Be. W:v. DSNNT. 
 
4£  Ufus  Oh^uint/:
THE
PRINCIPLES
OF
SURGERY.
By JOHN BELL, Surgeon.
            ABRIDGED BY

       J. AUGUSTINE SMITH,

 OF THE ROYAL COLLEGE OF SURGEONS, LONDON,
   AND PROFESSOR OF ANATOMY AND SURGERY
     IN THE COLLEGE OF PHYSICIANS AND
         SURGEONS IN THE UNIVER-
          SITY OF THE STATE OF
             NEW-YORK.

    WITH NOTES AND ADDITIONS.

          ___________*4>Glfr'

            NEW-YORK:

PRINTED AND SOLD BY COLLINS AND PERKINS, NO. 189,
            PEARL-STREET.
1810. 
ANNlfiK
       Dijlrifi of New-Tori, ft.


             JDE IT REMEMBERED that 6n the thirteenth day of February,
             in the thirty-fourth year of the Independence of the United States
    tx  q %      r™1."1"' C°l"ns & Perkins,of the faid Diftruft, have de-
    li., b.)    pouted in this office the title of a book, the right  whereof they claim
             as proprietors, in the words following, to wit:

  CJbIr*m»lplei, °fSurSfy~>By John Bell,Surgeon....Abridgedh J. Augustine
  iT^nt rP al^"eS'of Surgeons, London, and professor of Anady and Sur-




« A^iafor^EnToL10 ^  ^^ J3™?"* °f thcUnited States, entitled,







                                              CHARLES CLINTON,
                                         Clerk of tbe Di/lri8 of Netv-Yori. 
EDITOR'S
PREFACE.
  1 HE great celebrity and acknowledged merit of Mr,
 John Bell's Principles  of Surgery, render it
 entirely unnecessary for me to say  any thing in their
 praise.  In the Edition  of them noAv presented to the
 public, care has been taken to select those parts which
 were deemed most useful and important.  Mr.  Bell's
 descriptions of diseases and operations,  which are un-
 rivalled by any modern surgical Avriter in animation
 and effect, are retained almost verbatim,  and where
 they  were  thought not  sufficiently full and minute,
 the additions  which  were  deemed requisite will be
 found in a note distinguished by the letter S, at the
 foot of  the page.  Where I have differed in  opinion
 from  Mr. Bell on a  point of  practice,  his opinion is
 stated in the text, and mine in a note,  so that the reader
 can adopt that which he may think preferable.

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

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

  Since that period also, the celebrated Scarpa has written
a work upon Aneurism,  in which he diners from Mr.
Bell, and indeed all  his immediate predecessors, as to
the manner in which these tumours are formed.   Ap-
pendix D will enable the reader to judge of the correct-
ness of Scarpa's  doctrine.

  I have deemed it unnecessary to transcribe Mr. Bell's
observations  intending to prove that the inosculating
vessels are  sufficient  to support a limb when the main
artery is tied, as  no Surgeon is now deterred by the
fear  of mortification from tying any accessible artery
in the human body.  Three instances  of this  have
hoAvever occurred, tAVo are related in  Wishart's appen-
dix to Scarpa, and one  in the  Medical and Physical
Journal for April 1809.

  With regard to the best method of treating fractures
of the  lower extremities,  I  never doubted that a state
of flexion  and  consequent  relaxation of  the  muscles
during the tendency to inflammation, was the best po- 
                      PREFACE.                     V

sition in which they could be placed, until I understood
that Dr. Physick entertained a different  opinion and
taught a contrary practice.   So great is the deference
Avhich I pay  to the judgment of Dr. Physick, that I
am noAv not without my doubts on the subject; as hoAv-
ever I have uniformly practised the plan recommended
by Mr.  Bell, and haA'e never seen any ill consequences
from it, I have  deemed it unnecessary to state any ob-
jections to his mode of treating these  accidents.   But
where the thigh-bone is fractured at its neck or near  its
trochanters, then undoubtedly the straight position is
the best, and Boyer's apparatus* I should think superi-
or  to  Deasault's ;  either, I  am afraid,  would fail in a
strong muscular subject, the latter certainly has.f

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

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

   It is unnecessary for me to point out all the omissions
 Avhich I have  made.  They will  be found to consist
principally  of histories, anecdotes, and operations,  and
machines now no longer in use.  Some apology  may
be thought due to Mr. Bell for thus abridging his work,
but Avhen it is remembered that his object in writing
must have been the benefitof his profession, and through
it the good  of mankind, he can not be offended at hav-
ing his fame and usefulness thus diffused through this
extensive country. 
CONTENTS.
DISCOURSE  I.
 Of Adhesion.....Pa^
 Of Sutures      -        -        •        -      -      3
 Rules for the re-union of wounds of the Skin                  5
 Rules for the re-union of deep muscular wounds        -       7
 Rules for  the re-union of complicated wounds, where there
     is a wounded artery or fractured bone                    8
 Of cutting out the stitches        -        -        .      j0
 Description of those wounds in which adhesion is not easily
     obtained, and of the accidents by which it is prevented     ib.

                   DISCOURSE II.

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


                   DISCOURSE III.
0
Of the various uses of bandages
Of the four-tailed bandage       -      -       -      -     37
Of applying a roller to the head and jaws        -      .     39
Of bandage for the body         -        .        .      .41


                   DISCOURSE  IV.

On Tixmorrhagy          -          _           -        4°
Of the natural causes by which an hsmorrhagy is stopped      44 
Vlll
CONTENTS.
                                                         Page
  Of the artificial means of suppressing hemorrhage              45
  Of the condition of an artery when tied with a ligature          48
  Of the causes of secondary haemorrhagy, and first of the burst-
      ing of the artery from the diseased state of its coats         49
  Of the bursting of the artery from ulceration of its coats         51


                      DISCOURSE V.

  Description of aneurism
  Of various anomalous cases of aneurism
  Aneurism from fracture of the bones
  Peculiarities of popliteal aneurism


                     DISCOURSE VI-

 Of the progress of aneurism and their cure
 Hunter's operation       ....


                    DISCOURSE  VII.

 Of the formation of an aneurism over a wounded artery     •    78
 Of the operation  for such an aneurism         •     •     •    79
 Rules of practice........84


                    DISCOURSE VIII.

 Of wounds of arteries    •    •
 Of wounds of superficial arteries
 Of an artery wounded with a lancet
 Of aneurismal varix
 Of oblique wounds of arteries
 Of wounds of the thoracic artery


                    DISCOURSE  IX.

Of aneurism from anastomosis  •


                    DISCOURSE  X.
55
65
67
71
73
76
 85
 86
 02
 93
 95
101
On fractures of the limbs
Of the formation of callus
111
 ib. 
CONTENTS.
IX
                    DISCOURSE  XI.

                                                       Page
Rules for the management of simple, compound and gun-shot
     fractures       •                                   *  121
Of simple fracture       •                          ,  *     123
Of the fracture of the humerus   .    •               V      ib.
               of the fore-arm      .   •     •     *    *    124
               of the clavicle              •       *       125
               of the sternum         *     '     *         126
               of the ribs      •             *      •     ib.
               of the spine         •        '             127
               of the lower extremity       •       *       128
               of the thigh        •         •         -129
               of the patella      '                       132
               of the olecranon      •      •       •       133
Rupture of the tendo achillis     ...               -134
Concluding observations on simple fractures     •    •        136
Rules for compound fracture     •                        '138
Of gun-shot fracture       ...                 146
Of complicated fracture      •                            147

                    DISCOURSE  XII.

On the accidents and diseases of the hip-joint              •  150
Diagnosis of the various affections of this joint     *     •     ib.
Of luxation of the femur downwards     •                    158
Of luxation of the femur upwards     •                      161
Pathology of the diseased acetabulum      •               •  163
Of the scrofulous disease of boys, affecting this joint      •     164

                   DISCOURSE XIII.

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

                   DISCOURSE XIV.

Of obstruction of urine     ....           .      192
Of introducing the catheter               '              •    ib. 
CONTENTS.
DISCOURSE XV.
 Of the various causes of obstruction of urine
 Of stricture
 OfSstulx in the perinxumand urethra
 Of the causes of fistula:
 Of the cure of fistulas

                   DISCOURSE XVI-

 Of total obstruction of urine and puncturing the bladder       224
 Of distention and rupture of the bladder       •       •       227
 Of the several methods of puncturing the bladder    *    *   232
 Of puncturing above the pubes    •     .    .    •          233
 Of cutting into the bladder from the perinxum        •       234
 Of passing a trocar into the  bladder from the perinxum       237
 Of tapping the bladder from the rectum     *                 239
 Of forcing the catheter into the bladder              •       240

                  DISCOURSE XVII.

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

                  DISCOURSE  XVIII.

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


                  DISCOURSE XIX.

Of fractures of the scull     *      •     "         *     •     301
Of fractures of the scull with depression       •      •        3lo
Of cases requiring the trephine and lever        •       •     327

                   DISCOURSE  XX.

On ri-.e states of concussion and depression      •             34fc
Of concussion                           »                345
Page
 199
  ib.
 209
 210
 220
256
 ib.
259
274
28Q
29, 
CONTENTS.
XI
                                                    Page
  Of the operation of the trepan     ....     .     260
  Aphorisms or rules of practice    .     .    .     <    .     355


                    DISCOURSE XXI.


  On Tumours,      •     •      •      '            •  373
  Of the parts most subject to tumours        ...    375


                   DISCOURSE XXII.


  On tumours of the bones       •        •        *       383

                  DISCOURSE XXIIL


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

                   DISCOURSE XXIV.


 Of the various operations practicable in the several stages
     of polypus........427
 Of the first stage or small and incipient polypi   •    •        ib.
 Of the second stage  of polypus,  or of large and  guttural
     polypi      ......    439
 Of the third and last stage of polypus    ....    455


                  DISCOURSE  XXV.

 Of tumours of the gums, lips, cheeks and throat         -    582


                 DISCOURSE  XXVI.

  On salivary tumours        •                         521

                     APPENDIX.

                           A

Of the process employed by nature in the suppression  of
    haemorrhage         •    •  .  *.   •    '           551

                           B

On  the effect of ligatures upon arteries                *    5 53 
 XII                       CONTENTS.
                                c
                                                          Page
Further observations upon secondary haemorrhage         *    553
                                D
Scarpa's doctrine with regard to the formation of aneurisms      555
                                E
Further observations upon the same subject     •     •     -559
                               r
Directions for performing the operation for popliteal aneu-
     rism   *    '               ....
                     ERRATA.
Lor DISCOURSE VI. in the Contents, page viii. read Section IV.
For DISCOURSE VII. read DISCOURSE VI.
lor DISCOURSE VIII. read DISCOURSE VII.
560
                               G
Directions for reducing luxations of the hip-joint                5 61 
PRINCIPLES
OF
SURGERY.
►<©
DISCOURSE  I.
                        SECTION I.

                      Of Adhesion.


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

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

                         section  ir.

                         Of Sutures.

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


   • In injuries of the head, this rule should  not be too strictly observed.  Read
 what is said upon that subject in the Chapter on Injuries of the Head.  6. 
4                       Of Sutures.
ter with needles and  thread.   The drv suture is made  some-
times with  gum,  as in our  common court-plaster, which is
merely  gum arabic,  with a  little laudanum added to it, spread
upon black silk.  The older surgeons often used g'ue,  some-
times whites of eggs, for we find that their agglutinative plasters
took two hours in drving, which shews that they were made
merely of glue.  But these are dissolved by the moisture which
flows from a great wound, therefore in amputation and al! great
wounds, we are obliged to betake ourselves to adhesive plas-
ters, made of wax, resin, and oil*;  though  straps of that kind
are far from being pleasant to use, for they must be applied  ex-
ceedingly warm, and the slightest degree of moisture on the ad-
jacent skin prevents their adhering.
**7.2.JtI

%w
   The bloody suture is  of various  forms, the first  the inter-
rupted suture, (Fig.  1st.) when in place of making the stitches
close, and continuous, as in a seam of cloth, the surgeon just pass-

  This marginal plate reprefents the various futures ufed by he modern fureeon
and as each future is  defenbed, the particular figure in this plate explainingfuch
future will be marked.                                       *

  • By far the best adhesive plaster, for all purposes, is the Emp. Lytharevri cum
refina of the Pharm.  JLond.  S.                             bJ 
Of Wounds of the Skin.
5
ed the needle once through both lips of the wound, taking care that
the needle passed as near  the  bottom of the incision as pos*
Bible, tied the ligature and cut the ends away, and repeated the
stitch  from  point  to point,  all  along the wound:  the several
stitches are usually about an inch  distant from each other, care be-
ing taken to put one at every angle of the wound.   From this it
was named the interrupted suture,  and is almost the only one
of this class now employed.   Some  surgeons yet retain the
hare-lip suture, as it is called, from being principally used after
operating for that deformity.  It is made by thrusting pins or
needles through both lips of a wound, and twisting a fine thread
around their projecting  ends;  whence it is often named the
TWISTED  SUTURE*.

                        SECTION III.

         Rules for the Reunion of Wounds of the Skin.

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

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

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

       Rules for the Reunion of deep Muscular Wounds.

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

  * Even if a part were entirely feparated, if called to the cafe immediately, the
furgeon fhould  endeavour to reunite it. Adhefion may take place, and fhould it
not, the attempt can be of no injury to the patient.  S.
  f This point is well illuftrated by the cafe of a foldier, who being wounded at
the Corps de Garde, acrofs the fhoulder through the belly of the deltoid mufcle,
his furgeon fewed the wound that night with many deep flitches: thefe Mr. Pi-
brac was next morning obliged to cut on account of convulfions of the  arm, which
ceafed the moment he had done fo.
                             f JVTrmoirrs de L' Aradamir df Ghjri<rgie.~\ 
8
Of Complicated Wounds.
sequently heal with a gap;  and besides being weakened by loss
of substance, their action is still more impeded by their being fixed
to the skin and the parts beneath.   If the wound then be broad,
you must sew it with such  stitches as its size and the mass of
parts  you have to support  may require,  aiding your ligatures
with plaster, compresses and bandage*   But if the wound be
exceedingly deep, as that made by the stab of a sword, or of a
pike or bayonet, you must not think of stitching it, for the mouth
of such a wound bears a very small proportion to its size :  you
squeeze it, wash it, and trust entirely to the compresses, one of
which you put  upon the mouth of the wound, and should the
blade have passed slanting along, you must lay a long compress
wherever you think by means of it you can put the sides of the
wound in contact with each other.   Gentle pressure is here pe-
culiarly useful.   This is a proper case for the uniting bandage*.
                        SECTION  v.

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

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

  •  Vide Difcourfe on Bandages, fig. \i.  The uniting bandage is there repre-
sented as  applied to the forehead, but it is a bandage more appropriated to  the
umbs or body.

  f ThU subject is treated more at large under the head of  Compound  Fracture.
—Which »ee. S.                                    * 
Of complicated Wounds.
9
in view, is  to put the divided portions into contact, and to re-
tain them in that position.  The same plan is to  be pursued
where a joint is laid open, even though the integuments should
be greatly bruised and lacerated : try at least to save the limb;
the attempt can do no harm*.
   But there is  one case, and perhaps one only,  where adhesion
is  physically  impossible; and that  is the  case of gun-shot
wounds ; for the parts are not hurt and lacerated merel}', but they
are so bruised by the ball that they are killed, and a partial gan-
grene and  sloughing must precede their cure.   It is only after
the sloughing,  and during the granulation of the wound, that
the parts can adhere;  and the adhesion does  not take place at
once, but  slowly and successively.   But we  have every mo-
tive,  especially where flaps of skin  or muscle are torn up by
shot or splinters, to bring the parts  closer and  closer, as the
sloughing proceeds, in order to give each point, as it resumes
its healthy action, a chance of renewing its  connexion with the
sound adjoining parts; and thus there were certain cases, where
a  judicious surgeon,  departing  from the  established rule,  will
venture to put a stitch in even a gun-shot wound, drawing up
the points not so firmly and  closely as in other cases, not with
any expectation of the wound's uniting by adhesion at those
points where it is sewed, but with  the design of merely sup-
porting a flap, in order to preserve it, and keep it nearly in that
direction,  in which he would like it should adhere; for it does
adhere in the second period of that  cure, where sloughing  is
over, and the parts begin to reunite.
   Even in wounds of the belly and breast,  it is adhesion  of
the parts inwardly wounded which saves the patient: it is quiet,
perfect silence and composure,  and  the natural powers,  that
bring about this adhesion.  You bring the lips of the wound
gently  and softly together,  and  retain them so: you wait pa-
tiently the  event of this natural process: you can do  little  to
assist,  but you must  do nothing to disturb it.   Many a patient
died, in consequence of the older surgeons thrusting lint into
the wounds of the large cavities:  and even now, we are apt  to
 do harm, by the unmeaning and too curious  probing of such
 wounds.


   * When the knee-joint has suffered compound luxation, it forms an exception
 to this rule.  Under these circumstances, there is little prospect of union by  the
 first intention.  I  should therefore advise the amputation of the limb, for fear
 the patient should die from the symptomatic fever, which  would probably ensue.
 Amputation,  indeed, would afford no great chance  of recovery, a«  a vast ma-
jority of those, whose limbs are taken  off  immediately  after  an accident, die.
 For this reason, among others, I would always endeavour to save ajatient who
 had a compound luxation of the ankle-joint.  S.             w%»
                              B 
10               Of cutting out the Stitches.
                        SECTION VI.

                 Of cutting out the Stitches.

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

Description of those wounds where adhesion is not easily ob-

     tained,  and of the accidents by which it is hindered.


  A wound will probably  not  adhere where its edges are  not

  • Adhesion arrests the progress of inflammation in contiguous surfaces, as well
as in wounds. Thus where the pleura becomes inflamed,  adhesion takes place
between it and the part with which it is in contact; by which means the further
progress of the disease  is prevented. For much important information upon the
subject of Adhesive Inflammation, see Hunter  on the Blood, p. 477, Burns on
Inflammation, vol. 2. p. 7. 
                        Of Wounds,                     11

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

         Of ill conditioned and complicated Wounds.

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

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

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

  * I can by no means agree to the propriety of the practice here recommended
 by Mr. Bell.  If the opening be not fufficiently cxtenfive and dependent to evacu-
ate the matter, it muft, by being confined, keep the fides of the abfeefs apart, and
 thereby prevent their union.  In a foul hofpital the pradice may be proper, but
certainly under no other circumftances. I do  not mean that an extenfive fup-
puration fhould be laid open from one end to the other, but I hold no principle
in Surgery better eftablifhed than  that openings fufficiently  extenfive for the
evacuation of matter fhould be uniformly made. Where matter has formed under
the fafcia of the thigh, I have feen the beft effeds, even in an hofpital, from an in-
cition three or four inches in length.  S. 
          Of ill conditioned and complicated Wounds.        15

thus separated from the fascia beneath, is so far deprived of its
nourishing vessels, that it is hardly alive ; it is thin, livid, rea-
dy to burst, and the least accident  will make it slough, and fall
off in gangrene.  If the inflammation be near the haunch, the
abscess undermining the skin of the thigh, bursts at the knee ;
if in the leg, the matter follows the muscles to the ancle ; if in
the fore-arm, it bursts out at the  wrist; and some degree of
management is necessary to give a free vent for the matter, so
as to preserve the skin.
  In gunshot wounds, or in bruises from great splinters in bat-
tles at sea, you will most particularly  observe this course of the
matter from above downwards.  It is from this working of the
matter to distant parts, that the surgeon, after long searching, is
often  disappointed of finding the ball, and feels  for  it at the
point most distant from its real place.  If, for example, a man
is shot with a musket ball in the haunch, the whole thigh will
swell, the  integuments will  be  separated  from the thigh, the
muscles too (especially if the wound be deep), will be, as it were,
dissected by the matter; the chief abscesses will burst near the
knee, the surgeon will search there  in vain for the foreign body;
the patient will be exhausted by  pain and hectic fever,  and
when he dies the ball will be found lying flattened against the
haunch bone,  or sticking about the  trochanters  of the thigh
bone:  or  a ball passing clean through the fore-arm, the absces-
ses, which begin  to form about the elbow, will extend down to
the wrist;  or the elbow being only bruised and slightly wound-
ed with a  splinter, the abscess which forms will cover the whole
of the bellies of the extensor muscles, and burst at last near the
hand*.
   Here, then, you may easily perceive, that it is not the foreign
body lodged  in the wound,  nor the bruising of the parts, but
the matter itself following the tract of the  muscles that causes
this extensive disease: to prevent which, you must attend chief-
ly to these things ; first, To open the abscess early, knowing
what destruction the confined matter will make, if left soaking
its way downwards through the cellular substance of the skin :
Secondly,  If you find that it has already made great progress,
and that the abscess points  below, you must introduce your
long probe, pass it down to the very lowest point, and cut it
out, so as  to make a counter opening, by which the abscess will
have from all parts a free discharge:  Thirdly, The skin being
thus weakened, being already highly  inflamed, unsupported bv
vessels on its lower surface, its cellular substance  being entirely
destroyed by the suppuration, there is  great danger lest it slough,

  *  But this takes place only where the abfcefsforms under the fafclie with which
the limbs are inverted.  S. 
16       Of ill conditioned and complicated Wounds,
with a total loss and destruction of the integuments of the fore-
arm, for example:  injections, even of the most simple kind, arc
in these circumstances so dangerous, that if unfortunately a sti-
mulant injection be thrown in under such an extensive surface
of diseased skin, it will gangrene and slough;  or if, under pre-
tence of evacuating the matter freely, this inflamed skin be im-
prudently cut up with a history, the skin must inflame to the ve-
ry highest point, beyond what  it can bear; and  being unsup-
ported by its  natural vessels,  it will die and slough off.  For
these reasons, then, you never are to use the knife ; you are on-
ly to make fair counter openings; when you push through your
probe,  you may draw after it a small and fine seton*; but even
a small seton is too irritating, and you are to continue it only a
few days till the opening be thoroughly established ;  whenever
you are sensible that the course of the matter is free, you  must
try to  lessen the cavity, and to keep this great  surface of the
skin in contact with the parts below by a gentle roller; but the
bandage must be rolled very gently and very equally, and vour
compression must  be  made, not so much with firm bolsters, as
with a  handful of plucked lint  laid over the whole ; you thus
press down the skin that is already injured,  so  as to make it
reunite, and you oppose a barrier to the further progress of the
suppuration.
  If the inflammation, in place of merely undermining the skin,
go deep among the muscles, then the matter finds new cavities
and hollows to  lodge in, makes new and crooked passages for
itself from point to point; one  abscess forms after another, the
suppurations  become very irregular and  extensive, and this is
what surgeons incorrectly call a fistulous sore.  It is not so !
for while the parts  continue inflamed, and the suppuration good,
the disease, however extensive, is merely an irregular abscess;
and what  is chiefly required is  some means of diminishing the
number of irregular suppurations, and as it were concentrating
the disease; for the surgeon seeing matter confined, the open-
ings narrow and  irregular, and new abscesses  forming  from
day to day, is  uncertain which way the  matter tends.   He
knows  that it is destroying the muscles, and fears that it may be
spoiling the bones; therefore he chooses from  among the num-
ber of  openings those two which seem most convenient for his
purpose, and introduces a seton from the one  to the other ; or
Irom one opening  he pushes down his long steel probe to the
bottom of some recent suppuration, cuts  out the  probe,  and so

  * From Mr. Bell's own reafoning we  apprehend the feton would be altogether
improper :  a piece of lint, introduced between the lips of the wound, would pro-
duce all the good effeds he feemsto expect from a feton, without materially increal-
ing the inflammation, already too great.  S. 
Of ill conditioned and complicated Wounds.       X7
 draws a seton through the most central part of the suppurations.
 This  seton is  not  to be removed when  the new opening is
 established;  it is to serve a more important purpose, it is to lead
 the pus to those particular openings which  the surgeon has cho-
 sen, it  is to prevent the matter working deep among the mus-
 cles, and draw  into this single channel the matter  of all the col-
 lateral abscesses.  The seton concentrates, as I may express it,
 the inflammation and suppuration, and brings the disease into
 one direct line, so that we know where to apply  our compress
 and roller; we so narrow the passages, and lessen the quantity
 of matter, and  empty the  collateral abscesses, by  the operation
 of this  seton,  compression, &c. that in the end the seton may
 be withdrawn;  but more commonly  a fistula proceeds from
 some foreign body lodged deep, a ball, a piece of iron, a rag of
 cloth, or a spoiled bone, which prevents the healing of the
 wound: and the circumstances and peculiarities of a fistula are
 very easily and naturally deduced  from this cause! for  where
 foreign bodies  are lodged in the part, and of course foul matter
 is allowed to stagnate, tbe part cannot  easily heal; but the pas-
 sages where this foreign body is not immediately lodged, reco-
 ver almost their natural condition, and  the  only inflammation is
 at the bottom of the wound, where the  foreign body lies  irrita-
 ting and supporting the flux of matter, which must find its way
 out.
   Here our business is rather to excite inflammation, and pro-
 voke the sensibility of the  parts*.  We use setone and injections
 in this case, with a very different, and much bolder design.  Se-
 tons are used rough and large, that  they may irritate;  they are
 used,  as bougies are (in cases  of stricture), to force the parts
 into a state of suppuration, and to destroy the callosity.   They


   * It will be in vain to attempt the cure of thefe fiftulas until  the foreign bodies
 are removed in a great majority  of inftances.  In fome rare cafes foreign bodies
 become enveloped in a fac, which prevents their irritating the parts in which they
 are lodged; but  this is fo unufual that it ought never to  be calculated upon, and
 never takes place I  believe where a  piece of dead bone or cloth is the irritating
 fubftance. Thefe facs moft frequently form around leaden bullets.  After the fo-
 reign fubftance is extraded, fhould the fiftula not heal, then the plan of treatment
 recommended by Mr. Bell may be adopted.  Where thefe extraneous  bodies can-
 not be removed, all that the furgeon can do is to fupport the ftrength of the pa-
tient, prevent  the formation of new  abfceffes as  far  as is in his power,  provide
dependent openings fo  that the  matter may  not lodge, and bandage the part fo
that it cannot burrow, and laftly,  examine from time to time fo as to extrad thefe
fubftances as foon as poflible. The openings may be prevented from  clofing by
introducing preffed fponge.  When  a bone is  fhattered by  an accident,  the
furgeon fhould carefully remove all the fplinters which are fo nearly detached that
they cannot live, and all other foreign fubftances which  he can difcover without
too much probing and examining of the wound. It is true thefe things may be dif-
charged in the fuppuration which  muft enfue, but it is likewife true that their early
removal will tend very materially to diminifh that fuppuration.  S
                               C 
18       Of ill Conditioned and complicated Wounds.
 are, like bougies, often loaded with irritating medicines, as red
 precipitate  mixed  with basilicon, and  the cords are drawn
 through every dav.   We also inject a fistula sometimes with
 barley water, merely to cleanse it; but oftener with tincture of
 myrrh, along with  bark decoctions, to correct  a putrid  ichor,
 especially when there are corrupted bones in the  fistula, or where
 blood  has  been  extravasated through the  cellular substance,
 which produces always very foul and foetid suppuration.   Some-
 times  we are really under the necessity of using escharotics, as
 injections of aerugo with oil, or strong stimulants, as turpentine
 diluted into the form of a balsam, with oil, basilicon ointment,
 or balsamum arcaei, which balsams we pour into the fistulous
 holes hot, but not too strong;  yet  for a slightly stimulant  and
 cleaning injection, perhaps there is not a  better than rough red
 wine.
   Even small incisions are  allowed here.   We lay open  any
 smaller fistula in order  to get a more direct passage for  our
 seton or injection into the greater fistula,  or to enable us to cure
 and heal up some collateral fistula.  We also use sometimes a
 sponge tent, or piece of gentian, to dilate some  particular open-
 ing, or to make way for confined matter  ;  and  when, by care,
 and various inventions and practices, we have  obliterated  the
 collateral fistulas, made good counter openings, procured a  free
 vent for the matter, and brought the whole disease into one di-
 rect line;  when, lastly,  we have brought the tube or  inward  sur-
 face of the  great fistula into  the  state of an inflamed, active,
 and granulated sore, and have converted the thin ichor, into  a
 well conditioned pus, we endeavour, with our rollers and com-
 presses, to reunite the parts, forming, by the manner of rolling,
 what the old surgeons called their Uniting and  Expulsive Ban-
 dage.
   Wounds with collections of matter round a joint, are the
 most afflicting of any;  the matter is resisted by the  capsule,
 and makes its way round  the joint,  among the loose cellular
 substance; it finds out the weak parts, as  the axilla or ham,  and
 works towards them, and often it draws the acromion process
 of the  scapula,  or the olecranon of the ulna, or any other  pro-
jecting bone, into disease. The joint then becomes stiffened
 and deformed,  the  integuments swell round it;  in some parts
 abscess forms,  in others the  skin is wonderfully thickened;
 there is all the appearance of white swelling, but the cavity of
 the joint itself  is not  affected, though at last, if neglected,  the
 disease penetrates into the cavity, and the true  white swelling,
 or disease of the joint,  is produced.  When  the  shoulder or
 knee is thus massed by inflammation, hardened, as it were, in-
 to a cartilaginous knot, and perforated at all points with fistulous 
         Of ill conditioned and complicated Wounds.       19

sores, the ligaments of the joint are thickened, its motions are
lost, and even the partial cure by a stiff joint, or Anchylosis, is
hardly to be obtained.  The agonizing pain and want of rest,
the diarrhoea, and  hectic fever, which are inseparable from this
degree of irritation, often destroy the patient, or hurry us on to
amputation.  But while the diarrhoea and pain  can  be modera-
ted, while the strength lasts, you should try to cure the disease
by varying those practices which I have just mentioned.   You
should be careful not to relax the parts, nor hurt the little vigour
that is left in them, by the application of poultices;  you should
remember, that the skin covering such a joint is much insulated,
and tends greatly to inflame, and therefore you should be cauti-
ous  in  using injections! you should be  well assured that the
parts are really fistulous before  you inject, and  you should be
the  more anxious and prudent, because the joint itself may be
affected, and you may be driving a very irritating injection into
the cavity of a diseased joint; nevertheless, cleansing, or even
stimulant injections,  barley water, diluted tinctures,  or wine, I
do not condemn.   You should  be careful to  watch abscesses,
and prevent their extension, by small and frequent openings
with the lancet; perhaps it may  be right to use a seton, in order
to procure a free drain of matter.  You may occasionally en-
large one fistulous hole, in order to heal up two or three colla-
teral holes depending on it.   You  should use a poultice only
after an incision, when the parts are irritated, and must be ap-
peased;  a fomentation you will use often, but you should make
it hot and stimulant, and continue it but for a short while; you
should support the joint with compresses, or rather puffy cushi-
ons of lint, and a gentle roller;  but be fearful  of tents, winch
both irritate the parts and confine the matter, rather enlarge the
fistulas with the knife.   If by a shot, or other wound, the bone
be crushed, you easily discover it at first, but not perhaps  the
whole extent of the injury.  If in a scrophulous boy, the acromion,
or the sternum, or any  other bone, be spoiled by suppuration, you
know it by the black and peculiarly foetid discharge ;  you feel it
with the probe through the many fistulous openings which run
along the ridge of  the bone ;  a man of  experience learns even
to know by the  eye this state of the sore ;  and, if there be such
a diseased bone, added to the other disorders, and  if the bone
be projecting at one end, you shake it from day to day till you
get it out.   Or if diseased integuments cover the carious bone,
having fistulous holes from point to point, you take your round
edged scalpel and lay  the openings all into one, and take away
the diseased bone.  Far from  sparing  the integuments, you
should open them  freely ;  you will find them almost insensible,
cartilaginous like the tube of a fistula, not bleeding when cut, but 
20
Of Ulcers.
rather needing an incision to excite them, and  especially need-
ing to be delivered of the diseased bone, before they  can enter
again into a healthy action, and granulate or unite.
                       SECTION  II.

                        Of Ulcers.

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

   • When ulcers are caufed by conftitutional difeafes, it is evidently vain to at-
tempt their cure until the general diforder is removed.  After thii has been effect-
ed they are to be treated as above direded.  S.
   f Vide  Difcourfe on Bandages.
   i Ulcers of the lower extremities are fometimes caufed by varicofe veins, and
cannot be cured  until the caufe is removed.  '1 he operation  is very fimple, dif-
fed down and tie the vein with two ligatures, and divide it between them, as you
would do an artery when performing the operation for Aneurifm.  Trifling as this
operation is in appearance, death has been caufed by it in three Liftances, one of
which, a patient  of Mr. A. Cooper, of London, I examined.  The internal furface
of the vein appeared inflamed, as well as I recoiled. 1 have frequently feen ulcers
improved  by powdering them  with prepared chalk, powdered rhubarb, &c. and
then applying the flicking plafter and bandage, as recommended by Mr. Home.
The beft adhefive plafter is that recommended in the note * page 4.        S. 
Of  Ulcers.
months,  and spreading continually; for this tendinous  sheath
which lies under the skin being dead, deprives?tbe skin of nou-
rishment, by destroying the intermediate vessels ;  the skin can-
not close over a part which  is dead, any more than flesh can
close over a carious bone;  nor can it  continue  sound at its
edges, since its edges lie over the dead fascia, unconnected with
it, and  no longer  nourished by vessels: the skin thus shrinks
from a part with which it can  hold no  connection, and the in-
flammation  and the matter working backwards in every direc-
tion, destroy more  and more the cellular substance  which lies be-
twixt the fascia and the skin.   This I know is the condition of
most of those sailors  ulcers and hospital  sores which   I have
seen.  What can a sprinkling of precipitate, or of some drug
still  more insignificant, do in such a disease ? The fascia when
once brought into this condition, is like  a diseased  bone, its con-
nections are strong, it does not slough off  soon,  but keeps its
place ; the filthy, yellow, thick, and mucous-like matter of such
an extensive ulcer, is produced by the gradual melting down of
this fascia.   Upon removing this cream-like stuff  from the sur-
face  of a deep ulcer, we see the fascia covering the bottom like
a sheet of soaked ciiamoy leather;  with such a bottom  as this
the ulcer can never heal, the fascia itself is dead, and will never
recover; it sloughs off more  slowly than even a  diseased car-
tilage or bone.   Now I know that this  is often the impediment
to the healing of great ulcers; that the  ulcer is perpetuated on-
ly from this diseased and yet unyielding state of the fascia, and
this has been the occasion of many losing their legs.   The ha-
bit which first produces such an ulcer is very bad; the ulcer it-
self,  which extends so as to uncover the fascia in this manner,
cannot be easily cured, although the fascia were cut away;  but
while it is left the ulcer cannot heal; you must therefore learn to
pare and clip the fascia;  and it will be some encouragement to
you to know that I have often cut it up with the knife, then pa-
red the flaps with  scissors, cleared the leg of it in a few days,
and  brought the ulcer very suddenly into a healthy and granu-
lating state.
   When ulcers are long neglected, the worms which breed in
them give a dreadful appearance to the disease.   These worms
may be killed by washing the sore with the juice of the leaves
of green elder (Sambucus Nigra Linn.)  These vermine are
not the only ill consequences of uncleanliness, for without any
other cause that we can perceive, they  produce the most extra-
ordinary ulcers.   I subjoin M'Gillivray's case as an example
the best calculated to explain this position;  for his wound was
extremely small,  the ulcer which followed was very singular,
both in extent and appearance,  and was finally cured, rather bv 
Of  Ulcers.                      23
care and cleanliness than by surgery!  Yet what is surgery in
this case but cleanliness and care ?
  This  man had been wounded  on the  Continent, by a ball
which had entered under the clavicle and passed out behind.
The great blood vessels had escaped, but he lost a considerable
quantity of blood from the  small arteries, which were divided
by  the ball.  After this he  was thrown  into a French prison,
where he endured every sort of misery for two years and eight
months, by which the wounded part was brought  into  the
wretched  condition in which it was when I saw it.  In winter
he  suffered extreme cold; he lived on bread and  water  only;
and of the black bread which he got, his  allowance was but one
pound a-day; no surgery, no opportunity of cleanliness,  no
care.   After his  health had been injured by cold and hunger,
the heat of summer, in a close wooded country,  corrupted the
skin, and covered his shoulder with this terrible ulcer;  half a
year had  elapsed from the time of his being wounded before
the surrounding parts began to degenerate into this very singu-
lar sore.
   The sore never appeared to heal during the heat of summer.
The skin  all around both wounds  (and  to great extent), grew
livid and  verv  dark coloured, then broke out into white pim-
ples ; the pimples afterwards burst, and  discharged imperfecdy
a white viscid matter; two or three  pimples  ran together into
one, and formed a sore ; then a scab covered that sore, confined
the matter, made the inflammation  spread, and comprehended
other pustules;  these, again, were  in their turn  closed up, the
skin was undermined by successive pustules uniting; from pus-
tules they  became abscesses, and from trivial abscesses, deep
inflamed sores.   During the progress of this ulcer, the foetor of
the matter was such, that the whole prison was infected with it.
The poor man  could indeed  get  his  sore washed with water,
but no diligence  could mend his condition; the foetor was quite
sickening and oppressive  to himself; the ulcer spread first round
the wound in the breast,  then  round the back over the  whole
skin, which covers the shoulder joint, then over the scapula,
then up the neck, and down the whole side ;  the skin became re-
markably  livid,  every where  greatly thickened:   in one place,
hard and callous,  in another,  soft  and boggy, as if there were
matter under it, although there was none ;  in one place an ab-
scess was forming, near that was another abscess entirely ripe,
and close  to that another burst, and discharging yellow, very
viscid, and mucous-like pus-, which undermined and destroyed
the skin.   These various abscesses,  in  all  stages of progress
(like ripe and unripe fruit on  one  branch), worked, not super-
ficially, but deeply among the cellular substances, and the whole 
24
Of Ulcers.
skin was puffed up; you might have felt the matter in these ab-
scesses fully a month before they burst;  and while thev were
working under the skin, the veins were eroded, and the blood
burst out, sometimes so freely as to bleed like the vein ol  the
arm.  He frequently bled to  the  amount of two pounds at
once, and much of the blood was, at the same time, driven un-
der the skin, by which there  was mixed with the dark red of
this chronic  inflammation the blackness of echymosis;  and
along with  the hardness and  callosity of  inflamed skin, there
was from  point to point  a  pulpy  feeling,  as  if of anasarca,
echymosis, and abscess, united.  There  were besides two or
three flat, thrombus-like tumours,  fully three inches in diame-
ter, which when pricked with the lancet emitted only blood.
  This disease being merely a corruption of the skin, arising at
first from his dirty and miserable situation, and perpetuated by
one little abscess after another undermining and destroying the
skin;  the plan which I laid down  for curing him was this: I
ordered him the warm bath, gave him a purge, and put him on
good diet, with a little wine ;  I directed the warm bath to  be
repeated three times a week, to support a soft and pleasant state
of the skin; and a fomentation of camomile decoction, crude
sal-ammoniac, and a little spirits to  animate the skin, was appli-
ed to the  shoulder for one hour every morning and evening.
The chief point was to manage the little abscesses and throm-
buses so as to  prevent their undermining  the skin.   I opened
two or three with the knife; and taught his dresser how to cut
each irregular abscess as it formed, down to the bottom, with a
direct incision, till he reached  the sound  flesh.  Each abscess
was accordingly cut before it  was fully formed, with the knife,
if large, (as some of them were three inches long), and  with
the lancet, if small.  The incisions were not made in what may
properly be called an abscess, but through a piece of diseased,
spongy, and suppurating skin.   The matter and blood were thus
prevented from undermining the skin;  the inflammation was
drawn away from the  swelled parts towards those occasional
incisions, which became  then, as it were, the centres to their
own proportion of the disease, and each scarification was filled
with a strong mercurial ointment,  rubbed in very thoroughly
with a hair pencil.   The  consequence was, that  each incision
being stimulated into a right and healthy suppuration, was made
to relieve the adjoining skin before it was permitted to  heal.
By these practices, varied according to the circumstances, this
strange disease was entirely cured; it had continued two years
and nine months; but by persevering in this plan, especially in
respect of the scarification, (which was indeed a  daily and se- 
 

m^ z.^fi

• "..■


M.JQarny.dc.
          JOINER



.A  EOT o£ the TMIUMJPH. 
Of the Hospital Sore or Gangrene.           25
vere operation) he recovered perfectly in six weeks.  Even the
dark colour of the skin almost disappeared, and it became soft,
pliable and clean.

                       SECTION III.

               Of Hospital Sore or Gangrene.

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

  * When I was in Paris I was agreeably furprifed by the cleanlinefs and regula-
rity of this Hofpital, after having heard fo much of its filthy and crowded wards.
y.
                              n 
26
Of the Hospital Sore or Gangrene.
the trochanter was almost laid bare, the hamstring muscles ex-
posed to a considerable extent, and all the muscles of the thigh
dissected in a manner which no drawing can express.
   While these ulcers made their dreadful progress in any  of
the wounded, I could observe  them  pass through the several
stages, first of inflammation, then of insensibility and gangrene,
and then  of renewed pain and sensibility.  First, when the
health is affected, the patient languishes for a few days, and the
sore inflames; then  come vomitings, diarrhoea, and a distinct
fever, and the disease seizes plainly upon the wounded part.  In
its first stage the wound swells, the skin retracts, wastes, has a
dark erysipelatous redness  verging to black, the cellular mem-
brane is melted down into  a foetid  mucus, and the fascia is ex-
posed.  But in the second stage, the fascia and skin unable to
bear their inflammation, and deprived of mutual  support, be-
come black, foetid, soft, and fall into perfect gangrene ;  yet there
are no vesicles,  and the mortification is confined within the ca-
vity of the sore.  This is the stage of insensibility;  the parts
within are covered and defended with a  perfect slough, which
no medicine can penetrate, on which no  applications can make
any impression; and stimulants are used, without pain, of such
a hot and  fiery nature, as none but dead parts could resist: but
when these  sloughs  open  in the natural course of the disease,
and  the living parts  are exposed, and the medicines  begin  to
make an impression, it is imagined  that these applications are
restoring life and energy to parts which, before they were appli-
ed, seemed entirely dead!  It is under this impression, that sti-
mulants are  continued of a strength which parts thus inflamed
cannot bear; the disease is aggravated by them, and  the cries
from all sides are such as would melt the most rugged nature.
   In the third stage, this gangrene ceases, the sloughs fall off,
the muscles  become exposed, the part  assumes once  more the
appearance of a  common  sore, but fearfully enlarged ; a high
and glossy red,  and a smooth, shining, uninterrupted surface,
mark the continuance of the inflammation aud disease; but if
the sores are to do well, it is known  by  a rough,  granulating,
surface, somewhat dry, and of  a paler colour.
   If the patient is to die, the gangrene or wasting of the cellular
sheaths proceeds; the skin first sloughs off;  then the fascia is
destroyed; those divisions and lamellae of the fascia, which dive
betwixt the muscles  to enclose, protect, and nourish them, are
next affected; the matter continues slimy and thick, and in pro-
digious quantities;   the muscles are divided  from each other
more and more.   In many who suffered under the disease at
the same  time with  Joiner (the boy above mentioned), you
could have laid your hand edgeways betwixt the several mus- 
Of the Hospital Sore or Gangrene.            27
cles of the thigh.  Then the vomiting, diarrhoea,  and nervous
symptoms increase, the pain is dreadful;  the cries of the suffer-
ers are the same in the night as in the day-time; they are ex-
hausted in the course of a week, and die: or  if  they survive,
and  the ulcers continue to eat down and disjoin' the muscles,
the great vessels are at last exposed and eroded, and they bleed
to death*.
   These are the forms which this disease assumes when it at-
tacks an amputated stump, a broad and open wound, a laceration
of the skin, or any surface which is apt to become a flat sore.
But when it attacks a narrow wound, as a bullet wound, a wound
with any pointed instrument, even the prick of a nail in the fin-
ger, it assumes at once the form of an Erysipelatous  Gangrene
(Erysipelas Gangrenosa); and when this disease prevails in the
hospital, you may see even a nurse, from some slight hurt in
the hand, which at another time could have done no harm, have
one day a swelling of the wound,  on the next an erysipelas of
the arm, with dreadful pain and low fever ; on the third day the
arm will become livid, and covered  with  vesicles, and  in two
days  more  fall into gangrene; the woman oppressed  in  the
mean while with hiccup, low delirium, and other symptoms of
approaching death.
   A  stump which has not adhered is a flat wound  peculiarly
apt to be seized with  this dreadful  disorder;  and  in  wards
where the disease prevails, amputation should not be performed.
It is almost impossible to  heal the stump; it sloughs, ulcerates,
shrinks,  becomes pyramidal; and to the  very last moment of
its healing, and even when the scar seems  formed,  or is about
to be formed, the  patient is liable to rigors, slight vomiting, a
quick and irritable pulse; and then,  in  the  course  of a few
days, the  stump is burst open by inflammation, and spreads it-
self into a broader surface than even when the limb was cut off.
The danger of this inflammation and ulcer of the stump is ex-
treme ;  the least evil that can ensue from it, is a great wasting
of substance, an exfoliation of the bone, and a conical stump:
but we are often disappointed  even of this imperfect cure, viz.
in the form of a conical stump; for it happens in an ulcerating
stump, as in other sores, that the greater arteries are eroded, and
then the patient almost inevitably dies.   In one day I saw three
stumps burst open in this manner, each of which was so nearly
  *  The author hasdefcribed this difeafe as it appeared among the Englifh failors
wounded on the nth Odober, 1798, in an engagement with the Dutch, and after-
wards put into an hofpital at Yarmouth.  There were three hundred wounded
Dutch failors in the fame hofpital, feparited by a wall, amone; whom there was no
ippearance of the difeafe. S. 
28           Of the Hospital Sore or Gangrene.
cicatrized, that you could have covered the small spot that was
left unhealed with the tip of the little finger.
   This ulcer and gangrene is in an hospital, what puerperal fe-
ver  is in  a  lying-in ward; it is  an infection  to which  all are
equally exposed; but it is resisted  by health and strength, and
favoured by weakness  or disease.   Excesses, drunkennesses,
cold, and  every cause of weakness, expose the constitution to
its attack.   If diarrhoea, fever, dysentery, or an old  inter-
mittent, or even a common cold, attack a wounded  man who
lies in an unhealthy hospital, the first febrile symptoms  are im-
mediately followed by this terrible disease.  The moment that
a man is struck with it, you may observe him become pale, sal-
low, languid, low-spirited, with a heavy eye, a confused head, a
loathing of food, a fretful pulse, and in short, a universal disor-
der,  which he can neither account for nor describe; and whether
this  disease  appear first in the system, or in the part wounded,
its progress is the same.   When I  have observed  in any case
the sore to be first affected, I have noted it as a sure symptom of
the approaching disorder of the whole system;  or when the
system was first affected, I have marked that as a sure presage
of the sad change that  was soon to appear in the sore.  What,
then, is the surgeon to do ?  Is he to try experiments with oint-
ments and plasters, while men are dying around him ? Is he to
seek for washes or dressings to cure such a disease as this?  Is
he to expend butts of wine, contending, as it were, against the
elements ?  No!  Let him bear  this always in mind, that  no
dressings have ever been found to stop this ulcer; that no quan-
tities of wine or bark which a man can bear, have ever retard-
ed this gangrene; let him bear in mind, that this is a hospital
disease ; that without the circle of the  infected walls the men
are safe;  let him, therefore, hurry them out of this house of
death ;  let  him  change the wards, let him take possession of
some empty house, and so carry his patients into good  air; let
him  lay them in a school-room, a church, on a dunghill, or in a
stable.
  Till some change of situation be accomplished, little can  be
done for men labouring under this plague; but  when  the dis-
ease first breaks out and  rages, and while you are meditating
some change,  or concerting plans for suppressing the disease,
you  will find opium of  infinite service in checking the diarrhoea
and fever, for these are greatly aggravated by the irritation and
pain; you must try to  support the  strength of your people  by
wine and cordials, and  generous food, administered sparingly ;
and  be  careful not to overload their stomachs with bark, at a
time when they are little able to bear any thing but a decoction,
or a small dose of the  powder.  As for external applications, 
             Of the Hospital Sore or Gangrene.           29

tinctures of myrrh, aloes, and other drugs, still more stimulant,
are improperly used in this case, as they  have no  effect  while
the slough remains, and when it gives way, produce unspeaka-
ble torture.   Of these I cannot approve;  keep your  tinctures
and balsams for fistulas, and your torturing stimulants for those
local diseases which may be cured by them ; but this not being
a local disease cannot be cured by local applications, and there-
fore the mildest are the best; as, for instance, a solution of sal-
saturni, which is a  gentle astringent.
   I think that in this hospital ulcer  I have seen gentle evacu-
ants useful; but I am so undecided with regard to the true prac-
tice in this disease, that I speak with diffidence, and would have
you, if you do venture into this difficult path, proceed  with so
much caution, that you  may, as it were, feel your  own way; if
you use evacuations, or a strict diet, it is  but for a time, and in
the expectation of  renewing your stimuli gradually, and giving
them  a greater power over the system. 
(  30  )
DISCOURSE  III.
ON BANDAGES.
                        SECTION  I.

              On the various uses of Bandages.


JjANDAGES are useful  not only for the mere tying up of
a wound, but by them many important operations  in  surgery
are performed, more interesting, though less striking, than the
cures effected by the knife.   In wounds, in abscess, in  fistulas,
in any general disease of a limb, bandaging is the chief opera-
tion of surgery; what the knife cures, it partly destroys; what
the bandage cures, it saves.
   1st. Although in recent wounds, it  is with plasters and  su-
tures that we unite the parts point  to point,  yet it is with  the
bandage that we support the limb,  preserve the parts  in conti-
nual and perfect contact with eaen other, and prevent any strain
upon the sutures with which the parts  are immediately  joined
and we often unite parts by the bandage alone.   The Uniting
Bandage has been long known by that name.  But it is  particu- 
Of the various uses of Bandages.            29
iarlyto be observed, that in gunshot wounds, and other bruised
wounds, though it would be imprudent to sew the parts,, since it
is impossible  that they should altogether  unite, yet the gentle
and general support which we give by a compress and bandage,
prevents them from separating far from each other,  unites the
deep  parts early,  and lessens the extent of that surface which
must naturally fall into suppuration.
   2dly.  Although in the haemorrhagy from amputation,  or in
any regular piece of surgery, we  trust to ligatures  alone ;  in
the haemorrhagy of wounds, we cannot always find the artery;
we dare  not always cut the parts, for fear of greater danger; we
are often  alarmed with bleedings from uncertain vessels, or
from members of vessels,  or from veins  as well as arteries:
these are haemorrhagies  to be suppressed by  a compress, or
sponge, which is  but an instrument of compression, serving to
give  the bandage its  perfect effect.   Frequently, in bleedings
near the groin, or the arm-pit, in the angle of the jaw, wherever
the bleeding is rapid, the vessels uncertain, the cavity deep, and
the blood not to be commanded by a tourniquet, and  where the
circumstances forbid  a deliberate and sure operation, we trust
to compress and bandage alone.
   If  a  compress  be  neatly put upon the  bleeding arteries,  if
there be a bone to resist the compress, or even if the soft parts
be firm below, and the bandage be well rolled, the patient is al-
most secure*.   But such a roller must be rolled smoothly from
the very extremity of the  fingers or toes; the  member must
be thoroughly supported in all its lower parts, that it may bear
the pressure above.   It is  partial stricture only that does harm,
creates intolerable  pain and anxiety, or brings on  gangrene.
Haemorrhagy  requires a very  powerful  compression, which
must therefore be very general, and must be made very cunning-
ly and skilfully, to be either supportable or safe ;  it must not be
made only over the bleeding arteries, which is all that the sur-
geon  thinks of in general, nor must it be begun at that part
where it is particularly required; the bandaging, for example,
by which a wounded artery at the bending of the fore-arm may
be cured, must be begun at the very tips of the fingers;  each
individual  finger must be rolled; the  roller must be  continued
over the  hand, with the greatest attention to leave not a single
point  unsupported,  nor subject to strangulation.  It must be

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

   *  I cannot agree with the  author in this  reafoning: if you apply a bandage
 with fufficient firmnefs at the upper part of the limb to ftop the circulation, I  do
 not fee how preffure upon the lower part will prevent gangrene  ; and unlefs the
 circulation is prevented, mortification will not enlue.  S.
   f  This rule is not admiffible in the unlimited degree in which it is here laid
 down ; on many occafions the many tailed bandage is preferable, as in a fuppura-
 tirig compound Iradure, and in all cafes where moving the limb frequently would
 be injurious.  S. 
On the various uses of Bandages.
33
loires, of the roller * lie over one another by just one third of
the breadth of the bandage;  and secondly, that at every difficult
part, as over a joint, you turn the roller in your hand, make an
angle, and lay the roller upon the limb with the opposite flat side
towards it; you must turn the bandage  so as to  reverse it,
making what the French call a Renversee of the  roller, at the
ancle, at  the calf of the leg, at the  knee f; wherever, upon
making a  turn of the roller, you perceive that it will fall slack,
you make a reverse of the bandage, and at each reverse you
put in a pin to prevent it falling down;  you must be careful to
roll your bandage from below upwards, and support the whole
limb by a  general pressure, that you may be  able to support the
diseased part with a  particular  pressure; you must lay com-
presses upon the hollows, and upon the  bed of each particular
abscess, and change the place of these compresses from time to
time, so as now to prevent matter sinking into a particular hol-
low, now to press it out from a place where it is already lodged,
and again  to reunite the surface of an  abscess already com-
pletely  formed,  from which the matter has been already dis-
charged.
  4thly, In the case of a fistula, or where the abscess has
hardened into a callous tube,  while you pare away the callous
edges, or cauterize them; while you open particular mouths of
the fistula with the knife, or dilate them  with sponges (which
you should prefer if you are afraid of an hospital sore);  while

  *  The Dolloires are marked in the plate, i, a, 3.
  f Renverfees of the roller are marked in the fame plate, a, b, c. 
34
On the various uses of Bandages.
 you stimulate the internal surfaces with gentle solutions of cor-
 rosive sublimate, spirits,  or stimulant balsams, as solutions ol
 gum, aloes, &c.  in spirits; you  must lay such a train of com-
 presses along the course of the fistula as will bring the sides in-
 to contact;  and  when you use a seton, whether it be in fistula,
 to excite the tube, or in irregular abscess, to lead the matter, and
 concentrate the disease, you learn by means of the seton the di-
 rection of every irregular passage, and hollow tract in the limb,
 and know, of course, where  to lay your train of compresses,
 and what form to give them.
   It is in the complicated case of a swelled and diseased limb
 that we are sensible of all the uses of a bandage, which is a uni-
 versal cure for all its disorders.   By the bandage we dissipate
 the leucophlegmatic swelling, abate the  inflammation, prevent
 the extension of  matter, lessen suppurating cavities, close the
 walls of fistulas,  procure the reunion of surfaces which have
 suppurated.  The patient is sensible of an easy and pleasant
 firmness from the bandage, and the limb is actually supported
 against accidents, and the further extension of the disease.  This
 effect of bandage is observable, not merely in this  single case
 of an ill bandaged limb, but is equally obvious and interesting
 in other cases; for in varices, though a permanent bandage is
 usually required, yet sometimes the parts are so strengthened
 by a roller  that they  recover their tone.   It  is also by curing
 this  low inflammation, restoring the  tone of  the  parts, and
 strengthening their action, that bandage  cures ulcer in the leg.
 Ii you have seldom seen an ulcer even rendered stationary by a
 bandage, much less cured by it, remember how very ignorantly
 you  have seen  such  rollers  applied.   You  have  seen them
 drawn round the ulcer, round the shin alone,  with the firmness
 of a tourniquet;  the middle  of the leg  bound very tight, the
 foot swelled, the  ulcer inflamed, the marks of the roller left in
 large ridges; you have seen it recovering in the morning, only to
 be tortured into the same condition before night! Instead of this
 it should be rolled from the very extremities of the toes, and then
 roll it as tight as you will you can do no harm.  It should be rolled
in the morning upon rising from bed, in such  a manner as to fit
it to bear the fatigues of the day;  to support and  defend the
ulcer, and keep the swelling all above the sore;  this constitutes
the true value of the sticking  plasters, which  have been so suc-
 cessfully used by Dr.  Bainton:  First, The sore is  thoroughly
 cleansed, its edges smoothed and wrought forwards, and firmly
compressed by the drawing of the plaster: Secondly, The limb
is rolled from the toes to  the sore, then over the sore, and some
 way upwards, so as to secure the relaxed parts;  the  bandage so
rolled, by a skilful hand, is the only certain cure ; neither oint- 
On the various uses of Bandages.
35
ments, nor mercurial preparations, nor  sponges, nor leaden
plates, will cure an ulcer: it is to  be cured only by firm, equa-
ble, and perfect compression, which must be renewed more than
once a day if the bandage becomes loose.  There is no inflam-
mation of the lower extremities in which I do not experience
the good effects of firm rolling.  Even mere feeling and vul-
gar experience instruct a man when he has an ancle sprained to
bind it firm;  and in a diseased bursa (as in a relaxation of the
knee joint), that disease, which with but a  little indulgence, a
very little encouragement of fomentations, poultices, bleedings,
and low diet, would end in white swelling of the knee ;  may
be stopped even by so simple a matter as a well rolled bandage.
Stimulants, as calomel, opium, and good diet, will keep the sys-
tem well; and the joint itself may be excited  to a healthy ac-
tion, by pouring hot mineral waters on it, by animal oils,  cam-
phor, laudanum, frictions, and most  of all by supporting the
action thus excited by a general roller, well and carefully appli-
ed, and by particular compresses applied upon each bursa.  By
a compress, merely on each side of  the knee joint,  when the
great Capsule of the joint itself  was swelled, I have reduced
the size of a dropsical knee by the  quantity of three or four
ounces in  a night's time; the fluid being fairly and unequivo-
cally absorbed, without any deception arising from  its being
pushed into the surrounding  cellular  substance.  I  have fre^
quently in a few days reduced prodigious dropsical swellings of
the knee, relieved  the patient from great pain, restored the use
of the limb, and made an absolute and permanent cure.  The
common sprain of the ancle also is a  slighter disease, a tempo-
rary one of those bursas which accompany the Peronaei tendons.
It seems to be accompanied with very quick and active inflam-
mation ; if it be but a little  indulged by long  fomentation in
tepid water,  leeches, poultice, and such things as  relax the
parts, it is rendered a very tedious disease,  and the  joint be-
comes swelled and gummy, lame for months, and  rheumatic
for years,  and liable to be easily hurt again by the slightest strain
upon it; but  if this swelling be opposed vigorously by hot fo-
mentation, continued but for a short time, camphorated spirits,
a very firm bandage, and long compresses firmly pressed down
behind the ancle, and if after a few days cold water be poured
upon the joint, if it be rubbed, and still firmly bandaged after it
seems well, it will be easily cured, and no remaining weakness
left to remind us of the  accident.
   I have reduced all bandages to those few which are repre-
sented at the  head of this chapter.   They are as follow.
   The Linteum  Scissum, or  Split  Cloth, marked  No. 1. is
peculiarly adapted  to the  head: it covers the  whole  scalp, and 
36
On the various uses of  Bandages.
 its legs or split parts tie firmly round the occiput and forehead;
 it may be made with six or with eight tails, according to the
 parts you wish to compress*.
   The Single  Split Cloth, or bandage with  four tails, No.
 2. which is called the Capi strum or Stirrup, or the Fund a or
 Sling, is the proper and peculiar bandage for the face: in cuts
 of  the forehead, or of the face, of the nose, of the lips, in frac-
 tures of the jaws, and in every wound which is  beyond the  cir-
 cle of the hairy scalp, we use the Sling, or Double-tailed Ban-
 dage.
   The T Bandage, No. 3. which is  named from its resem-
 bling the letter T, is the peculiar bandage of the body.  If the
 breast or belly  be wounded, we make the circular (a) very
 broad, which serves as the proper bandage of the body, and we
 split the tail-part, (b) and passing one leg over each side of  the
 neck, we pin it to the circular, so that it forms a suspensary for
 the main bandage, which prevents  its  slipping down.   But if
 we have a wound, or disease, or operation near the groin or pri-
 vate parts, the tail-part becomes then the most  important part
 of the bandage;  then  the circular is smaller, and  goes round
 the pelvis, while the tail-part is made very broad.   When  the
 disease is in the private parts, perineum or anus, we often split
 the tail according to circumstances ; but when the disease is in
 one groin, we generally leave the tail-part of the  bandage entire
 and broad.
  The Roller, No. 4. is the  peculiar bandage of the limbs,
 for accomplishing all those objects which I have just explained
 to you ; it serves for the limbs, shoulders, haunches, and occa-
 sionally for  the body; it is often singularly useful in bandaging
 the head, where peculiar firmness is required, and there always
 you are to use the double headed rollerf.  You take one head
 of the roller in each hand, and by that which is in your left hand,
 you fix down the turns of that which is  in the right, so that you
 can make your bandage smoothly firm over the whole head, can
 knot it at particular points, can turn it in every direction, and
iit it to every occasion.   Wherever the  roller is to be used as a
 uniting bandage (i. e.) to be applied round any part, so that  the
 legs meet and cross each other over a wound  (to draw its lips
 close together), we make a slit in the roller, see No. 5. and pass
 one of the rollp  through it, and thus we make the decussation
 of the bandage  very sure, and  give it  peculiar  effect upon  the


  •  Marginal plate at the beginning of this chapter.
  f In all injuries of the head, which render bandaging neceffary, a double headed
 roller is by far the bed : generally a common night-cap will confine the dreffings,
 and anfwer the purpofes of a bandage. S. 
       Of the four-tailed Bandage or single split doth.      37

wound.  These are the four bandages which I proceed to de-
scribe, and I  believe I shall satisfy  you that you may throw
aside every other.
section II.
Of the four-tailed Bandage or Single Split Cloth.
  The Four-Tailed Bandage, or Single Split Cloth, is the pe-
culiar bandage for the forehead, face, and jaws;  if the forehead
be the part wounded, this simple and very convenient bandage
is applied as in fig. 7.  The bandage is made by taking a strip
of cloth not quite so broad as the palm of the hand; it is to be
torn or split up at each end, so as to leave  only a convenient
length of the bandage entire to be applied to the wound; the
middle or unsplit part (a) is applied to the forehead,  one  tail
(b)  is carried round the back head  to meet its fellow.  The
other tail (c) is carried, as seems best, either upwards  over the
crown of the head, or downwards so as to tie under the chin. 
38     Of the four-tailed Bandage or single split cloth.

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

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

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

                 Of Bandage for the Body.

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

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

  + A broad roller paffed feveral times firmly around the body, would, I think,
anfwer better than the napkin. S.
 
C  43  )
DISCOURSE IV.
ON  HjEMORRHAGY.
                Preliminary  Observations.


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

 Of the natural Causes by which an Hamorrhagy is stopped.*

   When an artery  has been tied securely, we are,  from that
moment, free from  all uneasiness ;  but when  it  stops  merely
by pressure, by astringents, by the formation of  clots,  by the
contraction of the artery  itself,  whenever haemorrhagy stops
from any  natural cause! it is apt  to return  ; and we  inquire
anxiously into  those natural causes  for  this reason.  When
haemorrhagy stops of its own accord, it is neither from the re-
traction of the artery, nor the constriction of its fibres, nor the
formation of clots,  but by the cellular substance which sur-
rounds the artery being injected with blood; and  to be assured
of this, we have but to observe, what happens  in arteries of va-
rious sizes.   First,  Let us suppose the wounded artery to be
so small as just to spurt out its blood;  the  stream of blood
gradually  lessens, because the artery is emptied, and  the re-
sistance to the arterial action taken  away; the stimulus being
gradually lessened,  the artery every  moment acts less  power-
fully ; and the blood being no longer solicited or urged on by
the arterial contractions, forsakes the open artery, and moves
along the neighbouring branches.   The surgeon claps the point
of his finger upon the mouth of the artery, and holds it there;
the outward bleeding is prevented; the blood is  extravasated
into  the cellular substance  round the mouth of the artery; the
cellular  substance  is  slightly injected with blood ; that blood
coagulates ;  and this slight barrier is sufficient to restrain the
bleeding of a small artery, till the parts inflame, and the artery
is  entirely stopped.
   Secondly, Supposing the artery still larger and more power-
ful,  and that it drives its blood very furiously among the  cel-
lular substance, it is not this slight injection of the cellular sub-
stance that will restrain the  bleeding !   The injected cellular
substance will not support the artery,  unless it is itself also sup-
ported.   Suppose then that the surgeon  first claps his thumb
firmly upon the artery, and then thrusts down a piece of sponge
close to the wounded artery,  applies  over that a compress, and
bandages  over all to support  the sponge and compress in their
place;  the artery still bleeds (though in a  restrained way) both
• Vide Appendix A. 
Of suppressing Haemorrhage.               45
into the cellular substance beneath  the sponge, and  into the
sponge itself, till at last the blood  coagulating in the  sponge,
and in the cellular substance, they become as  one  mass, and
often the sponge keeps its place  till  the parts  inflame  and sup-
purate,  when, of course,  the wounded artery heals along with
the other parts.
   Thirdly, But often it happens that  the blood, which was at
first firmly coagulated,  begins  to lose its  consistence ; or that
by some unwary motion, or by a febrile excitement, the artery
acts violently; more  of the  cellular substance is  filled with
blood, and the first firm  coagulum and  the  sponge being re-
moved  from the mouth of the artery,  the softer  cellular  sub-
stance behind them is filled with  fluid  blood, and the artery,
forcing that slighter obstacle,  bursts out again.
                           SECTION  II.


      Of the artificial Means of suppressing Hcemorrhage.


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

  * Mr. Astley Cooper, of  London, mentions in his lectures a case in which the
actual cautery was  successfully applied to the artery which passes through the
foramen incifivum, when no other application could stay the haemorrhage.  Mr.
Hey,  of Leeds,  I have been informed,  uses the same remedy in  hxmorrhagies
from the tonsils.—S.

  f Agaric, Bovista, or Puff-ball, was strongly recommended some years ago as a
substitute  for  the needle and ligature; but pressed sponge, which has been chief-
ly used by the celebrated Mr. White, is more useful than the agaric ;  it is like
it in its operation, is really of value in practice, not to take the precedency of the
needle, but to assist it. The sponge can be very thoroughly dried,.it can  be com-
pressed into a very small compass, it can take any shape, and may be thrust down
into cavities and  narrow wounds, where the  needle cannot go; it can be made so
hard,  and pressed so firm, by laying compresses  over it, as to  have  at once the
effect of a compress and of a sponge ; or rather of a compress having this curious
property,  that at  first it presses moderately, but if one drop of blood escapes, the
compress swells by absorbing that blood, still preserves its contact with the bleed-
ing artery, and swells more, and presses harder, exactly in proportion  as  such
pressure is required.  This  is plainly the effect of a sponge, whether it be nitched
in betwixt two bones to compress an artery,  which  the needle cannot reach ; or
whether it be laid flat  upon an open sore, as after  cutting out the breast; or after
an amputation done according to the old fashion, where the surgeon used to dres«
his stump open, and to heap compresses, tied with a firm bandage, above each piece
of agaric or sponge.  The agaric, possessing a degree of this property, is of  use ;
even our common lint possesses this quality of absorbing and swelling in a slight
degree. But the  agaric and sponge are both so excellent in this respect, that even
those who are the least inclined to use them,  must acknowledge, that though the 
46               Of suppressing  Hemorrhage.
 which set him higher in  surgical, than Harvey is  in medical
 science, and it is altogether his own.   Had this invention been
 well received, it must, in the course of two long centuries, have
 improved surgery very greatly,  and  saved innumerable  lives.
 It would have rendered many operations practicable, which the
 older surgeons  never ventured upon;  and  have  made  those
 operations safe, which were not so till of late years.
   Par6e neglected nothing which could  give effect  to  this im-
 portant discovery.   He tried to demonstrate, that even the an-
 cients would have approved of the practice.   He also supported
 his reasoning by facts; by his amputations, and other operations,
 and by his successes  in the most dangerous wounds.   Nor can
 we observe, without  surprise, how perfect his operations  were,
 even in the infancy of this discovery.
   Paree had three general ways of tying an artery; by passing the
 needle round the artery, down on one side, and up on the  other,
 and so  tying in along with it a quantity of flesh ; or, by  draw-
ing the arteries out from the wound, as from the face of a stump,
by the artery forceps  with a spring handle, which he called Va-


 agaric will often fail, it has yet enabled surgeons to perform the greater amputa-
tions safely; and the sponge, as is proved by Mr. White's  Practice, is the only
thing that can stand by the side of the ligature to assist it.   I am sensible,  that by
thrusting down a sponge I have  saved a patient's life, when I could not have ex-
tricated myself by any nicer operation.  The sponge is often more useful, than the
needle, and that,  too, in cases  of the greatest  danger.  Wherever the wounded
artery lies deep, and  we cannot cut for it, on account of the  nearness of some
great  artery or important nerve, as, for example, in the axilla, about the*neck,
or about the angle of the jaw; wherever the bleeding artery is so nitched in be-
tween two bones that we cannot draw it out with the tenaculum, nor reach it with
 our crooked needle, as, for example, in the fore-arm, or between the  bones of the
 leg:  in short, wherever we cannot see the artery, or cannot strike it safely with
the needle; wherever the bleeding is not so much from a particular artery  as from
 a general surface; or wherever the blood is thought to flow rather from great
 veins  than from arteries (as in tearing out cancerous  glands from the arm-pit)
 in all such cases we use the sponge, and we use it in the following manner:  We
 keep the sponge dry, and hard compressed, and always ready for use ; and when
 it is to be used, it is cut into small pieces, square or long,  as the incision requires,
 and small threads are  tied  to the sponges, by which they may be drawn away in
 due time.  In any dangerous haemorrhagy of this kind, we choofe out a piece of
 fponge proportioned to the fize of the wound, thruft it down to the bottom of the
 wound,  fix it there with the point of the finger, either exprefsly  upon the mouth
 of the bleeding artery, or, if that cannot be diftindly feen, upon the place at which
 the artery bleeds; then lay one comprefs  above the fponge, a fecond comprefs
 above the firft, a third above the fecond; and taking care to keep the compreffes
 always fteady with one finger, to prevent the blood foaking into  the firft  fponge,
 and diftending it, we pile one comprefs above the other, till the whole rifes fo
 above the level of the wound, that our bandage operates well upon the whole of
 this pile, which is called Graduated Comprefs.
  I advife you, on fuch occafions, to keep  your tourniquet fcrewed during the
 whole operation,  that you may not be troubled with blood; to flacken it flowly,
 that the dreffingg may not be difcompofed by the too fudden return of blood ; and
 ftill let your tourniquet remain loofe  about  the limb, and ready to be fcrewed, it
 the artery fhould bleed again. 
                Of suppressing Hemorrhage.              4>7

let a Pathp. oa^fc^trikjng the  needle above the  place of the
wound, tnrougWJie^fesh of the limb, down quite to the bone,
so as  to tie in the grraf artery of the limb, and along  with it
much of the flgflt
  "  If there be a bleeding artery, says Paraeus,  in any wound,
dress the wound with astringents;  but be careful at the same
time to lay a firm compress over the wound, and  settle it well
with a bandage, and then lay out the wounded limb in an easy
way.
  u  If this do not serve, clap your finger upon the point of the
artery,  and w^St patiently till a  clot be formed.
  "  If the afrtery continue to bleed, cut up the wound, (if it
have been sewed) anrj^^ss-a needle under the artery, enclos-
ing along  with it in the ligature much or little flesh, according
to the circumstances of the case.
  "  If the artery have shrunk  up among the flesh, cut up the
wound, and tie the artery higher.
  "  But should both ends' of the artery have been still further
retracted, then continue  your  incision, and cut open the skin
freely, still pursuing the artery; but still careful of the very artery
that  you are pursuing, lest you  should cut it a second time.
  "  In an amputated stump, draw  your arteries out with the
forceps, tie them neatly with a thread; but if once  you miss the
artery,  or your first thread give way, do not use the forceps
any  more; but pass a needle four inches long into the stump,
so as to tie in the artery,  along with much of the flesh.
  "  These ligatures  we are careful  not to withdraw too  early ;
nor must  they ever  be removed  till the granulations of flesh
have grown up to protect and strengthen the artery.
  "  If these operations fail, we must have recourse to caustics,
vitriols, or the actual cautery, which make eschars and crusts;
and  we must be careful to prevent these eschars falling off  till
the flesh be formed.
  "  Sometimes also  the surgeon needs to cut the  vessel entire-
ly across, by which its ends, shrinking both ways among the
flesh, the  flux stops: but always the surest way is to tie the
vessel before cutting it thus across."
  This is a system of instructions which is fairly extracted from
Paraus's books, without mending the text, and though this sys-
tem  be now one hundred and fifty years old, it is such I believe
as the best surgeon at this day in Europe could hardly improve.
In correctness of practice, surgeons, from his time, went back-
wards for  many ages; and it is  only after much experience, and
by very slow degrees, that we have learnt at last, that the  draw-
ing out an artery, with the forceps or tenaculum, and the tying
it fairly with a small ligature, the method which  appeared to the 
48              Of suppressing Haemorrhage.

older surgeons to have every fault, is absolutely  the most se-
cure.*

                        SECTION III.

  Of the condition of an Artery when tied -with Ligatures.-^

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

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

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

                         SECTION  IV.

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

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

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

                        SECTION v.             i

    Of bursting of the Artery from Ulceration of its Coats.

   Yet it  is not to  this unhealthy condition of  an artery alone
that I ascribe the death of those who have perished from secon-
dary haemorrhagy.  The diseased state of the  arteries never
can explain the difference of danger  in the two  operations of
aneurism and amputation.   In amputation of the thigh we tie
the great femoral artery; we tie also the profunda, and its mus-
cular branches; we perform amputation daily,  and we  tie  ma-
ny  great  arteries in  each  amputation;  each ligature is  seen
moved and raised up from the face of the stump at every pulse
of  the artery; the stump remains open.   These arteries conti-
nue for weeks to bear the whole force of the circulation, unsup-
ported, yet they rarely give  way.
   But, in the operation for aneurism of the thigh, the differ-
ence of security  is  very great;  for this operation is,  on the
other hand,  so full of uncertainty and  danger, that hardly any
case  can be mentioned in which  the surgeons have not been
alarmed, and  the patient  in great danger, from secondary hae-
morrhages : it is an operation never performed but by surgeons
of the first eminence ; and yet more, perhaps, have died than
have survived it*.   Hunter himself has lost his patients: those

  * The fuccefs attending this operation has been much greater of late. S. 
52              Of Ulceration of the Artery.
whom he did save were endangered by secondary  hemorrha-
ges ;  and the celebrated  Mr. Pott, from the ill success of one
operation, was forced to amputate the thigh.  It behoves us
then to inquire, What the difference is betwixt tying the femo-
ral artery in  aneurism,  an  operation so full  of difficulty and
danger, and tying the same artery in amputation, an operation
which is so perfectly safe, that the death of a patient by hae-
morrhagy would be a flagrant disgrace."
   Secondary Haemorrhagy arises from Ulceration of the
Artery more frequently than from any other cause!  In am-
putation, such ulceration rarely happens, except when the liga-
tures, having been firmly tied  round the nerves, are prevented
from slipping off, or when the whole surface of the stump falls
into disease, and is eroded;  but in aneurism it is peculiarly fre-
quent, from the manner  in which a great length of the artery is
insulated and detached from the surrounding parts.  If the sur-
geon, forgetting how  slight a force  suffices for suppressing the
pulse  of a naked artery, and for laying its sides in contact, pulls
his ligature with all the  firmness which the artery can bear, al-
though the artery be not immediately cut across, its coats may
be twisted and weakened; or, though not even weakened, the}'
may be so violently compressed that not only the portion of the
tube intercepted between the two ligatures, but the part imme-
diately under each ligature will fall directly  into gangrene in
place of adhering, so that, on the third day, when the ligature
is withdrawn, it may bring along with it the end of the arteryf.
   If the surgeon,  in place of dissecting the artery fairly, passes
his needle under it, and includes much of the muscular sub-
stance, or other soft parts,  there is  little pressure upon the
artery, there is no adhesion of it under the ligatures, there is
no  amputation of its intercepted part, the cellular substance
and muscular flesh fade and give way on  the third or fourth
day :  But the artery itself is still entire, and the blood, by this
slackening of the ligatures, passes along the canal of the artery,
and out at the wounded  point; and as the structure of the ar-
tery is but litde affected by  so slack a ligature, the artery con-
tinues entire,  the ligature keeps its place round the arterv, and,
though it does not compress  the artery, it irritates it, and is ne-
ver disengaged till the artery falls into ulceration and bursts.
   If the surgeon  should pass  his needle  any considerable dis-
tance   from the vessel, he will include  not flesh only, but will

  f From the obfervations of Dr. Jones, it would appear that there is not fo much
danger  to be apprehended from drawing the  ligature with a confiderable deerec
of ughtnefs as Mr. Bell feems to fuppofe.  The ligature ought to be tied tieht
enough to divide the two internal coats of the veffel, and the furgeon had better
err on that fide, than incur any rifk of having the ligature thrown off.  S 
Of Ulceration of the Artery.
53
take the nerve into the loop of his ligature! for every great ar-
tery has a great nerve of  the limb  accompanying it, the  bra-
chial artery has the great radial nerve,  the femoral  artery has
the great anterior craral nerve, the great  artery, nerve, and in-
ternal veins of each limb, lie in a peculiar sheath,  and, in order
to tie the artery apart from the vein and nerve, it is necessary
to dissect this peculiar sheath of cellular substance.   Now, au-
thors have always talked slightly of tying the nerve, as if the
tying it related only to the nerve itself!  No! it relates to  the
security of the artery ! an artery, tied  with a ligature, is de-
stroyed in a few days, but a nerve tied with a ligature is hardly
affected by it:  The nerves are peculiarly strong, their coats
hard and firm ;  a ligature  tied round a nerve  and  artery toge-
ther, as it cannot destroy the nerve, keeps its hold upon the
artery, till, by the irritation of the ligature, and other  obvious
causes, it ulcerates and bursts ;* or, if this  can  be prevented, it
is only  by cutting the ligature timeously away,  which cannot
be done without a degree  of difficulty and danger.
   But there are still other causes of the  ulceration of arteries.
If the surgeon, anxious to insure the obliteration of the artery,
resolves to lay a considerable length of the sides of it in con-
tact, what does he do but insulate the  artery,  tear it up from
its bed among the cellular substance, separate it from all those
vascular  connections which  kept it alive ! he exposes  it to al-
most inevitable ulceration!   This has been practised upon the
femoral artery in a great variety of ways, all of them ingenious,
but  all in direct opposition to the principles of surgery.   These
contrivances  for insulating  the  artery are  sure to  cause that
ulceration which too many natural causes conspire to produce;
and it is  this ulcerated  state of the artery that makes it neces-
sary to apply successive ligatures,  and  the same causes make
these ligatures, in their turn, give way.   As  far  as  possible
then,  to avoid insulating  the vessel, I would tie  it clear of the
nerves, which, being indestructible, hold the ligatures too long:

  * The following experiment, which is extracted from Jones, p. 179, very re-
markably confirms what is ftated in the text.
  " In the month of September,  1756,"  fays  Ponteau,  " I tied the crural  artery
of a dog of moderate fize with a ligature, which likewife included the nerve of
the fame name ;  the artery was not opened, and the animal was left to itfelf.  On
the fourth day there fupervened an hemorrhage, which flopped of its own accord :
on the next day it recurred, and was fo profufe that the animal died.   Upon lay-
ing open the artery lengthwife, I found it open at its anterior part, immediately
under the thread of the ligature;  there was in its cavity a clot of a pale red colour,
of a moderate confluence, and in the form of a fpindle : the fuperior extremity of
the coagulum floated in the artery above the ligature; the middle portion was
lightly attached to the pofterior part of the artery under the ligature ; the inferior
portion, which was the moil flender, floated in the artery below the ligature; this
coagulum was about four lines in length, and lefs than a line in diameter, at its
thickeft part."  Pouteau Melanges  de Chirurgie, p. 80.--S. 
54                    Of Aneurisms.
I would also have it clear  of the muscular  flesh, which pre-
vents the ligature from having its full  effect  upon the  artery;
and  with a ligature smaller than the  one commonly used, I
would tie the vessel, with moderate firmness, as near as possi-
ble to the sound parts.

                        CONCLUSION.

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

X1.NEURISM, when it arises without blow or hurt, steals on
slowly.  A small tumour is felt, for instance, in the ham; it
is small at first, and firm, and but little affected by the pulsation
of the artery.  It lies deep among  the flesh, and must be felt
for by working in the  fingers and pressing aside the adjacent
parts.   It is supposed to be a knot or kernel, has little pain, is
neglected for many weeks, and might be mistaken,  even by a
surgeon, for a swelled gland.  These tumours begin  during
sickness and convalescence, while the patient is in a state of
perfect quiet, and while there is not even the slightest fever  to
account for this dilatation of the artery; but if doubts concern-
ing its nature remain,  we generally find them  all resolved by
the dissection of the body.  These aneurisms  are found to be
true dilatations of the artery ;  there is no breach of the arterial
coats, the cellular, the muscular, the villous coats are thickened
as they approach the dilated part, and  may be fairly traced
over the aneurismal tumour ;f it is  on the tumour, indeed, that
the several coats are most distinctly traced.   But strong as this
predisposition is, we are astonished  to find these dilatations end
gradually and gently in the sound artery,  which has in the  in-
termediate parts not the slightest mark of disease, the arterial
system being throughout limber, soft, and natural.
  But aneurism arises not only from this inscrutable  predispo-
sition, but often  from an actual and manifest disease of the ar-
terial system.  We frequently find  throughout  the arterial sys-
tem, the coats of the arteries thickened and brittle, their cellu-
lar substance loose and spongy, with spots and  specks of ossifi-
cation  besetting the great arterial trunks.f   We find the  great
arteries dilated where  they give off  their larger branches, and

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

  * It  is much more probable that in this cafe the coats of the artery were rup-
tured,  notwithftanding the appearance reprefented by the drawing.—S.
H 
58                    Of Aneurism*.

ham, when he observes that he  has from that moment consi-
derable pain in  laying his leg across ;  when, on the third or
fourth day he  feels distinctly the pulsation, pain and lameness,
which are the peculiar signs of aneurism, what reason can there
be for doubting that the artery is burst ?  None,  surely, but the
slowness with  which the aneurism grows.  The slow  manner,
then, in which even the greater arteries of the body form their
aneurism, must next be explained.
   We are naturally inclined to believe, that an artery thus bro-
ken or lacerated, must form its aneurism the moment its coats
give way, and must be able to overcome all resistance from the
surrounding parts in a few days!  But here we are deceived; we
must not regard the artery as a naked and insulated tube, such
as is represented in Figure 1st, merely laid along the limb, un-
connected with the surrounding  parts, unsupported by cellular
substance.  The artery has a cellular coat in which it is lodged:
this coat is so peculiar as  to be  called the sheath or capsule of
the artery, and is closely  connected with the proper  coats of
the artery by cellular  substance  and numerous  vessels, which
strengthen, support, and nourish  it; and when the  proper coats
of an artery are torn, the blood  is not widely extravasated, but
is confined by this sheath  of cellular membrane, which is very
slowly forced,  or separated from the artery.  Even after the
sheath is separated from the artery, it  does not entirely  give
way,  but its cellular substance is kneaded as  it were with the
half  coagulated  blood, and rises into a tumour  somewhat re-
sembling the thrombus which rises over an ill closed vein.
   Fig. 2d represents the true and natural condition of the arte-
ry which is everywhere nourished by its  cellular  sheath,  and
represents a laceration or rupture  of the artery, showing how
the  sheath and  cellular  substance  are opposed to  the  exit
of the blood.
   Fig. 3d represents the aneurism already beginning to form.
Here  is  once   more  represented, the  continued  sheath,
within  which  the great artery  is  enclosed; large branches,
such as the profunda femoris,  and smaller muscular twigs,
are seen going off from the great trunk,  each having  its own
peculiar sheath.   For the  smallest arteries are as well support-
ed with cellular substance, and have sheaths as  peculiar as the
femoral or carotid arteries; each little artery, as it penetrates
among the muscles, is enclosed  along with its  corresponding
vein, and often with a small twig of a nerve, in a peculiar fascia.
Aneurism produced by the bursting or laceration of an artery
dilates slowly, because, the  continued canal of the artery  is
still open to the ')l)od, the  cellular substance yields very slowly,
the blood coagulating in  hard  and firm clots, walls up the 
Of Aneurisms.                     59
artery, and is so mixed with the first lamellae of the cellular sub-
stance, and is so firmly clotted as to make  a strong resistance.
At first,  while the blood is confined to its natural course, the
progress of aneurism is  slow.   But when the  cavity of the
aneurism  is  enlarged, when the blood begins to collect there,
and the circulation becomes irregular, these clots give way from
time  to time, and by exercise,  working, or accidental excite-
ments, there  is from time to time a new impetus against  the
sides of the  sac itself, and  t enlarges; the  clots  which line the
cellular substance become biprger  and firmer;  layer is added to
layer, and at every addition of this kind, the  fluid  contents of
the aneurism accumulate, the open part of the bag enlarges, and
the cellular  sheath  of the  artery, which  in  fact corresponds
with  the  sheath  in Fig. 2d, is condensed  into a firm aneuris-
mal sac, which gives  the whole tumour sometimes the appear-
ance of a spontaneous and natural dilatation of the artery itself.
Thus there is formed a great tumour of clotted blood, surround-
ed with a firm cellular sac, and bounding a cavity which is con-
tinuous with  the artery, where the circulation of the blood is ir-
regular, and often accompanied with a whizzing noise.

          Sketch  explaining the Fascia of an Artery.
    I. The Naked Artery.    %. the Sheathed Artery.    3. False Aneurism.

Artery.                                               AneurLm.
  This hard and firm tumour, rising higher and higher over the
artery, begins at last to compress the canal of the artery itself;
the clots sometimes loosen, fall  down, and almost choke the
current of the blood; the limb grows cold and benumbed, from 
60
Of Aneurisms.
the compression of the great trunk,  and it swells and  inflames
from the enlargement of the inosculating arteries.   By the per-
petual and increasing pulsation, the pressure and straitness in-
crease,  the bones  are spoiled within,  and the integuments are
almost destroyed without; the limb is safe, for the inosculating
arteries are enlarged, yet,  when the tumour  bursts, the  patient
dies from the bursting of the main artery, and the immediate
loss of blood.
   Thus  we perceive that the increase of such  an aneurism,
where the artery is absolutely broken across, is naturally slow;
that the resistance  is uniformly great;  that the artery does not
lie as in our preparation glasses, or on the  dissecting table, insu-
lated and unconnected,  but is surrounded  with cellular sub-
stance ; its rupture is  walled up with coagulated blood;  its ca-
nal is open  to the  circulating fluids,  and there  is, for a long
while,  a firm  pulse even in the  artery which  is  desperately
wounded, provided it be not entirely cut across*.
   But  where  the femoral artery  is  not merely wounded,  but
entirely  cut, or broken  across, it will no doubt form its aneu-
rism more  rapidly, perhaps in three  weeks, instead  ot three
months, as happened in a case which  occurred  to my friend,
Mr.  Harkness.   The patient was master of a  small  trading


               *  Explanation of the Etched Plate.
  Aneurifm proceeding thus, from violence done to the artery, is very eafily dif-
tinguifhed from that which proceeds from a natural dilatation of the tube.  1 have
given this fheet of Etchings to explain this piece of Pathology.
   In Figure ift is feen a Femoral Artery where the dilatations are plainly of that
kind which is called Natural Aneurifmf, the dilatation being fpontaneous and gra-
dual; and in this Iketch it will be noticed, that  fince the profunda (a)  comes off
from one of the aneunfmal facs, had that fac increafed fo as to become a formida-
ble aneurifm, had the operation been performed, and the ligature been tied above
that aneurifm, the inofculating arteries communicating with the profunda would
have poured their  blood  into the  fac, and caufed a fecondary hxmorrhagy if the
fac was cut open, or fet it a pulfating again, if it was left untouched.
   In Figure  ad you have a Iketch of that Aneurifm  which  1 have been juft dc-
fcribing, where the old woman,  by her violent bending of the knee, injured the
artery, and, I have very  little doubt, broke it acrofs, and left the breach  in the ar-
tery fuftained only by its external coat of common cellular fubftance.
   In Figure 3d you have another fketch of an Aneurifm,which was operated upon
by Mr. Hunter.   The man died fome years after, the  artery was differed out, and
the following circumftances deferve particular notice: ift, The artery  (b b) was
offified throughout the whole length of the thigh; this does not feem to have been
the confequence of the operation merely, for the profunda, which was not touched
by the ligature, was alfo offified :  therefore this man's fyftem of arteries was predif-
pofed to this rupture of the arterial coats,  and his trade, viz. that of a hackney-
coachman, expofed him to blows, twifts, and ftrains.   2dly, The aneurifmal fac
£c) lay altogether upon  the back of the artery; it was formed all on one fide, as
if the artery had given way on one fide;  it lay fo  over the artery, as to pref*
ftrongly upon it.  " The aneurifm had, in fome meafure, the appearance of a ft-
p3rate bag, it was oblong, a little flattened, and like a  hen's egg, and contained a
folid coagulum."  3dly, It is indeed very interefting  to obferve the inofculatiom,
   f Vide Appendix E. 
^J..?t€w//<7?//j  .•/'   'f'/Mrtt/ ^f'2<e//'?i6ym*J
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&fl
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■	& o5
	ArW
'+	1H#
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AnAneunsm e/tAe Aam_/rom WiltAer
a.reftresenls die. .Aneurismal Sac, 6
small O/ii/icatiens just ielaurthe
d&afed/uz-rC c t&e Tiiial A rfczy
                J*y.3.
 AJtyiliteal AMeurtsm wAlcA Aad' ieen cfurrvtled'on
 fy MTffunfer;irAere tAe e/iz/icalianwAieA Aad/brvdis-
^Hotect' /AeArtery to dilation is teen afi Tie small
 utosttdateiw Antfrres neeeinnf-Blood/rtrm aAoye
^Mi m tnairAed ee, cmdone larye inoseu/atinp
Jmra7.£& trartsrmifftnyiieSiloot^totAeArtiayie-
-lm> it mmiedy
            M91
_A ^teased state gftAe Femonxl Artery.
 where a 6c refiresenta succe/iion ofAn-
•eurisfrtal  Sacs, d one of t/iose Sacs ojbe*
-ned,and e tne ftiofunda and its Aruneh-
-es aoinyofi'lrffntAeu^berTnostArteuris.

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

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

  * Except  in thofe cafes in which a rupture takes place in that part of the aorta
included in the duplicature of the pericardium, in which event death immediately
enfues.  Vide Wifhart's Scarpa, p. 81, for an inftance, and citations of others.—S.
  Another cafe, which  is an exception to this rule, is ftated by Mr. B. from War-
ner, who relates it, apparently from memory, in few words, but  very decifively ;
the general  impreffion of the cafe upon his mind feems to have been very ftrong.
" Some years ago the operation for aneurifm was performed in a fimilar cafe with-
in a few hours of the rupture of the veffel, the tumour increafing fo faft, and the
pain proving fo intolerable, that it was neceffary to lofe no time.  The tibialis
poi'tica was  Lurft in the  middle of the leg • it was taken up with fome difficulty,
and the patieiit recovered."
  An immediate operation is the only means of faving the limb, and probably
the life of the patient, under fuch circumftances.—S. 
Of Aneurisms.
63
Pringle.   A hiccup had come  on,  the  pain was now constant,
sharp, darting to his back,  groins,  and testicles; it was especi-
ally severe when he turned to  his  right side,  but he never at-
tempted to turn upon his left.  These were the decisive marks
of some organic disease.  The disorder was  quite  unaccount-
able.   His pulse  was quicker, harder, and fuller than natural.
He had some degree of thirst, but  his  head was clear.   Such
was the degree of watchfulness,  that for six weeks  he had not
been sensible  of slumbering half an hour: for the last three
weeks of his life he was  hardly sensible of having even closed
his eyes.   His feet, he  observed,  were sometimes benumbed,
which made him call for more wine than usual;  and though he
had  no sickness at his  stomach,  his appetite was  gone.   He
was bled,  but as  he grew daily weaker, they were afraid to re-
peat the bleeding;  and  for his hiccup, he took musk and ab-
sorbents, without effect.   Opiates were not omitted ; and both
on account of the hiccup, and  in order to procure  sleep, lau-
danum was given; at first in smaller doses, but his physicians
were soon obliged  to  give  it  to the  amount of one hundred
drops during  the night,  without checking the hiccup, or obtain-
ing sleep;  but it raised a  general perspiration.  He seemed,
after this, to be relieved: his spirits revived, the pain ceased;
but this was the deceitful prelude to death.  On the day of his
death, he continued all  the morning wide awake, sensible and
in good spirits, but with an incessant  hiccup.   About  four in
the afternoon  he  called for drink; but before the servant could
warm it, he suddenly expired.
   The dissection of this gentleman's body proves to us a very
unprecedented fact, that the aorta itself sometimes gives way;
that the aneurism, which its laceration forms, is hardly more
rapid in its growth than  that of a smaller artery ;*  that the sac
which it forms out  of the loose cellular substance, is firmly at-
tached to the  artery,  as  if the  aneurism had arisen from mere
dilatation.   The abdominal viscera were sound; but there was
a tumour larger than the fist, of an oblong figure, lying close to
the spine, by the side of the aorta descendens, and in the direc-
tion of that vessel.  It began as high as the emulgent arteries,
descended nearly to the  pelvis, and was of a very firm consist-
ence.  It was found to  consist of  coagulated blood, condensed
in the cellular substance, and  under the  adjacent parts of the
periosteum were some detached  parcels of extravasation.  This
  * The rapidity with which an aneurifmal tumour enlarges, depends rather up-
•n the extent of the breach in  the arterial coats, and the fituatioa of the artery
with regard to the furrounding parts.  Thus a popliteal aneurifm muft neceffari-
ly increafe flowly  from its confined  fituation ;  whereas an aneurifm of the exter-
nal iliac artery would  increafe with much greater rapidity, from the oppofite
syufe.—S. 
64
Of Aneurisms.
abdominal portion of the aorta,  along with  its tumour, were
dissected out of the body, together  with a part of the thoracic
aorta, and of the common iliac arteries, and the middle part of
the aorta being laid open through  its whole length,  there was
observed, in the space between  the emulgents and lower me-
senteric arteries, a complete rupture of all its coats.  The aper-
ture had  lacerated edges;  was big enough to admit the point
of the dissector's thumb, and led  into a tumour, which  now
appeared  to  be a spurious  aneurism  of the great  arte-
ry ; that is, a sac formed of the cellular membrane, containing
blood  of different degrees of coagulation,  which apparently
had issued  at different times from  the aorta.
  The  neatness of this dissection prevents all those doubts
which puzzle us in cases  less correctly related;  but the  case
is written by Sir John Pringle ; the dissection was performed
by Hunter; the tumour was  not first mangled, more canino,
and then the connections and causes of it stated in idle conjec-
tures.   The aorta was slit  up on that side which was sound.
The dissectors saw clearly  the  connection of the tumour with
the artery.   The artery was  burst, the laceration had ragged
edges,  preventing all suspicion of  previous  dilatation;   the
breach was such as to admit of the  dissector's thumb, and was
proportioned to the size of the artery.  The sac was formed in
the cellular substance, condensed in proportion to the driving
of the blood, and it  adhered so to the artery  as to be cut out
along with it,  and certainly would have been  reported by less
dexterous dissectors,  as a natural  aneurism  which had burst.
The blood was collected by several successive extravasations;
the artery making (according to the exertions of the body) suc-
cessive impulses against the cellular substance, and against the
peritoneum, which serves  as the sheath for  this  vessel.  For
our entire satisfaction in regard to the  nature  of this disease,
we, in  another paragraph, learn also the cause, for " the aorta
was not dilated above the  aperture, but its coats were at that
place harder than natural,  as  if tending  to ossify, and  having
lost their natural elasticity and  toughness, were  parted asun-
der.1'*
   Here then is the  greatest artery of the body  burst; fairly
torn  asunder,  and that without any strain or blow."]"   The

  * « Upon the review of the whole, we conclude that a fmall aperture had at
firft been made at this weak part of the aorta, fome confiderable time before the
death of the patient; that the tumour had been gradually formed of the oozing
of the blood into the cellular membrane furrounding the artery,  and which there-
upon was dilated into that fac mentioned above."  Vid. Sir  John Pringle's Me-
dical Effays and Obfervations of Edinburgh, Vol. III.
  t Mr. Elfe obferves, That " the arteries fometimes become ruptured without
any previous dilation. I have (fays this author) a preparation of the aorta afcen- 
Of Aneurisms.
65
 greatest artery of the body,  not supported like the femoral ar-
 tery by a peculiar sheath, nor bedded in firm cellular substance
 of muscles,  but merely covered by the peritoneum, and lodged
 in the loose cellular substance of the kidney, is yet so supported
 as to form its aneurism very slowly.  The  blood is forced in-
 to the cellular substance by  successive  impulses.   The  sac is
 fairly circumscribed,  and forms an  oblong tumour not much
 bigger than the fist, though of  considerable length, lying close
 to the side of the artery, and so connected with it as to be cut
 out along with it:  well may such a  sac be mistaken for that of
 a natural aneurism in bungling dissections.
   Thus have I proved to you, that an artery  is sometimes dila-
 ted gradually,  sometimes is  hurt in  its coats, but very often is
 burst, lacerated, or entirely broken across*.  That  after being
 burst, it is supported by its sheath.    That the cellular substance
 receives the blood; while the breach in the artery thus  walled
 up with coagula, forms its aneurism slowly; that the greatest
 arteries of the body form their aneurisms slowly,  and have the
cellular substance and arterial sheath beaten into  the form of a
distinct sac; and that an aneurism which truly arises from a la-
ceration of the artery may be  mistaken for a natural aneurism or
simple dilatation of the tube!
SECTION  II.
 Conclusion.—Containing a description of various anomalous ca-
                        ses of Aneurism.

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

 dens, appearing in no place dilated, which exhibits two ruptures, one is fmall, and
 iituated about half an inch diftance from the valves, from which a coagulum was
 formed about the fize of a large nutmeg,  that wasfeated between the trunk of the
 aorta and the trunk of the pulmonary artery.  From the white appearance of the
 coagulum, and the regularity of the edges of the rupture, it feemed to be of long
 itanding.  The  other rupture is much larger, feated at the curvature between the
 exit ot the right and left carotid arteries, the edges of which are torn and irregular
and formed a tumour, which preffing againft the lower part of the trachea,  and
the branches of the bronchia,  deftroyed  the patient by  fuffocation in lefs than a
month from its  firft  rife, and  before there  was any appearance of an external

  * This laft is  probably a very rare occurrence.  S.
                                I 
66  Description of various anomalous cases of Aneurism.

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

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


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

  f For more particular directions for taking up wounded arteries, vide chapter on
thn* fubjecr.   S. 
Of Aneurism from fracture of the Bone.        69
the hip-joint, in luxations of the thigh-bone from the acetabu-
lum, in fractures of the cervix femoris, in compound fractures
and luxations of the  wrist,  and in fractures of the shoulder-
bone, bony  cavities  are often formed as big as the head of a
new-born child.  In cases of aneurism, it is more difficult for
the periosteum to live, or to form those bony cavities, but when
such cavities are formed,  they are filled with blood like coffee-
grounds, and constitute a most irregular, or as it has been term-
ed, anomalous disease ; and round the outside of such bony ca-
vities go the enlarged branches of the artery, which preserve the
limb notwithstanding all this disorder.  It is in such cases that
we are almost at a loss to say, whether aneurism or  exostosis
has most share in forming this fatal tumour.
   I shall illustrate this species of  mixed aneurism, by relating
a case which was communicated to  me two years ago  by my
friend Dr. Jeffry, professor of anatomy in Glasgow, whose abi-
lities and zeal are universally known.  • Dr. Jeffry had the good-
ness to send me along with the preparation, the following short
narrative of the case :
   " An old woman of about fifty years of age, was rode down
in the streets by a cart, and her arm broken in two places.   One
of those fractures was about two  inches above the elbow, the
other was above the  middle of the arm, and the whole bone was
greatly shattered; yet this poor creature had no assistance, no
surgeon  was called, the arm remained unattended to  for six
weeks, when Mr. Parlane, a  surgeon in Glasgow, visited her
and found the arm greatly swelled, so that he could neither dis-
tinctly understand the nature of the injury nor the condition of
the bone; it was presumed that there was a fracture,  and the
patient was laid in a posture  favourable to the reunion of the
bone."
   " The tumour never subsided but increased, occupied the
whole arm  from the elbow to the top of the shoulder; pulsation
was distincdy felt at the top of the shoulder, but of such a kind
as might proceed from some artery near  the surface,  it was
judged  to  be really so, the idea of an aneurism  certainly had
never struck the gentleman who attended her, for he opened the
tumour which was soft and fluctuating, there was  no doubt of
 its containing a fluid of  some kind or other; the lancet was
 struck into  it,  but  instead of matter,  as was  expected,  blood
 flowed in a full stream."
   u This puncture  healed up easily, the  tumour which had
 subsided when it was thus  imprudently opened, soon filled  up
 again to its full size, and the  hand and fore arm became (Ede-
 matous  and cold.   In this condition  the  patient survived five
 months, the tumour pulsating manifestly, especially in its upp(' 
TO        Of Aneurism from fracture of the Bone.

part; but how this woman died, or after what kind of suffer-
ings, is not related in the case."
  "  On opening the body alter death,  eight months and more
having elapsed from the time  of the  fracture,  a prolusion of
mixed and putrid blood like coffee-grounds was discharged.
Two inches of the lower part of the bone retained its natural
form, all the  middle part of the bone  was destroyed, the head
only remained  on the  upper  part ot the tumour, but with its
cancelli quite  eroded, nothing being left  but  the  mere  shell.
Through the whole length of the bone, the cancelli  were com-
pletely dissolved, and the outer bony lamina were found adher-
ing to the whole  inner surface  of  the sac, many pieces of the
bone  were found  in the heart of the  tumour, and on the lore
part  and  middle of the tumour was found one piece  of bone
two inches  and  a half long and nearly two broad."
  "  Although  the humeral artery was injected, it could  not be
perceived from what branch of it the tumour was produced."
  We need but to review in the history of this case a few  cir-
cumstances, in order to understand the  whole disease  in the
most unequivocal  manner.   First, The sudden rising of the
tumour,  the swelling of the whole arm, the fluctuation, the pul-
sation in the  upper part of the tumour, prove, that though the
chief part of  the  tumour is found  upon dissection to be bony,
yet aneurism, and not  exostosis, formed the basis of the  dis-
ease. Secondly,  The  striking of the lancet into the tumour
shows that there was blood very early ; the sudden filling up of
the tumour to its  full size, after having  been  punctured with
the lancet,  shows that the artery was  open at that time,  and
throwing its blood freely into the sac ;  and finally, the bony ca-
vity  being filled at the time of death with nothing but corrupted
blood, which always after long  delay  assumes the appearance
of coffee-grounds, proves the tumour to be merely an aneurism;
but it is a complicated aneurism ; it is combined with a frac-
tured bone; and the condition of the  periosteum accounts for
the generation of such extensive  plates of bone, equal to a crani-
um in size, and something like it in the breadth and flatness of
the ossifications.   Thirdly, It  being  proved that the disease
was aneurism, it is next to be observed, that there is not belong-
ing to the humeral artery, as to the femoral, a great profunda,
or collateral branch, as  large as the trunk  itself; there are  but
two  muscular branches in the arm, and  those  not larger than
crow quills ;  there is no artery,  except the trunk itself, equal to
the production  of such  an aneurism.   The branches which run
on the inner surface of this tumour, were  all singularly well in-
jected, which shows that  none of these had any share in  pro-
ducing the aneurism ; and surely none of them had terminated 
Of popliteal Aneurism.                 7\
in the bag ;  even the force of the injection had not burst their
most  delicate branches; they were full of the injection, and
the bag empty.  While the entireness% of these branches proves
that they had no share in forming  the  aneurism,  the enlarge-
ment of the  profunda inferior, to such a size as to rival  the
trunk itself in diameter,  is another  proof that the trunk was
wounded; for nothing but the wound of the trunk could  thus
enlarge the profunda.
   This is one of those cases in which, as I have expressed my-
self, one is almost at a loss to decide,  whether aneurism or ex-
ostosis has the greater share in forming the disease.   The con-
fusion of the case is almost an  apology for any mistake of the
surgeon ;  yet the suddenness of the tumour, the pulsation, the
blood following  the lancet, were signs  too  conclusive to allow
of any doubt.  There must have been in a certain stage of this
case such oedema, oppression, coldness  of the limb,  and sup-
pression of  the  pulse, as might have intimated to the surgeon
that the  change in the state of the  circulation had  taken place,
on which the fate of such a limb depends.  The patient living
with an aneurism certainly proceeding from the rupture of the
great artery ; living also under such a complicated and oppres-
sive disorder, fracture, exostosis, and extravasated blood, proves
to us that there  is hardly any case in which we need despair;
and the enlargement of all the arteries in this limb, is authori-
ty  for performing the operation for aneurism, even when the
main  artery is ruptured, along with a fracture of the bone.
                        SECTION  III.

              Peculiarities of popliteal Aneurism.

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

  f Does not the entirenefs of the trunk as fully prove that the ancniFifm was  not
taufed by  a wound of it ?—S. 
72
Of popliteal Aneurism.
is affected. It also lies under the gastrocnaemii muscles, whence
it is endangered by every strain of a limb which is very pow-
erful, and which supports the whole weight of the body.   A
man, for example, has a fall from his horse, and hurts his ham,
or strains it in mounting  his horse ; or his limb falls in  be-
twixt the rounds of a ladder,  and is violendy and  suddenly
bent; or he receives a blow upon the ham, or he is seized with
a sudden cramp in the calf of his leg, and from that moment
his pains and  lameness begm.   Whether the artery be merely
stretched  and inflamed, or whether it absolutely gives way  un-
der such accidents, is little to the  present purpose ; but thus it
is that the disease begins, and is long unsuspected  by  the sur-
geon, while the patient walks, or refrains from walking, by fits,
as the pain happens to be more  or less violent, rubbing the part
perhaps with  camphorated oil.
  Thus all parties continue indifferent to one of the most fatal
diseases.   The ham is straitened, whence the tumour, even
from the first, is  of a stonv hardness.  From this straitness it
loses very early the marks of aneurism, for the pulsation often
ceases,  or is  very obscure.  The  tumour (even in natural  a-
neurisms of the ham) is not always clearly circumscribed, nor
to be fairly traced to any connection with the  artery; and  be-
ing covered,  and its pulse suppressed by the great thickness of
the muscles and  skin, the nature of the disease remains  un-
known.  From the same  pressure the leg becomes very early
cold and (edematous; for the veins, lymphatics and artery, all
pass in this straitened cavity of the ham, the pressure upon these
produces a general swelling of the limb, which conceals the par-
ticular tumour.   From the elevation of the  bellies of the gas-
trocnaemii muscles over the tumour, and from the distention of
the  hamstring muscles, the  limb is thrown into  severe  and
painful cramps ; and from the  nerve passing over the tumour,
(pressed sometimes  quite flat)  a very distressing numbness is
always felt, and the lameness and pain are  such as the exter-
nal swelling cannot account for.   All these distresses of pain,
cramps, swelling, and general numbness of the limb, increasing
every day, the patient sometimes dies of locked-jaw, fever, or
long suffering and want of rest,  the disease  becoming fatal be-
fore that period arrives in  which the tumour  bursts.
   Although  it is very certain that aneurism is often  unattend-
ed with pulsation, yet it is not unlikely that sometimes those
collections of blood which fill the ham,  and hurt the joint,  and
end in caries of the bones, proceed from ruptures of the veins;
for  the veins,  more delicate than  the  arteries, are exposed to
the  same violences as the  artery,  since they  accompany it;  and
varices of the internal veins are capable of producing similar 
Natural progress of Aneurisms.
73
effects with proper aneurisms.  The  destruction of the bones
arises not from the pulsation of aneurism, nor from any  thing
peculiar in the nature of the arterial blood, but merely from the
injection of the cellular substance with the  blood, together with
the general pressure, and the  internal  ulceration, from the  pre-
sence of a  foreign body.   Perhaps the sudden rising of a tu-
mour from a strain of the limb, a sense  of laceration in the part,
the slow increase of the  tumour, and the total  absence of pul-
sation  through all its stages, may be esteemed among the signs
of a ruptured vein.f
                         SECTION IV.

        Of the Progress of Aneurisms, and their Cure.


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

  •f- In one cafe the diforder was fairly traced to the veins. Mr. Elfe, in his works
relates a cafe of this kind, in which the limb was amputated on account of the ca-
ries of the bone.  Upon throwing a wax injection into the arteries, it was not tx-
travafated in the tumour, but ran freely along the arteries to the foot.  Upon ex-
amining the great vein, a rupture was found immediately above one of the valves.
  Any tumour, lying in contact with an artery, will receive a pulfatory motion
from it; therefore, a tumour from a ruptured vein might pulfate. If the tumour
be fufficiently foft, to enable you to prefs out all, or even a very large proportion
of its contents, it is evident that, if it arifes from a ruptured vein, it will not fill
with  the fame rapidity as frqm a divided arterv,—?,
                             K 
T4
Guattani's Operation.
 tion of an aneurismal  limb, which, though hitherto unnoticed,
 is too full of important conclusions to be omitted;  and the con-
 dition of the aneurismal limb is still the same, whether we per-
 form the cure by  tying the artery, or attempt it by compres-
 sion, or whether we neglect the aneurism  till it obstructs the
 artery,  and  obliterates  it by its pressure, or bursts  inwardly
 among the cellular substance.
   When the celebrated Guattani succeeded in curing aneurism
 by long confinement, with compression and firm bandaging,  he
 believed that he had repressed the aneurism, and actually saved
 the  channel of the  blood,  by  preserving for it  a free course
 through the main  artery of the  limb.  Were this opinion cor-
 rect, the tumour should yield at first, then become flaccid, then
 its blood should be altogether discharged  into  the artery, and
 the artery should be apt, on removing the bandage, to inject
 the empty bag  and fill it again:  in short, the  sac of the aneu-
 rism should be repressed as a prelude to the cure of the disease.
 Again,  suppose (by some process of the economy, which I can-
 not foresee, and which surely never did happen) that this were
 really the succession of the phenomena in  this cure, the  artery,
 after such a cure, should carry its blood freely, the pulse should
 be  as  strong as ever, and whatever remained of the tumour,
 though  it were but a thickening of the parts, should receive the
 stroke of the artery, and this residuum or  remains of the tu-
 mour continuing to pulsate thus, the operator never  could  be
 assured of his cure, and would never lay aside his compress.
   But in truth,  the last stage of the process is this: The arte-
 ry being  for some  time opposed by the gradually increasing
 tension of the parts, the blood is thrown upon the collateral
 branches ; the blood passing along the collateral  branches, al-
 lows the compression to be increased  without that intolerable
 sense of numbness and pain, which the compressions of the first
 week cause.  At last the compression is supported boldly, firm-
 ly, unremittingly.  If the  operator stop short of  this, the dis-
 ease returns; but if he entirely compress the artery, the blood
 forsakes it,  the  pulsation stops,  the tumour remains solid and
 firm, and does not enlarge, because the blood no longer flows
 into it,  nor does it even beat again, because the artery which
 lies  under it is obliterated by  the pressure.   Thus, we per-
ceive, that Guattani, when he  cured by compression, had no
reason to continue  his bandages for years, nor to fear a return
of the disease.   He performed, in fact, a radical operation ; he
obliterated the artery as fairly as if he had tied it with the four
tapes, which have been so often used in this piece of surgery.
   A grave-digger had an aneurism, which was large,  attended
with pain, fever, a throbbing pulse,  and great swelling  of the 
Spontaneous Cure.
hmb, but not particularly hard; you rather seemed to feel in it
a sort of fluctuation.   But the case was well marked ;  for " in
the last week of July he had hurt his limb in a very violent ef-
fort ; it was while he strained very hard in  lifting the confes-
sion-desk from one part of the church to another, that he felt
something  give way in his ham, with a sudden pain, but yet
bearable, so that he was able for some time to  continue his la-
bours.   He was ignorant of the nature of his disease, and had
used only the more harmless  applications,  till the time of his
being laid in the Hospital of St. Peter, under Guattani's care.
   " This man was brought to the hospital in the first week  of
August.  For the first eight days he was bled, dieted, confined
to bed, and reduced so that the stricture of the bandage might
be safe and tolerable.   Then the compression was begun, car-
ried on  step by step, and  occasionally renewed;  but on the first
week of November, Guattani found that the pulsation of the tu-
mour had entirely vanished, and  the tumour remained move-
able."   " Yet I failed not (says he) to renew the  compression,
and with such happy success, that  by  the  middle of January
my  patient left the hospital perfectly cured, excepting a halt in
his gate, and that not  remarkable."  u Two months after, I
sent for him to  examine the parts, when I found in the  ham
nothing but a small hardness, about the size and shape  of a
chestnut, resembling an exostosis."
   There cannot be  imagined a more correct history of an arte-
ry  obliterated  by compression.  The patient was bled, kept
upon very  low diet,  and  confined to bed, which relaxed the
parts, and the tumour was so compressed, that in the course of
one month the pulsation  disappeared!   The pulsation had dis-
appeared, though the tumour remained, which shows that there
was not pulsation enough  in the artery even to affect the tumour.
He next performed a work of supererogation, for the artery
was obliterated, the pulsation gone, the  rest should have been
left to nature ; but he applied his  compress and bandage again,
and in the two succeeding months did no more than  stiffen the
ham.
   Let us next observe,  whether we have not  the same marks
of obliteration of the artery,  even in those cases  of spontane-
ous cure, where the surgeon  thinks that the canal of the  great
artery is still pervious.   Mr.  Blagden,  surgeon at  Petworth,
was consulted  by a man of about  fifty years of  age, tall and
muscular, who had his humeral artery wounded in opening the
basilic vein.  The blood flowed in great  quantity ; and, per
saltum, was stopped by strong compression.   First,  an ecchy-
mosis extended itself generally from the shoulder  to the wrist;
then the aneurismal tumour formed, and  in six months it had 
ro
Hunter's Operation.
increased to the size of a cricket ball.   The arm was oppress-
ed, cold, shrunk, and, as the patient  expressed it, painiully
lifeless : he was advised  to have the operation performed, but
he first thought of consulting Mr. Blagden.
  Mr. Blagcicn found  the aneurism of this great  size, hard,
with a strong pulsation in it,  but the fore-arm below was cold
and pulseless.   Now the patient had assured Mr. Blagden that
the tumour had been larger ;  that it was subsiding; that the
pulse in it was  somewhat abated; and  Mr. Blagden did not
scruple to advise, that he should  wait the issue of these changes,
rub the arm with the flesh-brush, and refrain from exertions.
  In a few weeks the arm grew a little warmer:  in  about three
months he began to be sensible of a tremulous pulse at the wrist:
the tumour gradually diminished, and the strength of the pulse
at the wrist increased:  in eight  or ten months  the  tumour in
the bend of  the arm was reduced to the  size of a hazel-nut,
while the pulse at the wrist was  quite restored,  and the arm as
full and fleshy, as capable of as powerful exertions, as the sound
one ; but he was desired to avoid such exertions.
  The author concludes with this sentence:  " It is too evident
to admit of any doubt, that the  circulation is carried on in its
usual course through the artery,  and not through  the  lateral
anastomosing branches  of it."
  I am well assured, that in  this case the blood passed only
through the anastomosing branches; the profunda  and ramus
anastomoticus were enlarged, the trunk  obliterated, and the
circulation along the fore part of the arm gradually subsided in
proportion as the vessels upon the back part  enlarged.
  As, however, spontaneous  cures  are rarely to be expected,
and  as there are  but  few cases in which compression can be
used, I should, in every instance, recommend the operation
first discovered,  or  at least introduced into practice, by Mr.
Hunter.*  This  operation is one of the  most important im-
provements  in  modern surgery, and one which only  a  great
surgeon could invent.  In this operation you imitate the  natu-
ral and spontaneous cure : the limb is prepared  for that change
which you mean  to complete by your operation : the main ar-
tery is compressed by  the aneurism: the collaterals  are  enlarg-
ing : nature has begun  a process, with which it is dangerous to
interfere, which you are to complete:  you cannot, with' pru-
dence, make an incision into the diseased mass:  you would
not choose to cut the parts  which are supplied with  blood by
those  very  inosculations which  you wish  to save.  In Mr.
Hunter's operation, you tie  the  artery far above the aneurism,
and thus avoid  a  part  of the artery, which is frequently dis-
  * This operation ij practicable in the neck or extremities only.—S. 
Effects of it.                     77
eased: you  stop  the blood, and  throw the whole  circulation
upon the inosculating  arteries: you  but complete that process
which nature had begun, and leave the absorption  of the  tu-
mour to time.
  You make this  small and  superficial incision (hardly three
inches in length) upon the fore part of the thigh, above the part
of the limb affected with aneurism, and of course you have no
thickness of  parts to cut through, except what arises from the
general oedema of the limb.  Your first incision is through the
skin ; your next is through the strong fascia of the thigh ; you
encounter no inosculating arteries; you deprive the  limb of no
one blood-vessel,  except the great artery, which it is at any rate
about to lose,  and which  is already much compressed; )ou
make no disorder in  the limb;  you touch  no diseased part;
you have no deep digging for the artery ; you have no difficul-
ty, no uncertainty in tying it;  you run  no risk of secondary
haemorrhagy, at least from the articular arteries; you make no
incisions among  parts which are choked  with extravasation,
where the muscles themselves seem hardly more alive than the
coagulated blood which they contain; you expose no joint to
ulceration, nor any bones to caries.   Far from increasing those
disorders, which  are within the  injured  part,  you rather  take
away the cause of disorder,  by preventing any further effusion
of blood.  Your incision is small; your way  to the artery is
direct; you feel your way by the pulse of the artery, and are
assisted  by  your knowledge of  the parts; if you be really an
anatomist, you must perform this operation in a few minutes;
if you be not, and dare to undertake  such an operation, I know
of no punishment too severe for such unprincipled conduct;
no human reproaches can touch a mind which does  not feel the
punishment within.*
  Let us now attend to the effects of our ligature, not upon the
artery which it  intercepts and cuts across, but upon the tide of
blood which it diverts to the other arteries of the limb.  When
we operate with a ligature on an artery, we  can mark the very
instant in which it is obstructed : we perceive, after a moment-
ary coldness and deadness of the limb, a renewed action of its
vessels and increased heat.  We find the limb cold when its
blood is for a moment obstructed : we  find  its  beat rising far
above the natural pitch, while, as yet, there is no pulse in the
great arteries of the lower part of the limb ; for at this time all
the smaller arteries of the limb are enlarged and acting very
powerfully.   The  smaller arteries perform,  for a certain term,
the office of transmitting blood ;  but when one  artery takes the

  * For particular directions for performing this operation, vid. Ap. F. 
78
Natural progress of Aneurism.
lead, and acts with such power as to become  the direct trunk
for all the arteries of the lower part of the limb, then the gene-
ral vascular action of the limb subsides ; the blood is drawn in-
to one or two channels ; the vessels  in  general resume a natu-
ral and quiet action; and the  heat, which  had risen 6 or 8 de-
grees above the natural temperature, falls to 96.
   Thus, you will observe, that the aneurismal limb,  which has
suffered the operation, and whose main artery has been tied, is
not deprived of circulation, as has been represented, nor cold,
nor apt to fall into direct gangrene; its circulation is  intense:
if  disposed to  gangrene, it must be to that gangrene  which
arises from excessive action.*
DISCOURSE  VI.
ON WOUNDS OF THE ARTERIES;  OF THE A-
  NEURISM WHICH FORMS OVER THE WOUND-
  ED  ARTERY;   WITH   GENERAL   INSTRUC-
  TIONS AND  RULES OF CONDUCT FOR THE
  OPERATIONS ON SUCH  ANEURISMS.
                        SECTION  I.

    Of the formation of Aneurism over a wounded Artery.


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

  • There are two cafes on record, in which mortification took place in confe
.pence of the collateral arteries not enlarging fufficiently to carry on  theVrcuIa"
tion.  Vid. Appendix to Scarpa on Aneurifm, by Wifhart, p. 4Vl_S 
       Formation of Aneurism over a wounded Artery.     79

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

                  The operation described.

