arteries, as in palpitation, do not produce the  slightest
symptoms of fever, which serves to show that these two
parts of the circulating system have diseases as distinct
and different from each other, as their functions.

               Symptoms of Typhus.

   The  symptoms of this disease, may be divided  into
such  as affect the functions of animal life, and such as
affect those of organic life.
   The  changes produced in animal life, may be refer-
red to affections of the mind, of the organs of sense,
sensibility, and voluntary motion.  Those occurring in
organic life, to changes  produced in  the  respiratory,
circulatory and digestive systems, to secretion and ex-
cretion  generally, together with its effects on the  ani-
mal heat.
   Amongst the earliest symptoms belonging to the first
class, are dull, aching pains in the head, back and limbs,
usually commencing in the head and back, but in some
cases in the lower extremities, attended generally  with
a sense of lassitude and fatigue.   The patient's flesh, as
he often expresses it, is very sore.
   The  symptoms,  as they appear in the nervous sys-
tem,  are a disinclination to  make any mental  exertion, 
 CO            SYMPTOMS OF TYPHUS.
 forgetfulness, inability to measure time, total incapacity
 to pursue any train of thought, or to attend to business.
 As the disease advances, delirium often  makes its ap-
 pearance, sometimes continuing day and night, at others,
 it is present in the night only.  In a still more advanced
 stage coma supervenes, but not often so profound that
 the patient cannot be roused from it by speaking loudly
 to him, although  upon ceasing to speak he immediately
 falls back into the same state.
   In a few  instances, I have known patients in their
 delirium impressed  with an idea of some person having
 abused them; and this idea has continued till after they
 have recovered,  and  was even  then obliterated with
 difficulty.
   In two cases which I have met with, instead of deli-
 rium, a kind of insanity appeared pretty early  in the
 disease; and in both, as the insanity came on, the pecu-
 liar symptoms of  Typhus abated.
   In one instance it was of a playful childish nature^ in
 the other there was a  display of great wit and humour.
  In both it continued about four weeks,  and  as  it
 then gradually subsided, a restoration to health took
 place.
  There  is in this disease not  only a forgetfulness of
 the lapse of time and of occurrences that  have recently
happened, but though the patient appears sensible, and
gives rational answers through the whole  course of the
disease; yet after his recovery, the whole time elapsed,
and all the circumstances that have taken place during
that period, are entirely blotted from the memory, and
are never after recovered.
  The hearing is often impaired, almost from the com- 
              SYMPTOMS OF TYPHUS.             61
mencement of the attack.   Sometimes  false hearing
occurs, and  the patient  imagines  he perceives voices
and sounds when nothing of the kind exists.
   The sense of vision is not so much impaired as that
of  hearing; and blindness, I believe,  never occurs  till
near  the point of dissolution.   But  false, double, and
distorted vision sometimes arises.
   To an observer, the eyes present a peculiarly heavy
and languid  appearance and are a little watery, but in
the beginning of the disease, there is not much evidence
of inflammation.   The red vessels, however, on the con-
junctiva are  often a little enlarged,  and appear more
numerous than in a state of health.  In the latter stage
they become more turgid and of a darker colour.
   The secretions of the mucous membrane of the eye
are often  considerably  affected,  become  thick  and
viscid, and accumulating in its angles, dry and put  on
the appearance of scabs.
   There is sometimes a considerable  increase of sensi-
bility to light.
   The voluntary motions are  unsteady,  the  tongue
trembles when an attempt is  made to protrude  it, and
the patient's  hand shakes when he attempts to bring it
to his head.  There is often more or less starting of  the
tendons, and  the muscles of the face are agitated, espe-
cially when asleep, so as to produce momentary distor-
tion.
   The voice is altered, from the beginning.   Early in
the disease it is usually rather plaintive and  small,  but
as  it advances, and more  particularly in bad cases, it
.becomes guttural, and at last truly sepulchral.
   The patient is generally inclined to lie on  his back, 
62            SYMPTOMS OF TYPHUS.
and he insensibly slides down towards the foot of the
bed.
  It has appeared to me, in some instances, that the
moral principle has been affected.   One patient in par-
ticular, who had been extremely sick with this disease,
after his recovery had a strong propensity to steal, and
did in effect take some articles of clothing from a young
man to whom he wras under great obligations  for the
care he had taken of him during his sickness.   He at
length stole a horse and some money, was detected, and
punished.   I took some pains to inquire into the young
man's former character, and found it good, and that his
family were respectable.
   The symptoms of Typhus indicating a disturbance of
the functions of the circulatory system are an increased
frequency of the pulse, without fulness, or usually any
considerable degree of hardness, from the commence-
ment of the disease.
   The pulse is generally rather easily compressed, and
when the disease is severe, has often a peculiar, undu-
lating stroke, or a second small beat following each
full one.
   The animal heat is always deranged in this disease.
In the commencement, there is generally some degree
of chilliness felt  by the patient, although his skin feels
warm to the touch.  This sense of cold often continues
at intervals for three or four days.
   The heat on the surface of the body varies in intensi-
ty at different times of the day, and  is greatest during
the exacerbations, of which there are generally  two in
 the course of twenty-four hours.   They do not however
 appear regularly at the  same hour each day, but vary 
              SYMPTOMS OF TYPHUS.             63
both in the times  of  their appearance and m their se-
verity.
  In the commencement of the disease the most marked
exacerbation occurs oftenest in the eveninsr.
  The heat  is ordinarily very unequally diffused  over
the body; sometimes  the head and trunk will be exces-
sively hot, while the extremities are cooler than natural;
at others,  the extremities will be pre tern aturally hot,
when the body is  but moderately so.   One cheek will
often appear of  a deep red  colour and  be very hot,
while the other remains pale and cool; as its colour and
heat subside, they seem to cross over and affect the
opposite cheek in the same manner.  This colour and
heat usually  extend so far  as to include the ear of the
affected side.
  Haemorrhage  is not an uncommon symptom in this
disease.  In  a majority of instances in which it  takes
place, it arises from the intestines, not  unfrequently
from the nose, and more rarely from the kidneys.
  In females of adult years it is often from the uterus.
  This symptom  is most apt to show itself at about the
height of the fever.
  Livid spots occasionally appear on the skin, and blis-
tered surfaces sometimes become black and gangrenous.
  The effect of Typhous Fever  on the  secretions is
sudden and universal;  they  are all  changed either in
quantity or quality from the very commencement.
  The saliva is  generally  diminished in quantity, be-
comes glutinous and  produces great thirst; but in some
cases its secretion is augmented and the  patient spits
great quantities of frothy mucus, without any desire to
take liquids as in the other case. 
64            SYMPTOMS OF TYPHUS.
   The tongue, in the commencement of this fever,  is
covered with a white fur, which as the disease advances
assumes a yellow tinge, and from that, gradually changes
to a brown, which eventually becomes almost black.—
Arrived at  this state, it cracks and peels  off,  leaving
the tongue smooth, dry, and very red.  It is then again
renewed and again comes off, making these changes, in
severe cases, several times in the course of the disease.
   The teeth are often incrusted with a brownish mat-
ter, which adheres to them  closely, near the gums.
   The fauces  are covered with a  thick tough  mucus,
which is sometimes thrown  off in large quantities.
   The urine is changed both in quantity and quality.
In the commencement of the fever it is not high colour-
ed, and is considerably  copious, being often above the
natural quantity, and deposits  no sediment.  In voiding
it  into a vessel it often  foams like  new beer.   As the
disease  advances,  the  urine becomes  more  highly
coloured, and  as it begins to decline, lets fall an abun-
dant sediment. In very severe cases, the patient evacu-
ates his bladder  but seldom,  allowing  the  urine to ac-
cumulate there in very large quantities.
   The changes produced in the functions of disgestive
apparatus are a vitiated taste, want of all appetite and
desire for food, and a total  loss of the power of diges-
tion in the  stomach.  Sometimes  nausea and vomiting
take place;  whether this last is spontaneous or produced
by art, the  matter discharged shows, that the secretions
of the stomach are entirely  changed.
   Sometimes,  the matter thrown up consists wholly of
vitiated  mucus, at others,  it  is mixed  with bile of an
unhealthy colour and consistence. 
              SYMPTOMS OF TYPHUS.            65
  The peristaltic action of  the intestines is sometimes
suspended and at others preternaturally increased, and
whether the stools appear naturally, or are solicited by
art, they are always liquid, generally of a dark colour,
and have an unnatural and  excessively foetid odour.
  The latter stage of all severe cases of Typhus is at-
tended with diarrhoea; the stools are frequent, copious,
liquid,  and extremely foetid.  The  bowels are often
tympanitic, the  flatus not passing off  with  the liquid
stools.
   The danger of the disease  is in proportion to the
violence of the diarrhoea; when the  patient has not
more than four or  five liquid stools in the twenty-four
hours, it is not alarming, as it does not  seem to weaken
him much, but if they exceed that number, serious con-
sequences may be apprehended.
   I have never lost a patient, whose bowels continued
 constipated through  the whole course of the disease,
 and have never  known a fatal case of Typhus, unat-
 tended by diarrhoea.
   The respiration is always affected in a greater or less
 degree.   There  is generally  a correspondence between
 the state of the respiration and that of the pulse, which
 is frequent and  undulatory,  when the breathing is hur-
 ried and unequal, or  accompanied, as  it frequently is,
 by occasional long and full inspirations like  sighing.
   After the patient has been sometime sick, if the dis-
 ease proves severe, there is  a peculiar whistling sound
 produced when he breathes through the nose, and when
 asleep or lying in  a state of coma,  the mouth is gene-
 rally kept open and the breathing has somewhat of a
 stertorous sound,
         9 
66           SYMPTOMS OF TYPHUS.
   In  some instances, there is  no sensible perspiration
for several days succeeding the attack of the disease,
in others, there will be more or less sweating about the
head, face and superior part of the body, while the other
parts  remain dry and hot.
   Occasionally, the patient will sweat, during a part of
the twenty-four hours, almost from the beginning of the
fever.
   In  fatal cases, there  sometimes  appears, what has
been called the washer-woman's sweat, which is extreme-
ly profuse over the whole surface of the body and extre-
mities, standing  in large drops on the face, and giving
to the cuticle, on  the palms  of the hands and soles of
the feet, a corrugated appearance and a light colour, as
if it had been long macerated in water.  In such cases,
the perspiration is warm till a short time before the pa-
tient expires.  I have never seen an instance of recovery
after this kind of sweating.
   After the fever begins to decline, the perspiration be-
comes universal, especially while the patient sleeps; in
this case it is  not very profuse and produces a  cooling
and not unpleasant effect.
   The skin has a peculiarly dirty appearance, and feels
harsh and dry except when covered with perspiration.
In some instances the surface of the patient's body com-
municates to the touch a sense of scalding, or a certain
kind of pungency, which it is difficult to  describe, but,
when we are  accustomed to  it, readily distinguished
from the sensation given in any other fever, which would
perhaps equally affect the thermometer.
   In the advanced stage, it is not uncommon for biles
to appear; if they have a bright red colour and proceed 
              SYMPTOMS OF TYPHUS.             67
to suppuration, it  is a  favorable symptom.   Sometimes
there appear eruptions about the mouth; these are con-
sidered by most physicians as a good indication, and I
think I have generally found them so.
  There is a remarkable odour arising  from a  person
affected by this disease, so peculiar that I feel assured
that upon entering a room, blindfolded, where a person
had been confined for some length of time, I should be
able to distinguish it from all other febrile affections.—
This is an additional circumstance in favour of the ex-
istence of the  specific cause  assigned above; as several
other diseases  which arise from contagion are attended
by an odour peculiar to  each, which, when once fixed
in the mind, enables a person to recognise their presence
ever  after.  This  is strongly  evinced in  small-pox,
measles, malignant sore throat,  &c.
  The absorbent system is  perhaps less affected than
any other, and, in consequence, emaciation takes place
rapidly.  This is  rather a good symptom, for I have ob-
served that patients who emaciate rapidly are more likely
to recover, than when they retain their ordinary degree
of fatness, or when the face appears full and bloated. This
last symptom, occurring after  the disease  has  existed
some days, indicates great danger.
  In some instances, the power of absorption in one of
the lower extremities is in a degree lost, and one  leg
and thigh become enlarged.  As the fever abates, the
cellular substance appears to be loaded, the muscular
power is weakened, and the limb  feels heavy and un-
wieldly.
  In some cases,  it is eventually restored, in others, the
enlargement continues through life. 
68            SYMPTOMS OF TYPHUS.
   After the fever has subsided entirely, and the appetite
is perfectly restored, the patient generally  gains flesh
very fast, and often acquires a greater size  and weight
than he possessed before the attack.
   This increase in size  takes place much earlier and
more rapidly than the acquirement of muscular strength.
   In cases where the disease has been very  severe, and
the patient has recovered, the hair comes off from the
head, and is succeeded by a new growth; this happens
more frequently with those who have  much and long
hair.   The new hair, however, never acquires so great
a length as the old.
   After a very severe attack, the cuticle peels off from
the palms of the hands and soles of the feet, and some-
times from the whole surface of the body; as is perceived
when the skin is rubbed by the hand, when in a state of
perspiration.
   The cuticle never separates in this way till the dis-
eased action  diminishes and the patient  begins to re-
cover.
   As respects  critical days, much  has been  said and
written from the earliest physicians to the present time;
for my own part, I have  never been able to determine
that any exist, and if they do, they can be of no use, in
a practical  point of view, for two reasons; first, the dis-
ease attacks in such a gradual manner that we hardly
know on what day to fix its commencement; and second,
when it terminates favourably, it often happens that the
patient remains a week or more in such a situation that
the practitioner is  unable to decide whether he is
mending or failing. 
TREATMENT OF TYPHUS.
69
               Treatment of Typhus.

   If the pathology  of Typhous Fever  which we have
just laid down, be correct,—if it  arise from a specific
cause and has a natural termination, it may be a question,
how far wTe are to attempt a cure of it, or if we possess the
power, whether we can with propriety  cut it  off in its
commencement,  and by art  prevent  its  running its
course.
   Physicians in this country are divided in opinion on
this subject.   Some imagine that they have often cured
it immediately after  its first attack, nipped it in the bud,
as they say, while others of perhaps more experience will
tell you they are not certain that they have ever arrested
this disease by medicine.
   I confess the subject is a difficult one, and that it is
next to  impossible to demonstrate the  truth  of either
the positive, or negative side of the question, and as ab-
solutely so to those who have already  made  up their
opinions on the subject, as to that still larger class, who
have yet to learn to doubt their own skill  and mistrust
the powers of medicine.
   When a person is taken  unwell, has a pain in the
head, takes medicine, and the next day recovers, if the
attending physician  is disposed to  consider it  a case of
Typhous Fever, we can bring no  testimony  to prove
that he  would  not have  had the disease, had  he not
taken the remedy.
   In such cases we can only make the truth  probable,
and what appears so to one, may not to another.
   In the first place, Typhus in its commencement ex-
hibits so many symptoms in common with  other febrile
affections, that it is not easy  for anyone, especially the 
70            TREATMENT OF TYPHUS.
unexperienced, to  determine  whether the  disease  is
truly Typhus or  not; even those, who hold  to the opi-
nion that they often cure it suddenly, have confessed to
me that they cannot distinguish it from other febrile af-
fections upon  its  first attack, and never  positively, till
the disease has, in a considerable degree, developed itself.
   This  confession is alone sufficient to render the cor-
rectness of their previous opinion doubtful.
   Again, these very physicians, or at least a portion of
them, have acknowledged that when the disease is ful-
ly formed, that is, when  the patient has the Typhous Fe-
ver, it cannot  writh any certainty be interrupted or cut
off,  as they express it.
   Besides, we have to oppose to the opinions of those,
who think they often cure this disease in its commence-
ment, the belief of others of quite as much experience,
who think they have never interrupted its  course in a
single instance.
   Indeed, I am myself of this latter  opinion,  for du-
ring the whole course  of my practice  I have never
been satisfied that I have cut short a single case of Ty-
phus, that I knew to be such;  nor have I seen a solita-
ry instance  of its having  terminated  within fourteen
days from its first attack.*

  * This assertion of the author has been objected to by journalists
who have reviewed the first edition of this work, as inconsistent with
some of his own statements.  They remark that the author himself
subsequently speaks of having interrupted the disease by the asper-
sion of cold water.   He does, it is true, speak of sudden  and sur-
prising amendment resulting from the judicious employment of this
remedy; but let it be carefully observed that this is  stated to have
occurred in cases of protracted continuance, in which the character
of the disease is entirely changed, the fever being connected with
the sequelae of Typhus.                           N. R. S. 
             TREATMENT OF TYPHUS.            71
  Cases have occurred to me often where the distress
and sufferings of a patient have been alleviated in less
than  half  that time;  but the morbid action has not
ceased, nor the healthy one of the secreting surfaces
been  established, and a natural appetite restored, with-
in the time above-mentioned.
  It does not follow, because we have no expectation
of arresting  the disease, that  we are to  neglect  doing
any  thing.    In cases  of  the other  contagious diseases,
which are destined to run a certain course, as the
small-pox, we often prescribe early in the disease, and
with evident good effect, but not with a view to stop, or
cut off the disorder;  for whatever we do, we expect it
will pass through all its regular stages, and our prescrip-
tions are calculated only to render it milder and safer,
and enable the patient to live through it.
  With the same views, I prescribe for Typhus, both
at its commencement, and through the  course  of the
disease; for Typhus has a natural termination like
other diseases which  arise from specific causes.
  On the other hand, it does not follow of course, that
this disease in all cases requires remedies, or that a pa-
tient  should necessarily take medicines because he has
the disease.  In  other specific diseases,  we proceed on
the principle of  withholding  our  remedies unless they
are  called for by particular  circumstances,  and thus
many cases of measels, hooping-cough, and other conta-
gious diseases, go through their course to their natural
termination without medicine.
   In cases where the disease is going on regularly in its
course, without  any  symptom denoting danger,  and
without any local distress, it is  presumable that medi- 
72            TREATMENT OF TYPHUS.
cines, especially powerful ones, would be  more likely
to do harm than good.   Although Typhous Fever is a
more formidable disease than measels or hooping-cough,
yet there are many mild cases, and in such cases, I ap-
prehend that the use of powerful means, with a view
of curing the disease, is liable to do great mischief.
   I have seen many cases, in which persons in the early
stages of this disease were moping about, not very sick,
but far from being well, and who,  upon taking a dose of
tartrite of antimony, with the intention of breaking up
the disease, have been immediately confined to their beds.
   In  fact,  1  feel  well  convinced, that  all  powerful
remedies or measures, adopted in the early  stage of Ty-
phous Fever are very liable to do  harm, and that those
patients, who are treated with  them in the beginning,
do not hold out so well in the  latter stages of the dis-
ease*
   If it is determined that something must be done at or
about  the commencement of the disease, the question
is, what  that something shall be, and the first thing usu-
ally suggested  is blood-letting.

  * Happening in company with a physician with whom  I was
slightly acquainted, he observed that he had adopted a new method
of treating Typhus, which I was aware had been prevalent in the
vicinity where he lived, and stated that it had proved very success-
ful. Upon my inquiring into his peculiar mode of treatment, he
informed me that it consisted in giving his patient milk and water,
and nothing else, through the whole course of the  disease, and he
affirmed that he had treated quite a number of patients, and had not
lost a single one since he had adopted this mode of  treatment.
  I take this to be a confirmation of my  opinion, that powerful re-
medies  are not properly used in this disease, unless called  for by
particular circumstances, and that these circumstances are more rare
than is generally supposed. 
             TREATMENT OF TYPHUS.           73
  From  the  time Dr. Cullen published his "First lines
of the theory and practice of Physick," till very lately,
students  were  generally taught to believe, that Ty-
phous Fever was produced by some weakening power,
and was, in effect, a disease of debility.
  Dr. John Brown  enlarged upon this theory, and in-
culcated  a notion in accordance with it, that it should
be treated by the most powerful stimulants.  He con-
sidered  bleeding and  all other modes of depletion as
highly reprehensible,  because Typhus was  placed  at
the lower  end  of his scale of diseases, that is, below
the standard of health.
  This  theory  was carried into practice by many, and
those, who might not have been converts to Brown's
peculiar  doctrines, not having sagacity enough to per-
ceive that  this  debility was the same thing as specific
disease, were nevertheless cautious about bleeding in a
fever, which they  considered Typhus, or  possessing
what they called a  Typhus type.   The most approved
English authors since  Cullen have held this doctrine till
within a few  years.
  Very lately several writers * have ventured to recom-
mend bleeding in this disease.
  Some  of them have advised this practice in certain
cases, where  there  appeared to be more than an ordi-
nary degree of  excitement in some particular organ, in
the brain or lungs for example, while others have recom-
mended  it, simply  because the disease was Typhus,
without waiting for any particular symptom, or set of
symptoms  to  indicate  its necessity.

              * Armstrong, Pritchard, &.c. &c.
       10 
 74           TREATMENT OF TYPHUS.
   The practitioners of medicine in New-England, have
 been divided on this subject; and while one part have
 become converts to the doctrine of blood-letting to a
 high degree in  this affection, the other has condemned
 it in tolo, and, as though opposition had produced a kind
 of re-action on their part, they have had recourse to the
 most powerful stimulants both internally and externally,
 such as opium,  wine, alcohol, and the most acrid stimu-
 lants, as cayenne pepper, arsenic, &c.   Indeed, indivi-
 duals of this latter class have carried their prejudices
 to such an extent, as even to boast of having made their
 patients swallow three pints of strong brandy,  accom-
 panied with large doses of laudanum and cantharides.
   I  have myself seen a written prescription,  in which
 opium, wine, alcohol, cantharides and arsenic, were all
 directed to be taken  several times in the course  of
 twenty-four hours.
   It is remarkable, that though the practice of these
 two  sects, for such they seem to  be, is  as opposite as
 possible, each considering the other's mode of treatment
 as highly deleterious, yet all boast of success  and enu-
 merate various  cases,  which  have fallen under their
 care, with scarcely the loss of a single patient; yet, not-
 withstanding these two highly improved modes of treat-
 ment, it is a notorious  fact, that  Typhous Fever often
 proves fatal.
   There are but two ways of accounting for  the equal
 success of these two opposite modes of cure, for as far
 as I  can  judge there is not much difference in the suc-
 cess  which attends them.  Either  the disease is not so
much under the control of blood-letting as they  would
have us  believe, or these two  extremes produce about 
             TREATMENT OF TYPHUS.           75
an equal degree of mischief; for it is not conceded, that,
if a patient does not require bleeding, he stands in need
of opium, arsenic, cantharides, or alcohol.
  It has been observed that in certain cases of Typhus,
there is great pain accompanied  with a sense of fullness
in the head, and in other cases, the patient complains
of severe suffering in the chest, which is increased by a
full inspiration.
  Under these circumstances, the loss of blood, to the
amount of from twelve to sixteen ounces, often mitigates
these troublesome symptoms, and probably may not only
alleviate the patient's suffering,  but may enable him to
go through the disease with more safety.
  So far as I can judge from my own experience, bleed-
ing does not generally produce any considerable change
in  this disease; the pulse is not  rendered slower by it,
and after the faintness, if there is any produced by the
operation, disappears, the heat is not perceptibly dimin-
ished.
  In some cases, in which I have resorted to this ex-
pedient, I  feel  confident that the  pulse became more
frequent and the temperature of the body higher in con-
sequence of the loss of a pound of blood.
  As haemorrhage sometimes makes its appearance in
Typhous Fever,  and generally at  about the height of
the disease; the advocates for indiscriminate bleeding
have imagined that taking blood early in the disease
will prevent its occurrence.  Upon this subject little
need be said, since it is next to impossible to  disprove
the assertion; for my own part, I  have never seen any
evidence of its truth.
   In the  autumn of 1812, Professor Perkins, now of 
  76           TREATMENT OF TYPHUS.
  New-York, and myself, attended between fifty and sixty
  cases of Typhus in the vicinity of Dartmouth College,
  and many of them students of that institution.
    Of  the whole number, which came  under our care,
  one only was bled, and that on account of a sense of ful-
  ness in the head, of which he complained.
    This patient had afterwards a haemorrhage from the
  bowels, which was pretty profuse, but he eventually re-
  covered.
    This symptom did not occur in any other of our pa-
  tients, of whom we lost but one.
    I am sensible that  it is not safe to  rely on  one fact
  alone in making up  an opinion on a  practical  subject.
  This case is mentioned only to show that bleeding does
  not always prevent hasmorrhage; and from the success
  of our practice, it would seem that blood-letting is not
  so essential, as some would persuade  us to believe.
    That patients often recover from  this disease after
  blood-letting has been practised is an unquestionable fact,
  and the inference which should perhaps be drawn from
 it, in conjunction with the facts mentioned above, is,
 that the loss of a moderate quantity of blood in Typhus,
 is not of itself dangerous, and in  a majority of cases,
 may be allowed with  impunity.  There are cases how-
 ever in which it may be essential to the patient's safety,
 while in others it may prove highly injurious.   The
'judgment and skill of the  physician is  necessary in each
 individual case to determine the propriety of  its adop-
 tion, as well as the quantity which should be abstracted.
   I have never seen  any  benefit from blood-letting in
 typhous Fever, where there was no local inflammation
 or congestion, that particularly called  for it. 
             TREATMENT OF  TYPHUS.           77
   The symptoms, which would induce me to bleed, are
uncommon pain in the head, accompanied  with great
heat in that part, a sense of fulness, and a throbbing of
the temporal arteries; or marks of congestion in the
viscera of the thorax, such as pain in one or both sides
of the chest, increased by a full inspiration.
   The state of the pulse also should be considered be-
fore we bleed; a very frequent  one does not indicate
blood-letting, on the  contrary, in such cases I have sel-
dom or  ever seen this  evacuation  attended with ad-
vantage.
   Many of the French physicians prescribe leeches in-
stead of  general bleeding, and  where they can be pro-
cured, the remedy may be tried with safety, as there is
less to be apprehended from the loss of an equal quanti-
ty of blood by leeches than in any other way.
   The blood, drawn in Typhus, seldom shows a buffy
coat, and as far as I  can judge, is found rather darker
coloured than in ordinary cases of active inflammation.
   Emetics and evacuants from the stomach and bowels
are generally prescribed after the question of the pro-
priety of blood-letting has been decided.
   From  what has been said on the subject of attempt-
ing to interrupt or  arrest Typhous Fever, it  will  be
readily understood, that  I do not deem it necessary  in
every case to give either emetics or cathartics; but as
these remedies  are often necessary,  it is important that
we should point out, if possible,  the  circumstances
which demand their use.
   In cases of simple, mild Typhus, where  there is no
nausea at the stomach, no  pain in  that region, where
the heat  is moderate, and the pulse  not greatly altered 
78           TREATMENT OF TYPHUS.
in frequency, I am clearly of opinion that we had better
leave the disease to cure itself, as remedies, especially
powerful ones, are more likely to do harm than good.
In such cases,  the patient gets  along  better without
medicine than with; all that is required is to give him
simple diluent drinks, a  very small quantity of farina-
ceous food, and avoid as much as possible all causes of
irritation.
  The symptoms, which require the use of emetics, are
nausea, sickness and  oppression at the stomach; and
when required, it may be an important question what
kind of emetic should be given.
  The tartrite of antimony  is an old remedy in the
commencement of fevers, and when  active inflamma-
tion exists, there is no one with which we  are acquaint-
ed, that possesses so powerful an effect in suppressing it.
  As some consider Typhous Fever  a local inflamma-
tion, or an affection of the circulatory  system dependant
upon it, preparations of antimony would not seem inap-
propriate  remedies.  I will not take upon  me to say
that this fever is never connected with local inflamma-
tion, but if so, it is not with that kind which we gene-
rally denominate phlegmonic, or that which  tends to
suppuration, nor that  which has been called sthenic,
as is conclusively proved by the effects  produced upon
it by blood-letting,  since  this evacuation possesses  a
controlling influence over the one, while it has but  a
slight power over the other.  Though it may in certain
cases obviate some of the troublesome symptoms of Ty-
phus, and perhaps render the disease safer,  yet it  does
not cure it, and in many cases is highly improper.
  So likewise, as far as I have been able to judge, tartar 
               TREATMENT OF TYPHUS.            79
emetic should not be used in this affection,  even  at its
commencement; and  in the later stages of  the disease,
it is sometimes followed by fatal consequences.
   From the bad effects, which I have seen result from
the use of antimony in this complaint, I have long since
neglected it in my practice, and have.substituted for it
the ipecacuan, eupatorium, or the sulphate of zinc.
   The use  of this class of medicines has generally been
Confined to  the commencement of the disease, but they
are frequently proper and useful in its later stages.—
The articles, which I have just mentioned, either simple
or combined, may be given, with safety and often with
advantage,  at any period when the symptoms are such
as to  demand an emetic*
   Cathartics are recommended in almost all febrile dis-
eases, and in many cases, much dependance is  deserv-
edly  placed upon them;  their general  use, however,
should not be indiscriminately recommended.   In this,
as in  similar cases, we should consider the necessity of
their  administration,  and whether they would probably
produce the desired effect, not neglecting the particular

  * The author has, perhaps, not been sufficiently particular in re-
gard to these  circumstances which indicate the employment of
gentle  emetics.  In the onset of the  disease, they are useful, as
given by Dr.  Armstrong, for the purpose of favoring re-action, de-
termining to the surface, assisting to unload the heart, great vessels,,
and viscera, and equalizing the circulation.
  In the after progress of Typhus they are salutary for the pur-
pose of removing those acrid secretions which irritate the stomach
and re-act on the disease.  Irritability of the stomach, and the occa-
sional  discharge of morbid secretions are the symptoms which then
point out their use.
                                            N. R. S. 
80          TREATMENT OF TYPHUS.
means to be employed, and  the extent to which we
consider ourselves justifiable in carrying those means.
   There are no remedies capable of doing much good,
which under certain circumstances  and in certain doses
may not do harm, and I  am persuaded  that powerful
ones of this class are always injurious.
   Costiveness  often  occurs in the commencement of
this disease.  This kind of costiveness, is however, of a
very  different  character from  that which is habitual
with some individuals, and which we so often meet with
in stomach and bowel complaints, where the stools are
unfrequent and the faeces hard and  indurated.
   The stools in this disease, except at  its commence-
ment, when there is generally an accumulation in the
great intestines, are always liquid and possess a peculiar
colour and odour.
   The costiveness, therefore, consists only in the un-
frequency of the discharges, and not in their consistence.
   If a strong drastic cathartic  be administered,  it is
often followed by  a diarrhoea, which, though not always
injurious whew  moderate, is always  liable to become so.
   I have never known a patient die of Typhus whose
bowels  were  slow  and  required  laxatives  to  move
them, during the course of  the disease.  Laxatives,
therefore, and not purges are required in this affection;
and the milder they are, if they have the effect to excite
the bowels to throw off their (ontents, the better, and
even these should not be used too freely.  If the bowels
are shut up too  long, their contents  become offensive to
the intestines, stimulate them violently, and a diarrhoea
is more likely to follow, than if  the bowels had been
excited by a gentle laxative. 
              TREATMENT OF TYPHUS.           81
  Laying aside the strong purgative drugs, we have a
considerable number  of mild cathartic ones  to select
from; epsom salts with senna, rhubarb, alone or with a
very small quantity of calomel or ipecacuan, given in
small and repeated doses, are amongst the best articles
of this kind. *
  Blisters have long been employed in fevers under the
general impression that  they were useful, without any
very definite notion of the  mode by which they  pro-
duce a good effect, and without waiting for any particu-
lar symptoms indicating their use.
  So far as my experience extends, they do not pro-
duce  any very considerable influence  on  the disease;
like  bleeding, they  will sometimes  relieve local pains,
when applied near the part effected, as on the forehead
or back of the neck when there is pain in the head—
on the breast, when the chest is affected.
  In most cases if they do no  good, they produce no
bad effect;  but when there are  petechias, or a disposi-
tion to haemorrhage, indicating great debility in the sys-
tem of  capillary vessels, they are liable to do harm, for
in such cases, the blistered surface often becomes black
and gangrenous.
  Upon the whole, we cannot consider blisters as pos-

  * In regard to the  employment of cathartics, we  are to be go-
verned in a great degree by the aspect of the stools.  If they are
dark, acrid, and offensive, gentle  purgatives ought generally to be
repeated till their character is changed.  Tenesmus and tumidity
of the belly also indicate their necessity.  Calomel or the blue pill
should be occasionally associated with them.
  \*                                          N. R. &
        11 
 82           TREATMENT OF TYPHUS.
 sessing much  influence in Typhous Fever, and  they
 may in most cases be dispensed with.*
   With regard  to  the  perspiration, there  can be no
 doubt, but that a great quantity of aqueous fluid es-
 capes from the body in the form of vapour in Typhous
 Fever; but it does not become so condensed, during the
 hot stage, as  to show itself in the form of a liquid on
 the skin, till  there is some abatement of heat on the
 surface.
   As there is more or  less of sweating in the decline
 of most  febrile diseases, and as a general perspiration
 is often accompanied with other symptoms  of amend-
 ment, it has  been looked upon  as the natural cure of
 the disease.  Under this impression, it has been a pret-
 ty universal practice to encourage sweating; but  with
 respect to the grounds upon which  this practice is
 founded, it is a question, whether the effect has not, in
 this case, been mistaken for the cause; that is, whether
 the sweating is not the effect of the amendment, rather
 than the cause of it; and if so, it is still more question-
 able,  whether sweating, produced by art  in  the begin-
 ning of the disease, would be attended with good ef-
 fects.
   In  all cases, where I have seen this sweating regimen
 adopted, especially when much external heat has been
applied, the practice has been obviously injurious.

  * When great inequality of  excitement exists—the extremities
cold and insensible, while other parts may perhaps be morbidly hot
—wben, too, the  blood and nervous energy are concentrated in the
deep organs, and the surface is lifeless  and pallid, blisters to the
extremities and over the  congested organs are of great value.
                                           N. R. S. 
             TREATMENT OF TYPHUS.          83
  There are some medicines in the class of diaphore-
tics, which may be given with impunity, such as the
ipecacuan, contrayerva, and the  Virginia and  Seneca
snake roots, though they seldom or ever produce any
sensible perspiration till the disease has formed a crisis,
and then the patient will perspire freely without their
assistance.  When stimulating remedies are given in-
ternally and heat applied externally, to force a sweat,
as it is called, the  consequences are always bad at any
period of the disease.
   Opium in some form  or other is often used in Ty-
phus, and in many instances and under certain circum-
stances, may be useful, but is by no  means an universal
remedy, nor can it be administered with impunity in
every stage of the disease.
   When the patient is hot and suffers from pain in the
head,  and throbbing  of  the  temporal  arteries accom-
panied with confusion of mind, opium is generally hurt-
ful, and seems  to augment rather  than diminish these
troublesome symptoms.   But after  their violence is in
some degree abated, and the heat has become mode-
rate, it may be used,  and when  combined  with ipeca-
cuan,  sometimes gives  rest  and quietness during the
night; although in many  cases it will have the opposite
effect;  and serve to  make the  patient more watchful
and restless.   Under such circumstances, if persisted
in, it does harm.
   When diarrhoea occurs, opium  combined  with ipe-
cacuan and camphor, is generally useful; and if it does
not succeed in checking  the discharge, does not appear
to produce an  injurious effect.
   The use of this drug has also been advised in cases 
   84           TREATMENT OF TYPHUS.
   of great prostration of strength, that is, in cases where
   the morbid action is kept up in kind, but has abated
   in force, owing to the exhaustion of the  sensibility and
   irritability of the capillaries.   In cases of this descrip-
   tion it has been prescribed as a stimulus to support the
   patient, and in such instances it must be acknowledged,
   that it is sometimes used  with apparent  advantage.—
   But under the same circumstances, it does not always
   agree with the patient; and sometimes instead of  quiet-
   ing and giving him ease,  produces a contrary effect,
   rendering him restless and  watchful, and not unfre-
   quently brings on or  increases delirium, especially if
   given in large doses.
     Upon the whole, opium may be used to advantage
   under  certain circumstances  in Typhous Fever, but
   cannot be considered as a specific in any stage, and is
   at best but a doubtful remedy.
     A few years since mercury was, by many physicians
   in this country, considered a specific in Typhus, and its
«.  influence over the disease explained upon the  principle
   that two kinds of morbid action could not exist in the
   system at one and the same time, and it was supposed
   that giving mercury so as to excite its specific action on
   the  mouth,  was  substituting  the mercurial  disease,
   which  was  of short duration  and safe, for the  more
   dangerous febrile disease called Typhus.  This ingeni-
   ous  explanation appeared  very well in theory; all that
   seemed  necessary was, that  the facts should  be found
   corresponding.  Had this desirable incident happened,
   we should have possessed a very easy and  safe  mode of
   curing this somewhat intractable disease, by simply put-
   ting our patient  under a regular course of mercurial 
              TREATMENT OF TYPHUS.          85
 remedies, so as to affect  his mouth for a reasonable
 length of time.  But unfortunately, we have as yet dis-
 covered no such sure and easy method of curing Ty-
 phous Fever.
   It  was always acknowledged by the advocates for
 this practice, that in some  and very severe cases, and
 those in which medical aid was most necessary, the
 mercury would not have its usual effect, and ptyalism
 could not be produced, and  it was  further confessed
 that in such cases if the mercury  was pushed to any
 considerable extent, it produced a very bad state of the
 mouth,  occasionally terminating in  gangrene of the
 gums.
   I have had several  cases of  necrosis of the under
 jaw, where  I was compelled to remove a considerable
 portion  of that bone, which had died evidently in con-
 sequence of an inordinate  use of mercury during this
 fever.
   In  other cases, where calomel has been used early in
 the disease, and the mouth has been as favorably af-
 fected as could be wished,  the disease nevertheless has
 run on forty or fifty days, and sometimes  terminated
 fatally at a very advanced period.  In some  instances,
 after  the mercury had affected the mouth,  there has
 been  a  copious discharge  of tough,  ropy mucus from
 this part, which has been kept up for a long time after
 the other specific effects of the remedy had ceased.
   This vitiated discharge of saliva is often accompanied
with a vitiated secretion of the gastric fluid, and atten-
ded with a total want of appetite, and a constant ejec-
tion of every thing taken into the stomach.
   Such patients have  frequently recovered with  diffi- 
86          TREATMENT OF TYPHUS.
culty, eight  or ten weeks after the commencement of
the disease.   I have been consulted in many cases of
this description.
   Mercury, therefore, cannot be considered a speci-
fic in Typhus, but may be an useful auxiliary in cer-
tain  cases, that is, the blue pill or a small portion of
calomel, combined with some other medicine, may be
used with advantage.   A small  quantity of calomel
with opium has in some cases checked a colliquative
diarrhoea; and a grain of the same, joined to five or six
of rhubarb, has done very well as a laxative.
   Those physicians who consider Typhus as a disease
arising from debility, have highly extolled the virtues of
the Peruvian bark, and some have employed it through
the whole course of the disease, while others have re-
stricted its use to its later stage.
   It is not from ingenious reasoning or fine spun theo-
ries, that we should estimate the value of a remedy, but
from the effects actually produced by it m the majority
of cases.  Judging in this way, this remedy cannot be
allowed a very high place, since as was before observ-
ed, the physicians just mentioned, who treat this disease
with tonics and stimulants, have not been remarkable
for their success.
   I have prescribed the cinchona in many cases, and
as far as I am able to judge, when  there was a  con-
siderable heat present and while the mouth was inclin-
ed to be parched  and dry, and especially when  there
was  pain in  the head, its use  was  injurious.  But in
some cases, when there was a sense of  coldness creep-
ing over the  patient, and where there was haemorrhage,
it produced a good effect. 
             TREATMENT OF TYPHUS.           87
   Upon  the  whole,  the bark like mercury may be an
auxiliary but cannot  be considered an important reme-
dy, much less a specific.
   Bitter infusions may be used  through  the whole
course of the disease, such as the eupatorium, (perfolia-
tum,) chamomile, and various others.  When taken  in
considerable  quantities, though they do not cure the dis-
ease, they may assist in preserving the tone of the sto-
mach in some degree, and in that way aid in conducting
it to a favourable termination.
   Some twenty-five years since, the alkalies were pro-
posed as  remedies in febrile diseases, and for a  time
were considerably used.
   They  were introduced on the supposition that  they
possessed antiseptic properties, but they have not fulfil-
ed  the  expectations of  those who  introduced them,
nevertheless,  I have occasionally seen them  produce a
good effect.   Fever does not prevent the fluids from be-
coming acid  in the stomach,  and where  this happens,
the moderate use of  the carbonate of  soda or of potash
removes the irriation and burning sensation in  the sto-
mach caused by the  acid; and thus far they may serve
as palliatives, but I could never perceive  that they pos-
sessed any other power over this disease.
   The alkaline carbonates given with some acid, so as to
evolve carbonic  acid gas in the stomach, are generally
grateful  to the  patient, and perhaps sometimes useful.
   Those physicians,  who adopted the notion that alka-
lies were antiseptic, of course considered acids as sep-
tic, and proscribed their use; and there were not want-
ing instances of  their disagreeing with the stomach, es-
pecially the vegetable acids. 
88           TREATMENT OF TYPHUS.
  We have already mentioned, that fever did not pre-
vent the fluids from becoming acid in the stomach, and
I have, in several cases, witnessed a sensation of burn-
ing accompanied with an indescribable feeling of dis-
tress  in that organ, coming on after taking lemonade
and other vegetable acids; but such cases are rare.  In
most instances, the vegetable acids, diluted with water,
will be found grateful to the patient, and may, in almost
all cases, be taken with impunity.
  The mineral  acids have been used  as remedies in
Typhous Fever, especially the muriatic and sulphuric.
I have oftener prescribed the former than any of the
others belonging to this class, and have thought that the
moderate  use of it aided in preserving the powers of
the stomach; but it is not a medicine upon which much
dependence can be placed.
  We were formerly taught to place some reliance on
that class  of medicines called refrigerants, viz. the  acids
and neutral salts.  We have already had occasion to
mention  the acids; their refrigerating  power is very
trifling.  As for the neutral salts, some of them may be
used  as cathartics in the early stage  of the disease,
when the  heat  of the body  is considerable.  The sul-
phate of magnesia, and the  tartrite of potash are the
best;  but  in the  advanced stage of the disease, they
sometimes produce an injurious effect on  the stomach,
and are apt to induce diarrhoea; this is more particular-
ly the case with the sulphate of soda.
  Nitre,  or the nitrate of potash, was  formerly  a  fa-
vourite prescription in fevers of all kinds.  When this
article is given in very small doses, it produces no per-
ceptible effect,  and if given in  large, it does a positive
injury to the stomach. 
             TREATMENT OF TYPHUS.           89
  All things considered, we can place no  dependence
on internal refrigerants, and if we wish to produce this
effect, that is, if we desire to  diminish the  temperature
of the body, when above the ordinary standard, we must
have recourse to cold water, or cold air.
  The heat may  be lessened by covering the patient
lightly, and admitting cool air into the room, when  the
season of the year will admit  of it; or by admitting the
air in contact with the skin, by raising the bed-clothes
on one side of the bed, and bringing them down  sud-
denly again;* in this way we can pause a current of
cool air to pass over the body, which will conduct off
the heat and greatly refresh the patient.
  But the  most effectual method of reducing the tem-
perature of the  body is by the use of cold water, which
may be taken internally, or applied externally.   When
persons, sick of this disease, desire cold water to drink,
it should never be denied them—they should be allowed
to drink ad libitum.   The quantity of heat  abstracted
from  the body by  the wrater which they will drink,
however, is but small, and except in cases where, by its
influence on the stomach, it produces perspiration, its
effects are very trifling.
  The only effectual  method  of cooling  the body, in
these cases, is by the use of  cold water applied exter-
nally; by this means we can lessen the heat to any de-
gree we please.   Different physicians have adopted dif-
ferent modes of making the application.   Some advise
to take a patient out of bed, pour buckets of water upon
him, and then to replace him again; while  others prefer

  * Fanning the patient with the bed-clothes.       N. R. S.
       12 
 90           TREATMENT OF TYPHUS.
 sponging him with cold water.   We have cases, where
 cold water would be of service, in which our patients
 are too much reduced to be taken out of bed and plac-
 ed in a sitting posture without injury.  In these cases a
 different management will be necessary.   The method,
 which I have adopted,  is to turn down the bed-clothes
 and to dash from a pint to a gallon of cold water on the
 patient's head, face and body, so as to wet both the bed
 and body linen thoroughly.   It is better that he should
 lay on a straw bed when this is done, it is not however
 essential.   If his body should be  very hot, he may be
 turned  upon his side, and the water dashed upon his
 back.
   As soon as his linen and the bed-clothes begin to dry,
 and the heat in the head and breast begins to return to
 the  surface, the  water should be again applied, and in
 this way the  heat may be kept down to the natural
 standard or rather below, on the  surface, so that the
 skin may feel rather cool  to the hand of a healthy
 person.
   It is not very  material what the temperature  of the
 water is, if it is  below blood heat, excepting the shock
 given by its first  contact, which in cases where there is
 much stupor or coma, is of some importance; in general,
 the effect  is produced chiefly by the evaporation.
   All additions  made to water used for this  purpose,
 such as vinegar,  spirits, &c. are injurious. The former,
 on being evaporated on the surface of the body, covers
it with a thin pellicle formed by the sediment,  which
makes the skin  feel stiff and unpleasant;  and spirits
evaporated about a sick person  produce an offensive
odour, and likewise leave some impurities  on the skin
and clothes. 
             TREATMENT OF TYPHUS.           91
   When water is used to wash the body, as is often
necessary in this fever, soap, or the carbonate of potash
may be added, but when used to reduce the heat alone,
pure water will be found best.
   When the temperature of the  body is such, that it
does not require the general application of cold water,
still it  may be occasionally applied with advantage to
the head and face.
   Whenever there is any dryness of the lips,  teeth or
tongue, it may  be relieved by letting water, slowly
squeezed from a sponge  or cloth, fall on the mouth and
over the  whole face; this should be repeated often
enough to keep the mouth clean and moist.
   I have produced a good effect  by laying a  piece of
thin, loose muslin over the face, so as  to have the  air
drawn through it in the  act of inspiration, at the same
time keeping it constantly wet with cold water; in this
way, the  vapour inhaled into the lungs, proves very
grateful to the patient.
   I could state many  cases in which  cold water  was
applied with the most unequivocal advantage.
   In the summer of  1798, the first year in which  this
fever occurred  in my practice, T. B.,  a young man of
about twenty-five years  of age, was  brought into my
neighbourhood sick of Typhus, for which he had been
bled before I saw him;  the fever was severe, and his
unfavourable symptoms increased  for several days.  In
a consultation, it was agreed  to put him into a warm
bath, which was done.
   He was a little delirious before he went into the bath,
and when he came out,  was raving.   From this state,
he sunk,  in the course  of the next night, into a  low 
 92           TREATMENT OF TYPHUS.
 muttering delirium, with a great degree of coina and
 starting of the tendons, and with scarcely the ability to
 swallow.   His pulse was irregular, but still  possessed
 some force, and his heat was above natural.  Twenty-
 four hours  were passed  in this situation, without any
 symptoms of amendment.   The next day when I  visi-
 ted him, about nine o'clock in the morning, the weather
 being very warm,  (as it was in the month of July,) a
 young man, who had engaged  to attend him  that day,
 came in,  bringing  a gallon pitcher full of cold water,
 which he had just drawn.  Finding the patient's pulse
 had some strength  and his heat  continued above natural,
 I stripped him naked as he lay on a straw mattrass, and
 then poured the gallon of water over him from head to
 foot.   He seemed  to feel  the shock, but did not speak.
 The young  man in attendance was ordered to repeat
 the affusion as often as he began to grow dry and warm,
 which was punctually performed.
   When I visited him a little after sunset, his heat was
 diminished, and his pulse did not intermit as often as it
 had done.  He was then taken off the wet bed and laid
 on a dry one, likewise of straw, with nothing but a linen
 sheet spread over him.  The windows of the chamber
 were kept open through the night, and a dose of opium
 and musk was prescribed  and taken.   No other inter-
 nal remedies were administered.  The next morning
 there was no alteration.  The  affusion of cold water
 was renewed as the day grew warm and the heat was
 kept down through the day as it had been the preceed-
 ing one.  Before night, the patient recovered so as to
 speak, called for more water, and said he wished to be
put into the river.  From this period he became conva- 
m
              TREATMENT OF TYPHUS.           93
 lescent,  and recovered without the use of any  other
 remedy.
   In the month of September, of the year 1800,1 visi
 teded A. P.  a strong robust man, aged between thirty
 and forty years.  He had been sick about a fortnight,
 his head was not much affected, but the heat was great
 and his thirst urgent.  My visit was in the evening.—
 The body was stripped, that  is, the  sheet which was
 thrown over him was removed, and his  shirt divided
 down before so as to expose his body, and about a quart
 of cold water was applied by sprinkling it on with the
 hand.  The sheet was then thrown over him; and the
 water applied as often as he  became dry and the heat
 began to return.   A little peruvian bark, mixed  with
 some nitrate of potash, was all the medicine  taken.—
 Previous to this he had drank, every night, two quarts
 of some diluent drink, for several nights in succession.
 After  the first application of the water, that parched
 sensation of the lips and mouth,  which urged him to
 drink  so much, abated,  and he lay the whole  night
 without  any desire to drink.  The  next  day he  was
 convalescent, and recovered without medicine.
  I. B. a strong robust man, aged between thirty and
 forty, had been sick a fortnight when I first visited  him;
 his pulse was frequent, his heat great, and his mouth ex-
 ceedingly parched, so much so  that he could not sleep but
for a very few minutes at a time without being awaken-
 ed by a sense of thirst.   His  feet were very cold.
  This individual had  been  badly  treated, and his
friends had been prevented  from  changing his  linen
and bed-clothes by the physician, who had fears that he
would take cold! 
94            TREATMENT OF TYPHUS.
   The patient was first shaved, an operation which had
not been performed for something like a fortnight, he
was then slipped down in the bed so as to drop his feet
into a vessel of warm water and soap, where they were
rubbed  till they became  clean  and warm.   The bed
and body linen were then changed and he was properly
placed in bed. The affusion of cold water was commenc-
ed over the head and breast, and repeated sufficiently
often to keep down the heat.   The distressing  thirst
was removed at once, he became convalescent the next
day, and recovered without any further medical  treat-
ment.
   I could detail a great many additional cases, where
the good effects of cold water were as apparent and as
immediate as in the cases just cited; and in no instance
where I have used it,  or seen it used by others, has  it
done harm.   There are cases, however, where its ap-
plication is not called  for; at the same time there are
but few in which it may not, in some  stage of the dis-
ease, do good.  It is always grateful when applied to
the face and mouth, and its vapour is very salutary and
refreshing to persons sick with fever.
  It will be observed,  that the first time I used cold
water externally in fever, was in 1798, the first hint of
which I took from Dr. Robert Jackson's work on Fe-
vers of warm climates.
  With regard  to diet, it is not necessary to say much;
if patients were left to select for themselves without the
interference  of nurses and friends,  who  are always
afraid they will starve, they would  generally decide
right, since they would not often take any thing, that
could be called  food.   The farinaceous and  mucilagi-
nous substances are the only articles of nutriment ad- 
             TREATMENT OF TYPHUS.            95
missible, with the exception, perhaps, of milk largely
diluted with water, or whey prepared from it.
  All solid food is injurious, and all sorts of broths pre-
pared from animal substances should be  prohibited.
  After the fever has formed a crisis, and  the secre-
tions of the mouth have become  healthy,  the appetite
generally returns; and if we then allow the  patient to
choose for himself what he will eat, and take care that
the quantity taken at first is very small, he will not often
be injured by it.  But it is not safe to let patients judge
as to the  quantity.   Their minds are weak, and their
appetites strong, and they would,  if allowed, often hurt
themselves by too much indulgence.
  With respect to liquids, I have generally  let the pa-
tient choose for himself, provided he does not select any
of the stimulants, such as ardent  spirits  or strong beer,
which, however, is almost never the case.  Cold water,
©r water acidulated with one of the vegetable acids,
small beer or brisk cider, are the drinks  which are usu-
ally preferred.  The infusion of the pleasant aromatic
herbs may be always allowed.
  Beside giving directions for the use of medicines,  it
is important that we should direct, what may be called
the general management of the patient.
  When an individual is'first taken sick with Typhous
Fever,  we  should  expect  a  disease of considerable
length, and make our arrangements accordingly.  If the
thing is  practicable, he should be kept in a spacious
room, the larger the better.  His  bed should be  of
straw or husks, especially if it is in the warm season;
and it should not be placed in the corner, but brought
out into the room.   We should contrive to have a cur-
rent of  air pass over the bed by means of  doors and 
96           TREATMENT OF TYPHUS.
windows.  It is well to have a chimney and fire-place
in the room,  and in the night when the air is very still,
(though the  wreather should  be warm,) a small fire
kindled with a little dry wood, so as to cause a current
of air up chimney, and by that means often to change
the atmosphere of the room, will be found of service.—
In the warm season of the year, the  windows  should
be kept open night and day.  All the  furniture should
be removed, except such articles as are required for the
patient's use.  The windows  should  be darkened, or
something opposed to the light, in such a way as to still
admit the air.  The room  should be kept  as quiet as
possible, since noise is injurious, and  no more persons
should be admitted than are necessary to take care of
the patient,  which will, if he is very  sick,  require the
labour of more than one.
  The  room should  not be  carpeted, and the floor
should be often washed with pure water, or soap and
water, and in the hot season, it, as well as the walls,
may be kept  wet with water during the heat of the day.
  Cleanliness is absolutely essential  to the  patient's
comfort, and  no dirty dishes or useless medicines or food
should be suffered to  remain in the room.   All  excre-
mentitious matters should be removed  immediately. In
the warm season of the year, the bed and body linen
should be changed every day, and in the cold, every
other day at farthest.
  The  patient's body and limbs should be  cleansed
every day with a piece of sponge and warm water, or
soap and water.   If a male, he should be shaved every
day, or every alternate day, and if a female with long
thick hair, it  should be cut off or thinned, so as to leave
but little of it the full length. 
               OBSERVATIONS

                      ON THE

PATHOLOGY AND  TREATMENT

                        op

             NECROSIS.
  The etymological definition of Necrosis is, the death
of some part of the bony structure.  As technically em-
ployed in medicine and surgery, however, it designates
a particular form of disease, characterized by peculiar
symptoms, and often,  generally indeed, terminating in
the death of a portion  of the bone in which it is located.
We may perhaps  question  the propriety of the above
appellation, if it be made  to appear, as I shall attempt,
that the death of the part affected is not the necessary
sequel of  the disease,  although the most frequent.   It
is the same inconsistency of language that obtains  in
the application of the  term  hydrocephalus to those in-
flammatory  affections  of the  meninges of the brain,
which sometimes terminate  in dropsy of that organ.
  This disease  was formerly known in  New England
under the name of fever-sore, given to it, undoubtedly,
because it is generally accompanied, from the very com-
       13 
 98                  NECROSIS.
 mencement, with a high degree of constitutional irrita-
 tion and  symptomatic fever.  The  constitutional dis-
 turbance, in most cases, being nearly synchronous writh
 the  local affection,  induced medical men, while the
 humoral pathology prevailed, to regard the general dis-
 ease as a fever, and the local affection as nature's reme-
 dy, by which she eliminated the peccant  humours.—
 They probably would have explained it in the following
 manner:—The fever, to expel the morbific matter from
 the system,  throws it on the part affected, which causes
 the inflammation and subsequent collection of matter.
   The following pathological history of this disease has
 been the result of extensive observation,  the disease
 very frequently occurring  within  the  sphere of my
 practice.
   Necrosis  co'mmences  with an acute inflammation,
 either  in the bone itself or its investing membrane, ac-
 companied with an  acute pain, not alwrays at first in
 the part affected,  but  often felt  most severely in the
 joint nearest the disease.   In a day or two, however, it
 generally leaves the joint, and permanently locates itself
 in the part inflamed.
   Almost from the  first commencement of the  pain,
 there occurs severe symptomatic fever of the inflamma-
 tory character.  The local  affection generally termi-
 nates in suppuration, frequently as soon as the fourth
or fifth day,  and this event,  if it occur, is  rarely pro-
 tracted beyond the tenth  or twelfth.  The matter is at
 first deposited  between the external periosteum and the
bone.  When  the shafts of the long bones are the seats
of disease, about the  same time that matter is deposited
beneath the  external periosteum, there is formed a cor- 
                     NECROSIS.                  99
responding collection between the internal surface of
the bone and the membrane surrounding the medullary
substance, so that there then exist two collections of
matter bathing the opposite sides  of the walls  of  the
bone.  This fact, which I deem of great importance, as
being essential to the correct treatment of the disease,
I have ascertained in repeated instances, by the  opera-
tion which I have performed for its relief, namely,  the
trepanning of the bone.
  Very soon after the attack, the whole limb swells, but
there is no marked tumefaction immediately in the part
affected, till  after the matter makes its escape from the
periosteum,  and is diffused  beneath the adjacent  soft
parts.  Whenever this occurs,  the extreme pain  and
symptomatic fever, which till then have continued un-
abated, in some  degree  subside,  but do  not entirely
leave the patient.
  When this kind of inflammation attacks the  spongy
bones, the matter is  at first  collected on both sides of
the external lamella, or plate of compact bone,  which
covers the cells, so that it is similar to the same  disease
in the long bones, except that in the  latter the  matter
within the bone is  lodged between the  medullary sub-
stance and  the walls of the bone, the medullary sub-
stance not being affected nor penetrated by the  matter.
  The death of  a portion of bone, in this disease, does
not appear to arise from any extraordinary malignity in
the inflammation,  nor from its  exerting any peculiar
lethiferous influence upon the  part  affected, as some
specific diseases destroy the parts which they attack.—
Abundant cause for the death of the part is found in the
insulation of the bone, effected by the accumulation of 
 100                 NECROSIS.
 matter on both sides of its parietes, and the consequent
 destruction of those vessels which, from the two  peri-
 ostea,  furnish it with blood and nutrition, so that the
 denuded portion receives no vessels but those extremely
 attenuated ones, which  permeate it from the surround-
 ing margin of healthy bone.   These  last being  insuffi-
 cient for its nutrition, it consequently  perishes.  Nature
 then sets up  a process of ulceration for  the separation
 of the dead portion, and the evacuation of the matter
 contained within it, this occupying a greater or a less
 time, as  influenced by  circumstances.  The dead and
 insulated bone, from its indestructible nature, remains
 as a foreign body in the living parts, until,  by the recu-
 perative  efforts of nature, it is dislodged entire and re-
jected  from the system; or, being constantly  bathed in
 the secretions which protect the surrounding parts  from
 its contact, is gradually dissolved and wasted away; or,
finally, is removed  by art.
  When the  disease has arrived at that period at which
the matter accumulated  beneath the periosteum has
 made its way to the surface, and that contained within
 the cavity of the bone has issued through  a fissure in
the same, relieving the parts from the irritation  of dis-
tension and pressure, the symptomatic fever in a great
degree ceases.   If, however,  the  collection  has  been
large, and the portion of necrosed bone be considerable,
hectic  fever is liable to  supervene, indicating the con-
tinuance, though a change of irritation.
  Whenever there occurs a favourable respite, the con-
servative powers of nature, always active so long as
vitality remains, rally for the purpose  of remedying the
injury  inflicted upon the bone.   The process instituted 
                     NECROSIS.                 101
for this purpose varies according to circumstances.—
When the portion of dead bone is small and situated on
the side of one of tjie long bones, granulations will shoot
from the surface of the sound or living bone, and as oc-
curs in mortification of the soft parts, will push the dead
bone off from the living, and finally urge it through the
opening previously formed, and  disengage it from the
body.  This is  more likely to happen when the soft
parts have been divided, early in the disease, over  the
whole length of the dead portion of the bone.
   But in those cases  in which a large portion of the
circumference of the bone is affected, and especially
when the life of the whole circumference, to some ex-
tent, has been  distroyed, there is formed a bony struc-
ture, which attaches itself to the healthy bone, near, or
at the part where it has separated  from the sequestra
or dead  portion, around which it forms  a bony case,
complete, excepting the apertures through which mat-
ter flows, and which must thus remain open. The new
cylinder of bone does not  closely embrace the dead;
hence, and  also because it overlaps  the  ends  of the
living bone,  it is to the feel considerably larger than the
bone of the sound limb.
   Necrosis is almost exclusively confined to young sub-
jects.  I have very rarely seen it in persons under five,
or  over twenty-two.    I have, indeed, witnessed  a dis-
ease in old men which might perhaps be denominated
necrosis, as terminating in death of  the bone, but cha-
racterized by very different symptoms.  Three  cases
have fallen under my observation, in each of which the
upper part of the femur was the part affected.  Two of
the patients were over seventy, the other much younger, 
102                  NECROSIS.
but with a broken constitution, having some years before
lost the prepuce and glans penis by a gangrenous inflam-
mation.  The disease attacked w ith considerable pain and
constitutional affection;  there  was, however, for some
days, no swelling nor appearance of inflammation exter-
nally; but at length the limb became tumid, and a fluc-
tuation was perceived. On opening the part, a considera-
ble quantity of dark and  very offensive sanies was dis-
charged; the bone appeared denuded of its periosteum,
and of a dark colour.   These cases all proved fatal in a
short time.   In  one, the  affected portion of bone was
separated before the patient died.
   In regard to the locality  of  necrosis, although, per-
haps, every portion  of the bony fabric is liable to its  at-
tacks, yet it occurs in some bones much more frequent
than in others.
   I have never  seen  it  in  the scapula,  sternum, nor
spine.  It very rarely occurs in the bones  of the carpus,
although I  have  occasionally seen it attack the fingers.
The bones  of the cranium are not exempt from it, and
it  often attacks the lower jaw, the clavicle, and the ribs,
but especially the long  bones of the arm,  fore-arm,
thigh and leg.  I have seen it in the femur, patella, both
bones of the leg, os  calcis, metatarsal bones and the
bones of the great toe.
   My own experience would determine the tibia to be
the most frequent seat of the  disease; next to this, the
femur, and then th& humerus.
   I am induced to  believe, that this kind of inflamma-
tion never  attacks the articulations in the first instance,
but, in the  long bones, is  confined to their  shafts, and
when it attacks the spongy  bones, as the os calcis, it 
                     NECROSIS.                 103
 does not commence in the articular surfaces, nor within
 the capsular ligaments.   The joints are, indeed, some-
 times affected by this disease, but, when this does occur,
 it is the result of disease extended from the shaft of the
 bone.  The margin of the sequestra is often accurately
 defined by the line of junction between the shaft and
 epiphysis of the bone, the articular portion being thus
 left untouched.  It sometimes happens, however, that
 when  the attack is in one  of the  larger bones of the
 limbs, and near to the apparatus of the joint, the inflam-
 mation extends to  the latter, matter is formed within
 the capsular ligament, and the limb is lost.  Such cases,
 however, are exceedingly rare; in  the whole course of
 my practice I have had occasion to amputate  but twTo
 limbs, for the purpose of rescuing the patient from this
 formidable variety of the disease.
   Necrosis is not always confined, in an individual case,
 to one bone, but may occur simultaneously  in  remote
 parts, or, which is  more common, successively.  The
 secondary attack is not so often on a bone of the same
 limb as on one of another.   When the first attack has
 occurred in the femur, the second has located  itself in
 the humerus, and  vice  versa.  In  a few instances,
 however, I have observed it in a bone of the same mem-
 ber, attacking, for instance, the femur  and the tibia
 successively.   In a few instances it has attacked secon-
 darily the same bone in the opposite limb.   I once saw
a patient who had had, in the course of a few years, an
 attack of this disease in almost every bone in his body.
   In regard to the general prognosis of  the  disease, I
have observed that a very great majority  of  patients
 survive its attack, though often with long confinement, 
104                 NECROSIS.
protracted suffering,  and great  emaciation.  In a few
cases, however, the disease proves fatal, and when it
does so, it frequently  happens at an early period of its
progress, and life is destroyed by the extreme degree of
constitutional irritation and symptomatic fever.  These
fatal symptoms are especially apt to occur when the dis-
ease occupies a considerable portion of a large bone.—
This severity of the constitutional symptoms probably
depends on the peculiar structure and sensibility of the
part particularly affected.  The periosteum, beneath
which the matter  first accumulates, being  a  fibrous
membrane, possesses, indeed, but  very little sensibility
in health, but when  inflamed, especially when put upon
the stretch by distension, it is known to  be the seat  of
the keenest sensations, and to be  a source of extreme
general irritation, giving a greater shock to the nervous
system, than almost any other diseased structure.
   In some cases, in which the disease has destroyed the
vitality of a large portion of one of the long bones, and
in which there must necessarily have occured extensive
suppuration and copious discharge of pus, the patient,
as in similar results of other diseases, has died of ex-
haustation.
   The patient, also, after having survived one  or  two
severe attacks, sometimes is cut off" by the accession of
another, and when this is the case, death  generally oc-
curs in the stage of excitement and constitutional dis-
turbance.
   Diagnostic Symptoms of Necrosis.—It is impossible,
even by the most vivid description, to express the cha-
racter of this disease with the precision with which the
observation of a few cases will convey it; and yet, before 
                     NECROSIS.                305
one can observe with accuracy or profit, he must know
something of its history.
  At the disease is an acute inflammation, characterized
by the peculiar vital properties of the parts  affected,
many of the symptoms must be analogous to those  of
other inflammatory  affections.  I have often known  it
to be mistaken, and for a considerable time treated, for
acute rheumatism, even although suppuration may have
been observed.
  In  my pathological observations  on the disease  in
question, I  stated that it commenced with acute pain
in, or near, the part affected.  It frequently  happens
that, when the disease fixes on one  of the long bones
and near its extremity, the pain is complained of in the
adjacent joint; thus, when the disease attacks the lower
portion of the tibia,  the pain is for a  time chiefly felt in
the ankle.  If  in the upper part of  the  tibia,  or lower
part of the  femur, it is referred to the knee joint.  It is
not long, however, confined to the joint, but fixes itself
in the inflamed part.  It is  this circumstance of pain,
referred to the joint, that often causes the disease to be
denominated rheumatism.
  The pain experienced in necrosis  is extremely acute,
unremitting, and not much influenced by  the  motions
nor position of  the  limb.  The pain is often  a  day  or
two antecedent to  the swelling, and when the latter
first occurs, it is generally diffused over  a  considerable
part of the limb, especially below the part affected.—
The surface is  rather firm to the touch,  but the skin is
not discoloured till after matter is formed and advanced
towards the surface.  The symptomatic fever is coeval
with the pain,  they both usually occuring on  the same
     14 
  1Q6                 NECROSIS.
  day.   The pulse is both frequent and quick, the stroke
  tudden, and the artery small and hard to the touch.  At
  first the patient has occasional chills, but when he com-
  plains of a sensation of cold, the skin, to another person,
  feels hot.   The pain is so tormenting, that he gets but
  little or  no sleep, during the night is often  delirious,
  though during the  day rational.   The tongue is furred
  with a soft, white coat.   The face is not flushed, but
  rather pale; with the exception of occasional red spots
  on the  cheeks.   The hands are often hotter than other
 parts of  the body, and in one violent case I observed
 that the points of all the fingers were red, swollen, hot,
 and  very painful.  The appetite for food is lost; thirst
 considerable, but the  stomach and howels  are  not so
 much affected as  they generally are in other febrile
 affections.
   It has already been stated, that the disease is acute,
 and that suppuration takes place promptly, but there is
 often a difference  of  several days  in different cases,
 though  this difference is often more apparent than real.
 But few  surgeons have  the tact to  discover  matter
 while it is confined  beneath the periosteum, and more
 especially  where the  part  is covered by  voluminous
 muscles, as is the case in the thigh.  In this instance it
 is probable that an  experienced surgeon might not be
 able to detect the presence of pus, till after it had made
 its escape through the  periosteum, and accumulated to
 some extent in the soft parts.
  I have  observed  that the locality of the pain, in the
 early stage of the disease, caused necrosis to be some-
times confounded  with  rheumatism.  Most, even of its
early symptoms, however, are very different from those 
                      NECROSIS.                 107
of that disease.   The symptomatic fever and constitu-
tional  irritation come on sooner after the local attack,
and  are much more severe.   The pulse, as described
above, is also very different from that of acute rheuma-
tism, it being smaller,  harder, and less easily compres-
sed.   Suppuration, which very  rarely occurs  in rheu-
matism, finally removes all  ambiguity.   Necrosis, also,
usually attacks at that period of life when rheumatism
is not so liable to occur.
  The fever attending necrosis  is distinguishable from
typhus by the local affection, by the pulse, which is
harder and less easily compressed, and by its not being
attended  with so  much  stupor.  The  stomach  and
bowels are also much less affected; besides, there is the
different expression of countenance, which is very ap-
parent and  characteristic to the eye, but is not easily
described.
   Causes of Necrosis.—The inflammation which pro-
duces necrosis of the bones, has sometimes been excited
by blows and injuries inflicted  upon the limbs.  The
sudden suppression of perspiration,  by application of
cold to the  surface, has the same relation to this dis-
ease as to many others.  In several cases I have known
it to occur immediately after the patient had imprudent-
ly bathed in cool water, when the surface of the body
was  warm.   It often, however, seizes the patient with-
out the intervention of any obvious exciting cause, by
which the lurking diathesis is sometimes developed, or
concentrated upon a particular part.
  It is customary with physicians and surgeons to
ascribe necrosis  to  a scrofulous diathesis as  its predis-
posing cause.  This term is employed with  much lati- 
108                  NECROSIS.
tude, and is often used, like  the  sign  of an unkown
quantity in algebra, to express something  with the na-
ture of  which we are unacquainted.   When used in
this way,  there  is perhaps no impropriety  in  naming
scrofula as the diathesis which predisposes to necrosis.
Necrosis, however, is by no means to be identified in its
nature with the  affection  of  the lymphatic glands, to
which the  terms scrofula  is,  with more precision, ap-
plied, since necrosis may repeatedly occur in the same
individual without being accompanied by lymphatic tu-
mors.   Whatever  the  remote cause may be, it is un-
doubtedly one which produces an enfeebled state of the
capillary system, in consequence of which the nutrition
of the bones, usually requirring the exercise  of nature's
powers  in their  integrity, is performed  in an imperfect
manner, and they become liable to the  encroachments
of disease.
   Treatment.—I have already, I  believe, hinted  that
it  very  rarely happens  that  this kind of inflammation
terminates by resolution under the ordinary treatment.
Though I have seen a very great  number of cases of
necrosis in their progress, yet the  number of cases
which have fallen under my care, in the first instance,
has been  small; almost all the cases of which I have
had the management.have been under  treatment for a
longer or shorter time before I have been consulted; so
that I have  drawn my inferences-as to the effects of
the different modes of treatment employed in this stage
from wrhat I have known to have been  done by others,
rather than from what I have  myself done.
   The  treatment first resorted to has been, in some
cases, bleeding;  and  in all,  cathartics.    Sometimes 
                     NECROSIS.                 109
emetics have been tried.  The topical applications have
been blisters, evaporating lotions, and cataplasms.  In
some cases all these remedies have been employed be-
fore I have seen the patient.  But I do not  recollect a
single case in  which I had reason to believe that the
inflammation  was seated in, or on  the bone, that has
not terminated  in  suppuration.   One I  recollect, in
which I saw the  patient on the third day after the at-
tack, when I bled as freely as I dared  to do, and kept
the part constantly covered with cloths, wet with cold
water, besides giving cooling cathartics; but suppura-
tion, nevertheless, took place.
   The following case will serve to illustrate the  patho-
logy of the disease, and the mode of treatment wrhich I
shall recommend.   It occurred in 1798. The patient, a
colored girl, nine years  old.  The  attack  was on the
femur, and had  been of sometime  standing before I
saw it.   There was a large collection of matter in the
thigh, which extended from a small  distance above the
knee to near the trochanter.  An incision was  made
on the outside of the thigh, commencing near the knee
joint, and extending upwards eight inches in length.—
A  large quantity of matter was discharged, and on ex-
amining with  the finger, the bone was found denuded
of its periosteum, from two or three inches above the
articulation of  the knee, upwards, two-thirds  of  its
length;  and near the lower end the whole circumfer-
ence  of the bone was  stripped of its periosteum, ex-
cepting  the linea aspera; which formed a kind  of sep-
tum between  that part of the matter deposited on the
inside of the bone, and that  on the outside.   But on
the anterior surface of the bone there was a free com- 
110                  NECROSIS.
munication, so that I could pass my finger over the
bone, and turn it down to the linea aspera, where the
muscles, tendons, &c. still adhered to  the  bone.   At
this time I had but little knowledge of the disease, and
no book  which I had seen rendered me much assis-
tance.  Benjamin  Bell, in his Treatise  on  Ulcers, di-
rects, in such cases, to perforate the bone down to the
living parts, in order to  produce exfoliation.  This I
had tried in several cases} but with no good  effect.   In
this case, as the bone, to some extent, wras exposed to
the sight, I concluded to wait a few days, and see if
granulations would appear  on the denuded bone.—
But in a short time  the bone which was exposed to the
sight began to assume a darker colour.  I then deter-
mined to remove a portion of it, in such a manner as
to go through the dead part, let that be more or less.—
For  this  purpose I used the round saw employed in
operating on the scull, applying it to the outside of the
femur, nearly in the centre of the  denuded part, and
sawed  through the walls of the bone down to  the me-
dullary substance, and then removed the piece  circum-
scribed by the saw, which  exposed to view a portion
of the medullary substance, in extent equal to the di-
ameter of the saw.
   On sponging out  the blood, the medullary substance
appeared  healthy, and was firm to the touch, but on
looking attentively at it, I perceived purulent matter is-
suing, by  pulsations, from beneath the sawed edges of the
bone, and between the bone and medullary substance.
I repeatedly wiped it away, and it  continued to gradu-
ally issue.  The  walls of the bone being fixed, the mat-
ter was not forced out by their collapse, as it is in the 
                     NECROSIS.                 Ill
soft parts; but as there is an increase in the quantity of
blood in the medullary substance, at each systole of the
arteries, this substance  is enlarged, and of course  the
matter is pressed out.
   After the operation of sawing the bone, the wound
was treated with the simplest dressings.    In a few days
after this, the bone, which was of a pearly white, a lit-
tle verging to brown, where exposed  to  the  external
air, changed its appearance, assuming a carmine  co-
lour, and finally recovered, with no other loss of  sub-
stance than a thin scale, which separated from the sur-
face of that portion  which  had been touched by the
saw, the whole of which did not exceed ten grains.
   This case established  in my mind  the pathology of
the disease and the proper mode of treating it; that is,
when the disease has advanced so far as to form mat-
ter.  But it would be a desirable thing to  prevent  the
formation of matter in such  cases, if possible.  I have
already stated that, in the common mode of treatment,
this is rarely effected.  I did not, however, intend to be
understood that this is  impossible, or  that there is no
other mode of treatment that might be adopted, which,
if seasonably employed, might  arrest  the progress of
the disease, prevent the collection of matter, and, of
course, preserve the bone from injury,  or  the  necessity
of making a breach in the bony structure.
   As the disease passes  through several different stages,
which require different modes of treatment, the prac-
tice must vary  accordingly.  If the surgeon has  the
good fortune to  be  called  on the first attack of pain,
supposing the disease to be in one of the long bones of
the limbs, as soon as the disease, by swelling and ten- 
112                 NECROSIS.
derness of the part, has sufficiently marked the seat of
the inflammation, an incision should be made, in a longi-
tudinal direction, through all the soft parts down to the
bone, and through the periosteum.  The extent of the
incision should be equal to the extent of the inflamma-
tion.  Since I have adopted my present opinions of ne-
crosis, I have not been fortunate enough to be called in
till matter has been formed, and therefore have not had
it in my power to test this mode of treatment, but have
communicated my views on the subject to those who
have had  opportunities  of  applying them to practice,
and in every case that I have heard of, the incision has
arrested  the further progress of the  disease, and  the
case has been reduced to the state of a simple incised
wound, which has soon healed, without  any injury to
the bone.  This effects a very great saving of time,
pain and confinement to the patient.
  Necrosis, on the larger limb, is somewhat analogous
to the felon on the finger, where the parts beneath  the
strong fascia of  the part are inflamed.   In both cases
a fibrous membrane  is concerned, and, as in felon, an
incision carried  through the fibrous membrane to  the
extent of the inflammation, stops the further progress
of the disease—so,  in  necrosis, when  the soft parts,
with the periosteum, are divided, the disease is cured.
After the incision, the treatment, both general and topi-
cal, should be such as we recommend in cases of sim-
ple incised wounds, attended  with considerable inflam-
mation ;  excepting that we should not try to approxi-
mate the edges of the incision by adhesive plaisters, but
dress them with simple applications, such as lint, spread
with simple cerate, and evaporating lotions applied to a 
                     NECROSIS.                 113
considerable  portion of the limb, as least as far as the
inflammation has  extended.  The general treatment
consists in cooling purgatives, nauseating doses of anti-
mony, and opium sufficient to allay irritation and pro-
cure rest.
   When the disease happens to be seated on the  spon-
gy bones, as the os calcis, metatarsal bones, &c. the in-
cision should be made in the direction of the muscles,
tendons, arteries, &c. which may pass over it, so as to
avoid wounding these organs.   In other respects  these
cases  are to be treated  in a  similar manner, as the
above.
   When the disease affects a bone thinly covered with
soft parts, as the anterior part of the tibia, lower part
of the fibula, or  the humerus, clavicle, ribs, &c. sur-
geons at this day would not hesitate to  make the pro-
per incision.   But when the^femur is the bone affected
it will be otherwise.  The precise part affected  is not
so easily detected, and probably few practitioners would
venture to make so bold an incision under such  circum-
stances.   But  when the seat of  the disease  can be
clearly ascertained, the propriety of making  such an
incision  cannot be  doubted;  and  when we  consider
that the pain and confinement consequent to an incised
wound of almost any extent, is so trifling,  compared
with the evils attendant on a long-protracted  case of
necrosis in this bone, it should  render us bold in direct-
ing the incision.
   The second  stage of this  disease, when the matter
has formed  between the periosteum and the bone, still
admits of a cure without any loss of bone.  If, in this
stage  of the disease, an  incision is made  through the
        15 
114                  NECROSIS.
soft parts, and the periosteum be divided as far as it is
separated from the bone, and a portion of the  bone be
cut out  with a saw, or several perforations be made in
the bone which has been denuded, down to the medul-
lary substance, so as to allow the matter collected be-
tween that substance  and the walls of the bone to es-
cape, the necrosis or death of the bone will be prevent-
ed.  By this mode of treatment I have succeeded per-
fectly in arresting the further progress of the  disease
in the bone, and the patient has recovered without  loss
of any  portion of it.   If this  mode  of treatment be
put in practice early enough,  and the perforations be
made in the bone sufficient to afford a free exit to the
matter, it will  always succeed.   The  best instrument
for perforating the bone is a small trephine that cuts
out a piece about the size  of a nine-penny-bit; but I
have often succeeded by making a number of  perfora-
tions  through  the denuded  portion  of bone, with  the
perforator used in trepanning.   When this instrument
is used,  there should be several perforations made, more
or less, according to the extent of the  denuded portion
of bone, and the instrument should be carried a little
into the medullary substance, otherwise  the  aperture
will be too small to admit the matter  to pass freely.—
After this operation has been performed, the case is to
be treated as we have directed, where the incision has
been made before matter had been formed, that is, in
the simplest manner.
   In  the  third stage of this disease, the matter  has
made its escape through the periosteum, and obtained
a lodgment in the soft parts, with more or less tumefac-
tion  of  the part, and a perceptible fluctuation.  The 
                     NECROSIS.                 115
treatment, in this stage, is precisely the same as in the
second stage, but the favourable result is not so certain,
as a portion of the bone may have been deprived of its
circulation too long, or may be perfectly dead, and the
separation between the living and dead bone may have
commenced.  In that case, the operation cannot save
the bone entire; a portion must necessarily be cast off.
Nevertheless, the incision should be made through the
whole length of the collection, taking care not to divide
any important parts, such as tendons or large arteries.
The  bone  should then be perforated and a  portion
sawed out, so as to give free vent to the matter con-
tained within lit, and the wound treated  as  after the
operation performed during the two first stages.
   I would  advise a free incision, with a  view to the
subsequent treatment of thexase;  for if a large portion
of bone should be detached, it  affords a better opportu-
nity for its removal.
   As we cannot always be certain whether the bone
may, or may not, be  in a recoverable  state, the opera-
tion,  though  late, may prevent the destruction of any
portion of it, as I have several times had an opportuni-
ty of witnessing, and when I had  not  expected such a
result, on  account of the length of  time which had
elapsed before it was performed.  If a portion of bone
should  be cast  off, the perforation will enable the ope-
rator, if it should require  an operation for its removal,
to break it  the more easily, which  is often a necessary
part of the operation in removing a large sequestra.—
The  operation  of sawing and perforating  fhe bone
gives no other pain to the patient than  what arises from
pressure of the  instrument on the limb, which need 
116                 NECROSIS.
not be considerable.   After the operation has been per-
formed, in either stage of the disease, nothing more
need be attempted, and no instrument, not even a probe,
should be  thrust into the wound.  If the collection of
matter in the soft parts has been great, and the  dis-
charge continues to be copious, the patient should take
bark freely, and should be supported by as nutritious a
diet as the stomach will bear.
   In some cases, in which the discharge has been very
copious, I have checked it by throwing in a solution of
corrosive  sublimate, of the strength of ten grains to a
pint of water, to be repeated once in four or five days,
and when  the matter has  been very offensive, a weak
solution of carbonate of potash, thrown  into the sore
with a syringe, from time to time, removes the offensive
odour.
   As it will often happen, either from nothing having
been attempted to prevent the death of a portion of the
bone, or from the necessary operation having been de-
layed too long, that a portion of bone, of greater or less
dimensions, loses its vitality, and becomes a foreign body,
surrounded by the living parts.  When this happens,
if the portion of dead bone is of any considerable size,
there will  be a discharge of matter kept up as long as
the sequestra remains.
   The object of the  surgeon, then, is to remove the
sequestra.  The first question is whether we shall at-
tempt  to  remove the  sequestra by  an operation,  or
leave it to the unassisted efforts of nature, and the de-
cision must be determined by contingent circumstances,
like every thing else relating to our art.
   If the portion of  dead bone is small, and but  a 
                     NECROSIS.                 117
trifling discharge of matter be kept up by it;—and if it
is so situated that  it does not give much pain, nor im-
pede the use of the limb,—and  especially, if it is situa-
ted near the surface, it may be  left to the operations of
nature, till it appears to be  coming away, when its re-
moval  may be facilitated with the fingers or forceps.
  But where the  portion of dead bone is large,—a
considerable  discharge kept up by it,  and  especially
when it deprives the patient of  the use of the limb, an
operation, undertaken for the purpose of removing it,
is generally to be preferred, and the first question to be
settled in such a case, is, at  what time shall the opera-
tion be performed?
  When the disease has not extended over  the  whole
circumference of the bone, that is, when only a portion
of one side  of the  bone  is  affected, the dead portion
may be removed, if the operation be thought necessary,
at any time after  the dead bone is detached, which is
generally in  no  very great length of time.   This can
be  ascertained by the sound it gives on  rapping it with
a probe, or any other instrument, and more certainly by
pressing directly upon it with the end of the probe, for
sometimes we can perceive that the sequestra is moved
by the pressure.   When  this cannot be perceived, if,
when you fix the end of the probe directly on the dead
portion of bone, you make  considerable pressure upon
it, and the patient complains of pain, you may be  cer-
tain that the bone is detached, as such pressure will
otherwise cause no sensation, for they are granulations
which have started from the edges of the living bone
that are hurt by the pressure.   In such cases the dead
bone had better be removed early, otherwise a new bo- 
118                  NECROSIS.
ny structure will be formed over the sequestra, which
may make it necessary to remove some portion of the
former with  the  saw, which  w7ould  be avoided by a
timely operation.
  But when  the  whole cylinder of the bone has been
destroyed, that is, when the sequestra consists of the
whole bone for a certain portion of its length, the ope-
ration must be deferred till the new bony structure has
formed round the sequestra.   This is necessary to pre-
serve the length and shape of the limb, for if the opera-
tion should be performed before this process is perfect-
ed, the member would be reduced to the state of a bro-
ken  limb, with a deficiency of  bone between the two
ends of the livipg bone, and the limb would undoubted-
ly be shortened; and it is not quite certain that the bone
would form in such a manner as to support the  body.
  It is not difficult to ascertain whether the new bone
has formed round the  sequestra or not.   When this
has taken place, there is  considerable enlargement of
the limb at that part of it, and it  feels hard, as though
the bone were much larger than natural, which is real-
ly the case, and if a probe is inserted  into the opening,
through which the matter issues, the dead bone will be
felt, and  around the  edges of  such  opening the new
bone  also, though not yet firm and solid, and the probe
may often  be inserted between  the new bony covering
and  the  dead  bone.   Under  these circumstances, the
sooner the operation is performed the better.
   Respecting the operation, the cases which occur are
so peculiar, and require such different methods; that
nothing more  than general directions can be given.—
The  object, however, in every case is the  same; that 
                    NECROSIS.                  H9
is, to remove a piece of dead bone, which has become
a foreign body as it relates to the living.
  The instruments which may be wanted in this ope-
ration are a probe, knife, round saw, and one or  more
of Hey's saws, several pair of strong forceps, and a
pair of cutting forceps.  The  elevator used in trepan-
ning the skull is  also an instrument which is often re-
quired in such operations.  When we undertake this
operation, we should be  provided with all the instru-
ments named, as we cannot always forsee at the com-
mencement of the  operation, what  instruments  we
shall need before it is finished.
  In  some  cases, where only  a small portion of bone
is detached, it may be removed with the common dres-
sing forceps.  But in  a case  where  any considerable
portion  of bone is to be removed, it will be  necessary
to make  an incision in  the soft parts to some extent.—
The length of the incision required will depend on the
length of the sequestra to  be  removed, which may be
estimated by the length  of the  enlargement of  the
limb, or diseased par£.  But, as the sequestra is always
shorter than the new-formed bone, it will not be neces-
sary to extend the  incision  the wrhole length  of the en-
largement ; besides, if the first incision should be found
insufficient  to give us  free access to the bone, we can
enlarge it at any stage of  the operation.
  The better mode of procedure is—first, to insert
a probe  into one  of the  principal openings, through
which the matter issues, or if  there is more than one,
to insert  the probe into that which presents  the fairest
opportunity to  reach the sequestra  by an  operation,
and then to introduce the  knife, and  carry it upwards 
120                 NECROSIS.
as far as may be thought necessary, and if the seques-
tra extend below the probe, commence another incision
from it, downwards, as far as may be deemed proper.
The incision should be carried down  to the sequestra,
if there is no new-formed bone intervening, and if there
should be, as is commonly the case, the incision should
be carried  down to  it.  It  sometimes happens that,
though the new bone  has formed and partly enclosed
the sequestra, yet we  find a sufficient space open, or
covered only with soft parts, through which we may
extract the sequestra; and in order to effect this with-
out sawing away the new-formed bone, it is often ne-
cessary to  saw, break, or cut, the sequestra  into two
pieces, for it is often covered by the new bone to some
extent, at each end, so that, by cutting it in two pieces,
we can withdraw each through a small opening.
   I would observe that, in making the incision through
the soft parts, we should avoid wounding any artery of
considerable  size, and especially any  tendon.  We
cannot always avoid wounding the muscles, but if they
are divided in  the direction of their fibres, no serious
evil arises.
   The treatment of the wound, after the operation,
should be perfectly simple, and similar to the treatment
of a simple wound.
   When I first  began  to perform  operations of this
kind, I was under apprehension  lest so much bruising
and handling of the soft parts, as is sometimes necessa-
ry, to dislodge a large sequestra unfavourably  situated,
might be followed with bad consequences, and some of
these operations have been  the most laborious and te-
dious, both to myself and the  patient, which I have 
                     NECROSIS.                 121
ever performed, yet I have never known any untoward
circumstances to  follow  such operations, of which I
have performed a great many.
  If the whole of the sequestra is removed, the cure
will be perfect; but if any  portion of it is left, it will
keep  up a discharge, somewhat in proportion to the
quantity of dead bone left in the limb.
  As a supplementary to the foregoing Essay on Necro-
sis, I have subjoined  the following  interesting Case,
which recently fell under my observation.
                                       N.  R. S.
Singular  Case of Necrosis,  in which a part of the
   Tliigh Bone having been destroyed, the continuity of
  parts was restored by Ossification of the Muscles
   John Lewis, a  coloured boy, eleven years of age,
small of stature, but hitherto  healthy and active, was
admitted  into the Baltimore Infirmary, August  23d,
1829, for  the  treatment of disease of the thigh.   The
member wras found to be tumid—something hotter than
natural—soft, and apparently fluctuating in some places,
and in others, especially  near the knee, feeling as if the
bone were irregularly knobbed.  His general health
was less impaired than might have been expected.  The
tongue was white, pulse a little quicker and more fre-
quent than natural.   Appetite rather inconstant, but
rarely altogether absent.   The skin was dry and harsh,
but occasionally there occurred, at  night, colliquative
 sweating.
   After careful examination I became perfectly satisfied
        16 
122                  NECROSIS.
that pus was present in considerable quantity, and that
the bone  was  undoubtedly extensively  necrosed.   I
therefore immediately made an incision into the outer
part of the thigh, above the external  trochanter.  Un-
fortunately, although the fluctuation seemed here to be
most distinct, this incision  did not freely lay open  the
abscess, and there escaped but an inconsiderable quan-
tity of pus.   The instrument undoubtedly divided that
portion of the vastus externus which arises from  the
external division of  the linea aspera,  and which forms
a kind of partition  between the anterior  and posterior
regions of  the  thigh.  Two  or three  days  after this,
however, there took place a spontaneous discharge of
fetid pus from between the ham-strings, near the knee.
This opening having been dilated, the discharge became
very copious, seeming to consist of crude pus, largely
diluted with serous fluid, and containing flakes of lymph,
precisely of the character that is discharged from ordi-
nary scrofulous abscesses, except that it was unusually
fetid.  Through  this opening I introduced a probe ob-
liquely upward, and immediately encountered the de-
nuded, rough surface of dead bone.   But this being not
directly accessible from the spontaneous opening, I im-
mediately dilated the incision  which I had  previously
made, and examined the diseased organ with my finger.
I found that a prodigious abscess had existed immediate-
ly around the bone—that I was able with my finger to
touch every part of the circumference of the bone  at
that  place, and  that the muscles and  tendons  were
completely detached.  The shaft  of the bone was  in
this condition to  the extent of five inches.   The lower
 extremity of the dead portion was very near the  June- 
                     NECROSIS.                 123
tion of the shaft and epiphysis.  The periosteum ap-
peared to be entirely destroyed.  Above, shooting from
the lower extremity of the upper  portion of healthy
bone, were two or three irregular  spiculae of bone, by
which nature seemed to be endeavouring to restore the
continuity of healthy bone, and to enclose the sequestra.
One of  these projecting on the inside of the thigh felt
like  an exostosis.   The sequestra  was, however,  no
where detached from the living bone.
   Such being the condition of the parts, I determined
to wait the operations of nature; indeed, it appeared to
me that no other course could at that time be prudently
pursued.  I was anxious, also, to observe, from time to
time, the recuperative  process which might be institut-
ed.   The patient, therefore,  was put  upon a  gentle
tonic plan of treatment, for the purpose of obviating the
colliquative discharges  which seemed to be in some de-
gree wasting his strength.   He was kept  constantly in
the horizontal posture, the limb being sustained  in an
easy attitude.   In  this condition he remained till the
last of October.  His general health was, in the mean
time, not a little impaired.   His tongue was white and
occasionally dry—his appetite somewhat defective. He
often had copious  night sweats, and not  unfrequently
was annoyed with hectic diarrhoea, attended with grip-
ing pains.  This could only  be relieved by the free use
of oak bark enemata.  Opium had little or no effect in
arresting it.
   At the end of this time, I  again presented the patient
before the attending class—dilated  the opening which
I had first made—introduced my finger into the cavity,
and carefully examined the bone.  It was found to be 
124                 NECROSIS.
in the same state as before, except that it was  more
rough and decayed.  I exercised some degree of force
upon it with a lever, but found  that it was still firmly
attached at either extremity.  There was still a large
space betw een the bone and the  surrounding parts, and
no new bone had been formed in contact with the old.
This cavity was filled with matter when means had not
been recently employed to expel it, and,  when emptied
of it, the walls of the abscess were too rigid to collapse,
but remained open and drew in  air.   On carefully ex-
amining the walls of the cavity, with one finger on the
inside and another  without, I discovered that they were
formed of the internal layers of those  muscles which
arise from, and envelope the thigh bone.  I discovered,
too, that the most deeply seated fasciculi were evident-
ly about being converted into bone—bony spiculas were
distinctly felt in many parts.  The  patient, in conse-
quence of this disorganization of the muscles, had com-
pletely lost the power of moving the leg.  I requested
many of the medical pupils who  were present,  to ex-
amine the limb with care.  Several gentlemen felt  it,
both within and without, and  became  satisfied of the
condition of the parts.
   I then remanded the patient to his bed, and directed
that the same plan of treatment should be continued.
I was careful that the opening which I had made should
be  preserved by introducing firm tents.    My  expecta-
tion was, that nature would soon  effect  the disengage-
ment of the dead bone at its extremities from the living,
 and that the shell, then forming in the muscles, would
 restore the continuity of sound parts.  The patient was
 suffered to remain  in this condition (being occasionally 
                    NECROSIS.                 125
examined,) till December.  I then became alarmed for
the safety of my patient, on account of the very copious
and offensive discharge which continued  to be poured
from the limb.   The whole ward in which he lay was
filled with the stench, and the dressers had extreme dif-
ficulty in the discharge  of their duties.   The hectic
symptoms were more decided, and he appeared to be
evidently losing ground.  The shaft of dead bone seem-
ed, indeed, to be operating  as an immense foreign body
to  keep up irritation  in the part.  Amputation was
thought of, and in this state of things would, no doubt,
have been justifiable.
   I determined, however,  although the bone  was  still
firm, to  attempt its removal—thus  to withdraw the
source of local irritation, and to place  the limb in the
condition of a  fractured thigh- -trusting to the process
which was then going  on in  the muscles  to re-establish
the continuity  of the bone.  I had so far succeeded in
dilating the incision which I  had previously made, that
the bone, to a considerable  extent, was easily  acces-
sible.   Before  applying an  instrument to the bone, how-
ever, I dilated this opening  upward,  where  the dead
portion of the  shaft extended beyond the reach of my
finger.  Then, with the chisel, Hey's'saw, bone-nippers,
levator and strong forceps, I succeeded in breaking up the
dead bone.  As soon as I  had cut it entirely  across, in
 one place, I discovered that the thigh was in the condi-
 tion of a fractured member, and that a considerable de-
 gree of motion took place  at the point of fracture.
    Having removed nearly all the dead portion of bone,
 (to the extent  of about four or five inches of the shaft,)
 I extended the limb, and,  as the most convenient for 
 126                 NECROSIS.
 this object,  applied the apparatus of Hagedorn for the
 purpose of gently extending the  thigh, and preserving
 its rectitude.  The patient was  placed on his back,
 upon a firm mattrass, and  subjected to such treatment
 as the constitutional symptoms seemed to require.  For
 a  time the  discharge was  as copious as  before, and
 equally as offensive, but, in  the course of two weeks, it
 began sensibly to diminish,  as did also the hectic symp-
 toms  which  appeared to have arisen from  so  exhaust-
 ing a discbarge.   The cavity formed by the removal of
 the bone began to fill with granulations, and, from time
 to time, the limb appeared  to become more and more
 rigid.  At last, at the end of about eight weeks from the
 time of the operation, the limb was found on examination
 to have perfectly healed, there remaining not even the
 smallest fistulous orifice for  the discharge of matter.—
 The limb felt firm and  sound, and had become so rigid
 that he could raise it  without assistance horizontally
 from  the  bed.   The splints were then thrown aside,
 and, at the end of a few days from this time, he  was
 able to leave his  bed and to hobble upon crutches.  At
 first he appeared to have no muscular command over
 the leg whatever.  But, by  constant efforts the leg ap-
peared, at length, to become slightly moveable, and the
 patella began to play.   On examining the limb this day,
 March 27,1830,1 discover  that he is able  to bear his
weight upon the  member,  and even to walk a little,
without the aid of a crutch.   The limb is much larger
in  diameter than natural.   In place  of the  bone there
seems to be a large mass of  callus.  The knee, leg, and
foot, have their natural  attitude—the patella plays with
some  freedom—he can  slightly flex and extend his leg 
                     NECROSIS.                  127
by the effort of the muscles.  The  limb is, however,
nearly an inch shorter than the  other.   This circum-
stance arose from the difficulty of maintaining perma-
nent extension in his feeble state (though, by the way,
I have very little confidence in the utility of permanent
extension in any case.  No part of the body, not even
the soles of the feet, can bear continued pressure, for a
considerable time, without injury.)   The condition of
the lad is, therefore, such that I have no hesitation that,
as regards its utility,  the limb will, in a  short time, be
almost perfect. 
 
OBSERVATIONS
                        ON


FRACTURES  OF  THE  FEMUR,


         WITH AN ACCOUNT OF A NEW SPLINT.
   In the treatment of fractures, the first object is to
place the extremities of the fractured bone in accurate
apposition.   In  general, this  is accomplished without
difficulty.  It sometimes, however, happens that the
muscles  are  so  contused, or otherwise irritated, as to
become  morbidly rigid, and to resist a considerable de-
gree of  force although the limb be placed in the most
favorable position for the reduction.  Under these cir-
cumstances, it is with some difficulty that the fractured
surfaces  are brought in contact with each other.  If
the position of the limb be injudicious in relation to the
action of the muscles, or if the forc.e be suddenly and
unequally applied, the difficulty is often  insuperable.—
When, however, the  contraction has been overcome
by the necessary degree of extension, if the fracture is
at all oblique, the muscles will repeat the displacement
as soon  as the extending force is discontinued; conse-
quently there is indicated the employment of a perma-
       17 
130         FRACTURES OF THE FEMUR.
nently extending force, a remedy which, from the diffi-
culty that attends  the employment of it, and from the
want of tact in adjusting it, is exceedingly equivocal in
its results, often defeating  its own  object, with  regard
to the limb,  and occasioning a great deal of suffering te>
the patient.
   The principal difficulty,  then, in the treatment of
fractures, is not in the manual operation of reducing
the bones to their places, but in keeping them accurate-
ly there  till union can be  effected.   This difficulty,
however, does  not  altogether  consist in the liability of
the limb to be shortened by the contraction of the mus-
cles, but  also  iu the tendency  which is there to the
other kinds of displacement.  The limb,  below the
fracture, may assume  such a position, that  the axis of
the inferior  fragment may not coincide with that of the
superior,  but  may make an angle with  it; or the limb
may rotate, so that the fractured surfaces shall not cor-
respond.  This often occurs in fractures of the thigh,
from not properly supporting the  foot, which, acting
transversely upon  the  axis of the limb, operates like  a
lever to rotate it.  Or, finally, there may be a displace-
ment of  the fractured  extremities laterally, occasioned
by the unequal action of the muscles, or by the limb
 not being equally supported.
   The liability to these  kinds of  displacement and
 consequent deformity will depend, in a great measure,
 upon the length and weight of the limb below the frac-
 ture.  It is obvious that the greater the length the more
 power will the weight of the extremity have to bend
 the limb, and  the  less apt will the portion below the
 fracture  be to accompany the part above in those mo- 
            FRACTURES OF THE FEMUR.        131
tions which it is impossible to avoid.   The nature of
the difficulty, in  these cases, should indicate the means
which are best calculated to remedy it, and hence it is
obvious that the most important indication is to employ
such  an apparatus as shall command the whole limb,
so that the part below the fracture shall preserve its
proper range with that above, and in the different mo-
tions  which may be necessary, that  the whole shall
move as one, the fragments maintaining  their relative
position in all  respects.
   Another important circumstance to be attended to is
the attitude of  the  fractured limb, which should be
such  that,  as much as possible, the antagonizing efforts
of the flexor and  extensor muscles  may be made to
balance each other.  From the neglect of this circum-
stance, almost every kind of evil to the limb is liable to
occur; the muscles will exert an unequal force lateral-
ly, tending to  lateral displacement; the contractile force
to be overcome must necessarily  be greater; the appli-
 cation of  the extending force can not be made in the
 direction of the axis  of the broken bone, and in addi-
 tion to all these, the ease and comfort of  the patient, so
 necessary to the healthy process  of union, are greatly
 impaired.
   Another object to be attained is, so to contrive the
 apparatus that  the patient may be moved from  place
 to place, or taken from one bed and laid upon another,
 without injuring the limb, or retarding the cure; for it
 is no small penalty to be confined on the back for forty
 or fifty days.
    The above are the principal indications to be kept in
 view.  But while we attend to them, there are certain 
 132        FRACTURES OF THE FEMUR.
 injurious circumstances to be  avoided, or  obviated,
 which might frustrate our intentions, or give the patient
 unnecessary pain  and inconvenience.   The  most im-
 portant of these is injurious pressure.   This is often
 produced in two ways; and first, by the weight of the
 limb  resting upon a small part of its under surface.—
 This cannot be continued for any length of time, even
 although it rest upon a cushioned support, without pro-
 ducing injurious effects.  The softness of the support
 is too often a circumstance which deceives the surgeon.
 A little  reflection, however, must convince every one
 that, if the weight of the limb rest upon an inch square
 of surface, the effect  will be the same, whether it rest
 upon eider-down or adamant, provided the surface of
 the latter be accurately adapted to that of the limb.—
 To obviate this difficulty and source of injury, the sup-
 port upon which the limb  rests, whatever it may be,
 should be so adapted to the whole under surface of the
 limb, as to divide the pressure as  equally  as possible
 throughout  every part of it.  If this be done, it will
 make no difference  whether  the support be hard or
 soft, the  benefit  of soft substances  as an easy support
 consisting entirely in their receiving the weight upon  a
 greater surface,  and  thus dividing the pressure more
 equally.
  The other kind of injurious pressure, which is often,
 I may even say generally, produced upon fractured
 limbs, is  occasioned  by the application  of splints and
 bandages immediately to the neighborhood of  the frac-
 ture, with a view to keeping the extremities in place by
 means of lateral pressure.   This occasions injury by
the partial contact of the narrow or flat splints bound 
             FRACTURES OF THE FEMUR.         133
tightly to the limb, and which, notwithstanding  the
compresses  which  are  interposed, gall and chafe it in
particular places.   The circular bandage, by making
pressure entirely around the limb, intercepts the return-
ing blood in the veins, and causes the limb to swell be-
low the bandage; or if the limb be equally bandaged
throughout, impedes the  healing process to which  a
free circulation is necessary, or  irritates the soft parts
by pressing  them upon the fractured extremities,  and
not unfrequently, by the inflammation  and ulceration
which is produced,  converts simple fractures into com-
pound.
  This kind of pressure is  employed from a mistaken
notion, which prevails too generally, that  such banda-
ging  and partial bracing  of the limb xontribute much
to keep  the bone in place.   If surgeons, who are in
the practice of applying bandages tightly around frac-
tured limbs, would  take the trouble to investigate the
subject, I think they would perceive that such practice
can do nothing but  mischief.  They cannot be applied
sufficiently tight to prevent the shortening of the mus-
cles without interrupting the circulation, and it is doubt-
ful whether any degree of  tightness would aid  in the
least, to effect this object;  nor can they contribute at
all to prevent  displacement of  the  extremities, if the
limb below the fracture is moved from its proper posi-
tion, or if the limb above the fracture  is, by the  mo-
tions of the body, moved out of  its relative and natural
position.   If, in a case of compound fracture, in which
the ends of the bones are in sight, or in which they
can be  touched by the finger,  the surgeon  will take
hold of the limb below the fracture, while he keeps his 
134         FRACTURES OF THE FEMUR.
finger on  the fractured ends of the bone;  he will find
that, by moving the limb into its  proper relative situa-
tion  with  the  limb above the  fracture, the bones will
readily  come into  apposition;  but if he attempts to
bring the ends of the bones into apposition by pressing
them down with his fingers, he will find it utterly im-
possible to do  it with any force, unless he moves the
limb below  the  fracture  with  the  other  hand.   The
weight of the  limb is acting against him at the end of
a lever  which gives it an infinite advantage.   For this
reason no  pressure which the  limb can bear without
destruction will  prevent ends of  the  bones from being
displaced, if the limb is moved out ef its proper  posi-
tion.  This  mistaken idea of  the  utility of bandages
in maintaining the natural form of the limb, and the
necessity of  them to attach the splints which are  com-
monly used, has led to  an  unremitted  employment of
them, which could not fail  to be  exceedingly injurious,
even were they capable for a time  of effecting the ob-
jects for which they are intended.  It is too generally
presumed that, when a fractured limb has been  once
dressed, or set, as  it is  vulgarly expressed, it  must re-
main perfectly fixed  till the bones have united; and as
it receives its  support from the splints which are  com-
monly  employed chiefly  through the  medium of the
bandages, there  is generally a great unwillingness to
relax the  support by loosening them; nor indeed can it
be done, as the apparatus is usually applied, without oc-
casioning  more or less displacement.   There is  often,
however,  a more insidious and  much  more  fatal mis-
chief resulting from this  apprehension of relaxing the
supports of the limb.  The  unreasonable fear of un- 
            FRACTURES OF THE FEMUR.         135
binding it, thus enveloped as it is in the dressings, for
the purpose of noticing its condition, is a timidity which
has  proved the destruction of many  limbs  and some
lives, and almost always occasions excruciating torment
to the patient.  It is rare that bandages encircling the
limb are not either at first applied too tightly, or be-
come so, soon after their application, by the swelling of
the limb.   To the surgeon a part of the dressings may
appear sufficiently loose, while by the unequal swelling
of the limb, other parts may occasion and  conceal a
great deal of mischief.
   It is unnecessary  that I should speak  of the great
variety of methods which have been employed to main-
tain the reduction of fractures of the thigh, in order to
point out in them the deficiencies which I have spoken
of above.   Observation and reflection will, as I think,
convince every one that the difficulties which I have
enumerated are  completely obviated  by none of them,
and that they are for the most  part deficient in the
general principles which  govern their application.  I
would  particularly, however, call the attention of my
readers to that which  is now used almost  exclusively
by scientific surgeons, and which, with its modifications
 appears to be  regarded,  though acknowiedged  very
 often  to fail, as the ne plus ultra of inventions  for this
 particular purpose.   I mean the method of Desault.—
 This is so familiarly known that I will not attempt  to
 describe it minutely.   The principal object, which this
 apparatus is intended to effect, is permanent extension.
 One long splint  is essential to it.  This, in the original
 apparatus of Desault, was a flat piece of wood applied
 by bandages to the outside of the limb, with compres- 
 136         FRACTURES OF THE FEMUR.
 ses intervening, extending above the hip and below the
 foot.   Oblique bands were cast between the thighs and
 over  the  extremity  of the splint, which  thus effected
 the counter  extension, while extension was made by
 passing bands from the ancle and foot to the lower ex-
 tremity. Short splints were also bandaged to the thigh,
 and the whole was  closely enveloped in dressings.—
 The patient  was of  course confined to his back, and
 the limb  was made  to rest upon cushions  throughout
 its whole length.  The above  apparatus has been in-
 geniously  modified by Drs. Physick and Hartshorne.—
 The former gentleman extended the superior extremity
 of the long splint to the axilla, in the form of a crutch,
 with a view to relieving  the perineum from the  galling
 pressure of the counter-extending band;  the latter, by
 employing two long splints, divided the resistance more
 equally  around the base of the limb.
  The first objection, which occurs to every variety of
 this apparatus, is the  attitude of the limb, by which an
 unequal degree  of tension  is produced  in  the  flexors
 and extensors.   It is obvious, that when the thigh is
 extended  upon the pelvis, and  the leg upon the thigh,
 all the extensors have their utmost degree of relaxa-
 tion, while the flexors have a corresponding degree of
tension.  It is said, indeed, that, although this posture
is at first  painful to the  patient as being unusual, yet,
when the extension has  been continued for a time, the
contraction of the muscles is overcome and he  ceases
to  complain.   This, however, is only an evidence of
what mechanical force can effect, and that the muscles,
after the extension has been continued for  some time,
become paralysed, and their sensibility  obtunded.  It 
           FRACTURES OF THE FEMUR.           137
does not prove that the two classes of muscles, which
are thus unequally stretched, exert an equal degree of
force obliquely upon the bone; for although their vital
contractility may be suspended, we know that the con-
tractility of texture increases with the increased degree
of extension, so that although the sensations of the pa-
tient do not indicate it, yet it is absolutely certain that
an  effort is constantly making by the muscles to dis-
place laterally the bones to which they are attached.—
It is obvious, also, that a greater degree of force will be
necessary to give the limb its natural length,  than if the
muscles are in harmonious relation with each other.
  A little reflection must  also convince us that, under
these circumstances, it is impossible to make the exten-
sion precisely in the direction of  the axis  of the thigh-
bone ; for the force which is applied to the limb below
the fracture,  is communicated to the part which  is
above, wholly through the medium of the  muscles, and
this will chiefly be done by those  which are the most
tense.   These will be drawn into the line of direction
in which the force acts, while the bone, not being equal-
ly supported on the opposite side, will be crowded from
it.  The more  nearly  the muscles  antagonize each
other, the more nearly the extension be made in the di-
rection of the axis of the bone, and vice versa.
   Another  objection to this apparatus is,  that the sup-
port which it receives  from beneath, although it rest
upon cushions, is, for reasons mentioned  above, neces-
sarily confined to a small part of  the surface, and must
occasion pressure  more  or less injurious.  Another
great inconvenience to the limb and to the patient, ari-
ses from the support  not constituting a part of the ap-
       18 
138        FRACTURES OF THE FEMUR.
paratus attached to the  limb, and  consequently not
moving with it, in the different unavoidable motions.
  The remarks, which  were made upon  the pressure
of flat, straight splints, and circular  bandages, are ap-
plicable to this method.
  The  apparatus which I have used  for several years
past was designed to answer the general indications of
which I have spoken, and was  the result of long ex-
perience of the difficulties which attend the treatment
of  fractures  generally,  and  particularly  those  of the
thigh.   It consists of two thin broad pieces of wood *
so warped as that the concavity of one shall correspond
to the convexity of  the under surface of the thigh, and
the other to that of the leg.   The  lower extremity
of  the thigh-piece,  and  the upper extremity of that
of  the leg,  are jointed together.   This  is done  by
paring out the margin of each of them, in the middle,
so as to make  them deeply concave.  The projecting
corners of the  extremities, which are thus produced,
are applied  to  each other, so that those of the thigh-
piece embrace  and  overlap those of  the leg-piece, and
each pair being fastened together by a pin, performing
the office of a pivot, a perfect hinge is produced, which
admits of no other motion but flexion and  extension.—
The superior margin of the thigh-piece is then pared
away, so as to adapt it to the shape of the pelvis against
which its circumference rests.  Where it  presses upon
the pubes and  the tuber of the ischium, as  it may be
made to do, it  should  be bordered  with  soft leather,
and stuffed.  The. leg-piece is  to be made longer and
  * Bass is that which I have employed, as being more flexible, and
less liable to split  than almost any other. 
\ A
  Figure 3 and 4 represent an instrument hereafter to be described,
designed for removing coins from the cesophagus. 
 