  When you are to operate on any great aneurism high  in tl. 
80           Operation for Aneurism described.
limb, take all the advantage that compression or the tourniquet
can give you; but do not trust to them ; do not allow yoursell
to be confounded though the blood rush out upon you; be pre-
pared to do your operation with an intrepidity which shall make
you  independent of every assistance.   First  draw  your knile
deliberately  and fairly  over the tumour, so as the great livid
bag of the aneurism, surrounded  with its strong fascia*,  rises
into  view.   Next push your lancet into the sac, and then do all
that  remains in your operation  with great  boldness; run your
history  upwards and  downwards so as to slit up the tumour
quickly  ; plunge your hand suddenly down towards the bottom ;
turn out the great clots of blood with your hand and fingers, till
having reached the bottom entirely, you begin to feel the warm
jet of blood, and directed  by that, clap your  finger upon the
wounded point of the artery! as  it is but a point, your finger
will  cover it fairly, and  your feeling the beating of the artery-
will  assure you that all is safe.
   Now the  bleeding, confusion and  fainting are over in a mo-
ment ; the operator breathes, and the assistants are  composed ;
and  all  the operation goes on easily and safely.   The artery is
effectually  commanded  by this pressure with the finger; but
the first movement in such an operation, viz. the act of stopping
the blood, ol getting at the artery, is all boldness, and nothing
of caution;  no danger is to be apprehended, but that of suffer-
ing your patient to lose blood.
   Being now composed, you take time to arrange every thing
for  the next step of your operation, you feel the beating of the
artery with  the point of your finger, perhaps you raise the point
of your finger for a moment, to  discover whether the pressure
of your assistants, at the groin or clavicle, commands the arte-
ry:  if so, you lift your finger,  and examine  round the  artery;
if not, you keep your finger steady, make the assistants clean the
sac  round the artery ;  then, if the artery lies fair and free in the
bottom of  the cavity, you proceed to tie it; but if not, you
must dissect  round the  artery, until you see it free from other
parts, and have it so insulated that you may put your ligature
easily under it, unless, indeed, the  recollection of some great
trunk being near the wounded artery (as of the profunda, when
 you are tying the  femoral artery), should stop  you.   But yet
 the  nearness of any great artery or nerve  is an argument as
 strong  against your diving with the needle to catch the wound-
 ed  artery,  as against your dissecting with the knife.   Since,
 therefore, the dissection is done with  your eyes open, and you

   •  The fac of fudian aneurifm is always formed by the fafcia covering the limta
 or mufcles.  S. 
Operation for Aneurism described.            81
 sun see and feel before the point of your  knife, rather dissect,
 or sometimes tear the artery naked with the point of your fin-
 gers, tie its open mouth, if cut  across, as fairly as  in an ampu-
 tated stump; or if it be punctured only with the point of a knife
 or sword, put two ligatures round  it, one above and one below
 the wound, and put them neatly and fairly round the, artery, and
 then cut the artery across betwixt the two.
   But should it happen that the parts are so confused by inflam-
 mation, so disordered by the driving of the blood in old aneu-
 risms, or perhaps so hurt, as to be almost in a state of gangrene;
 if the  surgeon cannot by any means get a fair view of the arte-
 ry, and that his patient be losing blood, pouring from some
 great trunk, then he must strike his needle at random, in order
 to come at his object the nearest way ; and the only satisfaction
 that he can have, or the only proof of his having tied the artery
 at all, will be the sudden stopping of the blood when he draws
 his ligature.  In circumstances  like these, the greatest surgeons
 (even Mr.  Pott himself,) have been accused of having missed
 the artery; the  artery at all events, in such a case, is irregularly
 and insecurely tied, the attendants that  are  appointed must be
 skilful, and must  be  interested;  both friends and  surgeons
 should watch over the patient's  life most faithfully, for succes-
 sive bleedings will happen sometimes from so slight an  acci-
 dent as a sudden turn, or unwary motion in his bed during the
 night.
   Of one thing I am chiefly afraid, namely, that my description
 may seem  overcharged;  that I may appear to have exaggerated
 the difficulties of an operation like this;  that it  may be thought
 that an accident requiring all* these  precautions, and this plun-
 ging down  of the hand, can  hardly occur.  Therefore I sub-
 mit to your consideration the following case, and  I dare say,
 you will find that it needs no apology; but that  as it is new and
 interesting, it deserves  its place.
   " A poor man, who was by trade a leech-catcher, fell as he
 was stepping out of a boat, and the long and pointed scissars
 which are used in his business being in his  pocket, pierced his
 hip exactly over the place of the sciatic  notch, where the great
 iliac artery comes out from the pelvis.   The artery was  struck
 with the point of the scissars, it bled furiously, the patient faint-
 ed ; and in so narrow and deep a wound, the surgeon, when he
 came, found little difficulty in stopping it up, and less difficulty
 still in making it heal.   The outward wound was cured; the
 great tumour soon formed; and  the  man travelled up from the
north country, where the accident had befallen him, and in six
weeks after arrived in our hospital here, with a prodigious tu-
mour of the hip, his thigh rigidly contracted, the ham bended,
                            L 
82           Operation for Aneurism described.
 the whole leg shrunk, cold and useless, as if it had been an
 aneurism rather of the artery on the fore part of the thigh.
    "  The tumour was of a prodigious size, and by that very cir-
 cumstance of Us being one of the greatest aneurisms, it had lost
 all the characteristics of aneurism.   There was no pulsation, no
 retrocession  of the blood when the  tumour was pressed upon;
 there was nothing else peculiar in the tumour except this, that
 the great and sudden distention  occasioned great pain; and
 from the continual pain, and lameness, and from having  some
 hopes of a cure, he was ready to submit to any thing, beseeching
 us to operate.
   "  There was  little doubt of this being a great aneurism, but
 there was  a  possibility of its being a vast abscess;  and it was
 resolved in consultation that the patient should be  carried into
 the operation room;  that a small incision should be made ; that
 the skm being cut, the bag itself should be just touched with the
 point of a lancet;  if  found to contain matter, it should be fully-
 opened ; but if blood, then it was to be considered as an aneu-
 rism  of  so particular  a kind, as to entitle us to call for a full con-
 sultation.
   "  I made  an incision two inches and a half in length; the
 great fascia of the hip appeared blue, and very strong, forming
 the coat of the tumour, and under that were seen the big fibres
 of the great  gluteus muscle.   The knife was struck into it, and
 large clots  of very firm  black blood rolled out;  for such was
 the tenseness of the  tumour, that it began  to emit the clots in
 this way, the moment it was punctured.  There was one thing
 further desirable, that  before we  put the patient to bed, we should
 understand the case so far as to be able to report to the consul-
 tation, whether  the artery was  absolutely open, and whether it
 was the great artery of the hip.  I continued therefore (know-
 ing that the opening I had made could be covered with the point
 of the thumb) to  pull out a few more clots,  till the warm and
 florid blood  began to flow;  I  then pushed in a tent-like com-
 press  into the small wound of  the tumour (viz. of  the fascia)
 laid a broad compress over the  outward wound, and put the pa-
 tient  to bed,  with one of the pupils holding the hand upon his

   " This was done at one o'clock, and at four the consultation
 met,  and the operation was performed.   And in mv notes  I
 find two  steps ol  the  operation chiefly marked:—First  That
 upon our opening the tumour  fully  with an incision of eio-ht
 inches long, and turning out the great clots, the blood was thrown
 out witn  a great u hizzingnoise, and with such impetus, that the
assistants were covered with it,  and in a moment twenf hands
were about the tumour, and the bag was filled with  sponges 
Operation for Aneurism described.           83
and cloths of all kinds, which had no better effect than the cloths
which, in any accident, the friends in great confusion wrap round
a wounded arm ; for though the blood was no longer thrown in
a full stream, nor in  jets, it was seen rising through the edges
of the incision; it floated by the sides of the cloths, which were
pressed  down by the hands of the  assistants.  But we knew
also by a more alarming sign that the blood continued to flow,
lor the man, who was at first lying not flat, but supporting him-
self on his elbows,  fell down,  his arms fell lifeless and without
pulse  over the side of the table, his head hung down, his face
was livid, he uttered two or three heavy groans, and we believed
him dead.
   Secondly, Seeing, in  this critical moment, that if he was to
be saved, it was to be only by a sudden stroke, I ran the history
upwards and downwards, and at once made my incision two foot
in length :  I thrust my hand down to the  bottom of the tumour,
turned off the great sponge which was  over the artery,  felt the
warm jet of blood, put the point of my finger upon the mouth
of the artery; then I felt distinctly its pulse, and then only was
I assured that the man was still alive.  The assistants laid aside
the edges of this prodigious  sac, and  sought out the several
smaller sponges which had been thrust in, and the sac being de-
liberately cleaned,  and its edges held aside,  I kept the fore-fin-
ger of my left hand steady upon the artery, passed one  of the
largest needles round under my  fore-finger, so as to surround
the artery:  one of my friends tied the ligature, and then upon
lifting the point of my finger,  it was distinctly seen,  that it was
the" posterior iliac artery, that the  artery had been cut fairly
across, and had bled with open mouth; that it was cut and tied
exactly  where it turns over the bone: and although the extremi-
ties were  cold, the  face of a leaden colour,  and the man had
ceased to groan, and lay as dead;  though  the faint pulsation
could not be felt through the skin, in any  part of the body; we
saw the artery beating so strongly  under my finger,  that we
were assured of our patient's  safety ; however, he was so low,
that after laying down the sides of the sac, and putting bandages
round his body to keep  all firm, we were obliged to have  a
bed  brought in, and having given him  some cordials, we left
him to sleep in the great operation  room,  attended by the pu-
pils and by nurses.   He passed  his urine and faeces involunta-
rily for some days, and was long in recovering his voice.
   He was cured of this great wound in less than seven months,
although his cure was protracted by the foul suppuration of such
a sac, and by the exfoliation of the ilium and sacrum, which spoil-
ed, not so much from their having  been laid bare by the last
sudden  stroke of the knife, as Ivy the aneurismal blood having 
84           Operation for  Aneurism described.
 passed upon them ; the exfoliations  were very large, and the
 sacrum especially  continued exfoliating to the very day  on
 which the wound closed.
   I do not know whether this man have recovered entirely, for
 he left the house lame, from  the contractions of the hip and
 ham, and  walking  by the help of a stick; but, however, he
 thought himself fit  to undertake his profession, and went  to
 England with that design.*


                        SECTION III.

                     Rules of Practice.

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

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




                  DISCOURSE  VII.
OF WOUNDS  OF ARTERIES.
                        SECTION I.

                  Preliminary Observations.


 VV HEN an artery, like that of the hip or thigh, is wounded,
it forms an uncontrollable aneurism.  Such an artery drives eve-
ry thing before it, forms a large sac, distends more and more,
till it is in danger of bursting, and if allowed to burst, proves
fatal.
   But when smaller arteries,  like those of the fore-arm or leg,
are wounded under the bellies of the muscles, the aneurism is
more irregular, the operation  very  difficult, and  the dangers
quite of another kind.   The  blood  is injected slowly among
the cellular substance  and under the muscles ; no sac is formed;
the blood is not  collected, but diffused;  the pulsation is slight,
or there is none ; the limb is swelled and hard ;  the skin black,
as in a mortification; the blood  bursts out from time to time.
It is considered only as an haemorrhagy, while it is in truth a
diffused aneurism ; the patient, by repeated loss of blood, is re-
duced  to extreme weakness,  and the limb gorged with  blood,

  • There is no neceffity for opening the aneurifmal fac in thofe cafes in which
you can tie the veffel above where it  has been wounded, unlefs the fac is very
large; operate, in fhort, as in fpontaneous aneurifm.  S. 
86           Of Wounds of superficial Arteries.
and with its parts so insulated and disjoined from each other,
by the extravasation, often falls into gangrene.   These  are the
usual consequences of such a wound.   If the patient escape,  it
is after long continued suppurations, foul sinuses, and a great
destruction of the limb.
  There are  also certain parts of the body where the smallest
arteries produce the same consequences.  The axilla,  for ex-
ample, is a very large  cavity, filled with the  loosest  cellular
substance, fit for lodging the vessels and glands.  The exter-
nal thoracic or pectoral  artery, which,  if it  lay along the tem-
ple, and were wounded there, could not do the smallest harm,
is capable of forcing the cellular substance of the axilla  ; it has
as much effect on the loose cellular substance of the axilla, as the
femoral artery has on the  firm cellular  substance of the thigh;
it has often filled the axilla completely with blood, forming a
very large and dangerous aneurism.   These subjects  I  pro-
pose now to explain to you.
                        SECTION  II.

             Of Wounds of superficial Arteries.

  The radial, ulnar, and tibial arteries, in the lower parts of
the limbs, lie so superficial, that their bleedings ought  to be
easily suppressed; awkward  and imperfect  operations are dis-
astrous only from the successive haemorrhagies, and  not from
the important size of these arteries.
  The radial artery is one  of that order and size which cannot
be restrained but by the ligature.  The superficial  situation of
this artery, the nakedness of the bone on which it lies, the great
swelling  of those  naked and tendinous parts a few hours after
the artery is wounded, the difficulty of finding the  artery, and
the cruelty of the operations which have been performed, make
the case important, both as a  common piece of surgery, and as
a general example of this kind of wound.
  The Radial Artery, at the place where we  feel the pulse,
lies quite superficial.   We even see the beating of the artery-
through the skin, and  when  we  dissect the wrist, or look to a
preparation, we see nothing but the artery betwixt the skin and
the bone ; yet, when this part is  wounded, we  seek  in vain  for
this superficial artery; we  search  for  it by cutting through a
most unexpected thickness of parts :  this  artery,  which was
felt so readily with the finger in  its natural  condition,  we can-
not  now feel beating, even though  the  skin  be open, and the
wound deep.  We observe the  best surgeons at a loss to find 
Of Wounds of superficial Arteries.           87
the artery: we find them thrusting down sponges, leaving tour-
niquets half screwed about the arm for many weeks;  making
unsuccessful incisions,  diving  in vain with the needle, and, at
last, striking the needle through the whole thickness of the arm,
so as to intercept the  artery, with a coarse ligature at the dis-
tance  of three inches above  the wound.*   These difficulties
never can be explained by attending only to the anatomy of the
natural parts;  here the diseased and sound state of the parts
must be described together, and anatomy and surgery must go
closely hand in hand.
   The artery of the wrist lies not immediately under the skin,
but under a thick fascia, which,  in its natural state, attracts but
little notice.  The general fascia of the fore-arm, strengthened
remarkably at the two condyles of the humerus, and farther
reinforced  by  the tendinous expansion of the biceps muscle;
descends very strong along the fore-arm, enclosing all the flesh;
the fascia is very thick at the wrist, where, though it is a firm
and continuous web of tendon, its glistening fibres are distin-
guished running across the arm, and binding down the  flexor
tendons.  Under this fascia the radial  artery lies: this  fascia
is connected with the tendons below by a  loose and gliding cel-
lular substance ; and it is moreover to be remembered, that all
through the body each artery has its own peculiar sheath of cel-
lular substance! even the smallest muscular arteries have such
a sheath.   This fascia, which is itself but a firmer cellular sub-
stance, is surrounded with a looser tissue  of cellular membrane,
both on that surface which lies upon the  muscles, and on that
which is connected with the skin.
   No sooner  is the radial artery wounded,  than the awkward
attempts of the assistants prevent the blood bursting out freely;
the cellular substance of the skin is injected with blood ; and
the skin, long before inflammation  could come on, is inflated,
as it were, to a great thickness.   The artery shrinks  under its
fascia; the cellular  substance of the fascia  is injected with
blood ; it rises over the mouth of the wounded artery; it is in-
jected not like the looser cellular substance of the skin.  This
firmer cellular substance of the fascia is so crammed with blood,
and that blood is so firmly coagulated, that the parts are, as it
were,  baked together, and. the haemorrhagy is rather an oozing
of blood from  a substance resembling the Corpus Cavernosum
Penis.  The whole bottom of the wound is  a fine fleshy pla-
centa-like  mass; and,  after dissecting with the knife through
a great thickness of parts, the artery is not to be found ; or only
by those who  are perfectly acquainted both with these changes
* Mr. O'Halleran. 
 88            Of Wounds of superficial Arteries.

 and with the natural place of the vessel.   This is the confused
 fleshy-like  mass, into  which  the  surgeon  strikes his needle.
 Here the blood is seen oozing, as through a placenta, at many
 places, but not one of those bleeding points corresponds with
 the mouth  of the artery ;  so that when the surgeon strikes his
 needle at these bleeding points, he must fail.   The oftener the
 blood bursts  out and  is  suppressed,  the more does the wrist
 thicken; the farther is the artery removed  from  the  surgeon,
 and the more confused the parts become.  It is by this extra-
 vasation into the cellular substance that the artery always dis-
 appears, and the bleeding ceases,  before the surgeon is ready
 to take it up with the needle :  the patient loses blood from day
 to day ; he becomes pale, sickly, and exhausted, till at last the
 blood hardly retains so much colour as to tinge  the sheets.*
   But another phenomenon often presents itself, a natural con-
 sequence of this state of the parts.  A person  is brought to us
 a  week after the radial  artery  is wounded; it has burst  out
 again and again; perhaps the haemorrhagy has been suppressed
 by sponges, by compression, or by  a rude stroke of the needle j
 but, upon  undoing  the dressings,  we  are  surprised  with the
 appearance  of a distinct aneurism in  the bottom  of an open
 wound; we see a small  distinct  pulsating  tumour,  regularly
 circumscribed, throbbing strongly,  with  thin and almost trans-
 parent coats.   We are at first at a loss  to imagine how such tu-
 mours are formed or supported.  But  though the wound be
 open,  the artery  is not  so; the cellular substance  is partly  in-
jected with blood ; the first effusion of blood is driven into the
 cellular substance, mixed with it,  and firmly coagulated;  the
 second effusion has filled more of the  cellular  substance with
 recent and fluid  blood, and raised it in the  form  of an aneu-
 rism ; and this aneurism has for its transparent coat the general
 fascia of the wrist; but yet it is so fairly circumscribed, that one
 would hardly  doubt of its being a dilatation  of the  artery itself.
   If  I  do not mistake the importance of this accident,  it is a
 sort of duty to explain it to you still further; for though the
 operation of tying the radial, or ulnar artery, does not range in
 the catalogue of important operations, along with trepan and
 amputation, yet, if I be not deceived,  it is more difficult than
 either, and certainly more frequently required.
  "  A shoemaker, having been at an annual dinner with some
 young men of his own  trade, had got merry,  but was not in-

  • Many cafes may be found in White, O'Halleran, Aitkcn, &c. where a per-
 fon, wounded in the radial artery, has  bled for three weeks or a month, till the
 blood was little better than a reddifh ferum.  I have taken up the radial artery
 after a perfon has been fuffered to  lofe blood ten or twelve times during the
 courfe of a fortnight. 
Of Wounds of superficial Arteries.
89
 toxicated; and  some of  his companions  walking home with
 him, he swore a hearty oath that they should not pass his door
 without tasting a glass.   Accordingly they went in along with
 him, and as he  was reaching up to  a  cupboard for a bottle of
 spirits, an unlucky foot encountered his, and tripped him.  He
 fell forward, and a nail which stuck out from the  wall run into
 the palm of his hand, and wounded  the Palmar Artery.  In-
 stantly there was a dreadful  bleeding.  He fell  down at last in
 a faint;  and so unskilfully was this poor fellow  managed, that,
 in the course of a fortnight, he had been allowed to bleed no
 less than  eight times.   The blood burst out afresh on the
 slightest motion, and at intervals of  no more than two days,
 till he was reduced to extreme  weakness.  He had  lost im-
 mense  quantities  of  blood.  It was only by his shape that I
 could perceive  that he had been originally a fine athletic and
 healthy young man.
   " I found him, indeed, in rude hands. The surgeon who had
 attended  him, and who  was to perform the operation, knew
 nothing of the palmar arch,  where it began, or  to which of the
 two arteries it belonged, nor whether it lay above  or under the
 ligament of the palm; and so much was  he alarmed, and  so
 ignorant of any  but the rudest means of stemming the torrent
 of blood, that he had a coarse bandage twisted round the hand
 as firm as a tourniquet!  The tourniquet itself was  still round
 the arm hard screwed;  and the hand, by long continued pres-
 sure, was now black, not merely from extravasated blood, but
 from actual gangrene; vesications appeared on it betwixt every
 turn of the roller.   The palm of the hand was  greatly heaved
 up and swelled,  with  a puffy kind of swelling.  In seeking for
 the artery, the thick skin of the palm was  first cut through; it
 was very thick, and  exceedingly crammed with blood.  The
 cellular substance, belonging to the  palmar aponeurosis was
 crammed also with blood, was  fully two  inches thick, quite
 black ; it was all one uniform mass, which cut like the Corpus
 Spongiosum Penis, and no  one  part was to be distinguished
 from another.
  " The artery, with its usual perverseness, (though it had al-
 most bled the man to death) would not give one drop of blood
 during the operation.  The surgeon unscrewed the tourniquet,
bathed the parts  with warm water; made the patient swing his
hand  most painfully; made several  rude incisions, but still
 could get no jet of blood from the artery, nor any  more than a
general oozing from this spongy mass.  Without  fear of the
palmar nerves, he made many relentless and unsuccessful at-
tempts with the needle;  at last he was most unwillingly forced
to make an incision upwards along the artery: he cut the skin
                            M 
90
Of Wounds of superficial Arteries.
 by the side of the flexor ulnaris muscle, and looked in vain for
 the artery; was surprised that he could not see an artery which
 he felt plainly with his  finger,, not knowing that the artery was
 still covered with its fascia:  but having at last slit up the fascia,
 the artery was forced out  by the tenseness of the fascia; and
 from its fullness it assumed a contorted form, and was especi-
 ally turgid at each pulsation.  Three inches of the  ulnar artery
 now lay exposed ; it was seen running over the Pisiform bone
 into this spongy mass in the palm; the artery beat strongly, and
 was seen serpentine, and working with a sort of spiral motion,
 and a distinct pulsation; but there was no corresponding jet of
 blood,  nothing but a general oozing in the palm.
   " The conclusion of the case is as extraordinary as all the
 rest ot  it; the surgeon laid a ligature under this part of the ar-
 tery, but would not draw it; he made  another desperate dip
 with the needle.   The  lad  was put to bed,  and  the bleeding
 broke out so furiously in the night-time, that had there not been
 a pupil watching to tie this occasional ligature, he  surely must
 have lost his life."
   1 his case explains to us what confusion the continual driving
 of the blood makes; how deep  the artery lies in parts  which
 seem to have little cellular substance, and how vain it is to look
 tor the artery in the midst of such a mass; the artery will not
 bleed till all is quiet again ; and even when it does bleed, it is
 not with a fair jet, nor with an open mouth.  To suppress such
 bleedings with a styptic, or a compress, seems  to  be a lenient,
 but is,  truly, a cruel practice, and not without danger.  The
 patient's constitution, if not his life, is often endangered before
 the surgeon gets courage to make the incision; and at every
 return of haemorrhagy the cellular substance is more and more
 injected; the artery buried deeper;  the incision must of course
 be more extensive,  and the operation more difficult.
   The  aneurism which I have described, as formed under the
 fascia,  and protruding from the  bottom of the wound, I choose
 rather to exemplify from the writings of another person, than
 from my own case-book.    Mr.  Ford, of the  Westminster
■Hospital, " was called to a butcher who had, about a fortnight
 before,  wounded his wrist,  by pushing his  hand  through a
 pane of glass.   The wound was just below  the  Carpal liga-
 ment, over the pisiform bone.   It had bled several times since
 the accident, and the haemorrhagy had, with difficulty, been re-
 strained by bandages and common dressings.   There  was  a
l*dsating tumour  covertd with  a thin  membrane, where the
 wound Had been  received; the pulsation was,  with difficulty,
 checked by a strong compression on the ulnar artery, but re-
 turned again on removing the compression. 
Of Wounds of superficial Arteries.           91
  »' I dilated the wound instantly," says Mr. Ford, " towards
the palm of the hand, and made an attempt to include the ves-
sel within a ligature, by means of the common crooked needle.
This proving ineffectual,  I represented to the patient the neces-
sity of a farther dilatation of the  wound, in order to restrain
the haemorrhage,  without injury to the ligaments and tendons
of the wrist; but, notwithstanding the most urgent entreaties,
he could not be prevailed on to submit to any farther operation,
till the ensuing day: he was therefore left  with a bandage  on
the wound,  and the tourniquet applied on the upper arm,  with
directions to tighten it, if the haemorrhage should return.
  " I saw him again on the next day, in company with Mr.
Lynn, surgeon of the Westminster Hospital, and finding that the
bleeding had recurred, it was determined to prosecute the in-
cision farther, and to secure the artery higher up in the arm.
  " I began the incision where the  wound had been received,
carrying it  superficially over the  carpal ligament, in the direc-
tion of the  ulnar artery, for six inches upwards in the arm.
  " The operation was done with the utmost caution, to avoid
wounding the tendons and  muscles, which  were carefully held
aside with  our fingers  as they were  exposed  by  dissection.
This proceeding was of course tedious, in order  to ensure safe-
ty.   The pulsation of the vessel could not be felt; neither could
the haemorrhagy be  provoked by friction,  by putting the arm
in warm water, or by flannels applied hot to  the  part.   At
length, however,  the artery was discovered, and a ligature car-
ried  round it, without including any other part,  about an inch
and a half  above the wrist.  Some time was then  employed
in endeavouring  to  promote an  haemorrhagy from the  lower
branch of the artery ; but this not taking place, the wound was,
carefully cleaned,  united with strips of sticking-plaster,  and
rolled up with a flannel roller.
  " The patient was bled, had an opiate administered, and in
every respect was treated in a most antiphlogistic manner.  No
circumstance occurred to render it necessary to open the wound
for six days ; no swelling, tension, inflammation  or fever, came
on.   Now, it  may be remarked, that the circular ligament of
the wrist, together with the tendons and muscles contiguous to
the ulna, had been laid bare, and exposed to the air for more
than three  quarters of an hour, during our search for the artery.
The ligature came away on the  eighth day,  and the wound
healed rapidly by the first intention, so that  the patient was per-
fectly well  on the twenty-eighth of the same month."
   I  know  Mr. Ford, and am sure he will pardon any obser-
vation that is meant for the improvement of others.   I believe
it is needless, in any such case, to  cut downwards into the palm 
 $■2           Of Wounds of superficial Arteries.

 of the  hand, which is usually so injected  with blood, that the
 most dexterous anatomist, dissecting deliberately on the dead
 body, would not find it easy to show the open  mouth of an ar-
 tery ; and it were superfluous to repeat to you  how improper it
 is to dive with a great needle into the palm of the hand: nor is
 this necessary ; for the palmar fascia and  skin are so swelled,
 as to prevent the return  of  the blood from the lower mouth of
 the artery.   I  never saw it necessary to tie the lower end of
 the artery;  and I think it important to  mention this, as an ex-
 ception to the rule commonly laid  down of tying both  ends of
 it; it is only the direct  impetus of the blood  from the upper
 part of the artery that bursts through this injected and  spongy
 mass; it is only the upper end of the artery that we need to tie.
 Irregular  and unsuccessful operations are performed only from
 not having a very decided intention of dissecting for the artery;
hut it comes always to this in the end; and you should resolve,
 the moment you are called to such  a case, to apply the tourni-
 quet to cut backwards along the artery ;  to dissect it clean ; to
tie it fairly; to disregard the bleeding from the  lower  end of
the artery;  to put a small piece of sponge into  the place where
the blood oozes out from this confused mass,  except  in those
very rare cases where he sees a direct jet of blood from the
lower end of the artery,  and then you may use the needle; but
that rarely happens, except in very recent cases, and before the
palm is much injected with blood.
                        SECTION  IV.

            Of an Artery wounded by a Lancet.

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

  * Should the perfon, who is unfortunate enough to puncture an artery in bleed-
ing, be competent, he had better cut down, and tie the veffel immediately.  For
it fometimes happens that no diftinct aneurifmal  is formed ; but the cellular fub-
ftance of the whole arm becomes injected,  forming what is called diffufe  aneu- 
Of Aneurismal Varix.
93
for the arterial coats are, in their nature, hard, unyielding, and
callous :*  a wounded artery never heals :  a clot is usually  in-
terposed  betwixt the lips of the wound ; the blood runs freely
along the canal of the artery, ready to flow through the slit up-
on  the slightest exertion of the arm, or slightest motion of the
clot; and  there lies a considerable collection of blood betwixt
the wound of the artery and any compress that we  can apply.
                            SECTION v.


                       Of aneurismal  Varix.


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

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

              Mr. Park's Anomalous  Aneurism.
I.I. Branches of the Median Fein.
3.2. Branches of the Bafilic  Vein.
3.3. The Brachial Artery.
4.4. The Vena Comites furrounding
   the Artery.
5.  Union of the Vena Comites, ivith the
   Trunk of the Bafilic Vein.
6.  The ivounded artery.
7.  Dilatation of the Vena Comes.
8. Dilatation cf Med. Cepbal. Vein.*
SECTION VI.
                 Of oblique Wounds of Arteries.

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

   * This rule has fome exceptions:  thus, in thofe cafes in which, if the furgeon
were to attempt to  follow  the wound, he would be in danger of dividing fome
important nerve, or have to cut through a great  depth of mufcle.   Under fuch
circumftances, let him diffecl down to the artery at the moft convenient place, as
near the wounded part of the veffel as poflible, and  tie it firmly :  fhould the liga-
ture be above the wound, of coutfe every thing will be fafe; if below, in con-
fequence of the obftru<5tion to the  circulation, the  blood will immediately guih
out,  as happened in the cafe mentioned a little below in the text, and thus point
out the exacl: fituation of the wound.  The veffel  may then be tied in the man-
ner directed in the text. 
Of oblique Wounds of Arteries.             97
pupil in surgery, so ignorant that he bled him in the other arm,
and tied up the wounded one, merely laying a compress upon
the wound.
  Till the 8th day, there was no farther  alarm, when a very
slight cough brought on a violent bleeding;  then, fortunately,
a surgeon was called, who really understood  the dangerous na-
ture  of the case,  and he, in his turn,  called Mr. Duschamps,
upon  whom the care of the  patient  devolved; he  found  the
arm enormously swelled,  from the armpit to  the elbow, and
covered with ecchymosis down to the wrist.
   " At nine in the morning," says Mr. Duschamps, " I began
the operation,  the  patient being  seated, and every thing pre-
pared.  But behold, when  I introduced  my  probe into  the
wound, it passed so far upwards  towards the axilla, that I fear-
ed the wound was very high,  perhaps in the Axillary Artery it-
self;  so that instead of the operation for aneurism, I might find
myself obliged to amputate at the shoulder joint.  I begged to
have another surgeon joined in consultation,  and accordingly
Mr. Sabbatier met me in the evening at five o'clock.   The ope-
ration was performed in the following manner:"
   Mr. Duschamps made an incision, not  by enlarging the na-
tural  wound, but by a new cut along the inside of the arm, in
the tract of the humeral artery, full six inches  long, extending
downwards from  the tendon of the  pectoral muscle along the
arm; and by this incision he penetrated into the aneurismal bag,
and  cleansed it thoroughly  of coagulated blood.   Mr. Dus-
champs and his assistants, then suspending the compression un-
der the clavicle, hoped  to see the wound, or at least to be di-
rected to it by the bleeding; but though they examined  and
wrought a full quarter of  an hour, and although they saw and
felt the main trunk of the artery beating under their fingers, they
could not by any endeavours make it  discharge one  drop of
blood; so that one of them ventured to say,  he thought it could
not be the main artery that was wounded;  while others agreed,
that nothing but a wound of the main artery could account for
the first loss of blood.
   In this state of uncertainty, it was resolved to lay an occa-
sional ligature under the artery, which  at any time might be
used, if necessary,  while the artery itself should be subdued by
compression alone, with agaric and dry lint.   Mr. Duschamps,
first,  enlarged  a  little the wound of the knife, and  introduced
his finger into it, pushing it upwards towards the axilla; and by
this dissection, he applied his occasional ligature half an inch
higher than the point of his finger.
   Secondly,  He  covered all the coui'se of the  artery, within
the wound, with agaric and lint, secured by an eighteen tailed
                            \T 
98
Of oblique Wounds of Arteries.
 bandage;  but  so  slightly bound  that it  did not suppress the
 pulse.
    At four in the morning the blood burst out,  but  it stopped
 again of its  own accord ; it burst out twice the next day, and
 in like manner stopped again.   On the third day  it burst  out
 yet again ; but the haemorrhage, which came on upon the fourth
 morning, was  frightful indeed;  the  bed was soaked through
 and through  with blood, which, from the foulness of the dress-
 ings, had contracted  a horrible smell.  At ten in the morning
 I reached my patient, says  Mr. Duschamps, and  undid  the
 bandages.  The agaric and lint were left in the incisions, which
 I had made  with the knife ; the lint was drawn out of the ori-
 ginal wound  ; there was now no bleeding, and the patient was
 was dressed  as before ; but again, at mid-day, the blood  burst
 out with amazing force, and again it was  stopped by the attend-
 ing pupil.  Mr. Duschamps now undid the  dressings entirely,
 and cleaned  the parts, hoping to see the wound of the artery,
 or at least the jet of blood, but not one drop flowed.   " With
 a  patient so  exhausted," says  Mr. Duschamps, " I durst no
 longer trust to compression ; I  now resolved to draw the occa-
 sional ligature,  and the instant that it was drawn, the blood was
 thrown out with force, proving very plainly that this ligature
 was below the place of the wound.  I applied instantly a se-
 cond ligature above the first;  the blood was  immediately stop-
 ped,  and as immediately did the patient  lose every degree of
 heat and of feeling in  the limb."  At this last operation of Mr.
 Duschamps, his patient had lost about three porringers of blood;
 half an hour after,  he fainted ;  in a few minutes he  revived a
 little, but a storm passing over head,  at  this critical moment,
 with  some loud peals of thunder,  affected him  so much,  that,
 on the third hour after the operation, he expired.
   u Upon opening the body," says  Duschamps, u we found
 the brachial artery wounded from the outside and from behind;
 the wound was above the giving off of the  profunda humeri,
 small, punctured, made with the point of the knife, just under
 the border of the great pectoral muscle; the  occasional  liga-
ture surrounded the artery immediately below the wound, and
that ligature, which had suppressed the bleeding, was half an
inch above."
   The depth  and obliquity of a wound may prevent the bleed-
ing at first; and it  may not be even suspected  that an artery is
wounded, when suddenly, on the tenth or twelfth day, it bursts
out with such violence, as to endanger the patient's life.  It is
not in gunshot wounds alone that this  happens,  where the ar-
tery is not actually open till the slough falls off on the eighth or
tenth day, but in clean wounds  with a pike or  bayonet; for in 
               Of oblique Wounds of Arteries.             99

these only,  can  the delay of haemorrhagy be attributed to the
obliquity of the wound.   In the practice of the older surgeons,
we have  many examples of  this; for in their days duels were
frequent, and were always fought with the  sword,  and when
a gentleman was wounded in the sword-arm, it often happentd,
that although the sword had run obliquely  along from the wrist
to the elbow, and wounded the brachial artery  at the bend of
the arm,  no bleeding appeared outwardly, the  first issue of
blood was so resisted by the  cellular substance, that it soon co-
agulated, and filled up the narrow wound, assisted by the in-
flammation  and swelling of the parts.  A firm  coagulum was
formed, and it was only on the  tenth or twelfth  day when the
suppuration was free, and the clot began to  separate, that the
blood burst out.  Le Dran's Forty-eighth Observation,  con-
tains the case of a gentleman  in the regiment of Noailles, who
was  thus wounded  with a rapier in the sword-arm;  the slight
bleeding was stopped with small dossils of lint, and the next day
his hand and fore-arm were in good condition. Le Dran, in ex-
amining them, found no symptoms of a wounded artery, there
was  a little ecchymosis  towards the elbow, and  a moderate
swelling of  the whole  arm.   The  dossils were at  last  with-
drawn, the  cure went on well, the pus was formed, the arm
was  not  swelled, no symptoms of a wounded artery appeared
till on the seventh day in the afternoon.  Being pressed to go
backward,  he went behind his tent with his arm  in a  sling, and
having, in adjusting  his clothes, either streightened or twisted
his arm, a considerable haemorrhagy appeared suddenly.  When
the consultation met  next day, it was plainly  seen that the
artery was open, the bloody tumour now extended from the el-
bow to the arm-pit; Mr. Le  Dran advised the opening of the
tumour,  or the amputation of the arm: his advice was neglect-
ed ;  the army  made a movement;  this gentleman  was sent to
Namure; the  haemorrhagies  returned ; the surgeon was long
in resolving on amputating the arm, and when  he did at last
perform it, the gentleman was so far exhausted by successive
haemorrhagies, that he died.
  This artery was found, upon dissection, to be wounded above
the condyle, and a hard clot of blood, which pressed it down
against the bone, prevented the bleeding.
  Thus it  often happens, through mismanagement, that the
swelling, the haemorrhagies, the gangrene, suddenly terminate
in death ; but in such wounds,  the case is often protracted to
a greater length, displaying, as it were in detail, all the dan-
gers of an oblique wound.
  A ball, we  shall suppose,  passes along the fore-arm, rakes
along the two bones,  wounds the radial or ulnar artery in the 
100           Of oblique Wounds of Arteries.
bottom of a deep and narrow wound, and then passes  beyond
the elbow,  making an opening too small to let out the  blood ;
or, we shall suppose the oblique stab of a knife, sword or bayo-
net, touches an artery, lying thus in the heart of the  fore-arm,
under all the  muscles, and close upon the bone; then the fol-
lowing consequences ensue.   The profuse bleeding,  at first,
proves that some  artery  is wounded ; the direction  of the
wound ascertains that it is the  radial or ulnar artery; the stop-
ping of the outward bleeding causes an internal aneurism,  dif-
ferent from the  greater aneurisms of the  arm or thigh, as  it
lies not under a fascia,  forming a fair circumscribed aneuris-
mal bag, but under the bellies of all the muscles, which are se-
parated from the bones, by a very irregular and a very danger-
ous  collection of blood.  The  outward bleeding is soon stop-
ped by compresses and a bandage; the friends are less alarmed,
seeing nothing but  a narrow  slanting wound;  but when the
next morning they see the arm  black with the injected blood,
and  swelled to an enormous degree,  their fear is like their in-
difference before, quite ignorant, and beyond the  true  measure;
they believe this to be an  absolute gangrene, and that the pa-
tient is lost; while the surgeon sees in this blackness,  not the
signs of gangrene, but the marks of a wounded artery, and
foresees a difficult and tedious operation of seeking it out.
   But if again the surgeon have not the skill to perceive all the
dangers of the case, the apparent gangrene is  soon changed in-
to a real one ; the limb becomes cold, benumbed, and has a
livid redness upon its surface;  the skin without runs into a low
inflammation; the blood within increasing every day  in quan-
tity, corrupts and bursts out; and thus,  as I  have hinted be*
fore, it is not merely by the wound of its  great artery,  and by
losing  the  great trunk  that nourished it, that a limb is  lost;
but in a case like this, it is lost by the deep driving of the blood
among the flesh  and y bones.   Either the   outward bleeding  is
allowed, and the patient is in danger of  immediate  death, or
the blood is confined, and  the bleeding goes on within :  so that
every time the artery bursts out,  the limb is injected anew, as
it were, by the arteries.   The matter is bloody,  fetid, corrupt;
it prevents the reunion of the  bones (if any bones be broken;)
it makes foul suppurations, and extensive and fetid sores; and
each new  suppuration is  succeeded by a dissolution of those
clots which had for a time stopped up the  artery, so that again
the blood bursts out; till at length, after many months of suffer-
ing, the patient is forced to part with that limb which he has
undergone so  many  dangers  to preserve.  The extensive si-
nuses, and foul sores, the disorder of the joints, and the total
caries of the bones,  make  every such case incurable; there is 
Of Wounds of the thoracic Artery.
101
even from the very first moment, no other alternative for the
surgeon, than either to perform immediately a bold decisive
operation, or to resolve at once (not keeping  the patient in this
lingering and cruel condition)  to cut off the limb.  To the pa-
tient himself, the question may be honestly  proposed in these
terms:  " Will you have this tedious,  but necessary  operation,
of tying the artery, regularly performed? Or will you, to shun
a present pain,  linger for months in this miserable  condition,
consenting at last to lose the limb, when it is perhaps too late
to save your constitution, or even your life !"
   The thoracic artery, though small and apparently unimpor-
tant, produces often the most distressing consequences  when
wounded, and requires a bold operation.   This arises from the
looseness of the cellular substance, which surrounds the great
vessels and nerves in the axilla;  and such is the power of this
long and slender artery over the cellular substance, that it drives
its blood freely under the pectoral muscle.  The aneurism
which it forms, is as large  sometimes as that of the  thigh.  It
often happens,  after a wound  of the thoracic or external  mam-
mary artery, that the whole side is blackened  with the suffusion
of blood ; the great cavity of the axilla itself is filled with blood,
(and it is capable of containing a  great quantity) the back and
breast are black with the ecchymosis.   The appearance is so
formidable that the  surgeon suspects some mortal wound; the
side is so loaded with blood that the  patient is oppressed, and
he labours so in his breathing, that  we should believe  him
wounded in the thorax, but that there is no cough,  nor  blood
coming up from the lungs, nor emphysema from  air issuing
by the wound. • From the size of the aneurism in the axilla,
one would, on  the other hand, be apt to believe the axillary
artery itself wounded, but  that the pulse at the wrist continues
firm.  When the  axilla is thus filled with extravasation, and
the back and breast blackened  with ecchymosis, a gangrene  of
the skin must sooner or later ensue; the discharged blood will
become foul and very fetid; the destruction of cellular  sub-
stance, and the irregular abscesses,  must extend far and wide ;
the disorder will be  several months in being cured; it  arises
from ignorant surgeons thrusting their stopples of lint into that
wound, which is very distant from the place where the wound-
ed artery lies, which of course continues to bleed within.
   This must be prevented.  It would no doubt be very wrong
to cut up the axilla, or touch the pectoral muscle in pursuit of
every trivial artery that may be wounded on the fore part of the
breast; nor  would it be sensible always to make incisions when
the long pectoral artery itself is wounded; for  often the tho-
racic arteries, when wounded with swords or musket shot, bleed 
 102          Of Wounds of the thoracic Artery.

 \try smartly, and yet stop of their own  accord, upon applying
 merely a piece of lint to  the wound.  Indeed it is not on ac-
 count of the  actual wound of the artery  that we perform  any
 operation, but to prevent the destruction  of  the cellular sub-
 stance and the diffusion of the blood; therefore, when you  find
 that applying a  piece of lint with  slight  compression stops the
 bleeding,  without any appearance  of extravasation, you remain
 satisfied.  But if you be called to  your patient a few hours af-
 ter the first dressing, on  account of an incipient  swelling and
 slight oppression of the breast,  and find that the extravasation
 among the loose cellular substance in the armpit is begun, you
 must undo your bandages, withdraw your bit  of lint, which is
 merely a stopple confining the blood, dilate the wound, put in
 your finger and advance it till you feel the jet of warm blood;
 hook out the clots which lie over the mouth of the artery, and
 lay your compress directly  upon  it.  Then  pile compresses
 over it on the outside, and apply your roller; for it is seldom
 necessary to cut  the wound entirely up, or to use the needle in
wounds of the thoracic artery.
DISCOURSE  IX.
OF THE  ANEURISM  FROM ANASTOMOSIS.
 A HAT kind of aneurism which I venture to name Aneurism
from Anastomosis, resembles those bloody tumours which ap-
pear in new-born children, occupying chiefly the  lips,  cheeks,
eyelids, or hairy scalp, and which grow in process of time to an
important size, bursting at last, and bleeding furiously,  so as to
oblige us to cut them out.
  The disease which I am now about to describe arises, not on-
ly from such natural deformity,  but also from various and hid-
den causes:  it often begins in adults, increasing from a trivial 
             Of the Aneurism from Anastomosis.         103

 pimple-like speck, to a formidable disease.   This aneurism con-
 sists in a mutual enlargement of the smaller arteries and veins.
   I have reason to believe that it sometimes originates from so
 slight a cause as a tight hat or a trifling bruise;  it frequently
 begins in  adults, in pure, hale, and sound skin, where no spot,
 nor mark,  nor tendency to disease, had ever been  observed.
 The marks which children are  born with  are often superficial
 stain-like spots, which never change, except that their colour
 becomes occasionally deeper.   But sometimes those spots are
 also defects in the substance of the skin, they are a  species  f
 aneurism, or they create a tendency to this disease ; and from
 almost imperceptible stain-like spots, not  elevated above  the
 surface of  the skin, they grow  to  dangerous bloody tumours,
 which require extirpation.
   In both diseases, viz. of connate aneurisms appearing, when
 the child is born, in the form of a small livid tubercle, and of
 those forming spontaneously or arising from a blow, the process
 of their growth  and increase is the same.  When a set of cuta-
 neous vessels first enter into this diseased  action, a few of the
 extreme  arteries in the skin itself  are originally in  fault, and
 commence an increased action,  which draws the  arteries of all
 the adjoining parts  into sympathy with  them; the arteries be-
 hind them convey more blood and push it on rapidly;  these
 larger arteries begin to feed the disease, while the central group
 thus supported by the arteries behind, acts  powerfully, the tu-
 mour begins its pulsations, and,  like a punctum saliens, forms
 vessels as it were, by enlarging those small branches which were
 not visible  before.  The little  arteries work powerfully and are
 dilated, the corresponding veins are proportionably enlarged, the
 number and activity of those arteries and  veins are slowly in-
 creased.   This increased circulation solicits more blood towards
 the tumour; and while the central  branches impel their  blood
 with greater rapidity, the trunks  they come from, follow up that
 action and  work so as to keep them full.
   In women,  the phenomena  of these  tumours  are  very re-
 markable ;  the haemorrhagy from them usurps the place of men-
 struation, the action of their vessels is as regularly periodical as
 that of the  arteries of the womb.   The state of menstruation is
 a state of general excitement, and the particular action may be
 turned off towards  any  set of  vessels, as those of the stomach,
 nostrils, or lungs.   The excitement of menstruation affects the
 breasts, it  is felt through the whole system, its effect on  every
tumour is remarkable!  and I am daily provoked at seeing can-
cers, even of the breast, (which is always peculiarly affected), and
other tumours which actually rise and fall with each menstrua-
 tion, extirpated without the smallest regard to the menstrual pe- 
104
Of the Aneurism from Anastomosis.
riod,  though the change at such a time upon every tumour is
such as the most ignorant observer might remark.  The disease
which I am now explaining,  this aneurism from anastomosis,
consists in the increased action of certain arteries; and the men-
strual excitement, and the local action coinciding, cause periodi-
cal pulsations, periodical enlargements of the tumour,  periodi-
cal haemorrhages, and a bursting of the tumour at each menstru-
ation, which alternations I have known continue for many years.
  Having endeavoured to settle the character of this  singular
species of aneurism, I shall  proceed to relate, in the first place,
a pure unencumbered case.
  Mr. R—n, a young gentleman of about twenty-five years of
age, had an aneurismal tumour  upon his forehead, which  had
been growing for seven years.   It began with a small spot like
a pimple, of the size of a pea, and was, when he consulted me,
of the size of an egg; there passed along the centre of the tu-
mour the scar of an operation which had been performed about
a year before.  Nothing could  be more singular than the cir-
cumscribed form, strong pulsation, and various  peculiarities of
this aneurism.  Nearly seven years before, he had first observ-
ed a small pimple-like tubercle rise on his forehead (which had
hitherto been smooth and sound), which was seated close upon
the eyebrow, and was so small and so little troublesome, that he
believed it to be a pimple merely, ascribed  it to the  tightness of
his hat, and disregarded it for some time.  When he consulted
a physician of  very  excellent abilities, Dr. Cleghorn  of Glas-
gow, that gentleman ordered gentle physic,  and other trivial pre-
scriptions, in perfect confidence that it would disappear; for at
this time it was of the same  colour with the rest of  the skin,
had  no character of aneurism, and was so little troublesome,
that it was for a long while after entirely disregarded.  But
when it had attained  to the size  of a sparrow's egg, he thought
he felt pulsation in it  at times,  he began to be  alarmed;  and
when at last he resolved to  consult a surgeon, the pulsation was
manifest, the surgeon recognized it as an aneurism, and advised
that it should be cut out, but not with that earnestness which is
necessary to persuade a patient,  who seldom has at first a seri-
ous impression of the nature or consequences of such a disease.
Mr. R—n  advised,  or rather talked, with others, but in so
careless a way, that he began to be himself indifferent about the
tumour, was easily prevailed upon to believe that if it increased
at all, it must be very slowly ;  this little tumour seemed at first
to  have arisen merely from a  tight hat, and he was easily per-
suaded to hope that it would go away.
   One gentleman directed  him to try compression, and accord-
ingly, a plate of lead was bound firmly down upon the tumour ; 
            Of the Aneurism from Anastomosis.          105

he  suffered the pain of this pressure with great constancy for
some days,  and for several weeks he continued a less painful
degree of pressure; but finding the aneurism beating more pow^
erfully, foreseeing no good effect, and irritated with  the con-
stant and  ineffectual trouble of supporting the pressure,  he
threw away the bandage, and let the aneurism grow as it pleas-
ed.   This was about seven years ago;  during five years  had
his tumour continued to grow, when the nature of it being no
longer equivocal, and the consequence of allowing it to increase,
much to be feared, it was resolved  to perform the operation.
There is  every apology for the  theory  which the surgeon had
formed of this tumour, for its form was very singular.   It was
seated immediately over the eyebrow, and was about the size of
a small egg; it lay exactly in the course of  the frontal artery.
The small orbitary artery was found entering into the lower end
of this oval tumour, while a branch of the temporal artery, re-
markably enlarged and tortuous, went curling along the temple
and passed also into the  upper end of the tumour.   No other
vessels, neither arteries nor veins, could be traced  to  it, but
these two  arteries,  and  the intermediate tumour beat in con-
cert ; the arteries beat much more powerfully than in their na-
tural state, and  the tumour had a very  powerful throbbing.
This tumour, which became turgid  whenever the  pulses  beat
strong, seemed to be merely an enlargement of the frontal arte-
ry, (vid. fig. 1. p. 108.) and under this apprehension was the ope-
ration arranged as follows: The surgeon first made an incision
in the lower part of the  tumour, and passed a ligature under
the orbitary or frontal artery; but when he had tied this artery
the pulse of the aneurism was nothing abated.   He next made
an incision along the temporal branch, where it ran into the up-
per part of the tumour, and tied  it also with a ligature, but in
vain; the pulsation of the tumour was still unaffected.   It was
then necessary to operate upon the tumour itself; it was opened
its whole length,  and bled very profusely; one  ligature only
was used, that ligature was struck with the needle into the cen-
tre  of the  tumour, where there was one  artery larger than the
rest; but from all the surface besides there was one continual
gush of blood;  the haemorrhagy was repressed, and the wound
bound up with a compress and bandage.  The tumour in short
was thoroughly cut open, but it was not cut  out.  It healed
slowly, the ligature came away with difficulty;  after a fortnight
the patient was left  to  dress  the wound himself;  he felt dis-
tinctly, before the wound was healed, that the pulsation had be-
gun again; the pulsation became very strong, and the tumour,
bv the time the wound was actually healed, had attained the full
                            O 
 106        Of the Aneurism from Anastomosis.

 size it had  before the operation; it was indeed rather larger
 than before.
   But it might easily have been perceived, that this could not
 be a mere dilatation of the frontal artery, for the tumour  was
 some thousand times the diameter of that artery.  The press-
 ing the point of the finger upon both arteries stopped their pul-
 sation, but did not in the slightest degree affect the tumour; and
 since the striking a needle and ligature under each artery, did
 not affect the pulse of the aneurism, it was plain that the tumour
 was of such a nature, as  to draw its blood from a variety of
 sources, and that it was necessary, not to  cut it open, but to cut
 it out.
   For nine months longer the tumour was suffered to grow un-
 molested.  When Mr. R----first desired  my advice, the  cha-
 racter of the tumour was very strongly  marked.
   It was very  protuberant from the forehead, of a regular oval
 form, about the size of a small hen's egg.   The scar of the for-
 mer operation,  about three inches long, ran across the centre of
 the tumour.  The tumour was not purple  on its surface,  like
 the flesh  spots  of children, it was covered with a firm and sound
 skin; the scar was white, the rest of the skin was of a deep red,
 from  inflammation, and not from the blood appearing through
 it;  its throbbing was exceedingly strong, and of late it had be-
 come very painful, so that  he was in fear of the  bursting of the
 tumour, or the  corruption  of the bone;  it was  from  the pain,
 which  had of late been considerable, that he was inclined to ask
 advice, or to submit to a second  incision.  The notes taken at
 this period, in  relation to the appearance, size, and pulsation of
 the tumour, are as follows:
  The lower artery,  the ocular, which comes from within the
 orbit, is very large, and is  felt entering into  the lower corner of
 the tumour; the temporal branch is very greatly  enlarged, is re-
 markably tortuous, pulsates with great force, so that  I  am sur-
 prised it has not wrought out other aneurisms near this first one.
 He wears his hat quite off his face;  when his hat presses upon
the tumour, it increases in  size ; when he runs, when he is heat-
 ed, when he stoops, when he breathes hard, it increases in size,
and its pulsations are very strong: when he drinks spirits or
 wine, it swells, pulsates, assumes a deeper tinge, and every per-
son at table can perceive the change;  and when I handle it rude-
ly,  it swells up, and when he chooses to retain his breath, it is
inflated like the gills of a  turkey cock.   It  is only for ten days
 that the throbbing pain has been remarkable,  but that pain increa-
 ses, and as it runs backwards along  the  course of the artery, [>.
 is, by compressing the artery, in some slight degree relieved.
  Were this aneurism a mere dilatation of one artery, it should 
Of the Aneurism from Anastomosis.         107
 be emptied at once by compression, and the continuing of that
 pressure, should prevent its being filled again.  But when it is
 compressed  firmly,  it yields very gradually, as if the veins re-
 ceived its blood;  the compressing of its  two great  arteries,
 does not prevent its filling again;  you are able to suppress their
 pulsation, but the aneurism still pulsates, it throbs from the bot-
 tom, it rises  very gradually when you cease from pressing, and
 soon fills to its full size; it seems to receive its blood from one
 knows not what sources, from small arteries  which cannot be
 perceived.   The sudden inflation of this tumour, like the gills
 of a turkey cock,  its various fulness, according to the season of
 the  year, its falling in autumn when  the blood is low, and its
 rising in the  spring when the circulation is rapid, the variations
 of it in respect of fulness, and its colour varying according to
 the degree of turgescence, its sudden puffing up upon taking wine
 or using exercise, its slow subsiding, and yielding in some slight
 degree by pressure, and its being so little affected by compress-
 ing the great artery which feeds it, are  sufficient indications of
 its nature.   All this proves, that it is a tissue of small arteries
 and veins, it  fills not like a varix, slowly ;  there is, indeed, no
 dilated vein to be seen near it;  its  filling is by distinct throbs,
 it is filled by  its small and numerous arteries, and its swelling is
 (like the erection of the penis) produced by the pulsations of the
 arteries, stroke after stroke, pouring out their blood intothe cells.
   With this  view of its nature, I was  sure that it was a kind of
 tumour which was not to be cut open, but to be cut out.  Dr.
 Jeffrey, and Mr. Cooper, surgeon in Glasgow, had the goodness
 to assist  me.   I tied this rampant temporal artery before touch-
 ing the tumour, that it might  be once more ascertained how
 little this interruption of any one artery  could affect such a tu-
 mour.  The pulsation of the  tumour was nothing affected; I
 knew by this  what sort of an enemy I had to deal with;  I knew,
 that if I cut within  the active circle  of this tumour,  I should
 have innumerable branchings of the  artery to tie up; but that if
 I cut wide where the arteries were  undivided, and before they
 had  formed their  anastamosis, I should have  to deal  with but
 one  or two.   I disregarded the bleeding, I knew that  I had no
 means of saving blood but by making the  operation rapid.  I
 made an oval incision which comprehended about a fourth part
of the surface of the tumour ;  dissected the skin of each side
down from it rapidly; I went down  to the  root of the tumour,
and turned it out  from the bone.  The tumour was a perfect
cellular mass, like  a piece  of sponge soaked in blood; it was
tolerably  solid, and dissected out very clean,  in the form of a
regular tumour; it bled furiously during the  operation (that I
had resolved  to disregard), but the moment  the tumour was 
108         Of the Aneurism from Anastomosis.
turned out, Acre was not one drop of blood, the surface was
clean,  the pericranium quite bloodless, the lower artery stood
wagging out of its hole in the orbit, and I held it with the hook
while Dr. Jeffrey tied it.   The upper tortuous artery was also
tied; the eyebrow, which was divided exactly in the middle,
was brought nicely together,  the  incision healed in  ten days ;
the wound  has been now two years healed, and the scar is small,
reddish, and very litde perceptible, and the two extremities of
the eyebrow, which were two inches distant in the time of the
operation, are perfectly close.

           Plans of the Aneurism of the  Forehead,
  But there are  varieties  of this disease, which nothing but
a variety of cases can explain; and one consideration should
give us a particular interest in investigating its nature; that if ne-
glected, it becomes incurable, and when it is incurable, I think
it cannot fail to be in time fatal.  It becomes incurable, when
having been operated upon with a partial incision,  instead of
being extirpated,  it is but irritated, and grows till it spreads its
roots among the adjacent parts.. It becomes incurable when it
occupies a great extent of skin: It is an incurable disease when
it affects any of the viscera.   One phenomenon of this disease,
I think, is very remarkable; often, in the course of this  dis-
ease, various sacs are formed,  which receive sometimes serum
and sometimes blood, according to the state of the tumour, so
that tumours of this kind sometimes burst like a ganglion, or
great salivary tumour,  discharging a thin serum like saliva.
  This kind of aneurism sometimes grows in the limbs, and to
a very remarkable size: bleeds profusely, and reduces the  per-
son to extreme weakness, and yet is easily cured; for the rule
which I have laid down, gives you a perfect command of this
aneurism.   You  must  not cut into it,  but cut it out.   If you
merely  cut into it, the haemorrhagy is terrible, and the cure im-
perfect; if you cut round it, and at a little distance from its 
Of the Aneurism from Anastomosis.
109
root, in place of the profuse haemorrhagy, from numberless ar-
teries, you have but a slight bleeding from one or two,  which
are extremely small.
  A tumour of this kind, which had  grown to a remarkable
size, and done infinite injury to the constitution of the patient,
was extirpated by my friend Mr. Harkness.  The history of
it is as follows:
  " Jean Smith,  a house-servant, about thirty-nine years of
age, had a tumour upon her arm of a very singular appearance.
It was seated exactly over the middle of the triceps muscle, on
the back part of  the arm; but the disease belonged merely to
the skin.   The tumour had a very firm fleshy basis, and a sort
of dead and throbbing pulsation  through the whole thickness of
it.  The tumour had something of the  appearance of a scrotum,
with an enlarged  testicle: It was about eight  or nine  inches
long; the walls of the tumour were very thick and fleshy; there
seemed to be a sac, or rather many sacculi within the tumour,
but quite flaccid.   The tumour hung  down flabby and pendu-
lous ; it was of a  livid colour, as if it  contained blood,  or the
remains of blood; where it was not blue, like  a vein,  it was
mottled of a deep  red, or  lakey colour.   This tumour had burst
often, and poured out prodigious quantities of blood, and at the
place where it had burst,  and especially at one point, where the
blood had always  of late  been poured out,  the  surface of the
tumour was covered with thick  white  scabs, as if the bleeding
orifices had been  plastered up.
   1 he history7 of  the tumour was singular.  It was about eigh-
teen months  before, that there had appeared  a  small  purple
spot upon the back of the arm, which soon grew into a tumour.
The tumour enlarged slowly,  and had, in the course of five-
months, attained  to the size of a hen's egg; then, for the first
time, it burst, and discharged a great quantity of blood.   The
blood was red and florid, and thrown  out with  great impetus;
but it stopped of  its own accord.   It increased  in size from
this time forward very rapidly,  and in four days  more  it was
thought necessary, by  the surgeon in  the country, to open the
tumour.   This was  done by incision; there had been a sac
formed, even at this time; a great quantity of coagulated blood
was taken out,  the haemorrhage was  very  profuse, from  the
whole surface, but no particular artery was seen.  No vessel,
great or small, was taken up;  the haemorrhagy was stopped
with flour, firm compresses,  and bandage.  The wound was
healed, the tumour grew, and, from the size of a hen's egg, it
increased in a few months to its  present dimensions, of eight
or nine inches in  length,  and six or seven in breadth.
   But this incision never healed entirely; a succession of scabs 
110
Of Aneurism from Anastomosis.
 formed upon that part of  the tumour, and from time to time
 the  blood burst out from  it on the slightest accident or injury,
 and most infallibly the hiemorrhagy returned at every menstru-
 ation.
   Her menses continued  regular; at every menstrual period
 she  was sensible of a  heat, pulsation, and swelling in the tu-
 mour ;  at each menstruation, blood burst out  afresh from the
 central opening; she lost immense quantities of blood, but still
 the  menses held on their regular course, and flowed  in due
 quantity.
   About three weeks before she came under the care  of Mr.
 Harkness,  she had her menses, the blood again flowed in  the
 usual quantity from the tumour in her arm.  The  blood  burst
 out again from her arm  just two days before this second ope-
 ration was  performed.   The bandages which had been kept
 firm from the time of the last hyemorrhagy, chanced to be loosen-
 ed and thrown aside; the blood, on the day of  menstruation,
 and just two days before the operation, burst out impetuously,
 and  she lost no less than four pounds of blood.
   Operation.—This haemorrhagy was so dangerous, and im-
 plied also something so peculiar in the nature of the tumour,
 that  Mr. Harkness very prudently called together a full  con-
 sultation, especially of the older surgeons.  The tourniquet
 was  applied, the foul cloths and tight bandages were taken a-
 way  from the tumour.  It hung like a thick and massy bag half
 empty.   Mr. Harkness did not set about  the operation without
 a degree of apprehension,  nor were the gentlemen,  who  Were
 convened to see the operation, without fear of a very trouble-
some haemorrhage.  Mr. Harkness went round the  base of the
tumour with two strokes of his knife; he separated  the tumour
very rapidly;  when the tourniquet was slackened, there was
not the smallest haemorrhage; the place where  the tumour had
been, remained almost clean of blood; one small artery  bled
smartly, and was taken up with  the  tenaculum.   Those  who
had seen the alarming haemorrhagy of the preceding day,  were
astonished, while those who saw the tumour for the first time,
and had been called together as to an important case, were  al-
most offended  to find themselves so  formally summoned to at-
tend on an occasion of so little danger.*.
   When such tumour is seated among the viscera, or in any
inaccessible part, it must  be an incurable, and, in  the end, a
fatal  disease.   It is likewise incurable in those  cases when,  al-
though occupying an external surface,  it is of such extent that

  • Upon differing this tumour, 1 find it like a placenta, ftringy, cellular, con-
futing of a coniuled tiffue of fmall arteries, veins, and cellular fubftance, like the
fubftance of the placenta, or of the womb. 
                 Of the Formation of Callus.              j 11

no operation can be performed.  But in all cases in which an
operation is practicable,  the rule is, " not to cut into them but
cut them out."
                    DISCOURSE  X.



          ON FRACTURES OF THE  LIMBS.



                          SECTION I.

                  Of the Formation of Callus.


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

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

  • The meaning of the  horfe breaking the boot, as well as the leg, will not be
underftood by thofe who are not acquainted with the peculiar manner of accouter-
ing a bidet or hack-horfe in France.  It has two large fixed wooden boots, flung
on each fide of the faddle, and when the rider mounts, he thrufts his leg, boot 3nd
al], into thefe wooden boots.
P 
11 -i-              Of the Formation of Callus.
we understand why a fractured callus is more speedily reunited
than a broken bone, where nothing is  prepared  for the gene*
ration of new bone.
  I  think I cannot illustrate the condition of  a  callus, at the
time that it is broken, better, than by comparing it with the con-
dition of a bone, where, by the perpetual restlessness of the pa-
tient, a proper callus has been prevented, where the bones  have
covered themselves with a sort of cartilage, and an unnatural joint
has  been  formed; where the surgeon makes an  incision, turns
out the ends of  the bone,  pares off the callus from each end of
the bone,  returns  the pared ends of the bone  again  into  their
place, and lays them among the flesh, opposite to each other, and
sews up the wound;  then  adhesion takes place, the communion
of vessels, from bone to bone, and also the continuity of all the
surrounding soft  parts, is restored ; then all  the surrounding
vessels are drawn  into action, a mass of parts, active and in high
circulation, is formed round the broken bone, the blood and hu-
mours are worked towards it,  and the vessels of the bone  itself
being thus supported in their new action,  the  ossific process is
renewed  with  great energy.  This is the result of an experi-
ment, or  rather of an operation, which has been  several times
performed, and  particularly by Mr. Park, of Liverpool,* and is
a fine analogy for  explaining the condition of a  fractured callus;
for in proportion as the organization is advanced, and the  parts
full  of  blood and in high excitement, the second  fracture is
more rapidly re-united than the first.
  This accident,  of breaking the  leg  a second  time, is in no
case so  grievous a misfortune as might be imagined;  in a very
ill-reduced fracture,  I should  rather  esteem  it  fortunate.  It
was the practice of surgeons in all  ages, to snap the limb across
their knee whenever they  were  ill-pleased with the shape of it;
and although, in the present day,  such a practice would be es-
teemed a mark of the grossest ignorance,  it is but one exam-
ple out of ten thousand, where opinions which  now pass  Ollly
among  the vulgar, may be traced  to the highest and most re-
spectable  authorities.
   That the ancients had very generally engaged in this practice,
I could easily prove by direct authority :  and men of  the first
eminence in our profession, the  very best surgeons in the world,
have been in the practice of performing this operation.  "  1 was

  * This operation has fo frequently failed,  that  it is, I believe, never now per-
formed  But to  Dr. Phyfick, of  Philadelphia, we are indebted for the difcovery
of another, much more eafily performed, and likewife much  more fuccelsiul.  He
advifes a feton to be paffed between the frailured ends of the  bones, and to be re-
tained there until a confiderable  and fufficient degree of inflammation is excited,
when it may be withdrawn, and the limb treated as in a cafe of recent fracture. S. 
                  Of the Formation of Callus.               115

called," says LaMotte, " to ayoungman of sixteen years of age,
who had the thigh-bone broken seven or eight weeks before, and
it was so re-united that he could not walk ; the broken  thigh-
bone  was shorter by half a foot than the sound one, and he
called me, in order to learn whether  some sort of shoe  might
not be invented, by which the leg might be raised so as to en-
able him to walk.
   I found the hone broken about the  middle of the thigh ; the
bones were so awkwardly joined, that  they  absolutely crossed
each  other.  There was a great elbow looking outwards, and
a proportioned  hollow within;  but the lad being  young and
healthy, and the callus as yet soft, I formed  the resolution of
setting the thigh-bone again, in its right shape, by extension and
counter-extension; for I knew that the attempt could do the boy
no harm, and I remembered from the accidental breaking of
the callus, that the callus was long of obtaining its perfect con-
sistence.   So, having made his bed, and prepared bandages and
splints, I made a powerful extension  by the help of my  young
men, and pushed in this elbow with the flat palm of one hand,
and resisted with the other.   I succeeded perfectly to my mind,
so that, without one cry from the lad, I reduced this angle, and
made  his fractured thigh as straight  and  as  long as the other.
In a month he was  freed from his splints, and walked without
pain  or halting,  while his thigh  was as  straight as an arrow."*
    From this history, I draw no  rash  conclusions.   I do  not
propose to break limbs when they are  almost healed, that they
may  heal faster; nor to take even a crooked and  unserviceable
limb and lay it across the knee, like La Motte;  but I do, with
perfect confidence,  advise you, to leave  off  bandages, which
you see were originally designed for no other use than to mould
and fashion the callus; to reject those  long compresses, which
were bound so  firmly round the limb for  the same purpose; to
use such splints only, as when laid along the  whole limb, may
serve to maintain its posture, and preserve it steady,  and to tie

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

                   Definition of Fractures.
   Having corrected some prejudices, and initiated you into the
history  and theories of this  interesting subject, I  propose next
to lay before you the various characters and distinctions of frac-
tures.
   First, Simple fracture is that  in which the bones, though bro-
ken, do not  protrude.  The soft parts, though  inwardly torn,
are but little injured.  The periosteum is not separated  in any
remarkable degree from the bone; but the periosteum clings to
the bone, the tendons and muscles to the periosteum, and the
surrounding soft parts are so compressed around the fracture,
in consequence of the limb being entire, that adhesion soon takes
place among them.  The interstices  are filled with a gelatinous
effusion, which soon becomes organic, and the continuity of ves-
sels is immediately restored.   Even in  a comminuted fracture,
each little piece of bone retains  its connexion  with the soft parts,
and lives, and is nourished,  and re-united with the bone to which
it belongs, so that when we  dissect a fractured bone in the first
days, we find the periosteum thickened like  soaked  shammoy 
Definition of Fractures.
11?
leather, the soft parts massed together by inflammation, and the
secretion of bone beginning in separate  points; and when we
dissect an old fracture, we find little pieces  and splinters per-
fectly consolidated into the callus, which had been entirely se-
parated from the bone.  This case, then, requires nothing but
ease and quiet, and a favourable posture of the part.  The cure
may be resembled to the adhesion  of an open wound, where
there is immediate re-union of vessels, no suppuration, no waste
of parts,  no remaining mark of injury, there is a spontaneous
and perfect cure.  The cure  is spontaneous, the work 01 nature
alone; the surgeon has nothing to care for but the form of the
limb; to lay it even at first, and  to redress  its posture when it
happens to be disordered.
  Secondly, Compound fracture is  that where the fracture is
accompanied with an outward wound, and it is called Great
Compound Fracture  when  the bone  protrudes.  And in this
case the flesh is often cruelly  mangled, and  the bone  shattered
into many pieces, and yet the parts  retain (though not always)
their life and vigour.   The protrusion of the bone makes a rude
and lacerated cut; the soft parts, as the periosteum, muscles
and skin, are all cruelly mangled, but they are not destroyed;
the periosteum still clings to the bone, the muscles to the peri-
osteum, and the skin to the muscles;  there is a very shocking
outward injury, but there is happily no proportionate disorder
of  the inward  parts.   The inward parts are lacerated  and
wounded by the protruding bone; they are hurt by the violence
(as the crushing of a chariot wheel)  which caused that protru-
sion ; but they are still alive, still adhere to each other, and give
mutual support; no part is so entirely killed,  as by its death to
draw on the death of the whole.  But then  these parts, though
not killed, nor separated from each other, are so torn that they
seldom re-unite; they run into inflammation, and the  cellular
substance is so filled with extravasated  fluids, and the bones so
crushed,  and re-unite with so much difficulty, that the suppu-
ration is very profuse.
   The case, then, which is here defined, is a compound of frac-
ture, with a great suppurating wound, not void of danger. The
gorged vessels are soon unloaded by a free  and timely suppu-
ration : after the first swelling subsides, the parts become flac-
cid, the matter profuse, the  patient is in danger of being  ex-
hausted with pain and fever,  and the dangers of the  case  are
chiefly those of a great suppurating wound.   If we  are forced
at  any time to amputate such a limb, it  is  only for want of
strength in the patient to support the pain,  fever, and profuse
discharge ; for through time and care the lax swelling subsides;
the  suppuration lessens  in quantity; the loose bones are di*- 
118               Definition t>f Fractures.
charged:  the living bones (whose  periosteum still adheres to
them) though broken in a way seemingly destructive of all orga-
nization, recover their connexion with the fractured bone, in  a
manner which has long been admired.   Of the bruised parts,
those which lie deep come to be pressed into contact with each
other; the vacant spaces  within, and the external wound, are
filled with granulations, and then the continuity of vessels is re-
stored, and the callus is completed.  This continuity of the ves-
sels is essential to the regeneration of the bone; and we see the
reason of a phenomenon which has excited the surprise, not only
of Dr. Hunter, but all surgical writers from time immemorial,
viz. that during the suppuration, and while the wound continues
open, no callus,  or at least no complete callus, ever forms.
   Thirdly, In compound fracture  and luxation, where,
along with  the protrusion of the  bones,  there  is a laceration of
ligaments,  tendons, and capsule of some great joint, the case is
peculiarly dangerous.  When,  for  example,  the ankle-joint is
burst up, the astragalus broken to pieces, or turned out through
the wound, the lower end of  the tibia shattered and protruded,
and  the fibula also broken, the disorder is such as to defy the
powers of nature, and art can do but little.  This is of all cases
the most  perplexing to the judgment,  and distressing  to the
feelings of  the surgeon, who often  wavers in fear and anxiety,
for some days desirous of saving  the limb, and yet fearful of
losing the  patient's life, till at last the  fatal gangrene appears,
and he feels most poignantly the fault he has committed,  if, in-
deed, the  surgeon can be  said to have committed a fault, who
has attempted to save a man's limb, though at the risk of his
life.   Yet the surgeon, though he have acted  deliberately, con-
scientiously,  sensibly and  humanely; though he has been sup-
ported by  the countenance of his fellow-surgeons ;  still,  when
misfortune comes, must feel himself unhappy.
   The French surgeons, with one accord, declared amputation
to be, in such  cases,  the only chance of saving the  life.   Palfin
says,  " In luxations  of the ankle,  there is seldom any thing to
be done but amputation."   The same is laid down by Duver-
ney, as an express  unconditional rule  of practice.   We do
not comply with any  such  barbarous rule ; we take it  only as a
denunciation of the danger which is observed to attend this par-
ticular case ;  we keep our  minds free and unbiassed, so that we
may be able to decide this question according  to the circum-
stances.  We know  that  nature will do wonders,  but thev are
wonders, and we never enter upon the attempt of preserving a
limb  thus desperately fractured, without awful hesitation, and
wtu-n we do venture to dilate the wound, and push  back the
bones, we feel all the responsibility of what we have just done. 
Definition of Callus.
119
We watch the appearance of mortification for some days, and
wait with inexpressible anxiety the natural issue of the case, life
or death.*
   Thus the simple fracture terminates in adhesion of the parts
inwardly bruised and injured; compound fracture ends some-
times in adhesion, but more frequently in suppuration of parts
too much bruised to adhere; but the fracture of a great joint,
as of the  ankle, is attended with lacerations too terrible to ad-
here, or even to suppurate easily; this is the case which, while
it sometimes suppurates,  is most apt  to terminate in gangrene
and death.
   Fourthly,  Gunshot fracture has many dangers peculiar to it-
self; and of all  those circumstances by which,  in other frac-
tures,  the soft  parts  recover their healthy condition, and the
splinters regain their natural connexion with the bone, not one
Can take place in gunshot-wound: for here there  is infinite  loss
of substance; the bone is not merely broken, it  is  destroyed,
contused, and deadened  by the  blow, and condemned to the
absolute exfoliation of every individual particle  and splinter
that has been shaken by the ball.
   From the moment  in which the bone is struck by a ball,  it
loses its life and circulation, and all its connexions  with the soft
parts.   The bone is deadened to some extent by  the force of
the blow; it is splintered into many pieces; the periosteum too
is killed by the shot, so that, of the injured or splintered pieces,
not one  can recover  its  life, or resume its connexion with the
living system.
   Nor is the bone only killed, but all the surrounding parts al-
so ; for the bone is the resisting body which,  by receiving the
force of the  ball, reverberates  it upon the adjacent parts; so
that that portion of the flesh which most immediately surrounds
the bone, is particularly affected, is deadened, and thrown out
in the form of sloughs.
   These are the accidents of this species of fracture, which dis-
tinguish it from all others; for the death of all the internal parts
insulates  the  broken bone.   There can be no  adhesion among
parts which are actually dead; the continuity of contused vessels
can in no shape be restored:  instead  of a  knotting of the  soft
parts into a vascular mass, full of life and action, supported by
a continuity of vessels, and fitted for  the generation of callus,
there is a cavity full of foetid matter,  dead  and sloughing flesh,

  * I would recommend, in every cafe of compound luxation and fracture of the
ankle-joint, to endeavour to fave the limb, not only becaufe many have been pre-
ferved, but becaufe I believe the patient is more apt to die where the leg is taken
off from gangrene, than he  is from fymptomatic fever and mortification, wfaere it
is fuffered to remain.  When fuppuration is once completely eftablifhed, the ex-
tremity may then be removed with perfect fafety, fhould it be neceflarr.  S 
120               Definition of Fractures.
and insulated fragments of bone;  a narrow opening, a deep and
ill-conditioned wound, and a prol usion of foul and  putrid ichor
flowing from the narrow openings, or bursting through various
fistulas from time to time.
   Thus a gunshot-wound, with a great fracture,  resembles in
many points the worst kind of caries.  The detached bones are
discharged with difficulty ; the dead parts which have sloughed
off, are very slowly replaced; it  is long  before  the wound be-
gins to heal from the bottom, or, in other terms, before the con-
tinuity of vessels is restored,  or the mass of vascular substance
prepared, in which the  callus is to be formed.  In short, the
parts are with  difficulty regenerated ;  they are slow to heal; apt
to run into ulcers, fistulas, and collections of matter; while the
patient is exhausted by pain, fever, and profuse discharge.
   Having thus explained to you the general nature of a gunshot-
fracture, I believe you can be at no loss to imagine the peculiar
difficulties of each case; for where the limb that is  wounded is
small, there is less destruction of parts; the  sloughing is not
great, the suppuration is slight, and the bones being near the sur-
face,  the shattered fragments are easily discharged.  Thus it is
in wounds of the radius and ulna, and of the os humeri.
   But where the bone is greater, the mass  of soft parts more
bulky, the  wound of  course deep, and the destruction of parts
proportionably great,  the matter is apt to insinuate itself among
the muscles,  to insulate the bones, and to  make, in the end,
crooked and fistulous passages, and  an almost incurable sore.
Such are often the consequences when the bones of the  leg are
broken, especially  where the joints of the  ankle  or knee are
concerned.
   But where  the bone is the largest in the  body,  and covered
with a great thickness of flesh, as in the thigh, there is a very
extensive destruction of parts, the mass of disease is very great,
and ii the patient escape gangrene in the first days of the wound,
he generallx perishes  afterwards from the fever, the incessant
suffering, and profuse discharge.  From a  gunshot-wound in
the haunch-bone, or in the femur, near its neck, about the tro-
chanters, or any where high in the bone, not one of twenty es-
capes.  The sufferings of such a person may be easily imagined,
since  he  lives, or  rather,  one might say, continues dying for
five years, and while he lies on this bed of torture, with matter
running in profusion  from various  fistulas every where  sur-
rounding the joint, irregular callus shoots out in fantastic forms
round the bone, so as to unite the  bones in that crooked form
in which he lies; yet, even while the callus is thus forming, the
fistulas being  incurable, and the  discharge profuse, amputation
is impossible, and the patient expires. 
'■-■•'(<  121  )
DISCOURSE  XI.
RULES FOR  THE MANAGEMENT  OF SIMPLE,
   COMPOUND AND GUN-SHOT  FRACTURES. ^
 OYSTEM-WRITERS still retain the  old  descriptions and
 terms of art, of which there is not one that does not imply an
 absurdity.   Of  these the most conspicuous  are,  extension,
 counter-extension, coaptation and diligation.   Thtse
 terms were descriptive of operations which were actually per-
 formed by the glossocomas of the ancients, and by the block and
 tackle of the modern surgeons.
   Extension was the fixing of lacs and bandages upon the  low-
 er part of the fractured limb, to which were applied ropes and
 pulleys, by which the assistants pulled.  Counter-extension was
 the resistance which other assistants made by tablecloths, girths
 and bandages, put round  the pelvis and upper part of the thigh.
 Coaptation was the thumbing and working the smaller fragments
 and the broken ends of the bone  into nice contact with  each
 other; but diligation was a process which it would take hours to
 describe, as  it took hours to  perform!  of compresses applied
 round the broken ends of the bone, pads and cushions laid along
 the sides of the limb, splints above these compresses and cush-
 ions, with distinct rollers for each several stage of the operation.
   But I will describe the  real operation in plain words, in which
 there  is no occasion for  any such terms as extension, counter-
 extension, diligation, rope, pulley,  compress or bandage!  That
 is indeed rampant surgery!  Were it possible for a limb to re-
quire  such extension, it never could be maintained.   When a
limb,  the leg, for example, is broken, you  need no nice and cri-
tical diagnostic signs to distinguish the fracture by;  the  broken
limb yields under the weight of the body, the patient hears and
feels the snapping of the bone at first, and is sensible, v. hen the
limb is moved, of that grating of  the broken  ends of  the  bone
against each other, which was in the old vocabulary termed Cre-
nitation ; and the surgeon, when he begins to handle the limb.
                             Q 
122     Of simple, compound and gunshot Fractures.

is sensible of the same grating, he perceives by the bending of
the limb that it is broken, and there is indeed so little difficulty
in  distinguishing a fracture, that I have never seen a patient who
was not sensible of his condition, nor heard of a surgeon setting
a sound limb,  except by design.  In setting this  broken  limb,
there is no extension required but such as common sense would
direct you to use if you were not a surgeon.   You lay the pa-
tient in bed, and lay the limb on a pillow, or if you design to use
splints, you have two long troughs or pieces of pasteboard bent
into a hollow form, lined, or rather cushioned, with two or three
plies of flannel, and with tapes or ribbands, four or five in num-
ber, attached to the outside  of one of the splints, by which both
splints may, after all is over, be gently tied together with bow-
knots, to be slackened or tightened according to the swelling of
the limb ; you also soak and soften the pasteboard a little, that
it may take a shape suitable to that of the limb.
   A long splint of this kind being laid flat upon the bed by the
side of the fractured leg, you desire one of your assistants to ap-
ply his hands broad round the upper part of the limb, and grasp
it gently and steadily;  you take the foot and ankle in the same
manner in your own hand;  you slip, perhaps, your left hand un-
der the  broken part of the limb, and thus you and your assis-
tant carrying, or rather sliding the limb gently along, lay it upon
its pillow  (which should not be a common one, but rather like
a mattress or settee pillow flat and firm), or upon its splint.
   Then you begin to lay the limb smooth; your assistant grasps
it again by spreading  his  hands upon the  thigh  or below the
knee, with the design of extending along with you, not by lift-
ing the leg from the pillow, but rather by  spreading his hands
over it, pressing it down to the splint or pillow, and steadying
and holding it by the pressure, while you, with both  hands, lift
the foot and ankle, grasp them gently but very  firmly,  raise
them a very litde from the pillow or splint, and draw gently,
steadily,  and  smoothly, and when you have  extended  and
smoothed the broken leg in a manner which you almost suppose
agreeable rather than painful to the patient, you press it down
upon  the  splint, you and your assistant both keeping the  limb
steadily and gently pressed down.  You keep it flat and press-
ed with all your hands till  it gets a sort of seat and bed in the
pillow ; or if splints are to be applied, the limb is now pressed
against the lower splint; the upper splint is then laid above it
by a third, assistant; you now grasp the limb with your  hands
on the outside of the soft and moistened splints; you grasp and
model them a little, and when the whole has taken a form, you
tie the several tapes one after another, and after having tied them
in a  general way, you go over them again one by one a second 
        Of simple, compound and gun-shot Fractures.     123

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

           Rules for the setting of Simple Fractures.

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

  * I here am careful to defcribe the common operation, and that only : there are
certain cafes  afterwards to be mentioned, efpecially of compound fracture, with
protrufion  of the bone, where a more powerful extenfion is neceffary, but ftill nei-
ther pulleys nor ligatures are ufeo, only, the furgeon fometimes twifts a hand tow-
el round the ankle to give him a fteadier hold. 
 12-t         Fractures of the Arm and Fore Arm.

 gendy, but not carelessly applied, because the common splints
 merely tied with tapes would slip off, and because the arm hangs
 naturally away from the body, so that it is easily rolled.
   n.  B. When the fracture is near the lower end  of the hu-
 merus, near the condyles, or in what is improperly called the
 neck, viz. near the head of the bone, it is apt to be more oblique,
 and then firmer splints, a steadier bandage, and more careful pos-
 ture of the arm are necessary;  and  when it happens  that the
 shaft  of the humerus is separated from  its head, the axilla
 should be filled with a compress to keep the bone out and in its
 right direction.
   2d,  When the fore arm is fractured, although one bone on-
 ly  be broken,«it is easily distinguished, because the  slightest
 turning of the hand produces rotation  ot the radius, and con-
 sequent crepitation, the radius being fractured ; whereas, when
 the ulna alone  is  fractured, the change of shape is almost as
 great as if  both bones were broken.   When one bone is bro-
 ken, the arm manifestly  cannot be shortened, and even when
 both bones are broken, the general surface formed by the two
 bones and their interosseous membrane is so broad, that they are
 fairly opposed to  each other, and soon reunite.  The fracture
 of the fore arm requires two flat  splints which are to be laid one
 on the inside, the other on the outside of the arm, and in place
 of rolling the fore arm with a roller, I usually tie the splints with
 three or four broad  tapes or ribbands, each about  a  foot  in
 length,  not connected with the splints, but laid upon the table
 under the lower splint when the arm is about to be laid upon it.
  n. b. In the fore arm I have remarked two things,  first, That
 the hand must not be turned in any degree, i. e. it must neither
 be in  what anatomists call a state of pronation,  nor a state of
 supination, but the thumb even with the line of the Radius, and
 the little finger with that of the Ulna;  and to preserve it in that
 position, the splint that lies on the inside of the arm must  be
long enough to reach to the palm of the hand, so as to keep the
 wrist steady, and  prevent rolling of the radius; and this splint,
 where  it is lodged in the palm of the hand, must be a little pad-
 ded and a little bent, so as  to let the fingers bend easily over it.
  Observe also, that the representation I have given of the ad-
hesion and massing of parts about a fractured bone, is so far
 true, that the callus is formed, not by the particular ends of each
 individual bone, but by the whole mass of bone, inflamed peri-
osteum, and cellular substance; whence it often happens, espe-
cially in compound fractures, where the mass of parts engaged
in the process is great, or in gun-shot fractures, where the arm,
from the tediousness of the sore  lies very  long  extended upon
its splint, that the ends of the bones are united in one mass  of 
Fracture of the Arm and Fore Arm.         125
calku, by  which the motion of the radius is hindered, and of
course the turning motion of the hand is lost.   This produces
a  more  awkward and distressing  kind of lameness  than  you
would easily imagine, the patient cannot carry any thing to his
mouth without turning the arm at the shoulder, the effect is the
same precisely with that of an  anchylosis of the elbow joint.
I saw several examples of this at Yarmouth in the Dutch hos-
pital, where men shot through the fore arm had been permitted to
remain in their cradles all the time of the cure, their arms lying all
the while flat and unmoved, till at last they became immovt able.
   3d, In  fracture of the clavicle, or collar-bone*, the
weight of the arm pulls down the scapula, for in tact the clavi-
cle is  the only  connexion the scapula has with the trunk; the
scapula itself only glides upon the ribs, without being connected
with them,  large muscles lie betwixt the lower flat surface of
the scapula and the thorax.   The accident is easily distinguish-
ed, as the  bone can be  felt  in its  whole length;  perhaps there
never was a patient sober enough to know any thing of his own
situation, who wras  not  conscious of the nature of the accident
that had  befallen him when the collar-bone was broken.
   This particular fracture is both reduced and retained,  by first
pulling both  shoulders  strongly  backwards, and then  turning a
firm linen roller round  the shoulders, crossing upon the back, so
as to leave the place of the breast where the fracture is, exposed
and open; for this no  more requires splints nor compress than
any other  fractures, it is only in consequence of  the  weight of
the arm that the fractured clavicle requires firm bandaging.
   n. B. This particular fracture is rarely accompanied  with  a
wound, nor is there any difficulty in reducing or retaining the
clavicle in its right place;  but sometimes it may be useful to fill
the axilla with a large  compress, in order to support the shoul-
der and to keep it  off from the thorax, so as to extend  (if we
may use  such an expression) the broken clavicle to its full length.
When the  arm is  big and heavy, when  the patient has to com-
plete his  journey in a  carriage, &c. it is proper to add to the fi-
gure of 8 bandage round the shoulders, another bandage sup-
porting the fore arm and confining it close to the body.   This
second bandage is  indeed necessary in every case, to prevent the
swinging of the arm and the unavoidable rolling of the collar-bone.
   In respect of the fracture of the acromion process ot the  sca-
pula, it maybe sufficient just to remark,  that it also is known by
a falling forwards of the shoulder, and the place of the fracture
is  easily distinguished  as the bone is superficial.   This fracture
requires chiefly that the shoulder should be pushed upwards, by

  * See what is faid on this fubject, in chapter on Bandages, page 41. S. 
126
Fracture of the breast Bone.
which the head of the shoulder-bone, pressed upwards against
the fractured process of the scapula,  raises it to its right place.
In this fracture, the  shoulder must be firmly bound, and the
fore-arm particularly well supported.*
  4th. In fracture oftlie sternum, the broken bone is moved,
not by the  motion of the trunk or body, but by respiration: at
every motion of the thorax, the patient is sensible of the  grat-
ing or crepitation of the bones;  the  surgeon feels it  with his
hand, and  hears  it by approaching his ear to the breast.   The
motion of the broken sternum soon inflames  the mediastinum
under it, and by degrees the inflammation  extends along the
pleura and whole of  the  thorax.   There  comes on a frequent
cough, and during every paroxysm of coughing, the crushing
of the fractured sternum is dreadful.
   This fracture  admits neither compress nor splints, and yet
it must be  kept perfectly steady; to do this, nothing is required
but a simple swathe  or  bandage round the chest, but it must be
so firm as  to  prevent the respiration being in any degree per-
formed  by the motion of the thorax;  the motions of the thorax
must be entirely suppressed by  the  bandage, and  respiration
performed  by the diaphragm alone.
   N. B.   In this fracture,  the motions of the thorax  being in-
cessant, the re-union of the fracture, without bandage, is impos-
sible : if you fail to apply the bandage, the motion of the bones
will raise the inflammation to that height, that the patient will
be  suffocated by the general  affection of the  lungs, or  by the
effusion of matter round the broken bone; and  the least mis-
fortune that can happen,  is tedious suppurations under and
around the broken parts  of the sternum, and  caries  of the bone
itself, so  that it becomes necessary sometimes to apply the tre-
pan.  The bandage which we have directed,  though drawn  ve-
ry firm,  is far from oppressive, the patient feels it to be rather a
relief; before  the bandage  is applied, the grating of the bones,
the inflammation, high breathing,  and terrible cough, are  in-
creasing every moment;  but no sooner  is the bandage drawn
firm, than the crepitation ceases,  the pain is relieved, the cough
and high breathing,  begin  to abate; and  by plentiful bleedings
and opiates, all comes right again, and the patient is saved.
   5th Fractures of the ribs  are like those of  the limbs, simple
or compound, with or without injury  of the surrounding flesh;
and when there is injury of the adjacent parts, it is by the ribs

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

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

  • Whether fplints ought to be applied in the firft inftance, or not, to a fractur-
ed leg, there can be no doubt of the neceflity of ufing them when  the inflamma-
lion has fubfided.  Martin's whalsbone-fplints  are the  belt, though the common
wooden ones will anfwer  They fhould be applied with fufficient firmnefs, to pre-
vent all danger of the fradured bones being deranged by any ordinary accident y
the roller will require re-applying about twice  a-week, during the progrefs of the
cure; at each time of doing this, the furgeon fhould afcertain that the bones arc in
tlieir proper pofition.  S.
                            R 
130             Fracture of the Thigh-Bone.
breeches; and into a slit in this bandage must be fitted the top of
the splint.  The resistance which is to elongate the limb, is to be
accomplished by the pressure of the top of the splint against this
circular, and therefore the circular must be prevented from being
pushed upwards by a strap going round under the pelvis, like
that of T bandage ; or why should we not actually take the top-
band of a pair of buckskin-breeches, keeping also a part of the
thigh of the breeches to make the pressure more  general, with
a pocket something like the fob or  side-pocket inverted, to slip
the top ot the splint into, as an ensign lodges the colour-staff in
his side-pocket ?   1 need  not relate to you how,  after the chief
resistance is established, the limb  may be extended  and secured
by lacs round the knee and ankle;  as to the permanent exten-
sion, if you will attempt it, it must be easier with the assistance
of this splint: after fixing your lacs or bandages round  the  an-
kle, you may bring one of them round the lower end or point
of the splint, and extend it occasionally, without any ill-looking
apparatus,  any apparent cruelty, or real violence.*
   Secondly, When the fracture, in place of being in the neck, is
below the trochanter* in the shaft of the bone, where fewer mus-
cles are  implanted, the  retraction is less powerful, but still there
is retraction, and the shortening of the limb must be resisted by
the long splint of Duverney  alone; it  is  not a  torturing ma-
chine ; does  not  grasp the limb at particular points, but lodges
the whole  limb, and gives friction and resistance at  every point.
   Thirdly, When the thigh-bone is fractured in the middle, there
is no reason, even in  the most muscular man,  to fear retrac-
tion, and the thigh  may, with all possible propriety and safety,
be laid smoothly out upon a pillow, being careful of the posture
of the body, that it be not higher than the thigh,  so as to gravi-
tate downwards upon it; the thigh  should be laid on one side;
should be laid a little out from the body, and a little higher, (in-
deed  the  body naturally sinks into  the bed)  and  the  surgeon
should also be careful of the  posture of the heel and foot; for
the leg is apt,  by its weight  and wrong inclination, to  turn the
thigh upon its axis.
   Fourthly, In fracture of the very lowest part of the thigh-
bone, in the part adjoining to the condyles, or lower head of the
bone, the  fracture is apt to be very oblique; and sometimes it
happens that the  bone is  fracture^d so very  obliquely, that the
effect is the same as if  one of the condyles only  were broken a-
way.   In this  oblique  fracture there is indeed no  forcible re-

  * Boyer'afoufcuije might certainly be added with advantage to this apparatus!
whether the furgeon attempted permanent cxtenfion or not;  nor mull he by any
means omit keeping the thigh wet, as long as there is any danger of inflammation,
with a folution of acetate of lead.  S. 
Fracture of the Thigh-Bone.            131
 traction of the bone,  but a continual tendency to obliquity.  Ve-
 ry often  I have seen such a fracture so ill cured, that there has
 been a shortening and weakness in consequence of the in-kneed
 posture of the limb, which was both very distressing, and a ve-
 ry great deformity.   Then,  although  there is no occasion in
 this fracture for any  powerful machine, there is a necessity for
 the perpetual resistance of a very strong splint.  The leg turns
 outwards; the splint  of firm fir board, &c. is therefore to be ap-
 plied (with proper compresses to prevent pain)  upon the inside
 ot the  knee-joint, and bound very firm with circulars  above and
 below the knee.   You cannot bend the leg too much inwards ;
 it always inclines to turn out.
    n. b.  In fracture  of the thigh-bone, we foresee a very uneasy-
 confinement of six weeks to the  most irksome postures, and the
 ease and comfort of our patient are principally to be studied.
 He should be laid on a hair mattress, which is cool and firm,
 rather than on a bed, in which he is apt to sink down; and it
 will be of infinite  advantage to  him to have a fine flat and thin
 hair mattress cut into four or  six pieces, and the cut  parts sew-
 ed again and covered with pieces of sheet; then first laying
 boards in place of the canvass across the frame of the bed, then
 laying an entire mattress for the bottom of the  bed, and then
 laying the several pieces of the  cut mattress according to your
 pleasure, you can raise or  depress any part of the body to any
 degree, and alter your patient's posture with the least possible
 motion.   If any other pillows be required,  they should be the
 firm and flat hair-cushions, like those of a couch, and indeed the
 best bed is a couch, which friends and attendants can go round
 about in all directions, which can be wheeled to the window,
 or towards the fire,  without discomposing the fracture,  and
 which should be placed in  some public  room, where the pa-
 tient will have as little as possible of the feelings of a sick bed.
   You must have  a hand-rope for the patient to raise  and move
 himself by, without any strain of the limbs or body, urinals and
 bed-pans  for  his conveniency, and  he must have occasionally
 anodynes to abate the irritation of his confinement  and distress-
 ing posture, and laxatives of castor oil, cream of tartar,  lenitive
 electuary,  sulphur, or whatever suits his constitution, to pre-
 vent the constipation  which proceeds from opiates and confine-
 ment.
   9th. In  compound  luxation  of the tibia and fibula,  in that
where the bones are broken, the joint burst up, the heads of the
bones turned out through the wound; the astragalus and heads
of the tibia, or of the  fibula,  almost separated, there is such de-
struction and laceration of parts, that we  are doubtful whether
to attempt preserving  the foot; we can do little  more than lav 
132
Fracture of the Patella.
the limb on the sound side, and keep the foot as nearly as pos-
sible in its natural and  proper direction.   I have  sometimes
seen the ankle-joint wonderfully distorted, from being fractured
and  dislocated, even without that laceration  of the skin which
constitutes the case of a compound  fracture; and by  drawing
upon the foot very gradually, but powerfully, and working and
modelling the disordered joint in the hand,  I have restored  it
to its right shape, have set it with  a  firm splint well  covered
with flannel, &c. and bound pretty firm with a figure of 8 roller
round the foot and ankle.
   N. b.  In this fracture still the tendency of the foot is to turn
outwards, and you have to lay your  splint along the inner side
of the ankle-joint, making a small window  or opening in your
splint to receive the projection of the inner ankle.   By the re-
sistance of this splint you draw the  foot, which is  inclined to
turn outwards in  a splay-foot posture, inwards into a natural
one.  It is the process of the fibula that guards the ankle on the
outside, and keeps the foot right; and it is the fracture of the
fibula,  and the yielding of the outer  ankle, that makes the foot
fall off towards that side.
   I  mention this luxation here, because it is the only luxation
where  the head of the bone being replaced does not  remain;  it
is the only luxation that needs to be bandaged as a fracture.
   10th. In fracture of the patella, the chief difficulty is to pre-
serve the bones in perfect contact with each other, insomuch
that Dr. Hunter, unable to account  for the difficulty of accom-
plishing a perfect cure, imagined that the failing of the usual
process in this particular instance, could be owing to nothing
else  than some part of  the  membranes surrounding the  joint
falling in betwixt the two bones,  so as to prevent them coming
into proper contact.
   In this  particular fracture the  leg must  be kept extended to
the  utmost;  the upper piece of the  fractured patella, which is
retracted to a great distance above the knee, must be smoothed
and  thumbed  downwards,  and put in as close contact as possi-
ble with the lower fragments.  To put it in close contact is the
difficulty: it seems to  be  in close  contact at the time of your
operation, and you are only convinced that the pieces  have not
been in contact when  the cure should  be  complete ; for when
the swelling has subsided,  when the patient begins to walk,  a
hollow is seen betwixt the two ends of the bone, and a ligament
of some length is  felt  uniting  them.  The patient losing the
pulley-like projection of the patella or rotula (and the extensor
muscle being shortened) is never able to stand on one leg, ne-
ver  able to bear up the body on that  limb, never able to  mount
a stair without  carrying that leg before, and is never out of 
Fracture of the Patella.
133
 danger of forgetting himself, trusting  the  weight of the body
 upon  that limb, falling backwards, and so breaking the other
 patella, or snapping the same one a second time, as I have seen
 happen very often.
   To preserve the bones in absolute contact,  and prevent this
 imperfection in the cure,  is  almost impossible.  The swelling,
 before you are called,  is  so  great, that in  many cases bandage
 cannot be applied for six or eight days.  When the swelling is
 gone, the pieces of the bone cannot be made to approach each
 other, nor  can the bandage, from the remains of  the general
 puffy swelling, be applied close  to the bones.   The bandaging
 has been attempted in various ways.   The common bandage is
 a belt of leather split like the common leather  retractors, with a
 small opening in the middle of the slit, for  receiving the pa-
 tella ; each of the sides or semicircles of this opening is padded
 up with leather, so  as to make a pretty firm compress ot a cir-
 cular form ;  and when the bandage is  buckled round the knee,
 and drawn firm, the two sides of the slit are  of course  drawn
 so close together, as to press the two pieces of the patella be-
 twixt them.*
   n. b.  Before applying these rollers, they should be all soaked
 and wetted (best in  spirits)  to  make them stick closer to the
 flesh,  and if (having applied them) you are perfectly satisfied
 with their operation, you may easily  convert them into a firm
 case, by taking a  glue-pot and soaking them with  glue, so that
 each turn of your roller would stick to  another, and the whole to
 the  flesh, the knee being thus enclosed in a  very  perfect case.
 Both during the cure and  for some time after  the patient begins
 to walk about, I find it convenient and safe to stiffen the  joint,
 by laying a strong splint behind the ham, lest the patient should
 make a false step, and the knee yield before the ligament joining
 the bones were become strong.
   n. b. Though I prefer  simple and moist rollers, which stick
 thus close to  the parts, yet there is no doubt that the clumsy
 compress-like  roller contorted round the  knee in the form of
 figure of  8,  has sometimes  succeeded  remarkably well.  In
 proof of this, remember what Meibomius reports of a cow-herd,
 who having broken  his knee pan, made a very perfect cure by
 twisting round it a firm straw-rope.
   11th, In fracture of the Olecranon (which  is another excep-
 tion to the general rule  of keeping a fractured limb gently and

  • A fimilar roller paffed firmly from one extremity of the thigh to the other, fo
as  to prevent the contraction of the extenfor mufclesof the leg, will be of great
icrvice.  I have, within this day or two, feen a perfon whofe right patella has been
broken, and  is re-united by a ligament, who fays that leg is as Jlrong as the other.
 The lpace between  the fractured portions is about half an inch. S. 
134              Fracture of the Olecranon.
 pleasantly bent), you must keep the arm  completely extended*,
 for the triceps muscle pulls up the olecranon to an incredible de-
 gree, it  mounts absolutely half way up the arm,  and although
 you thumb it down  again, yet if you keep the  fore arm in any
 degree bent, the interstice betwixt the  end of the  ulna and its
 broken process will be filled up with bone, and the fore arm be
 so far anchylosed, that the patient will never be able to  extend
 it,  for this filling up of the interstice will be just equivalent to
 the lengthening of the ulna.
   In setting this fracture, you force down the retracted  olecra-
 non,  which  is broken  away from the end of the ulna, and you
 completely extend the fore arm so as to make the end ot the ul-
 na meet its broken process, you cover the broken process with a
 compress, and fix it with a double-headed roller, turned in  form
 of figure of 8 (as in bleeding), making occasionally turns purely
 circular round the broken part, and you make all sure by laying
 a stiff  splint in the bend of the arm, and  fixing  it with a  second
 roller  in order to prevent the arm being thoughtlessly bended;
 indeed, nothing in such cases should be trusted to the discretion
 of the  patient.
   n. b. In this fracture there is abundance of callus: there is
 no danger of that imperfect and ligamentous union which takes
 place in the broken patella, nor is there any danger of that pro-
 fusion of callus, running like molten lead, into the cavity of the
elbow  joint, which was supposed to happen, and to occasion an-
chylosis.   When this fracture has been neglected or ill set, the
 fore arm kept at right angles with the arm, and the person lamed
perhaps in his  right arm, it has been proposed to make incision
to cut out the intermediate callus, with the design of setting the
bones  properly with the arm extended;   an operation which is
surely not impracticable.
  12th,  The rupture of the Tendo-Achillis, or great back tendon
of the leg, more justly ranks  with fractures than  with  lacera-
tions ;  for while it was considered as a laceration of a soft  part,
it was actually the practice of surgeons to sew the ends of the
tendon together with great embowelling  needles;  but now be-
ing ranked with fractures of the bones, it is set like a  broken
bone, like the fracture of the patella, for example, and the sur-
geon has  no care but  merely to  smooth down the muscle, to
prevent the retraction of the tendon, to  preserve the ruptured
parts as nearly  as possible in contact with each other.

  *  It is neceffary in this accident to ufe great care to prevent the joint  from be-
coming ftiff from want of ufe.  In the firft place the fore-arm ought not to  be ex-
tended farther than is neceffary to allow the fractured ends to be placed in contact.
2dly, Moderate  flexion and extenfion ought to be ufed as early as the third wo !c
and repeated every day or two to as great an extent as can be fafely done.  S. 
Rupture  of the Tendo-Achillis.
135
  The tendo-achillis is broken  as the patella is, not by a blow
or fall, but  by a sudden and violent exertion  of its  own mus-
cles, in consequence of making a false step, the patient being in-
stinctively incited to make an exertion too sudden and violent for
the  tendon to withstand it; an exertion which sometimes, in
place of tearing the tendon, breaks the heel bone.   When the
tendon is  broken, the patient,  from its insensibility,  feels no
pain, he feels as if he had been struck a smart blow with a stick;
it commonly happens, in dancing, or in making a false  step, as
in slipping, though not  untrequentlv it happens when walking
apparently securely on even ground;  the patient instantly  1 alls
down lame, the shortening  of the  bellies of the gastrocnemii
muscles, the retraction of the tendon, and the interstice between
the two ends of it are perceptible, and the  patient himself  is
conscious he has broken the tendon.
   For setting this ruptured tendon, various machines have been
invented, and especially various shoes with  straps and buckles
behind to draw up the heel, while the  upper part of the tendon,
on the other hand,  is pressed downwards.   According to my
experience, this extension of the toe  and drawing up of the  heel
are unnecessary*; the foot may be safely left in its natural  pos-
ture ; it is chiefly important to prevent the slightest contraction
of the gastrocnemii  muscles; for this purpose, the calf of the
leg should be smoothed downwards with the hands, the whole
of the calf of the  leg from the ham downwards must be rolled
with a firm roller, proceeding from above, but the bandage should
not pass the biggest part of  the calf, nor at all approach the  rup-
tured part, nor even  the inflammation and swelling which  sur-
rounds it.
  n. b. The chief danger in rolling the  leg in rupture of the
Tendo-Achillis, consists in approaching  the part  actually frac-
tured.  I was once called to a gentleman whose whole leg from
ham to heel was firmly bandaged  with a roller, the turns  of
which made deep impressions on the swelled ankle; and at the
point where  the  tendon was actually ruptured, the turns of the
roller (so firmly was it drawn) had sunk down very deep indeed
betwixt the  ends of the tendon, they were thus separated to a
great distance from each other, there was no possibility of their
uniting, and had they been left so, the old gentleman must have
continued perfectly lame.   It was on  the fourth day after the
accident that I was called and undid this bandage, yet the cure
was in the end tolerably perfect.   The muscle should be  well
rubbed and smoothed down, and neatly rolled, the ankle and cel-
lular substance  surrounding the ruptured part should be left  per.

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

                        Conclusion.

  In this section, consisting altogether of rules, which should be
perfectly minute, I fear there must be  many omissions which I
shall hardly be able to compensate for  in the following general
observations.
  First,  It is uncomfortable for the young surgeon not to know
at what period he may venture to undo the apparatus in any par-
ticular fracture; for this reason, though there can be no specific
nor absolute rule,  yet surgeons have been at pains to mark the
period in which they  suppose each  individual fracture to be
healed.  Without  warranting the propriety of these rules, allow
me to mention, that authors say, the smaller bones, as the Cla-
vicle, the  Ribs, the Fibula, are cureable in twenty days; the
bones  of the Cubitus  or Fore Arm, the  Radius or Ulna,
are cureable  in thirty  days;  the fractures of the  humerus or
Thigh Bone require fifty days to reunite; though, to be perfect-
ly reunited and strong, the fractured Thigh Bone requires seven-
ty days.   But rules so specific as these, mentioning  the  very
day on which a fracture may be supposed to be cured,  cannot
be useful without  being understood.   Allow me  then  to ob-
serve, that as it appears to me the process is either slower and
more  imperfect in children, or at least, in children the  bone is
more apt to be  broken again, v/e cannot indeed wonder at cal-
lus being slowly formed, since the bones  themselves are  still in-
complete and growing for two-and-twenty years:  in fractures
then happening in children, you keep the roller and pasteboard
splint longer applied.   Nor is it from the slow formation of cal-
lus that the cure is delayed in fractures of the great bones; the 
General Observations.
137
process is not slow in proportion to the  greater mass of bone
that is to be formed, perhaps a callus will form as rapidly round
the bone of an ox as round that  of a boy,  and be as speedily
completed in fracture of the thigh bone, as in fracture  of the ra-
dius, for every part has vessels proportioned to the mass of cal-
lus that is to be formed; but the cure is, slow in  proportion to
the size of the bone, from the larger bone having to support a
greater weight; or rather the mass of  callus is slow in acquiring
firmness proportioned to its size, or to the weight  it has to bear.
It is for this reason that we are cautious of trusting the weight
of the body  too early on a broken limb ;  in  fracture of the hu-
merus,  as the arm hangs  and does not necessarily carry any
weight, the patient may leave off his  splints in six weeks;  but
in fracture of the thigh bone, which has to bear the  whole weight
of the body, we dare not expose  the unconfirmed callus under
such pressure, till fully three months have elapsed.
   Allow me also to observe, that on particular occasions, parti-
cular precautions must be taken; that while a man  is in  his
sound health and reason, no bandage nor  splint is required in
fractures of the lower extremity ; but that when a  man is mani-
acal or delirious, besides the ordinary  precautions  of splints, the
limb, after being set, must be laid betwixt  two pillows, tied to
them,  and  the' pillows in their  turn  fastened to the  bed; that
when a man has to be carried far with a fractured limb, besides
being regularly bandaged  with splints, there should be laid along
the sides of the limb, above the  splints, long and firm pieces of
wood bandaged like the splints, and extending beyond the heel
to prevent accidents.  And  finally, that in the sea service, and
in the armyr, when either an army is to retreat, or  an hospital to
be moved,  or when a storm is  expected at sea, the  surgeon
should be as carefully advertised of the approaching storm, or of
the present movement of the  army, as any higher  officer, for he
has many precautions to take for the safety and comfort of his men.
   The  surgeon when he wishes to make any part or bandage
particularly  secure, has it in his power to convert his rollers into
a firm case, either by  soaking the  bandages in whites of eggs,
which soon hardens in a very firm varnish; or with  the whites
of eggs  may be mixed a little flour and sugar to make  it into a
paste, or he  may apply any common varnish over his bandages,
as white  spirit varnish, but that  is slow of fixing, and is very
thin,  or he  may strew a little powdered rosin on his bandages
before they  are applied, and then by soaking the bandages with
spirits of  wine, the rosin is dissolved, and the whole  adheres to
the limb with  very singular  firmness; or finally, the bandages
may be soaked with fine  and well made glue, which  makes a
very firm case, and is very far from being offensive.
                             S 
138            Rules for Compound Fracture.

  These methods are all of them more  cleanly, less cumber-
some, and indeed I think more effectual than  the old Arabian
method of bedding a fractured limb in stucco  or Paris plaster.
  Lastly, I would observe, that  though in a fracture ot the leg
or thigh bone, or of the  patella,  splints are quite unnecessary
during the  cure*,  yet when the patient rises from bed, rests the
weight of the body on the fractured bone,"and begins to be  ex-
posed to  accidents, light but firm splints should  be  laid along-
side of the limb;  while he wears those splints he is in a man-
ner under your controul, will walk with restraint,  and be careful
of using  dangerous freedoms  with the limb, and thus he may
be saved  from a second confinement more terrible than the first,
as it is incurred by precipitation and rashness.

                        SECTION III.

               Rules for Compound Fracture.    "

  The moment you arrive at the place  where your patient lies,
if called to the spot at which the accident  happened, you  must
proceed to extend the foot, while your assistants  hold the limb,
and by pulling firmly,  steadily,  and, remember,  very strongly,
(for in this case a good deal of extension is required) you  get
the  bone to go back within the integuments,  and though per-
haps you do not get the bone and the edges of the  wound  ar-
ranged exactly  to  your  mind, you get the foot restored to a
right direction with regard to the leg, the bone tolerably co-
vered by the  integuments, the  patient relieved in some degree
from the pain of this protrusion,  and the whole member put in
such a posture that you  can lay  it  on  a  splint as a safeguard.
There  are two forms  in  which the  compound fracture usually
presents  itself; first, when the patient having leaped or  fallen
from a height, the bone is merely broken, and protruded per-
haps to the length of some inches, then the foot being extended
and the bone reduced,  you, after laying scraped  lint upon  the
wound, (which presently cakes with the blood)  lay it upon a
stiff splint, made  of  fir board, properly  covered and  padded
with cloths, to which the  limb being fixed by broad circulars of
any common ribbon gently tied, and with proper folded com-
presses, put for softness under each of those circulars, the whole
becomes  pretty firm, and  can be carried with safety.
  Perhaps you have at first only  turned down the stocking, or
cut the breeches; but the patient being now brought to his own
home, you proceed to perform your operations more regularly.
* See note, page iz<). S. 
Rules for Compound Fracture.            139
You have had your patient  conveyed along with all  possible
tenderness; but you now proceed to operations  which require
a degree of harshness,  and even of apparent cruelty.
   First.  You prepare the  bed,  by lifting the mattress and
clothes, and in place of the laced canvass-bottom, you lay boards
across the bed-frame, which make the bed  hard, and keep it
perfectly level and true during the cure.   You next, in place of
the feather-bed, lay only a mattress  above the boards; for a
feather-bed permitting the patient  to sink down, the body gra-
vitates towards the  fractured  leg, so as often to make the bones
overshoot each other, with a dangerous shortening of the limb.
You next cut another mattress into four pieces, and round each
piece you sew a piece of sheet; these are laid over the first mat-
tress, and shifted under the patient from time to time. You then
lay a pillow for receiving the limb;  and having laid your patient
on this bed or couch, you proceed to cut off the breeches, stock-
ings, &c.
   The first and most important point of practice  I have to teach
you is,  how to reduce  the bone ; and to instruct you, I must be
careful to represent the several possible conditions of the parts.
Let us first suppose then, that the tibia protrudes through a very
narrow opening, the foot turned entirely over to one side ; the
bone, as if strangled by the flesh, under these circumstances,  it
is difficult to extend the limb so as to  get the  bone to go back
again through the skin ; but it is possible, and you try it in the
following manner: You lay the whole limb quite flat; you make
two strong assistants, with both  their hands, grasp the leg very
firmly below the knee; you then grasp the foot firmly over the
tarsus, and behind the heel, with both your hands, and begin to
pull gently, steadily', and very  powferf ully, turning the foot a little
from siae to side ;  you also twist a hand-towel round the ankle,
and take the assistance of it to give you a firmer hold on the foot,
and to make you pull more steadily and  equally.   But  if the
bone  will not  go back, you must give the foot to another sur-
geon  or assistant, and clasp your own hands round  the broken
part,  and with your thumbs,  without much reserve or affecta-
tion of delicacy, endeavour to force in the bone,  which, though
it needs this force to reduce it, yet lies easy when it is reduced.
   Should it be impossible to reduce the bone, on account of the
narrowness of the wound, and  its  swelling and strangulation,
you proceed to dilate the wound;  you try to push in your fore-
finger, or your little finger, to conduct the bistoury,  or, if ne-
cessary, you push in the bistoury, which makes way for itself;
it  is  the  straight probe-pointed  bistoury you use.  You  have
only one danger to avoid, that is, the cutting of the tibial artery;
and to avoid that, you keep to the inner side of the leg, and op- 
$
 140            Rules for Compound Fracture.

 posite to the highest ridge of the tibia (not to the outside of the
 tibia, for the artery lies in the middle, betwixt the tibia and fi-
 bula ;) you run your bistoury forward, and carry it pretty deep,
 till your finger, which  follows  behind the bistoury,  passes  in
 easily, and till you feel the stricture quite relieved*.  But if you
 find the bone splintered with points and  spiculae, which  (if it
 were reduced) would run into the  flesh, instead of reducing the
 bone in this dangerous condition, you cut off the sharper points
 with  the cutting  forceps of an amputation-case;  and having
 smoothed the bone, you may then, after dilating the wound, re-
 duce it safely.
   If you find, at the same time, the bone strangled by the nar-
 rowness  of the wound, and pointed at its  extremity, so that it
 would be dangerous to return it among the soft parts; if  you
 are sensible that the bone is broken so obliquely, that though
 reduced, it would not keep  its place, but allow the other  bone
 to shoot  over it, and at the same time so sharp pointed that the
 spicula? would run into the flesh, you have then to make your
 election betwixt the two operations of  dilating the wound and
 of cutting the bone; and as  you prefer  cutting the bone,  you
 proceed not merely to smooth it with the cutting forceps of the
 amputation-case, but  to amputate  it in  the following manner:
 Your assistant takes a flat iron spathula to defend the soft parts
 with from  the teeth of the saw, lays it  flat under  the bone be-
 twixt it and the flesh, he holds  it  steady by one or two fingers
 on each side of the bone, and presses or draws it up edgeways
 betwixt the bone and the flesh, and the spathula being thus fixed,
 you proceed to saw the bone, as close as possible to the wound,
 with the  small spring-saw, commonly put  into the amputation-
 case for the purpose (though never used) of sawing the finger-
 bones.
  Let us next suppose that the bone does not protrude, but that
 a loaded  waggon has passed over  the limb, and that the bones
 have been so  crushed, that  through  one  great wound a large
 piece of  the  tibia has been squeezed out; that the separated
piece of the tibia projects, and is easily pulled  away; that upon
introducing the finger through this lacerated  wound,  you feel
 the bones all shattered,  the  splinters loose and moveable, the
tibia destroyed to a great extent,  of three or  four inches, ac-
cording to the broadness of  the wheel, and that upon insinuat-
ing your finger, you hardly  distinguish the lacerated flesh from
the bruised bone.  In dressing a limb thus shattered,  you take
away the pieces which are entirely  loose, because they are plain-

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


                  Of Dressing the Wound.

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

                Of the stage of Suppuration.

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

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

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

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

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

weight of the body, that we are to look for such complicationi
of injury as is described in  these words; and  however a com-
pound fracture of the arm, or fore-arm, may destroy the part
itself, life is actually in danger only in great  fractures  of the
lower extremity, which  forms so  great a proportion  of the
whole body.  Whether the Tibia only  is protruded, or  the as-
tragalus displaced, or both, you  perform the same operations;
and whatever may be the decision of a consultation afterwards,
your  duty  is immediately  to replace  the  foot, and close the
wound.  Always, you proceed in the first instance as if you had
no doubt of saving the limb.
   In general it happens, that the Astragalus or Tibia having
burst through the integuments, the  bones  are  so strangled in a
small slit or opening,  that no degree of force will reduce them;
you do not, in this case, cut off a bone  so necessary to the joint
as the inner process of the tibia; you never, unless it be already
entirely separated, cut away the astragalus;  you first extend the
foot very powerfully,  and press in the astragalus, and try to re-
duce the bones; but failing in this,  you make a free incision,
taking care to avoid the tibial arteries;  extend  the foot, replace
the astragalus betwixt the processes of the Tibia and Fibula,
and  having closed the wound, you lay a piece of lint upon the
lips of the laceration.   You then place  the  limb on a large and
stiff  splint, in a manner which surely I need not explain,  and
with such pillows, compresses, and bandages, as you find neces-
sary for keeping the foot in  its right  position, with regard to the
leg.
   The limb being thus laid, you  are not  to promise  yourself
absolute success, but the surgeons whom you have sent  for be-
ing arrived, you consult together upon the probable event of the
case; and so very favourable is the aspect that matters assume
after those operations have been nicely performed, that the con-
sultation will very rarely order the limb to be cut off; they soon
leave you to  your own prudence, and  advise  in general terms
that every thing should be done to preserve the limb.  You are
now afloat, and  must abide the chance of time and circum-
stances, for after a day's delay the limb is inflamed,  and you
never call a second consultation; it is too late (whatever changes
come upon the limb)  to perform amputation with success ; nor,
indeed, must you be alarmed at the appearance of gangrene,
even in this case, where gangrene is so  often the cause  of death,
for the force with which the parts are twisted, or the bones dri-
ven through the skin,  occasions an extensive ecchymosis, which
reaches along the leg, and up the thigh itself, so that the whole limb
is almost black.   N ay, you must not be alarmed even though this
blackness turn into a true  gangrene, though vesicles rise, the 
            Of Compound Fracture and Luxation.         149

part lose all feeling, and the patient lie in a degree  of stupor;
for such  gangrene is often but superficial; it is confined to the
skin;  it is limited even to a small portion of the skin, and  in
eight or ten days  small sloughs are thrown off, the suppuration
is established,  and the patient revives.   Such laceration sel-
dom or never adheres immediately, yet is often cured by  sup-
puration ; and  sometimes,  when  pieces of the tibia and fibula
have been separated and thrown  off,  when the astragalus has
been fractured, and one half of it cut  out by the  surgeon, the
joint has healed;  nay, it has even happened that the astragalus
has been so entirely twisted out of its  place, that it has  morti-
fied and  been removed by the surgeon,  and  yet  the gangrene
has ceased, the suppuration has been established, granulations
have filled up the great hollow, the outward wound has closed, and
(though it is difficult to believe so  surprising a fact)  the bone
has been so far regenerated, that the  patient  has walked firmly
on that foot,  and with a free motion of the ankle,  a new joint
having been formed.  Yet you should be aware, that such cures
are never perfect; after even the least of those  accidents the
joint  continues long weakly, always rheumatic, apt to swell
with  the slightest fatigue, and  requires  to be firmly supported
by a well-padded  buskin laced firmly round  the joint:  I  have
seen some patients, indeed, who did  not absolutely need this,
but few who did not acknowledge the comfort,  security, and
strength it gave them. 
(  150   )
DISCOURSE  XII.
ON THE ACCIDENTS AND  DISEASES OF  THE
                      HIP JOINT.
SECTION I.
  Diagnosis of the various accidents and diseases of the Hip
                          Joint.