             FRACTURES OF THE FEMUR.         139
larger than the leg, and as its concavity can not be ex-
actly adapted to the convexity of the calf of the leg,
this part of the limb is  to be slung in the splint, by
means of strips  of cloth, or leather, which pass  across
it and hang loosely into its concavity, being attached to
one side of the splint by tacks, and on the other by
hooks or buckles, which will admit of their being tight-
ened or loosened, as may be necessary, without disturb-
ing the limb.  The circumference of the thigh-piece is
to be a little less at the inferior than at the superior ex-
tremity, to adapt it to the  tapering shape of the limb.—
A strap, passing from the upper extremity of the thigh-
piece, to the lower extremity of that of the leg, will
enable the surgeon to fix it at any angle that he pleases.
   In applying  it, there may  be  laid along under the
whole splint, bands of firm  cloth, long enough  to  em-
brace the  splint and the limb.  A  broad linen cloth
may be laid in the thigh-piece.   The limb is then to
be carefully laid in the splint, the size of the one hav-
ing been adapted to that of the other by measuring the
sound limb; the linen cloth may be folded over the limb,
and the whole splint then secured to it by overlapping
and pinning the  bands along its whole length  from the
hip to the ancle.  As the pieces of the splint are flexi-
ble, they will be made  by the bands to embrace the
limb  firmly enough, although they may not have been
precisely adapted in size.   In  most instances, in  which
the limb has been thus dressed, almost every  source of
irritation being avoided, and the  attitude  natural  and
easy to the muscles, I have not found it necessary to
use permanent extension.   I am confident that the ne-
cessity for its use is  often occasioned by the apparatus 
140         FRACTURES OF THE FEMUR.
itself which is employed to effect it.   Where, however,
the fracture is very oblique, and the muscles are dispos-
ed to contract and shorten the limb, I have employed a
mode of extension, which can be graduated to any de-
gree of force, and which may always be  made in the
direction of the axis of the thigh-bone.   It  is accom-
plished  by lacing a soft band of leather  round the leg,
just below the knee, and to this attaching a cord, which
is carried in the direction of the bone over a pulley in
a stand  nailed to  the foot oi* the bed, and which  may
be lowered or raised at  pleasure.  To the end of the
cord is attached a weight, equal to the necessity of the
case.  The weight of the body  makes the counter-ex-
tension, which may be increased, if necessary, by rais-
ing a little the foot of the bed.
  The reader will readily perceive that, by this appa-
ratus, all the indications which I have spoken of above
are intended to be answered.   The limb  may be  plac-
ed at any angle which the muscles may require, without
at all disturbing the fracture.   It is completely protect-
ed from hurtful pressure, as it rests upon the whole sur
face of  its  semi-circumference, and  as  it  is no where
girt by  bandages, being protected from their unequal
pressure by the splint, suffering them  to touch it only on
its upper surface.  Along the angles of the splint and
bandage, there is no pressure at all, so that the blood
returns with perfect  freedom.  The weight of the leg
being perfectly commanded by the lower piece, and the
limb easily  fixed in  any position, its control over the
fractured extremities is completely obviated.   The
splint being light, and the whole of  it  attached to the
limb, and the support being the splint itself, there  is no 
FRACTURES OF THE FEMUR.         141
difficulty in moving the whole limb as one, or in trans-
fering the patient from one bed to another.  The ban-
dages may be at any time relaxed without the least dan-
ger of disturbing the fracture, they being only necessary
to secure the limb when it or the body moves.   It is to
be  particularly noticed,  as one  of  the excellencies of
this method, that the weight of the  limb  itself, and the
reaction of the hollow splint in which it is lodged, con-
stitute all the force, which, under ordinary circumstan-
ces, is necessary to maintain the reduction.   It is par-
ticularly adapted to compound fractures, which may be
examined and dressed, without in the least disturbing
the limb, and even although the wound be on the under
surface, by cutting away a portion  of the splint oppo-
site to it.  The few words which are necessary to de-
scribe this splint are a sufficient evidence of its simpli-
city:  almost any person can construct it in a very short
time.   The objections  of complication, and  expense,
therefore, which prevent the general use of some others
can not be made to this.   I do not,  however, rely solely
 upon the theoretical principles which indicate;its use.
 Its present form is the result of twenty years extensive
 experience  in the employment of some modification of
 it, and I never have seen sufficient reason to induce me
 to abandon it for any other.
    The reader will have no difficulty in forming an idea
 of the splint and its appendages,  by attending to the
 cut, figure 1 and  2. 
 
 
\
         - =  . -; ■
,  Af<&>* Mr:

Jhth. fff^rulicott Jc Swtte. 
DESCRIPTION
                       OF AW


    IMPROVED APPARATUS FOR THE TREATMENT

                        OF


FRACTURES OF  THE THIGH & LEG.
BY N. XI. SMITH, M. D.
   Observation has thoroughly convinced me, that no
instrument will be generally employed in the treatment
of Fractures, but one  which is made with facility—
cheaply, and of common materials; one, also, which is
applied with ease and dispatch.   Very few practitioners
are so provident as to have, always ready for exigencies,
instruments of a  complicated and expensive construc-
tion.   Even if they possess such, they  are  extremely
apt to be out of repair, and to be generally unfit for use
on the spur of occasion.  The surgeon, therefore, will
do most for this department of practice, who devises an
instrument which any individual, with common inge-
nuity, can construct in  a short  time, out of materials
easily procured.
  It is also important  that the instrument employed
should be one, that when once applied, shall not require
constant watching in order to keep it properly adjust-
       19 
 144         FRACTURES OF THE FEMUR.
 ed; for if this should be the case, it will certainly fail of
 accomplishing its end.  Experience has suggested, and
 will confirm this  assertion.   It is scarcely necessary to
 say that the apparatus, at the same time that it is simple
 and permanent, must accomplish, in a satisfactory man-
 ner, the indications for which such machines are de-
 signed.   Whatever apparatus does  this,  in  the best
 manner, consistently with  simplicity of construction,
 and ease of application, will certainly become the most
 useful and the most generally employed.
   Mr. Amesbury's apparatus for fractures, is probably
 better calculated to accomplish the indications of treat-
 ment, than any other which is at present employed by
 European surgeons; but it is so complicated in its con-
 struction—so expensive and difficult to procure, that
 although its adaptation  is very generally admitted, it is
 rarely employed, except in hospital practice.
   The apparatus  here  represented  is similar to Mr.
 Amesbury's in the principle by which it acts.   It is de-
 signed, indeed, to  accomplish nearly the same  indica-
 tions, but is so simple  in  its construction—formed of
 such common materials, and those so easily put together,
 that any ordinary mechanic, or, indeed, the surgeon
 himself may prepare one in a very brief time.  The cost
 of the instrument is trivial.
   The material which I now  use for the body  of the
splint, is a very stiff paper trunk-board that can be pro-
 cured.  If those which are very firm are not to be had,
 two of them should be pasted together.  The size  of
one board, if  it be properly cut, is generally sufficient
for both  the thigh and leg-piece.  Sometimes I have
had the apparatus made of tin, and I have no  doubt 
            FRACTURES OF THE FEMUR.         145
that thin sheet iron would prove a very excellent ma
terial.   Formerly I used to make them of bass or poplar
boards, of the thickness of a quarter of an inch, warmp-
ing them with the aid of steam, or hot water.  A pupil
of mine informed me  that, in the country, upon the spur
of occasion, he had  once made  one of the bark of a
sapling chestnut.  It was sufficently firm, and answered
the purpose in all respects extremely well.  This may
be a valuable hint to  country practitioners.
   But the material  which I prefer,  is the very thick
trunk-board.  This I cut in two pieces, one  for the
thigh, and the other for the leg.  The thigh-piece ought
to be, for an adult, about sixteen inches long, thirteen
inches broad at its superior extremity,  and ten at the
lower.  The leg-piece should be about  nineteen inches
long, and ten broad at both extremities.  These pieces
are then to be  very slightly moistened with a wetted
sponge, or cloth, and then to be bent into a semi-cylin-
drical shape with the hand.   The concavity, however,
should be a little deeper than a semi-cylinder, in  order
that the sides may rise a little  above the middle of the
thigh,  and be somewhat flattened.  I have been ac-
customed to shape these pieces  on blocks  of wood of
the proper form.   I  warp them over these whilst moist,
and binding them firmly with a cord, leave them till
they are dry, when they  will retain their  shape perma-
nently.  The block  for the leg may, if a very neat ap-
paratus be desired, be shaped, at  its upper and back
part, like the calf of  the leg, swelling out like it. When
the board is bent upon it and properly  moulded, it will
be adapted to the calf of the leg.
   The upper part of the thigh-piece is  now to be care- 
 146          FRACTURES OF THE FEMUR.
 fully pared away, in such a manner as that, when it is
 applied to the member, the superior margin  shall be
 properly adjusted to the perineum on the inside, and to
 the tuberosity of the ischium  behind.   On the outside
 it may be suffered to project  in the form of an angle a
 little above the trochanter.  It is obvious that it  must
 be deeply cut away on the inside, to fit the perineum.
 A glance at the plate will give a better idea of this than
 words can convey.   The lower  extremity is also to be
 truncated obliquely, so that the lower convex part shall
 not project so far as the angle, by about an inch  and
 a half.
   The angle of the thigh-piece, which  projects above
 the trochanter, is now to have a piece attached to it,
 which may extend  up along side of the body, and be
 bandaged to it.   Sometimes I have done this by nailing
 a piece of wood to the side of the splint, so as to make
 a suitable angle.   But the better  mode is to use a piece
 of iron, of the thickness of an eighth of an inch.  This
 may be made without a hinge, having an angle at the
 corner of the thigh-piece, the lower leg of it being four
 or five inches long and applied to the side of the splint
 —the other, six or eight inches long, and ascending on
 the side of the body;—or  there may be  a hinge made
 at the angle, by merely making the two pieces, which
there will  then be,  a little  broader, and rivetting them
together at the angle.   This will enable the operator to
adjust the angle to the attitude of the limb.  The lower
piece of this hinge may  be continuous with the  piece
which  extends  down to the lower extremity of the
thigh-piece, to fortify one of its angles  there; this will
render the whole  more firm. 
          FRACTURES OF THE FEMUR.          147
  The iron should have numerous small holes made in
it.  Through these it is to be nailed to the splint, which
can easily be done, with great firmness, by placing  an
iron upon the inside of the splint,  and clenching the
tacks securely on the inside.  The  upper piece of the
iron hinge is  to be nailed,  in the same manner, to a
piece of binder's board, a little broader and longer than
itself, and then to be bent a little  inward.
  The two  lower angles of the thigh-splint are also to
be fortified with thin pieces of iron, extending up, along
the sides of the splint, the one on the  inside about six
inches—that on the outside continuous with the hinge
above.  They should project beyond the angles, about
two and a half inches, and be pierced with holes half an
inch  apart.
   Where the thigh-piece is applied  to the perineum
and tuber of the ischium, the margin should be wrapped
with  three or four folds of soft,  old blanket, and  this
covered with leather.
   The leg-piece should be shaped at its upper extremi-
ty like the lower end of the thigh-piece, and fortified in
the same manner with pieces of very thick sheet-iron
these, however, not projecting beyond the angles,  nor
having holes, but, instead of them, having short strong
pins  projecting from the  outside, adapted to the holes
in  the irons attached to the thigh-piece.  I think it well
that  the  concavity of the upper end  of the leg-piece
should be a little deeper than that of the thigh.
   When I have been desirous of making the apparatus
a very complete one, I have appended to it a  contri-
vance for fixing the thigh and leg-pieces at any angle
that  might be desired. This consists of two pieces which 
 148          FRACTURES OF THE FEMUR.
 are attached, the one to the thigh-piece, and the other
 to that of the leg.   The former is  a piece of flat steel
 three fourths of an inch broad, and about ten or twelve
 inches long.   At one extremity it is broad and pierced
 with holes, for nailing it to the back part of the thigh-
 piece.   The other end is narrower, and at a quarter of
 an inch from its extremity, it is bent up at a right angle.
 This  piece  when attached  to  the  thigh-splint projects
 beyond  it, down four or five inches on  the back part
 of the leg-splint.  It should have  a spring temper.—
 The piece attached to  the leg-splint is  merely a piece
 of sheet-iron, or tin, fastened to the back  part of  the
leg-splint.  In  this there  are transverse slits,  half an
 inch apart, to receive the bent extremity of the spring.
 Whenever the leg-piece is bent upon that of the thigh,
 the spring will catch in one  of these slits and immedi-
 ately fix the two splints at a permanent angle; and by
 adjusting the  spring to one or other of  these holes,
 they may be fixed at any desired  angle.
  I wrou!d observe, that in using  tacks on  the binder's
board, for the purpose of fastening the various appen-
 dages, a little piece of leather should always be  put
under the head of the tack.   When this is done they
hold very securely.
  When the various pieces of the  apparatus are thus
put together, the  paper should be  brushed over with
strong glue-water, and as often as it dries  this  should
be repeated three  ©r four times.   At last it should be
varnished with  the  black spirit-varnish used  by sad-
dlers, to prevent its imbibing moisture, and sticking to
the  limb and the bandages. 
            FRACTURES OF THE FEMUR.         149
  Mode of applying the Apparatus.—One of the  ex-
cellencies claimed for  this instrument, consists in  the
ease and  dispatch  with which  it may  be applied.—
Commonly I place within the thigh-piece, (in case  the
fracture be one of the thigh, and it is only in  relation
to this fracture that I am now speaking,) a linen cloth,
to keep the skin from contact with the splint.   Across
the leg-piece I place two bands of  firm cotton or linen
cloth, about two  and a  half inches  broad, and about
half a yard long.   One of these  is  across the upper
part of the leg-splint, just below the joint, and is  suf-
fered to  drop, like a festoon, deep into  the  hollow of
the splint, but not quite to the bottom, as it is designed
to support, in some degree, the upper* part of the  leg.
Below this, the calf of the leg will rest in the hollow of
the splint. The  other band  is to be laid across  the
splint, in the same manner, at the  part  which will re-
ceive the  ankle, and is  designed to sustain  that part of
the limb,  in such a manner that  the  heel  may  be pre-
vented from touching the splint, a circumstance which
always creates pain and may produce displacement.—
The limb having  been  coaptated, is  then  to  be care-
fully raised by the hands of assistants, who  at  the
same  time keep  it carefully extended.    The   sur-
geon then brings the  thigh-piece  separately under
the  member,  and adapts it  to the  whole lower part
of  the thigh, and  nicely adjusts   it  to  the peri-
neum, ischium, and hip.  The  assistants grasp  this
piece  and sustain the thigh  in it.   The surgeon then
takes  the leg-piece and bringing it  beneath  the  leg,
places that member in it, in  such a manner that  the
upper part shall  bear  on the upper cross-band,  the 
150            FRACTURES OF THE FEMUR.
calf resting in  the  hollow of the splint, and the ankle
on the lower band.   The  iron pieces at the upper ex-
tremity are then to be fixed in the upper holes of those
of  the thigh-splint, and the two pieces may then be
adjusted  at such an angle as may be desirable.   Near
the knee, it will be necessary to interpose, between the
splint and the member, small compresses.   The bands
on which the leg partly rests are to be drawn  to the
necessary degree of tightness and pinned beneath the
splint. The whole limb now being suffered  to repose
in the splint, the patient  is almost perfectly at  ease,
whilst the surgeon proceeds to apply the bandage that
is to secure the member in the apparatus.
  The bandages consist merely of two rollers, one for
the  leg  and the other  for the  thigh.   These  should
each be  at  least four yards in length.  The surgeon
commences the application of one of these on the foot,
as in the ordinary  way of bandaging the leg.   After
two or three turns, he carries it obliquely across the
instep, oyer the margin of  the splint, and underneath it
to the other side.  Then it is again carried  obliquely
down over the instep, and once round the foot—then
again beneath the splint,  and spirally up the leg, bind-
ing it to the splint.  It stops at the knee, so as to leave
the  angles  exposed.  Then  the surgeon applies the
second roller to the thigh,  beginning just above the
knee, and including both thigh and splint.  But  the ap-
plication  of this bandage to the hip is highly important.
When it  has been  carried by direct  circular turns as
high as the perineum, the  bandage  having reached a
point opposite  to  the  great   trochanter,  is  thrown
obliquely upward across the hip—over the lower part 
          FRACTURES OF THE FEMUR.           151
of the belly and round behind the back—then oblique-
ly down over the anterior part of the  hip, into the pe-
rineum and again round the thigh.
   This  turn is to  be repeated once or twice, and then
the roller is to be carried  circularly  round the body,
two or three times, to bind the projecting piece to the
side.  These circular and oblique turns should be made
with great care, as they add very much to the firmness
of the apparatus, and the support which it gives to the
limb.  It makes the thigh and body one piece, a very:
important indication as we  shall presently see.
   This being  done the surgeon, for the purpose  of
giving as much extension to the member as it can en-
 dure, grasps the  leg, together with  the lower piece,
 (while some one supports the thigh) and detaching the
 angles from the upper holes of the angles of the thigh-
 splint, moves them downward as far as appears to him
 necessary to make the proper degree of extension.—
 As the leg is snugly embraced by the lower piece, and
 as the upper piece is  firmly resisted  by  the perineum
 and tuberosity of the ischium, the thigh-piece is in  ef-
 fect  lengthened  by  this movement, and  the thigh per-
 manently extended.   This extension  may evidently be
 increased or diminished at pleasure.
    Its application having been thus  accomplished,  the
 apparatus, with  the limb, is to be placed upon a firm
 mattrass, and  sustained by a bolster placed under  the
 splint below the knee. There is then scarcely a possibili-
 ty of its getting displaced,  as, if even the bandage be re-
 moved, the limb  sinks so completely into  the cavity,
 that its support will  be perfect.  The apparatus must
 never be fastened firmly to any part of the  bed.  This
        20 
  152        FRACTURES OF THE FEMUR.
  is a very injurious expedient in the  application of any
  apparatus.  Whatever  splint  is  used  should, in my
  opinion, be attached to the body of the patient, and al-
  ways move with it.   If it  cannot  be moved with the
  limb, in consequence of its weight, or because of the
  manner in which  it is applied to the bed, the involun-
  tary movement of the patient's body from the yielding
  of the mattrass, or the impossibility  of preserving one
  uniform attitude, will certainly change its  position, in
 reiatioaa to the splint, and drag with it to the upper frag-
* ment of the bone.   It is easy to conceive, how, if the
 apparatus be fixed to the bed, the slightest lateral move-
 ment of the body will cause the thigh  to press unequally
 on one side of the splint, and bend the limb at the place
 of fracture. For the purpose of obviating this difficulty
 still more completely, I have, in some instances, suspen-
 ded the whole apparatus, or rather the lower part  of it,
 by means of pieces of hoop, nailed together and placed
 over the foot and knee.   To these, cords were attach-
 ed,  and then  secured to  the splint.   When they are
 drawn sufficiently, the whole apparatus and limb will
be made to swing clear of the bed.  This will be found
a very useful expedient.  But it is by no means essential
to  the utility of the apparatus  which I have here de-
scribed, that it should be even as complex as is here re-
presented.   If it be necessary to provide one on the in-
stant, any individual can construct one in a few minutes,
wilich will  serve very tolerably for a single case, by pre-
paring the  two hollow splints of binder's board, or  of
warped wood, or of  chestnut-sapling bark, and then, the
ends being  cut so that the angles will project  farther
than I have before described, pinning the angles toge- 
            FRACTURES OF THE FEMUR.         153
ther with wooden pegs, clenched nails, or tacks.  The
length of the thigh-piece should be such as to keep the
thigh gently extended,  and it should project an angle
of considerable length along the side of the body.   The
oblique turns of  the bandage  around the hip and body
are then very important.   The bands  across  the leg-
piece are to be used as before,  and by drawing or re-
laxing the upper one,  the  degree of extension of the
thigh may  be slightly increased or diminished.   The
same thing may  be accomplished in part by increasing
the thickness of the pad in the  perineum.   The whole
apparatus must be swung up; and this is  more import-
ant than when the splint is more complete, in order that
it may not be  displaced in relation to the body.  It will
be necessary also to support it a little beneath the knee,
in order to sustain the angle.
   The  utility of the apparatus  in ks most perfect form
will be best explained by adverting, for  a moment, to
the various indications, which  ought always to be ac-
complished in the treatment of a fractured thigh.
   1.  It is of  great importance to give equal and firm
support to the whole thigh and leg, and to distribute the
pressure, which the support occasions, as generally as
possible over the whole inferior surface of the  limb,
relieving the prominent  points—the heel,  hip, &c. as
much as possible.   Those  who have used the more im-
 perfect  splints for  this purpose,  (and  especially  those
who have worn  them,) know well the annoyance which
the patient suffers from the imperfect  accomplishment
of this indication.   The point of the heel is a part which
suffers  exceedingly, and is often made  to slough.  The
whole inferior face of the limb  lying upon a surface 
154        FRACTURES OF THE FEMUR.
which is not at all adapted to it in form, must be galled
in various parts.  Surgeons are not  generally aware of
the mischiefs which result from this local irritation.—
The mere topical injury is the least of it.  When any
hard substance is pressing upon a part so as to  cause
constant pain, there is always an involuntary effort, on
the part of the muscles, to withdraw the part from the
irritating substance; this produces painful, unequal, and
spasmodic contraction, not only distorting the limb, but
causing it to contract.   Let me illustrate this by a fami-
liar example:—A  person has on  a tight boot,  which
pinches a toe, or irritates a corn  when he attempts to
walk; the muscles of the leg will act unequally in order
to relieve the injured part from pressure, and prevent
the foot's being applied equally to the ground.  Thus
the harmony of muscular action is destroyed,  and in a
short time the person will discover that the muscles of
the leg and thigh are excessively sore, and prone, when
he  sits  or lies, to painful spasm.   So also, when one
sleeps in a posture that is painful, or on a hard support,
the soreness which he  afterwards experiences  in the
muscles, is not owing so much to the pressure  which
they may have suffered, as to the efforts which they
have made to relieve certain  parts from pressure.  It
will be found that the limbs of a person who sleeps thus,
will by no means repose so tranquilly as on  a soft bed;
all the muscles of the body will be  found, in some de-
gree, in the same state of involuntary tension that they
are in when we are sitting or standing.  Just so is  it
with the fractured limb, which does  not repose with
perfect ease on its support.
   There is another evil w ich results from this  injuri- 
            FRACTURES OF THE FEMUR.        155
ous pressure.  Whenever there exists a  fracture, and
irritation is inflicted upon any part of the limb, however
remote it may be from the seat of injury, it  will im-
mediately excite  irritation  there, and under such cir-
cumstances all the unpleasant effects that are the result
of irritation will  follow.   The patient also is made ex-
ceedingly restless by the pain and fever which is pro-
duced, and distorts the limb by the motions of his body.
   If  the whole weight of the limb rests  upon but two
or three points, the softest cushions that can  be used
will have but  little influence in preventing mischief.—
A down cushion  is easy only because it becomes spon-
taneously concave when the member is  laid  upon it,
and because it diffuses the pressure  over a considerable
surface; but it cannot apply itself so extensively to the
surface as a concave, well adapted splint can, nor can
it give so easy support, because those parts which first
touch the cushion will suffer the greatest pressure.—
Besides, cushions cannot  be made to sustain a limb
equally from  one extremity to the other, consistently
with  the support  which the limb must receive  from the
splints and bandages.  Hence,  then, the advantage of
making the splint at the same time the bed of  the limb.
Soft supports  also create too much heat around a limb.
   All the ordinary modes of treating fractured  thigh are
liable to the inconveniencies  to which I have alluded.
The limb receives unequal support, the greater part of
the weight being often, thrown upon the heel, or upon
some part which is sustained by a band that lashes it to
a side splint, instead of reposing on a well adapted sur-
face.   It is  no evidence, because this pressure  cannot at
first be felt, that  it will do no mischief.  The pressure 
156        FRACTURES OF THE FEMUR.
of the soft point of the finger, if continued sufficiently
long upon a part, would  cause sloughing.  The pres-
sure on the soles of the feet, produced by standing, well
as the part is fortified by cuticle and adipose substance,
can be endured but for a few minutes without pain.—
When we stand we are constantly shifting from foot to
foot, but let any one bear the weight of the body on one
foot for a few minutes and the pain becomes insupport-
able.  Much more will this be true in regard  to parts
which were  never designed to sustain such pressure.—
Now  the splint which I recommend is designed to be
adapted to almost the whole inferior convex surface of
the entire limb.   The thigh drops snugly into the con-
cavity of the upper splint, and reposes upon it with per-
fect equality.  The leg, at the upper part, rests on one
of the cross bands—the  calf lies in  the hollow of the
splint, and the ankle is supported on another sling; while
the heel, which is least capable of enduring pressure, is
not suffered to touch.  The hardness of  the splint by
no means renders it a less easy support.   As I  remark-
ed before, the softest cushion  is easy only because  it
diffuses the pressure  over a considerable surface.  Iron
would be easier than down if the surface could be ac-
curately  adapted, and its  relative  position could  be
maintained.
   2.  The next  indication is to place the limb in the
easiest attitude, and to obviate,  as completely as pos-
sible, the unequal action of the muscles.   The very ex-
cellent observations of Mr.  Pott on this subject have,
in my opinion, never been superseded, although a prac-
tice hostile to them has been very generally adopted.—
He says  with truth, that the  semiflexed posture of the 
            FRACTURES OF THE FEMUR.         157
thigh and leg is the easy attitude into which the mem-
ber  is always  thrown  for repose, and in which the
muscles are most uniformly relaxed.  When the leg is
perfectly  extended on the  thigh, it is obvious that the
muscles on the back part of the thigh are as  perfectly
extended as they can be, and those on the anterior part
as perfectly relaxed.  It is true that  the extension of
the thigh on the pelvis in the straight position, will relax
the posterior muscles a  little, and in the same  degree
extend those behind, but this will by no means be suffi-
cient to counteract the  effect produced by the  perfect
extension of the leg on  the thigh.
   When  muscles  are unequally extended, they  will
seek to relieve themselves by voluntary  spasmodic ef-
forts.  The limb, in regard to some of them, is elongat-
ed, and they will endeavor  tg make it shorter.   Now it
is infinitely better and easier to prevent the occurrence
of this, by placing the muscles in such harmonious rela-
tion  that  they will  be  equally at  rest,  than  it  is to
counteract it by the permanent extension,  which then
becomes necessary.  Those can easily  appreciate the
value of this precept, who  have witnessed  the  torture
and frequent inefficacy  of the permanently extending
apparatus.  Even should extension be necessary, it will
be effected with far more ease when the muscles are in
harmonious relation.  But I am perfectly certain  that
the necessity for permanent extension is often produced
by the mal-position of the  limb, and  the irritation ex-
cited by badly adjusted  splints and supports.
   3.  The next circumstance necessary to the  secure
position of a fractured thigh, is  the accurate support of
both  the leg and foot in  such a manner that they shall 
158         FRACTURES OF THE FEMUR.
not operate as levers to throw the lower fragment out
of its proper relation to the other.  The weight of the
leg operates with great power on the inferior fragment
of the  broken femur, and it  is mathematically demon-
strable that no force which can be applied to the sides
of the thigh itself, can act with sufficient power, through
the medium of the muscles,  on  the fractured extremi-
ties,  to antagonize in any degree the tendency to dis-
placement.  The leg, therefore, must be carefully sus-
tained, not merely by cushions  and bolsters, for these
are perpetually undergoing displacement, but by some-
thing which shall give uniform, unyielding, and yet easy
support.   That it may  preserve the leg in a proper
attitude in relation to the thigh, it must be securely fix-
ed to the thigh-piece.  The weight of the foot, when
that organ is unsupported, tends to rotate  the leg  and
thigh outward, or  inward,—the  more  so  when  the
weight of the bed-clothes is  added to it.  This force is
not great, but the constant operation of it, if not obvi-
ated, is certain at length to  produce this result.  Now
the  support of the leg and foot, by the apparatus here
described, appears to me to  be  perfect.   The  firmness
of the leg-splint,  and the immobility of it on the thigh-
piece, when the angle is fixed, render it impossible that it
should drag upon the lower fragment of the femur.—
The foot is sustained with equal effect by the very  sim-
ple  turns which  are made  with the  bandage round it,
and round the extremity of  the apparatus.
   4. It is equally important that every apparatus for
 fractures of the  thigh  should be secured to some part
 of the body, that, if the body moves in any degree, and
 it is impossible that it should not, the whole apparatus 
            FRACTURES OF THE FEMUR.         159
may move in correspondence with it; otherwise, when
the body moves, it will drag with it the upper fragment
of  the  femur, leaving  the  other fragment  and the
leg, attached to the splint, in its former position.   But
if the  splint is secured  to the body, then, whatever
movements of the latter may take place, the limb main-
tains the same relations, and the fracture is undisturbed.
From this, too, it must  be obvious that a light splint,
neatly  adapted^ and  which  readily accompanies the
slight involuntary movements  of the body, is far pre-
ferable  to a cumbrous apparatus, which is so fixed to
the bed, and so heavy, that  it cannot move.   Hence
also the twofold  objection to the apparatus  of  Mr.
Charles Bell, as it is commonly employed in this coun-
try.
  The apparatus  which I recommend is firmly secured
by the  hip-piece to the side of the body, so that when
the latter changes its place, the splint moves in corres-
pondence with it.   Its lightness, also, and its convexity,
where  it rests upon  the bed, are circumstances which
conduce to the same result.  But when I wish to make
it even more perfect  in this respect, I sling up the  low-
er part of the splint,  so that it may not touch the  bed.
Then,  if the patient slides down  in the bed a little, in-
stead of crowding one fragment  down upon the other,
the whole splint and  limb will instantly move in corres-
pondence, nor meet  with the slightest resistance; and
so in all other movements.
  5. Another excellence belonging exclusively, I be-
lieve, to this apparatus, is the complete security of the
limb, when  reposing  in  the hollow of the splint, even
though no bandage be applied, except to bind  the  hip-
       2t 
 160        FRACTURES OF THE FEMUR.
 piece to the side  of the body.   The bandage is only
 necessaiy for the  purpose of sustaining the foot and
 giving firmness and strength to the apparatus.  It also
 adds to the security of the member during sleep.  But
 even  when  the bandage is applied, it will be observed
 that the limb is no where ligated by any  strap, band,
 or bandage, the use of which  is now pretty  generally
 admitted to be injurious.   The bandage being on the
 outside  of the splint, the limb can no  where be une-
 qually constricted by it—the sides of the apparatus are
 merely  compressed upon the limb.   That the limb will
 swell  more, if a bandage be not directly applied to it,
 is a lost fear—we may obviate it far more effectually
 by elevating the lowrer extremity of the splint.
  There is  scarcely any more prolific source of mis-
 chief  in the treatment of fractures, than the direct ap-
 plication of  bandages.   Many years ago  they were
 snugry applied at the place of fracture, for the purpose
 of moulding  the callus, and  shaping the  new-formed
 bone.   More recently, they have  been used  because
 our fathers  have done  so before us, and because they
 are supposed to obviate swelling.  But I am persuaded
 that their effect is  directly the opposite—it certainly is,
whenever a bandage does not act with perfect equality,
 and I  defy the most skilful dresser, to apply a bandage
to a member varying in size from day to day, that shall
not constrict it unequally, unless it be frequently re-
applied ; and this is impossible, without greatly disturb-
ing the injured member.  In some modes  of dressing,
in which bands are firmly applied to the neighborhood
of the fracture, it  becomes necessary to apply banda-
ges below, to prevent the mischief which might result
 from its being bound but in one place. 
             FRACTURES OF THE FEMUR.         161
   All bands which press upon fractured limbs for the
 purpose of tying them to the supporting splints, do more
 or less injury.  If possible, the  weight alone of the
 member, sinking it into its bed, should maintain its pro-
 per form, and this is  the  case  in the  apparatus above
 delineated.   There is  no necessity here that the sur-
 geon should perpetually watch for the relaxation of a
 band, or the displacement  of a  piece of the splint—
 nothing, which is necessary to the security of the limb,
 can give wray.
   Another great advantage consists in the facility with
 which the limb may be examined without the necessity
 of relaxing any  part of the apparatus which gives sup-
 port to the  member.   Indeed, as the bandage can  be
 removed without inflicting the least pain, it will often
 be found  salutary to  remove it every day, and  to use
 gentle friction upon the limb with the hand.
   6.  This   apparatus  is  especially  applicable to the
 treatment of compound fractures.   It is so,  first, be-
 cause of the uniform  and  easy  support which every
 part of the member  receives; and, secondly, because
 it  is  so easily accessible.   Even  should the wround in
 the soft parts exist on the inferior part of the thigh,
 nothing is easier than  to cut away a portion of the walls
 of the apparatus, opposite to  the place of  injury.—
 This  will enable us to dress it with perfect facility.
   7.  In cases in which it becomes necessary to employ
permanently extending  force, (and I believe that they
are not  numerous when this apparatus is used,) noth-
ing can enable us, as  it appears to me, to  accomplish
it with more ease  than  this.   In  the  first place, there
is  always a gently extending effort  made  upon  the 
1<$2         FRACTURES OF THE FEMUR.
thigh, from the attitude in which the member is placed.
The thigh is placed on one inclined piece, and the leg
upon another; the  leg, therefore, inclines  to drag in
one direction,  and the thigh in the other, by their own
weight.  The leg  will act on the lower fragment of
the thigh to prevent its following the other, which sinks
toward the bed.
  But when a more powerful effort is required, the
leg-piece musty as we have before described, be separa-
ted from that  of the thigh, brought lower,  and  again
fixed.  This has the effect  of elongating  the  thigh-
piece.  The leg cannot slide  upward, because of the
manner in  which it is sustained by the slings and ban-
dages.  We may  also have  the foot fixed to the ex-
tremity of  the leg-piece.
  The counter-extension is made with peculiar advan-
tage, because  it  is  effected  by  nearly the  whole
cushioned  margin of the upper  splint, applying itself
very extensively to the perinasum, to  the tuberosity of
the ischium, and to the trochanter, diffusing its pressure
extensively over the surface.
  8. Another excellence  which  I claim, is the  facili-
ty with which the  angle of the apparatus is varied, the
member  being more or less flexed or extended.   A lit-
tle variation in this respect sometimes gives great re-
lief, when a uniform attitude has  become tiresome.—
This also renders the apparatus peculiarly useful when
an injury has  occurred in the vicinity  of the knee joint,
and when, after union is  supposed to be taking place,
we wish to prevent anchylosis of the joint by  gentle
flexion and extension. 
REMARKS
                        OK


DISLOCATIONS OF THE HIP-JOINT,
BY XT. R. SMITH, 3YL D.
  (The principles which, in the following pages, I shall
endeavour to establish, relative to the reduction of the
dislocated Os Femoris, were in part derived from my
father's lectures. The discriptions and illustrations are
altogether my own.  I shall not endeavour to furnish a
complete treatise on these dislocations, but shall  refer
the reader  to  the  systematic works for the common
doctrines and methods of practice.  That which I hope
to present is designed to be supplementary to the1 fe-'
formation which we now possess, and to subvert ceHafflS
erroneous practices.  I shall presume the reader, there-
fore, to be acquainted  with  the  anatomy of the hip-
joint, the  varieties of dislocation which  there occur—
their symptoms, and common modes of treatment.  Some
circumstances, however, I shall recapitulate.
                                       N. R.  S.)

   Great violence is not always necessary to effect the
dislocation of even a very strong articulation.  It is ef-
fected by peculiar  violence, so  applied as in a degree 
 164        DISLOCATIONS OF THE HIP-JOINT.
 to evade  and render useless the common defences and
 supports  of the joint,  and so operating on the bone
 about to be dislocated, as to multiply itself by mechani-
 cal  advantage.  It  is peculiar, too, in the  manner  in
 which it  co-operates with the muscles, throwing the
 member into  such  an  attitude that these organs are
 compelled to aid in  effecting the mischief, although, in
 their harmonious action, they contribute greatly to the
 security of all important  articulations.   It provokes
 those muscles also to spasmodic—preternatural efforts.
   The accidental forces which effect the dislocation  of
 the hip-joint generally operate on the inferior extremity
 of the femur, either directly, or through the  medium  of
 the leg.   The thigh-bone thus becomes a lever, on the
 long arm of which the violence acts with great  effect.
 When  violence  acts on the  bone in the directions  in
 which it  is flexed  and extended,  no mischief results;
 because, by its freedom of motion, the member evades
 it, and because, too, those motions of the thigh are the
 most secure, they being accomplished by a mere  rota-
 tlOD upon  the axis  of the head and neck, the most free
 and the most secure motion which  can occur in a ball-
 and-socket joint.   It is in effecting the motions of ad-
 duction and abduction, that violence inflicts injury upon
 this articulation. A  moment's attention to its structure
 and motions must  convince the reader that  neither  of
 those movements can be carried far, before the appa-
 ratus of the joint becomes violently strained.  Abduct
 the thigh to some extent, and immediately that portion
 of the capsular ligament which is below the joint,  is
 put upon the stretch, and is operated upon by a prodi-
gious force, because  of the length of the lever.   At the 
        DISLOCATIONS OF THE  HIP-JOINT.        165
same time, the upper part of the neck of the bone is
checked upon the upper  border of the acetabulum.—
Motion in that direction  must then cease; but if  the
effort be continued, and  with violence, the bone  be-
comes a lever of  the first kind—the power operating at
its  inferior extremity—the  fulcrum being the  point
where it checks upon the  upper  margin of the  acetabu-
lum—and the  head of  the  bone being the  point  of
resistence.
  The abducting violence will then lift the head of the
bone, with great  force, from the acetabulum,  and will
press it against the inferior part of the capsular ligament.
This being already  violently stretched, at length bursts,
and the  head of the bone is protruded through it.—
While this violence is  being  inflicted upon the joint—
destroying its defences upon  the inferior side—the  ex-
treme degree of  abduction which will have been  pro-
duced, painfully extends and irritates the muscles which
perform  the office of adduction, and others which  are
inserted  into the  inner  part of the thigh.  The whole
extent of the triceps adductor will be violently put upon
the stretch; so also will  be the pectineus—the obturator
externus—the psoas magnus, and  the iliacus iuternus.
The force with  which muscles, under  such  circum-
stances, involuntarily contract and struggle to relieve
themselves  from their painful  condition, is truly  as-
tonishing.  They are threatened  with  laceration, and
all their  contractile power is brought  into exercise to
resist it.  The effort of these organs is similar to the
violent  cramp  which  occasionally seizes on  an indi-
vidual muscle, producing so powerful a contraction that
several  muscles of equal size are not able, by a volun- 
166        DISLOCATIONS OF THE HIP-JOINT.
tary  effort,  to  antagonize  it, and the limb becomes
distorted.
  Now this powerful contractionof the muscles tends
directly to drag the head of the bone downward and
forward into the thyroid hole, or  forward and  inward
upon the body of the os pubis.   This it is undoubtedly
capable of accomplishing, and in  most cases does ac-
complish, without direct aid from the external violence,
which  may be concerned merely in the violent  abduc-
tion.  Such violence may, however, sometimes conspire
to produce the same result; for, at the same time that it
forcibly abducts the limb, it may strike a blow upon the
knee in the direction of the shaft of the bone.  But I
am persuaded that dislocations would very rarely take
place but for the co-operation of the muscles. Let any
one who  doubts this position attempt the dislocation of
a large joint upon  the dead  subject.   My father once
directed his pupils to dislocate the hip joint in the dead
subject, in order that he  might illustrate the method of
effecting its reduction.   Every mechanical expedient
which  could be devised was in vain put in  requisition
for this purpose, and the attempt was  abandoned.  I
have in the same manner been foiled in attempting the
dislocation, in the dead subject, of joints less strong than
the hip.
  The violent adduction of the thigh effected by force
which  impels the knee directly  inward beneath the
pelvis,  inflicts the same injury upon the upper  portion
of the capsular ligament.  In the same manner also the
head of the bone  is lifted from  the  acetabulum, and
raised  upon the upper border of the cup.   By the great
degree of adduction which  wiU have been produced 
       DISLOCATIONS OF THE HIP-JOINT.       167
before this occurs, the  abductor muscles (the glutei,)
will be most painfully extended, and will be provoked
to the most powerful spasmodic contractions.  It is the
struggle  of those  muscles which, in most  cases, then
drags the  bone  from its place  and  effects a dislo-
cation upward and backward  on the dorsum  of the
ilium.  That the effort of those powerful muscles is
adequate to the effect is perfectly obvious.  The effect
which they produce when acting in the ordinary ex-
ercise of their  functions, although  they act  on  the
femur as a lever of the third kind, and under every
mechanical disadvantage, is  very great  indeed.  But
here they spend all their force in a direct effort on the
joint, not only to effect displacement, but to aid in pro-
ducing the laceration of the ligament.
   So active  a part do  muscles perform  in effecting
dislocations, that not unfrequently they alone, when con-
vulsively acting, luxate important articulations.   Dislo-
cation of the shoulder, in a paroxysm of epilepsy, is a
thing of very frequent  occurrence.  The  hip  also is
sometimes dislocated at the moment of the production
of very slight distortion, by the action  of the powerful
muscles  concerned in the motions of the femur.
   I am  satisfied, from both observation and reflection,
that the  accidental violence  which effects the disloca-
tion of a joint, in most cases, does little else than vio-
lently bend the member, lacerate the ligaments on one
side,  and provoke the  unequal  action of certain mus-
cles.   The final distraction of the bone from its natural
position, I believe to be in almost all cases effected
by the action of muscles alone.  This I confidently infer
from the manner in which I have known violence to
       22 
168       DISLOCATIONS OF  THE HIP-JOINT.
effect the dislocation of bones.   I  am persuaded, also,
that violence can scarcely act in any other manner; for,
when a blow is struck upon the extremity of a  bone,
the joint  is not endangered till the bone is violently bent
—distorted; and in becoming so, the member necessarily
evades in a  great degree that part of the force  which
operates  in the direction of its length, and  feels that
chiefly which violently bends the joint.
  If the muscles are thus actively concerned in effect-
ing the dislocation of joints, and especially the hip—if
they so generally  exercise the  final effort which drags
the bone  from its place, does not this indicate that the
action of muscles may be made powerfully subservient
to the replacement of  the dislocated bone?   Does not
this render it probable that, by moving the member in a
direction counter to that in which it  may have been bent
at the moment of the occurrence of the dislocation, we
may compel the muscles  which are the  antagonists  of
those  which effected the displacement, to throw the
head of the bone in the opposite direction, and thus to
effect its  reduction?
  By grasping the  distal extremity of  the  dislocated
bone, and making bending movements like those which
violence employs in producing  dislocations, we have it
in our  power to call  into exercise, with great effect,
certain muscles attached to the bone.  We do this with
great mechanical  advantage, because we use  the bone
as a lever, on the long arm of  which we impress our
force.  The muscles which  we wish to put upon the
stretch are inserted near the head of the bone, and they
represent the  fulcrum.  The  head of ftie bone is the
point of resistence. 
       DISLOCATIONS OF THE HIP-JOINT.        169
  Thus; if the hip be dislocated upward and backward,
and we grasp the knee and powerfully abduct the mem-
ber, we put powerfully on the stretch the abductor mus-
cles.  The power which  we exercise on them is very
great, because the thigh-bone is the long lever which mul-
tiplies the force. Those muscles, then, will be called into
the same kind of powerful, convulsive action  which oc-
curs in those muscles that cause the dislocation. But now
the muscles drag the head of  the bone directly toward
its natural position.  They may certainly be supposed
to do it with as much effect as that with which  the
others drew it from its natural relations, for it is impos-
sible that the head of any bone should be so securely
and firmly fixed in any position, after it  is dislocated, as
it is in its natural socket before dislocation.   Hence the
muscles, if their  action be employed to the best ad-
vantage, will  more easily draw a bone back into  its
natural place, than from it.   To cause certain muscles
thus to act, the limb must be bent in  such  a manner
that they  alone, if possible, shall be strained  by the
movement.
   That  muscles do thus powerfully co-operate in the
reduction  of dislocated bones, is manifest from  what
occurs when the replacement  is  effected.   When we
 use the ordinary methods of reducing a bone, at the
 moment that it returns to its socket, we usually hear a
 distinct  snap.  We also feel a concussion, or jar of
 the member, at the same time.  It is this which gene-
 rally  announces to us  that  we  have succeeded in
 our attempt.  Now, these  phenomina are owing to
 the quick  and energetic  effort  with which  certain
 muscles pull the  bone into  its place, as  soon as the
 limb is placed in an attitude to favour their action. 
 170       DISLOCATIONS OF THE HIP-JOINT.
   Although great force may have been exercised  in
 effecting  the dislocation of the hip-joint, it  does not
 necessarily follow that an equal degree of violence must
 be used to replace  the  bone.   Although the reduction
 of the femur is undoubtedly more difficult than  that of
 any other dislocated bone, yet the  object  is  some-
 times accomplished with a very slight effort, provided it
 be used with tact and mechanical ingenuity.  Dragging
 efforts might be made upon the limb  till it should  be
 almost torn from the body, and the  reduction would not
 be accomplished, unless such movements  of  the limb
 were made as should favour the action of the muscles,
 and throw the head  of the bone towards its  socket.—
 It has often occurred, in the dislocation of this as well
 as other articulations, that after very powerful efforts
 have  been made in vain, under apparently the most
 favourable circumstances, an accidental movement  of
 the limb, made with little force, but in a manner  to
 favour fortuitously the efforts with  which nature is dis-
 posed  to  co-operate with our  endeavours, has,  in the
 most unexpected manner, at once accomplished the re-
 duction.  A case (which, however, I am not at liberty
 to relate)  fell under my observation, in which the most
 powerful and persevering efforts were made by the aid
 of pullies, but without success,—made, too, by men of
 science and skill.   The  case was then dismissed as un-
 manageable.   In a  few  hours  the patient fell into the
 hands of a quack, utterly ignorant of the anatomy of the
joint, and of the nature of any of its dislocations.  He,
 however,  without any assistance, and  with merely the
 effort of his own hands, moved  the knee in a careless
 manner in various directions, when, to the astonishment 
       DISLOCATIONS OF THE HIP-JOINT.       171
of himself, no doubt, as well as others, an audible snap
was heard, and it was discovered that the bone was at
once reduced.
   Every one is  familiar with the memorable case re-
lated by Mr. Cornish, a respectable surgeon  of  Fal-
mouth, Eng., and  recorded by Sir A.  Cooper  in  his
valuable Treatise on Dislocations, page 80.  The  pa-
tient, McFadder, a seaman, had  suffered a  dislocation
of the head of the os femoris upward and backward on
the  dorsum ilii.   Repeated attempts were made by
Sir Astley  Cooper and other surgeons, at various times,
to effect the reduction, all the  adjuvant means—bleed-
ing—warm bath—nauseating medicines &c. being cal-
led into requisition.  It is to be presumed that the pullies
wrere employed in  the usual way, although this is  not
distinctly stated.  At  all events, the case was abandon-
ed as utterly hopeless.
   Twelve  months after the accident, Mr. Cornish saw
the man, examined the hip,  and  saw all the evidences
of a dislocation of the femur on the dorsum ilii.  Seve-
ral years after this, he again saw the  patient, and, to
his surprise, the bone had in the mean time been reduc-
ed.  It had been effected by accident, five years after
the dislocation.  The man had suffered a fall, in which
a blow was inflicted upon the member, and instantly all
deformity disappeared and, from that time, he threw
away his crutches.  Here the  reduction must certainly
have been immediately effected by the action  of  the
muscles alone; for, although the limb may have been
powerfully bent at the time, yet there  was none of  the
extending  effort made upon the  limb  which surgeons
employ in effecting  the  reduction. The lateral move- 
172       DISLOCATIONS OF THE HIP-JOINT.
ment of the limb, in this case, could have done nothing
more than to throw the member into an  attitude  fa-
vourable to the  action of the muscles.
  In the first volume of Dorsey's Surgery, page 242, a
very pertinent case is related as having occurred in the
practice of professor Physick.  The fact is the more
valuable, as  coming from thchand of one unequalled
among us in judgement and skill.
  In a case of dislocation of the femur directly back-
ward, after very powerful efforts had been made to
effect the reduction by extension, professor Physick,
conjecturing that  the head might be confined in a slit
of the capsular ligament,  discontinued  the extending
force entirely, and then, with no more force than that
of his own hands, abducted the thigh, when the bone
instantly slipped into its place.   Here certainly the ab-
duction (although there was some pressure made upon
the head  of the bone with the hand) could have  done
little more than place the limb in a favourable attitude
for the action of the muscles.   The operator appeared
to think that  the impediment  to the reduction by ex-
tension arose from the bone's being confined by the
button-hole rent.  Sir A. Cooper does not believe that
such an impediment can ever occur, and, from the mag-
nitude of the head—the shortness of the ligament &c. I
am persuaded that this is correct.   At  all  events, the
operator succeeded by an effort much more gentle than
is usually deemed  necessary,  even when  there is sup-
posed to be no unusual impediment.
  Dr. Dorsey remarks that "in all difficult cases it will
be proper to try every possible  motion of the limb before
abandoning the case as hopeless; very often, after great 
       DISLOCATIONS OF THE HIP-JOINT.        173
force has failed, a gentle effort in some new direction is
found successful."
   But  if these  gentle  efforts—these experimental
bending movements of the limb, so often succeed in the
worst cases, and after the most powerful efforts have
been made in vain, does it  not go  far to prove  that
gentle  means, if  adroitly  employed,  would succeed
better in all cases?
  There is, no doubt, a constant mechanical principle
upon which the reduction is  effected in such cases^ and
one which would perhaps succeed in nearly all cases, if
we knew how to employ it  understandingly, and  with
precision, and did not avail ourselves of it by mere hap-
hazard.   If a gentle movement of a peculiar kind suc-
ceeds in one case of complete dislocation on the dorsum
ilii, after  all other means have failed, ought not this
movement, if well understood, to succeed in  other cases
better than the usual mode.   The mechanism of these
dislocations is certainly the same in all of this variety—
the bone assumes the same  attitude, and the muscles
assume  the same  relations—furnishing the same im-
pediments, and the same aids in every case.  This fre-
quent failure of art, and the  success of  accident, satisfy
me that there is some important principle relative to the
mechanism of these dislocations, which is not yet under-
stood.   Accident ought not to accomplish the reduction
of a bone with more ease than art.   When it does so,
such  accident should  be our instructor,  and  teach
us the mechanism by which it operated, and this we
should repeat in similar cases. 
 174       DISLOCATIONS OF  THE HIP-JOINT.

 Mode of applying force in the reduction of dislocations
                     of the hip.
   The propriety of employing pullies for the purpose
 of multiplying power in the treatment of dislocations of
 the hip, appears to be so tacitly and universally admit-
 ted, at the present time, that one who contends against
 it can scarcely expect  to obtain a  favourable hearing.
 But the facts which I have stated above, and the in-
 ferences which they justify, are certainly hostile to their
 general employment.   If it be important, as I have en-
 deavoured to show, that during the  attempt, the attitude
 of the member should be so varied as to favour  the
 action of those muscles which are  so important in aid-
 ing to effect the reduction, then certainly there is to be
 deduced from this a strong objection to the use of any
 mechanism  which precludes the possibility  of taking
 advantage of the action of the muscles.   While power-
fully extending  the limb with pullies, it is obvious that
 no bending movements by which we use the bone as a
lever to throw the head into its place and call the mus-
 cles into action,  can be employed; the effort must be
made in  one undeviating direction.  In the use of the
pullies, also, we are compelled to extend powerful mus-
 cles, the resistance of which can, by a method hereafter
to  be pointed out, be  completely evaded by a little ad-
 dress in the movements of the limb.
   Thus, when, in a case of  dislocation on the dorsum
 ilii, we endeavour to effect the reduction of the bone
by extension made by pullies from  the  knee  or ankle,
the extending effort which we then make is directly
resisted by the glutei muscles, the most  powerful  in the 
Zith. tf IZnclicott ic Swett. 
 
        DISLOCATIONS OF THE HIP-JOINT.        175
body.   Indeed,  the reduction can not be effected by
dragging the limb directly downward in  this manner,
without putting them violently upon the stretch, because,
before the head  can  be returned to  its  place by this
movement, the trochanter, where the muscles are in-
serted, must be carried far outward from the pelvis at
the moment that the head mounts over the margin  of
the cup, and also downward as low as its usual attitude,
and thus will the points of origin and insertion of those
muscles be widely removed, and they of course render-
ed very tense.  But could the thigh be abducted at the
moment that extension  is being made, it is apparent
that the trochanter would be thrown upward at the
moment that the head descended, and thus would the
points of origin and insertion be approximated, and the
muscles relaxed, while at the same moment the adduc-
tor muscles, which aid the reduction, would be called
powerfully into exercise.   Indeed, it is obvious that, in
effecting the reduction  of this dislocation by pullies,
nearly all the muscles which are inserted into the thigh-
bone are violently strained, and in such a  manner  that
they resist with great  effect.
  When we have effected, by the force of the hands, a.
partial approximation  of the  head of the bone to the
Socket, we find that the business is suddenly taken out
of our hands by the contraction of the muscles, and the
bone springs  into its place with an  audible snap, and
we feel  a shock—an impulse given to our  hands by the
effort of the muscles.  Now this can not so readily oc-
cur when the pullies are employed, because the limb is
too rigidly fixed;—the pullies  furnish an unyielding, in-
elastic force which will not yield the limb  to the action
      23 
176        DISLOCATIONS OF THE HIP-JOINT.
of the muscles, which, if  they had command  of it,
would throw the dislocated  extremity  home.   They
perhaps make spasmodic efforts, during  the extension,
to effect this, but they are foiled by the resistance of
the pullies, and as their effort can not  persist long, it
accomplishes nothing.
   The pullies rarely succeed in the reduction of this
dislocation,  without  the employment of vene-section,
and other means to effect the  relaxation of the muscles,
and the violence employed is necessarily such that often
alarming prostration results. It is impossible to estimate
correctly the degree of force which we  employ with
the pullies.
   Lastly, the pullies, exercising great power, are often
employed without effect in cases in which, subsequently,
very gentle  force, employed  with  address, as by  pro-
fessor Physick  in  the case to w,hich we have alluded,
or accidently, has accomplished the reduction with the
greatest facility.
   I  am  not, however, prepared to say that  the pullies
may not sometimes be useful.  Perhaps  by placing the
patient on a revolving table, and fixing him securely to
it, the direction in which they  operate might be so  varied
that the lateral movements of the limb might be made,
consistently with extension  by these machines.    I at
present incline  to the belief,  however, that they might
be altogether dispensed with.

Proposed method of effecting the reduction of theos
       femoris, dislocated upon the dorsum ilii.
   Professor Nathan Smith used to relate, in his surgical
lectures, a case of dislocation of the os  femoris  on the
dorsum ilii, in which  he projnptly succeeded  by the 
       DISLOCATIONS OF THE HIP-JOINT.       177
mere force of hands, in effecting the reduction.  Notes
of this  case unfortunately I am not able to discover
among his papers.   The principal facts, however, are
fresh in my memory, and will undoubtedly be borne in
mind by many who have listened to his instructions.
  After attempting the ordinary methods by extension,
in vain, he bent the  leg upon the knee, seized the  leg,
and using it as  a lever, rotated the thigh a little outward.
Then he gently abducted the thigh, and lastly flexed it
freely on the pelvis, by carrying  the knee toward the
face of the patient   These movements instantly suc-
ceeded, and with but little effort of strength.
   A  medical  gentleman of Massachusetts, who  had
been a pupil of my  father, saw a similar case of dislo-
cation—practised the same method, and succeeded with
equal facility.  A letter from him to professor Smith,
detailing the particulars of the case, I once saw, but
unfortunately it cannot now be found.
   The case quoted above, in which professor Physick
succeeded in effecting reduction by a gentle abduction
of the thigh, was one of dislocation backward, behind
the posterior border of the acetabulum.  The case in
which my father succeeded, was one of dislocation on
the dorsum ilii, and he  accomplished the reduction by
a compound movement.  The free flexion of the thigh
forward on  the pelvis, would have the effect, by calling
into exercise the gluteus maximus, to throw the head of
the femur downward, behind the border of the acetabu-
lum,  precisely in the position in which it was  fixed in
professor Physick's case.  The  rotation of the thigh
outward, and  the abduction of the member must, as can
be anatomically demonstrated, have thrown the head of 
 178       DISLOCATIONS OF  THE HIP-JOINT.
 the bone forward into the acetabulum. When the bone
 is dislocated on  the dorsum, the trochanter is dragged
 forward, the femur rotated inwards, and  the head and
 neck of the bone are applied flat-ways on the pelvis, as
 is represented in fig. 1 of the plate.  The rotation of
 the limb outward would, therefore, throw the trochan-
 ter outward, and cause the  head to present in  an atti-
 tude favourable to its entrance  into the acetabulum.—
 The abduction of the bone at the same moment, would
 have the effect to call powerfully into exercise the ad-
 ductor muscles which come from  the anterior part of
 the pelvis, and are inserted into the linea aspera.  The
 strong effort of these muscles will necessarily tend, when
 this movement is made, to drag the head of the bone
 directly forward and downward into the acetabulum.
 If we consider these muscles to  represent the power,
 the hand of the surgeon (abduction being completed)
 applied  to the knee, will be the fulcrum, or centre of
 motion, and the resistance is at the head  of the bone.
 The adductor muscles  will then act on a lever  of the
 third kind, but, acting near its extremity and nearly at
 right angles to it, will exercise a power far greater than
 muscles ordinarily  do—far greater than those muscles
 themselves do in the ordinary exercise of their  func-
 tions.  The effect of thoir  contraction, then, as they
 will be much excited, must be very great, in aiding the
 reduction.
   If, while  abduction  is being made, we regard the
 hand of the surgeon at the knee as' the power, then do
 the tense abductor muscles furnish the fulcrum, and the
head of the bone, the resistance.    The power exercis-
ed by the surgeon  then operates  upon far the  longest 
       DISLOCATIONS OF THE HIP-JOINT.        179
arm of a lever of the first kind, and therefore with great
mechanical  advantage, in throwing  the head  of the
bone toward the acetabulum.
  It should be particularly noticed that, while this com-
pound movement of the bone thus calls into exercise,
with their utmost power, the muscles  which aid the re-
duction, it most effectually  relaxes those (the  glutei)
which tend to resist it, and which were instrumental in
effecting the dislocation. It will be observed that these,
as well as all the other muscles inserted  into the upper
portion  of the  bone, must powerfully resist when the
reduction  is attempted by direct extension.  Two very
important objects then are at once accomplished; 1st,
we  call the adjuvant muscles most powerfully into exer-
cise ; 2d,  we effectually avoid the resistance of those
muscles, the action of which is by all surgeons regarded
as the chief  impediment to the reduction of all difficult
dislocations.
  As I before  remarked, the cases in which  lateral
movements with gentle force have succeeded, either by
design or fortuitously, in promptly reducing dislocations
which have resisted more powerful means,  induce me
to believe that  there  is a secret method in  which we
may uniformly  thus succeed;  and that method I believe
to be the one in which the movements described above
are employed.   This I infer from facts which I have
stated, and from the anatomical mechanism of the joint
and appendages.
  The practical precepts derived from  the above, are
concisely  these.  The patient being prepared for the
operation by whatever means may be deemed necessary,
may be placed  in an attitude convenient for the opera- 
180      DISLOCATIONS OF THE HIP-JOINT.
tion with the body securely fixed, by placing him in the
horizontal posture, on  a narrow table  covered with
blankets, and on the sound side.   To  the table his
body should be firmly fixed, and this can be conveniently
done by folding a sheet several  times,  length-ways—
then applying the middle of the broad band thus made
to the inner and upper part of the sound thigh—carry-
ing its extremities under the table, crossing them beneath
it, and  then carrying them obliquely up and crossing
them firmly over the trunk, above the  injured hip.—
The ends may then be secured beneath  the table.  To
support the  trunk  the  more firmly, a  pillow may be
placed  on each side of it upon the table, and be includ-
ed in the bandage.   Should the operator design to em-
ploy any degree of extension, a counter-extending band
may be placed in the perinaeum, and carried up to the
extremity of the table, be fixed to some more firm body,
or held by the hands of assistants.
  The operator now standing on the side to which the
patient's back presents, grasps the knee of the dislocated
member with his right hand, (if the left femur be dislo-
cated—vice versa, if the right) and the ankle with the left.
The first effort which he makes is to flex the leg upon
the thigh, in order to make the leg a lever with which
he may operate on the thigh-bone.   The  next move-
ment is a gentle rotation  of the  thigh outward, by in-
clining the foot toward the  ground, and rotating the
knee outward.   Next, the  thigh is to  be slightly ab-
ducted by pressing  the knee directly outward.  Lastly,
the surgeon  freely  flexes  the thigh upon  the pelvis by
thrusting the knee upward toward the face of the pa-
tient, and at the same  moment the abduction is to be
increased. 
       DISLOCATIONS OF THE HIP-JOINT.       181
  Professor N. Smith regarded the free flexion of the
thigh upon the pelvis  as a very important part of the
compound movement.  He believed that it threw the
head of the bone  downward, behind the acetabulum,
where the margin of the cup is less prominent, and over
which, therefore, the adductor  muscles  would drag it
with less difficulty into its place.
  The operator  may slightly vary these movements, as
he increases them, so as to give some degree of rocking
motion to the head  of the os femoris, which will thereby
be disengaged  with the more facility from its confined
situation among  the muscles.
   Should the  operator deem  it necessary to conjoin
extension with these efforts,  a  band may be  attached
above the knee,  in the usual manner.  With this, ex-
tension is first  made horizontally—in the direction in
which the bone  presents.  Then it is directed a little
outward, so as to favour the  necessary rotation and ab-
duction.   Lastly, it is made in  a  direction obliquely up-
ward from the table, in order to favour the flexion upon
the thigh.  This last extending effort may be made by
an assistant standing on the  table, near its foot,  with a
band thrown round his neck  and  shoulder, and attached
to the  limb in  the  usual way.  When the  head of the
bone is supposed to be approaching the cup, an assistant
may press with  his hands firmly upon  the trochanter,
downward and  forward, toward the acetabulum, thus
aiding the effort of the muscles.
   When the femur is dislocated backward into the ischi-
atic notch, abduction seems  to be the  only movement
which is necessary, since the  head of the bone is already
behind the acetabulum.   This was precisely the move- 
 182       DISLOCATIONS OF THE HIP-JONT.
 ment with which professor Physick succeeded in such
 a case.
   Of the other less difficult varieties  of dislocation of
 the femur, it has not been my present  purpose to treat.

              Description of the Plate.

   Fig. I, represents the attitude of the femur when
 dislocated upward and backward on the dorsum ilii.
   Fig. 2, represents the attitude of the  bone when its
 rotation  outward has been effected, in the attempt to
 reduce it.
   Fig. 3, represents the bone when rotation, flexion on
 the pelvis, and abduction being all performed, the head
of the femur is mounting over the margin of the cup. 
REMARKS
RADICAL, CURE  OF HYDROCELE,

                     BY THE

     EMPLOYMENT OF THE TEXT.
BY N, R. SMITH, 3YL D.
  Professor N. Smith, at different periods, practised
various methods of radically curing hydrocele.  At one
time, he practised the method of Hunter—at another,
that of Mr. Pott, with the seton—subsequently, he used
the various injections. At length he fixed upon the em-
ployment of the tent, as that which he learned by ex-
perience to regard as the safest, most certain, and least
painful method—also that which is  performed  with
most facility;
  He was opposed to the injection of wine, because he
regarded it as not altogether safe.  He observed  that,
notwithstanding the precautions which are abundantly
given in all works on surgery, and although the operator
may be fully aware  of the hazard, yet it  still occasion-
ally happens  that the fluid injected, in consequence of
the pipe getting disengaged from the  tunica vaginalis,
is thrown into the  cellular tissue of the  scrotum, and
extensive sloughing  is produced.
       24 
184                 HYDROCELE.
  I was myself once conversing with a very intelligent
medical gentleman on the subject of this operation, and
advocating the use of the tent, while he expressed a
decided preference for the injection.  He remarked,
that he could not conceive how  any accident in this
mode of operating could occur, in the hands of one
aware of the danger to be guarded against.   The very
next  day, he  performed the  operation, and, in conse-
quence of some defect of his  instruments,  or the awk-
wardness of an assistant, threw the wine into the whole
tissue of the scrotum.   The result was so extensive a
sloughing of the parts, that the testes were left  com-
pletely exposed, and  suspended merely by the  sper-
matic cords.
  It was the occasional occurrence of such accidents,
although this never happened to himself, that induced
Professor Smith  to reject this mode of operating, and
to use exclusively the tent.
  In the employment of the  tent, he  considered that,
in the first place, there was no possible danger;—also
that the method is more simple, requiring a less compli-
cated apparatus  of instruments.   He  found, too, that
the desired result was more certain to take place; be-
cause, riot knowing the precise degree  of sensibility in
the tunica vaginalis, we cannot accurately adapt  the
strength of our injection, and therefore we sometimes
stimulate the parts not enough—sometimes too highly.
But in the use of the tent we can leave it in the tunica,
until the necessary degree of  excitement  is produced.
  Professor Smith's method of executing the operation
was the following. Having shaved the scrotum, he grasp-
ed it with his left hand, in such  a manner as to render the 
                  DTDROCELE.                  185
integuments tense, being careful, however, not to suffer
them to glide upon the subjacent parts.  With a lancet
in the right hand, he then incised the integuments, with
the shoulder of the instrument, to the extent  of two
inches, on the anterior  and inferior portion of the tu-
mour, dividing the cellular tissue carefully down to the
tunica.   This being done, he struck the lancet into the
membrane, and ripped it up, to  the  extent of three
fourths of an inch.  Then, while the water was gushing
from  the orifices, he introduced into the tunica a probe,
bent so as to form a hook.   This was  very necessary,
in order to preserve the parallalism of the external and
internal cuts, as the integuments glide freely, and often
entirely conceal the internal incision, and render it very
difficult to recover it.   Holding  the orifice with the
probe, he took from an assistant another probe, over the
end of which  a narrow slip of linen wras folded.   This
slip of linen, he conveyed, with the probe, to the bottom
of the tunica,  and then  pinching the integuments upon
the tent, he withdrew the probe, leaving the linen slip
in that situation.   The usual dressings were then used,
and the tent left generally till suppuration ensued, but
removed earlier  if too much irritation  resulted.   This
method, in his hands, was successful almost without an
exception.
   The method now most approved in  France,  is with
a  species of tent.  M.  Dupuytren  introduces a por-
tion of a  catheter, and, by means  of  threads  attach-
ed to  its extremity, fixes it in its place for the requisite
time.   The piece of catheter answers  the double pur-
pose  of a  tent, and  a  conductor  to  convey off the
water, which still continues to accumulate for  a time, 
 186                  HYDROCELE.
 and which is said sometimes to defect the adhesion of
 the tunica, by distending the sack.  The only difficulty
 in its use consists in confining the catheter, as, from its
 smoothness, it is liable to slip out.   This I have ef-
 fectually obviated, in one case in which I  have used it,
 by securing to the extremity of the instrument a small
 piece of dry sponge.  This, when introduced, becomes
 expanded—holds the catheter securely, and, coming
 in contact with a more extensive surface, excites more
 irritation.  It is preferable to the common tent, on ac-
count, also, of the danger of pulling out the tent, when
the probe, with  which it  is  introduced, is withdrawn.
In the case in which I used this apparatus,  I  was ex-
 ceedingly pleased with it. 
                     REMARKS

     ON THE  SPONTANEOUS SUPPRESSION

                        OF

              HEMORRHAGE,

With Comments on the Physiology and Pathology of the Circu-

                   lating System.
   The very popular treatise of Dr. Jones on the pro-
 cess employed by nature in suppressing hemorrhage is,
 I believe, still regarded as  a sufficient  and satisfactory
 explanation of the  phenomena of which it treats.  In
 surgery his  deductions  are, I believe, generally receiv-
 ed  as principles, and  his  opinions quoted with confi-
 dence ;  nor am I aware that they have been contro-
 verted by any recent author.
  If, as I believe, I correctly understand the  general
 conclusions of Dr. Jones, the causes which  he assigns
 for the  spontaneous suppression of hemorrhage, in ca-
 ses of divided arteries, are purely mechanical, that is,
 the blood does not  cease  to flow by the cessation of
 any vital action in the artery, but is suppressed by
physical obstacles which result from the division of the
artery  and  the wounding of contiguous parts.   He
mentions, indeed, the vital  action of the artery, but he 
188        SUPPRESSION OF HEMORRHAGE.
supposes this to employ mechanical means for accom-
plishing the effect.
  In  treating of the pathology of  the  arteries, Dr.
Jones, and others who have discussed this  subject, re-
gard  the  propulsive power  of  the heart as the sole
cause of the effusion of blood, not taking into account
any independent vital action of the artery  itself as in-
fluencing the  current of that fluid.
  The first cause which Dr. Jones has assigned for the
spontaneous suppression of hemorrhage, in  cases  of
divided arteries, is a contraction of the wounded organ,
both in length and calibre.   It is not asserted, however,
that this  double contraction  immediately closes the
mouth of the divided vessel.  The second cause is la-
teral pressure made on the extremity of the bleeding
vessel by the  blood  being  thrown  back  on the artery,
and injecting the cellular sheath.   The third is the for-
mation of a clot, or coagulum of blood, within the mouth
of the artery, and  also  of another exteribr to it, but
attached to the mouth of the vessel, adhering to its cut
edge, and  closing its orifice.  Lastly a diminution of
the impetus of  the circulating blood, occasioned by the
hemorrhage.
  Now  if, on careful  observation, the same  effect,
which has been attributed to  the co-operation of all
the above causes, is ascertained to be produced under
such  circumstances that  no one of them  can  be sup-
posed to have the smallest influence, we shall be com-
pelled to seek for  other  causes, and to  adduce some
principle in explanation of these phenomena which Dr.
Jones has overlooked.
   If  we carefully examine each  one of the causes to 
           SUPPRESSION OF HEMORRHAGE.       189
which  Dr. Jones has ascribed the suppression of he-
morrhage, we shall find that no one is adequate to the
degree of influence winch  he supposes.   The sponta-
neous  contraction of the  artery  is in itself certainly
got sufficient, for no artery  is capable of that degree of
contraction which shall obliterate its own calibre; conse-
quently it can only diminish the stream of blood.
   The lateral pressure, effected by means of blood in-
jected  into the  cellular tissue around the artery, cer-
tainly cannot be supposed to occur when the artery is
completely divided, together with the adjacent parts, as
in amputation;  because there is then nothing which
may repel the jet of  blood and throw it back into the
arteral sheath.  Arteries thus severed, however, cease
to bleed even more promptly than when divided under
different circumstances.
   In amputating the thigh  I have in twro instances tied
only the femoral artery, all the others ceasing to  bleed
almost immediately, without the use of any mechanical
means.   One of these patients wras a child six years of
age—the other a young man of less than thirty.   Both
survived the operation and are still living.
   In three instances I have amputated below the knee,
when I had no occasion to  tie any artery, and in neither
of these cases was the action of the  heart and  arteries
remarkably depressed, nor did there occur,  at the time
of the operation, any unusual degree of faintness.
   Respecting the coagulum of blood  which is supposed
to be formed at  the orifice  of the divided artery, and to
oppose an obstacle to the further effusion  of blood, we
can  scarcely  conceive  how  it can  be  formed in the
mouth of the vessel while it is still emiting a full stream 
 190        SUPPRESSION OF HEMORRHAGE.
 of blood; hence it would seem to be rather the effect
 of the suppression than the cause of it, and is probably
 formed from some of the last drops effused.  Perhaps,
 however, it may still be thought that, although the co-
 agulum does not itself suppress the hemorrhage in  the
 first instance, yet it may prevent  any subsequent effu-
 sion.   This, indeed, appears plausible, but  there  are
 certain facts which  render  it  quite improbable that
 even thus much is  effected by it.
  In  cases  of arteries wounded under circumstances
 calculated to favour the greatest possible degree  of la-
 teral pressure, and the formation of a firm coagulum,
 these causes are found to be by no means adequate to
 the suppression of hemorrhage.  I have  witnessed a
 considerable number of cases in which deep  seated ar-
 teries of  the limbs have been wounded by sharp point-
 ed and narrow instruments, when the soft parts have
 become very much injected with blood  and the  he-
 morrhage long enough suppressed to ensure  the fullest
 effect from the lateral pressure of blood and the forma-
 tion of a coagulum, and yet  the bleeding  has recurred
 again and again, and only been suppressed by tying the
 artery which has been but partially divided.  Such ca-
ses must  have occurred in the practice of  almost every
surgeon.
  The rationale of Dr. Jones does not in a satisfactory
manner explain the fact, that  arteries, which are sud-
denly broken by a violent pull, do not emit blood so fu-
riously as those which are divided by  a sharp cutting
instrument.  In  many cases,  in  which arteries, and
those  of  very considerable size, are torn off, together
with a limb, there occurs  no  hemorrhage.   Several in- 
           SUPPRESSION OF HEMORRHAGE.        191
stances of such accidents are upon record  and famili-
arly known.   A  remarkable case of the kind recently
happened in Vermont and has been reported by Pro-
fessor Mussey.  The arm, together with the scapula,
was torn from the body by a mill-wheel; there occur-
red at the time but a very trifling effusion of blood, nor
did there follow  any secondary hemorrhage, although
no ligatures were employed.
   Now we should be inclined to think that such vio-
lence done  to  the contractile textures of   the artery
would so paralyze them as to destroy their vital power
of contraction; and as it often happens that scarely a
drop of blood is effused  at the instant  of the separa-
tion, we should hardly suppose that the coagulum can
form so promptly as to contribute  any thing to the ef-
fect, but should be rather  inclined to  ascribe the ab-
sence  of hemorrhage, in such cases, to a loss of vital
power in a portion of the artery which is left attached
to the body.
   The following cases strongly favour  the  supposition
that blood will not be propelled by the heart through a
portion of an artery which is inactive, although it re-
mains perfectly open, and the heart acting at the same
time with its usual force.
   In  the  year 1802,1 was consulted by a patient on
account  of an obstinate ulceration upon  one of his
great toes.  On examination I found the affection  to
be dry gangrene.   The whole of the  last  joint was
dead, and it had progressed half way up the second.—
I was not at that time aware that such affections are
generally accompanied with ossification of the arteries
of the leg.   As the sound parts were sufficient to co-
       25 
192     r SUPPRESSION OF HEMORRHAGE.
ver the end of the bone, if amputated at the first joint,
I performed the operation.  I was much surprised on
observing that, although I used no  tourniquet, there
did not a drachm of blood follow the  knife.
  The operation, however, did not subdue the disease;
the gangrene recurred in the stump, and gradually ex-
tended up the foot  as far as the instep, which  assumed
a dark red hue, became hard to the feel, a little enlarg-
ed, cold and extremely painful.  Whenever any thing
stimulating was applied to the part affected it greatly,
aggravated the pain  and hastened  the progress of the
gangrene.  Warm applications, of the  temperature of
the body, produced intolerable anguish.
  Several months after the first opperation I again saw
the patient, found the disease advancing and the  foot
exhibiting the same appearances described above.   His
pulse at the wrist was strong and full,  and there was no
want of force in the action of the heart and large arte-
teries of the superior extremities; his muscular strength
was not much reduced.  The pain endured by the pa-
tient was so severe as not to be subdued by opiates.
  From the circumstance that the part on which I had
at first operated was in an unnatural  state, the greater
part of the foot having been changed in its structure
and become cold, swollen  and hard  to  the feel, while
the soft parts above the ankle were quite natural in ap-
pearance  and  feel, I was  induced to hope that, if the
diseased  member were  removed above the ankle, the
operation might result more favourably than in the pre-
vious instance.   I therefore advised to remove the  foot
at the same time informing the patient  that should the
operation not succeed agreeably  to our wishes, yet, as 
          SUPPRESSION OF HEMORRHAGE.        193
the stump would be a less sensitive part than  the foot,
there would probably be less pain.   The patient, more
desirous to be relieved of  his intolerable anguish than
to protract his existence, readily consented.
   In this  operation I employed no  tourniquet, but di-
rected a pupil to compress the artery with his hands.—
After cutting through the soft parts, and while turning
back the flaps, I perceived something hard in the flesh,
and felt something crush under my fingers.
   After sawing the bone,  and when I came to look for
the great arteries, I found them all in a state of com-
plete ossification.   They  were, indeed, mere tubes of
bone, and I had broken them  in the  flesh  above  the
place were they were divided in the operation.   I  dis-
sected out that portion of the posterior tibial which was
thus broken, an inch and  a half in length, and found it
to be an osseous tube with a  perfectly free calibre.
   Though all pressure was immediately removed from
the artery above, and no other means were used to sup-
press the hemorrhage, yet not  half a table spoonful of
blood followed the operation.   At the same time the
action of the heart and of the arteries at the wrist  was
vigorous.   Although this last wround  never healed, yet
the vigour of the patient's constitution protracted his
life for between two and three years after this event.
   This case in my mind overthrew  the whole of Dr.
Jones' theory of the suppression of hemorrhage in di-
vided arteries.   Here certainly there was no contrac-
tion in length  or breadth, nor was there any lateral
pressure.  The orifices of the divided arteries stood
permanently open, and their canals were entirely un-
obstructed.  Surely we  cannot suppose  that coagula 
 194        SUPPRESSION OF HEMORRHAGE.
 were formed while I was cutting  through the divided
 arte'ries, for no blood of any consequence followed the
 knife.
   There was an important circumstance attending this
 case  which remains yet to be explained, and which I
 could not at first comprehend.   There certainly must
 have been some blood conveyed by those ossified arte-
 ries  previously  to  their  division,—otherwise  there
 could not have been maintained, in the foot, the degree
 of action which actually  did exist.  Had  the  blood
 been conveyed to the foot by the anastomosing branch-
 es, as occurs in the application of a ligature to a large
 artery, these collateral branches should  have been en-
 larged, and  should have bled freely on being -divided.
   What then, let us inquire, could have so immediate-
 ly suppressed the flow of blood in these ossified arte-
 ries on their being divided, there being no mechanical
 obstruction  of any kind to its egress; or rather,  what
 power could have maintained in these arteries the flow
 of blood which so instantly ceased on their division?—
 The vis a tergo of the  heart  was certainly  not  dimi-
 nished.
   The solution of these queries, which to me appears
 most satisfactory, is the supposition that the active pow-
 er, lost by the division  of the arteries, resided in the
 capillary system of blood vessels in the foot.
   That the  capillaries exercise a control over the cur-
rent of blood in the large arteries, promoting its trans-
mission, is rendered highly probable by numerous facts
which may  be adduced.   It is  well ascertained that
when arteries are partially divided, the hemorrhage is
often obstinate, even in small vessels, and although sup- 
           SUPPRESSION OF HEMORRHAGE.        195
pressed for a time by mechanical pressure, or by a weak-
ened  circulation  from loss of  blood, yet  the  bleeding
will repeatedly recur, till subdued by the application of
a ligature, or the complete division of the artery; for
it is well known  that the latter, unless the artery be
very large, suppresses the bleeding.
  Now these facts have been accounted for by the sup-
position that while the artery is only partially divided,
it cannot effectually contract;  but  in the case  of the
ossified arteries, the blood ceased  to flow  as soon as
they were divided, although there occurred no contrac-
tion to which that event might  be attributed.
  There are other facts relative to the case in question
which should  not escape  observation.   When  any
thing warm or stimulating was  applied to the  foot  (this
being colder than any other parts of the body,) it great-
ly increased  the  pain.   This I apprehended to have
arisen from  the action of the capillaries being excited
beyond the degree corresponding  to the quantity of
blood received through the ossified arteries, which un-
availing action of the capillaries may be supposed to
have created much pain.
  In confirmation of a position, that in cases of ossified
arteries the pain produced by the application of  heat
to the extremity, is owing to the capillaries being too
much excited for the quantity  of blood which they re-
ceive, I would observe, that in  other similar cases in
which gangrene  has commenced, I have  observed the
pain to be  increased by placing the limb on a level with
the body in the bed, and to be  rendered more tolerable
by placing it in a  depending position.   I used to re-
monstrate  with my patients in regard to this particular, 
 196        SUPPRESSION OF HEMORRHAGE.
 and earnestly charge them to keep the limb elevated.
 They, however, persisted in asserting that the pain
 was intolerable when the limb was  raised to a level
 with the  body in bed, and greatly relieved when de-
 pressed.
   This interesting phenomenon is accounted for by the
 fact that,  in such cases, the vis a tergo of the blood in
 the  arteries  is not sufficient to carry it through those
 vessels, which are themselves inactive and unconnected
 with the  capillaries.   Therefore as the blood  is with
 difficulty,  and not in sufficient quantity, furnished by the
 arteries to the capillaries, these latter  are compelled to
 increase their action in proportion to the defect of ac-
 tion in the arteries.
   That there exists in the capillaries such a power of
 thus increasing their action, as peculiar circumstances
 may require, the following facts will prove:—I  once
 had occasion to tie the external iliac artery for inguinal
 aneurism.  The instant the artery was tied, the patient
 experienced a most severe pain through the limb, and
 before we had applied  our  dressings the limb was sen-
 sibly colder  than the other.   At  the end  of three
 hours, however, it became obvious that the  diseased
 limb was  sensibly warmer than the other, and at the
 end  of six hours both limbs were  of the same tempe-
rature.
   My  conjecture was,  that in the first  instance the
cold  was  produced   by sudden  diminution  in the
quantity of  blood sent to  the  capillaries  by  the ar-
teries, causing a  suspension of their  action, and that
the heat which followed was the result of  the increas-
ed action  of the capillaries to  attract blood to them- 
           SUPPRESSION OF HEMORRHAGE.       197
selves, a phenomenon analogous to many other opera-
tions  which take  place in  the  animal  economy, and
which are usually ascribed  to the recuperate powers
of nature.
  It may seem paradoxical that the capillary vessels
should possess  the power of soliciting  forward blood
from the heart, which has been heretofore regarded by
most as the only organ actively concerned in the circu-
lation of the blood, and even at the  present  time has
chief importance attributed  to it.  A recent  writer of
reputation  states,  as I  observe, that  the  heart, in his
opinion, is adequate to the complete circulation of the
blood through the  arteries and veins.  We have, how-
ever, many unequivocal facts which prove the contrary.
  In every case  of local inflammation,  before the ac-
tion of the heart and great arteries is in the l6ast chang-
ed, there is an accumulation of blood in the capillaries
of the part inflamed.  This could not, indeed, take
place if the  blood was not furnished to them by the
heart and arteries; but, in such cases, the action of the
heart is not  directed to the inflamed  part more than it
is to every other part, nor more to that  particular part
than  it was  before the inflammation took place.   It
follows, therefore, that the change in the part diseased,
producing  an increased quantity of blood and  an  in-
creased evolution of heat, must depend on some chango
in the action of the vessels of the part,  and not at  all
on the vis a tergo of the blood impelled  by the heart.
   There are other causes which render this power  of
the capillaries  still less equivocal.  In  certain morbid
vascular structures, the blood  vessels,  of  which they
are chiefly composed, are observed to have the  power 
198       SUPPRESSION OF HEMORRHAGE.
of drawing blood from the  surrounding parts and dis-
charging it from the system.
  A lady had a small vascular tumour on the neck, of
the size of a common strawberry.   It was attached to
the skin by a neck less than half the diameter of the
tumour, and was in a degree pendulous.  This tumour
often bled, and  it  was observed that emotions of the
mind frequently caused it to effuse blood.   Sometimes
the blood flowed in a small stream, but it generally
dropped in large drops, which followed each other in
quick succession.   When the patient, after my being
called, was informed of my arrival, the agitation which
she experienced immediately caused  the  tumour to
bleed, and on my examining it, I found it still bleeding
freely.
  I  immediately  cut  off the tumour level with the
sound skin, and the bleeding at once ceased; not three
drops of blood  following the opperation.  In this case
the vascular  tumour seemed to operate like a pump,
attracting the blood  from surrounding parts  and dis-
charging it from  the system.  This is by no means a
new  or solitary  case; it has been long known that, in
cases of fungous tumours which bleed, the only effec-
tual and certain method of restraining the hemorrhage
is to cut off the whole  tumour down to the  sound
part.
  Another example  of the same nature,  and which
serves to illustrate the principle under consideration, is
found in those  vascular tumours  often met with  on
children,  called mevi  materni.   Those tumours are
composed chiefly of blood  vessels of a very tortuous
form; they are always of a higher temperature than 
           SUPPRESSION OF HEMORRHAGE.       199
the adjacent sound parts, and if wounded bleed furious-
ly;  the  blood is thrown out  from  the divided vessels
with much greater force than from the divided arteries
in sound parts of the same volume, as I have had seve-
ral  opportunities of  witnessing.   For this reason we
have been advised by surgeons, in case we remove such
tumours with the  knife, to make the incision in the
sound parts beyond  the limits of the disease, that we
may thus avoid fatal hemorrhage.  If this be done the
hemorrhage is as  easily restrained  as it  is in similar
wounds on any other part of the body.
  These phenomena can  not be accounted for upon
the principle of mere debility or relaxation of the arte-
ries and veins of the  part:  their thus receiving a larger
quantity of blood but proves  the existence of a pecu-
liar action which enables this congeries of vessels to at-
tract the blood from the surrounding vessels.
  The fact which  I now proceed to state is familiar to
most  practitioners and especially to  accoucheurs.  In
natural and healthy labour when the child is born alive,
if we examine the umbilical  cord, immediately after
the birth and while the placenta  remains in the uterus,
we  find  the two umbilical arteries beating strongly.   If
we  then wait  a  few  minutes and examine that part of
the cord next the placenta, we find them beating rather
faintly, and by waiting still longer we perceive that the
pulsation  has ceased in that part of the cord farthest
removed from the  child.   Gradually the pulsation cea-
ses  along the cord  from its placental extremity until it
is no longer felt even at the  umbilicus;  and  if it be
then divided there will occur no effusion of blood.
  Now  the question to be solved is why, after the birth
      2G 
 200       SUPPRESSION OF HEMORRHAGE.
 of the child, does the blood cease to pass through the
 umbilical arteries, in which, a few minutes  before, it
 circulated  with so much force.   These  arteries  are
 branches of the hypogastric, and  there appears to be
 no more impediment to the entrance of the blood into
 them than there existed before the birth of the child.—
 To me it does not appear attributable to the change of
 temperature which the part experiences, for the circula-
 tion in  the  arteries ceases  while the placenta remains
 in the uterus of the mother;  and as for the cord, it is
 not more exposed to cold than the legs of the child:
 and we therefore can see no cause why the impression
 of cold should  not stop the circulation in the latter as
 well as the former.
  The fact  cannot be accounted for by a hemorrhage
 from the extremities  of the arteries; for the blood ves-
 sels of the child have no communication with those of
 the mother.   When the birth is perfectly  natural, and
 the placenta separated  entire without laceration, there
is never any bKJod from the  child discharged by the
placenta.
  I am not aware that in this cord there exists any me-
chanical obstruction to the circulation  of the blood
through the cord, and yet the result which I have men-
tioned  is constant and uniform.   Here, as there is no
division, there can be no retraction of the arteries,  and
no coagulum formed which  can directly or by  lateral
pressure obstruct the artery; and yet the blood ceases
to circulate as promptly as when  effected apparently
by these causes.
  To explain this phenomenon, we must have recourse
 to a law of the  animal  economy which  I have not seen 
           SUPPRESSION OF HEMORRHAGE.        201
noticed by any medical author; and yet it seems to be
a general principle, and certain in its operation.   I al-
lude to  this,—that when any function is cat off from
the system or totally destroyed or  superseded, all that
action which went to support that  function in a longer
or shorter time entirely  ceases.  The placenta during
gestation performs  the  office  of lungs for the foetus,
and after the birth, when respiration is established, this
function of the placenta is not  wanted and of course
ceases; and the action of the arteries ceases because it
would not subserve the functions of the economy, but
rather would be injurious.  Instead, therefore, of refer-
ring this change to mechanical causes, it must be refer-
red to a law of the animal economy; which is the ulti-
matum  of many of our researches, and seems to  be
pursuing the subject as far as it can be traced. 
 
SPONTANEOUS CESSATION
                     OP


           HEMORRHAGE

                    FROM


LACERATED  ARTERIES,
BY N. R. SMITH, M. V*
  The  opinions which have been stated by various
surgeons, relative to  the spontaneous cessation of he-
morrhage from lacerated arteries, are exceedingly vague
and contradictory.  From this we may infer that the
subject has not been thoroughly investigated by experi-
ment.  M.  Richerand states, that large arteries, when
ruptured, become closed (se resenent) partly in conse-
quence of the chill which they suffer, producing spasm;
and partly  by the pressure which the muscles, within
which they retract, exercise upon them*   M. Delpech
states, that when a limb has been torn from the body,
the  principal artery is sometimes  broken within the
parts of the stump which have resisted the violence, and
sometimes within the lacerated limb, so as to hang out
at the wound.  In neither case, he says, is hemorrhage

  *Nosographie Chirurgicale, torn. 1. p. 70. 
204             LACERATED ARTERIES.
apt to take place.   He has so much confidence in the
security of the vessels, that he advises not to seek for
them, in treating lacerated wounds, unless they bleed.*
Mr. Charles Bell says, "A torn artery does not bleed.
I have heard it affirmed that, in this case, the blood was
stopped by the rugged portion of the inner coat of the
vessel, which is torn into shreds by  the  violent elonga-
tion of it.   It has been said, if we disclose the radial ar-
tery of a dead body, and, putting a probe under it, tear
it forcibly, the inner coat will present an appearance of
valves to intercept the flow of blood.  I believed in this
statement, but, upon the experiment being repeated, I
found that in  a young and healthy artery, the change
could not be exhibited."   Professor  Gibson asserts that
the indisposition manifested by a lacerated part to bleed,
is owing to the injury sustained by the nerves, not only in
the immediate vicinity of the wound,  but  to a greater
extent around than the eye can discover.   Hence the
arteries are paralyzed, and  do not contract to  propel
the blood,  which coagulates in their cavities, or among
the torn muscular fibres.f
  It is apparent, therefore, that the mode in which he-
morrhage from lacerated  arteries is arrested, is by no
means an  established principle in surgery.  For the
purpose of furnishing facts which may aid to render  it
such, the following experiments were instituted:
  Experiment 1.—Having exposed the femoral  artery
of a young slut, not fully grown, I passed a smooth iron
Jaook under it, andjacerated  the organ with a sudden

  * Precis Maladies Chirurgicale, torn. 1. p. 188,
  f Gibson's Surgery, yol. 1. p. 92. 
             LACERATED ARTERIES.             205
pull.  Blood  immediately  gushed from it in  a rapid
stream, and continued to flow copiously, for about four
minutes.   At the end of that time, the blood on the
table began to coagulate, and, simultaneously, the bleed-
ing began to be less impetuous.   It gradually diminish-
ed, and in ten minutes had ceased altogether.  The
animal was then shut up,  but suffered  to move about
the room.  No  bleeding  recurred.  At the  end of
twenty-four hours she appeared quite well, moved the
limb with freedom, and took food greedily.  She was
then killed  with prussic acid.  On examining  the limb
it was found  slightly swelled.  Blood was injected in
small quantity into the common  tissue, and a coagulum
was formed in the sheath around the artery.   The up-
per extremity of the artery was not retracted  between
the muscles, but was  quite superficial.   The  external
coagulum did not exercise much pressure upon it, for
its extremity  was larger than natural.   I then dissected
the artery from its sheath, to the extent of three or four
inches, and opened it longitudinally, from above down-
wards.   Two inches from the wound I encountered a
slender coagulum, which  increased in diameter as I
traced it downward, and which completely stuffed the
organ for one inch from its orifice.  The external coat
presented a lacerated margin, which, however, had be-
come somewhat  indistinct by the effusion of lymph.—
The internal  coat was lacerated transversely, in many
places.  Into  many of these) slips of the internal coagu-
lum were  inserted; the blood which had issued  from
the fissures, appeared to have incorporated itself with
that which filled the vessel, and  thus to have at first at-
tached the coagulum.   From many other fissures a very 
206             LACERATED ARTERIES.
apparent quantity  of lymph had been effused—had
blended itself with the coagulum, and fixed it so firmly
in its place, that it was difficult to scrape it away.  The
artery was so firmly stuffed with the coagulum as to be
considerably dilated.  Not a drop of blood could possi-
bly have escaped from it in this state.
   Experiment 2.—The carotid artery of a  full-grown
dog, of large size, was exposed on the left side of the
neck, and lacerated as before.  The artery broke deep
in the chest, and bled for five minutes with great  rapi-
dity.  The animal then gave signs of fainting, but they
soon disappeared, and the blood quickly ceased to flow.
He was suffered to  live four hours, during which time
there was no bleeding.   He was then killed, and while
dying he struggled very violently, but there was still no
bleeding.  The chest was then opened and the artery
traced from its origin.  It proved to be a branch of the
innominata.   Its internal coats were broken at its very
origin.  The external tunic was broken at the distance
of an inch and a quarter from the innominata, the in-
ternal coats were withdrawn from within the external,
which formed a loose pouch projecting from the in-
nominata, and stuffed with a firm coagulum.   In this
case  there  was no lymph  effused,  time enough not
having elapsed.  The external coagulum was volumi-
nous and firm, occupying the interstices of the adjacent
organs, and extending to the external wound. It had
not, however, made pressure enough to interfere with
respiration.   The cervical portion of the broken artery
was hanging  from the  wound, to the  extent of two
inches.  This had also bled freely, at the moment of
the rupture, but had soon ceased to do so.   Its internal 
LACERATED ARTERIES.
207
coat was ruptured transversely at many places, to the
extent of three inches.  Near the extremity it was fil-
led with  a coagulum which adhered to the  transverse
fissures  in the  internal  coat.  It must have  been, of
itself, an effectual barrier against the effusion of blood.
   Experiment 3.—I procured a horse twelve years of
age, of pretty good constitution, though very lean, and
having cast him upon his side, laid bare the carotid.  I
then passed a smooth iron under the artery, and broke
it, as  I had done in the previous experiments.  The
blood gushed in a torrent from  the wound, and, in a
few minutes, the animal lost two or three gallons.  In
about ten minutes the blood upon the  ground began to
coagulate, and then the diminution of the  rapidity of
the current was manifest.   The extremity towards the
chest hung out at the wound, to the extent of three in-
ches.  While the blood was flowing rapidly the animal
moaned  once or twice,  as if a faint, but soon after, he
rose from the ground without difficulty,  and  stood till
the blood had entirely ceased to flow, which was after
about thirty minutes from the time the artery was rup-
tured.  The projecting artery was then returned to its
place and the wound closed.  The animal was suffered
to live for twenty-four hours, during which time he ap-
peared nearly as vigorous as before the operation, and
took food with avidity.  He was then killed by a blow
on the head, but, while dying, he struggled very violent-
ly.  Blood gushed from  small vessels  in the wound,
and I feared, at first, that the obstructions in the artery
had given away.   But on examination I discovered
that not a drop of blood had issued from either extremi-
ty of the artery.   The lower portion of the artery was
       27 
208             LACERATED ARTERIES.
found perfectly naked, to the extent of three inches
from the rupture.  Beyond this, its sheath was occupi-
ed with a coagulum of blood, as was also the common
tissue in the vicinity.   No lateral pressure, however,
was  exercised on the  artery to impede the  passage  of
blood, as the organ was even increased in  volume.—
The interior of the artery was found plugged with a
coagulum six inches long, which completely filled its
cavity for nearly its whole extent.  The internal coat,
as in the preceding experiments,  was ruptured trans-
versely at a great many places, and little productions of
the internal coagulum  were inserted into them so firmly
that  they must have securely fixed the  coagulum, as
soon as coagulation had taken place.   From many  of
the fractures in the internal  coat, lymph, in quantity,
had been effused, and  become blended with the coagu-
lum, which was thus so firmly attached to the surface
of the organ that it required an effort to detach it.  No
blood could possibly have passed through it, and as the
coats of  the artery every where retained their vitality,
no secondary hemorrhage could have subsequently oc-
curred.   The  accompanying Plate accurately repre-
sents the preparation which I made of the parts, by slit-
ting  open the  artery longitudinally, and leaving the
coagulum in its place.
  Figure 1, marks the entire artery; figure 2, the coagu-
lum; figure 3, the internal surface of the organs marked
with the transverse fissures in the internal coat; figure
4, the point at  which the thyroid branch was given off.
Here  the coats were much  lacerated,  and a great
quantity of lymph was effused, sealing up the organ.
  Experiment  4.—The carotid of a large dog was laid 
             LACERATED ARTERIES.            209
bare, raised with a hook from its sheath, and divided.
Its  extremities then retreated  into the sheath.  The
gush of blood was impetuous, but, at the first moment,
little if any more so than when, in experiment 2d, the
artery was torn.  There occurred no abatement  in its
force, however, till the animal fainted, which was after
five minutes.   The bleeding then almost entirely  ceas-
ed for a  moment, but presently returned, and in less
than ten minutes the  animal expired.  The abdomen
of this dog was then opened, a hook was passed under
the aorta and the vessel* was broKen.  The organ  being
dissected out, was then examined  Its internal coat
was ruptured, precisely as by similar means in the other
experiments.  In some places it was peeled up  from
the middle coat, so as to form pockets  on the side  of
the artery; but  this was  the only instance in which I
found any thing of the kind.
   Experiment 5.—I  opened the abdomen of a large
dog, and having exposed  the aorta above its bifurcation,
I attempted to break  it in the manner mentioned above.
 The flow of blood was  very rapid, and this, together
 with the irritation necessarily produced from the ex-
posure of the abdominal organs, rapidly prostrated the
 powers of life, and the animal died in about five minutes.
 There was, however, an  ineffectual effort at reaction.
 No other result could have been expected  in this ex-
 periment, because the bleeding was so copious as  to
 destroy life before coagulation could be  effected.  On
 examination, I  found that the aorta itself was not rup-
 tured, and that the laceration had taken place  in the
 external and internal iliacs.  The blood, therefore, had
 flowed  from several  large trunks, a wound of either of 
  210            LACERATED  ARTERIES.
  which is ordinarily fatal. I was surprised to find, how-
  ever, that each of  the lacerated arteries had its orifice
  closed with  a coagulum, which had probably been
  formed in articulo  mortis.   The internal coat of each
  was lacerated, as in the other experiments, and  a por-
  tion of the external coat, in every instance, projected
  beyond the lacerated margin of the internal coats, to
  the extent of half  an inch or more.   The extremity of
  each artery appeared enlarged and  bulbous, from  the
  presence of the coagulum writhin  it,  adhering  to its
  rough, cellular surface.  I was persuaded that, had not
  the flow of blood been so rapid as to destroy life before
  coagulation could be completed, this animal  would not
  have perished immediately.
    The above experiments will, I think, justify the fol-
  lowing conclusions:
    1st.  That Dr.  Jones errs in ascribing the cessation
  of hemorrhage from lacerated arteries, mainly  to the
  same'tauses wdiich avail against bleeding from divided
  arteries.   In the experiments detailed above, the retrac-
  tion and contraction of the organ availed nothing. The
  same was  true  in regard to the external coagulum,
  which according to Dr. Jones is the principal agent.—
  In each of the experiments, the extremities of the vessel
  were rather dilated than constricted or compressed.  In
  one instance (Qxper. 3.) the artery  hung naked from
  the wound, and yet the bleeding ceased as promptly as
  under other circumstances.
    2d.  Equally untenable  in the  doctrine  that  the
-  artery is paralysed by the shock inflicted upon its con-
  tractile tissue, and that the blood refuses to flow through
  a passive tube.  In every  experiment there was  ex- 
             LACERATED ARTERIES.             211
tensive injury inflicted upon the artery, and in one, the
organ was torn from the surrounding parts to  a great
extent;  consequently  its vital intercourse  with them
must have been for a  time  interrupted, and its  own
action suspended.  This paralysis of the artery should
be most perfect instantly after the injury; but we find
that the blood  then  flowed  in a rapid stream, wrhich
was undiminished till it had had time to coagulate.  It is
true that in those cases on record, in which limbs have
been torn from the body, there has been,  even at the
moment after the injury, no considerable bleeding. But
this has undoubtedly arisen from the shock given to the
general system, and the suspension of the action of the
heart, till the blood had coagulated in the extremity of
the artery.
   3d.   Although the pockets, or valves mentioned  by
Mr.  Bell, wTere in one experiment formed on the sides
of the lacerated vessel by the rupture and partial de-
tachment of  the inner coat, yet  these were not found
efficient in suppressing hemorrhage in  a single instance,
when the experiment  was  performed  on the living
animal.
   4th.   The efficient, and  almost  only cause of the
cessation  of hemorrhage from lacerated arteries, is the
unequal  laceration of the external and internal coats.
Generally the internal coat is fractured transversely at
numerous places, so as to present an indefinite number
of small fissures, into which the blood of the artery is
injected, and thence, perhaps, conveyed by interstitial
absorption into the arterial tissues. Blood, also, probably
flows from the ruptured tissue, and mingles with that
in the cavity of the artery.   As soon as  coagulation 
oj2            LACERATED ARTERIES.
begins to take place, blood concretes, probably first on
the fissures  produced in the internal coat, attaching
itself to the rough surface which is there produced, and
insinuating itself into the interstices in such a manner
that the coagulum becomes so firmly fixed  as to resist
the impulse of the circulating blood.
  When an artery is smoothly cut, and the integrity of
the inner coat is  uninjured, the  coagulum finds no
point-d'appui, or roughness upon  which  it can  take
hold.  The  surface is every where polished and lubri
cated for the very purpose of facilitating the passage of
the blood, and therefore the internal coagulum,  as it
forms, either glides from the artery, when the  organ is
very large, or perhaps does not form at all, the particles
finding no rallying point within the vessel.  But when
the  internal membrane is  extensively ruptured,  the
blood must necessarily concrete upon the lacerated sur-
face, precisely as it is uniformly observed to do in other
wounds.
   In some instances the complete  separation of the in-
ternal coats will take place at some distance from that
of  the external, or cellular, which will then bang as a
loose pouch from the end of the more rigid middle coat.
Its surface being cellular and lacerated, the blood, rush-
ing along it with force, is injected into this tissue, coagu-
lates upon it, and attaches itself firmly to it.  The ex-
ternal coagulum, which forms in  the lacerated sheath,
will then aid to sustain the internal coagulum  and sup-
press the hemorrhage.
   After the internal coagulum has remained  attached
 for some hours to the  fissures produced in the internal
 coat, from each one of the ruptures  there takes place 
             LACERATED ARTERIES.            213
the effusion of lymph.  This still more firmly attaches
the coagulum to the internal surface of the organ, and
the more  effectually stuffs its cavity.  Finally, it takes
the place of the coagulum of blood, and obliterates the
cavity of the artery.
  It may be asked, if nature resorts with so much uni-
formity, precision  and effect, to these means for sup-
pressing hemorrhage from lacerated arteries,  how does
it occur that fatal hemorrhage should so often result
from the rupture of arteries which are broken without
a corresponding rupture of surrounding parts and of the
skin?  These injuries are sometimes inflicted on large
vessels in  effecting the reduction of old dislocations.—
Many cases of the kind are on record.  The probability
is that arteries thus yield in these instances, sooner than
the  surrounding parts, because  they are diseased and
brittle.  The external coat having lost its extensibility
in consequence of the deposition of lymph in and around
it, breaks  abruptly without effecting the laceration of
the  internal coat  at more than one place.  Besides,
we know that when there is no external wound, effused
blood does not  coagulate  with  facility, and remaining
fluid, opposes no obstacle to fatal hemorrhage.  If Mr.
Scudamore's explanation of the coagulation of blood be
correct, it  refuses to  coagulate promptly, under these
circumstances, because it cannot  exhale  its carbonic
acid.*
* Scudamore on the Blood. 
 