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

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

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

tort the leg to give himself ease in the bruised part, yet the sur-
geon can, by a little force, make the limbs even.  Figure 1st.
  2d.  When the thigh-bone is luxated, the limb is always im-
movably fixed by the  entireness of the neck of the bone, and
the awkward posture in which the head lies  against the pelvis;
and when the thigh-bone is luxated upwards, we have the fol-
lowing decisive marks of its condition:  The head and neck of
the thigh-bone are firmly  braced down against the  back of the
pelvis by the surrounding muscles, whence the limb, which lies
in a very awkward  posture, is  absolutely immoveable.   The
head of the bone having started fairly over its socket, and lying
even as high as the sciatic notch, that is, at the distance of three,
or rather four inches from its natural situation, the limb is very
remarkably shortened, the heel of the luxated limb touching the
sound one a little higher than the ankle.  Next the  neck of the
thigh-bone being entire, and the head of the bone looking back-
wards towards the sciatic  notch, the whole limb is singularly
distorted, the toe is turned inwards, or rather backwards, and
the knee of the luxated  limb falls in behind the thigh of the
sound  one, and in this  awkward posture the  limb is so im-
moveably fixed, that when you attempt to turn the  thigh-bone,
you give great pain; in the moment of the attempt, you are sen-
sible of insuperable resistance;  indeed, if you  could  turn  the
thigh-bone, you would reduce it.
   Now, when the limb is thus luxated upwards, if you lay your
patient on his belly, you will find the leg half bent, and stand-
ing up at right angles with the  thigh;  and taking the leg  in
your  left hand, and working it like a rudder,  backwards and
forwards, laying your other hand at the same time flat over the
haunch, you will be sensible, every time the thigh-bone is turn«
ed, of the ball or head of it turning under your hand; and when
you persist in turning it very largely and rapidly,  you will be
very sensible of the head and neck of the bone clucking against
the haunch-bone.  But of all the marks, none is  more particu-
lar than this, that the great trochanter rises very high, the pro*
minence which we call the haunch, seems to  be transferred ve-
ry high up upon the hip, the thigh is remakably shortened and
flattened, and when you first begin to roll the thigh-bone, and
to feel the joint, you would be apt to mistake the  trochanter for
the head of the bone, and the clucking noise of the luxated bone
for the grating of a fractured one.  Figure 2d.
   3d. When the thigh-bone is  luxated  downwards, the bursal
and central ligaments are lacerated, the  obturator muscle which
fills the thyroid hole,  is in  part torn up from its origin, and the
head of the  bone is lodged in its place; the turning or rotation
of the  thigh-bone  is in this luxation also entirely prevented bv 
p.  Id*.
Flf 2. -i wcattd ufwards,
  explain* J. P«jt. id'*
Fig iNatural .tiflanid.
     Page. ISt
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  iXfla'mtd Pagt 15$

Upwards and tht
 let tamed in-
Denmryards andthe
 tut turned out
Sketch for the D layrw^-u- ofZuxations
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       Of the accidents and diseases of the Thigh-Bone.    155

the awkward posture of the neck ; the head of the  bone looks
forwards, or rather upwards, and the limb is as much fixed as
when luxated upwards.
   All the  peculiarities of the distortion first described, are re-
versed in this luxation;  the head of the bone is now lodged in
the thyroid hole, a part of the pelvis so much lower than its na-
tural  socket, that the leg is lengthened fully three inches.   The
head of the bone in this luxation looks forwards and upwards,
so that the toe, which was turned inwards in the luxation last
described,  is turned outwards in this; and the head being  now
turned forwards, the knee, which in the upward luxation  lies
under the sound knee, is in this turned remarkably outwards,
while the whole limb is kept in a very remarkable manner strad-
dling away from the body.   In  the luxation upwards,  the head
of the bone is less distinctly felt, because the trochanter is apt
to be mistaken for it, the head  and  neck lying deep under the
glutaei muscles;  whereas in this luxation, the head of  the bone
is felt rolling very  distinctly and superficially in the groin,  very
nearly in the place  of the venereal  bubo, for at  this point the
joint of the hip is not covered with large muscles, such as the
Glutaei,  but with one thin and flat muscle, the  Pectineus,  and
the joint is so near the surface here, that the suppuration in the
hip-joint disease usually bursts first in the groin.   Figure 3d.
   4th. The peculiar signs of fracture of the neck of the thigh-
bone, are not less decisive.   The moment the neck of the thigh-
bone  is broken,  the bone is retracted by the power of  its mus-
cles ;  it is turned somewhat round by the rotatory muscles (the
Obtur. Internus. quad. Femoris, &c.) operating  upon the shaft
of the bone ;  and while  the head and neck of the bone remain
in the socket, the broken part of the bone at the root of the tro-
chanters  mounts upwards.  The following signs then  must fol-
low those  peculiarities  in the posture of the bone.  First, the
moment the  neck of the thigh-bone is broken,  the shaft of the
bone  is so retracted by the power of its muscles, that you would
imagine  the bone to be luxated  upwards; secondly, observing
next the  posture of the leg, you find that the toe is not  turned
inwards, nor the knee of the hurt limb bent in under that of the
sound one, it is turned outwards, but not in that fixed, awkward,
and straddling posture,  which  indicates  luxation downwards.
Thirdly, you next begin to turn the limb and to hearken for
crepitation ; but you will remember that this fracture is distinct
from  all others, in having no crepitation, for the ends of the
broken bone are  not opposed to each other (as where  a bone is
broken across its middle)  but  the broken neck of the bone re-
mains in  the acetabulum, while the  part (i. e.  the root of the
trochanters) where the neck of the bone was broken away from 
156    Of the accidents and diseases of the Thigh-Bone.
the shaft  is so retracted, that the fractured parts are never op-
posed to each  other, unless indeed in the moment of extending
the limb with  the design of setting the fracture,  for then the
limb being drawn out nearly to its natural length, the fractured
parts come to  be opposite to  each other,  and the crepitation is
distinguished.   Fourthly, It is to be observed,  that  the  limb
cannot be  fixed and embarrassed by the neck  of the thigh-bone,
as in luxation; the connexion betwixt the head and shaft of the
bone is destroyed; the limb is not only free, but absolutely loose;
the natural thigh-bone moves easily,  but  the broken thigh-bone
turns loosely,  as far as a bone can turn  loosely which is encum-
bered with such a mass of muscles lying about it.
   This also is very particular;  it turns vertically like a spindle.
If you take in  your hand a sound limb with the design of turn-
ing it,  and lay the palm of your hand over the trochanter, you
will be sensible that the bone moves  slowly  and steadily, be-
cause it is connected with its neck.  The head of  the bone is
the centre of  the motion, the trochanter is  at the distance of
three inches from that centre, and moves in large  circles, of
which   the                                       neck of the
thigh-bone           J|Pil,^^^*^:^            ls  tne  ra"
dius;  but   •,      Jp?  cJP*^lL \           when   the
shaft is bro-    ^Mjj^S^^^^m} *   ika^k  ar^/    ken  away
from    the  ^^n^p^:^^p«||^^^K,' ^ ^Sf^    neck,   the
shaft of the  |B@fl*«  if       vmfc '"tf^%iwl$PS>   bone is it-
self thecen-   TOf^  *1L      j j^^^v ^SPjlM/   tre °^ m0"
tion,    the    wfe,V  'f§""""""""........\$K0*^&^  f   trochanter
of  course    ^fe\  IT      IkbI    ] ^jp^   f    turns verti-
cally in its      lL   1       IH,  J  Ml,   $    place with-
out making       ife  \      | Kp^ f   ft   i'i     any circle,
it   merely       f?V-       |1  I    F   f     turns    on

  Thefrac-                  ]§'•.                 ture of  the
neck of the                                       bone then is
easily  distinguished from luxation, by the ease with which  the
limb is turned, by the thigh-bone turning vertically upon its
axis, by the leg being much shortened, easily  lengthened by  ex-
tending it, but very difficultly retained.   But though I affirm
that the thigh-bone is easily turned and moved in various  di-
rections, I mean so only in reference to the  mechanical resist-
ance, for  it is  not moved without dreadful  pain ; the ragged
trochanters, and broken part of the bone, are  lodged among the
soft parts, and every time you try to draw the leg outwards, the
patient  suffers dreadful pain from the  pressure  of the broken
part of  the femur against the lacerated  parts which lie on the
back of the haunch-bone; thence it is, that  the patient  is no 
       Of the accidents and diseases of the Thigh-Bone.     157

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

                        Of Luxation.

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

            Of Luxation of the Femur downwards.

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

  • When the  fracture takes place within the capfular ligament, if this is not
torn,  its ftrength prevents this effect from immediately taking place.  S. 
Of Luxation of the Femur downwards.        159
 ted parts, the slightest motion occasions excruciating pain, and
 as the slightest motion prevents adhesion, the head of the bone
 continues long reducible.   When the bone is first driven out of
 its socket, the patient hears the crash of the lacerating ligaments,
 and when a recent luxation is reduced, the head  of the bone
 being distorted in respect to its posture, and very firmly braced
 down  by the contorted muscles, goes home into its place with a
 violence proportioned io the tension of the muscles with a loud
 snap;  but when an old luxation is reduced, the reduction, which
 is opposed by the  strong  adhesions, requires  a  force equal  to
 that by which the bone was luxated, if not greater; and in the
 instant in which the adhesions give way to that force, the pati-
 ent and the surgeon both feel the same crash of laceration which
 accompanied the first displacement of the bone;  it often sounds
 as if the  neck of  the bone were broken by the violence.  This
 is the  sign of the  luxation being  reduced,  and the  surgeon
 should be aware of it;  for I  have  often been sensible of this
 crashing and laceration among the ligaments, which announces
 the yielding  of the dislocated bone; but as the head of the bone
 does not,  in such old luxations, go home with a sudden  nor dis-
 tinct snap, the extension has, to my certain knowledge, been of-
 ten continued, even after  the bone has been reduced, and that
 with a degree of violence almost sufficient to tear the limb from
 the body.   Observe this in your future practice, and you will
 find that I am not incorrect; and if what I have alledged be
 true, the vis percussionis (far from being a subject for thought-
 less jokes)  is perhaps absolutely necessary to the reduction of
 old and confirmed luxations.
  2d,  Though the capsule so entirely surrounds  the joint, that
 it can in no case escape sudden laceration when the head is dri-
 ven from  its  socket,  yet the muscles, which are small, which
 turn round the joint with  small  tendons, and are implanted
 about the  roots of the trochanters, and are but slightly connect-
 ed  with the capsule are very seldom torn.   The head of the
 bone bursts through the capsule, and tears it in a very irregular
 way;  but it passes out betwixt  the tendons  of the  muscles,
 without tearing them; therefore it happens, that  as soon as the
 bone is reduced, as soon as the head of the thigh  bone is drawn
 out from  among the lacerated parts, and again lodged in its
proper socket, all pain ceases, the patient exclaims that he is re-
lieved ; and  as  the muscles preserve their  attachments to the
bone, and  are now restored to their offices, he moves the joint
as easily,  and walks upon it as firmly as before,  and returns to
his business or pleasures sometimes without one day's interrup-
tion ; and  though the capsule is completely lacerated, yet as it is
 connected on its external surface with the surrounding parts. 
160
Of Luxation of the Femur downwards.
and these also are injured, they swell, and the surrounding parts
being close, the edges of the lacerated capsule are regularly op-
posed to each other,  and the entireness ot the capsule is soon
and easily restored:  rest is not necessary to these adhesions.
   3d,  When the head of the bone remuins unreduced, new and
important changes take place on the head of the bone itself, and
on the part against which it rests.  When  the thigh bone is
luxated downwards, it displaces in some degree the obturator
muscle, and rests in  the hollow of the thyroid hole covered by
the lacerated muscle, and pressing against the bone, and there
it lies braced  down by the distortion of the other  muscles.
The surgeon cannot turn it  in examining the parts, except in  a
very slight degree, so firmly is it embraced by the muscles; and
besides, the patient is careful to prevent even the slightest mo-
tion,  for motion is productive of excruciating pain.   He lies
immoveable for some weeks! the hollow in which the head of
the thigh-bone lies, is lacerated and raw; the parts surrounding
the neck of the thigh bone are also lacerated,  which parts mu-
tually  adhere  so as  to form a new and perfect capsule.   The
head of the bone  resting in  the thyroid hole, as in a socket,
comes at last to move in it with a  degree of ease ; and the pel-
vis, resting thus fairly upon  the head of the thigh bone, is stea-
dily supported; and though the leg is much lengthened in  this
luxation, so as to  make the patient halt towards the sound side,
yet the limb thus luxated downwards bears up the body firmly.
   This is one striking peculiarity of  the luxation downwards
into the thyroid hole.  But still farther changes take place, very
slowly indeed, for the changes I mean now to speak of affect the
bones  themselves.   It seems to be after the thigh bone is fixed
in its new situation,  and after the continuity of vessels is restor-
ed, that the bones begin to change their form.  The  soft parts
connected with this surface of the  pelvis are all swelled,  vascu-
lar,  inflamed, and in the condition of  the periosteum and  soft
parts surrounding a  fractured bone.  This mass of active ves-
sels connected directly with the vessels of the bone itself, draws
them also into an active state.  A secretion of bony matter be-
gins, the new bone is deposited in the  now inflamed  capsule  in
the surrounding cellular substance, and  among  the lamellae  of
the obturator ligament, against which the head of the bone rests,
and which is  of course irritated  and  inflamed.   The  thyroid
hole  comes in time to be filled up with ossification, so as  to
make a bottom for the new  socket.  The edges of the thyroid
hole sprout out so as to form lips or edges for the socket; and
these edges sometimes are so deep as to surround entirely the
neck of the thigh bone, and  to form a complete box of bone, in
which the head  of the  thigh  bone is so enclosed, that though 
            Luxation of the Thigh-Bone  upwards.         161

perfectly moveable, the head cannot be disengaged from its new
socket.
   Nor does even the thigh-bone itself always retain its original
shape; while excitement enlarges a bone, pressure, on the  con-
trary, prevents its growing in a young person, or even lessens it
when  full grown.   The thigh-bone, when  thus luxated, bears
the weight of the body in a new direction, the obliquity of the
neck is lost, the head of the bone now receives the pressure in
one direction only, whence the head  of the bone  is  flattened,
and the neck is in time depressed, loses all its obliquity, is short-
ened,  and stands out at right angles from the shaft of the bone ;
and as the shoulders and neck of the bone now press against the
lower part of the empty  socket, that put yields to the pressure,
the lower edge  of the socket is depressed inwards, and the ge-
  I have given in this drawing one of the moft extraordinary facts in this depart-
ment of pathology.  I have reprefented here  a thigh-bone  which was luxated
downwards and backwards into the fciatic notch, and there formed for itfelf a new
locket, where, though entirely enclofed in the box, as the French academicians have
chofen to call it, it was ftill moveable. One thing is very curious, that in this
Hew focket there is a certain opening feparated from the reft by a thin partition ol
bone, through which the veffels enter which fupply the joint.
                               X 
162        Luxation of the  Thigh-Bone upivards.
neral  cavity of the socket,  now forsaken by  the head of the
bone, is almost filled up.

           Luxation of the Thigh-Bone upwards.
  4. When the thigh-bone is luxated upwards and remains un-
reduced, the new joint and all its apparatus is less perfect, and
the patient continues very lame.  The head of the thigh-bone is
now lodged on the back of the haunch bone, upon a flat and gli-
ding surface, the head of the thigh-bone obtains a fixed place
very difficultly;  there is no hollow like the thyroid hole to re-
ceive it; the convex head of the thigh-bone is applied to the flat
surface of the haunch bone, so as to touch it almost by a mathe-
matical point; there is not here, as in the luxation downwards,
a variety of surface and great extent of bone wrought upon by
the head of the femur ; the generation of bone is very sparing ;
an accidental socket is indeed formed, but shallow, smooth, irre-
gular, not deep, not sufficient to receive or lodge the head  of
the thigh-bone ;  it is rather a dimple than  a  solid socket, and
looks merely as  if the  haunch bone  being softened had been
slightly impressed by the head of the thigh-bone.   How does
the patient walk |then in this case ? Very miserably; his thigh-
bone rather lies upon the side of the haunch bone than under it,
so as to support the weight of the body;  the weight of the body
is suspended upon the  head of  the thigh-bone by the strong li-
gaments that are generated out of the lacerated capsule, aided
by that cellular substance which connects the lower surface of
the glutse muscles with the bone.  The dislocated leg is remark-
ably shortened, and when the patient rises  on the sound limb to
make a new step, the luxated bone hangs in air ; and when the
dislocated limb is in its turn put to the ground, the whole weight
of the body falls heavy upon those thickened ligaments ;  at eve-
ry &|£p the patient twists the body, and turns the pelvis so as to
throw  the haunch bone  flat upon  the head of the thigh-bone,
and this inclination of the trunk, together with the shortness of
the limb, distorts the whole body;  and in  this case the weight
falls so heavy upon the neck of the thigh-bone, that it gives way
under  it.   The head of the thigh-bone is flattened, the neck is
shortened,  it is also bent downwards, as if  it had given way, as
if it had slided a little lower along the shaft of the bone.   When
we look at the thigh-bone  which  has been  long luxated,  we
should at first believe that  it had been actually  iractured, and
the neck shortened ;  but upon examining the neck, we find no
mark of fracture, while we  easily distinguish many marks of the
long continued pressure, for the whole of the upper part of the
thigh-bone, even to the trochanters, is extenuated, the neck is
somewhat extenuated and bent down, the  head also is smaller 
Luxation of the Thigh-Bone upwards.         163
than that of the sound thigh-bone, and on the top of the globu-
lar head of the thigh-bone is a depression or flatness, indicating
the place where  the back of the haunch bone rested upon it.
   In  such a luxation remaining unreduced, the weight of the
trunk is ill  supported, the motions of the joint very imperfect,
the limb  remarkably shortened, and wasted in some degree,
while the whole  person is distorted and hent towards the lame
side.   Though  such  luxation  happened  during infancy,  the
person never recovers, but continues lame, pained, unable to ride
on horseback, easily fatigued, equally unfit for business or plea-
sure, and reminded of his misfortune every moment of his life.
                       SECTION  III.

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

   The  disease I am now to  describe proceeds from a fall  up-
on the haunch (as when the foot slips upon  ice, &c; in which
the trochanter being directly struck, the head of the thigh-bone
is beaten down  into the socket, the round ligament, which oc-
cupies the bottom, and the mucous fringes, which are contain-
ed rather in the  lower part of the socket, are violently bruised,
whence arises immediate and very terrible pain, continuing for
many months.   The torture is excruciating, the patient cannot
be turned, nor even moved, in the most gentle manner  in bed ;
after, perhaps, a year's suffering, he  begins  to  move about up-
on crutches, entirely lame.
   This  accident is  clearly distinguished from fracture,  because
there is neither crepitation nor shortening of the limb; from
luxation, because the limb  turns easily; and from those and all
other affections by this, that though it turns easily, and there is
no mechanical obstruction  to motion, the patient cannot suffer
it to be turned, every motion of the head of the bone rolling a-
gainst the injured parts of  the socket producing delirious  and
frantic outcries.   Sometimes this inflammation of the joint sub-
sides, and  after  long confinement and torture,  perhaps after
using  warm  baths,  frequenting  watering-places,  fomenting
and gradually exercising the joint,  the patient  recovers the use
of his limb; but much more frequently he continues lame.
   It is not difficult to imagine, and  indeed to prove by dissec-
tion, various changes by  which the joint is destroyed.  The
first effect of such inflammation and insufferable pain is, to pro-
duce a trembling solicitude on the part of the patient to prevent
the slightest motion of the limb.  The patient lies in  all  the 
164              Affection of the Hip-Joint.
filthiness of a sick bed, will not permit a pillow  to be changed,
or a sheet  to be rolled under him ; even the trembling o» the
floor, when people walk  rudely, increases his irritability, it not
his actual  torture.   This is almost like a provision of Nature,
for motion actually  does harm, excites inflammation, brings
the inflammation forward to abscess of  the  joint and caries of
the bones, and prevents anchylosis, which is often the only pos-
sible cure: the presumptuous interference of quacks  with the
process of Nature, their daring to twist and turn such a limb,
under the pretext of reducing luxation,  has actually  proved fa-
tal.
   The stillness of the patient, and the uniform posture for ma-
ny months, favours  all those changes  which are apt to take
place in a joint thus highly inflamed.   Sometimes the  inflam-
mation stops short of ulceration, the capsule, tendons and mem-
branes surrounding the  joint, are merely thickened by the in-
flammation, and the joint remains  stiff,  rheumatic,  but move-
able,  and,  as far as pain will allow,  useful.  Sometimes, and
especially  in younger people, the inflammation  runs high, ab-
scess forms, and after repeated paroxysms of inflammation  and
most excruciating torture, the matter  bursts out at the haunch
or in the groin,  with proportioned relief of pain.  Often, you
may suppose, before the matter thus bursts out, the bones them-
selves are  ulcerated, the capsule is destro) ed,  the head ot the
bone is  extruded from  the  acetabulum, and retracted by the
force of its muscles upon the back of  the  haunch-bone; then
the leg is shortened ; and this is what  the ancients  called Sub-
luxation, the French, Luxation Consecutif, and  which has been
by almost  all  surgeons acknowledged  as a luxation  under the
title of Luxation from an Internal Cause.   Often  the  bones,
thus eroded, become carious,  and not unfrequently hectic en-
sues, and the patient dies.
   If, escaping all those dangers, the patient live, and the bones
granulate,  they  unite with each other; for the persevering pos-
ture of the patient prevents the process of ossification being dis-
turbed, more  effectually than  our  most severe and curious
bandages could do; the bones unite  with each  other often  in
the most awkward direction, the  thigh-bone being fixed and
united with the pelvis at right angles in respect  to the body.

                        SECTION  IV.

Of the scrophulous Disease of Boys, or  the Disease of the Bones
                which compose the Hip-Joint.

   The scrophulous disease of this joint is peculiarly frequent  in 
Affection of the Hip-Joint.
165
 boys from five to eighteen or twenty years of age, and is of that
 insidious nature, that its approach is hardly observed;  the dis-
 ease is established before its symptoms are noticed, even by the
 most affectionate and attentive parents, and it ends in total ca-
 ries of the joiht, with anchylosis or cohesion of the diseased
 bones, though often, from the suppurations and dreadful pain,
 hectic and death prevent this imperfect cure.   The bones, and
 not the soft parts, are the seat of the  disease,  therefore its pro-
 gress  is very slow;  the  pain is so dull, that the boy walks and
 runs about for months after the disease is formed.  The parents
 first observe an awkwardness and trailing of the affected  limb,
 as if it were weakly; the boy complains little, except of weari-
 ness after play, and of that numbness and stupor, with dull and
 heavy pain,  which the parents mistake  for growing pains, so
 frequent in boys.
   The boy now begins  to stand  always on the sound limb, and
 in such a posture, that the parents chide him for awkward ha-
 bits.   After sitting a little while, his joint stiffens ; when he re-
 turns to  play, he begins  to feel pain; when he is warmed by
 exercise, the joint moves more easily, and he runs his race with
 his play-fellows; but when his bout of exercise is over,  he falls
 again into a state of languor.   The limb seems weakly,  and be-
 gins to waste, the boy loses his health and complexion,  from
 day to day he complains more and more of pain, till at last he
 is confined, and a puffy swelling appears about the joint.
   During all this stage of the disease, the bone is swelling and
 becoming more vascular, the lining of the acetabulum,  and the
 periosteum covering the head of the thigh-bone, are thickened
 in common with the bones themselves, which  are now swelled.
 The head of the thigh-bone is protruded in some degree from
 its socket, just as a diseased tooth is protruded from its socket
 by a bag of suppuration forming under its fangs.   Still  the dis-
 ease is limited to the bones; there is not, as in the disease aris-
 ing from  bruises of the  acetabulum, excruciating acute pain;
 although the leg be remarkably elongated, so as to straddle a-
 way from the*body, though it be so elongated that when the
 boy stands on the diseased leg, the toes  only  of the sound one
 touch the ground, yet he is almost without pain, and walks with
 a degree of ease: exercise, or the common  degree of motion,
 during this stage, is not so difficult on account of pain, as im-
prudent, from its increasing that  affection of the bones which
 unhappily is too late of declaring itself by acute pain.
   But at last the stage of acute  pain does  come ; the  boy be-
 comes unable to move ; the pain  becomes very acute ;  the soft
parts which connect the bones begin to partake  of the inflamma-
tion ; there is redness now, as well as swelling, round the haunch. 
166
Affection of the Hip-Joint.
The pain is often, though not always, excruciating;  abscesses
form round the joint;  the matter bursts out, first at the groin,
then at the hip;  as  the abscesses give vent to the matter, the
torture is in some degree relieved, as one sinus or ulcer dries
or closes up, another runs more plentifully,  or new  abscesses
form.  Then the cartilages are ulcerated, the matter which had
distended the capsule is evacuated, and the swelling of the parts
within the acetabulum,  which had in some degree extruded the
head of the bone from its socket, subsides,  the head of the bone
tails down again within its acetabulum; the limb, remarkably
elongated at first, is shortened in this second or  suppurative
stage of  the disease.
  The cure of the disease is now to be looked for, or the pa-
tient's death.  The patient, wasted with suppuration, and tor-
tured night and day with excruciating pain, becomes greatly ex-
tenuated ;  he  is reduced to skin and bone; he is pale, and ca-
daverous in the face, the nose is pinched, the eyes staring from
their sockets,  and the face altogether shrunk  and shrivelled up
with  discontent and pain.  Often, the  suppuration and  caries
extending along the bones, the whole pelvis is affected, the dis-
charge is profuse, and the child  dies of hectic ;  but sometimes
the matter ceases to flow, the high inflammation subsides, the
bones begin to granulate within, like soft  parts, (as they indeed
are in the boy extremely vascular) and by  perseverance  in one
uniform  posture, the bones unite, a proper anchylosis is formed,
smaller suppurations are occasionally observed and opened, till
at last the bones, after  successive fits of inflammation,  are en-
tirely united with each other.  The thigh-bone is generally  united
with the haunch-bone at an angle more or  less acute, according
to the posture which the  child had iound  the most easy ; fre-
quently it is found, when the boy begins to walk with his crutch,
that  the thigh  protrudes forwards; sometimes it is in the natu-
ral direction of the body; but even then  the limb hangs in air,
it  is  extenuated  by want of exercise and  by disease; the dis-
eased limb has been stationary in its growth for eighteen months
or two years,  while the other limb,  and the re« of the body,
has been growing; thence the affected limb is always shortened,
and often useless.
  This is plainly a disease, and a slow disease of the bones; it
is a disease of boys, because in them the  bones are but form-
ing; it is a disease of scrophulous boys, because in that state
of the system ossification is a slow and imperfect process; it is
a disease most frtquent in the bones of the great joints, because
thev are  large, and are,  till the  twentieth year, very imperfectly
formed.
  In this disease the pains are dull, because the bone is insens,i- 
Affection if the Hip-Joint.
167
 ble; slow, because the firm system of a bone does not easily
 enter into disease;  the elongation of the joint  is  a  sure  sign
 that  the disease is established, and the head of the bone,  the
 socket and the soft  parts beginning  to swell, the excruciating
 pain demonstrates that the soft parts are  fully inflamed and ul-
 cerated, and that to the original disease of the bone is now add-
 ed a disease of the surfaces, such as takes place after the bruise
 of the acetabulum; and finally, the shortening of the  limb inti-
 mates  to us that the bones are wasting, which is often confirmed
 by small fragments and scales of bone coming away along with
 the matter.  Finally, When the matter ceases to flow, the fistu-
 las to close, the limb to shorten still more, and the pains to sub-
 side, then the bones come into actual contact, granulate, unite,
 and anchylose firmly in due time, for the hectic ceases, the ap-
 petite returns, and  the cure goes on well, if only the patient can
 survive the degree of debility already incurred.
   This final destruction of the joint is the ordinary issue of the
 disease, for where the bones are once thoroughly diseased, they
 are in general carious, or in other terms, dead, or (as we should
 say of soft parts) gangrenous to some extent.  The carious part
 then must be separated; the bones which enter so slowly into dis-
 ease, must of course recover slowly; but besides the extent of
 surface,  the disease is attended in its  first stage with so little
 pain, the patient walks so long while the disease is forming, and
 the joint bears so entirely the whole weight of the body,  that
 being once diseased it cannot easily recover; it is indeed en-
 tirely ruined in its structure almost  before  the  disease is  ob-
 served.
   The cure in the  bruise of the acetabulum is leeches, fomen-
 tations, blisters, general bleeding, and perfect quiet; but in this
 scrophulous disease of boys, the cure is best conducted by cold
 bathing,  generous food, wine, and whatever will contribute to
 the restoration of the health and strength.  The immediate pro-
 gress of the disease is best antagonized by the counter irritation
 of blisters, or rather of deep and large  issues upon the hip, or
 by the  application of cauteries (the oldest and perhaps the best
 method of cure) along with prudent openings, and careful, but
 unofficious surgery.   But the object of chief importance in pro-
 moting the anchylosis, is to prevent motion, for even the weight
 of the limb is very painful, the very turning in bed inflames the
 part and interrupts the process; and quacks,  by turning and
 twisting joints during  this process (the patient being  in a fair
 way of being cured)  have caused death.
  When the period  of ulceration, granulation, and  healing  of
the bones arrives,  a  remarkable, but very gradual, shortening
of'the limb takes place, because the bones must first be  ulcerat- 
168                Affection of the Hip-Joint.


ed, then fall into closer contact  then granulate, and then adhere,
before the  anchylosis  is  complete.   During the whole of this
process the parts are wasting, coming closer and uniting: at least
it most generally is so.   I observe  in anchylosis, even  of the
knee-joint,  where the bones  are flat, and  the cartilages remark-
ably thin, that there is a very remarkable  shortening of the limb.
  When such a suppuration  and caries,  beginning in the bones
themselves, does happen, not in boys, but in adults, not from
any constitutional disease,  but from a blow,  the blow is  in a
very particular direction, and affects only  the bone ;   for it is not
a blow upon the trochanter striking the head of the bone  down-
wards,  so  as to bruise the soft  parts  at the bottom  of the ace-
tabulum ; but it is by a  person making a  desperate leap and
lighting fair upon the feet, for the head of the thigh-bone  is then
struck  upwards  against  the  deepest  part of the acetabulum,
where the Os Inrjominatum  is particularly large and firm ;  the
bone  only is  bruised, there is no immediate pain, the lameness
comes on slowly, the disease usually  makes that slow progress
which is described in the case related  in  the foot note from the
Posthumous Works of Justamond.*


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

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

                 Preliminary Observations.
(JF all the operations of surgery, lithotomy is that in which the
true principles  of the operation may be most safely deduced
from the anatomy of the parts.  To conjecture a priori^ which
form of incision would be attended with fewest dangers, would
not  be difficult;  but now that we  have before us such a suit of
experiments, performed  in  various countries  by the  greatest
masters in surgery, and  accompanied with  such authentic re-
cords of their various successes, we  are able, from  experience
as well as theory, to resolve that  important problem;  " How
we may, with least danger, open  our way into the bladder, for
the extraction of the stone."   And the universal adoption of
the lateral operation invented by Chesselden, sufficiently attests
its superiority to all others.
   Accustomed with teaching, I have had occasion  to observe
that the mind of the surgeon is ill at ease,  who has  to perform
an operation for which he has no theory; he must operate with
little decision who merely imitates the motions of others.
   I  have also observed  that, to perforin an operation like this 
17B                    Of Lithotomy.
with an intrepid spirit and steady hand, the mind of the young
surgeon must be composed; he must have an entire and perfect
confidence in his own knowledge ; he must be familiar with the
structure of the parts; he must see them exposed in every variety
of posture, and must have their relations to each other explain-
ed ;  he must dissect them often, to make this knowledge fami-
liar, and to acquire dexterity and address, for no operation in
surgery can be so properly defined  a dissection performed  on
the living body as  this.  While  the young surgeon studies the
connections and relations of these parts,  he must also be in-
structed  in all the accidents which may occur;  he must be
taught to foresee every possible difficulty, that he may not in the
midst of an operation be overcome  with the sudden apprehen-
sion of some interruption which  he does not understand.   The
teacher who is to describe so eventful  an operation as  this of
lithotomy, must first explain in detail,  circumstantially and se-
parately, each important movement of the hand or instruments,
and every precaution with  which each is to  be accomplished;
and then close his lesson with such a rapid enumeration and de-
scription of the successive acts, as will leave a vivid impression
on the mind of the young surgeon of the manner in which he is
to proceed.  This last description should serve him  as  a dra-
matic  picture of what he is to perform, which he may look up-
on anew every time he has to operate.
   Before I proceed to describe the several stages of the opera-
tion of lithotomy, there are  some preliminary points  to be ex-
plained,  which relate not to the dress of the patient, nor the height
of the table, but to the main design of the operation, and es-
pecially  to the posture of  those  very  moveable parts, the rec-
tum and bladder,  with regard to each other, and the manner
in which the surgeon should feel and ascertain every thing that
is interesting to him.  The kind and degree of distress which
your patient suffers, will enable  you to guess at the state of the
parts; in a boy who cannot have passed many years in this con-
dition, whose parents, from observing his pulling  out the penis
and pressing the thighs,  and crying when passing the urine, can
ascertain both the duration of his complaints, and  the degree in
which his health is affected, you are sure of every  thing favour-
able for your operation; for boys  are naturally  healthy ; the
stone  has not with them time to acquire any uncommon  size,
it usually is small like a gall-nut, and very rough  and irregular
on its surface; the bladder is not contracted  nor ulcerated; you
can feel  the stone with the  fingers, in the  rectum, and press
it forward so as to make it prominent in the perinaeum; in a
healthy boy, with a small stone recently formed, you undertake
the operation with confidence.  In an adult, who  retains much 
Of Lithotomy.                    17z
 urine, who, though the symptoms of stone are  decisive, yet
 passes long intervals with little pain, in whose urine there is not
 great  sediment of mucus, and seldom any  blood, with whom
 the  paroxysms of the disease, i. e.  the temporary  inflamed and
 irritated state of the bladder, is not frequent; the bladder is pro-
 bably capacious, the stone small, and the state of the parts  most
 favourable for operating.  But the scene is sadly reversed when
 the  patient, shrinking from the  pains of the operation, has  long
 endured the tortures of the stone: when  he has  endured  this
 disorder for many years, he  is pale,  languid, and emaciated;
 the  parts are unfavourable  to the operation, and his constitu-
 tion to recovery:  he can retain but one or two ounces of urine:
 the  bladder is, by its frequent contractions, thickened in its coats,
 and, its inner and most delicate surface being in almost continual
 contact with the stone, he feels  excruciating  pains in  the gland
 penis every time he passes his urine :  when he walks, he has  a
 gravitating and dragging feeling, accompanied with tenesmus or
 diarrhoea, from the increasing size  of  the stone, by which his
 paroxysms  of particular distress  are  frequently renewed; his
 urine is  so mixed with mucus,  that, of the  quantity which he
 passes into a glass for our inspection,  the urine being poured
 off, one half remains a pure white mucus, and each paroxysm of
 pain, especially if it arise from walking,  is accompanied with a
 discharge of blood: the day he passes in almost unremitting
 torture,  and, during  the night, he is  every half hour on his
 knees, straining to pass his urine with dreadful pain.  In  such
 a patient the bladder is small, contracted, subject to  inflamma-
 tion ; from frequent paroxysms of the stone, the parts  are in
 a state sometimes peculiarly disposed  to inflammation, and ne-
 ver  favourable to the operation, while the strength and consti-
 tution are exhausted by suffering and want of rest.
   It is only when your patient is free  from  pain,  when he has
 had a long interval after a paroxysm of pain, when  he is  free
 from irritation and fever, and in no danger from the infection
 of any reigning epidemic, that you can venture to perform the
 operation.   You wait for the more favourable seasons of spring
 or autumn : you nourish and strengthen your patient,  if ex-
 hausted, and prepare him so by opiates and  the warm bath, as
 to ensure a favourable state of the  skin and bowels.   The  sea-
 son of any epidemic disease is  much to be  avoided.   I  have
 frequendy, during the prevalence of influenza, or  of dysenteric
 diseases, been cruelly disappointed in  the adhesion of wounds,
 after common operations, in cases of the most simple incisions,
 as in the extirpation of a cancerous breast;  but the inflamma-
 tion, which merely prevents adhesion  and retards the cure in
 common operations, produces in this,  where the wound is so
near the  viscera, in abdominal inflammation and death. 
174                   Of Lithotomy.
   And let me advise the surgeon to be slow  in  pronouncing
his opinion, to be careful to ascertain the existence of the stone,
by sounding, and to feel it also by introducing the fingers  into
the rectum, and  to establish and authenticate his  own opinion
by a regular consultation, before he presume to operate.  He
should almost live with  his patient for some days, for, unless he
inquire carefully into his history, he cannot proceed  with confi-
dence, or his confidence may draw  him into dreadful  errors.
The patient may  have no stone,  but an ulcerated and thickened
bladder; he may have a stone, but too small to require so dread-
ful an operation, one which the patient might be able to engage
in the urethra, and pass  naturally by drinking floods of diluents,
and passing the urine upon his knees ; a small stone, being im-
pelled by the force of  the urine into  the  urethra,  sometimes
forms  there a sac for itself,  and the sound grating  along  this
small calculus, in passing along the urethra, persuades the  sur-
geon of the existence of a stone in the  bladder: a  patient has
been unfortunately cut for a stone  so  small, that it has been
swept out along the channel  of the  gorget with the  flood of u-
rine, and none been found to sieze with the  forceps; at other
times a small calculus,  of a cherry-stone size, has been  found
in the hinge of the forceps, and  such accidents have  been men-
tioned with as much indifference as if the surgeon were not re-
sponsible for the cruelty and lolly of thrusting a gorget into the
bladder of a patient whose stone was so small as to  be passed
by the  urethra.  In short,  these are accidents which nothing
but uncommon precaution, and a most faithful attention,to the
complaints, feelings, and whole history of the patient,  can de-
tect or prevent.
   However distinctly the sound may plump upon the stone, and
satisfy every one of its  existence, the surgeon  never is to omit
introducing one or two  fingers into the rectum; from this mode
of inquiry, various circumstances may  be  discovered, and in-
estimable advantages arise to the surgeon,  who, in place of imi-
tating the motions of other operators, proceeds with  intelligence
and design.  1 hold this mode of examination  to be little less
important to the operator who cuts  with  the  knife or gorget,
than to him who cuts on the gripe:  By introducing  two fingers
into the rectum he feels the staff distinctly, upon which he is to
perform the most delicate part of his incision: he feels the po-
sition of the rectum, which he is to keep out of the  way of his
instruments: he distinguishes, through the walls ot  the  rectum,
the membranous part of the  urethra, which is  to be  his aim if
he  cut with the gorget, and the prostrate gland, which he is
to divide, if he  cuts with  the knife: he feels the manner in
which the stone  lies in the bladder,  which, after his incisions, 
Of Lithotomy.
175
  he is to grasp with the forceps : if the stone be small, he may not
  feel it very distinctly; but if it be large, it falls low towards the neck
  of the bladder,  is easily felt,  its very form may almost be dis-
  tinguished, the staff being plainly felt passing under the stone,
  when large, and holding it in its bend or curvature. The surgeon,
  by occasional examinations,  may almost estimate its size, and,
  if he do  not expressly proportion his  incision to its size, may
  at least avoid the error of making a great  incision for a small
  stone, or the still greater  danger of making a small in.ision
  when the stone is very large ;  and when the stone is so large as
  to require to be broken by strong forceps,  he may always be
  aware of the nature of the operation he  is  to perioral.   I re-
  member to have been  called to  a consultation, in which the
  gentleman, who  invited the consulting surgeons, wrote in these
  terms:  " To consult upon the case of a patient who has a stone
  in the urethra, and another in the bladder."  The patient, in
  fact, had laboured long under the disease, the stone had increas-
  ed to an enormous size ; upon passing the sound, it encountered
  the stone  almost before it had entered the bladder, so low was
  the stone  depressed by  its own weight, and the patient's strain-
  ing dilating  in some degree  the  neck of the  bladder and pro-
 jecting into it. Upon examining by the rectum, I felt a stone near-
  ly the size of the fist, and intreatcd the surgeon to  have strong
  forceps  in readiness to break it  in  case of difficulty.  When
 we were met for the operation, I used the freedom of asking,
 " Whether forceps were at hand to break the stone r"  He said^
 " No ; that he had sent for forceps, such as I wished, but could
 not easily procure them."  Then I said, " Sir, if you value your
 own reputation,  or  your patient's life, refrain from operating
 till you are better provided, which you may easily be  to-mor-
 row morning; to perform this operation  in  the ordinary  way,
 will be murder."  He  turned about and proceeded  with his
 operation :  the scene which ensued was dreadful; two or three
 forceps were  successively twisted, or broken ; all present  were
 in the most distressing perplexity.  Mr. Wood bethought  him-
 self of a pair  of  large and strong forceps,  which had lain as
 lumber among his apparatus ; these were  sent for to his house,
 and with them the stone was extracted;  but the operator had
 never one moment refrained  from  labouring with  one  instru-
 ment or another; the patient had struggled  under his hands a
 full hour, in the most dreadful agonies; I need hardly say, that
 in two days he died.
   Not to break the stone, when of so uncommon a size, is cruel
 and dangerous, and no one accustomed with this operation will
 scruple to do so for fear of fragments of the  stone remaining in
the bladder, for he must be conscious that he seldom operates 
176
Of Lithotomy.
without the forceps chipping off small  fragments of the stone,
which are more dangerous than the fragments of a stone de-
signedly broken, as they are less observed.
  The condition of the rectum and bladder should be an object
of particular attention.  The bowels must be emptied by a purge
two days before operating, for fullness and irritation of the bow-
els, will dispose to abdominal inflammation.   The rectum must
be emptied by  a clyster on the morning of the operation, lest
the fullness  of  the  gut should expose it to be wounded: This,
if not a fatal, is yet  a blundering wound,  of which the surgeon
should be much ashamed:  although  we have the best authori-
ty for affirming that the intestine may be wounded by the most
dextrous  operator. Chesselden acknowledged  to  Mr. Mo-
rand, that he  had twice, in operating, wounded the rectum.  As
it is chiefly important to prevent the cutting edge  of the gorget
injuring the back part of the bladder, it is ot the first  impor-
tance, in operating with  the gorget,  to have the bladder lull;
the fullness of the  bladder allows the staff to be turned easily to
every side of the bladder, in feeling for the stone; it allows the
surgeon to set the staff before cutting, in the  precise  direction
he wishes to  have it.   The fullness of  the bladder presents the
fore part of its bod)', viz. that where the prostrate surrounds it,
fairly to the cutting edge of the gorget, and gives the bladder a
steadiness to resist  the push.  This fullness of the bladder pre-
vents the cutting gorget being driven through the fundus among
the bowels, and the quantity of urine running off freely along
the channel or hollow of  the gorget indicates to  the  operator,
that this, the  most dangerous movement in the operation, is pro-
perly performed.   The patient for this end  must retain his u-
rine  four or  five hours in the morning of operation ; in boys,
and even in men, a linen rag must be tied round the penis to
prevent the urine flowing off.  The string must not  be undone
upon introducing the staff for operation, for the  body of the pe-
nis  is so  compressible, that the staff passes as easily when the
string is left, as when it is taken away.  I have often been pro-
voked to see  the string taken off, the staff introduced, and the
whole of the  urine allowed to run off by the groove of the staff,
in the very moment in which the surgeon is  about to drive his
gorget into the  bladder.
  As one great purpose of many things which the surgeon does
immediately  previous to  the operation, is to ascertain the re-
lative posture of the parts,  and  revive his own recollections of
the  several points,  he should  never fail to  introduce the staff
himself, though often this is committed to the assistant.  May
not an unskilful assistant drive  the point of  the  staff through
the membranous part of the urethra,  and lodge it between the 
Of Lithotomy.                    177
rectum and bladder, where, of course, the gorget when driven
along will follow the groove ?  Is it not a satisfaction to the sur-
geon to pass the staff himself,  that he may  do it gently without
irritating the parts;  that he may feel and  distinguish any  rub
from  any small calculus, sticking in the urethra ;  that he may
lodge fairly in the bladder that  grooved directory,  which is to
guide the most important  stroke of  his knife; that he may
plump his staff against the stone, and feel it distinctly before he
operates; that he may, after introducing the staff, pass his finger
into the rectum, feel how the staff lies, incline the  handle of it
to the right groin,  and so protrude  the heel  in the  perinaeum
where he is to cut ?   Will not the introducing and  setting the
staff and feeling its curvature,  both in the perinaeum  and from
within, give the operator more decision, and a more distinct
recollection of what he has next to perform ?   To deliver the
staff to the assistant, that he may introduce it, is a slovenly, a
timid, or an evasive practice;  I have seen  this often done, but
it always seemed to me that the man who dared  to undertake
the operation  of lithotomy,  was doubtful whether he could in-
troduce a staff; or  that he was so jealous of his reputation as a
rapid operator, that he  would  not allow the more ignorant of
the attendants to calculate the operation as begun, when he  was
only introducing the staff; or  perhaps he feared lest his hand
should be unsteadied by  some slight  opposition to the introduc-
tion of the staff; a part of the operation which should, in fact,
by reminding him of all the important relations of the parts, in-
spire him with steadiness and manly  resolution.
   There is a gradation  in the length and curvature of the in-
struments which are on  various occasions  to be introduced in-
to the bladder.  The catheter,  as it needs not enter far into
the neck of the bladder, though  it should always be as big as
the urethra will easily admit,  should not  be long, and should
have a very gentle and simple  curve: the  sound, with which
we feel for the stone, must be round, smooth, longer, and more-
curved;  but it must not be very long, nor much curved,  lest it
do not turn easily from side to side in the bladder; and it should
be introduced when the bladder is moderately full, that it may
be turned easily in various directions  in search of  the stone,
which, if it be not found when the bladder is full, or  the patient
seated, or lying on the ground, may perhaps be felt after he has
been permitted to empty the bladder, or allowed  to stand up.
The staff along which  the  surgeon designs to  run the gorget,
should have a prominent heel, that it  may be easily felt through
the membranous  part  of the  urethra; it should have a wide
groove, but should not  be protracted  into a  beak, lest it  should
Z 
178
Of Lithotomy.
hold the knob of the gorget too long engaged in the groove, and
carry it so deep as to endanger the fundus of the bladder.
  The posture in which the patient is bound,  is horrible, most
oppressive, but yet it is essential to the performing of an  opera-
tion, where the slipping of  one instrument,  or the misgiving
of one stroke of the knife, makes the difference,—of safety or
death.   He must be made to grasp his feet with his hands, and
secured in that posture by strong  garters, encircling the wrists
and  ankles, and thus, bended into a curve, he rests almost up-
on one point of the spine, and is brought so near to the edge of
the table,  that he is almost suspended in air, by the two lateral
assistants,  who support each a  foot and  arm.  Unless the pa-
tient is brought thus far over the edge of the table, supported
by the assistants, and his breech bolstered up by a pillow ; un-
less his breech project over the edge of the table ; unless the pe-
rinaeum be turned almost directly upwards, and the surgeon
seated low, and rather under his patient, he cannot pursue his
incision so far beyond the tuber ischii as he should do, in order
to  cut the transverse  muscle,  for the incision should pass the
curvature of the hip.
   The patient should be brought out for operation, dressed in
a loose gown, stockings,  and slippers:  his  neck-cloth  should
be loosened, or a light silk handkerchief put about in place  of
it: three  medical assistants should  support  him, one on each
side should hold, each, a leg and wrist, supporting the sole of
the  foot  in the  hollow of one hand;  the third assistant should
 support his head and shoulders, and keep him forward  accord-
 ing to the operator's directions.  The table should be  big, firm,
 and steady, covered with a folded blanket, with one or two small
 pillows placed  for the head to rest upon, and one longer and
 bigger to support the breech, or rather the  loins; a little sand
 should be strewed under the lower end  of the table.  A friend
 should stand by to speak to him, to encourage and support him,
 and to give him occasionally a little wine and water; and, as no
 unseemly contusion should be allowed, every thing on the  ta-
 ble of instruments should  be fairly arranged, and everv atten-
 dant steady,  silent, and observing.   One only should hand the
 instruments; while the  assistant-surgeon, taking his place  be-
 hind the young man who supports the  right foot,  waits there
 till the surgeon, having introduced the staff, and felt and placed
 it,  lays it down towards the right groin, and gives it to him in
 charge;  when he is to grasp it firmly and  hold it  steady with
 his right hand,  but without pressing hard, supporting the testi-
 cles and scrotum with the flat palm of his left hand, and pulling
 slighth upon them so as to stretch the perinaeum, and  make v.
 tense for the incision. 
Of the External Incision.
179
   Upon the table are placed,  a decanter  of wine, another of
cold water, and a large glass of cool wine and water, which may
be poured  into a small tea-pot, as more convenient for the pati-
ent in the awkward posture in which he lies;  a basin of warm
water, with the  forceps and scoops in it;   and in this basin of
water the surgeon heats the staff with which he chooses to ope-
rate.   The staff he chooses, and the gorget suited to the  size
of the patient, and well and smoothly fitted to the groove of the
staff,  and the knife with which he is to cut, are laid on a plate
upon a fine cloth or towel.  These instruments lie on the plate ;
the staffs and forceps and scoops are placed in the basin of hot
water; the sponge, for wiping the wound, in  another basin of
warm water: the needles, the lint, the dry sponges, or agaric,
to be used in cases of unusual haemorrhagy, together with the
canula, round which the sponge  or lint is to be wrapped in case
it should be necessary to thrust a canula into the wound, lie be-
hind  the basins and apart; and along with these is to be laid, in
another basin of warm water, a strong syringe, or a large glyster
bag and pipe, for washing out any small calculi or fragments of a
broken stone.   When the surgeon, advancing to the table, thus
arranged, warms the gorget, and then sticks it in his  girdle or
apron string; warms the  staff and oils it, with the purpose of
introducing it;  twists a towel  into his girdle, for it is impossible
to perform the several parts of an operation neatly, with soiled
hands ; and leaves upon the plate only the incision-knife, which
his assistant hands  him, upon  receiving the sign ;  and some-
times also the gorget is left to be handed by the assistant.
   The  operation  of lithotomy, as performed with the gorget,
may be divided into these stages:   1st,  The external incision,
by which we  divide the skin and  the transverse muscle ot the
perinaeum: 2dly, The internal dissection,  by  which we divide
the fat and cellular substance, and  the fibres of the levator ani
muscle, and open the urethra:  3dlv, The settling of the gorget
in the groove of the staff, and pushing it onwards through the
prostrate gland: 4thly, The introducing the forceps,withdraw-
ing the gorget,  and grasping and extracting the stone.
                        section ii.

                  Of the External Incision.

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

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

                        SECTION  III.

                  Of Cutting the Urethra.

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

                         SECTION IV.

                 Of introducing the  Gorget.

   Keeping  his thumb-nail firmly fixed  in the groove, the sur-
 geon gives away the knife,  and lifts the gorget; poises it, and
 then holds it firmly in his hand.   He  then passes the gorget in-
 to the wound, where it enters pretty deep before it reaches  the
 staff;  then, pointing the beak  of the gorget to the  groove of the
 staff, he lodges it fairly in the  groove, and running it once or
 twice backwards and  forwards to be  sure that all is fair, and
 holding the  gorget steady with the right hand, and reaching the
 left hand over the pubis  to receive the staff from his assistant,
 he lays hold of the  handle of the staff, holds  it steady for a
 moment,  then, moving the gorget with the right hand, feels by
 the left whether the beak runs fairly and smoothly in the groove;
 then, the two hands acting in concert with each other, the ope-
 rator balances the staff  and  gorget, and by making the two
 hands feel  each other, prepares  them for co-operating in  the
 most critical moment of driving in the gorget; and when all is
 prepared for driving home the gorget into the bladder, the sur-
 geon depresses the handle of the staff, so  as to carry the point
 of it deep into the  cavity of  the bladder; his staff  stands, at
 this  moment,  at right angles  with the patient's body; he rises
 from his seat, stands over the patient, for an instant of time,
 balancing the  staff  and gorget once  more,  and,  feeling once

   *  I intreat thofe who are not perfectly confident, to make their incifion of the
 urethra more than half an inch in length; an incifion of halt an inch in length is juft
fufficient to be diftbctly felt, and to allow the beak of the gorget to be fairly intro-
duced; but it is an incifion which a furgeon unaccuftomed with operation might lofc
and fall into confufion.  I advife him rathtr to flit up nearly the whole length of
the membranous part of the urethra, when his incifion will be  nearly an inch in
length. 
Of extracting the Stone.              183
more that the beak is fairly in the groove, he runs it home in-
to the bladder, pointing it rather upwards, than directly back-
wards: then the  urine  gushes out; the beak  of the  gorget
goes off from the point of the staff with an audible cluck, and
the operator withdraws the staff with the left hand, as the con-
clusion  of that movement with which he drives in the gorget
with the right.

                  Of extracting the Stone.

   The  moment the gorget is driven home, as it always is, up
to  the hilt, (the thumb of the operator, which lies upon the
gorge  of the instrument,  being actually within the wound,)
the fundus of the bladder is in danger,—for the horrid and un-
natural feeling of being thus impaled excites the patient to press
downwards,  as  in passing the faeces and urine; the bowels are
forced down upon the bladder; the fundus of the bladder is for-
ced, by this pressure from above, and its own natural contrac-
tions, upon the edge of the instrument; matters stand now in a
very dangerous condition, and the best means of preventing
harm,  is  to introduce the forceps quickly! no time should  be
lost in the foolish ceremony of introducing the  fore-finger to
feel for the stone!  Those who use only the knife, use the finger
as a conductor for the forceps; but those who use the gorget as
a conductor for the forceps cannot feel the stone with the finger,
for it lies under, the gorget, and the gorget exceeds the length
of two fingers.
   The moment  the gorget is thrust home,  the operator with-
draws the staff, and gives it away; takes the  handle of  the gor-
get with the left hand, and the forceps in the right; the  chops
of the forceps being close, he passes them along the channel of
the gorget, and the moment the right hand has introduced the
forceps, the left  hand withdraws the gorget.  Then the opera-
tor, taking the handles of the forceps, one in each hand, be-
gins to feel  for the stone;  the forceps must, by passing along
the gorget, inevitably pass over the stone ;  let him, therefore,
taking the two handles of the  forceps, one in each hand, stand
high above his  patient, point  his forceps downwards  towards
the bottom of the pelvis, to that sac or bulging of the  bladder,
in which  the  stone usually lies,  and there  he, in nine of ten
cases, will encounter  the stone; if he feels it with the forceps
and cannot seize it, it  is because he has passed  over it, and
touches it only with the lower side of one of the chops. When
he feels that,  he  presses the stone with the point of the forceps,
he then opens the blades with both hands, grasps the stone, tries
the hold he lias of it ;n away which it is impossible to describe, 
184      Of the causes of the Slipping of the Gorget.
then, by grasping very firmly with the right hand at the extre-
mity of the handles, he holds the stone firm, and by laying the
left hand on the forceps,  and holding with it also, he assists the
right, confirms the  hold, and  prevents at the  same time  (by
slipping  his left fore-finger into the hinge) any undue pressure,
such as a soft stone will not easily bear.   Having thus fixed his
hands, he begins to pull; and if the stone be small and the inci-
sion free, it comes easily and smoothly along.   But I have ob-
served that the young surgeon, when he feels  the slightest op-
position, expects  to succeed  by turning, twisting, and  every
kind  of unmeaning  violence,  and  has no absolute rule for  a
stage of  the operation, which should yet be performed with an
intention and manner as determined as any other.   If the sur-
geon holds firmly and pulls in one uniform direction, though he
had the strength of a Cyclops, he could not succeed; if he turns
and twists his forceps from side to side, " this way and that way,
c,a-et-la," as if he were dilating, not extracting, according to the
directions of Paraeus, since he  is pulling without any design, he
still has  but little chance to succeed.    If he will but reflect on
the operation of the forceps, that the forceps are two levers with
which he is  to act alternately, depressing first  one  side of the
stone, then the other, he will not  scruple to adopt that decisive
manner  in extracting, which, though it  seems harsh, is really
easy, and relieves his patient the  most speedily, and with the
least violence.   Let him, after having  seized the  stone  fairly,
press the handles of his forceps first down, then raise them up,
then depress them again, with a wide  and free motion, and he
will be sensible, that by this slow  and equable motion, the parts
are little bruised by the  cheeks of the forceps, and the stone
will be,  in a few strokes, brought to the mouth of the wound,
and turned out, by one  wide  but gentle movement, into the
left hand of the surgeon, which is held with the palm upwards
ready to receive it.*

                        SECTION  v.

          Of the causes  of the  Slipping of the Gorget.

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

   * If the Hone be large, it will be obftructed by the arch of the  pubis, unlefs the
operator prefs downwards towards the rectum: this muft be particularly attended
to in women. S. 
          Of the causes of the Slipping of the Gorget.      185

 tatiotf and evident alarm on the part of the operator, as convin-
 ces' me that it is a most important  duty to explain the va-
 rious  causes of  the  gorget slipping  off from  the  groove of
 the staff: he will best guard this accident, who is  aware of
 every possible cause: it proceeds, like every important  error,
 from want  of knowledge in anatomy: since we often see the
 surgeon seeking  the femoral artery for an  hour, to  tie it in a
 sound thigh, (the aneurism  being in the  ham,) we need not
 wonder if such an executioner  mangle the  urethra in  attempt-
 ing to perform  lithotomy, and conclude with thrusting his gor-
 get betwixt the  bladder and the rectum.
    1st, It sometimes happens, that the surgeon, deceived by the
 common description, and expecting to cut his incisions fairly
 upon the bend  of the staff, goes deep into the  hollow of the
 pelvis, and yet, after  much  dissection,  feels no staff; falling
 then into confusion, and anxious to be relieved from this dis-
 tressing scene,  he begins to believe that he must somehow have
 cut the urethra, and, believing this, he at a venture  thrusts in
 his gorget: sometimes  the surgeon, having felt the staff, and
 distinguished the  membranous part  of the urethra, and turned
 up the knife, cuts into the groove with so tremulous a hand that
 he hardly wounds it; and having failed to dissect  the  urethra
 naked, before making this incision, the fibres  of the levator-ani
 muscle close upon the small slit which he had made in it, and
 thus,  after feeling distinctly the groove of the staff, he loses it
 again, and his gorget passes betwixt the bladder and the rec-
 tum.
   2dly, Confusion and alarm, in the simple business  of cutting
 the urethra',  is a sure indication that  the surgeon is  in danger
 of doing something very terrible.  Often you will observe  the
 surgeon, in place  of turning up his  knife at once, and striking
 it steadily and  firmly into  the  groove of the staff,  lay down
 the knife, and lift it alternately  several times; first  he be-
 lieves  that he has cut  the urethra, and  then again   becomes
 sensible, either  that  he has not  cut  it, or that he has lost the
 small slit that he had made.   I have seen the  operator give
 away the knife,  receive  the gorget from  the assistant, point it
 at the groove  of the staff, and  try to  introduce it, resume the
 knife,  and make new incisions  in the  urethra, five or  six suc-
 cessive times.   I  have seen the gorget driven twice, not  into
 the bladder, but  deep among the bowels, for although  there
 was a stone,  the surgeon never reached the  bladder,  never one
 drop of urine flowed,  the stone was not extracted, and the boy
 di.-d;  this last mistake is mere butchery;  the first is little  short
of  it, for.if everv time that the surgeon  resumes the knife, he
has lost his first incision and makes a new opening in the ure-
                            2 A 
186      Of the causes of the Slipping of the Gorget.
thra, if every time  that he loses one incision, the urethra has
turned in  some  slight  degree upon the staff,  before he makes
another, the successive incisions will almost  entirely separate
the urethra from the bladder, and the slightest push of the gor-
get will drive off the gland from the urethra.
 '  3dhy, There  is much too in the direction in which the gorget
is  driven forward,  for though the urethra be fairly cut,  ytt the
angle at which the staff is held, or manner in which the beak
of the  gorget is laid to the groove of the staff, may disappoint
the surgeon of  his purpose, and make the gorget shoot past tile
bladder or push off the gland from the urethra.   If the handle
of the  staff be too much depressed,  so as to turn its point high
up towards the  fundus of the bladder, while the gorget is point-
ed too low towards the  rectum, the gorget, in place  of enter-
ing smoothly, will start off from the staff: or  if,  on  the other
hand,  the handle of the staff be  held  too high, is too near the
groin,  too much in its first  position,  and the gorget pointed
much upwards, the directions of the groove and the beak of the
gorget will not correspond; the cutting edge of the gorget will
not be so  directed as to cut its way forward; the beak will hitch
against the point of the gland, and may, especially if the ure-
thra be mangled, force off the neck of  the bladder and prostate
from the  urethra.
   4thly, The surgeon,  in place of moving the gorget along the
groove of the  staff, sometimes allows both gorgit and staff to
go together deeper into the bladder, till  they touch its fundus;
sometimes the operator, by an awkwardness in the posture of
the gorget, needs to  use such force,  that the gorget,  when it
starts through  the  first obstruction at the neck of the bladder,
may, (especially in a contracted bladder) wound the fundus.
Even the forceps, blunt as they are, may, by rudeness and ig-
norance,  be  driven through  the fundus  of  the  bladder, the
stone  escaping by the rent, where the forceps cannot follow it,
into the cavity  of the abdomen.  Those who prefer the gorget,
and regard it as the  ultimate improvement of this  operation,
avow these facts.   " I have more than once (says Earle) known
a  gorget, though passed in a right direction,  pushed on so far
and with  such violence, as to go through the opposite side of the
bladder."
   5thly,  If the staff be short and the  assistant unskilful in the
management of it, he may, after the  surgeon has cut the ure-
thra, allow the staff to recede from the bladder, and in thrusting
it back, push its point not home again into the bladder, but out
through  the wound  in  the urethra!    The  staff being thus
lodged betwixt the rectum and bladder,  the gorget must follow
it; the surgeon feels the groove of the staff quite naked, fixes 
Of the causes of the Slipping of the Gorget.      187
the beak of his gorget,  and drives it home in the true direction,
but no urine  flows! upon introducing the forceps, he feels  no
stone! he is  in the end, after much violence, obliged to put his
patient to bed to  die.  Such an accident is recorded  by Mr.
Earle, it proves the dangers of this particular operation with
the  gorget,  and the superiority of that  with the knife; the
plunge  of the gorget,  to those who know to operate only with
the gorget, is irremediable, but a surgeon perfectly acquainted
with the parts,  and skilled in dissection, would,  in such a case,
introduce his finger, feel for the prostate, strike  his knife into
it,  and, putting in his finger, guide the forceps into the  bladder,
and at least extract the stone,  if not save the patient.  Chessel-
den once performed this,  when  another operator  had failed,
and pushed his instruments betwixt the bladder and rectum.
   6thly, Though the gorget has passed right, the forceps may
be  directed  wrong, for after a first attempt at extraction, and
when the  forceps have slipped,  the scoop or finger are intro-
duced, and the forceps re-entered; but, the opening which the
gorget makes does not  very easily admit the forceps, even when
the gorget lies in the wound,  to guide them; after the gorget is
withdrawn,  the forceps enter with  greater  difficulty, they slip
more easily in among the loose cellular substance of the rectum.
The operator opens the forceps, and feels  in vain  for .the
stone; he  at last has  an  indistinct perception of the  stone,
closes them  upon it,  grasps it, and begins to pull; but the for-
ceps slip; the  bladder is  betwixt the  stone  and the  forceps.
These are the true sacculated stones,* but the sac is the bladder
and the  cavity is  that which  is made among  the  cellular sub-
stance of the rectum, by the turning of the forceps in search of
the stone, and the opening their blades violently to grasp it.  In
one unfortunate case, the surgeon groping thus upon the outside
of  the bladder,  actually grasped with the  point  of his forceps,
and twisted away  the great part of the prostate gland, which,
when he had thrown  it down among his feet, was picked  up
by a professor of anatomy who assisted at the operation, and,
when the gentleman died, the parts were dissected out, and are
preserved.
   It is unquestionable that the  gorget is often thus  plunged
among the viscera, and perhaps it is to be lamented that ever
cutting for the stone ceased to be a distinct profession,  or that
the operation was brought to that kind of perfection which in-
duced ignorant men to venture upon an operation,  which, even
thus  simplified, requires  consummate skill  and knowledge.
Whatever may be  the apparent facility of this common operation
with the gorget, that with the knife is alone secure, it is indeed
  * There are inftances of flones contained in fac's: I have feen a preparation of
one : the circumftancc is probably rare.  S. 
188
Of the Operation of Lithotomy.
to the last degree simple, as simple as that of cutting on the
gripe;  for it is cutting with the knife upon the staff, which  is
more  easily held, fixed, and directed, than  the stone.   But
since the operation with the gorget has been approved, and
will continue to be performed,  I have taught it faithfully ; no-
thing can, in my opinion, so well prepare the  young surgeons
against this fatal accident, the slipping of the gorget, as knowing
perfectly the causes from which  it may arise.  And I will now
fulfil  my  purpose of describing the several acts and stages  of
the operation  in that rapid succession in which they should be
performed.*

                         SECTION VI.

                 Of the Operation of Lithotomy.

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

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


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

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

  * If the internal pudic artery  be  divided, which it fometimes is, particularly
when Mr. Clinc's Angle-edged gorget is ufed, it may be reftramed;  for I have
feen it done, by introducing, after the  operation is  concluded, a large doffil of lint,
and preffing it firmly for fome minutes againft the artery. S. 
192             Of introducing  the Catheter.
brocating the lower part of thebeHy with spirituous applications,
are the chief means for preventing abdominal inflammation.
  I hope that,  in preparing my reader for understanding this
description,  I have with proper seriousness inculcated the im-
portance of study, and the fatal consequence of imitating, with-
out intelligence or design, the motions of other operators; that
I have not, by any presumption on my part, incited the young
surgeon to any rash or unpremeditated attempt or new exploit,
but have described  perspicuously,  simply,  and  with a sincere
sense of duty,  the most  important and  eventful operation in
surgery.
DISCOURSE  XIV.
OF OBSTRUCTION OF URINE.
SECTION I.
                 Of introducing the Catheter.


 X HE operation of introducing the catheter,  if it do  not re-
quire intrepidity and courage,  requires at least peculiar  deli-
cacy, a perfect knowledge of the parts, and, above all, a humane
and steady temper;  for  when the surgeon is at any time  con-
scious that he  is in danger of committing violence, he must
submit to the imputation of having failed, even at the risk of
his reputation.  The obstacles and difficulties to the introduction
of the catheter are besides of so peculiar a kind, that while all
our diligence to learn  this art is necessary, our utmost  dili-
gence is sometimes unavailing, for  the most unskilful surgeons
have succeeded, by a sort of chance, even after the most dex-
terous have failed.
 .There are no circumstances in which the patient is more per-
fectly grateful, than for the relief which the skilful introduction 
Of Introducing the Catheter.             193
of the  catheter procures; for it is a sudden and  entire relief,
from anguish more excruciating than any  description of pain.
Often the value of our assistance is enhanced by the unsuccess-
ful attempts of others less fortunate or less  skilful.   To feel this
uneasiness and intense desire to pass the urine,  to submit to  a
dreaded operation, and yet to be disappointed of relief; to see
the blood streaming from the penis, and still to continue in ago-
ny ;  to  lie tossing with  fever and pain, aggravated by  dismal
recollections of many having died of obstruction of urine; and
then in the midst of  these sufferings, to receive sudden relief,
from the hands of a  skilful man,  must be accompanied with  a
deep sense of gratitude.   Such reflections  as these, my  reader
will not think unnatural.  I would condescend to  suggest even
selfish motives, to the few who are born to feel no others, as in-
ducements to study  those diseases of which I am now to offer
a short practical sketch;  1 should be  inclined to blame the sur-
geon very much,  who was not equally prepared to use the  ca-
theter as to use the lancet.
   The  introduction of the catheter is  an operation which a good
surgeon, who is able to perform with ease,  would be apt to  de-
scribe with little care  or minuteness ;  and there  is  unfortunately
in this, if any part of surgery, a kind of address which is to be
attained only by practice.  Yet this  experience and  acquired
dexterity is founded on  previous knowledge of the  parts.   I
shall give, as the first and most simple lesson  in this depart-
ment of surgery, that of introducing the catheter, in cases where
the urine is retained, not from any resistance arising  from tu-
mour or other obstruction in the urinary  canal, but from para-
lysis or mere want of power in the bladder itself.
   When, from remaining too long in ceremonious companies,
in assemblies,  in  processions,  or in courts of justice; when,
from travelling in  public carriages, or from any cause of delica-
cy or restraint, a man resists  too long the calls of nature,  the
bladder being over-distended, loses  its contractile power, and
when he would pass his urine he makes vain and painful efforts
to discharge it: a spasm  about the neck of the bladder then a-
rises, and resistance is added to  want of contractile power; eve-
ry repeated  effort  increases the difficulty, and pain succeeds to
the simple desire of emptying the bladder.  It is this  pain and
spasm alone  that prevents the catheter passing with perfect ease,
and makes all the  opposition we experience in performing that
operation  on the living body, which is so easily performed on
the dead; for, the introducing the catheter in a corpse, is not
a lesson of that importance which has usually been supposed.
  The catheter passes with  perfect ease, when the retention of
urine proceeds  from  a paralytic affection  of the bladder, as in
                           2  B 
194
Of Introducing the Catheter.
fractures of the spine*  in palsy or apoplexy, in confluent small-
pox, in the end of low  fevers.  Even in cases whin strangury
and pain, accompanied with intense desire,, have followed the
simple retention of urine; in cases  when  the  canal is generally
inflamed, as in gonorrhoea,  the  surgeon should still be able to
pass the catheter with tolerable ease.  But in cases of stricture,
or other  disease in the urethra, the catheter is seldom  useful;
and where the prostate  gland is diseased,  it passes with the ut-
most difficulty, if, indeed, it can be made to pass by any means.
You proceed in the following manner:
  You place your patient with his back resting firmly  against
the wall, striding, but  not  very wide, his feet being  projected
before him a very little ; and you place yourself on his left side,
kneeling  on your  right knee ; you may lay him across the bed,
his feet resting on the floor, his buttocks touching  the edge of
the bed,  and his head and shoulders supported with the pillows ;
or he may seat himself upon a chair,  resting with his hands up-
on the seat, the  perinaeum  projecting a  little over the edge of
the chair, and one of  his friends  standing behind to support
him.   In whatever posture you place  your patient, you find the
posture of kneeling  on the right knee the most convenient to
yourself; it gives you  perfect steadiness;  and, by placing your-
self low with regard to  the patient,  you  obtain a perfect com-
mand of your catheter, which, while  you are introducing it,  is
to move  in a circle.
   You lift the point of the penis betwixt the fore and mid-fin-
gers,  securing the posture  of  the penis  by pressing the  glans
with your thumb: then taking the catheter, which is previously
warmed, and smeared  with  oil, white of eggs, or butter, in your
right hand, you hold it  firmly by the ears, betwixt the thumb and
fore-finger ; and while  you hold by the wings with the finger and
thumb, you lay  the middle, ring, and little fingers, flat across
the shaft, just as you would a pipe.   You then apply the point
of the catheter to the opening of the urethra, and glide it down
steadily and rather rapidly along the urethra, drawing the penis
with the left hand, pressing the catheter onwards with the right,
and guiding it with a semicircular sweep round the pubis, in pro-
portion as the catheter passes along the urethra.  The two hands,
thus re-acting, the catheter glides onwards without obstruction,
till it has turned round the pubis, and you become sensible by
the turn, by the length it has passed, and by the degree of resis-
tance, that it has  approached the neck of the bladder, and is just
about to enter it.
   This is the  critical moment, in which may be seen  whether a
surgeon  can or cannot pass the catheter ; tor if he knows how
to pass it, he suddenly, but not violently, changes its direction. 
Of Introducing the Catheter.             195
He depresses the handle with a particular kind of address, and
raises the point, which, as if it had suddenly surmounted some
obstacle, starts into the neck of the bladder, and the urine bursts
out in a jet from the mouth  of the catheter.
  Those who are unskilful press the tube forward, and persist;
as they had begun, in drawing up the penis, pulling it out to an
immoderate length, imagining, as indeed they are plainly told,
that by stretching the penis, they lengthen the urethra, and make
it straight, whereas, they elongate only that part of the urethra
along which the catheter has already passed.
   In truth the elongation of the penis does not at all affect that
part of the urethra at which the catheter is interrupted, the part
which lies in the  perinaeum, and which is fixed by various con-
nections: a dextrous surgeon indeed generally passes the cathe-
ter with  one continuous motion uninterrupted, and without let-
ting go the penis ; but  when he does feel that he is obstructed
he  lets go the penis, as of no further assistance; he, (while  his
assistant holds up the scrotum,) lays two fingers along the peri-
naeum, on each side of the urethra, and draws the fingers along
the perinaeum towards the scrotum,  soothing the parts, and  re-
laxing the spasm, by the pressure  and motion, and acting as if
the design were to work the urethra along the catheter, as  he
would put the bait on a hook.  If this fail, he kneeling before
the patient, oils the  left fore-finger and passes it into the anus,
the effect of which, is, I am  persuaded, neither the elongation of
the urethra, nor the unfolding any inequalities, of the  canal, but
merely  lifting up the point of the catheter,  by the pressure of
fhe finger, and with a degree  of force and effect which the sur-
geon has not the confidence to use  in the  proper way of bending
down the handle of the staff.
   From the moment in which the catheter begins to pass along
the perinaeum, the point should be pressed strongly against the
upper side of the  urethra which lies under the pubis  ; the cathe-
ter must be all along carried so close to the arch of the pubis, as
never to lose the  feeling of  pressing hard against the bone, and
when it approaches the neck of the bladder  the point must  be
turned quick under the arch of the pubis, as if it  were the sur-
geon's intention to keep it pressed close to the  inner surface of
the  pubis.   While  the  surgeon makes the  point  run  thus
along the bone, as if to avoid  the angle at the lower part of the
urethra,  he must  guide the  catheter  steadily  along, holding it
firm and with an  action something like that of pulling,  as if it
were his design  to hook the pubis.   He must turn  down the
handle and raise  the point of the catheter, I will not say  sud-
denly, or strongly,  but with  quickness  and  address, as  if it
were his design to catch at some orifice, distinct from the canal 
196
Of Introducing the Catheter.
in which the instrument is passing, and to catch it with address
and quickness, as if it were an opening which might otherwise
escape.
   If these  manoeuvres do not succeed, the surgeon changes his
catheter, choosing one bigger or  more slender, with a greater
or lesser curve, according to what observations  he may have
made  in his  first attempt;  but  if the catheter has been of a
good form  and commodious  size, yet  has not passed easily, he
should, instead of choosing a rigid catheter of  another  size or
form,  take one that  is flexible for his second attempt.  The
flexible catheter is generally slender and of sufficient  length,
and its shape may be accommodated to all occasions, and to all
forms of the urethra ; for, having a stiff wire, we can give that
wire (either before or after it is passed into the catheter) what-
ever shape we please; and, what  is of still greater importance,
we can introduce the  instrument  without  or with the wire as
circumstances may direct; or what I find far more advantageous,
we can introduce the  wire partially so  as not quite to reach the
point of  the catheter, but within  two inches or a little more of
the point, by which contrivance the point, if previously warm-
ed and wrought in the hand, has  so  much  elasticity that it fol-
lows the precise curve of the  urethra, and has yet sufficient rigi-
dity to surmount any slight resistance.   If this too fail,  and es-
pecially if there be the slightest reason to suspect that the resist-
ance is not merely spasmodic, but arises from stricture near the
neck of the bladder in the young, or swelling of the prostate in
the aged, we  take a small bougie, turn up the extremity of it
with the finger and thumb,  so that the hooked point may look
towards  the pubis, oil it lightly  and rapidly, and allowing no
time for the softening of the  wax, pass it into the urethra, run
it down nimbly to the place of the obstruction,  turn it with a
vertical or  twisting motion,  and  stick it fast in the constricted
part; and having left the  bougie thus fixed for ten minutes or a
quarter of  an  hour, we usually find  upon withdrawing it, (es-
pecially if,  in  withdrawing, we feel a pull as if it would invert
the urethra,) that either the urine will begin to flow, or at least
that the catheter will now pass.
  But  when we are unsuccessful in these operations, just as
when we fail in our  attempts to  reduce a hernia, we resort to
other means of relieving  the stricture of the parts, before ma-
king a  second  attempt;  first  we bleed, bleed repeatedly, which
at once prevents the most fatal of all symptoms, inflammation
of the  abdomtn, and serves  as an anodyne, and never cnn be
superfluous where the future dangers of the case, and in some
degree the  present obstruction,  proceed from  inflammation;
when we observe the condition of our patient,  his flushed face, 
Of Introducing the Catheter.             197
parched tongue, and rapid pulse, we can feel no reluctance in
bleeding.   We immerse the patient in a warm bath,  and rub
the perinaeum  and  lower part of the abdomen with stimulant
embrocations,  as  spirituous and camphorated balsams or oint-
ments ;  we lay hot  and stimulant applications to the pubis, co-
ver all the  parts with a thick made poultice, impregnated with
camphire or onions, and, above all, give opiate injections very
strong,  for we find  this the  most effectual means of alleviating
the pain and desire, or in other words, the spasmodic action of
the parts:  it  is spasm merely that intercepts the catheter; for
were the patient dead,  no such opposition would  be experien-
ced ; innumerable dissections  have proved that the catheter,
which was not admitted in the living, passes easily into the dead
body.   If after a few  hours of these applications,  the  pain is
relieved, and the patient, by the force of the opium, is inclined to
rest, we are then able to pass the catheter with ease ; and when
we have relieved such  a patient, we must continue our attentions
to him  unremittingly; we  give him prudent  advice  lest the
same continued life of thoughtlessness and dissipation  confirm
the complaint; we charge ourselves with drawing off the urine
thrice a day, till the parts recover their tone; and we never dis-
miss such a patient without acquainting him, that on the slight-
est excess or imprudence, he will relapse into this painful condi-
tion ; for the bladder once distended is apt to be again distend-
ed, without creating any sensible effort, and,  being over-dis-
tended, it loses altogether its muscular power.
   The  period at  which a patient will recover the contractile
power of his bladder must depend much on the conduct of the
surgeon, who will be able to restore its tone by being careful in
his attendance, and preventing the bladder being at any time
filled; by directing the patient to make occasional efforts to
discharge his urine, even although not incited by any desire; by
applying stimulant embrocations to the pelvis; by giving stimu-
lant and purgative injections, or, by giving, if necessary, a few
drops of tincture of cantharides; and finally by applying blisters
from time  to  time to the sacrum, which I hold to be the most
powerful  means  of restoring  the contractility of the bladder:
along with these means the  walking barefooted on a stone floor,
or having cold water  dashed or sprinkled about the pelvis,  is
very effectual in seconding the efforts of the patient.
   If in introducing the catheter, you find your instrument stop
early in a lower part of the urethra, and have reason, from the
history of the case, to  believe that the  obstruction arises from
stricture, you must not persist  in  pressing on your  instru- 
198             Of Introducing the Catheter.
ment, but withdraw it, and pass a small bougie, or use a caus-
tic*
  If, in passing the catheter, you encounter a stone, which you
know by the catheter grating against it, be not rash to drive it
back into the bladder, but press your finger upon the perinaeum
behind the stone, lest it should be driven back,—withdraw your
catheter, and stop to consider of the case, and the means of giving
safe  and permanent relief.
  But if from  the age of your patient and  the history of his
complaint, you suspect the prostate gland to be diseased, and
especially if, from introducing your finger into  the anus, you
are  assured  that the complaint  is of that dismal  nature, you
may, after having failed in the common way, turn the concavity
of your catheter towards the  perinaeum, and turn it at that
point of your progress in which you are sensible  of the opposi-
tion from the diseased gland  and would pass  your instrument
through it.   I  have  sometimes imagined that this method of
operating contributed to open the cleft or valve-like mouth  of
the tumid prostate.
  I  am next, I confess, anxious to  make the  due impression on
my reader's mind, when I come to explain a prejudice which has
indeed almost ceased to appear in this odious light, from being
avowed by men of high reputation  and supported by facts.   It
has  been  asserted, that, though upon introducing the  catheter,
blood flows  from the  urethra in a  full stream, " No harm  is
done;  such  haemorrhage is rather  useful, and facilitates  every
future attempt  to pass the instrument."  I will freely acknow-
ledge that often, from a slight injury a great profusion of blood
will flow; this is an inevitable consequence of the peculiar struc-
ture of the  parts, and no great harm ensues;  but that such a
discharge of blood is entirely harmless,  is a sign of dexterity,
or of any thing  but awkwardness, violence, and a breach  of the
cellular substance, I cannot allow.

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


 X. HE stream of urine small and tortuous, even in the sound
 state of the parts, impresses  us  naturally  with  an erroneous
 conception of the size of the urinary canal.  Mr. Home, having
 injected it with wax, was surprised to find the roll which repre-
 sented the urethra  so large;  and I myself, when I made a
 drawing  of the  urethra, could hardly  believe  my draw-
 ing  at all correct or faithful; for the  urethra  though corru-
 gated in the living, is, when expanded  in  the dead  and dis-
 sected parts,  full half an inch  broad.    This canal,  made
 for dilatation, is full of  rugae; and the  bigness of the stones
 which pass along the canal, and the size of the catheter which
 it receives with ease,  intimate  to us its natural dimensions and
 peculiar conformation, which  is such as  to enable  it to dilate
 into a large sac, wherever the  passage is obstructed by a stone
 or stricture, and the urethra is forced by the propulsive power
 of the bladder.
  It is to no peculiarity of organization, that I would ascribe
 the disease we  call a stricture of the urethra :  I ascribe it nei-
 ther to the rugous  form of the internal membrane, nor to  the
 muscular and contractile power with which the whole  canal is
supposed to be endowed; though the fact of an occasional or
spasmodic stricture, ending in permanent disease, seems to  ar-
 gue this very strongly.  As the tumour, which is a wart on the
skiu, is a pile when growing near the anus,  or a polypus when
in  the passages  of the nose or throat;  so that vascular action
and thickening of parts, which externally would form a tumour, 
200                    Of Stricture.
forms a stricture in any hollow tube; and the stricture is still
the same, whether it form in the throat, rectum, urethra,or pre-
puce.  Stricture is tumour,  and, as a tumour must perpetually
increase while the circulation survives  in the part, unless a to-
tal adhesion of the canal,  by obliterating the cavity, put an end
to the action.  " When in a small degree, (says Mr. Home)
this  contraction appears,  upon examination  after death, to be
simply a narrowing of the canal at that part; but, when the con-
traction is increased,  it becomes a ridge, projecting into the ctf-
nal."  Page 21.
   Those  who have been troubled with an occasional  or spas-
modic stricture of the urethra,  have every reason to fear that
it will become permanent: yet I have  often observed  stricture
to be merely spasmodic, and I think  I have found it  often a
sort of febrile disease.   The stricture  I  speak of is more fre-
quent in winter, arises from cold, is  attended  with fever, and
is more easily cured by any thing than the bougie, which but
aggravates the complaint.  This  febrile  stricture I  have fre-
quently cured in men of the most chaste  and exemplary  live6,
free from the slightest pollution, married, and of  intelligence
much above any kind of secrecy, where they were once pleased
to give their confidence,  men who never  were diseased.   The
fit of obstruction is preceded by  head-ach, languor, and listless-
ness, while the obstruction continues ; and the accession of the
hot stage, which comes  on  in the evening, and especially the
paroxysm of perspiration, which comes on during the night, is
generally a forerunner of relief.   I have seen the obstruction so
complete that not one drop' of urine has passed, though accom-
panied with a degree of desire which urged the patient to place
himself in the posture  every  quarter of an hour, and with such
violent straining  as produced  a  partial erection of the penis,
whence always the obstruction became complete, though not so
before; the bougie being at the  same time  resisted at a single
point as fairly as  if the stricture were permanent and organic,
I have gone to such a patient  at  midnight, with catheters and
bougies,  resolving to relieve him from the  distension of the
bladder:  yet feeling a degree of reluctance at using  harsher
means, I have, by ordering a sharp emetic, followed up  by a
strong dose of laudanum with hot wine and water; by rubbing
the perinaeum very hard at the same time with camphorated
mercurial ointment; and by fomenting the lower  part of the
belly, if necessary,  with a hot stimulant fomentation, or wrap-
ping  the parts in a large poultice,  been saved from doing any
thing painful, and have been rewarded for  my patience and pru-
dence, by seeing the urine discharged freely next day, and con-
tinue to flow in a full and easy stream. 
Of Stricture.                    201
    I have,  after a scene of this nature was  over,  found the
 bougie pass with  perfect ease  into the bladder,  and have the
 pleasure  of knowing that many who have been  alarmed with
 these symptoms  have continued for years free  from organic
 disease, though thus affected from spasm.
    The sudden and total  obstruction, which I have just describ-
 ed, is often seen in the conclusion, but rarely in the commence-
 ment, of proper stricture, which usually betrays  itself by  little
 accidents, and symptoms not at  all distressing.  The patient,
 who has a real stricture, whether from venereal complaints, from
 excess committed in warm climates, or from any  accidental
 cause, is far gone  in  this malady before he is conscious of it.
 He is first thoroughly alarmed by a sudden interruption of his
 urine, when, having sat at table with his friends, he has allowed
 the bladder to fill beyond its natural  and easy condition; for
 that straining which accompanies over-fullness of the bladder,
 causes a state  of half erection of the penis, the  cellular sub-
 stance thus filled with blood, compresses the canal of the ure-
 thra, and aggravates any latent stricture, till the  urine is  actu-
 ally  interrupted.   The patient, the  more he strains, feels the
 difficulty the more; he but increases it by straining, and now
 tjbserves, in a particular manner, the smallness and  the  spiral
 form of the stream of urine: from this unfortunate hour his
 situation  attracts  his  attention,  and his disease increases; he
 recollects that at times, especially after coition, he has had such
 a degree of running for three or four days as has inclined him
 to  believe himself infected  with  gonorrhoea; he has  felt occa-
 sionally slight pain in the urethra, accompanied with very fre-
 quent desire to pass urine,  which he is in the custom of dis-
 charging every three or four hours.   He now remembers that
 for some time  he has been forced to rise, according to the quan-
 tity he drinks  at supper,  three or four times during the night;
 and all this he  would  willingly  ascribe  to spasm, because or-
 ganic stricture is indeed  always  accompanied with spasm; the
 difficulty of making urine, far from being permanent,  returns in
 paroxysms, is  aggravated by cold, increases  in winter,  and in
 summer almost disappears, is easy while the patient is  in a warm
 chamber, is absent almost entirely when he perspires, returns
 upon exposing himself to the air, and those paroxysms, which
 last three or four days, proceed usually  from changes of habit,
 so slight, that he can hardly mark the cause.  But  this  run-
 ning  like a gleet, returning, upon using venery, accompanied
 with irritation,  but never arriving at the virulence of a clap ; this
 occasional difficulty of passing urine, and the frequency of the de-
sire to pass it, are among the most certain signs of incipient stric-
ture,  which ends at last, sometimes  in  the course  of a few
                            2 C 
20.v:
Of Stricture.
months,  (though often it is delayed for years) in unequivocal
disease.
  This scene of suffering once begun, is renewed from time to
time.  The running,  and the desire to pass his water, increase
every time he attempts coition, and he is threatened with abso-
lute and total obstruction every time he drinks hard, or rides a
hunting,  or travels  post, exposes himself  to  cold, is  seduced
into debaucheries, or any way interrupts the  quiet tenor of hia
life; and when  stricture  is  thus confirmed,  it is accompanied
with new and unequivocal sensations, for along with urine the
semen is obstruction, coition is attended, in the moment of eja-
culation,  with  a spasmodic  action  of the accelerator  muscle,
creating a sharp and thrilling  pain; though the sense of emission
is complete, the  point of the penis  continues dry;  the semen
recedes into the bladder,  and sometimes is observed to flow a-
long with the urine:  in this  state of things  barrenness is one
consequence of the obstruction, though  it be in such a degree
only as retards, without entirely preventing, the rapid  ejection
of the semen.
   Betwixt that obstruction in which the urine is forced off drop
by drop,  with violent straining, and that in which the bladder is
entirely obstructed, the limits are extremely narrow, the slight-
est imprudence, the being  unavoidably exposed to cold  and
moisture, will suddenly bring such  a  patient (like one labouring
under hernia)  into extreme  peril; for after the obstruction has
passed a certain point, no straining  will force off one  drop of
urine; nothing but the  introduction of the  catheter  can give
relief, and it is not in every village that assistance  can be pro-
cured.  If the surgeon arrives but a  little  too late, the bladder
is distended to its  utmost pitch,  and far beyond its natural size,
the tossing and uneasiness are very great, the abdomen begins to
be inflamed, the pulse is quick, the tongue  parched,  the lips
black, the eyes inflamed,  the visage pale  and ghastly; and the
 patient,  after twenty-four hours of insensibility, or of low and
 muttering  delirium, expires.   Thus,  in villages and  parts re-
 mote  from help, many valuable lives have been lost; and when
 in this doubtful state, not apparently ill,  yet bordering on the
 greatest dangers, no officer  can go to sea, no soldier can go in-
 to service,  no country gentleman can retire to his estate, with-
 out extreme hazard.
   Without most culpable imprudence the  disease is rarely fatal,
 but the  patient, by the natural course of things, falls, if neglect-
 ed, into a most miserable and loathsome condition ;  for, from
 the moment that the obstruction is nearly  complete, the portion
 of the urethra,  which lies behind the stricture, is exposed to the
 whole force of the bladder and  abdominal muscles, it is soon 
Of Stricture.                   203
affected, as an artery is in natural aneurism, (i. e.) it is first di-
lated, then inflames, then bursts, then the urine  spreading (as
yet not widely) among the cellular substance, causes indurations
of a singular hardness, as if they were rather knots of callus,
gathering round a fractured bone, than inflamed cellular sub-
stance surrounding a breach  in this thin  and delicate tube.
Such thickening, excited by the urine, forms  but a slight and
temporary barrier to the ruptured part of the urethra; the knot
extends and grows, it becomes red on the surface and softens,
it suppurates with little pain, and  bursts slowly; but when  it
bursts, the urine issues through the  opening, the abscess spreads
in various directions; the surrounding parts are all affected ; the
patient often loses, from mere irritation, the power of retain-
ing his urine,  the ulcers and fistulas  become foul and sloughy,
the linens and the bed are incessantly moistened with  urine.
The patient is exhausted  with fits of incessant vomiting, and is
shaken by paroxysms  of fever, apparently  peculiar to this dis-
ease, such as make his teeth chatter and the bed shake  under
him during the  cold stage, and when  the sweating comes on,
the sheets and bed-cloaths, the bed, and even the mattress, are
soaked with perspirations, and the  smell  of his room  resem-
bles that of a Russian bath.   If in  this condition he be neglect-
ed but a few weeks, or unskilfully  treated,  if that fever is com-
bated with  bark and emetics, which  ceases only when proper
surgical incisions are  performed, if the obstruction is left un-
touched, and the sinuses unopened,  and the  matter  permitted
to work its way deeper among the cellular substance of the pel-
vis, the patient sinks  gradually lower and  lower, loses all de-
sire  for  food,  has  a cadaverous and jaundiced aspect,  faints
when raised in bed, and at last dies.
   Stricture is a tumour or growth,  and the striking a firm  bou-
gie into the ring,  and wedging it there, can do nothing but ex-
cite the action, by which the stricture  is produced.  I have seen
the patient under the  old regimen, endure  much torture, and
with wonderful fortitude.   The  wedging the  bougie  into  a
stricture, recalls all the feeling to that part, and  excites  an in-
expressible desire to pass the water,  to retain the bougie half
an hour at first  using it, is impossible ; the  irritation does not
cease when the  bougie is withdrawn ;  after the passages are in-
flamed the mucous flux is increased, the desire to  pass urine
becomes extremely urgent,  if the  urine  passes  more easily  at
first, the relief  is  but momentary; never can the patient feel
relief till after he has  learnt to endure the bougie for hours, and
continued to wear it for months.   To live  thus  for months or
years, is but protracted misery; and to see  the stream ot urine
gradually lessen at every intermission of torture, and to be sen- 
204
Of Stricture.
sible that the disease, never cured, tends incessantly to return,
make  the patient desperate, and he feels that life is not worth
holding on such terms.  It is this state  of protracted  torture
and disappointment  that affects so visibly, the physiognomy,
temper, and general  health of a patient who has stricture; it is
this that  produces  the chagrined  countenance, sallow  com-
plexion, and wasted habit; and often it happened, while bougies
were used,  that false  routes  were  produced  by the irregular
pressure of the point of the bougie, cavities  were  formed by
the sides  of the canal, and the canal itself well-nigh obliterated
by this new cause of compression;  the bougie passing thus in-
to the  cellular substance by the side of the stricture, the  ure-
thra behind the stricture, dilated under the force of the bladder,
and the parts fell into a complicated state of disease.
  With this long suffering and ill  success, let  us contrast the
effects  both immediate  and ultimate of the caustic  bougie.
When the caustic is pressed against the ring of a stricture, none
of those  ill consequences predicted by theorists, ever are pro-
duced; there comes over the patient a confusion and a  sort of
alarm  arising from the novelty of the sensation, which  makes
the most  vigorous and hardy man tremble like an hysterical girl,
and shiver for  ten minutes with the pale  and contracted visage
of one in terror.  Yet the patient is not  in a state of suffering ;
he talks all the while freely, and feels neither  any deep sense of
burning,  or any other description of pain.*   Nor is there any
thing of that immediate inflammation and swelling which it  was
so natural for  the theorist to predict, which  it was supposed
would infallibly close the canal, and  entirely  suppress the flow
of urine, at least for  a time.   There is indeed very often, a
haemorrhagy, but it is of that kind which has been thought so
slightly of,  when it flows from introducing the catheter; and in
the present case alone is such haemorrhagy desirable ; for, as it is
a sign of  the caustic having penetrated to the cavernous body of
the urethra, it is a sign of  success.  Neither does the effect of
the caustic extend along the canal, nor operate, except  on that
point  against  which it is pressed; the swelling  even of the
burnt  part is  not perceptible; the mere act of touching the
stricture  with  the caustic, instantly  gives a degree of relief; for
the caustic kills what it touches; there  is no intermediate state
of inflammation; the  part shrinks, and the  opening,  though

   * Notwithstanding what Mr. Bell  here  fays, patients fometimes evince  by
their actions that they fuller the moft excruciating agony upon the introduction of
the cauftic,  as I have often feen ; and wherever the common bougie would anfwer,
(and that it frequently will, I can aver) I ihould prefer it.  S. 
Of Stricture.                    205
affected but in a trivial degree, is actually and instantly enlar-
ged;  in short, the name only of caustic is alarming.*
  The bulb of the urethra is a natural  dilatation of the canal,
fit for receiving the semen,  which is poured into it during coi-
tion,  and ejected from it by the smart action of the  accelerator
muscle,  in the moment of emission.   Immediately behind this
dilatation or sac of the bulb, the urethra, where it enters the
bulb  is  naturally  narrow, and  joins the  bulb with something
like a ring, or natural stricture;  and it  is here, at this point na-
turally strait, that the stricture is formed 5 a second stricture is
often found a little beyond this point, about half an  inch nearer
the neck of the  bladder: and  whether  there  be one  or more
strictures, they lie so far down in the urethra, that  one, unac-
customed  to introduce the bougie, would believe that he had
passed  it along the whole  canal, and  that it had  entered the
bladder  ;  and  when he  feels  resistance,  he would  suppose
it to arise  from  the natural straitness of the prostate gland:
if there be other strictures than those near the neck of the blad-
der, they are usually in the penis, often about the middle, very
commonly in that part of it from which the scrotum hangs."!"
  It is the number of successive strictures that makes the most
formidable resistance to the passage  of the urine, and a person
unacquainted with this department of practice, having applied
his caustic,  and  at last plumped his bougie  unpremeditatedly
and suddenly through  a complete  stricture,  would be apt to
triumph, but the  urine  flows  not a  whit the more  easily; and
upon introducing a  bougie as a probe, the second stricture is
distinctly felt.
  There is  no other evidence  of the  existence of permanent
stricture but the bougie, nor is it even a very absolute test:  I
have found the bougie  stick firm, as if engaged in a stricture,
which,  after  the  spasm which stopped  it had subsided, has
passed  with perfect ease.   I have often  seen the bougie  intro-
duced by the patient, and so fixed,  either by its point hitching
within one of the  lacunae, or by some other accident, that no de-
gree of force could have  driven  it onwards,  whereas, upon
withdrawing it a  little, and passing it on in a true direction, or

   * For a very ludicrous denunciation of dangers to be apprehended from cauf-
tic, by half a dozen of grave and learned Doctors and  Profeffors, fee in Mr.
Home's book on Strictures, page 5.
  f " Strictures occur moft commonly," fays Mr. Home, '' juft behind the bulb of
the urethra, the diftance from the external orifice being fix and a half or feven in-
ches; the  fituation next in order  of frequency, is about  four and a half inches
from the orifice of the glans; they do occur at three anci a  half inches, and fome-
times almoft clofe to the external orifice."   Home on Strictures, 2d Edit.  pp. 27,
28.   S. 
206
Of Stricture.
 withdrawing it altogether out, and using a fresh and firm one a
 little larger, it has gone on easily to the bladder.
   When your own or your patient's suspicions of stricture have
 gone so far that you meet with him to decide  the question, you
 first make him pass his water before you, that you may remark
 the size and form of the stream: you next take a bougie of a
 respectable size, by no means  a  small one ; and, having oiled
 and bended it somewhat in the form  of a catheter,  you intro-
 duce it before it softens ; and always, in passing the bougie,
 whether simple or caustic, you are quick and dexterous in run-
 ning it up to  the constricted part,  before  it begins to soften,
 which it does very suddenly, when affected by the heat of the
 urethra.   You  proceed  thus:  you raise the point of the penis
 with the  left hand,  you then introduce  the bougie with the
 right, and run it on suddenly, till having passed the scrotum and
 reached the perinaeum, you change your left hand from the pe-
 nis  to the perinaeum, you press in the points  of the  fingers of
 your left  hand  behind the scrotum,  and run them back along
 the  perinaeum,  accompanying, as it  were, the progress of the
 bougie; and  while you push the bougie  smartly on with the
 right hand, you press in the  perinaeum with the fingers of your
 left hand, directing the points of  your fingers so as to turn the
 point of the bougie directly  upwards, before the anus, at the'
 place where you expect to feel  the stricture.  You feel the re-
 sistance  and  assure  yourself  of the stricture.   You satisfy
 yourself that the bougie, in place of  going onwards, is curling
 up under the force of the pressure, you  then withdraw the bou-
 gie and find it curled like a pig's tail,  but with a point not at all
 ruffled, because it was never admitted within the ring of the
 stricture,  so as to receive any impression from it.  Either now
 or at some future occasion, you measure the stricture, by using
 a bougie small enough to enter into it; you take a small pointed
 and  stiff bougie, give it  the  bend, introduce  it after the same
 manner, but instead of stopping, for fear  of giving pain,  you
 press it on and wedge it firmly  into the stricture, where, if it be
 pressed but a very little, it takes a hold and is withdrawn again
 with difficulty, and with a sort of feeling as if  the urethra were
 inverted by it.  Upon being altogether withdrawn,  the wax is
 found ruffled on the point of the bougie, a sort of ring marks the
 part  embraced by the stricture, and the progress which the coni-
 cal point of the bougie had  made in the stricture, denotes the
 size  of the ring.
   The application  of the caustic really and  effectually to the
 stricture thus discovered,  is no easy matter.  The most dexte-
rous  apply it sometimes twenty or thirty times without success,
while it happens not unfrcqnently, that the armed bougie plumps 
Of Stricture.                      207
through the stricture at the third or fourth experiment.   Those
bougies which are  made in London, are certainly the best, for
they have a long caustic securely lodged, and sufficiently expo-
sed ; yet I make  armed bougies  perfectly satisfactory  to my-
self, by cutting the pencils  of caustic nicely,  introducing the
point of a sharp pen-knife into the point of the bougie, and turn-
ing it vertically,  till the centre rolls of cloth, of which the bou-
gie is composed, are scooped out and the outer circle only left;
then the caustic being lodged in the hollow and the edges of the
cloth, of which the bougie is composed, folded over it, a small
round  knob of the caustic is left exposed, and the bougie which
had softened under the modelling of the fingers,  is laid by to
harden; the edges of the plaster having then taken a firm hold
upon the caustic.
   When the caustic bougie is to be introduced, I like to pass a
common bougie before it, liberally besmeared with oil, not to as-
certain the place of the contraction so much, as to lubricate the
passage,  and  make the caustic glide quickly to the destined
point.   Then placing the patient, and bending the bougie as just
directed, you  (having oiled the point of the urethra, and spread
its lips, that the caustic may not,  as often happens, touch the
point)  glide the bougie down nimbly and quickly down the ure-
thra till it is resisted by the stricture; you then change the fingers
of your left hand quickly from the penis to  the perinaeum, and
there, by pressing them in succession, you direct and work on
the bougie with the left hand, and prevent it bending, while you
force it into the stricture with the right;  and all this must be
smardy, nimbly, and dexterously done, for the bougie soon sof-
tens and bends, and you have no longer any power over it: ha-
ving struck the bougie firm into the stricture, you keep  it pres-
 sed home against it for a few minutes; the patient at first feels
 very little indeed, only the slight pain of pressure, which, howe-
 ver together with the novelty of the sensation and the alarm,
 makes him blanch and almost faint, or at least be seized with a
 cold and trembling fit, shaking as if in an ague.    The  pain is
 nothing compared with the patient's imaginings;  though the
 name of the caustic sounds alarming, the sense of burning which
 it occasions  is very slight, the bougie,  after a few minutes, is
 withdrawn, and  the  slight  irritation occasioned  by  it sub-
 sides.
    There sometimes accompanies the application of the caustic,
 a slight tinge of blood, a degree of ardor urine, an increased de-
 sire to pass the urine, but indeed the pain and irri:ation are so
 slight, that the  patient is contented and easy in his mind, and
 his urine flows  more  freely than before;  he  is at all events
 freed  from that apprehension which he could not but feel when 
208
Of Stricture.
 he thought of having a caustic bougie passed into the yard. But
 the stream of urine which was a little enlarged by the first ap-
 plication,  becomes smaller again, the caustic is again  applied,
 and on the fourth or fifth,  or perhaps the eighteenth  or twen-
 tieth application, sooner  or later, it  passes  through the stric-
 ture, and the urine,  if there be no second stricture, flows with
 perfect ease.
   The young surgeon, in the  course of his practice, will observe
 and be  perhaps alarmed with several unexpected circumstan-
 ces.   First, he will sometimes be alarmed  with the apprehen-
 sion of the caustic having dropped from the end of the bougie,
 and it often does actually excoriate a great length of the canal,
 but the worst consequences produced even by this accident, are
 an unusual degree of irritation in the course of the canal, running
 as in a smart gonorrhoea of thin and bloody serum, a heat  of
 urine, slight pain in the perinaeum, and sometimes slight pain
 in the testicle.  I have seen large flakes of the lining membrane
 of the urethra discharged  along with  the bloody serum;  but
 the worst of these symptoms  subside,  and in a few days  the
 caustic can be applied  again.   Secondly, he will  be surprised
 to find, when he chooses the  largest caustic bougie in order to
 make sure of the effects of his caustic,  that it  has actually no
 effect, for though a large bougie exposes a greater surface  of
 the caustic, that surface does not come in contact with the stric-
 ture ; a smaller bougie is more fairly admitted into the ring of the
 stricture, and has, according to my observation, a much happier
 effect*  Thirdly, he will  be surprised with the rude and unu-
 sual sensation the bougie conveys to his finger when  passing
 through the stricture; for at that particular application in which
 it passes through, there is no  determined interruption ! but in
 the moment when the bougie approaches the neck of the blad-
 der and is passing through the cauterized ring, it is felt to grate
 along as if it were passing through a shot hole in a rough deal
 board.  Fourthly, he  will sometimes be alarmed  even  by the
 happiest presages ; for often there comes on so profuse a  hae-
 morrhagy, that, instead of  urine, nothing but blood seems to
 run from  the urethra,  in a full stream, as freely as from a vein
 in the arm, hanging in coagula from the point of the yard.  Yet
 such  haemorrhagies  imply nothing but success, for they arise
 from the sloughs having destroyed the stricture, and penetrated
 into the cavernous body of the urethra : a profuse haemorrhagy,
 while it is actually harmless, is a prognostic of a speedy  cure.
   The horror and shivering which the patient, though suffering
neither fear nor pain, cannot suppress; a shivering so violent as
to make the teeth chatter audibly,  is no sign, as far as I  can
distinguish, either of safety or danger, of success or failure; but, 
Of the Causes of Fistula.              209
 if, any thing, it  intimates the successful  application and action
 of the caustic, for in the same patient I  do not find the same
 paleness or trembling upon introducing the common bougie.   I
 have sometimes on the evening after applying the caustic, found
 my patient  vomiting from the nervous affection, and some-
 times I have seen him, after a long fit of shivering, slightly de-
 lirious, without  any perceptible fever.  The sickness and deli-
 rium,  resemble those from intoxication.  The sickness is of so
 unusual a kind,  that the  patient has not time to stretch out his
 hand for the basin, and the delirium or  confusion  of the head,
 accompanied like that of drunkenness, with particular stupor.
 Fifthly, the young surgeon will  be often surprised to find, while
 he is despairing of success, that his patient informs him of his
 cure, of having passed his urine freely and in copious streams,
 and especially he will be surprised when informed, that the flood
 of urine has pushed on before it a stone  of considerable size.
 But,  in truth, stones are often formed behind a stricture, from
 small particles of gravel  sticking there and  accumulating;  and
 when the stricture is destroyed,  the stone passes and drops into
 the water-pot the first time the urine is freely discharged.  The
 surgeon and  patient are alarmed at the first,  by every unusual
 symptom,  are soon reconciled to the  use of the caustic, then
 become familiar, and are at last doubtful of any effects, bad^r
 good,  from this application; but a  surgeon  experienced  irrthe
 use of it is not dismayed, although  he perceive  no effect after
 many  applications.  The  bougie   often starts  unexpectedly
through the  stricture, the fifteenth or twentieth time it is ap-
plied ;  it has been  applied  forty times, by the most skilful, with-
out effect, and has at last  succeeded.   To mention thus the oc-
casional circumstances which  accompany  the  cure, is  perhaps
the surest way of preventing alarm,  and ensuring success.
                        SECTION II.

          Of Fistula in the Perina-um and Urethra.

   From these simple obstructions I proceed to  describe more
complicated scenes of distress,  arising not solely from stricure,
but from any cause obstructing the urinary canal: for whether
a stone  sticks in  the urethra,  or by  a blow on the perinaeum
swelling and inflammation are  produced, whatever  cause pre-
vents the urine from  passing freely exposes the  urethra behind
the obstruction, to be dilated, inflamed, ulcerated, or even burst
by the force of the bladder.
  It is not  to be told what difficult and perplexing forms this
                            2  D 
210
Of  the Causes of Fistula.
complaint assumes, how anxious, careful and curious, the sur-
geon's inquiries must be  before he can understand the extent,
form, and other circumstances of  any particular fistula;  I shall
thorefore be at pains, both by my arrangements and descrip*
tions, to give the young surgeon clear  conceptions ot this dis-
ease.
  There are three general cases  which demand especial atten-
tion:
  First, The obstruction of urine proceeding from some vio-
lence  to the perinaum,   from a  blow,  a  fall, or other accident
by which, though the skin remains entire, the urethra itself is
lacerated, and the urine, obstructed in its natural passage,  bursts,
along with  the  extravasated blood, into the cellular substance
of the scrotum and perinaeum, and makes external openings by
causing a gangrene of the parts.
  Secondly, The  canal  obstructed by the sudden impaction of
a stone  in it.  The case  ill understood, and the urethra  expos-
ed to the force of the bladder, by which it is dilated into a sac,
in which the  original stone is  gradually augmented in size,
while other  stones are often generated.
  Thirdly,  The fistula arising sometimes  from stricture; some-
times from  venereal or  scrophulous ulceration, which, in its
progress, is  accompanied  with a succession of abscesses, various
openings through which  the urine is discharged,  and extensive
indurations  of the surrounding cellular substance; till at  last,
the perinaeum and scrotum, perforated at various  points,  and
discharging urine, pus,   and  flatus from the  putrid  cellular
substance,   resemble in  lividness and hardness  the integu-
ments covering a  diseased bone, while the patient  is wasted
with successive paroxysms of fever and pain ;  by want of rest,
and by  the uncleanliness and offensive smell.   Let these slight
definitions serve  to indicate the chief subjects of the following
discourse.
   The  membrane of the urethra  is delicate and easily ruptured,
and the  cellular substance surrounding it is  like a vein full of
blood continually circulating in it.  The urethra itself,  or  the
cellular substance of the  urethra,  is often  burst by a blow or fall
upon the perinaeum, as in trying  to leap across forms or chairs,
or  slipping a foot in crossing a stile ; or by  masons, miners, or
sailors,  falling from a height and  alighting among loose  stones,
or  upon projecting beams, or upon the  breech of a gun, or the
fluke of an anchor.  The urethra, or cellular substance of  the
urethra, being burst by a blow, the blood either flows from the
penis, or is extravasated in the perinaeum according to  the de-
gree of injury.
   When the lining membrane of the  urethra alone is burst by 
Of the Causes of Fistula.
211
th* fall, the blood runs from the penis in a full stream to the
g^-eat terror of the patient,  who apprehends the most horrible
consequences; but it is like that  haemorrhagy which  follow*
the  rude introduction  of the catheter, harmless:  the blood
flows indeed as freely as from a vein, but it coagulates, and the
haemorrhagy stops of its own  accord: it is  indeed renewed by
the  passing of the urine, the clots which are in the urethra be-
ing forced off in long strings, or bolted out in small knotty co-
agula ; but it stops again: and though I have often  seen such
haemorrhagy proceeding from a venereal  ulcer in the  urethra
bleed  thus for three  days, and  though I have at  last been o-
bliged to lay a compress upon the  penis, and lay it down upon
the  belly with a bandage to stop the haemorrhagy, I never yet
saw the patient injured  by the loss of blood.
   I have had patients run into  my room with their pantaloons
filled with blood, but I have seldom been obliged to use pres-
sure, to which the whole canal of the urethra, and  especially
the  bulb, is so fairly exposed, that no harm can  ever happen.
When blood flowingalong with the urine comes thus from the cells
of the urethra it flows in a stream; and when coagula are form-
ed they  are  long, slender, and stringy; but when the blood
flows, as I have seen it, from the kidney into  the  bladder, or
from the ulcerated surface of the prostate (a part which is sur-
rounded with a plexus of veins) the clots are very condensed,
round, and  firm;  they obstruct the urethra and neck of the
bladder  so  that  the  force required  for  their expulsion is very
great; the patient, every time he passes his urine, stalks about
his room in all the agonies that those feel who have actually the
stone; and  when, after many efforts, the clots are  propelled
through the urethra, they bolt out to a great distance.
   When the blow is very violent, the bulb  of the urethra is
completely  burst, blood flows from the penis in great profu-
sion, and a tumour is observed in the perinaeum  arising  from
the same extravasation of blood.  The extravasated blood,  like
that of an aneurism,  makes a rapid  progrees among  the loose
cellular substance of  the scrotum, which swells sometimes to
the  size of a child's head.  The blood is pushed  forward also
under the skin of the penis, till the swelling of the prepuce en-
tirely  hides  the  glands; and the blackness extends upwards
over the belly and down the thighs.   A  surgeon well acquaint-
ed with the structure of the parts, even though not skilled in
this  department of practice,  will easily perceive that the urethra
is burst, and will no sooner see blood effused and an extending
ecchymosis,  which is comparatively harmless, than he  will ap-
prehend, next  an effusion of urine into  the  cellular  substance,
which is full of danger; and, the moment  he sees an effusion 
212
Of the Causes of Fistula.
of urine, he  will make no delay, but perform  those incisions
which are necessary to save the parts, especially the skin of th*
perinaeum and scrotum  from destruction.  When the patient
feels the sense of passing urine so distinctly that he  cannot be
persuaded that it is not passing, but by seeing the  point of the
penis  dry; when the scrotum and perinaeum, which were at first
swelled and livid, become puffed  up suddenly; when the swell-
ing, which  was at first firm  and resisting, becomes soft, and
gives  a crepitating feeling, and especially  when no urine passes,
and yet the patient feels the usual relief, the surgeon  may be
assured that the urine is  passing into  the cellular substance;
that the parts will soon fall into gangrene ;  that the testicles, and
perhaps the  penis, will, by the sloughing of the  skin, be  left
naked and exposed, and  the  skin of the perinaeum partly or en-
tirely destroyed.   These are  most dangerous circumstances,
and the fate of the patient depends directly and plainly on the
talents  and discernment of his  surgeon:  and there are two
modes of proceeding, one of which leads to safety,  and con-
verts  a dangerous accident into a very simple case  in surgery;
the other, of which there are unhappily  too many precedents^
leads to destruction.
   If,  when the surgeon arrives, he is not aware of all the con-
sequences of the accident; if he  do not reflect  more upon the
effusion of urine soon to take place, than upon  the present diffi-
culty of introducing the catheter; if he calls a consultation of
surgeons chiefly to assist him in the introducing of the catheter,
or in consulting about tapping the bladder: if one or two  days
are lost in  vain attempts to  introduce the catheter, and in the
unmeaning and trivial occupation of applying fomentations, em-
brocations,  and poultices to  the parts;  the parts fall inevitably
into gangrene; and it has actually happened that, while a grave
consultation has been deliberating on the  means of drawing off
the urine, it has been escaping  into  the  cellular substance and
causing gangrene ; and  after gangrene has actually taken place,
they  have, in a fit of despair, and to accomplish they knew not
what, tapped the bladder from the  rectum; and yet, after all
this   destruction  of surgery and disease has been consummated,
the parts have healed in so  kindly a manner as to prove  that
nothing was required but a few superficial incisions to keep the
patient in safety.
   The stricture of the parts  and  usual consequences then of this
accident being considered,  the surgeon  cannot easily mistake
what is to be done.
   First, no doubt he is to introduce the catheter; it is the most
obvious and easy means of preventing  effusion  of urine, and
restraining the extravasation of blood:  and, if  the  flexible  ca- 
                  Of the Causes of Fistula.              213

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

                       SECTION I.

                  Preliminary Observations.


J. SHALL conclude  this  subject with  the  description of a
desperate operation, which is yet our sole resource in  the last
stage of misery.  The operation of paracentesis is less frequent-
ly resorted to as the means of saving the lives  of young and im- 
Of Paracentesis  Vesica.
223
prudent people ; it is more commonly resorted to as a means of
prolonging the years of the aged and infirm.   When in a young
and otherwise healthy man  it happens, that  by a blow or fall,
the perinaeum is injured; or when,  from a  neglected stricture
and  a sudden  suppression of urine with fever, it is necessary
to perform the operation of paracentesis vesicae, the scene is ve-
ry distressing;  but  when in a man far  advanced in years, the
prostate gland has been  long diseased and has  occasioned  fre-
quent obstruction;  when, at last, the bougie  gives no relief, and
the catheter cannot,  even with any degree of force  or rudeness,
be driven  into the  bladder, the scene is not less affecting, for
this swelling of the  prostate is a disease almost peculiar  to learn-
ed and sedentary men ;  and the patient's age,  infirmities,  and
present sufferings;  the dignity with which he supports them;
the presence of his family depending perhaps on the survivancy
of his  offices,  and the melancholy dispersion of his family,
which must follow his death, create a  strong sympathy.   His
genius and literary talents give  us  a  particular interest  in his
fate;  the operation  is, it must be acknowledged, but a tempora-
ry resource, yet such a man can bear to linger on a little longer,
and, with his family around him, think it happiness.
   It  is not possible to refrain  from alluding to a melancholy
scene, which returns too often not to leave serious  impressions,
and it is most natural to feel some degree of anxiety in trying
to resolve  many doubts concerning the proper conduct of the
surgeon in circumstances naturally perplexing; where the chief
masters in surgery deny us the benefit of their advice and counsel.
" I must own," says one of the  first surgeons of our own coun-
try, " that I have  not seen cases enough to enable me to give
all the varieties that occasionally happen, and, of course, all the
advantages and disadvantages of each method."  But are those
who presume to teach, entitled thus to decline giving  their best
advice because every such case is full of difficulty and  danger ?
Is it fair thus to devolve the most difficult questions in our art
upon the individual  surgeon  perplexed at once by the delicacy
of his situation  and the selfish  reserve of authors, whose  pro-
vince it is to lay down the plain line of his duty ?  Whatever
presumption there  may  appear  in offering  to explain  a subject
which has been declined by so great a master in surgery as Hun-
ter, I cannot but reflect that this is an operation which may e-
ventually fall to the lot  of  every surgeon  to perform:  that no-
thing could be more ungracious  on the part  of a teacher than to
devolve on every young man the difficult task of going unassist-
ed through a long process of reasoning upon the  choice of in-
struments or methods, attended with the imminent risk of think-
2 F 
226
Of Paracentesis Vesica.
ing too long, or of acting too rashly: I cannot but recollect that
the young surgeon coming unprepared to such  an operation,
may make his incisions in the perinaeum deep and wide, and yet
miss the bladder, and  find no better way of retrieving his error
than by performing  a second  operation by incision above  the
pubis: I have seen  this, and,  to my utter amazement, have
seen a patient so mangled, survive.
                          SECTION  I.


           Of Distention and Rupture of the Bladder.

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

  * Either the neck of the bladder,  or the beginning of the urethra, certainly
 ruptures in fome inftances; in confequence of which, the urine becomes extrava-
fated in the perinaeum.  The impreffion on my  mind is very ftrong that I have
feen bladders evidently lacerated from over diftension.   S. 
Of Paracentesis Vesicte.
227
 when it reaches the scrobiculus cordis, and can rise no higher;
 when the distension is at its extreme, and neither the bladder
 nor the space  in  the  abdomen can receive more, the general
 pressure  acts  like  an expulsatory  power, and one of  these
 things must happen: either the bladder must give way and la-
 cerate, which it never does,  so equally is it supported by the
 pressure  of the surrounding parts ; or its orifice must dilate,
 and the urine begin to flow.  The urine actually begins to flow
 from the third day of the suppression, and whatever urine de-
 scends from the kidnies is evacuated in small quantities from
 time to time.
   Now this gradual and dribbling evacuation  of urine, which
 empties the bladder, which begins with the full distension of it
 and continues till  the  eighth  or tenth day, or  till the bladder
 yields,  has been long understood by good surgeons, and has
 been especially  named by the French writers,  " Urine par re-
 gorgement."  This evacuation of urine, proceeding from  over-
 distension, is most dangerous and deceitful.  The friends feli-
 citate themselves that the urine begins to  flow; they  commu-
 nicate their information to the physician, which he is too apt to
 believe; basins and cloths wet with urine are easily produced,
 but the patient lies unrelieved; and the. continued distension of
 the bladder is followed by  universal inflammation of the abdo-
 men : the insensibility and low delirium of incipient gangrene,
 are mistaken for that relief which  was expected from the  flow
 of urine,  till either hiccup comes on, and the patient dies  of fe-
 ver and  inflammation; or the urinary bladder actually  gives
 way, and the acrid urine is  poured out into the cavity of the
 abdomen.   Cases  innumerable of this description are to be
 found in the writings of the  older surgeons ;  the quantity of
 urine corresponds  so well with the quantity of drink,  that the
 physician is apt to  be  deceived ; and  Colot tells of many  cases
 in which, while they  believed this, overflow of  urine to be an
 incontinence, they  actually  mistook the distended bladder for
 an abdominal abscess,  and made appointments to open it by in-
 cision.
   Let no surgeon then trust to the reports of nurses or friends,
 nor partake of their inconsiderate jov, but lay his hand upon the
 abdomen and tap with the  finger,  that he may distinguish the
 distended bladder and  the  fluctuation of the urine.
  Since then the bladder suffers no farther distension from the
third  day,  why should it burst ?   Not from laceration, for it is
supported by the uniform pressure of the surrounding viscera,
and the general tension of  the abdomen:  not by yielding, sud-
denly, for  it is distended to its utmost  on the third  day of sup-
presbion, and yet seldom gives way before  the tenth: not by at- 
228
Of Paracentesis  Vesica.
tenuation, as a substance merely elastic gives  way fibre after
fibre, or bursts suddenly, for the bladder, even more than  the
womb,  increases in thickness in proportion  as  it is distended.
The term laceration never was more unfortunately applied than
to the bladder ; for when there is a breach in it, we find upon
dissecting it to be a small round hole, such as might be covered
with the point of the finger ; it is round like a shot hole, with
a rough and ragged margin, in short, the rupture is at a single
spot, not longitudinal,  but circular; the bladder, and  all the
adjacent viscera, are red and inflamed, while this single point is
black and mortified.
   The  signs of death are  not  merely similar to those of pro-
tracted  labour or  strangulated hernia, but  are essentially the
same, as proceeding from the same cause.  While the bladder
is distending, the abdomen feels hard and firm,  and the tumour
is circumscribed in the  hypogastric region : when the bladder
reaches the scrobiculus cordis, the symptomatic vomiting comes
on, the pulse becomes rapid, the belly becomes extremely sensi-
ble, and the patient cannot endure the gentlest touch: and soon,
the particular swelling of the bladder is concealed, because  the
abdomen in general becomes tumid  and elastic, like a drum,
while the pulse becomes frequent and irregular, the  mouth is
parched, the face ghastly, and the extremities cold;  and when
after a period of insensibility or low and muttering delirium,
the patient expires, we  find, upon dissection, the bladder deep
coloured, of a dusky  red, thick and fibrous,  or fleshy: often
the bladder has formed  adhesions  with  the surrounding parts,
and  the  viscera of the abdomen  are very generally inflamed
before  actual  grangrene comes on, or the bladder gives way,
and the patient usually expires thus, not of rupture of the blad-
der,  but of fever, irritation and suppressed  discharge.   But
when the bladder has actually yielded, its rupture is accompa-
nied with a sense of something giving way within, and  we find
that the opening is in the  centre  of the fundus, in one round
gangrenous spot,
   To those who imagine that the extension of parts in the living
body, is like that of the dead, an attenuation or  mere dilatation!
who expect to find the bladder, upon dissection, thin and trans-
parent! its real condition must appear  very surprising.  The
bladder has not indeed time to grow by an actual deposition ot
parts, but it is thickened by the fulness  and turgescence of its
vessels, and by extravasation into its cellular substance.   I find
always  the veins extremely  turgid, the  muscular fasciculi big,
fleshy-like, apparently injected with blood,  (as in a preparation
where the bladder is injected with size,  till the size is extrava-
sated among the coats).   And while much blood h extravasated 
Of Paracentesis  Vesica:.               229
  into the cellular substance of the coats of the bladder, some ex-
  udes into its cavity, thence  the urine is always  deep coloured,
  obviously tinged with blood, and the last pound of urine drawn
  off,  either by the catheter or trocar, from a distended bladder,
  is as thick and as deep coloured as coffee-grounds, tinges the in-
  struments black,  and is extremely foetid.  The slow and gradual
  distension of any living part is invariably accompanied with ac-
  tual growth or a secretion of new parts ; sudden extension is ac-
  companied only with a turgescence of vessels, a fullness of blood
  in the part, and an extravasation into the cellular substance : in-
  flamed viscera, have always from this extravasation, a livid ap-
  pearance : a strangulated intestine,  and a distended, and conse-
  quently inflamed bladder, resemble  each other in this respect,
  and though such  parts seem gangrenous, yet, upon  macerating
  them in water,  the blood being washed out, they  resume their
  natural complexion.
   That these several stages  of dilatation of the  bladder may be
  exemplified, I shall briefly recapitulate the circumstances of such
 a case : A woman having fallen in labour on Saturday morning,
 the  head of the  child descended into the pelvis, the pressure on
 the  urethra prevented any  urine being  discharged, the head
 descended lower and lower, till the scalp appeared, on Monday,
 protruding through the orifice of the vagina.   In this state of
 suffering the woman was permitted to remain till Tuesday even-
 ing, when she was delivered.  During four complete days  the
 pelvis had been so occupied  by the head  of the child, that the
 urine could not be discharged.
   The catheter was never introduced,  nor  did the medical at-
 tendants make even the slightest inquiry into the state of the ab-
 domen : the  nurse, when changing her linens, after delivery,
 was sensible of an unusual degree of fullness, and the patient
 expressed her desire to pass her urine, but she lay down, the de-
 sire returned again at the distance of two hours, and then she pas-
 sed  about a pint of urine, next day she suffered much from pain
 in the abdomen, with frequent desire to make water, which  she
 discharged in tea-cup-fulls.   On Saturday, (the eighth day of
 her distress) the physician who attended her was again called:
 her belly was now greatly distended, with great  torments, diffi-
 culty of breathing, and oppression,  an intense thirst which she
 durst  not indulge,  fever,  furred tongue,  and very frequent
 pulse: about an hour before his visit, she felt something with-
 in, at the navel, crack,  with great pain.  For thirty hours pre-
 ceding this she had made no urine,  nor did she pass one drop
 from that  time forward.   A few ounces of very foetid and dark-
 coloured urine were now drawn off by the catheter, and on  the
second day after, she died delirious.   The abdomen was found, 
230
Of Paracentesis Vesica.
upon dissection, universally  inflamed: the bladder had given
way, and the opening was found to be in the centre of  the  fun-
dus, of a circular form, and with a black and gangrenous mar-
gin.
  Obstructed  urine,  hernia,  and  lingering labour, resemble
each other so entirely, that in each case the same signs indicate
the same danger.  In the common fate of the patient those three
cases unhappily agree but too well ;  delay is the greatest
danger,* and perhaps I have not,  in this book, announced a
maxim of more importance than this !  I  entreat  the young sur-
geon to beware of delay.   In suppression of urine it is most
painful to see that the needful operation is usuallv  performed
too late, that  the  patient's resignation avails  him nothing, and
that the dexterous operator has no reward for his skill and dex-
terity.   In these three cases it requires talents, experience, and
a spirit of observation, to conduct the patient safely : to give a
fair chance of relief from the powers of the constitution, without
exposing the patient to danger, by delay  : to decide  whether in
cases of retension of urine, the abdomen be still uninflained, so
as to allow time for the good effects of fomentations,  poultices,
with a variety of trials,  to force the  passage ? or whether the
danger be not  pressing, requiring the bladder to be relieved at
every  risk, either by forcing the  catheter  violently  through
every  obstruction, or by piercing it with the trocar ? This  I am
well assured of, that there is no mode of operating, no kind of
danger equal to that of delay..  It were better that the  surgeon
cut into the bladder by  any cruel method ! better that he cut
above the pubis, or make his way by incisions in the perinaeum,
after the manner of the lateral lithotomy, than to delay the ope-
ration one hour beyond that in which the signs of inflamed ab-
domen manifest themselves;  for,  after  l,he rudest  operations,
the patient sometimes survives,  but  from delay thousands have
been lost.   It is,  I  believe,  the opinion of all good writers, the
maxim respected in all aeras of our science, the  fair deduction
from all the fatal  or prosperous cases on record, that we should,
in retension of urine, as in hernia, operate early.
   But while I speak thus the language of conviction, and repeat
die injunctions of the most experienced of our profession, I can-
not be without some anxiety,  lest the young surgeon should be
led into rash measures.   I know it  to be true that  few have

   • This maxim is undoubtedly correct where the operation is or will be neceffa-
ry ; but this is so feldom the cafe that  in  ten years Default performed it but onct,
 in the Hotel-Dieu, of Paris; and even in that inftance, he afterwards tLou^ht it
might  have been avoided.  Mr. Abernethy is of  opinion that the  operation is
rarely if ever necelTary, that the remedies above mentioned will, in almoft every
cafe, procure a difcharge of the urine.  5. 
Of Paracentesis  Vesica.               231
 suffered by precipitation, such is the natural  aversion to opera-
 tions, and the reluctance of friends! while in my own limited
 practice I have  seen many victims to timid measures  and ope-
 rations  performed too late; yet I am inclined to trespass with
 one observation more, which may  serve to qualify the opinion
 I have  laid down.
   Although the greatest danger is  to be apprehended from in-
 flammation of the abdomen, yet  the whple aspect of the case is not
 to be ascribed to this cause: the low delirium, trembling pulse,
 or even hiccup, do not portend  death in distension of the blad-
 der so  absolutely as in a gangrened limb : these are not always
 signs  of internal gangrene,  often  they  manifest themselves
 while the parts continue sound:  nor does every degree of swell-
 ing of the belly, vomiting, and faintness, infallibly indicate abdo-
 minal  inflammation :  many of the worst signs proceed, in some
 degree, from mere irritation, and the patient's exhausted state.
 In retension of urine,  the fullness of the  bladder  and suppres-
 sion of the natural discharge, the tossing and misery of the pa-
 tient, from desire to pass urine, and the ineffectual endeavours
 to introduce the catheter, exhaust him, and he seems in  the
 last stage of the suppression, to lie almost in a comatose state.
 In short I have, in the course of my practice, observed that in
 all these cases delirium comes on very early, in consequence of
 the  pain, fever, and want of rest, for many days and nights.
 The inference then is plain: that though in  such cases nothing
 but operating can save the patient's life, we  never must so far
 prejudge the question, as to say  he  is beyond the reach of art!
 Every, surgeon of experience must have observed, that in dan-
 gerous  distensions  of the  bladder,  the  abdominal pain ceases,
 the pulse subsides, the tossing of the patient, and all  the signs
 of indescribable uneasiness, vanish as  soon  as  the catheter or
 trocar  is forced into  the bladder: after  those  several opera-
 tions, the delirium goes  off, the senses become clear, the fever
 abates,  and the natural sleep is  restored.
   In short, the worst signs are no sure proofs of gangrene ; the
 patient  is perhaps exhausted with sickness, irritation, and pain;
 we never must prejudge  the question, saying, " It  is surely
 too late to operate."  In the most hopeless cases, let the
 patient have his  chance for life.
   And  now that I am to analyse  the  several operations,  and
 teach that which is fittest in the several circumstances to be per-
 formed, I shall say a few words on a subject of some delicacy.
 The talent of operating  is not  merely useful, as  enabling  the
 surgeon to perform  safely, a dissection which is not without
 danger,  but still more  in giving him perfect  possession of  his
own mind.  The degree of skill we have or suppose ourselves 
232             Of Puncturing the Bladder.

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

                        section  III.

       Of the several Methods of puncturing the Bladder.

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

                      first method.

   The most common operation, because the most obvious,  is
to penetrate from above  the  pubis.   Every ignorant tyro,
though unable to  strike the bladder from any other part, is able
to plunge the trocar into it,  at a point where he feels the fluctu-
ation so plainly :  that superficial objection of the danger  of
wounding the peritonceum, so often urged against this  method,
Is indeed of no importance ; there  is  no danger of wounding
the peritonceum, for the bladder, when greatly distended, reaches
high above the navel,  carries the peritonoeum, of course, before
it, and exposes a space ot several inches, in which we may per-
form our incisions without incurring this kind of danger.  But
the abdomen is inflamed; the preliminary incisions, which pre-
pare for the introduction of the trocar, pass, in a gross old man,
through several inches of fat and cellular substance:  the inci-
sions must be wide  in proportion to their depth:  the canula is
no sooner lodged here than it is displaced,  in  some degree,  by
the contraction of the bladder, which, when emptied, subsides
under the pubis:  the canula stands so obliquely that the urine
never flows with ease but by running out upon the  wound, and
by being injected among the  cellular substance,  it causes the
wound to inflame, the wound, by  its proximity to the  inflamed
peritonoeum, soon mortifies, and thus, notwithstanding the tem-
porary relief produced by the emptying of the bladder, the pa-
tient dies on the third or fourth day.
   Those who have been forced by fatal experience to condemn
the puncture above the pubis,  have entered  into no investiga-
tion,  and have not always  been able to assign a cause for their
ill success ;  but it is well known that the wound is apt to gan-
grene, the operation is  so  easy that nothing  but experience of
its ill consequences could prevent its being universally prefer-
                           2  G 
234              Of Puncturing the Bladder.

red: but the unfavourable issue  of the operation is now so uni-
versally  acknowledged, that even the difficulty and deep inci-
sions in the perinaeum are preferred.
second method.
   To perforate the bladder with a trocar, from the perinaeum, after
making incisions, like those of lithotomy, is the sole method now
mentioned in systems of surgery, a harsh, cruel, and dangerous o-
peration.  For when the surgeon is to make "incision in the peri-
naum, an  inch and a half in length, at the commencement of the
membranous part of the urethra, and continuing it towards the anus
in a line parallel with, but at least half an inch distant from the
raphe perinai /"  he has to operate according to precepts so in-
consistent with the actual relations of the parts, so unintelligible
to one who is an anatomist, and so nugatory to one who is not,
that he must cut at random : having made deep incisions in the
perimcum, he no sooner begins " to search for the bladder with
his finger  in the bottom of the  wound," than he directly  en-
counters the  enlarged body of the prostate : If he understands
what he feels, and  dissects backwards till he distinguishes the
bladder itself, he actually reaches that part of the bladder which
lies  upon  the rectum ; (viz. the space betwixt the  visculae) he
arrives  exactly at the same point which he touches in perfora-
ting from the rectum, and no one will deny that he might per-
forate with more security and less pain from the rectum, through
its thin walls, than from the perinaeum by these incisions: Bat,
having  made his  way to the gland, he points his trocar (which
is  usually too short for any purpose, and not at all appropriated
for this) directly  upon  the gland, drives it deep into its sub-
stance, and no urine flows,  or-flows only when both trocar and
canula are withdrawn.—How this happens  it is  not  difficult
to conceive:  " An old man  who, for the last twelve or fourteen
years of his life, was subject to occasional difficulty, was at  last
affected with entire suppression,  so that for five days  preced-
ing  the operation, he had not passed  one drop of urine: all at-
tempts  to introduce the catheter,  or  give relief by passing bou-
gies, were in vain, the tumid bladder was felt above the navel,
he  had continual straining to  avoid  his urine, with siokness,
thirst, and a feverish pulse.   But in his disease, nor in his pres-
ent  distress, there was nothing peculiar or worthy of notice.
A young surgeon  performed the operation of puncture in ptri-
naeo by all the usually prescribed rules.   After dissecting into 
Of Puncturing the Bladder.
235
 the hollow of the pelvis,  he struck his trocar deep, but upon
 withdrawing the  stiller., no  urine flowed, it was only when he
 was withdrawing the  trocar also, that a litde urine run out;
 nothing intimidated by this ill success,  he struck his trocar once
 more, now the urine  flowed freely; the canula was left in its
 place, the urine  continued to be  discharged,  but the abdomen
 inflamed and the man  died."
   " Upon dissecting the body, the first thing that could be ob-
 served was the fundus of the bladder hanging flaccid upon the
 point of the canula, which projected, some inches iuto its cavity;
 upon opening  the bladder, the  canula was seen in its place ;
 upon withdrawing the canula and cutting out the parts from the
 pelvis,  laying them on the dissecting board, and investigating
 the inner surface  of the bladder, not the slightest mark of punc-
 ture  was to be found;  so that had not the  trocar been seen in
 its place,  upon opening the abdomen, no one could have believ-
 ed that it had penetrated!"
   This case I noted down as peculiarly instructive; an opera-
 tion essentially bad was performed in  a manner so rude and
 barbarous, that a coroner's  inquest might  have taken cogni-
 zance of the affair :  This culpable  homicide  was a consequence
 of the same ignorance of anatomy, which makes many an ope-
 ration for the stone miscarry  : There is no vyonder if a surgeon
 who  would, if he were cutting for the stone,  nick the urethra
 several times before he was sure  of having divided it,  strikes
 Ws trocar twice before he  punctures the bladder: This gentle-
 man directly encountered the diseased prostate without knowing
 it! He  not only plunged into its substance,  but that transverse-
 ly, so as to transfix the gland; for  the point of this canula being
 buried  in the farther side  of the gland, no urine flowed when
 he first withdrew the stillet!  but while he was withdrawing the
 canula,  after he  had drawn  its point from the farther lobe of
 the gland, and before it was withdrawn altogether, it received,
 in passing from side to side, a few drops of urine which flow-
 ad out: The  second  time he struck  in his trocar, it neither
 passed deep behind  the gland, which is the proper intention in
 this  method, nor into the  substance of the gland, and through
 its thickness into  the cavity of the bladder, as usually happens,
but directly onwards  in the line  of the natural canal,  first
through the urethra, and then through  the centre of  the gland.
 Thus it happened,  that, after death,  no wound of the trocar
could any  where be found ; as for the death of the patient there
cannot be  a matter of wonder.
  .There is no more heinous fault than that of practising surg.-ry
without a knowledge of anatomy,  unless it be  that of studying
anatomy independently of pathology, and applying the descrip- 
236
Of Puncturing the Bladder.
tions of parts in the sound body, to the same parts in a state of
disease.   The effect of the enlargement of  the prostate gland,
upon  our operations, has (as I  know by fatal examples) been
but little  studied.  The plan 1st, of enlarged prostate is very-
simple,  i have represented in a true drawing the enlarged pros-
tate which in truth fills all the lower part of the pelvis, and pre-
sents itself to the surgeon, so that without a perfect conception
of its form,  and actually feeling it with the finger, he can per-
form no operation without blundering.  The extent of the en-
larged gland  is designated by the figures (a a a) ; the contracted
bladder  (for it  thickens and corrugates  in  proportion as the
gland grows) is  marked (b b);  the membranous  part of the
urethra  is marked  (c) ; while  the original and natural size of
the prostate  is  marked in dotted lines ; and let it be observed
that as the gland enlarges, the space (d) betwixt the ureters and
vesiculae seminales ot the two sides, is increased; by being re-
moved  from each other, they leave a wider space open to the
puncture of  the trocar, so  that they  cannot be wounded, and
though  it were not so, the wounding of the vesiculae, though it
has been represented as a mighty objection to the puncture from
the rectum,  is none: the vesiculae  would heal as easily as any
other part, and the  vasa deferentia would reunite (unless indeed
they  were cut  across), as  easily as the bladder reunites, but
this is a question of no importance,  the operation is performed
in people advanced in years and ruined in constitution, and the
question is not about saving the organs ot procreation from any
slight injury, but about saving life.  The plan 2d,  presents the
same parts in a vertical section.  The staff is stopped at (a),  in
the membranous part of the urethra, by a stricture.  The gland
(b b) is represented as enlarged, filling the  lower and fore-part
of the pelvis, and compressing, in some degree, the rectum.
   That the  surgeon can hardly perforate behind the diseased
gland  through the body of  the bladder itself, except by a very
deep and dangerous dissection, is  what I  have always conjec-
tured, when observing the  size of the diseased gland ; every
operation  I  have since witnessed has  contributed to strengthen
a suspicion,  which has been absolutely confirmed by a miscar-
riage more extraordinary and less pardonable than  that which I
have just mentioned ;  for though it is unpardonable to begin the
operation by incisions in the perinaeum, without introducing
the finger in ano,  to feel the condition and size of the gland,
yet nothing can exceed the folly, in actually perforating from the
rectum, of having the finger introduced for the purpose too of
guiding the  trocar, without estimating the extent of the gland,
or choosing a trocar sufficiently long.
   A  gentleman  being resolved  to practise the newest piece of 
JH. 136.
Ifanl.dutartd, Prvrtatt.
 
 
Of Puncturing the Bladder.               237
 surgery;  viz.  puncturing from the rectum ; used, in spite of
 every remonstrance on my part, a common trocar, hardly more
 than  three inches long !  a common trocar for tapping the belly
 in  ascites!  The consequence was most lamentable, for the in-
 strument being buried in  the substance of  the enlarged gland,
 not one drop of urine flowed; the trocar and canula were both
 withdrawn, and the  operation of puncturing above  the pubis
 performed.

                      third method.

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

                     fourth method.

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

                      fifth method.

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

        sixth method  of forcing the catheter.

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

  * Mr Home relates four cases in which he performed this operation; in one
instance some inconvenience enfued from the paffage of the  urine through the
rectum.  See " Home on Strictures,'' vol. 2. c. 7. p.  329.  S. 
Of Puncturing the Bladder.
241
  Then the  surgeon is sorely tempted  to  do a thing which will
  give instant relief, but which is yet attended  with unequivocal
  danger !  he feels that he  could drive the catheter forward into
  the bladder, but not perhaps in  the regular canal, nor without
  tearing through the membranous part of the urethra, and plung.
  ing through the substance of the diseased prostate.   Authorities
  for such  a practice we have none, or next to none; unless it be
  an authority for this desperate plunge,  that the case is desperate,
  and  very desperate the operations to which  we must next re-
  sort.
    Mr. Ware, in dissecting a patient who had died of this dis-
  ease, having begun his dissection by drawing off the urine, found
 that his catheter had, with no great force, been driven through
 the membranous part of the urethra, into the cellular substance
 of the rectum, and  thence  into  the bladder,  through the sub-
 stance of the prostate gland; and he naturally and justly infers,
 that had the same force been used in the living body, the vio-
 lence  would not have been fatal, the relief would have been
 perfect.    The celebrated Dr. Hunter being occupied along
 with a surgeon, in trying to introduce  the catheter, was entire-
 ly foiled,  and the surgeon had gone home for a trocar to punc*
 ture the bladder; but the doctor meanwhile trying the catheter,
 and using perhaps unjustifiable force,  it started  suddenly into
 the bladder: the patient was for the time  relieved, but the ab-
 domen being inflamed, he  died on the third day; and it  was
 plain, upon  dissection, that the  catheter had  burst into the blad-
 der, through the  substance of the gland.   Dr. Hunter  affects
 to say, that  this was his design: but since the surgeon was ac-
 tually  gone  for the trocar,  we have reason to believe that the
 doctor did not design to perform so important an operation, so
 unprecedented, and so adventurous, in the absence of the surgeon,
 but gave  a  post  facto reason  for what happened merely  by
 chance, by what might have been named, in a less  eminent per-
 son, imprudence and rashness.
   Dease,  a man intrepid and fearless, and  who had not (to  a
 surgeon perhaps it is no reproach)  all the delicacy and gentle-
 ness of nature, which were so justly  admired in Dr. Flunter,
 and which,  in his own peculiar department, had so conspicu-
ous an influence on his practice, was in the habit (and I can assure
the profession of this  curious fact) of driving his catheter right
onwards into the bladder,  when at any time, gentle means and
art, or cunning, failed: he  allowed no degree of difficulty to
frighten him from his purpose: he assured me of his  success:
and upon leaving me, presented me, as a token of remembrance,
with two flexible catheters of uncommon size, bent at the heel,
into a very  acute angle, and  iurnished with verv strong iron
                           2  H 
242
Qf Puncturing the  Bladder.
 wires, assuring me that he had often used them  thus success-
 fully, and soliciting me to make that bold use of them,  which,
 thank God, I have never had occasion  to think of.  I would
 not willingly acquaint a tyro in surgery,  with an expedient so
 ftjll of danger; if the catheter, ever  is to be forced thus, let it
 be done by a man of judgment and  skill, one who has experi-
 ence to distinguish, when it  is allowable  to  have recourse to
 such  an expedient, and  who has  so much address as to be in
 no danger of using force, merely by being foiled for want of art.
 Whether  it is from conversation or books, that I have some re-
 collection of a catheter, with a concealed  canula, I do not dis-
 tinctly remember.   But if so rash a thing has been done, I pro-
 test against it, " as a sword put into the hands of a fool." Such
 an instrument (a trocar-pointed catheter) would soon be in  the
 Hands of every young man, and would prove, in surgery, what
 the crotchet is in midwifery, a merciless resource: in cases real-
 ly simple  it would be used, by young surgeons, with little dis-
 cretion.   The catheter is, I  am persuaded,  sufficient, if skil-
 fully used, to make its way through almost any obstacle.
  The operation of paracentesis vesicae is  one which the sur-
 geon must perfecdy understand, since the occasions are sudden
 and imperious; and while he is balancing amidst imaginary
 difficulties, or comparing a variety of expedients, (none of them
 without danger) his patient may  be lost.   It is an operation
 which it is most important to scheme and study, for various ex-
pedients may suit the circumstances of particular cases.   Of all
 the operations which I have reviewed, any one must seem pre-
 ferable to  that in common use; and that perhaps is  best which
the surgeon can best perform. 
(  243  )
DISCOURSE  XVII.
.«•
PRELIMINARY DISCOURSE ON THE ANATOMY
   OF THE  CRANIUM,  AND THE RULES OF
         PRACTICE DEDUCED  FROM IT.
                        section I.

                 Introductory Observations.


 IN injuries of the head, the chief object of your studies must be to
 learn the signs and causes of danger, and to judge wisely of the
 motives which should induce you to operate.   For in the  ope-
 ration of trepaning, as far as the operator is concerned, there is
 ftothing formidable, nor any thing which the most unskilful can-
 not easily, I fear too easily, perform.
   But such is the uncertainty of these signs; so  often does our
 patient fall suddenly into slight paralysis, and faints and expires
 while we apprehend no harm; so often does  he revive  from
 that stupor which seems to arise from  extravasated blood op-
 pressing the brain; that the diligent investigation  of the  true
 signs of danger, of the causes of oppression, Or ulceration of
 the brain, (a severe and complicated study) should be the chief
 occupation of the surgeon.  But it has not been so; operations
 have been more studied than the means of avoiding them.
   Those who, on the revival of learning, assumed the Weary
 task of  explaining the first writers oh  medicine,  were not men
 Of practical  skill, but philologists,  commentators, men of mere
 learning; and  they commented best,  most learnedly,  and in-
 deed  most suitably to the text, who shewed  themselves  most
 ingenious m multiplying the distinctions of fractures; as those
 were thought to operate best, who fbuhd means of applying the
 greatest number of trepans to one scull.   But of ali the lessons
Ot the old school, the one most dangerous to  the  young  sur-
geon is  that  which teaches how to distinguish fissures from su-
tures ; for the  rules  for distinguishing  fissures  deafly implv, 
244            Of the Anatomy of the Cranium.
that wherever such fissure is  proved to exist, it is allowable it
is necessary to trepan the patient; and thence  a fracture of the
scull, and the necessity of trepaning the injured part, are so
inseparably connected in  the  surgeon's  mind, as to form the
most essential rule in his practice.
  In surgical systems, I do not know any two arrangements
more irrational, or more exceptionable, than  these two:  First,
That in treating of amputation, the subject is always opened
with a dissertation on gangrene, as if the fear of gangrene, or
its actual  existence, were the sole motive,  or at least the most
frequent,  for amputating a limb.  Secondly,  That  in explain-
ing the operation of trepan, the subject is invariably introduced
with remarks on the sutures, the cancelli, the variable thickness
of the  cranial bones, and the many scholastic distinctions  of ca-
pillary fissure,  fractures,  depressions, and  depressed fractures
of the scull,  as if such fracture or fissure were the sole motive,
or the most prevailing one,  for applying the trepan.  This is not
the meaning of our operation ; we often perforate with the tre-
pan, to give vent to the purulent matter, often to give vent to
extravasated blood, sometimes on account  of a  depression  of
the bone, sometimes to cut away sharp points which may hurt
the brain or  membranes, or to take away balls  or foreign bo-
dies nitched into the substance  of the  bone,  but never on ac-
count of mere fracture of the scull.*
   First,  You  are desired to remark the constitution of  these
flat bones, " that they  are  composed of two tables or plates of
solid  bone,  with intermediate cancelli, (or cellular substance,
such as is natural to  bone, full of blood-vessels) which   bleed
when  with your trepan you have sawed through the outer table,
occasioning  at the same time a change of sound."   This, though
occasionally  modified, you are taught to  regard as  a rule of
practice; and,  to every elementary book,  you find it to be a
most important subject of debate, whether, in perforating the
scull,  you should use the trephine, which  saws rapidly,  or the
trepan, which, from making only half circles,  cuts more slowly;
or, whether  you should first use the trephine, till you  have cut
down to the cancelli, and finish the more delicate part, the saw-
ing off the inner table  with the  trepan.  Never, perhaps, was
any remark  more  unfortunate than this, which refers the sur-
geon to the  bleeding and the change of sound, as signs of hav-
ing cut through the outer table, and teaches him to be proud of
sawing rapidly.  Of all operations, this is the one where pre-
cipitancy and hurry have the fewest apologies, since the  patient
usually lies insensible, since the sawing of a  bone occasions no
   *  All the directions  therefore, which the older phyficians, from Hippocrat.«
downwards, have given for tkc difcovery of fractures  and iiltures, are now uft-
lefs.  S. 
Of the  Anatomy of the.Cranium.          245
  pai*f since the trepan is an operation where haste may occasion
  dnj most dismal consequences,  from wounding the dura mater,
  which,  when left uninjured, supports the  brain, (after  the re-
  moving of a piece of the cranium) like a second scull.
    Secondly, But this first suggestion is inconsistent with a rule
  much  more  worthy of notice ; viz. " that in all circumstances
  the surgeon should saw cautiously, on account of the incalcula-
  ble irregularities in the thickness in the cranium, which is uni-
  versally thin  in boys and very aged people, and is, during all
  the middle stages of life, extremely irregular,  generally thick*
  but at certain  points extremely thin, or excavated by the deep
  impression of tortuous veins."  I approve of sawing the cranium,
  in all circumstances, with prudence and deliberation; but yet I
 discover, in all these rules, intrinsic marks of their having been
  invented by mere speculators in surgery, not by surgeons; for
  in truth we almost never operate in a mere fracture of the scull;
  we almost never operate where the bone is  sound, and the dura
 mater closely attached to the bone;  even in cases of extensive
 fracture, we rarely operate except on account of some affection
 of the brain.
    Thirdly, The artery  of the  dura mater is described  with a
 particular reference to the operation of trepan.  " As an artery
 of considerable size, the chief artery of the dura mater,  run-
 ning along the inner surface of the parietal bone, marking the
 anterior  corner  of the bone with its trunk, and the upper part
 with  the impression of  its branches, and making a groove so
 deep,  that the bone cannot be entirely cut through by the trepan,
 without the artery being divided.  For these reasons it is ad-
 vised, that the surgeon should avoid the whole tract of this ar-
 tery, and especially that he should not trepan the lower corner
 of the  parietal bone."  That the surgeon should, except in ca-
 ses of  the  most absolute necessity, avoid even the shadow of
 danger,  is a precept from which I will not allow myself to dis-
 sent.   But in  this, as in all these notable observations on the
 cranium, there are strong intrinsic marks of the reflection com-
 ing from one little  acquainted with practical surgery •, for in all
 circumstances, and on all points of the scull, have I seen the
 trepan applied without much skill, or any thing of this fore-
 sight, but never have I seen or heard of a hemorrhagy from
 the artery of the dura mater*.

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

  • Vide Warner's Cases, p. 10.  Pott's Surgical Works, vol. 1. p. 196. 
Of the Anatomy of the Cranium*          247
 selled  not to apply the trepan exactly upon a suture, when the
 dunk mater  adheres so, but on each side of the suture, so as
 to be  thus sure of finding the extravasation.  But I no more
 find  this  adhesion capable of limiting extravasation, than the
 sutures capable of stopping fractures.  I find the extravasation
 always extending beyond the place of the sutures, and covering
 very generally one entire hemisphere of the brain.  I never saw
 any occasion for applying the trepan, first on the one side, then
 on the other side of the suture, though much has been written
 on this subject.   I find in no book a proof of extravasation hav-
 ing been limited and interrupted by intervention of a suture, nor
 one  case unequivocally stated,  where  the  surgeon,  having
 applied his trepan on one side of a suture,  was obliged to repeat
 his operation on the other side.
   Sixthly,  In describing the  frontal bone, its internal spine
 or ridge running longitudinally along its inner surface, is point-
 ed out as particularly  interesting to the surgeon,  as being  an
 absolute bar to the perforating of that  part of the bone.  The
 observation seems important, the difficulty seems demonstrable;
 but this,  though it be a difficulty which must naturally present
 itself to the imagination of the  speculative anatomist, is one
 which can have but a slight influence over the resolution of the
 practical surgeon.  He  recollects, that in most of his operations,
 even upon the most level and equable parts of the cranium, he
 seldom dares to cut both tables of the cranium entirely through,
 but leaves part of the circle uncut, and begins with his elevator
 to poise out the sawed piece of bone, before it is entirely insu-
 lated j the part that is uncut usually breaks and splinters with
 an audible noise, and he smooths the ragged edges of the trepan
 circle, with the instrument named Lenticular.   Though a well-
 instructed surgeon will not fail to recollect this internal ridge of
 the os frontis, he will nevertheless perforate here when the ope-
 ration is required at this point, with this  sole precaution, that
 he will saw more circumspectly,  will cut through  all that he
 safely can of the circle,  burst up the rest,  and smooth the rag-
 ged edges of the hole.   It  is only in one single point,  at the
 very root of the nose,  at a point  considerably lower than we
 ever need to perforate, it is only in the very middle betwixt the
 brows, and in a space no  bigger  than one crown of the  trepan
 will cover, that this spine can at all prove an interruption.  I
 know no mischance, by which the most ignorant person could
 be induced to apply the trepan so low, and believe that there is
 more  danger of a  thoughtless operator doing harm when tre-
 paning upon the  ridges of the occipital bone ;  but in neither
 the one place or the other is the trepan required;  of an hun-
dred  cases in  which this operation is required, the instrument 
248
Of the Anatomy of the Cranium.
is placed in ninety-nine cases upon the  upper parts of the scull,
upon the  parietal or frontal bones.
  The rules which I deprecate, often incline the young surgeon
to deviate from the plain way of common sense, and, by avoid-
ing imaginary, he runs into real dangers.   To understand  the
case I am now going to relate, you must assent to one principle,
which I shall  afterwards prove in the most unequivocal terms ;
and it is this :   "  That mere depression of the scull, which was
once believed to be the most perilous of all accidents, has really
but a very slight effect in compressing the brain."* The  line of
a depressed bone deviates  but in a very slight degree from the
natural convexity of the scull; the depression, as such,  produ-
ces no compression, for the  patient walks about  unaffected, or
but very slightly ; and if  he falls into  a dangerous state, it is
indicated by tremblings of the hands and knees, a sort of imbe-
cility, slight shiverings and nausea, which are signs, not of com-
pression, but ulceration of the brain or its membranes.   The
bone itself  is sometimes deadened  by  the blow,  or its spicules
and fractured edges stick  in the membranes,  and occasion sup-
puration ; while the integuments continue entire over a fractu-
red bone, the interstices often are filled  with extravasated blood
and gluten, and soon  become vascular,  so that  the bone re-
unites,  as in the fracture of a limb,  and the brain and its mem-
branes remain sound; but if  the integuments be much injured,
and the depressed and fractured bone exposed, ulceration is apt
to ensue.
   " W-------  L———, a chimney sweep,  fell from the third
storey of a house, upon a street paved  with very  coarse  round
stones ;  though he  had sustained a very dreadful fracture of
the scull, he was very little  affected, and not brought into our
hospital till eight days after the fall.   The clerk or surgeon,  far
from expressing an alarm either at the  nature of the accident, or
the peculiarity of  the symptoms, described the case thus in the
books:  " He has,  on the lower part  of  the  frontal bone, a
fracture in the form of the letter V,  about an  inch in length, and
with a spot of the cranium,  which  you  could cover with the
point of your finger,  bare, but  without any mark  of  depres-
sion." By marks  of depression was meant, perhaps, " signs of
oppressed brain :" for, though  he had no such  signs,  the de-
pression was  great, and  was easily  distinguished by the finger
or the probe.    When I first saw this man, he was sitting up in
bed, submitting to the operations of the dresser,  talking ration-
ally, and apparently little injured ; and I was told that I might,

  * That mere depression of the scull, and that to no great degree, will frequeiitly
produce all the symptoms of opprefTed brain, is clearly proved by the relief \vhi«.l»
ensues immed'-.te'y the <Vpre=5<d bone \r elevated <;r removed.  S. 
Of the Anatomy of the Cranium.           249
if I pleased,  feel a  fracture pretty distinctly, but without de-
pression;,, and that the patient was in no danger.
  I formed a different conclusion from every circumstance of
this case. The height from which the patient fell was very great;
he had fallen  perpendicularly upon the forehead, else itcouldnot
have been fractured, and he had not broken,  nor even sprained,
a wrist or ancle, so that there was no intermediate shock to break
his fall.  He was indeed sitting on the side of his bed, but ex-
tremely meagre,  sickly, pale, languid,  and  dejected; his eye
was sunk, his cheek hollow, and his face somewhat distorted
with spasmodic twitches.  Upon opening the lips of this trian-
gular wound, which was now suppurating, and puffy, I found*
that  the fracture seated exactly in the middle of the forehead,
was very wide, and  that the bone at the lower part of the frac-
ture, and immediately over the eye-brow, was much depressed;
and\ worse than all, I found the bone so completely discolour-
ed, that though the depression  did not affect the brain, the  ca-
ries, I was sure, would, in  process of time, affect its mem-
branes, and cause suppuration.   That the fatal symptoms were
begun, I was convinced, by a more deliberate examination of
his- nurse and attending friends ; for, though he sat on his bed,
bore the perpendicular posture, and suffered the operations of the
dresser;  though  he answered pertinently to all our questions j
his  articulation was slow, his motions  languid and listless,  his
eye oppressed,  his  breathing anxious, and  accompanied with
sighing.   There was a sort of sardonic grin, or  distortion of
face, and a silliness  or fatuity of look*  His pulse  was quick
and irritable,  his tongue parched ; he had a hectic flush upon
his cheek.   Though he made no complaint,  he was sickly,  his
hands trembled, he vomited  frequently during the  night.  He
was always slightly delirious during the night, before he was
thoroughly roused;  and during the day, he  walked round  his
bed, fumbled about  the cloaths, seemed to  wish to  do some-
thing,  yet had no purpose.  In short, he was in a  state of  in-
describable disorder, never soundly asleep, nor entirely awake;
and, though  his sickly condition conveyed no intimation of ap-
proaching danger to his ignorant friends,  it  could not  but  be
observed by*his  medical attendants ;  for  these are  the signs,
slight as thev appear,  which announce suppuration  within the
cranium, and approaching palsy.
  A consultation having  advised  that  the  patient  should be
trepanned, the operation was performed with such circumstan-
ces of  misconduct,  as I  think verv impressive and instructive.
                            21* 
250
Of the Anatomy of the Cranium.
 There was a large transverse fracture across the lower part of
 the frontal bone,  with one limb extending into the orbit.  The
 lower part of the  bone above the frontal sinus was depressed the
 full thickness of the bone, and the depressed portion of the bone
 was plainly carious,  black, and dead.   Unhappily the rules of
 surgery, which the operator but too well remembered, and ap-
 plied too accurately, were in every thing opposite to the dictates
 of good sense.   The rule says, " apply your trepan  upon the
 sound  bone, which can best bear it, that  you may be  able to
 press your levator under the depressed bone through the trepan-
 hole."   But common sense directs no man to cut away a sound
'and living portion of the cranium, to save by elevation a part
 which is depressed, and perhaps dead.  The rules of surgery
 say, " You shall not trepan on or near the frontal sinus ;" while
 common sense requires the surgeon to perforate wherever any
 cause of danger exists.   The rules of surgery would impress
 us with the belief, that " of all the accidents of fracture, depres-
 sion of the scull is the most fatal cause of compressed brain, and
 the one which most  immediately requires the operation of tre-
 pan ;" while this very case, combined with a thousand colla-
 teral proofs, shows how slightly the greatest depression of the
 cranium affects the  functions of the brain,  for fifteen  days had
 elapsed before it was distinctly known that the bone was depres-
 sed, or the  man  in danger.
   Though the depression of the scull was, in this case,  the cir-
 cumstance which should chiefly have attracted the attention of
 a tyro, thinking  only about the anatomy of the scull,  and ima-
 gining  nothing more correct or absolute  than these mechanical
 rules; the carious or dead  part of the bone affecting the dura
 mater as a foreign body, would alone have  appeared important
 to one who  reasoned on the affections of  the brain, and knew
 them by their signs.  The one would have thought only of ele-
 vating the depressed portion of bone, the other of cutting away
 whatever was dead.  The one would have applied the  trepan
 upon the sound bone, the other would have applied it upon the
 injured part.
   Resolved to perforate as far as possible from this formidable
 sinus, the frontal sinus, the operator,  instead of elongating the
 triangular wound of the integuments downwards, prolonged  it
 by incisions upwards, and applied the crown of his trepan upon
 the sound and undepressed bone above the fracture.   The os
 frontis  was  extremely  thick, like that of a rachitic person; in
 avoiding  the  frontal sinus, he  encountered the frontal spine,
 and was, though it  may seem  incredible,  fully  an  hour in ac-
 complishing the perforation, the patient all the while crying out, 
               Of trepanning the Frontal Sinus.           251

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

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

  *  Although the frontal finus may undoubtedly  be trepanned, it is certainly
rarely, if ever, neceffary to do it, fo as to expofe the brain, which is the reafon
why the furgeon is directed to avoid it.  As to merely opening  the finus'itfelf,
there can be neither difficulty nor danger in the operation.  S. 
252
Of trepanning the Frontal Sinus.
 immovably wedged betwixt the beam which they were lifting,
 and that which had just been laid upon the frame; and so hea-
 vy was this log, that his companions were obliged to take their
 hand-spikes and poise it up.  He cried out during the time his
 head was wedged between the logs,  and when released was able
 to rise; though giddy, he was not insensible ; nor did the blood
 burst from his nose and ears, as might have been expected af-
 ter such an injury.
   " Though his head suffered this pressure on the sides, being
 compressed from temple to temple, there is every reason to be-
 lieve  that the forehead had suffered, and the frontal sinus  been
 injured; for he walked home under the agony of an acute head-
 ach, which soon,  however,  subsided  into a heavy, dull, and
 continued pain, aggravated at times, but  never entirely absent.
 His head was confused;  he gradually lost  his hearing, and by
 the third week from the time of the injury, was entirely deaf:
 he returned to work, but his headach,  giddiness, and deafness,
 were unremitting, and he  had occasion  to remark,  that " he
 never, from the moment of that  bruise,  had a good head  for
 standing or working in difficult places."
   " The sudden manner in which he regained his hearing, and
 the profuse flow of matter from  the ears and nostrils, which
 opened the passages, are very remarkable.   It happened about
 a fortnight after losing his hearing, that  while he was working
 in the fields, upon blowing his nose, there rushed out from one
 ear a great quantity of  matter, with a painful noise.   He fell
 down by the wall in a sort of fit, lay for some time insensible,
 and when his senses returned, he was as much surprised at hear-
 ing the barking of dogs, and the voices of the people in the
 neighbouring village, as  if he had  been  born deaf.   He now
 found that matter was flowing from the nostrils, as well as from
 the ear, with a smell so offensive, that at  first he imagined that
 his hat in his fall must  have lain in some  foul place.  He smelt
 his hat  first, and looked  to it, but found  it not soiled,  nor foul,
 and upon blowing  his nose,  there run out into his handkerchief
 a profusion of foul and very foetid  matter, mixed with blood.
  " When he had fully recovered his senses, he  found that the
 discharge of blood and matter from the nose was accompanied
 with agonizing pains in his head; he retired to the shelter of an
 unfinished  house,  where his companions had  been working,
 and threw himself down on a bed-frame, and lay there alone till
 evening, with his head  hanging over the bed-frame, a black, foe-
 tid, and bloody matter distilling profusely  from his right nos-
 tril, while an acute and confused pain ran through his forehead.
 He got  up, after some hours, and walked to his father's house,
about a  mile distant, in great pain and confusion of head. 
Of trepanning the Frontal Sinus.           253
   f From this time the pain in his forehead was unremitting
and severe, and when heated at  work, it was particularly vio-
lent.*  This pain, at the root of the forehead, was aggravated
at times to violent paroxysms; it affected the  eye,  puffed up
the eye-lid, swelled the whole side of the face  and  forehead.
The discharge from the nose  continued very profuse, and this
local disease,  accompanied with general headachs, afflicted him
for five years, and a permanent bony swelling, marked by a ve-
ry conspicuous protuberance of the right eye-brow, at the place
of the frontal sinus, was formed.
   " But his complaint underwent a sad revolution  in  conse-
quence of  a second fall, which happened thus:  After mowing
hay in weather which was oppressively hot, he retired with the
other labourers at mid-day,  to rest in the hay-loft; being over-
come with labour, and having fallen into a perturbed  sleep, he
by successive  restless  motions got so  near the edge of the loft,
that he at  last slipt over.  One of his  fellow-labourers chanced
at that moment to observe him sliding, and ran to catch him by
the feet, but too late, for he  fell from the loft headlong, upon
a rugged pavement of big round stones, and alighted  exactly
upon  that part of the forehead which had been long the seat of
disease; for I find the scar of the wound which he then received,
just over the bulging of the right frontal sinus.  He lay  insen-
sible  during a quarter of an hour, and when he revived he felt
sick,  faint, and languid;  and his companions being gathered a-
bout him,  he waved his hand as for room, and a freer breath-
ing-space.   They carried him  into the open air,  where  he in-
stantly  fell into  an epileptic fit, which epilepsy  has  continued
ever since.
   " The epileptic paroxysms returned frequently, at least every
night and morning, from the time of this fall.  He was weakly,
almost parylitic, walked only with the  help of stilts, and trailed
his limbs along.   In about five weeks he had so far recovered,
as to  think himself strong enough for work, and the paroxysms,
which had at first recurred three or four times a-day, became
less frequent, ceased at last,  and were absent  entirely for a
week.  Thus encouraged, he returned to his daily labours, and
by  the  violence of his labours  the fits  came on again.  He had
been  now six months labouring under this disease, is reduced,
weakened, and dispirited ;  is distorted with these fits of spasm
or convulsion twice a-day at least,  and tormented from hour to
hour with severe threatenings.  Fits so peculiar,  and proceeding
from  so unusual a cause, I think it right to describe with par-
ticular care.

  * He recovered, about a fortnight after this, the hearing of his other ear, by a
like difcharge of matter, which alfo happened fuddenly upon blowing his nofe. 
254            Of trepanning the Frontal Sinus.
   " The  convulsion is distinctly connected with the disease of
the forehead.  The approach of each paroxysm is announced
by pain of the forehead, with a sense of fulness;  first his jaw
begins to shake with a trembling, and convulsive motion, and
the tongue, too,  trembles, and is  retracted into  the mouth.
This  is the  warning or first alarm of the approaching parox-
ysm,   which  sometimes,  as  he  imagines,  he prevents by
clenching  the jaws, and holding them firmly.  Being once at-
tacked when reading,  he,  in hopes of stopping the convulsion,
thrust the book into his mouth, the convulsion increased, and
was as usual propagated  along the neck, arm, and side;  the
book  was  so fixed by the.convulsion of the jaw, that he had no
power to withdraw it,  and the  suffering was so dreadful, that
he remembers having howled with agony.
   " But the convulsion only begins in the jaws, then trembling
and convulsive motions run downwards along the neck: his head
is turned to the right side, while his neck is tortured with the
spasm ; the convulsion  descends from the neck down the arm,
and to the hand, which is clenched and contracted, till the whole
of the right side is affected with it.
 "Besides frequent threatenings, and incessant fear, he has three
or four regular paroxysms during the day.   He is warned of its
approach,  like those who have the aura epileptica, by slight dis-
tortions of the parts, and a confused sensation in the forehead; he
immediately clings to a bed-post,  a chest of drawers, a door, or
some firm body, continues sensible, and feels all the horror of its
slow  approach, and all the pains of the convulsion; and the per-
petual fear of this attack has given his countenance an anxious,
subdued, and melancholy cast. First in orderly succession, comes
the pain and fulness of the forehead, then the tremblings of the
jaw and tongue,  then the sore contractions of the neck, which
draw his  head over the right  shoulder, and then successive
cramps and convulsions of all the right side of the body, till it is
bent down; and  in this state of agony he continues four or five
minutes, when the muscles of the side, of the arm and of the neck
gradually  and successively tremble,  and fall into  a quiescent
state,  and the convulsions of the neck and arm having remitted,
the spasm of  the jaw, and trembling and retraction of the tongue
also cease, and then he returns slowly to his seat.  He is always
in great confusion, but never insensible, during the fits, unless
it be  during the night; for it would  appear, that during sleep
he is  seized with fits more nearly approaching to the nature of
true  epilepsy.  He passes his  faeces and urine involuntarily
during the night.  His  disease has, if not the express form, at
least  the  effects of  epilepsy ; for his faculties begin to fail, h\
memory is injured, certain  words he is unable to pronounce, 
               Of trepanning the Frontal Sinus.            255

  or pronounces them  with a painful and convulsive hesitation.
  Although he does not actually fall down, his confusion during
  a paroxysm amounts almost to insensibility,  and each paroxysm
  is followed  by drowsiness and a degreee of  oppression, so that
  very commonly he falls asleep, his right eye is turned obliquely
  inwards, the swelling of the frontal sinus over it is very promi-
  nent, and gives an  obliquity to  the whole countenance; the
  matter which runs from the right nostril only, is in great profu-
  sion,  it is  partly glairy,  partly  purulent, amounts  to two or
  three ounces in the day, and sometimes entirely fills a bleeding
  palate*.   His speech, especially after a paroxysm, is slow, dif-
  ficult, hesitating, and interrupted.  When pain  of the forehead
 comes, and  is not followed by  convulsions, he has a general
 feeling of weakness, as if all his joints were loosened; he trem-
 bles,  and his knees shake under him,  and he has a trembling
 and paralytic feeling in the arm."
    This is  the whole state  and  condition of this young man,
 who, from uncommon health, and bodily strength, is  reduced to
 great weakness and despondency ; and since the first signs of
 the paroxysm  are distinctly referable to the frontal sinus,  and
 since  the convulsion affects the same side of  the body with the
 injured part of the head, all suspicions of its arising from  any
 disorder of the brain are removed.  I have  resolved, (encour-
 aged and supported by the unanimous voice of the  consulting  sur-
 geons), to trepan the sinus,  hoping, by curing this ulcer, to re-
 move a possible cause of  disorder: The dismal situation,  and
 earnest irttreaties of the patient, are arguments too powerful to be
 resisted;  and  the operation, though unusual, is  no rash enter-
 prise, but, on the contrary,  entirely void of danger.
   I laid  open the diseased  and  much enlarged sinus with an
 incision of little more than an  inch long,  and  perforated the
 bone,  which was of such thickness, that the assistants believed
 that I had mistaken the case, and  pierced not the outer plate of
 the sinus, but the whole thickness of the scull; and they plainly
 said,  that the membrane now exposed was not the lining of  the
 sinus,  but the dura mater.  But it was merely the lining of the
 sinus; the injections passed from this small trepan-hole, into  the
 throat and nostrils, and  the patient could at pleasure draw it
 back again through the trepan-hole.  By a little skill and practice,
 and by inclining the head of the patient, properly, the dresser
 soon learnt to direct his injection,  so that the whole of it flowed
 out by the right nostril.  The lad  continued under my care  for
 three months, and I injected the sore first  with barley-water,
then with  solutions of vinegar and honey, then with tinctures of
tark and myrrh, and finally with tinctures of corrosive  sublimate
                • Containing from four to five  ounces 
256
Of the Connections of the Scull.
and crude sal  ammoniac; but (as I must confess) without the
slightest alteration on the matter, (which ran profusely from
the nostril), or the slightest improvement of his health:  Des-
pairing of doing  good, and  wishing that he should leave the
precincts of an hospital not always healthy, and enjoy his native
air and better  food, I sent him home, having first withdrawn
the tent, and  healed  the fistula, which  closed  solidly in two
days, and had always been inclined to close.   So untrue are all
these idle tales about the danger of wounds, and the rashness of
trepanning this part.

                     --->»<g>—---
DISCOURSE  XVIII.
OF THE  PATHOLOGY  OF THE INTEGUMENTS,
           SCULL,  AND  DURA MATER.
                        SECTION  I.

        On the Vitality and  Connections of the Scull.

 As you are now aware of the important truth, that the rules
 of our art are not to be deduced from the external forms of the
 scull, I shall now begin to unfold the true theory of injuries of
 the brain, by explaining, not the outward form of the cranium
 and the anatomy of its several bones, but the internal organiza-
 tion,  the living powers,  the susceptibility of  injury,  and the
 sympathy  of  the pericranium, the scull, and dura mater with
 each  other :—these are the  integuments of the brain, and from
 the slightest injury  of the most remote of these, there often en-
 sues,  slowly, imperceptibly, and at a distant and unsuspected
 period, suppuration of the  brain itself.  Life  is endangered
 more frequently by a laceration  of the  integuments, or by a
 mere  contusion of the scull,  or by an imperceptible  separation
 of the dura mater, than by  the  widest fractures.   Now,  the
proofs of this consist in facts,  which even in their  simple  de-
tail, though not connected by theory, nor recommended  by any
ingenious explanation, would be of  th mselves useful;  but  the
mutual dependence  of the scalp, the scull, and the dura  mater, 
Of the Connections of the Scull.           257
 is so clearly made out by innumerable practical examples :  the
 progress of disease, from a slight puffy tumour of the scalp, to a
 fatal suppuration of the dura mater, is so plainly traced; the
 slow but undeviating progress of fatal signs, from the first nau-
 sea, and slight tremblings of the hands and tongue, to the fatal
 convulsions, is so easily traced, and forms so interesting a sub-
ject for judicious prognostics, and sensible and manly practice,
 that I know not in the circle of our profession a piece of pathol-
 ogy more intelligible,  nor a subject of inquiry more easily pro-
 secuted, to sure  and interesting Conclusions.  And  we have
 this encouragement  to  consider  the pathology in place of the
 anatomy of the scull, as the rule of our prognostics,  that while
 anatomy, and the enumeration and classification of fractures,
 has led to an undue propensity to operation, the study  of the
 living powers, and  mutual dependence of these parts, leads to
 a reserved, modest, and rational practice,—-to a just confidence
 in the powers of nature,—to a careful and solicitous attention to
 all the insidious symptoms of suppurating brain.
   The  integuments or scalp,  i. e.  the  successive layers of the
 skin, occipito-frontalis muscle, cellular  substance, and pericra-
 nium,  are  closely connected with each other, and with the scull,
 by  one continued tissue of vessels.   When these integuments
 are seperated from the scull, even in the dissection of  the dead
 body, the scull sweats out drops of blood from every  point of
 its surface.  The outer table of the scull is so plainly alive, that
 the surgeon can perfectly  judge of its death:  when alive, it is
moist, clear, and bleeds upon being perforated ; it is by its dry-
ness and faded colour, and its bloodless appearance, (and when
 trepanned,) by the dryness of the dust turned out in  sawing,
that the surgeon is able to pronounce it  carious and dead.   The
 scull is nourished, yet not altogether dependent for its  circula-
tion on its  periosteum and scalp : a piece of scalp may not on-
ly be raised by a clean cut of the sabre, and laid down again so
as to adhere to the bone, as to any soft part,  but being cut off,
it is replaced, in part at  least, by granulations from  the scull.
The integuments not cut, but lacerated,  detached from the scull,
flapped down over the face and ears, soiled with earth and mud,
will, upon  being cleaned, and laid in their place, adhere to the
scull.
  The scull re-unites thus easily with the integuments, from hav-
ing every essential provision for life and  circulation within itself.
It is by means of the same provision that when large and broad
pieces of the scull are  apparently insulated  by fractures sur-
rounding the piece of bone on all sides, with the dura mater as
completely detached from the internal,  as the  pericranium is,
by laceration, or by  scraping, from the  external surface  of the
                           2 K 
258
Of the Connections of the Scull.
scull, and  after being depressed by violence, areas violently
raised by working with the levator, that  they live and are re-
united, and granulate and heal.
  The circulation  thus maintained by  the pericranium from
without, so vigorous in the structure of the bone itself, is like-
wise well supported from within; for, indeed, if we were  to
assign the nourishment of the scull to any one source, it  would
be to the dura mater, which is more properly the internal peri-
osteum of the scull, than a membrane belonging to the brain ;
with the brain it has no vascular connection, but is seperated by
a halitus or secretion similar to that of other cavities, as those of
the pericardium or peritonceum : with the scull it is so connect-
ed, that the scull-cap is in dissection torn up with the greatest
force, and every point is covered with the  ruptured mouths of
delicate and bleeding vessels.
  The dura mater  is very firmly attached to the whole internal
surface of the scull; it is hard, firm, grates like a cartilage* when
cut with scissors, and has a glistening surface, like the capsule
of a joint: it has no appearance of delicacy or sensibility,  for
indeed it has none,  since acids, caustics,  and even the  actual
cautery, have been applied to it, and it has been cut and torn  in
experiments on living animals, without exciting pain.  It enters
very slowly into diseased action, and has as little appearance of
vascularity as of sensibility; often it is inflamed,  and even sup-
purated, without changing colour, and is little affected by our
most subtile injections.  But the  injection, which  does not
change the colour of the dura mater,  colours  the  bone,  passes
through its vessels, and runs out from innumerable minute ori-
fices, when the dura mater is torn away :  it appears from every
circumstance, that the vascularity of the dura mater is destined
for the nourishment of the scull, and  may be truly  named its
Internal Periosteum: and the great arteries and veins (as they
are called) of the dura mater, might be more justly described
as the Nutritious Vessels of the scull.  Were we first to observe
this vascular connection, and then glance our eye  hastily over
the facts relating to it, we should be apt to pronounce the scull
entirely dependent for its nourishment on the dura mater; and
that its connection cannot be dissolved by disease, without cor-
ruption of the bone, and suppuration of the brain,  nor detached
by  violence, without effusion of blood.  Yet this  important
source of nourishment,  the  scull can also dispense  with, and
live;  for, in cases of the most extensive effusions of blood un-
der the scull, and where this membrane is divided from it by
a thick ahd solid cake of coagulated Wood, we find, that the
scull  bleeds in  trepanning,  and granulates during  the cure ;
and although it may seem a  fact difficult to  ascertain,  I shall 
Of Injuries of the Scalp.
259
 prove to your conviction, that the dura mater may by a shock(be
 detached from the scull, and adhere again to it without harm,
 leaving unequivocal marks by  which, in dissection,  it can be
 known that it had been seperated and re-united.
   I take  a pleasure in submitting to your review these facts, so
 Opposite to the doctrines, and so inimical to the practice of the
 older surgeons; for they will teach you, if you dwell upon them,,
 to have a perfect confidence in the powers of nature. , With so
 many sources of circulation, the life of the scull is very secure:
 the scalp, the scull,  and the dura mater, are the successive in-
 teguments of the brain, they mutually support each other, so
 that they cannot be individually injured ; and we have reason to
 believe, that when the dura mater suppurates, and  the brain  is
 endangered, the whole system of  this vascular connection has
 suffered a fatal shock,  or the bone, the centre of that circulation,
 has been deadened by the blow.  I fear  that those general con-
 clusions,  which  by a sort of anticipation I have laid before you,
 may seem more allied with speculation than practice, yet are
 they the true and genuine source of  your prognostics.

                        SECTION  II.

                  Of Injuries of the Scalp.

 ,  However extensive the laceration, if the scull be uninjured,
 the  scalp not irrecoverably bruised, the patient in health, and
 not exposed to contagion or fever, it may (with only slight and
 partial interruptions)  be made to adhere again to the bone.  Of
 such recoveries,  every practical surgeon  has  seen examples,
 and many interesting  cases, made remarkable by the circum-
 stances of the accident, are recorded.
   The following case is related by Mr. Hill: " A drunken coun-
 try-man, aged about sixty-six years, riding furiously along the
 street, was flung with such force against  the sharp edge of a
 door-post, that about the length and breadth of a hand was strip-
 ped off the right side of his head,  and laid down on the cheek.
  " Some people, in the dark, took his wig out of the kennel,
 and, not knowing what had happened to  his head, put it on full
 of mud, and squeezed his  hat  over it.   He did not complain
 of his head, but complained greatly of  his neck and shoulders.
  " The dirt was rubbed into the Tunica  Cellulosa in such
 a manner, that it was impossible to  clean it fully out.   I there-
 fore pulled up the loose piece of the scalp, and, after washing
 and stuffing it with soft  liniments, put four stitches into the up-
per part, but so loosely, as to allow  the matter a free passage.
  " The  wound digested so well, that in five days all danger- 
260
Of Injuries of the Scalp.
ous symptoms were over, and his friends carried him home
without acquainting me.   Having no proper person to take care
of him, the stitches gave way, one after another, and it healed,
leaving near two fingers-breadth of the scull bare, the teguments
lying in folds on the Os Petrosum.  This circumstance might
easily  have  been prevented  by renewing the stitches.   He,
however, lived and enjoyed  good health above twenty years."
  Yet a laceration of the scalp is a state of danger and uncer-
tainty.  We never can be assured that the bone is not too much
injured to admit  of its re-uniting with the scalp, or that the
constitution is not  too weakly, or the season  or the air unfa-
vourable ; we never can be assured, even when the prospect at
first is most flattering, that a laceration of the scalp will not be
followed by a suppuration of the brain.
  " Thomas Sharpe was  an  itinerant dancing-master,  a fidler,
a performer in a military band; he died trumpeter to the Dum-
frieshire militia, and had attained to  all the perfection of liber-
tinism, and dissolute  behaviour, that such  occupations  natural-
ly entail upon those who practice them.   One morning, reel-
ing out of a low tavern,  he, after scrambling up the stairs of it,
staggered forwards into  the unguarded area of a house that was
building, and, without any other apparent  injury, had his scalp
torn down over his face.  The scalp was  ragged in its edges,
and mangled every where, with several penetrating wounds;
it was  separated from the whole upper part of the head, from
the lambdoid suture nearly to the eye-brow, and from  the ver-
tex to the right ear; much of the scull, and especially of the os
frontis of that side of the  head was laid bare : nor was the op-
posite side without bruises, and lesser wounds, for it  seemed to
have been jammed in among the loose stones.
  " The scalp was sponged, cleaned, and dried, and smoothly
applied again to the scull; and as the edges of  the  laceration
were irregular, and bruised, and in no fit condition to be nicely
joined with stitches, they were held by plasters only, they were
united in a few days with each other, and even seemed re-united
on the lower surface  with the surface of the scull; whatever
inflammation there was, seemed a very natural consequence of
the general bruises, and lesser wounds of the scalp;  and we
were confirmed in this good expectation, from the  man's hav-
ing recovered from his intoxication, and continuing in apparent
health. He felt his bruises,  and complained of the  pain, slept
well,  had neither  delirium, sickness, nor  fever, and was bled
only on account of the fulness of the  pulse.
  " On the fifth day, the little discharge,  which issued from
the irregular openings, and smaller wounds, was good; the ad-
hesion continued apparently sound; on the sixth, the discharge 
Of Injuries of the Scalp.
261
 from  under the scalp was more copious, and compresses soon
 were nicely applied to  keep the scalp and the scull in contact
 wrth each other.  On the eleventh day  it became necessary,
 from fluctuation and softness in all the lower part of the de-
 tached scalp, to make an opening over the ear for the discharge
 of matter,  which flowed so profusely, and was accompanied
 with such fits of rigour,  that I abandoned all hopes of any firm
 or general  re-union, and began to fear that the brain wtis in a
 state of suppuration.  Upon pushing the probe through the soft
 and downy granulations which united  the edges  of the scalp
 with the scull,  I was  persuaded, that all below the mere edge
 was disengaged, that the whole extent of the parietal bone was
 rough and naked.  The probe, in its progress between the scull
 and integuments, encountered what all my assistants conceived
 to be a fracture of the scull; yet still the  patient  retained his
 senses, and suffered little in his health.
    " The symptoms of suppurated brain  are, as I know from
 much  experience, far from  alarming when they first appear.
 The detached state of the scalp, the roughness of the bone, the
 profusion of matter which flowed through all the openings, and
 the slight rigours,  dejected looks, and tremblings  of the hand
 and tongue, though they are such as alarm the surgeon, can
 hardly vindicate him in taking any decisive step.   I was per-
 suaded that the bone was dead, and the brain in a state of sup-
 puration : I saw no prospect of interposing with success at so
 late a period as  the sixteenth day from the injury:  I was sup-
 ported by the consulting surgeons  in  the preliminary step of
 opening the scalp, and exposing the diseased bone; but they
 seemed to suffer a disappointment, when that rough line, which
 was so curiously traced with the probe, was found  not to be a
 fracture,  and, as there was no fracture, I was, fortunately for
 my reputation, prevented from applying the trepan; for though
 there was every motive for operating, the patient died next day
 ot  a disease, inevitably fatal, connected indeed  with the acci-
 dent, but having no relation to the state of the brain.
   " Let me now, then, proceed to give you an account  of the
 condition of this man before the operation, of  the  manner of
 his death, and of the appearance on dissecting the body.  Be-
 fore the operation of cutting up the scalp,  there  were no deci-
 sive signs, nor fatal  prognostic; for of all the fatal affections of
 the brain, this of suppuration of the dura mater is the most in-
 sidiohs in its progress; and our patient, before we  apprehend
 him to be in danger, is in  general beyond the reach of help.
 This man, though he had the cranium  naked,  the scalp in full
suppuration, and a profusion of thin matter pouring out fron:
various openings, had  no other symptoms  than slight  rigov.r*. 
262               Of Injuries of the Scalp.
  and no more violent rigours, indeed, than often accompany die
  slight fever of a lacerated scalp.   It was towards the sixteenth
  day, perhaps about the fourteenth, that these rigours  were fol-
  lowed with a sweating stage, that  they became sensibly more
  frequent and violent, and  that they were accompanied during
  the day with unusual languor, and  in the night with a  slight der
  liriura, which disappeared only when he was thoroughly roused
  from'sleep. Yet, at this most critical  period, I could not make
  him say that he had any corded feeling  over the brow,  any head-
  ach, any thing which might indicate to his own apprehension
  a disorder within.  I could not perceive the slightest wavering
* in his intellect; I could not find, in   the irritable  state of his
  pulse,  the .foulness of his tongue, the dullness of his eye, in his
  perturbed  sleep,  and  alarming dreams, any thing more than
  the feverish disorder naturally accompanying so extensive a la-
  ceration of the scalp; and yet at that moment was the suppura-
  tion of the dura mater fairly established, and the brain itself
  deeply tainted.
     " An increased drowsiness, with rigours more violent than
  usual,  a degree of headach, and a sensibility  to light, induced
  us, upon the sixteenth day, to cut up the slight adhesion of this
  great flap of suppurated scalp,  which immediately fell over the
  ear,  and left the whole parietal  bone exposed,  in a condition
  perfectly decisive, in my  opinion, of the state of the brain, and
  indeed of the patient's fate.   There was a portion  of the parie-
  tal bone broad as the palm of my hand, of a square form, appau-
  rently insulated  from  the rest, black, carious, and elevated a-
  bove the  level of the surrounding bone, and circumscribed by
  a line  as  decisive as if it were a  fracture.   This  part, which
  was the centre of the parietal bone, was rough, dry, and  pro.
  minent, of a dark yellow colour, engrained with black spots like
  a toad's back.   The pores of the  bone, or, in other  terms, the
  minute and almost  invisible holes by which  the blood-vessels
  enter it, seemed wide, and not red as when blood is circulating,
  but black.  In the margin immediately surrounding this, where
  the bone was still alive, and in a state of ulceration, the bone
  was wasted, so thatthe carious part was left prominent, with a line
  so fairly circumscribed, that, when felt with the probe, it might
  be mistaken for fracture ; this is  indeed, uniformly  the condio
  tion of a dead and" exfoliating piece of the scull.   Beyond this
  ulcerating circle,  where the integuments  and muscles adhered,
  they adhered with particular firmness,  being crammed with ex-
  travasated blood, and hardened by inflammation.  Though the
  certainty of the  brain being in a state of suppuration,  inclined
  me to  perforate the cranium,  the certainty now of there being
  no fracture inclined my assistants, and the consulting surgeons* 
Of Injuries of the Scalp.
263
to refuse their consent to that operation, which alone could save
our patient: thus I was destined to escape  the  opprobrium of
having shortened the life of a man, whose death, from a very
different cause, was inevitable.
  " He was perfectly sensible during this preliminary operation,
and would most willingly have  consented to any measure we
might judge expedient.  But,  when he was conveyed to bed,
he seemed weak, his breathing was low and difficult,  his pulse,
which had beat 124 in the afternoon, was this evening extremely
feeble  and  slow, and  he broke out into a very profuse sweat.
His features were shrunk, and his  face pale and  ghastly.  A-
bout four  in the  morning he was seized with sickness and se-
vere vomiting, and with  a rigour, which lasted fully twenty
minutes, and at eleven in the morning his  breathing was ex-
tremely oppressed; it  was painful to witness his  struggles for
breath,  and the anxiety and cold sweats which it brought upon
him: in half an  hour after his most violent struggle for breath,
he  was seized  with  a profuse haemorrhage from the  lungs,
brought up, with coughing and  struggling, fully a pound of flo-
rid blood, and expired.  Thus, in  the very  moment in  which
he came into manifest danger from suppuration  of  brain,  he
died from the bursting of a  blood-vessel in the lungs.  What
bruises, besides the wounds of the  head,  he may have received
unconsciously in his state of  intoxication, we do not know; but
nothing is more  likely, than that in the fall which thus hurt his
head, the  lungs  had also suffered material injury; it  is perhaps
from such injuries passing unnoticed, that  suppuration  of the
liver so frequently accompanies fractures of the  scull; indeed,
I know not how a man can fall from a height, without so heavy
a viscus as the liver suffering  by the shock,  independent of any
direct blow.
  " The appearances on dissection were as follow: The ap-
pearance of the  brain implies danger;  but it was the dissection
of the lungs that explained his sudden death.   Upon raising
the  cranium, all that surface of  dura mater  which  lay un-
der the diseased bone was in full suppuration, covered with
white and mature matter, and,  in many  points, perforated with
ulceration.  The pia mater,  in contact with the diseased dura
mater, was not yet ulcerated, for  the brain cut sound and firm
up to the very surface; yet the  whole mass of the brain was in
some degree  affected, an increased action  of its vessels had
unquestionably taken place, for all  the ventricles were enlarged,
and  full of  serum, but not obviously inflamed.    Thus our pa-
tient was in that state of  danger from suppuration of the brain,
from which so few are recovered even by the most timely ope-
rations ; but the sudden bursting of a great vessel in the lungs 
264               Of Injuries of the Scalp.
 was the immediate cause of the death;  for, upon opening the
 right side of the thorax, there  was found in the lungs ot the
 right side a great effusion of blood, and a small superficial ulcer
 on the largest lobe of this part of the lungs."
   Whether  is it to the mere laceration of the scalp that we are
 to  refer all  this  disorder?  Was the scalp so mangled by the
 sharp and irregular stones  among which this man had fallen ;
 was it  perforated in so many places'by these irregular wounds
 I have  mentioned,  as  to destroy  its texture, and make it no
 longer capable of maintaining its connection with the scull ? Or,
 was the bone itself so much injured in its internal structure and
 circulation as to be incapable  of pushing out granulations to meet
 those of the scalp? Does not the practice here pursued, of
 holding the  scalp in its place, of supporting partial adhesions,
 and endeavouring to extend them by using compresses, and
 confining the inflamed scalp in contact with the diseased bone,
 tend rather to increase  that inflammation, and indeed to widen
 the separation? Were not those symptoms of shiverings and lan-
 guor which (slight though they be) indicate suppuration of the
 brain, too long neglected ?  Should I not in place of making suc-
 cessive  openings,  when new abcesses were generated,  have
 thrown down the scalp to  examine the bone ? Should I not,
 according to the strict  rules of good  sense and good surgery,
 have proceeded to trepan a scull, carious to such extent, unequiv-
 ocally dead, quite incapable of maintaining any connection with
 the  dura mater, sure, on  the contrary, to operate upon it as a
 foreign body, and  to produce suppuration ? For this was not one
 of those circumscribed and superficial exfoliations, which can be
 thrown off without danger  to the  brain.   Finally, since this
 patient survived so horrible an injury for three weeks,  and died
 by a sort of accident, is not  the long delay of  this fatal suppu-
 ration a sort of proof, that it happened not from primary sepa-
 ration of the dura  mater detached  by  the shock, nor  by  a
 secondary  separation depending on slow disease  of  the bone,
 but from this destruction of the scalp, followed in succession
 by death of the scull, and suppuration of the dura mater, the
 internal periosteum of the scull ?
  Though I regard every fatal case as an occasion of reflection,
 and almost of self-reproach, yet I am sensible that this case was
 too complex not to admit of many apoligies : There are in such
 cases of lacerated scalp  certain irregularities and  anomalies
 which incline me  at all  times to proceed with caution.   There
are conditions of the individual systems, and varieties of climate,
or air, which, without any local cause, without the scalp or the
scull being essentially ruined in their texture, prevent their re-
union, and even occasion death.  The air of particular countries 
Of Injuries of the Scalp.
265
 has been remarked through ages as peculiarly noxious to those
 wounded in the head.   Lusitani has celebrated " the noxious
 air of Florence and Bologna, while the air of  Ragusa, seated
 upon a  rock, is so extremely favourable, that even where the
 cranial bones are fractured and destroyed,  hardly any patient
 dies, but all recover."
   The  ill air of an hospital is more fatal to the re-union of the
 scalp, than either  the bruising of the  scalp, or the injury or
 contusion  of the bone.   The air of the  hospital, the Hotel-
 Dieu, in Paris,  is more noxious than the climate of Cremona,
 Florence,  or Mantua, and has been a matter of regret in all
 ages.  The  good old surgeon, Saviard, shows us what danger
 there is in  making even the slightest incisions, by a case in-
 structive in many respects.
   "■ Nurse Bernard of the Hotel-Dieu, no more than twenty-
 three years of age, was struck on the back of  the head by the
 falling of a poll,  set up for drying cloaths, and fell senseless to
 the ground.   Upon giving her a little eau de vie, she revived,
 when there  was observed upon the injured part a small bump
 only, of the size of a nut, and without any wound.
   " The same evening she vomited, and was oppressed at in-
 tervals with  a degree of  stupor, which having continued four
 days,  we became  anxious,  (says  Saviard), and  resolved  to
 open the  tumour, which was full of coagulated blood, the peri-
 cranium adhering soundly to the scull beneath.   From this time
 forward she had irregular shiverings, which lasted at each return
 four hours uninterruptedly ;  and  during  the  seventeen days
 in which they continued, we reckoned  twenty-five returns.
 Bleeding  we  were so little sparing of,  that in the first days of
 her  illness we bled her no less than fourteen times in the arm,
 and  once in the  ankle; her vomiting continued  incessantly,  ac-
 companied with pungent pain in the region of the liver.
   4t  After the seventeenth day, gangrene came upon the wound,
 which forced us to make repeated incisions; bad symptoms
 continued, notwithstanding, for forty days,  and two  months
 and  a  fortnight  had  expired  before  the wound closed.  Nor
 did her sickness end here, for shortly after the closing of the
 wound,  her face  was puffed up  with an oedematous swelling,
much serum running  continually  by the ears and nostrils for
fifteen days;  deafness supervened, with lancing pains, and con-
tinued disorder of the head; more than a point of reddish mat-
ter flowed from  the  nose, and  a rheum inundated  the chest,
and threatened suffocation to such a degree, that for a long while
 we looked  for nothing but sudden death.   It were impossible
to enumerate (besides the twenty-six bleedings) the  various
 medicines  she used ; it was bv  the frequent use of ass's milk
                           2 L 
266               Of Injuries of the Scalp.
that her health was  at last restored.   Her pains in the head
continued for two years, with beating of the temples which in-
creased with every change of the weather."
   Without having the misfortune to have served in any hospital,
wlmre,  to use the language of Saviard, " I saw innumerable
victims," or, being driven to absolute despair,  like Dessault,*
and abandoning all hopes of being useful in wounds of the head,
I have yet learnt a degree of caution, with which I would fain
impress you in your first conceptions; for of all the abuses of
practice, the most grievous to one who reflects  soberly and mo-
destly on what art can do, is the confident and presumptuous
hope which young  men are too apt  to  indulge, of re-uniting
every piece of lacerated scalp by the main force of sutures, and
relieving every symptom of oppression, or slight delirium, or
temporary fever, by trepanning the scull.  I  have often  ob-
served,  that though  the season seemed  favourable,  the heat
moderate, and the air of an hospital untainted;  while other pa-
tients, and less important wounds, were recovering a-pace, and
no sign of  infection could be  perceived,  those wounded in the
scalp became, after a few days confinement, languid, feverish,
and oppressed,  and had every usual symptom of an oppressed
brain.  Not to specify innumerable cases, from  which my ge-
neral observation is  deduced, I have seen a boy whose  scalp
was lacerated so very largely, as to shew the scull naked,  but
uninjured, continue  well, and free from fever or delirium se-
veral days, then seized with vomiting, like  that of oppressed
brain, with rigours and foul tongue, and rapid pulse, and deliri-
um.  I have seen a  boy lying  in this doubtful  and dangerous
state for fifteen days, the suppuration of the wound being inter-
rupted,  and its  complexion as  much affected  as  the general
health,  exhausted  by successive paroxysms of fever, and,  yet
in no imminent danger.  I  have  seen  three soldiers  hurt, in
the confusion of a fire, from bricks or beams falling on them,
all the three wounded in the head, all seized at once  with  the
same temporary fever and delirium, and yet not one  of them
in any kind of danger.   I have often seen, in an aged person,
where the scull was laid bare by a blow, the integuments slough
entirely away, and fall off in cakes as black  (to use the expres-
sion of nurses) as the soot on the pot, and, after an interval of
imminent danger, in which even the outer plate of the scull has
exfoliated, I have seen with admiration the scull push forth its
granulations with such  vigour in extreme  old age,  (at seventy-
five years of age) as  to replace  the scalp with a broad and firm

  • Deffault was fo unfuccefsful, that at lafl he renounced all thoughts of ope-
rating in fractures of the fcull, and with a few ordinary precautions and remedies,
abandoned every fnch cafe to nature. 
Of Injuries of the Scalp.               267
 cisatrix.  These accidents of fractured scull, or lacerated scalp,
 are frequent only in  an hospital; and  you will  often observe
 your patient, whatever  his age or constitution, attacked with
 sickness or fever,  which seems to imply danger, but which is
 to be cured by antimonials, opiates, and the warm bath.  " Ne-
 ver permit yourselves to  be  alarmed too much at these  first
 symptoms of fever,  nor hurried into any precipitate step,  for
 many have narrowly escaped the knife and the saw, the scalping
 process, and the useless perforation of the scull,  to whom,  du-
 ring the continuance of such a temporary fever, the slightest of
 these operations would  surely prove  fatal."
   That aphorism of  Hippocrates, which relates to the fever
 of intoxication, may be transferred, without reserve, to that ac-
 companying wounds of the head.   " If a man be so intoxicated,
 as to lie speechless, and he be seized  with fever, he is in no dan-
 ger; but if not seized with fever, he dies the third day."  We
 may, with much greater truth, pronounce the patient safe, who,
 having a wound of the head,  has his  delirium and vomiting ex-
 plained by concomitant fever; while he who has the slightest
 shiverings, a less perceptible  oppression, and no concomitant
 fever, is in a doubtful state.
   But that a wound of the  integuments, naturally slight, and
 void of  danger, may, by misconduct, cause not merely caries
 of the bone, but suppuration of the brain, the following incident
 will prove to you.  " A young man of seventeen years  of age,
 was struck in play, by one of his companions, with a small stone
 on  the left side of the headj over the parietal bone.  He put
 himself  into the hands of a sort of surgeon, who dressed this
 slight wound with a heavy hand,  cramming it so  with rough
 lint, that the sore rankled and inflamed, with a daily wasting
 of the integuments.   Yet the boy  was well in all  other respects,
 went daily to market,  and served his master with his usual ala-
 crity.   I saw this slight cutaneous wound at the time of his first
 committing himself to the hands  of  the  barber, with whom I
at the time remonstrated concerning his coarse manner of dress-
ing the wound ; but he replied, " That it was the duty of a sur-
geon to be  cruel, and not faint hearted."   It was because the
wound seemed  so very slight, that I  gave up attending the lad,
but on the eighteenth day, he came  to me of his own accord,
desiring me to see how things went  on.   I  found all the sur-
rounding integuments fistulous, down to the bone, and there
was one  great abscess,  full of putrid matter, which could not
be emptied but  by pressure of the hand.   I, of course, advised
that  this abscess should be opened at its lower part, which the
surgeon promised to do.
  14 At  this  time I had no fixed quarters, but was obliged to 
268               Of Injuries of the Scalp.

follow the royal army,  so that I was prevented from seeing the
patient, for some time ;  but, about the twenty-filth day, 1 was
called to him, and his friends mentioned to me, that the fever
which I found him in, had continued four days.   His eyes were
heavy and swelled ; he was in a sort of stupor, and was reduced
to extreme weakness.   The sinus was still unopened, and con-
tained very foetid pus;  for this blockhead of a barber had, either
through pride or fear, altogether neglected what I advised.
   " I had now no reason to doubt that the brain was affected,
and proposed that the integuments should be laid open, and the
bone  perforated, thinking a doubtful remedy preferable to cer-
tain death.   But the presumptuous fool,  when  he heard that
I  had proposed to perforate the scull, protested,  "That if it
were  not for the fever,  or  if the fever should cease, he  could
make the cure of the wound a very easy matter.
   " On the twenty-sixth day, this  young man  expired;  I re-
quested that his body might be opened, and  the empyric  con-
sented with all possible alacrity, assured in imagination that his
patient's death proceeded merely from fever, not  from any in-
jury of the head; and in this presumption he was  hardened by
recollecting,  that from the  first  there  was no sign  nor  appear-
ance of any injury to the bone.
   " Upon opening the head, the  cranium was,  indeed, found
free  from fracture; but there was  found betwixt the scull and
dura  mater a considerable quantity of matter,  the brain being
at that place suppurated, and melted into pus."* ,
   Thus  are  we assured, that the mere detachment of the  scalp
(if it  continue detached) will destroy the  scull, and endanger
the brain;  for, though it has (in the dura mater, and in its own
structure) various sources  of nourishment, though .ft is  little
injured by  a temporary or partial privation of blood,  yet the
permanent separation of the pericranium manifestly kills, de-
stroys at least,  the outer portion of it, and sometimes its whole
thickness.   In the older times,  when the doctrine of exfoliation
prevailed, when they were in the practice of cutting off the scalp,
so as to occasion the death of the scull, when the  separation of
the dead part was mistaken for an essential process in the cure,
it  was reckoned the duty of the surgeon to procure exfoliation
in every wound of the scalp; and he attained his end by  remov-
ing the scalp, and by scraping and cauterising the bone.
   In  modern surgery, nothing is to be seen  at all correspond-
ing with this; the scalp is never, by any accident, kept separate
from  the scull, unless it be by an effusion of blood.
   These effusions happen in rambling school-boys,  and are of
• Botallus, p. 736. 
#-«■
                   Of Injuries of the Scalp.              269

  sucfr a description as might tempt  the inexperienced surgeon
  to open them.   Whether from opening such  tumours any ill
  consequences might result, I  shall not venture to predict, and
  do not by experience know.  But  of ihis  I am assured, that if
  left alone they  are generally sale; that if the  young  surgeon
  were to yield to the suggestions of his own fear, whenever in
  those cases he imagined he felt a depression, and were upon this
  presumption to cut open the integuments, and trepan the scull,
  the issue ot his adventure would be very often fatal.   The de-
  ception proceeds  from this peculiarity, that where'the vessels
  ruptured  by the fall have madeihe greatest effusion, the blood
  continues long  fluid; bnt,  towards the margin  of this cavity,
  where the cellular substance is not entirely detached from  the
  pericranium, the blood is so injected into the cellular substance
  and  mixed with its fibres,  that the basis  and margin of the tu-
  mour are uncommonly  firm, and the hardness such as actually
  to resemble that of bone.  From  this hard circumference,  the
  surface apparently declines towards that part where the  cranium
  is more distinctly felt through the fluid btood; and the declivity
 is so distinct, and the hardness  of the margin so entirely re-
 sembles that of the centre, where the scull is felt unequivocally
 that the surgeon has not the slightest doubt that he feels a wide
 and deep depression of the scull; and when along with this the
 boy lies oppressed, and  vomiting, he can  hardly refrain from
 opening the tumour, or think himself vindicated in leaving  the
 boy without help.                                      ;
   I know no deception which experience so effectually  corrects
 as this, of an apparent depression felt through a bloody tumour
 of the scalp;  nor can any thing  but experience  correct it;  for
 to the sense of  touch, the depression  is  so palpable,  and the
 boy s danger so very obvious, that even an experienced surgeon,
 on any new occasion of examining  such a tumour, is confused
 with the very peculiar feeling  of that deception, which he is al-
 ready aware of.   Many  times I have fbeen  called to rambling
 boys, who had fallen in climbing walls, or in playing about saw-
 pits, and unfinished buildings; and have often found them with
 great effusions of  blood over  the parietal  bone,  and apparent
 depression; the  face ghastly, and  the extremities  cold, in a
 state of insensibility, with the eyes not closed,  but turned up-
 wards, as in the convulsions of children.   But, fortunately for
 me, the case ot the  boy that I first  saw lying in  this stupor, in
 the earliest part of my  practice, was so perfectly decisive, that
 1 have never since been in danger  of any precipitate step; for
 this boy, who had fallen from a  garden-wall,  lay in a state of *
absolute stupor,  and with a degree  of conyulsipn, during four
days.   He vomited incessantly, and his extremities  were cold, 
2ro                Of Injuries of the Scalp.
  and his face  ghasdy.   The appearance of depression  was  so
  striking and singular, that I made not the slightest doubt, thsft
  if he did recover without any operation, manifest marks of de-
  pression must remain.  But he recovered in a few days perfect
  health and spirits, and the appearance of depression  vanished,
  as the blood was absorbed.*
     I know not whether any specific and unalterable rule can be
  proposed for the treatment of cases so various in their forms,
  their causes, and probable effects, but something I feel inclined
  to say on  this subject.   When the tumour assumes the proper
  form  of aneurism,—when there is a large and circumscribed
  tumour, fluid blood in the centre,—a hard basis and margin,—a
   distinct  pulsation  through  the whole tumour, and its size in-
   creasing from day to day, there is great  danger to  the scull:
   the tumour should be laid open without delay, and dressed with
   lint; and it will, after two or three days of suppuration, (in which
   the matter will be  fetid, from being tainted with the blood),
   heal  kindly; for the arteries of the scalp, when thus bruised,
   and pouring out blood,  have sufficient force to maintain, or
   even  to enlarge, the effusion of blood which cannot be absorbed,
   in opposition to such a cause.  Yet,  when opened, such arte-
< ^ lies do not bleed much, the haermorrhagy  is suppressed merely
   by applying a bit of lint; they rarely need  to  be tied.t  Lastly,
   Effusions of blood, though unaccompanied with pulsation, if they
   continue fluid,  and  do  not gradually subside from the period
   of the sixth or seventh day, must not be regarded as of a slight
   or  indifferent nature, and, before the tenth or twelfth day,
   should be opened.   From all the experience  I have had, these
   rules  of conduct  will be useful to you; and while I warn you
   to refrain in general from opening such tumours, it is also my
   duty to state unequivocally and plainly, that there are others
   which occasion  caries of the scull, where a little imprudence, a
   little delay,  endangers the patient's life.
      " Mr. Harrold, parn^erito  Mr.  Wilmer,  had a boy brought
   to him, of fourteen years of age, with a tumour on the  crown of

     ♦' Though the author's practice, in this cafe, was fucctfsful, I fhould not be
   difpofed to imitate it.  It is certainly exceedingly difficult, in thefe cafes, to afcer-
   tain by the feel alone whether the bone is depreffed or not, a point of the greatcft
   confequence to afcertain; and as 1 know by experience that no injury refults from
   laying open fuch tumours,  even though  the  bone fhould not be injured, I
   fhould recommend it in every  cafe where the tumour was confiderable, or from
   circumftances attending the accident, there was reafon to apprehend an affection
   ot the fcull. S.
     t The hemorrhages may be rcftrained by a comprefs, and the bandage recom-
   mended for the head, (fee Difcourfe on Bandages p. jo-—40.) provided the artery
   be completely divided, which alone will be in moft cafe« fufficient.  This Bandage
   is particularly adapted to  thofe cafes, in which the fcalp  has been feparated from
   the cranium.  5. 
Of Injuries of the Scalp.
271
the h#ad„ the size of a hen's egg. It was seated on the middle
Q& the sagittal suture:  it was occasioned, as his father related,
byl a  blow,  the  boy having been struck over the head with the
arm of a broken chair : the swelling ensued immediately after
the blow.   The father had  flattered himself with hopes of its
dissolving by time, and the simple  remedies recommended by
his neighbours; but about two months after the blow, he brought
the boy  to Mr. Harrold, the tumour undiminished, and con-
taining, according to Mr. Harrold's apprehension, nothing but
blood.  As a measure of precaution only, and without appre-
hending the disorder  which had already been  produced, he
opened the tumour with a long incision, and discharged a quan-
tity of blood, yet fluid, and not in the slightest degree grumous
nor blackened;  and, as  the  artery from which it had flowed
was  still  open,  and a considerable hermorrhagy  ensued, he
dressed the  cavity hastily with dry lint.
   M On the  second day, he removed the external dressing; but,
not chusing to risk a second hermorrhagy, he left the lint which
adhered more immediately (and very strongly) to the surfaces,
untouched:  when this also was removed at next dressing, much
ichorusand putrid matter was discharged, and, upon looking into
the bottom of the cavity, was surprised to percieve distinctly the
pulsations of the brain, and that the bone was entirely wanting
in all that part which corresponded with the basis of the tumour,
a space of two inches  in diameter."  The danger of this boy,
then,  was most conspicuous and imminent; fortunately the dura
mater granulated,  and the opening healed kindly.
   Such are the dangers proceeding from delay, those arising
from  misconduct are no less to be feared.
   " A school-boy, having his hair severely pulled in a quarrel,
there rose a small bloody tumour of the scalp, which he concealed
for three weeks, till it had extended from the size of a pea to that
of a large tumour seven inches long, and  four inches broad,
rising very high in its centre,  and covering much  of the parietal
and  frontal  bone.   This was an aneurism too large to be void
of danger, and required decision in the opening of it, and delicate
dressing to  prevent ill consequences, and  bring it to a right
suppuration.   Mr. Hill of Dumfries was desirous of having it
opened with caustic.  The gentleman who had him under his
care  preferred the lancet.  Upon puncturing the tumour, four
inches of pure and florid blood flowed from it, and the peri-
cranium appeared entire.  Mr. Hill now proposed a loose ban-
dage, till  the  parts  should  have time to contract; but again,
says  he, " I was overruled,  and a thick compress was bound
down over the tumor, and a dossil put into  the orifice."  Next
day,  the  integuments had adhered  closely to the pericranium, 
272
Of Injuries  of the Scalp.
and a full sac was formed at each end;  and, to discharge these,
the gentleman tore  up the scalp, by  thrusting a probe under
it, and then renewed-the  compress.   On the* third day,  the
Sacs were  again  filled, the parts  adhering so firmly, that the
probe could not be introduced,  though  he tried it several ways,
and  with so much  force,1 that the bone was laid bare in three
places.
• " Then  followed  an cedema over all the scalp.  The gentle-
man to whose care the case was committed being out of town,
the sore was neglected for three days;  the swellings increased;
there was much pain, fever, sickness,  and a degree of delirium
and raving.  On the'fourth, two caustics,  notwithstanding the
inflamed state of the scalp, were applied ; and on the fifth,  the
bloody and purulent' matter being discharged, and a fomentation
applied all Over the head, the delirium subsided, and the swell-
ing soon vanished.   There were now three openings, each of
which continued to run for many weeks,  till the bones which
had been laid bare exfoliated."
   Before I fdrsake this subject of injuries external to the cran-
itifrr^^sball represent to  you one which  is attended with no
danger of caries, but relates to the scalp only,  a nervous and
most singular disease ; resembling that which arises from some
injury in bleeding in the arm, attended with little danger, but
marked by convulsive motions, nervous  affections of  the most
undefinable nature, and sometimes with agonizing and period-
ical pain ;  pain varying  according to  the state of the weather,
or the patient's health.
   " The man whose case I am going to relate to you, was about
thirty-two years of age,*sallow, sickly, arid, I  fear, dissolute.
He had lost his health, his industry,  and his morals,  by an un-
fortunate blow on the head, which had deprived  him of reason
for many  months; and, afwr a second blow on the head,  he
suffered, in consequence of the sewing of  the temporal artery,
a very singular nervous affection.
   " First, about three years  ago, he  was attacked  by some
drunken companions of  his own, who, knowing he had in his
pocket thirty shillings of wages, and he refusing to treat them,
way-laid him in a dark passage, and knocked him down in re-
venge.   He fell backwards into a cellar-stair, struck the back
of his  head against the  stones, and was carried  to the hospital
senseless ;  where, notwithstanding every care of the surgeons,
he lost his reason, continued many months insane, left it at last
in a weakly and languid  state, ill able to return to his hard la-
bour, that of press-man in a printing-office.   From that time he
wrought little, and irregularly,  became  a miserable vagabond,
subsisting chiefly on charity,  and living  among his friends. 
                  Of Injuries of the Scalp.              • 273

   l' About three months ago, as he was coming down an open
 stair, which had no hand-rail, and was so dangerous as to have
 been the occasion of frequent complaints to the landlord, he fell
 over the stair, and lighted among  sharp stones, and  his fore-
 head was laid open with a ragged  wound, about four  inches in
 length, extending from the forehead to the temple.
   u The stair was notoriously dangerous, and  the night dark,
 but he confesses that he was a little tipsy. Nothing so surely in-
 dicates a vagabond and idle life, as indifference to cleanliness and
 health ;  he did not return to his old asylum, the hospital,  but,
 with a penny-worth of Wade's balsam,  and  some filthy appara-
 tus of rags, made a fashion of dressing his wound, till, by filth
 and neglect, it ulcerated ; the temporal artery was eroded;  the
 blood sprung briskly from the corner of his sore, and thus he
 was brought to the infirmary.
   "• The house-surgeon sewed the artery ;  he was laid in bed,
 and enjoined not to stir, lest it should burst out again.   He was
 very timid by nature, and the students took a pleasure in alarm-
 ing him from time to time, with saying, that  it would surely-
 burst out again. About a  fortnight after, the ulceration still ex-
 tending, the artery was again eroded ; and at night, betwixt ten
 and eleven  o'clock, when turning gently in bed,  he felt his fore-
 head moist:  and,  upon putting up his hand, found it wet with
 blood. The artery soon began to  bleed per saltum; and  the
 house-surgeon being called, the artery was again secured, by stri-
 king a needle  and ligature under it.
   " After the first sewing of the artery, he felt nothing unusual;
 but after this second stroke of the needle, he found, next morn-
 ing, his mouth pussed up and contracted,  his jaws so  clenched
 that he could not speak, while spasmodic contractions extended
 along the neck and throat.  His cheeks  were flattened, and his
 mouth pursed up, and at the same time protruded as in a ludi-
 crous  simpre,  or like one attempting to  whistle,  and prevented
 by an inclination to laugh.  The form of the face was remarkably
 changed ;  the  sphincter oris  pursed up the mouth, while- the
 zygomatic  and  triangular muscles retracted the corners of it,
 and made the dimple natural to that part very deep; the cheeks
 were  flattened, the mouth protruded;  when he attempted to
speak,  which  he did imperfectly,  the whole face was  agitated,
and his tongue got entangled between the upper  and lower ran-
 ges of teeth, so that he imagined, if he persisted, he might bite
it across ; and the throat and the whole neck was obviously con-
 tracted in a spasmodic state, accompanied with remarkable pain;
 and he could not open his  jaws to  receive the smallest particle
 of food, but lived on spoon-meat.".
                           2 M 
~T4            Of Separation of the Dura Mater.

  Having pointed out with deliberation, and, I hope, with preci-
sion and clearness, the various injuries of the  scalp,  I  hasten
now to a subject more  interesting in an  infinite degree ; I
mean, the consequences resulting from a separation of the  dura
mater from the internal surface of the scull.

                        SECTION III.

              Of Separation of the Dura Mater.

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

    This cafe proves how flow and infidious fuppurafions of the dura mater are,
but by no means that this  membrane can be feparated by a fhock: the contrary I take
to be the more probable inference; for had it been feparated by the accident, and
had not re-united, fuppuration muft,  I think, have immediately taken phce.  S. 
276
Of Separation of the Dura Mater.
tached,  forms fungi, and destroys the scull.  " This man  was
about fifty-one years of age, fell from his horse, and was sensi-
ble ot a violent concussion of  the head ; a distressing pain en-
sued, but it soon vanished, and the  patient thought no longer
of his fall, nor of this pain.   About  four years  after, he be-
came conscious of a loss of memory ; and this malady increased
so, from day to day, that he at last forgot what he had said or
done the moment before.  Then came cruel and  incessant  fits
of epilepsy.  Those paroxysms  seemed for six  months to be
appeased by the medicines he took; but there  followed next
pains of the head,  excruciating, unremitting, and continual,
which no remedy  could  alleviate,  and which, in six months
more, proved fatal; and so dreadful were  these pains which
affected the left side of his head,  in  the  form of  megrim, that
the left eye was convulsively  turned in its socket, by the excess
of pain.
   "  On opening the scull, the middle and fore part  of the right
parietal bone was carious, and destroyed in a space equal to the size
of a half-crown.  Lesser spots of caries were observed in vari-
ous  parts  of the scull-cap, while the  left parietal  was corrupted
by a fungous excrescence from the dura mater, which extended
towards the orbit,  and had destroyed also the cribriform plate
of the cethmoid bone."
   Here we see again the sudden shock separating the dura ma-
ter,  perhaps to a great  extent from the scull.   The bone dying,
and  falling into  general disease,  by the loss of its  nourishing
membrane ;  and that fungus  (which it  seems the peculiar dis-
position of the dura mater to produce, when healed apart from
the  cranium) destroying the  parietal  bone, making its way
through the thin plate of  the cethmoid bone, and causing death
before it had growth sufficient to produce an external  tumour.
   In speaking of tumours proceeding from  within the scull,  1
have been insensibly led on to  this subject, by considering the
various consequences of this  separation of the dura mater; and
my  object has been to impress you  with just  and serious  fears
of entering upon any surgical enterprise,  where  such tumours
arise from within the  scull.   The cases which I have already
detailed, are not merely destined to adorn the works of a learned
society, or to be a matter  of stupid wonder,  but to serve as use-
ful warnings; they  are forms of disease, horrible,  indeed, in
their conclusion, but in their beginnings, hardly to be distin-
guished from the most trivial tumours; and that surgeon is in
great danger who does not, from  reason and reflection, (for ex-
perience few can have in such rare cases) form a decided opi-
nion the moment such  a tumour is exposed,  who does not re-
solve, with a steadiness not to be shaken, a not  to touch it for 
Of Separation of the Dura Mater.          277
 the world."  The  good that can be done is problematical, the
 danger dreadful; and the surgeon who but allows himself to con-
 sult upon such a case, or to hearken to the intreaties of a patient
 weary of existence, is  in danger of robbing him of life.  The
 disease,  it must be acknowledged, is fatal in the course of na-
 ture ; yet, wherever an operation has been attempted, it has u-
 niformly accelerated the death of the patient.
   Let these facts, then, stand to you  in  place of experience.
 Examine, with a scrupulous and jealous precision, into the his-
 tory of all tumours seated on the head.  Regard, as suspicious,
 those which are connected with venereal affections, with blows,
 or falls, or concussions of the head.  Regard, as peculiarly dan-
 gerous,  all tumours of slow growth, of deep  pulsation,  reced-
 ing within the cranium, covered with puffy scalp,  and causing,
 upon being repressed, not pain, but sickness, confusion of head,
 convulsions,  and tremblings of the limbs.  When the scull  is
 first destroyed, and the brain, or the internal tumour protrudes,
 a  temporary relief sometimes ensues.   Occasional ease is some-
 times procured by gentle pressure, and equable  support, but
 the event is inevitably fatal; and frequent swoonings, insensi-
 bility, coma,  or quivering of the limbs, an involuntary discharge
 of urine  and faeces, delirium, and convulsion, close  the  scene.
 Touch no such tumour, at the peril of  your reputation ; for, it
 is either a caries of the cranium, through  which the brain pro-
 trudes, or an aneurism from without, or a fungus  from within,
 which has destroyed the bone.
   Let us now  return to reflect on one  indisputable fact, and it
 is this: Within the proper structure of the  scull, the circula-
 tion is so vigorous, and its sources of blood so varied, that the
 bone by no means depends on any one set of vessels for nourish-
 ment, nor even on that which seems the  most essential to its
 health, the dura mater.  Almost the whole  of the dura mater
 may be separated from the internal surface of the scull, and yet
 the union be restored.  We often, upon  applying the trepan,
 perceive that the oppression of the vital powers proceeds from
 an effusion of blood under the scull, compressing  the  brain.
 The blood is hooked out with probes,  washed away with mild
 injections; diluted by the  natural secretions, and by the puru-
 lent discharge from the suppurating surfaces of the dura mater
 and scull; and the clotted  blood being  thus  dissolved and dis-
 charged, the surfaces unite again"  We  are often persuaded, by
 the quantity of the extravasated blood,  that  it must have co-
 vered the whole hemisphere of the brain, up to the sagittal su-
 ture.   We sometimes feel the  extent of the separation, by in-
 troducing the probe ; but we seldom have so  clear a conviction,
as in the following case of the whole extent of the dura  mater,
/ 
278
Of Separation of the Dura Mater.
 of the whole  internal periosteum of the scull  being detached.
 " A young man, of about thirty years of age, was struck re-
 peatedly on the head with a crab-stick, and with a loaded whip.
 Next morning, he was found lying in  a state  of profound le-
 thargy, and with his right side paralysed, but without the slight-
 est appearance  of fracture,  or  depression  of  the  scull.   The
 marks of the blows being chiefly on the right side, that  side
 (contrary to a well-established rule) was first trepanned, and the
 dura mater was found disengaged to such an extent, as to con-
 tain, at least,  six or seven ounces of blood, betwixt it  and the
 scull.
   " This first perforation gave him some respite, but his friends
 resisted all further attempts  to  relieve  him, till four days had
 elapsed, when there appeared no longer any hopes of life, and
 he was left to die  among the surgeon's hands.  Then the left
 parietal bone  was trepanned.   The whole hemisphere of the
 brain was seen to be surprisingly compressed  by a thick black
 cake of coagulated blood, of the consistence and colour of cur-
 rant-jelly.  The cake of blood extended actually from the falx,
 or sagittal suture, to the bottom of the os  petrosum; in short,
 from the vertex to the base of the scull;  and seemed  to con-
 sist  of the same quantity  that was discharged  from the other
 side, amounting, of course,  to  six or   seven ounces of blood.
 Although it was not thought prudent to bring away at once the
 whole mass,  yet, so much was  discharged, that, upon speaking
 to the patient, he instantly looked up,  like one awakened from
 sleep, named every one, and raised the arm,  which had been
 paralytic, over his head; and much of  the coagulum being re-
 moved, he recovered apace, so as to be able, by the fifteenth,
 to walk into an adjoining room; but by the accidental bursting
 out of an artery in the  scalp, he was weakened, the confusion
 of head, and even the paralysis, in some degree, returned.
   "  Some days after this, his  friends, despairing of his  life,
 laid  him  on  a  litter, and, without acquainting his surgeons,
 (Mr. Hill, and Dr. Gilchrist, of Dumfries), carried him home,
 a journey of eight miles.  The left side  of the brain suppurated
 five or six times, each paroxysm of inflammation being accom-
panied with fever, stupor, and difficult deglutition, and relieved
by an eruption of matter ;  and it was remarked,  that when such
suppuration formed towards the fore part  of  the  brain,  the
candle appeared to the patient double ;   but when the suppura-
tion  was  backwards, the light  appeared to have  a halos, or
circle, round it; and after each  eruption of matter, the candle
appeared single and distinct.  Notwithstanding these occasional
interruptions,  he was, in three months,  compleatly cured; be>
came the father of a family, and lived long in perfect health,. 
Of Separation of the Dura Mater.
279
 excepting a  slight defect  of memory, and slight convulsive
 twitches,  to which he continued subject."
   In this most interesting  case, related by Mr. Hill,  he had
 taken every pains  to ascertain the extent of the separation.  He
 found  no apology for introducing his probe under the scull,  on
 the right side,  because the blood flowed freely out;  but, on the
 left  side, his probe, while hooking  out the coagulated blood,
 passed from the trepan-hole,  in the centre of the parietal, down-
 wards,  along the temporal bone, till it was stopped by the cur-
 vature of the os petrosum, and upwards again by the lambdoidal
 suture, all along the sagittal suture, and over the orbit, along the
 frontal bone; " and it is my persuasion," (says Mr.  Hill), "that
 the separation of the dura mater was not less  extensive over the
 right side."
   What, then, are we  to infer from these phenomena ? Surely
 this: That, as  lacerated scalp adheres readily with the external
 surface, the dura  mater has an  equal aptitude to re-unite with
 the internal surface of the  scull: and these phenomena present
 themselves daily to the observation of the practical surgeon.  He
 presumes, from the sudden oppression of his patient's senses,
 and the palsy of his limbs, that the dura mater is  separated, by a
 shock, or blow,  not slightly, so as merely to endanger suppuration,
 but to such extent as to cause a great effusion of blood from all its
 vessels.   He trepans the scull, and by the general pressure, and
 rising of the'brain, the blood is, (as I have  generally observed
 it) spued up in grumous  clots, through the trepan-hole.   He
 puts in his finger,—turns it round,—feels  no solid resistance,
 and is conscious that the dura mater is much depressed, and the
 effusion of great extent.  Sometimes he finds a cake  of solid and
 firm coagulum, which bears the pressure of the finger.  At each
 dressing, he introduces  his probe, binds it, and turns it in every
 direction; by  injections of  tepid water,—by the  help of the
 probe,—by the purulent secretion from the surface of the scull,
 and dura mater, the  blood is  gradually discharged, and by every
 mark it is certain, that  the extravasation has exuded under the
 whole  of one parietal bone, from the forehead  to the occiput,
 and sometimes from ear to ear.   Yet, by the secretion of pus,
 and by the heaving of the brain, the blood is entirely discharged,
 and purged  away.  The scull and dura mater are in  a state of
 suppuration by the  time  they are allowed  to approach  each
other.   The dura mater  is  covered with a velvet-like pile oi.
 granulation.  The  margins of the trepan-hole, and (by inference)
the internal surface of  the scull, is covered with a  similar pile
of granulating flesh.   The dura mater is, by the pressure of the
brain, supported in  close contact with the scull, and the surfa-
ces are united, and the trepan-hole closed by a process of nature. 
28,0
^ Of Contusio Cranii.
 visible to the surgeon, in every stage, and expressly resembling
 the re-union of soft parts.

                        section iv.

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

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

 implies no more than that the dura mater,  if it escape the first shock, may secede
 ro  slowly from the deadened bone, as to lessen the danger; in short, that a contu-
 sion of the scull may terminate in mere  caries.  But this is no reason why we
 should depart from that just and important role of the ancients, that we should in
 all cases of contusion,  operate early. 
284
Of Contusio Cranii.
is  a mark too decisive, and  too certainly fatal, to be waited
for."
   But as yet, I have related no fact, nor advanced any thing,
which might lead you to conceive the notion of an  injury affect-
ing a part only of the system of a bone, of a caries of one only
of the tables,  and of an abscess of the diploe which lies betwixt
them.  It was what I myself never suspected; so that  the oc-
casion in which  I first observed it was extremely interesting.
   " A young man,  in the prime of life and health, fell from his
cart,  and the wheel,  passing obliquely  over his head, slided
upon  his scull as upon a stone.  The integuments were t-irn
down to a great extent.  There were three large and triangular
flaps  of scalp so  ingrained with mud and  sand, that the blood,
hair,  integuments, and scull,  seemed baked into  one mass  of
filth.   The man was profoundly drunk ; upon cleaning the flaps
of the scalp, with the design  of replacing them, the marks  of
the cart-wheel upon the scull, which was  rough and scratched,
were so  visible,  as to preclude all  rational hopes of re-union ;
yet the  flaps were nicely cleaned,  replaced, and  held together
with  slight  stitches.
   "  That integuments so lacerated,  and a scull so plainly inju-
red,  should recover,  was not to be looked for ; but the injured
bone  might exfoliate, as a mere caries, and the violence, besides,
was of a peculiar kind, there  was no fracture; the patient had
received no blow by which the bone might  be contused through-
out ;  the injury was apparent on the surface only, and was pro-
bably limited to the external table of the  scull.  The external
table  might  exfoliate, but it was infinitely more probable, that
the caries should penetrate and affect the dura mater; and it was
our duty to watch for signs of danger; and yet to trust to nature
so long, as the  injury seemed local, so long as it  was possible
that it might exfoliate superficially,  and as a mere caries.
   " The man, more  astonished than hurt, was no sooner resto-
red from his  brutal state of intoxication, than he appeared to  be
in perfect health; there were no shiverings,  no fever, no con-
fusion of head during the day,  nor  delirium  during the night;
much as we were persuaded of his danger,  it was only danger to
be apprehended, no symptom as yet announced it.   The sup-
puration from  the  integuments in such a case  is profuse and
foul; and, while such a lacerated wound, so ingrained with filth,
is cleansing and granulating,  it visibly mends,  and the surgeon
 is too apt to  indulge hopes,  which are never to be realised.  In
this case, the integuments first thickened, as they always do, by
inflammation; were next wasted by suppuration, and remain-
ing still insulated, the edges  became livid,  and sloughed off*
while the scull  blackened more extensively ;  a slight fever was. 
Of Contusio Cranii.
28£
inseparable from  such a state; his face was  full, and his eye
heavy and languid; yet that was not much to alarm us; but he
sickened; on the thirteenth, he was reported delirious during
the night.  We could no longer be responsible for delay, and he
was trepanned ; and circumstances of the most singular nature,
which I wrote down, (as always I have done by the bed-side of
my patient), persuaded me on the instant that this was as truly
an abscess in the substance,  in the cancellated part of the  bone,
as ever  a  boil was an abscess  of the cellular substance of  the
skin."
        Remarks in the time of operation, and after it.


  " The integuments, by retraction, by suppuration, and most
of all, by the gangrene or sloughing of the edges and angles of
the several flaps, were so wasted as to have left an extent of na-
ked bone, as broad almost as the palm of the hand.  The bone
dry,  and scabrous,  was black in two places.   The perforation
was made near the centre of the parietal bone, on a point of bone
black as a coal.   In perforating the outer table of the scull,  not
the slightest tint of blood appeared; it seemed dry through all
its substance ; the saw-dust was black at  first, and became  white
in the progress of sawing, and as  dry as hair-powder; it was
easily blown away, and the working of the saw was like the cut-
ting of button-moulds from  a piece of horn.   The whole scull
was extremely thick ; the sawing, which was  deliberately per-
formed, was of course extremely slow;  at last thick and viscid
pus spouted up round the instrument,  and I had no doubt,  (al-
though I had before affirmed the dura mater and brain to be  still
unaffected), that there was an abscess;  that the operation was
fortunate, and might eventually save the patient's life.   But the
most accurate probing of the circle with the point of a quill did
not discover to us even  a single point in which the perforation
was complete.   The  inner table, to our utter amazement, was
perfectly entire ; and  there appeared,  for a moment, no  other
rational explanation of this phenomenon, than that the inner ta-
ble must have been  fractured,  permitting the pus  to exude
through some oblique passage, from an abscess of the dura ma-
ter, to the cancelli betwixt the tables of the scull.
  " The crown of the trepan was again applied, and,  under the
impression of there being an abscess betwixt  the scull and" dura
mater, it was turned boldly and freely, without fear of wounding
that membrane, when  suddenly there issued through the trepan-
hole much blood ; and it was feared, that some ill accident had 
286
Of Contusio Cranii.
 happened, in short, that the dura mater was wounded. But, upon
 probing with  the  quill, the inner table was found still entire;
 there was every reason for sawing slowly and  cautiously ; and
 it was, accordingly, very long in cutting through.  During all
 this stage of the operation, the blood flowed profusely; and, when
 the circle of bone was at last taken out,  the blood and matter
 ceased to flow. The dura mater was seen white and clean, firm-
 ly attached to the edges of the boney circle, and no where sup-
 purated ;  and every circumstance of the operation  inclined mc
 to examine the trepanned circle with particular accuracy.
   " The circle of bone sawed out with the trephine was, except
 one, the thickest I had ever seen.  The external surface was
 perfectly black ; the  hole where  the centre-tooth of the trepan
 pierced this carious table, and all the sides  of the same table,
 were of a  dead, white, or ash colour ;  the cancelli were gaping
 and irregular, yet without any very particular appearance.  But
 the inner  table was red in its  substance,  and bloody  in  its
 edges.
   *' The state of the dura mater was, during the cure,  the sub-
ject of my most careful investigation.   There  was, I am well
assured, no abscess; its surface changed,and it went through the
process of granulating without more matter than that which that
process implies, and  such  as the exposed surface alone might
produce.   These descriptions, taken  carefully  from my case-
book,  require no comment.  This at least is sure, that the in-
ner table may remain sound, and full of blood,  while the exter-
nal table and cancelli  are contused  and dead; and I have no
doubt,  that this man was saved from most imminent danger.
Every  such caries  should be  trepanned; very  slight indeed is
the chance  of such an injury being partial at the first, or conti-
nuing so ; still less likely is it, that after penetrating just to the
dura mater, it should be separated by an effort of nature."
  The following interesting case,  communicated to me by my
able and much-esteemed friend, Professor Jeffrey, and related
by his  nephew Mr. M'Dougall, who  attended the patient  in
her last moments,  will, I  believe, be highly gratifying to you.
  " A   young  woman, living then in  London, about six and
twenty years of age,  was struck down by a smoothing-iron fal-
ling from a height, where it had been carelessly  hung, perpendi-
cularly upon her head.   It struck heron the  top of the head, on
the upper part of the left parietal bone.  She was conveyed  to
an hospital in a state  of insensibility,  and continued delirious
for some time.   She was bled,  the head shaved, the wound in
the scalp  enlarged;  and when she  recovered   her senses, she
complained of a sense of giddiness, accompanied with pain of
the head, which continued for  many weeks.   Of the state of 
Of Contusio Cranii.
287
  the  bone she had never been distinctly informed, but could per-
  ceive at the end of some months, that the surgeon, or his assist-
  ant,  at each dressing, attempted to extract a large piece of dead
  bone,  which was moveable, and which they shook and pulled in
  various directions.   During these attempts, the sore was dres-
  sed with  lint, and a poultice was occasionally applied.
    " She  remained very  long in  the hospital,  (eight  or  nine
  months), where her health having suffered gready, the physician
  suggested to her the propriety of removing to the country.  She
  complied with this advice ; and after three or four months spent
  with her friends, she  returned to  the  hospital much recruited.
  Many and  various attempts were now made to disengage the
  insulated piece of bone.  Her health began again to decline, her
  appetite failed, she was greatly reduced by fever, fits, and pro-
  fuse perspirations.  The discharge from the carious ulcer,  pro-
  fuse  as it had always  been, was  now greatly increased,  becom-
 ing more profuse and extremely fetid, as  she  became  weaker.
  Nourishing diet and  cordials were not spared.   She  felt  that
 her health could not improve in the air of an hospital in London,
 and resolved to return to Scotland,  to live  or  die among her
 friends ;  weak as she was, she actually performed this journey
 of 400 miles in a mail-coach.
   " When leaving London, the gentlemen under whose care
 she had been, charged her never to permit any operation for the
 removing of the carious part of the  scull.  They remarked, that
 the bone, which was slowly decaying,  would be at last disenga-
 ged by the ulceration and erosion destroying those parts by which
 it was surrounded;  that to this alone should she trust;  the pro-
 cess of nature, they said, was safe, and sure to happen, if  she
 could but regain her health ;  the expedient which would proba-
 bly be proposed  to her,  of applying the trepan, extremely dan-
 gerous.
   " On her arriving in Glasgow, and applying to Mr.  Ander-
 son, an eminent surgeon in that city, his opinion was so  entirely
 opposite to this,  he was so persuaded of the propriety of remo-
 ving this  insulated bone, (now entirely uncovered, and of great
 extent), that he remonstrated with the  patient,  argued with her
 friends, and assured all who had an  interest in her, that the pain,
 irritation, diarrhoea, and fever, the want of appetite, and pro-
 fuse discharge,  could not fail  to  bring her  soon to the grave :
 But still his advice was neglected, till at last her health manifest-
 ly declining,  and her situation being in all respects hopeless, the
operation  was assented to.
   " With the design of afterwards bursting up  the corrupted
part of the  bone, he applied the  crown of a very large trepan
nearly on the centre of this extensive caries ; an operation which 
288                 Of Contusio Cranii.
was not accomplished easily, nor at once ; for such was the per-
verse and fretful temper of the patient, fatigued  with pain and
suffering, that she submitted very ill to the operation ; such, in-
deed, was her real weakness,  that in place of completing the
perforation at once, Mr. Anderson thought it prudent to allow
two days to elapse  betwixt  the first and second application of
the trepan.
   " By this central perforation, the insulated bone was convert-
ed into a broad ring; it was of the form of a quoit; and a  se-
cond perforation, with a smaller crown of a trepan,  would have
divided the ring, have reduced it in the form of a crescent, and
have enabled the operator to break  up  and extract the caries,
without endangering the dura mater.   But he was not permitted
to complete his operation; if there was either danger or pain in
the operation, he had done all the harm,  but was permitted to
do none of the good that might have  been expected.   Though
prevented from fulfilling  his  more important duties, he conti-
nued his  charitable  visits to  the patient.  He still hoped, in
some period of pain,  or from a deliberate conviction of her dan-
ger, that she would allow him  to complete  his operation;  but,
wearied with opposition, and  finding himself really useless, he
at last withdrew.
   " It was from charitable motives only,  to soothe and alleviate
her distress, without the slightest hope or  design of offering any
more important assistance,  that  Mr.  M'Dougall  now agreed
to attend her, and assist her  friends in applying the dressings,
and keeping her sore in the best condition.  The state of mat-
ters at this period is excellently well represented in the following
report by  Mr. M'Dougall.
   " On removing the bandage and dressings,  I had now an op-
portunity of seeing the extent and appearance of the disease.
The scalp had ulcerated and sloughed off to the extent of five or
six inches in diameter, exposing almost all the upper part of the
scull. The insulated  piece consisted of the upper and back part
of the right and  left parietal bones. It extended from the lamb-
doid suture   behind, to withm two inches of the  coronal suture
before.   The sagittal suture was seen to run along the middle of
this caries, which measured  transversely five inches,  and lon-
gitudinally three inches and  a half.   A great part of the^ exter-
nal table of the loose  bone had mouldered away, and the dura
mater was seen through the trepan-hole, and through many ul-
cerations in the scull, covered with pale unhealthy granulations.
The edges of the scalp were swollen, livid, and painful, and the
discharge of pus was profuse, of a dark colour, and very fetid.
The insulated piece of bone was immersed in matter, blackened
on its surface, andincrusted with the discharge.   I could easily 
Of Contusio Cranii.                 289
move this piece of bone a litde way upwards or downwards, or
to either'side, the thin edges of it passing at each movement un-
der the edge, or between the  tables of the surrounding bones.
It could even be depressed a few degrees, though the resistance
to this was  very considerable;  nor did the  patient com-
plain  of any uneasiness.  It was this resistance that enabled
Mr. Anderson to apply the trepan  on the insulated piece of
bone itself.
   " Compresses had  been  applied to prevent the matter from
descending betwixt the cranium  and scalp,  but without success.
The matter had worked its way downwards, forwards and back-
wards, had destroyed the cartilaginous tube of the external ear,
giving a free exit to the discharge through the external meatus,
and had separated the scalp from the squamous portion of the
temporal, from almost the whole of the left parietal, and from
a great part of the occipital bone.  The matter had descended
to the  neck, and formed a large collection there, which poin-
ted ; but the  patient would  not allow  of a counter-opening.
The application of compresses, to prevent its accumulation,  was
now out of the  question, for the scalp covering the left and back
part of the  cranium had become  livid, and  extremely painful to
the touch, and  as thin as paper.   A bent probe, when introdu-
ced under the  scalp directly backwards, could be passed down
to the  neck, and made to turn round the convexity of the scull,
till it was withdrawn opposite  to the ear.   The bone felt rough,
and denuded of pericranium throughout this whole circuit. The
matter exuded also from under  the bones of the  cranium,  and
had detached the dura mater from them to a considerable extent
laterally, and downwards to the  base of the scull.
   " The  ulcerated scalp was dressed morning and evening
with a pledget  of lint, covered with spft ointment.   Tow  was
applied above the lint, to absorb the matter,  and the whole
was retained by a bandage loosely applied.  At each  dressing,
about  an  English pint of a dark-coloured fetid matter, very
much resembling coffee-grounds, could, with gentle  pressure,
be forced up from the neck, and from betwixt the cranium and
scalp on the left side, and discharged at the large opening above.
The scalp bled  on the slightest touch, but the blood was almost
without colour.
   " The patient had at this time survived the accident twenty-
three months.   She lived about  a  month longer, her debility
daily increasing till she died.*
  * " I need not, Sir, send you a copy of my notes of the dissection; as nothing
very remarkable presented itself.  I may remark, that the dura  mater adhered
very firmly, where it was connected with the parietal bones anteriorly, and was
m general much thickened in its substance.        " Peter M'DnuGALi "
                            20         ' 
2S>0
Of Suppuration of the Brain.
r, It is my opinion, that the carious bone of a member may be
left,  till it be discharged or loosened by nature ; but that when
a vital organ, as the brain, is endangered by slow  exfoliation,
the bone should be removed as soon as it begins to shake;
that  life being at  stake, nature, when she  makes the effort,
should be assisted, but always modestly and delicately.  Then
are circumstances, in  which it is plainly our duty, not only by
shaking and  moving  the  deciduous piece, but by cutting  and
trepanning the  scull, to remove it; for,  when the integuments
have sloughed off; when much, or the whole of the cranium
is bare;  when the dura mater is ulcerated  over almost all its
surface; when one separated piece of bone supports  an ulce-
ration and caries over a great extent of the scull;  I should (in
hopes of removing that insulated piece of bone)  proceed to
the most dangerous and fatiguing (for these  are  not  painful)
operations, as freely as I should pull a thorn out of the flesh.
                        section v.