REMARKS
AMPUTATION.
  It is not my present purpose to give a history of Am-
putation, or  to  point out the various  improvements
which have been made in that operation by different
individuals, but to contrast the method  which I have
adopted, with the present mode.   I say  the  present
mode, for, as far as I know, amputation is performed
generally in a similar manner throughout the United
States and Europe, which is as follows:  The tourni-
quet being fixed on the limb, the operator standing by
the side of the patient, with an assistant, who draws
up the flesh, so far as to straighten  the skin with a long
straight-edged knife, makes a circular incision around
the limb, through the skin and cellular substance down
to the muscles.  He then separates the adipose  mem-
brane from the muscles  with  the  scalpel, and folds it
back with the skin, and in this manner lays the muscles
bare to  a certain distance above the place where the
skin was divided.  He then cuts the muscles down to
the bone, as high up  as they are laid bare, and having
again separated the muscles from the bone to a certain
       28 
216                 AMPUTATION.
distance above  where  the  muscles Were  cut, retracts
the soft parts, and  saws off the bone, as  high as the
muscles have been separated from  it.   The arteries
being tied, the soft  parts are brought together and se-
cured by sticking plasters.
   This I believe to be substantially the mode of operat-
ing in  this country, and when the operation is nicely
performed, and a due proportion of soft parts is preserv-
ed to cover the  stump, and well  secured, the cure  is
effected in a short time, and the stump is a pretty good
one.   But in an operation of so much importance, and
attended with such serious consequences to the patient
as amputation, every circumstance which can render
the operation less painful, or effect a cure with less in-
convenience, or obviate  with more certainty the acci-
dents that occasionally produce a bad stump, deserves
attention.
   The objections to the present mode of amputation,
 as I have above described it, are, 1st, that in the most
 perfect operations, where the soft  parts are  brought
 together, so that the edges of the skin on the opposite
 sides meet each other, the stump will be angular, that
 is, there will be two projecting portions of skin, one  on
 each side of the limb, which give it a disagreeable ap-
 pearance, and when healed will render it liable to ex-
 coriation and inconvenience from an artificial limb.
   2d. As the skin and cellular substance are to a certain
 extent separated from the muscles, and project or fall
 belowr the cut  muscles, the  end of the  bone will  be
 covered sometimes by the skin, and cellular membrane
 only.
    3d. As there can be no rule given for the length of 
                 AMPUTATION.                 217
the soft parts, which are to  be preserved to cover the
end of the bone, which will apply to limbs of different
sizes, it must be left to the surgeon, whilst operating, to
judge how far lit will separate the skin from the mus-
cles, and the muscles from the bone.  And as a large
limb will require much larger flaps to cover the stump
than a smaller one, it happens occasionally that in large
stumps the bone will project, whilst in small and ema-
ciated ones, the soft parts will fall too far below the
bone, and form a kind of pouch, which is sometimes
filled with matter during the  cure.  Charles Bell ac-
knowledges  that such accidents frequently happen in
the hospitals, and I have known them in private prac-
tice.
   Now a method of operating which will with certainty
obviate all  these unpleasant  circumstances that will
form a round and seemly stump, without any projecting
angles of  the soft parts; that will cover the end of the
bone, not only  with  skin and cellular  substance, but
with muscles, and will also preserve just the length of
the soft parts  requisite  to  cover  the  stump  without
straining, or without any superfluous portion, should un-
doubtedly be preferred.
   The following method I have found to possess all the
advantages  above stated.
   Having fixed on the part where the operation is to be
performed, let  the operator  take  a piece of paper of
sufficient  length to encircle the limb, and four or five
inches in width, and apply it around the limb, so as to
obtain the exact measure of it, and all the superfluous
length should be cut off.   It should then be folded, and
the ends of the paper laid together upon a table, and a 
218                 AMPUTATION.
semi-circular arc  drawn  with a pair of dividers, by
placing one leg upon the middle of the lower side of
the paper.   The paper cut off upon this line will form
two equal semi-circles; and when placed upon the limb,
will describe two  semi-circular arcs, meeting at two
angles.   These lines should be marked upon  the limb
with ink or a crayon.
  Then, whilst an assistant draws up the skin so as to
straighten it moderately, the operator, with a short knife
having an edge on the convex  side,  passes his hand
under the limb, and fixes the point of  the knife on the
side farthest from him, at the angle where the two semi-
circular lines meet; with the edge of  the knife turned
obliquely upward, he cuts  in the direction of the line
through the skin, cellular substance and muscles, down
to the bone, with repeated strokes.  Thus  having divi-
ded one-half of the soft parts of the limb, he passes his
hand above the limb, fixes the point of his knife on the
angle where he began, and  follows  the line upon the
upper side of the limb till it  meets his first  incision.—
He will then have two semi-circular flaps, composed of
all the soft parts connected by their natural adhesions;
these are to be turned back, a retractor applied, and
the bone sawed off.   After the arteries are secured, the
flaps are to be brought together and secured by adhesive
plasters.  If the operation is performed in this manner,
the time taken up will be  a little less  than in  the com-
mon method; for there is no skinning up of the adipose
substance from the muscles, and no necessity for cutting
with a guarded stroke, to prevent cutting the  muscles.
I generally  endeavour to cut through the cellular mem-
brane into the muscles at the first stroke, and then follow
this incision down to the bone. 
                 AMPUTATION.                 219
  In this operation, if the method I have described be
followed, the soft parts will be  in exact proportion to
the stump; for by measuring with the paper, and mark-
ing as above directed, the flaps will come together with
mathematical exactness, whatever the size of the limb
may be, for their length must be in proportion  to the
size of the limb.
  The soft parts will therefore come together without
stretching, and will be easily retained in their places.—
The stump formed in this manner  is covered not  only
by  adipose substance,  but by muscles, and  is better
cushioned with flesh, and  from  repeated  opportunities
of comparison, it is well ascertained that such, stumps
are more calculated to accommodate the  machinery  of
an artificial limb.
  There is still another advantage in this mode of  ope-
rating, which is,  that it is often in the power of the sur-
geon to save a  greater length of limb than could be
done in the common mode; for  where the skin  is dis-
eased, being ulcerated  or  having fistulous openings  in
it, I have frequently made my incisions in such a man-
ner, as to bring  the diseased part of the skin  in the
angles between the semi-circular lines, having the  flaps
extend some ways below; so that an inch and a half  of
stump has been saved, which  would have been lost by
the circular  incision; and  as  a general rule, it may be
observed that the longer the stump is, the more useful
it is to the patient.  And if I am not mistaken, the pa-
tient experiences less of those  spasmodic twitches of the
muscles  and  tendons  after  my operation, than are
usually consequent upon  the  former method.  This  I
attribute to  the  circumstance of a greater length  of 
220                 AMPUTATION.
muscles being left projecting below the bone, connected
by their natural adhesions; so that when brought toge-
ther, and retained by adhesive plasters and cross banda-
ges, they are secured and kept steady by pressure.
  The operation which I have described can be perform-
ed with any knife that has a sharp edge, but the knife in
common use is not so well adapted to this mode of ope-
rating as another form, and if any  surgeon will make
the experiment, it  will be found that the knife, which
I have  delineated, will be found more convenient even
in making the common circular incision around a limb,
than the long straight-edged knife.   Being shorter, the
hand has a more perfect command of it, especially its
point.  The convexity of its edge likewise renders less
force necessary to  cut through the flesh.   The  desire,
which some operators seem to have, of cutting a great
deal at one stroke, arises from want of experience; for
in fact  it makes no difference whether we  cut all toge-
ther with a drawing stroke, or whether we push the
knife in a contrary direction; if the edge is perfect, the
operator will find  no difficulty in dividing the soft parts
on account of the shortness of his knife; and the shape
which  is delineated in the plate is better adapted to
cut the angles marked out on the limb than  any other
form.
  I have given a drawing of a limb with the semi-circu-
lar lines made on  it, appearing as they do before the
operation is commenced.   In amputating  the thigh,  I
generally make the angles on the outer and inner sides
as marked on the drawing, except in cases where  I
operate so high up as to  have the artery exactly on the
inside of the thigh; in that case I make the angle a little 
                 AMPUTATION.                 221
above or below the artery, so that the artery may not
come directly in the angle between the two flaps, which
mieht render  it a little more difficult to take up; al-
though  this has happened to me, and  the  artery was
secured without difficulty; or if there should be any dis-
ease in the soft parts, so situated that by making the two
angles in a different part, more length of stump can be
saved, they should be  placed differently, for it does not
make much difference in amputating a thigh where we
make the  angles.
   In amputating the leg  below the knee, the angle
should be made, the  one anteriorly, and the other pos-
teriorly; for if the angles are made as in the  thigh, the
one on  the inner, and the other on the outer side, when
the flaps are brought together, the  flap on  the anterior
part of the leg will fall over the sawed edge of the tibia,
which will be apt to cut through it.
   This happened in one case where I operated in this
manner; but by making the angles one anterior and the
other posterior, the flaps  will approximate  in a  very
easy and  handsome manner, and the diameter of the
 leg is less from  right to left, than from before  back-
 ward.
   The mode which  I have recommended for  the am-
 putation of all the limbs, has been practised by Charles
 Bell, in amputating the fingers, toes, and also the fore-
 arm.   In amputating the fore-arm, one angle  is to be
 formed over the  radius; and the other over the ulna.—
 In  amputating above the  elbow, the angles and flaps
 may be adapted  to  the circumstances of the case  or
 convenience of the  operator, who will always find it
 most convenient to stand so as to have his left hand 
222                 AMPUTATION.
towards the upper part of the limb; therefore, when he
operates on the right arm, he will stand behind the pa-
tient; and when he  operates on the left, he will stand
before him.
  The adhesive  plasters which I have used have been
applied differently from the common method; instead of
applying them in  large strips, I cut them in the following
method.  Take a strip fifteen inches in length,  and two
in width, and by doubling it in the middle, divide it in
the manner represented in the plate.
  In applying a strip, the shoulder should come within
half an inch of the  cut edges of the skin; and the cor-
responding one in a similar manner on the opposite side;
draw the tongues of the plaster across the  stump till
the edges of the  skin are brought  together; when they
are to be secured.   This mode approximates the edges
more closely than is done in the common manner, and
is equally applicable to all cases where the object is to
unite divided parts by sticking plasters.
  This mode of amputating I have followed for the last
twenty years, during which time I have performed the
operation  a great  number of  times;  and during that
period, have never made a bad stump, or any trouble
about the length of the flaps.
  Lately, some improvements have been made in the
mode of performing the operation.  The knife recom-
mended is along  straight catlin, double-edged  at the
point.  It is intended to transfix the limb, and then to
cut obliquely outward, forming two semi-circular flaps
similar to those made by my operation.
  The suggester of this improvement estimates very
justly the importance of leaving the parts of the stump 
                 AMPUTATION.                223
connected by their natural attachments, and thinks that
by cutting in this manner, the patient suffers less pain.
  I have  not had an opportunity to put this mode of
amputating to the test of experience on the living sub-
ject, but have repeatedly performed it on the dead.  It
may be performed with this kind of knife very neatly
and speedily, and in most cases, I think it preferable to
the other mode of cutting from without inwards.  The
stump will be the same  in both cases,  if the flaps are
alike and of a proper length for the size of the limb;
b'jrt I would advise that the limb should be  marked by
an exact measurement in the manner I have described
above.
  I have mentioned the  use of the tourniquet, but it is
more than ten years since I have used the common one.
The instrument should indeed be condemned as worse
than useless.   The means I have employed to stop the
hasmorrhage, are the handkerchief and stick, which are
easily and quickly  applied, not  liable to  slip or break,
and  always  effectual.   Their  application  is  simple,
being nothing more than tying the handkerchief loosely
round  the limb, passing  a piece of wood a fewr inches
in length underneath it,  which upon being turned, pro-
duces a powerful and quick compression.
  Mr. Symes has made what he  considers as an  im-
provement in the method of restraining  haemorrhage;
which consists in making direct pressure on the artery
alone, and thus diminishing the quantity of blood in the
limb.   When the artery is effectually compressed a
few minutes before the operation is commenced, it must
certainly have that effect.
  An objection  against the common form of the tourni-
       29 
 224                 AMPUTATION.
 quet  acting with a screw, is that it operates so slowly
 as to retard the blood in the veins some time before the
 circulation in the  artery is stopped; consequently  the
 limb contains more than its due quantity of blood when
 it is amputated.
   This objection  does  not lay  so much against  the
 handkerchief and stick, which operates much quicker,
 and if the precaution is taken  to elevate the limb above
 the body a little while before the  handkerchief is fitted,
 and the stick be turned suddenly, this objection may be
 obviated; or if it were important that a small quantity
 of blood only, should be lost, the  artery might be com-
 pressed a little before the handkerchief is straightened,
 and the  operator  would have complete command of
 the haemorrhage.   This I think the preferable method;
 for if  I have been correctly informed, the want of this
 precaution, and an entire dependence upon compressing
 the artery, has in one instance in  this country, been  at-
 tended with bad consequences, which wrould have pre-
 vented by the method which I have suggested.
   It is certain that a pressure  on  an artery, which will
 prevent its pulsations in the limb below, will not always
 prevent the artery from bleeding  when  divided.  In
 amputating an arm at the shoulder  joint, pressure was
 made where the artery passes  over the first rib; which
 stopped the pulse at the wrist.   When the artery was
 divided, it projected a full stream of  blood.  The end of
 the artery was grasped  with the  fingers, however, and
tied so that no bad consequences ensued.
  Upon the whole, I am decidedly of opinion  that the
method I have proposed is the safest and best, 
AMPUTATION.                225
             Explanation of the Plate.
1. Amputating knife with the edge on the convex side
  the blade about five inches long, and one inch wide.
2. Piece of paper long enough to encircle the limb, but
  folded up so as to be but half its circumference, and
  cut out by  the dotted line marked by a pair of com-
  passes.
3. Same piece of paper spread out.
4. Limb to be amputated; the dotted  lines representing
  the marks  made with the pen or crayon, guided by
  the two semi-circular edges of the paper.
5. Appearance of the stump before  the dressings are
  applied.
6. Imaginary section of the stump after it is healed.
7. Strip of adhesive plaster doubled and marked where
   it should be cut.
8 and 9. The same cut and spread out. 
 
A CASE OF
        OVARIAN DROPSY,

SUCCESSFULLY REMOVED BY A SURGICAL OPERATION.
  The subject of this operation was a Mrs. Strobridge,
of Norwich, Vermont, aged 33 years.
  The following account of the case, previous to the
operation, was taken from the  patient:—Seven year's
before, she had perceived a small tumour in her right
side, situated in the right iliac region; when about the
size of a goose's egg, she could move it with her hand to
the opposite side of the linea alba, and to some distance
above the umbilicus. The patient had borne five chil-
dren, two previous and  three subsequent to her  disco-
vering the tumour.   The youngest child was 10 months
old, and was nursed at the breast wiien she submitted
to the operation.   Soon after her first pregnancy, from
the commencement of  the tumour, and  when, as  she
thinks, it was about four or five inches in diameter, it sud-
denly disappeared, probably burst into the abdomen.—
In four or five weeks it was as large as before.  Before
and  after the bursting of the tumour she had turns of
faintness, which lasted from two hours to half a day.—
During parturition of her second  child, after the com- 
228            OVARIAN DROPSY.
mencement of the tumour, it having acquired a conside-
rable size, it burst again, and nothing was perceived of
it till eight months had elapsed.  In four days from its re-
appearance it was as large as it had ever been.  It was
again burst  by a fall; great soreness  of the abdomen,
and confinement of the patient  for several weeks were
the consequence. The tumour filled again in a fortnight
and from this time continued  to increase; it did riot
burst in  the dilivery of her last child, which was ten
months previous to the operation^  The patient's health
was not much affected by the tumour.  She was costive;
and the size  of the tumour incommoded her in the ordi-
nary duties  of her family, especially  in stooping.   On
examination I found a large tumour in the nght side of
the abdomen; it was considerably moveable, and I could
produce a distinct fluctuation through it.
  Having decided on the operation, and determined the
mode of operating, on  the 5th of July, in the presence,
and with the  assistance  of Doctors  Lewis,  Mussey,
Dana, and Hatch, I commenced the  operation as fol-
lows:—
  The patient being placed on a bed,  with  her head
and shoulders somewhat raised, an assistant rolled up
the tumour  to the middle of the abdomen, and held it
there.  I then commenced an  incision about  an inch
below the umbilicus, directly in the linea alba, and ex-
tended it downwards three inches.  I carried it down
to the peritoneum, and then stopped till the blood  ceas-
ed to flow, which it soon did.   I then divided  the pe-
ritoneum the whole extent of the  external incision.—
The tumour, now exposed to view, was punctured; a
canula. introduced, and seven pints of a dark coloured 
                 OVARIAN DROPSY.             229
 ropy fluid was discharged into a vessel. About one pint
 was spilt, so that the whole fluid was about eight pounds.
 Previous to tapping the tumour, by inserting my finger
 by the side of it, I ascertained that it adhered to some
 extent to the parieties of the abdomen, on the right side,
 between the  spine of the ileum and false ribs.   After
 evacuating the fluid I drew out the sack, which brought
 out with it,  and adhering to it, a considerable portion of
 the omentum.  This was separated from the sack with
 the knife; and two arteries which we feared might bleed,
 were tied with leather ligatures, and the omentum was
 returned.  By continuing to pull out the  sack, the
 ovarian ligament was brought out, this was cut off, two
 small arteries secured with leather ligatures, and the
 ligament was then returned.   I then  endeavoured  to
 separate the sack from its adhesions  to the parietes of
 the abdomen, which occupied a space about two inches
 square; this  was effected by a slight stroke of the knife
 at the anterior part of the adhesion, and by use of the
 fingers.  The sack  then  came out  whole,  excepting
 where the puncture was made, and I  should think it
 might weigh between 2 and  4 ounces.   The incision
 was then closed with adhesive plaster, and  a bandage
 was applied over the abdomen.  No unfavourable symp-
 toms occurred after the operation; in three  weeks the
 patient  was able to sit up  and walk, and has since per-
 fectly recovered.
  I was induced  to undertake this operation from the
following considerations:—The patient, though her
health was not greatly impaired, was sensibly affected
 by the disease. She was quite certain that the increase
of the tumour, in a given time, was augmented; proba- 
230             OVARIAN DROPST.
bly, at no very distant period, it would have destroyed
her.  I had, also, had an opportunity to dissect the body
of a patient, who had died of ovarian dropsy, after being
tapped seven times.   In this case the sack wras found to
be in the right ovarium, which  filled the whole abdo-
men; but it adhered to no part except the proper liga*
ment, which was not larger than the finger of a man,
J have seen two other ovarian sacks which  were taken
from patients after death.   They had been tapped seve-
ral times; the sacks were equally unattached, except to
their own proper ligaments.  Hence,  I inferred, that in
a case of ovarian dropsy, while  the  tumour remained
moveable, it might be removed with  a prospect of suc-
cess.   The mode of operating, practised in the above
case, is the same that I have  described to my pupils iq
several of my last courses of lectures on  surgery.  The
event has justified my previous opinions..
                     NOTE.
  Before the extirpation of the Ovarian Tumour was
accomplished by Professor Smith, as related in the fore-
going pages, the same operation  had been performed
successfully in Germany.  Of this,  however,  he had
no knowledge, and  the  operation was  therefore with
him altogether original.  As such, it must certainly be
acknowledged to be one  of the boldest achievements of
modern surgery.
  The discouraging circumstance in regard to these
operations, is  the difficulty under which  the  surgeon
must ever labor in establishing the true character and
relations of the tumour, before attempting  its  extirpa-
tion.  It  is for this  reason, that many of  the most en-
terprising surgeons  of the present day are disposed to 
OVARIAN DROPSY.
231
decline the operation.  And here, candour compels me
to state  that  this difficulty of determining the true
character of  such  tumours,  and, consequently, the
feasibility of the operation, before opening the abdomefl,
was  experienced by Professor Smith, in two cases in
which he attempted the operation, but was compelled
to desist.
   In one of these cases, it was ascertained, on opening
the walls of the  abdomen, that the uterus was also hv
volved in  disease, and, indeed, constituted the most
voluminous part  of the tumour.   The attempt  which
was made in the second case, I witnessed.   There was
no difficulty in ascertaining from the history of the case,
the character of the disease, but  as  the tumour filled
the belly,  it was impossible to  ascertain  its  attach-
ments, as it could  not be made to move in  the cavity.
Knowing that the practicability of the operation was
doubtful, the operator proceeded with great caution-
opened the belly along the linea alba—exposed the sur-
face of the sack—punctured it, and drew from it its fluid
contents, which were very copious.  He then introduced
his finger between the walls of  the belly and the sack,
and endeavoured to ascertain its connections.   Its  ad-
hesions were found to be extensive and firm—so much
so that he at once desisted from further attempts, and
closed the  external  wound.  Some  degree of perito-
neal inflammation  took place after the operation, but it
was subdued without much difficulty; the wound healed,
and the patient survived for three or four weeks, when
the sack again filled, and  also the cavity of the  belly,
and she died with the ordinary symptoms of dropsy.—
I should  here remark, that the operation of paracentesis
abdominis,  had  been performed  in  this  case, two or
three times.
   The occasional performance of this operation will
undoubtedly induce  a more careful inquiry into  the
diagnosis of the ovarian tumour,  and enable us to de-
termine with more precision the feasibility  of the ope-
ration in particular cases.
       30 
232               OVARIAN  DROPSY

  As the operation has several times proved perfectly
successful,  and has thus arrested the progress of a dis-
ease which must  otherwise  have  inevitably resulted
fatally, the  propriety of resorting to it, in those cases
in which a clear diagnosis can be  established, appears
to me to be obvious, provided, at the same time, that
disease  is  making alarming progress, and  threatening
life.
  The principal traits  with which we are yet acquaint-
ed, as characterizing the ovarian dropsey are; 1, the
purely local character of the disease—-the organic func-
tions of the system being but little, or not at  all dis-
turbed—even the uterus often manifesting no morbid
phenominon;^2, the location of the tumour, it first pre-
senting itself  in the iliac region; 3, its mobility.  The
ovary being loosely attached by the broad  ligament to
the  uterus, and to the walls of  the pelvis} is, when it
first becomes enlarged, capable of being made, by pres-
sure, to glide  into  almost any part of the lower region
of the abdomen.   Yet there is  one part of the cavity
which seems  to be its home, and  to which it most
tends to retract, and that is the iliac region.  4. As the
disease advances the uterine  system is observed to be
more disturbed in  its fuctions than the other viscera of
the abdomen.
   The  practicability of removing such a tumour is  to
be  determined by carefully ascertaining its  degree  of
developement, its mobility, and thus, as far as possible,
its connections. When the tumour becomes so volumi-
nous as to fill the cavity of  the abdomen,  and distend
its muscular walls, the operation should,  in my  opinion,
never be attempted, for then, the surface of the tumour
being pressed into close and permanent contact with
the viscera and walls of the belly, will have established
numerous  adhesions.   Besides,  it will be impossible, as
the tumour is then immoveable, to ascertain its attach-
ments.   In a case of  this kind  which I dissected two
years since, I found the sack very extensively adherent
to the intestines, mesentery,  and peritoneum. 
OVARIAN DROPSY.              233
  When the tumour is very moveable, the presumption
is, that its attachments are not numerous nor close.—
The points of  attachment  we  may  also sometimes
ascertain by pressing the tumour in various directions,
and  observing the resistance which is made, and the
pain which is produced by its dragging upon particular
parts.
   I ought here to state, that the  same operation has
been performed in this country in several instances by
Dr.  McDowell, of Kentucky, and more  recently by
others.   I am not confident that the first operation by
Dr  McDowell was subsequent to that of my father.
                                       N. R. S. 
if 
LIGATURE
EXTERNAL ILIAC ARTERY,
        for the cure of aneurism.         /
                                        ti
  Achilles H. Elliot, of Killingworth, Connecticut,
some time in the month of June last, felt a pain in the
left groin, and soon perceived a small pulsating tumour:
it was situated just below  Poupart's ligament, and in-
creased pretty rapidly.   On the 25th of July, with the
assistance of Dr. J.  Knight, professor of anatomy in
this institution, I undertook the operation of tying the
external iliac artery.  The aneurismal tumor was situ-
ated in the left groin.  It  pulsated strongly, and  from
its size, it might contain eight ounces of blood.  The
whole limb was considerably cedematous.  We follow-
ed Dr. Dorsey's mode of operating in this case, which
is not materially different from that of Mr. Abernethy,
who was the  first that attempted this operation, and to
whom we are so largely indebted  for other important
improvements in surgery.
  The patient  being placed  in  a  proper situation, I
commenced an incision, about an inch above Poupart's
ligament, and directly over the external iliac artery, ex- 
230           EXTERNAL ILIAC ARTERY.
tending it obliquely upwards, nearly  in the direction of
the fibres of the external oblique  muscle, about three
and a half inches.  The skin  and adipose membrane
being cut through, the fibres of the external oblique
were  divided longitudinally, and  the internal oblique
and transverse cut across, which brought the perito-
neum into view.   I then insinuated my finger between
this membrane and the muscles down to the external
iliac artery, which I readily found, and endeavoured to
detach from the surrounding parts.  By means of Dr.
Physick's curved forceps, I then  passed the aneurism
needle under the artery; but owing to an imperfection
in the needle, which  was made on the spur of the oc-
casion, it slipped out  of my fingers, after I had hold of
the point of it.   I was obliged to withdraw it and fix it
again in the forceps, and when I brought the point out
a second time, Dr. Knight took hold of it  with a firm
pair of forceps and drew it through, wiiich carried the
ligature under the artery.   After examining, to be cer-
tain that the ligature  included nothing but the artery, I
drew it very tightly.  At this moment the patient com-
plained of severe pain, but it lasted only a few minutes.
The pulsation in the aneurismal tumor  ceased imme-
diately on tightening the ligature.
   The wound was then dressed with adhesive straps,
with a compress and flannel bandage over the whole,
adjusted in such a manner as to afford moderate  pres-
sure on the wound and aneurismal tumor.   Before we
had finished the dressing, the limb of the affected side
was sensibly colder than the other.  The operation was
performed about 10 A. M.  At 2 P. M. the  left limb
was warmer than the other; in the evening I could per- 
           EXTERNAL ILIAC ARTERY.           237
ceive no difference in the temperature of the two limbs.
The affected limb as well as the whole body was in a
state of perspiration, the wreather being very warm at
that time.  The next day a pulsation was felt in the
posterior  tibial  artery, where  it passes under the
malleolus internus, and the  aneurismal tumor was con-
siderably diminished.  It continued to decrease, until it
wholly disappeared, which happened  in about four
weeks.  The ligature came  away on the twentieth day.
There was not the slighest  haemorrhage, and no  unfa-
vourable  symptoms occurred  during the cure.  The
limb was somewhat debilitated  at first, but it has now
entirely recovered its power.  The ligature made use of
in this case  was  linen shoe-thread, made  small and
hard, and I endeavoured to draw it so as to kill the
artery in that point on which it acted.   I tied with a
single ligature, and did not  divide the artery.
   There was not the least embarrassment in the ope-
ration, except what arose from the imperfection of the
needle.   To remedy  this  in future operations of the
kind, the needle should have a broad point, and  be  so
curved, as to describe nearly half a  circle in its shape.
   Yale College, Dec. 16, 1820. 
 
DESCRIPTION
                       OF A

           NEW INSTRUMENT

                      FOR THE

EXTRACTION OF COINS & OTHER FOREIGN SUBSTANCES

                      FROM THE


            CESOPHAGUS.*
  I have twice been called upon to remove coins from
the throats of children.   In  both  instances, they had
descended to  near the inferior  extremity of the oeso-
phagus; where the passage is  a little narrowed, just be-
fore entering the stomach.   Of course, they were en-
tirely beyond the reach of forceps, or any instrument
which might be employed to grasp and thus withdraw
them.
  "The instrument which the exigencies of the case
suggested, and with which I succeeded, was unlike any
thing which I have known to be employed for a similar
purpose.   A very few  words, with the acompanying
plate, will be sufficient to give an idea  of it.
  "The shaft of the instrument is a rod of whalebone,
twenty inches in length, and of the size of a small quill.
31
* See cut at page 138 
240                 CESOPHAGUS.
Half an inch from one extremity there are attached, at
acute angles, like the barbs of an arrow, twro wings of
silver, an inch and a quarter in length, a quarter of an
inch wide, and so thin as to be very elastic and flexible.
The extremity, which  stands  off from the instrument,
is convoluted so as to render it blunt, and is a little curv-
ed  inward toward the  shaft of the  instrument.  The
two wings are  pinned to the shaft of the instrument, and
may be continued over its extremity, which should ter-
minate with a  bead, or obtuse point.
  "From the position of the oesophagus between the tra-
chea and spine, the faces of the coin present forward
and back.   When the instrument is thrust  down  the
oesophagus, avoiding the glottis, as may  be done with-
out difficulty, and presenting the barbs one forward and
the other back, it will pass either behind or before  the
coin, and the barb will spring beyond it, and catch it be-
tween itself and  the shaft, when it may be very easily
withdrawn.  The manner in which the shaft is embrac-
ed  by the oesophagus above, prevents its slipping  off
laterally.  In  both the cases alluded to,  I  accomplish-
ed the extraction of the coin without any difficulty, and
at the first trial.  In the second case, after I had once
raised the coin into the mouth, the child  instantly swal-
lowed it again, though I had almost seized it with  my
fingers.   It  returned  to the same place, and  I again
withdrew it at the first trial.
  "The barbs  are made so  thin that should they catch
in any of the follicles of the cesophagus,  they would be
everted sooner than rupture the membrane." 
HINTS
                   OVTHH


OPERATION  OF LITHOTOMY.
BY N  B. S1VXXTH, M. D
   Professor Nathan Smith performed the operation
of Lithotomy twenty-three times.   Of this number of
patients, he lost three.  These, however, were cases of
an extremely unpromising character, the calculi being
uncommonly large, and as is then  usually the case, the
patients much worn down with suffering.   They were
also men of  advanced age.  When we compare this
result with the average of deaths in the hands of other
operators, it  must be admitted that Professor Smith
was more  than  usually successful.  Although he has
left no memoir on this subject, yet, as I have witnessed
several of  his operations  for stone, and am  familiar
with the principles which governed him in the ope-
ration, and with  the mode of treatment which he adopt-
ed after the  operation, I  shall  here offer a few com-
ments on his  practice in this disease.
   The operation which  Professor Smith  exclusively
performed was the lateral, and he, with one exception,
invariably employed the gorget for his deep incision. 
 242                  LITHOTOMY.
   I have heard him remark, that he had, in several in-
 stances, known an  error to be committed  in regard to
 the supposed presence of a calculus in the bladder, in
 consequence of the  sensation  communicated  to  the
 hand of the surgeon through the wound, by a sabulous
 incrustation upon the internal  surface  of the bladder.
 He believed that in those cases in which the operation
 is sometimes  incautiously performed, and no stone
 found in the bladder, the error has arisen from this cir-
 cumstance.
   In one instance,  in which my father removed from
 the bladder a  small  mulberry  calculus,  the ordinary
 mode of  sounding  failed to detect  the presence of  a
 stone.  The symptoms, however, were very decisive,
 and had existed from infancy, to the age of nineteen.
 Professor Smith, on once sounding  him, could detect
 no stone,  and of course was not  sufficiently assured to
 cut for  it.  He used the common sound, the  bladder
 containing a fluid; and then the catheter, to completely
 empty the organ, and bring the calculus in contact with
 the instrument.  Subsequently, the  symptoms continu-
 ing with unabated severity, he caused a flexible elastic-
 gum catheter to be  tipped with  a  bead of silver.  This
 he introduced into  the bladder, and caused it  to glide
 over the surface of the organ in various directions.  In
 this  way he promptly struck the  stone, and proceeded
 to perform the  operation.
   In making his external incision, he used the knife
 with  freedom,  believing  that mischief rarely  results
 from too extensive  an external  wound, and  that great
 inconvenience may result from the incision being so
 narrow as to impede the subsequent, more difficult and
important steps of the operation. 
                  LITHOTOMY.                  243
  The gorget which he employed, during the latter
years of his practice, was that invented by Professor
Physick, of Philadelphia.
  The incision which he was accustomed to make iri
the prostate gland and neck  of the bladder, was free,
for  the  purpose of enabling him  to extract the stone
with facility, and with the infliction of but little irrita-
tion, or contusion, upon the  parts through  which it
was to be  drawn.  There was no circumstance which
he more dreaded than the tedious and difficult extrac-
tion of the stone.  To obviate at once the necessity of
this, and that of making a wound of dangerous extent,
and which might be  attended with alarming hemorr-
hage, he  was always desirous of accomplishing  that
which many operators have deprecated,  the fracture of
the stone by the forceps.  He was then enabled to re-
move the  fragments successively, without violence.—
The frequent introduction of the forceps, for this pur-
pose, he regarded as by no means mischievous, compare
ed with the violence necessary to extract a large stone
entire.  He had no fear that any portion of stone would
be  left to form the nucleus of a new  calculus.   He
found it easy to search the bladder with the finger—to
remove  all considerable  fragments  with the forceps,
and to  wash away  all sabulous particles with  the
syringe.   He believed, too, that these substances would
generally be discharged spontaneously from the bladder,
through the cut, if officious endeavours were not made
to close the external wound, and to prevent the escape
of urine and blood.
  A large stone he always endeavoured to break,  and
in order to effect this with facility, he devised a pair of 
244                  LITHOTOMY.
very strong forceps for the purpose of crushing it.—
These were contrived with a screw at the extremity of
the handles, for the purpose of compressing the blades
with  great  force, when the stone was  grasped.   He
was well aware that large stones, having their external
shells formed of the phosphatic salts, are generally soft
and friable.
   His mode of dressing the wound, after the operation,
was extremely simple.  He  used  for this purpose
merely a loose fold of linen, confined by the bandage.
His after-treatment of the case was in nothing peculiar.
He learned by experience, however, not to be too offi-
cious in the employment of those  medicines which are
regarded as lithontriptics.  On one individual he ope-
rated  three several times—the stone returning twice.—
After the first operation, believing the calculus to con-
sist chiefly of the lithic acid, he exhibited the alkalies.
After the second operation, the calculus having more of
the phosphatic  character, he  gave  acids.   After  the
third, he left him to the efforts of nature, and allowed
him the diet which his appetite indicated, and the cal-
culus never again formed.
   Prefixed to the present article, is a plate representing
an instrument  which  the writer  has devised  for  the
purpose of facilitating the most important of the steps
of this  formidable operation—the incision into.the blad-
der.   Before I describe its construction, or explain its
utility, I would offer a few preliminary remarks, in re-
lation to the principles which have governed my prac-
tice in this operation.
   I have now cut for  stone, on  the male subject, seven
times.  My patients  are all now living, and in good 
                  LITHOTOMY.                 245
health, nor in any instance  have the symptoms of the
disease as yet recurred.  This gratifying success, I am
very free to admit, may be rather owing to my good
fortune  than to any particular dexterity with which I
perform  the  operation, or  judgment  with which  I
subsequently manage my patients.   Still, however, this
degree of success may entitle me to be heard on this
subject, and the method which I adopt, to some con-
sideration, as perhaps contributing to  these happy re-
sults.   The cases on which I have operated have by no
means been selected ones.  One was that of an individual
of forty-five years, who had long suffered from the dis-
ease, and was exceedingly worn down by it—the calcu-
lus being extremely large.   Another was of a lad of
fifteen, who had been cut  eight years before by a sur-
geon who found no stone in the bladder.  From that
time he had suffered the most agonizing torture  from
the disease, and  when at  length  he was cut by  me, I
removed two large calculi, and found the bladder to be
in an extremely diseased condition.   He has perfectly
recovered.
   I would premise  what I have  to  say on this subject
by remarking, that  if I have been  more successful in
this operation than  most others have been in their first
essays, I consider  that it is not because of any thing
which I have done; but, as I believe, because of what
I have not done.  I have ever endeavoured, in the first
place, to accomplish the operation in the simplest man-
ner possible, and have then left my patient entirely to
the recuperative efforts of nature.
   My two first operations were with the gorget;  but  I
then laid aside that instrument, with a full determination 
246                  LtTHOTOMY;
never to employ it again—not because  I encountered
any particular difficulty in its use, but because I found
it, on the whole, to be a very awkward and inconvenient
instrument, with which to make a simple incision along
a grooved staff into  the bladder.  I became satisfied
that I could use the scalpel with far less hazard of acci-
dents, and in a  measure to affect, with far more preci-
sion, the desired extent and direction of the cut.
  I next employed a common scalpel, both for the ex-
ternal and for the deep incision; but finally fixed upon
a straight, strong bistoury, with  a narrow blade about
four inches in length, but having a cutting edge only for
an inch and a half  from the point.  This  instrument
I have generally used only for the deep incision, through
the prostate; but in one instance I struck it at once into
the groove of the staff, and accomplished both the ex-
ternal and internal incision at a single thrust.
  It has always been my object to make a free exter-
nal incision, but a narrow one into the neck of the
bladder.   Indeed, I have,  in  almost every instance,
made an opening into the bladder so small as barely to
admit the point of the finger,  and have then gently dilat-
ed this by introducing the finger.
  I am well aware that many surgeons are averse to
such an  expedient, as savouring too much of the old
method by the  apparatus major, and as  causing lacera-
tion and contusion, which  must be  more mischievous
than simple incision.  But I would have it understood
that I by no means endeavour to  form an opening for
the passage of  the stone by this kind of dilatation, ex-
cept at the point where the incision terminates  in the
shoulder of the bladder.   I always endeavour to incise 
                  LITHOTOMY.                  247
freely the  anterior portion of the  prostrate, that no
lacerating violence may be inflicted upon this body.
  Tfte tunics of the bladder are exceedingly distensible,
and that, too, without the infliction of any considerable
force.  By a gentle effort, an opening which, when the
bladder is but  little distended with its contents, is very
small, may be made one of considerable magnitude,
without any laceration or contusion  whatever.   When
this is done gently, with the soft finger, I am confident
that not the least mischief results—at  least there has
never arisen from it the  slightest unpleasant circum-
stance, in any  one of the several cases in which I have
employed it.
  The advantage which  I propose to myself in this
method, is the avoiding to wound the blood-vessels of
the bladder and  prostrate.  Hemorrhage from these
vessels I have  always been accustomed to regard  as the
fatal circumstance, in most cases of lithotomy  which
have an unhappy issue. I judged so from what I had wit-
nessed in the  practice of others, and from what I had
learned in relation to it from the records of surgery.—
I am confirmed in my opinion by my own experience.
There is nothing which, after this operation, has given my
patients so much annoyance, as the lodgment of coagula
in the cavity of the bladder, and in ;he incision.  When
in the former  situation, they provoke the bladder to re-
peated, convulsive, and often ineffectual efforts to cause
their  dislodgment.   When acted upon by  the  urine,
they speedily  undergo chemical changes, and then in-
flict the most serious irritation upon the mucous surface.
  When  the coagula obstruct the wound through the
prostrate  and urethra, the urine is expelled from the
       32 
 248                  LITHOTOMY.
 bladder by the contractions of that organ, but not being
 able to escape from the external wound, it is injected
 into the cellular tissue, and is  there productive of the
 most fatal consequences.   I have several times witness-
 ed the agony of the patient at the time that the bladder
 has been labouring with often repeated and convulsive
 throes, to expel the internal and external coagula, from
 its  cavity and from the wound.  No remission of the
 most acute suffering is experienced, till the  coagula are
 removed, either  by these involuntary efforts, or  by the
 aid of  the surgeon.
  Now, it is hemorrhage from the deepest vessels which
 are wounded—those of the bladder itself—that is most
 apt to  pour blood into the cavity of the organ, and to
 block up the canal of the wound, before the blood can
 escape from the  external opening.   It is true that the
 surgeon can remove  these coagula by a  careful use of
 the syringe; but  then, besides the prostration which is
 liable to occur from the continued  bleeding of these
 vessels, and perhaps death from that circumstance, the
 injection of water into the wound is always  painful, and
 is liable, itself, to occasion infinite mischief when thrown
 with the force which is  often  necessary to break up
 the coagula.  The introduction of a sound, or other
 instrument, for the removal of such substances, is also
 productive of  extreme irritation, and when  there is a
 disposition  in the parts to hemorrhage, will provoke its
 continuance by rendering them the seat of irritation.
  It is therefore earnestly to be desired that we should
 avoid the necessity of these expedients, by wounding as
 few of the vessels in the deep portion of the cut as pos-
sible.  It is unnecessary to say that, when they are 
                  LITHOTOMY.                  249
wounded, they cannot be reached for the application of
the  ligature.   Now, by making an  incision into  the
bladder of only brief extent,  and gently dilating this
with the finger, but few of these vessels will be wound-
ed; or, if any are  ruptured, in the dilatation, they will
be placed in the condition of a lacerated vessel and will
not bleed.  A great deal depends, it is true, on the man-
ner  in which the  dilatation is effected.   Tissues like
those of which the bladder is composed we know to be
dilatable to a  great extent, without inquiry.  We can
so dilate the anus and  rectum by a gentle and continu-
ed effort, as to introduce the whole hand into that gut,
without inflicting much pain or injury.
   In extracting the stone through a wound thus partial-
ly dilated, it is necessary that the further dilatation made
by the passage of the  stone itself, should be effected in
a gentle and  gradual  manner.   The operator  should
endeavour  to do this rather with the blades of the for-
ceps, than with the stone which they grasp.   This he
can  accomplish, by making the movements from  side
to side, which are necessary in thus dilating, in the di-
rections of the blades of the forceps, rather than in the
directions of  the exposed surfaces of the stone.  Thus
will  the necessary force be impressed upon the sides of
the wound by the  smooth blades of the forceps.
  Nothing is so reprehensible in the surgeon, as hurry,
and the affectation of despatch in these steps of the ope-
ration.  A degree of dilatation which may be perfectly
safe  when  gently and  gradually effected, may be fatal
laceration, when it is rudely and hastily accomplished.
  After  extracting the stone  from the bladder, it has
never been my custom to inject water or any other fluid 
250                 LITHOTOMY.
into the organ, for the purpose of washing  away any
supposed fragments of stone, or sabulous particles.   I
have  always been able to remove such with the finger
—at  least, all that I deemed it necessary to remove;
for I am persuaded that, if nothing be done to obstruct
the wound, and hinder the escape of such substances,
the bladder will* itself disgorge them from the opening.
To effect the removal  of such  substances, if water be
used, it must be thrown in with force, that the particles
may be washed  away iu its current.  I have  always
been apprehensive that in throwing it in with this degree
of violence, I should inject water into the cellular tissue
of the wound.  This may very easily occur, when the
syringe is employed for this purpose; for the beak of
the instrument is exceedingly  apt  to get disengaged
from the bladder  at the moment  that the  thrust  with
the piston is made.   Even when the elastic bottle is
used, the water regurgitates from the bladder  with  a
good deal of force, and as the  external wound is ob-
structed, it is urged  with greater or less impulse into
the cellular tissue.
  When we have reason to believe that coagula of blood
are distending the bladder,  and provoking it  to  inef-
fectual  contractions, it is then certainly  proper that
means should be employed to facilitate their escape.—
Under such  circumstances, I found it necessary, in one
instance, to gently open the wound with the extremity
of a catheter, and, afterward,  to  throw a  stream of
warm  water into it with a syringe, until I had  broken
up the coagula which obstructed  the external  wound.
I believe that this will generally be found sufficient, for
the bladder has power enough to expel its own coagula,
if the external passage be free. 
                   LITHOTOMY.                  251
   In the several cases in which I have operated, there
 has never occurred the slightest symptom of returning
 calculus, although  I  have never been as  officious in
 washing out the bladder, as  I  know many of my pro-
 fessional brethren to be.
   It is the practice  of  very eminent  surgeons  of the
 present day to introduce into the bladder, through the
 wound, or through the   urethra, a  catheter or gum-
 elastic canula, for  the purpose of facilitating the dis-
 charge of urine from the  organ, without permitting it to
 flow along the surface of the  wound.   This, could  it be
 accomplished, would certainly be a desirable object*;
 but it appears to me that the introduction of such an
 instrument, will not only fail to  effect this,  but must
 necessarily  cause  great  annoyance  to the patient, and
 great irritation in the wound.  In one  instance I intro-
 duced a  large gum-elastic catheter into the wound, and
 left it for a short time.   I was careful to introduce its
 point fairly into the bladder,  and to place it in such an
 attitude that it should give as little annoyance as possi-
 ble.  My patient, however, soon  began to  complain of
 it, as giving him great uneasiness, and begged me in the
 most importunate manner to  remove it.  I have never
 since employed any thing of  the kind,  nor  shall  I  ever
 again use it, for the following reasons.
   Any hard  foreign substance, whatever it may be,
when present in the bladder, is observed to create great
irritation, and to provoke the organ  to repeated  efforts
to affect  its discharge.  Certainly, then,  a catheter in-
troduced into this organ, while  it is  in a morbidly irri-
table condition—introduced through a wound—must oc-
casion extreme irritation, and cause spasmodic contrac-
tions of the viscus. 
252                 LITHOTOMY.
   To pass such an  instrument  with precision into the
wound in the bladder, the finger must be introduced to
conduct it to its place of destination.   If this be not
done, it is impossible to tell where its point may  be
lodged.   But the contractions of the bladder, and the
unavoidable movements of the body, will be exceedingly
liable to urge the point of the instrument from the blad-
der.  When  this occurs, the catheter must  be pushed
back again by hap-hazard,  into the bladder, or the
finger must be introduced  to  conduct it.    There is
mischief and danger in both of  these attempts.   What
surgeon has not experienced the difficulty of  maintain-
ing the position of an instrument in the  bladder, even
in its healthy condition?  Unless the  utmost care  be
taken so to secure it that the contractions of the blad-
der and  of the urethera shall be obviated, it is perpetual-
ly slipping below the prostate.  The instrument is also
liable to become soon filled with mucus, or coagula, and
thus to become in a short time completely obstructed,
so that it  shall be necessary, either to open its canal by
injecting water through it, or to remove it  altogether
and introduce  another.   This  necessity may occur in
a few hours,  so copious  is  the  discharge of  tenacious
mucus, under these circumstances.
   Whenever the catheter, or canula, does become ob-
structed, or displaced, so that it no longer conducts  off
the urine, infinite mischief  is liable to result.   Then,
instead of facilitating the discharge of  water, and pre-
venting  its contact with the surfaces of the cut, and its
infiltration into the  cellular tissue,  it directly impedes
the escape of the  fluid by assisting to  block up the
external wound.  And  even when its canal remains 
                  LITHOTOMY.                 253
clear, It is obvious  to every one that all  the  urine
secreted can not flow through it, since it is impossible
that the catheter should always reach the most depend-
ing part of the bladder.  But, in regard to the wound,
the passage of a small quantity of urine along its surface,
if it be sufficient to wet it from time to time, is as mis-
chievous as that of a larger quantity.
  To the above objections we may add the annoyance
which often results from the  external extremity of the
instrument being liable to be disturbed by the contact
of the dressings—the unavoidable motions of the patient,
and by the contact of the bed-clothing.  Every touch of
this kind, as it must necessarily disturb the internal ex-
tremity of the instrument, can not fail to  create great
irritation.  The mere contact of it, also, with the sur-
faces of the  wound, must give- greater or less annoy-
ance.
  These, to me, have appeared sufficient reasons, espe-
cially after trial of the expedient, to  reject every thing
of this kind.  But if this be productive of so much mis-
chief, what may we not apprehend  from officious at-
tempts of some to close at once the external wound by
the first intention.
  This is sometimes attempted by the  use of adhesive
straps, and the  application  of compresses and  the
bandage.  But to me it appears that such a practice is
fraught  with danger.   To effect the immediate closure
of the wound in the bladder  and prostate, is obviously
impossible.  This must be prevented by the contact of
the urine which must necessarily flow from the bladder
into this  part of the wound.   When, therefore, by an
attempt to close the external wound, the escape of that 
254                  LITHOTOMY.
urine which lingers in the internal wound is prevented, it
must, especially when the bladder contracts, be forced
into the cellular tissue in the vicinity of the parts divi-
ded, and become productive of incalculable mischief.
  Immediately after the extraction of a stone, the urine,
unless obstructed, continues  to  flow freely from  the
wound, for about twelve hours.   At the end  of this
time, in  consequence of the irritation produced by the
cut, and especially in consequence of that produced by
the flow of urine, the parts will have begun to swell.—
The  artificial canal will then be encroached upon and
the surgeon will learn, on inquiry, that no urine passes
by the wound, it being sealed by the swelling, and per-
haps by the effusion of lymph.   This fluid now passes
(at least in many cases,) entirely by the urethera.  Its
passage is accompanied  usually with pain and difficulty,
and this period of the patient's confinement is the most
perilous that occurs after the operation.  If the swelling
continues, and still closes the  external  wound, there is
great danger that the urine may find its way into sur-
rounding parts—that blood also  may be confined, and
that depots of matter may be formed in the vicinity of
the bladder.  Sometimes, it is true, where the condition
of the patient is most favourable, he being young and
vigorous, and when the  operation has been accomplish-
ed with facility and the cut is small, the urine may con-
tinue to be discharged by the  natural passage, and the
wound, by the  lymph which  will  have been effused,
may be closed by the first intention  to a considerable ex-
tent, so that all the evacuations of  urine, pus, or blood
shall  take place  by the urethera, and the  wound be
never again opened.  Usually, however, at the end of 
                  LITHOTOMY.                 255
 three  or  four days, when suppuration will have com-
 menced in the wound, the swelling begins to subside, in
 consequence of the purulent  secretion.   The parts
 become relaxed and lubricated with pus, and then urine
 begins again to flow from the cut with pel feet freedom.
 As soon as this occurs, the patient experiences a degree
 of relief, and, in most cases, the period of danger is then
 past.  I never cease to feel painful solicitude in regard
 to the safety  of my patient, till the  urine begins, the
 second time, to flow freely from the wound.
   Now, when an endeavour is made to close  at once
 the external opening, it is true that sometimes it may
 succeed in favouring union by the first intention, and
 thus occasionally a very speedy cure may be obtained,
 but in most cases  it will contribute to  the very result
 which is most to be dreaded—a premature suppression
 of the flow of urine from the wound.
   As regards dressings, after lithotomy—I employ
 none whatever, in which, however, I am not  singular.
 I cannot conceive of what utility a  compress of lint and
 a bandage caiTbe,  when it is once  established that any
 thing which obstructs  the wound, can be  productive
 only of mischief.   It is true that the bandage and com-
 press will defend the external wound from  the contact
 of the atmosphere, but of what utility is this, since the
 wound  must continue to be bathed with urine, which
 is far more acrid and irritating?  Indeed, the compress
 and  bandages immediately imbibe  the  urine w7hich  is
 effused, and instead of suffering that fluid to flow off by
 coming in contact  with but  a small portion of integu-
ments, diffuses it more widely over the surface, and
keeps  it in contact with the skin till often it  becomes
       33 
256                 LITHOTOMY.
excoriated.   I, therefore,  place  my patient in bed,
entangled in no dressing whatever, and allow him to
assume whatever attitude he pleases.