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

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

  • Although the operation fhould certainly be performed under thefe circuni-
ftances, as giving the only chance for life, the furgeon fhould not be too fanguine
as to the event.  S. 
Of Suppuration of the Brain.
293
ses the bone, deadens the scalp, and that surface which is next
the cranium, is chiefly affected, in consequence of the hard resis-
tance of the bone:  the surface of the scalp,  in contact  with
the contused scull, is  gangrenous, and thence the tumour is em-
phyematous, soft, uninflamed:  the deadened  part being lim-
ited, gives a circular  form to the tumour ;  by the extravasation
of blood, and inflammatory thickening of the surrounding parts,
it is circumscribed; and by its relation to the contusion of the
bone, and the probable  separation of the dura mater,  such
tumour becomes the  most infallible sign of danger.  Nor is it to
be doubted, that such puffy tumour  arises from  the contusion of
the bone, and  the bruising of the scalp ; for the separation of
the dura mater will not cause it.  Often have I seen the pa-
tient, who had  great effusions of blood betwixt the scull and
dura mater, lie  for days or weeks oppressed and  unassisted;
but never have I seen such separation of the dura mater marked
with puffy tumour.
   " T. a big  gross man,  of about thirty years of age, was
(upon I know not what quarrel, but I believe in defending a little
boy who  had  been  abused)  knocked  down with  a brick bat.
The fellow who had  abused the boy, and then revenged himself
upon the innocent man who interposed, was notorious for his
savage dispositions,  and for such uncommon bodily strength,
as to leave  no apology for his lifting any  thing like a weapon.
He lifted half a brick, and, standing on a stair to which he had
retreated, threw  the brick  with all his force, and hit T. on the
head a blow which felled him to the ground.  He lay very long
insensible, for the space of a day and a  night, in his own house,
so that had we  seen him at this period, we might  have appre-
hended some  bursting of blood-vessels,  and extravasation
within; but he revived, recovered his senses entirely, found
the cut on his head very trivial, and would have returned to his
trade,  but for  that indescribable sickness  and languor which
hung about him, without any remarkable symptoms, to the hour
of his death.
   " Deep as the ulcer had penetrated into the brain, and early
as the  symptoms began  in this man, they were all along very
slight.  He had hardly recovered from the insensibility,  when
the shiverings  commenced.   On  the  3d day he had frequent
fits of shivering, of a quarter of an hour's duration, followed by
heat and thirst.  A  purge  (which  I prescribed on the 4th)  of
jalap, and submuriate of mercury, operated  smartly, and re-
lieved the pains in his head.  Next morning, I found the ver-
tigo, head-achs, and tinnitus aurium, almost gone, and he felt
nothing but a degree of weakness, and languor, and disturbed
sleep.  On  the 6th  day,  I found this  giddiness, languor, and 
294             Of Suppuration of the  Brain.
pain,  increased,  but again relieved on the 7th, by the operation
of a second purge; and, on the 8th, he mentioned but slighdy
the pain of the head, and seemed chiefly distressed by the de-
bility and languor.  In this state did I watch him carefully, the
headachs being relieved, but the languor increasing, till the
10th  day,  when, besides the oppression and languor, he felt
sickness,—an increase of the headachs,—long-continued dullness
and horrors,-*-a degree of confusion during the night; and he
awakened,  not as from a refreshing sleep, but oppressed in an
unusual degree, with a hot skin, and fretful pulse ; and he had
that degree of constipation which I know not whether to ascribe,
in such cases, to sudden confinement after a state of health, or
to an incipient state of paralysis, which affects always, I observe,
the viscera, before it sensibly affects the limbs.   By a repetition
of the purge, his confusion of head,  and sickly feelings, were
again abated, and  something of cheerfulness and content was
visible  in  his countenance.   He remonstrated strongly against
the cutting of his hair, under pretext of the ill effects  which he
had always experienced from cutting his hair, which infallibly,
he said, produced headachs ; but really, I believe, for fear of
this being  but  a prelude (as it was indeed designed) to some
operation.
   " The small  wound  was now puffy and livid; the adjacent
skin began  to be undermined,  and the probe,  when introduced,
ran along some extent of naked bone.  The pulse had risen be-
yond a hundred, the tongue was white, the belly still costive,
and the night of the 14th he passed in a sleepless perturbed
state,  succeeded in the morning with headach, a permanent
sense of coldness, sensibility to light,  and that character* in his
features, and in all his motions, of oppression and extreme lan-
guor, which is  inseparable from a suppurating brain.  An un-
informed person would  expect suppuration  of  the brain to be
marked by convulsions or delirium, while one at all acquainted
with such scenes knows, that it is distinguished only by extreme
weakness, not by the violence, but by the total absence of symp-
toms.   The man knows not  what ails him ; the surgeon per-
ceives his condition, but the patient hardly complains, unless  it
be of sighing,  oppression, slight confusion of head, shivering,
with a feeling of coldness at the accession of each febrile parox-
ysm,  and  trembling  of  the  hands, and  tottering of the  knees,
when either his mind is alarmed, or he endeavours to exert his
strength.
   " This man  I had destined for the knife, conscious that no
earthly power could save him, if that  suppuration was allowed
to come to maturity, which was plainly begun.  But he was
reserved for a different fate ; for the natural course of rotation 
Of Suppuration of the Brain.
295
 «f the hospital  having delivered  him into other hands,  I met
 him wandering in the cold stairs of the hospital, his eyes indeed
 open,' but his senses gone, at the moment he should have been
 under the operation of trepan.  On the 13th day an incision had
 been made, so as to prolong the cut on his head, and expose
 the naked part of the scull, which was nearly on the top of the
 head, close by the sagittal suture.  The bone was bare, and was
 known to be so for many days ; but it was not supposed dead.
 The incision healed, or seemed at least in a healing condition ;
 and for his sickness, effervescing draughts were prescribed.  He
 continued,  with slight variations of pulse, countenance, and in-
 tellect, in the same ailing condition, from the l Sth to the 17th
 day; but his vomiting was now  severe; his rigors lasted some-
 times half an hour; his complexion was wan; his  features con-
 tracted and pinched ;  his eye heavy  and melancholy ; his fever
 increased, and his pulse  beating 112;  and though generally
 feeble, it was sometimes very strong: even in the  hour of visit,
 his vomiting  was so  incessant, his  shiverings so violent, and
 his  pulse at  the  same moment so weak and trembling,  that it
 could not be felt.  On the 18th, the confusion of head, the
 ringing qf the ears, the fever and shiverings, and all the marks
 of disorder, were so much increased,  that the operation could be
 no longer delayed, but unhappily, the man was, by eighteen
 days of suffering, reduced so very  low, that the chance of his
 being saved by it was indeed very slight.   Upon perforating
 the scull, a profusion of ripe pus flowed from the  trepan-hole;
 and he was committed to bed,  where he passed an indifferent
 night.  In  the  morning, though  no shiverings were reported,
 he was chill;  and, in place of the oppressed and dejected coun-
 tenance  which he had before operation, his looks were wild,
 and his pulse extremely rapid.
   " On  the second day after the operation, the  dura mater
 looked black and sloughy,  the discharge fetid,  the matter con-
 tinued to flow profusely from the trepan-hole; yet his looks had
 changed again  from  wild and  distracted  to oppressed and
 anxious;  the  shiverings, he said, had ceased, because he had
 refrained  from cold drinks, but his head was sadly confused.
 On the 3d  day he fell lower ; his senses were perfect, but his
 looks expressed unspeakable distress: the  matter  was brown,
 thin,  and fetid, the wound dry  and glazed, the skin hot, and
 the pulse feeble and quick, and the breathing oppressed : with-
 out having  shiverings, he had  frequent  chillness ; with less
 feeling of pain in  the head, he has a miserable feeling in eve-
ry part of his body.   By the 4th day, he  had  fallen  extremely
low;  the  universal uneasiness seemed very distressing;  his
pulse extremely weak; his voice feeble ; his features shrunk ; 
296
Of Suppuration of the Brain.
he never slept, but  moaned and tossed continually.  On the
evening of the 5th day, after a severe  shivering, he swt ated
profusely;  his features shrunk perceptibly, his  pulse  was ex-
tremely quick, his extremities cold; the night  was passed in
great disorder; he  struggled to  get out of bed, and towards
morning fell low, and expired."
  The affidavit  which  I presented on this occasion to the ma-
gistrates, I  have unfortunately lost.  But in this case, I have
given  a faithful picture of a condition of the system which I
have often observed and watched, from the slightest glimmer-
ings of danger,  to the last fatal struggle of delirium or convul-
sive tremors.  By this instructive  case,  you are taught at once
the slightness of the symptoms,—the danger inseperable from
these phenomena of shiverings and puffy tumour combined,—the
deadly suppuration  that infallibly lurks under a dry and discol-
oured  piece  of  cranium,—the  folly of  delaying, till deadened
bone degenerates actually  into black caries ! and you are now
conscious, that though  the  fate of the  patient is terrible, the
symptoms  are  not  so: that the most deadly and decisive are,
debility, anxiety, shiverings, and  slight  confusion  of  head:
that to wait for symptoms is to wait for death,  for the first
slight  convulsion, or decided delirium,  is the immediate fore-
runner of death.
  The case I am now about to lay before you, is of a very dif-
ferent complexion.  " Elizabeth Barrow,  a woman of the most
dissolute life and manners, about .thirty years  of age, was
knocked down in the dark,  in a drunken tumult, with a candle-
stick, poker, or some such weapon, but immediately7 recovered
her senses,  and  continued in health.
  " The blow she  had  received was near  the vertex, upon the
corner of the parietal bone, and not far from the sagittal suture;
and there rose over the contused part a circular tumour, not ex-
actly a puffy tumour,  but rather aneurismal, containing blood.
For six weeks  the tumour was stationary, and  the woman,
though weakly,  and having pains in the  head, was without any
formal  complaint.  Perhaps there is no greater mark of a dis-
solute  life,  and vicious dispositions, than a disregard of health;
and this woman ran her usual course of vice and wickedness,
undisturbed with any thoughts concerning her health, till febrile
paroxysms and  pains  of the  head  forced  her  to apply to a
surgeon, who opened the  tumour, which was then of the size
of  a hen's  egg, with the  point of a lancet, and it discharged
chiefly blood.  But the puncture soon closed, matter gradually
collected, and the  tumour was soon of its original size.   In  a
month more, it  was again opened,  and discharged blood mixed
with matter, healed again,  and again formed. 
Of Suppuration of the Brain.
297
   " The  tumour was  pointed, and about half the size of a
tennis-ball, soft, puffy,  and little elastic.   The centre soft and
fluctuating,  the circumference hard,  firm, and  bulging; the
bottom solid, and  giving  that very peculiar feeling,  by which
we are apt to be deceived,  in recent extravasations of blood; it
felt as if  the  tumour covered a vtry remarkable  depression of
the scull.   Upon laying it open with free incisions, the matter
which flowed was thick and purulent, much mixed with blood;
one  of the  arteries of the scalp bled profusely ;  the bone was
felt  rough and scabrous to a great extent,  and from part of its
surface a loose  fungous growth, so loose that you could push
the  point of your  finger through it, protruded into the cavity
of the abcess.   In these circumstances, how to proceed was in-
deed a question of  delicacy.   In a recent contusion, with even
the slightest of these symptoms, where there was, with occasional
shiverings, a  naked  bone  at the bottom of a puffy abscess, the
rule  would have been express.   But this woman was in appa-
rent health; much  time had elapsed without any signs of  dan-
ger ; the  bone might be carious merely on its external surface,
and might exfoliate, or might granulate,  (as indeed it did in
the end granulate) : There could be no apology for precipitate
operation  ; there seemed  to be time for reflection ; the perfo-
ration of the cranium was accordingly deferred.
   " But she had been induced to present herself to the surgeons,
from having headachs, sometimes severe, with  confusion of
head,  chilliness, and fever-fits, which were very distressing ;
she was at the same time so nervous and alarmed, and her suf-
ferings altogether  so  great, that she  received with pleasure
the first proposal of an  operation.   The catamenia, which had
disappeared after the blow, were now flowing,  but were sud-
denly stopped with  an increase of headach, a costive belly, a
hot skin,  and a febrile pulse, counting always above 100.   On
the  4th day of putting herself under our care,  the incisions
being already very free, the operation of trepan was performed
by Mr. Lawson, who made his perforation near the sagittal su-
ture, and on the anterior part of the caries, through a very un-
usual  thickness  of  bone :  but  the  bone  was  in  part alive ; a
great profusion of blood flowed from the cancelli; and the mo-
ment  the inner  table was divided, and  before the perforation
was complete, matter spouted up in  great prolusion by the sides
of the saw.
   " The  night following the operation, the patient was restless
and feverish,  for, upon opening an abscess within the scull, as
in opening one in any part of the body, the fever and nervous
symptoms, hardly perceptible before, became very conspicuous.
Though the wound looked well, the head was  in confusion, and
                          2 P 
-98             Of Suppuration of the Brain.
 she became extremely sensible to noise or light.  The succeed-
 ing night was calm; and the headach, which was violent the
 first day, was relieved by rest and quietness on the second.  The
 flow of matter from the surface of the dura mater was good and
 copious, and its surface began to granulate.
   " Even on the 5th, I found her complaining of great depres-
 sion of spirits, nausea, and sickness, and great pain of the head;
 but, by the prudent use of clysters of opiates, and  a little  wine
 dashed with water, the  sickness abated in two days, the wound
 contracted apace,  the pus was thick and well-formed,  the sur-
 face  of the  dura mater was  florid and granulating.  By the
 8th day,  the margins of the trepan-hole  were  red and fleshy,
 and the  whole surface of the diseased scull was covered  with
 a rich pile  of granulations.   In about twenty days more, the
 wound was contracted; the cicatrix of the scull, scalp, and du-
 ra  mater, consolidated; and the woman perfectly  cured in six
 weeks."*
    Without any suggestion on my part, you will reap every ad-
 vantage  from the  contrasting of this with  the  preceding  case,
 and learn by experience the duty of watching with  extreme so-
 licitude the slightest changes of the eye, countenance, or pulse;
 the slightest shiverings, oppression, or sickness, in those who
 have this contusion of the scull.
    In cases of fracture, there may, indeed, be doubts as to the pro-
 priety of operating:  the danger is eventual, the operation mere-
 ly  preventative.   Fracture may cause a suppuration of the brain
 and membranes at some  future period; but contusion is the
 disease itself, it is  the actual suppuration of the brain, announced
 by infallible signs.   Of all the  cases in surgery, this is the least
 equivocal.   Of those who have fractures of the scull, many e-
 ven in the most alarming circumstances survive unassisted; but
 in  contusion, followed by suppuration, unless the scull be per-
 forated,  unless the abscess be opened,  all must die.
   O'Halloran says a thing  at  once untrue and discouraging;
 untrue at least as a general aphorism, and discouraging, since
 it tends to make us indifferent to the most interesting question
 in practice,  and to  the condition of  many who might be saved:
 " In the course" (says O'Halloran) u of many years  practice
 and careful observation, I cannot give myself credit for a  sin-
 gle cure I ever performed in this way, (by  trepanning) when
 the symptoms of deposit were formed; for  whether the patient

  *  This woman, who made no fecret of her vicious life, or fyphilitic taints, had
a new fuppuration over the trepanned part of the fcull nine months after the ope-
ration ; the abfeefs was opened ; a fcale of bone exfoliated ;  and fhe had a mer-
curial courfe adminiltered to her for the  cure  of very fufpicious pains,' accompa-
nied with flight nodes on the clavicle and fternum. 
Of Suppuration of the Brain.
299
was or was not trepanned,  the scene closed with death.11  This
does but prove the culpable delays, even of this good practical
surgeon, forewarned as he was of the dangers of  matter being
formed ; and demonstrates to us,  that those who die  are  lost
by temporising and timid counsel.*
  Pott, our celebrated surgeon, whose opinions  and writings
are so justly esteemed,  was engaged in that tumult of practice,
which left him little time to frame general laws;  yet he could
not fail to act with good sense and  skill in  each individual case:
he was sure to practise right, but in danger of teaching wrong,
or at least imperfectly:  his opinions want but one short expla-
nation, for they are such as will never be  disputed, where they
are understood.
  " For my own part, (says Pott) I have  no doubt, that,  al-
though by establishing it as a general rule  to perforate  in all
cases, some few would now and then be  subjected to the ope-
ration, who might have done very well without it;  yet, by the
same practice,  many a valuable life would be preserved, which
must be inevitably lost without it, there being no degree of com-
parison between the good to be derived from it, when used ear*
ly as a. preventative; and what may be expected, if it be  defer-
red  till an inflammation of the dura mater,  and a symptomatic
fever, make it necessary."
  A preventative !  How could the operation of trepan prevent
inflammation of the dura  mater?  Could perforating the scull
with a saw,  tearing up  the vessels  which naturally  connect  it
with the  dura mater, and exposing that membrane  to  rude
dressings,  and the touch of instruments, prevent inflammation?
Yes, surely: it could prevent all the dangerous  consequences
of inflammation: it could  prevent matter accumulating,  and
inflammation  spreading:  it  could prevent  ulceration  pene-
trating to  the  brain:  it could convert an  extending  and most
dangerous abscess into an open sore:  it could enable the dura
mater to granulate and unite with the integuments. There is no
good  purpose that a timely  operation might  not serve ;  and if

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


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

  * In the accounts which we have of the former practice in France, it is related
that furgeons made  numerous perforations along the whole track of a fracture ol
the cranium; and, as far  as I am  able to judge, without any very clear defigu.
Mr. Pott tifito advifes fach an operation, with  a view to prevent the inflammation
and fuppuration of the dura  mater, which he fo much  apprehended.  But many
cafes have occurred of late, where, even infradtures with depreflion, the patieoti
have done well without an operation.  Abernethy s FjJ'ayt. 
Of Fractures of the Scull.
30S
 a circular incision:  he, in every suppuration of the dura mater,
 and in every case of extravasated blood,  applies the largest tre-
 pan, though he has no other purpose than to give vent to such
 matter or blood:  dissatisfied (as he had reason to be) with the
 small trepans in  common use,  he ordered them to  be forged
 for him of an unusual size, and  did not spare their liberal ap>
 plication.  After perforating the scull once, in place of provid-
 ing by other means for the free evacuation of the matter, he
 applied his trepan again and again, till all  the suppurated sur-
 face of the dura mater was displayed, declaring it to be his in-
 tention to cut away all that part of the scull, however extensive,
 under which the suppuration existed.
   " When the  operation, says Mr.  Pott,  has been performed,
 not as  a  preventative,  but to  give discharge to matter, the
 only chance of  relief is  from laying bare a large portion of the
 dura  mater, that the discharge  may be as free, and the  con-
 finement as little as possible, as nothing but this can  do good."
 And  again he  says, w Yet perforation is absolutely  necessary,
 in seven  cases out of ten of simple undepressed fracture of the
 scull."  He does  by no means deliver these rules with temper-
 ance or modesty,  but says, " I am as well satisfied of this as of
 any truth which repeated  experience may have taught me."
   Such bold words  lose  all power when we begin to find  how
 ill experience may teach  a man, and how unreflectingly such
 language is used.   At first, the reader would naturally say with-
 in himself,  " Surely Mr.  Pott, before he  could  use such confi-
 dent language, must  have seen repeated and afflicting proofs of
 the  necessity of using the trepan:" but to his utter confusion,
 he  finds the very  words  repeated in commending the now  ob-
 solete  operation of scalping, and, indeed,  on  every occasion,
 trivial or  important,  for it is with this author, a manner, and no
 more :  He says, " The way of doing this, (viz. of scalping) has
 formerly  been the occasion of much difference of opinion ; but
 there can be no doubt about the greater propriety of remov-
 ing a piece  of scalp for this purpose, by an incision  in a circu-
 lar form /"  Even when Mr. Pott applied the trepan, not on ac-
 count of any present, but of some eventual, perhaps imaginary
 danger, he  set no limits to the number of perforations, but the
 extent of  the fracture. - He says, " If the trepan be applied in
 a preventative sense  merely, the length of the fracture must de-
 termine the number! one  or two only  may be made at first."
 In short,  all his precepts,  most of his cases, and even the very
 form and size of  his instruments,  contributed to  renew  and
 strengthen that passion for frequent perforations and large open-
 ings of the cranium,  which  the decline of false learning and the
progress of plain good sense had almost allayed:  and I will ven- 
304
Of Fractures of the Scull.
 ture to  say, that whoever has studied his writings,  or imbibed
 his principles,  must imagine that, in the work of trepanning, he
 can never do too much, and is only blameable where he has left
 any possible thing undone.  But a few men of  strong natural
 sense, among whom Platner is one, have had the sense and cou-
 rage to protest against such frequent applications of the trepan.
 " There is by  no means any necessity  (says Platner) to have
 recourse, in all cases of fissure or fracture  of the scull, to in-
 struments to cut them out with: where there are no evil signs,
 the trepan is not required:" but unhappily the most extravagant
 and foolish things are best remembered, and oftenest repeated,
 while  these solid  remarks of a man of skill and judgment are
 but too easily forgotten.
   We find that it had been the practice of the older surgeons
 not only to apply their trepans the whole length of a longitudi-
 nal fracture, but along each of the radii of  a star-like fracture,
 and in short, to repeat the expression of Platner, * to cut it out.'
 The  testimonies of  the most sensible writers  are against  the
 operation, and  most unfavourable to the  men who have indulged
 it, for it has been ascribed not  to reason, but  to pride.   " If
 the opening (says Wiseman)  in  the fractured scull  be not suf-
 ficient,  make one in the  most  declining part, and raise up the
 bones, and free the membrane of whatever may offend it,  but
 do not take out any more bone than needs must, like some of those
 surgeons I have met carrying  them  about in their pockets,
 BOASTING IN THAT  WHICH WAS THEIR SHAME."   Never is
 the apology wanting to those  who are proud of making numer-
 ous perforations: if they do not find a conspicuous depression,
 or a great length of fracture,  they affect to be seeking for pus,
 or that they are anxious  to let  out extravasated  blood.   They
 dare  not forsooth, after making the necessary opening, allow
 the pus to ooze out gradually,  or the blood  to melt  down and
 be resolved into  serum.   They affirm, " that  it is infinitely
 more dangerous to wait the dissolution of the coagulated blood
 than to make numerous perforations  for the evacuation of such
 pernicious juices, for not only  such openings as that we have
just mentioned of 12 trepans,  but openings  much more exten-
sive, close  easily."  "  I have seen  surgeons, says Ravaton,
so infatuated, so desperately bent on discovering abscess on the
dura mater, that, after applying six crowns  of the trepan, they
would, I verily believe, have pulled away  all the  remaining
bones of the cranium, had not their patients  been delivc red by
death from such operations."    In short, their  doctrines and
pi actice outraged common sense : every thing was to be  done
by the surgeon,  nothing left to nature: rvery depression was to
be elevated; trie whole matter to be evacuated;  the whole  ex- 
Of Fractures of the Scull.
305
tent of the extravasation to be covered by trepan-holes, and the
limbs and whole extent of a radiated fracture were to be cut
away.   There  were no limits assigned for these openings, but
the extent of the extravasation or fracture, and they were well
contented to find that 40 crowns of the trepan might upon ne-
cessity be applied to the human scull.
   But there is a scene of practice very different from this, where
men,  engaged in the actual duties of the profession, in peace or
in war,  in cities or in the field,  learn to look coolly on wounds
of every description, and know from experience what nature
will do, and how impertinent and vain those operations are.. It
often happens to grooms or farriers,  trimming horses feet with
too little precaution, that the horse  striking out, they receive
the kick full in the forehead: the scalp is torn up, the scull ma-
nifestly injured, or not a  little depressed; these men live a
eoarse irregular life, and yet such fractures heal easily, but, were
the trepan applied on every such occasion, we should have many
dismal scenes.   It often happens that boys playing with horses,
plucking hairs from a colt's tail, for example, are knocked down
by a kick  in the forehead; often the bone is deeply  depressed,
very often the  marks of the  heels or caukers of the shoe are
impressed upon the os frontis; sometimes a piece of the bone is
actually turned  upwards along with the scalp; but the scalp being
re-applied to the scull, the splinters of the bone picked away, and
die ragged integuments smoothed and secured with stitches, the
boy, without one hour of sickness, recovers as if his wound
were only of the skin.   But were such pieces of  depressed or
shattered bone  cut out; were  openings made at all proportioned
to the depressions,  or to the extent of the fractures; were the
delicate dura mater of  a boy  left exposed to that force of circu-
lation, which dilates the brain,  and fretted  by every stroke of
the arteries against the  margins of the opening, the dura  mater
would slough, perhaps, the brain protrude and suppurate, and
the boy expire  howling and convulsed.  Examples of such im-
prudence  and such consequence I shall presently relate,  for I
know, that when my business is to impress you with any prac-
tical truth, the  best way of confirming the maxim, and making
you feel the force of it, is plainly to represent the  scene.
   Often the recovery,  where the scull is very  deeply wounded,
is so rapid, as  to surprise those even  who are  the most resolute
m refraining from the use of the trepan,  and the  best prepared.
to expect  a happy issue.  The  faith and credit of  Pareus stand
tfnimpeached; and the case he relates, of a cure performed with
his own hand, is the most remarkable of any yet recorded; since
even the segment of the scull itself in a clean sabre-wound, ad-„
hered again in common with  the wounded scalp.   a'I advise
                          2 Q 
306
Of Fractures of the Scull.
(says Pareus) wherever there remains a portion of the skin still
connected with the wounded scalp, that neither that skin, nor
the divided portion of bone be cut away,  but the bone sewed
up along with the skin.  What Celsus commends (says Pareus)
I performed in the case of Captain  Hydron,  who was a short
while ago wounded in this city with a sword through the centre
of the os frontis, the bone being cut  down  the length of three
inches,  so that it  hung over his face,  connected with the scull
only by its pericranium,  and about  three inches of the fleshy
scalp.   At  first sight, I  questioned  whether or not I  should
complete the separation of this piece of skin with its adhering
bone, but remembering Hippocrates's  maxim  never to uncover
the brain, I cleansed the blood,  which was upon the dura ma-
ter,  laid up the separated piece, and,  for the better retention
thereof,  made three points of the needle in the upper part, and
put in three small dossils in the sides of the wound,  the whole
being so nicely replaced, that, by God's grace,  it healed perfect-
ly,  though the gentleman was otherwise much wounded on the
face, in the thigh, and in the right  breast.  I finally  beseech
you (says Pareus) never to amputate neither skin nor bone, lest
the brain should be left bare."
  In the work of Berengarius,  De Fracturis Cranii, so  much
and justly praised, you have no instructions for discovering, nor
any warrant for trepanning fissures.  He seems to have been taught
a very different practice by his father in his earliest years.  They
seem, in these times,  always to have felt a sort of trepidation
when they seWed the scalp;  and Berengarius  gives many anxi-
ous  directions about undoing the stitches upon the slightest ap-
pearance of fever or abscess; but  still he directs that the scalp
be sewed.
  Especially when the bone was wounded,  they feared to sew
the integuments; yet Berengarius, while he  complies with the
rule, relates an  exception highly  worthy  of  notice.  He re-
minds his reader that he had  advised the suture of the scalp on-
ly when the bone was unhurt and the  pericranium entire; " for
a suture (says Berengarius)  being drawn close over a diseased
bone, the patient dies, wherefore,  such wound must be dilated
and opened, not sewed and closed: Yet, I  call God to witness
the truth of the following narrative, so unprecedented that I dare
hardly  tell what I saw.   While I was a young man, a  soldier
wounded his fellow with a weapon, and cut down the os frontis
from its upper part to  the  superciliary  ridge,  so that the os
frontis, with its integuments,  hung over his eyes, dividi d from
above and at the sides, and connected  only below.  My father
went first to his assistance, and removed the bone from the in-
teguments ;  the  bone was the whole length of the os  frontis; 
Of Fractures of the Scull.
307
the dura mater was untouched.   The  skin of the forehead was
replaced and stitched without that opening at the lower part of
the wound which surgeons are  accustomed to leave as a drain
for the matter; being closed with white  of  eggs, and  dressed
daily, it was in ten  days completely re-united, and ever after
the systole and diastole of the arteries was distinctly seen where
the bone was wanting.   This I  have put down,  says Berenga-
rius,  to make  medical men keen  and  courageous in  curing
wounds."
   Besides  these  instances in domestic life, it is remarked, to
the dishonour of our trade, that in times of war and  trouble,
when men are not allowed to take care of their  wounds, those
who are least cared for are soonest  cured;  and a man, who is
forced to wrap a clout  about his head and ride for his life, is
safer than one who is chambered up, dieted, and dressed, per-
haps  trepanned by the  surgeon.  The great rebellion  was full
of such adventures and  hair-breadth  escapes, many of which
are related by Wiseman: among others, that of " a gentleman
who, a day or two before the battle of Worcester, attending the
Earl of  Derby in his retreat thither,  received a large wound be-
tween the sagittal and coronal sutures by a sword, which  went
through the cranium to the dura mater, is exceedingly remark-
able : the membrane was covered with small shivers of bones:
he had  only a thin linen cap over it, his haste  not  permitting
him to be dressed, and it may be it was the  better for  him, for
if dossils had  been hastily crowded upon the  bones, severe
symptoms  would have followed;  whereas the shivers  lying
lightly  upon the membrane, he was free;  and being  ignorant
of his danger, rid a great journey:  I after  took them  out, and
dressed the membrane  with  digestives, the  short time  we were
together."  It was upon such proofs that Wiseman came to be
persuaded of this general truth, that " recent  fractures of
THE CRANIUM DO FREQUENTLY UNITE LIKE THOSE IN OTHER
parts,  if the matter  hath  liberty  to discharge from within.
Therefore having raised up  the bones that are loose, dress the
others dry.'1*
  "  During the war," (says  Wiseman) u I was frequently em-
ployed in the dressing  of some  one person or  other, wherein  I
have seen all or most of the several  sorts of fractures.  I have
dressed many that have been cut through the scull, the shivers
of the bone lying pashedwith the flesh and the hair,  upon  the
dura mater;  yet the patient hath had no symptom of such  a
wound."  Here, in a few sterling words, are descriptions which
will  better satisfy all your doubts than the most learned argu-
ments.
* Wifeman, page 113. vol. ii. 
308
Of Fractures of the Scull.
   So much for open wounds, when the clean incision of a wea-
 pon seems to have done the business of the trepan.  But, even
 in cases where the bone is fractured with a wide and portentous
 fracture, or when it is actually depressed in a way which might
 vindicate the application of the trepan;  in cases where it re-
 quires some courage to refrain  from operating, the patient is
 cured with surprising  ease.   I can be at no loss in proving this
 in a thousand various forms; if I  could  feel any difficulty, it
 must be only in selecting the cases  which best represent the va-
 riety of circumstances.  In Mr. O'Haloran's paper in the Irish
 Transactions, we find, among other cases, that of Edward Pow-
 er, " who received a desperate, wound of a back-sword, extend-
 ing from the top of the coronal bone to the orbit of. the left side,
 forming an extended and frightful chasm, in which were includ-
 ed the  bone, membranes, and brain.  It bled considerably, as
 may be  well supposed.  He remained exposed to the  air for
 near three hours after,  and had not so much as a bit of rag to
 cover it: fever and inflammation of the brain might reasonably
 be apprehended;  yet, by a couple of bleedings, and some other
 antiphlogistics, the man was completely cured  in five  weeks,
 without exfoliation or the smallest operation."
   On one point you may naturally  feel some  hesitation: You
 see that clean wounds, as when a trooper is cut to the scull with
 a sabre, are not, (even when the scull is fractured, or part of it
 sliced away) attended with that danger which was once sup-
 posed;  but fracture of the scull produced by a heavy blow, where
 the bones are broken, perhaps depressed, may be, nay, must be,
 an injury of quite a different nature.  You are not only to re-
 frain from trepanning fissures, in the absence of dangerous symp-
 toms, but, if I may advise you, even fractures  very wide and
 gaping.   " John Smith," (says Mr. Hill in his Book of Cases)
 " when forty years of age, had several inches of the scalp torn
 off by the kick of a horse, and some of the hair was beaten in-
 wards through a long fracture of  the scull, which  was so wide
 that there was no occasion for the trepan.   He recovered in a
 few weeks, and is well."  Why does Mr. Hill announce this
 fact  in such abrupt familiar terms,  but because he well knew
 that  this  was no unusual accident, that he had often seen such
 fractures of  the scull spontaneously  cured?
   Even deep depressions and very irregular fractures heal, and,
 what is more rarely  to  be found, are permitted sometimes to
heal,  undisturbed.  The case of  James M'Cartney, a  boy of
between five and six years of age, is of this nature: " He had
a  large  piece of the parietal bone driven deep in  by a stone.
A few days after he was stupid, dosing, starting, and vomiting :
there was a large tumour and obscure fluctuation on the depres- 
Of Fractures of the Scull.
309
 sion, owing to some ounces of blood below the pericranium;
 on piercing of which, it sprung out to about  a toot's distance*
 The  incision  was continued across the depression and fissures:
 to prevent such exfoliations as often happen, the scalp was in-
 stantly laid close down again, with soft dossils only in the wound
 to keep it open.  As no bad symptoms intervened, the fissures
 being wide enough to allow a passage from within the scull, no-
 thing farther was done but lessening the dossils gradually, till
 it healed,  which happened in a short time,  without exfoliation.
 The  hollow is considerable, and will continue for lite."*   He
 is in good health,  and at sea.
   You will naturally say, What then should we infer from these
 cases ?  Are we to do nothing in fractures of the scull ? Are the
 instruments hitherto appropriated to fractures of the scull to be
 thrown aside ?  The trepan  is not the instrument appropriated
 to fractures of the scull,  but that with which we perforate  the
 bone, when either fracture or  any other kind of occasion re-
 quires such opening; and of all the motives for using it, that of
 fracture of the scull is the least  frequent: you perforate the
 scull  to let out extravasated  blood,  which oppresses the brain,
 to open abscesses which could never force its way through such
 resistance, to  raise depression,  if you will, but never on account
 merely of fracture.   Allow yourselves but to consider in what
 fracture of the scull differs from that of any other bone : not in
 want  of circulation in the scull, you have every  proof that its
 circulation is  lively and perfect, since the dura mater is detach-
 ed, the pericranium scraped off, the bone itself  bent  from its
 right  direction, sometimes raised  up, sometimes depressed,*
 and yet it does not die: you see the integuments coarsely  torn
 off with a stone or a carriage-wheel; you see  the scull rough,
 yellow, and apparently void of circulation; you see every threat-
 ening appearance  of caries, and  would believe it dead: often
 the wound seems as if a part or the whole would exfoliate,  yet
 in a few days  all the naked part of the bone begins to look red ;
 a fine velvet-like down of vivid granulations begins to appear in
 spots  and  clouds upon the bone ; sometimes these granulations
 are, out of mere  wantonness  and ignorance, scraped off,  but
 they instantly  sprout out again  : what becomes of the  rima fis-
 sure,  or fracture,  is never observed; it is  covered in by  this
pile of granulation spreading slowly over the bone, and uniting
it with the integuments.  This process I have seen with ad mi- /
ration, where  I could least expect it to take  place; in old crea-
tures  of ninety years of age, very poor  and miserable, and in
whom, along with fracture,  the integuments had  been  so man-
* Hill's Cafes, p. ir~. 
310              Of Fractures of the Scull.
gled as to slough off in flakes.   It is just such a delicate pile of
granulations that covers the surface of the dura mater, when it
appears after the operation through the trepan hole, uniting the
dura mater with the integuments  and with the margins of the
perforation.  Those who affirm that there is no danger in tre-
pan, affirm of course that there is none in fracture of the scull,
for the perforation and the fracture heal by  one process, and
with an equal pace.  If this, which I have observed many times,
be the regular and natural  process of healing both in the trepan-
ned and in the fractured scull, what apology have we for per-
forating the scull, and tearing with levers all those  parts we
think suspicious, or perceive to be depressed ?
   The motives assigned for making large and frequent open-
ings are, in case of simple fracture, to prevent danger ;  in case
of depressed fracture,  to raise up the  depression; in  case  of
extravasation or abscess, to let out the blood and matter freely.
But,  are not  the smallest openings we can make sufficient to
give vent to any suppuration,  as the smallest  puncture is suffi-
cient for the cure of the largest abscess in any other part? Is it
possible, would it be prudent in any case to lay open all that part
of the scull  under which blood is effused ?  Though you were  to
work with  your trepan  as industriously and unconcernedly as a
button-maker, or to trepan as this Henry Chadborn did twenty-
seven  times, you still would never get to the end of your opera-
tion, if the extent of the extravasation were its only limits; 1 have
rarely seen a case of  extravasation where the cake of blood did
not  extend over one entire hemisphere! under a whole parietal
bone, and generally down to the basis of the scull, nor an abscess,
but where much of  the surface of the dura mater  was  coated
with pus :  I have never had the good fortune to perform or as-
sist at any  operation in which it  was possible, had we been so
extravagant as to design it, to expose the whole coagulum  of
blood by perforations:  in short, what I have observed, is this :
that, where, in the case of abscess,  we are fortunate enough to
be alarmed  early,  one perforation gives vent to the pus as well,
to my  apprehension, as fifty: the matter bubbles out at each
systaltic motion or heaving of the brain; nothing prevents it but
that fungus or protrusion of the brain,  which so frequently hap-
pens when  the openings are large. That  I  may almost assure
you that, where the openings are made large,  they never conti-
nue long free, but are plugged up by profusion of the brain.   In
the case of extravasation, which  has no  certain limits,  I have
always been sensible of the folly of trying to lay it all open, tor
the n the l.mits of our operation could only be limits of the scull:
but after om- perforation,  when,  by  the heaving of the brain,
the clots have rolled out of the trepan-hole, as thick  and black 
Of Fractures of the Scull.              311
as pitch, there succeeds a more  fluid blood, the patient often
finds instant relief, moves his paralytic side, raises his eyes, and
though,  without being able to speak, knows his friends ; from
day to dav,  the blood by the natural process of its dissolution,
and by a sort of secretion from the surface of the  dura mater, is
diluted and flows out.  The introduction of the probe, often to
the extent of  six  Inches in every direction, proves how vain it
were to attempt laying open the whole extravasation: the deep
introduction of the probe has probably  suggested that practice,
which is mentioned in books, of making a second and far dis-
tant perforation as a counter-opening, but which I  cannot  ap-
prove because I have never seen it necessary : the probe bent
and surrounded with a little  lint,  or a long hair-pencil, is very
useful in hooking out the clots, and an  injection  of  tepid milk
washes them away.   While  the coagulum is thus resolving, the
dura mater is suppurating and cleansing on its surface ; it is at
last seen through the trepan hole of a lively red, granulating and
bleeding upon the slightest touch :  then it  comes  into close con-
tact with the lower surface  of the scull, protrudes with gentle
convexity through the trepan hole : the granulations of the inte-
guments, scull, and dura mater gradually adhere, till the whole
becomes  one undistinguished granulated surface, where bone
cannot be distinguished  from flesh.   This is the  state of mat-
ters, (with occasional interruptions and  variations) in the third
week, and thus the  opening closes and  heals.  1  have often
found it  necessary, from the strong protrusion of the dura ma-
ter into the trepan circle,  if not through  it, to  repress the dura
mater at each dressing with the probe wrapt in lint,  in order to
give exit to the matter or blood.*
   This lean most safely affirm, that wherever I  have seen  ca-
ses of fracture, whether simple or  depressed, committed not in-
judiciously nor  carelessly  to nature,  they  have  done well.
Wherever I have found  the surgeon impatient to perforate, in-
tent on raising every  depressed part of the  scull,  careful to in-
clude in the circle of  his saw every suspected piece of bone, and
anxious to secure  a free evacuation of matter by large openings ;
I have seen such tearing up of the  scull,  especially in boys, as  I
could not witness without  pain,  uniformly followed by profu-
sions of the brain,  and death.   In no other part of the body do
you open  abscess, or discharge   extravasated blood by large
openings ;  is the brain the only part to  be thus roughly treated

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

                        section  n.

          Of Fractures of the Scull with Depression.

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

  * In fuch cafes I would not attempt  completely to re-unite the integuments
becaufe fhould they adhere, it will be frequently neceffary to open them to let
out matter.  Interpofe a fmall piece ot lint between the edget of the  fcalp, fo  as to
prevent a complete ^e-union, and as foon as all danger of bad fymptomsis vanifhed,
it can be  healed in a few days.  S. 
Of Fractures of the Scull with Depression.
MS
ver, or cut out with the  trephine:"  Yet there is  no general
conclusion I should more unwillingly allow:  I should be inclin-
ed rather to  reject  the  general  rule than to qualify it with so
many perplexing exceptions as it would in my judgment require:
There are many depressions so  fixed that no force of instru-
ments could raise them ;  so extensive, that to cut them out, or
loosen and pull away each fragment of bone, would be to open
half the  cranium, and expose the brain to protusion, on ac-
count of imaginary  dangers.  Depressions  seem  many times
so alarming  to the  surgeon, that to raise them, or cut them
out, he  will use the  most unjustifiable violence ;  yet, though
he fails,  and the depression remains, the  patient, notwithstand-
 ing this  additional violence,  survives : and many times the de-
pression, which has been the subject of  such unjustifiable  vio-
lence, though very conspicuous while the surgeon is labouring
to raise it, is  really so slight as to be invisible before the wound
 is closed.
   The  striving to elevate  depressions of the  scull,  while the
patient,  far from having  any oppression of the brain, is crying
with torture,  struggling and resisting, though it has been long
 esteemed the  most meritorious work in surgery, is extremely
 censurable, and has, to my  certain conviction,  brought many a
 patient to an untimely grave.  "  I shall  now  (says O'Haloran)
 remark  on such fractures as necessarily require the operation in
 the first instance :  these are fractures  accompanied with de-
, pression, with or without wounds: for,  not  to advert to the
 restraint such pressure must necessarily cause to the brain, suf-
ficient in itself to produce fatal effects,   &c."  This  is affirm-
 ing, in its utmost  latitude,  that very mistake  on which all the
bloody doings of past and present ages are to be attributed.  " If
 a single  operation (says Warner) be insufficient, (as I have of-
 ten known it to be) to effect the elevation of the depressed bone,
 a second and a third must be performed, that the surgeon  may
 be enabled to raise up every part of the  depressed bone ; which
 rule must be strictly observed, otherwise the  operation cannot
 be expected to be attended with success,  as the bad effects of the
 oppressed brain must remain."  In every elementary book you
 read the same language,  and from every lecturer hear the same
 general  conclusion ;  for,  in describing the scull, he assigns de-
 pression of it  and its fractured part intruding upon the brain, as
 the principal occasion for using the trepan.
   This  passion for  leaving nothing  undone will naturally glide
 into your minds ;  for the prejudice of every profession is in fa»
 vour of what its art can accomplish, and in ours, this  bias is pe-
 culiarly strong: trepanning fractures, raising depressions, and
 making ample openings for blood or matter, are the surgeon's
                              2  R 
314      Of Fractures of the Scull with  Depression.
chief pride.  But  I  cannot help recollecting the droll expres-
sion of Permanmus,  who says, or his translator for him, "there
are many persons who fondly imagine that  boring a hole in the
scull is an easy matter, and to be done  at any  time, whereas it
requires mature consideration,  a very  able head, and a skilful
hand to undertake it."
   Aware of the deceptions to which you are exposed, I should
feel myself much  to blame did I neglect to warn you of them.
You will say within yourselves, " though it is  plainly our duty,
and is  most natural, to leave a mere incision or wound, although
it affect the scull itself, untouched and but lightly dressed, since
we know that wounded bone will re-unite with  the soft scalp;
though it be equally natural and right to treat a compound frac-
ture of the  cranium, even where it is much shattered, like a
compound fracture of a limb, by picking away the  loose bones,
cleansing the wound, composing the soft parts,  and  laying all
smooth and close ; is it equally natural or proper to leave unre-
duced a  depressed portion of  the  cranium, which cannot but
press  upon the brain ?"   " Surely, (you would say), the visi-
ble depression of  a piece of the scull must  be an oppression to
the sensorium, of the worst and most dangerous nature, be-
cause  it is  sudden  or  rather instantaneous, and  because it is
produced by a firm  and solid  body :  blood and matter being
fluid,  may be absorbed, and thus time may lessen that kind of
pressure ;  but what can remove the compression of a firm  and
solid bone ?   Are we to remain,  you would be inclined to ask,
unconcerned spectators, whilst our patient  labours  under a visi-
ble depression of  the cranium ?"—These  are real difficulties,
and must be answered ; and  facts will hardly persuade you
when  balanced against such strong probabilities : but the  whole
question shall be fairly laid before you  ; it is one of those which
I stand  pledged to discuss with soberness and deliberation; it
is one in which you must  learn  to decide on sure  principles,
since you are about to enter on that scene where responsibility
rests on each of you, where you must trust to your natural rea-
son, not to the dogmas of any teacher, and suit your practice
to the various exigencies of each case.
   There is a wide difference, in theory and in fact, betwixt the
oppression proceeding from extravasated blood,  and  that  from
depressed bone.   It is because bone  is firm and immoveable
that its depression does no harm !  for the pressure it causes is
permanent, not progressive ; it is fixed and complete at once :
if the patient be not struck insensible the moment  the  bone is
beaten below its level, he never  can become so ;  and you will
find, by a singular variety of proofs, which I am now to lay be-
fore you, that he  seldom becomes insensible.  The brain is ca- 
 
P. su.
<„Tlg,l.  i
Fig, 2.
JBell. Me.
F.Xavny.'ft
-at. 
          Of Fractures of the Scull with Depression.      31 a

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

  * Is preffure upon  the dura mater nothing, or there is no chance of that preffure
caufing inflammation of the membranes of the brain ? S. 
 S16         Of Fractures of the Scull 7vith Depression.

 difficult to prove that it is safe to leave such fracture untouched.
 But  a thousand favourable accidents  have  betrayed  the im-
 propriety of this rash practice, and proved,  in various ways,
 that  the surgeon has been  usually occupied, and often with ex-
 treme violence,  in elevating fractures which had been better left
 alone.  Sometimes, in the hurry and confusion of such a bloody
 scene, a remarkable depression of the scull  has escaped investi-
 gation,  the patient  has escaped the violence and dangers of an
 operation, and the surgeon has been sensible of the deep de-
 pression only by feeling it through the scalp when the man was
 well: Sometimes relations and friends have interposed and pre-
 vented the  well-intended operations of the surgeon, who has
 protested against  leaving  a great  depression unreduced, and
 prognosticated death, yet  the patient has  recovered:  Some-
 time?, the surgeon having leave to do his work, having made
 his perforations  and pushed in his levers,  has  found the depres-
 sion too deep and too firm to  be raised ;  after every justifiable
 and every unjustifiable violence, he has been unable to raise the
 depression, and has not dared to cut it out; he has left the pa-
 tient  in this desperate state, and yet seen him recover after such
 violence, added to the deep depression :  Sometimes when, from
 the foul air of hospitals, or the prevalence of epidemic diseases,
 the surgeon has  been  deterred from his favourite work, he has
 discovered, with equal pleasure and surprise, that " more reco-
 ver (to  use the words of Perusinus) by medicines  than by the
 knife and the saw."   Indeed,  the  conclusion  against the pro-
 fession  and its general propensity  to operate,  in  mere  injuries
 of the scull, is stronger than I believe you are aware.   I know
 that if you had seen with me the precipitation  and violence with
 which depressions of the scull are torn up, and the miserable
 consequences arising from large  openings, both your reason
 and your feelings would revolt against the practice.
  " I*chanced once (says Platner) to be called to the assistance
 of one who had fallen from the third storey of a house, and lay
 quite  torpid and oppressed,  as in a deep  sleep.  The surgeon,
 having shaved his head, found there a very deep and wide de-
 pression of the scull.   While we were wondering how the scull
 could be thus deeplv impressed by the fall, the integuments be-
 ing but  slightly  ruffled, the man recovered  his senses in a for-
 tunate hour; alarmed at the proposal  of an operation, he told
 ns that the impression we had observed was of no importance ;
 he had it from his childhood ; and yet had lived in perfect health:
he recovered without  assistance."  We are at a loss to conceive
how,  even where the integuments remain entire, so wide a frac-
ture, and so much depression,  can be consolidated without any
ill symptoms; but several cases, which I have myself witnessed, 
          Of Fractures of the Scull with Depression.       317

make the process quite familiar to me:  and one related by JJo-
tallus I think particularly worthy of your notice: " Some" (says
BotaHus) " will very readily  acknowledge that bones,  fractured
without an external wound, are easily cured  in other parts of
the body, while they deny the bones of the scull to be thus cured:
I will relate plainly what I have myself seen.  While I prac-
tised surgery, a boy, as I guess about seven years  of age, fell
from  a gallery twelve feet  high,  and pitched directly upon his
head: the parietal and  part of the frontal bones  were so  frac-
tured that you could feel distinctly the several fractured pieces,
yet the skin (he having fallen upon a flat pavement) was not
wounded, nor  even the hair ruffled.  When called, 1 was alto-
gether confounded at finding such a fracture,  the boy speaking,
and in his perfect senses, with only a slight acceleration of pulse,
(he was however  insensible at first, and had vomited up his
dinner along with some bile) a thousand thoughts passed across
mv mind,  while those  I had sent to the apothecary's were re-
turning with some medicines.   I was for some time  irresolute
whether to make an incision and pick away the fractured bones,
or to leave the parts entire: at last I resolved on this more lenient
plan.   In place of making an incision, I covered the whole head
with Armenian  Bole, Myrtle Berries, and Rose Leaves, mixed
with vinegar and white of eggs ;  and this astringent application
I used during four days.   The boy perfectly recovered without
incision; he lived many years;  and, though  I do not recollect
his name,  I have reason to believe he is still alive."*   This in-
genuous avowal of Botallus, that he was altogether confounded
at feeling such a fracture, and that a thousand thoughts had fleet-
ed across his mind,  makes the case highly interesting: we are
conscious, from the conclusion of the case, how dangerous these
thoughts were to the patient, and must feel that when they pre-
sent themselves  to our imagination, they should be resisted.
   Parents have often, with seeming perverseness,  refused as-
sistance in  the  last  extremity,  and even the earnestness with
which it is offered,  is  a motive for refusing it;  despair makes
them unwilling to disturb the last moments of their child, which,
being left undisturbed,  recovers; what the fate of such a child
might be if trepanned, must ever remain doubtful.
. *  I was called once to a child, whose circumstances seemed so
very desperate that I urged the parents to allow of an  operation,
which fortunately they refused.   " This little girl, about twelve
\ ears  of age, was  playing with her school companions on the

  VI cannot a^ree with Mr. BeJI in the propriety of the practice here commend-
ed, although the patient recovered. Though the general argument is correct, that
it is not neceffary to trepan cvety depreflion, the doo?rine muft not be puttied too
far. S,                "■ <:i.                           , •• 
318       Of Fractures of the Scull with Depression.
very steep declivity of the Earthen Mound: two of them were
running, hand in  hand,  when  this little girl, losing die hand of
her play-fellow, rolled from top to bottom of the Mound, with
continually increasing velocity, till at last she pitched with her
head full against a low wall, at some distance  beyond the bot-
tom.   She was carried home in a chair, stiff  and motionless,
perfectly pale, and without pulse; she  hardly breathed; and
we had no evidence of her being alive but a slight degree of
warmth, which, after cutting off her clothes, (for she was stiff as
Well as motionless) was difficultly increased to a natural warmth.
   " From this time she lay in a deadly stupor, with a blemish
on one temple;  there  was no tumour,  but flat integuments,
through which I imagined I could feel a fracture and  depres-
sion of the parietal bone, while the signs of accompanying ex-
travasation seemed ver\  unequivocal: her limbs were stiffened;
her whole frame in a  sort of tonic or permanent  convulsion :
her jaws firmly and immoveably  locked;  her extremities cold,
and her  pulse oppressed  and intermitting.  In this state she
lay for four or five days  immoveable ; hardly was a  tea-spoonful
of wine and water admitted betwixt her teeth, which were firm-
ly and immoveably closed.  I was then persuaded, and remain
so, though she happily recovered, that there was extravasation
under  the parietal bone ; and my  persuasion was so great that,
on the fourth and fifth days, I  solicited her parents to allow of
an incision,  and even spoke to the clergyman, who was called
to them at this dismal time, to persuade them to consent.  On
the sixth day she yawned widely, and from that moment her
jaws were loosened : we could now put in a few spoonfuls of
wine and water, and give purgative medicines; but she lay still
and dead, in the most profound stupor I ever witnessed.  She
btgan  in the second week to stir the limbs of one side a little,
and in two days  more she stirred sometimes an  arm, some-
times a leg, of the opposite side: then her eyes opened at times,
and she began to mutter and speak ; but it was  the fifteenth day
before this low muttering came on; and then, and till the twen-
tieth,  though her eyes were open, we had unquestionable evi-
dence  that she could not see;  a candle approached to the eye
gave no sensation, the eye did not follow it, nor were the eye-
lids closed as expressive of impatience of light, and the pupil
was as much dilated as if she had lain in a dark place.
   " She now became restless, the  struggling of the limbs of both
sides increased, she put out her hands and stretched her limbs
with a sort of trembling, and  muttered perpetually.   On the
fourth week, she came to swallow more easily, to take the drink
which hud hitherto been poured into  her mouth, and to spt ak
rationally.   She next sat up in bed, was raised into a chair, and 
Of Fractures of the Scull with Depression.
31»
gradually recovered her senses and her strength.   She was then
able to be led  about  the room,  but two months elapsed before
she could be said to walk:  even then she was never left alone,
nor walked unsupported.   She  was led about the whole sum-
mer in this  weakly condition; but is now a strong and healthy
girl."*
   But the practice of those who believe it to be their  duty to
scrape every fissure, and raise every depression,  who are ever
ready to go to work  with their  instruments, affords the  com-
pletest proof of the improvidence of such practice  ; and  we find
practical errors narrated,  by the best modern surgeons, with a
non chalance,  and want of consciousness, altogether astonishing.
u I cured a boy, (says Marchetti) of seven years  of  age, who,
from the kick of a horse in the forehead, had a very remarka-
ble depression, which neither tripod nor lever could any way
elevate ; but there being a fissure in one part, I  betook myself
to the rugin, dilated the fissure, so that the serous humour had
leave to exude, while the medicines had leave on the other hand
to  penetrate to the  dura mater, so that in the course of forty
days, flesh being regenerated in the fracture, the wound was
safely aud soundly cured."  But,  had the celebrated Marchetti
been permitted (as it was a wonder his  authority did not pre-
vail)  to trepan this little  boy, to tear up the scull with his tri-
pods and levators, it is  possible  at least,  that even after such vi-
olence, he might have survived, and then the operation and the
operator would have been applauded for saving the patient's life;
and had  the  elevation of the bone been accomplished, though
with every circumstance of violence and rudeness, the operation
would have become memorable.  Such a  case is that recorded by
Mr. O'Haloran, in  which  every principle of sound surgery
was violated.   He found a child with a depression of the scull
with the integuments entire, and the senses quite  composed and
perfect, when, without any motive but  his  own  fears,  he  cut
open  the scalp; and that depression, which had  hitherto done
no harm to the child, he elevated in the rudest and most shock-
ing manner, making no fewer than four perforations in the scull
of the child, thrusting into each  hole  a  levator, and to his  four
levators he had two surgeons, who seem to have had as little
tenderness as  himself,  for  they pulled with might  and main,
till the depressed bone rose with a sudden spring.   But here is
his own narrative.
   " A girl, about seven years of age received a severe fracture,
wit/iprofounddepression, on the left parietal bone ; the integu-
ments were entire, the girl quite composed and sensible, but the

  * This cafe fhews what may kappen, but would Mr. Bell himfclf prognofticate
a fimilar iffue, under fimihr circumftances ?  S. 
320     Of Fractures of the  Scull xuith Depression.

depression  was so deep that it could contain a very small egg.
Such was her situation when brought to me half an hour after
the injury.   Seeing that it  would require three or four crowns
of the trephine to raise  this extended fracture, I requested of
Mr.  Wallace,  a military  surgeon,  and Mr. Pierce, to  assist
me in this charitable work.   I  removed all the integuments,  wi-
ped away  the blood,  and whilst these gentlemen with their fin-
gers made  compression over the bleeding vessels, I began to
opc-rate on  the inferior parts of the bone.  I then commenced a
second on the upper part, and  in a line with this ;  but two eleva-
tors,  though acting at the  same time, had no effect on the de-
pression.  Two more crowns were then applied to the sides of
the bone, and parallel to each other.   Four levers acting in con-
junction, it astonished me to see with what  a sudden spring the
depressed parts resumed their former station.   Notwithstanding
the great extention of this fracture,  the loss of covering, and of
the bone itself, bv four crowns of the trephine, this  girl  never
after had the smallest untoward symptom."
   Is it by  such narratives and such proceedings that the good re-
pute of surgery is to be preserved?  by no means:  we should at
first sight be inclined, both from the  violence used in raising
this depression, and from the success of the operation, to as-
cribe the patient's safety to the intrepidity of the surgeon ; but
what should  we have said of Mr. O'Haloran's  practice had he
miscarried,  and been unable, with his military assistants, his
pair of surgeons and double pair of levators,  to raise the depres-
sion, and yet the patient, after all kinds of violence being added
to the depression,  had lived ?   There is not in the narrative of
this case any shadow of proof that the patient was saved by this
 mode of operation; the child was composed and sensible, had
 no bad symptoms, and would (might) have had none  to the
 very end of the cure, had she been left alone :  it proves merely
 what is but too surely true,  that often  the patient survives the
 most imprudent things the surgeon  can do.
   I will now produce you evidence that I put no  worse con-
 struction upon  this case than it should bear; it  will prove to
 you, that, even where the depression is broad and deep, where
 convulsions  have ensued,  where the surgeon,  alarmed at these
 signs of danger, has made  his incisions and his perforations,
 and tried  ineffectually  to  raise the depression, the patient has
 survived  both  the depression and  the  ineffectual operation,
 which must ever be a violent one.   Mr. Hill undertook, in an
 unfortunate hour, the following operation.  " A boy of the
 name of Carson, betw-en five and six years of age, by the kick
 of a horse,  had a long oiece  of the os frontis beat in flat: he
 slept sounc1, as the people termed it, about two hours, and then 
           Of Fractures of the Scull with Depression.      321

 fell into strong convulsions.   The extravasation was so great
 externally, that the precise quantity of the bone depressed could
 not be determined, till the blood was  discharged by a horizon-
 tal incision along the  depression, by  which I discovered it to
 be of an elliptical form, extending above two inches across the
forehead,  and above the right sinus frontalis, with  a fissure all
 round it.  The external discharge not relieving him, showed
 that the perforation would be necessary ;  and,  therefore, after
 allowing the first incision to bleed some ounces,  it was stopped
 by dry dossils.   Being determined, for the  reasons  formerly
 given,  not to touch the depressed part,  unless some symptoms
 should afterwards make it necessary, J continued  the incision
 till there was room for perforating a quarter of an inch from the
 fissure,  at the right end of the depression.   The bleeding was
 troublesome ; but no arteries required to be stitched,  but were
 stopped by dossils dipt in ardent spirits,  and applied for half an
 hour.  After which just as much of the  pericranium was  remo-
 ved as was necessary to admit the- smallest head of the trepan.
 The connecting blood-vessels betwixt the dura mater and scull
 were broken through the whole extent of the depression,  being
 at least two inches; for so far I introduced the levator, without
 opposition, and attempted, with  a good deal of force, to raise
 it; but in  vain.—After the extravasated blood was  discharged,
 three intersected stitches were put into the first  incision  above
 the depression, and it united in a few days ;  and the rest  of the
skin healed in four weeks, without the intervention of any bad
symptom.—He is  well, 1771 ; and  the depression, owing  to
his youth,  is so expanded by  natural growth and callus,  as not
to be much perceived."
   If any thing could repress the  presumption of a  man  of an
adventurous temper, this must:  to propose an operation  under
protest, that it was the only possible means to save the patient's
life ; to attempt that operation ; to  see the patient  survive the
depression which had been declared fatal, unhurt by the addi-
tional violence of incisions, trepans, and levers !   Surely these
facts should lead the surgeon, who had been in the habit of ele-
vating inexorably every slight depression,  into a new train of
thought.
  The prominent points of this  case of Mr. Hill's, stand, in
common sense and plain argument, thus  : First, the depression,
While it  continues, does no harm, the boy being in his entire
senses : Second, the surgeon  is so alarmed at the very  appear-
ance of depression, that he labours with every  degree of vio-
lence  to raise it, his own reputation, as well as the  patient's
                            2 S 
322      Of Fractures of the Scull with Depression,

health, seeming to be at stake :  Thirdly, abandoning the opera-
tion,  and leaving the depression as he found it,  he puts three
stitches in the wound,  and so the integuments unite  over the
depression in  a few days : Fourthly, the  patient is no sooner
recovered, and the wound healed, than  the depression, which
appeared so formidable to the surgeon when seen and felt at the
bottom of a  bloody wound,  the depression, to raise which he
willingly risked every thing, disappears spontaneously, so little
is it off the level.*
   I will now relate  the circumstances of an operation in which
I  was a party ;  where  although I was obliged to be a witness
and unwilling  assistant in  much mangling, I saved the man a
great deal more.  There was, along with a  wide fracture of the
parietal bone, through which the  extravasated blood  was  seen,
a slight depression of it at one corner of the  fracture: the trepan
was applied : the extravasated blood rolled out: the  duty  of
the surgeon  was, according  to my  apprehension, completely
fulfilled; but he was urged by others who were present to raise
this depression, with a degree of earnestness which left him en-
tirely responsible for  the consequences.  I most unwillingly
witnessed, but would not  consent  to assist  in  this part of the
operation.   After extreme violence  (for always the violence  is
extreme where the  surgeon works till he is foiled) it was found
altogether impossible to elevate the depressed bone.  The ope-
rator was now  called upon,  under the same  responsibility,  to
make one, or, if necessary,  two perforations,  on  the   sides  of
the  depressed portion, to raise it.   I saw plainly that, if the
operation, now  protracted  for an  hour, should continue still

   * Thefe are  nor folitary, nor even rare cafes.  Read the following from Mr.
Hill.  " February 14, 1750.  Mr Robert Rae, when a young man, fell back-
ward  from his horfeona rock, about twelve miles from Dumfries.  By his foot
sticking in the stirrup, he was dragged  fome way,  till the girth broke, and  left
bona with his head betwixt two ftones in a rill of water,  where he  would foon
have been fuffocated had not a fhepherd boy drawn him out.—A large piece of the
left parietal bone was driven in backward to the lambdoid future, with a fiffure in
the right parietal forward, being like a fhepherd's crook : notwithftanding the lar-
ger depreflion, there was no  extravafation; nor -would the bontt. rife, though a very
great farce -was employed; but they exfoliated like the former, and, the aperture be-
ing wider, theprotufion  was greater.  The cicatrix continued foft for three years,
when it offified completely.
  t Mr.  Bell's criticisms on  Mr. Hill's operation, if the cafe  is entirely related,
do not appear to be altogether correct. He fays " the boy was in his entire fenfes,'
when Mr. Hill fays" he was in ftrong convulfions." Although the deprtffcd bone
was not elevated, yet the extravaftted blood was difcharged ; a circumftance of no
flight importance.   Mr.  Hill fays, that" owing to natural growth and callus,"
which implies confiderable length of time," the depreflion was not mueb perceived''
and not that it difappeared when the W- recovered.  S. 
Of Fractures of the Scull  with Depression.      323
another hour, the man would be carried off delirious; that if
the scull was widely opened by two perforations,  and by the
tearing away the depressed bone, his  chance for life was very
slight.   I said across to the surgeon, that if he would permit
me, I should most willingly take the responsibility upon myself.
On his consent,  I put aside the busy  fingers that were search-
ing for depressions, clapped a piece of lint on the dura mater,
and conveyed him to bed, where he mended daily, and became
a very stout and healthy man.
   The bloody decrees of the surgeon against all who have de-
pression of the scull are never so absolutely suspended, as where
the ill constitution of the air in a great hospital is known, by the
experience of centuries, to destroy all  those who suffer opera-
tions on the head.   Under  this imperious necessity was Des-
sault,  surgeon of the  Hotel Dieu, who,  during his  adminis-
tration, declined, even in  the  most urgent  circumstances, to
perform the operation of trepan.
   Dessault's clinical practice, when he merely allowed the pa-
tients to lie undisturbed and quiet, with a poultice to the frac-
tured and depressed scull,  and a dose of  calomel to move the
bowels,  exhibits a splendid series of examples of what nature,
undisturbed by  partial operations,  will do; and taught  Des-
sault himself, and proved to the profession, how great a pro-
portion of those who are trepanned would live without the help
of surgery : for many recovered after lying long in  a state of
stupor, accompanied with symptoms every way alarming, such
as would,  in any other circumstances, have  induced Dessault
or any surgeon to have trepanned.
   But Dessault, who was too much inured to bloody scenes to
fear operating, and too indifferent to the reputation of being an
operator to feel any  thing of the passion for cutting  and trepan-
ning,  tried, for the first time, the great  and important experi-
 ment of leaving his  patients, having  fractures  and depressions
 of the cranium, at quiet in their beds.  Among others, one Jo-
seph Gautier's condition was in every  sense interesting, but es-
pecially in the slow absorption of that general suffusion of blood,
which we must presume to have taken place in the brain after so
 violent a concussion as he seems to have  suffered, and the gra-
dual recovery  of his senses, proportioned in all likelihood to
that absorption, and accompanying it step by  step.  " Joseph
 Gautier, a hale young man,  twenty-three  years of age, was
found in the morning under a window, which he was accustom-
 ed to scale when late abroad, lying in a state of stupor, and ba-
 thed in his blood, which streamed from his mouth and nostrils,
and from  his left ear.   When he was brought from his village,
a few  miles distant from Paris, into the  Hotel  Dieu, he was 
324
Of Fractures of the Scull with Depression.
 still bleeding from the mouth and nostrils, and insensible ; the
 body cold, the face deadly pale, and the  pulse small and con-
 tracted.   On  his  head  were many marks of  contusion ;  and
 one over the lower and fore part  of the parietal bone, was ac-
 companied with a depression, deep in the  centre, and rising to-
 wards each side.   The clavicle, which was  also fractured, be-
 ing set and bandaged, the head  was  wrapped in a  large poul-
 tice :  next day he was better ; the poultice was  continued,  and
 he was bled in  the foot;  and in the evening his senses in some
 degree returned.  On the sixth, he began  to articulate, but in-
 distinctly.  By the seventh his senses were restored;  his taste,
 smell, and touch were perfect, but his vision somewhat impair-
 ed : he heard also imperfectly ;  and, in respect to his  intellect,
 the faculty of memory seemed much weakened;  he could by no
 means recollect whence he came.  He had no pain:  it was  on
 the tenth day that he first rose and walked :  on the fourteenth,
 he walked abroad  upon the bridge, and took  his airing  there
 daily,  till the twentieth,  when,  the fractured clavicle being  re-
 united, the bandages  were undone.  His memory mended dai-
 ly ; his hearing became  more acute ; his eyes gained strength,
 but still the pupils remained dilated somewhat wider than in  the
 natural state, and the scull remained manifestly depressed.  On
 the twenty-seventh, he was carried into the hall at lecture, and
 shewn to the pupils:  this  was before  he  was dismissed.   At
 the end of three weeks, he  returned to show himself, his sen-
 ses being entirely restored, and his memory perfect:  the pupils
 of his eyes had recovered  nearly  their natural smallness, except
 that the pupil of the left eye continued a little wider."*
   In this case, when about the third day,  the bumpy swelling
 and ecchymosis began to subside,  they felt  the fracture and de-
 pression very distinctly, the fracture being  of a circular form,
 about two inches and  a half in diameter, with one  edge more
 raised  than the  other;  and after his recovery  it was still  more
 plainly felt.
  " The invariably  fatal  consequences of using the trepan in
 the Hotel Dieu, deterred Mr. Dessault from using it on this
occasion ; nor had he any reason to repent  of his resolution."
 Even when the depression seems to  produce the worst signs ;
 w hen the patient bleeds from the nose and ears,  and  lies inscn-
sio.c ;  when his senses were not  merely stunned and shocked,'
but so materially injured that they recover slowly, it is safe  to
leave the depression untouched; to trepan where there are  no
such signs would be destruction.    Mr. Abernethy "  had a man
brought to St. Bartholomew's, who was hit  on the  forehead
* Deffault's Chirnrgical Journal, Vol. i. p. J 7 
Of Fractures of the Scull with Depression.       325
 with a brick: the frontal bone was fractured half an  inch above
 the orbit; the fracture measured two inches in length, and  the
 upper portion of the brow was depressed about the eighth of an
 inch.   He was not even stunned by the blow,  and walked to the
 Hospital without assistance,  complaining only of soreness in the
 wounded integuments.  He  was  bled ; was  confin/d,  much
 against his inclination,  to a scanty and liquid diet, and was pur-
 ged every second day.   This patient did not experience any ill-
 ness,  and the wound soon healed."   But  had Mr.  Abernethy
 been a surgeon of the complexion I have  sometimes  ventured
 to describe;  had the patient  been confined, much  against  his
 inclination, to an operation-table, and  trepanned,  there  is little
 doubt, I think, how it would have fared with him.
   But this is the difference betwixt the proceedings of a man of
 sense and  experience, and a  man of theory.   There has  been
 too much of surgery !   A master in  surgery  can look,  calmly
 and composedly, on that depression upon which a novice would
 instantly fasten his levers ;  he can see  the scalp \whirled off from
 both sides of the scull ;* the parietal  bones laid bare;  the tem-

   * " A lad, feventeen years of age,  had his head preffed between a cart-wheel
 and a poll ; by which accident the fcalp on both fides was turned downwards, fo as
 to expofe the lower half of the parietal bones, the fquamous part of the temporal,
 and alfo part of the frontal and occipital bones; about a quarter of the cranium be-
 ing thus denuded of its coverings.  The periofteum was in feveral places ftript off
 from the fcull, the fcalp much bruifed, and the poferior and inferior angle of the left
parietal bone was beaten In.  The  depreffed portion, which was  viuble,  ivas an
 inch in length, aud more than the eighth of an inch below the level of the cranium ; but
 the fracture extended along the fquamous part of  the temporal  bone, towards the
bafis of the fcull :  it could not, however, be traced, as the temporal mufcle had not
 been removed from that part by the injury.  The fcalp being cteanfed, was repla-
 ced, retained in its fituation by flips of flicking-plafter, and a fligbt preffure by ban-
 dage, was  applied.  The boy was perfectlyfenfible, his pulfe regular, and not quickened.
 He had bled confiderably  from the temporal artery, which had beiui divided by the
 accident: eight ounces of blood were, however, taken from his arm; and fome
 purging medicine was adminiftered next morning, which procured three  or four
 ftools.  The next day, (Friday) his pulfe beat nearly  iao  in a minute;  his fkin
 was hot and dry ; and he complained of pain in his forehead.  Tw elve ounces of
 blood were taken away,  and four grains of pulvis antimonialis ordered to be given
 three times a day.  On Saturday,  the former fymptoms ftill continu ed, and  were
 rather increafed.  The antimoriial powder made him fick, or at leaft increafed his
 difpofition  to be fo.  Fourteen ounces more of blood were  taken fro.ii him ; the
 vibratory feel of his pulfe not bein^ altered until that quantity  was taken away :
 the blood,  on (landing,  appeared very buffy.  His fkin, notwithstanding all this,
 ftill remained extremely  dry ; fome antimonial wine was given, which produced
 vomiting.  On Sunday, his pulfe was evidently lowered by the evacuations he had
 undergone, but it was ftill quick  and fufficiently ftrong.  The pain of his head
 remained as before.  Having  a fufficient number of ftools, and the fick'Jiess ftill
 continuing, the antimonial powder was omitted.  He was bledr however, in the
 venafaphena, and his feet and legs afterwardsimmerfed in  warm water ; during
 which, he,  for the firft time, perfpired copioufly.   A blifter  was alfo applied to his
 neck.—The fcalp united, with only a trifling fuppuration over  the fracture d part
 of the bone ; and to this ready union,  the lowering plan, by  preventing inflamma-
 tion, feems very materially to have contributed.   I he matter collected over the
 fracture was difeharged by a puncture, and the boy got well."—Abernethy. 
326       Of Fractures of the Scull with Depression.'

poral and frontal bones also denuded; part of one of the bones
beaten in, for an inch in length, and more than the eighth of an
inch in depth, and a fracture extending downwards to the basis
of the scull,—and yet refrain from  trepanning.   He can see a
fracture similar to this, with a part of the bone depressed  even
a quarter  of an inch below its natural level, without thinking of
making an effort to raise it;  and can even see the boy sicken on
the third day, with headach  and disturbed sleep, with dozing
and a slight convulsion, without being moved to do any thing
rash or unbecoming.*   While the tyro, just sent out from the
schools, makes  diligent inquisition into all the circumstances
of  a fracture, will allow  not even a capillary fissure to escape
his jealous search; and, where there is hardly any visible fissure,
imagines such internal damages as  may  entitle  him to " set to
work with his  instruments," and perform that great operation,
which is to be the pride of his  future years,  " boasting of that
which is his shame."
   It is not honourable to our profession to have  it thus proved,
that while the opinion is almost universal that depression of the
scull must oppress the brain, the fact is entirely the reverse :
that,  wherever  by chance such depression  has passed unob-
served, or the friends have refused all surgical help; wherever,
by  the deepness and firmness of the depression,  it has been im-
possible to raise it;  wherever the  danger  of  infection  has. de-
terred the surgeon from operating, or he has resisted  the temp-
tation,  and,  by an effort  of good  sense,  has ventured,  at  the
risk of his reputation, to disregard the established maxim,  the
patient has done well.   This is enough to throw a doubt upon
all  that has been doing for centuries ; and makes  it a duty to tell
you plainly, and without reserve, that the desire of leaving, in
a dangerous operation, nothing undone, is not wise,  and leads
to  nothing but rashness and violence : it  is a prejudice so na-

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

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

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

   * There are, in my recolledtion, no cafes, and I find in my readings very few,
 in which the depreflion feems to have occafioned ftupor, or the elevation of it gi-
 ven relief.  The following obfervation from La Motte, is perhaps worth your no-
 tice as much as any.
   " A boy" (fays La Motte) " was rode over by a young prancing horfe, which
 pranced upon him.   There was a great wound, and  much bone naked ; and be-
 fides there was a confiderable depreflion, apparently  made by the  cauker or heel
 of the fhoe. This boy 1 found  lying on his back, crying out  continually that he
 was falling, that he was falling down !   I trepanned, iutroduced the levator, and
 raifed the depreffed bone.  This boy, while the bone continued depreffed. had
 continually the feeling of a drunken perfon, of the room running round  with him :
 but the  moment the bone was raifed, and the extravafated blood evacuated, he reco-
 vered his fenfes."  P. 320.
  f A  cafe  is related by Mr. Cline, in his Le<Stures,*of a feaman on board an
 Englifh  fliip in  the  Mediterranean, being knocked  down by fomtthing  falling
 from aloft.   He was rendered infenfible by the blow,  and in this ftate was carried
 to Gibraltar, where nothing was done for him, and thence to London, to St. Tho-
 mas' Hofpital, ftill in a ftate of infenfibility.  Thofe who were with him knew
 when he wanted  to eat  or drink, by  certain motions which he made. He had
 likewife a catching of the fingers of one of his hands. His head being Jhsved, u
depreflion (ol one of the parietal bones, I think) was difeovered, for which  Mr.
 Cline operated   That very evening the motion* oi" his fingers ceafed, and in a
few days his fenfes were entirely reftored.   What is very rtmakable, when he firft
became  rational he thought himfeli ftill cruifing  in the Mediterranean,  having no
idea of the lapfc of time, or change of fituation,  which had t.ikcn place.  I  do not
recoiled how long he remained 111 that  infenfible ftate, but it muft hav« betr
feveral months.   S. 
Of Exceptions to the general Rule*          329
ef a fractured scull, and cause it to inflame the bone, and affect
the dura mater: These are  the exceptions, and they must be
defined, and I will now describe that kind of depression which I
judge to be safe.   It is  not by present pressure that fracture is
dangerous; therefore, when it runs in a right line, when there
is a general depression, but no particular point forced in upon
the  brain;  where  the  declination of  the depressed from  the
sound part of the scull is gradual and uniform;  when the whole
line of fracture is generally depressed, and the central point sinks
rather deeper only; though you can feel the hollow with your fin-
ger, and can see it (not without apprehension) when the coagulat-
ed blood is discharged ; yet as the centre does not intrude materi-
ally upon the brain, as this point does  not dip so as to present
points or spiculae to the dura mater; as there is no rough edge
presented on the inward surface, nor any rude shock, like that of
a ball, to deprive the bone of life, and prevent its healing; as it
is broken  by such a force as fractures other  bones, and is sur-
rounded (as  marked at d, fig.  1.) with a mass of cellular sub-
stance, thickened by inflammation, and by the injection of blood
into it, such as re-unites other fractures, the scull, pericranium,
and dura mater,  all mutually adhere,  and the effects of such
depression are never felt.
   Upon every principle, and every precedent, taking care, how-
ever, to watch the  slightest appearance of fever,  rigour, puffi-
ness of the scalp, flabbiness, or gleety discharge from the wound,
we are bound to commit such a case to nature: it daily happens
that boys have the  forehead thus flattened by the kick of ahorse;
sometimes dangerous spiculae, as where the caulkers of the shoe
have pierced the bone, are cut away, and very properly, with the
trepan: sometimes, too, the bone is elevated; but very often it
is left untouched, the wound lightly stitched, and dressed dry,
and the parts re-unite and heal as in any other wound, a visible,
but harmless,  depression remaining.   While the  integuments
are  entire, the inducement to  leave them so  is  particularly
strong ;* when left entire, the  consolidation of the parts, and
the absorption of  the blood, is  certain, or almost  so:  to open
it, is to  convert a  simple into a compound fracture, with every
danger  of its  not healing favourably.   I remember to have put
in my finger, through a wound in the scalp, and felt, in a very

  * If you follow this advice, how can you know whether or not there are any
ipicuke of bone driven in upon the dura mater ?   1 have been, after the example
of Mr. Birch of St. Thomas' Hofpital, in the invariable habit of laying open  fuch
tumours,  never with any injury to the patient that I could perceive, and often with
manifcft advantage. When all danger of bad fymptoms vanifhes, the incifion may
be healed in a few days.  S.
2 T 
330          Of Exceptions to the general Rule.
old woman, near 70 years of age, a depression of the parietal
bone of two inches of extent, the fracture wide, the edges rough,
and the depressed bone apparently driven  far below the unhurt
part of  the  scull; and the only  notes I have taken of the case
are, that she never passed one sleepless night, nor had one hour
of sickness  ; her appetite never declined; that she sat up to be
dressed, and kept her bed a  few days only, through precaution,
rather than for want of spirits or strength, and recovered as
from the most ordinary wound.   In those less advanced in life
there  is less danger; and we have the best authority (the au-
thority of those whose general practice is to  use the trepan) for
affirming, that in  such  cases, not only the present depression
does no harm, but the fracture unites, and the wound closes;
the patient may even  be seized  with shiverings, and the part
with suppuration, (strong reason  for suspecting a carious  bone)
yet such abscess, being punctured, will discharge " a consider-
able quantity of matter," and the patient be in no danger: nay,
we are  assured, on the same impartial testimony, that a hone
loose, and somewhat depressed,  will fix again.*   But in boys
especially, where depressed  bone has  in general no sharp edges;
where the scull rather  bends than breaks;  where the bone  is
vascular and growing, and  the circulation in it and in the inte-
guments sound and vigorous, the chance of a fracture's healing
is so great, that I would not presume to touch it, unless in most
peculiar circumstances; especially as in boys the dura mater  is
too tender to serve as a second  scull to sustain the pressure of
the circulation  within  the brain*: wherever it is necessary to
make large  openings in the   cranium of boys, protrusion  of the
brain  and death ensue.
  It is not then the present, but the remote  consequences of
depression we have to dread ; a  depressed fracture is more apt
to become carious than one that is direct or linear;  and it  is
as a fractured Rib  or Sternum.inflames the Pleura or Pericar-
dium, that depressed fracture of the  scull  by becoming carious
inflames the brain.   This is an  accident  which  may happen
in any form of fracture, where  the bone  is but laid bare, or
scratched, or punctured,  as  well as where it is depressed; it  ib
one for which the surgeon,  who  has  endeavoured to re-unite
the fracture, can be no more blamed than he could be blamed

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

  • I do not fcruple to copy expreffions of this inaccurate kind from my cafe-
 book, when I find them, however incorrect, to be fuited to convey thofe lively im-
pfeflions which one has only in the moment of looking upon a patient. 
Of Exceptions to the general Rule.          333
 should advise him to submit to an operation.  After passing one
 night more in this oppressed condition, he allowed us  to elon-
 gate the incision,  making at the  same  time a crucial one, by
 which these terrible fractures (fig. 2.) were displayed ; but the
 inner surface of the flaps of skin was so exquisitely sensible, and
 he was so far from feeling all his misery, that he insisted upon
 being carried to bed.
   But, two nights more  of that indescribable suffering, which
 he had tried to express to us, quite  subdued  him :  he  said,
 u whatever we pleased to do with him,  was now welcome."
 The flaps of scalp  were now, on Thursday, in a state ot suppu-
 ration ;  the black blood was, at  the time ot incision,  distin-
 guished through the fissures ; and  upon the circular piece of
 bone (d) being cut with the trepan, rolled out in large clots.   I
 could feel a great hollow betwixt the  scull and  dura mater,
 which was depressed by the extravasated blood, and the probe
 passed along unobstructed for  several  inches, in every direc-
 tion, from the  trepan hole.  To talk of repeating the perfora-
 tions till an extravasation of this extent were uncovered,  would
 be to think like a school-boy: the process was in this case  sim-
 ple and uninterrupted.  The patient's anxieties and opprtssion
 were gradually relieved.  He was trepanned on  Thursday : on
 Friday he felt quite relieved ; on Saturday, his slow, tnrobbing,
 and intermitting pulse,  had risen from fifty to eighty in the mi-
 nute ;  and at each dressing the blood diluted with a  sort ot se-
 rous exudation from the  surfaces melted and flowed out.   At
 the first dressings, I made way for its flowing out more freely,
 by introducing the probe, wrapped in oiled lint, and moving it
 gently round betwixt the scull  and dura mater ;  and as the du-
 ra mater rose,  which it did visibly from  day to day,  it assu-
 med a vermeil  colour : the scalp, bone, and dura mater were,
 in course of  a fortnight, one undistinguished mass of red gra-
 nulations ; the  process of healing was rapid and uninterrupted,
 not even interrupted by the loosening of a  small piece ot bone,
 which was partly  cut by the trepan and partly insulated by the
 fracture, and which I picked away, without the help ot forceps,
 with the probe.   I find that, on the Sunday following, I had
 been obliged to turn out large  clots  of  blood with the probe,
 which presented at the trepan hole, and extended far under the
 scull; and that, on  the following days, I was occasionally obliged
 to* use the syringe, with tepid  milk to wash out clots.
   Fourthly, Yet you must perceive,  that it is not in such cases,
 that the gaping fracture, or even  the excessive depression, that
is an object of concern, but that the extravasated blood is at once
the cause of the danger and of those signs which denote its exist-
ence ;  and those signs of extravasation may be so decisive, es- 
334
C(f Exceptions to the general Rule.
pecially when conjoined with fracture and depression,  a* to in-
duce you to cut open the integuments  and perforate  the
scull.  This was  proved  by  the  following  case  of a  fine
sailor  boy,  about fourteen years  of age,  spirited,  active,
and very thoughtless.   Whilethe vessel was unloading, he trip-
ped in skipping about the deck,  pitched headlong into the hold
among casks, and was carried up into the air in a state of  stu-
por, bleeding from the nostrils  and vomiting.   There was no
external wound, but a  universal extravasation of blood into the
cellular substance of the scalp, especially over the right eve-brow,
by which the eye was almost closed.   It was some time before
he was removed from  the  ship  in the roads; and when I first
saw him,  it was easy, through the integuments, swelled as they
were, to distinguish fractured edges, and a  depressed bone ; but
the extent or form of these  could not be ascertained, and indeed
they never should have  been with  me a motive for  making in-
cision into the swelled  scalp, but that he lay stifj in a state of
stupor, vomiting, and  bleeding  from  the  nostrils: his stupor
was not the deadly  snoring  of the apoplectic state ;  it had the
peculiar character which I have just attempted to delineate : he,
could be  roused,  was  sensible  and rational when excited, but
still he was in a state of stupor, into which he instantly relapsed.
Generally  the removing the patient to an  operation-table,  and
almost always the first incisions, excite the patient,  though de-
lirious, he becomes rational, though torpid, he is roused; yet
still, even when thus roused, his actions bear the character of
stupor or delirium.  This boy,  when  carried to the operation-
table, was roused to a  perfect consciousness of every thing
around him -$ and, when the operation was done, said,  " I think
I have borne it with spirit."
  This boy then was perhaps a fit  subject for  the experiment of
trying how far the powers of nature might prevail, in at once
supporting the system under oppression, healing wide fractures,
and absorbing much extravasated blood ; for  while there  was
such extravasation outwardly, along with conspicuous fracture
of the scull, there was great probability, almost  a  certainty, of
extravasation within.   It was an experiment  I did by no means
feel myself intitled to make ;  because the stupor, the vomiting,
the  haemorrhagy from  the nostrils  continued: I therefore made
an incision into  the tumour, a  long incision, which, directed
by what I felt without, uncovered  a long fracture.   The  lower
part of the forehe.id  was  more swt lied with suggilat'.on ; the
eyf  was  more closed  ;  the  edges of the  incision, when  laid
aside, w^-re more choaked with coagulated  blood th;»n could
be  well represented in a drawing: the coagulated blood was 
Of Exceptions to the general Rule".          335
also injected so into the cellular substance about the  pericrani-
um, that the fractures could be better felt than seen: but, one great
fracture running down the forehead,  passed into the orbit, and
was so very wide that it easily admitted the handle of my scal-
pel : another limb of the fracture ran round in the direction of the
coronal suture ; a whole piece and corner was deeply depressed,
and so far locked under an edge of the sound bone, that it was ne-
cessary to make two perforations, and to cut off a small project-
ing corner with the finger-saw, before we could think of using the
lever.   The blood rolled out through the first perforation. The
depression of the  dura  mater by the blood was as great as in
the former case ; the  circle  in which, I could with the probe
feel it detached, was as  wide: the rising of  the pulse,  which
had been oppressed ; the recovery from  the  stupor ;  the gra-
nulation of the dura mater,  and  the closing of the wound ; and
the daily issue of clotted blood, make  this,  in all respects, a
just parallel with the case I  have just related.  The extent of
the wotand was such,  that the boy was not dismissed till the 9th
of January, the 7th of September being the day of his fall: but
what surprised and gratified me was this,—the piece of bone,
which had been depressed  and  elevated, actually moved with
each pulse of the brain, so loose  did  it lie upon the dura mater.
I  feared, when I saw the dura mater through the trepan holes,
red and granulating; when  on  the 20th day from that  of the
operation, I found also all the exposed part of the scull covered
with a fine and florid pile of granulations, this triangular piece
of bone excepted, (which  continued yellow, quite  bare,  and
still moveable), that it must become entirely  carious, and exfo-
liate ;  and that this, by protracting the cure, or, by its exposing
the brain,  might bring the boy into new danger : I had this im-
pression on the 30lh of November,  and marked it  in my daily
report;  but by the 6th of December, the same pile of florid gra-
nulations had crept along over the whole surface of this portion
of the scull, and by the 14th the whole wound was cicatrized.
   Such wide  and gaping fractures, then, imply a very heavy
blow,  or a fall from a great heighth  : I find them often accom-
panied with deep apoplectic stupor,  with palsy of one  side,  di-
lated pupils, and involuntary stools ~, with groaning and sighing,
an uneasv tossing from side to side in bed, as if from oppres-
sion, and a frequent  raising of the hand to the affected side  of
the head.
   Fifthly.  There is a kind of danger inseparable from  certain
forms of depressed fracture, which no experienced surgeon will
despise.   A flat  and even  fracture, having no particular point
depressed,  causing no  stupor,  and  attended  with no ill signs,
is bv no means  a fit  subject  for  operation : but, where  (as 
336
Of Exceptions to the general Rule.
in fig. 3.)  the  fracture is radiated and  pointed, where the
bones do not " lie pashed or  loose upon the  dura mater," and
yet are much shivered ;  where not a long flat  edge is driven un-
der the sound  bone,  but particular points are depressed, pre-
senting probably on  their  inner surface spiculae and irregular
and jagged edges,  there is imminent  danger, not from the de-
pressed bone lying heavy upon  the  brain, but  from its points
pricking the dura mater, whence, on  the eighth or tenth day,
inflammation extends from the membrane to  the  brain, shiver-
ings and tremors come on, and the patient dies.  Not the long
and  wide fracture (a a,  fig.  3.)  nor the general depression pro-
duced by the yielding of the three triangular portions  (b, c, d.)
are the cause of danger, but the dipping in a more perpendicular
direction of the point (d), which, being  central,  has received a
great proportion of the force, and which, by being driven deeper
than the lateral parts (b and c),  is likely to carry down splinters
from the inner table of one or both these portions : it is because
the scull consists of two tables, and not by the peculiar fragility
(though it  is  more fragile) of the inner table, that points, and
spiculae of it are so apt to  be driven into the  brain :  when the
pointed portion (d) is driven below the level of the contiguous
parts (b and c),  it leaves  behind it the outer table of each  of
these portions, but it passes the inner table, and, as it is driven
inwards, every inequality, or angle of the fracture, makes a re-
sistance by which splinters are  not only carried before the
point  (d), but  driven  vertically, like  pins  or sharp wedges,
through the dura mater. The experienced surgeon distinguish-
es at a glance the forms of fracture in which  there is  danger ot
this kind : and, in a fracture of the form here described,  radia-
ted, pointed, and depressed,** there is no room betwixt fragments
lapped  over each other, like fingers  when plaited and  squee-
zed together,  to admit  a lever,  I think it right to apply the tre-
pan at the angle (e),  (as usually there is such an angle in every
fracture of this  species), through which the  lever, being intro-
duced under the depressed pointy raises them, and the  probe,
being turned round within the scull,  will ascertain whether any
rough edges still present, or  whether any spiculae or  dangerous
 points stick in the membrane.
   Sixthly,  Fractures of this form may prove dangerous, but
 depressions of the kind which I am next to describe must be so.
 The form of depression which happens when a man is thrown
 from a stumbling horse, and  pitches with  his head directly a-
 gainst a stone; or when he falls from a yard-arm, for example,
 and pitches upon the deck; or when a block and tackle, or a
 corner-stone  from a building, falls directly upon his head. This
 fracture is described by the ancients under the title of Camera- 
Of Exceptions to the general Rule.          337
tio, the camerated fracture,  as resembling the inverted tiles of
a house ; that centre is depressed in a direct line, the sides  de-
cline towards that centre, like the form  which the  two hands
make when laid together edgeways.  The form of this peculiar
fracture has been but too minutely described ; while its charac-
ter has been  less an object of attention, though, from its very
form, these inferences are plain :  First, that  in consequence of
its great extent, both lengthways and from side to side, the op-
pression of the brain, if such an effect could be  produced  by
depression of the scull, should be most manifest; yet I affirm,
from experience, that such effect is rarely felt, and shall prove,
at the least, that oppression of the brain is not inseparable from
this kind of depression:  Secondly,  it  follows that from  the
depth to which the  central line, or direct fracture, is depressed,
there must invariably be presented two rough and very dange-
rous edges, which, by irritating the dura mater, will cause sup-
puration : Thirdly, that though the patient should escape this
danger,  the circular fracture or crack which surrounds the
whole,  and which must invariably accompany depression of this
form, (without which  indeed the bone, in an adult at least, could
not yield), must almost always  insulate the depressed pieces,
they must in nine of ten cases become  carious,  and to prevent
these manifest dangers, I imagine it to be clearly the  duty of
the surgeon  to elevate  and pick them away, by  pressing in
his kver  betwixt the edges of fissures usually very wide ; or
this being  either impracticable, on account of the  wedge-like
impaction  of the depressed  portions, or dangerous  from the
dipping of one end of so long and broad a fracture, while the
other is rising,  he should apply  the crowns of the  trepan suc-
cessively, till the bone  can  be  raised  without being turned in
upon the brain.
   The case which  I have selected for illustrating this principle,
is that of an old man, of the name of Thompson,  who might
have been saved by a  timely operation,  but who was lost by de-
lay.   He had  fallen headlong down a precipice, (the  Calton),
fractured his scull,  had a double depression in the very course
of the great longitudinal sinus, and of the falx, which, if any
thing could oppress the brain and disorder its  circulation, should
have produced that effect : but so slightly was he affected,  that
nineteen days  elapsed without himself feeling, or his friends
suggesting, the propriety of procuring assistance.   At the end
of twenty  days,  this  was his condition:  the  depression  was
manifest to the touch  and to  the eye ; the whole extent of the
bone was black and bare, and a pale granulated fungus surround-
ed it: he had never, from the moment of the accident, had one
                            2  U 
338         Of Exceptions to  the general Rule.
 hour of sickness, or vertigo, or any considerable pain, but,  on
 the twentieth, began to lose his appetite, became drowsy when
 undisturbed, and languid when forced to speak or move ; his
 pulse was rapid and small, his nights were passed in confusion.
 On the twenty-second day, he  complained of more than usual
 pain, of slight vertigo, and of nausea ; and these symptoms suc-
 ceeding a night of confusion and delirium,  in which he struggled
 often to get out of bed, made it necessary  to perform straight-
 way an  operation so  obviously  necessary, which had  indeed
 been resolved on, and delayed  only by necessary arrangements.
 The crown of the trepan was  applied twice,  and through each
 perforation the lever was introduced,  and  the bone poised up,
 but could not be  safely moved till the third perforation set it quite
 free,  when  all the blackened  bone was taken away.
   But  long  before the operation  was  performed, the fatal in-
 flammation had  begun ; so it appeared from the depth and ex-
 tent of the fatal abscess, which had indeed destroyed one entire
 hemisphere of the brain.  Hitherto his state  might  rather  be
 described by the  term drowsiness than stupor : but the delirium
 ot  the night  preceding the  operation was a decisive and fatal
 sign.   Th« delirium never ceased : in the present, as in all ca-
 ses that I have watched, the symptoms were aggravated during
 the night: in suppuration of the brain, every long slumber is fol-
 lowed  by a degree of delirium, and the fate of a patient, whose
 condition cannot be  suspected from  any symptoms occurring
 during the day, may be prognosticated from the confusion in
 which  he passes the night.   Through the night following the
 operation, our patient started up frequently, struggled  to get
 out of bed, talked incoherently, but the return of light restored
 his senses, and during the day he was rational and composed,
 but still he slumbered.   This was his condition during the nine
 days that he survived the operation: his pulse was a  hundred
 and twelve,  weak and  variable ; he was restless and confused
during the day, especially after slumbering, and was delirious
during the night: from the opening in the scull,  there was a
considerable oozing of blood and  of bloody serum.   The third
and fourth nights after the operation,  were less perturbed : du-
ring the fifth and sixth, he was  extremely  restless and agitated,
speaking much, and struggling to get out of bed : the dura mater
appeared now black and sloughing, with a fetid, thin, and bloody
discharge. On the seventh, he became comatose ; his cheek had
a circumscribed and hectic flush ;  his pulse beat 120,  there was
no more delirium, he lay insensible, and passed his urine and
faeces inconsciously:  on the sixth, seventh, and eighth days, the
coma  became deeper;  he lay  still, and muttering  ; and, after
slight convulsive rigors, expired, on the  ninth day after  the 
Of Exceptions to the general Rule.
339
operation, the twenty-eighth from the time of his fall.  In de-
scribing deep suppuration of the brain, to speak of the laxavities
and draughts that are administered, or of their  effects, were a
very trivial detail.
   Upon dissection,  the  whole of the right hemisphere of the
brain was found in a state of suppuration ;  the basis  of the ab-
scess was very large ; the opening through the dura mater, was
like that made by a  large abscess lancet, into the  sac of any
great tumour : the medullary  substance of the brain  was soft
and gelatinous;  the part immediately surrounding  the abscess
was gangrenous, marked  by a black  or leaden colour, extend-
ing an inch or more  round  every part of  the abscess, and ter-
minating in a disk or halos of a deep green colour: the left he-
misphere was also, in a degree, tainted  with the  same  colours,
and slightly ulcerated on its surfaces.
   Seventhly.  Punctured fracture is that form of wound in the
bone which has the same  relation to  these wide fractures and
broad depressions, thatthe stab of  a  bayonet has to the cutof a
sabre: plainly  and indisputably requires the trepan, for  in no
case can we divine how deep the point may have  gone ; how
far the ball,  weapon, or point, may  have sunk into  the brain ;
in what degree or form the bone, especially its inner  table, may
be fractured:  blood  is often extravasated, and  often spiculae
stick in the  dura mater, or in the sinuses : the present injuries
are sufficient motives for  applying the trepan, and  caries is, in
this form of fracture, almost inevitable.   I hold it to  be the du-
ty of the surgeon  in all such fractures to use the trepan ; to place
the centre-pin  of his instrument as  close by the centre of the
fracture as  its  irregularities  will allow;  and to  operate with a
crown so  large as to cover all  the fracture, and cut it out at
once.
   Such cases remind me of the necessity of establishing this as
a rule *' that all punctured  fractures should be trepanned,"' and
of enumerating the general accidents by which they are produ-
ced.*   When a man  falls backwards against the sharp corner

   * The melancholy conftquences of fuch a fracture, are admirably cjcpictcd in
the following Angular  cafe, where the fracture was fo minute tha', hud the in-
teguments been fully opened, it might have efcaped inveftigation ; and  yet the
cutting out of fuch punctured piece of bone early, could alone have faved the boy's
life.
  --------Brand, aged about 14, was ftruck on the temple by a pair of fciffors
flung at him, the point of  which ftuck a little above the external canthus of his
eye, till it was  pulled out.  A bit of fugar tied on the wound by his mothef ftop-
 [>ed the blood.  He complained little lor two or three days ; but the  pain gradual-
 y  increafed every day after.  However, he went about till the eighth day, when
he fell into convulfions, and I was fent for.—There Was a hard tumour under the
pericranium and crotaphite mufcle, fo tenfe,that a fluctuation in it could with dif-
ficulty be perceived.  The tumour lay fo exactly under the artery,  that it could
not belaid folly open without wounding the artery.  To prevent an  hemorrhage., 
340
Of Exceptions to the general Rule.
of a stove or grate ;  when,  by the bursting of a  fowling-piece,
either the fragments of the gun-barrel, or the breech-pin enter
into the forehead ; when, by a blow  from a hammer, from fcbe
keys of a crane swinging and hitting the head;  when, by the
blow of a sharp-pointed stone,  making a radiated wound of the
scull, depressed  in  the  centre ; when a splinter from a carro-
nade, or  bolts, nails, or other fragments of iron have,  in a sea
engagement,  penetrated the scull; when a musket-ball, a dag-
ger's point, or the point of a pike or bayonet, sticks in it—the
fractured bone, and the  fragment  of the weapon  or the ball,
must be  cut  out  with the  trepan,  else,  slightly as the patient
feels  the  wound, he will, by the inflaming of the bone and the
suppuration of the dura mater,  be irrecoverably lost, before  the
symptoms indicate danger.  These  are  almost  the only frac-
tures in which  I think the largest sized trepan should be used.
   Shocking as the accident was, which I am now going to re-
late,  I hardly ever saw a punctured fracture that I would so wil-
lingly have left to nature as that which happened to Billy Came-
ron,  a  boy of about twelve years of age.   He was occupied a
whole morning with  his little play-fellows, in swinging upon an a-
rea door : thestaple was loose: the insecurity ot the door math  a
part of the pleasure they had in swinging upon it. When it came
round to this  little boy's turn, the stone  in which the staple was
socketed, gave way; the gate of cast iron, the corner-stone, and
the boy, tumbled all  at once into the area : a good woman ran
out instantly to lift the boy, and found him lying  with  his head
pinned  to the ground, betwixt  two  iron spikes, one  of which
had grazed and wounded the left  side of the head, while ano-
ther had pierced the scull, and was sticking in the parietal bone,
the weight of the gate and the stone lying  above  him.   She
carried him in her arms into her house, where he lay without a
sigh or a struggle, cold, pale, and death-like, for ten minutes:
he then began to draw long breaths,  to groan, and  to open his

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

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

                 Preliminary  Observations.


 J. O  treat fractures, wounds,  and  other  open  and  manifest
injuries of the scull, prudently and skilfully,  may be  thought
difficult;  but how to reason concerning those internal injuries
which  are hidden from the senses, and marked only by variable
and uncertain signs,  must ever be perplexing.   Perhaps there
is nothing more generally desired by the profession than some
decisive marks, denoting the particular nature of that stupor, in
which  a patient lies  oppressed after  a fall or a heavy obtuse
blow.  But there is no such sign ; we  are doomed to proceed in
our profession always with  a degree of uncertainty, and  to re- 
344
Of Concussion of the Brain.
gtitete our conduct by a perpetual and attentive exercise of our   •
judgment and senses.   It is only by a deliberate and calm re-
view of the circumstances attending concussion,  that we can
arrive at any thing like a conclusion.
   To reason upon the  cause of every phenomenon in the liv-
ing body, is natural and unavoidable, and does by no  means
contribute either to multiply or confirm whatever prejudices wc
may have : it is only from refusing to reason that our worst pre-
judices have arisen : and prejudices of ignorance are infinitely
more dangerous than the prejudices of th«se who, being willing
to reason,  are of course open to conviction, and inclined to en-
ter into the discussion  of whatever new  views or  unobserved
phenomena are brought to light. Nothing perhaps can be more
unmeaning than the word Concussion^ which is not, in the com-
mon acceptation, accompanied  with any   conviction of  the
structure of the brain being disordered by the shock, the term
implies a belief that the affection is of the nature usually deno-
minated Nervous ! that it is inscrutable in its nature !  that, as
we know nothing of the immediate cause, we can  do nothing to
recover  our patient!  that whatever phenomena we observe, are
such as are usually designated 6igns of debility ; and from this
persuasion, and an indistinct and  confused analogy,  (as Mr.
Abernethy observes) betwixt fainting and concussion, stimulants
and  wine, the most  dangerous of all medicines,  are  poured
down.
   If concussion be indeed this inscrutable nervous affection, un-
attended with physical disorder, we must become mere specta-
 tors ; there is an end of reasoning, and in such uncertainty it
were better to refrain from  practice.  But, the comparing the
brain with other parts and organs of the body,  will bring to ouv
recollection many consolatory circumstances, which will encou-
rage you to believe, that here also our profession may be useful.
What does  a bruise, a shock, and a general injury, do to a
 limb ?   Does it  produce any sort of disorder in a limb, which
 it may not produce in the more delicate substance of the brain ?
 When a man is hurt by the oblique blow of a cannon-ball, or has
 his thigh bruised by riding furiously against a carriage, by a
 fall,  or by a log  of wood, a block of stone, or any heavy body
 falling upon him, what does he feel? nothing but numbness:
 the part is torpid ; he hardly knows how much  he is hurt; he is
 lame ; and we can hardly  believe that any  internal or  physical
 disorder has taken  place  so suddenly! yet before he is reco-
 vered from his confusion, or is able to mount his horse,  the
 limb is stiff and swelled; the swelling increases every moment -t
 th- suffusion of blood,  under the   transparent skin, shows,  by
 the speedy  discolouring of  the part, that the swelling, (too sud- 
         Of Concussion and Compression of the Brain.     345

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

                       Of Concussion.

  The patient who has fallen from a great height, and lies in-
sensible from the  shock, has sustained the principal injury  in
that system  of vessels which,  from all that I have  related to
you, is the most delicate, and  the most susceptible of extra-
vasation.   Nor is  there  any mark wanting  of  extravasation,
slighter or greater, general or local, having taken place in  the
brain : nervous affection  (if we are still to use this  unmeaning
term) might, for a moment, confound the functions of the brain,
as a man is not only stunned, but sickened by a blow of the fist;
but the patient,  who has suffered a concussion, lies insensible,
snoring, and with his senses oppressed, and is in a state resem-
bling that of apoplexy or intoxication; his forehead is swelled,
his eyes often closed, and his features deformed with extrava-
sated blood; blood gushes at once from his nostrils, mouth, and
eyes;  his pulse is slow and pausing; his limbs and joints loose
and relaxed; the pupils of his eyes dilated; his breathing slow;
his whole body cold; you hardly know that he is alive, but  by
his groans.  If blood has thus  burst from  every part of this
system of vessels,  is it likely that  the brain  has escaped ?   If
the blood-vessels of the  nostrils, of the throat, of the ears, have
burst from the shock, and blood is also effused under the skin,
is it likely that the delicate  substance of the brain  should  es-
cape the same degree of suffusion?  It is  indeed true that, when
the patient dies, and his brain  is dissected in that coarse and 
«346     Of Concussion and Compression of the Brain.

slovenly manner, which is but too common, and by boys  whjD
hardly know its natural colour and forms, it seems as if nothing
had happened  to account for the sudden  death of the patient;
and it is confidently reported so, because there is no fracture of
the scull, nor any conspicuous effusion of blood: but when a
brain thus  deranged is dissected by a master who, by judging
what  is likely to happen, knows what to look for ; the pheno-
mena, though little perceptible to an ignorant man, must be in-
teresting to a thinking observer.
   " A man" (says  Mr. Abernethy)  M having fallen from  the
roof of  a brew-house,  a height of at least  eighty feet, had his
fall broken by touching the ground first with his  wrist, which
was dislocated and  mangled ;  his forehead  next struck the
ground, and his face was bruised,  but his cranium was  unin-
jured: he lay at first almost inanimate,  cold, and with a feeble
pulse: when he  became warm, he had stertorous breathing, a
dilated pupil, and a profuse perspiration;  his pulse rose to 140,
he recovered a degree of sensibility, his pupil contracted, and
his eye-brows were drawn into a frown; but his pulse again sub-
sided ;  the animal functions gradually failed; he  died the fol-
lowing day ;" and his  head was dissected by Mr. Abernethy,
who reports the state of the brain in these  words:  " On dissec-
tion,  there appeared every mark denoting violent inflammation
of the brain and pia mater, of short duration.  The minute ar-
teries of the pia mater were turgid  with blood;  in many places
THERE  WAS THE APPEARANCE CALLED  BLOOD-SHOT, which
was also to be  seen  in the lining of the ventricles.   Dark-co-
loured,  and in  some places bloody  coagulable lymph,  filled all
the recesses between  the tunica arachnoidea and pia mater.
On dividing the substance of the brain, all  its  vessels ap-
peared AS IF  INJECTED WITH BLOOD."*
   Every word  of this report, (more impartial than any I could
relate on my own  authority,) conveys the  idea  of turgescence
of vessels, and general cellular effusion, throughout the whole
substance of the brain, and makes good the parallel betwixt that
state designated by the term Concussion of the Brain, and the
benumbed  and  torpid  condition of a lim'i  whose arteries arc
burst  and cellular substance suffused by a blow:  it is not possi-
ble to imagine circumstances more suited to support the paral-
lel than  that suite of phenomena which takes place in concussion.
The patient who has fallen from a  great height, or otherwise
suffered that shock which so deeply affects the functions of the
brain, is found, when lifted from the  ground, cold, pale, mo-

  *  There is a preparation in the mufeum of St. Thomas' Hofpital of a braidkwitb
a laceration in one of its hemifpheres from a fall, which the fubjecl, from whom
it was taken, received,  S. 
Of Concussion and Compression of the Brain.     347
tionless, without  pulse, without sense, and is as in a fainting
fit; if he continues cold, and passes his urine and  fasces  invo-
luntarily, he dies.  The first signs of returning life  are  deep
and oppressed groans, the cold sweat  breaking on his temples,
and a fluttering motion in the  pulses: when laid in bed,  when
warmed and restored to life, the groans become more frequent,
he seems deeply  oppressed, he tosses his limbs from time  to
time ; his face is  flushed, his nostrils dilated, his breathing la-
borious and noisy, his pulse  slow and heavy,  and has all  the
symptoms of  deep apoplexy:  by the second  day his pulse has
risen to 120; his lips  are parched, his skin dry, his  eye more
open; he stares widely, but is insensible; and being roused, he,
after a short  and confused struggle, and muttering,  as in low
delirium, falls down again into a heavy slumber, from  which,
if bled and purged profusely, and his head bathed with cold vi-
negar, the surgeon having the good sense to refrain from giv-
ing  opium or wine, he gradually recovers.   It would appear,
from this series  of symptoms, that whatever general  effusion
takes place in the moment of the shock, is slowly absorbed; and
that the febrile inflammatory  action,  which such a state of the
sensorium excites, in  the days immediately succeeding the fall,
is harmless: yet not unfrequently there is a  true Typhomania;
the pulse rises higher, and throbs powerfully ; and the patient,
after long  tossing and  oppression, starts from  his bed, strikes
and struggles with his attendants, and subsides  again  into a
state of torpor;  but by profuse evacuations, and bold prescrip-
tions, escapes the danger of an inflamed brain, though the ac-
tion sometimes terminates in continued insanity, followed by
 imbecility.
   These successive states, first of coldness and stillness in all
 the vital actions, with oppressed brain, and next of high arterial
 action, accompanied with delirium, have always struck me, as
 intimating strongly the parallel (so natural in every  other point
 of view) betwixt a contusion of a limb, or of any other organ of
 the bodv,  and concussion of the brain: nor am I over anxious,
 when I find my patient quite insensible, lying in a state of stu-
 por,  resembling intoxication, if that first stupor be followed by
 arterial action and the signs of inflammation,  for then 1 know
 the oppression is from no local cause: nor am 1 alarmed when
 he becomes delirious, for that is a state litde more than iebnle,
 which  I have usually observed to be a sure forerunner of reco-
 very ; there is in such case nothing essentially  to oppress  the
 vital functions, or to cause death.





^  t'U€fLA~/*6Ju~'(* /£  c^^  //-^-/ 
■»{■»  348  )
                        SECTION III.

                      Of Compression.