Description of  the Instrument (represented in the plate)
   designed for the pwyose of facilitating the incision.
   It has been my practice, as I have remarked, to use
a straight bistoury for making the internal incision.—
Some  of the operators of London  and Paris,  at the
present time, occasionally practice, on the young subject,
and on adults whose perinaeums are very thin, the bold
and, as it would seem, hazardous method of plunging,
at once, with the bistoury,  for the groove of the staff,
without first making the usual external incision, by which
the groove of  the staff is  sought before  the knife or
gorget is introduced.   This I  have myself once  prac-
tised with success and thus accomplished the operation
with great celerity, the several stages of the operation
all occupying not more than a minute and ten seconds.
I must confess, however, that even in that case, which
was one  of a child, I was  conscious, while executing
the incision, that it was quite too much of a hap-hazard
business.   On the adult, this method is generally alto-
gether inadmissible, and, indeed, no one  presumes to
attempt it, unless the parts  are unusually thin.
   If this method of making the cuts could be practised
with safety and precision, in all cases, I think it must
be apparent to every one that  the operation would be
greatly simplified—be rendered a great deal easier of
of  accomplishment—more expeditious—infinitely less
painful to the patient, and more favourable  to speedy re- 
 
"-jIsBsv
Xich of J2n,d,i£jie & S'wett. 
  The instrument here represented bears a strong re-
semblance to the double staff devised by Chesclden for
a similar purpose; yet it differs in some important par-
ticulars.  Although the construction of my instrument
was suggested solely by the exigencies of I he operation,
yet it is possible that  an instrument  precisely similar
may  have  been  used by  others.   I  claim  nothing,
therefore, on the score of priority of invention.
                                 N. R. SMITH. 
'-•-ini-T 
                   LITHOTOMY.                 257
 covery.  I know not how it may appear to other ope-
 rators, but to me, the cutting with the scalpel for the
 groove of the staff, the introduction of the gorget, or
 knife, into the groove of that instrument, the  anxiety
 which is felt in regard to its being properly fixed, and
 the means which are necessary to determine with cer-
 tainty whether it may be pushed forward with safety,
 constitute the most tedious, painful, and perplexing part
 of the operation.
   The parts on which we make our external cut, are
 in some degree loose and mobile, and when the  knife
 is applied to the integuments, they glide more or less
 upon the subjacent  parts.  So  also does the perinaeal
 fascia, upon the subjacent muscles.   In consequence of
 this, it happens that, when the membranous portion of
 the  urethra is exposed by several successive cuts, the
 relative anatomy of the parts becomes  confused as we
 proceed, and the cuts through the successive tissues are
 not every where  parallel and coincident.  This causes
 the  wound to be irregular, complicated, and  perhaps
 confined, although the cuts may be extensive.  For the
 same reason, too, the operator is in infinitely more danger
 of inflicting unnecessary injury upon parts which it  is
 unnecessary to incise—especially the  bulb of the ure-
 thra. If we could safely cut down upon the membranous
 portion of the urethra with one  stroke  of the knife—
 incising at once the different tissues that are to be di-
 vided,  there would not occur the same difficulty; but
 this cannot prudently be done.
  In the method of thrusting the point of the bistoury
 at once upon the groove of  the staff, in a manner that
I have  mentioned above, the design of the operator u 
258                  LITHOTOMY.
to transfix, instantly, the various parts which are to be
divided, and to identify the cuts through each.  The
deep and  superficial portions of the cut will then be
coincident with  each  other, and we have  a  simple,
straight incision, the sides of which are smoothly cut.
The incision, too, is made precisely of the  size which
is desired, at  the moment that the  bistoury is  with-
drawn from the wound.  But, as I have before remark-
ed, this plunge of the knife is perilous and not to be at-
tempted, even by the boldest operator, but in a few
select cases.
   But it occurred to me, that if any instrument could
be devised which should enable the operator to do this
in all cases with precision and safety, a great improve-
ment  would be made in- the simplicity, safety, and ce-
lerity of the operation.  After some reflection, I became
persuaded that an appendage might be attached to  the
grooved staff in such a manner as perfectly to accom-
plish the object.  I  became persuaded  that  something
might be attached to the handle of the staff, which, by
a hinge  to allow of the  necessary  degree  of motion,
could be placed in  such an attitude in  relation to  the
staff, as to furnish a perfect director which should con-
vey the knife directly to the part of  the staff which we
are desirous to reach.
   At length I succeeded in constructing an instrument,
which accomplished my object, and which is represen-
ted in the accompanying plate.   To the lower part of
the handle (1) of the common grooved staff, I attached
an instrument (3) of an arched form, and long enough
to extend from the place of its attachment to the part of
  he perinaeum which we design to incise. It is attached 
                  LITHOTOMY.                  259
to the staff by means of a strong hinge (2) which suffers
no lateral movements, but will allow the operator to
raise it high enough to pass the staff into  the  bladder
without any impediment from the scrotum.  The shaft
of this appendage is made firm enough to prevent any
lateral bending.   In order that it may be  adjusted, so
as to reach  any part of the perinaeum which  m .y be
desired, the hinge is attached  to a slide, which, in turn,
is fastened to the steel portion of the handle of the in-
strument by a projecting piece  passing through  a slit
in it, and fastened on the back part by a button,  or  a
screw, or by a mere bead.   This will then permit the
piece appended, to be slipped up or down  without its
being at all weakened  so  as  that  it shall become an
insecure director.   This inferior extremity of the in-
strument (4) is bent about an inch, or more, from' its ex-
tremity, backward, at a right angle, or nearly so.  It
will  then point to the groove  of the staff',  a  little ob-
liquely downward.   On the inferior side of the portion
thus bent backward, there is a groove with flat sides,
and  deep enough  to  receive more than half of the
breadth of a common-sized scalpel.  The sides of this
groove are made parallel to each  other, and  perfectly
true and smooth.   To this groove, a scalpel,  bistoury,
or whatever knife the operator designs to use, is  to be
adapted.  The back of the latter is to be so ground and
fitted that it shall apply to the groove with  perfect'ac-
curacy—glide in it without  impediment, and allow of
no lateral  play which  might render its direction un-
certain.
   This inferior portion of the appendage to the staff—
the portion in  which the groove is formed for the lodge- 
 260                 LITHOTOMY.
 ment of the back of the knife—I,shall cnll the conduc-
 tor. The groove in this portion of the instrument points
 directly to the centre of  the groove of  the staff, and if
 the instrument be well made, cannot deviate from it.
   I would here remark, that the staff which I prefer to
 employ is grooved neither directly on its dorsum, nor
 yet on its side, like that of Mr. Bell, but obliquely, and
 mid-way between these two aspects.  This is to enable
 the operator, after having introduced his knife into the
 grooved staff, to give its edge an outward and down-
 ward  inclination, so as to make the incision in that di-
 rection without danger of the  knife being thrown out
 of the groove of the staff by the prominence of the edge
 which is on that side of the groove.
   The mode of employing the instrument, modified as
 above, is to  introduce the staff in the usual way, ele-
 vating the appendage, and then bringing it down over
 the scrotum, so that the director shall point toward that
 part of the  perinseum which we design  to pierce, in
 order to reach the membranous portion of the urethra.
 This portion of the instrument may, indeed, be adjust-
 ed  so as to reach any part of the perinaeum, and  the
 operator has only to observe his land-marks—the tuber
 of the ischium—the anus—and the arch of  the pubes,
 and then fix  the appendage, so that when he  presses
 down the director upon the parts, it shall point directly
 to the membranous portion of the urethra, and through
those parts which we may wound  with safety.
  When the director is then pressed upon the parts, it
is obvious that it immediately fixes them upon the dor-
sum of the staff.  The skin, fascia, muscles  &c.  are
compressed upon each other, and no gliding of these 
                  LITHOTOMY.                 261
organs is suffered to take place.  By the pressure of the
director, the parts are kept in precisely the same rela-
tions, till the incision is  completed; and also, by being
condenced upon the dorsum of the staff, are made more
firm and steady to the thrust of the knife.
  The operator presses the director upon the parts with
his  left hand (the handle of the staff being held by an
assistant,) and taking the scalpel, or bistoury, the back
of which is fitted  to the  director, in  his right, in  the
usual manner, he applies it  to the groove, and  then
pushing forward the point, thrusts it down to the groove
of the staff without the possibility of its deviating so as
to occasion the least solicitude in the mind of the ope-
rator.   When the knife  reaches  the groove, and by a
slight movement upward  and downward the  membra-
nous  portion of the urethra has been  divided to some
small extent, the operator, still holding the knife steadily
fixed in the groove of the staff, seizes the appendage of
the staff with the  finger  and  thumb of the  left hand—
extends it, so  as to disengage it from the back of the
knife, (which, being now fixed in the groove of the staff,
requires no further support from it) and carries it out-
ward, at right angles to  the staff.  He  may then, by
holding the appendage, steady the staff while it is  still
held by an assistant; or he may grasp the handle of the
staff in the usual way, and carry forward the knife, to
make the incision of the prostate and shoulder of the
bladder.  In doing this, he should  incline  the edge of
the knife obliquely outward and downward, as soon as
it is introduced into the groove of the staff, and preserve
that inclination until it has fairly entered the cavity of
the bladder.   The entrance of the knife into the organ 
t
262                 LITHOTOMY.
is known by the diminution of resistance, and by the
gush of urine which will occur, if the operator has been
careful that some of that  fluid be retained in the blad-
der before  commencing the operation.    Then,  still
endeavouring to keep the point of the instrument in the
groove of the staff, he abducts the handle of the kuife
from the staff, obliquely outward  and downward,  and
withdraws the instrument in such a manner as to dilate
freely the external portion of the wound.
  The  operator then lays aside the knife, and introdu-
ces the fore finger of his right hand, to ascertain whether
a practicable opening has been made into  the bladder.
The narrowest portion of the wound he will find to be
that which enters  the coats of the bladder, and  if the
finger be constricted at any point, it will  be  there.—
Before the staff is withdrawn, he gently urges his finger
onward into the bladder, cautiously rotating it, and pres-
sing it from side to side, in order to dilate this portion*of
the wound, and obviate the necessity of a wider incision,
which  might endanger the adjacent blood-vessels.—
The wound being rendered sufficiently free to  admit
the finger with facility, the staff is withdrawn, and the
extraction of the stone is effected in the usual manner.
We have then a simple smooth cut—the edges of all the
divided  tissues coincident with each other—not near so
liable, therefore, to suffer  infiltration—and far  more
favourable to a speedy cure than the wound produced
by  the  ordinary  mode of dissecting  down upon  the
membranous portion of the urethra. 
 
 
HERNIA,
RADICALLY CURED BY AN OPERATION IN WHICH IT BECAME
            NECESSARY TO EXTIRPATE THE


    HERNIAL. SACK AND THE TESTIS,
BY N. R. SMITH, M. D.
   On  the 1st of March last, Andrew Ferree was re-
ceived into the  Baltimore Infirmary to be treated for
irreducible hernia.  He had been afflicted with hernia
from boyhood, but I have been unable to learn whether
the case was distinguished by any thing remarkable at
its first occurrence.  It gave him but little annoyance
till adult age, when (at what period precisely I cannot
ascertain) the tumour became so troublesome and pain-
ful that he sought surgical advice, and was directed to
use a truss.   Being a mechanic, he undertook  to con-
trive and adjust an instrument for himself.
   The  truss which he made  was of course very im-
perfect and very rude in its operation, although it gave
some degree  of mechanical support  to the parts, and
enabled him to continue, though with suffering, his labo-
rious occupation.  Occasionally  the  hernia  was pro-
truded, and  the difficulty of returning it seemed to in-
crease.  At last he found that, even when he had suc-
ceeded in returning what seemed to be protruded from 
264                  HERNIA.
the belly, there remained a degree of tumefaction and
hardness  in the scrotum  and along the cord.   This,
however, gave him but little inconvenience, when he
could completely succeed in  returning the  bowel and
retaining it; but he found that the difficulty of effecting
the reduction still increased, as  did also the external
tumour which seemed to cause the impediment
   It appeared subsequently,  on  the dissection of the
tumour, that  this external disease consisted of an en-
largement of the cord  and testicle, and an extreme
thickening of the herniary sack,  though for  reasons
which are by-and-by to be stated, this could not be very
satisfactorily ascertained before the operation.
   Some few weeks before he came under my observa-
tion, the bowel became strangulated, and he found  it
necessary to  seek surgical aid.   Dr. Worthington, an
intelligent physician of Ann Arundel, was called in, and
with some difficulty succeeded in effecting the reduc-
tion of  the reducible part  of the  tumour.
   He then resumed  his  labors, but, soon  after, the
bowel became again protruded and he found it impossi-
ble to return it.   At intervals, also, there occurred signs
of strangulation.  Dr. W. was again called, but his at-
tempts to effect the reduction  were not so successful as
before.  The protruded viscus was  evidently in some
degree constricted, and the tumour of the adjacent parts
had now become so great that it was impossible to em-
ploy the taxis with advantage.
  Having used, without success, the  means usually re-
sorted to in such cases, and the patient remaining in a
critical situation, Dr. W. sent him to the Baltimore In-
firmary  and placed him under my care.  I found the 
                    HERNIA.                   265
tumour, at this  time, to be  nearly of the  size of  an
infant's head.   Its form was almost sherical, and  the
upper part of it was firmly pressed against the abdomi-
nal ring.   Near the upper  part, and anteriorly, there
seemed to be a small tumour implanted upon the larger
one of about the size of the testicle.  This  was  soft
and elastic—more so than the testicle ordinarily is, yet
from its form, size, and situation, we judged it to be this
organ.   The rest of the tumour was very hard and un-
yielding.   It was impossible, by pressure, to alter its
form, in any considerable degree.  The inferior part of
it was less hard than the anterior.  It was very obvious
that there was something very unusual in  the morbid
alterations  which had taken place.   We could discover
nothing which, by its  form and its elasticity, appeared
to be a portion of intestine, nor any thing possessing the
doughy feel of the omentum.
   Occasionally the bowel seemed to become constricted,
the passage of its contents was interrupted, and slight
symptoms of strangulation supervened—the pulse being
frequent, the belly painful, and the stomach nauseated.
These symptoms  would yield, however, to mild cathar-
tics, horizontal posture, and fomentations, and the  in-
testines would resume their functions.
   The case was seen  by Professors Potter, Hall, and
Baker, in consultation with myself, and we resolved to
relax the system by the abstraction of blood, rigid absti-
nence, and cathartics, hoping thus to be enabled to re-
duce the tumour by the taxis.   We also directed  the
employment of evaporating refrigerant lotions.   These
endeavours were ineffectual, though carried as far as
prudence  would  permit.   The patient, after  having 
266                    HERNIA.
remained in the house for two weeks, was by no means
in a condition to leave it with safety.  Besides that he
was totally disqualified by the magnitude of the tumour
for any  laborious occupation, he  was  in  perpetual
jeopardy from the occasional occurrence of slight symp-
toms of strangulation
   My colleagues and myself, therefore,, resolved that an
operation should be  performed, the extent and object
of which should be governed by what might be ascer-
tained, in  relation  to the character  of the tumour, on
making a free incision.
   In presence of the above advisers, and other medical
gentlemen, I  commenced the operation by making the
usual incision from a little  above  the external ring to
the lower part of the scrotum.   On carefully deepening
this, I  found  that the whole tumour  was invested by
very dense and voluminous laminae of cellular tissue.—
As I cautiously incised these, I  could discern  no fibres
of the cremaster, but thought, from the thickness of this
investment, that I might perhaps be dividing that muscle.
I endeavoured to lift the laminae of tissue, and to divide
them successively  by inserting the director  beneath
them—but this I found impossible.
   At length,  as  I  proceeded with the knife, there oc-
curred suddenly a  copious gush of serous fluid.  I then
presumed that I had entered the cavity of the herniary
sack, the external investments being less distinguishable
than usual.   To my surprise and perplexity, however,
I found that  I could not insinuate  my finger  into the
supposed sack, in consequence  of its strong adhesions,
by cellular bands, to its contents.  The contents, as far
as they could then be examined, were evidently not in- 
                    HERNIA.                    267
testines, but presented a rough surface, a firm feel, and
spherical  form.   The size of  the tumour, by the dis-
charge of the water, was but little diminished.  From
the partial examination which  we were then enabled to
make, we conjectured that the mass within must be a
portion of omentum which, in  consequence of inflam-
mation, had established numerous connexions with sur-
rounding parts.  These I  therefore determined to break
up as far  as  I could.  This with some difficulty I ac-
complished, using the handle of the knife and the finger
alternately.
  It was impossible, however, to pass the finger up  to
the ring,  and I  soon discovered that we had not yet
reached the interior of the sack.  Nor did the anterior
part of the tumour, now exposed, present the appear-
ance of the cremaster muscle, or peritoneal covering. I
examined every part of its surface with the utmost care,
and at length discovered  a distinct fluctuation near the
middle and anterior part  of the tumour.  After  some
hesitation I determined to enter this cavity with the
knife.  I did so, and from this also there escaped a con-
siderable quantity of fluid, leaving an excavation of a
triangular shape, broad  at the surface, and narrow at
the bottom.   The walls of this cavity were as firm  as
other parts of the tumour, nor  in it could  we touch any
portion of a protruded bowel, or approach the abdomi-
nal ring.  The cavity was more than an inch deep.—
Here we  were again exceedingly perplexed.  I then
took a strong steel director and pushed it  in various di-
rections against the  walls of this excavation, in order to
ascertain their strength and thickness.   At length, on
the mesial side of the tumour, I pushed the  instrument 
 268                    HERNIA.
 into a deeper cavity, situated directly behind the trian-
 gular space.   I could then feel the point of the director,
 within  the upper and inner part of  the  tumour.  I
 therefore elevated the walls of  the cavity on the point
 of the instrument, and cut  down upon it.   This  was
 done on the inner side of the tumour.
  I, of course, then had a considerable portion of the walls
 of trie tumour, on the inner side, raised on the shaft of
 the  instrument.  Turning the  groove of the director
 towards the inside, I seized a narrow bistoury, and glid-
 ing it along the groove, divided the elevated portion of
 the walls.  Then immediately I found that I had open-
 ed the herniary sack, and that my finger was in contact
 with a protruded  portion  of intestine.   The walls of the
 tumour, being at  least the third of an inch in thickness,
 and  very rigid, of course did not retract from the intes-
 tine.   I had no difficulty, however, in passing my finger
 up to the ring, dilating the stricture, and returning the
bowel.   The true herniary  sack was small, compared
with the size of the tumour, and the knuckle of intes-
tine  contained in  it was  not large.  The large portion
of the tumour which was above the  triangular cavity,
and  above and before the herniary sack, consisted of
the  testicle and  tunica vaginalis, much diseased.   At
the upper and anterior part of the testicle, the tunica
vaginalis  seemed adherent to  the  tunica albuginea,
beneath which, at this place, the testicle was the  seat
of a  soft sarcomatous growth, which had distended the
 albuginea and produced the  circumscribed soft tumour,
felt before the operation, and which was supposed to be
 the testicle.
  That  part of the tunica vaginalis,  which enveloped 
                    HERNIA.                    269
the lower part of the testicle, was distended with water,
and formed a hydrocele, the walls of which were ex-
tremely thick, and which  formed a large part of the
mass of the tumour.
   When I had returned the protruded bowel, I found
that the  sack, together  with the testicle  and  diseased
tunica, formed a pendulous mass of disease which, du-
ring the several steps of the operation, had been sepa-
rated from the surrounding parts.  We were, therefore,
apprehensive that, if left in that condition, especially as
the testicle was much diseased, the process of healing
would  be  much impeded,  and perhaps entirely de-
feated.
   By the advice of Professors  Baker and Hall, I de-
termined at once to  extirpate the whole mass, by cut-
ting across the  neck of the tumour, which embraced
the  cord and the upper part of the  sack.  This  was
accomplished with ease.  The vessels of the cord, to
my suprise, wrere found involved in the posterior part of
the neck of the sack.   I say, "to my  suprise," because
it  will be borne  in mind, that the testis  was situated
above and in front of the herniary sack, a very unusual
arrangement of parts in this disease.    The mouths of
these vessels are accurately represented in the engrav-
ing, (Fig. II,) they being incorporated with  the walls of
the sack at the lower part.
   I  cannot  account  for this arrangement but on  the
presumption that the cremaster muscle which, in hernia
by the  oblique  descent, is detached from the cord by
the tumour, and placed in front of it,  must have drawn
the testicle upward over the face of the hernia.  This
would the more  readily occur, in this case, because of
       35 
 270                    HERNIA.
 the existence  of hydrocele, for by such a tumour the
 cremaster  muscle would be put upon the stretch, and
 hence it would firmly brace the tumour against the
 ring, as is often the case  in common hydrocele.
   The whole diseased mass being thus extirpated, I
 proceeded  to secure the  vessels of the cord, and then
 to cover the exposed parts  by bringing together the in-
 teguments  with interrupted sutures and adhesive straps.
   Although the patient had necessarily been a long time
 upon the table, and had suffered severely, though with
 fortitude, yet he did not appear much prostrated by
 Irritation, nor did there  at any time occur any con*
 siderable degree of constitutional disturbance.
   The patient was then placed quietly in bed, an opiate
 was administered and he was directed to be  furnished
 with the most bland and unstimulating aliments, in small
 quantities.   On the second day there was considerable
 swelling and hardness in the left iliac region, along the
 course of the cord, together  with symptomatic  fever;
 but there was no general swelling or tenderness of the
 belly.  A cathartic was  administered which  procured
 a free and easy evacuation, during the passage of which
 he was not suffered to rise.
  From this time he rapidly convalesced.   The wound
healed very kindly, by granulation, and there was formed
at the ring  a firm cicatrix,  which, since that  time, has
been an effectual barrier against protrusions of the visce-
ra.  At the end of three weeks, he left the house perfectly
well,  and has ever since remained so, although engaged
in laborious occupations/ 
HERNIA.
271
            Description of the Engravings.
   Fig. I. Is designed to represent the front aspect of
the tumour, which  was oblong from  above downward,
and pretty uniformly convex before it  was opened.—
The seat of the testis is marked (1)  where an incision
was made into the tumour after its removal.  It was
here also that the  elastic swelling was  felt, before the
operation, and which proved  to be the  distended coats
of the testis, and the epididymis.
   The cavity marked (2) is the triangular fossa, which
was opened at  the  second stage of the operation, and
which was  found  to contain a fluid.   At  the  place
marked (4) the side of the tumour is deficient.  It was
here  that  the  director was  thrust  through into  the
deeper cavity, and the walls divided with the bistoury,
inwrard.   The  anterior convexity of the tumour is
marked (3).
   It is to be  borne in mind  that this whole mass was
involved  in  an external cyst, formed of dense cellular*
tissue fortified by layers of lymph.  It was from this
cyst that the water gushed in the first stage of  the opej
ration.
   Fig. II.  Exhibits the posterior aspect of the tumour.
The testicle (1) is  seen in the upper part, the cavity in
Which it is lodged being that of  the  tunica  viginalis
greatly distended and  thickened, so as to retain this
form in  the preparation.  The part of the testis here
seen is that which usually presents downward and for-
ward.  The epididymis is in front.  The cavity marked
(2) is that  of  the  herniary sack.  Its  marginvbelow,
shews'the orifices of the vessels of the cord.  They are 
272                    HERNIA.
passing beneath the tumour to ascend over its anterior
face and reach the epididymis.
   The drawings were accurately taken from the pre-
paration which is  in my possession.   They  are, how-
ever, on a reduced scale.   The preparation measures,
vertically, five inches—horizontally, three. 
ON THE
INFLUENCE OF HEAT AND COLD*

                      IN THE

      PRODUCTION AND CURE OF DISEASE.
BY N. R. SMITH, IMC. D,
   On this topic I by no means design to furnish a com-
plete and systematic treatise, but rather  to call the at-
tention of the profession to certain points which I think
have not been  sufficiently adverted to, and especially
the remediate agency of Heat and Cold in the treatment
of  disease.   The disorganizing  effects (burning  and
freezing) of these agents, I shall not discuss, but confine
my remarks to their less intense and more general in-
fluence on the nervous and vascular systems.
   The agency of atmospherical vicissitudes, in the pro-
duction of disease, has long been correctly estimated.—
In  the etiology of almost every disease, and by almost
every writer, they are accused as either the predispos-
ing or exciting  causes.   But agents which exercise so
powerful a controul over  the living system in exciting
disease, must, when properly directed,  be often equally
efficacious in allaying it.   Almost all the valuable reme-
dies which we employ are powerful poisons, and when
wisely directed, they are active and  powerful in  the 
*ft4             ON HEAT AND COLD.
cure of disease, in proportion as they are, at other times,
violent and  destructive.  Such remedies supplant dis-
ease by creating a new morbid excitement, which  is
inconsistent with the former, more  powerful than it,
and at the same time under the controul of the powers
of life.
   From  analogy, then, we should infer that heat and
Cold, so powerful in the production of disease, may often
be trained to act powerfully as remedies, in obedience
to the directing hand of the physician.  But first—what
is the modus operandi of vicissitudes of temperature in
prducing  disease?
   Heat is the most  common and necessary of all the
stimuli which operate on the  vital qualities of the or-
gans, to produce the active phenomina of life.  Every
form of animal and  vegetable life seems  to be, indeed,
the indirect offspring of solar heat.   Where the beams
of the sun reach the earth with  unremitting intensity
throughout  the  year, there its vital products  are the
most varied and abundant; but where its rays are absent
for long  periods, both  animal and  vegetable life are
languid and brief. The best illustration of the influence
of heat upon the vis insita vitalis, is seen in the process
of incubation.   Here the  vital principlev is perfectly
dormant, and would  remain so until it perished, but for'
the influence of heat, which  immediately rouses it  to
action.
   That the living system may never be deprived of an
agent so necessary to the vital  functions, it is generated
within the  body itself: indeed, it is vital heat chiefly
which acts  upon the living tissues, and very rarely are
they stimulated by artificial heat, or the heat of the sun 
               ON HEAT AND COLD.             275
 and atmosphere.  Has external heat, then, no influence
 on the living system?  It does exercise an important
 and constant one, but it is for the most part  negative
 and indirect.  The presence of external heat merely
 prevents the escape of the vital heat, and causes it  to
 accumulate  till, perhaps, the body  becomes greatly op-
 pressed with it.   The living system has the power  of
 resisting the entrance and accumulation  of  external
 heat in a suprising degree.   So long as the vital  func-
 tions are unimpaired, the general  temperature of the
 body is never raised above ninety-eight degrees, although
 it be immersed in a medium many  degrees hotter than
 itself.   Even an egg has this power in some  degree,
 and so also have plants.  It is unnecessary to particu-
 larize the numerous experiments which have been  made
 in relation to this subject.
   When the body is placed in a cold medium, there  is
 still as much heat  generated as before, and probably
 more,  but it passes off so rapidly that its stimulating in*
 fluence is insufficient, and action is diminished.  The
 system is by no means so capable  of resisting the de*
 clension of temperature below the  vital standard, as  it
 is its rise above it.   It is true that the temperature of
 the deeply seated vital organs  will remain  uniform,
 because, before all the other organs  are chilled, life will
 be extinct.   The surface and members, however, be'
 come cold, and their vital powers dormant.  This di*
 minution of temperature is not confined to the surface,
 Sometimes a portion of a limb is deeply frozen, and yet,
if the proper means be employed, its vitality is restored
and its  integrity preserved.  Now,  in such a case, the
temperature of the part must slowly sink from  98° to 
276              ON  HEAT  AND COLD.
32°.  It is certain, therefore, that the temperature  of
some part of the  living system  is very often in  some
degree depressed  below the standard of vital heat.
   It appears, then, that the  living system  is far  more
capable of defending itself against excessive heat, than
against excessive  cold; for although some parts of the
body very often sink  much  below the temperature  of
98°, yet they never rise above it.   Hence, undoubtedly,
it  is, that cold is, far more  frequently than excessive
heat, the cause of disease.  . This is also in part  to be
accounted for by the fact, that the temperature of the
atmosphere is very rarely as  high as that of the human
body, but often ranges far below that point.   Another
reason too is found in  the fact, that far the most sudden
changes of atmospheric temperature are from heat  to
cold.   The recurrence of warmth is always much more
gradual, and is therefore less  felt.  The phrase "to take
cold" is very common, but no one complains of having
i;taken heat."
   Heat being the  natural stimulus of the body, and that
without which the vital functions cannot be exercised,
it  seems very suprising that  cold, or the mere absence
of heat, should have been regarded by some as an exci-
tant.   Such a belief appears to have been suggested by
the corroborant effect which sometimes results  from
the sudden abstraction of redundant heat from the  body.
Over-stimulation  by heat must, of course, produce  in-
direct exhaustation and the loss of tone, and, conse-
quently, the diminution of  such heat will remove  a de-
bilitating influence, and thus preserve the powers of the
system; but in no sense whatever can cold be regarded
as a stimulus.  The nature of its influence will be better
ajnderstood as we  proceed, 
               ON HEAT AND  COLD.             277
    As the tissues of the body have both vital and physi-
 cal qualities, it is obvious that heat must operate upon
 them both vitally and  chemically.   The irritability of
 the system is chiefly resident in the nerves, and, conse-
 quently, the' vital influence of this agent is manifest in
 the increase of nervous excitement.   Any excitation of
 the nervous system  will necessarily accelerate action in
 all the organs, and thus we have an increased develope-
 ment of vital  phenomena.   But if this excitement be
 long continued, or excessive, the organs become fatigued
 and no longer  obedient to the  influence  of the nerves.
 We then have nervous excitement with general lassitude
 of the muscular and other tissues.   This is the prevail-
 ing temperament  of warm climates.  The excitability
 of the nerves  does  not seem  to be exhausted by the
 continued influence  of heat, but is rather increased by
 it, because the nerves are not weakened by the physi-
 cal effects of heat as we shall presently see the muscular
 tissue is.   Frigus nervis inimicum, says Hippocrates—
 meaning that cold diminishes the energy of the nerves,
 while heat increases it.
   Hence it is that diseases,  in which  morbid nervous
 excitement plays a conspicuous part, are mostly those
 of warm climates, as, for instance, tetanus, chorea, hys-
 teria, &c. &c.   Hence  also one reason  why this class
 of diseases is moire  incident to females, whose bodies
 are  more  influenced by  artifical  heat  than those  of
 males.
   But the chemieal influence of heat is more remarka-
 ble in its action  on the muscular system.   We very well
know that heat expands all bodies, and that its abstrac-
tion, or cold, causes all  bodies to contract  to an inde-
       36 
278             ON HEAT AND COLD.
finite extent.  The material of the living system is not
exempt from this law.  When, therefore, the body is
operated  upon by an increased degree of heat, all its
tissues are expanded.  Those which have a contractile
property (the muscles) will have their particles in some
degree removed from each other, and hence their vital
and cohesive attraction will be diminished.  It is proba-
ble, also, that this effect on  the muscular system is, in
part, owing to the influence of heat on the vital qualities
of the muscles.   Be this as it may, there is no doubt
that excessive heat attenuates  and weakens the muscu-
lar fibre, and diminishes the energy  of all those organs
which are essentially muscular.
   Cold, on the other hand, condenses  the  contractile
tissues, by bringing their particles  into closer contact
with each other, thus increasing  the  tone  and rigidity
of their fibres.  The cohesive and vital  attraction of
the constituent parts is thus increased.   This, however*
is probably altogether a  physical effect, for if heat be
a stimulus, and  this  we cannot  doubt, its  diminution
can certainly be nothing else than  the diminution of a
stimulus, as I have before remarked.
   When, however, the system has been over-stimulated
by heat, and has become physically relaxed by it, the
abstraction of that excess of heat will exercise an in-
vigorating influence, for two reasons.  First, it will
check the  exhaustion  of vital  power which results
from too much excitement, and thus obviate the indirect
debility which will have been produced; and secondly,
it will condense and give physical firmness  to the con-
tractile tissues.   Indirectly, then, cold certainly is, in
this way, a powerful corroborant.  We shall  presently 
              ON HEAT AND COLD.             279
 ■discover also, that it often, by an indirect agency, exer-
 cises an invigorating influence on the vascular system.
   The texture of the extreme vessels is probably essen-
 tially muscular.  At  least they possess contractility in
 a high degree.  We expect, therefore, to find them in-
 fluenced by vicissitudes of  temperature  in the same
 manner as are the muscular organs generally.  Many of
 the extreme vessels are so situated  as to feel sensibly
 the  alterations of heat and  cold.  Those of the  skin
 and the extremities are thus exposed, and, as they are
 but parts of the general system of the circulatory organs,
 all of which must be dependant upon each other, the
 general function of the circulation must be much affect-
 ed by the  agents of which I am treating.  When the
 body is subjected to the influence of a warm  atmos-
 phere, the fibre of the vessels will become relaxed; they
 will then yield to the vis a tergo of the heart, and their
calibre  will become increased.   The quantity of blood,
then contained  in  the capillary vessels,  will become
greater than ordinary.  The action of the heart is, by
the stimulus of heat, at the same time increased, so that,
for a time, there occurs no stagnation of the circulation.
But at length the blood, being in part withheld from the
circulation by lingering in the  dilated capillaries, and
the heart not feeling its usual stimulus of distension, and
being wearied by the nervous  excitement which  heat
produces, the balance of the  circulation is disturbed.—
A great part of the blood becomes stagnant in the small
vessels,  and is withheld from the  general circulation.—
Congestions, hemorrhages, varicose  swellings, local in-
flammations, and watery effusions, are liable to occur.
  But when, after the relaxing influence of heat on the 
280              ON HEAT AND COLD.
surface and the extremities, the body is exposed to the
impression of a cool atmosphere, the vessels of those
regions are constringed.  Their vital contractility, aided
by the tone which  they thus acquire, acts with vigor
upon their contents, and  they are  sent back upon the
heart, great vessels, and capillaries of the deep regions.
The heart distended by the blood which-is thus return-
ed to it, is roused to more vigorous contractions, and
thus the circulation is every where  accelerated,  and
none of  the blood is withheld from the circulation.—
Thus  does cold, or  the  abstraction of heat, indirectly
invigorate the living system.
   But if the cold  be intense or  long continued, the
vessels of the exposed parts become too much  con-
stringed; they become so rigidly contracted as not only
to expel their contents, but to refuse receiving the blood
that is  sent to them from  the heart, and especially
because the whole system, feeling the frigorific influence,
the heart does not  drive its blood to the surface  with
its accustomed energy.  The result will  then be that
the surface and extremities will become exangnious—
the  blood  will accumulate  in the great veins  near the
heart, and in the vascular  tissues of the organs which
are deeply seated and protected from the influence of
external cold.
   The skin is an extremely vascular tissue; no part of
it can be pierced without  the effusion of blood.   The
quantity of this fluid contained by the skin, at ordinary
temperatures, is very great.  Consequently, when it  is
made to recede from the surface, and, together with it,
that of the extremities, it must  be poured upon the
deep seated organs in such quantity as to engorge their 
             ON HEAT AND  COLD.             281
vessels, interrupt their functions, create venous conges-
tions, effusions, inflammations, morbid nutrition, &c.—-
Whatever  deep-seated organ  may be at the time pre-
disposed  to disease, its vital powers  feeble, and its ves-
sels relaxed, will especially suffer  from this  unequal
distribution of the fluids.  Sometimes this organ is the
brain, and  then there result cerebral congestions, he-
morrhages, effusions or inflammations.   Sometimes the
lungs are the centre of fluxion, and hence arise disorders
of respiration,pleurisy, pneumonia, &c. &c.  Occasional-
ly the liver suffers in the same manner, and sometimes
the mucous lining  of the stomach  and the intestinal
canal; gastritis, dysentery, cholic or cholera morbus
being produced.  The effect, however, is undoubtedly
in part owing to the impression made on the nerves,
of which, I shall speak in another place..
  It will be perceived, that I adopt, in  relation  to the
succession of morbific causes and their effects, the opin-
ions of Dr. Armstrong.   The theory of Dr. Cullen  is
also similar, in many particulars, to the rationale which
I  have given.  A spasm of the  extreme vessels  is
certainly produced by cold,  and then the train of phe-
nomina is very similar to that described by Dr. Cullen.
I do  not, however, see  the necessity of  resorting  to
that vinculum of broken logic, a vis medicatrix naturae.
The train  of causes and effects which result, seems  to
proceed  in a necessary and very intelligible order.
  It is probable that in the general circulation there is
constantly taking place a kind of vibration between the
heart, great vessels and  viscera on the one hand, and
the capillaries  on the other.  Even slight impressions
of cold  on the  surface cause the blood  for a time  to 
•282             ON HEAT AND COLD.
recede, and to fall upon the heart and  viscera.  The
heart then re-acts, being stimulated  by distension, and
by its energetic effort drives the  blood again into the
capillaries  and rouses them to the  exercise of their
functions.  So, also, heat, when applied to the surface,
causes all the vessels of the skin to become dilated and
full; thus deriving blood from the great vessels,  and re-
Heving them of what may have been an oppressive load,
if the surface has been for a long time constricted.
  Alternations of heat and  cold,  then, and the vicissi-
tudes of excitement  which they produce, are by no
means injurious to the vital functions, but highly saluta-
ry,  the heart and the capillaries being alternately reliev-
ed of the burden of  their functions, and  again  excited
by the rush of blood.  There is undoubtedly a sort of
tide, or flux and re-flux of this kind, perpetually going
on between the centre and the surface. In the morning,
when the  atmosphere is cool, and  the  body is  unin-
fluenced by the various causes which create excitement,
the surface is pale and the vessels  contracted.  The
pulse, too, is smaller than at other periods.  During the
day, vital heat is increased by exercise; the surface of
the body, also, is exposed to a warmer  atmosphere.—
Then, the capillary vessels become dilated and engorged,
and the blood is in part withdrawn from the heart and
great vessels, and accumulated in the skin and extremi-
ties.  It was undoubtedly this  flux  and re-flux of the
blood  between  the surface and the  centre, which in-
duced the ancients to believe, that the only circulatiou
of  the blood consisted in its flowing from the heart «to
the surface by day and returning at night.
  The changes of temperature, which occur more or 
              ON HEAT AND COLD.             283
 less in all climates, are, in this w^y, when not extreme,
 exceedingly salutary to the vital functions, and not, as
 is the vulgar belief, generally injurious.  The impres-
 sion of a cool atmosphere on the surface, when not too
 long continued, is precisely that of a cold bath, and like
 it produces a re-action on the part of the heart which,
 indirectly, even accelerates the circulation in the capil-
 laries on the surface.  When the body is confined to a
 temperature perfectly uniform, the circulation is observ-
 ed to become sluggish, especially in the capillaries.—
 There are then wanting those  periods of excitement
 which rouse the energies of the organs, and, by oppor-
 tune exercise, increase their powers.
   I  have already stated that cold, which may give firm-
 ness and tone  to the contractile tissues, invariably  ob-
 tunds the sensibilities of the nerves, and tends to pro-
 duce a general torpor of that system; whereas heat, on
 the  contrary, not only stimulates the nerves, but aug-
 ments their vital sensibility.
   When the body is in perfect health, and in a medium
 temperature, there is an equality of  nervous excitement
 in all parts of the system, except in those organs  the
 functions of which, are exercised, periodically.  The
 diffusion of nervous influence,  however, seems to be
 modified by external agents  in a manner very analogous
 to that of the free circulation of the  blood.   The opera-
tion  of heat  on the surface of  the body invariably in-
creases nervous excitement, and augments the sensibi-
lity of the nerves.  In health, the nervous system seems
 capable of sustaining but a  certain  amount of nervous
excitement.  If it be increased preternaturally in one
part of the system, it is observed generally to be dimin- 
284             ON  HEAT AND COLD.
ished in other organs. * When, therefore, the nerves are
excited to increased action on the surface and in the
extremities, by heat, nervous influence is derived from
the deep organs, in a manner analogous to the deriva-
tion of blood from the deep-seated parts. The sensibili-
ties of  such organs are then temporarily diminished, and
if the  cause be long continued,^the exercise  of their
functions rendered languid.  I by no means undertake
to explain,  with precision, the mode in which this takes
place.  Those who adopt the belief that the brain gene-
rates, and the  nerves convey, a subtile fluid, would ex-
plain what I assert by the supposition that this fluid is
repelled from those nervous  conduits which  are near
the surface, and driven inward upon  the deep organs,
which  do not feel, except by sympathy, the vicissitudes
of temperature.
   However this may be, the assertion that there often
occurs a repulsion of nervous excitement by the agen-
cy of cold, as well as a repulsion of blood  and of vas-
cular excitement,  will I think  be generally admitted.
But perhaps the strongest proofs  are  drawn  from the
phenomena of disease.  Whenever  there occurs mor-
bid nervous excitement (irritation) on  the  surface, or
in the extremities, no fact is more familiar than  its  re-
pulsion from such a situation upon more deeply seated
organs.  Such a repulsion occurs in erysipelas, the mor-
bid excitement, by the influence of cold, being trans-
ferred  from the skin  to the mucous lining  of the sto-
mach or intestines, or to the brain.  The same occurs,
also, in gout.   By the  application of cold to the feet,
the extreme irritation which characterizes this djsease,
is driven from these outworks  of the system,  but  in-
stantly seizes upon more deeply-seated organs. 
             ON HEAT AND  COLD.             285
  So also, when morbid nervous excitement (irritation)
has primarily seized upon the central organs, (it being
perhaps produced by the sudden  repulsion of healthy
excitement from the surface,) the  application of heat
to the surface of the body will derive  nervous action
from the deep organs, equalize excitement, and relieve
the symptoms of irritation.   This often takes place in
colic and other painful affections of the deep organs. In
such cases we know that warm stupes, the warm bath,
&c. are among the most effective  means  of relieving
the morbid excitement within, and they do it by trans-
lating it to the surface.  It would seem, in such cases,
that the nervous system is capable of sustaining only a
certain amount of nervous excitement.   Some irritat-
ing cause has concentrated it in a particular organ.   If,
then, agents are employed  for the  purpose of forcing
nervous  excitement in remote parts, and those agents
operate with more intensity than the primary cause, the
current of nervous influence will be diverted  from  the
deep organ, and directed to the surface.  One of the
most efficient agents which I employ for this purpose
is heat,  for, as  I have before stated, it is the natural
and necessary stimulus of the nerves.
  It is obvious then, that heat and cold are productive
of disease, as well by the morbific influence which they
exercise  on  the nervous system, as by  their more pal-
pable action on  the blood-vessels  and  their  contents.
Indeed it is undoubtedly necessary that the influence of
these agents should be the  same in both these systems,
for when the blood is  driven inward upon the vicera
they are  compelled to a more  vigorous exercise of their
       37 
286             ON HEAT AND COLD.
secerning functions, and consequently, require a corres-
ponding increase of nervous energy.
   It is, then, by the combined influences which heat and
cold exercise on the nervous and vascular systems, that
these agents by  their inordinate action generate dis-
ease.
        Remediate agency of Heat and Cold.
   The foregoing remarks will, in some degree, prepare
us to appreciate correctly the influence  of atmospheric
vicissitudes in the removal  of diseased action.   It may
certainly  be regarded as an axiom in  medicine, that
it is the first duty of the physician, when contending
against disease, to direct the most careful  attention to
the cause of the particular affection which may de-
mand the exercise of his therapeutic skill.  This is ob-
viously of essential importance; first, in  order to enable
the physician  to remove  an agent wrhich will otherwise
be constantly labouring to perpetuate, or re-produce the
disease; secondly, because,, if the disease be recent, the
remedy should  always be suggested by  the  cause—
should be its direct antagonist, indeed, and produce on
the system an impression that shall be inconsistent with
the diseased action excited by the morbific agent.
  Both heat and cold, I have shown to be  prolific sour-
ces of disease.   They are  often both the predisposing
and exciting causes of some of the most formidable af
fections which  we treat.   When,  therefore,  disease
has resulted from the direct  influence of cold,  what
should be the first care of the physician?  Certainly to
arrest as promptly as possible the operation of the cause
by the substitution of heat; thus will he often break the
train of morbid phenomena which are  following each 
             ON HEAT  AND COLD.             287
other in rapid succession, and then will the sanative ef-
forts of life be often sufficient to overcome  the disease.
But if disease be already established, and the restora-
tion of the natural temperature of the surface be not
sufficient to restore the equality of nervous and vascu-
lar excitement, then should we resort to a degree of heat
as much above that to which the surface is accustom-
ed, as the temperature which produced the disease may
have  been below it.  Heat, thus applied, will produce
a series of  vital actions directly the reverse  of that pro-
duced by the cause of the disease.  If the blood has
been  driven  from the surface  to the  deep  organs—if
nervous excitement or irritation has been translated by
cold to the sensitive organs within, then will heat relieve
the heart and great vessels, the liver, the lungs, brain,
&g. by deriving from them the load of blood  which op-
presses them.  The vessels of the surface will be dilat-
ed and filled, and incipient congestions and  inflamma-
tions be promptly relieved.   A similar revulsion will be
produced in  the  nervous system.  Nervous influence
will be diverted from the centre to the  surface.  The
sensibilities of the extreme nerves will  be  roused, and
an equality  of nervous  excitement will  thus be pro-
duced.
   When, on the other hand, disease has resulted from
the inordinate  action of heat on the  system, then, for
similar reasons, does cold stand in the relation of a reme-
dy.   It is to be observed, however, that heat is not of-
ten the immediate, but frequently the predisposing cause
of disease; hence cold, under these  circumstances,  is a
chronic remedy.   When an individual has suffered long
from the  debilitating influence of extreme heat,  the 
288             ON  HEAT AND COLD.
transition to a cool atmosphere is observed, if it be not
too sudden, to be always attended with  an increase of
health and vigor.
   When, however, as occurs in certain fevers, the sur-
face of the body becomes preternaturally hot from the
redundant evolution of vital heat from the extreme ves-
sels, then is cold often  a remedy immediately efficacious,
at least in alleviating the symptoms of the disease.
   I would now direct the attention of the reader to the
employment of these  remediate agents, heat and cold,
in the treatment of particular forms of disease, and to
the mode of their application; and first, the employment
of heat, in the cure of those  diseases which arise from
the influence of cold.
   Whenever there occurs a sudden transition from tem-
perate, to extremely cold weather, the living system is
always  strongly impressed by the change.   The  more
sudden the transition the less capable are the powers of
life of resisting the effect.  At such a period there fre-
quently takes place a variety of diseases which every
one immediately ascribes  to the influence of  cold.
The character of these affections will very often depend
on the peculiar susceptibilities of particular individuals.
Some, for instance, have irritable lungs; others  have
digestive organs which  are predisposed  to disease; a
third class are prone  to cerebral disease; and a fourth
to rheumatic inflammations of the muscles and fibrous
tissues.   Sometimes there  will exist, at the time,  an
epidemic constitution of the atmosphere,  (to use the
phraseology of Sydenham) which predisposes the sys-
tems  of nearly all individuals to the same form of epi-
demic disease.  Cold, under  these  circumstances, is
  erely the exciting cause of disease. 
              ON HEAT AND COLD.             289
   Commonly, when  the injurious  impression of cold
 has been made on the surface of the body and in the
 extremities, there will take place, before any specific
 character of disease  is made manifest, a general com-
 motion of the whole nervous and vascular systems. The
 circulating fluids being driven inward on the heart and
 great vessels—upon the stomach, intestines, liver, lungs,
 brain, &c. &c. these organs are immediately disturbed
 in the exercise of their functions.   The fact that diges-
 tion is at  once interrupted by such disturbance of the
 balance of action, has undoubtedly been observed  by
 every individual  in his  own person, and especially  by
 those who labour under the  occasional symptoms of
 dyspepsia.  When such an individual immediately after
 taking food exposes himself to unusual cold,  he soon
 begins to experience  uneasy sensations in the stomach
 —flatulence, erutations, nausea, perhaps vomiting, and
 cholic pains.  The other deep-seated organs are also
 disturbed, but in a less obvious manner.
   The symptoms of  general disorder thus produced,
 and which will perhaps soon result in some local, per-
 manent, and more distinctly marked disease, may gene-
 rally be at  once arrested by the  employment of heat
 applied to the surface.  When the cold has not been so
 extreme as to freeze, or render perfectly torpid the parts
 exposed, so that a sudden transition will create disease
 in the chilled parts, the use of warm baths, of warm fo-
mentations, frictions with warm cloths, the atmosphere
 of a warm room, or gradual exposure to the more  in-
tense  heat of a fire, will, with surprising promptitude,
interrupt the train of morbid phenomina, and restore
the equilibrium of action.  This result will be greatly 
290              0N HEAT AND COLD.
accelerated by the employment of warm drinks. Those
which are aromatic and gently stimulant, such as  tea,
coffee, or the infusions of sage, balm, mint, &c. &c. will
be found far more salutary than the ardent, spirituous
stimuli.   In the employment of the latter, the  effect is,
at best, equivocal.  The action of the heart and ar-
teries is, indeed, increased, but unless the constricted
vessels of the surface  be made simultaneously to yield,
the blood will  not be equally  diffused on the  surface,
but will be driven with violence upon the organs already
disposed to become engorged.  The  action of alcohol
under  these circumstances,  is known  to  produce a
feverish excitement, which is  nothing else than unequal
excitement.
   But the physician is not often called upon to counter-
act the  injurious effects of cold, till disease has become
more completely developed.  In the winter season  of
frigid climates, the organs most obnoxious to the in-
fluence of cold are the  lungs.  The reason is, that no
other organ of the human body is exposed to such vicis-
situdes of temperature.  When we leave the atmosphere
of a warm room, and expose the body to a temperature
perhaps not much above zero, the surface of the body
being protected by abundant  and warm garments, does
 not immediately feel  the impression.  But by respira-
 tion the atmosphere is necessarily brought into imme-
 diate contact with the lining  membrane of the lungs.—
 Not only the mucous membrane, but the parenchyma
 of the lungs,  feels the impression, and so also does the
 pleura pulmonalis, for we know that it is but at an in-
 sensible distance removed from the mucous surface. In
 the superficial cells their adherent surfaces are almost 
              ON HEAT AND COLD.              291
 in contact with each other.   Consequently the extreme
 vicissitudes of temperature  to which  the lungs are ex-
 posed, may produce catarrhal inflammations, pneumo-
 nia, or pleuritis.   Each of these forms of disease, when
 produced by cold,  is ushered in by  a  chill, attended
 with a recession of blood from the surface.   The more
 severe and  the  longer continued the chill, the more
 intense and  persistent is generally  the  disease.  The
 cold stage, or that  of oppression, often  continues long
 after the  disease is located.  It becomes then of the
 utmost  importance, that efficient  means should  be
 promptly employed for the  purpose  of diverting the
 circulation to the surface and equalizing excitement.—
 Heat, it  is true,  when used under these circumstances,
 will increase the general action of the vascular system;
 but this evil is more than doubly counterbalanced by the
 promptitude with which it cuts short the forming stage.
 Heat, for this purpose, should be associated with mois-
 ture, for,  thus applied,  it stimulates less,  and relaxes
 more.  When I have once restored the  warmth of the
 surface and the extremities, and established  a reflux
from the engorged organ, I have had it more completely
in my power than before, to command the  force of the
general circulation.  Indeed, before we have accomplish-
ed  this, it is  sometimes  almost impossible to  abstract
blood with sufficient rapidity  and in sufficient quantity,
because of the sluggishness with which it circulates.—
This difficulty I have several times  encountered in the
treatment of these affections, and after  making an un-
successful attempt,  have been compelled to delay till
warmth was restored to the surface.
  When, from the usual re-action of the heart and great 
292              ON  HEAT AND COLD.
vessels, the second stage of the disease has resulted—
that of morbid excitement, heat as a remedy is of course
not generally  admissible.   Tho rush of blood which
then takes place to the surface, results from the stimula-
tion of the heart, the  action of which becomes greatly
increased.  The effect is very different from that which
is produced by the stimulation of the capillaries by heat
applied to the  surface, for in  the  latter case the heart
is  gently excited through the medium  of the extreme
vessels, and the blood is solicited toward the surface,
not forced by a vis-a-tergo power alone.
   When general  febrile excitement has  taken place,
heat will, for the most part, only aggravate this morbid
state.  But still we shall often be able, in the progress
of the disease, to put this agent in requisition.  Often it
will be observed that, while one  portion of the surface
of the body is preternaturally hot, another, and  most
frequently that of the  extremities, will be cold.   While,
then, we suffer a cool atmosphere to bathe one part of
the surface, another may, for the important purpose of
equalizing action,  be  cherished by warmth.
   In  the latter stages of the disease, when collapse has
taken place, the heart and arteries having become  ex-
hausted by their ineffectual struggle, the surface again
becomes cold and exanguious.   Then  again is heat
necessary, not only for  the  purpose of equalizing  ex-
citement, but  as a general stimulus to the system.
   Sometimes  the class of diseases of which I am speak-
ing  in  consequence  of some epidemic  tendency,  as-
sumes the typhoid character.   Pneumonia typhoides is
a disease which has  ravaged almost every part of  the
northern section of our country.  This disease is charac- 
              ON HEAT AND COLD.             293
terized by a remarkable retrocession of the fluids from
the surface, by long continued  and repeated rigors,
with coldness of the extremities  and skin.   There are
few diseases in which the revulsive influence of heat i»
more beneficial than in this.  During the years 1812,
1813,1814, when it prevailed very generally in the north-
ern section of our country, so  pre-eminent  was the
vapour bath found to be as a remedy in this formidable
disease, and so  generally was  its utility  known and
acknowledged, that, when  physicians  could not be
promptly obtained, it was used in the domestic  way,
and  often with such complete  success  as at once  ta
overcome the disease.
  Dr. Gallup, from whom we have the  most  complete
account of this epidemic, speaks of external warmth as
a remedy second to none in importance, in the treat-
ment of the disease.  "Bleedings" he says, "without a
particular regard to external warmth and collateral cir-
cumstances, are often injurious."*  Again.   "As the
causes of the disease act upon the nerves, and show their
morbid influence on the surface of the body, by coldness
in the first stage, want of perspiration, &c. the natural in-
dication is to restore warmth and activity to the surface
as quickly as possible.  I have succeeded  in this often
times by the use of the warm bath.  It is one of the
most powerful agents we can employ, while, at the same
time, it is safe and agreeable.  Nothing is more com-
mon than for  patients to express it as  a great luxury.
If it does not immediately bring on  sweating, it invites
the circulation to the  surface, relieves external chills,

      •Gallup on Epidemics, p. 75.
       38 
294             ON  HEAT AND COLD.
and internal pain, and prepares the  system for the
remedies which are soon to follow.   Where the bath
cannot be obtained for immersion,  rolling  the patient
several thicknesses in blankets, dipped  in warm water,
serves as a substitute."!
  Nor is warmth less important as a remedy in the
treatment of spotted fever—(typhus petechialis—typhus
syncopalis—cold plague.)   This disease seems also to-
be the offspring of cold operating  upon an epidemic
predisposition.  It prevailed in New  England imme-
diately previous to the disease of which I have  been
speaking.  It also bore to  it a very strong analogy.—
Like it, it was ushered in with chills and torpor.   The
deep organs  were greatly  oppressed, and  the  blood
seemed to desert  the  surface.  In this disease no one
remedy was so efficacious as the vapour bath. Its  utility
was so generally known, that no sooner did the disease
announce itself, than the remedy was put in requisition,
whatever might be the distinguishing traits of the indi-
vidual case.  When the remedy came to be generally
known, it robbed  the epidemic of half  its terrors.  All
the usual modes of applying warmth  to the surface were
also used.  A medical writer who has probably  had
better opportunities than any other individual to become
familiar with its effects, speaks of it thus—"Perhaps no
remedy is better agreed on among physicians as  being
generally useful in this disease, than  sweating,  or, in
other wTords, the application of external heat.  If  it is
not  always useful, it is in  some solitary cases, where
there is an abundant heat from re-action having taken
t Gallup on Epidemics, p. 300. 
              ON HEAT AND COLD.             U95
 place in vigorous habits.  At the onset of the disease,
 however, this remedy may be said to be always useful."
 "External warmth is  of vast  importance  in  keeping
 up the centrifugal action of the system.  If the action
 is allowed to recede to the centre, by neglect of external
 warmth, after sweating has been used with advantage,
 the patient is apt to be exercised with sinking distress,
 and will be in danger, if heat  be not  immediately ap-
 plied."*
    In typhous fever, warmth,  if used, requires to be
 managed with the nicest discrimination. In this disease
 perhaps cold is a more frequent remedy than heat; yet
 the latter is undoubtedly of great value in the forming
 stage of  simple typhus, and indispensable in the con-
 gestive typhus of Armstrong.  This form of the disease
 is, indeed, nearly allied to, if not identical with spotted
 fever. Dr. Armstrong remarks, in regard to simple  ty-
 phus, "the warm bath is a safe and efficacious remedy,
 and, with the means above mentioned, has considerable
 effect in  equalizing the circulation."  Again, in speak-
 ing of the stage of collapse he remarks—"This depres-
 sion of the animal heat, however, occasionally comes
 on in the collapse of typhus, without any apparent cause;
 an instance of which I  have witnessed  in  a  medical
 gentleman, who I believe would have died  if external
 and internal warmth had not been promptly and per-
 severingly employed."   On the treatment of congestive
 typhus he says—"when the pulse still remains oppres-
 sed, and  the tide of the  circulation does not return  to
the surface, and more especially if blood has been freely