  When, in place of general suffusion and disordered  circu-
lation, some greater vessel has  given  way, and either  under
the dura mater,  or in the substance of the brain, there is a par-
ticular effusion of blood,  the  scene  is very different from that
now described :  the  patient,  oppressed by an effusion of blood,
is never insensible, (unless he is about  to expire) and rarely de-
lirious; his pulse never rises, but is slow, heavy, and pausing
at every fifth stroke; his pupil is sometimes dilated; one side
usually paralysed, or at least still  and  motionless, while the
other often shakes  with  a sort of tremulous convulsion,  which
returns at regular intervals, and is  attended with  a quivering
and irregular pulse, cold extremities,  and insensible evacuati-
ons, when he  is about to expire.
  Extravasation more frequently arises from a blow or fall up-
on  a hard body, and is more  connected with fracture  of the
scull than concussion,  which arises  rather from a shock than a
blow: extravasation is more of the nature of a local injury : the
patient, when raised up, is cold, pale, and motionless, but to this
no  usual heat ensues ;  he tosses as under some oppressive feel-
ing, and often lifts his hand towards the injured side of the
head ; he lies with his eyes  shut, groans as from  oppression,
but is always  sensible ;  stares  at you when  roused; answers
whatever questions you ask rationally, but in monosyllables ; he
seems impatient when teazed with  questions;  his answers are
pronounced with a sigh or a groan ; he is correct in answering
to the circumstances of his fall, even  to the nature of the op-
pression he suffers, and  to the  part of his head that is pained,
towards which he moves his hand,  though irregularly,  when-
ever he is  desired :  in his tossing he sometimes rises upon his
elbow; when  requested to rise, he  sits up, and takes the drink
which he calls for, but soon  sinks down again  into a slumber,
more like sleep than apoplexy, and tosses and groans more as his
sleep becomes deeper: the oppression and tossing are insepara-
ble :rom this condition of the sensorium, and the pulse is slow,
pausing, beating no more than fifty  in a minute, and interrupted
at tvery fifth or sixth stroke, especially while  the  patient is ly-
ir ^ in deeper  slumber, or when in particular danger.  I believe
I have rarely seen a pat.ent, to whom an operation or any kind of
assistance  could be useful, quite insensible from mere oppres-
sion of  xtravasated  blood ;  and of this I am very sure, that* I
have innumerable times  seen the patient whose extravasation 
Of Compression.
349
 was so great as to prove fatal, such as was found upon dissec-
 tion to cover one entire hemisphere of the brain, retain his per-
 fect senses, and recollect minutely the circumstances of his fall,
 with a consciousness all along of every thing that was said or
 done about him.
   I have just described a condition which,  I would fain flatter
 myself, can hardly  be mistaken, which at least is not likely to
 be confounded with the total stupor of concussion.  In THt
 first degree of  extravasation, the person lying oppnss-
 ed with  extravasated blood, is  not insensible, but tosses  and
 groans from oppression, replies when spoken to, feels giddy,
 and, when able to  express his feelings,  says that every thing
 seems to turn round; he pukes from time to time,  and has  a
 slow, heavy, and pausing pulse: if you add to these signs, that,
 in his tossing, you perceive that one leg or  arm  still moves,
 while  the opposite  arm  and leg lie almost still and motionless,
 you will seldom be deceived ; and  finding  these  symptoms to
 continue for days, the oppression to become deeper, the vomit-
 ing  to cease, and  the pulse to decline  in strength, becoming
 slower as it becomes feeble, it is your duty to apply the trepan,
 and  often you are  successful.  These are the signs of slighter
 extravasation, which yet, without the assistance of the surgeon,
 becomes desperate:  for, in a few days,  the side opposite to that
 which received the blow becomes manifestly paralytic; and  as
 the extravasation and oppression  of the sensorium increase,
 the palsy is followed by convulsion; while the one side becomes
 paralytic,  the other is  seized  with slight tremors, and soon
 after the pulse becomes  weaker, though  it can hardly  become
 slower, the natural heat declines, the patient  expires: wherever
 such  convulsion accompanies the palsy, it is too late to operate.
   In the second degree of extravasation, when the pa-
 tient is paralytic, or completely oppressed, from  the first mo-
 ment,  and there is no perceptible interval betwixt the paralysis
 of one side and declining of the vital powers; when he lies op-
 pressed and moaning, raises  his hand  frequently  towards his
 head, but is not deeply insensible,  nor has the pupil much di-
 lated ; if he speaks, when teazed, though slowly and difficultly,
 and then in a particular manner raises his hand to  his head,  the
 evidence of extravasation is complete,  the patient  is in the ut-
 most danger, the operation should immediately be had recourse
 to, and perforating with a large  trepan, and  giving vent to the
 coagulated blood,  which rolls out thick  and black, sometimes
 relieves the palsy, restores the senses,  and finally saves the pa-
 tient's life.
   But there is a third degree of extravasation1, invari-
ably fatal; and  1 believe the symptoms I am now to describe 
350
Of Compression.
indicate in general, that extravasation which either expands it-
self over the lower parts of the brain,  or  extends from the up-
per parts to the basis of the scull, raising the nerves from their
origins, and distending them betwixt the basis of the brain and
the foramina through which they pass out.   The  condition I
have here to describe is that of total insensibility and grinning
convulsion ; an insensibility unaccompanied by stertor or snor-
ing, but, on the contrary, with a pale face,  cold extremities,
and a fluttering pulse ; a convulsion agitating  not one side, but
chiefly affecting the features of the face, jerking the head back,
and stiffening the neck: the convulsion  resembles that of the
locked jaw; and it is very distracting to look upon such a pa-
tient, for the  symptom brings an absolute conviction to the
mind of the spectator that the disorder is fatal.
  The patient's condition may be thus characterised; he is taken
up cold,  insensible, with a dilated pupil, and hardly any  signs
of life, and recovers heat very slowly  and imperfectly: alter
lying  oppressed, groaning, deadly pale, with a  dilated pupil,
the extremities cold, and the eye-lid remaining raised  as  you
open it, unless you lay it down again,  he begins on the second
day to be affected with convulsive  twitches;  the cheek is par-
ticularly distorted, the whole body is still and cold; the con-
vulsion increases in violence, and returns with a degree of re-
gularity every ten minutes or quarter of an hour: at each return
of the  convulsion he continues, while you  can count  two hun-
dred or more, to have the cheek and corner of the mouth raised,
the eye-brow and all the features of that side violently distort-
ed, with spasmodic twitches, the  neck  rigid, the head jerked
violently round and bent backwards upon the neck, with inter-
rupted strokes; and each convulsive twitch is accompanied with
a catch of the respiration, a  distortion of the mouth,  and with
a noise of hick! hick.' repeated at each twitch,' while  the con-
vulsion lasts.   It seldom continues long: on the third or fourth
day the  convulsions  grow  weaker;  the extremities and the
whole body become cold ; the pulse,  which is not at all to be
felt during the convulsion, trembles  during the  intervals, and
the patient expires.
  These two states of concussion and compression bear a
strong analogy with the relative states of apoplexy and pal-
sy.  Concussion, there is every reason to believe, is not a mere
nervous affection, else  it could not be  permanent,  but a suffu-
sion into the substance of the brain, resembling the ecchymosis
or bloody suffusion of a. bruised limb,  attended with symptoms
resembling apoplexy, and terminating usually in a gradual ab-
sorption and  slow recov»-rv; sometimes  in high inflammatory
action and sudden delirium, in Typhomania,  or rather that al- 
Of Compression.                   351
 ternation of Delirium  and Coma, which is almost inseparable
 from such a state of the sensorium :  while compression, pro-
 ceeding from  extravasation of  blood, is plainly palsy ; begiifc.
 ning in stupor,  without insensibility, and ending in Hemiplegia
 and convulsions; but,  with this special  distinction, that Palsy,
 proceeding from rupture of vessels overcharged by the apoplec-
 tic arterial action, is a disease of the brain itself, is attended
 with destruction of the cerebral substance, and is thence incu-
 rable;  while the Paralytic  State,  proceeding from a  shock or
 blow, consists in extravasation, foreign to the  substance of the
 brain, external even to the dura mater ;  is merely a local com-
 pression, not directly injurious to the cerebral substance,  and
 thence is curable: the moment the extravasation  is let out, the
 patient raises his eyes, knows  his friends, and moves  the af-
 fected side.  The truth or probability  of these  parallels  will
 best appear from narratives of such accidents as you are likely
 to meet with in practice.
   Being called to Hamilton, to visit a gentleman, an officer in
 the  "th Dragoons, who was supposed to have a fracture  of the
 scull; I found that, in riding a wild horse, in the  court-yard of
 the barracks, unaccustomed to the heavy bit of the cavalry equi-
 page, he had checked his horse in  rearing,  and pulled him back,
 and the horse  falling upon him, he  was knocked down and
 6truck  to the ground with  great violence, his occiput encoun-
 tering the hard beaten gravel:  he  lay pale, pulseless, and insen-
 sible, was restored to heat very slowly, and continued in a pro-
 found stupor, snoring and motionless.  I arrived the following
 day, and found him still  insensible;  his pupil not dilated, his
 tongue  furred, his hand hot and dry; his pulse high, his  face
 flushed; his looks, when roused,  wild  and distracted; he in-
 stantly, after being disturbed,  fell down  again  into a state of
 stupor, and nothing could rouse him to any recollection of his
 situation, nor  enable him to articulate  even a  monosyllable.
 Upon consulting with  Mr. Taylor, the  regimental  surgeon,
 formerly  of Mercer's Hospital, a man  of the best education,
 and  of strong good sense, we agreed, however unpromising his
 condition might appear to his friends, to report to Colonel Heula
 that he  was in  no danger; that we should make  no incisions;
 that, by profuse evacuations,  this fever might  be prevented
 from rising  to delirium; that, after slumbering a few days, he
 would  gradually recover his senses.  Presuming, from this in-
 fallible  mark of quick pulse accompanying the stupor, that the
 stupor was void of danger, I left him with confidence ; and, by
 letters from Mr. Taylor, had the comfort to  learn that, after
 slighter dawnings of sense and reason, he was, by bleeding and
 strong purges of calomel and jalap, perfectly  restored,  before
the week had elapsed. 
352                   Of Compression.
  Concussion, in a greater or less degree, is almost  insepara-
ble from that kind of shock  to which the head is exposed when
a man is thrown from on horseback ; sometimes it is accompa-
nied with fracture or  extravasation,  and thence  questions of
great delicacy and difficulty often arise.   The first head I ever
dissected, after an accident of this nature, was that of a young
gentleman, who having rode on  a pleasure-party to Roslin, ex-
ceeded in wine,  was ill able to manage his horse, was thrown,
and died on the fourth day : but in  his  scull  was found not the
slightest trace of fracture, nor within,  the slightest extravasa-
tion ; nor could any  peculiar appearances be remarked in ex-
amining the substance of the brain itself, except general red-
ness of the pia mater,  vessels extremely  turgid,  and many
bloody points.  Whence we perceive  how narrowly  those es-
cape who have violent  concussion;  they invariably die, if the
pulse continues low, or is at any time intermitting.
  Another young gentleman,  on his  return from a like excur-
sion, was thrown from  his horse, lay in a death-like stupor for
ten  days, during  which period the blood, which had  at first
gushed from his nose, mouth, and ears, continued to flow un-
remittingly from his right ear.  The  shock,  which thus bursts
the vessels on these delicate surfaces, cannot but have a like ef-
fect  on the delicate cerebral substance within:  the senses and
intellect suffer from this suffused state of the brain, but the hae-
morrhagy from these vessels probably saves the internal part of
the system from any  extreme violence; at all events, it is cer-
tainly observed, that such issue of blood from the mouth and
nostrils, though a sign  of  great violence, is favourable to the
patient's recovery ; and if any such haemorrhagy is dangerous,
it is that from the ear, for there is little  doubt that it must come
from those internal vessels which traverse  the ear: yet this
young gentleman entirely recovered.
   In such cases, wine  and the heat of exercise, youth, and
health and strength, prepare the vascular system but  too well
to assume  an  inflammatory  action,  and to re-act powerfully;
thence it often happens that, in place of lying like these young
men, torpid and oppressed, the  patient bursts out of bed, strug-
gles with the attendants with maniacal strength, and is yery
difficultly subdued, and in great danger of ultimate violence to
the structure of the brain from  such  high and  continued vas-
cular action.  This I saw conspicuously exemplified,  in a young
man, uncommonly athletic,  accustomed to  violent  exercises,
who, being thrown from his horse when riding extremely hard,
not  brutally intoxicated, but furious with wine,  lay for five days
in a state of profound  stupor, from which he, after staring,
struggling,  and muttering, wakened to such  a phrenzy  that 
Of Compression.
353
tour stout men with difficulty held him down in bed, and yet he
recovered,  and reformed, and now lives in perfect health.
, These familiar examples, such as you will daily  meet with
in practice, cannot perhaps be more happily  closed than with a
short case from Jacotius; it stands recorded  in his commentary
on the third aphorism of the first book of Hippocrates.  " We
have observed" (says this author) " of those who have the brain
injured,  some dying suddenly, others lying oppressed and snor-
ing, while  others  have blood issuing from the nose, ears, and
mouth,  and yet live : one patient of mine having  lain speech-
less a long while, and apparently  dying in convulsions, started
suddenly from his bed, in the middle of the night, fell upon the
attendants  with maniacal fury, and felled every mother's son of
them to the ground, except a Franciscan monk, a lusty able fel-
low, against  whom he maintained a long battle, with feet, and
hands, and talons: the monk  called loudly for help to those
who were  already felled, but in vain;  they lay strewed on the
ground,  while he  struggled alone with the furious patient, who
seized alternately clubs, fire-irons, piss-pots, whatever he could
lay hands  on; and laying hold at last of an iron stanchel, he
tore it from the window with  incredible strength:  he had now
nearly levelled the monk with his fellow-watchers, and would
have beaten out his brains with a stone of forty pounds weight,
which he lifted and aimed to throw at his head, when the monk,
breathless  and  exhausted,  but  desperate, collected  all  his
strength into one  last effort,  and gave him a kick on the cods,
whkh brought him to the ground.  This man, says Jacotius, I
entirely  cured."   This example of horrible  phrenitic  delirium,
I quote in  proof of what I have constantly remarked, that de-
lirium is the  least unfavourable  symptom and the most curable.
   The   more fatal accident of extravasation is attended with
symptoms less terrible, and  with a comparatively  slight affec-
tion of  the intellect and senses:  I have been confounded  often
to see the  patient  recollected and sensible, under a compression
so  decisive as to cause paralysis of one side: somnolency, not
stupor, is truly the mark of  this state.
   John  Hutchison, a sailor lad, of twenty years oPage,  fell
down stairs, and  lay  in a state singularly characteristic of com-
pression of the brain: his condition was described to me by a
good woman, who was very careful of him from the  moment
of  his fall, for he was the companion of her son,  who  had fol-
lowed him to sea; when the one boy was gone abroad, the o-
 ther would not stay at home.   This lad, on  a visit to his father,
 perfectly sober, going negligently up an outside stair,  fell, but
 whether three steps, as a workman reports,  or the whole flight,
 as  tHis  woman's  husband believes, we could never  certainly
                          2Y 
354
Of Compression.
 learn: this good woman, who lived in the  house under his fa-
 ther, was abroad at the time, but her husband heard the fall, so
 violent was the shock, and running out, carried him up stairs
 with the assistance of a mason who was working in the close.
 When she came home, she went up to him,  and found him ly-
 ing oppressed, as in a deep sleep; she asked him often what
 happened, and  how he was, which he answered always in  two
 or three words, passionately and iinpatiendy pronounced, " that
 he was beuer,"  ** that he would soon be well," " that he would
 lie and sleep a little," still he begged that they might let him lie
 still and sleep. His tongue sometimes faltered; he answered  best
 wheo most roused; there was a cold  sweat all  over him ;  his
 face  was exceedingly pale,  he yawned  perpetually, and always
 when offered drink, &c. cried, " let me lie  and sleep:" he vo-
 mited frequently during the two  first hours after the fall:  his
 left side, his left arm at least, was  plainly powerless, he never
 moved it in concert »rith the right: he lay in a slumbering con-
 dition, groaning and tossing as if oppressed ; muttering, but al-
 ways conscious of his condition; complaining of his head,  and
 able  to answer: when this  good woman sat him up in  bed, or
 when he raised himself to pass his urine,  he complained often
 of his breast, and sometimes of his belly, but continually of his
 head: while quiet he had no snoring, and slept like a child, till
 after being bled by  the surgeon of his ship, from which time he
 enjoyed no more of that placid  sleep.  On the  third day,  this
 woman brought him up a basin of warm  milk, and he seemed
 to like it;  she raised him in bed, he sat up and took  the basin
 in his own hand, and when  she gave it him,  saying, take it  my
 good lad, he answered, " I will, I will, but do not trust to  my
 hand only;" yet, with her  help, he held  it to his head, and
 drank it off.  He complained continually of  his head ;  and  in
 whatever way roused or disturbed, he begged they would  let
 him sleep ; " if they would let him sleep a little longer, he said
 he would go down to Leith  and  go on board."
   This good woman went up to  see him at seven in the morn-
 ing of the fourth day; she found him still slumbering, and con-
 tinuatly complaining of his head; suddenly he was seized with
 a strong convulsion,  raised himself a little in bed,  and thumped
 incessantly with his hand upon the side of the bed, striking with
 the paralytic arm  as well with the sound, and all the while he
 kicked and struggled with hU feet; at last his left hand was sud-
 denly seized with a violent spasm, the  wrist was strongly bent
down towards the fore-arm, the fingers stood out rigid  at right
angles with the hand, and from that moment he  never moved
that arm more, his hand continuing rigid in this distorted form.
But the convulsion did not then cease; it continued from seven 
Of Compression.
355
m the morning till eight: notwithstanding these terrible con-
vulsions, and this spasmodic palsy of the left hand, he retained
his senses, spoke sensibly when roused,  supported himself in
some degree in bed, complained sometimes of his belly and of his
head ; and when asked about the state of his bowels from  the
time of his fall, answered collectedly and correctly.   This was
on Thursday, the fourth day from the fall: on Friday morning,
I saw him, for the first time ;  and in the evening by six o'clock
he was dead.
   " In the last day of his existence, he still retained his senses ;
he lay in a perpetual slumber, but had no puking; his tossing
and anxieties were very distressing to see; his face was deadly
pale, his right eye  stood immoveable when opened,  the pupil
being widely dilated; while  his left (though his left side was
paralysed) remained irritable and moveable,  the pupil of it was
contracted, and it turned quickly from the light; his pulse was
small, quick, and fluttering,  like that of a sick child; and the
vital motions so affected, that it appeared manifestly that they
could not go on ;  his extremities  were cold, and I judged him
dying: but nothing surprised me more than to find, upon lifting
his eye-lid, that I could rouse him to speak ; when I bade him
put out his tongue, he did so,  and when I spake loud and im-
pressively, and asked where  his pain was,  he raised his right
hand, though in an irregular way, and laid it upon his head."
   " This very stout young man expired about six o'clock on
Friday evening; and the following evening we found, upon dis-
secting his head, no tumour, nor even a bloody effusion in the
integuments, but in the cranium a large and wide fracture,  tra-
versing the parietal bone, and running through its whole length:
unconnected with that, on the vertex, was a small  fissure, pe-
netrating only through the first table : under the  centre of the
parietal bone lay  a  very large  coagulum  of blood; it was  as
large as the whole hand,  bating the points of the fore and mid
fingers, and thicker than the fleshy part of the palm ;  it was ve-
ry firmly congealed, and came off in one cake like  the placenta
of a foetus, leaving a very  deep depression in  the brain, into
which you might have laid the back of your hand."
   It is not my intention  to accumulate authorities for what  I
know to  be a plain fact,  but will go on to represent to you the
condition of the patient while labouring under symptoms un-
doubtedly mortal.
   41 A very old man was carried into the hospital, who, after a
fall, lay insensible and convulsed:  no  relations accompanied him
to tell what had happened: two  sons, who aftt r wards  came,
were at once brutal  and perverse, seemingly indifferent  to his
sufferings, and yet sternly and impudently refusing to allow us 
356
Of Compression.
to proceed in the way that prudence and the necessities of the
case required.   He was a very old man,  with  bald temples, a
naked scalp, and not the slightest appearance of injury  on the
head:  he lay in a deep stupor, immoveable, except when agi-
tated with a convulsion,  which returned every ten minutes, and
became more frequent as his strength declined; his eyes,which
were closed during the interval of stupor, opened when the con-
vulsion approached,  and stood staring  wide, with a  much di-
lated pupil: first the cheek and features on the right side of the
face were drawn up into a ludicrous grin;  then  the neck stiffen-
ed, the head was jerked backwards, and the jaws worked back-
wards and forwards with a violent spasm; the tongue and throat
were also affected, and the  lips  made that kind of noise that
follows when we draw the breath through the  closed  teeth, to
prevent  the saliva escaping by  the angle of the  mouth:  after
continuing  two minutes or  more, the  convulsion terminated,
with deep groans, in a state of stupor.  His unnatural sons
would not suffer us to touch one hair of his head; and on the
evening of the second  day,  when  he  died, they came,  with a
mob of vagabonds at their heels, and carried  away  the body,
with a degree of precipitation which inclined us to believe that
there was something particular in the manner of this blow which
they were afraid dissection might reveal."
   Not a moment should be lost  when  such symptoms appear:
the extravasation may  be in the ventricles, on the basis, or with-
in the substance of the brain; and if so, the  man is gone be-
yond redemption; but if it  be only on the surface, and there  is
a possibility of saving his life, it can  be only  by immediate o-
peration: when the  symptoms of  extravasation are  accompa-
nied with fracture running downwards  towards the basis of the
scull, we may despair of doing good.*
   " A big and strong  man, a common labourer, fell down three
steps of a stair; but there  was every reason to believe he had
struck his head on the edge  of a bucket, hitting that part where
a  projecting iron  hinge joins the iron handle with  the tub:
when raised up, he was pale, cold, and pulseless; cordials were
given him, he was restored to heat, and then blood was  observ-
ed to distil from his nostrils and right ear.   Being carried into
his own house, he passed a  disturbed and  restless night, till to-
wards morning that he enjoyed  a calm  sleep.   He lay still and
motionless  the  second day ;  his eyes  seemed dead and  glazed,

  " Whenever there is a fracture at the anterior and inferior  angle of the parietal
bone, accompanied with fymptoms of compreflion, nothing but an immediate
operation can probably fave the life of the patient; becaufe, fhould the princi-
pal meningeal artery be torn, as it frequently is under fuch eircumftances, it
pours out its blood with fuch force  as to prove very quickly fatal.   S. 
Of Compression.                  357
the pupils of both were dilated, contracting only with the very
strongest  light; his jaws seemed clenched, his teeth closely
shut, his lips  retracted and turned backwards, uncovering the
teeth as in grinning; he breathed slow and heavily through his
nostrils; he was paralytic of his left side, had involuntary stools,
and passed his urine in the bed.
  " Yet,  upon being stirred  and roused, he looked up  wild
and bewildered, and had frequently, during the night, attempt-
ed to get  out of bed;  his pulse was weak and fluttering,  and
his body cold; he was not so  insensible  but that a purge  ope-
rated briskly, though then and always his stools passed uncon-
sciously:  his face was  pale and shrunk; he lay but a few  mi-
nutes in one posture; he then  turned and  struggled, and a sort
of foam issued from betwixt  his closed  teeth, while  his  lips
were retracted into a grin;  his cheek was distorted,  and his
jaws  worked perpetually, so that you heard his teeth grinding.
He was permitted to lie too long in this desperate state unassist-
ed.  When my brother  and  I saw  him  together on the  third
day, the paleness of the face and  coldness of the body had in-
creased, the stools  were  involuntary, the  pulse extremely  fee-
ble, almost imperceptible; we called immediately a consultation,
rather to witness what was to  be  done, than to give advice in a
case so plainly desperate: perceiving, though there was not the
slightest swelling, a degree  of livor on the temple, my brother
made an incision, and, turning down a large angular flap of scalp
and temporal muscle, uncovered the temporal bone down to the
zygoma, and in doing so felt  his knife grate  against  a rough
and wide fracture ; the flesh of the muscle being cleared away,
a very rude fracture was seen to run horizontally through the
parietal and temporal bones, its  branches  passed down under
the zygoma to the  basis of the scull, blood oozed through the
chinks of it, and a large trepan being applied directly above the
zygoma,  very black grumous blood rolled out.  He died in
about fourteen hours."
   Your own good sense will  suggest to you that, besides those
decisive conditions of the intellect and  bodily functions which I
have endeavoured  to characterize, there must be many interme-
diate states, extremely perplexing and difficult to resolve into
any simple principle ; in all things I wish to leave you to your
own discretion ; in many,  I am sorry  to say, vou can have no
precise rules from any teacher, but must trust  to  your own pe-
netration and judgment: experience, or, in  other  words, the
habit of reasoning, so as to  infer from external signs the  kind
and degree of internal injury, will enable you to resolve the most
anomalous s\ mptoms ;  but that condition of the brain  in which
general suffusion of biood is followed by inflammation, delirium, 
358
Of Compression.
 and death, that condition which is marked by convulsions and
 spasms  resembling  those of Hydrocephalus, and with a pulse
 indicating nothing of oppression,  is of all the anomalous states
 of the organ the most frequent.  I cannot remember that I was
 ever more perplexed how to act than in the following case.
   " A poor boy, of thirteen years of age, in scrambling with
 his play-fellows, on a  Sunday  afternoon, about the ruins of a
 house which workmen were pulling down, fell from one of the
 windows, a height of fourteen feet, and struck his forehead
 against a beam.  There  appeared  upon the forehead, close to
 the root  of the nose,  a soft elastic tumour, and a general suggil-
 lation of blood, which entirely closed the eyes ; he was stunned,
 and lay  in a death-like stupor for a quarter of an hour, but en-
 tirely recovered : he  had been universally bruised, for he vo-
 mited blood, which also flowed in  a full stream from his nose ;
 his pupil was contracted ; his pulse regular and strong, beating
 90 in a minute.   Next day the vomiting continued ; his pulse
 was still  full and strong:  upon being bled, the vomiting ceased,
 and the  pulse subsided both in strength and frequency :  the
 night he  passed tolerably, though restless, feverish, and in pain ;
 he often  carried his hand to his forehead, complained of the
 pain, and sometimes talked wildly through his sleep.  The se-
 cond night he passed in great confusion, with much'delirium,
 and  when most rational he complained grievously of his head,
 while a thin and bloody serum distilled from his right ear, with
 great pain behind the ear,  where it would  appear he had sus-
 tained a  degree of injury, which might well happen  in a fall so
 irregular among stones and beams.  On the third day,  the  tu-
 mour of the forehead subsided, and the  eye-lids opened : on
 pressing  the tumid part of the forehead, he complained of intol.
 erable pain ; his pulse continued high and rapid ; the bleeding,
 purges, leeches, and other sedatives, were renewed ; his sleep
 during the night of the third was more composed and  natural,
 and he had no unfavourable change, till ten o'clock in the morn-
 ing of the fourth day ; when he became very hot, feverish, and
restless ;  vomited much ; the vomiting was excited by repeat-
ing the cathartic, and even by taking the acidulated drinks which
 were ordered him; at four in the afternoon he was seized with
extraordinary contortions, and strong  spasms of the abdominal
 muscles,  with violent tremors of the whole body, and grinding
 of the teeth : his breathing was affected by the violence of the
 spasms in the abdominal muscles ; it was noisy and laborious,
but not slow nor oppressed, and the pulse  beat 120 in the mi-
nute : towards afternoon  all  parts  of  the  body  were at times
convulsed;  he howled as if distracted with pain ot the head,
 and his eyes squinted horribly ; he  grinded his teeth continu- 
Of Compression.               359
aUy, his features were distorted, his arms and fingers stiffened
and crooked with cramps and spasms: his condition this day and
evening reminded me of the condition of boys in the worst stage
of acute hydrocephalus or inflamed brain.  At ten at night,  he
had, after suffering thus violently all day,  subsided into a sort
of stupor, without vomiting, but with a rapid pulse.
   " The night of the fourth was restless and  miserable, but
much of it he passed in a state of stupor : on the fifth  day the
swelling of the forehead had entirely flattened; that of the eye-
lids was gone ;  nothing remained to denote the place of injury,
but the general sugillation of blood with which the forehead
and eye-lids were discoloured :  at five this evening I found him
quite sensible, complaining of excruciating  pain in  the head,
screaming with the torture, and his eyes horribly distorted, es-
pecially the  right one, which was  turned downwards and in-
wards  till the iris was almost hidden under the  inner angle of
the eye.  This night he had much delirium, and while conscious
complained  of  pain of the head, especially behind the ear; for
though he felt pain of the forehead when pressed, he felt pain
behind the ear  and through  the  head at all  times : he  howled
much this night from eleven o'clock, and his thighs were rigid
and his toes crooked with the spasms.
   41 On the sixth I found him dead ;  he had raved the whole
night long, had cried continually with the pain of his ear and
forehead, was seized betwixt two and three in the morning with
such universal spasm, squinting,  and howling as he had on the
afternoon of the third, and at six in the morning he expired."
   Here was no  symptom of extravasation nor of compression ;
none but of inflammation; and against inflammation what could
I have done by tearing the scull with the trepan ?  It was not
for want of those marks which are usually thought a vindication
by those who are impatient to apply the trepan, that I refrained
from  using it,  for  I distinctly felt a fracture in the forehead,
accompanied with a degree  of depression in the place of the
frontal sinus : but from a perfect consciousness that my opera-
tion could do nothing but increase the inflammation, and from a
persuasion that  the fracture was a concomitant merely of a more
fatal disease : I reflected  seriously, and found myself assured,
from the symptoms, that inflammation  was  the principal dis-
ease ;  that fracture at this point could be  attended with no re-
markable  depression  ; that  if it  was  extensive, it must run
through the basis of the scull ;  and 1 had  the satisfaction, me-
lancholy though it was, of discovering, on dissecting  the boy's
head, not the slighest extravasation upon  the  dura mater, but
the surface of the brain  universally reddened, and its  vessels
turgid, and  there was a wide fracture, beginning at the  orbi- 
360             Of the Operation of Trepan.
tary plate.of the frontal bone, and running quite across the oc-
cipital bone into the foramen magnum ; but without any remar-
kable appearance either under the  bruised part of the forehead
or behind the ear.
  I will no longer detain you, but hasten, after a short section on
the mechanical part of your duty, on the operation of trepan, to
lay down rules for your general conduct,  not without  a confi-
dence that,  among the variety of delineations of the disordered
conditions of the brain, narrative or descriptive, which I have
laid before you, you will be able to find  rational parallels for a
great proportion of the accidents  which  may overtake you in
your future practice.
SECTION IV.
                Of the Operation of Trepan.

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

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


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


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

                        SECTION V.

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

                  Preliminary Observations.

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

  • Blisters are ftrongly, and 1 think iuflly recommended by Mr. Abernethy. S. 
374
Of Tumours.
functions of the brain itself, bring the patient, and that too in
the vigour and  prime of life, to an untimely grave.   In each-
subdivision of our subject I shall have occasion to lay before
you examples of neglected and fatal  tumours, of dismal scenes
which the surgeon did not dare to  prevent;  of operations rash-
ly begun, and abandoned in  the very  moment of execution ;
we need not seek for sad and persuasive examples of such dan-
ger to impress the importance of the subject upon our minds,
nor strive to recollect minutely the long-continued sufferings of
those who have died of  tumours.   The scenes we  have wit-
nessed in Hospitals, or in private practice,  return to the ima-
gination from time to time, accompanied with all  their tragical
circumstances; we  recollect the  sufferings of our patients, and
we also remember that the most  loathsome,  painful, and, in  the
end, fatal tumours, were once trivial; we also know that thou-
sands, at  this present  time,  are verging towards that hopeless
desperate state from which even the most intrepid  surgeon will
not attempt their rescue, at the peril of his reputation and eter-
nal peace of  mind.
   Tumours are the most frequent of all surgical diseases; eve-
ry surgeon must  find the treatment of tumours, a part of  his
daily  practice : a tumour, in whatever part of the  body it is
seated,  requires an intimate acquaintance with the structure  of
that part, and a clear recollection of all the precedents or rules
which may serve  either to direct the judgment, or to guide  the
hand.   The surgeon should know how  to resolve a tumour, or
to excite it to suppuration ; how to evacuate the matter, and  ob-
literate  the sac; when to suffer the mild and harmless to grow,
and how to extirpate at every risk that which is prone to ulce-
ration or cancer.   Every tumour is a subject of new and anxi-
ous consultation,  and every operation of this  irregular nature,
demands a knowledge of blood-vessels and  nerves not easily
remembered,  and perhaps no where truly described.
   Need I remind you what torture a skilful surgeon may pre-
vent,  what misfortunes ignorance may cause ? Do we not  see
surgeons mistaking tumours, malignant in their nature, for indo-
lent and harmless swellings of the glands?   By tormenting a
simple tumour  it  may  become malignant,—by neglecting a
moveable tumour it may become fixed,—by allowing a small and
seemingly harmless tumour to grow, it may wax to so great a
size,  and acquire such intimate ^connections with the more im-
portant vessels and nerves as to defy all kind of surgery.
   Look well, then,  to the nature and probable consequences of
evcrv tumour; for a tumour, though void of any character of
peculiar malignity,  will,  if seated in the passages of the nose
or the throat, on a bone, or in connection with great vessels or 
Of Tumours.                     375
nerves,  have all the ill effects of a malignant tumour without
being so, by bringing caries upon the bones, causing disease and
ulceration in the nostrils, compressing the throat, and weaving
in its roots with the great vessels and nerves, and from this uni-
versal fact results this incontrovertible  rule of practice,  " That
no suspicious tumour,  seated in a dangerous part, should  be
permitted to grow."   Secondly,  That almost every tumour,
though seemingly indolent in its nature, has its period of ulcera-
tion.  A tumour of mere fat, a tumour in which the adipose
membrane is alone diseased, a steatomatous, or an ulcerous tu-
mour in which is collected an  increased secretion, partly fluid
and partly solid,  or purely of fat,  is indeed harmless, unless by
its bulk and weight, and when it suppurates it suppurates mild-
ly :  but wherever any part of the body,  except the cellular fat
or muscular flesh is engaged in the disease,  wherever the eye,
the breast, the testicle, a bone or a joint; wherever, in short, any
part, having a complicated structure, is affected, however long it
may have held the character of a mere overgrowth or simple
tumour, it is ever to be feared, that sooner or later, its structure
will undergo unfavourable changes, from long distention, from
occasional excitement, from blows or other injuries,  and from
changes seemingly internal and spontaneous;  or, in other words,
from physical causes which our patient has not remarked, and
which we cannot trace.   Thence  results another rule  equally
established in my mind, that  no  tumour of a doubtful nature
should be  permitted to grow, even through that period in which
it seems indolent;  for when it inflames or compresses the sur-
rounding parts, when it is likely to suffocate our patient, or to
end in a malignant and  fetid sore, it  is so fixed as to defy all
surgery.
    I have perhaps reason to suspect the opinion  I have  concei-
ved of the importance of a subject, which, from long contem-
plating it  in its various relations, has made an impression on
my mind which  gains strength while  I  endeavour to  infuse it
into  yours ;  to  an author,  his favourite theme,  his  present
theme, seems  ever important.  The  surgeon, no doubt, when
he proclaims the importance of a  favourite subject, is bound in
a peculiar  manner  to prove  it in detail,—to prove it by facts ;
yet I know not why he should be debarred the  common privi-
lege of explaining without a pointed reference to facts,  whence
the general impressions he has received have taken their rise :  he
most of all may be pardoned an overweening  love of his pro-
fession, who sees it daily a source of relief from pain, from dan-
ger, and from death  inevitable,  but for his interposition :  he
may be acquitted of any affectation of extraordinary sympathy
and feeling, who has been called at all hours and seasons, from 
376
Of the parts most subject to Tumours.
his bed, his table, his family, to witness the agonies of a friend
suffocating from the bulk of a tumour,—alarmed with hemorr-
hagics which threaten life,  or wasting under the cruel pains of
cancer.  Can the surgeon be  accused of affected sensibility,
who describes with interest scenes in which he has so great a
share, so far different from that even of the nearest friend  so
much the more responsible ?  He  alone sees all the variety of
misery, the least part of which, if witnessed by common spec-
tators, is related in affecting terms ; he alone knows the trivial
beginnings and sad conclusions of diseases, and can form a true
estimate of their importance.  The surgeon,  in  representing
the interest which particular diseases should excite, deals not in
the fantastic horrors which the  moralist conjures up  when  he
declaims against the vices of  a declining age, or the politician
when the iniquity of public measures is his theme, and he pre-
dicts the ruin of his country: the surgeon's mind is occupied
with distinct, impressive recollections of what individuals have
suffered;  though steeped  in the colour of his trade,  inured to
blood, he  maybe allowed to feel every degree of sympathy with
scenes of  distress, presented to his imagination in such various
and afflicting forms.
   Believe  me, Gentlemen, I use no art to engage you in this
department of study,  and  do not  seek  by exaggeration to en-
hance its importance :  what I think and feel, I must, in justice
to you, speak freely, and without restraint; and surely no way
can be so faultless as to lay before  you a slight and preliminary
sketch of  the various parts subject to tumours, and the various
consequences of their growth, as they  affect  the skin, the
glands, the bones, the eye, the  breast, the testicle, the  throat,
the rectum, or  other hollow passages  of the body,  ruining by
pressure and ulceration, the  structure of the affected, and the
adjacent parts.
                        SECTION II.

            Of the parts most subject to Tumours.

  The Skin is the part of the body perhaps the most vascular
and delicate, and is often  by injuries,  as by the pulling off the
hair, or the pinching or bruising of its vessels so excited, that
its vessels taking on  a lively action, its arteries and veins are in
process of time  dilated, and form aneurisms, or Meeding tu-
mours  ; or they are merely by such excitement so quickened in
their ordinary function of nutrition, that the whole web of in- 
Of the parts most subject to Tumours.        377
teguments becomes a tumour, retains its natural form and sub-
stance, with only some slight enlargement of its pores and pa-
pilla?, but becomes so voluminous as to be wrapped round the
body, forming thus the most extraordinary tumours, which are
still nothing but skin.
  The Bones, as vascular as the softer parts, and perhaps more
regularly and unceasingly absorbed and replaced, form,  when
they are injured, the most bulky, and, from their solid texture,
the  most permanent tumours, which, when they turn to ulcera-
tion and caries, are the most incurable and fatal.   We very fre-
quently observe a tumour of a bone to follow a blow, and, when
the blow and the swelling take place near a joint, when the knee,
the wrist, the shoulder, or the ankle are involved in the tumour,
its growth is extremely rapid. Often I have seen the radius, when
the wrist has been fractured and ill re-united, form an enor-
mous bony tumour; or the heads of the tibia and  fibula swell
out in consequence of a bruise into a  tumour  cavernous and
gristly, partly occupied with matter and partly formed of a solid
increase of bone,  till  the  thigh  almost  equalled the  body in
thickness.  Very often  such  tumours  bursting pour  out the
most fetid matter; and large bony cavities, or numerous honey-
comb-like cells are formed.   Often too without external vio-
lence, without any conspicuous marks of  a  scrophulous habit,
without any possible  relation to venereal diseases; the  bones
universally are disposed to form tumours, by which sometimes
the hands are deformed, the wrists swelled, the fingers crooked
like birds' talons, and sometimes the long bones, as the thigh-
bones, shoulder-bones, ribs or scapulas,  are studded with large
knobs or grow  out in tumours.   These  are  diseases still more
dismal, quite irremediable.
  The Glands,  when  their vessels are excited by blows,  by
cold, by the absorption of foul and virulent matter, are enlarged
beyond all credible limits, and draw the adjacent parts into dis-
ease, insomuch that the tumour which originally was a simple
gland has,  in the end, a very anomalous aspect, and  conveys
such confused impressions to the feel, that we know not how to
pronounce  upon its nature, which the history only of the tumour
can  in any degree elucidate.  These are the tumours which,
when seated either within the mouth, or at the angle of the jaw,
repress the tongue, displace the trachea, or obstruct the free pas-
sage of the food  and  air, and connect  themselves so with the
branches of the carotid  arteries, that the hand of  the most in-
trepid surgeon can no longer avail, and  wise and prudent men,
met in consultation, shrink from those duties  which  the patient's
manifest danger  plainly imposes,  lest  they  should bring, not
themselves onlv, but their profession into disgrace.
                           3  B 
 378         Of the parts most subject to Tumours.

   The Eye, a part at once exquisitely sensible, and exquisitely
 vascular, and consisting of humours which are in a state of con-
 tinual circulation, being  continually secreted and re-absorbed,
 grows by the slightest excess of vascular action into a tumour.
 Sometimes the secretion of Aqueous humour, not changed, but
 merely augmented, distends the globe of the eye into a tumour
 continually increasing, till first vision is deranged, (not destroy-
 ed) next head-aches ensue, and, finally, the coats of the eye
 give way.  On other occasions the adnata, or loose and vascular
 coat of the eye,  arising from the  inner surface of the eyelids
 and connecting them with the skin, is so swelled by inflammation,
 that its cellular substance being of a spongy nature, the tumour
 of it covers and involves  the whole eye, conceals the eye-ball,
 protrudes far beyond  the eyelids red,  flesh-like, and often ulce-
 rated, so as to seem in the hasty opinion of ignorant surgeons
 a cancer of the eye:  even for such a disease, so little connected
 with  the globe of the eye, or allied with cancer,  have I known
 the whole eye-ball extirpated.  Sometimes  the deeper parts of
 the eye are so  inflamed as  to terminate in  suppuration of the
 globe, after delirium and dreadful pains; then the central parts
 having suppurated, the firm coats of the eye at last ulcerate, the
 globe bursts, the eye subsides into its socket, and the eyelids
 close upon what  remains of its coats : but these, thickened by
 continual inflammation, harden and grow into a new and  more
 formidable tumour ; and the eye protrudes again from its  sock-
 et, of a schirrous hardness, with a painful and burning ulcera-
 tion.   Sometimes from a suppuration  less deep or  extensive,
 where not the vitreous humour or  whole body of the eye, but
 only the cornea and the iris, are diseased, the eye becomes can-
 cerous ;  for when, after a partial suppuration and ulceration of
 the eye, the iris very often throws out a fungus, bearing the true
 character of cancer, even  from the first, or becoming so by the
 excoriation of the tears, and  the friction of the eyelids.  The
 lachrymal gland seated within the socket is often, as I shall have
 occasion to explain  by examples, a cause of incurable disease,
 and the small glands or lacunae of the tarsus, or cartilaginous
 borders of the  eyelids, form tumours extremely  firm and  unal-
 terable in their nature, sometimes indeed stationary,  but never
 resolving under any course of treatment, and often causing such
 pain and inflammation of the eye as to require extirpation.  All
 the parts,  in short, of this delicate organ,  whether  proper or
 merely adjacent, are subject to tumours more frequently cance-
 rous than mild.
   The Breast is a gland destined to perform a secretion more
profuse and rapid, in proportion to its size, than even that of the
salivary glands, and more elaborate.  It is subject to great pe- 
Of the parts most subject to  Tumours,         379
 riodical excitements ; at each menstrual period it swells slight-
 ly, is greatly enlarged  by pregnancy and suckling, and in warm
 climates, or diseased constitutions, in all countries, it is the part
 first and most conspicuously  enlarged.  The period of life at
 which menstruation ceases  is so critical for this gland,  that it
 then falls into scrophulous and cancerous diseases, having every
 variety of  aspect.  Sometimes  the  whole breast is indurated
 and enlarged, with a swelling so' truly scrophulous, that I have
 seen  the breast  suppurate, burst out like other scrophulous
 glands, heal at one point and ulcerate in another, become indu-
 rated to an extreme degree, and  pour out from various openings
 a limpid serum in profusion, proportioned  to the natural secre-
 tion of the  gland.   Often there takes place, both in women who
 give milk and in those more advanced in years, a voluminous
 abscess, which is both formed so slowly, and lies involved in so
 thick a mass of indurated gland, and so void of pain, that it is
 distinctly marked as a scrophulous disease.  In both the affec-
 tions  of the mamma here  described,  though as far removed
 from  schirrus, as scrophulous swelling of the testicle from can-
 cer of that part, I have seen the breast amputated with circum-
 stances of particular cruelty.  From scrophulous inflammation,
 blows, milk-fever,  or,  in consequence of that indescribable
 change which takes place at the ceasing of menstruation, the
 gland of the breast is hardened, either in one mass or in sepa-
 rate kernels, which, however  long  they may remain indolent,
 become sooner or later inflamed, and then the proper gland of
 the breast,  the lymphatic glands connected with it, the skin, and
 cellular substance, even the  pectoral muscle itself, are apt to be
 massed together into one hard globular and ponderous tumour,
 with separate glandular tumours interspersed in the surrounding
 cellular substance.   When  this mass ulcerates,  the  axillary
 glands, previously indurated, also inflame;  the skin of the axil-
 la reddens, as that of the breast ulcerates;  the  whole armpit
 swells, the arm becomes oedematous, and lies powerless; and
 the patient  dies in a most loathsome state, with foul and very fe-
 tid matter  running from the  sore in great profusion, so as to
 make the last offices of friends difficult to perform.   Sometimes
this disease begins like a kernel in the centre of the gland, some-
 times like an excoriation of the  nipple, sometimes like a mere
 contraction and induration of the skin, not beginning invariably
 round the nipple, but extending, as I have several times remar-
 ked, from the axilla downwards, so as to affect the breast.   Thus
 a careful observer sees in the course  of practice a sad variety of
disease in this part, according with the various structure of those
parts  in which the disease begins, or the species of the malady, 
380         Of the parts most subject to Tumours.
whether varicose,  scrophulous, or cancerous; varieties which,
simple as the part seems to be, are as widely different from each
other, as venereal, scrophulous, or simple inflammatory affec-
tions of  the eye are from one another, or affections of the cor-
nea from those of  the humours.
   The Testicle  is a part subject, like the eye  and breast, to
cancerous affections, often commencing  in  venereal inflamma-
tion,  affecting the  structure of the gland,  or arising from blows
or fails,  complicated almost always with a watery tumour of the ,
tunica vaginalis, and indurations of the spermatic chord. These
diseases, too often concealed even from the surgeon, arrive at
their last stage undivulged :  but the scene is  dreadful indeed
when either before operation the  testicle bursts out into open
ulcer, or, after an  operation performed too late,  the chord,  be-
ing diseased, protrudes from the upper angle of the wound in the
form of  a fungus or cauliflower-like tumour, which it is in vain
to extirpate with either ligature or knife, for it shoots out again
in a day, bleeds, and discharges the most fetid sanies,  accom-
panied with cruel pains ot which the patient expires.
   The Membranes lining  the Nostrils are of so vascular
and glandular a nature, so continually exposed to the air,  and
yet so delicate and sensitive, that  tumours arise  even from the
very slightest irritation.  These tumours, mild perhaps  in their
own  nature, are dreadful in  their consequences, from being
seated in narrow passages, limited not by dilatable membranes,
but by unyielding bones, which suffer every kind  of disorder
when the passages  begin to be  filled with  even the softest of
these tumours, while the cavities of the antrum highmorianum,
and other cells far out of the reach of instruments, are often oc-
cupied by tumours of a more malignant nature.  So destructive
are the consequences of even the mildest tumour, growing  and
distending these passages, that we know not how to  admit or
refuse that  definition of tumour so often mentioned in books,
u The Cancerous Polypus ;" for no cancer can be more des-
tructive than even the most simple polypus. Little does the patient
apprehend the fate that awaits him, when a small tumour which
he can just touch with the point of the finger, soft,  pendulous,
void of pain, and attended with no  worse disorder than sneez-
ing and watering of the eyes, first appears :  it is  not  that slight
sense of suffocation which first alarms him,  increasing to a to-
tal obstruction, that occasions his death ; but the narrowness and
crookedness of the passages  of the nostrils  and throat,  and  the
vicinity of those parts  to  the brain, separated indeed only by
the thin plate of the ethmoid bone that occasions death.  The
bones first become soft and carious,  and discharge a fetid and
acrid matter, which distils in such profusion as to excoriate the 
Of the Parts most subject to Tumours.         381
lip, and to cause diarrhoea by  running down  the nostrils and
throat.  The blood bursts  impetuously from the corroded ves-
sels from time to time :  the hearing is entirely interrupted  by
(he pressure of  the  tumour on the mouths of the  Eustachian
tubes: the teeth fall out from the  sockets, in  consequence of
the caries of the alveolar processes :  the head seems  rending
asunder with distracting and continual pains : usuall) the patient
is exhausted by  long  suffering,  and  frequent loss of  blood :
♦sometimes he lives till caries ot the ethmoid bone admits the ul-
ceration to the brain, and he dies lethargic.
   The Gums, when they fall into a  diseased condition, hard
as they are, (and their hardness approaches more nearly to  the
consistence of the teeth and jaw-bones, which  they connect to-
gether, than to that of flesh,)  throw out  tumours  so luxuriant,
so truly fungous, so profusely supplied with blood',  that the he-
morrhagies from them are, even from the  first, alarming,,and
are in the end fatal ; and the tumours, when extirpated with the
scalpel, or torn away with  ruder instruments, often sprout up,
(after the very bones have  been  laid naked,) in the space  of
twenty-four hours, and effloresce in the course of a  tew days
into cauliflower-like excrescences, and still grow so rapidly, ac-
companied with dislocation of the teeth and caries  ot  the jaw,
that the patient expires of  haemorrhagy, diarrhoea, and cance-
rous pain. There is no form of tumour I so greatly dread, none
 so rapid in its growth, as those proceeding from these callous
gums,  nor anv disease in  consequence of which I have suffered
such severe, unlooked-for  disappointments, or seen such unsuc-
 cessful operations  and horrible  deaths.    Sometimes the extir-
 pation is successful, and,  I  think, I can often predict when
 it will be so ;  but, when it fails,  no  cauterizing, nor  the most
 cruel processes of surgery, will repress  the after growth ;  it is
 truly cancerous, and invariably fatal.
   Tumours  of the  Throat,  whether  external to the jaws,
 or visible only within,  give no alarm but by the effect they pro-
 duce on the  breathing and swallowing ; and yet they are, beyond
 all comparison, the most dangerous tumours, fatal if neglected,
 and yet so connected with great vessels  and nerves, that  to ex-
 tirpate them is almost  impracticable.
   Suppurations within the  throat of a  scrophulous nature are
 frequent ; and I shall have occasion  to lay before you examples
 of these bursting by  multiplied openings into the larynx and
 oesophagus occasioning suffocation by the matter falling into the
 trachea,  or inanition and death by the contraction of the oesopha-
 gus, in consequence  of long ulceration.  Other tumours again,
 which, at first sight, the surgeon is disposed to imagine are sacs
 of purulent or  serous  matter, and which I  confess  myseii to 
382        Of thejktrts most subject to Tumours.
have mistaken for such, are sacs of blood formed by dilatation
of the extreme  arteries and veins ;—aneurisms of  that kind,
which I have formerly described under the name of  aneurisms
by anastomosis, but lying too deep under the skin and the pla-
tysma myoides muscle, and too near to the great carotid arte-
ries and its  accompanying nerves, to  admit of extirpation.
Sometimes I have found tumours, especially occupyingthe fore
part of the neck, in the place of the thyroid gland,  to be sacs of
blood, but of a structure widely different from that of those an-
eurisms, and perfectly  curable, distinguishable from those ca-
ses of aneurism by anastomosis, in having no pulsation, and a
thicker sac.   The tumour  is stationary  in respect of size, and
not becoming more  turgid upon retaining the breath, nor flatter
when the blood is repressed by  the hand:  there is no conge-
ries of active vessels opening into them, and supplying them
with blood.   The blood, I find, has all the characters of having
remained long in the sac, and the sac itself is of a firm consis-
tence, difficultly brought to  suppuration, infinitely  more diffi-
cult to obliterate than those sacs which contain matter or serum,
and leaving behind  them  a permanent  thicking of the throat.
Aneurisms of the carotid arteries are not frequent, but I have
seen a pure and simple dilatation of this vessel under the angle
of the jaw, of the size of a fist, intruding upon the throat rather
than projecting outwards, little conspicuous as  a  tumour,  but
having an  awful throbbing pulse,  when the palm of the hand
was laid over it.  One would  fear nothing  in such aneurism
but the bursting, and the loss of life  by haemorrhagy  ; but long
before the sac inflames or ulcerates, the  fever with which it is
accompanied, and the  difficulty  of swallowing, arising simply
from its pressure upon the pharynx,  occasion death.
   The Salivary and Lymphatic Glands, lying under the
tongue,  and about the  angles of the jaw, are frequently disea-
sed, and form tumours  varying greatly in their form and nature,
and growing sometimes to an enormous size; usually they con-
tain a  gelatinous matter,  thick, ropy, sacculated,  and  mixed
with solid bodies like  grains of millet or mustard-seed,  some-
times a pultaceous matter :  often these tumours are so far fluid,
as to give hopes when first the sac is opened, that the tumour
will entirely subside, and the sac be easily obliterated ; but  so
far solid as to mock these  expectations, for, while  the matter
runs out, the base is indurated,  so  that before the  opening of
the sac is closed, the base has become a tumour,  firm, glandu-
lar, and visibly increasing.  Sometimes these  glandular tumours
especially sodi as are seated under the jaws, though of a stony
hardness,  are movgablp, subject to  no  pain  nor occasional  in-
flammation, not adhering  to  the skin nor subjacent parts, but 
Of the Tumours of the Banes.
383
 indolent and harmless.  Always in children and boys, some-
 times too in adults, such indurated glands are harmless, but of
 firm and knobulated tumours, especially of those seated in the
 cheek, covered with a coarse, porous, and puckered skin, and,
 connecting themselves strongly with the surrounding parts, livid
 on their more prominent points, and aching with every change
 of weather or season,  I have never seen a happy issue.   There
 b no safety for the patient who is endangered by such a tumour,
 except in extirpation ;  nor can we assure him that such opera*
 tion (not always void of danger,) will eradicate the disease.
   These preliminary sketches and characters of tumours, shall
 serve as a slight index of the  subjects I have to explain in  de-
 tail : the varieties of suffering will be but too truly confirmed by
 facts :  the distress  the patient suffers who dies of any form of tu-
 mour, whether suffocating, carious, or cancerous, exceeds what-
 ever the most eloquent writer  on professional subjects could
 represent, or the warmest imagination conceive.   Believe  me,
it is the sufferings  of individuals that have given me such deep
impressions,  and you shall feel, before I have finished the nar-
ratives of the cases corresponding  with these characters, hour
little I am inclined, how little I need to exaggerate, the impor-
tance of this subject.





                DISCOURSE  XXII.
           OF TUMOURS OF THE BONES.


 IN this discourse, which is devoted to the diseases of the bones,
 I shall first sketch out to  you my conception of those  changes
 which happen in the structure of bone, before it  swells  into a
 tumour ; and shall next lay before you the facts in detail, from
 which those conceptions, true or false, have arisen.
   Every tumour must derive its peculiar form from the structure
 of thitt part of the body from which It arises ; for it is not seated
 on the part as a new and accidental existence, but is engendered
 by its vessels,  and is of its actual  substance.  Many things
conspire to give the tumour proceeding from a bone a peculiar 
384
Of the Tumours of tfie Bones.
aspect; it is  always irregular and anomalous, never simple. 1
have rarely seen a single  bony protuberance arising from the
head or the shut of a single  bone.   When a bone falls into dis-
ease,  a large  proportion of tendinous and  muscular parts, of
bursa;, and of cellular substance, partake of the morbid action.
The bone lies in the centre of the limb, connected by its larger
head with the joint, and  by  its periosteum with the tendons,
bursa;, and muscles ;  and all this mass of parts is sooner or la-
ter affected ; and since every deposition from vessels appointed
for the secretion of bone is solid, and  every  increase of such a
tumour permanent, it soon attains a great size ; it is ponderous
and  massive from the proportion of bony secretion, and  from
the various structure of these several parts, it has every irregu-
larity of form and substance.
   When the'tumour of a bone has attained a considerable size,
much  of the original structure is destroyed,  and a new irregu-
lar mass of gelatinous and bony matter is substituted for it.  The
bony tumour is firm, bulky, and ponderous, but not solid ; feel-
ing it from without, we can conjecture of what substance it is
composed within; we are sensible that the tumour is covered by
a shell, bony in most part  of its circumference, cartilaginous in
some parts,  and throughout  the whole,  yielding and  elastic ;
we are sensible also, that within, there are irregular points or
spiculae traversing the  cavities or cells of the hollow tumour ;
that these are mixed with the cartilaginous substance, and with
irregular collections of  matter, partly  purulent, but chiefly ge-
latinous ; and we find at  last, by  pain and  partial ulcerations,
and  by the  increase  of fluctuation  and redness at particular
points, that ulceration,  the last stage of the  disease, approach-
es ; then the limb is effectually ruined, and  the  patient  must
submit to amputation,  or die hectic.
   When such tumour is dissected,  we find our suspicions of its
internal structure confirmed ;  we see that foul matter flow out,
when we open into the centre of the tumour,  which we felt but
indistinctly through its walls; the parts of which appeared the
most solid, are hollowed out by ulceration, and full of foul and
putrid sanies ; while the  bone has been  declining into disease,
the cancelli  and marrow have been  degenerating into a sort of
fatty mass, with which much of the cavity of the tumour  is fil-
led,  and thence such disease has been very generally described
under the name osteosteatoma.  This fatty secretion, occupying
the diseased cavity, is the part, which, when  the tumour bursts
into open ulcer, throws  out such prolific fungus, growing appa-
rently from the substance of the bone, and sprouting up when
amputated,  in the course  of a few hours. The solid bone,  whe-
ther radius or thigh-bone, is annihilated, and a mere shell of 
Of t/ie Tumours of the Bones             385
osseous matter substituted in its place, and that in a manner so
peculiar, that it must seem to the unintelligent observer, as if
the small and solid bone had been expanded into an extensive
and flat plate of osseous  substance, whereas the process is in
truth very  simple and very intelligible.   The  bone dies  piece-
meal of ulceration, or what, in technical language is termed ca-
ries, and is conveyed  away by absorption ; but the bone being
dead, the  surrounding membranes,  viz.  the periosteum  and
tendinous expansions, which once formed a part of its system of
circulation, continue still alive,  and ready to secrete new  bone  ;
and thus it happens that while carious abscess preserves a large
cavity  full  of foul matter,  the surrounding membranes continue
secreting bone, which,  like a shell, thin and expanded, covers
this cavity, and forms the  walls of the tumour, of which  some
part is  composed of thin expanded bone,  resembling a cranium,
some of cartilage, some of thickened membrane ; and this shell
is formed in  proportion as the  original  fabric of  the bone is
destroyed.                                          •
   Bone is  destroyed by this internal ulceration, just as it is by
open caries, piecemeal; the process  would not  be ulceration,
if, while one part were perishing the other were not active and
secreting new matter ;  so  vigorous still is the general life  of the
bone,  that while the internal parts are thus suffering, while one
side is  wasting with ulcer, the other side is often secreting bone
irregularly and profusely, and shooting out into fantastic forms
among the  membranes and surrounding parts,  whence the cen-
tre of the tumour is cavernous and cellular, and the walls often
rough  with spinous and projecting points.  So  merely local is
the action of arteries in a tumour, whether  osseous or soft,  that
one  side, or part, or bump of a tumour, grows visibly,  and
protrudes,  the features  and external form  of the tumour, gra-
dually  changing, without any sensible cause ; and so peculiar is
the secretion of each species of vascular structure, according to
the original destination of  the part, that in one part of a tumour
is generated bone, in another gristle, in another gelatinous effu-
sion ;  while in another part, the  vascular action is violent and
destructive, ind  the  solid bone,  marrow,  and  surrounding
membranes,  are all resolved into a foul and fetid  suppuration.
From the periosteum is secreted bone ;  from the marrow,  this
steatomatous and solid fat, with which much of the tumour is
filled ;  to the tendinous and aponeurotic  parts we can distinctly
trace the cartilaginous  secretion ; and the gelatinous effusions
we can perceive, even during life, are thicker or thinner accord-
ing to the degree of inflammation.
   These are  the external characters, and internal conditions of
                            3 C 
386
Of the Tumours of the Bones.
 a tumour, occupying any of the bones.  Such tumour arises often
 from a bruise or fracture; sometimes from a less obvious cause,
 or from internal disease.   The radius, for example, is fractu-
 red at the wrist, re-unites, and heals, but heals  clumsily;  the
 thickening never subsides, the pain never ceases, and though
 not great, is greater than what is natural to a fracture; at length
 a sensible tumour arises ;—at first it is firm, but in proportion as
 it increases in size, it becomes somewhat soft and elastic:  the
 thin  plate of  bone  of  which it is composed  yielding to  the
 distention from within.—From time to time the tumour  changes
 its form,  still increasing in bulk ; on the  side of the radius it
 is firm and solid;  it bends and yields at the  parts most dis-
 tant from it; it is plainly bony at  its  basis, and  as obviously
 cartilaginous in the extreme part of its circle ; it plainly contains
 matter in those softer parts,  where it yields to the impression
 of the finger : cartilaginous knobs arise, and sometimes are red-
 dened on the surface ; and at certain points the fluctuation is of
 such a kind as to imply, that the effusion  is in  part of a gelati-
 nous nature.  Thus the tumour grows and extends, with vari-
 ous irregularities in  form and consistence ;  it overhangs the
 dwindled hand,  the use of the joint is lost, and the patient, who
 would gladly be delivered  of  it at  an earlier stage, has in the
 end no choice left;  for when once it bursts into carious  ulcera-
 tion it never heals, the  fetor is inconceivably overcoming, at-
 tended with  hectic.   You are also to  remark,  that when  such
 disease takes place in the hand itself, the joints  of  each  of the
 fingers grow out into tumours, at first of a heart-like form, corres-
 ponding with the articulations of the finger-bones ; but in pro-
 cess of time, they grow to globular, irregular, and almost trans-
 parent tumours, still firm, or at least of a cartilaginous firm-
 ness.  The  whole hand degenerates into a deformed mass, dis-
 coloured,  ulcerated, and fetid ;  from  the  individual knobs of
which deformed mass, the points of the respective fingers project
like griffin's claws,  with crooked nails of  enormous length.
  You will conceive,  I trust, from these  general  descriptions,
an idea, not far from  perfect,  of the irregular forms, and inter-
nal disorder accompanying this disease : you may'imagine how
ill the surgeon is qualified for practice, who is not aware of these
changes in the internal structure ;  he feels fluctuation, and re-
 gardless of the  history of the tumour, of its firmness, or of  its
 connection with a bone, plunges his abscess lancet into  it, and
 it pours out,  if  he strike deep enough,  a profusion of thick  mat-
ter ; he then believes that it will heal, but it will  never heal. Or,
 knowing it tobelongto the bone, he imagines,  perhaps, that it
 is a firm and solid tumour, but believes that the tumour is move-
 able, because the radius moves along  with it, allowing it  to 
Of the Tumours of the Bones.            387
turn; he projects an operation for cutting off this tumour of the
bone, but,  after a slow and painful  dissection, he finds it  not
solid but cavernous, and full of fatty or fetid matter ;  he finds
the bone to which he imagined  the tumour attached, entirely
gone, and  thejoint to which that bone belonged entirely open ;
he  finds the smooth cartilaginous heads of the wrist-bones ex-
posed in the cavity of the ulcer;. and is forced, after the patient
has lost much blood, and manfully endured a slow excruciating
operation,  to cut off the hand.   Such are the lessons which ex-
perience teaches, and I have known  instances where  the case
and all its  probabilities have been maturely considered, by men
of great skill and judgment; where a Lynn, surrounded by his
approved and skilful  friends,  lias reckoned the probability of
success, such as to vindicate an operation;  the tumour small,
firmly attached to the radius,' turning easily along with it, not
yet distorting the tendons, not yet interrupting the use  of  the
hand, I have known the operation, performed even by such  an
operator, fail.  Now, in such cases, the tumour does-not cease
to grow, the incisions heal up, the part of the radius cut out by
saws  grows again, the tumour continues to increase, till it  de-
stroys the  wrist,  the hand dwindles,  the  fingers grow long,
shapeless,  and powerless, from  want of use, and amputation is,
in the end, the only resource.
   The  forms of this disgusting disease, which never fails to de-
stroy the limb, are infinitely various.   I  have seen the ankle of
a woman,  from a very slight accident, fall into this disease ; the
tibia and fibula grow into a common tumour ; the bones seemed
to me annihilated, and a  large shell of bone substituted in their
place.  The leg, in the course of the disease, twisted  round in
a singular  manner, and the limb enlarged to the size of the pil-
low of a settee.   This woman died of hectic, from the open ca-
ries of the  tumour.   The  wrist, more  exposed than any other
part  to sprains  and fractures is, very  liable  to  be  thus de-
formed and ruined; but the hand itself is still more liable, the
original injury is some slight  blow  or sprain ;—one finger is
first deformed, joint after joint  enlarges, one  finger becomes
crooked after another, the nails project unpaired like talons, and
force their way into the very flesh of the  swelled and  ulcerated
hand, which they  sometimes actually penetrate through  and
through ;  the hand degenerates into an unwieldy and  irregular
mass, studded  with knobs and bony  tumours.   From a ne-
glected fracture of the collar-bone, I saw once in a stout young
man, who, living a most dissolute life, left  the fractured part
no  rest to heal and unite,  a tumour formed, partly bony, partly
cartilaginous, rising to the height of six inches, round, insula-
ted,  moving when the arm was  moved, too large and too criti- 
388            Of the Tumours of the Bones.
cally seated  over the  axillary artery, to admit of extirpation,
and which, I doubt not, has by this time become  carious, and
occasioned his death.
  The stage and period of growth at which such a tumour may
be extirpated, if ever such operation be  practicable, I profess
not to know : the circumstances must be very  favourable  in-
deed, to incline me to undertake  such an  atchievement;  it  is
often indeed a matter of doubt,  whether it would  be advisable
even to amputate the  diseased limb,  for  occasionally  we see
both hands thus diseased,  and often the tendency to form such
tumours seems to  prevail through all the osseous system.   If
the disease proceed from a fracture or bruise, we cannot ven-
ture to extirpate the tumour,  for the joint is diseased, and we
have no resource but amputation:  if the tumour is spontaneous,
and without any violence or manifest cause,  we have reason to
fear it is a constitutional, and not a  local disease; and dare not
propose amputation with  confidence ; it is only in the rare oc-
currence of a  bony  tumour being altogether limited in  its
growth,  insulated in its form, solid and firm, and unaccompa-
nied with disease of the surrounding parts ; seated on the  shaft
of the bone, not connected with the joint,  and yet growing to a
great size, and threatening destruction, that we should think of
any  such operation.   Such,  perhaps, is  a case  recorded  by
Heister, of a great bony tumour rising from  the middle of the
sternum, equal in size to a child's head, which was successfully
extirpated.
  The general  description of this disease,  and the chief practi-
cal lessons, will be as fully illustrated by the follow ing case, as
by a hundred such,  for it includes  all  the principal features of
the disease, and all  the practical difficulties,  which the surgeon
may have to encounter.
  4' A labouring man, about  40 years of age, sallow, lean, and
meagre,  presented himself with a  tumour of an enormous size,
and of an anomalous character, partly solid, partly cartilaginous,
occupying two thirds of the fore arm,  from the wrist upwards :
the hand was sound, and all its joints limber, the wrist bended,
and the fingers  moved easily ;  it  was from  pain  only, and
weakness, and the incumbrance of so great  a tumour, that he
could no longer work: the tumour seemed also to move freely,
whence it seemed possible to dissect it away, and save the joint;
and the surgeon, a man whom I respect as a man of learning,
skill,  and consummate prudence, was  induced to begin a par-
tial operation,  a dissection of  the tumour, from a sincere desire
to preserve the right hand of a poor labourer.
  " But here you are to take notice, (and I should put no value
on a case which did not convey some practical lesson)  how un- 
Of Tumours of the Bones.             389
expectedly we are sometimes involved in great perplexities from
reflecting too slightly on the nature of a tumour:  a tumour of
this singular complexion, any tumour indeed which requires an
operation,  should be so particularly examined,  as to enable the
surgeon to prognosticate every thing that could  occur, and to
describe the disease before amputation, as  precisely as if it lay
already dissected before him:  much of what will  be  found on
dissection may, in almost every case, be anticipated, and every
such anticipation will be happy for the patient, and creditable
for the surgeon.  The surgeon should, at least, ascertain the
general character of the tumour, yet, I question whether, in this
case,  it was  absolutely known, that the  tumour was  at  all  at-
tached to the bone;  that it was merely a tumour of the radius,
assuredly not.
   " Little is to be learnt, even after  much inquiry, from those
of the lower orders concerning the early stages of their diseases.
This, perhaps, was of a nature originally malignant,  but cer-
tainly irritated by neglect at first, and, in the end, by imprudent
advice and rash applications:  the  man had, about six or eight
months before applying for assistance, first observed the disease,
in the form of a circumscribed swelling, rising upon his wrist,
gradually increasing, and becoming daily more painful: he ima-
gined it right to apply poultices, and, after some time, brought
it happily, as he imagined, to a suppuration : but, as it did not
heal,  a mischievous old woman undertook the cure, cramming
it with tents, and acrid and corrosive powders, and making so
very free with  the lancet, that he narrowly escaped dying of a
haemorrhagy,  caused probably by the erosion, or wounding of
one of the veins above the wrist.   The tumour was, at the time
of the operation, enormously large; it was at the lower and
bigger part of  a dusky brown,  but at its upper and smaller end
of a fresher  colour, with a wide  and open ulcer,  bleeding at
times, and disposed to throw out a luxuriant fungus, to suppress
the growth of which was, perhaps, part of the old woman's in-
tention, in applying the escharotics, if intention of any kind can
be imputed to so ignorant a creature.   The veins, as is usual in
bony tumours,  were far from being  conspicuous even <in this
part.
   " This poor man, having willingly assented to any operation,
however lingering or painful, which might save his hand, the
dissection was  carried all round the tumour and into its central
parts, before the surgeons present were undeceived.  As the
radius  turns vertically like a spoke or spindle,  it turns without
any apparent motion,  except in the parts connected with its low-
er end ; the hand turns freely along with the radius, so that we
never suspect till we become acquainted with anatomy, that it 
390
Of Tumours of the Bones.
is by the spoke-like motions of the radius that the hand moves;
it seems moveable in itself by its own immediate joints.   This
tumour, in like manner, moved easily, could be turned upwards
and downwards, so that the surgeon never once suspected that
the motion was in the radius, or that the tumour was fixed, and
made a part of that bone; it seemed moveable, and he began to
extirpate it, by drawing a long  incision round its root, on the
side of the ulna:  but, finding  it difficult,  with this limited in-
cision, to dissect the tumour, he prolonged  the incision, con-
tinuing it over the back of the  hand to the knuckles,  in the di-
rection of the extensor tendons.   He then dissected more free-
ly, and continued separating the skin from the tumour, till he
came to  a thick and solid  sac, which seemed to consist of mus-
cular and ligamentous fibres.
  u He continued this dissection, separating this thick and solid
sac from the interosseous  ligament, till he could go no farther;
finding that it terminated then in a solid and osseous basis, he
now plunged intrepidly into the heart of the tumour.   In cut-
ting into the heart of the tumour he found that he had opened
a very large sac, not firm  only,  but osseous:  but still as he was
penetrating into the  tumour at one side, viz. at the side nearer
the ulna, with  which the  tumour was manifestly unconnected,
and at  the greatest possible distance from the radius, from which
the tumour in  fact arose,  he continued still  unsuspicious, and
persevered in  dissecting away  what he imagined to be a com-
mon tendinous sac, ossified only  at certain points:  he made
thus a large opening into the tumour,  felt its cavity full of loose
and fatty bodies, pushed his finger under the extensor tendons
into the deepest part of the sac, began to hook out the fatty tu-
bercles with his fingers, and, at last, baling it out with his hand,
(for  the cavity was large enough to  admit his hand) hooking
with his finger and catching the  fatty  masses in his palm, he so
far emptied the cavity as to be able to search  with his fingers in
every direction, and then  he found, to his utter confusion, the
ball of the carpus, (formed by the scaphoid  and lunated bones)
at the  bottom  of the cavity, bare: he was now for the first time,
undeceived, and knew what sort of disease he had to contend
with;  he was now conscious,, that the radius was diseased, the
joint ruined, the original  bone ulcerated and destroyed; he felt
distinctly that  the  ball of the carpal bones, originally opposed to
the lower end  of the radius, was now, by the destruction of the
radius, left naked ; and, in fine, that the wrist-joint was irreco-
verably ruined.  There was no  going on  with this operation,
and no stopping here; he therefore  explained to the patient,
who had borne this severe and long  protracted dissection with
great composure, the necessity of amputating his hand,  which
he submitted to with equal resignation." 
Of Tumours of the Bones.              391
  The reflections naturally arising out of this case  are obvious
and impressive; we must be conscious how suddenly a surgeon
may, in a moment of thoughdess security, be plunged into cir-
cumstances extremely perplexing.  How becoming it is  to  in-
vestigate and examine  with care, the history of every disease
before operating,  and to ascertain the soft or solid,  the fixed or
moveable state of a tumour, its probable connections and eventu-
al dangers:  we should be aware of attempting (which is indeed
equivalent to promising) to extirpate a tumour, which, though
apparently moveable,  is  only seated on a moveable bone:  we
should be careful not  to promise a cure where,  perhaps, the
joint is destroyed:  not to enter upon a painful  and exhausting
operation, in  a case where nothing but  amputation can avail.
In a case, such as I have just described, it should  be recollect-
ed, that the metacarpal bones lie very deep in the hand, have
a considerable latitude of motion, and may communicate that
motion to the tumour; the  circumstances of this tumour and its
history, were such as might deceive the most circumspect; the
turning of  the radius conveyed an idea of the tumour  being
moveable; the elastic and cartilaginous feeling, that it had no-
thing  extraordinary in  its nature; the sac,  when  the surgeon
had dissected down to its root, was such as  gave him reason to
believe it was but in part ossified; the fat which he scooped out
from its cavity, that it  was merely a steatome; it wras not till he
felt with his finger  the ball of carpal bones naked, that he knew
the joint to be diseased; he had every apology for his mistake,
for, in a disorder of no more than six months duration,  he  had
no  reason to believe there could exist such universal destruction
of  the joint and of the radius.
   But a charitable  endeavour to save the hand of a poor  and
labouring man, even  when it involves us in a severe and fruit-
less operation, is not the worst error; the surgeon, alarmed by
the uncouth appearance of a hand deformed by  such disease,
and not calculating with due deliberation the individual bones
that are affected, might rashly amputate the whole hand, where
an  useful part of it might be preserved.  Among the cases of
this nature that  stand recorded, is one  by Severinus, short, in-
deed, but not the  less interesting:  " Hyeronimus Damianus,
a youth about twenty-two years of age,  crooked and scraggy,
and of a puny habit of body, had his right hand so enlarged as
to be a burden too great for him to bear : in lying, he  laid  it
above his head, walking, he carried it with difficulty on his other
hand: it was diseased, chiefly by  the enlargement of the pha-
langes of four of the fingers; the individual  tumours you would
have likened, in respect of size, to lemons, in respect oi colour,
to rotten apples,  beipg large, globule", and livid:  these  knobs, 
392              Of Tumours of the Bones.
or enlargements, were plaited over each other, and the points of
the nails projected like claws from the extremities of the seve-
ral tumours."  Men of ordinary genius and resources no sooner
stumble upon a difficulty than they are alarmed, and fear mag-
nifies every  danger  that is likely to affect their reputation or
practice.  Many surgeons, in a case like this, fearful lest, after
a  partial operation,  the  disease  should return, would  have
straightway chopped off the* hand.   Severinus acted quite other-
wise : cutting off each  finger by the last joint, by which it is
united with the carpus, he burnt the roots, and brought the parts
to a sound and healthy cure : he  thus preserved the hand, i. e.
the carpus and the thumb, the form, and something of the use
of the part, for such a stump antagonising the other hand, and
assisting it, would be very precious.  Enormous as this tumour
was, Severinus had  the skill and courage to save at  least the
patient's thumb: and we have the consolation to learn, from the
case  of  this  unhealthy  and  crooked creature, plainly disposed
to diseases of the bones, in whom the spine was deformed, and
the tumour of the  hand spontaneous, that it  is possible, even
where our incisions  can hardly carry us beyond the immediate
limits of the disease, to accomplish a cure.
   In the sketch of this hand, you will remark, that the bones
are alone diseased, that the several knobs or tubercles represent
DRAWINGS X"ROM SEVERINUS. 
Of Tumours of the Bones.
393
the several phalanges or joints of the fingers; that the handand
wrist (a) are dwindled, while  the  tumours (c. d. e.)  represent
the several joints of the ring-finger, which had far exceeded the
rest in size, forming the chief bulk of the tumour: the elonga-
tion of the whole hand, demonstrates the growth of the bones
in every direction.
   But extension such as this, especially  when proceeding from
the high action of vessels,  must end in ulceration, which is the
natural conclusion of the  disease.   The ulcer is fetid and ca-
rious,  affecting at once the bone and the flesh, and so ruinous
to the health that amputation cannot be delayed.  Such, for ex-
ample, is  the case communicated to  S- verinus by LarchjEus,
accompanied with a drawing:  it seems to  have been a tumour
of enormous size indeed,  involving all the carpal  and finger-
bones, very massive and  tuberculous, the hand weighing  no
less  than  seven pounds; the bones were thoroughly diseased.
This irregular mass  breaking out in  its centre (in the middle
of the carpus)  into ulceration,  destroying  not  only the  fleshy
parts, but the bones, there ensued a hectic fever, when the man
betook himself to the hospital  of St.  James for incurables, and
solicited to have his hand  amputated, which otherwise he would
not  have parted with, for he was a pauper, and lived by ex-
posing this monstrous mass of disease.
   So desperate do I account this kind of tumour, when accom-
panied with any general disease of the bones, and so loathsome
are  the carious ulcers, which sooner  or later ensue, that I  al-
ways think it a consolation  when the disease is in any degree
local, even though it admit not of saving the hand by any par-
tial operation ; if it allow of our saving the patient's life by am-
putation,  I think it a special piece  of good fortune.  How little
it was in  our power to save  the  patient whose wrist is  drawn
on the same page  with  this  of Severinus, you  will perctive
from the  following notes of his case: "His wrist is deformed
and  loaded  with a tumour, or rather a congeries of tumours,
surrounding the joint, knobby, hard, immoveable, of a  rocky
firmness, and plainly proceeding from  the bones, both radius
and ulna: the arm is weakened by  the tumour, the wrist al-
most  powerless, the hand dwindled from  want of use.  The
man is about twenty-six years of age, a weaver by trade, born
with this  disease,  and now in  a condition which hardly  admits
of any alleviation.   This tumour of the wrist was observed
even at his birth ; it was then very small, and waxed  slowh and
gradually to its present size:  from  year  to year  the tendency
to disease became more and  more conspicuous, tumours suc-
 cessively formed on various parts of his body.  The  bones of
his fingers, ribs, legs, are deformed with tumours of the same
                          3  D 
394              Of Tumours of the Bones.
rocky firmness; one of these arising from one of the ribs, is of
a most singular form, projecting from the flat rib like the han-
dle of some instrument, and sticking directly out.   These va-
rious bony tumours,  which have  appeared in  regular succes-
sion,  and grown slowly, have been hitherto void of pain, and
have  never yet prevented his daily labour;  but during the in-
clement weather of last winter, and taking mercur) for a slight
venereal affection, the tumours on the left leg, whether  lrom
the imprudent administration of the  remedy, or some lurking
taint of the disease, became so extremely  painful, that he was
disabled from work,  confined to  bed, and is now in the  infir-
mary. The papillae, or prominent parts represented in the draw-
ing, are the apices of those rocky  and firm tumours, which are
somewhat pointed; and each prominent point is  discoloured,
so as to assume the form of a  common  pimple, but vtr\ fiery
and red.  The painful tumours of the left leg,  are in like man-
ner reddened;  the whole skin investing them,  is inflamed; the
complexion in short of these tumours is such,  as demonstrates
the approach of that  ulceration, which  is to convert each tu-
mour into a loathsome, fetid and carious sore."
   Though I have upon my recollection many proofs of tumours
of this nature, being altogether void of pain;  yet, 1 have  a pre-
possession, that wherever there  are acute pains  in the  bones,
there is actually a tendency to such tumours ; the close connec-
tion of pains and tumours in venereal cases, vindicates my sus-
picion,  and I believe, that when a patient speaks  ot rheuma-
tism in his bones, and feels it deep-seated with oppressive pain
affecting the whole limb, the disease  is  actually seated  in the
centre of the limb, and substance of the bone:  of one very sin-
gular case of this nature, I find I have taken short, but accurate
notes: " John M'Donald went early in life an apprentice to
the West-Indies;  he was then a stout young man, and  in his
profession, as stone-mason, had a gang of workmen under his
charge;  and during a period of ten  years, which  he  spent in
that climate, had suffered no less  than ten successive and se-
vere  attacks of ague and  fever,  and had suffered much from
dysentery.  He is married, and has been so many years; he is
a sober and respectable man, apparently fifty years of age; ne-
ver had  venereal complaints,  never  had  general  rheumatism,
nor indeed any other pains in  his bones, but that which 1 am
now about to describe.
   u He had suffered very violent  pains about his shoulders
and arms, but especially  in the left  humerus, for the space of
a year;  those pains had  in some degree  ceased,  and the pain
in the left arm had been little distressing for three months when
one day, at a quarterly meeting for the regulation of a common 
 
P. 596.
Fi$.i
fig.-2
TK«imj,-tt'
J.Bie.dtu 
Of Tumours of the Bones.              395
subscription fund, or society subscription for the relief of dis-
tressed members, a  little girl of five years old, being in the
room, he lifted her over one of the benches, and in the moment
of doing so, felt a pain so sudden and acute, that he could not
be persuaded but that some one had hit him a smart blow from
behind, across  the arm; he  spoke, he  says, very testily, and
could not help crying out, that by that silly trick they had raised
his old pain,  which instantly became  more  violent  than  ever.
From that moment he  was incapable  of raising his arm to his l
head;  his  pain, upon every occasion,  of coughing, laughing, or
moving hastily,  is excessive : but when at perfect rest, he has
no pain.   From this period a swelling began to  arise, occupy-
ing gradually the upper and middle parts of  the humerus, sur-
rounding  it like the lump  of clay and straw which is wrap-
ped round a grafted tree."  In this very singular case, I have
little doubt, that the fibres at the origin  of the triceps, and in-
sertion of the deltoid muscles had given way, in consequence
of  the diseased state  of the periosteum,  and tendons, where
they are  implanted into the humerus,  and that from such injury
the tumour had  arisen;—the bone, I doubt not, is carious with-
in, supported only by this shell or new secretion ; I  could bend
the arm  gently, and could  perceive that the sac of bony secre-
tion, which at first seemed perfect and firm bone, is in part car-
tilaginous, and yields ;  the  arm bends  at this thickened part
with a sort of elasticity : having one day committed  his arm
for  examination to  a very brutal surgeon, and  turned  to go
away while he  was  thus employed,  he called me  back,  with
great exultation, to shew me, that he  had been able to bend my
patient's arm to an obtuse angle, so as to put the fact of the se-
paration of the bones,  and the flexile  and elastic nature of the
tumour, beyond dispute; a favour, which I acknowledged,  I
fear, in a very ungracious manner.
   I have given, along with  the drawing of the wrist of the
man whose whole osseous system was diseased,  one Irom Mr.
Mery, of the hand of  a youth of sixteen, which had attained to
a prodigious size and  monstrous form; it weighed, after am-
putation, from six to seven pounds ; it was one deformed mass
consisting of three  protuberances of various magnitude ; the
largest, (a figure  1.)  belonging to  the ring-finger,  appeared
chiefly on the back of the hand, and was seven inches in diame-
ter ; the tumour next  in size (b),  proceeding from the mid-
finger, was six inches in diameter; that proceeding irom the lit-
tle finger, was four inches in diameter,  and  is seen  only in the
second drawing, viz. in the  skeleton of the hand at  (c).   The
skin, wherever it lay   over these tumours, was coarse,  with
deeper ridges:—the surface was deformed with deep  ulcers, 
396
Of Tumours of the Bones.
affecting not the soft parts only, but the bones: though from tht
unsightly appearance  of the  whole mass,  it was by many pro*
nounced cancerous, yet these sores  were in truth  red, granu-
lating, and healthy ; even the deepest of them were void of pain,
and the veins of the hand, usually swelled in cancerous tumours,
'were flat.  Through the skin, which was thin from extension,
the tumours felt very  firm and osseous; the lad assigned, as
the cause of this monstrous deformity,  the hand being bruised
at the early age of six years: he was entirely well of this hurt
before the hand began to grow, but  it began soon after the ulce-
ration healed to increase in size, and continued to  enlarge for
ten  years.   The hand, he had remarked, during the two latter
years, had grown more than in all the eight preceding.  Upon
dissecting the amputated hand, the  tumour was found to lie ex-
clusively in the bones;  the greatest tubercles were merely en-
largements of  the first and  second phalanges of the three la9t
fingers; those  joints  of the fore-finger and  thumb being sound.
The joints, in this instance, at the  same time that they  were
enlarged, were motionless from being anchylosed; but their ar-
ticulations  with the metacarpal bones were fixed, by the rigid
state only in which the tendons  were, from motion being so
many years suspended.   The shell of these tumours was thm,
the internal parts crossed by bony  fibres, cellular, and caver-
nous, were filled with a juice resembling the jelly of meat in
colour and consistence ;  and  it is singular,  that the carpal  and
metacarpal bones being  but  slightly affected, and the extreme
phalanges on which the nails are  implanted, entirely sound, the
intermediate bones were enlarged  to this  prodigious degree.
One only of the metacarpal bones, that, viz. which supports the
mid-finger, was diseased, and so far enlarged as to be an inch
and a half in diameter,  studded with some small tubercles, and
exposed in part by carious ulcers.   The carpal bones were per-
fectly sound.
   There is no case from which some lesson, more or less im-
portant, may not be deduced : all this description is interesting.
The two drawings represent, 1st.  the deformed and fetid mass,
the enormous tumours, the roughened skin, and the ulcers pe-
netrating into the cavities of these tumours. 2d. The skeleton
of the hand, exhibiting  the respective tumours of the middle,
-ring, and little  fingers, and  the  heart-shaped enlargement (c)
of the metacarpal bone of the middle  finger, is also singularly
interesting, demonstrating that the whole tumour is bone, per-
manent, and firm,  and not an expansion of the phalanges, but
a new secretion.  The bone of the fore-finger was not so much
diseased as deformed, dwindled  in size, and bent into an atch,
under the pressure of this tumour : the  thin shells of bone, the 
Of Tumours  of the Bones.              397
cancellated texture of the tumours, and the carious openings,
are also well represented.
  From this description we learn,  that it is not during  the  pe-
riod ot  high and violent action that tumour is generated. Mat-
ter is added to matter  in  the  animal body b) a slow process ;
whereas high  action terminates in suppuration,  gangrene, or
some violent  crisis.   The  state  of vascular  action, which is
slower, more  nearly approaching to that ot health,  resembling
the slow accession of disease,  or the remains of high action not
yet subsided,  is more favourable to the generation ot  tumour;
for such moderated action does  not injure  the structure of the
part, does not interrupt nutrition, allows the secretion  of new
parts to proceed, and, in so  far  as  it is accelerated beyond the
natural state, augments it.   You will take notice that it was not
while this hand was inflamed and suppurating, ('.or it  seems to
have been not merely bruised but wounded, ilavoit ete gueri
parfaitement de sa blessure mais peu de temps apres sa gueri-
son,) but after the cure was so far complete, and the increased
action not yet  subsided, that his hand began to swell.
  This case brings an important practical question to  a very
short issue, for these  drawings prove the local nature of the
disease, viz. that it is merely  in the bones, always in the heads
or softer parts, that the disease is seated : that the phalanges of
the fingers,  which are  peculiarly spongy, and  the lower heads
of the radius and ulna are most liable to disease.   Mery con-
fesses (without being conscious how far in  that case he was to
blame)  that one hall of the hand was apparendy sound ; and that
upon dissection, the finger and thumb were found in their sound
and natural state.*  How  then can we acquit him of rashness
in smiting off  the hand of a boy of eighteen years of age, with
youth and  health on  his side, and all the world before him,
when, by a less  painful  operation, he  might have saved his
thumb, tore-finger, and wrist?  Surely we may pronounce him
wrong, if there be one word of truth in  the case  of Severinus,
in which the thumb and fore-finger were saved.
   Of the  various questions which  cases of this nature suggest,
there is one which I am almost afraid to investigate. Wht.n in
an adult such  tumours appear, we have reason to hope that they
may be local,  and  that, by cutting  out the bone, we may extir-
pate  the  disease.  Even when such tumours  grow  at  once
on  various parts, we may, by circumstances, be induced to ex-
tirpate the individual tumours, and cauterize  their roots; but
what shall we  do when, in childhood, the disease  manifests it-

  * Cependant la moitie ou environ, en paroiffoit faine extcricurement, et le Poucc
et 1'lndex dans leur etat nature!. 
398
Of Tumours of the Bones.
self in various parts of the osseous system ? when all parts of
the bones seem (like the cellular fat of some diseased people)
disposed to excrescences ?  When tumour after tumour appears
in quick succession ? and the fingers, the hands, the wrist, the
elbows, the toes,  the  tibia, become affected ? when both hands
are crooked alike, griffin's claws in every finger; and when the
arms and feet begin to be deformed ?  Shall we remain specta-
tors of the ruin, joint after joint, of  a  fine healthy boy ? shall
we calmly look on till  each tumour has acquired its utmost mag-
nitude, suppurated, and  burst into that state  of loathsome ca-
ries which must close the  scene ? or anticipate this inevitable
termination,  amputate and cauterize those tumours, and even-
tually subject our art  to discredit, and ourselves to the personal
reproach of trying rash, severe, and  yet lingering operations ?
Although, in a situation so hopeless  we must be sorely tempt-
ed, yet duty and  charity, I fear,  compel us to refrain.
 . The rapid manner in which bone is secreted and accumulated
to an astonishing bulk, is one of the most singular phenomena
that occurs in the living body.  The instance I am now  going
to relate will,  I am sure,  appear surprising, but  it  is selected
for a far better purpose, to serve as an example of  the difficulty
we sometimes find, in saving the patient's life, even where the
the disease is local, and growth of the bone sensible  and  rapid.
I fear too it is one of a thousand examples, of a man lost in the
prime of life,  and dying a most loathsome and miserable death,
from  the reluctance of the surgeon to charge himself with the
fate of such a patient, or to predict the future consequences of
a tumour while it is yet small.—It is the case of a young man,
" committed to my humanity and skill," by Dr. Forbes, of Inver-
ness.
   Alexander Macdonald, a Highlander from Fort Au-
gustus, a tall  and handsome  lad, exceeding six feet in height,
and uncommonly athletic, was put to the  Perth Academy tor
his education in writing, book-keeping, and such other parts of
learning as might qualify him for a counting-house, as it was in-
tended to send him  to America a clerk  in the North-West
Company in the fur trade.  In running  violently at tennis, on
the academy green, he fell, and hurt his shoulder :  it was such
a  bruise as  often happens  from a fall, without entailing the
slightest ill consequence, beyond the first pain and swelling : the
skin was blackened by the bruise, and the joint was sprained ;
he had  excessive pain along  the  whole arm for twenty-four
hours, but it vanished gradually :—He imagined  himself well ;
he had recovered every thing but the strength of his arm  ; but
after  the  violence of the  pain,  (which lasted no  more than
twenty-four hours,)  was gone, such  weakness  remained, that 
Of Tumours  of the Bones.             399
though, from his  great strength, he could lift perpendicularly
such weights as others  could not move, yet he could never
raise his arm to his head.
  I was at pains to question  his father, a respectable old man,
concerning the part which received  the injury ; and he clearly
and decidedly affirmed, that it was not the shoulder-joint,  but
the middle of the bone of the arm that received the shock, it
was  along the whole of the arm that he felt the pain, and could
distinguish the marks of  the bruise.   The pain had, after its
first violence, totally ceased,  as if the part had sustained no per-
manent injury,  and he believed himself well ; it  was exactly at
the end of a  month, that the pain returned, and  fixed in the
joint, with a very distressing sense of weakness, so that he could
not raise his arm at all; if he meant to put on his  hat with it,
he had to  raise it with the other hand,  and when thus raised, if
he lowered it again without support, the moment it fell unsup-
ported below the level, it descended like lead.  Still he could
lift perpendicularly a very great  weight: but from  this second
period of pain we must date the disease. The whole arm swel-
led, but  especially about the shoulder ; his cries  and shrieks
were wild and melancholy ; living in a remote part of the High-
lands, it is natural for the father to express himself  in  the  fol-
lowing words, which he invariably uses when I question him in
regard to  the degree of pain, " Sir,  there was no hour of the
night nor day in which you  could not hear his wild cries miles
off."' ■ He represented the particular pain, by  saying, " it seem-
ed as if he had been bored with hot  irons; and his cries were
so unceasing, as well as so piercing, that though they lived in
a very long house, they had  no sleep from this time forward."
   That such had been his condition no one could  doubt, who
saw him before his death ; for the swelling kept equal pace with
these dreadful sufferings; at first the arm  seemed chiefly to
swell from the shoulder-joint; gradually the whole arm swelled,
and the fore-arm and hand  dwindled.  His body,  before lusty
and strong, was wasted with the agony and want of rest.  Yet
even at this time, when the  arm was monstrously swelled,  and
before it was entirely  oppressed, or  the fore-arm wasted, he
could lift as heavy a \yeight with the left arm  as with the right;
and even  to the last stage, that in which  I saw  him, his hand
was strong to grasp.   In the first  four months,  the upper  part
of the arm had so increased in size,  that the prominent part ex-
ceeded the size of his head, but now, at the end of nine months,
it greatly  exceeds in size his emaciated body.
   When  I went to  receive this poor lad, I found him lying
deep in the hold of a small sloop, in which he had  been trans-
ported from Inverness, laid on a coarse mattress, and bolstered 
400              Of Tumours  of the Bones.
up against the shelving side of the vessel; and when the clothes
were liited,  I solemnly declare, that I hardly  knew, at first,
what it was  that I saw,  which was the tumour, and which his
body,  or how to connect in imagination the one with the other.
He lay in an inclined and irregular posture, extremely languid,
and hardly able to articulate ; his head inclining to one side, the
tumour, when first exposed  by lifting the  clothes, might be
mistaken  for his body ; in respect of size, it was of a suitable
bulk,  and when the lean, yellow, and emaciated thorax was
next exposed, the tumour seemed so  much to exceed it in size,
with a shining surface  and brilliant colour,  that at first  I wa9
more confounded  than shocked, so impossible was it,  in  the
first moments, to consider of it as a tumour,  or to see its rela-
tion to the arm.   The fore-arm was dwindled and shrunk, and
projected from the tumour at a strange and unnatural distance
from the shoulder : the veins were swelled, like those of a hor-
se's bt lly :  large fungous tumours, as big as oranges, projected
in a group from the outside ofthe arm, at the place where, about
two months before, a large abscess had burst; and such was
the foetor ofthe matter running from  under these fungi, and the
langour of this poor emaciated creature, that I had  no thought
for the present, but how to get him conveyed alive to town. Af-
ter a  few days, when he was somewhat recovered from the fa-
tigues of  his voyage, 1 proceeded to write  down the history,
and examine the actual state of this tumour.
   It consisted chiefly of bone, was  little cartilaginous ; hardly
in any part elastic or yielding, and  discharging matter, not from
any  superficial abscess, but apparently from  the centre of this
enormous mass.  I had every reason to believe, that  the bone
and the joint, which certainly were neither  broken nor dislo-
cated,  had been generally  injured,  not  merely by  the  shock,
but by the bruise : that the  parts  nearest the bone, and con-
nected with  it by  the  periosteum,  had been bruised and in-
flamed: that the extreme pain for the first twenty-four hours,
indicated only the violence of the immediate  injury, but the
slow  vascular action  which succeeded, at  the  distance of  a
month, proved how deeply the circulation of the bone was af-
fected, and caused that osseous secretion which generated  this
prodigious  shell of bone;  while  the  shaft  of the humerus,
from the  periosteum of which this  callus had been  secreted,
was in part destroyed bj an ulcerating process within:  that the
ulceration, deep seated,  not only in the bone, but in  the joint,
occasioned  those excruciating  tortures which were announced
by wild and desperate  cries,  night  and day: that  the  matter
bursting at  last  through every obstacle,  had made its way
through that ulcerated  part of the surface, which  is studded
with fungous excrescences. 
Of Tumours of the Bones.             401
   This bursting out of the matter brought relief from the pain;
 he now, lay in a state of extreme languor, moaning and slum-
 bering ; you found it  painful even to question him, he was so
 feeble ; he fell,  after a few  broken answers, into a slumber of
 mere debility, and closed his eyes as exhausted; and while I
 took the sketch  of his posture,  and  of the proportions  of this
 prodigious  tumour, he  slumbered continually.   His extreme
 weakness precluded every practical experiment, and left for
 our  discussion  the speculative question only; " In a case so
 deplorable and hopeless, what should  we have done at an ear-
 lier  stage, when the patient's strength was  more  entire, and
 youth and vigour (for he was but twenty-one years  of age) on
 his side.?"
   Here, for the first time, I felt that a bony tumour might, by
 advancing to the trunk of the body, preclude amputation as en-
 tirely as aneurism of the subclavian artery!   That the question
 here to be resolved was not, whether we  might dare to ampu-
 tate  at the shoulder-joint, the  question  was of amputating the
 scapula also, and along with it a tumour, exceeding in size
 even the trunk of the  body!  and the accident mentioned by
 Cheselden, (an accident which  has  often happened since)  of
 Wood, the miller, whose arm, scapula and all, was rudely and
 suddenly torn from his body, could not but come into our recol-
 lection.  There was hardly left us even  a  choice to exercise
 our discretion and skill upon ; for, from the state of the veins,
 large, tortuous,  and already ulcerating, and so numerous as to
 give a livid  colour to almost  all the surface of the tumour; it
 was  plain, that he  was in daily peril of haemorrhagy, and that
 this  was at no remote period,  certainly within a few weeks, to
 put a period to his life !  Could  there then be a question, whe-
 ther to wait in fear of that haemorrhagy, which was assuredly
 to end in death,  or to risk by  operating, that haemorrhagy by
 which he might  be saved alive ?  For my part I had not the
 shadow of a doubt: what should determine us in  any despe-
 rate case, to do desperate things ? Surely the possibility of safe-
ty through operation, the certainty of death ! I saw it possible,
by trying first the subclavian artery, the root of all the circum-
flex arteries of the shoulder  and scapula, to prevent any alarm-
 ing degree of haemorrhagy ; by sawing across the outer end of
the clavicle  to get command of the  scapula, and turn it  back,
as easily  as  the flap from an ordinary stump;  to tie when it
was cut, the arteria transversalis scapula?, and certainly to sepa-
rate  the whole,  without immediate death.   But had this been
an enterprise as certainly fatal  as the  Caesarian  section itself,
still it gave some chance for life.  Confident in the justness of
this reasoning, moral and physical, I  should have urged him
                            3  E 
*02             Of Tumours ef the Bones.
to this awful trial, and devoted myself to -the task; but he was
sunk too low for any trial, and to be regarded only as a? object
of charitable care.  He died in the Royal Infirmary, of hit-mar*.
hagy, about three weeks after his admission, and these are the
notes of the dissection.


             DISSECTION, July 13th, 1806.

  " Having divided the  integuments, which were extremely
thin,  we found, on attempting to cleanse  the tumour from one
extremity to the other,  that it was of a substance much resem-
bling callus; in many  places it was so firm and solid, that af-
ter trying in vain  to divide it with a strong knife, we were o-
bliged to betake ourselves to  the common amputation-saw.
  " The cells of this bony tumour were every where filled with
a matter resembling thick cheese; the tumour  itself, from its
great size, and the entire appearance of the  os humeri, seemed
only to be attached to that bone ;  but upon a more minute  ex-
amination, was plainly a production from its substance.   The
humerus could be traced through the whole tumour ; but  en-
larged, spongy, and ulcerated.  The upper part of the scapu-
la,  the acromion  process, and  the  outer end of the clavicle,
could, during life, he plainly distinguished to be enlarged, and
to form part of die tumour;  and upon dissection, all the  bones
forming the shoulder-joint were found to be deeply diseased.
The upper and most bulky part of the tumour,  seemed to pro-
ceed  as much  from these, as from the os humeri, and the joint
was completely anchylosed."
   There is a period in every such case, when the tumour  being
still of moderate  size,  and yet requiring an operation of  the
most desperate and unprecedented  nature, viz. the amputation
even of the scapula itself; the question must be of the most per-
plexing and agitating nature.   The surgeon must be conscious,
that the patient is to die a loathsome and miserable death;  yet
it is a consciousness which he never can bring home to the mind
of  the patient  or  his friends, and if he take upon  himself to
urge  an operation so  desperate,  and  the patient  should die,
the slight  impressions  his representations  have made vanish,
die danger, which was distant and problematical, has  been  ac-
celerated by his misconduct;  by his ill success he is condemned,
and never can it be put out of the minds of the  relations, that
the patient might  have lived, or that even  the tumour  might
have burst and resolved into  matter.  But a precedent like this,
and I have witnessed and could relate many, solves all scruples,
and he who knows the constitution of such a tumour, its inevi- 
Of Tumours of the Bones.             403
   table increase, and the loathsome end of the sufferer, will nor,
   I believe, shrink from  his duty.  This  case is; highly interest-
   ing, as it is the direct consequence of a very ordinary mischance^,
   of a slight fall,  and a bruise importing nothing: it is not mere-
   ly a prodigy to be gazed on, but an important precedent.
     Allow me, before I forsake this interesting subject,  to  give
   you one document  in  practice,  from the universal ignorance,
   or wilful neglect of which, 1 see every day the most dismal con-
   sequences.   A bone, both in itself, and in its surrounding vas-
   cular apparatus,  is as susceptible of inflammation, and while it
   is inflamed, or in danger of being inflamed,, should be as. deli*
   cately treated as  the soft parts.  How  often,  how continually
   you have seen this injunction reversed, I need hardly remind
   you: every bruised bone,  and sprained joint, is rubbed and di-
   ligently moved.   With an ignorant and stiupid fear, of the. joint
   losing its motion, it is wrought backwards and forwards' in eve-
   ry direction! and whatever inflammation is begun, is never per*
   mitted to subside !  Thus a military gentleman, whose humerus
   was  diseased,  with,  I doubt  not, an  internal caries, (tor h
   have dissected sueh cases, and kept in preparation very long, a
   shoulder-joint thus diseased internally,, which betrayed no out*
   ward appearance of disease) and who had.excruciating pains, a
   total lameness, a singular emaciation of the whole member; and
   who, though he could mount his horse, couldi not endure the
   motion of it, even at a foot pace, was ordered by die  physicfc
   ans he last  consulted, along with various other prescriptions, to
   have his arm turned and wrought backwards, and forwards by
   his servant with all his strength.  He fainted more than  once,
   under this discipline, and fortunately was not able longer to en-
   dure what must have killed him in the end;  by completing that
   caries  of the joint which was at that  moment just remediable.
   He came from Ireland, and put himself under my care, and by
   a course of stimulant fomentations,  by bandaging his arm  to his
   side with rollers,  as closely as if it had been fractured,  and by
   renewing caustic issues all  round  the  acromion process, and
   head ofthe shoulder, and keeping them running for six  months,
   he is now almost entirely cured.  His arm, notwithstanding the
»  stricture of the  bandages, has recovered its flesh and firmness;
   he can raise  it now without pain, and  finds that he could use
   it with confidence: but, I think it right for  a limited term to
   keep him safe,  with the arm slung,  and without motion, till
   every tendency to disease is gone.
     A young lady,  whose arm I have been obliged  to  amputate,
   fell, at  the age of fifteen, from a table, and sprained her elbow-
   joint.   The immediate pain was just sueh as is usual on such
   slight accidents;  it subsided,  and there remained  only that 
404             Of Tumours of the Bones.
dead and heavy pain, and stiffness of the joint, which indicates
that the ligaments and periosteum are not yet relieved from the
inflammation, and which requires stimulant fomentations; per-
haps a caustic issue, and  perfect rest:  what was directed?
Why,  that she should carry all day long  a heavy dressing-iron
in her hand, to straiten the joint by the continual extension,
and that she should, by frequent exertions of swinging this load
backwards and forwards, with the help of a servant to twist and
turn the joint, try to recover the free motion of it.  This im-
prudence has almost cost her her  life:  the internal inflamma-
tion was never permitted to subside; the joint swelled, burst
out in fetid ulceration;  the bones and the joint became  com-
pletely carious ; paroxysms of inflammation, new suppurations,
and weeks of excruciating pain before the bursting of each ab-
scess,  reduced her to the lowest extremity of weakness: she
had haemoptysis and every appearance of confirmed hectic, and
approaching death, when a consultation dictated the amputation
of the  arm as the only  possible means  of saving  her.   Since
the operation, and even before  the adhesion of the stump was
complete,  she had, by pleasant sleep, and the return of appetite,
recovered her strength  and freshness of complexion, and  is
now in perfect health.
   Such errors are so commonly and thoughtlessly committed,
that they are as it were contagious;  we do what we see  daily
done  before us, without thought or reflection, which  make9 a
document of this nature, on  an ordinary occasion, of no  slight
importance to the young surgeon. 
•-(  405  )
DISCOURSE  XXIII.
      ON TUMOURS OF THE NOSTRILS, GUMS, AND
                             THROAT.


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

lieved that these are cases of peculiar malignity ; that there are,
certain polypi which the surgeon need not disturb, and should
not tamper with, and others which he  assuredly cannot cure.
But were this conviction ever brought home to the mind of the
surgeon, then should  his good offices be at an end ; surely we
must not in any case pretend to meddle with a disease, which,
if mild in its species,  we should not irritate ; which,  if  malig-
nant,  we cannot cure ? But  I have some experience in this line
of practice, and some judgment in this department of reading;
and have strong suspicions of something wrong,  if not unfaith-
ful, in these opposite representations.  Polypus is never  mild,
nor ever malignant; time, and the natural  growth of the tu-
mour, and the  pressure it occasions* within  the  soft  and bony
cells of the nostrils and jaws, must bring every polypus to one
invariable form, in its  last and fatal stage.  Those who are em-
ployed in recording cases on unquestionable facts, give us the
true and only picture  of diseases, they speak of none  which
they have not seen ; but systematic authors, obliged to explain
each disease  in its order, give descriptions of diseases widely
distant from truth, describing what manifestly they  have- not
seen,  and explaining, without the slightest remission of their
wonted confidence, what they  have not  learned  and cannot
know.  Whatever you might learn, (yetthat would be in an
irregular and dangerous way) from books of cases, be assured
you  might  read  those  systematic  authors, (which  I  might
name, I  hope, without envy, and which  I  allude to without
malice,)  from  sun-set until sun-rise, without conceiving the
very slightest notion of the disease of which 1 am now to speak.
   Polypus is indeed a dreadful disease ; but like every other, it
becomes so by a slow progression, and advances by gradations
easilv characterised, and which you will do well to mark.  It is
described as " a small and pendulous tumour, projecting in the
nostril, void of pain, attended with  no worse symptoms than
watering of the  eyes, and  sneezing, sometimes soft, some-
times firm in its texture, and moving backwards and forwards
with  the breath.  You would imagine nothkig  more  simple   -
than to noose such a tumour with a thread, or pull it away with
forceps.                                                      #
   And so indeed  is every polypus in its early stages, a small,
tight, and moveable tumour, attended with sneezing, watering
of the eyes, swelling  in moist weather, descending with the
breath, but easily  repressed with the point of the  finger, void
of pain,  and in no shape alarming; and  it is easilv  extracted
too, so as for a time to clear the passage for the breathing! Yet
this little tumour, simple as it may appear,  is the germ ot a
very fatal and loathsome  disease; and this easy extraction, the 
      On, Tumours of the Nostrils, Gums, and Throat*   407

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

hangs over the fire, cold from loss of blood, pale as a spectre,
his lips colourless, and his face like wax, yellow and transpa-'
rent:  he hangs his head forwards, resting it on his hand, and
moving it incessantly from side to side, from the intolerable
pain, the saliva distilling from his mouth, and the foul matter
dropping from the nose : in this state he survives a few weeks,
desolate and hopeless.  During the last days of  his illness,  he
lies in a state of perpetual stupor, and dies lethargic.
   Never can you thoroughly know this part of your profession,
nor arrive at a just sense of the danger of this disease, till you
have seen your patients thus suffering and dying; nor have you,
from systematic books of surgery, the very slightest intimation,
that  scenes like these are passing  in the chambers of the  sick.
Perhaps, it will be said,  (I wish it could be justly said) these
are very exaggerated  pictures! they are, on the contrary,  so
very faithful  and true, that I, who have witnessed them many
times, know not how they can be exaggerated :  I have traced,
as simply as I could  describe,  with  any regard to truth, the
phsenomena of this disease,  from the stage reputed  harmless
and  mild, to that reputed malignant.   If, indeed, horrid symp-
toms could establish the fact of malignity, that there is not to be
found in all nosology  a more malignant disease  than this : but
aneurism, though it destroys the thigh-bone, the sternum,  or
the  cranium,  is not accounted  malignant; neither is polypus
malignant, though it  destroys the cells of the  face, and pene-
trates even through the ethmoid bone, to the brain.
   I  shall demonstrably prove to  you that polypus is a tumour
in itself indolent and  harmless; that it is no farther malignant
than as it does, by universal and irresistible pressure in the lat-
ter stages, destroy the bones: that circumstances determine the
growth,  and the more  or less rapid  growth,  determines the
fate  of the patient:  and I shall, I doubt not, prove to your con-
viction, that it is far better  to suffer the salutary pains of ope-
ration and caustic, than the  unavoidable  tortures of a disease*
which, as soon as it  becomes painful, is incurable.   You are,
by every law,  moral and professional, bound to continue your
good  offices to your patient, while he  consents  to suffer, or
there remains the slightest hope of success.  While the doc-
trine of benignity and malignity (and  these terms are repeated
in every page of Pott and other writers) is acknowledged,  while
the  surgeon pronounces every incipient polypus mild only, be-
cause it  is small, and as yet  harmless; and every polypus ma-
lignant which  has attained  a  conspicuous size and more solid
texture,  and begins to affect the bones:  while  he neglects the
beginning, and shuns all concern  in the  lamentable conclusion
of the disease, no patient's life is safe;  • 
Of Tumours of the Nostrils, Gums, and Throat.  4Q9
        Yet, with all these distinctions of mild from malignant polypi,
      and endless injunctions not to tamper with the disease, no au-
      thor can refrain from  praising that operation, whether by liga-
      ture, forceps or caustic, to which he is most favourably inclin-
      ed; and  in  such familiar terms  are  the several stratagems for
      reaching the roots of the tumour described, that I know not
      how the young surgeon  can  escape a deception so naturally
      suited to the complexion of an ardent and  inexperienced mind.
      It is impossible to read the  boundless commendations  lavished
      by each author on his  own peculiar operation, without being
      persuaded of its  efficacy,  and imagining  besides  a thousand
      other ways,  the  least perfect of* which will  equally succeed:
      but there is a sad disappointment when we put those  inventi-
      ons  to the test of actual practice.   Instruments and methods of
      cure have been imagined in the  closet, by men who have not
      even introduced a finger into the nostril,  much less felt the in-
      finite difficulty of  casting a noose  round a polypus ; and the re-
      sult is, that, while these methods are very seemingly perfect,
      declared by their inventors  to be  infallible, and allowed by all
      to be ingenious, they are altogether unavailing when put to the
      test.  The young surgeon finds these practices so described in
    .. books, that  he thinks of nothing  but the admirable ingenious -
      ness of the invention, nor can he admit a doubt, that he can in-
      troduce his  probes,  his tubes, and his catgut or wires, so as to
      noose the tumour: but when he goes to grapple with the actual
      disease, and while he is struggling to apply  his wires, the  nose
      is streaming with blood, the patient staring  and struggling as if
      in. the act of suffocation, the tubes and forceps are thrust perse-
      veringly into the nostrils and  throat, the  forceps are next dri-
      ven deeper into the nostrils, the blood streams again, and  the
      pendulous parts of the polypi, which are more prominent in the
      nostrils, are bruised and mangled, while their roots are left en-
      tire, and only fragments of the tumour mixed  with the clots of
     blood, are found upon the clothes.  The patient terrified, sick-
     ened, and spent with haemorrhagy,  prays for some suspense of
•  his  suffering, at the moment when the surgeon begins To be
     abashed at his ill success; he  desists, for awhile,  from farther
^  violence, but the  same unsuccessful operations  are  repeated
™  from time to time, and if but the slightest breath of air  pass
     through the nostril, he takes advantage of that seeming success,
     and introducing bougies, or a thick roll of  lint, persuades  his
     patient that his condition will  improve daily.  But the patient,
     after a season spent in vain and  miserable endeavours to pre-
     serve the nostril free, returns to town with carious  bones,  de-
     formed features, a projecting polypus, a frame exhausted with
     suffering, ami especially exhausted  by suffocation and want of 
410
Of Tumours ofthe Nostrils, Gums, and Throat.
sleep:  his life is threatened every  moment by impetuous hae-
morrhagies, and he is plainly beyond the help of better surgery.
  God forbid that I should impute such  negligence to a de-
sire of gain, or contempt of duty, to a haste to succeed, or a
vain desire to appear successful.   These are the consequences
merely of a deception, which no one who takes his ideas from
books can well escape.  The operation of noosing a nasal poly-
pus, which I shall prove to be altogether futile; or that of ex-
tracting it with forceps alone, which I know by experience ne-
ver can be perfect or successful, are yet represented as perfectly
effectual.   The operation of noosing a polypus is one which the
young surgeon is taught to perform with all the ceremonies and
circumstances of an operation;  and if it is but so performed,
that the wire  or ligature does not immediately drop away, all
the instructions he has ever read or heard of,  seem to be  ful-
filled, though  the tumour begins to project again in a few days.
He believes the cure of polypus to be  an operation to be ac-
complished at once, by a coup de main,  while in truth  it is  a
cure to be accomplished by various and  persevering  methods.
The operation of noosing or extracting a polypus is far from
being a splendid piece of surgery,  fit to be exhibited in an ope-
ration room.   I have  never known an  operator put  on his
sleeves,  and address himself to the work  with those  mistaken
notions; and  in the hopes of visibly unrooting the tumour with
the forceps, or entangling it in a noose, who did not retire from
the sce»e with confusion and dismay.  The horrid scene which
ensues,  the  quick re-production of the tumour, and the caries
of the bones, is not the effect  of tampering with a malignant
 disease, but the natural progress of a tumour  uninterrupted by
 operations so imperfect and  mal-adroit.   Let no man attempt
the cure of this disease  whose  sole purpose is to  shine as an
 operator; who has not perseverance  and diligence  enough to
 try, successively, every method, and humility enough to be
 contented with  the  happiness of saving his patient  by any
 means.
   I verily believe, that none are more innocent than those who
 deceive  us by commending such trivial operations, for they first
 impose  upon themselves.  They  invent an instrument  or  me-
 thod indisputably ingenious,  and with all the simplicity in the
 world imagine, because it is ingenious, that it must be useful.
 I believe the  very reverse of this might be proved  by all  past
 experience, in respect to surgical inventions; for the most cu-
rious and ingenious have invariably proved the most inefficient;
 and, if passing over the first inventor and his eulogiums, you
inquire ofthe next who tried the  instrument, you Jind it  quite
useless; or, if one have performed the operation, and it be left 
       .Of Tumours ofthe Nostrils, Gums, and Throat.    411

to another to report ite success, the reverse is sudden and mor-
tifying.   Speaking on this subject, I cannot  help laying before
you one example of this,  to me the more striking, as I remem-
ber how much I was delighted when a boy, with the piece of
mechanical  ingenuity which I am now going to explain:  so
much was I delighted,  that in my admiration of the author's
genius I  contrived to forget his ill success.   The operation is
related in the third volume of the Edinburgh Essays, Physical
and Literary.   " A  man of the name of Davison, very far ad-
vanced in years, was admitted into the Royal  Infirmary, with
a voluminous  polypus, which  had its root near the epiglottis,
lay within the oesophagus, and was occasionally vomited up,
when he was excited by emetics, or by thrusting the finger into
the fauces.  The polypus then occupied the mouth, extended
to the fore-teeth, and appeared to consist of four distinct lobes,
arising from one root or  neck.  But the polypus,  while it thus
occupied the mouth, prevented the breathing of the patient, by
covering the opening  of the  trachea; wherefore,  having just
shewn it to his surgeons, by vomiting it up into the mouth,  he
was obliged presently to swallow it down  again  for want of
breath.  His speech, his swallowing, and his  breathing, Vere
all so affected by this very voluminous tumour, that it became a
very interesting question how to extirpate the tumour:  and it
was proposed, that while the operation of bronchotomy was
performed to give him breath, the noose,  by the help of some
very ingenious useless machines  should be cast over the  tu-
mour, which latter part of the scheme was fulfilled in the fol-
lowing manner:  a  ring, mounted on a stalk, and  having the
thread designed for  ligature concealed within the  circle  ot the
ring, was  pushed down into the fauces : the pushing down of
the ring excited the  patient to  vomit, and the ring so occupied
the fauces, that when the tumour was vomited up it was  driven
through the ring ; the  ring was then pushed harder down  to-
wards the  root of the tumour;  the ligature was then  drawn
tight; other instruments with wheels and  pulleys for passing a
double ligature  (the single one not succeeding) were next  in-
vented ;  and finally, the purpose was so effectually accomplish-
ed, that the polypus was strangled:  he passed, by stool, lumps
which he mistook for clots of  blood; but he passed also along
with  those, the loop of the  ligature with which  the polypus
was noosed."  It is, in  short, insinuated  in the surgeon's nar-
rative, that the patient had passed the bulk  of the polypus by
stool; and it is directly affirmed, (by Mr.  Dallas, the operator)
that " having, at the end  of the month, sent for the patient and
examined his throat, and made  him vomit, nothing preterna-
tural appeared; and that, having presented himself  at the dis- 
412    Of Tumours of the Nostrils, Gums, and Throat.

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

      * It is by no means a matter of flight importance to afcertain this point.  Wc
    know by difiect.ion, and by much fad experience, that polypi are rarely folitary ;
    th;;t the whole membrane is difeafed, that both noftrils are frequently affec'ted j
    rhat the cells as well as the paffages of the nofe and throat are ftudded with polyp;,
    of various fizes.  The melancholy cafe which I am now to trartferibe, orrrther to 
414     Of Tumours ofthe Nostrils, 6ums, and Throdt.

   Polypi hang forwards in the nose, in a direction so unfavour-
able to their being noosed, that I see it, from the preparation,
                           plan  no.  1.
™tomife, from u.,e of the mod celebrated writers on th.s  dtforder, is a proof
wTarely it is local, how impoffible that it fhould be produced by p.ck.ng the
nofe or any fuch injury, how univerfalty the membrane is difeafed.
   « A young man," fays Manne, «• of twenty-feven yean of age, d.«Ut  La
Charitc.  Three vears after having the fmall pox, from which period .1, 1.. 
Of Tumours ofthe Nostrils, Gums, and Throat.     415
   as improbable, as I have felt  it in practice impossible  for the
   young surgeon to  succeed  in noosing them; and a  practical
   fact is the point to which I shall particularly call your attention;
   yet let  me acknowledge, that it  is  by experience alone that I
   have learned how  difficult  it is  to noose that lesser  polypus
   which hangs forward in the nose.   Had I sat down, like many
   ot  my betters, in the closet,  to contrive  ways of noosing such
   a tumour,  I could have imagined nothing more likely to suc-
   ceed than the common process.  I no more doubted than others,
   that the method which I found so ingenious, when described in
   books, could fail me in the act.   Allow me to explain, first the
    Plan  No.  1,  from which  you  will learn the actual  circum-
   stances of these kind of tumours.   Secondly, The plan, No. 2,
   which will illustrate this indescribable and unforeseen difficulty
   of noosing them.   In this plan 1, fig. 1, you cannot but remark,
    that the three polypi, with which the nostril is filled, the largest
    marked (aJ,  the  next in  size, (b), and the third, (c), hang
    from a point very high in the nostril, and very far back, that
    their roots must be in the posterior  end  of the upper spongy
    bone, under the socket of the eye,  and  not far from the open-
    ing of the Eustachian tube.   Of this you will be satisfied by
    looking to Fig. 2, taken from the  same preparation,  hanging
    still by the  same thread, only turned round,  so as to  shew the

    been afflicted with polypi in the nofe ; a whole hot-bed of  them (fays the author),
    if 1 may be permitted to ufe the term, appeared.  He had in the paffages of the
    throat and nofe, in the  antrum maxilhlre of each flde, and in the frontal finufes
    >iven  polypi in all.  His face was Ihockingly deformed ; he had a great bulging
    at the root of the nofe ; his eyes were removed from each other, by the fwelling,
    to  three times their natural diftance,  and feemed burfting from their fockets; the
    noftrils were expanded, and the nofe flattened and extended; while the cheek
    bones  were raifed  to the level of  the nofe, and the face and head fwelled to an
    enormous fize. The ears were obftru&ed on either fide ; the tears flowed over the
    excoriated cheeks, and fometimes fetid pus burft out from the fiftula lachrymalis
    on either fide.
      " While his head and face were thus externally  deformed, the palate  of this
    miferable creature was  fo depreffed that it lay upon the tongue, and bulged fo,
    that the lower jaw was depreffed; the mouth kept perpetually gaping,  fo  that
    the faliva diftilled continually from his jaw», while the noftrils were diftended by
    the bulbous extremities of two larger polypi.
 •    " In  differing his head thefe polypi were found  to have occafioned great de-
    vaftation ; the cheek was laid open by a crucial incifion, and the upper maxillary
6  bone feemingly annihilated,  nothing being left of the walls of the antrum but a
    thin fcale like the peeling of an onion : on opening the oppofite cheek they found
    the antrum burft open in aftar-like form, and on dividing  the delicate membrane
    which  clofed thi9 breach in the antrum, a thin and bloody ferum exuded, and
    there projected from the cavity a fmall portion of a very firm and elaftic polypus
    of  a red colour; and when, by cutting and tearing away the reft ofthe bone, the
    tumour was found very  large and quite inlulated, except at its neck,  which was
    of  fuch dimenfions as to be eafily embraced in the circle of the fore-finger and
    thumb.  It refembled a turnip in refpect of fhape; its lower end was bulbous and
    large;  but its pedicle, or immediate attachment, was fo exceedingly delicate  that
    it feemed difficult to imagine how fo great a tumour could grow, or evun be nou-
    :.fhrd,  \v'ien formed, by fo fmall a  roct.  Tr was no more than one line  ''the 
416    Of Tumours ofthe Nostrils, Gums, and Throat.
 back of the nostrils; and here the same  iron probe (d)  is'left.
 in the nostril.   You may see how this nostril (the right one) is
 dilated by the polypi.   The septum  or partition of the nostril
 (e) is inclined, by the  pressure,  towards the left.   The poste-
 rior opening of that nostril into the throat, marked (fj, is great-
 ly dilated; nor must you wonder at  this, for the tumour was
 once large and bulky.   Tumours which,  in the  dead body, are
 flat, long, and corrugated, by long  immersion  in spirits, may
 not  only have filled, but distended  the  nostril, and dilated it
 permanently:  (g) marks the centre of the septum  greatly  in-
 clined to  the  left, and  (hj marks the mouth or opening of the
 Eustachian tube;  the tumours taking their origin betwixt this
 and the  nostril, marks  the point of their  origin to be the upper
 spongy bone; and the patient suffering deafness  from the  pres-
 sure of the polypus against  this  opening, shows, that slender
 as the tumours  appear  in this preparation, they had,  when the
 patient was active,  and the blood in  full circulation, been suffi-
 ciently bulbous to  occupy the whole circle  of the opening,  (i):
 fk k) marks the whole length of  that slit-like opening, betwixt
 the septum and spongy bones, which the  finger can never pass,
 and which, from its narrowness,  occasions the chief difficulty
 in managing instruments of any kind, and  especially those tubes

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

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

the nostril opens  backward  into the throat.   Remember the
length of a polypus, (a circumstance which shall be demonstrat-
ed by other drawings) and that however low the bulbous part
may descend, or be felt bv  the finger, it is only by  pushing
your instruments deep, beyond the narrow cleft formed by the
projection of the spongy bone, that you can do  good.
plan no. 2.
   Let me next represent to you, in explaining the plan No. 2.
what I conceive to be the chief difficulty in applying the noose
to such tumours: the tube Fig.  (1), was invented by Mr. Lev-
ret,  for the purpose of passing a silver wire as a noose, and of
tightening the noose after being thus applied; and in the appli-
cation of the ligature, which was new, and peculiar to Levret,
he had no motive so much at heart as the guarding against hae-
morrhagy.   This was a vain fear, for though I have seen dread-
ful haemorrhagies in the last stage of polypus, I have never, in
twitching awav polypi with the forceps, seen a hamorrhagy
worth  regarding';  I have always kept a ligature in the  nostrils,
and a plug in the  mouth, ready to be drawn up, by the help of 
Of Tumours of the Nostrils, Gums, and Throat.   419  '
   that ligature, into the posterior opening of the nostrils, but have
   not found occasion actually to draw up the plug more than three
   or four times  in  my life; and then rather from  fear than dan-
   S"*- m The tube of Levret is thus used, the loop of the wire
   (bj is passed over the lower end or  hulbous head of the poly-
  pus, and hitched higher, towards the root of the tumour,  by
  pushing the tube deeper and higher into the nostrils, or others
  (I know not who, for such probes are drawn in every book) ad-
  vise us, after laying a noose of wire or cat-gut loosely about the
  tumour, to hitch it up to the  root, where the tumour rises from
  th« bone,  by pushing it higher,  first on one side,  then on  the
  other,  by  the  help of the forked probe, Fig. 2.   But when vou
  look to the scheme or imaginary plan  of such an operation,* fi-
  gure 3, you will foresee much  difficulty in  accomplishing it;
  for the tumour, long and slender as it always is, hangs in  the
  direction in which you are to push the ligature ; the ligature or
  noose,  you never entertain a doubt, is to run as clean and easi-
  ly  along the polypus as a ring slips upon the finger,  or as the
  ring of a window-curtain slides along the cord! but the  truth
  is,  that either from the polypus being forced backwards into the
  nostril along the ligature, or  by the hitching of  some  part of
  the noose against the  inequalities of the polypus,  or by the nar-
  rowness of the nasal cleft catching the wire, it certainly is not
  merely  difficult to apply it, but impossible.   I have seen such
  an  operation attempted fifty times, by  men of various degrees
  of skill, and ingenuity, some extremely awkward, some perfectly
  dextrous, but never have I seen  this method succeed: if even
  the ligature hung two days by the polypus, still the extirpation
  was but partial; usually the ligature gets  no hold  on long and
  slender polypi,  which hang thus  forwards in the nostril.   No-
 thing, gentlemen, could tempt me, in a question where I am to
 deliver,  not an  opinion, but  a pLiin fact, to prevaricate or dis-
 guise the truth, however unfavourable to myself; I have no
 curious  nor cunning  operation to  substitute  in place of that
 which I condemn;  but I solemnly and  impartially declare, that
 with my best and most sincere endeavour  to succeed,  I  have
 always miscarried in attempting to catch  a nasal  polvpus in a
 noose of wire or cat-gut; I have  planned nv little operations
 so cunningly, that I have imagined it impossible I should  fail,
 vet,  in my  best concerted schemes  I have been foiled as  com-
 pletely as the most awkward person I ever saw attempt the  ope-
 ration.   I shall ewr therefore  retain a suspicion, that the  me-
 thod  itself,  rather than any want of address on my part, is to
 blame.
   If  I am correct in ascribing this difficulty to the direction in
which the  nasal polypus hangs,  being  the same  with  that in 
420    Of Tumours of the Nostrils, Gums, and  Throat.

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

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

      PLAN NO. 4.
 
       Of Tumours of the Nostrils, Gums, and Throat.    423

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

the antrum, the operation of noosing is not practicable, and no
ordinary operation,  nor common degree of violence is likely to
be successful in eradicating the disease.   Thus far is early pain
a sign  of  greater malignity, or, in other terms, ot that  de-
structive pressure, which in the end causes caries, hasmorrhagy,
and death.
   One  thing more I beg leave to observe :  it seems to me that
the predisposition to disease is  universal in the Schneiderian
membrane ; that the earliest appearance of the disease  is, in
general, swelling, especially ot that part ot the membrane,
which involves  the  spongy bones ; that almost universally the
disease is produced by cold ; that many of those who have been
under my care,  having  got wet in riding, running, or  other
exercise,  have had a sudden and sensible cold,  attended  with
violent  paroxysms of sneezing,  which has never for a moment
ceased, till the polypus was perfectly formed, the breathing ob-
structed ; the  particular character of the tumour, viz. that of
moving backwards and forwards with the breath becomes per-
ceptible, and the polypus, in short, tangible with the finger.
Where  the polypi are incipient only,  they are flat and broad,
have  no pedicle, do not hang pendulous, but seem merely a
general swelling of  the membrane ; in  some  cases while the
complete polypi  in one nostril are long, slender, and pendulous,
the incipient polypus in the other is flat,  membranous, resemb-
ling one of the nymphae in form, without a pedicle, and to all ap-
pearance a general swelling of the membrane: but I hold it un-
questionable, that such an enlargement would in no long time be-
come a conical polypus, for it seems to me that the neck or pedicle
is formed by time, and the pendulous posture ot the tumour  : but
a conclusion far more important, not certain indeed but probable,
and not unworthy of consideration, follows, viz. that since the dis-
ease often is formed instantly, and sensibly, after a violent and sud-
den rheum or cold, and as it consists at first in a mere relaxation
of the membrane, there is a stage in which it is perhaps curable
by astringent solution, and the use of caustic.
  From the conceptions  which now open upon you of the na-
ture of  this disease,  you must naturally suppose, that in  place
of arranging polypi  according to the imaginary  characters of
soft, and hard, mild, and malignant, I should rather define the
several stages and periods of its growth, and describe the opera-
lions  corresponding with each stage.  It is not by books  nor
conversation, that you will ever be able  to  decide which mode
of extirpatiug a polypus is to be preferred : you will learn only,
that some have used ligature, some caustic, some forceps,  some
the cautery, some heated irons, some long needles, with which 
       Of Tumours of the Nostrils, Gums, and Throat.    425

they have bored and transfixed the polypus! That old surgeons
have been in the practice of cleaving the palate most unrelent-
ingly, to get at those  polypi which hang in  the throat ; while
others have most audaciously proposed, to cut open the nostrils
and cheek-bones !  Each praises his  own method as invariably
successful ; and the imagination of the young surgeon being
left, distracted among such a chaos of inventions,  though he is
at a loss to choose, never doubts, that with such a variety of
means before him, and the privilege of trying one after another,
he  cannot entirely fail.   Many an  operation, good and bad,
successful and  unsuccessful, have  I  witnessed ;  and  certain
practical conclusions,  which I  neither  sought nor imagined,
have come to be established in my mind ; but especially these :
That the surgeon who attempts to noose a polypus of the  nos-
tril, invariably miscarries ;  yet  this  is the kind  ot polypus,
which being easilv seen and felt, is supposed to be most easily
noosed.   That the big and bulbous polypus,  which descends by
the  back of the nostrils towards the throat, and depresses the
soft palate, though usually shunned as too bulky to be grappled
with, is truly the most favourable  for  this  operation ; this is
indeed the only period of  its growth,  in which the poly pus  can
be  effectually noosed.  That the polypus which has its  root
within the antrum maxillare,  is characterised by early and per-
manent pain,  the caries of the jaw-bone, and the dropping out
of  the teeth,  and that  it  is not to be reached with  the silver
tubes of Levret, nor to be  noosed, nor extracted by ordinary
methods, is too obvious to require illustration : it is equally ob-
vious, that the polypus which has already burst up the cells, and
produced  a general caries among the  spongy bones, is past all
surgery :  That the extraction of the polypus in such disastrous
circumstances, only hurries on the catastrophe, as I shall prove
 by sad memorials.  After being long perplexed,  as every one
 must be who takes his first ideas from books, concerning the
 preferable modes of practice,  I learnt from  experience, what I
 regard as a discoverv more precious and useful than that ot the
 most curious instruments, viz. that each  stage ot  the disease
 requires an appropriate operation ;  so that each method,  in its
 turn, becomes valuable ;  and  that with judicious distinctions,
 and moderate skill, every polypus  has  its appropriate mode of
 cure, except in its last and fatal stage.
    1 am now to define the several stages in the growth of  poly-
 pus, which require  appropriate operations; but do not  flatter
 yourselves, that, because  all seems  clear and simple in descrip-
 tion, every thing will be  so in practice:  I am,  indeed, an en-
 thusiast, but not in this degree ; for though 1 hope and  mean
 to  make the subject very simple, yet youvare in your turn to
                             3 H 
  426    Of Tumours of the Nostrils, Gums, and Throat.

  have your disappointments and uncertainties.   You are neither
  to judge by your eye,  feel with your fingers, nor act with your
  instruments so perfectly, nor so dextrously as you might expect.
     1- In its early stage  polypus  has invariably  that character
  which  is  usually denominated mild:  it is small,  moveable,
  pale, colourless,  and has not as yet begun to affect the adjacent
  parts by the pressure ;t here is a watering  of the eyes, sneezing,
  altered voice,  and interrupted breathing, but as yet  no pain,  nor
  any fetid ichor distilling from the nose : from the smallness and
  pendulous direction of such polypus, to  noose it is difficult; and
  from the numbers of smaller polypi which  usually lurk one
^  behind another, the perfect extirpation of all of them by apply-
  ing the noose is nearly impossible.  The happiest  and most
  successful process is to extract the body or bulky part of such
  polypi wth forceps, and  to destroy their roots with  caustic.
     2. In its next  stage, the polypus grows to a great bulk,  not
  only fills the nostril, but is visible in the throat, the voice is en-
  tirely changed, for not a breath  of air  reaches the bony cells,
  nor passes through the nostrils  : the hearing is greatly affected ;
  if you introduce your fingers deep  into  the throat, you feel a
  tumour so bulky7, as  at  once to  depress  the  soft  palate, and
  compress entirely the mouth of one or  both Eustachian tubes:
  the face is swelled and unsightly, the nose inclined  to one side,
  Wood begins occasionally to flow, and the matter distilling from
  the nostrils and throat begins to  be fetid; the pressure is now
  universal, and begins to affect  the bones, and the disease bor-
  ders on that stage which is, I fear, incurable.
     This bulky and seemingly dangerous  polypus,  terrifies  the
  young surgeon: he reads in elementary  books only of trivial
  tumours appearing in the nostril, and is alarmed  when he sees
  a polypus of this enormous size:  he has read in books of cases,
  of polypi thus oppressing the patient and descending into  the
  throat, but  he recollects that  the surgeons,  in these desperate
  circumstances, committed  every kind of  devastation, they  of-
  ten cleft the palate to reach the tumour, and were  willing even
  to perforate the trachea: yet this case, or this stage rather of
  the disease, is not desperate; it is indeed on the verge of that
  period in which the polypus is incurable, but from its very bulk
  it is easily and effectually noosed.  I find not the slightest diffi-
  culty in this case; passing a silver wire through  the nostril,
  bringing it  out through  the mouth,  and with the points  of  the
  fingers (thrust deep into the throat)  raising it over  the bulbous
  and most dependent part of the tumour, I draw it back into the
  nostril, and, as  it appears to me, quite to the neck of the tu-
  mour,  for I have often succeeded thus,  and never found reason
  to seek the roots ol/he polypus,  or apply caustic.

                     *'
                    V
                    j 
Of Tumours of the Nostrils, Gums, and Throat.   427
  3., In its third and last stage, when the passages of the nos-
trils and throat have  been  long obstructed,  and the face much
deformed; when the patient has long endured the rending head-
achs, and pains proceeding from the distention; when the sur-
geon can distinguish, by pressing with his fingers, that the cheek-
bones are softened, and the nasal bones become moveable, and
foetor and haemorrhagies intimate the  caries within; when the
integuments of the face are puffy, the skin reddened, or livid,
over the root ofthe nose, and the teeth loosened; when the stu-
por from pressure on the brain, and the chilliness from want of
nourishment and loss of blood are great and continual, the dis-
ease is declining into its last stage, which we can hardly palliate,
and cannot cure.  This is  the stage of the disease reputed can-
cerous, and operations undertaken in these  circumstances, and
performed, as I have seen them with rudeness, inflame the brain,
so that the patient presently sinks into absolute stupor, and dies.
   For every  practical purpose, the  definition of these  three
stages is, as I judge, altogether sufficient.
                DISCOURSE  XXIV.



OF  THE  VARIOUS  OPERATIONS  PRACTICAL
  BLE IN THESE  SEVERAL  STAGES OF POLY*
  PUS.
     Of the first Stage ; or, of small and incipient Polypi.

                        SECTION I.

 1 HE first stage of polypus I no longer characterize by symp-
toms, the enumeration of these, I hope, I am entitled to omit
in future.   I am now  to speak of the extirpation, of the means
of eradicating, not apparently, but effectually, that smaller po-
lypus, which hangs forwards in the nose, and only obstructs the
nostrils.   Of  the operation of ligatures 1 have spoken  with
little restraint,  I know too well what is usually done, what can
be done bv Levret's tubes, to mention that method with respect. 
428
Of small and incipient Polypi.
 On this subject I will use but one plain blunt expression, and
 take  notice that I say no worse of the attt mpts ot others than I
 do of my own, (for I have many times attempted this method)
 That  the disappointment of those who confidently expect and
 promise to noose such small tumours, is so frequent and so lu-
 dicrous, that I should be  loath to quote examples: many  are
 the times  I have seen the surgeon  thrust his tubes and wires
 into  the nostrils, and  withdraw them avain,  leaving the nose
 streaming with blood: the attempt  is, on such occasions, re-
 peated without delicacy or mercy, and if he but so fix his tube
 that it can hang without dropping away by its own weight, he
 willingly leaves it there, and trusts his reputation  to this first
 appearance of success.  But it drops away on the  second day,
 the breathing,  the voice,  the hearing, are still affected as they
 were before; even were there but one polypus, (and you know
 by these drawings, and I assure you from experience, that there
 are usually many) a second would  immediately descend, and
 occupy the place of the first.  But where a ligature is thus slight-
 ly applied, the point only,  the mere  bulb alone, of the polypus,
 is cut off;  the nostril is so far closed, that  the breathing is for
 a moment more free, but the long neck  and root, from which
 the disease germinates again, remain untouched, and the in-
 dividual tumour, which is the subject of the operation, sprouts
 again with renovated vigour in  a few days.  This then is  a
 harmless, but it is as  certainly an useless  operation; I  knew
 not how very trifling it was, till I had often tailed: be assured
 that,  however much you  may be captivated with these ingeni-
 ous tubes of Levrct, for  applying  ligatures,  and  though you
 may be still more captivated with your own inventions, (tor eve-
 ry one invents  instruments for extracting polyp;)  be assured
 that a grievous disappointment awaits you, which  I now wain
 you of.  As Richter observes,  there  are but  two  methods of
 extirpating polypus, viz. by ligature, or  by forceps, and ever
 since the time of Levret,  who, from a horror at haemorrhagy,
 and the fear of tearing away the spongy bones, invented instru-
 ments for passing the ligature, surgeons have uniformly prefer-
 red the ligature to forceps.
   I will not allow myself to protract my discourse  by any  but
 occasional  hints of the irregular and inefficient practices of the
 earlv  surgeons, nor defer what must be interesting to you,  the
 simple account of what experience has taught  me: I was early-
 aware of the little advantage to be derived from the ligature in
 smaller polypi,  and learnt to use the  forceps, the  knife, and the
 caustic with particular freedom.   I fear I tell you no more than
the truth,  when I say  that, in my  mind, every operation  for
polypus, must be one way or other, rude and cruel, to be at a!- 
Of small and incipient Polypi.             429
'successful;  and that these nice and curious  methods must be
 unavailing.
    The forceps, knife, and caustic, are the means I have found
 most suitable to the smaller polypi; and, according to the con-
 ceptions I form of each particular tumour, according to the pe-
 riod of its growth,  the  symptoms and effects of its pressure,
 and, by searching with the probe, or fingers, I use those instru-
 ments variously, and pursue them according to the progress and
 effect of the operations.  I begin  with the  forceps, and  con-
 clude with the caustic,  and I find the extirpation of a polypus,
 and the killing of its roots, not an operation  to be performed
 with such a show  of dexterity as to captivate the pupils  who
 assist or are present;  I find it to be a work at once slow  and
 difficult, and often,  I fear, it is imperfectly accomplished.
    It is assuredly neither the root,  nor even the body of  a po-
 lypus, that you are able to seize with the forceps; but the bul-
 bous point only; for you will observe in all these drawings, that
 the neck of the polypus, and all that hangs in the  passage,  is
 slender and delicate, that it forms a bulb  only where it hangs
 below the narrowed slit of the  internal nostril, or behind the
 palate; that  it is of  this bulb only, that I  can catch a slippery
 and insecure hold, so that you may sometimes, in consequence
 of the slenderness of the neck, and, by a sort of accident, twitch
 it  off from  its narrowest part,  and close to  the spongy bone.
 The pedicle  sometimes gives way spontaneously,  the tumour
 dropping into the  fauces: and  it will often, by a happy chance,
 break off from the root in extracting.*  In  such operation no
 man need affect unusual  address:  if the bulb retires before the
 instruments  when pushed into the  nostril, he  has  then a better
 chance of catching the neck : the bleeding so much dreaded,
 and made an argument, almost the sole one, by Levret, for a-
 dopting  his  method by ligature, is  indeed extremely slight:
 from much experience I can assure you, that such haemorrhagy
 will  never weaken the patient, nor require a plug,  which yet
 should always  be in readiness; but it is not so in extirpating
 the roots of the tumour with the knife, then  the  haemorrhage
 is  great.  Both nostrils are  usually diseased, and, on the  first
 day, I extract  whatever polypi present in either  nostril;  but,
 far from imagining that I have clone all my duty to the patient,
 I proceed at the next visit, and indeed at every following visit, to

  * The forceps, as they are now formed, feldom catch a fecure  hold. Thofe
 commonly ufed, and beft known by the name of Polypus  Forceps, are entirely
 ufelefs; arc bigger than the finger, and give no hold.  Their blades are too broad.
 Thofe which I  prefer and ufe are fmall, long, delicate, and their ftrength is put
 upon the thicknefs, not upon the breadth of the blade ; they enter eafily, and catch
 well. 
430            Of small and incipient, Polypi.
search for polypi, or their remains.  Some polypi, 1 find, come
out entire, as I judge by their form; others,  manifestly short
of their full dimensions, and mangled.*   The anterior nostril
being cleared, I  see down into the nasal  slit, and feel deeper
with my finger: often, upon  looking into the  nostril, I see,
even at a late stage of my operations, the remains of a polypus,
or feel it with the extremity of my finger, and still more  fre-
quently I am sensible of eradicating, by  various methods, po-
lypi  which are too deep to be visible;  for behind the  narrow
slit which the finger cannot pass, the nostril is enlarged, and in
that wider part, usually the vomer is pressed to one side, there
is left a hollow in which the  polypi  hang.  It is only by con-
tinual examination, and the most earnest attention, and a care-
ful calculation of  points and  distances, that such remains  of
polypi are discovered: first, by a rattling noise, when the breath
is driven  through the nostril, which, though  tolerably free, is
so only at times, and in particular postures: secondly, by feel-
ing with the proble, or with a bigger instrument, when we per-
ceive that the back passage is not clear, the point of the instru-
ment (I often use the Sound) encountering a resistance when
  * No. 7, a polypus of full fize, root and all.  No. 8, % 10, u, polypi fhor. o:
tfpic natural dimenfiens, or extradited in fragments. 
Of small and incipient Polypi.            431
it should descend to the fback of the nostril, so as to touch the
velum; the resistance we are sensible  is not solid, such as
would proceed from the  probe encountering one of the spongy
bones, but soft and yielding, such as we are sensible we could
overcome by  dashing the instrument down  into the  throat:
thirdly, when the patient, in consequence of our first operations,
inhales his breath freely, but cannot breathe out with equal free-
dom, we are sure that a polypus, or the remains of one, is still
hanging in the back part of the nostrils, nearer the palate; act-
ing like a valve, it recedes when the patient draws in his breath,
but, when he breathes out, it falls flat upon the back of the nos-
tril and prevents the exit of the  air.  Now, although  I am
pleased when  I  see the stupor lessen, the breathing more free*
and the hearing  restored, I am conscious that all is not safe, and
that there must be added other essential signs of the passage
being free.  It is in  this stage that the patient is  usually  dis-
missed, and most inhumanly, with some trivial directions of
introducing bougies,  or drawing  astringent solutions up the
nostril, to return in a few months with an incurable and carious
disease of all  the bones.  When I  find that, though  the pa-
tient breathes easily, the head reclining  backwards, he Cannot
breathe in the natural and perpendicular  posture; when I find
that though he  inhales  the breath easily, he finds  it suddenly
and vehemently stopped, however  strongly and  perseveringly
he presses it;  when I find (suspecting from  those signs  some-
thing wrong)  that though the anterior nostril is free, some co-
loured body appears within the nasal slit, is felt with the finger,
though indistinctly, and is directly encountered by the Sound,
or big probe,  passed  from the nostril towards the throat; whA
I  find that his breathing (even after having become  free) aftp
he is able to dash out by vehement efforts, the prodigious quan-
tity of thickened mucus,  which the inflamed state of the  pos-
tril generates, is yet  accompanied with a rattling  and snorting
noise; when that peculiar noise continues after the nostril is
cleansed by snorting,  and by wiping it within with the  probe
covered with lint, I am sure there are some dangerous remains
of the disease.   Often I see this, after I have begun to apply^
the caustic, and discover the  remains of the polypus, rounded
by ulceration, of a brilliant colour and bud-like ;  but never, af-
ter this stage, do I expect good from the  forceps: I proceed
to rougher and  more  decisive methods.
   When I find  the whole of  the posterior  nostril  closed by a
spongy .polypus, which  I either liave not reached, or have ex-
tirpated imperfectly,  I have recourse to the knife:  when I first
ordered knives  to  be forged for me of the form represented in
No. 6.   I little  imagined I had the least authority for proceed- 
432
Cf small and incipient Polypi.
ing in this enterprising way; yet I find that,  far from having
neglected those passages of ancient authors, where  the  use of
the knife, and the spathula, which was a sort of knife, was men-
tioned by Celsus, and by  the Arabians,  I had  made accurate
notes of their methods, which I had yet so entirely  forgotten,
as to proceed in cutting out polypi, with all the timidity of one
who was attempting a thing,  at once unprecedented  and danger-
ous.  I recollected no precedents, and reasoned only on the ne-
cessity, on the simplicity of  the  operation, and by analogy in-
ferred, that if we might extirpate a tumour of the cheek, or lip,
of the palate, or tonsil, with the knife, much more should we
adventure to extirpate that of the nostril, since, by  drawing up
plugs into the  nostril  from behind,  we could  entirely suppress
whatever haemorrhagy any operation produced;  we could ap-
prehend nothing from the  wounding of the spongy bones,  and
the operation  of incision,  in place of the rude method of tear-
ing and mangling with forceps,  seemed more  delicate in relati-
on  to  the membrane, and more effectual in respect to the tu-
mour.   I have never since that period (now  many years past)
spared the knife in operations of this nature : often I have used
it  in the first operations,  and in place of pulling away the more
bulky polypi with the forceps, have slipped in the knife into the
nostril, and carrying it flat and vertical, till I  reached, accord-
ing to  my  apprehension,  the root of the tumour, have then
turned  the edge towards  it,  and with some mangling, and not
without both difficulty and fear, have cut it off.   But when the
nostril is already in some  degree clear, when the anterior nos-
tril is free in so far as to admit  the  knives easily, but the pos-
   «ior nostril still encumbered with tumours, or the remains of
   nours, I find it particularly advantageous, to pass  the  knife
deep  through the nostril,  till it lies  in the posterior opening of
the nostril over the palate  ; then turning the knife, and striking
a stroke alternately to right and  left, or cutting with premedi-
tation* in that direction,  in which from the probe,  or the cir-
cumstances of the breathing, I suspect the tumour to hang, I
free the nostril of this last obstruction.  I do not know a greater
happiness for the patient,  or a greater victory'  on the part of the
surgeon, than that of clearing the nostrils of  this very danger-
ous disease: in whichsoever relation I stood, ot patient or ot
surgeon, I would set no  limits to the sacrifices I would make
for such a purpose : I have ever remarked, that the period of
suffering on the part  of the patient, or of necessary cruelty on
the part of the surgeon, thoQgh seemingly long, is  really tran-
sient, and, when the end is aVlBinplishtd,on the return ot health
and  pleasure, when freedom of breathing, and  of hearing  is
restored, is entirely  forgotten." Therefore, I intreat  you in 
Of small and incipient Polypn            43S
all  such cases to persevere: there is but one immediate  dan*
gvr, viz.  that of haemorrhagy;  and I leave you to judge, whe-
ther any  incision  these knives can make, although it were di-
rectly into the membrane  and among the  spongy bonts, much
less such as is made into the slender neck  or body of a tumour
so small as to be contained within the nostril, could be danger-
ous!  Confident that it could not, I have always used the knife
freely, and, though I have had the plugs for suppressing hae-
morrhagy ready, and have usually  indeed  had the ligature rea-
dy  passed from the nostril to the  throat, prepared to draw up
the plug,  I have not more than  twice or three times  at the ut-
most had occasion to draw it, and then only to save the strength,
and lessen the alarm of the patient,  not to save his life.
   Let me now represent  to you, after  these  general descripti-
ons, the particular acts of these successive operations.
   1st, For the extraction, you must be conscious, that with the
best imagined forceps,  you can grasp  only the  bulb or  most
pendulous point of the  polypus;  that if you are successful in
twitching out the polypus by its root, it must be by your good
fortune in having  to deal  with a polypus whose root is natural-
ly delicate; that your forceps are to be used with any degree
of  success, they must be  so formed as to  operate with  their
blades vertical, viz. one towards the forehead, the other towards
the chin  of  the patient;  or, in other words, according to the
length of the nasal slit.
   2d, Whether to amputate entire polypi, or to eradicate those
which have been partly extracted, you will do better  to  use a
knife sharp on its convex  edge. Those fashioned like the one in
plan No. 6, which I have hitherto used, will be found occasionally
very convenient, especially in cutting at the roots of polypi ly-
ing far back in the nostril, or in the arches  of the palate, and
where  you are to make your cut by hooking the crooked knife
beyond the root of the tumour, and drawing it towards you.
 But I am conscious that  I could manage  the form, No. 5, with
perfect saf-tv, and it is manifest that I could cut more decided-
 ly  with it;  lor the polypi hang down  from  the  upper spongy
bones,  in the form I have represented in all the drawings, and
especially in the drawings,  No. 1  and 3, but which I have more
correctly represented in  the plan No. 6,  which I drew in the
time of operating, and for the correctness of which I can be re-
sponsible.   After long reflection and  many partial operations
 on this patient,  I sketched this plan the moment after my fin-
 ger and instruments were out of the nostrils.  As soon as the
 gentleman,  being  freed from pain, could sit composedly and
 without  suffering, he seated himself before me,  while I made
 the plan, with every recollection and feeling fresh  and lively. 
434
Of small and incipient Polypi.
In this plan are represented the features in profile; the cavity
or hollow formed by the bending aside ot the vomer or parti-
tion of  the nose ; the roots of one polypus already  extirpated,
the remaining root being still sufficiently long to appear  move-
able upon looking into the nostril, and exposed,  of course,  to
the stroke of the knife, and requiring it; another polypus entire,
and deeper seated, obstructed the back of the nostril, allowing
the patient  to draw  his  breath,  but falling down  valve-like,  s»
PLAN no. 5.
?LAN NO. 6.
as to prevent the breath being driven out:  (a) a semicircular
dotted line marks the place where the cartilaginous wing of the
nose terminates, and the opening of the nostril is  narrowed by 
Of small and incipient Polypi.             435
 the arch of the nasal bone:  (b b) the hollow  produced by the
 receding of the vomer towards  the left, being pressed by the
 bulk of the polypus: (c) marks the upper spongy bone, where
 the polypi had their roots: (d) the remains of a large polypus,
 which htd originally filled the whole opening of the nostril, and
 of which only the root (d)  is left, but was left of such a length
 as to require a stroke of the knife : (e)  the direction of the
k lower spongy bone  represented in a  dotted line.   This lower
 spongy  bone, hanging on the edge  of the antrum under the
 cheek-bones, and  the  antrum being cut away, it can be repre-
 sented only by this imaginary line,   (fj marks  a longer and
 more entire polypus, which so obstructed the  back  opening of
 the nostril, (viz. that towards the  throat,) that neither the big-
 headed  probe, nor  even  the common probe or director  could
 pass freely: (g) demonstrates the direction of the knife, when
 passed down the nostril, towards the throat,  so as to cut the
 polypus, in withdrawing it, by  very slightly  turning its edge.
 But it  is obvious,  that had I used knives  cutting on the back,
 though  I could not have been sure to conduct them so harm-
 lessly through  the  nostril,  I  should  have  been sure of using
 them more effectually; for  a knife  so formed, scythe-like, and
 cutting  on its convex edge,  could not have failed to cut off, and
 that probably very near its root,  whatever  polypus  hung down
 from the upper spongy bone.
    3d.  For the  suppressing  of the haemorrhagy, it is necessary
 that you be made acquainted with the introduction of the noose,
 which is a method at once simple and effectual, of  drawing up
 a plug from behind the  palate to the posterior opening of the
 nostril,  so as to have it in your  power to  close at once both o-
 penings, to restrain the blood.  You are to take, not a piece of
 catgut,  for that is liable to twist very  provokingly, and to be so
 softened with the moisture of the fauces  as to lose its  shape ;
 but a piece of delicate silver wire, or, occasionally, I have used
 a harpsichord wire, and doubling it, you  make the patient gape,
 introduce the loop of the wire through  the nostril, and  watch
 its appearance in the throat;  the splendor ofthe silver wire shows
 it at once;  if you find the patient not at all excited to cough,
 you may be assured the  wire has not yet reached the fauces; if
 he  is in danger of suffocating,  you  may  be  assured that the
 loop of the wire  actually touches the epiglottis; then you will
 retract it a little, and the irritation will cease.  The way to suc-
 ceed is  to carry all quietly and  softly, to insinuate  the  wire
 along the nostril very gently, to watch for it in the throat care-
 fully, to mark its appearance  instantly, when  it begins to pass
 behind the velum, to push it no  farther,  for then it touches the
 irritable parts, to be ready with the crooked probe, or the dress- 
436             Qf small and incipient Polypi.
ing forceps,  or a blunt hook,  to  catch it the instant it appears,
and draw it  out bv the mouth.   Then, in the loop ot the wire,
you fix, with a piece of thread, a small pad of charpie, and
make  ready to draw it back through the mouth,  and up behind
the soft palate, into the back of the nostrils.   You prepare for
this act by twining the wire round the fingers of your left hand,
near the nostril, and  by  holding the plug upon the point ot the
fingers of your right hand ; you then draw back the wire through
the nostrils,  and push the  plug into the mouth by correspond-
ing motions  of your two hands, and when you have got the plug
to the  back of the  palate,  and just sticking in the fauces, you
must not leave it a moment there, but by a sudden jerk with the
left hand, pushing boldly at the same moment with the fingers
of the  right, y ou  bolt it up into the posterior opening of the
nostrils, above the back of the palate, and  fix it at once in the
cleft at the  back of the nostrils.   This being finished by plug-
ging, at the same time, the opening of the corresponding nos-
tril,  there is no longer a possibility of the blood escaping.  I
have several times  needed to use this method in  cases of epis-
taxis,  and three  or four times after extirpating polypus, but
especially after using the knife.
  4th.  When all is done that knife or forceps can do, I proceed
to use the caustic, and with  this conviction, that I should be
very indifferent indeed,  whether I destroy the  polypus only,
or the spongy bone, or much of the membrane, if but the po-
lypus-be destroyed.  However confident I am of having extir-
pated the tumours by  my preliminary operations, I never think
it superfluous to burn the roots, but apply  the caustic the more
boldly, when, by the frequency of my operations, I am sure of
being able to mark the points  of the nostril at  which I have to
expect the roots of  the polypi.   To apply the  caustic effectual-
ly,  vou must apply  it boldly ; and if you consider the important
object to be attained, you will be careless although it should af-
fect the spongy bones; or  rather, you will be fearless of every
thing,  but the error of not applying it effectually.  1 find much
address necessary in this, which  I confess 1 have learnt slowly.
  I alter my method occasionally, in the course of a cure,  and
according to the circumstances of each case.   First, I am care-
ful to have  the nostril entirely cleared of mucus, which, in the
inflamed state of the  fauces, and especially alter the operation
ofthe caustic is begun, is secreted in such profusion as almost
to suffocate the patient: he draws much back into the throat, he
drives much outward by blowing the nose, and I clear  out the
nostril effectually with  the probe rolled in lint, and then the  nos-
tril, raw and red with  the violence it has sustained, is so clearly
seen that. I have often perceived,  upon looking into it, a bud or 
Of small and incipient Polypi.             43?
 germ of the polypus still remaining, though very deep in the
 nostril, and very  small.   But  independent of this  process of
 clearing and inspecting the nostril, we  are able,  merely  from
 calculating the depth  and  distance of the  upper spongy bonts,
 and recollecting the  circumstances of the operation,  to  apply
 the caustic to the roots of the  tumour with much confidence;
 no dismal consequences have  I ever witnessed, nor even the
 slightest inconveniencies from  its beiny misapplied.
   I never have used a pencil of caustic* in a port-crayon ; that,
 I know, would be, extremely dangerous, but spread the caustic
 upon lint;  (I at first spread
 it upon leather) as I would
 for making a common caus-
 tic issue.   First,  I fold a
 piece of lint twice or thrice,
 and  give  it  a  triangular
 form, (fig. 13)  and after
 pounding  the   caustic,  I
 mix  it with  water into  a
 paste, and spread it in the
 form and dimensions fa J
 upon the lint, and then bend the lint over the point of a probe, or
 of a directory rather, the big obtuse point of which carries it, and
 deposits upon the precise point you wish, fairly and without get-
 ting entangled in it. In passing so big a caustic along the nostril,
 the parts would be cruelly excoriated, were We not careful to guard
 the canal,  which I do, by cutting a stripe of sheep's leather, and
 conveying  it high into the nostril with the  probe,  and laying it
 flat and smooth along the surface to be caut. rised.  I  leave it
 there, and turning the caustic towards it, I run it up to the point
 I design to burn.   Upon the slightest sense of disappointment
 I withdraw both, and begin anew; but being conscious that I
 have  succeeded, I  withdraw the sheath of leather at the  same
 moment that I push up the caustic to the part, and I  impress
 the caustic very firmly upon the part; for, the instant it touches
 the naked  surface, the eyes fill  with  tears,  the patient draws a
 long breath, and sneezes tremendously,  and instantly displaces


  * I find, in looking over my notes  of cafes, that  this is not quite correct;
 that when 1 firft began to ufe the  cauftic, I ufed it by foaking a large piece of
 camel's hair pencil in it, conveying the brufh along a canula made of a playing-
card; but finding fuch application quite ineffectual, and having alfo thought of
ufing a port-crayon, perhaps I may have tried it, but I even, in this firft cafe, re-
newed  the ufe ot it, and betook myfelf to the fcraped cauftic, which  being laid
thick, is equivalent to a folid cauftic, and yet abfolutely fafe.
 
438             Of small and incipient Polypi.
it:  but if you press  firmly, this irritation goes off;  if you have
passed it far beyond the strait ofthe nostril, and up  to that point
where always I conceive  the  roots of the tumour to lie, it sel-
dom  is driven away by any  future  paroxysm of sneezing.   It
does sometimes happen,  that the profuse secretion  of mucus
carries it down, and the operation being performed at ten o'clock,
for example,  the caustic is discharged by two or three o'clock ;
but often I have found the caustic  in both nostrils next day at
dn ssmg.   It will add  to your assurance and confidence when
I tell you, that deep as you may appear to yourself to  have in-
troduced the caustic rather beyond the nostril as you would
imagine, and on the very verge of  its posterior opening, just
over  the palate, it  never falls backwards  into  the throat,  nor
ever is swallowed ;  of the many hundred times I have used the
caustic,  no such thing  has ever happened.*
  There is one thing perhaps  contributes to  its coming always
forward, viz.  that the moment the caustic is placed, and  the
sncr zing is over, I instantly cram the nostril full of little dossils
of  lint, which are lying ready prepared, and are  quickly handed
to  me;  if this be not done first,  the nostril and upper lip  are
severely excoriated and deeply corroded with the  caustic; se-
condly, the caustic piece of charpie, if not supported by others
from behind,  is apt  to  be displaced; the nostril being enlarged
by  the polypus,  rtquires a great deal of lint to fill it;  and to
prevent any drop ot melted caustic  or mucus descending  this
way, I ram the  lint hard into the nostril at  each  dressing.  I
find the  lower dossils of  lint discharged, (those  I  mean, which
fill the cartilaginous mouth of the nostril) the caustic ones of-
ten are returned (they occupying the deeper, straitcr,  and bo-
ny part of the nostril, beyond the  narrow slit  formed  by the
nasal and  spongy bones.)  The  dossils and  mucus are hooked
out, the mucus picked away, and sometimes the nostril washed
with  barley-water or oxymel at each dressing.   The caustic 1
apply every second  or  third day;  1  ofttn  continue this severe
process, during  a whole month, with occasional intermissions,
and I confess the whole cure to be so difficult, that whether from
the presenting of polypi  already existing, or from  the quick re-
generation of those already  extirpated, I have had occasion,
even while using the  caustic, to repeat my incisions  with the
knife; and while I am making incisions upon  the remains of

  • It was long before I was entirely void of  anxiety on this fubje«; I find in
my notes,  a cafe of a young lady of i9 years of age, who is now in perfect health,
that in place  of ufing amply this plodget of charpie, coated with cauftic,  mount-
ed the lint upon a cone of ftiff paper, or card, the conical form of ,t,.the apex
l6okinK forwards  would, I expired, prevent die cauftic from puffing backwards
into the fauces.  I did not then know how fuperfluoui luch precaution  was. 
Of large and guttural Polypi.             439
the polypi, or consuming  their  roots with caustic, I find it ad-
vantageous to clear  the nostril,  especially  in its back parts,  by
methods  almost  approaching to rudeness, by wrapping a big
iron probe, of a curved form, round with lint, or mountiig it
with a sponge, and  running it  thus  guarded down the nostril:
I  make  it so large as not only to fill the nostril, but to pass
through it with great difficulty, and by forcing it through the
slit of the  nostrils,  quite  back to  the palate,  I often  force  off
these  remains of  polypi,  which are  already half  consumed, or
imperfectly cut.*   These,  gentlemen,  are the methods which,
used with perseverance and courage, have seldom  failed me:
of many patients  whom I have treated, there are very  few,  I
declare  solemnly, who have returned to put themselves  under
my  care:  of the  entire recovery of such  as   I  have  not seen
again, it would be presumption to speak confidently,  but from
many I  have had  the happiest assurances of their continuing in
perfect health.  Such is  my process with the softer, smaller,
and incipient polypi,  which occupy  only the  nostrils, and are
pronounced mild and benign :"j" the hard  and bulky polypi, pass-
ing  down into the throat, require other operations; and to ex-
plain these,  demands  a more methodical enumeration of the
various inventions,  and,  I may say,  cruelties, of the older sur-
geons.

                           SECTION II.

                   Second Stage of  Polypus.

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

   * I fee  occafionally  the half-confumed polypus,  or rather the root of it, of a
very florid red  colour, and touching it with the probe, I feel it hard and granu-
lated : fometimes the opening of the noftril is fo exulcerated as to require inter-
miflion of the procefs,  and the anointing of the excoriated parts with oil or oint-
ments.
   t I fhould be forry to omit mentioning an operation, which has been approved
and commended by the greateft practitioners, and has held  its place from the ear-
lieft times; it was invented, 1 believe, by  the Arabians; is  defcribed by Albu-
cafis, and was ufed fuccc-fsfully by La Faye, in the Hotel Dieu.  ft is the pafling
a large feton or cord from the mouth through the noftrils, knotted,  at  intervals
of an inch or more; the knots are meant to prefs upon the  roots of the polypus,
and made larger, and drawn  up  tighter, in  proportion as  the tumour yields, or
the paffage dilates. The mechanifm of this invention is eafily underftood by thofe
general terms, and I am not entitled to be particular, as no occafion has parted
itfelf, in which  I thought of ufing this method; but it is furely worthy ot being
mentioned, and I can imagine a variety of circumftances in which it may be ufe-
ful. 
44<J            Q£ large and guttural Polypi.
Stach a tumour left to itself, is indeed fuU of danger; the.nop*
trilsj ap4 throat are filled with its  bulk,  the  bones sorely  com-
pressed, as the pain and stupor sufficiently  evince; die  voice
affectedj the hearing injured;  the breathing and swallowing in-
terrupted;  the patient  is thence  in  the utmost jeopard\, and
tfrat».Stage  fast approaching which is so incurable.  But this
bulk, .which  threatens destruction to the bones, facilitates all
th^e .surgeon's operations, and is a probable sign of  the  tumour
being single*
  .Surgery was at °ne period rude, and  cruel in  all  its operati-
ons, but those used for the extirpation of polypus, were so in
a peculiar  degree.  The larger polypi, depressing the palate
and extending towards the throat, seemed to the ancient sur-
geons to vindicate every degree of violence.  They attempted
the extirpation, sometimes  by the most  cruel cauteries,  ottener
by main force.   They, if the polypus was long and pendulous,
tugged at  it  with merciless  rudeness; if beyond  their grasp,
they consumed it with  heated irons.*
   But of all the examples of successful violence upon  record,
none is so well calculated to shew what the parts will suffer, to
banish all fears of endangering the  brain  by violence done to
due. spongy bones, while extracting polypi with forceps,  as that
which I am now to lay  before you.   It will at once suggest ma-
ny practical reflections, and teach you much of what y ou ought
to know familiarly, concerning the relation of the tumour to
the  passages of the nose and throat.
   Mr. Manne, a respectable  surgeon of Avignon, was the ope-
rator, and he related the case in a small volume,  published at
Avignon,  anno 1747:  not contented with the ordinary means
of extracting the polypus,  finding even the strongest crow  bill
forceps  unavailing,  he transfixed a large and cartilaginous  tu*
m'our with many.ligatures, each of which successively he  twist-
ed round the body of it, and with the help  of these, used  like
a halter, and by pulling upon the projecting part of the tumour,
and pushing at the  same time that part of it which he  could
reach by introducing the fingers  into the throat, he delivered
the  patient of an enormous massy  polypus, which,  in bolting
through the  nostril, made  a noise like  that of uncorking  a  bot-
tle.   The  patient, from confusion, pain, and loss  of blood,
faulted; while the numerous assistants  were left in a degree oi

  * This method of deftroying polypi by cauteries, little ufed. by modern furge-
o'ns,  was univerfally employed in thofe times when fire fuwrfededblifters, fct^ns,
iffu.es, incifiohs! and nothing but fire was ufed for  headachs, white fwellings, ha>
morrhagies, rheumatifms, tumours!  Whatever, in fhort, was to be done, which
could not be done by iocifion, was  (to ufe the words of Hippocrates)  "  to be
 done^ by fire." 
Of large and guttural Polypi.            441
astonishment, from which they did not soon recover: but these,
with many other points, you will best learn from the narrative
of Mr. Manne, which is very  perspicuous.
  " Etienne Ducres,  a villager of the Duke de Gadagne, se-
venteen years of age, born in the village of Saint Saturnine, in
the Comptat, was attacked, in  the year  1745, with  a violent
haemorrhagy of  the  nose  and throat, occasioned by  extreme
heat,  from the direct rays of the  sun striking  upon  his head
during the labours of the harvest.  During months  the  hse-
morrhagy returned from time to time.  The rheum, and stop-
page of the passage, which followed this, shewed the thicken-
ing of the membranes and glands, and soon after  the patient
began to snivel through the nose: the passage was daily more
and more obstructed; he was no longer able to breathe through
the left nostril, which proved the  existence of a tumour.
  u He now betook  himself to Avignon, and there consulted
a surgeon,  who, though he found an incipient polypus in the
nostril, found nothing, at  that time, wrong in the throat: he
pronounced the heats of the autumnal season, to be very unfa*
vourable to any operation.  This unhappy delay gave occasion to
such a growth of the polypus, that in the space of a few monthsy
it had not only filled the cavity of the nose, but protruded back-
wards into  the throat, and forwards through the nostril.
  "  The patient,  alarmed by  this sudden growth, had  once
more recourse to his surgeon,  who now attempted the opera*
tion; and holding the mouth  open  with a speculum oris, he?
tried to twist and tear away the polypus from the throat,  with
Crow-bill forceps, and pincers of various forms; but succeeded
so ill as to tear away only one morsel, the size of a peach-stone.
  " Wearied with this frtiidess labour, he  was willing to try,
whether he could not obtain a  better  hold on the polypus hang-
ing out of the  nostril; but at the first pressure of his  forceps,
there came on a haemorrhagy so alarming, both to the  surgeon,
and to all who assisted at  the  operation,  that their work  was
instantly suspended: yet they  made four more attempts of the
same kind, within the eight succeeding days, and at each  time
were alarmed with the same haemorrhagy, and  obliged to de-
sist.   From the  time in which these fruitless operations were
altogether abandoned, the  patient suffered periodical  hsemorr-
hagies; sometimes from the throat, (issuing from the lacerated
end of the  polypus) sometimes  from the nose, (where also it
had been torn and mangled with the forceps) and often he bled
from both nose and throat, the polypus growing incessantly, so
as to burst  up the bones of the nose.
  " After the  attempts just mentioned, there came a violent
inflammation and abscess of one side ofthe face: the skin sup-
                           3 K 
442
Of large and guttural Polypi.
purated; the cartilage of the wing of the  nose  was ukrrate4
and  opened;  the  suppuration,  and all  its consequenci-y,  in-
creased daily for two months, and at last ceased ; and then  the
patient fell again into his  old disorder of periodical ruumorr-
hagies, the blood issuing chiefly from the  nostril, by the sid«j
ofthe polypus,  and through a fistulous opening  on the cheek
near the nose.                                            ,
  " In this desperate and most deplorable situation,  the  pa-
tient addressed himself once more to his  surgeon, requesting
his  help.   But this gentleman, unwilling to risk his reputation
further in so hopeless a case, contented himself  with prescrib-
ing some cathartic powders.  The patient knew well that this
was but an apology for leaving him to his fate,, was anxious to
find some one resolute  enough  to  do him good,  and  lighted
happily on Mr. Manne.
  u When this patient  came to me, (says Mr. Manne) I con-
versed with him, consoled him, supported  his hopes, and  his
courage; and after some  restoratives, and general  remedies,
undertook the operation in my own house,  on the 25th of Oc-
tober, 1747, two years after the commencement of the disease,
in presence of fifty  gentlemen  of  the profession.  I  did not
chodse to have so particular a case  reported only on my own
testimony,  or on that of a few partial friends.
  " In the presence then of this respectable company,  I began
my operations, without having recourse to the gag, or the spe-
culum oris, used in the former operations:  I placed  the  pa-
tient opposite to a window; and reclining his head a little back-
wards, I intreated him to  open his mouth  wide, which he did
very courageously; I then took a  crooked  bistoury,  passed it
betwixt the velum pendulum  and the tumour, and slit up  the
velum from the side of the uvula to the palate bones, and pro-
ceeded then to the tumour itself,  which was wedged in  the
throat.   It was so firm, that it resisted the knife, as the attend-
ants will testify, who cannot but remember the  quantities of
blood that flowed after  each incision.  The moment I began an
incision, the flood of blood suffocating the patient forced me to
desist; when it ceased I renewed my attempt, only to be inter-
rupted by a new haemorrhagy:  till at last,  at each incision, in
consequence of the hemorrhagy that ensued, the patient fainted,
so that we  were obliged to allow long intervals after each
stroke of the bistoury,  lest the patient should actually expire.
  u The assistants were careful during all  this time to support
the patient with spirituous liquor,  and occasionally  spoonfuls
of nourishing soups; and  thus from incision to incision,  from
haemorrhagy to hemorrhagy, after many paroxysms of faint-
ings,  did I, at last, partly  by the  knife, partly by tearing, se- 
Of large and guttural Polypi.            443
p irate completely this mass of tumour, which lay iri th&.throat,
and which I immediately delivered to the bye-standers, that
they might examine its extreme firmness and semi-cartilaginous
nature.   The patient, restored as it  were from death to life,
had still sufficient  strength to walk  from my house to the sub-
urbs, where he ■ lodged, when he was presently put to bed, and
a proper diet and regimen prescribed.
   "  It was not fit  that we should comply with the  spirited and
resolute request of this  young man, who besought us to finish
our operations, and deliver him at once, of whatever remained
of the tumour.  I thought it prudent to allow at least a few
days of rest and nourishment, to repair this loss of blood.
   *" After three days the slight fever excited by the operation hav-
ing subsided, and his strength seemingly recruited,  I resolved to
begin my operations  anew.  This was in October, 1747: I
placed the patient with  his back  resting firm, and his head  re-
clined and  fixed:  I knew too well the  firm and cartilaginous
nature of this tumour,  to think  of extracting  it with forceps,
which would but tear it into morsels, leaving perhaps, after  the
laceration of the  nasal portion, and of that which hung _back-
wards in the throat an  intermediate part, which would still  ob-
 struct the nostrils, and occasion endless operations.   I saw  the
 nostril besides, too completely filled with this polypus,  to  ad-
 mit  my forceps,  and the polypus itself too firm to  be grasped
 in them: I  had experience sufficient moreover of the  partial
 and imperfect success of the forceps, in the case of Jaques Gre-
 nau;  I therefore resolved upon a more decisive,  and more, di-
 rect method of unrooting the whole at one pull.
   " With this design,  taking in ray hand a needle remarkably
 curved, threaded with  a strong waxed ligature, I transfixed the
 polypus as far back in the nostril as possible: I then cut the nee-
 dle away from the ligature, and (the ligature being double) I
 took first the two lower ends,  and tied them  firm round  the
 lower part of the  tumour, and the two upper ends I tied in  like
 manner round its upper part, and then taking one end of each,
 viz. of the upper and lower ligature,  I  twisted them  on  one
 side, I tied and twisted the two other ends on the  opposite side,
 and thus having transfixed the centre of the polypus, and twist-
 ed these numerous ligatures round  the sides ot it, I had got a
 hold which could not slip:  I grasped the four ligatures, twisted
 them into one, and pulling by this hold, I brought the polypus
 bo low, that not merely the part thus transfixed with the crook-
 ed needle, but half an  inch more of the polypus appeared with-
 out the nostril.   I took now a  second crooked needle, trans-
 fixed the polypus with  a second double .ligature,  h.ke.the first,
 tied and knotted it in like manner, and having thus got a firmer 
444
Gjf large and guttural Polypi
 purchase, I twisted the four ends of this ligature along with
 the first, round the tumour; and now shaking the whole mass
 of the polypus from side to side, then moving it with a rotato-
 ry motion, then  pulling from right to left, and next revwBtng
 that motion, by moving the mass from left  to right; in short,
 by moving and shaking the polypus in every possible direction,
 I sought to disengage it from its connections, pulling towards
 me always with such strength, as to make the tumour follow
 every lateral motion, and yet with such a measured force, as to
 prevent the ligatures breaking; for had that unfortunately hap.
 pened, the  tumour itself  would have receded into the nostril,
 while a fragment only would have remained in my hand.
   " By successive and regulated efforts, I so far succeeded,  as
 to elongate the tumour still more; an inch more  of  its length
 appeared without the nostril;  I struck a third double ligature
 through the  polypus, which I twisted as formerly, and added
 to the others;  and with this new purchase,  I pulled so success-
 fully as to elongate the tumour still more; and transfixing  it
 again with a fourth ligature,  as deep as possible within the nos-
 tril,  I obtained, by pulling with the whole sixteen  ligatures, in*
 conceivable power and purchase.
   " I was now on the point of extracting  the polypus by the
 roots; and by  the happiest chance observed  a trifling circum-
 stance (for the most trivial circumstances are, in the critical mo-
 ment of an operation, of the very last importance) which con-
 tributed greatly  to my success: having introduced two of the
 fingers of my  left hand crooked, into the throat,  to feel  whe-
 ther  the hold I had upon the nasal branch of the polypus af-
 fected that within the fauces, and whether the guttural part  of
 the polypus  was of such a form as to pass  easily back again
 through  the  opening  from the throat to the nostrils, so as  to
 follow the nasal branch when it was extracted, I felt distinctly,
 that by pulling the ligature which surrounded the  nasal branch
 of the poly pus, I  not only moved at each puU, the branch which
 hung down into the throat, hut also was sensible that this lower
 branch (the branch which I had formerly cut with the bistoury)
 consisted of  two  tubercles  or heads, greatly exceeding in size
 the  posterior opening of the nostrils.  With my fingers of the
 right hand, twisted among the ligatures surrounding the nasal
 branch, I pulled upon it;  while with the  fingers of my left
 hand, ihrust into the throat,  I pushed bach towards the poste-
 rior opening  of the nostril, the tubercle  which was nearest to
 it j then by a second effort of the same kind, I forced the se-
 cond tubercle to follow the first; and being sensible that both
 were fairly entered into the passage of the nostril,  I continued
to thrust with trie fingers of the,one  hand against  -the guttural 
Of large and guttural Polypi.            4*15
partof-the polypus*, pulled with the other upon the nasal branch,
and redoubling my efforts, and increasing the force, in propor=.
tion to the progress of the polypus, it, after  much struggling,
and many repeated endeavours, bolted (after one final effort)
so suddenly out ofthe nostril, that the noise  was like that  of
uncorking a bottle.                                        ~
 > " The moment the polypus was torn away, you would have
thought the patient would have expired, the Wood bursting ocrt
in a full flood from nose and mouth: but  as the blood burSt
out thus suddenly, it ceased as instantaneously; for it proceed-
ed  chiefly from the vessels of the  polypus distended by the
compression, which were no sooner  emptied than they ceased
to bleed.
  " The spectators did  not soon recover the  amazement with
which they were struck at seeing so enormous a mass of turnout
issue from so narrow a passage.  This polypus  was covered
with a membrane, very white, smooth and polished, with an
infinity of  small  vessels circling upon its surface; and its sur-
face was dotted with an infinite number of Woody points, red"
with drops of blood,  denoting the manner  in which it had ad-
hered to the pituitary membrane.
  " No sooner was  the  lad  delivered of the polypus, than he
straightway breathed through that  nostril  freely, and was  as
suddenly relieved of an  insupportable headach, with which he
had been night and day tormented for more  than a year.  He
recovered his sense of smelling; but what is more singular, he
recovered at the same time the sense of tasting, which he had
entirely lost.  After this second operation we washed out the
passages with detersive and vulnerary injections, to which spi-
rituous tinctures  were necessarily added, to correct the putri-
dity of the foul  and  very fetid sanies, which, by its horrible
fetor, declared the disorder of the parts produced by this tedi-
ous disease,  and the recent violence done to them.
  " Yet the patient was in perfect health, weakness excepted:
he was free from fever: he slept as if he would never awake ;
and when he rose it was with the appetite of  a famished crea-
ture,  ravenous for food.  But the attendants  were inexorable,
and never permitted him to exceed the diet prescribed for him,
  " Two days, and no more, had passed, when the patient, all
at once  observed, that he had no longer that perfect  freedom
m swallowing and: breathing, which the operation  had restored
him to so suddenly.   He was sensible of a new obstruction .in
the  throat,  little differing from that  which he had  so long en-
dured :  1 visited him on occasion of these new symptoms, and
I will ingehuously confess, that if I was astonished at the Jsize"  ^
and nature  of the first polypus,' my surprise was inexpressible, 
446
Of large and guttural Polt.pi.
when I found the throat choaked anew, with a polypus of such
tnormous size, that it  seemed as if not a particle of the first
had been actually destroyed.  1, without loss of time, con-
voked the physicians and surgeons who had witnessed the first
operation.   They were, I believe, not a little astonished to see,
apparently, the  individual polypus which they themselves had
assisted to  extract,  re-occupying its proper place.  Curiosity
led  us to examine  how this  could  be,  and no conjecture
seemed more probable than that  this new  polypus had fallen
down from the upper and  back part of the nostrils, where it
had been squeezed  up by the former polypus, and nitched in
the  narrow  cavity : the extirpation of the former,  it would ap-
pear, had made way for this falling down.
   " I did not long hesitate how  to act, but waited only the re-
turn of my  patient's strength, to cut off  this polypus also:  for
I  was afraid, in his  present weakness, of the haemorrhagies in-
separable from such  operations.  I allowed however only  six
days to pass over, when convoking the same surgeons who had
assisted me at  the former  operation, I,  in their presence,- on
the third of November, cut out from the throat, a portion or
knob of the new polypus, represented in  the drawing, which I
accomplished now with much less pain, because it hung by two
pedicles, and was softer than the  former: the haunorrhagy was
moderate, and nothing to be compared with that of the former
operations.
   " The patient instantly felt the benefit even of this partial ex-
tirpation, for the throat was entirely  freed, and he even  began
to breathe through the nose: but this quiet state he  did not long
enjoy, for before morning a new lobe of the  polypus had de-
scended, occupied the  place of  that just amputated, and  all his
difficulties and  distresses returned with the tumour.  Nothing
remained for  me, but to relieve  the patient, by cutting off all
the heads of this Hydra, or abandoning altogether an operation,
in which I had  already atchieved  so much,  which had cost my-
self such anxieties, and my patient so much pain and suffering.
My spirit was  so raised, and the  patient himself so full of con-
fidence and courage, so well resolved  to submit himself to what-
ever I thought fit to do, thatit was determined to cut this poly-
pous mass once more, and to the  quick.   But I had found such
advantages in allowing an interval betwixt each  operation,  that
I imagined I could not, on the present exigency, act mote pru-
dently than to allow the patient a short respite.
   "  But while I was meditating this  new operation, the singu-
lar nature of the case drew together all those, who had hitherto
in compliment tome,  or through charity towards the patient,
watched the course of bis disease, and, by perpetually thrust- 
                Of large and guttural Polypi.            447

ing in their fingers, touching the polypus,  torturing the nostril,
searching in various ways, some to ascertain its size, others to
feel for its root,  others with  the hopes of reaching its pedicle,
and disengaging the tumour, without having further recourse
to the knife, the roots were finally so torn and lacerated, and the
body of the tumour itself was so compressed and bruised, that
in a few days it  began to shrink and shrivel, fell into suppura-
tion, became rotten and fetid,  and  dropt away  piecemeal in
small portions,  one of  which however was as long and as large
as a thumb: by this wasting of the tumour the patient was freed
of it in a few days, without the help of the  knife or cautery,
nor did I choose to meddle with the  roots of the  tumour, bodi
because I thought that  where nature had done so much,  it was
wrong to interfere ; and because I could perceive that the root
or basis of the tumour was melting  away slowly of its own ac-
cord."
   Mr. Manne has added in  his book, in testimonial of these
facts, the affidavit of nine of the Gentlemen who attended the
operation, and of  Francois  Payen,  in whose house  the patient
lived.
   " This," says Mr.  Manne, in concluding the narrative,  " is
a deadly blow to the opinion of those who believe  in the plurali-
ty of.polypi:"—by no  means : it is as I have said, in the words
of%he fable,  one looking on the side of the statute which is
white, while another looks on  that which is  sable.  Polypi of
this magnitude are usually, but not necessarily, solitary.
   A narrative so very interesting as this, should not be  dis-
missed slightly ; it suggests various useful remarks ; it opens
up to us much of the rude practice which prevailed even in the
last century, of slitting  up  the palate,  pulling with  great  iron
forceps, bolting  out the tumour at the same time, by pressing be-
hind the palate with  the fingers ; extracting by  main force of
pulling, with the help not unfrequently of a great  crooked knife.
We are led by this narrative to doubt the prognostic handed
 down from the times of Fabricius, or indeed of Celsus, of the
soft polypus being mild, the firm  and  hard cancerous !  Every
polypus is soft in its commencement, firm inks perfect growth:
I never have grappled with a polypus of this, size, or any thing
approaching to  it, which was not semi-cartilaginous of a stony
hardness ; such at least were those of a young man of the name
of, Reid, and of one Gow,  which I extirpated with ligatures ;
their cases I shall presently  mention, for other purposes than to
prove this fact.  But  surely, if ever a long and firm polypus
should by nature, and by irritating  causes, have become cance-
rous, this might have been so ; nay, I doubt not,  that in exa-
mining the records of our profession, you will find.those  rarti- 
443
Of large and guttural Polypi.
 laginous polypi the most frequently and effectually cured ; anil
 I shall presently  state to you my reasons, why I would rather
 grapple with a big polypus, than a small one ; rather with a tu-
 mour that reached the throat, and depressed the soft plate, than
 with one which were but indistinctly  felt in the nostril.  The
 latter is small,  delicate, and yields to the forceps ; the body is
 crusted so as to  give no hold, while the  neck  and root remain
 untouched ;  the  latter, in proportion  as  it grows firmer in its
 body, grows smaller in its neck, or pedicle, its root cannot
 much enlarge,  while its body does; the disproportion betwixt
 the tumour and  its pedicle is daily increasing,  and becoming
 more favourable  to all kinds of operation, whether rude or skil-
 ful.   The polypus, by  this process, has been known, I have
 known it myself, drop  away in process of time,  as ripe fruit
 drops from  the tree.
   The merit of the operator, in this singular case, is least of all
 to be passed in silence.   The enterprise  was bold, manfully
 conducted,  and attended with success every way gratifying.—
 Never perhaps was  there a more desperate  situation than that
 ofthe patient; the face deformed,  the cheek in a state of sup-
 puration, the grisde of the nose perforated, the polypus protru-
 ding through the opening of the nostril,  filling the cavity of the
 nose, and extending to the throat:  the  disease neglected for
 two years :  the patient tortured with pain and confusion of head,
 dying.of haemorrhagy,  and  soliciting the surgeon  to perform
 any desperate operation that might promise relief.  The polypus
 of chat firm and cartilaginous texture, which  all writers have
 agreed denotes a  cancerous disposition.   Even such a tumour
 was  torn, mangled, cut, one way or other extirpated, and finally
 cured ! From  this what should we  infer ?  First, that if  there
 seem something of  good fortune in that perpetual  laceration,
 with the fingers of inquisitive visitors, by which the patient was
 ultimately delivered by ulceration ofthe polypus, or its remains;
 still it was that sort of good fortune which  the bold and skilful
 deserve ;  and  next  it leads us to  indulge the belief that it is
 among the  first moral duties of our profession,  to attach our-
 selves more faithfully to our patient, in proportion to his dan-
 ger,  not to shrink with heartless policy from the ugliest opera-
 tion  his  condition may  require.   It is not because we are un-
 certain of atchieving a cure, acquitting ourselves with honour,
 that we are to abandon our patient:  where nicer and more de-
 iicate operations  fail, we must, at his request, betake ourselves
 to the  more rude and  desperate.   It is not the barbarous or
cruel manner of our operation, that we have to consider, butits
tendency to  preserve life: it is not by our feelings, but our rea-
son,  that  we are to  be guided;  eU  all great and important 
Of large and guttural Polypi*            443
operations  should be abandoned ; surgeons would decline ope-
rating ibr the stone or even trepanning; for these also manifestly
endanger life, and are attended, even in the most skilful hands,
with circumstances of 'particular  cruelty.  You  know now by
expijrienctyin this one case at least, that operations for the cure
of polypi, to be successful must be in some degree cruel: Ope-
rations within the narrow passages of the nose and throat,  like
those jof midwifery, where we are forced to introduce the hand
and  instruments, require perseverance, even \iolence and de-
termined  courage,, more . than skill or  delicacy: and in both
kinds of operations, these natural passages bear, without essen-
tially, suffering,, a degree of violence, which those unaccustomed
with: practice \vould be afraid to use.   Haemorrhages from the
womb,  or  from the nostrils,  and the  violence necessary  in ex-
tracting a  polypus, or delivering a woman, are  such as  would
terrify a timid man, and prevent  him from performing his
most necessary duties ; whereas to the man of experience and
courage,, these considerations are  but an incitement to  do his
wprk resolutely and speedily.  From this feeling it is that the
fear of  a  patient suffocating or bleeding to  death, incites the
operator;  like personal danger, he feels  that the  present fate
of his patient is in his hands,  he acts by an impulse like instinct,
he, is unconscious of the efforts he makes,  and accomplishes
things during such a  struggle, which,  in cold blood he could
not do.  This is the kind of merit that the operator had  in this
singular case.
   Often the methods of the older surgeons  are so  incorrectly,
or at least  so indistinctly related, that we learn little more  than
this, that  wherever  the polypus was sufficiently large to pro-
ject, they  could never resist  the desire of extracting it by main
force :  they seldom  used the knife,  or even cauterized the
roots of a polypus.  But Purmannus appears to have approach-
ed to a better manner than any of  his predecessors : for while
his assistant or apprentice, pulled upon a great polypus, which
hung pendulous from the nose, as large as a Muscadel pear, he
introduced the forceps towards the root  of the tumour, and
pinched it off:  and  indeed  it has often occurred to me, that
should  I ever fail of extirpating by the ligature,  those great
polypi which tend  backwards to the throat, and depress  the
palate,  I should operate, not as these gentlemen have done, by
slitting the  palate, by  cutting across the tumour,  when it ap-
pears  behind the  palate, or  pull with great  forceps introduced
by the mouth ; but in examining the disease I should, by feel-
ing  with  a  bent  probe, or  various shaped  hooks, search the
nostril .'for the rpot;  if  I could  then hook the neck of  the tu-
mour, so as vtsibly to move  the body where it appears in the 
450
Of large and guttural Polypi.
throat, I should be sure  of my stroke, and proceed with  con-
fidence ; if fixing a sharp hook into the tumour behind the pal-
ate,  and passing a blunt one  into the nose, I could move the
tumour alternately upwards and downwards, I should then be
able, either by pinching with the forceps, to pinch off the  root,
as Purmannus seems  to have done ;  or  rather, following my
usual method, I should pass one of the knives, small and bistoury -
shaped, 'such as I have hitherto  used,  deep into the nostril,
and  cut the root there:  and take notice, that the surgeon  who,
in handling a great guttural polypus,  reaches its root by the
nose, is sure of cutting it in the narrowest part of its neck,  close
byr the spongy bone.—This operation,  if  dexterously perform-
ed,  would be speedy,  almost  painless, and as effectual as  if the
tumour were cutaneous ; and the haemorrhagy would be  very
slight indeed, and easily suppressed by the plugs.   I have con-
stantly observed, that the haemorrhagy which is dangerous or
fatal, is that only which proceeds from the universal ulceration,
and an extensive surface ; not that it  proceeds from the  small
root of a polypus, or the stroke of the knife.
   There is yet,  among the practices ofthe older surgeons, one
which, though the most obsolete, deserves,  I think, the atten-
tion of a practical surgeon in an especial manner; because  it re-
lates to many of his  operations, and  may, I  think, suggest
occasional methods very useful;  it is an operation not very dis-
tinctly defined, otherwise  than  by its name, which expresses
 the  purpose of it, viz. The Compunctio Polypi, or, as I think I
have somewhere read it, Comminutio Polypi: it was a lacerating
 or transfixing of the root so as  to kill the body ; and though it
 seems to have been performed according to no very regular nor
 established plan, is yet commemorated  by various authors.—
 Heister mentions it in very brief terms, " There are yet several
methods (says he) of removing polypi; those which are recent
 will sometimes shrink and disappear, by  repeated punctura-
 tions or scarifications with a scalpel  or lancet, as Severinus
 asserts he  has experienced."   Hildanus  gives the  title  De
 Compunctione Polypi to his ninth chapter,  and speaks respect-
 fully of this operation  of Severinus.  He describes it as an ope-
 ration  performed by  itinerants  rather, whose method was not
 expressly known, than by regular physicians, and  says,  "The
 report goes,  that they tie together three long needles, and pla-
 cing the  head  of the  patient  in  a favourable  posture,   they
 scarify the tumour with  the points.   They  then  anoint  the
punctured  part  with  oil.   No ill consequences  are  found to
ensue ; the process is repeated from day to day, and the polypi
 shrink and waste till the patient is in  a little while restored to
.perfect hearth.   Such," says Hildanus,  " is the method sug- 
Of large and guttural Polypi.
451
gested by Hierocles, a celebrated writer in  the veterinary art.
Nor do I see why an operation so gentle should not be transfer,
red to ours ln  Nor can I imagine a reason against a practice so
likelv to  prove  successful;  so generally believed  among the
older surgeons to be profitable in the small spongy and blood-
less polypi,  which occupy the nostril alone.
   It is reported,  that the method of killing a polypus by a liga-
ture, drawn high round  its  roots, and  tightened from day to
day,  is of ancient date.  But though I willingly commend and
as willingly borrow  from the works of the  old surgeons, I had
nothing to praise in  their manner of applying the ligature,  nor
indeed any  thing but their boldness and courage, m grappling
willingly (sometimes, it must be confessed, alter  having bar-
gained for their thirty or fifty crowns,) with the most bulky and
formidable  polypi.   Ligatures, no doubt, they did apply ; but
assuredly they had no other design, than  to save that  blood,
which the patient could not but lose when they cut them off with
their bistouries.   The design of pushing up the ligature to the
basis of the tumour, never entered so  tar into their system ot
operating, as to lead them to think even of pushing the loop up
to the root with a forked  probe.   Glandorpius passed a  thread
of strong silk round the polypus,  drew it tight secured it with
a knot, and then cut off the tumour close to the ligature.  |  But
 to perform this  operation successfully," says Heister,   it will
 be necessary  to extract the polypus as far as you can out ofthe
 nose by pliers.   This too must be done gradually and  gendy,
 lest you  break off  the tumour before  you have made the liga-
 ture ; it must be left  upon the part after your abscission, till it
 is spontaneously digested off; and thus you  cure the disorder
 without running the risk of a profuse hemorrhagy, which is
 sometimes such as to kill the patient, especially when the poly-
 pus is removed by avulsion."  Such were the purposes of the
 Latures, used  by the older surgeons; it was  a tourniquet,
 merely intended to prevent the loss of blood in their rude ampu-
 tation of the  tumour.  Heister seems to have had a conscious-
 ness ofthe imperfection of  this method,  and to have sought a
 more effectual manner of fixing the ligature.  In the case  of an
 old ladv, afflicted with polypus, he struck his ligature through
 the  body of the tumour within the nostril, but far  from the

 *° But all these methods were violent and rude.  Seldom did
 the  older surgeons affect gentle  means:  never indeed  that I
 recollect except in this solitary instance, when they stood in the
 point blank danger of disgrace from haemorrhagy, when cutting
 with their crooked knives.                               .
    They scrupled not to slit up the nostrils ; and the cleaving 
452              Of large and guttural Polypi.
the palate, with the first stroke of their bistoury, from the uvuta
to the bone,  was no uncommon way of making room for cut-
ting the polypus itself  at the second stroke.   " Before 1 con-
clude," says  Garengeot, " 1 must  mention to you, that often
polypi so entirely obstruct the nostril,  as to prevent the possi-
bility of introducing instruments to grasp the tumour; and in
such circumstances the surgeon has no choice, but must dilate
the nostril with a cutting instrument.   The  sole difficulty is to
know at  what point, or  in what  direction.   These are  polite
terms, " dilating the  nostril with  a cutting instrument," for
slitting it up with a  bistoury ; and where the only difficult) was,
about the direction,  that would not  stand long in the way of a
surgeon of this complexion.
   Such was the horror of surgeons  at this disease, or rather at
this stage of it, that they seem to have  thought no way excep-
tionable,  that  afforded the slightest chance  of destroying the
tumour.   Petit, Garengeot, Dionis, Le Dran, Heister, Levret,
and Tulpius,  all the best authors,  mention every possible me-
thod with equal commendation, as if the surgeon had no choice
nor limits in his operation, but were to twist, tear, burn,  pull,
and destroy,  by whatever methods he best could, a part at least
of the polypus, if he could not unroot the whole.  They were^
you will find at all times, as ready to slit the  nostril, as to com-
mit any less  remarkable atrocity ; and no  operation was so uni-
versally applauded, as  that of slitting the palate.  " We cannot,"
says La  Faye, "extirpate by the nostril, polypi which descend
backwards and depress the palate ; for what we see of such
polypi in the nostril, is but a small portion, which easily follows
the body ofthe tumour, when it is extracted by the mouth ; and
to extract it by the mouth, we must  imitate the manner ot
Petit, viz. first, divide the fleshy palate  with a bistoury, and
then catch the polypus with crooked pincers on the fingers."
   This operation of cleaving the palate they never shrunk from,
because  it is neither  bloody  nor dangerous, and it  facilitated
their main design ; the consequences they never reflected on,
which, though in some degree distant, are not less melancholy.
For, whatever the patient, thus tn.-at.ed, does not  swallow with
great precaution, rather by letting it glide  over his throat, than
forcing it by the usual effort,  rushes  upwards into his nose;
and his voice resembles that of one who  had lost  his palate by
the venereal disease.
   To these rude and cruel  methods, the best of  us may need
to have recourse ; and it is a merit to bend up our mind to such
cruelties, for our patient's  safety:  but when the  polypus has
attained  this size, and fills the nose, and  depresses the palates,
its bulk  is peculiarly favourable to the operation of the ligature ; 
Of large and guttural Polypi.
453
and as it has not yet destroyed the bones,  the operation is al-
most always successful.   I like to be diffuse in my descriptions
and character of diseases: in my directions for operating, I at
least wish to be perspicuous and concise.  You would imagine
the apparatus for applying the noose round a polypus to be mul-
tifarious and complicated ; you would at least imagine the tubes
and other instruments of  Levret, to be essentially necessary,
and cannot perhaps at this  moment imagine that any  contri-
vances but what were extremely ingenious, could be at all suc-
cessful :  it is  quite otherwise : I have  often tried those much
reputed instruments,  with perfect confidence in them, and uni-
formly, I concluded with my fingers, the operation which I had
tried  in vain to perform with  this apparatus.  The operation I
am going to describe  requires address and courage, but no in-
strument great or  small : indeed the instruments are so descri-
bed,  that I am  persuaded those who write in praise  of them
never use them.  I require nothing but a piece of fine silver-
wire, and my fingers : I  have frequently used cat-gut,  but al-
ways found it soften, untwist, and become altogether unmanage-
able.   Ligatures of wetted thread are quite flaccid, and difficult
to apply : a silver-wire, of the size  of a common  harpsichord
wire, passes easily through the nostril,  preserves its  looped
form in the  throat, is easily cast round the polypus, and easily-
twisted, in a gentle degree, so as to kill without cutting it.
   First.  How  to  pass the wire through the nostril to the
throat.  You have already felt  the tumour depressing the pal-
ate,  and estimated its size :  you have  repeatedly placed the pa-
tient  before you, and made him open his throat, and depressed
his tongue, so as to occasion straining and retching, which un-
folds all the parts, and shews you their s.izeand relations : you
now  place him  before you opposite to a light, supported by as-
sistance,  resolute to bear whatever you do, and reconciled to it
by seeing that you have only a piece of silver-wire in your hand.
You  take the piece of  wire, about three  feet long, double it.
and  smooth  and arrange  the  doubled part, by pressing  and
modelling it in your fingers into a neat noose, a little open and
ready to expand when it gets into the  throat, but small  enough
to pass through  the nostril;  and taking this loop betwixt your
fore-finger and thumb, you enter it into the nostril, and  push it
gently along.  However big the polypus, you find that the loop
of silver-wire glides easily and smoothly along ; find it some-
times stopped, and then  it bends and resists, but withdraw it a
little, and then push it, and it will go on.   I have never found
occasion  to  use any  instrument for conveying the loop to the
throat, except when the  bones were destroyed ;  a  case in
which  I can  hardly counsel you to attempt the cure.   I have 
454              Of large and guttural Polypi.
thus imagined, that the wire  was turned aside into the antrum
Highmorianum, and  have used a catheter, cut or  open at the
point as a canula, for passing the  wire, and then  pushed on the
wire till it could be seen and catched in the throat, and then
withdrawn the catheter.
   Second.   How  to hook out the zoirefrom the throat.   You
cannot be one moment at a loss to know, when the wire reaches
the throat; for while  it passes along the nostril, it excites not
even sneezing or watering ofthe eye ; but the moment it passes
the uvula, or touches either on  one side the tonsils or the back
of the pharynx it excites a sense  of suffocation, and a desire to
cough, with  sneezing, which the patient cannot a  moment re-
strain.  Upon  looking  down into the throat, the  loop of the
wire is seen, it is easily hooked out by a blunt hook, or catched
with  common  dressing  forceps, or a  bended probe.   Then
quickly push the wire  onwards through the nostril with the fin-
ger and thumb of  the left hand, hook it forward through the
mouth with the  crooked  fore-fingers  of the right hand, and as
soon as you have  got the  loop without  the lips, all is quiet
again ; yet in all cases the hooking it thus is a painful struggle,
though in the hands of a dextrous surgeon, a momentary one.
Often you will find the loop of your wire passing actually down
into the glottis ;  the patient instantly cries, coughs, and strains
violently, while  the face  becomes turgid, and the eyes stand in
tears : instantly, knowing what kind of an  accident has hap-
pened, you withdraw the wire  a little towards the  nostril; by
this motion you retract it from within the  glottis, and you keep
it carefully there till the  straining  ceases; then you push it
gently on again, keeping the mouth open, and catching the wire
the moment it appears behind the tonsils.   In this part  of the
operation, there is much address and some practice requisite ;
first, in stealing the wire  on so gently that the patient scarcely
feels it ; secondly,  in  diving keenly and resolutely with the
finger into the fauces,  the moment the wire begins to excite the
throat, or becomes visible behind the velum : and lastly, in
quieting and composing the patient for the  next part of the ope-
ration, viz. that of casting the noose.
   Third. Of spreading the loop of the xvire, and  casting the
hop over the polypus.   You now draw out the loop of wire en-
tirely from the mouth, and spread it wide;  you prepare to re-
act with the right hand, in favour ofthe left; you take the two
ends of  the  wire, which project  from the nostril, firmly in the
left hand, twisting  it round  the  fingers for  a surer hold ;  you
gather the fingers of the right hand together with the thumb, so
Is to form a cone, and taking the loop of the wire upon the co-
nical fingers, vou, by drawing the wire up towards the nostrils, 
Of large and guttural Polypi.            455
 tighten the  loop  so upon the fingers, that  it is not easily dis-
 placed in the next step of the operation: you now  prepare  for
 that effort, by which you are to carry the loop over the biggest,
 and most pendulous part ofthe tumour; and in  this effort you
 are to succeed at once, or to fail; it can last but for a moment:
 the patient, while you  make this effort, cannot breathe, he feels
 the severe pressure of your fingers in his  throat, he is suffocat-
 ing,  struggling at once for breath, and striving  to vomit;  his
 eyes are staring, and  his visage inflated: you  dare  not keep
 him  one moment  in this  condition; you  must act resolutely
 and dexterously.   Your purpose is to push the ligature  home
 over the bulk and  body of the tumour with the right hand, while
 with the left you draw the ligature backwards towards the  nose:
 you first allow the patient time to take breath, and be composed ;
 you let him fairly  understand what you design to do, and how:
 you prepare yourself by making the  wire tense, by pulling with
 the left hand, and fix the loop  by  spreading and distending a
 little the conical fingers of  the right:  you then, in one moment,
 retract  the ligature steadily, but speedily with the left  hand,
 while you plunge the loop into the mouth, and carry it quite
 to  the back of the throat with the right.  The tumour,  which
 in  your previous examinations you were able only to touch with
 the points of yrour fingers, you are now, in the moment of ope-
 ration,  using every degree of violence, and pushing your hand
 boklly and deeper into the throat, able to grapple with, and by
 hooking and grappling with the points of your fingers, you get
 it in some degree within your grasp;  and pulling the bulk of
 the tumour towards you, with the crooked points of your fin-
 gers, and slipping off the ligature from the points of your fin-
 gers by bending them  still more, you  at once turn it over the
 lower part of the tumour with the right  hand, and pull the
 noose up towards the root of the tumour with the left.
   Fourth.  How  to hitch  up the  ligature close to  the root.
 With every operator this must be a matter of great anxiety, for
 he  has no sign nor mark by which to know, that the  loop is car-
 ried to the highest possible point, nor any sure means of doing
 so.   Do not let me  deceive  you, by representing  the  simple
 methods I am going to speak of as infallible ; so much the re-
 verse, that though they seem to me at once the best and the most
 simple, though I have always entered upon  this part of the
 operation widi confidence, I  have never finished without a de-
 gree of diffidence and uncertainty.
  I have  often  found, especially  in  firm  and smooth polyp:,
 that I have by that quick and forcible retraction of the ligature,
 by  which I draw it up behind the polypus, hitched it at once *«-»
high,  that no after-operation  was either necessary or useful. 
456
Of large and guttural Polypi.
But the attempt to hitch the ligature high, and place itcorrecdy
round the neck of the tumour, can never be superfluous: the
instrument I most frequently use is a boy's catheter, or one of
the smallest size, cut across  about the middle, or somewhat
short of the middle  of its curve.  Taking one of the ends of the
wire as it hangs out of the nostril, I pass it through the tube of
the catheter, and then  holding both ends of the wire or noose
firm,  1 pass the catheter deep into the  nostril,  along the wire
till I imagine the point of the catheter touches the  tumour;
then,  by  tightening  both ends of the wire, and turning the point
of the catheter upwards,  I try to raise that side of the wire or
ligature as high as possible;  I then withdraw the catheter, pass
the opposite side of the wire  through it; I  hold all tight again,
and try  to raise that side  of the noose as high  as  possible;  I
then  pass both wires through the tube of the catheter at once,
push the catheter along till it touches the tumour, pull both ends
of the ligature so as to tighten it round the neck or smaller part
of the polypus, and, twisting the wire  fast round the handle of
the catheter, I leave it there.  More  frequently I  use for this
latter purpose a shorter tube, or very small section of a cathe-
ter, a little bended, which, when fixed, projects no more than
an inch,  or an inch and a half beyond  the nostril,  and is less
apt to be discomposed by accidents during  the day, or change
of posture while the patient lies asleep.  Sometimes  I have
run  along the  line  of the ligature  to  hitch it  higher, a probe
with the point bent.  Sometimes, giving the loop a twist in its
middle,  I  have, before introducing  it through  the nostril into
the throat, tied a ligature of waxed thread, or cat-gut, to the
loop of the wire, the twist of which keeps the  regulating liga-
ture in the centre, so as to raise the proper  ligature and adjust
its place.  When a ligature of wire is thus mounted and in-
troduced into the nose, and the loop caught in  the  throat, and
retracted through die mouth, this assistant-ligature is fixed on
the centre of it; the noose of wire is then carried into the throat
upon the conical  fingers of the  right hand, and cast over the
tumour,  and retracted  behind it, as I  have already explained,
and of the  three ends hanging out of the nostril, you raise, first
this supplementary  ligature,   by running the catheter along it,
and thus you make sure of hitching the centre of the loop of
silver wire higher, after which you carry  each of the  sides
higher,  by running the tube along them, and if you know the
windings of the  passages, and  have formed a true conception
of the form of the  polypus you  have to deal with, your chance
is toh-rable of placing the ligature very  true.  If there be a se-
cond  polvpus, one  in the  nostril as well as one in the throat,
this  method enables you  to  carry the same ligature at once 
Of large and guttural Polypi.             457
round both.  I have occasionally done this with the common-
eyed probe, but the eyed-end of the probe, though from its flat-
ness it glides pretty well along the sides  of the tumour, is too
big to turn easily,  and too  sharp in its point; but a surgeon in
the country may, by clipping  off the point  with scissars, and
hammering and rounding it upon a stone, fit it for this use.   I
have occasionally used for this purpose a piece of suffer  wire
twisted  into a loop, for conducting the ligature down  into the
throat,  or  placing  it correctly, and hitching it high upon the
neck of the polypus.   In performing this operation then I take
only a catheter nicely cut and smoothed,  a few waxed  ligatures
and catguts of various dimensions, small and flexible wire, for
forming the noose, and thicker  and firmer brass wire to use
for this purpose, with cutting pliers, and  common pincers, to
turn and  twist the wires into whatever shapes best suit the oc-
casion, or the accidents of  the case.
   Fifthly, Of the effects ofthe ligature on the tumour, and of
the time of its separation.  When you first draw the noose, the
stricture is followed with extreme pain, the eyes fill with water,
the patient cries out and retracts his head, and violent  sneezing
follows ; during the whole of the first and second day, the pain
is like that of severe toothach} and, upon tapping with the fin-
ger upon  the catiieter or probe,  you find it firm.  On  the third
day, a  thin and bloody serum begins to distil from the noose,
and continues to flow in great profusion, the probe or catheter
is blackened by the putrid taint of this serum, the polypus, if
any part of it project so as to be felt, is perceived to be flaccid,
the breath begins to pass through the nostril, and the patient,
who had felt his fauces choaked with the polypus, and was deaf
from its pressure, now swallows easily, and hears very acutely,
because the tumour begins to shrink.
    These are the first suspicious signs of the fading of  the poly-
pus : the  fetor of the matter increases on  the fourth and fifth
days, the  probes and silver wire are still  more blackened, the
wire manifestly has become looser from the shrinking of the tu-
mour,  the catheter now  shakes,from side to  side, and, that it
may completely destroy the  polypus, you find it necessary to
draw it a little closer in proportion as the tumour  has already
vielded.   Not  unfrequently  it happens, that  at this  time the
probe or  catheter comes easily away; but if  the ligature con-
tinue to retain its hold, it is but for a day, or at the utmost two
days longer;  and though the pain is not renewed, the polypus,
being now less sensible, the parts are still more blackened, the
 discharge  is  extremely fetid, thin, and copious; some blood
 usually flows at this time, the swallowing improves, and the
 hearing grows  too acute,  irregular, and contused;  the tube
                            3 M 
458
Of large and guttural Polypi.
falls away on the sixth, seventh, or eighth day, and often it hap-
pens, that the tumour melts away so entirely, and is resolved
into this gangrenous ichor, that no perceptible portion of it falls
away: sometimes,  continuing more entire,  it drops  into the
throat,  and the patient rejects it; often when it drops  into the
cesophagus it is swallowed, and is passed  undigested by  stool;
sometimes the patient is conscious of having swallowed the tu-
mour, but more usually it passes over the throat insensibly, and
during sleep.  I have known it happen, especially in the  hands
of ignorant people, that, after the polypus has dropped off, and
actually been passed  by stool,  the  tube  and wire have kept
their place, without the reason being at all suspected:  it is this,
that the loop of the ligature is larger than that narrow  slit of
the nostril, through which it should pass, and thus it hangs sus-
pended, and I have known it bang so a month, but loose, move-
able, and easily taken away.  I  do not know  that the loop of
wire ever needs be left, even in the most bulky  and  cartilagi-
nous polypus, beyond the eighth day.
   These are, I believe, the most material rules and directions
I have to give you; but there are some of them, perhaps, that
I ought to explain or to impress.  The  operation which use
has made easy, or frequent success has inclined us to prefer to
all others, we are apt to praise too much; but I am conscious, that
it is a serious duty  to represent this not favourably, but  truly.
The operation of noosing a polypus, is not suited, in any de-
gree, to these small and soft polypi, which occupy  only the
nose, but to those big and solid ones, which depress the palate,
and are felt in the throat.  It is most natural for the young sur-
geon to believe a polypus the more formidable, the greater its
size; but indeed it is impossible to grapple with those which
are not large; those are most easily grappled with the points
of the fingers, and noosed with the loop or ligature, which are
very conspicuously large.
   Some apparatus you will assuredly require; you would ima-
gine many  and curious  instruments necessary ; you must have
small catheters, or other tubes,, you must have a blunt hook for
hooking the noose forwards,  as soon as it appears in the throat,
a pair of common dressing forceps, which indeed I find best,
silver wire of various thickness, and pliers for twisting, and cut-
ting forceps,  or strong scissars, for dividing it; but having had
much experience in such operations, and seen  every variety of
the disease, I protest I know of no  circumstances in  which  I
would not prefer a bit of silver wire managed with my fingers,
and passed down into the throat, without a tube, drawn  out
with dressing forceps from the throat, formed into a loop, and
thrust over the tumour with my  three first fingers of the right 
Of large and guttural Polypi.            459
hand, in a conical form, to the most ingenious instruments that
ever were devised.
  An operation so effectual and radical, and yet so little alarm-
ing,  I do not know; for the surgeon  presents himself without
instruments, with only a bit of silver wire in his hand, and with
the professed intention too, not of cutting, tearing, or cauteriz-
ing,  but merely of casting a noose round the tumour, as round
a wart on the surface of the skin.  Nor are  the  efforts  made
in applying that noose, though violent,  at  all dangerous; they
are not fatal,  like those of an unskilful surgeon groping in  the
lacerated bladder for a stone; there  is  here  no  incision, and
the surgeon is grappling for a hold of  an uninflamed tumour,
in natural passages,  which, though they be inflamed  by his un-
skilfulness or rudeness, (and I have seen them inflamed so that
the whole throat has swelled exceedingly)  yet such  inflamma-
tion does no material harm.
  But, though harmless,  the efforts necessary for noosing the
polypus makes it a moment of great agitation and anxiety for
the surgeon:  his patient strains, and  suffocates, during his at-
tempt ;  however long it lasts, breathing is suspended ; the eyes
are filled with water, the blood gushes from the mouth and
nostrils, the fingers, or rather the hand  of the operator, is dri-
ven deep into the throat;  and the patient is held staring, and
struggling, at once terrified for  suffocation, excited  to  vomit,
and alarmed and pained by the pushing  of the operator,  who is
obliged to push his  finger deep, before he even feels the tumour
behind  the palate, who  grapples hard before he  gets the lower
part  of it within the grasp of the fingers, and pushes still more
violently, and struggles much, before he can pass the loop  of
the wire beyond and over it: it  is a  painful, and to the spec-
tators an apparently desperate and unavailing struggle ; it is diffi-
cult to perform in the living subject, for in one moment of vio-
lent struggling a thing is to be accomplished, which you have no
opportunity of trying previously  in the dead body; it is also to
be accomplished at once,  for if the operator  suffers himself to
be once  foiled, he may be so fifty times,  and never succeed:
never, therefore, attempt this operation in the presence of stu-
dents, nor think of it as an exhibition of skill, but  privately,
with one or two  chosen  friends,  when having no concern about
your own  reputation, or shame or fear of being toiled, your
whole thoughts are  occupied with your patient.
  Like the operations of  midwifery,  such as turning the child,
or dilating the womb in  floodings, this requires a  degree ot
strength, and a sort of cruel violence, which the inexperienced
surgeon cannot allow himself to use ; insomuch,  that one who
has often performed it,  forgets that there is any skill required, 
460
Of large and guttural Polypi.
and knows not how to describe the  art he does use.  So great
is the force, that I long imagined that nothing but courage  was
necessary; I  was not aware, that in a matter so simple, there
was occasion for particular address; and among many,  whom
I have seen try in vain to noose a polypus, I represented to one
gentleman,  that he had but to push his fingers  more courage-
ously into the throat, and he could not fail to distinguish the
polypus, and  after a short struggle to noose it; this  was the
only point of  my instructions in which he  did not fail.   More
desperate struggles, I confess, I never witnessed; and when,
after twenty attempts,  I  perceived that  it was impossible  he
should  succeed, I found it as difficult  to disengage him from
the patient as a mastiff from his hold, he seemed furiously re-
solved not to  be defeated in what was esteemed easy,  and ne-
cessary for the patient, nor disgraced  before a whole theatre of
students.
   The surgeon must,  in performing this part of his operation,
be prepared to use great force;  he first draws out the loop from
the throat, theh spreads it, then passes the three first fingers of his
right hand in a conical form into the loop, then retracts the wire
in the nostrils with the left hand, so as to straiten the loop upon
the fingers of the right hand, that it may not shift, then pulling
back the wire with  the lett hand,  he  gradually  introduces the
right hand into the mouth, conducting the loop upon the points
of his fingers.  He next prepares for the final exertion, by pull-
ing the ligature smartly with the  left hand, thrusting the right
hand forwards into the throat,  distending the mouth more and
more, and  pushing the hand deeper, till he not only feels the
tumour, but  passes  beyond it  with the  points of his  fingers,
hooks it towards him with the crooked finger-points, as in the
motion of tickling, pushing the ligatures up with the backs of
the fingers at the same moment,  and pulling it very  strongly
back  into the nose;  the throat all the while re-acts and assists
him.   This,  as far as I am conscious, is the manner in which
I have successfully noosed the polypus, and in no instance have
I  yet failed  wherever I  conceived it to be of sufficient  size
for such an operation.*

  • It is eafy to  imagine the manner, and ftill eafier to underftand the effc<9 of
thefe manoeuvres, but to  execute them is extremely difficult, as I am now per-
suaded ; for I have feen furgeons, by no means awkward or ignorant, mifcarry
moft inexplicably in this fimple operation of applying the noofc. 
Of large and guttural Polypi.             461
                 HISTORY OF  THE  DISEASE.

   u The case of A. Gow  is one, I  believe, particularly suited
 to convey clear impressions  of this second stage ot the disease,
 in which the tumour is bulky, fit for the application of the  noose,
 and not yet accompanied  with any  caries of the bones.   Gow
 is a hard-working young man of twenty-one years of age, ap-
 prentice to a mill-wright in Blair  Athol; his polypus is big, and
 of a stony hardness ;  it choakes the  fauces, as if a fist with its
 knuckles downwards were  thrust  into the throat; the chief bulk
 ofthe tumour descending  from the back ofthe nostrils,  pushes
 out the soft palate into  a great convexity, so that it presses the
 root of the tongue ; two large knuckle-like tubercles of the po-
 lypus project below the curtain or moveable palate, and  on the
 center of the convexity formed  by  the protruded soft  palate,
 are two long gashes of incision, made apparently with the ex-
 pectation of letting out matter by his country surgeon, and now
 in suppuration.  There is  no part of the polypus projecting from
 the nostril, the bulk of the tumour is in the fauces, yet the face
 is deformed, the nose being  inclined to  one side, as if a branch
 of  the polypus were lodged there.   There have been frequent
 and very profuse hemorrhages ;  the parts  within the nose are
 greatly endangered  by  the pressure, which is  attended with
 considerable pain; but as yet, no matter distils from the nos-
 trils or throat, there have been no intense  pains in the  cheek,
 the maxillary  and nasal bones seem firm and sound, the disease
 is advanced to the farthest verge of the second stage, and be-
 ginning of the third, in which the bones and Schneiderian mem-
 brane fall into incurable ulceration :  nothing has saved the pa-
 tient from such caries, but that the tumour, though  very  bulky,
 is but of recent growth; it is of such a size as to be extremely
 favourable for operation : before  applying the noose, I take the
 following notes of its progress.
  " The lower  order of people are coarse  and  hardy, very
 little attentive  to their health ; it is not a slight alteration  of the
 voice, slight obstruction of the nose, or occasional hemorrhages,
 that can alarm them ;  thence it  happens,  that the  date they
 assign for  such a tumour, is not the beginning of its growth,
 but that stage  of its progress  in which it occasions particular
distress.    It  is no more than six months since Gow suspected
any thing to be wrong in his throat  or nostril; he  had  tooth-
ach, and had a tooth pulled, without any possible relation to
his present ailment, the first sensible sign of which was hemorr-
hagy from the nose :  during  eight or ten days, he seldom rose
in the morning without  violent hemorrhagy, which sometimes 
462
Of large and guttural Polypi.
recurred during the day, or in the evening, but it ceased spon-
taneously.
  " About a month after this first attack, the occasional hemorr-
hagy  returned in all  its violence ; he bled profusely from the
nose, not only in the morning, but at all hours of the day and
night; all the usual methods of restraining it now failed, he fell
into extreme weakness ; and, to use his own homely expression,
" seemed to have bled out all the blood of his body."
  " One day when he was out in the duke's woods, with his
master,  the mill-wright, cutting wood for their work, he ob-
served, in blowing his nose,  that he could not blow with his
right nostril; he felt, at the same time, something uneasy in
his throat, and directed by this feeling, pushed his  finger as far
back as it could go, and then he plainly felt a soft lump, obstruct-
ing his throat, and hindering his free breathing; and  being
greatly alarmed,  he begged his master to look into his throat,
who saw the lump very  plainly.  Thus you perceive  in this
coarse country lad, little in the habit  of observing his own feel-
ings, and  not easily discomposed by trifling uneasiness or dis-
eases, which in a more delicate person, and in a higher rank in
life,  would have caused great alarm.  The polypus was not ob-
served, till after it  had  occasioned very profuse hemorrhages,
and had grown to a very remarkable size.
   " The tumour  increased  rapidly; it was the  difficulty of
breathing, and uneasy feeling in the throat, that first led him to
the discovery; and being sensible that the lump in his throat
was still growing, and feeling his right nostril particularly stuff-
ed, he introduced his  finger there,  from time to time, and was
sensible also of a smaller lump obstructing his nose.
   " At this period when he had difficulty of breathing, with a
total  obstruction  of the right nostril, difficulty  of swallowing,
with  a degree of deafness in the right ear,  he had  no distinct
tooth-ach, but a general  uneasiness, sense of pressure, and con-
fused pain in the head: but he had  no returns of  the hemorr-
hage,  and only a thick,  white, and  starch-like mucus, a mere
increase of the natural secretion distilled from the nose.
   " In this stage of the disease it was, that he first applied to a
surgeon, a very ignorant one, who performed a singular opera-
tion ; the incisions  which he made are still in a state of suppu-
ration.   The lad went to this surgeon to complain of difficulty
of breathing, and a lump growing in  the throat, which he could
easily  see  and feel.   The surgeon  having heard of swellings
of the tonsils, and  obstructions of the throat, and read perhaps
of the operation of scarifying the tonsils, to let out the matter,
knowing nothing of diseases, and apprehending that the tumour
he saw could be nothing but the swelled tonsils, he proceeded to 
Of large and guttural Polypi.             463
make two long and deep incisions.   This bulky and  firm poly-
pus, having pushed down the velum, had depressed it to a right an-
gle with the bony palate : and the soft velum, with its uvula, was
thus protruded forwards in the mouth, in the form of a tumour,
so far, that you  could easily touch it with the finger.  He per-
haps imagined it some great abscess of the tonsil: he made, with
what instrument I  know  not,  two  long incisions, each more
than an inch long, parallel with each other, down through the
very centre  of the velum ;  and the  same pressure  which thus
extended the velum continuing and increasing, has so dilated
the two incisions, as  to prevent them healing: they are to this
day in a  state of suppuration, with  red and hardened edges,
though it is full two months since they were made.
   " The surgeon said  he would come back and complete this
operation ; what he designed next to do it is difficult to  conjec-
ture ;  but  fortunately for Alexander Gow, the operator, while
meditating upon the  operation, died,  probably from solacing
himself after hard rides with too strong a cup ; and  soon after
his death, Gow  came to  town to  have some operation per-
formed."

       NOTES OF THE OPINION IN THIS CASE OF GOW.

   " The tumour is big, distinctly7 felt behind the velum pendu-
lum, easily grappled with and noosed : the stage  of the  disease
is urgent, the   pain,  deafness, stupor, and affection of the
voice, shew the pressure to be such that we cannot for one mo-
ment  reckon upon the  part continuing sound,  the operation
should be immediately performed."
   The annexed figure is a true drawing of this polypus which I
found of this size, exceedingly hard and cartilaginous, and so firm,
that a delicate knife might be broken on it, before it could be divi-
ded.  Such is the tumour, which would in former  times have
been cut out, or torn imperfectly away, after cleaving the palate
not partially, as was done by the Dunkeld surgeon, but entirely.
I extirpated this polypus with a noose of silver wire, after the
usual  severe struggle  in  passing  and adjusting the  noose  ;
whether  the point (a) be that  small projection which was felt
deep within the  nostril, I do not know ; but the  broad  surface
(b), which either implied that this polypus had not a  narrow
pedicle,  or  that the  ligature had not been fortunately  placed,
alarmed  me.  I was  long  without  tidings of this young  man,
and feared lest he had been cut off by a return of the disease;
but just now, at the distance of eight years from this operation,
I have recognised him a waiter in a tavern, and in strong health,
and grown a stout and athletic man. 
*^$            VMrie and guttural Polypi.
   In another case of a boy of fourteen years of age I applied the
 ligature with the usual painful struggle, but he bore it well: the
 tube for tightening the ligature stood very firm : he was, on the
 4th day, relieved of the tube and ligature, which dropt away ;
 and at the same  time, of his deafness and stupor, recovering
 with all his natural voice.   But, though I have noosed many
 polypi  successfully, in this  I  certainly  failed ; I imagined I
 had noosed both polypi effectually, for both dropt away, and he
 was conscious one night of swallowing that one which choaked
 the fauces ;  but either the polypus projecting forwards into the
 nostril, had in part escaped ; or, from  the ligature embracing
 both, they had  been  imperfectly compressed; or there had
 lurked behind them a third polypus,  which indeed I conceive to
 be the most likely conjecture; but the disease actually returned,
 in a few months he came back  to me  with a voice as much
 affected, and the guttural part of the polypus as bulky as at first.
 Though mortified,  I was not discouraged by my ill success, but
 addressed myself again to the business,  and noosed this  new
 tumour, taking every precaution to  carry the ligature quite up
 to the root,  and  I  am confident this boy was, by this second
 operation, perfectly cured, I saw him grow a fine stout young
 man, and I must have been his sole  resource had the disease
 returned a third time, for the operation was bloodless, not at all
alarming, and little painful,  and his relief perfect.   When I
operated on this polypus I supposed there was but one  root to
 both tumours, but I have since changed my opinion on this sub- 
Of large and guttural polypi.
465
ject, and am persuaded that, wherever there are two or more
polypi, they are distinct in their roots, as in their bodies.  This
was just Gow's polypus in embryo, and I speak of it to you as
an example of  two polypi; and a warning of the unlooked-for
disappointments you will have to brook, if you are engaged in
tlus line of practice.
                       SECTION III.

            Ofthe Third and last Stage of Polypus.

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

  • In removing the plug, you firft undo the l-.not that fecures the anterior plu;^
in the noftril'-, yAttthenflacken the ftring,  that the pofterior plug may 1*11 dow^
towards the throat; if ic4o»ot iail doif n ipoiiUficoufiy, you pufli uguinft it by
vailing a probe though the nollril, holding the firing at the fame tune,  that the
plug may not go quite into the fauces :' you put in your drcfling forceps,  catch it
at the back of the palate, pull it forwards Irom behind the velum, and haying
brought'it out.©*  the mouth, yt>u «M the firing iu the noftnl, you  thus ex-
trad it. 
Of large and guttural Polypi.
4G9
him, he had not many days to  live.   The  ligature was again
passed, and the noose cast over the tumour, and in four or five
days, when its  operation was compleat, the nostril was so clean,
and at the same time so dilated, that I passed the finger, and
turned it in every direction with ease, almost to the throat.—:
But I may say, my finger was hardly out ofthe nostril, ere the
tumour began again to protrude; and on the 12th or  14th day
he had a dreadful haemorrhagy.
  u There was now no alternative but death, or the most reso-
lute operations : I  had not then learned to  use the caustic so
freely as I now do,  and considered the partial application of the
caustic as disproportioned to the size and rapid growth of these
polypi.   I resolved to burn,  with the actual cautery, whatever
remained of these polypi; and  to give access freely to their
roots,  I noosed the polypus, the polypus which presented, and
cleared the  nostril  a  third time,  and had a large cautery, with
a proper canula, forged for the occasion.   But it was now the
height of summer  ; the weather towards  the  end of July in-
tensely hot; the foul and  pestilent ichor which excoriated the
lips outwardly, passed in such quantities into the throat, that he
was seized with diarrhoea;  shiverings, and fever ensued : then
a state of stupor and extreme coldness succeeded;  in  five days
he became quite insensible, and after lying three days more in
a state of complete  stupor, accompanied with slight delirium,
he expired."
  From this narrative you will learn how much more terrible
this disease is  than liies or cancer ; for, with all  that is loath-
some or painful in those diseases, it is  attended with haemorr-
hages, stupor,  a confusion  of head, and affection  of the brain,
which I have always observed, is more than hectic or haemorr-
hagy7, the immediate cause of death.
  Since I have represented almost every other form and stage
of the disease,  let me represent this also, of delirium and in-
flamed brain, brought on by  a rash and ill-timed working with
forceps.
  I have often found the polypus advanced to its  last stage of
caries, and  external  abscess, even in the sixth month alter it
was first observed; if not  actually in the  sixth  month ot its
growth, and  fatal within the year.  So it was  in  the  good
woman, whose death  I am  now going to describe  ; in her case
indeed it would have been so, although no such rude operation,
as that I am now going to speak of,  had been performed.
  " G. T. a good woman of forty-five years of age, was afflict-
ed with polypus, which had long obstructed her breathing : for
halfa year or more, the right nostril had been impervious; dur-
ing the three  succeeding months she had been (leaf, and torpid: 
470
Of large and guttural Polypi.
 the tears flowed continually over her cheek, and the tooth-achy
 and rending pains of the face and head, became at times dis-
 tracting.   The right  nostril was filled manifestly, with a  soft
 and mucous polypus,  the eye watery and inflamed; the cheek
 suppurated and burst, near the  canthus of the eye  ; the whole
 side of the head  was pained, the cheek and jaws swelled, soft,
 inelastic,  and  doughy ;  a purulent and thick matter flowed
 from  the  suppurated parts, at  the  inner canthus of the eye ;
 while  a thin and fetid  matter distilled from the nostril, and ex-
 coriated the lip.   Her general  head-ach was aggravated by a
 more  pungent, and tooth-achy pain  in the nose and jaw:  yet
 she seemed hale, and vigorous ;  and there appeared no reason
 to fear such a sudden or dreadful catastrophe from any opera-
 tion,  however rude ;  let this case then be a warning to you.
   " A consultation decided that an operation was adviseable,
 and it was performed by the forceps.  To my apprehension, no
 polypus was extracted : little rags,  of a soft and mucous mat-
 ter, seemed to be squeezed by the forceps into a mere jelly ; the
 forceps were used for twenty minutes, with no great delicacy ;
 a small piece  of bone was found among these rags of the poly-
 pus ;  there was not even any remarkable haemorrhagy :  when
 invited by one ofthe attendants to look into  the largest portion
 of  the polypus, I found it no other than a roll of  lint soaked
 with  blood,   She was reported  to breathe more easily through
 the nostrils, but for that slight and momentary relief she paid a
 dear forfeit.
   " On the day following the operation,  her pulse  rose ; there
 were manifest signs of an increasing pain; the pain shot through
 all her  head; she was hot,  and thirsty, with a small and rapid
 pulse ; her anodyne draught produced no pleasant  nor refresh-
 ing sleep.
  ** On the second day, the nostril, the face, and  eyes, were
 extremely  painful, and the shooting pains and confusion of head
 increased ; but all this inflammation was internal, (not the less
 dangerous  for being so,)  the eye  and cheek were little apparent-
 ly affected.
  " On the third day,  the heat, thirst, rapid pulse, and general
 disorder within the head, were alarmingly increased.  The sa-
 line draughts, the shaving of the head, and the poultice in which
 the whole face was involved, availed nothing.
  " On the fourth day, at nine in the morning, she was found
 insensible,  and remained so; the pupils ofthe eyes dilated,  the
breathing  slow, and stertorous,  and the bladder paralytic,  so
that the urine needed to be drawn off with the catheter.
  " On the fifth day, she lay in  a deep apoplectic  stupor, had
no stool, passed no urine, was visibly sinking;  a blister applied 
Of large and guttural Polypi.            471
to the head had its effect; the sinapisms also inflamed the soles
of the feet, but she could not swallow.
   " On the sixth day she continued comatose, sunk gradually
during the night, and expired before morning : and upon dissect-
ting the head, the polypus was found a mere pulp of putrid
flesh :  the ethmoid  bone destroyed  on the  right side, and the
vessels of  the  brain were found turgid with blood ; its upper
surfaces suffused with water, and its lower surface in a state of
suppuration.   Here are the terms in which the appearances, on
dissection, were noted down."

                       DISSECTION.

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

   Having thus set before you  many lessons, and some exam-
ples, and proved what I have described, by true drawings, and
illustrated the operations I recommend to you by plans; 1 leave
you to your own discretion, sense,  and judgment, reminding
you only, that this like every tumour, should be resisted at an
early period of its growth : that these are not maladies to be cur-
ed by gentle and trivial practices. 
(  472   )
DISCOURSE  XXV.
      On Tumours ofthe Gums, Lips, Cheeks, and Throat.


  J_ HIS is, in every sense, an arduous subject; especially if it
 was my design, to reconcile every appearance of disease in those
 parts, with their complicated and curious structure : parts in
 perpetual motion, parts performing a variety of functions, as
 chewing, swallowing,  speaking,  breathing: parts  provided
 with various  glands,  salivary,  and lymphatic,  and  secreting
 even from their surfaces,  fluids of various properties.   Surely
 such complicated structure must be a source  of various disor-
 ders ;  for always  in the animal body, as in less perfect machines
 of human  invention, no  part is so formed as to serve various
 purposes, and to perform many functions perfectly.   Reasoning
 from the complicated  and intricate functions  and  structure of
 these parts, you would  find cause to believe, that their diseases
 must be very  anomalous ; observing, on  the other hand, the
 strange tumours, obstructions, and u'i-tural communications
 of one part with another, you would be  inclined, as every one
unacquainted  with our science is accustomed indeed to infer,
 that the complex structure of the parts abo itth' throat and jaws,
 is the source of much danger and n,'-,,jry.
  This confused impression of complex E'.uhure,  and propor-
 tioned danger, was all  that struck u^ when first I entered on
 my more mature  and serious studies ; without a hope of ever
 arriving at any satisfactory knowledge  of subjects so slightly
 mentioned in books.  But time and diligence have enabled me
 to do something  for myself, and something for you.   If you
 find  in this Discourse no pleasing and delusive speculation, you
 will,  I trust, find many  useful precedents, and such accurate
 dissections, and summary histories of diseases,  as will induce
 you to be studious, and help to make you superiorly useful.
  When we can distinctly perceive, that it is  from something
peculiar in the structure of a part that diseases are frequent and
complicated, precedents are very precious ; for we are irresisti-
bly inclined to  reason  on the  cause  of  such organic disease :
and it is onlv under the correction of plain facts and dissections,
that we can reason safely.
  I must acknowledge, while  I  can no way explain  the fact,
that the gums, lips,  and inner surface ofthe cheeks, parts seem-
ingly insensible and  indolent, give rise  to tumours which are 
On Tumours ofthe Gums, &?c.            473
indeed slow, firm, indolent, and void of pain in  their early sta-
ges, but in their latter stages, of unparalleled malignity, assu-
ming usually a fungous form ; and, when the firm and indolent
tumour thus bursts out into a fungous efflorescence, its growth
is so rapid,  that I know  nothing to equal it,  not even the fun-
gus of the brain! you almost  see it grow, and, when extirpated
partially, it sprouts up again before the blood of such imprudent
incisions is  dried up.  The tumours of the gums  are spongy,
luxuriant,  hemorrhagic,  and truly  cancerous : those lodged
within the substance of the cheek, knotty, indolent, slow, malig-
nant, and, however long they are of showing their  malignant
nature, they terminate, if neglected;  (and much it is to be la-
me nted, that,  from the patient's fears, and the surgeon's timi-
dity,  they often  are so,) in the most incurable and desperate
maladies.
  The gums are  subject to such an infinite variety of slighter
swellings,  to  boils,  to little  indolent tumours  resembling the
hordeoli,  or tumours of  the  eye-lid, and to harmless indura-
tions, that those which are the germs of the  most horrible dis-
eases, are too  little suspicious, too slightly characterised by any
peculiarity of form or aspect  to attract attention, till too late.—
A small, firm, seed-like tumour is perceived, but hardly noticed,
for months ; it  is seated between two of the fore teeth, begins
to separate, displace and  loosen them ; it grows imperceptibly
and slowly: the teeth are raised from their  sockets ; they be-
come loose and vaccillating ; they have no  longer any hold of
the jaw, but are  merely hanging  in  the tumour ; the tumour
retains its original gristly hardness at its basis, becomes rugged
and irregular  in its upper part,  with a cock's-comb-like edge:
though little painful, it bleeds from time to time ; it extends itself
to the gums of other teeth, which are successively displaced from
their sockets and loosened, and one side of the mouth is occu-
pied  with it.  Next the hard basis of the tumour extends into
the cheek ; the  tongue begins to be pushed aside, horrible  foetor
of the mouth  ensues, with frequent haemorrhages ; the tumour
now  protrudes and keeps the  mouth open ; the disease becomes
now  terrible and painful,  the patient  survives for a lew weeks,
with the mouth  and lower part of the face wrapped up in hand-
kerchiefs,  in a miserable and loathsome condition ;  the putrid
and blackened blood distilling with the acrid saliva through the
filthy clothes,  till wasted by suffering he dies in inexpressible
pain.   Such is  the kind of death, from which, I sincerely be-
lieve I have saved many by- a slight incision.
  " A young Gentleman, Mr. H-----, about 25 years of age,
of an  athletic form  and healthv constitution, and without the
slightest taint  of disease, hereditary or acquired,  had, from no
                            SO 
4T4
On Tumours of the Gums,
 perceptible cause,  a tumour firm, cartilaginous, and elastic
 seated so  fairly in  the centre of the gums, as to raise the two
 centre teeth of the  lower jaw from their  sockets far above the
 general  range of the teeth,  and separate the two that lay adja-
 cent.  Gradually,  but  yet in a short period, in a little  more
 than three months, it had separated those two central  teeth,
 projected from betwixt them, and increased to a very remarka-
 ble size  ; and, though  it had begun from the inside gum,  the
 greater portion seemed to be before the gum, just over the chin,
 projecting the nether lip.
   uThis tumour was about the size of a walnut, irregularly glo-
 bular, knobby, and shining ; when moved by pressing it with the
 thumbs, backwards and  forwards, it seemed firm,  fixed, and
 actually a tumour of the jaw-bone; yet I knew it by its smooth
 rounded form and its elasticity to be a tumour of the gum.   It
 felt, when pressed between the  finger and thumb,  so elastic,
 that a tyro must have believed it to contain a  fluid,  while I
 knew it to be in truth a  solid tumour, neither suppurated, nor
 capable of suppuration.   Its general aspect was that of a tumour
 so indolent, that nothing need be dreaded from it, and so much
 had it the form of one that might contain matter, that an unskil-
 ful surgeon might  have  been induced to strike his  lancet into
 it; but I  was well aware, that not a drop of matter would follow
 any puncture  made into  it,  tirnt the tumour inflaming, would
 turn out its edges, spread into a fungus, and, in a few months,
 cause a horrible and melancholy death.
  " Dr. Munro,  Mr. Allen, and  myself, having consulted on
 the nature  of this tumour; judging  by the analogy of former
 cases,  declared it to be of a most dangerous nature ; it had
 already displaced the teeth, probably injured the alveolar pro-
 cess of the jaw-bone, attained to an alarming size, and threat-
 ened, in no long period of time, to assume the most malignant
 possible  form : we  explained to our patient, that it contained
 no matter, was incapable  of suppuration, was of a size that for-
 bid all hopes of resolution, was sure to become cancerous, ad-
 mitted of no delay,  and  we explained, that we dared not,  even
 in its  first and least alarming stage, do less than  extirpate it
 from the very root:  we represented, the operation was harsh
 but not tedious, void of  danger, even of  haemorrhagy.   That
 nothing was to be feared but the not cutting it completely out.
  " In preparing  for such an operation, it is right to have ready
 the apparatus of a dentist, especially forceps to  twist out the
teeth, strong pincers to cut the  solid gums, engravers' knives
to cut away whatever is  corrupted of the jaw-bone,  and pieces
of dry and solid sponge, to thrust down into the void  left by
 extirpating the tumour, in order to prevent haemorrhagy; and 
Lips, Cheeks, and Throat.              475
two things the surgeon must be prepared  to  encounter, great
difficulty  in cutting  the  tumour, and such confusion  from the
mouth filling, like a cup, with blo< >d, that, after the first stroke,
he can see nothing of what he does, but must proceed by feel-
ing.  The surgeon has  much reason to fear that, in an opera-
tion where his view of the incisions  is so  obscured, he will be
guilty of much unseemly mangling and tearing ; yet the pain
of such  an operation, however rudely performed, is nothing
to be compared with that  of pulling  out a rotten stump, and
the motives infinitely more persuasive than a toothach.
   " In performing  this operation, I held the jaw-bone firm
with the fingers and thumb of my left hand, while my assist-
ant  inverted the  lower  lip, and, with a scalpel of  special
strength,  broad-backed like a cartilage  knife, I made the in-
cision in such a form as to  resemble the letter  V, or the Greek
delta.   The knife was carried by  the side of each of the dis-
placed  teeth ; all my strength of hand was requisite to cany
the knife down to  the  angle; blood instantly filled the  mouth,
so that, after the first stroke ofthe knife, every thing was done
by  feeling; but I cut with such decision, with such level lines,
and made them so fairly meet each other in the angle, that, by
pressing my two thumbs, one within side  of  the  tumour, the
other without, and  pushing alternately with my thumbs, and
poising with the flat handle of the scalpel, I pushed the tu-
mour out, clean and unmangled, leaving a very wide opening
bounded by the fangs of the  adjacent teeth;  and, after allow-
ing the part to bleed  till it stopped, I laid a piece of sponge in
the deep triangular cleft made by the operation, and closing the
upper range of teeth upon  the sponge, their pressure kept it in
its place.   This sponge was removed the second day ; simple
dressings of dry lint rolled in the shape of a pellet was substi-
tuted for  the sponge ; during eight or ten  days our patient ate
cautiously, and, in little more than ten  days, the incision was
completely healed.
   " I was greatly interested in knowing the internal state of the
tumour in this stage ; for I regarded  this  small tumour as the
germ of that terrible disease, which I knew so well by  experi-
ence, for which I had operated sometimes successfully, some-
times at so late a period as only to witness, perhaps to accele-
rate, its fatal catastrophe.   There had, upon making the incision
by the  side of one of the teeth, appeared a little matter, but so
very little as hardly to be  perceptible in the time  of a  bloody
incision, and not at all to diminish the size ofthe tumour; but
whether there was any fluid, purulent or gelatinous in the cen-
tre was still doubtful.  In the central  parts were small cavities^
and^ when they were  cut vertically, a gelatinous substance 
476
On Tumours ofthe Gums,
 oozed out.  The internal surfaces were studded with  small
 grains like millet seed : the thickness and cartilaginous texture
 ofthe coat of this tumour formed by the gums, shews that the
 matter would have been long in making its wav through tht m;
 its gelatinous nature proves that the cavity would not have clos-
 ed ; the irregular surface  studded with small grains of a glan-
 dular nature, explains to us how such a tumour,  after bursting,
 turns inside out, and degenerates into a granulated mass  of
 fungus,  sprouting in berry-like knobs, and little masses of vas-
 cular granulation.  Whatever cavity there is in a tumour of this
 solid consistence, seems to me like a calix ready to burst, and
 turn out its inner surface, with a new and  luxuriant growth of
 fungus.   The dissection of such a tumour, having fleshy walls
 and granulated internal surfaces, always reminds me ofthe im-
 prudence of partial incisions,  in consequence of which a part
 of the walls of the tumour being left, the  worst part of the dis-
 ease is  left: a fungus sprouting up from  the bottom of the
 wound,  is the first intimation of  the disease being imperfect-
 ly extirpated, a rapid growth,  haemorrhage, pain,  and, in one
 word, cancer ensues:  and these  are as  invariably the conse-
 quences  of striking a lancet into such a tumour, as of imperfect
 and ill-concerted operations.
  "■ This gentleman is perfectly cured, the gums and adjacent
 teeth firm and  sound, and I confess I could not reflect on the
 structure of this small tumour, without  saying within myself,
 what  would have been the  state of  this  tumour  in  three
 months? What would have been his condition in six or eight?
 In its second stage,  in little more than three months, it  must
 have filled the mouth with a fetid bleeding fungus!  In eight or
 ten months it must have assumed the perfect character of  incu-
 rabl-, loathsome cancer."
  It appears to me that,  in many cases which I have been in-
 volved in,  the disease appeared in a more insidious  form,  no
 circumscribed tumour, no formal disease awakening the attention
 ofthe patient, preceded the fungus ; no suppurated cavity open-
 ed, and turned its diseased surface out, in form of  fungus ; but
 the mere separation of the gums  from the  teeth, and alveolar
 process ofthe jaw, had the same effect,  for this is the description
 of what I have frequently seen, and it is exemplified in the fol-
 lowing case of a young woman who, I  fear, never recovered.—
 In this girl, not more than twenty years  of age, the gums of
 one or more teeth became spongy and rose in jagged points, se-
 parating  from the teeth : the roots of these diseased parts of the
 gum b-rime hard  and tumid,  in proportion as  their jagged
 points  became  more  soft and  luxuriant ; the disease spread
from gum  to gum, till  it extended along the whole range of 
Lips, Cheeks, and Throat*               477
the jaw; the whole substance ofthe gums became thus spongy,
thick, and fleshy, rising into the form of a tumour, of a deep
red or liver-colour, with a hard and schirrous basis, a  bleeding
surface,  and cock's-comb-like edges: haemorrhages burst fre-
quently from the general tumour, while a viscid and extremely
fetid  matter issued from  about the roots of the teeth.   This
tumour was so vascular, that the teeth, though poised  from the
sockets, and universally loose and vaccill iting, were almost
buried in it, and strong bridles of flesh extended across,  from
that which was external to that which was internal, in regard  to
the range of teeth, through  their interstices.  To look into the
mouth, you would imagine you  saw it occupied totally with a
very solid tumour ; when  you pressed it with the fingers, you
found it spongy and soft ; when you tried it with the probe, you
found it a mere tissue of vessels, through which you could push
the blunt point of it in every direction ;  when you felt for the
alveolar  process with the probe, you  were conscious  that ihe
bone was carious.   By the general aspect of such a tumour you
would be deceived, for you would imagine it, especially in its
early stage,  to be nothing worse than a spongy intumescence  of
the gums, which you might successfully clear away with ?. scal-
pel, or almost  scrape off with a spoon,  while  it is, in truth, a
tumour so malignant, that I have myself performed,  and seen
others perform, very painful and very unsuccessful  operations.
It is one of a character so  peculiar, that I know nothing but a
careful and early extirpation of it that will prevent mischief  in
its latter stage, nor any thing but a fair, open,  and candid prog-
nosis can protect the surgeon from obloquy : be assured,  that
when far advanced, it is unsubduable by the knife, cauteries, or
caustic ;  I have seen it, after long continued and cruel cauteri-
sing, grow for three months, the patient being permitted to re-
tire from this torturing process to the country, only waen hope-
less and desperate, there to die unobserved.
   The case which  I am now to  relate  to you, is one which
was confided to my care too late to serve any other end, than as
a melancholy  example of  the consequences of leaving such a
disease  to  run  its natural course ; a timely operation might
have preserved this worthy man in health to his ijmily.
  " Mr. Keil, of Monargan,came to town to consult me late in
the month  of August, 1802, after a regular  correspondence
with  his attending surgeons Dr. Stewart and Mr. Nimmo.—
Though past the prime of life,  he was a stout and lusty man,
healthy, laborious,  and active.  His  whole mouth was  filled
with a fungous tumour of the worst complexion, wanting no
character of cancer, but that it was void of pain  ; from imper-
ceptible beginnings, and by very slow degrees, it had increased 
478              On Tumours ofthe Gums,

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

              Opinion on  Mr. Keil's Case.