             •Gallup on Epidemics, p. £51— a. 
296              ON  HEAT  AND COLD.
drawn, some wine with warm water should be  occa-
sionally exhibited, and the patient speedily immersed in
a bath, strongly impregnated  with salt, and at least
about the temperature of 100°.   He should remain in
the bath till his skin becomes warm, and on being re-
moved, it should be well rubbed all over with hot flan-
nels; and he ought then to be laid in an aired bed with
bottles of warm water at his feet.   This plan together
with tepid wine and water occasionally, will often pro-
mote a flow of blood towards the skin, and considerably
relieve the viscera from congestion.  Indeed, if the bath
can be prepared sufficiently  soon, it is  far best to  im-
merse  the patient in  it  first, and either to bleed him
while he remains in it, or immediately after he leaves
it.  In some very severe cases, I have found it impossi-
ble to get enough blood until a warm bath had been
premised, so oppressed was  the general circulation be-
fore its employment."
   Dysentery is another disease  which is  much in-
fluenced by vicissitudes  of  temperature.   Its predis-
posing cause is heat—its exciting cause  is cold—sud-
denly suppressing the abundant cutaneous secretions,
and repelling the fluids in a copious tide from the sur-
face to the centre.  Some of the older writers regarded
it as a fever turned inward upon the intestines.  When
dysentery is excited by cold, no remedy is so efficacious
in subverting it,  as heat  associated with moisture.—
These agents reverse the series of actions produced by
the morbific cause—they divert the fluids and nervous
excitement to the surfacev As soon as universal warmth
is produced on the surface,  together with perspiration,
the symptoms are observed immediately to abate.  The 
             ON HEAT AND  COLD.             297
value of this  remedy is well appreciated by Mosely in
his valuable work on the diseases of warm climates.  It
is there dwelt upon with great emphasis, and ample
proof is given of its beneficial effects.
   There  is perhaps no disease  assailing  the human
system, in which heat is a more indispensable remedy,
than in cholera morbus.  The  disease, in its onset, is, I
believe, invariably accompanied with a rapid recession
of blood from the surface, extreme pallor, and remark-
able coldness, especially of the extremities. The  sto-
mach, liver and intestines, become the centre of fluxion,
toward which the circulating fluids seems to be power-
fully impelled.   Heat is most generally the predisposing
cause of this affection, and sudden transitions from heat
to cold, suppressing action on the surface, and inverting
nervous and vascular excitement, are as uniformly the
exciting causes.   I have become thoroughly convinced
of the importance of external heat in the treatment of
this disease, by my own observation and experience.—
It is not only in itself a powerful agent, (the  remedy
which nature seems to  indicate) with which to assail
this shivering offspring of cold, but it is an indispensable
adjuvant  to all other remedies.  Indeed, I  have rarely
seen the  symptoms  of  this malady yield  to  internal
remedies, until, by their means or  by others, warmth
had been restored to the surface and extremities. This
is precisely  what  I should  anticipate, because  the
absence of vital warmth and action from the surface,
and its  accumulation in the central organs, is the very
essence of the disease.   A  case  of this affection not
long since fell under my observation which proved fatal.
In this instance it  was found impossible by any means 
 298             ON HEAT AND COLD.
 to restore vital warmth to the  surface.   In another in-
 stance, an individual  having been reduced extremely
 low by this disease, and the  attending physicians, find-
 ing the usual  remedies  to be  altogether  inefficacious,
 (the usual modes of artificially warming the surface not
 being effectual) procured the warm skin of a recently-
 killed sheep, with  which  they enveloped  the body.—
 This proved singularly efficacious in re-animating  the
 surface  and  equalizing  action.   The patient was
 promptly relieved by it. I cannot conceive of any thing
 more admirably calculated than this to effect the object
 proposed.  The temperature is precisely such as would
 be most agreeable to the surface.  It would be convey-
 ed, too, through the medium of moisture  which could
 not speedily evaporate, and  thereby reduce the tem-
 perature.   The fleshy side being applied  to the skin,
 the woolly covering would serve to preserve its warmth
 for a great length of time.   Besides, there is something,
 I know not what, in  animal warmth which cherishes
 far more than artificial heat.  The knowledge of the
 fact seems to be as  old as the days of King David, but
 the rationale we cannot explain until we shall have learnt
 something more of the constitution of heat.   It is certain
 that there are different modifications, even of animal
 heat, winch are appreciable to our senses.   In  certain
 diseases, when the hand is applied to the surface, there
 seems to be something acrid in the heat which is given
 off from the body, creating a biting  sensation—hence
 the cator mordax, &c. &c. of the older authors.
  In the treatment of cholera morbus, while the usual
 internal remedies are in preparation, I lose no  time  in
re-animating the surface.   I find it convenient  to slip
4 
             ON HEAT AND COLD.             299
the patient down toward the foot of the bed, until the
legs can be  dropped over the foot-rail and  plunged,
nearly as high as the knees, in a deep bucket of warm
water, into which a handful of salt has been thrown,
and perhaps a spoonful of mustard.   At the same time
I apply cloths wrung out in hot water to the  stomach,
chest and abdomen.  Often I also place billets of wood,
which have been plunged into hot water and wrapt in
cloths, all round the body of the patient.  These means
soliciting the fluids to  the surface, and restoring the
equality of nervous excitement, will certainly, in many
cases,  enable our  internal remedies (Opium, calomel,
and diffusible stimulants,) to accomplish that which they
might otherwise fail promptly to  effect.  In such cases,
the citadel  of life is assailed by an impetuous enemy—
the garrison is surprised and in danger of being cut off.
It is true we may often foil  the assailant  by throwing
succour into  the fortress, but if we attack the enemy
without, and  create a  diversion in favor  of  the  vital
powers, we shall most certainly achieve the victory.—
Such a course is  as much stronger  than the simple
use of internal remedies, as double elective affinity is
stronger than single.
  Hysteria is another of those  affections which  are
powerfully  influenced by heat and cold.  Almost every
practitioner has seen a form of that disease, which, at
its onset, is marked by alarming and exceedingly dis-
tressing depression  of the powers of life—the surface
and extremities becoming cold and bloodless—the pulse
almost entirely ceasing at the wrist,  and the heart,
lungs and  great vessels being so  overwhelmed by the
accumulation of blood within, as to produce the utmost 
 300             ON HEAT AND  COLD.
 degree of oppression. There is then laboured breathing,
 deep sighing, or moaning, and palpitation of the heart.
 Here, it is true, we must immediately institute the treat-
 ment applicable to hysteria, but can we expect our pa-
 tient to be relieved before there is produced a reflux of
 the fluids to the surface?  Under such circumstances I
 proceed, with regard to external applications, precisely
 as in cholera, and I have seen such practice attended
 with the happiest  results.  Recently I have treated a
 very extraordinary case of this kind, in which internal
 remedies (even the most powerful stimuli) were totally
 inefficacious, till warmth was excited on the surface.—
 The patient subsequently had several similar paroxysms
 which her nurses  were always  able to subdue by the
 prompt employment of these conjoined means.
   In the treatment of intermittent fever,  warmth is
 always, in the cold stage, an important palliative means,
 and is also often an important auxiliary in interrupting
 the  paroxysms.   Generally, the more brief we render
 the cold stage, by  the employment of heat  and other
 means,  the less severe and protracted will be the subse-
 quent stages.  Hence most authors direct, in the cold
 stage, the employment of external heat.   When inter-
 mittent fever has existed for a considerable length of
 time, and the ordinary means  have been  ineffectually
 employed,  the  judicious  management  of external
 warmth will be  found greatly to increase  the efficacy
 of our remedies. In such cases it is important to break
 the established habit of diseased action; consequently,
 when the hour of  the expected chill approaches, I  di-
 rect my patient to be placed in a warm bed--if he has,
at the time any sense of chillness, to have bottles of 
              ON HEAT AND COLD.             301
 water applied to the feet, and perhaps around the body
 —I endeavour, indeed, to equalize as perfectly as pos-
 sible, the excitement and heat of the body.   By these
 means perspiration is ordinarily produced, but this we
 are to regard only as evidence of equal action.  To aid
 in producing these  results, I employ warm  aromatic
 drinks.   All this, however, must be accomplished with-
 out the  employment of ardent stimuli, or of intense dry
 heat, lest we should hurry action too  much, without
 equally  diffusing it, in consequence of which, there will
 be danger  of my producing local  congestions.  Moist
 heat  is   far  preferable for the purpose of equalizing
 action and overcoming  vascular obstructions, because
 it relaxes the  cutaneous  vessels, and by  sympathy
 probably influences the deeper  capillaries  in  a similar
 manner.
  When by the judicious  employment  of  heat, the
 equality of the circulation is preserved, the blood beingno
 longer suffered to rush upon the deep organs, overload-
 ing and  oppressing them, the tonic medicines which we
 employ are always observed to exercise a more salutary
 influence.  These, then,  should be renewed in the in-:
 terval, and  we are persuaded that, when thus seconded
by the equalizing influence of warmth, a  less quantity
 of such  medicines will produce the desired effect, and
with far less danger of the occurrence of permanent
congestions, indurations of the viscera, &c. &c.
  But external warmth is most imperiously demanded
in that prostrating and often fatal form of intermittent,
in which re-action  takes place reluctantly, or not at all,
and which  often terminates in death without the occur-
rence of the hot stage.   In such cases,  internal stimuli
       39 
 302              ON HEAT AND COLD.
 will often alone be found to produce no effect whatever,
 unless actively seconded by external warmth.  An epi-
 demic of this character occurred during the last year
 in Annapolis and its vicinity, and in some of the lower
 counties of Maryland.  Many patients were lost in the
 cold  stage, without the slighest re-action having taken
 place.  I have been informed by intelligent  medical
 gentlemen,  that in those cases, although occasionally
 all remedies were ineffectual,  external warmth  was
 found in those who survived, to be a most valuable and
 even  indispensable means.
   But  it is not only when there is universal coldness
 and pallor of the surface and extremities, that  heat is
 to be employed in the treatment of disease.  In many
 affections,  of absolutely  an  inflammatory character,
 there is often coldness and pallor of certain parts of the
 system, whilst others are hot, excited and engorged.—
 In such cases, the important indication is to equalize
 excitement, and what can be more important in accom-
 plishing this, than the employment of heat and cold, in
 such a manner as to equalize temperature?  Thus, in
 certain affections of the head, accompanied with great
 determination of blood to that region, heat, and sense
 of throbbing, we often find the  extremities to be cold
 and exanguious.  It is the dictate of the plainest com-
 mon sense, under these circumstances, to apply cold to
 the head, and heat to the extremities.   If  we Deglect
 either, we neglect half of our duty.   Nothing can be
more important than this effort to equalize excitement,
when local inflammation has taken place in  a feeble
and exhausted constitution.  In such cases, if we divert
the blood  from the  engorged part, and restore it to 
              ON HEAT AND COLD.             303
those regions which it has for a time deserted, we pro-
duce the same effect on local  inflammation, that we
should by abstracting blood from the body, and that
too, not by weakening the powers of the system, but
by absolutely increasing them, since the blood is retain-
ed in the body, restored to its proper  channels, and
the organs receive  their accustomed stimulation and
nutrition.
  In certain febVile  affections, the discriminating  prac-
titioner will often find occasion to employ local warmth,
even when the general aspect and sensations of the
patient would indicate a considerable degree of pyrexia.
Often, when the face is flushed, the chest and  abdomen
hot,  we shall discover that  the knees, feet, ankles,
wrists, and hands of the patient, are excessively cold.
Now, in restoring the natural warmth and excitement
of these parts, it is  perfectly obvious,  that we shall aid
in reducing the high temperature of other parts. There
are cases of typhous fever requiring the general  appli-
cation of  cold to the surface, which, with great pro-
priety, will admit of the  simultaneous  application of
warmth to certain parts.  Indeed, is there not  in almost
every form of disease, unequal  excitement in the sys-
tem; and is it not  an almost universal indication to ren-
der action uniform—a circumstance absolutely essential
to health?  The physician, then, should ever  be  ready
to apply warm stupes with one  hand, and ice with the
other. Let me not, however, be understood to  disparage
other remedies;  I merely  claim a due  consideration
for the means of which we at present treat.
   But warmth is, in some few instances, applicable as
a remedy, even where there appears to be a morbid in- 
304             ON HEAT  AND COLD.
crease of heat in a part.   This we have learned empy-
rically, if we  cannot explain it physiologically.  In
certain inflammations of the  joints, we very well know
that, when cold applications are often  ineffectual in
assuaging pain  and allaying constitutional disturbance,
these desirable ends are  promptly accomplished by the
employment of warm fomentations. Mr. Brodie informs
us that relief may be expected from the application of
warm stupes in inflammations of the joints, when the
integuments are observed to be tense over the inflamed
part.  He supposes  that ease is rendered by the relaxa-
tion, and relief of painful distension which exists.   But
I am  inclined to think that the seat  of pain is beyond
the reach of any such influence from warmth and mois-
ture.   The effect must  be one which  is exercised
through the medium of the nerves upon the deep vessels
of the part.  I have seen painful inflammation of the
female breast, where there can not be any great tension
of the integuments, relieved by the same means; also,
chronic  inflammations of the eyes.   It will, I  believe,
generally be found, that the cases in which warmth is
thus beneficial,  are  those which have existed for some
time, and which have assumed an atonic character; for
I by  no means regard inflammation as  being neces-
sarily associated with either increased or diminished
action. It is undoubtedly an altered, and irregular action;
but to restore the parts to soundness it is  necessary to
render the degree of action as nearly natural as possible.
Hence many local inflammations are assuaged by cold
applications, and some by warm.
  But warmth, as a local application, is more especially
applicable to local irritation, or that morbid excitation 
              ON  HEAT AND COLD.             305
of the nerves of a part which is about to terminate in
inflammation.  Heat, especially when associated with
moisture, as  in fomentations  and poultices, exercises a
remarkably soothing influence upon the nerves.  It re-
laxes the tissues  of the part, and  relieves the organs
from painful tension, and probably exercises, also,  a
more direct  influence  on the  nerves.   In contused,
lacerated, and gunshot wounds, the  sensibility of the
nerves is deadened;  there takes place a  suspension of
their action,  analogous to the suspension of the func-
tion  of the  blood-vessels in a chill.   In a short time, re-
action will  take place, and a high degree of irritation, in-
dicated by pain,  will result.   It  is  important to cut
short this period of torpor in the nerves; for, in propor-
tion  to the  length of its continuance,  will, for the most
part, be the subsequent  disturbance.   Warmth and
moisture accomplish this in  the  happiest manner.—
Hence the beneficial influence of poultices and fomen-
tations  after such injuries.   After protracted surgical
operations, also, when the wounded parts have been for
a considerable time exposed to the contact of the atmos-
phere, to an unusual temperature, and to the contact of
instruments, such  applications greatly palliate the evil
effects which are  liable  to result.  When the lips of
the wound have been brought as nicely in opposition as
possible, I  am accustomed, under  such circumstances,
to envelope the whole in a warm, moist poultice. Such
an application will by no means interfere with union by
the  first intention, but rather  promote it.   I  have
heard it remarked by the late Professor Smith, of Yale
college, than  whom, perhaps, but few  individuals of our
country have been more  extensively engaged in opera- 
306             ON HEAT AND COLD.
tive surgery, that  after severe operations, his patients
generally did better  when  the weather was warm.—
From this he drew two precepts; first, never to decline
operating (in the climate of New England) on account
of the warmth of  the weather;  and second, always to
dress warmly all wounds  inflicted  by  the knife.    I
do not mean that he always applied artificial warmth,
but that he enveloped the part in soft dressings.
  In the treatment  of burns, warmth is undoubtedly
often a remedy of indispensable utility.  We, however,
by  no  means  assent to its universal  employment,  as
recommended by some, or to the  employment of an
irritating degree of heat.   Warmth is  proper  imme-
diately after the removal of the cause of injury, for the
purpose of preventing the  abrupt transition from heat
to cold; for it is  often the transition which inflicts the
greater mischief.  The application of cold water, or
pounded ice to a burned part has always appeared to
me absurd in theory, and has been observed to be inju-
rious in practice.   The first morbid state of a  burned
part is irritation.   Often this is so intense that the sen-
sibilities of the part are overwhelmed with it, and re-ac-
tion does not immediately take place.  The seat of the
burn then  often becomes  cold  and lifeless.  This is
especially apt to be  the case, when cold applications
have been judiciously employed.  Warmth is then an
indispensable  remedy, and it may  be conjoined with
those articles which rouse  the vital sensibilities of  the
part
  Modes  of employing heat.—To  some of  the  con
venient modes of  applying heat  to the surface, I have
already had  occasion to allude, in  the course  of the 
              ON  HEAT  AND COLD.             307
 foregoing remarks:  I shall not, therefore, dwell upon
 them at length.  The most  perfect medium through
 which warmth can be imparted to the external surface
 of the body is water, or the vapour of water.  This
 fluid is a vehicle which applies itself to the whole sur-
 face of the body, with the  most  perfect contact—it
 readily imparts its heat, also,  in consequence, not of its
 being a good conductor, but because of the free motion
 of its  particles.  The temperature of  water is also
 managed  with the greatest ease.   The effect of heat
 thus applied is aided by the relaxing influence of mois-
 ture.   For these  reasons, when there is general pallor
 and coldness of the surface, with congestion of the deep
 organs, I prefer to apply warmth through the medium
 of the warm bath.   But sometimes, even in such cases,
 this use of warm water  will be inconvenient, or inju-
 rious, in consequence of the extreme exhaustion of the
 patient.  At other times the necessary vessels may not
 be obtained promptly enough to meet the emergency of
 the case.  When the patient is so feeble as to be moved
 with danger, or when motion is painful and difficult,
 no more effectual method can be adopted than to  apply
 to various parts of the body, and especially the extremi-
 ties,  stomach, chest, &c.  cloths wrung out in wrarm
 water—or, what is perhaps still better, billets of  wood
dipped in boiling water and wrapped in cloths.  These
absorb a great deal of moisture, retain their heat for a
long time, and rapidly give out vapour.  Heated bricks,
which have been quenched in water, answer a similar
purpose. When wetted cloths alone are  used, we must
be extremely careful that we  do not suffer the dress or
bed covering  to become  wet, or the wetted cloths to 
308              ON HEAT AND COLD.
become cool, lest, from the evaporation which will fol-
low, a counter-effect should  be produced.   It  was a
very favourite  practice  in New England, in the treat-
ment of spotted fever, to employ boughs of hemlock,
immersed for  a time in' boiling water, and then wrap-
ped in  cloths and placed by the body of the patient.—
These not only gave out aqueous vapour, but an essen-
tial oil which the plant contains in great quantity, and
which is highly stimulating.   When a soothing anodyne
influence  is desired, a  decoction of poppy-heads,  of
hops, or other narcotic, is employed in a similar manner.
  This mode of applying heat is also proper when, in
consequence of the inequality of temperature in various
parts, the general application  of heat is deemed inad-
missible.  They can often be used, indeed, when  it is
proper to apply cold to other parts of the body.  There
is  still another advantage, also, in our being able  to
continue warm stupes to the surface for a greater length
of time than it is prudent to use the warm bath, and in
our being able to  repeat them with facility.  The warm
bath is observed to  produce far more exhaustion than
any other mode of applying warmth. This is not owing
merely to the fatigue which the patient necessarily un-
dergoes, but, I am  inclined  to think, in part, to  the
pressure exercised by the water on the surface of the
body.  This pressure must necessarily render respira-
tion more difficult, and the exercise of it more fatigu-
ing.   Persons  in pleasure-bathing are far less capable
of muscular exertion than under other circumstances,
and they  are observed (I have  experienced  it my-
self) to become soon weary,  or to faint from exertion
too long continued.  This pressure, too, must  render 
              ON HEAT AND COLD.             309
 the capillary circulation more difficult.   The power of
 the heart is nicely adjusted  to the pressure  of the at-
 mosphere.  If that pressure be diminished, as  in ascend-
 ing high mountains, or, partially, by the application  of
 cupping-glasses  to the surface, the capillaries are no
 longer so sustained as  to resist the action of  the heart;
 the blood  rushes into  them and they become painfully
 engorged.   Precisely the reverse takes  place when the
 pressure of the atmosphere is increased by immersing
 the body of an individual in water.  The capillaries are
 then  subjected  to a pressure greater than natural—the
 blood is forced from them back upon the heart, which
 organ is then compelled  to  an  unwonted exertion, in
 order to relieve  itself of the load.  To effect the circula-
 tion,  then, the heart must necessarily labour more  than
 under ordinary circumstances.  These phenomina oc-
 cur in a remarkable manner when the body is deeply
 immersed in water in the diving bell.  We are inform-
 ed that there then occurs a high degree of oppression
 in the chest; the surface becomes bloodless, and  indi-
 viduals thus situated are not  capable of long continued
 exertion.   Now, in ordinary immersion of  the body,
just beneath the surface, it is true  that the pressure is
 not very great, but if  any one will take the trouble  to
 estimate the amount, he will learn  that the  additional
 pressure to which the body is subjected, is about one
 fortieth of the whole pressure of the atmosphere.   The
 pressure, indeed, is thus increased in the same degree
 that it is  decreased  by ascending a moderately  high
 mountain.  Now this increase of pressure on the surface
of the body is certainly a strong objection to the employ-
ment  of immersion, when the  patient is feeble, and
       40 
310             ON HEAT AND COLD.
especially when there exists already a congestion of the
deep organs, and an oppressed condition of the heart.
It is under  these circumstances, that we should resort
to steam bathing.   The vapour of water applies itself
as closely, and as generally, to the surface of the body
as water does—it requires little or no exertion on the
part of the patient,  and, instead of increasing the pres-
sure of the incumbent atmosphere, it slightly diminishes
it. It is for these reasons, undoubtedly, that steam bath-
ing is observed  to be far less productive of exhaustion
than immersion, although continued for a much longer
time.
   The modes of employing the vapour bath are various,
but ought always to be simple, otherwise they will cer-
tainly not be generally employed.  Ordinary ingenuity
will accomplish the object with great ease.   Indeed, it
is effected in part  by means which we have already
named, especially the billet's of wood, hemlock boughs,
bricks, &c. &c.   A method practised in New England,
during the  prevalence of spotted fever, was to place
over the body of the patient, as he lay in bed, a box of
boards, open on the under side to admit the body—the
edges of the open side to rest on the bed.   A vessel of
boiling water was then placed near the bed  (commonly
a tea kettle) and the nose of it being provided with a
tube of some kind, the vapour was conducted under the
box until a sufficient degree of heat was produced.   I
have practised the same thing in a manner  even more
simple  and less annoying to the patient than this, and
which will be found particularly useful when the lungs
are concerned in the affection, and expectoration is dif-
ficult.  It consists in placing over the patient a slight 
             ON  HEAT AND  COLD.             311
frame, and spreading over it sheets or blankets, in such
a  manner as to form a canopy.  Within this, and on
each  side of the bed, may be placed  a bucket of hot
water, into which heated bricks should be thrown,
which will  immediately produce  a cloud  of vapour,
completely enveloping the patient.  The bed-clothing
should be so far removed as to  give it access to the
body.  I have practised this method with the happiest
effects in the case of a lady extremely low with inflam-
mation of the lungs.  Expectoration  was  almost im-
possible, in consequence of the extreme soreness of the
lungs, and the toughness of the sputa.   Copious expec-
toration resulted from the free inhalation  of vapour,
and the engorgement of the lungs  seemed to be relieved
by the derivation which took place to the surface.
  Remediate influence of cold.—It is not my design  to
dwell so much at length upon the employment of cold
in the treatment of disease,  because, in fchis respect, I
believe it is less important as a remedy, and  because,
so far as  it is useful, I believe its virtues are better
appreciated.   I have shown that cold  is a far more
frequent cause  of  disease than heat, and that heat is
often  the  legitimate remedy  of those  diseases which
arise  from cold.   But cold being the remedy which
nature indicates for those affections arising from heat,
cannot of course so frequently be called into  requisition.
It is to be borne in mind, however, that cold is often to
be employed in the treatment of  those diseases which
arise  from cold itself, and  in  which excitement has
taken place from re-action.  Cold, too, is sometimes to
be employed in cases where there is feeble action,  or
torpor of the system, for the purpose of producing 
312             ON HEAT AND COLD.
re-action, and actually stimulating the body.  We dash
cold water upon fainting individuals—we throw it upon
new-born children, that  seem still-born, and we some-
times employ it where there is general torpor of the
system, in fevers, for the purpose of indirectly rousing
the powers of life.
   Since the days of  Sydenham, and especially since
Currie  wrote  and experimented on fevers, there has
probably been less prejudice against the employment of
cold, than against that of heat.  There is a tide in the
fashion of medicine, as well as "in the  affairs of men."
The abuse of warmth, in the treatment of disease, be-
fore the time of Sydenham, brought upon it a reproach
which it has not even now entirely cast off.  Cool air,
cool water to the surface, and cool drinks,  are, at pre-
sent, more in favour.
   The writers on the employment of cold  in the treat-
ment of disease are so numerous, and so recent, that it
would be a supererogatory affair for me to  dwell upon
it. I must refer for more full information on this subject
to Currie, Rush, Smith, Armstrong, &c. &c.   I  will
merely remark, that cold is for the most part applicable
to the general surface, when the whole surface manifests
a temperature  above  the natural standard—provided
the disease be one which is not liable  to metastasis—
and provided there exist no considerable congestion of
any deep seated organ.   The most remarkable diseases
which demand  its employment, are typhous fever  and
scarlatina.   Cold is also sometimes  applicable to the
surface, even when it is far below the natural standard
of temperature, for the purpose of producing re-action.
I have known  the cold shower-bath to be used with 
              ON HEAT AND COLD.             313
very striking beneficial effects, in protracted typhus, the
skin being, over the surface generally, far below the
natural degree of heat~-dry, harsh, and pallid; the pulse
feeble and contracted—indeed, a general torpor of the
whole system prevailing.   A patient in that condition
I have known to be taken from bed, placed on a rug,
and to have three or four buckets of cold water dashed
over his body.  He was then promptly  wrapped  in
warm blankets.   The cold aspersion appeared to give
a powerful impulse to the nervous system, the dormant
powers were  roused to re-action, the  pulse became
more vigorous, breathing more deep and  free, the sur-
face warm, and finally moist.  This I have known to
occur in  more instances  than  one.   The practice  I
learned from Drs. Powell and Pomeroy, of Burlington,
in Vermont, and have been informed that  they have
resorted to it in many instances with  success.   It is a
remedy, however, which should be  employed with the
nicest discrimination, lest there not being sufficient vital
power for re-action, it should prove suddenly fatal.
  When cold, water  is employed for the purpose of re-
ducing temperature,  as in the period of febrile  excite-
ment, I am inclined to think that it  ought  not to be
copiously dashed cold upon the body, lest it should ex-
cite too much re-action.  I prefer sponging the body
frequently with tepid water, and to suffer the abstrac-
tion of heat by evaporation.  This will be less apt to
disturb the balance of action.
  Cold water may often be applied with advantage to
certain parts of the surface which are above the natural
temperature, while, at  the  same time, other parts are
morbidly cold, and require  the application of warmth. 
314             ON HEAT AND COLD.
Remarks on this subject may be found in the foregoing
Essay on Typhus.
  The employment of cold lotions in  inflammations  is
so familiar an expedient that it is unnecessary for me to
remark upon it. 
RF.MARKS
                        ON THE

    TREATMENT OF THOSE CASES OF FRACTURE OF THE


               CRANIUM,

                     IN WHICH THE

       DURA MATER IS LACERATED,

AND ON THE PATHOLOGY AND TRBAMENT OF HERNIA CEREBRI.
BY MT. R. SMITH, JH. D.
   The brain is composed of a tissue endowed  with
 such feeble physical qualities—such imperfect tenacity,
 that unless effectually sustained  by surrounding sub-
 stances of greater  firmness, it is not capable, for  a
 moment, of retaining its form, or preserving its integrity
 of structure. To sustain and defend so delicate a mass,
 there are furnished the firm walls of  the cranium ac-
 curately adapted to its form, and the tenacious envelope
 of the dura mater.   When a portion of the cranium is
 broken  and removed, (if it be not very extensive,) the
 dura mater within it is still capable of sustaining the
 brain at that place, though not of so effectually defend-
 ing it from external violence. But, when the dura mater
is also torn, and the external firm envelop$egj|Jius com-
pletely removed from the organ at that place, the deli-
cate texture of the  brain, even although the rupture
may be  small, is very liable to suffer disorganization, 
316               HERNIA CEREBRI.
unless means be employed  which shall furnish a  resis-
tance, and yield a support, like that of the cranium and
dura  mater.   To  furnish such a substitute for  these
supports is a matter of extreme difficulty, and hence,
with the most judicious treatment, patients who have
suffered this degree of injury will, very often, ultimately
perish, even although the disorganization immediately
produced by the blow, should not be at once productive
of serious consequences.
  Various opinions have been entertained by different
individuals in regard to the nature and immediate cause
of hernia  cerebri,  the form of  disease which is very
liable to result from injuries of the above description.—
Mr. Abernethy believes that it results from a  kind  of
hemorrhage which takes place in the substance of the
brain, near the part  struck.  "This  hemorrhage," he
says, "was for a time restrained by the super-incumbent
brain and  its membranes; but these gradually yielding
to the expansive force exerted from within, and at last
giving way altogether,  the  fluid blood oozed  out and
congealed upon the surface of  the tumour."   Mr. A.
does not think these tumours to be organized.  In the
case detailed by him, the mass of the tumour seemed to
consist of  blood.  This, however,  has not been the
aspect of the disease as often seen by others.  I have
myself examined a case of this affection after death—a
case in which a portion of the tumour had been excised.
The cadaver was brought to my dissecting room.   The
disease haS°fesulted from a fracture  of  the os frontis,
attended with laceration of the dura mater.   A portion
of the brain had issued from the wound.  No unpleas-
ant symptoms, however, had arisen from the injury, till 
                HERNIA CEREBRI.                317
 the occurrence of the hernia.   Even then, indeed, he
 had seemed for a time to suffer no inconvenience»-com-
 plaining but little of pain, and his intellectual faculties
 being but little disturbed.  The tumour, when it  had
 acquired considerable size, was once cut away, and, as
 I was informed, presented very much the aspect of the
 brain itself, except that it was more vascular.
   Soon after this, the patient began to suffer the symp-
 toms of  cerebral irritation, and finally perished in con-
 vulsions.   At the time  that I examined the  head, the
 tumour had again risen above the surface  of the cra-
 nium; and  it was obviously a portion of the  brain itself,
 having undergone some degree of disorganization  by
 mechanical violence.
   Mr. Stanley, who has furnished a paper on this subject
 in the 8th volume of the Medico-Chirurgical  Transac-
 tions, confirms the doctrine of some of the  older surgeons,
 that these tumours  are, at least  in great part, protru-
 sions of the brain itself.   He found, it is true, a great
 deal of concomitant disease in the brain and its mem-
 branes, and seems to believe that such protrusions do
not occur but in consequence of degeneration of those
tissues, and a preternatural rush of blood to the brain,
caused by disease.
  Mr. C. Bell regards these tumours as organized  ex-
crescences, sprouting with  great luxuriance from  the
brain  and pia mater.   Such  tumours do undoubtedly
sometimes  occur,  as from  the extremely  vascular
tissues of other regions.   The vessels of the pia mater,
for instance, when its external investments are destroy-
ed, may commence the process of reparation  by the
production  of granulations, but these being unsustained
       41 
 318               HERNIA CEREBRI.
 by external  parts, and being forcibly  injected with
 blood by the very vascular tissue of the pia mater, soon
 begin to sprout with morbid luxuriance, and the intent
 of nature is entirely defeated.   Something of this kind
 may undoubtedly often occur, together with  the protru-
 sion of a portion of the brain.                     '
   I am persuaded, however, that the most frequent and
 fatal tumour, which thus issues from the surface of an
 exposed brain, is the brain itself, protruded  by the un-
 remitted impulse of the  arteries  of the organ.   My
 reasons for this belief, are:—1st. We should anticipate
 such a result from what we know of the  anatomical re-
 lations of the brain to its external  coverings—the  tu-
 tamina cerebri as they  are termed.   The integrity of
 the structure of  the brain  is not, as we see, at all de-
 pendant on its own tenacity, but entirely on the strength
 and firmness of the dura mater and cranium.  When
 we remove the  calvarium and dura mater from the
 brain, it is disorganized by its own weight.  But during
 Hfe, this resistance must be infinitely more necessary to
 the mechanical support of the organ, because it then
 sustains a powerful impulse from the copious streams of
 blood which are  rushing to the brain.  No  organ, in-
 deed, feels the beat of the heart so sensibly.   Any one
 acquainted with the  principles of hydraulic pressure,
 must form a just conception of the distension which is
 produced in the brain by the forcible entrance of blood
by these vessels.   The resistance of the vessels them-
selves will have but little influence in counteracting this,
because, as soon as they have yielded in  the least, the
 whole pressure will be thrown upon the brain.   The
pressure which the whole periphery of the brain will 
                 HERNIA CEREBRI.               319
 then suffer, will be every  where nearly equal to  that  ,
 which the carotid sustains.
   2.  True hernia of the brain  sometimes occurs in
 children, in whom  the ossification of the cranial bones
 is slow and imperfect; and  in whom, at the same time,
 there exists an unusual degree  of cerebral excitement
 and determination of blood to the head. Large tumours
 are  sometimes formed in such  cases, by  the protrusion
 of the brain at the fontanelles,  even although the dura
 mater is then entire.  An account of this affection may
 be found in the Memoirs  of the Royal Academy of
 Surgery, vol. 13.  This fact would certainly induce us
 to believe that, when,  in the  more perfectly ossified
 head, not only the bony support is removed, but also the
 dura mater, the brain must often be protruded at that
 part, especially since the same injury which destroys
 these tutamina, creates  excitement and increased force
 in the circulation.
   3.  If, in the dead subject, we remove a portion of
 the walls of the cranium with a large trephine—take
 away a  corresponding portion of- the dura  mater, and
 then  throw  coarse injection into  the vessels of  the
 brain, with force continued for some little time, we can
 cause the brain to be in some degree protruded at  the
 opening.
  4.  But we do not depend altogether upon a priori in-
 duction.   It is very rare indeed that any  of the forms
 of disease, termed hernia cerebri, occur  except when
 there is fracture of the cranium, together with lacera-
tion of the dura mater.   Sometimes, it is true, morbid
vascular  concrescence takes place  in the substance of
the brain, or in the  membranes, and  subsequently 
320                HERNIA CEREBRI.
causes the cleath or absorption  of the bone and dura
mater.  But such tumours present a very different ap-
pearance from the true hernia cerebri, and are attended
with  very  different phenomina.  They are morbid
growths, and not protrusions of  the train ; at least not
till they have caused the destruction of a  portion of the
bone and dura mater.  A very large  proportion even
of all those excrescences  which are commonly called
hernia cerebri, occur only after  fracture of the bone,
together with  laceration or death of a portion of the
dura mater.  The occurrence of hernia cerebri, after
such an injury, is, indeed, one of the results most liable
to take place, and the prognosis of the prudent surgeon
always  contemplates it.   Such being the fact,  then,
we have reason to infer, that the peculiar character of
the injury stands in relation of  a cause  to the  conse-
quence which is observed so often to follow.  If hernia
cerebri  is the result which we uniformly dread, when
the cranium and dura mater  are removed,  there is
certainly reason to  believe that this kind of injury has
something  to do with producing  it.  The bone and the
dura mater exercise but little vital influence upon the
brain; their offices are mechanical, they being especially
designed to support that delicate organ.  Consequently,
when they are injured, if the brain suffers, it is because
it has lost its mechanical support, and yields to the im-
pulse of its circulating blood.
  5.  But the most direct evidence that such is the charac-
ter of the tumour, is the appearance which a section of
it presents.  Many surgeons  positively  aver  that the
substance of the tumour is cerebral   I have distinctly
seen it to  be such.  That it should appear medullary 
               HERNIA CEREBRI.               321
throughout i§ not to be expected, because a laceration
of the minute vessels of the brain, which would  pour
their blood into the meshes of the pia mater  where  it
would coagulate  and produce  the appearance  of a
sanguineous tumour must take place. Indeed, it is easy
to conceive  that blood, thus extravasated, should often
obscure  the  character of a  tumour, essentially  and
primarily medullary.
   It may be presumed, also, that, before the protrusion
takes  place, or perhaps after it, nature  will have  at-
tempted  the process of reparation.  Granulations will
have begun to sprout; but cicatrization being defeated,
these  granulations will be protruded together with the
cerebral  mass.   After this, they will still  continue to
vegetate, and thus we have, associated with the cerebral
tumour,  a distinct vascular, organized excrescence.
   Hernia cerebri which occurs after a fracture of the
cranium  (that also lacerates the dura mater without in-
flicting much injury upon the brain itself,) most frequent-
ly commences without evidence of vascular disease in
the adjacent portion of the brain, such as can be  re-
garded as the cause of the occurrence.   Mr. Stanley,
it is true, speaks of collections of matter, foci of inflam-
mation, degenerations of texture  &c. as  occurring in
the brain, near the base of the  hernia, and probably
contributing to its production.   But have we not more
reason to believe  that these morbid phenomina  are the
result of the hernia, rather than its cause?  C ertainly
we ought to anticipate from the organic derangement
which the protrusion must cause, a great deal of irrita-
tion in the surrounding portions of the brain.
   In  most cases  of hernia cerebri which have come 
 322               HERNIA CEREBRI.
 under my observation, the beginning of the protrusion
 has been the beginning of the  alarming morbid phe-
 nomena.  Previous to its occurrence,  indeed, nothing
 indicating an unfavourable result has been present—no
 unusual pain,  or cerebral excitement—no unhealthy
 aspect of the wound, or appearance of degeneration.—
 Indeed, I have known the protrusion to take  place to
 some extent, without the occurrence of any symptom
 that would of  itself be premonitoiy of  the fatal conse-
 quences which are to  follow.  But, when  the  tumour
 has become considerable, and often very promptly after
 its occurrence, derangements of the cerebral functions
 begin  to manifest themselves, and, for  the most  part,
 they keep pace with the organic derangement which is
 caused by the protrusion of the portion  of brain.
   The symptoms which mark the progress of  a cere-
 bral hernia, are—extreme restlessness—pain in the
 wound—coma—irregular, interrupted respiratibn, with
 deep sighing and moaning—irritability of the eye, with
 contraction  of the pupil, in the early stages—convul-
 sions, partial paralysis, strabismus, dilation of the pupils,
 towards the close.  The pulse is but little  affected  at
 the commencement,  but  soon becomes frequent and
 irritated.  It may, in the latter stages, become unfrequent
 and sluggish, as in compression of the brain.  The
 gastric  functions, and those of the secerning organs,
 may not be particularly affected at the  beginning, but
 they become  greatly disordered in  its progress.   The
 tongue becomes, at first, white and tremulous—subse-
 quently it is dark and foul.  The stomach  is irritable,
 and the alvine evacuations are scanty  and dark.   The
 skin is  dry, unless when bedewed with  the sweat of
distress. 
HERNIA CEREBRI.               323
            Treatment of Hernia  Cerebri.

   The remediate measures employed in the treatment
of this affection and the injury which conduces  to
it, may be resolved into,—1st. those which are used for
Prevention; and, 2d. those which are subservient to the
Cure of the disease.
   1.   I have endeavoured to show that the legitimate
cause of true hernia of  the brain, is  the destruction of
a portion of the walls of the cranium and of the dura
mater—the brain being thus deprived of its accustom-
ed support.  Almost every  surgeon  of extensive  ex-
perience will learn  to dread the occurrence of the dis-
ease from a wound  of this character.   It is an obvious
duty, then, on the part of the surgeon, to counteract, by
some means, the influence of the cause, and to prevent
the effect which is to be feared.  The mechanical sup-
ports of the brain being removed, it  would seem to be
necessary that something should be supplied which may
act as  a substitute for the cranium and dura mater, in
sustaining the brain and resisting  the  impulse of the
blood,  which now begins to circulate  with increased
impetus in the head.   The indication is  to  employ
something which, like the cranium, shall  merely resist
without making any pressure on the brain, since this,
even in the slightest degree,  is observed to be at once
productive of the most serious consequences.
  To  accomplish this object, we  must employ some-
thing which is hard and unyielding, and which can, at
the same time, be accurately moulded and adapted to
the part. Professor Nathan Smith, was  in the habit  of 
324               HERNIA CEREBRI.
employing, for this purpose, a plate of lead, or pewter.
This  he endeavoured,  by  hammering  and  bending,
to fit accurately to the form  of the  head.  First, he
applied  a soft pledget of  lint  to the vacuity in  the
bone—over this a  thin  cerecloth, and then the plate
of pewter, which he bandaged  securely to the head.—
When the  parts  are placed  in  this condition, it is
obvious   that, as soon  as this  portion of the  brain
begins to rise above the general surface of the  organ,
it  will be met and steadily resisted  by the firm sub-
stance applied, before disorganization will have taken
place.   The plate of metal is so applied  to the  ex-
ternal surface of the  head, that it can make no active
pressure on the  brain, but merely furnish steady resis-
tance.  The resistance which  the protruding portion
of the brain encounters, is very gradually increased, as
the protrusion increases, and  the brain gradually  ac-
commodates itself  to  this resistance.   Were the metal
applied not  till after the protrusion had begun to take
place; and  were it then  so applied as immediately to
make pressure and to repress the protruding portion,
we have reason to believe that  it could not be endured
without creating, at once, the symptoms of compression
of the brain.
   Professor Smith treated several cases of fracture of
the cranium complicated with laceration of the dura
mater, in this manner, and with success in preventing
the occurrence of hernia cerebri.  He, however, found
it difficult to fit the plate accurately, and that it re-
quired  more  mechanical tact  than  most  surgeons
possess,  especially as the  surface of the part is then
rendered irregular by the injury.  It has since occur- 
                 HERNIA CEREBRI.               325
 red to me, that, if something could be  applied to the
 part which should a.t first be soft and pliable enough to
 adapt itself accurately to the configuration of the part,
 without injurious pressure upon any point, and which
 should then become hard, so as to accomplish the func-
 tion of the bone in regard to support, the thing would
 be effected in a much more perfect and uniform man-
 ner.   These  thoughts suggested to me the employment
 of successive layers of  strong paste-board,  wet  and
 softened in such a manner as to be easily moulded to the
 part.  Into the vacuity, over the brain, there should first
 be laid a soft  pledget of lint, spread with simple cerate;
 on the  out-side- of  this,  a  tjiin  linen cloth, broad
 enough to  cover the whole surface of the injured part.
 Over this, the first piece of wet paste-board is to be laid,
 and it may be incised,  at the edges, in  various places,
 in order to make it adapt itself accurately.   Over this,
 others are  to be placed, in  the same manner, until a
 sufficient number is applie^ to give the necessary degree
 of firmness when they shall have dried.  Usually, three
 will be-sufficient:   Over the whole a bandage is to be
 applied with gentle constriction.  In  the course of an
 hour or  more, the  paper  dries, and forms a firm shell,
 which will effectually  perform the office  of the lost
 portion of the  cranium, so far as the mechanical support
 of the brain is concerned.   When it becomes necessary
 to remove the dressings, this shell of paper may be re-
 moved at once, without altering its form, and, on cleans-
 ing and  re-dressing the wound, it  may  be applied in
 precisely the same attitude as before.  This application
I regard as more perfect  than the  plate  of metal, not
only because it is infinitely easier to adapt it perfectly,
       42 
   326               HERNIA CEREBRI.
   but because it is a great deal lighter, and less annoy-
   ing to the patient.               #
      Case.—In December 1828, there occurred to me in
   this city, a  case which I regarded as illustrative of  the
   utility of this apparatus.  The son of Mr.-------, of
   Howard  street,  ast. 7, wras kicked  by a horse, on the
   frontal bone, near the centre  of the right boss.  The
   bone was comminuted to considerable  extent, and the
   integuments extensively lacerated.  On my being called
   to visit him, in  consultation with Drs. Chapman  and
   Thomas, of Lexington street, we found the lad in a state
   of partial insensibility, though conscious of pain when
   the part  was touched, .and restless.  * On raising the
   scalp, a portion of the cranium was found to be depres-
   sed, and to  present its  sharp spicutee inward, upon the
   dura mater. To elevate and remove thisyit was necessa-
   ry to apply  the crown of a small traphine, and subse-
   quently to use the Hey's saw, for removing a projecting
*  angle.  On accomplishing  this, we discovered that the
   dura mater was lacerated to some extent, and transfix-
   ed with spiculas of bone. The arachnoid and pia mater
   were broken, and a portion of  the brain issued  from
   the wound.   I should here remark  that the portions of
   bone destroyed by the blow and removed with the tra-
   phine, were about equal, in extent, to the superficies of
   a half-dollar. The dura  mater  was lacerated half across
   this space.
     During the  performance of  the operation, the lad
   complained  much, but seemed unconscious of his con-
   dition.   When it was  accomplished,  he sunk into a
   comatose condition, with at first a  sluggish pulse, and
   irregular breathing. Stitches were used, and the wound 
                HERNIA CEREBRI.               327
was dressed with adhesive straps and  lint.   A few
hours after, he suffered a convulsion.   The pulse rose,
bounding violently, and requiring the free and repeated
use of the lancet.   The next day, his  nervous  system
was much more calm—his pulse  more  tranquil—the
system evidently recovering from the immediate effects
of the injury.  The. head was kept wet with evaporat-
ing lotions,—the bowels were opened by a gentle purga-
tive.   The danger  from irritation and  inflammation
seeming, now to be in some degree parried, our atten-
tion was directed to the dreaded occurrence of hernia
cerebri.  The head was dressed on the third day.  The
wound was found to present a favourable  aspect; but,
beneath it, the brain pulsated violently,  and the parts
received a powerful  impulse at each throb.
  There was now a probability that the case might re-
sult favourably, provided that  the protrusion  of the
brain, and the  occurrence  of hernia cerebri, could be
prevented.  This, then, became my, principal  object.
We dressed the wound as I have directed above—
found it easy to mould the  paste-board to the form of
the parts, and that, when it became dry,  it  furnished a
very perfect, firm support, that, without pressing direct-
ly on  the brain, resisted effectually the  throbs of the
organ, and appeared to obviate all tendency to  protru-
sion.  At first,  this dressing was not renewed  oftener
than once in two days.   It gave him little or no incon-
venience.   In other  respects, the case was treated in
the usual manner—with vene-section—spare diet-
perfect rest--an elevated attitude of the head—and oc-
casional laxatives.
  This boy perfectly recovered, in a brief space of time. 
328                HERNIA CEREBRI.
He is now a vigorous and healthy lad; but nature has
done very little toward supplying the deficiency of the
cranium, at the place of fracture.  Over the whole seat
of the fracture, the brain is defended and sustained only
by the membranes, and by the scalp.   The pulsations
of the brain are obvious to the  eye at a  considerable
distance.
   It is scarcely necessary to add, that, in the preventive
treatment,  copious  and repeated vene-sectipn should
always constitute a part of the plan.   In this we  have.
two objects in view; first, to subdue the vascular excite-
ment which of itself may soon prove fatal; and, second,
to diminish the amount of blood circulating in the brain,
and to subdue the violence of the throb, which, under
these circumstances, is preternaturally strong.  Indeed,
the increased impetus of the blood circulating in the
brain, is to be regarded as one of the  most important
causes aiding to produce this disease.—It is, of course,
impossible to give any precise instructions in regard to
the quantity of blood to be taken, or  the frequency of
the vene-sections.   This general precept may,  how-
ever, be borne in mind, that in this condition of things,
bleeding may be carried farther than under almost any
other circumstances, and  that the  force  of the pulse
should always be kept below the standard of healthy
action.
   The head should be kept elevated, in order that the
ingress .of blood  may  be  counteracted by  gravity.—
Evaporating lotions  may also be employed to keep the
head cool, and thus repel the fluids.  This may be done
without softening the paper,  if we lay over it a piece of
oiled  silk, or  brush over its external  surface  a little 
                HERNIA CEREBRI.               329
 spirit varnish.   Or, we might moisten our paper, when
 first applied, with  spirit varnish, instead of water.—
 Then, over  the whole  head, a  wetted  cloth may be
 laid, and kept  constantly  exposed to the atmosphere.
 Light—noise--conversation—every   thing,  indeed,
 which may be supposed to produce the least cerebral
 excitement, is carefully to  be avoided.
   2.   When the disease has already manifested itself,
 our prognosis must generally be unfavourable; but yet,
 the many cases  of subsequent recovery on record, en-
 courage us to contend with the malady.  If there has
 as  yet taken place no remarkable degree  of cerebral
 irr^ation, we need by no means  despair.
   When the tumour has not yet risen to a level with
 the external surface of the cranium, our mode of treat-
 ment is precisely the./'^nne as that which I have advised
 for the purpose of—thventing  its occurrence.    Our
 adjuvant measurenvith r> is  the  depletory  means &c.
 are to be  urged^be fataire vigor, because the result
 must necessarily           nless  we speedily arrest its
 progress.     he tumour  '
   But when V)       *" *he as risen above the level of
 the external surface 01  „._ Cranium, further interference
 on the part o\' the surgeon appears to be necessary, if,
 as is his duty,ftie would stiU labour to rescue his patient
 from  his perilous,  but not hopeless condition.   The
 first question to  be considered, is—shall the protruding
 mass be  cut  away, as  has  been  practised  by Stanley,
 Pring,  Hill, Richerand and others? or, shall we adopt
 the less active 'measures  of Larrey, who condemns all
irritating means?  Many cases are on record in  which
the former practice has been  attended with  happy 
 330                HERNIA CEREBRI.
 results.  It is true, when we consider that the tumour is
 chiefly composed of a cerebral protrusion, that the pro-
 posal to excise the mass is  at first startling.   $ut it is
 at  the same time to be  borne in mind that this portion
 of  the  brain, in being thus protruded, has already un-
 dergone a degree of disorganization—that it is already
 suffering extreme irritation from the mechanical violence
 which is continuing to be inflicted.  It is to be borne
 in mind also, that whatever course of treatment we may
 resolve to pursue, our remedies and our dressings will
 necessarily inflict much irritation upon the exposed mass.
 Indeed, if the case is to result favourably, the protruded
 tumour  must  necessarily undergo disorganization  be-
 fore the wound can cicatrize.  That it can be pressed
 back again into the cavity of the cranium, is not to be
 expected, as such  an attempt V s been observed by
 surgeons to  produce at once the   iptoms of compres-
 sion of  the  brain. This result     witnessed by Pro-
 fessor N. Smith, in  two or tb"       \ treated by him,
 and which he was accustom*          >in his lectures.
 Larrey  and  Stanley observed
  There appears then to be           amative.   We
 must either  leave the tumour           irts of nature
 entirely, trusting  that it may t           slough  away,
 and that the tendency to furth           n may sponta-
 neously cease,  and cicatrizat           cted; or, we
must at  once remove the tv           the  ligature,
or  the knife, level with  the surface of the cranium, or
below it.*
  It is true that, in some rare instances, the tumour has

  * The use of styptics to repress its growth, I regard as a proposal
unworthy of particular notice. 
                HERNIA CEREBRI.               331
spontaneously separated, and recovery has been the re-
sult.  But this is a thing so little to be expected, that
the interference of the surgeon seems to be imperiously
demanded.   If there is  any thing to be accomplished
by furnishing a  substitute for the natural supports  of
the brain, at an early period, it certainly must be equally
necessary at a later period.   Indeed, the tendency to
protrusion probably becomes stronger as the tumour in-
creases, because, by the loss of a portion of the brain
within, room is made for the ingress of more blood, and,
the vessels becoming excited, the pressure is increased.
But how  can we furnish the necessary support to the
brain, while we suffer the excresence to remain?
   I am persuaded, therefore, of the propriety of at once
paring away the tumour, at least  as low as the external
surface of the cranium.  Larrey, it is  true, condemns
this practice  as having been unsuccessful under his ob-
servation; but in the cases witnessed by him, the subse-
quent treatment seems not to have been adequate.  In
the hands of others, whose  names  I have mentioned,
this method has  been found  more successful than any
other, even when not associated  with the means which
I am  about to recommend.
   For the removal of the tumour, the knife is decidedly
preferable to  the  ligature, for reasons on which it is
unnecessary to dwell.  When the protruded mass has
been  thus excised, we are advised  by some to  make
direct pressure upon the exposed surface, not only for
the purpose of repressing the growth  of the  tumour;
but also for the purpose of forcing into the cavity of the
cranium that portion which, rises to the level of its ex-
ternal surface.   Both fact  and  analogy are decidedly 
332                HERNIA CEREBRI.
hostile to such a practice.  It is true that some degree
of pressure can be exercised on  the brain, provided that
pressure be gradually imparted, and  increased 'with
perfect uniformity. This, when  direct pressure is made
on the tumour, is impossible.   Larrey did not witness
a single case in which  such pressure could be endured
with advantage.   My father witnessed the trial of it in
two or three cases, and found it to be attended with the
most distressing consequences. In those cases in which
compression is reported  to have been successfully em-
ployed by Sir A.  Cooper, Pring, and Stanley, we have
good reason to believe  that the  means employed rather
occasioned steady resistence, than direct pressure.—
This, indeed, must have  been the case in  the practice
of Sir A. C. because he chiefly relied upon  the  pres-
sure of adhesive  straps.   Now these, however closely
they may be applied, will invariably yield a  little, and
that which was  pressure at  first, becomes mere  resis-
tance.
  Indeed, the very object which we have in view would
seem  at once to point out the impropriety of making
actual pressure upon the tumour. The attempt to force
back any portion of the  protruded mass, into  the sack
of the dura mater, is  now  regarded by all as utterly
futile.  Sir Astley  Cooper desires  merely to  keep  its
surface on a level with the external surface of the cra-
nium, when the scalp will heal over it.   If this be the
object, it  must certainly be unnecessary, as  well as
generally mischievous, to apply any tiling  which shall
make active pressure upon the  part.
   I am sanguine in the  belief, that  the sole object of
the surgeon should here be, merely to furnish something 
                HERNIA CEREBRI.               333
which shall serve as  a substitute for the portions  of
cranium and dura mater  which have been removed—
something hard and unyielding, accurately fitted to the
part, and which, like the previous coverings, shall mere-
ly make steady resistance, but never follow up the parts
ivith active pressure.   This is  certainly antagonizing
one of the  most important causes of the disease, and
therefore the remedy which  nature indicates.  Profes-
sor N. Smith,  accomplished  this  also, by the employ-
ment of  the metallic plate,  so  applied that  it merely
came in  contact with the  cerebral mass, without  mak-
ing the least active  pressure upon it.  Its rigidity, and
its being applied over a considerable surface, effectual-
ly protected the brain  from any varying and injurious
pressure of the bandage.   It therefore served as a firm
support to the brain, and at the same time as an effec-
tual shield for  its external protection, precisely as does
the natural bone itself.
   The metallic plate was applied in precisely the same
manner  as  for the  prevention of the  disease.   The
portion protruded  having been cut away as near to the
surface of the  brain as possible, a pledget of soft lint
was first applied—then a cerecloth, and lastly the plate
secured with bandages.  At  the time of its application,
the plate made no resistence to the brain; but as the
disease advanced, the protrusion encountered the firm
plate, and experienced the same resistence from it that
other portions of the brain did  from the cranium.  All
the pressure or re-action, then, which could be made
upon the brain, was occasioned by its own tendency to
protrusion.  Necessarily therefore, as the brain gradual-
ly came  in  contact  with  the resistance,  the pressure
       43 
334                HERNIA CEREBRI.
which the brain experienced would be very slowly and
uniformly increased, in precise correspondence with the
growth of the tumour.   Now we know that a gentle
pressure, thus  gradually imparted, can be endured by
the brain without serious consequences.  It is like that
which is made upon the organ by the growth  of a  bony
tumour within the cranium—like that which is inflicted
upon  the spinal marrow, by a gradually increased cur-
vature.
   This  mode  of treatment succeeded in my father's
hands in two cases which he was accustomed to relate
in his lectures, but the notes of which have unfortunate-
ly not been preserved.
   For the same reason that I prefer the shield of paper
in the preventive treatment, I should also prefer it  here,
and apply it in the same  manner.  I should  be  more
careful, however, that the paper layers might  nicely fit
the head, and that they should be thick, and firm enough,
when dry, to make steady resistence.  The same means
should be employed to  prevent the absorption of fluids
by the paper.
   But perhaps a better method than  either, to accom-
plish  the object in the most perfect manner,  would be
to beat up paper  in gum-water, to the consistence of
thick pulp, (papier mache) and to mould this to the
head. It would merely  be necessary to apply the lint as
before—then a thin piece of oiled silk, or plaster-cloth
—and then to apply the pulp, of such consistence that
it would soon  become hard.   That it might  the  more
quickly become firm and not alter its form in any de-
gree, we  might combine  with it a  small quantity of
plaster of Paris. 
                HERNIA CEREBRI                335
   The support, however it may be applied, should not
be removed, if it be possible to avoid it, till the third or
fourth day after its application, and then it should be
quickly re-applied.  It ought to be continued till cica-
trization is nearly completed. 
 
NEW  MODE
                         OF

MAKING COUNTER-EXTENSION IN EFFECTING THE REDUCTION

                         OF

DISLOCATIONS OF THE SHOULDER.
BY N. R. SMITH, M- D
   What surgeon of experience, in the reduction of the
 dislocated humerus, has not  encountered the difficulty
 which almost always occurs in fixing the scapula, while
 the dislocated bone is extended ? This arises from the ex-
 treme mobility-of this bone, its being connected to the
 trunk only by syssarchosis,and gliding with great freedom
 in whatever direction  the humerus drags or pushes it.
 The difficulty also arises, in part, from the fact that this
 bone being short, and closely applied to the thorax, is far
 from being accessible to our hands, and cannot, therefore,
 be grasped so  as effectually to resist the traction which
 is made upon the os humeri in the attempt to effect the
 replacement of the dislocated bone. To a certain extent,
 therefore, the  scapula, in such efforts, follows the head
of the os humeri, and thus renders the reduction dif-
ficult; because nothing is more important than that the
cavity, to which we would return the dislocated head,
should be steadily fixed;—if it  be not, we lose,  in a
great degree, the  effect of our extension. 
 338       DISLOCATIONS OF THE SHOULDER.
   When counter-extension is made by a sheet thrown
 round the thorax, thus sustaining the lower part of the
 scapula, we are directed to support  the acromian with
 resistance made by the hands of an  assistant while the
 extension is made.   It is very easy for the author in his
 closet, to indite with his pen such a direction, but he
 would find it a very difficult  matter  to execute it with
 his thumbs.  The fact is, it is an utterly vain  attempt,
 for as soon as the acromian is tilted  a little forward
 by the extension, it ceases to present surface for  resis-
 tance.  I have often seen this  attempted without any
 success; indeed, it is perfectly obvious that the thumbs
 of an assistant thus  applied can accomplish nothing in
 resisting the force of perhaps two strong men, who are
 extending from the wrist  or elbow.
   When a band, passing over the shoulder, is attached
 to the margins of the folded sheet, for the purpose  of
 sustaining the acromian, it will be found, as has occur-
 red in every case in which  I  have witnessed its use,
 that the acromian will insinuate itself beneath it, and
 evade the resistance.
   So also,  when the arm  is passed through a slit made
 in the sheet, or a ring of strong cloth twisted, which is
 designed to constrict the shoulder more closely, and
 thus to sustain the upper part of the scapula, the acro-
 mian, when it is necessary to  make strong extension,
 will still insinuate itself through the ring, and the scapula
 be thus dragged forward;—or if this does  not occur,
 because of the closeness of the ring, an evil will result
 which will more than  counterbalance the advantage.
 The ring will constrict  very forcibly the region of the
joint, and, by insinuating itself under the acromian, will 
        DISLOCATIONS OF THE SHOULDER.       339
 press the deltoid  muscle down upon the head of the
 bone, and thus prevent its reduction.
   That which I would propose, to supersede the above
 means, is counter-extension from the opposite  wrist.—
 This I  have no doubt  will at  first appear startling to
 some of my professional brethren, but I beg them, before
 they condemn, to consider the following anatomical
 reasons for such practice.
   The  two scapulas are, in their movements', very in-
 timately associated with each other.  Whenever an in-
 dividual makes a strong muscular effort, even with but
 one of  the superior extremities, he will find, by careful
 observation, that not only is the scapula  of that side
 firmly braced by the contraction of the muscles which
 fix it, but also the  one on the opposite side, and that the
 steady posture of  the latter sensibly contributes to the
 firmness of the former.  Let any one carefully observe
 the  anatomical connections which the two scapulae
 have with each other, and the rationale will be obvious.
 On the back, between the scapula, is situated the broad
 expansion of the trapezii muscles.  At the ligamentum
 nuchas,  these muscles seem to  arise from  each other,
 and there play with perfect  freedom over the  spinous
 processes  of the vertebras.   At  this place, therefore,
 these two muscles} with their common  tendon, form a
 continuous contractile band, which stretches from one
 scapula  to the  other.  It is apparent then that, when
 one scapula is drawn directly outward from the body
by an effort made  on the arm of  that side, the  scapula
of the other side will yield in some degree, and be drawn
nearer to the spine, thus allowing much more freedom
of motion in the shoulder on which the effort is made. 
340        DISLOCATIONS OF THE SHOULDER.
But let the scapula of  the opposite side be fixed, and
it will be found that, by the tension produced  in the
trapezii, the shoulder operated upon  will be far less
moveable.  Let the shoulder of one side be fixed, and
then let the individual endeavour to throw the other
shoulder forward  on the thorax, by the action  of the
pectoral muscles and the serratus; he will find that this
movement can not be accomplished with half  the free-
dom that it can, when the shoulder of the opposite side
is allowed to move backward in  a corresponding man-
ner, toward the spine.
  The scapulae are also connected to each other above,
through the medium of the cervical vertebrae.   From
the transverse processes of these bones, on each side,
the lavator muscle  descends to be  inserted  into the
upper part of the scapula.  The cervical portion of the
spine is very flexible.  When one scapula is forcibly
dragged outward, the  other not being sustained, the
spine invariably bends to that side with freedom.  But
if the scapula of the other side be also dragged outward,
then  will  both  the lavators be made  tense,  and one
counteracting the other, the spine will remain erect, and
the scapula acted upon will yield far less.  The  mecha-
nism of the rhomboid muscles is very similar.
   Anteriorly,  the two scapulae are chained to each
other by the intervention of the clavicles and the clavi-
cular ligament.   These being inextensible, the scapulas
can not, it is true, here influence each others motions in
the same degree  as  in some other directions.   Never-
theless, the anterior walls of the thorax, composed  of
the ribs and sternum, with which the clavicles are con-
nected, are susceptible of some lateral motion, when 
         DISLOCATIONS OF THE SHOULDER.      341
 strongly operated upon, and when, therefore, powerful
 traction is.made upon one arm, the scapula of that side
 will be more effectually sustained, if resistance be made
 from the opposite extremity.
   It is probably not necessary for the support of the
 scapula of the injured side, that all the counter-extension
 should be made from the wrist of the sound side.  My
 mode of employing it is to cast a folded sheet round the
 thorax, beneath the injured shoulder—to carry the
 extremities  out parallel with  the sound arm, and  to
 bandage them to the wrist.  The counter-extension is
 then to be made by grasping the wrist and  the extremi-
 ties of the sheet.   Extension  I make  from  the other
 wrist.
   The  dogma of Mr. Pott, that, when extension and
 counter-extension are made at remote points, a great
 deal of the force is lost in the intervening articulations,
 is scarcely worthy of serious censideration.  All forces
 imparted to the wrist must ultimately be communicated
 to the shoulder, without  diminution,  though with a
 degree of elasticity, which is that which we desire.
   Nothing,  it  appears to me, can be better calculated
 than these antagonizing forces to place the two shoul-
 ders in their symmetrical relations.   The trunk will
 thus be effectually sustained—the spine rendered per-
 fectly erect, and the scapula of the injured side sup-
ported and placed in the same attitude with the opposite.
 The muscles  around the  injured joint will thus be
 brought into exercise in the most favourable manner to
restore  the  symmetry of the two shoulders—in other
 words, to reduce the bone. This is because, in all other
 respects, the two sides are now in symmetrical relation.
       44 
342       DISLOCATIONS OF  THE SHOULDER.
But when the traction is made only on one extremity,
both shoulders are distorted, the spine is bent to one
tide, and the thorax  racked.   In  the method which I
propose, there is also this advantage—that the hands of
the assistants being applied remotely from  the  trunk,
the surgeon has free  access to the shoulder joint.  And
it is to be observed that, in this mode, there is no band
or strap which can constrict or irritate the muscles about
the shoulder, and thus impede the reduction.
   I place the patient  in a common chair, and direct the
assistants to make extension and counter-extension, at
first a little  inclining downward, but ultimately in nearly
the horizontal direction.   If this  does not succeed, I
place my arm firmly under the shoulder, and direct the
dislocated member to be carried downward, while ex-
tension is made.   The following case proves the prac-
ticability of this method.
   Case.  July, 1830,  I  was called  in  haste to visit
L. Barney, Esq. of this city, who, in  passing from the
wharf on board of one of the steamboats, had fallen into
the dock, and suffered a dislocation of  his left shoulder.
I found him in the office of my friend Dr. M. L. Knapp,
which was near the scene of the accident, and to  which
he had been taken for relief.
  Before my arrival, Dr. K. had made the usual efforts
to reduce the bone, but with inadequate assistance, and
his  endeavours,   though repeated, were unsuccessful.
This was partly because of peculiar difficulty produced
by the spasm of the muscles, caused by the plunge into
the dock.
   Dr.  Knapp kindly  gave me the direction of the case,
though I doubt not that his own judicious efforts would
have ultimately succeeded.  I then directed two of my 
       DISLOCATIONS OF THE SHOULDER.        343
pupils who were present, Mr. Selby and Mr. Hunt, to
make Counter-extension from the opposite wrist.  My-
self and Dr.  Knapp made extension from the wrist of
the injured side, at first directing it downward, but
gradually raising it to the horizontal direction, and then
gently depressing the wrist. On the effort being steadily
continued, for two or  three minutes, the bone was ob-
served to slip easily into its place. Mr. B. has  repeatedly
assured me, that the effort  gave him  much less pain
than that made in the  usual way.
^» 
 
DESCRIPTION
                    OP A

         SPLINT DESIGNED FOR THE

  TREATMENT OP FRACTURES OF THE

          OS  HUMERI.

ESPECIALLY THOSE WHICH OCCUR AT THE CONDYLES
BY N. R. SMITH-M. D-
  The apparatus above-named is made of binder's
                      board.  A broad sheet of
                      this material is cut in the
                      shape here represented.—-
                      From the angle which the
                      two upper projecting pieces
                      make with each other, in
                      the centre, the board is slit
                      vertically down to the mid-
                      dle, as represented. Where
                      this slit is made, the two
                     lateral, projecting pieces
are, by being pushed horizontally, made to overlap
and slide the one upon the other, till their margins be-
come coincident with each other.  This will immedi-
ately throw the splint into nearly the rect-angular form
rt 
346
SPLINT FOR THE
                           —the middle portion, which
                           is designed to fit the elbow,
                           becoming conical.  The two
                           projecting pieces, (the low-
                           er designed to sustain the
                           arm, and the upper, the hu-
                           merus,) are now to be bent
                           in a form to fit the convex-
                           ity of the member.   When
                           the apparatus, as represent-
                           ed in the cut, is applied to
                           the  arm  and  fore arm, it
 will be found to fit the member with great ease to the
 patient.   The  bandage adapts it nicely to the form of
 the limb, especially if it be  a little moistened when ap-
 plied.   A splint-cloth may be placed in  its hollow, and
 compresses used where they may seem to be necessary.
 The splint should be long enough to embrace the whole
 arm, fore-arm and hand, to the first joint of the fingers.
 It should be applied with the roller, from the hand to
 the shoulder.   When used for fracture of the condyles,
 a  compress should  be  placed in the bend of the arm,
 and  the roller should  make a few spiral turns  around
 the elbow.  No bandage should  be directly applied to
 the arm or fore-arm.
   The  apparatus accomplishes all  the indications  of
 the angular splints recommended by Sir A. Cooper and
 Dr. Physick—it is neater,  less cumbrous  than they,
more easily adapted to the limb, and occasions far less
irritating pressure.   The limb reposes in its concavity
with perfect ease and perfect support.  It is particular-
ly applicable to the fracture  of the condyles.   It furn-
 
              ARM AND FORE-ARM.              347
ishes a firm dorsum behind the limb, on which the
bandage may act, and thus steadily press the condyles
back into the concavity of the splint—thus preventing
the formation of an angle pointing forward, the deform-
ity  most liable to occur in  these injuries.
  I have found it extremely useful for other fractures
of the humerus, it being then  both a splint and a sling
-—also for those of the fore-arm.  I  can speak with
confidence of its utility,  as I have used it repeatedly
with marked success, and greatly to the comfort of pa-
tients.  It has been used, also, with similar results, by
other practitioners in this city.


  Note.—The two upper pieces which overlap each other, may
be fastened together with a strong needle and thread.
I 
 
PRECEPTS
DOMESTIC   SURGERY.
BY N. R- SMITH, Hff. D.
   It neither comports with the honour nor the interest
 of a liberal and philosophic profession, to withhold from
 those of other  avocations a certain amount of correct
 information,  relative to  its principles and  precepts,
 Medicine is  now so capable of asserting its dignity as
 a science, that  it  is no longer necessary to shroud it in
 a veil of mystery, and thus to win for it a superstitious
 faith, in place of rational confidence.   Mysticism can
 be employed as well by the ignorant as by the scienti-
 fic—indeed  with more zeal and effect, for  the former"
 are often the dupes of their own jugglery, or at  least
 are  not restrained by conscience.   When, therefore,
 he who relies  upon science for his means of success,
 disingenuously  mistifies the business of  his art  to gain
 the  confidence of the credulous, he is preposing the
 public mind to become the dupe of  empyricism.   Men
 of science  often complain that they are ill requited for
 their intellectual  toil, when empyricism is seen to win
 from them  the public confidence.  They do not reflect,
however, that this is chiefly because medical men have
first obscured their art, and deluded the community in-
       45 
350       PRECEPTS IN DOMESTIC SURGERY.
to the belief that in it there is "some charm, some con-
juration, or some mighty magic."   They are disap-
pointed,  therefore,  when they learn somewhat of the
limited resources of our art, and readily transfer their
faith to  those who are ignorant, or dishonest enough
to keep up the delusion.   Men are indignant when we
prescribe means as simple as the waters of Jordan, in-
stead of  smiting upon the part and uttering some tech-
nical incantation.
   To disinthral the public mind, medical men must
cast off the whole garb of the charlatan, nor suffer any
thing to remain which shall  confound medical philoso-
phy with empyricism. The profession must seize every
opportunity to educate the community in the first prin-
ciples of medicine, and when this is accomplished, the
medical  scholar may, in public opinion, safely rest his
ripened claims to reputation, which now is often w rest-
ed from  him, when he will not resort to the degrading
tricks of the charlatan to maintain it.
   Undoubtedly  the ingenuous  part  of our profession
•suffer  most severely, not from  the itinerant nostrum-
monger, but from the scientific  empyric—that member
of the profession  who  avails himself of  that which
science  reveals, but, in practice, associates  it with the
artifice of the charlatan.  Splendid instances of  suc-
cess achieved by such, can always be pointed out, and
against  them the honest part  of  the  profession can
vindicate itself  only  by educating the community in
the true character of the science of medicine.
   In addressing the following  precepts, therefore, to
the educated public, I  conceive that I am indirectly
 subserving the true interests of my profession, while my 
       PRECEPTS IN DOMESTIC SURGERY.       351
direct object is the instruction of others.  I consider,
also, that it is  an urgent dictate of humanity to furnish
the community with  a certain amount of knowledge,
particularly  in surgery, because  at this time they are
singularly ignorant of its simplest principles—because
infinite mischief and  suffering is created by its abuses
—and because the maladies which demand the surgeon,
are such as brook not  a moment's delay.  Accidents
often occur which prove immediately fatal, when the
knowledge of  a single fact would enable any individual
at least to arrest  the  hand  of death till more efficient
aid could be procured.
Treatment of Suspended Animation, or Extreme Pros-
   tration from injury produced by Blows or Falls.
  It is very seldom that a surgeon can be obtained to
direct the first steps which are taken  for the relief of
an individual who is struck sensless, either by any shock
which the body may have suffered, or local injury which
may have been inflicted upon an important organ.   It
is certainly desirable, then, that the knowledge of  the
means  necessary  at such a moment should be as gene-
rally diffused as possible.  Those means, at the present
time, are certainly not generally known to the com-
munity;—on the contrary, exceedingly  injurious  ex-
pedients  are generally resorted to.
  We will suppose the  case of an individual who  has
fallen from a height, and  whose body, although  there
may be  no fracture or obvious contusion, has suffered
so severe a shock that the heart almost ceases to beat,
causing the pulse to fail, or become feeble—the coun- 
352       PRECEPTS IN DOMESTIC SURGERY.
tenance  pallid—consiousness  suspended.    Although
humanity dictates that which is done for the relief of the
sufferer, yet, under such  circumstances, I have again
and again had occasion to observe, that the officiousness
of the by-standers generally adds to his  suffering and
peril.  The first thing usually done  is, to raise him into
the sitting posture.  Nothing, however, could be more
injudicious.   The horizontal posture is that which the
state of the system then demands. For restoration, it is
necessary that the blood should flow to the brain, and
when the patient is lying with the upper part of the body
low, the  first feeble beats of the heart will throw blood
into the head; but if he be raised erect, the heart has
the gravity  of the  blood  to  overcome, and  the same
power in its beat will not send blood to the brain. The
patient, indeed, is in a  kind of fainting fit, and every
one has  observed  that when, in  bleeding, a person
faints, he is promptly restored by throwing his chair
back upon the floor.  If he is raised too soon, the faint-
ing recurs.
  In the hasty endeavours to raise him, the body is also
contorted,  the  chest confined, and  breathing con-
strained.
  If then the sufferer be found lying upon a dry and
level surface, he should merely be placed on his back,
and be suffered for a few minutes to  repose, without the
slightest motion. If, however, the surface on which he
lies be broken or wet; or if the air to which he is ex-
posed  be severely cold, he must be  conveyed  to the
nearest shelter, great care being taken, while doing it,
to keep him still in the horizontal posture, and to avoid
confining his chest.   If cold, he is then to be covered 
        PRECEPTS  IN DOMESTIC SURGERY.       353
 with warm cloths.   Should the signs of returning ani-
 mation be faint, a small quantity of cold water may be
 dashed in the face; the nostrils and lips may be wet
 with vinegar, or hortshorne, if at hand.  Gentle friction
 on the extremities may also be used. When the patient
 can at length swallow, the pressing danger is usually
 past, unless there be disorganization of some important
 structure.   Officious attempts  to  convey  stimulating
 fluids into the stomach, before the patient has the power
 of swallowing, interrupt returning respiration, and are
 productive of infinite  mischief.  The first thing  swal-
 lowed should be cold water, this being the cordial which
 the patient invariably desires as soon  as he becomes
 conscious of his wants.  If the powers of life  still re-
 main  feeble,  some  cordial, wine, or a few drops of
 hartshorn in water, may be employed.
   There  is perhaps no popular error  which is  more
 general, or more productive of mischief under these cir-
 cumstances, than the use of the lancet.  No conviction
 can be  stronger than that  of a great part of the  com-
 munity that bleeding is absolutely indispensible in such
 cases.   The error has undoubtedly been derived by the
 people from our predecessors in surgery. Almost every
 neighborhood  has some individual capable of using the
 lancet, and, in cases like the above, if medical aid be not
 at hand, his skill is always  put in requisition.
   Foregoing facts and a moments reflection must con-
 vince even those not educated in medicine, that, when
 the vital flame is flickering and  doubtful of existence,
nothing can be more certain to extinguish  it, than the
sudden  abstraction  of blood.   It is an  agent, indeed,
which is capable of producing the very condition of the 
354      PRECEPTS IN DOMESTIC SURGERY.
system which we desire to remedy.  There is a period,
it is true, after injuries such as 1 have described, when
bleeding is imperiously demanded, but this is the period
at which re-action has taken place, and increased ex-
citement has resulted—effusion of blood into the injured
parts, or imflammation being threatened. But the treat-
ment of this condition belongs not to domestic surgery,
either from propriety or of necessity.
   So strong and general is  the  common prejudice in
favour of employing the lancet in cases such as  I have
described, that the surgical practitioner is almost always
assailed with the importunities of the  by-standers for
its immediate employment. The young surgeon is thus
sometimes, either urged to act contrary to his own judge-
ment,  or, by appearing to temporise, forfeits the confi-
dence  of the throng, every one of whom affects to be as
wise in regard to medicine and surgery, as in relation to
politics and the weather.
   Fortunately, blood usually refuses to flow in this con-
dition  of the system; but if the opening of the  vein be
successful, then will nature, in her struggle to re-ani-
mate  the body, be compelled to contend against both
the injury and the intended remedy, and when perhaps
just able to resist the enemy with effect,  she is over-
whelmed  by the mistaken kindness of an  injudicious
friend.  To her, then, the cut of the lancet is "the un-
kindest cut of all." 
          PRECEPTS IN DOMESTIC SURGERY.      355

 Means  of temporarily Arresting  the  Flow of  Blood
           from Wounds of Large Vessels.
   As many to whom the  following precepts are  ad-
 dressed may be unacquainted with the circulation of
 the blood, it is necessary  to observe that the arteries
 are those vessels  which receive  the blood from  the
 heart, by the  impulse of that organ,  and convey it in
 rapid currents to every part of the body.  The veins
 are those vessels which take the blood from the ex-
^ treme arteries, and bring it back, in less rapid streams,
 to the heart.
   When  a large artery is wounded, blood rushes from
 it with great rapidity, often spirting to  the distance of
 many" feet from the  body.  An  artery does not bleed
 with a  steady stream, but  the blood leaps from it by
 successive impulses, which correspond to the beats of
 the heart, though in the intervals the stream is still con-
 tinued with less force.  Blood which flows from an ar-
 tery is also of a bright florid hue.
   From a wounded  vein,  blood  flows with a uniform,
 and far less impetuous stream.    Sometimes, however,
 when a vein lies over an artery,  the current is slightly
 influenced by its beats.   The flood which flows from
 it is of  a very dark red hue.
   Bleeding  from veins is very rarely fatal, but a wound
 of a large artery is extremely dangerous.  Often, be-
 fore a surgeon can be procured,  the patient will have
 expired.  It is earnestly to be desired,  therefore, that
 every  one's education  should  embrace so much of
 the practice of surgery as shall  enable him to use the
 simple  means which are necessary to arrest the flow
 of blood till professional aid can be procured.  Were 
356      PRECEPTS IN DOMESTIC SURGERY.
such  knowledge general,  valued lives would undoubt-
ly often  be  rescued from  the  effects  of injuries  so
generally fatal for want of  prompt medical aid.
   When arterial blood is seen to gush from a deep
wound in the thigh, leg, or arm, with alarming rapidi-
ty, the by-stander should  reflect that the blood which
flows is  that which is passing from the body into the
limb.   Let him then expose the member as quickly as
possible  by  tearing up  the garment—snatch  his
handkerchief from his pocket and tie it loosely, though
with a firm knot, around  the limb above the wound.
Then let him take a small stick, four or five inches in
length, or the handle of his pen-knife,  which will  an-
swer perfectly wrell—put it under the handkerchief, and
then twist it round several times, till the limb is tightly
bound by the handkerchief, which  will thus be twisted
upon  the limb.  Almost any degree of force may be
exerted in this way, and a slight effort will  be sufficient
so to constrict the  limb that the effusion of blood shall
for the time cease.   It is  to be borne  in  mind,  how-
ever,  that these means can only temporarily arrest the
bleeding.  As it completely interrupts  the circulation
of the blood, bolh in 4he arteries and  veins, its long-
continued application would endanger  the  vitality of
the limb.  By it, therefore, time only is  gained till  the
surgeon can be procured,  in which there should be no
delay.  During the application  of  the handkerchief, it
should not be  drawn with unnecessary tightness.   Af-
ter it has been a short time applied, it should be slight-
ly relaxed  to ascertain if  the bleeding will return,  as
their  often forms a clot in the wound which aids  the
effect of  the ligature. 
          PRECEPTS IN DOMESTIC SURGERY.     357
   When the wounded parts are laid open by a broad
 cut, and the orifice of the artery can be seen, with the
 blood spouting from it, it should be known that a sim-
 ple  thread, tied firmly upon it, will effectually and per-
 manently command the  bleeding.   When, therefore,
 an individual who knows this fact can be firm enough
 to act with decision in such a case, or when a surgeon
 can not be obtained, he may seize the vessel with his
 fingers, and, dragging it a little out, direct some one to
 tie a thread  around it.  Or, if it cannot  be grasped
 with the fingers, he may take a  darning needle, anneal
 it in the fire, and bend the point.  With this he may
 seize and so  drag the artery outward that the ligature
 can be applied.
   When a bleeding artery lies upon a bone, the bleed-
 ing can easily  be commanded  by firm pressure made
 with  the  point of the finger, or some small and firm
 body.   The  mere pinching together the lips  of the
 wound, however, will do no good, but rather occasion
 mischief, because the blood will then be forced into the
 parts below the skin.   Bleeding from an artery in the
 temple, or on the  head, may easily be commanded by
 pressure—also  on the top of the foot—often on the
 wrist.   The surgeon, however, should, in all such cases,
 be called  as  quickly as possible; but if he cannot be
 procured, the pressure may be kept up by first apply-
 ing a small roll of linen to the artery; then a broader
 one over  this,  and then a third  still broader.   These
 are to be pressed firmly upon the artery  by a  bandage
rolled  many  times round the part.   But if it  be uot
possible, either from  the rapidity of the  bleeding, or
because the  means are not at  hand, or  because the
       46 
 358     PRECEPTS IN DOMESTIC SURGERY.
 wounded  vessel is not upon one of the limbs, to em-
 ploy with effect either the tourniquet (the handkerchief)
 or the ligature, the by-stander should have sufficient
 presence  of mind to  expose the wound from which
 blood is rushing, and, if the wound be deep and nar-
 row, such as is made  by the thrust of a knife, or dirk,
 or by a musket shot, let him cover the orifice as close-
 ly as possible with the extremity or ball of the thumb.
  To cover the part with cloths and bandages, to hide
 the mischief, and then to attempt pressure, as is usual-
 ly done in the  trepidation of the moment, is generally
 altogether ineffectual.  The force is then more diffused
 over the surface, and is less directly opposed to the ori-
 fice of the wound.
  If the pressure be continued  for a time, coagulation
 will take place within the wound, and an aneurism often
 be formed, which must be submitted to the manage-
 ment  of the surgeon.  I have known a patient  to
 perish  from such a wound, when the application  of a
 finger over the orifice would have gained time enough
 for the successful exercise of the skill of  the surgeon.
  When blood flows from a wounded vein, it may, un-
 der some  circumstances, be necessary to use efficient
 means  to  arrest  the bleeding.   Sometimes, when  a
 vein has been opened in the arm, the  orifice being
 large, it may, even after some hours, again, bleed with
 rapidity.   This is often caused by the bandage getting
slipped above  the elbow, in consequence of /which it
binds the veins, and causes them to bleed as when the
 arm is ligated for the purpose of taking blood.   When
this occurs, the  member should be exposed, and the
bandage, or any part of the dress which may constrict 
         PRECEPTS IN DOMESTIC SURGERY.      359
the arm, removed.  A small roll of linen, of the thick-
ness and breadth of the finger, should then be laid up-
on the vein, and bound firmly upon  it by a bandage,
which should be drawn more tightly below than above
the elbow.  Motion of the arm should then be avoided
Wounds  of veins in other regions of the body are to
be treated in the same manner.
Treatment of Wounds inflicted by cutting instruments.
  Unquestionably  the  most  valuable acquistion of
modern surgery, is the method at present employed by
intelligent surgeons in the treatment of simple wounds.
But although it is now near fifty  years since it has
been generally adopted by English surgeons,  and al-
though it is extremely simple, rational, and intelligible,
it is by no means generally known and approved by
those  who are uneducated  in  medicine.  Indeed its
very simplicity is perhaps the reason why it is not gen-
erally received.
  After some thousands of years' experience had elaps-
ed__after almost  every substance which  the  three
kingdoms of nature can furnish had been tested, and
balsams, vulneraries, styptics &c. without number, had
tortured the wounds of  sufferers for ages, it  was at
length discovered that there is no such thing as a heal-
ing virtue in any remedy—that the healing of a wound
is not the result of any application; that it is, in short,
nothing but  the work of nature—of a restorative prin-
ciple identified with the principles of life, and by which
each organ is, to a certain extent, enabled to repair the
mischiefs of injury and disease. 
360     PRECEPTS IN DOMESTIC SURGERY.
   When a part founded has been  previously in per-
fect soundness—when the general health  of  the suf-
ferer has also  been perfect, and no untoward circum-
stance defeats  her  admirable  work, nature scorns as-
sistance from our hands.   Nothing can then be applied
to the wound which will exercise the slightest influence
in accelerating the recuperative process.  A certain
series of changes must necessarily take place in the
part,  before it can be  restored to soundness, and these
changes must necessarily occupy a certain time.   If
irritating medicaments are applied,  with a design to
hurry this, it is with precisely  the same absurdity with
which we should administer bark and wine to a person
in perfect health, after having taken food,  in order to
hurry the process  of  digestion.  And  yet I very well
know that with many I shall contend unsuccessfully
against an ancient prejudice. " What!" say they, "noth-
ing in nature that is healing ? no such thing as a balsam ?
'no balm m Gilead?'  a fig, then, for your science  of
Surgery.   Have I not cured wounds on my own per-    \
son a hundred times with balsam apple, or burnt sugar,
or rum and red-pepper, and other soothing remedies ?"
True; but have you  ever tried  the experiment of ap-
plying nothing ?  " No, for then I should have practis-
ed as absurdly as yourself. "
   The  belief in the healing  virtues of certain plants,
and other simples, is so wrought  into our language, that
it is  impressed upon  the mind with the first lessons of
childhood. The phrases " healing balsam," " soothing
balm," are uttered in prose, and sung in verse. We shall
spoil, it is true, a thousand beautiful metaphors, by es-
tablishing the truth; but it is better that we should mar 
         PRECEPTS IN DOMESTIC SURGERY.     361
 the works of man, than those of God. The story of the
 good  Samaritan, who  poured o:l and  wine into the
 wounds of the stranger, has, no doubt,.caused many a
 wound  to  be  tortured.  But holy writ was  given
 neither to instruct in Medicine, nor in Astronomy.
   But although we reject the  farrago of herbs, and
 balms, and balsams, yet there is still much for the hand
 of the surgeon to accomplish.   In the first place, great
 good may be  effected  in removing impediments  which
 might defeat the intent of nature; second, by placing
 the parts in a state  of  repose, and in the most favoura-
 ble attitude for the restorative process; third, by check-
 ing, or exciting, those efforts, when they appear to be
 too energetic, or too feeble.
   1.  The first of these objects is effected by removing
 dirt and all foreign substances from the  wound-—by
 staunching the blood by the modes advised above, and
 removing the masses of coagulated blood which keep
 open and irritate the wound.
   %  To effect the second, it is necessary to bring the
 lips of the wound as closely together as possible, adapt-
 ing part to part as they were  situated before they were
 divided.   This can  often be accomplished by placing a
 little dry lint directly upon the wound—pressing together
 the sides of it with the hand, and then permanently sus-
 taining them by passing a bandage around the part.—
 The lint imbibes a little of the blood,—soon dries—ad-
 heres strongly to the skin, and aids to sustain the lips
 of the wound.
   But this is more perfectly effected by using straps of
adhesive plaster half an inch wide. These are warmed 
 362     PRECEPTS IN DOMESTIC SURGERY.
by the fire and then, the lips of the wound being pressed
together, are to be applied closely to the skin.  Shoe-
maker's  wax,  thinly spread upon  strong  linen,  will
answer the purpose sufficiently well.  The injured part
should then be covered with a folded cloth and a  ban-
dage, so applied as to protect it from the  contact of
the air, while the body should be so placed that the part
shall be as perfectly at rest as possible, and no strain be
made upon it.   This dressing should not be disturbed
till the fourth day. The bandage may then be softened
with warm water, and removed, the wound cleansed and
dressed with a salve  made of bees-wax,  1 part, lard, 3
parts.  It will be found, at  the end  of this  time, that,
where the  surfaces are in contact, they have almost
every where at once grown together, by what surgeons
call the first intention, or the first effort of nature. Some
places may be still open, and in these, matter will  now
form, and the vacuities will be filled up with new flesh,
which may be seen sprouting up from the bottom of the
wound.   This appears red, and bleeds when touched.
It sometimes rises above the skin, and is  then  often
called proud flesh, but nothing need be feared  from it.
It may be pressed down by a compress of lint and the
bandage.  If it  shoots out very far, it  may be taken
down by applying burnt alum.   Over  this, the  scar
at length forms.
   Nothing for the  purpose of  promoting the healing
process, should, on any account, ever be introduced into
the wound; nothing  is so congenial  an application to
the exposed flesh as  the flesh itself; besides, any thing
intervening between the lips of the wound is sure to
defeat the process of union by the first intention. 
         PRECEPTS IN DOMESTIC SURGERY.      363
   3.  Often, in a recent wound, there arises too much
inflammation for the healthy process of healing.  When
this  is the case, the parts will swell, become hot and
painful.  The patient should then loose blood, and be
purged.  Over the dressings which cover the part we
should place a cloth wet with four parts water, and one
of whiskey.  This the dressings will imbibe, and the eva-
poration  which will result, will reduce the morbid heat.
If the pain continues, and  be severe, a bread-and-milk
poultice may be applied over the first dressings, and be
occasionally renewed.
   Should there, on the contrary, be but  little excite-
ment in  the part, in consequence perhaps of a languid
state of the system of  the sufferer, and  the part about
the wound should be unusually cold and without sensa-
tion, warmth should be applied through  the medium of
Warm cloths-—or a warm poultice frequently renewed,
and  a little wine and  water should  be administered.
The  surgeon, however, should be obtained as promptly
as possible.
   Treatment of Lacerated and Contused Wounds.
  Wounds in which the parts are torn and bruised are
far  more dangerous than simple cuts,  although  they
are much less apt to bleed*   Parts near the wound are
often disorganised  and killed by the injury—or, if not
thus destroyed, they are so injured that inflammation
results which will  terminate  in mortification to some
extent   These wounds, also, if neglected, are liable to
terminate in tetanus (lock-jaw.)
  •Limbs  are sometimes torn from the body without any loss of
blood. 
364     PRECEPTS IN DOMESTIC SURGERY.
  In such injuries, we are not able to bring nicely into
contact the ragged margins of the wound, consequently
we  do not expect  to effect complete union by the first
intention.   We can generally, however, accomplish it
to some extent, and should therefore always use the ad-
hesive straps to bring the parts in as close apposition as
possible.   Then, as the parts will  be  insensible, and
in a degree lifeless, we should  apply warmth, by the
medium of a soft warm poultice, or by cloths wrung
out in a decoction of poppy heads, hops, or chamomile.
The application of spirit and water, or warm wine, to
the surface which can not be covered by the skin, also
to the skin itself  around the wound, is proper.   Some
employ, with happy effect, the oil of turpentine. These
remedies not only rouse the vital energies of  the part,
but also prevent that morbid action and state of irrita-
tion in the nerves  which prepares the way for lock-jaw^
  In case a high degree of inflammation should result,
bleeding and the cold lotions are to be resorted to, as I
have before directed.   Should mortification result from
the severity of the inflammation, or from the destructive
character of the injury, the best domestic application is
the fermenting poultice.   This is prepared of ground
malt, two parts;  rye  flour, one part; these are to  be
boiled with water to the consistence of mush.   There
should then be added a small quantity of molasses; and
a little yeast to begin the fermentation.   The poultice
should be large and not be renewed for 24 hours.  The
system must be sustained, in case the pulse should be-
come feeble, with cordials and bark.
  Lacerated wounds are most apt to result in tetanus
when they are inflicted upon the  foot, hand, and other 
        PRECEPTS IN DOMESTIC SURGERY.       365
parts, the nerves  of  which are abundant, and which
are otherwise complicated in their structure.  Tetanus
is also more apt to result from wounds of  the foot, be-
cause this member is  almost always imprudently used,
it being impossible that it can be in a ^tate of repose, if
the patient be up at all. The wound, therefore, is liable
to perpetual irritation.
  To guard against this appalling disease from lacerated
wounds, the injured part must be placed in a state of
perfect  repose.   The oil of turpentine may be applied
to that part  of  the wound which is  exposed, and the
member should then be enveloped in  a warm poultice,
which should be frequently renewed.   Particular at-
tention should be paid to  the stomach and bowels, as
tetanus  rarely,  if ever, occurs without some derange-
ment of function in these organs.  Mild cathartics should
be  occasionally given, and  mild,  unstimulating food
should alone be allowed.
  The  symptoms  of  formidable tetanus occur usually
from the 7th to the 9th day after the injury, and one of
the first signs of its approach, is a degree of stiffness
about the back  of the neck and the jaws.    The spas-
modic affection, (cramp,)  which occurs on the  first or
second day after a wound, is a far  less formidable dis- ,
ease, and usually subsides spontaneously. True tetanus
is almost always fatal.
  Punctured wounds are to  be treated in a  similar
manner.                                      -.<■ '
47 
 366       PRECEPTS IN DOMESTIC SURGERY.

 Mode of Managing a Fractured Member till a surgeon
                  can be procured.
   If the thigh be fractured near the middle, the usual
 place of the injury, the nature of the mischief is easily
 discovered.   If the patient  be far  from any dwelling,
 two boards,  six feet long and a foot wide,  should  be
 placed side by side and be nailed  to two  cross-bars
 which shall  extend one or two feet beyond the margin
 of the boards, and serve as handles.  On this, place a
 mattrass, or blankets. Then carefully place the patient
 on the latter, inclining him to the side  of the fracture,
 and placing the injured thigh on the outside.  The thigh
 should be a little bent forward, and  the leg bent on the
 thigh.  A pillow should be  put beneath the outside of
 the knee.  He is thus to be conveyed to his dwelling;
 but his  position must not be changed  till the surgeon
 arrives.
  When the  leg is fractured  below the knee, place
 three broad tapes, or strips of cloth, each a  yard long,
 transversely on the mattrass or blankets ,about six inches
 apart. On these lay a towel, also cross-wise of the bed;
 then place a pillow on these, length-wise with the bed.
 Next, get two flat pieces of board, two inches wide, and
 longer than the leg.  Lay the  leg length-wise on  the
 pillow, and double the pillow up on its sides; then fold
 the boards in opposite ends of the towel, and roll them
 over and over, till they press the opposite sides of the
pillow upon the leg.  Then the tapes should  be tied in
 such a manner as  to snugly embrace the  leg.  The
patient should be placed on his back. The support will
be more perfect if, by means of a piece of a  hoop bent 
       PRECEPTS IN DOMESTIC SURGERY.       367
over the leg, it be swung up so that the pillow shall not
touch the bed.
  If the arm be fractured above  the elbow, place a
small narrow pillow between it and the chest, and bind
the arm gently to it by passing a towel around the body.
The hand and arm below the elbow must be sustained
in a sling, thrown round the neck.
  When the  arm below the elbow  is broken, the sling
alone is sufficient.  These expedients, however, are to
be regarded only as temporary, and as designed to pre-
vent mischief till the surgeon shall arrive.
               Treatment of Burns.
  Almost every family has its nostrum for burns and
scalds. There are a hundred applications, under which
they have been seen to get well, and  as  the common
prejudice is that nothing heals except by virtue of some
application, each  one would acquire some reputation
though all were mischievous.  No  one has  tried the
experiment of doing nothing more than carefully pro-
tecting the part from the contact of  the atmosphere,
and from vicissitudes of temperature.  What the result
of such an experiment would be,  we may infer from the
fact that the most inert applications  have generally the
highest reputation, as oil—bats of cotton—water &c.
But we will not contend with the good wives in regard
to this matter. In slight burns, it is of little consequence
which of the common remedies  is applied;  Nature is
then  able to conquer both the disease and the doctor.
Nothing, however, is better than  olive oil—a bread and 
 368      PRECEPTS IN DOMESTIC SURGEY,
 milk poultice, or if the skin be not broken, a bat of
 cotton.
   But severe burns are fraught with danger, and it is
 earnestly  to  be desired that the  community should
 possess more correct knowledge in regard to the use of
 means which ought to be instantly employed.  Far be
 it from me to encourage domestic quackery where life
 is concerned; but as we know that in these cases fatal
 mischief is often done by erroneous applications before
 medical advice can be obtained, some knowledge in re-
 lation to this subject  ought to be a part of every one's
 education.
   It is not the deepest burn which is always the most
 dangerous.  Those which are extensive, over  the sur-
 face, are always alarming, even  although the scarf-skin
 alone be  destroyed.  This  is because  of the extreme
 sensibility of the skin, and the shock which is therefore
 given to the nervous system, producing prostration of
 the powers of life.
  The worst burns are produced by scalding liquids,
 which diffuse themselves over a wide surface; and by
the burning of cotton or linen articles of dress.   The
first effect of the burn is a depression of the powers of
life.   The pulse  becomes feeble—the  face pale—the
extremities often cold.   Vomiting' is apt to occur, and
convulsions sometimes are produced in irritable children.
This prostration often terminates in death, without any
re-action.   If the case be badly managed, for  the first
 half hour, it may make all the difference between life
and death.  Here we must come in as the active auxil-
 iaries of nature, and rally the flagging powers.
  Most persons having observed the soothing influence 
         PRECEPTS IN DOMESTIC SURGERY.     369
of cold applications  to slight burns, it is by no means
uncommon to apply them extensively in cases of which
we are now speaking.  They may, it is true, allay local
pain, but they treacherously contribute to the depressing
effect  of the burn, these two extremes producing  the
same effect.  I have known a child to be irrecoverably
lost by the application of a large mass of scraped pota-
toes to the breast, in case of a burn which need not have
been fatal.   It ceased to complain after the application,
and slept; but its sleep was the harbinger of death.
  The object should always be, in such cases, to rouse
the system to prompt re-action, by both general and local
means. The part should be smeared as quickly as pos-
sible with  oil  of  turpentine—warm vinegar—warm
wine—or sweet oil;—then be covered with a cloth dipped
in oil, or spread with lard, and enveloped in warm bats
of cotton, or soft flannel.  The camphorated tincture of
opium (paregoric) should be given internally in liberal
doses; or laudanum in doses, to an adult, of 60 drops;
to a child of 5 years, 10 drops.  Wine, or brandy-sling
may be given in default of these, and  may often be
necessary in association with them.  What remains to
be done, in the  province of the surgeon.
Mode of Extracting Foreign  Substances from within
                    the Eye-lids.
   Sometimes an inflammation, fatal to the eye, is excit-
ed solely by the presence of some irritating substance,
so fixed upon the surface of the eye-ball that it cannot
readily be extracted. When the mote is loosely floating 
 370       PRECEPTS IN DOMESTIC SURGERY.
 in the tears, if it be not spontaneously washed away, it
 can be removed  with great facility, by any one who has
 good vision and a steady hand. It may be brushed away
 with a piece of silk—the point of a feather, or a camel's
 hair pencil.   When, however, there are numerous fine
 particles of dust in the eye, they are best removed by
 throwing within the lids a stream  of  warm milk  and
 water.
  But occasionally the  foreign substance so  conceals
 itself in  the eye that, unless it be  sought in a peculiar
 way, it  escapes  the  keenest vision, and may remain,
 exciting  severe inflammation, after its presence ceases
 to be suspected.   I have learned from observation, that
 motes in the eye are exceedingly apt to conceal them-
 selves just above and behind the border of the superior
 eye-lid,—attaching themselves closely to the eye-lid,
 and following it in all its movements; thereby  creat-
 ing more irritation than  if they  were  fixed to  the
 ball itself.  The mote is liable to fix itself in this situa-
 tion, because there is a slight concavity in the lid, above
 its margin.   In a great  many  instances, in which indi-
 viduals have suffered extreme annoyance for hours from
 the presence  of motes in the eye, which could not be
 discerned, I have at once discovered the source of mis-
 chief, by seizing the eye-lashes of the upper  lid with
 the thumb and finger of the left hand, and turning out
 the inner surface of the lid, so as to expose it  to view.
 Then, with the blunt extremity of a needle, the point
 of a pencil, or other obtusely-pointed instrument, I have
 removed it.
  Persons who are employed  in grinding steel instru-
ments, or in usiDg  such instruments upon stone, as, for
instance, stone-cutters  and millers, are exposed to  a 
        PRECEPTS IN DOMESTIC SURGERY.       371
species of injury which is often extremely destructive
to the eye.  A little pointed particle sometimes breaks
from the edge of the instrument,  and flies with the
swiftness of shot into the eye—piercing the outer coat
of the transparent  part of the eye, or the white, and
fixing itself as tenaciously as a barbed  arrow.   Some-
times it enters obliquely, and fairly buries itself in the
membrane.
  The  usual  means of removing motes from the eye
will  here be found altogether unavailing, and their fre-
quent employment will only aggravate the irritation.  If
it be not removed, there will  either result a diffused in ■
flammation  of the eye, or  an ulcer will  be produced,
which will at length open the eye-ball and discharge its
fluids.
  It has been  advised, in such cases, to apply the mag-
net to the particle of steel, and thus to elicit it from the
eye.   But this will  never be found  effectual when the
mote is firmly  fixed in the membrane.   When it is pos-
sible, the patient should  immediately seek assistance
from the surgeon; but, when he cannot be procured, let
some one who has a firm hand,  take a sharp needle, or
the very sharp  point  of  a small  knife, and,  opening
the eye-lids, endeavour to disengage the mote from its
situation.  This will sometimes require some force, and
the repeated use of the needle.  Sometimes it will be
necessary to divide the external membrane slightly, with
the point of a  lancet.   When this, or any other mote is
removed from the eye, a bread-and-milk poultice should
be applied, to sooth the organ.  If inflammation arise,
a rag, wet with cold water, should be kept upon it. 
APPENDIX.
  Since the pages of this volume were printed, descri-
bing the instrument which I employ in making the in-
cision into the bladder in Lithotomy, I have  used it in
the case of Mr.  James Longgon, of North Carolina.
All that I had promised myself, in regard  to its utility,
was fully realized.   The incision was made with  one
thrust of the knife, and I had my finger upon the stone
in half a minute from the time that I took the instru-
ment in hand.  My patient is very rapidly recovering,
nor has their  occurred  the  slightest unpleasant symp-
tom.
  The director attached to the staff, represented in the
plate, is not sufficiently long; and the part of the staff
which is below its beak, should be a little more nearly
straight.
                                N. R. SMITH. 
INDEX.
 1. Dedication,  -------------   9
 2. Preface, -----------~---^-    5
 S. Biographic Memoir,   ----------   9
 4. Practical Essay on Typhus,   -------   39
       Preface,.........:.--  41
       History of Typhus,    ---------   43
       Contagiousness of Typhus,   -------  47
       Origin of  Typhus,   ---------    49
       Liability to Typhus, ----------  51
       Changes pf Typhus,   ---------   53
       Combinations of Typhus,  --.------  53
       Causes of Typhus,   ---------    56
       Symptoms of Typhus, ---------   59
       Treatment of Typhus,........    69
 5. Observations on Necrosis,  --------   97
       Pathology of Necrosis, --------    97
       Diagnosis of Necrosis,    --------  ]04
       Causes of Nprrosis,  ---------   107
       Treatment of Necrosis,    --------  m8
       Case of Necrosis.  By N. R. Smith,  -  -  -  -   121
 6. Observations on Fractures  of the Femur -  -  -  129
 7. Description of an Apparatus for Fractures of the
   Thigh and Leg.  By N. R. Smith,  ------  143
 8. Remarks on Dislocations of the Hip-Joint.  By N.
   R. Smith,.......-  -  -  -  -  -   163
 9. On the Operation for Hydrocele,  -----  183
 10. On Suppression of Hemorrhage from Wounded
   Arteries,  -------------   187
 11. On Spontaneous cessation of Hemorrhage from
   Lacerated Arteries.  By N. R. Smith,  - -  -  -  203
12. Remarks on Amputation,  --------215
19. Extirpation of the Ovarian Sack, -----    227
      Note.   ByN. R.Smith,........230 
374
INDEX.
14. Ligature op the Extenal Iliac Artery,   *  -  -    235
15. Discription of An Instrument for removing Coins
   from thr CEsophagus,  ---------   239
16. Hints on Lithotomy.  ByN. R.Smith, -   -  -  -   241
17.  Radical Cure of  Hernia by a> Operation.   By
  N. R. Smith,........-----263
18. On the Influence of Heat and Cold.  ByN. R.Smith 271
19. Remarks on Hernia Cerebri.  By N. R. Smith,  -   815
20. On Dislocation of the Shoulder. ByN. R. Smith,   337
21. Description  of a Splint for the Arm and Fore-
   arm.  By N. R. Smith,  ---------   345
B2. Precepts in Domestic Surgery.   By N. R. Smith,   849
      Treatment of Suspended Animation, or Extreme Pros-
        tration from injury produced by Blows or Falls,   351
      Means of temporarily Arresting  the Flow of Blood
        from Wounds of Large Vessels,  -----   354
      Treatment  of Wounds  inflicted  by  cutting instru-
        ments,    --*-_-______   359
      Treatment  of Lacerated and Contused Wounds,   363
      Mode  of Managing a Fractured Member till a Sur-
        geon can be procured, ---*k____   866
      Treatment of Burns,    --------     867
      Mode  of Extracting Foreign Substances from within
        the  Eye-lids,    --------,-   369
TH* END. 
ERRATA.
  The Reader is requested to correct with the pen the following
errors:—
  Page 49, second line from the bottom, (Note,) for mentioned, read
maintained.
  Page 122, fourth line, for trochanter, read condyle.
  Page 144, sixth line from the  bottom,  read the stiffest paper
trunk-board that can be procured.
  Page 150, sixteenth line, for four, read seven.
  Page 152, tenth line, for with it to  the upper, read with it  the
upper, Sfc.
  Page 157, fourteenth line, for voluntary, read involuntary, Sfc.
  Page 239-40, strike out the quotations. 
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