   " Mr. Keil cannot have witnessed the doubts and difficulties
of his attending surgeons, without being aware of that imminent
danger, which it falls to my lot to  announce to him :  and my
duty  and conscience equally incline me, to declare it without
loss  of time, and  without reserve.  A tumour  so  unusually
rapid in its growth, cannot cease to grow, but must continue  to
extend the disease by increasing the caries of the jaw-bone,and
propagating  the  morbid action  among the surrounding parts :
the hardened basis of the fungus will soon spread into the cheek ;
abscess, and  indurations of the lymphatic glands will ensue,
each  ulcer will throw out its fungous efflorescence, and the dis-
ease will burst out upon the face and  angle of the jaw, with all
the virulence, and more than  the deformity of  a real  cancer ;
this resembles in its form that  fatal fungus which sometimes
sprouts from  the  axilla,  after amputation  of a  cancerous
breast, or that which still  more frequently proceeds  from the 
Lips, Cheeks, and Throat.
475
spermatic chord, after extirpation of the schirrous testicle, and
which no methods, even the most severe and rude in surgery,
have ever been known to subdue.
  " I am of opinion that, though not accompanied with pain,
nor as yet with much foetor, nor with profuse bleeding, nor bear-
ing the precise character of cancer, this tumour is equally incura-
ble except by the knife,  and sure to prove fatal if neglected, (as
I fear it has already been neglected,) too long.  When  I speak
in favour of operation,  I must do so with a degree of reserve :
I wish  I might propose it as a sure resource, but the  difficul-
ties, and the chances of success are  so equally balanced, that
he would,  in my mind, be an inconsiderate  and  presumptuous
man, who would, in these circumstances, confidently promise
a cure; but he would, on the other hand, be inhuman and sel-
fish in  the extreme, who, for fear of any reproach that might
attach to his own reputation,  would refuse our patient the only
remaining  chance of life and  health.   The terrible stage of
ulceration, protrusion, and haemorrhagy, and probably  of pain,
which is soon to ensue;  the loathsome and miserable condition,
which is inevitably approaching,  would be more grievous to his
friends, if, from any  want of constancy, we should decline our
help ; and they will feel, at  some future period, a degree of
self-reproach for any present loss of time.  But I am beginning
to reason on moral feelings and duties, which belong to others,
when I am expected, perhaps,  to deliver only my opinion on
the medical import of the case.   I have, in the previous part of
this letter,  explained  the grounds of this opinion, with unaffect-
ed deference to the judgment of these professional Gentlemen,
who, having seen the beginnings,  and watched the progress of
this disease, have had time to reflect seriously on its nature and
consequences.  I advise the operation, and, should this be your
opinion also, and the  wish of our patient and his friends, shall
be ready to perform it,—the best proof I can give of the sincer-
ity of my opinion."
   This Gentleman, conscious of his impending fate, advised by
his surgeons, that  this was the only chance he  had for life,
without concealing that it was but a slender chance, gave his
consent, and became every moment more anxious that it should
be done quickly ; but so critical was his situation,  that before
the necessary arrangements were completed, a gland at the an-
gle of  the jaw had swelled, an abscess there was distinctly per-
ceived,  the hard basis  of the tumour had  run  deep  into the
cheek,  and, at this most inauspicious moment, when every
hing had assumed the  most unfavourable aspect possible, the
importunity of the patient, and his friends,  became very great, 
400
On Tumours ofthe Gunn,
and I received repeated notes from Mr. Nimmo requesting and
urging me to come.
   Nothing can be more unpleasant  to a surgeon, who has any
pretensions  to skill, than  an operation necessary,  mangling,
cruel,  and savage  in appearance,  performed within the morth,
beyond the sight of the assistants, and where even the lorg in-
cisions must be guided by the finger, where the dissection must
be  irregular,  and the whole  must be done blindfold, from the
blood with which  the mouth is filled ;  where the best surgeon
can hardly say he  is sure of what he has done,  nor confidt ntly
think he  has cut away the whole disease.   The operation  in
this case  consisted, first, in picking away  some of the  loose
teeth which lay in  the way of the dissection :  secondly, in a te-
dious  and painful  dissection, by which the tail, as I may ex-
press it,  or a prolonged and firm part of the tumour, which
connected itself with the cheek, was separated  from its  inner
surface, near the angle of the jaw, and  dissected down nearly
to the  chin ; the cheek being reduced  in all this extent  to ex-
treme  thinness :  thirdly, in a long and direct incision guided by
the finger, which separated the firmest part or basis of the tu-
mour,  from the whole length of the jaw-bone, from  the angle
all round past the chin, and nearly to the canine teeth of the left
side, where alone  the  gum  remained  sound.   Fourthly, in
carrying a like incision,  more dangerous by far in point of hae-
morrhagy, round the opposite or inner surface of the jaw-bone :
fifthly, in dissecting away the tumour from the jaw-bone,  from
the side of the tongue,  and from the whole circle of the mouth,
a work not accomplished without frequent interruptions from
haemorrhagy,  irregular,  and which was performed by incisions
rude and  mangling : and, finally, all the teeth of the right side
of the  lower jaw were  twisted away with the tumour, and the
bone scraped clear  of all remains of the fungus, down to that
decided line of incision, by which the root of the tumour was
separated.
  I need not say  how  careful I  was  to make the extirpation
complete ; or how much I risked in dissecting the cheek, so as
to leave merely the thickness of the  skin, not without a  thou-
sand anxieties and fears, lest it should slough off.   I left this
Gentleman, on the  third day, under the  care of Dr. Stewart and
Mr. Nimmo, ;md am sure that never were assistants more care-
ful of their patient,  nor more sincerely interested in the success
of another;  his pastor, Mr.  Smith, took upon him, with the
most charitable disposition,  every  little arrangement, nursed
him, and watched him.  The  part exhibited a promising appear-
ance at one  period, but a dismal, though- not unexpected re- 
Lips, Cheeks, and Throat.              481
verse followed,  after a few days of retirement in the country,
he died in a painful and loathsome  condition, with thia terrible
and fetid fungus, protruding both from the mouth, and through
the opening of the gland which had suppurated at the angle of
the jaw.  Far from  being any argument against  the early  ex-
tirpation of tumour, the whole scene  struck me as a most me-
lancholy instance of the danger of delay.
  Perhaps it is the peculiar structure of the gums, perhaps  the
proximity of the bone, that gives this  malignant complexion to
these tumours ;  for I have had many  occasions of remarking a
singular contrast betwixt the malignity of these, and their sud-
den growth,  after an imperfect operation ; and the indolent  na-
ture  of those of the rectum, though very awkwardly and imper-
fectly extirpated.  Sometimes, though rarely, I have found
long tumours, like polypi, depending  from the walls ofthe rec-
tum, protruding every time the patient went to stool: and cre-
ating inconceivable irksomeness and unnatural pain.  Very  of-
ten I find the folds of the  integuments, where they are gather-
ed and plaited at the opening of the gut, and the glands with
which the rectum is surrounded, growing into ragged tumours ;
sometimes  of a prodigious size,  fungous  and  loose  in their
texture, swelling like a turkey'9 gills, when the  patient strain-
ed at stool, usually concealed within the rectum, but sometimes
protruding  partially.  But these tumours,  formidable as  the
annexed sketches express them, I have always found of a mild
character, void of pain, attended only with irritation and a sense
of gravitation ; but never ulcerated, seldom ha;morrhagic, and
bearing to be treated by every rough method, to be tied with
ligatures, or extirpated with the knife, or destroyed by caustic,
without returning.
   The history of such a disease has so little interesting,  so lit-
tle variety of circumstances, that  even in the case of a friend,
for whom I had a particular regard, I  tound, after many an anx-
ious conversation, nothing to mark but what I have found in
every case, viz. a tumour slowiy forming, indistinctly perceiv-
ed at first, long  conceived to be merely an irritation,  unwilling-
ly recognized as a tumour, growing very  slowly to that size
which  requires operation ;  protruding at each time of going to
stool;  but easilv  repressed with  the finger, like a  mere pro-
lapsus  of the rectum, and occasioning, through many years, in
which the patient was  sensible ot its existence, no worse symp-
tom than irritation, and a sense of  gravitation.
   "  M. D. a young gentleman of about twenty-five  years of
age, had, if not from  infancy, at  least from the earliest of  his
recollection, a tumour in  the  rectum, which, every time he
went to stool descended, so as to leave a long continued  tenes-
                            3  P 
482             On Tumours ofthe Gums.
mus,  with irksome squeezings  of the sphincter, and frequent
squirts of urine :  but it was easily repressed  with the fingersy
after which the strainings ceased.   The  tumour was not pain-
ful, but hemorrhages frequently burst from it,  though never to
a great excess :  it was manifesdy of great length.   The head
or bulky and dependent part of the tumour is extremely firm,
and bolts out before the faces at  each time of going to stool;
the stalk or  pedicle, is four inches long,  not that its origin is
that far from  the  opening of the rectum  ; for the   neck is lax
and fleshy, and lies, after being pushed back within  the gut, in
somewhat of a coiled or convoluted form :  when the finger, be-
ing passed  into the rectum, is laid along the tumour, a large
nutritious artery is felt, distinctly running the whole length of
the tumour, and beating along the whole length of  the finger,
just as the artery of the testicle is felt running along the sper-
matic chord ;  a circumstance, which makes it, if not necessary,
at least desirable,  to kill the tumour, by a ligature  applied at
its root, and close as may be to the walls of the rectum.
  " I know no disappointment  so provoking,  no sense of awk-
wardness so irritating,  as that of  miscarrying in an operation
seemingly so simple as this: yet I confess  my sense of awkward-
ness,  and want of adioitness,  was very unpleasant  to me.  I
confidently  expected to apply  a noose,  with Levret's tube, or
what  is  equivalent, the eyed-probe  which I  sometimes use
in tying  a polypus; and it is my duty to make this  confession
to you, that I endeavoured in vain to apply the ligature, by this
simple operation, to the root of the poly pus, and kept my young
friend long under an irritating  operation,  in a painful posture.
But on these occasions, I have by me wires, probes, and eyed-
needles of all shapes : I abandoned the intention of slipping the
noose thus over the pedicle of the  tumour : I threaded a long-
eyed  needle, mounted on a stalk,  with  a ligature of waxed
thread ; I  passed  into the rectum  a lithotomy conductor, or
blunt gorget,  filled with cork in its concavity, and  introducing
the needle,  and striking it through the root of the tumour, very
close to the walls of the rectum,  I with a  common hook, run
along the face of the cork, picked out the ligature from the eye
of the hook, (a hook like that is used in aneurism of the thigh
or ham,) drew it  down,  and brought it out  by the anus, and
turning it over the knob, or bulky lower part ofthe tumour, re-
tracted it so  as  to make the loop strangle the tumour, which
dropt off in a few days."
  But watery and yet very bulky  and protuberant tumours, en-
circling the whole verge  of the  anus,  corresponding  in their
form, viz.  three,  four, or five tuh. rcles,  with the   great lurks
or folds in skin, are infinitely more frequent than tumours with- 
Lips, Cheeks, and Throat.               483
in the gut.  Those tumours of the verge ofthe anus, though
bearing the  most  formidable  aspect, rarely  degenerate  into
cancer of the rectum, except in extreme old age, and when irri-
tated, neglected, or disregarded.  But if any  thing can incline
the disease to cancer, or  make it alarming, it is the imperfect
extirpation of it, or an ungainly attempt to kill it with ligature.
Among other varieties of this tumour, the following instance is
one  which, after being  imperfectly extirpated, grew again in a
few months to twice its original size ; after this second growth,
the surgeon, more anxious and  more timid from his ill success,
applied ligatures, by which, far from having strangled or killed,
he irritated and inflamed them :  they had suddenly increased
in size, and he was not a little  alarmed, and doubtful whether
to draw the ligatures firmer, or to extirpate the whole with the
knife.   The subject was a very  hale and  vigorous young  man,
in the prime of  life ;  though the basis of the tumour was  very
hard, and the tumours themselves towered to  a great height, I
found  all the verge of the anus, down to the  very  circle from
whence they arose, soft, limber, and natural,  as if no such dis-
ease were even in its vicinity.   With three or four strokes of
the bistoury I extirpated  the whole, and cleared the verge of
the anus entirely of disease, or the seeds of.it, so that the young
man continues now in perfect health ; but to do this,  I spared
nothing;  I pulled each tumour out with all the strength of my
finger  and thumb, and cut out along with it  that  part of the
verge of the anus that belonged to it, muscular as well as cuta-
neous : to whatever d°pth the hardness extended I cut, introdu-
cing the bistoury quite within the circle ofthe anus.  Conscious
that if the operation should prove again  unsuccessful, the lad
could not escape a miserable death, I cut away the whole circle
of the anus, and have so often cut away the  whole,  or much of
the circle, without the  slightest  ill consequence, that I cannot
but admire the story related in Keill's Anatomy, which, when I
was a boy struck me with so much horror ;  where,  in speaking
ofthe verge ofthe anus, the case is related of one, who  having
the whole circle of the anus  extirpated for piles, I believe, had
the anus so constricted,  that he  could never after pass harden-
ed fosces,  nor go to stool without a glyster.
   Wherever it becomes  necessary to extirpate the whole circle
of the anus,  I  have found  it safe : the necessity  of the case
would vindicate us ; but  experience of the little inconvenience
it produces entirely reconciles us.   In another case a tumour
of prodigious volume, rolled out lump after lump, every time
the patient chose to squeeze it down, and still left great rolls
within the rectum, which could be hooked out with  the fingers,
as you would hook out a  poney's tongue from its mouth, wheu 
484
On Tumours of the Gums,
 preparing to give it a drench.  From  such a voluminous tu-
 mour, you may imagine the distress this poor creature suffered.
 He was by natural growth, a big, strong,  and clownish^ellow :
 by continual feeling of sickness  and disease, he was  become
 sallow,  and meagre ;  and by frequent, I may say  incessant,
 diarrhoea, he was gready reduced in strength.   The  sense of
 pressure was inseparable  from this enormous tumour, whether
 reduced or protuberant;  and this tenesmus and sirainingso in-
 cessant, that twenty times in a day, a pressure, which he could
 not restrain, pushed it out; you may easily imagine,  what un-
 ceasing feelings he must have suffered,  when so voluminous a
 tumour was repressed within the gut.
   Yet the character of the tumour was singular, in being at-
 tended with not the slightest pain, not a speck of ulceration, and
 little haemorrhagy ; it  was soft, woolly, lubricous,  and of a
 shining red like velvet, and as  smooth, except in its extreme
 edges, which were toothed, and scolloped, like a cock's comb.
 The whole mass of tumour might measure  about thirty inches
 in circumference ; it belonged to the circle of the verge of the
 anus in such a manner, that that circle was the root of the dis-
 ease, and the tumour could not be extirpated without the whole
 circle being cut out: and it was so compressible, that when you
 thrust the fore  and mid fingers through  the centre of the mass,
 into the rectum,  your  knuckles, and  almost your  hand, were
 buried in the tumour ;  the tumour receding on each  side, and
 allowing you to penetrate as deep with your fingers, as  if there
 had been no  such disease, and you had the consolation to feel
 from within, that the verge of the anus, a very little way with-
 in the circle, was entirely free.  This tumour, by far the largest
 of the kind I have ever seen, was extirpated by ligatures, driven
 through the verge of the rectum, with a common embowelling
 needle, passing it alternately from within outwards, and trying
 each  stitch, or round, as firmly as the biggest waxed ligature
 could bear to be drawn.   The  whole operation was completed
 at once ; the whole of the tumour faded and died at once; the
 patient was entirely and perfectly delivered of his disease ; and
 the circle of the anus was entirely extirpated, the patient never
 complained, nor even suspected the slightest inconvenience.
   You remember that I  do not profess to  follow any perfect
 order ; yet, if I did, I know none more natural than to arrange
 with tumours of the  gums those of the cheek ; or to  compare
 the diseases of  adjacent parts, especially where  their constitu-
 tion, form,  surface, and  internal texture, their glands, exha-
 lents, and other  apparatus of secretion, in short, their entire
 structure is similar;  and where by a very allowable inference,
their diseases may be expected to be allied*  So it4s, I believe. 
LipSy Cheeks, and Throat.              485
 with the cheeks and the gums, where the schirrous indurations of
 the early, and the cancerous excrescences and fungi of-the lab.
 ter stages, are so extremely similar,  and where there are but a
 few special differences, which are easily described.
   The cheek is a part where no conspicuous gland, (the parotid
 and the socia parotidis excepted,) are known to exist; and yet
 the tumours I am now to describe, are plainly not  diseases of
 cellular substance, nor ofthe secreting surface, but assume very
 early, and always before they arrive at ulceration, a knobulated
 and glandular form; where, the first  knot or kernel is plainly
 glandular, and where the tumour, when it becomes irregular,
 and  threatens cancer,  plainly is so, being  irregular, by the
 spreading of the disease from gland to gland.   I know no dis-
 ease which I stand  more in awe of, and chiefly I fear  it from
 these considerations, that it is rarely mild or stationary,. almost
 always progressive  towards  something  more alarming; and
 either the tumour is seated so much in the centre of the cheek,
 and so adheres to  the inside membrane, as to make it difficult
 to extirpate it, for fear of making  a large  opening there ;  or by
 being seated further back, is  so entangled with important ves-
 sels and nerves, as to make the extirpation a matter  too critical
 to be attempted lightly.   This is a disease ofthe most insidious
 nature, so  slow in its growth that we are, from its  long dura-
 tio», diverted from  any sense of danger ;  I have known it ex-
 ist for twenty years, and even from infancy, without assuming
 a threatening aspect; when all at once, without any  sensible
 cause,  it  has shown its malignant nature.   While you are en-
 couraging your friend or patient  with hopes, that the  tumour,
 which he  cannot but think of at times with apprehension, is
 mild in its nature, it grows suddenly hard, reddens, ulcerates,
 and becomes cancerous.   Or when you have extirpated the tu-
 mour, and dismissed your patient, confident in his sound condi-
 tion, and self-contented  in  respect to what you have done,
 when you have long forgotten  the operation, and the patient,
 and can hardly prevail with yourself to believe that a disease so
 extirpated can return, letters  come, announcing to  you that it
 has grown again.  Various inexpressible circumstances, of con-
 sistence, colour, and form, intimate to the surgeon the lurking
 danger.   The tumours which I most dread, are those seated
 in the centre of the cheek,  deep within its substance, connected
 at once with the inside membrane, and with the skin,  not move-
 able, firm, glandular, hard in their general  substance, and irre-
 gular in their form, knobulated, and having, as a sort of centre,
 someone  or more globular masses, also very firm, but which,
 in place of being hard, have a sort of elasticity which gives the
conception of their having cartilaginous walls of extreme thick- 
486
On Tumours ofthe Gums,
 ness, containing a small proportion of gelatinous matter.   And
 in truth it is so ; these central globes are found usually to con-
 tain a gelatinous fluid :  but sometimes, nay frequently, a thick
 and gelatinous blood, partly clotted, partly fluid.   Such a tu-
 mour is extremely slow  in its growth, but is still growing; lit-
 tle painful, but yet communicating a  general sense of tooth-achy
 pain, or  shooting;  sensibly  aggravated in moist weather, or
 east winds ;  and it is usually  covered with a coarse and granu-
 lated skin, very thick and porous, like that of a lemon,  firmly
 attached, in a considerable extent, to the surface of the tumour,
 and incorporated, as it were,  with the substance of it; this ad-
 hesion of the skin is ever a sign of danger.
   Of such tumours, I shall lay before you various examples,
 not uninstructive, with operations sometimes  fortunate,  some-
 times unsuccessful:  nor  shall I be so unmanly as to conceal
 from you the cases in which I have been unfortunate, especially
 where the ill success may be  imputed to any want of skill or
 conduct, for every such  avowal must  be invaluable to you___
 No man  can be always  wise, nor  always fortunate ; he who
 pretends  to  unvaried success, is either a knave or a fool.   I
 take especially pleasure in laying  before you a case where this
 species of tumour was strongly characterized ;  where it existed
 perhaps from birth, certainly from early childhood ;  where the
 operations were such as  I could not enter upon without  reluc-
 tance, nor perform without encountering various difficulties___
 In the first, I fear, a slight fault on my part proved the occasion
 of great pain, and danger to  my patient, of a weary journey,
 and a  second  operation ;  the recollection of which, though
 painful to me,  may be  useful to you ; and this I feel  to be
 the surest way  of  restoring  myself to placid and  approving
 thughts.
   " Mr. Taylor, a tall and slender, but strong and active man,
 not exceeding thirty years of age,  was afflicted with a tumour,
 which had indeed existed from his earliest years,  but had in-
 creased lately with alarming  rapidity ; assuming,  at the same
 time, so malignant an aspect, that all those whom he consulted
 declared it dangerous, wished that it might be extirpated,  but
 declined performing an  operation attended with so many  dif-
 ficulties.  In this disturbed and agitated state of mind, he tra-
 velled from a remote part of  Ireland to commit himself to  my
 care.   The indolence of this  tumour from childhood upwards,
 its sudden increase of growth, from imprudent and violent ex-
 ertions, its hard  irregular form, the coarse and  porous skin with
 which it was covered,  the firmness with which it adhered to
either surface, viz. to the skin of  the cheek, and to the mem-
brane ofthe mouth;  the redness it contracted,  and the shooting 
Lips, Cheeks, and Throat.
487
pains which began, towards the latter stage of the disease ; the
manner also in which  it was consolidated into one  substance
with the whole cheek,  and the apparent impossibility of extir-
pating  it without cutting actually the cheek itself away, were
circumstances particularly worthy of attention.   This tumour,
he was well assured,  had existed, if not from his birth, at least
from his early infancy, in the forni of a small, firm, kernelly tu-
bercle, seated within the substance  of the cheek,  not far from
the angle of the nose ;  nor can he recollect, during all the peri-
od of his youth, or manhood, any circumstance,  either of pain,
swelling, or change of  colour, which called his attention to this
tumour, much less alarmed him.   He had arrived at his thir-
tieth year,  when suddenly, in consequence, of violent exercise,
in very sultry weather, and in the open air, he observed, first,
slight and transitory  pains  in the tumour; but  such as never
would have alarmed him,  had  he not been wakened from this
supine and unreflecting state of mind, by a manifest and sudden
increase of  size.  Then he thought of rubbing the part with
mercurial ointment, and applied to his brother, who is of our
profession,  for his advice.  Then,  for the first time, he began
to feel all the unhappiness of a  man in danger  of cancer, and
doubtful whether even the severest  operation could afford him
relief; and with all  the agitation of  one occupied with such
dismal reflections,  he consulted every one who was accessible
to him, and still as he passed through the country sought new
counsel, and every  where he had the unhappiness to find, that
his disease was regarded as desperate, and the operation as bare-
ly practicable.
   " Six months had now  elapsed,  from  the time of this  con-
spicuous  increase of size ; the tumour had attained to more
than twice its original bulk; there had been an accretion of many
lesser  lumps to the main body of the tumour ; in little more in-
deed than three  weeks, the tumour had increased to four times
its original size, the pains were become more pointed and fre-
quent, he was obliged  to be careful  of it,  and preserve it like a
part affected  with  tooth-ach or  rheumatism, from cold, and
the vicissitudes  of the air ; and in  damp weather or  severe
cold, he was tortured with pungent heat and shooting pains, the
heat and shooting pains being peculiarly felt in that part of the
tumour which was most conspicuously increasing in size.
   " But if those shooting pains, and  this sudden  increase  of
size were ominous, the change which next ensued was more
perplexing,  and  alarming; for on its internal surface, it began
to connect  itself  not only with the inside  surface of the  cheek,
but with the substance of  the gums : an irregular excrescence 
4W              On Tumours ofthe Gumf,
projected into his mouth,  which he compared with a claw or
horn, and of such length and bulk, that, being checked by the
teeth during sleep,  it was  torn away with a considerable effu-
sion ol black and fetid blood.   On the external surface of the
cheek, the skin thickened,  became porous and coarse, adhered
to almost the whole  extent of the tumour, was puckered and
pursed up, at the place where the lesser glandular lumps were
grouped and knotted round the chief body ofthe tumour, which
was ver\ nearly in the centre of the cheek.
   " Alarmed  by such decisive changes in the character of the
tumour, he called upon a Dr. Henry, who had promised to per-
form the operation, but he now expressed his reluctance on
account of certain  blood-vessels, especially of the infra-orbi-
tary nerve and  artery, which he feared would  retire into their
hole under the  cheek bone,  before the artery could be secured.
This discouraging suggestion, and an express declaration that
the tumour was of a schirrous nature, induced Mr. Taylor  to
apply to a number of gentlemen who told him  of the danger of
the disease, ofthe difficulty ofthe operation, and the prudence
of coming direcUy to this city.
  " My patient was of a pale complexion  and melancholy tem-
perament, and, after a journey so cheerless  and inauspicious.
where he was told at every  step the  danger of this disease, and
the difficulty of that operation from which alone he could ex-
pect relief, he  was too  unhappy and dejected to receive any
consolation from  my assurances.  The tumour was not of that
size to be esteemed monstrous in any glandular or fleshy part,
but it was great in proportion to the part in which it was seated,
it was of a stony hardness,  firmly connected with the substance
ofthe cheek,  of a globular form, and surrounded by small sub-
sidiary  tumours, seemingly of a glandular nature, firmly con-
densed and mixed in their substance with the main tumour and
with the substance ofthe cheek. The skin was thick, with gaping
ports, a coarse granulated texture, and a very firm adhesion to
all the tumour, except its very apex ; and, in the centre of this
granulated skin were livid  tubercles, about the size of a boy's
marble, extremely hard in their substance, and of a very omi-
nous appearance ; and where these projected a  little below the
centre of  the cheek, the skin  was puckered and drawn in.—
While the external surface  was thus connected with the skin of
the cheek, so as to  draw the angle of the mouth obliquely up-
wards, the internal surface  was very dangerously attached, not
only to the inner surface of the cheek, but to the gums:  the
inner surface ofthe cheek felt,  upon introducing the finger, tu-
berculous, and rugged, and extremely hard ; and the  tumours,
when felt from within, appeared distinctly to be the same indu- 
Lips, Cheeks, and Throat.
469
 rated schirrous substance  which projected  from  the  external
 substance.   Upon inverting the cheek, these tubercles  were
 seen knotty, irregular, and rugged like piles, or like those vene-
 real warts of the anus, which are termed fici.   Where this dis-
 eased substance approached the angle of the nose, it  adhered
 very firmly  to  similar tubercles springing from the gums, and
 the shooting pains, now severe and constant, together with the
 dejected  appearance, and  sallow complexion of Mr. Taylor,
 joined to the united opinion of many of our profession, could
 not fail to impress me with a confirmed apprehension of its ma-
 lignity ; but that only inspired  me with a greater desire to give
 him the only chance of life.
 .  " In respect  to the  projected operation, no circumstances
 could be  more  discouraging than those I have just described:
 I was conscious that, in attempting to save him, I must not
 merely extirpate a tumour by nice dissection,  but cut through
 the cheek and dissect away almost all its substance;  that I must
 divide the facial artery below, and the transversalis faciei com-
 ing from the  temple,  and the labial artery returning from the
 lip; that  I must not merely wound, but  cut away the  salivary
 duct, and lay the whole side of the face open, making a breach
 larger than the mouth : it could not  but  seem problematical,
 whether, after such an operation, the saliva, or food, could ever
 be  retained again, whether the attempt would not involve me in
 disgrace,  whether I should not be blamed deeply for adventu-
 ring on that operation which so many had declined.   But I was
 emboldened  by this recollection, that, often by a grape-shot, or
 by  a splinter in batde at sea, the whole cheek is carried awayT,
 and sloughing succeeds to immediate loss of substance ; that I
 had every reason to believe, though much of the substance of the
 cheek must be  cut away,  I should be able to bring together the
 remaining skin of the cheek; I most of all considered that this
 gentleman had travelled from a distant country,  and, leaving
 behind many skilful and dexterous surgeons, came  to  commit
 himself with resignation and confidence into my hands, that  I
 owed him some sacrifices in return, and that, unless I attempt-
 ed  to save him, he must, at no  remote period, die of cancer; I,
 therefore, prepared myself for  the operation."
  The hooks, knives, and forceps necessary for such  a dissec-
 tion  being  properly disposed, with needles for tying  the
arteries, I proceeded with  an  operation  which could  not  fail
to  be extremely slow,  since its  principal purpose was to dis-
sect out the whole disease,  and save as much as possible  the
 sound parts.
  I drew  my knife in the direction of that line of feature which
                          3Q 
490               On Tumours of the Gums,
 marks the levator anguli oris,  and surrounded the tumour with
 a second incision like the first;  but,  approaching very  closely
 the angle of the mouth,  I proceeded to dissect away the tumour
 frorrt'it, and from the jaw-bone, and thought it singular, that the
 labial artery where  it approaches the lip, and  the facial artery
 where it turns  over the angle  of the jaw, were  so elongated
 without being divided, that I slipt a ligature under each of them
 with the needle, without pricking  even the cellular substance
 and tied them before cutting them across.
   Having turned the tumour upwards, I cut through the inside
 membrane ofthe mouth, cut clean away the tuberculous promi-
 nences of the gum,  dissected upwards  towards the eye ;  and,
 when much  of the tumour  was detached, regarding the  infra-
 orbitary nerve as the most important  and painful  part of the
 dissection, I reserved this as the last stroke, and, while I dissect-
 ed this part,  and especially when I  cut the  nerve across,  he
 suffered an intensity of  pain which made  him  quite savage,  it
 was then only that he stamped with his feet and  cried  out in
 agony.*

   • I have always obferved that the cutting acrofs a nerve produces an inconceiva-
 ble fhock,  and of this nerve efpecially a dreadful pain, which is on no occafion fo
 manifeft,  as when the operation of cutting acrofs the nerve for the cure of the tic
 douteUreux is performed; for then the cutting acrofs the nerve is complicated with
 no other incifions to confound  the fenfation,  which is at once fo peculiar, and fo
 alarming,  that  the patient feels as if fhot, and ftarts up in agony inexprcfffble;
 and this firft fenfation is inftantly followed by  a pleafing calm, and a happy and
 perfect relief from pain.   Thofe whom I have  feen labouring under this Angular
 nervous difeafe,  have had the affected fide of the face reddened,  the cheek con-
 vulfed, the lip  quivering, and  the eyes filled  with tears from the intenfity  of
 pain.  One old man, about 70 years of age, who was cured in an inftant of a dif-
 eafe of many years duration, by my worthy and much refpected friend, Mr. Har-
 rifon, of Ulverfton,  had this convulfion, and trembling of every feature, in a An-
 gular degree.  Another old gentleman, Capt. G.  of R----,  in Ivernefhire, had
 this inceffant trembling  of every feature, as if each mufcular fibre of the face had
 been ftruggling  in an indetermined condition, betwixt convulfion and paralyfis;
 and this convulfion  was  accompanied with fuch agonizing pains, and wild and
 piercing cries, as actually alarmed the  ftreet in which he lived : but I fhall de-
 fcribe his condition in his own  words, as dictated  to  my affiftant Mr.  Allan :
 Capt. G.  was, at the period of the operation, about 75 years of age.
   " One afternoon, about eleven years ago, while fitting at dinner, I was fudden-
 Iy and feverely attacked with fharp and thrilling pains, beginning at the root  of
 the wing of the nofe, extending all over the right fide of the face, centering in the
 cheek, but (hooting in a particular manner upwards by the corner of the eye into
 the temple : the fit was momentary, but the cheek, the lips,  and eye-lids quiver-
 ed, and were convulfed.
   " From this time I have been always fubject to this torturing difeafe, which has
 been the occafion of various journies to town,  and innumerable  confultations :  my
 fufferings fometimes  intermitted for weeks,  during which I  was almoft entirely
 free from pain ; and often again I fuffered fix or feven fevere paroxyfms of convul-
 fion and pam, in one day, and as many during  the night: I was  for  two years
 contented with the advice of my furgeon-. in the country, who prefcribed blifter%
dftd many other applications both fevere and trivial, Lut with  fo little good effect,
that they afcribed my difordtr  to worms in the cavity of the upper jaw.  About
two years alter the fix ft attack,  my difeafe affumtd  a more determined form, and 
Lips, Cheeks, and Throat.
491
     It was removed,  and before the  next  step  of  the operation,
  the gap seemed horrible, even to me.   The side of the face was


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

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

that ?"  he fat down inftantly in perfect compofure, free from pain, uncasfcious
of the operation being performed, and expecting it: when queftioned about the
fenfation which made him ftart up, he faid, he felt nothing but as if he had  been
fhot in the head, followed by a  momentary confufion, and a total relief from  pair\
He faid he did not imagine the operation done, becaufe the firft operation had
been a deliberate diffection; he felt now  perfectly confident that he was cured,
and returned home in two days, fince which time, he has lived in perfect health..«
happily married, and continues well at this moment.
    January, 1807. 
Lips, Cheeks, and Throat*              493
swallowing it.   Happily the skin  adhered in a  few days, the
needles were withdrawn,  in a fortnight he was cured.
  But the slightest speck  or  spot of imperfection in such  a
work is followed by severe self-reproach.  I am not sure that I
observed my fault during the operation, but certainly after the
cure, I took an alarm, far from groundless.  I observed a small
glandular-like knob towards the lower part of the cheek, which
I ingenuously  warned him might be the source of future dis-
tress, as the  small tumour,  indolent during his infancy and
youth, had been suddenly the cause of this mischief; I took his
promise that he should be observant of  it.
  This error,  so  opposite to my experience and conviction, so
unlike my general maxims and conduct, I sorely repented.  It
was at the distance of three years from the  period of this ope-
ration, that I received a succession of letters from my patient,
announcing the return of the disease, and asking permission to
come once more to this country, to put  himself under my care.
The small glandular knob, which  I required him to watch, had
increased in size, and the gums also had begun again to shoot
out small tubercles; that the new swelling,  and the  return of
the disease had begun in this small glandular knot, no  bigger
than a pea.  I remember, only from his conversation, not from
his letters: from the complexion of these, one should rather
have concluded, that the new growth was only in the gum, be-
ginning in the angle  betwixt the gum and cheek,- and  in the
centre of the  cheek; a part of the  tumour, in  the-extirpation
of which, I surely had not to accuse myself of any fault;  and
from the slightest and most  imperceptible  beginnings,  viz.  a
small longitudinal thickening along the scar of the wound,  a
small pea-like  hardening near the lower part of that scar,  and a
similar hardening betwixt the cheek and gum ;  it grew with
such rapidity, that from week to week its increase was manifest,
and  in less than two years,  it had attained fully its original
size ; accompanied with pains, more distinctly lancinating, more
poignant, and  frequent, than in its first stage.  Again he travel-
led from Tyrone to this city, and after many perplexities and
fears, submitted again to the operation.  I, on my part, had no
slight motives for anxiety, for now actually the whole  cheek,
the skin excepted, was to be  cut away  ; the buccinator muscle,
and  the living membrane  of  the mouth,  were both to  be cut
out; and I was shocked to think, how  possible it was, how far
from improbable, that the whole cheek, even from the slightest
overstraining of the  suture,  or the slightest accidental  fever,
might gangrene and  slough, and leave a horrible chasm.
   The tumour was  almost as large as at first:  the great glan-
dular-looking  substance,  rounder and more uniform ; thedivid 
494
On Tumours of the Gums,
part of the surface of greater extent, and a stage nearer ulcera-
tion, and the scar of the former  operation binding the tumour
firmly along its whole length ; and, except in the  very apex of
the most bulky and prominent part, where indeed it was more
elastic, the whole was of a stony hardness, accompanied  with
perpetual pain, by which, together with his fatigues, and fears,
in this wearisome journey, he was greatly cast down.   It now
also approached so close to the angle of the mouth, that I saw
no way of extirpating the tumour, and leaving more  than  a
quarter of an inch, hardly so  much,  entire,  betwixt the gap
made by the extirpation  of the tumour and the mouth.
   I  proceeded to make  first, a long incision, bending a little,  so
as to include all the tumour that was below the cicatrix, and
which, in bending round the tumour almost touched the angle
of the mouth next, a similar incision bending upwards, in such
a direction,  as to include the scar of the former operation, the
puckered and adhering  skin, and a part of the tumour, all that
part to which  the skin inseparably adhered.   Those two  inci-
sions included that part of the adhering skin, which required to
be extirpated,  in the same  manner,  that we usually include
within an oval incision, the nipple of a much indurated mamma.
Thirdly, I made a transverse  incision, from  the  temple, i. e.
from the tip of  the ear  over the zygoma, directly across the
face, which meeting the  first oval incision made two flaps.  The
tumour I found now more regular in its form than I expected,
sacculated, and very dark and  bloody; I, after raising the an-
gles of the skin  from the cheek and face, and saving all of the
skin that I could save, dissected all round the tumour, and re-
served those parts of the dissection for the last, in which I had
to divide arteries.   I then dissected out the  tumour from the
angle of the mouth,  and tied the labial artery; then dissecting
down through the lowest part of the incision, into the cavity of
the mouth, I tied there the trunk of the facial artery ; and finally
dissecting out the tumour from  under the cheek-bone, and tearing
it from the zygoma,  a most difficult and painful dissection,  I
tied  a large branch  from the transversalis faciei.   The veins
spouted put blood profusely  when cut, but  shrunk instantly :
the  arteries thus successively  tied bled none.   I never indeed
performed so unseemly, and at the same time so bloodless an
operation.
   Now observe, that in all  these points, and to the full extent
of the tumour,  I was obliged to go  fairly through the cheek,
and cut every thing completely away, for it  was all tumour.
The tumour looked formidable when it presented itself, in time
of dissection,  high above the separated flaps of the skin, and
'he chasm was horrible when it was cut away; the flaps consist- 
Lips, Cheeks, and Throat.               495
 ing  of skiri only, were so thin, that I was  in despair when I
 laid them together;  I solemnly declare,  that nothing evtr asto-
 nished me more, than the speedy cure, which was such as must
 give me courage on  all occasions that may in  future  occur.
 First, my assistant,  Mr. Allan, brought the edges nicely to-
 gether, and passing a needle through the three points of  the in-
 cisions, I brought them all together  in one star-like  centre, ex-
 actly in the middle of the  cheek.   But one  ligature, though it
 approaches two points nicely, cannot go under a third, and bring
 it into contact with the other two, without turning over and pass-
 ing  from  within outwards; in consequence  ot  this awkward-
 ness, for  which  I  was provoked  with  myself,  I  had  almost
 balked  the  great purpose of re-union, and that too at the very cen-
 tre of all the sutures, and therefore endangering  each of them,
 and of  course  in the  centre of the cheek,  so that the  whole
 cheek was endangered : but fortunately the suppuration,  in this
 central point,  was very slight: yet, however slight, it grieved
 me,  as  it  plainly proceeded from my awkwardness.   I  then
 took the most delicate sewing needles, mounted on small wooden
 shafts, like  pencil-sticks, and passing two needles from  side to
 side across each long incision,  I brought  the sides of the three
 radiated incisions, into the nicest contact imaginable, careful al-
 ways not to twist my threads round the needles too  tight; and
 I passed one very delicate  needle  close  to  the  angle of the
 mouth, to secure that point.
   This I do on all occasions, and always  very deliberately, and
 at some distance of time after the operation,  and when there is
 no longer any  bleeding to discompose  me  ; and every thing
 sponged, clean, nice, and dry, I take narrow strips of linen, and
 dipping them in  warm glue, lay them across the incisions, and
 these being well dried, and hardened, and the needles kept clear
 of the glue, I can, without risk, on  the end of the second day,
 or on the third, before there can be the slightest risk of  suppu-
 ration,  slip out my needles one by one.
   So I did in this case ; the less necessary needles I withdrew
 on the second dav ;  those  on which more depended,  I  left till
 the third and fourth days ; and the needle nearest the centre I
 left longest.  I draw each needle with nice  forceps, turning it
 first a little  vertically, that  th« re  may be no tugging.    I often
 pass a thread into the  eye  of the needle, that I  may pull quite
 vertically,  and  often pass a flat stick betwixt the ends  Of this
 thread,  and, twisting the ends round the  stick, turn the  needle
 vertically,  and so loosen it with so true a motion, that there is
 not the  slight  st  sensible  violence, nor  the  smallest drop of
 blood :  and, before  I attempt  to move a needle,  I  take a hair
pencil, and, by washing and cleaning the point, and  oiling it, 
496              Cm Tumours ofthe Gums.
 prepare it for passing easily.   This method I have long used in
 all delicate  sutures,  especially in extirpating small tumours of
 the face and jaws, and in hare-lips.  It was in this manner I
 re-united, a second time  (the operation having been very malr
 adroitly performed upon him when a boy,) the hare-lip of Mr.
 Whirter, surgeon, of Newcastle,  with a scar hardly visible, and
 with an evenness of lip which enables him to blow the flute very
 delicately.   He was conscious of the necessity of this second
 ^operation, and gratified with the success of it.
   I have another remark to make to you, that, though a needle
 is withdrawn, its twisted suture remains upon the surface, cak-
 ed with blood, and is a security to the wound ; and always,  up-
 on withdrawing each needle, I heat the glue-pot again, and,
 dipping a hair-pencil in it, I wash the remaining ligature, or
 twisted thread, with  glue, so that the needles being removed on
 the second, third, and fourth days, there are substituted to them
 various strips  of fine linen,  with glue, and  the pencil being
 carried over all parts of the incision, the whole is held firmly, yet
 gently  together, by  a cake or plaster of glue,  which need  not
 once be troubled till  you find  it safe to  wash off the whole at
 once.
   This, compared with the common adhesive plaster of wax,
 is a nice and cleanly  manner of performing those operations in
 which so much depends upon delicacy, and the nice and curious
 contact of all the edges ; for any one point left open endangers
 the whole line of suture ;  and this method had, in  the present
 instance, such perfect success, that, in ten days Mr. Taylor be-
gan his journey to Ireland perfectly cured,  and with less mark
 of incision,  and a more perfect evenness of cheek than at first.*
 In an hospital, an unhealthy season, or an unsound constitution,
 the whole of such incisions must have sloughed  off, a dreadful
 and an  irremediable calamity ! but in this healthy and vigorous
young man, the parts united most happily.
   In operating on this tumour,  I was surprised to find a very
 singular connection betwixt the veins and the central and more
 conspicuous tubercles, which were indeed firm but  elastic sacs,
 of pure and coagulated  blood, inclosed in very thick  and solid
 walls ;  and, upon dissecting the tumour after  it was  laid upon
 the table, the great  tubercle  being cut open, and the hard and
 clotted blood turned out, it was manifest and visible, distinctly
                       *
  * The part was not covered with lint or comprefs for fear of diforderingthe
 needles, or concealing any accidental inflammation, but to prevent any ill confe-
 rences from the extreme hollownefs of cheek, a nice fitted plumper,  or comprcfi
 *f ib/t rolled lint, was introduced into the mouth, and the jaws bandaged, to  pre-
 vent motion during fleep, and he was hardly permitted to tic down in bed for k.r
 of fome mifchacce. 
Lips, Cheeks, and Thtstat.               497
visible, that these cellular cavities had communications with the
greater veins.
  Many distressing, and some fortunate cases of this nature
have been under my care ;  tumours of.a less malignant nature,
andAeasily extirpated, present themselves daily, and excite no
£6rGurbation ;  but I would endeavour, by relating less favour-
able or fortunate cases, to  enure you to difficulties,  and disap-
pointments.
1  u Mr. S-----,  a venerable old man of 60 years of  age, re-
markably strong, active,  and athletic, for his time of life, had
been long subject to a very dangerous swelling of the parotid
gland, which  now manifestly declined to a state of. cancer.—
The tumour began early in  life, and was* extirpated twenty years
ago by Mr. Dunlop, a celebrated surgeon  in Glasgow : but a
gland in which the trunk of the carotid artery is so entirely im-
bedded,  can never  be entirely extirpated, thence it has grown
again slowly.  Mr.  Dunlop  declining himself to perform the
operation, and yet desirous that  Mr. S-----should have every
possible chance for life, has requested me to receive him under
my care.
  '* The tumour is divided in the middle by the scar of the for-
mer operation ;  along that line it is irregularly straightened and
bound down ; it rises on each side of the scar, in knobs or api-
ces of a stony hardness, reddened of late on the  surface, with
a coarse granulated and adhering skin.  The  whole surface  of
the tumour is of a dusky red, and its extent very great, for it
covefs all the flat part of the cheek ;  a flattened part rises over
the zygoma, towards the temple, to which it adheres very firm-
ly ; one glandular and almost separate lump, lies far forwards
upon  the cheek, and seems to me a  tumour of the socia paroti-
dis, while the rest is a tumour assuredly of the parotid itself.—
The  tumour is so  large as to be flat though  bulky; the most
salient point is that  which  lies immediately before the ear, the
lap of which is turned back by it; another branch, I may call it,
ofthe tumour, lies under the lap ofthe ear, and presses it up-
wards ;  the chief mass ofthe tumour lies upon the cheek, but
a very bulky part lies deeply  imbedded behind the angle of the
lower jaw-bone ; its appearance  was unpropitious, for jt was of
a deep red colour, sensibly inflamed, the inflammation increasing
every day, with  a deep and stunning pain, while all the basis of
the tumour was as hard as stone.                  *t
   " Nothing  can be more unpropitious than the state of this
gland ; first, it is a disease returning long  after its growth had
been  interrupted by amputation : secondly, it is very firm, of a
stony hardness,  very irregular and knobby ; that  part which
lies out  upon the cheek is bound down firm, and flat, by the
                          3  R 
498              On Tumours ofthe Gums,
 fascia, or tendinous membrane that descends from the zygoma,
 and by the platysma  myoides  muscle : thirdly, it is growing
 sensibljrand rapidly, and  its surface has begun to take a deep
 and livid colour, while very poignant and torturing pains shoot
 through the tumour, prevent his sleep, and distract him while
 awake.  This schirrus has every character of approaching can-
 cer, it is most likely too late to  attempt the operation, yet what
 would not one do or suffer to preserve life ? The operation too
 is full of danger;  this gland cannot be extirpated but by deep
 incisions, and a very severe and slow dissection ; at the best, it
 cannot  be  separated from the angle of the jaw, without cutting
 the portio dura of the auditory nerve, and paralyzing the cheek;
 nor without dividing  the  temporal, facial, and other arteries :
 perhaps it may not be possible to extirpate it totally, for fear of
 wounding the very trunk ofthe carotid artery, and that  opera-
 tion which is  begun with the  knife,  it  may be necessary to
 finish less perfectly with the ligature.  This is the first  time I
 have been obliged to think of such a resource : the latter part of
 the operation must be performed by poising out the gland from
, the deep hollow under the zygoma, and behind the angle of the
 jaw, and then it may be necessary to strangle with the ligature,
 what assuredly we dare not amputate with the knife.
    u I came to this decided conclusion  in my own mind, that,
 though a case the most unpromising I had ever witnessed, it
 was my duty, in  compliance with  Mr. Dunlop's and his pa-
 tient's wishes, and with  Dr. Monro's advice, to perform the
 operation, difficult as  it seemed, and it was plainly such as ad-
 mitted of no previous plan,  but required that I should be guid-
 ed by  circumstances,  and my past experience, for I had often
 [partially]  extirpated the diseased parotid.
 "  " I can hardly enter too much into the detail of such an opera-
 tion,  seeing especially that it had an unfavourable issue ; I en-
 tered upon it with more than usual composure, with more than
 I thought  natural to the occasion, but, I believe, it was the
 very difficulty of the case that reconciled me to my task, for I
 was conscious, in such difficult circumstances, I was entitled to
 stop, that it was my duty to stop, the  moment  I  approached
 any dangerous point, that I was no way responsible for extirpa-
 ting the whole tumour, nor for doing all with the knife.  The
 peculiar complexion ofthe tumour, for it was now inflamed al-
 most to ulceration, and accompanied withlancinating pains, was
 unfavourable to our hopes ;  its  growth, after being once extir-
 pated, confirmed the  suspicion of its being of a cancerous na-
 ture ; and  the parotid has the temporal and  maxillary arteries
 imbedded  in it, while the portio dura, or middle nerve ofthe
 fece, that great nerve  which runs across the cheek, and goes  to 
                 Lips, Cheeks, and Throat.              49

all the side of the  face, passing through  it in many branches,
so that it absolutely cannot  be cut away from its root,  which
sinks deep  behind the branch of the lower jaw-bone, without cut-
ting the carotid artery ; and it cannot be torn  away, the firm
nerve being entwined with its substance ;  even the casting a lig*.
ature about the root of the gland is accompanied with excrucia-
ting and maddening pain, the nature of which may be imagined
from the agony which a tooth-ach or a rheumatic affection of
the temple causes.  The act of tying a nerve, I am conscious,
produces a kind of injury, accompanied with terrible inflamma-
tion : this  injury is permanent, and  the inflammation becomes
habitual.   It often happens, for example, that the nerves of an
amputated stump are  so engaged in the cicatrix, that their ex-
tremities  being superficial,  and covered  only with a delicate
and thin cicatrix, the  slightest accident  irritates  and inflames
them ;  and I have  seen a stump exposed by this  to paroxysms
of inflammation, in which the stump  swelled to  the size almost
of the patient's body,  attended with fever, and such convulsive
fitartings of the stump as usually occur immediately after am-
putation.   The cutting ofthe portio  dura, or nerve of the face,,
occasions the most excruciating pain,  as I have already explain-
ed  in the case of Cap. G-----, (vid. foot  note to page 490) and
I have  reason  to believe, that the pain  proceeding  from  the
truncated extremity of this nerve being unavoidably engaged in
the cicatrix after an operation such as this, causes the return of
the  swelling, revives the disease  in whatever remains of the
gland, and is the cause of its cancerous nature.
   " My incisions were made in a tripod-like form  ; not straight
but bending, so as by their prolongation over the cheek, ear,
and temple, to make a triangle, in direct lines with three corn-
ers, which being  dissected away, exposed the convex part of
the tumour.   By giving these three incisions a circular form in
the centre, I left the  adhering part of the skin, attached to the
most diseased  part of the gland, and this centre of knobular and
stony glandular substance, with thickened and adhering skin,
connected  firmly by  the scar  of the  former operation,  I  left
untouched, and cut up three flaps of thin and sound skin.
   " After dissecting  back the flaps and exposing the surface of
the tumour,  I  dissected away that  part of the tumour which
approached the mouth,  and  lay upon the  masseter muscle, with
which it was so connected that I chose to cut away large pieces
of  the  muscle, hardened and identified with the  tumour, leav-
ing the jaw-bone bare near its angle, rather than leave anv part
of  the  disease.   Next, I  turned the tumour down  from the
ear; but  do not imagine this was  accomplished easily, as in
ordinary tumours bedded in loose cellular substance;  this tu- 
500
Ok Tumours of the Gums,
mour was so firmly embraced by the fascia, and adhered so firm-
ly to the zygoma,  to the thick  fascia  which descends from it,
and to the tendinous parts of the temporal muscle, that I  was
cutting through a firm, mixed, cartilaginous  substance, and
could not distinguish where 1 had got through the gland, or its
adhesions, but by distinguishing that I was  cutting muscular
flesh, or  encountering a naked bone.  The third part of the
dissection was at once  cruel and full of danger ; it was the dis-
secting away the tumour from the cartilaginous tube of the ear,
which was yet done so  effectually, as to detach the  tumour li cm
the whole length of that tube, down to the temporal bone :  but
there, a big and firm root seemed so fixed, that I durst  go no
further with the knife ; I had dissected the tumour backwards
from  the cheek,  and upwards from behind the  jaw-bone, and
insulated it up to that point where the temporal artery transfixes
the gland just before the ear; there, it will be recollected, the
great internal  maxillary artery divides from the temporal arte-
ries ; I could go no further, the next stroke ofthe knife would,
in severing the gland from its root,  have cut the common root
of the maxillary and temporal  arteries ; would, in short, have
truncated the  carotid artery ;  what remained of the operation
could therefore be  done only by ligature.
   " In this dissection I experienced all the difficulties peculiar
to a second operation ; for a gland which grows  again after be-
ing cut, is so bound down to every  subjacent part, by the scar
of the skin, and  by new and strong adhesions, that its connec-
tions  are of an unusual and cartilaginous firmness  : and I had,
in this case to encounter the additional danger of a tumour far
advanced in its progress towards the last stage of schirrus, and
ready to degenerate into cancer ; and it appears to me that that
unfavourable change which is marked by shooting pains, consists
in inflammation, is accompanied with adhesions,  or, to speak
more truly,  with a consolidation of the diseased gland,  with
surrounding bones  and muscles, just as the schirrous breast is
united solidly and in substance, with the pectoral muscles, and
the ribs:  in the present case,  the fascia,descending from the
zygoma over the surface of the tumour,  was identified with its
substance, and, when  cut,  was  like a cartilaginous ligament,
hard, and thick. The dissection of the part ofthe tumour which
lay over the jaw, and masseter muscle,  was equally rude, and
imperfect; for the tumour  was equally identified with the sub-
stance of this muscle, which was,  in its own substance,  of a
gristly hardness.   The tumour, in short, adhered to the fascia
ofthe temple, to the zvgoma, to the  masseter, to the jaw^bone^
and to the cartilaginous tube of the  ear ;  from all of which, it '
was more or less rudely or delicately dissected; but with such ' 
Lips, Cheeks and Throat.              301
 '■x'.ruciating pain that Mr. S-----, though a man of the most
 perfect composure, courage, and constancy, grew deadly pale^
 hiccuped, fainted, would have fallen  from the chair, had he not
 been supported, and that so early in the operation, that even hi*
 neckcloth was not yet stained, at  east not wet, with blood.
   " We were obliged to lay him down, to  lave cold  water on
 his face,  to suspend the dissection for a whole quarter of an
 hour ; this was in the beginning of the operation, which lasted
 ten minutes  after it was resumed.
   " The first artery which sprung was the transversalis faciei,
 but it was too small to be heeded, and it was  to be cut again,
 wherefore I disregarded it, and it shrunk :  the next artery, in
 dissecting the lower part of the tumour, was the labial or facial,
 where it turns  round the  angle of the jaw; in this, as in all
 other dissections of the like nature, it stood out from its cellular
 substance so insulated, to the extent of half an inch, that I found
 it easy, without the needle or tenaculum, to cast a ligature round
 it, by laying the loop of the ligature over its mouth, and draw-
 ing it: the third artery was the great temporal artery; the man-
 ner in which it presented was not pleasant, for, first, in dissect-
 ing downwards that part of the tumour which covered the zygo-
 ma,  the artery was necessarily opened ; but,  knowing that  I
 had not approached any dangerous point, I clapped the point of
 my left fore-finger on the mouth of  the artery, while grasping
 the body of the  tumour in the hand,  I continued to dissect if
 downwards from the  temple, and to dig it away from the carti-
 laginous tube of the ear ; then, lifting the  point of my fore-fin-
 ger, the mouth of the artery appeared in the very centre of the
 tumour, throwing  out its blood, and was tied.   By dissecting
 the gland down from the zygoma, and from behind the angle
 of the jaw, I had almost touched the  point where  the carotid
 forks into the internal maxillary and temporal arteries ; to have
 gone further, would  have been  rash and  unpardonable ; the
 next stroke of the knife would have truncated the carotid arte-
 ry, and left no possible chance of saving the  patient, but instant
 compression of the artery at that point with the thumb,  and a
 desperate dive with the crooked needle at that part behind the
 angle ofthe jaw, where the trunk forks into the external and in-
 ternal carotid arteries.
  " I wrought so successfully with my fingers,  as to insulate
 the gland all  but a trivial root; I then pushed the flat handle of
 the scalpel round and round, so as to lessen that root still more:
 I next  with the fingers alone passed a big  and thick ligature
 round the root of the  tumour,  and tied it in  a general way, and
 by the hold  of  this  ligature was  enabled to turn the tumour
round like a  button upon its stalk, and by compressing it, was 
*Q$               On Tumours ofthe Gums,
enabled to feel more distincdy to the root of thia slender neck.
I believed, but I was mistaken, that I could drive the eyed end
of my needle through this;  it was of far too firm  a  substance
for any such attempt; but resolved any way to get at  its root, I
turned at  last the point of the needle to this pedicle, struck it
through behind the general  ligature, and having thus carried a
very thick waxed ligature through the root, I cut the ligature at
the eye of the needle,  tied two of the ends  round one side of
the tumour, the two others round the other side of the tumour,
then crossing them, and bringing the respective ends  round the
opposite sides of the tumour, I tied them again ; and as this
was the point necessarily including the portio dura, or great nerve
of the side of  the face, the drawing of the ligatures proved the
most cruel part  of the operation,  was accompanied with an
outcry of intolerable suffering ; the cheek fell paralytic, and be-
came instantly oblique, and I was impressed also with the con-
viction, that I had so pulled  out the gland by the help of  the
general ligature from its deepest seat, betwixt the jaw and tem-
poral bone, that I had, in tying the root of the schirrous gland
and the portio dura,  tied also the carotid."
   " The gland was cut off, and only a button left with those lig-
atures about it; the whole operation was bloodless : at the first
dressing, at the distance  of four days, the whole  surface was
found ui a state of kindly suppuration, but the ligatures, espe-
cially that which encircled the lower part of the tumour, needed
to be drawn firm, which occasioned  once more excruciating
pain, which  continued through the whole night, during which
our patient was feverish and restless.   On the second dressing,
at the distance of seven  days from the operation,  I  found the
gland, or the remains of it, not killed by the ligature, but adhering
round all  its edges, to the surrounding parts  ; and especially 1
found it adhering firmly to the  flap of the ear.   1 diseugaged the
adhesions with the probe, and  examined the ligatures and found
them loose ; but having fixed them with running knots at the last
dressing,  I now finding it impossible to draw them  tighter,took
another method, viz. passingthe ends ofthe upper ligature through
the eye of a large crooked needle, and carry ing it, eye foremost,
round the gland, I carried the same ligature a second time round
the neck ofthe tumour, and tied and drew it again with considera-
ble pain.  The button-like head and neck were now so liard and
brittle, that I might safely have snipped them across, but I thought
it best, since the ligature still occasioned pain, to leave it to kill
the part completely.   At a third dressing I found still the gland
not killed, but adhering to the ear, and bleeding when touched,
so that I)r.  Monro could  not be persuaded that  the ligature
actually surrounded the tumour.  I drew the ligature now a 
Lips, Cheeks, and Throat.             50$
fourth time with great pain;  I waited for its sloughing, as this
root of the gland seemed to delay  the cure, which  was other-
wise far advanced; but at the next dressing I found the tumour
hard, brittle, entirely blackened,  and turning in every direction
upon its narrow neck,  which I twisted off with a very  slight
twitch, merely by turning  it round and round.   The surfaces
suppurated fairly, and granulated ; and the cheek healed even-
ly and  well:  but the pains never entirely ceased ;  our patient
had rheumatic feelings  in all that side of the head, always re-
ferable to the diseased part:  they were increased in moist wea-
ther, or when the  east wind  blew.   He  retired to a delightful
climate near the mouth of the Clyde, and while there the thick-
ening of the parts daily lessened, and I flattered myself he would
entirely recover ;  but after  receiving  from our patient a suc-
cession of very afflicting letters, he returned to me in the month
of January, in a very calamitous situation, with the  tumour al-
most as big as in the month of July, when the operation was per-
formed, and having all the aspect of a part ready to burst out into
cancer. The surface and the cicatrix, and all that belonged to the
skin, seemed to be particularly diseased, and  prone  to  ulcera-
tion.   Three points stood particularly prominent like knuckles,
from the centre of the sore: these were the three corner points
of the skin formed by  the triangular incision; they were of a
dull red colour, extremely  painful, with an indistinct  sense of
fluctuation, or rather of boggyness, (soft and hard mixed,) and
resembled in short the livid skin of a schirrous breast, when the
operation having been  unsuccessful, the part is about to burst
into open cancer.   The pain which had for some months been
moderate and  tempered with intermissions, was now unremitt-
ing,  extremely severe, shot across the cheek during  the day
with stunning violence, and at night was so fierce and intolera-
ble, like the burning of live coals, that he wished for ice to apply
it to the side  of his head ; and even with these large doses of
opium which he had learned to use,  he passed much of the night
without closing his eyes.   With Dr. Monro's consent, the usu-
al, the hopeless, prescriptions of hyosciamus and mercury were
given him, and he returned to the care of his surgeon at home,
whose  letters announced to us only a succession of sufferings
daily more and more,  and were terminating at last in a fatal
cancer : he survived but a few months."
   Those more ordinary operations on tumours rolling under
the skin, insulated, easily extirpated, and which we know it to
be our duty to dissect out, as a measure of precaution,  I need
not describe to you ; but those in which there is any thing either
singular in the place of the tumour, or critical in the dissection
required, I hold it my duty to represent; and I am permitted 
504               On Tumours ofthe Gums,
by Mr. Dunlop,  surgeon in Glasgow,  to explain to you some
things very singular in the operation which he lound it prudent
to submit to in his own person.
   Mr. Dunlop, surgeon, after deliberate and frequent consulta-
tion with his father, resolved to rid himself of a continual anxi-
etyin regard to a glandular swelling, deep seated, lying imme-
diately under the lobe of the ear, and which had been increasing,
though  slowly, for five  years.   No well instructed surgeon
could be indifferent to the  consequences of such a tumour in
hi? own person.  Had  the gland  been  a mere scrophulous
swelling, he might have waited the event patiently, of its sup-
purating, shrinking, or remaining stationary ;  but a gland, hard
as a stone, gradually increasing  in size, deep seated, extending
its adhesions,  and connecting itself with the  carotid artery and
portio dura, was  not to be long disregarded.   Much as I have
been in the habit of comparing external with the corresponding
internal parts,  and planning operations, there were many things
in this dissection altogether unexpected, and for which I was in
no shape  prepared.   I felt (more than even  in those cases in
which I had been correct in my conjectures,)  the necessity of
thinking long before lifting  the knife: I was sensible of some-
thing very uncommon and anomalous in this tumour, for though
it did not seem to adhere,  it lay very deep, though  moveable,
its form could  not be distinguished, though extremely hard and
globular, it seemed to be  covered with coats of an extraordina-
ry and unaccountable thickness ; and, if I can pretend to re-
member any conjecture I made, it was  a very mistaken one,
viz.  that the fascia, fat, and cellular substance had thickened tQ
a singular degree  over it.  But Mr. Dunlop, passionately desir
rous of being rid ofthe tumour,  required that I should perform
the operation without delay.
  The usual apparatus of knives and needles, a fork to transfix
and  hold the tumour with, tenacula and dissecting forceps, to-
gether with sponge, and a long bandage being prepared, I began
my operation by an incision carried over the centre of the tu-
mour of three inches long, running behind the line of the jaw-
bone, and parallel with it from the tip of the ear downwards;
the edges of the skin being then drawn strongly to either aide,
I proceeded to dissect the tumour, but after 1 had dissected off
the fascia, the tumour seemed still soft and shapeless ; nothing
like a firm gland or circumscribed tumour appeared; what pre-
sented under my knife was flat and fleshy, and undefined; and
when this fleshy  mass was pinched up betwixt  the finger and
thumb, the hard tumour was distinguished under it: I now re-
collected that I was cutting directly over that part  of  the paro-
tid gland which lies behind the angle of the jaw, and as instant- 
* 
P. 6O6  .
NS17
J£iU. ^r
r. Kjamy • tJe. 
Lips, Cheeks, and Throat.
505
\y distinguished, that the surface I had laid bare, was no other
than the  flat  white granulated substance of  the gland.  I per-
ceived that the tumour,  the object of  my operation, lay under
the parotid : I first dissected round this lobe of the parotid on
each side, then  turned off the lap of the parotid, or that lobe
which lies behind and under the ear, and then saw the indurat-
ed gland lying beneath it.
  This was  assuredly a delicate piece  of dissection;  for first
the lobe of the  parotid was turned back and carried behind the
angle of the jaw, at that point where the division of the external
carotid enters into its substance.  Under the gland lay the trunk
of the carotid, and the space was far from being free for making
so dangerous a dissection  confidently : there was no  want of
courage  on the part of my patient, but it was somewhat of an
obstreperous and boisterous kind; for having imagined the tu-
mour a simple and moveable one,  to be cut or dug, or torn out
easily and quickly ; he was provoked at my tedious way of dis-
secting, and called for  a  mirror to inspect, if not  to direct my
incisions.  The gland itself was now laid bare with its glistening
bluish capsule of cellular  substance, and while the lobe of  the
parotid was held up by my assistant, I dissected cautiously and
slowly into the anglt, to separate the tumour from its connec-
tions.  In the accompanying sketch, No.  17,  made instantly
after the dissection, the sides of the incision are marked fa a)
the parotid gland held upwards by a  hook struck through the
fascia is marked  (b), the tumour lurking under it, and entirely
enveloped in it, (for it is flat and cushion-like,) is  marked (c).
The  operation lasted long, and was not a very tranquil one :  but
it was safe,  and by making the  incision merely longitudinal,
without any cross  incision, and immediately  under the whisker,
and by pinning it nicely  and delicately with fine sewing needles,
and laying slips of court plaster curiously betwixt each needle,
the adhesion was accomplished in a few days, with only a very
slight leaking of pure saliva  from the wounded surface of the
gland, which lasted but two days, and in eight  days my friend
was well and had  returned home : it is by his express permis-
sion  I lay this slight sketch ofthe dissection before you.
   Slight as these difficulties may appear in  this narrative, it is
fit you be aware of them ; for the young surgeon, in the moment
of seeing something altogether unexpected, a flat and shapeless
mass, in place of a firm circumscribed gland,  is in danger of
losing courage, and falling into confusion.   I hope I need not
remind you how unpleasant an accident it would have proved,
had  a young and thoughtless operator  in these circumstances
proceeded rashly,  and cut across the parotid, mistaking it  for
the tumour, or cut at a venture, down into the angle where the
                              SS 
SGb*              Ok Tumours of the Gwns,
Carotid and Portio Dura lie.*  It is just such a tumour as this,
that by adhesion and induration affects all the surrounding parts,
becomes too formidably connected to be  extirpated, and at last,
by causing cancer and destruction of the bones, and by its enor-
mous size,  lays the patient's head upon the pillow  from which
it is never to be raised again.   I have  once seen, just from  so
slight a beginning, a boy with an osteo-sarcomatous tumour of
the head, where  bones,  muscles, and glands, were all massed
in one common tumour, big as the original head, of a  weight
too great for the neck to raise, and which, when it  was to  be
moved, was moved with the help of both hands; the lad died
of stupor and apoplexy,  from suppuration of  the brain.
   It has often  struck me that the things a surgeon ventures to
do in the  moment of operation, resemble in one  respect those
which a soldier does in mounting a breach:  what is past looks
like a dream,  and upon returning to the scene, and consider-
ing the danger  that is over, he  shudders at his hair-breadth
escapes, and is conscious of having done, what  he can never
venture to do again.  This has been especially my feeling eve-
ry time that I have, in turning over my case books, glanced mv
eye on the following case of Jane Sharp.

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

  * The fketch of  this diffeilion explains the difficulty and delicacy of it.  The
lobe of the ear is marked (a);  it was from the hollow betwixt the ear, the angle
of the jaw,  and the vertebras, that hollow where the carotid arteries lit, that the
tumour was diffecled.  In order to avoid deformity,  I had made the incifion lon-
gitudinal only, and not very long, no more than three inches;  (b) marks the
lower lobe of the parotid gland, which in its natural fituation extends almoft to
the angle of the jaw. and which in this cafe entirely involved the fchirrous gland;
but at (b) the parotid was differed from the furface of the gland, turned up-
wards and held afide by the hook, till the gland (c) was differed out from be-
neath it.  The whole appearance of the parts was in this cafe like that of a dif-
fered hernia, the fafcia of the gland (d) refembled in fome degree that of the
herniary fac; the parotid refembled a thickened omentum, which being turned
afide expofed the gland, as the laying afide of the omentum in operating for her-
nia fhows the turn of the incarcerated intcftine. 
Lips, Cheeks, and Throat.             5Q7
nied occasionally by lancing pains; since which time it has in-
creased gradually.  It is at  present about the size of a large
hen's egg, hard, unequal on its surface, quite colourless,  and
at times accompanied by stinging  pains.   It extends considera-
bly behind the jaw, and on the anterior part of it is seen the
cicatrix from the former operation."
                           17th.
  A tolerable night's  rest, no haemorrhagy, but she complains
of pain in the throat and difficult  deglutition.
                           18th.
   She complains  to-day of difficulty of breathing, the pain of
the throat continues, the bandage  being slackened, there is im-
mediate relief to both,  she  sleeps ill, opium is substituted for
the draught.
                           19th.
   The sponges adhere firmly to the surface of the wound, there
is little tension or  inflammation of the parts, but she still com-
plains  of the pain  in the throat, chiefly on deglutition.
                           20th.
   Two of the sponges  were removed with little difficulty or
pain, no haemorrhagy.  The wound is filled up with lint.
                           22d.
   All the sponge is removed.
                           25th.
   The discharge is copious.
                       February 4th.
   The cavity fills  up  rapidly.
                            15th.
   She continues to do well.
                           25th.
   She was dismissed nearly well.

      Report of the Operation by Mr. Bell, January 16.
   " The one half of the parotid gland, that which lies behind
the angle of the jaw,  had been left: the scar of the former ope-
ration was on the fore part of the tumour: the tumour lay be-
hind and under the ear, pressing  deep betwixt the mastoid pro-
cess, and the rising branch of the jaw-bone.  It seemed  out-
wardly a small tumour, but it had shot down very deep, ad-
hering to the pteregoid process and to the back of the pharynx.
The dangers of the operation were these;  the portia dura, and
the 9th pair of nerves passed through the tumour: immediately
under it lay the trunk of the carotid.  The external carotid be-
hind the lower jaw, but chiefly the large jugular vein,  was in
danger, for the tumour lay so entirely under the mastoid mus-
cle, that part of the muscle is taken away with the gland.   The 
506              On Tumours of the Gums,
 gland being dissected free in its lower part, where it lay near
 the carotid artery, was  torn  up from the roots where  it ad-
 hered to the back of the fauces.  The internal maxillary arte-
 ry bled very profusely;  a  small piece  of sponge, the size of
 the thumb, and  supported by other pieces of sponge filling up
 all the hollow, was pressed upon the artery  at the back  of the
 nostril.   The swelling of this piece of sponge caused a difficul-
 ty of deglutition, which ceased when the  sponge was removed.
 After the operation I put my  finger  into the hollow whence the
 gland was extracted, which 1 felt to be two  inches and a half
 deep; at its lower angle, (i. e.) behind the corner of the jaw-
 bone, the carotid lay  bare, beating  strongly, not dilated; the
 upper part of the wound was deep, so that the  finger touched
 the  pteregoid process forwards, and the apophysis cuneiformis
 of the occiput backwards ; and when she  swallowed, the mor-
 sel, in  passing down the pharynx, pressed upon the point of
 the  finger."
   When it happens that a glandular swelling, small in its first
 stage, and but too little  formidable  to excite alarm, grows in
 its second stage to such magnitude  as  plainly to require extir-
 pation,  which the surgeon, even after he  has begun the opera-
 tion, dares not complete;  when the  same unhappy person pre-
 sents himself again, claims the assistance of the surgeon, will-
 ingly offers to subject himself to any operation, however severe
 or cruel,  but is by a formal consultation rejected and  bereaved
 of all hope of relief, is  not the doctrine explained in my pre-
 liminary observations, but too certainly proved?  In this sense
 I venture  to call  your attention in a particular manner to the
 case which I am  now to  relate, and to the reflections which oc-
 curred to me on this consultation.
   " Jenny Brown was a poor solitary thing, who worked la-
 boriously to maintain her aged mother,  her father being some
 years dead:  she  slaved  at all kinds  of work as an out-servant
 in a farm-yard. After churning milk, being exceedingly heated,
 she  went  out with her cap loose, and jaws  exposed, and by
 carrying bundles of wet grass for the cows, upon her head, had
 a severe toothach,  for which a tooth was pulled,  and  still con-
 tinuing the same  labour,  she got cold; thence arose a kernel-
like  swelling of a gland  under the lower  jaw near the gum of
 the corrupted tooth.  Her face was swelled,  so that her eyes
 were closed;  the lump grew as big as a hen's egg, with severe
 pain; the swelling of the face  subsided,  the pain ceased, but
the glandular tumour remained.
   Whenever an operation  is ill-concerted ;• when the surgeon
proceeds to extirpate a tumour with this vulgar notion in his
head, " we shall try to take it away," he is almost sure to fail: 
Lips, Cheeks, and Throat.              509
accidents, no doubt, will prevent the most dexterous surgeon
from accomplishing all his purpose, and a zealous man will
sometimes attempt what he dare hardly perform; but a sur-
geon really acquainted with the uncertainties and difficulties
of his profession, will,  even in the least dangerous  circum-
stances,  reflect long and much on  the nature of the tumour
which he is to extirpate, and the anatomy of the adjacent parts;
whether it consists of various smaller glands, or ot one only,;
whether it has its arteries  from one point or stem, so that  it
could be dissected round and insulated, this point being left to
the last entire,  or from various sources,  so as to make a slow
and bloody operation necessary; whether these  arteries  must
be  cut near to their going off from  some large  trunk, as the
carotid; whether a large vessel itself, or its immediate branches,
may not be entangled in the roots of the tumour.  Such calcu-
lations I will venture to say never entered into the mind of the
operator, who first adventured to extirpate this tumour: he en-
tered upon it with little premeditation, and stopped short at the
first slight appearance of danger.
   To  extirpate any tumour safely, you must  keep to its sur-
face ;  dissect cellular substance only; never touch,  if possible,
its system of vessels;  if once you plunge into its centre, you
are inundated with blood,  (unless it be merely a steatoma) and
your future dissection is irregular and imperfect.   A very long
incision being made, the operator seemed to me to plunge into
the very heart of the tumour, several arteries  (not, it is  mani-
fest, of very dangerous size, for he had never even approached
the  roots of the  tumour)  threw  out blood,  all  the  assistants
thrust in their fingers to  stem the blood, and  the operator tak-
ing advantage of this consternation,  little confident in himself,
and having  calculated no circumstance beforehand, obtained
an easy and unanimous vote,  that the incision should he sewed
up.   This was to me manifestly the  result  of an imperfect
knowledge of the route and size of the several arteries, of the
error  of cutting  towards the centre of a tumour, and of the
worst  of all faults and weaknesses, that of turning round with
fear and trepidation, in the midst of occasional difficulties, to
consult those, who from  the moment an operation is  begun,
should be no more than  spectators.   It proceeds from a paltry
desire, to make the attendant surgeons parties, not to the gene-
ral  operation, for which they have  given their voice,  but to
each step of it.   Let the surgeon act from himself according
to the best of his judgment, cut slowly when he is conscious
of approaching too near the great vessels, and stop when alarm-
ed  by that immediate sense of danger, of which  he  must be
the sole judge,  or at least the most competent. 
510              On Tumours of the  Gums,
  One advantage this poor creature derived from this unsuc.
cessful operation, viz. the relief from pain, for she was relieved
by the loss of blood, insomuch that  she recovered her  health,
and, in some degree, her strength, and  returned  to work, for
the support of her old mother;  at least she could spin.  For
a long while she has been unequal to this; she has lingered and
wasted in a very helpless condition, and is now in a state of ex-
treme weakness for want of food:  she walks but a few paces
without stopping for want  of breath; her swallowing is  diffi-
cult ; she has great pain night and day from the mere distention
and size (I am  persuaded) of the tumour, which is not red-
dened in the very slightest degree:  the weight of the tumour
is intolerable,  and it appears to  me that, in not many weeks,
at the utmost in a few months, she must be released from her
sufferings.  She has saved one shilling  to enable her to travel
to town, from the village she lives in, (Falkirk) which is about
20  miles distant; and  now, from the  first and unsuccessful
operation, she presents herself, after no great lapse ot  time,
with a tumour so enormous,  as to  make the question of ope-
rating  difficult to resolve, but  in a  condition  which admits
no delay, she is sure  to die, and  willing to suffer any  thing
which may tend to save her life: there is one inducement to
comply with her request, viz. that she must surely die, though
from no  other cause  than the bulk of the tumour : the tumour
not being cancerous, leaves us nothing to dread after the
operation.
   A consultation has decided that no  operation can be per-
formed.  I imagine there  are very many safe and easy  ways
by  which this tumour, great as it is, may be extirpated, or de-
stroyed ;  and, reflecting upon the  possible success of such an
attempt,  I think I  have estimated the  dangers  fairly, and an
impartially as if the operation were  my own appointed task.
   This  poor creature's difficulty of breathing seems to me to
proceed as much from  the weight of the tumour, as from the
hold it has upon the parts; from the immense  mass resting up-
on the  trachea and  oppressing  even the breast.  The tumour
has every character of what is usually called a wen ;  the whole
mass incredibly hard in proportion to its bulk,  so that she sup-
ports it continually with a sling round the head and neck : it is
extremely firm,  not very vascular throughout its substance,
but receiving its arteries at particular points; it has no great
veins  running over  its surface, whence  it may be presumed
that it has no very irritated circulation, nor any thing of a can-
cerous  nature.  The whole surface of the skin  is healthy and
free from redness or any blemish,  except where the scar of the
former operation passes obliquely  over it: it is plainly -hr.Ju- 
Lips,  Cheeks, and Throat.
Sli
 lar, the  most prominent parts indeed consisting of individual
 glands:  two large distinct prominences  lying one  before, and
 another  behind  the ear, form the chief bulk ot the tumour at
 that part, and are plainly separate glands,  moveable both in re-
 lation to each other and to the main tumour.  The extirpation
 of  that part which lies under the chin could give  us no con-
 cern; there we  could cut  no  arteries but the facial, which
 would be divided in separating the tumour from the line of the
 lower jaw:  its own weight seems to have lengthened its root
 and drawn it down from under  the ear, and from the angle  of
 the jaw : it hangs so that I  can  push the points of my fingers
 deep behind it, without feeling any strong adhesion, and, I am
 confident, it has  no dangerous connection  with the carotid at
 that critical point, where it  forks  behind the jaw-bone into the
 ex  ernai and internal carotids.   I am confident that the carotid
 and greatjugular vein lie together safe  in  their sheath,  while
 the tumour, lying external  to the sheath,  might be dissected
 away from it, from the mastoid muscle, and from the vessels
 beneath  quite safely, as we often find immense  tumours of the
 thigh (equal almost in size to the patient's body) are dissected
 from under the Sartorius muscle, without injury to  the femo-
 ral artery.  The worst effect of  the tumour, and the most dan-
 gerous adhesions of it are to the side of the throat, to  the os
 hyoides  and its muscles ; there, by pulling down the os hyoides,
 it makes the swallowing difficult, and oppresses the  breathing
 by  its weight; and at that point there might be infinite trouble
 from arteries proceeding into the body ofthe tumour from those
 ofthe thyroid gland. But the tumour is, by its weight, dragged
 so  away  from the jaw, and  admits the points of all the fingers
 ranged in a line, so deep on all sides, that,  though  I foresee much
 difficulty, I  find no absolute danger in the attempt.  Yet it must
 be  doae  by one who goes not to  work with the general and con-
 fused nc<ion, of extirpating the tumour " as circumstances will
 admit,   a»r^ proceeding according to the best of his judgment.
 His judgment must be  decided  and designs matured before he
 begins;  he  nust calculate at what points  the  arteries enter;
 what the probata size  of those that come from under the chin,
 from the lingual  aperies ; what the size  of these derived to  it
 from the facial, wh^e it crosses the angle of the jaw; what the
 size and probable diction of those coming to it from the oc-
 cipital, or temporal brashes of the carotid; or those deep ones
 coming from the  thyroid Series . he must resolve in what suc-
 cession to cut them, and, W*h what precautions.   The surgeon,
 who sees an artery throw ou, blood furiously, and  in the neck
 too, not  knowing from what >oot ;t coitus,'must instantly fall
•into great contusion :  but if he has calculated every probable 
512
On Tumours of the Gums,
danger,.he.is prepared, and his patient  comparatively  safe.
In the present case, the incision should be made, not over the
centre ofthe tumour; the purpose of saving all the skin which
invests  it,  is absurd, and the conception of dissecting into its
substance, extremely  ignorant.  The oval incisions should be
made to encircle its upper and lower parts;  there are points in
which it should be opened freely, as there the  chief dissections
are to  be  performed.  The great  and dangerous dissection
would be in the  line of the lower jaw, about three inches from
it, and extending from behind the ear. to  the  throat:  the skin
being laid back, this dissection would follow the  convex of the
tumour ; the tumour falling by its weight would widen the in-
cision and expose the parts, the  left  hand  laid  upon  it would
press it down, while the assistant retracted the skin; the fore-
finger of the left hand would  guide the dissection; the  point
of it,-fixed upon  each lesser .artery successively  as it bled, would
stop it till it shrunk:  the form of the tumour, the line of inci-
sion, and the direction of the jaw-bone, would keep the relation
of parts distinct; the operator would certainly know  when he
approached any dangerous point; in drawing down the tumour,
and dissecting it from under the chin, he would  cut branches
of the lingual arteries; pressing the tumour next down from
the angle ot the jaw, he would cut the facial artery; and would
go no further in  that direction; having  tied the. facial artery,
he would next, in tearing away the tumour from  under the ear,
divide branches of the occipital and temporal arteries: ij  is the
seeing;those arteries bleed furiously  in succession, without fort-
sight, without knowing from what  trunks, in  what directions
they come, or knowing what may next happen, that makes an
operation seem bloody and dangerous.
   In next dissecting deep into the. angle  or cavity below the
jaw, there must  be danger;  every  incision must be mack with
caution, the point of  the fore-finger must go before tr feel for
the beating  of the carotid artery; and  much  shouU  be  done
now by laceration, the tumour being inclined  fi/st from  the
chin backwards,  then from .the  occiput forward and pulled
so as to give a distinct feeling of the parts with which it is con-
nected, whether, for example, pulling, upon -'ne tumour moves
the os hyoides fairly along with it, whethe  the tumour sends
down roots,  involving the carotid and  Eternal jugular vein:
this deliberate and daring proceeding vould,  I doubt not,  en-
able the surgeon to approach by diss^ion, or  laceration,  quite
close to the only dangerous point, 'fc.  that where the carotid
lies  under the angle  of the jaw : if, having reached that point,
he found a clear and distinct ctlular  substance to lead him m
his dissection, he would, pressing aside  the  dangerous  part? 
Lips, Cheeks, and Throat.
513
  with his finger, continue it with equal deliberation through its
  next stage; if he found inextricable adhesion, and increasing
  haemorrhagy, he  would stop;  but, having so far  insulated the
  tumour, he could, if forced to stop,  tie its root,  even though
  several inches thick, and strangle it,  if not with a surgical li-
  gature, at least with a garter or coarser string.
    I should not,  in the slightest degree, shrink from such an
  operation, and would  dissect so very large a tumour with less
  reluctance, than  many a smaller one I  have dealt  with.   I
  have even a persuasion, that this second stage of growth may
  be accompanied with circumstances favourable to the  opera-
  tion, the weight  of the  tumour elongating its roots, weakening
  its adhesions, and concentrating its arteries.  I beg leave to
  remind  you of  another circumstance  in such an  operation,
  which you will do well to attend to.  Do not dissect in haste
  and in a hurry, for by  time  and circumspection, you can ac-
  complish things which  seem  impossible, and I would explain
  my opinion and my practice  more  fully thus: " Would there
  be much danger  had you to deal  at once with one only of all
  the arteries which are  cut in extirpating a tumour ?"   None
  assuredly.—" Would there be much additional  danger  were
  the pain of this dissection extended from a quarter of an hour
  to an hour ?"  None.   Let us apply this reasoning to the case
  before us: I have uniformly found, that permitting the  blood
  to stop entirely, and the incisions to become dry  before bind-
  ing up a wound,  contributes to its speedy adhesion; in all ope-
  rations I wait long: this is  with me one universal rule in ope-
  rating.   I have as uniformly found, that, when a dissection be-
  came perplexed and confused, the taking up  of the large ves-
  sels, and allowing the bleeding from lesser ones to cease, and
  waiting till the surfaces get that raw  look, which betokens the
  drying up of the  blood, explains every thing, and restores that
  clear conception which  I had at first of the relation of parts, of
  the arteries I have actually cut  and tied, and of  those  which
  are still endangered: and this I regard as a rule in all difficult
  operations.   In dissecting this tumour,  or  such a one,  I am
  convinced that the danger might be  brought within very nar-
  row limits, and am confident that, in the present instance, even
" the lower lobe of the parotid gland, as well  as the sheath, con-
  taining the carotid artery and internal jugular vein, lie  under
  and behind the tumour; in short,  that  the  gland lies betwixt
  the tumour and the artery, and defends it.
    But are there not various ways, independent of direct inci-
  sion, for working out,  or  weakening the roots and adhesions
  of  this, or even  of a more formidable  tumour I  May  not a
  greater enterprise than this be atchleved bv  partial incisions,
                           3  T 
.U4
On lum'Airs of the Guvh\
 by ligatures, or by both combined ?  The  two  great  globular
 knots which form the upper part of the tumour, and project
 before and behind the ear, are, I am persuaded, so insulated,
 that they might he dissected away by one operation, reserving
 the great mass of the  tumour for a second: or the  operator
 might go as far as he safely could by direct incision,  and then
 striking a long needle,  like those with which I have  been  ac-
 customed to transfix large strumous sacs, pass a ligature through
 the  tumour to be tied  on either side of it; or the tumour,  I
 am persuaded, might be so pulled  away from the throat, and
 the  long and crooked needle  I  speak of  passed so cunningly
 round and under the tumour, as  to pass the ligature  round it
 without any preparatory incision.  It is  possible  to penetrate
 so into the body of the tumour with caustic, as to  pass a liga-
 ture through its centre,  and after extirpating the chief  mass by-
 stricture,  to destroy the roots by a continued use of the  caus-
 tic.   It is possible,  without penetrating into its centre, to dis-
 sect up one side, or to pass the  long needle obliquely through
 one side,  so as to give a hold to the ligature, make it  embrace
 the neck of the tumour,  and by twisting it with a tourniquet
 (made by  twisting a stitch in the ligature, and  slipping a  piece
 of pasteboard  under the knot) from day to day, mortify and
 extirpate the whole mass.*
  -  But there is no need  for subterfuges  in a  plain  and simple-
 piece of dissection,  which,  though not without danger, is vin-
 dicated by the suffocating condition of  the  patient, and by the
 inevitable  nature of that death  which awaits him, an operation
 which, though not absolutely safe, is so, in  the  hands of a dex-
 trous surgeon, witness  the  following  most interesting  case.
 The most considerable  tumour,  seated in so dangerous a part
 as  the neck  which I have ever in my life extirpated, (says M.
 Petit)  occupied all the side ofthe face, neck, and jaws;  it was
 almost  entirely  circular,  extended  from around the ear, both
 before and behind, upwards to the angle of the eye,  forwards
 to  the corner of the mouth, and downwards over the jaw,  along
 the neck, to the articulation of the  clavicle with the acromion
 process.    It was seemingly  eight inches in diameter,  and the

, i, .?■ My reader, unless he be  a practical furgeon, will not readily feel the reafon
 of. my enumerating thus  the many refources which will prefcnt thcmfelves,  nor
 the iad.riecrffity of having recourfe to fo many means.  What dangers in thfe way
 of operation,  what continued tortures by any flower and lefs dangerous method,
 will not a man uodergo  to/fave life?  ThU P"or creature probably died, as
_ rhoufajnis have died, ii) a ftate  of  protracted fuffering; and the furgeon who hh~,
 wnnefTed  fiich a fcene, wlio h-is felt compunction at having lightly dilmiffed  j
"•p;iti«««*t in&e early ft age of a tumour, which has afterward- prowd fatal, or who
 har<.t»itj-ehe diffirul/y of .deciding when a tumour  was plainly to prove fatal, but
 yet  toofr-^ly co.inei'ied to allow of extirpation, will think over all the poffiblc
 efoarces with fhi.vre irtv-r.il. 
Lips, Cheeks, and Throat.
515
patient, about 50 years of age, had carried it twenty years; for
itiwas of slow growth, its first beginning being a glandular in-
duration, seated about two inches under the ear, and lying on
the mastoid muscle.
,   Wheu this tumour was no bigger than the fist,  I advised
him, and often repeated the advice,  that he should have it ex-
tirpated.  When he refused,  I  prescribed  such  discutient re-
medies as I imagined might have some  effect; and every time
I repeated my advice, he rejected it  entirely, because he could
still conceal the tumour under a voluminous  peruke, such as
was then in fashion:  but the tumour increasing in bulk, so .as
no longer to be concealed, and growing  so painful  as to excite
alarm, he convoked a number of surgeons to have riieir advice.
I alone, of all the gentlemen consulted,  advised the extirpation
of this tumour; each of us, as the consultation was not held in
the presence of the patient, spoke his mind freely; and when
it came to my turn,  I explained myself thus: " Of all the rea-
sons, gentlemen, which  you have advanced against the opera-
tion, one only  affects me, and  that is the fear of hsemorrhagy
from the numerous arteries of  this tumour, which not having
one root or pedicle, would bleed at once from all points, and
from the number of its arteries,  some most likely of consider-
able size, the patient might lose much, blood,  perhaps his life.
These, said I,  are the dangers, but have I not skiffuL assistants
willing to stand by me ?  What then should I fear ? I shall cut
away the skin along with the tumour which it covers,  because
they adhere, I shall first dissect away the/part that lies over the
cheek, and some one of you appointed  for that duty, shall. be
ready to clap a finger on the  first artery I cut; and as I pro-
ceed in my dissection, he will have a finger ready for each ar-
tery that springs.   Thus shall  I pursue  my  operation, and
whatever number of arteries are cut,  so  many fingers will there
be ready to compress them; and the whole being accomplished,
finger after finger being raised,  first from the  greater arteries,
and next from the smaller, each in succession will be secured
with the needle and ligature.  The  scheme was acceptable to
all of them.  It was  deferred only till the  following day,  and
never  was a project better fulfilled,  for never perhaps had u
young surgeon  so many of his  masters  in surgery to  support
him.   Arnould, Tribauld, and the elder Le  Dran, held their
fingers on the arteries.  The smaller ones of the eye-lids, lips,
he. were considerably dilated,  but those which occasioned1 the
most  trouble were the anterior and  posterior branches of the
temporal artery, and the facial where it  turns round the lower
iaw.   Each ligature held its place ;  at  the  first dressing not. a 
516              On lumours of the Gums,
drop of blood flowed;  in two months, or little more, the wound
was cicatrized."*
   You  will observe that M. Petit's confidence in undertaking
an operation so formidable, arose  from a conviction of the tu-
mour being superficial;  not under the  mastoid muscle, but
above it;  not connected with the carotid artery, but endanger-
ing  only  the temporal, and facial branches.   But the  question
is a very awful and serious one, when the tumour is seated be-
neath the mastoid muscle, projecting from under it in conse-
quence of its great size, and probably connected at its root with
the sheath which includes the  carotid artery and greatjugular
vein: such a tumour,  if firm, glandular, growing rapidly, and
pressed inwards by the perpetual bracing ofthe mastoid muscle,
will connect  itself so with the parts  beneath  by adhesion as to
make its extirpation  dangerous  in the last degree, and it will
at the same time press so upon the throat as  to make the at-
tempt an act of necessity and  duty.   Often I have had occasion
to consider the anatomy of this part  of the neck, and especial-
ly ofthe vessels and nerves lying in  the angle under  the jaw-
hone, but never  more anxiously, than when  preparing for the
following operation.   The subject of it was a gentleman about
35 years of age, of the best, and most grateful dispositions,
and the stoutest  heart.  He  confidently required me, on my
allegiance and duty, to perform the operation  if I found it at all
consistent with safety, although it  had  been forbid in ma-
ny former consultations with  other surgeons:  his courage was
not in words only.  While I  performed a very painful and slow
dissection, he sat like  a  monument.  The tumour projected
from under the ear, of a stony hardness, and of such a bulk as
to fill up all the angle betwixt the  ear, jaw-bone and neck:  it
extended backwards. behind  the ear three inches, forwards to
the chin? and downwards along half the neck ;  it already dis-
placed the larynx and  throat, pressing them  over towards the
left side; and made the swallowing difficult,  and  the breathing
so laborious, that he could no longer sleep at  night, but started
out of  bed, partly from suffocation, partly  from fear;  it in-
creased withal very rapidly  in size.  The sum of the opinion
which I delivered to him in  writing was this: u that a tumour
so situated  could not cease to grow, and could not fail to pro-
duce, at no  very distant period,  the  most distressing  conse-
quences : that upon comparing the tumour with the great ves-
sels and nerves of the neck,  it was my persuasion, that though
it lay upon the great carotid  artery and jugular vein, it had no
essential  connection  with them,  and  that  the  only arteries

H-   •
   *  Quvrage Pofihume de J. L. Petit. 
Lips, Cheeks, and Throat.              517
which would be unavoidably cut were the temporal, occipital,
and facial arteries: that the carotid, with its accompanying vein
and nerve, were involved in their  own  peculiar sheath; that
the angle where the great carotid branches into the thyroid, fa-
cial, occipital, and temporal branches, was protected by the mas-
toid muscle, and by their sheaths of cellular substance: that I
thence inferred, that, though no such operation can be void of
danger,  there was in the present case, nothing to deter the sur-
geon  from  attempting so  needful a duty:  that I should with
pleasure assist  at this  operation, or with equal alacrity to per-
form  it; but, that I conceived it a necessary privilege that the
surgeon, who made himself responsible  for  the life of a pa-
tient, should be entitled, in all irregular operations, especially
in one so full of danger as this, to stop at the first apprehension
of danger."
   The history of every tumour must be alike:  and I found in
the history of this particular tumour nothing interesting.   Were
I inclined to draw any inference, from what my patient told me
of the origin and growth of this tumour, or from the severe and
dangerous operation he was forced to submit to, it would be that
so strongly enforced in my Preliminary Discourse:  viz. That
no tumour, when it passes the  usual limits of a swelled gland,
and begins to  adhere to the surrounding parts, should  be  per-
mitted to grow ; for this too, like that of  Jenny Brown,  was
but a swelled gland.   The description of every dangerous tu-
mour is delivered by the patient in the same phrase, " It be-
 gan like a little knot or kernel, and grew slowly:"  it is there-
fore  unnecessary to detain you with insipid and trivial details
 of its growth."
   My  first desire, on all occasions of danger, is  to make just
 conjectures in regard to the internal relations, and probable ad-
 hesions of the tumour ; and on these to found a true prognosis,
 to be delivered to the patient, or his friends, and a rational
 scheme of the  several parts  and steps of my intended opera-
 tion.   First, I found the tumour of very  formidable dimen-
 sions,  projecting to  the  perpendicular height of four inches,
 and terminating in an apex, which stood as prominent from un-
 der the ear, as the chin from  the face  and throat;  and this
 pointed apex  was the  smallest part of the  tumour, which in-
 creased in bigness towards  its base, and  there,  especially in
 the part lying under the mastoid muscle, though it was move-
 able,  because  the  muscular parts of the  neck are moveable, it
 seemed solidly connected with the parts beneath it.   Secondly,
 though that never could be regarded as a  superficial tumour,
 which lay,  in  its biggest part, under the belly of the  mastoid
 muscle; vet I found no motive for despair, for I was, by eve- 
 518              On Tumours of the Gums,

 ry calculation, persuaded  it had no very  intimate relation to
 the more important vessels, but stood thus connected: it  lay
 so close upon the carotid artery, that it entirely  covered that
 very dangerous point behind the angle of  the jaw, where  the
 carotid forks  into the great branches destined to the thyroid
 gland, tongue, face, and temple : that it lay closer still upon the
 root of the  occipital artery, and covered the  whole length ol
 the facial artery, but, though  deep in respect of the mastoid
 muscle, and firmly compressed by it, it was superficial in respect
 of the carotid artery, for the angle where it forks into its great
 branches is covered by the styloid process,  and the muscles
 arising from it; and is even bound down and protected by them.
 The great carotid, the jugular  vein, and the eighth pair, were
 not only thus protected by the styloid process, and  muscles,
 but are  farther involved in their peculiar sheath of fascia.   It
 thus seemed to me less dangerous to extirpate even this great
 tumour, than the  smaller one of Jean Sharp,  seated as  it was
 deep behind the ear, where the carotid artery  lies; yet the de-
 gree of security, arising from  this interposition of the styloid
 process, betwixt the angle  of the carotid, and  the body of  the
 tumour, only rendered  the operation possible,  not safe:  there
 were other  manifest dangers to be encountered, the tumour
 passed under  the  mastoid muscle,  and  was so connected with
 its inner surface as to require that muscle to be turned entirely
 backwards in  dissecting the tumour  from beneath it; the  tu-
 mour could not, without a degree of danger, be detached from
 the side of  the throat,  where, as it seemed to  me, the carotid,
 the temporal, and occipital arteries, could hardly  escape, and
 where the inosculations  ofthe external jugular vein, with  the
 great internal  jugular,'would not fail to be cut across, so as to
 cause, if not a dangerous, at least a very perplexing  haemorr-
 hagy.
   With  these conceptions I formed that plan for the operation
 which succeeded so far, as to carry me to  the very roots  of the
 tumour,  and  save my  patient from very  imminent  danger.
 First, I  resolved to have full room for such a dissection, and
 to carry the external incision obliquely across the neck,  in  the
 direction of its natural wrinkle, following, in some degree,  the
 edge ofthe  mastoid muscle, beginning the incision on the  oc-
 ciput three  inches above and behind the ear,  and ending ffour
 inches below the chin:  Secondly,  to dissect up the skin  large-
 ly and widely, and, turning it back, proceed to dissect up  the
 mastoid  muscle from the  tumour: Thirdly,  to dissect  away
the tumour from the lower  and lesser point, where it projected
from under  the mastoid muscle backwards* but not fat; and to
 dissect it next down from the  cur  and from the chin, towards 
Lips, Cheeks, and Throat.               519
 the place of the carotid artery: Fourthly, the tumour and the
 mastoid  muscle being moveable  in  respect of each  other, in
 place of merely raising up the tumour gently from under  the
 mastoid with  the design of dissecting, resolved to poise it up
 strongly,  in the intention of tearing it away from its adhesion,
 and gouging it out with my fingers.  I perceived that using
 my knife  here, though it might not much endanger the carotid,
 would wound its branches close to the trunk.  1  considered la-
 ceration as the true principle of our proceeding in all such dan-
 gerous points, and the thrusting  in  a piece of sponge, as  the
 best means of suppressing any occasional haemorrhagy.   I have
 gouged out tumours with the fingers " more laniario,"  which
 I should never have dared to attempt with the knife.
    From this plan of operation, I confidently expected that there
 would  be  no other haemorrhagy than  from the general wound,
 viz. blood oozing out slowly, from  the  cut-surfaces, as  men-
 struation does from  the surface of the womb;  unless it were
 that sudden gush of blood which  flows from the jugular veins
 when cut across, but which will cease instantly,  and will be
 distinguished by its black colour and by the want of  pulsation,
 so as not to create even a momentary  alarm.
   This plan I  put in execution with great success, and it rests
 upon my own mind as a conspicuous  instance of an operation
 performed in very inauspicious circumstances, without spilling,
 I may say, one drop of  blood, where  it seemed difficult  to es-
 cape wounding even the greatest arteries ; his shirt was hardly
 moistened, and I had no other cause of alarm, than feeling with
 the point of my finger, the great arteries beating.  First, the out-
 ward incision of folly eight inches  long, being carried round the
 neck, and over the apex of the tumour, the mastoid muscle was
 dissected away from the body of  it, and so entirely  insulated,
 that my assistant taking  it on his fingers, turned it before or be-
 hind the tumour, according to the part that I meant to dissect;
 and thus I dissected sometimes before, and sometimes behind the
 mastoid muscle.   In this dissection the platysma  myoides mus-
 cle and strong' fascia ofthe neck were dissected back along with
 the skin.   Secondly, in dissecting down  the  tumour from the
 occiput, and from.the chin, no conspicuous artery bled, and my
 assistant,  while I dissected  along the line of die  jaw, followed
 my knife with  his finger-points of both hand*, so  arranged in a
 line,  and following the incisions in its whole length so correct-
 ly, that, by holding down the surface from which I was dissec-
 ting away the tumour, he saved the arteries which might other-
 wise  have been cut, and was ready, had an artery bled,  Xo
 cover it instantly, and make its place by clapping the point of,a
finger upon it;  and thus lie followed the dj&sectiou over 'de. an- 
520
On 1 umours of the Gums,
 gle,'and along the whole length of the jaw-bone, repressed
 the throat where the lingual arteries and nerves run along, and,
 by pressing down the carotid artery and its sheath, enabled m<
 to  carry my dissection down very low, I  dissecting and pull-
 ing the tumour away  from the  jaws, while he repressed  the
 parts, at one time  with the line of his fingers, at another period
 of the dissection with  a long flat piece  of sponge, cut  for the
 purpose.   Thirdly, turning the  mastoid muscle now off from
 the  tumour, I began to  tear upwards  and  dissect the lower
 part, that which projected,  according to the natural relation of
 the parts, from under the mastoid muscle at its back part: and
 here, for the first time, I found reason to hesitate; for this
 part of the tumour was connected actually with the  spine, it
 seemed to shoot down  strong thick roots, or fangs, betwixt the
 transverse processes;  the external branches of the nerves which
 proceed from betwixt the cervical vertebrae,  I  had no scruple
 nor fear of  dividing across, but I was come now almost to the
 flat fence of the vertebrae.  I was going deep behind the pha-
 rynx and the sheath of the carotid, and was sensible that the  di-
 viding the phrenic nerve, (for the  principal part you recollect of
 the third cervical nerve is destined for the diaphragm,) would
 probably prove fatal.  The harm  I might do was terrible, the
 good problematical; very little ofthe tumour remained, it was
 such  as even my assistant could hardly perceive,  much less a
 spectator, but I found myself not intitled to venture farther, I
 therefore cut these roots across, and, having thus delivered the
 patient  from  this  tumour, I felt  the great chasm left  by it.—
 Now, Gentlemen, I am explaining these matters  for your in-
 struction, and the good of humanity, and with thoughts  far
 above any politic regard for my own reputation,  such as might
 tempt me to conceal or palliate any fact: the little  portion that
 was left of this tumour I could  hardly feel: I had no misgiv-
 ing in my own mind beyond that vague, indefinable  anxiety,
 which an  upright man should feel after an  operation, however
 promising, and which I have never failed to suffer from, even
 where most  successful, for  I am ever  apt to imagine, that I
 might have performed the operation  better, and this was all I
felt at the time, it was  only by future consequences that I was
struck with  regret for  not  venturing a little deeper.*  The
chasm left by the extirpation of the tumour I next examined ;
the dissected  mastoid  muscle  lay loose and flapping, and  we
turned it occasionally over, from  one side to the other,  to look
for bleed'mg vessels, but there were  none, there was nothing

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


OUT it is not the discussing of interesting doubts, and ques-
tions of life and death, nor the performing  operations within
the extreme  limits of possible success or possible safety, that
constitutes the chief occupation of one engaged in practice.—■
The more homely talent of distinguishing  the various aspects
and characters of tumours,  and treating them judiciously, is far
more desirable to acquire ;  and, indeed, there is a very per-
plexing variety of tumours within the  mouth, and round  the
jaws,'which  one  learns to  distinguish, only by referring their
various aspects to corresponding peculiarities in the structure
of the parts.  The tumours which I have just described are of
a very malignant  character, and,  I confess I know not  whether
to refer them to the salivary or the lymphatic glands  ; to the
latter, rather, I  believe.  This, for example, of Mr.  M----,
though it looks like a tumour of the sub-maxillary, I  know to
be" a tumour of the lymphatic glands: had it been a tumour ofthe
sub-maxillary gland, which holds imbedded, I may say, m its sub-
stance, the facial artery, it could not have been extirpated without
dividing that artery: the sub-maxillary gland is divided  into  two
masses, and  the trunk of this artery is received into the rece* 
£22
Of Salivary Tumours,
or cleft, the artery seems to twist round the gland, and I have,
both in extirpating the sub-maxillary gland, and in assisting at
such operations, recognized it by this mark.
   The following  case,  if not full of interesting particulars, is,
at least, accompanied  with  useful rules ; and  I transcribe it
from my case-book, with those reflections which arose in my
mind, when forming my opinion and preparing  for the opera-
tion, as I have ever done with a scrupulous and conscientious
desire, to foresee every eventual danger, and recollect every
circumstance,  anatomical or pathological, which might contri-
bute to my patient's  good :  the reflections, you will perceive,
bear a mutual  relation to the instruction of my pupils, and my
own improvement.  It is the case of a young Lady who came
from a very great distance,  urged by her own  fears,  and the
persuasions of her surgeon, whose letter I shall transcribe.

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

                      OBSERVATIONS.

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

                 NOTES OF  THE OPERATION.

  We had agreed either to dissect so as to lay the artery to one
side, while employed  in  extirpating the gland ; or to tie  and
cut across, and so procetd with greater freedom, in the taore
dangerous part of the dissection ;  but, after the first incision
which I made,  according to the length of the jaw-bone, the in-
cision being long and more free,  the several parts appeared in
so advantageous a state,  as to leave no doubt or difficulty in
the rest of our proceedings.   The artery presented itself arch-
ing over the diseased gland, much elongated and serpentine ,
so that, in place of embarrassing the operation with any need-
less delicacy, or endangering the shrinking up of such an arte-
ry towards its trunk, we passed two ligatures of single thread
under it, cut betwixt the ligatures, and then proceeded more con-
fidently in extirpating  the gland : there we found no such  ad-
hesion of it to the trunk, or rather to  the sheath of the carotid,
as we had reason to apprehend ;  the tumour was of such a sto-
ny hardness, the cellular substance so loose, the arteries so dis-
engaged from it,  that, without the help of the knife, with only
the swallow-tailed end of its handle,  which I used as a scalpel,
I turned out the tumour in a few seconds, and  the tumour
carrying its cellular substance along with it, the styloid muscles
were left as clean, distinct, and bare,  as after a  neat dissection
in the dead subject.
  In regard to operations where blood-vessels of great size are 
Of Salivary  Tumours.               525
endangered, or actually  wounded, I think I may safely pro-
pose  those  simple rules to my pupils for their general con-
duct  :
   1st. To consider well the anatomy ofthe natural parts, and
the probable connections of the tumour, so as not to plunge un-
advisedly into difficulties,  which may unnerve his hand in the
most critical moment ;  never to  endanger any unexpected
bursting out  of blood, such  as  might cause  alarm : for,  fo
wound an important artery, without having foreseen the possi-
bility of so doing,  or  to encounter any danger of this nature,
without having approached it by slow and delicate dissection,
and provided against the sudden eruption of blood, by concer-
ting with his assistant,  what is to be done in each possible case,
would be an indelible disgrace to the surgeon.
   2.  The surgeon, while he approaches a dangerous point with
all possible  circumspection, and with precaution amounting al-
most to timidity, and  tries to avoid  any important artery, or is
careful as he approaches it, to distinguish it by its place, to feel
it with his finger, to dissect so as to avoid, or to tie it, should,
the moment the artery he fears, or any  artery is wounded, and
blood bursts out, dismiss all fear, then let courage and rapid ex-
ecution take place of fear, or circumspection: let him plunge
his finger down to stop, or to catch the artery, or  dive  with
his needle to surround it. If there be nerves, important nerves,
as in the axilla, which are endangered by this stroke of the nee-
dle, he must be prepared to decide instantly how far the danger
authorises such a plunge.   If the long  course ofthe wounded
artery gives him room to seek it at another point, he must be
prepared instantly to run his knife backwards along its course,
or to cut with his  scalpel, or  plunge with  the needle, into the
hollow where it lies, without  a moment's delay ; a man  who
is not prepared for  this by his knowledge of the blood-vessels,
and able for it by his courage and presence of mind, is no sur-
geon.
   Thus, circumspection  and daring have  each  their peculiar
point of time ; neither is to be regarded as forming a promin-
ent feature in the temper of the surgeon ; but that knowledge of
parts, and   firmness of mind,  which prescribes circumspection
and caution in approaching a dangerous point, will ensure con-
fident and rapid execution, when danger is actually present.
   3.  The  surgeon, when he speaks of courage, must always
distinguish the discreet and deliberate boldness which belong
to his professional  character,  from  the  personal bravery, or
fool-hardy contempt of danger, which he is entitled to indulge
in his own individual case ;  it  may to himself seem heroic, or
gallant, to endanger, or to throw away life ; but, when respon- 
526
Of Salivary Tumours.
aible for that of  a fellow-creature, he has no such  latitude of
sentiment or action, and must be guided, not  by feeling,  but
reason.  So stricdy is he bound to avoid danger,  that ht is ac-
tually  bound to afflict his patient with  protracted and severe
pain,  to ensure  his safety ; and  to endure the unmerited  re-
proaches of whatever ignorant or ill-judging person may choose
to report his operations  as awkward or slow.   Dispatch and a
show of dexterity will ever be a poor apology for endangering
life,—and pain, a bad reason for hurry  or perturbation, where
loss of blood may be the forfeit;  the pain of pulling the stump
of a corrupted tooth is more severe and often more protracted
than that ofthe most important operations ;  the pain of simple
incisions is never deadly.
   4.  Protracted pain is  attended  with  danger, only in those
Operations where, from such torturing, inflammation of some
internal part, or great cavity, as the knee-joint, the thorax,  the
abdomen, may ensue.
   There is another  species  of tumour, of a complexion the
most opposite possible to this ; a vesicular transparent tumour,
seated on the tongue : as the hydatid of the testicle, brain, li-
ver, Sec. was long supposed to be a mere enlargement of a lym-
phaticvessel, this clear vesicular tumour on the tongue has been
supposed to be a mere distention of the  sublingual ducts, which
are indeed delicate and transparent, and lie in this direction be-
neath the  tongue. One  instance of this disease occurred in an
infant on  the breast;  the tumours had continued for  several
months, had been punctured three times, but returned inces-
santly, and had grown  to such a size as to prevent the child
sucking, by  turning  the tip  of the tongue away  from the nip-
ple :  there were three vesicles, two of  which lay in that place
and direction which correspond with the situation of the saliva.
ry duct, but the third affecting more the tip  of the tongue,  de-
monstrated how futile  this  common  idea  is, for this third
vesicle was situated altogether out of the course of the ducts.
These  vesicles are  merely accidental; they  are stationary,
which they would not be if they were dilatations of the duct;
they pour out no more  fluid, than what the  vesicle itself con-
tains,  which would not  be so if they were connected with the
salivary gland; upon being punctured  they rise again in a week
to their original size : this had been so  punctured, and had re-
turned three successive  times.   A more singular appearance
cannot be  seen  than such a pure and pellucid vesicle, project-
ing from the red and  moist surface ofthe tongue ;  it is harm-
less, and seldom in child or adult exceeds the size or the pro-
portion, at least, which 1 have represented in this sketch ;  it is
stationary, for I  have seen it continue in children, or in young 
Of Salivary Tumours.                527
people,  for years, without harm ; when slit open, it leaves no
sore, nor even a discernible mark, but in a  week it is just what
it was before : I have  found no way of ridding the patient of
this, which,  in a child, is but an inconveniency, but in an infant
prevents sucking, but  to transfix  the vesicle with a little hook
and cut it freely out with scissars.
   A proper tumour of a salivary  gland is more frequent in the
adult, and is a truly formidable disease  ; for the salivary glands
are inclosed by the muscles of the throat and tongue, the sub-
lingual  gland especially, which lies under the tongue, is cover-
ed by the genio-glossi and hyo-glossi muscles, it is thence so in-
vested  with  thick  masses of flesh, and so compressed, that,'
when it falls into disease, the collected fluid, unless it should be
pus, cannot make  its way through so great a thickness of
parts;  it continues  for years, and, if  idly punctured, without
any care being taken to obliterate  the sac, or distended part of
the gland, repeated distention of it, accompanied with inflam-
mation, so thickens the root or vascular part of the gland, that
it grows into a solid tumour, sometimes fatal, by compressing
the throat and tongue.  Misconduct in not distinguishing  such
tumours, in not obliterating very carefully the  cavity of all sac-
culated tumours of the neck, and in not preventing the forma-
tion of firm and indissoluble roots, or bases, is an error so  very
frequent that I think I cannot do you a greater kindness, than to
lay before you a few examples as  documents.
   " Margaret Murray, a Woman about fifty years of age, had
crawled from one of the miserable Edinburgh closes into the
Infirmary, asthmatic and suffocating, with one of the most for-
midable and bulky  tumours I had ever seen; it resembled that
of Jenny Brown in situation and nearly in size, but its nature
was altogether  different.   Hers  was  throughout of a ston^
hardness; this,  though  of a degree of hardness  resembling a
cartilage, was hard only on its surface, while there was within
an obscure fluctuation, which determined  my opinion both of
its nature, and of what should be done.  The tumour was as
big as the patient's head, it stuck close under the jaw, and so
compressed  the throat that the poor creature lay gasping for
breath; the  least necessary motion in putting out her hands, or
struggling to raise herself, threatened suffocation ; her  eyes
were staring, her nostrils widely dilated, and her hands grasping
every thing near her as if for help ; her friends supported her
perpetually in the recumbent posture ; her face was livid,  and
the lips purple with stagnant blood ; the tumour itself was uni-
versally lurid, or of a deep purple cast, as if  verging towards
gangrene ; and indeed I doubt not if  it had been possible for
the woman to have  survived in this condition, it must have fall- 
52a
Of Salivary Tumours.
en.into gangrene ; it seemed so solid withal, that the surgeon
was doubtful what should be done, and refused to puncturt- it.
My importunate representations at length prevailed, and, at an
irregular hour,  and in no very regular way, it was  punctured;
a trocar too small for such a purpose, was plunged  into the tu-
mour ;  the matter which flowed was thick and  ropy, like that
which is most frequently discharged from a diseased ovarium;
it resembled sago  made  with port wine ; about  two pounds
flowed without any sensible diminution of the tumour.  It was
expected, that this first discharge, and the thinner gluten which
afterwards flowed,  would give relief; but those who indulged
such an expectation did not recollect, that to produce a secre-
tion so profuse, a great mass of vascular substance is required;
and the consequence of permitting a gelatinous collection of
matter to attain to such a size is, that the vessels by which it is
secreted, not being, as in a case of suppuration, ulcerated or
destroyed, the stool or basis, consisting of those  vessels, is con-
solidated into a tumour; there is a sac indeed, which may be
emptied, but there is also a stool or nucleus to  that sac which
cannot be discussed, which indurates more and more, and ac-
tually increases in  size as soon as the sac is emptied, and the
surface exposed to ulceration v. thus the stool of a fluid tumour
becomes itself a solid one ; and I have  seen the  imprudent
treatment of such a sac establish a solid tumour, so large as to
impede the  motions of the jaw, and  threaten suffocation,, yet
too intimately connected with  the great vessels and nerves to
be extirpated.   So it was in this poor woman; there was no di-
minution of the tumour, not even a temporary relief from the
suffocation,  though the matter continued, while she survived,
to run from the opening, thin and pellucid like saliva.  She lay
reclined, always struggling for breath, and sometimes attacked
with  violent asthmatic paroxysms; the  jaws almost entirely
closed; the mouth continually open :  the nostrils dilated  ; and
the stupor, which such difficulty of breathing causes, increasing
every moment, and her swallowing being equally difficult with
her breathing, she expired in the fourth week."
   Timid and irresolute sentiments on the part  of the surgeon,
often bring  the patient into  those desperate circumstances : one-
surgeon confidently and sensibly advises that a tumour should
he unrelentingly opened; affirms that an incision, since it is in-
stantaneously performed, cannot be much more painful than a
puncture which is but a momentary pain, and protests that, by
incision is the  only way in which the sac can  be obliterated,
 and a tumour, more formidable by being more  solid than the
first, prevented from growing : another surgeon contends, that,
 inasac.CQntaining merely  a fluid, a puncture will suffice  ; this 
Of Salivary Tumours,.               529
opinion is too flattering to the little fears of a patient, not to be
received ; the puncture  is made, and the patient becomes the
more credulous, since the tumour disappears ; but it returns
again, and is again  punctured, till, in  the course of  a few
months of expectation,  and, after  various trivial operations of
this nature, the basis, probably the body of the gland itself, is
hardened into a solid tumour, and then not even that operation,
which would have succeeded at  first, not  even the slitting it
open and  ulcerating with escharotics, whatever surface still re-
mains, will prevent its continued growth.
   Though I find salivary tumours usually filled with a pellucid,
gelatinous fluid, I have found  them  not  unfrequently filled
with a mixed matter, resembling honey, or rather resembling
mustard, and consisting of a tenacious, gelatinous matter, mix-
ed with grains and lumps of a bright yellow colour,  and  an in-
tolerable smell.   I have taken notes of one case of this  nature
in a young woman from  Berwick, whose native peculiarity of
accent, had  got  a singular aggravation, by such an uncouth
obliquity and imperfect motion of the tongue, as conveyed the
notion of her attempting to chew, and turn each vocable with
her tongue before she proceeded to  swallow it,  in place of ut-
tering it.  This was produced by a tumour of very great size,
and of a character so peculiar as plainly to denote its nature : it
consisted in a vast collection of matter in the sub-lingual gland,
and as that gland is covered by the whole thickness ofthe tongue
within, and by the mylo-hyoidei muscles without,  and bound-
 ed by the line of the jaw-bone, it  had the  following singulari-
 ties of character : it could not be distinguished as a tumour,
but had rather the appearance of a general swelling of the lower
 part ofthe face,  jaw, and neck, such as often accompanies se-
 vere tooth-ache  or mumps :  upon laying  the  hand upon the
 outside of the neck, below the lower jaw-bone, the whole hand
 was filled with a swelling, apparently solid, but  so little  convex
 or circumscribed, as to  resemble in no degree  the tumour of
 any particular gland ; and yet so limited and so firm, as not at
 all to resemble the general tumefaction proceeding from tooth-
 ache.  Upon introducing the finger into the mouth, you found
 the tongue raised, turned edge-uppermost,  and  pressed entire-
 ly towards the left side of the mouth, the external tumour being
 in the right side  ; upon  pressing the fingers very  firmly down
 by the side of  the tongue, and  re-acting  from without, you
 could sensibly perceive, not so properly a fluctuation as an elas-
 ticity, which implied the presence of a fluid ; the tumour seem-
 ed elastic, like a foot-ball, but with a degree of tension which
 made it seem almost solid.   It was by comparing a variety of
 .ircumstances, especially the original plate  and  slow growth of 
*»30
Of Salivary Tumours.
 this tumour, that  I confidently referred it to the sub-lingual
 gland;  in this I had the advantage of the surgeon under whose
 particular care she was, but I did him  the justice to send her
 back to him again and again, expressing my opinion, and m\
 wish at the same  time, that he should  do whatever he might
 imagine right.  By good fortune she called upon me the day-
 she was to return  home, nothing being  as yet  done to the tu-
 mour, but supplied with abundance of  blisters and plasters to
 apply at a fit opportunity  to her throat: I felt now that pro-
 fessional ceremonies  should give way to essential charities :  I
 placed her in a chair, and almost without her consciousness, at
 least before  she was  aware, struck a fine bleeding lancet  deep
 into  the tumour  by the side of the frenulum linguae,  where,
 from the firm compression of the surrounding parts, the matter,
 though too gross  to pass freely through such an  opening, was
 spewed out  from  the orifice in a manner expressly resembling
 that, in which yellow paint is squeezed out from the bladder
 upon a painter's palette.   It was of a deep saffron colour, thick-
 er than mustard,  mixed like gruel with  seed-like particles, and
 extremely fetid.   I knew  that the tumour was not emptied,
 though  the  outward swelling  was almost gone ; but  1 also
 knew, that, even though I should not enlarge the opening, the
 second secretion from the surface of the sac, which is in all ca-
 ses thin, would dilute and wash out whatever viscid matter re-
 mained ; and, when she saw how suddenly my prognostic was
 fulfilled, she expressed a perfect confidence in whatever I pre-
 dicted, and a perfect willingness to submit cheerfully to what-
 ever I proposed to do.  Next day I introduced the point ofthe
 probe-bistoury into the orifice made by the lancet, and knowing
 that the lingual artery lies on a lower level, imbedded among
 the muscles, and  running along the lower surface of this tu-
 mour, while  I had over the point and  blade  of  my bistoury-
 nothing but the inside membrane of the mouth much thicken-
 ed, I ran it  fearlessly, and at one stroke,  as the less painful
 way,  along the whole length ofthe tumour, when the thickest of
 the yellow mucus flowed  freely, or was raked out with the
 points ofthe  fingers, and the handle of  the bistoury ; and the
 tongue descending now to  its natural level,  was in  a capacity
 once  more of delivering the peculiar dialect of her native city
 in all its purity.
   So tense and apparently solid was this tumour, in conse-
 quence of the compression of so many surrounding muscles,
 that her surgeon mistook it for a solid and strumous swelling.
 I reckoned that in this,  as in  all cases  of sacculated tumour,
the second secretion, which is  thinner, would w ash out the
thicker mucus, and I was not deceived, but she  left me too 
Of Salivary Tumours.                .531
early for me to witness the obliteration of this sac.   I find it in
all such cases a matter of  some importance, especially in a girl,
to anticipate the outward suppuration of any sacculated tumour,
by puncturing  it, though to a great depth within the  mouth,
and under the tongue, and equally necessary, to be at pains in
preserving the opening, and obliterating the sac ; a slight mis-
conduct in this respect, occasions much distress to the patient,
and much superfluous labour to the surgeon ;  among the ex-
amples of this which I have had occasion to remark, the fol-
lowing is the most instructive.
  "  I^&gy Hall was an*ected with a Mainour which, in all  its
stages, and for a course of three years,  was ill understood, and
worse treated: it was of  a great size, sacculated,  and  its con-
tents  were fluid.  She was a stout and lusty girl about twenty-
two years of age ; the tumour occupied all the left side of the
neck,  from the lobe   of the ear  and angle of the jaw, quite  to
the sternum,  displacing the mastoid  muscle.   This, like the
tumour of Jenny Brown, arose from  that slight inflammation,
which follows the extraction of a tooth.  More than two years
ago,  after being distracted with tooth-ache, she had two cor-
rupted teeth pulled from the lower jaw, and she distinctly re-
members, that,  two days after  the  extraction of the second
tooth, she was sensible, upon  undoing the flannels in which
her s^oln and inflamed face had  been for some  time wrapped
up, that there was  a little  lump,  about the  size of a  small
plumb ; it lay under the angle of the jaw, and has never ceased
to grow, and has now, without the slightest pain or change of
colour, attained its present size.
  " In the month of April,  1799, she was directed to apply
some kind of plaster ; in the month of May, she was advised
by Dr. Munro  to have it opened ;  in a few weeks after, this
was attempted by the surgeon of the village in which she lives,
who made a large incision,  but being soon alarmed,  he laid
aside the  knife and  lancet, and prosecuted his work rather by
boring than by cutting ; he tried  with probes  and directories
to make good his way into the sac, but, having pushed them
very deep, and  toiled half an hour in vain, he abandoned his
purpose:  the scar of this ill-concerted operation, remains on
the face of the tumour.  The certain conviction that a respecta-
ble surgeon did, three months before we saw it, dig to a consid-
erable depth, without finding matter;  the manifest  proof of his
good  will to reach it in this large scar left after his operation,
and the firm adhesions under it ofthe skin to the mastoid mus-
cle ;  the difficult'/ too, of distinguishing fluctuation  in a very
tense  sac, made  more tense by the general  construction of the
platvsina mvoides, and the strong pressure of the great  mas- 
332
Of Salivary Tumours.
toid muscle, was enough to disconcert us, and impress a t*>
lief that this tumour could not be of a fluid nature, and indeed
these considerations induced  almost every surgeon who had a
share in the consultation to pronounce, that the tumour contain-
ed  no matter,  and should  not be punctured.   But to  decide
thus is to  forfeit the natural advantages of our own  skill, and
indeed is little better than  yielding our own  deliberate judg-
ment in favour of the opinion of a man plainly ignorant and  auk-
ward :  so far from trusting any thing to his judgment, or believ-
ing that he miscarried, only because  the tumour was solid and
not fluid, I think it no difficult matter to demonstrate the  kind
of aukwardness, which made him miscarry in his operations.
   tw The tumour is distinctly, to my apprehension, a great sac
of fluid secretion:  there  is nothing doubtful in the case :  this
sac lies under the platysma-my oides, and under and before the
mastoid muscle ; the  belly of the mastoid, being raised upon
the bag or tumour, feels soft and flaccid, and might have seem*
ed to an unskilful surgeon,  to form a part  of the tumour  j by
making his incisions over the belly of the  muscle, he could not
penetrate  to the sac otherwise  than through the  body of the
mastoid muscle ; having cut to a considerable depth among so-
lid and  quivering  flesh, he  became  alarmed ; willing still  to
penetrate farther, and yet without danger, he bored with his fin-
ger, cut a little obliquely with his knife, and bored a little more
with his directory, till having  buried it  apparently in the tu-
mour to the depth of three or four inches, he  believed,  and  to
the ignorant relations  and patient, seemed to prove, that there
was no fluid in the  tumour, while there was nothing singular  in
all this but his own aukwardness : he had penetrated entirely
under  the belly  of the  mastoid  muscle, pushing his probes
obliquely betwixt it and the sac;  to  avoid the great vessels  of
the neck, he wrought obliquely backwards ; by cutting oblique-
ly backwards,  he  made good his way under the belly of the
mastoid muscle.   The young woman endured the disappoint-
ment, and suffered  the tumour stirl to extend, not without
great inconvenience and deformity, for seven or eight months :
the operation being then performed more correctly and confi-
dently,  every circumstance  ten^d to confirm the notions I had
formed of this aukward proceeding: the  surgeon who now
operated was timid in  his maimer of performing the operation,
and careless in conducting the cure.  The incision through the
skin only was freely made ; the incisions through the platysma
mvoides were made timidly, the flesh of its  fibres retracting:
and quivering  as they  were  cut:  the sac then  burst  from be-
twixt the divided fibres ofthe muscle,  white and  transparent.
I could almost distinguish  the  fluid through it; and this hy- 
Of Salivary  Tumours.                533
drocele-like sac being cut, several  pounds of thin serous fluid
gushed out:  then the long iron probe was  passed  across  the
cavity of the tumour; and  its point cut upon at  the anterior
edge of the mastoid muscle ; in short, near the  place ofthe
former incisions: whereas, to lie across the tumour, the point
should have been cut out behind the belry of the mastoid,  and
then the seton or cord would have more effectually inflamed the
sac, and obliterated the cavity.
   If these sacculated and solid tumours of the neck and jaws
are interesting from their frequency, there are others still more
so  from  their danger: they are  carefully to be distinguished
from  other  tumours, especially from those  of an aneurismal
and varicose nature; and I especially request  you  to  remem-
ber,  that, of the tumours  which  occupy  the fore-part of the
trachea, and are connected with the vascular system of the  thy-
roid gland,  a great proportion are  venous:  aneurism of the
carotid artery is indeed so rare a disease, that it is not certain-
ly known whether such a disease exists, it absolutely is not un-
derstood how or from what causes the patient dies.*
   The profuse plexus of inosculating veins about the angle of
the jaw,  and the corresponding branches of the maxillary and
facial arteries,  are frequently thus diseased, and still more fre-
quently the  veins  and  arteries of the  thyroid  gland, whose
trunks, as they run down the fore-part of the neck, are dilated,
and  form a conspicuous part of the tumour.   Jean Bryce has
a tumour of this nature, growing  from  her early years, which,
like those occurring in the skin,  the  lip,  the eye-lids* the rec-
tum,  &c. began in a very small tumour, having nothing pecu-
liar in its form:  it began when she was a little girl,  has  been
waxing gradually larger for these  thirteen  years, and seems to
me almost purely  an enlargement of the vessels and cellular
substance of the thyroid gland.   It  is difficult,  in describing
such a tumour, to distinguish the  sensations conveyed  by the
touch and by the eye, from those  conjectures  which  imagina-
tion presents to us  in handling the tumour.  The marks I  have

   • I faw a young woman, not 24 years of age, die of this difeafe, in the fixth
week after the dilatation of the artery  began.  She had a cough and quickened
pulfe and her diforder was miftaken for a cold: fhe had great difficulty of fwal-
fowine, and it was miftaken for the effecT: of fore throat and fwelhng  of the
elands • fhe had a conftant ftupor, and  it was afcribed to fever: but the com-
preffion of fo large a tumour, lodged clofe upon  the  trachea, and braced down
upon it by all the ftrong mufcles of the throat, and compreffed too by the jaw-
bone, could not fail to excite at once difficult deglutition, dyfpna-a, and ftupor,
and thefe were the fymptoms of which fhe died.t
   + There is now at ltaft no doubt of die exiftenre of this difeafe :  Mr.  Aftley
 Cooper has operated twice for it, once with complete  fucaft, in the ott>r caie
 the patient died, but not from the operation. S. 
J34
Of Salivary Tumours.
taken in my case-book are of a mixed nature ; they arc these;
the tumour was in its early stage small, knuckle-like, but soft,
round,  moveable, and without pulsation: whatever its nature
may have been at the first, the  structure of the part is now en-
tirely changed; the tumour  is  now large, soft, spongy, and
spreads equally  on each  side of the throat,  filling the whole
neck, and occupying expressly the  place of the thyroid gland:
though  soft, it rolls loose  under the skin, is moveable also in
respect  to the muscles  and internal parts, and may, on  each
side,  be worked backwards under the mastoid muscle, especi-
ally  towards  the  right side  of  the  neck, where  the  tumour
seems more condensed: it suffers a general subsultus, or shock,
from each stroke of the carotid arteries, but it has also a particu-
lar and  distinct pulsation within itself, which, though never in-
termitted, is yet more sensibly felt when the  blood  contained
within it is  repressed through the veins into the general course
of the circulation; for, while the cells of the tumour fill again,
the blood seems, at first, to ooze or pour insensibly into the tu-
mour, but,  when  it is a little  filled, the stroke of the arteries
which are filling it begins  to be felt, and, as it fills, the pulsation
strengthens  still, being  completely injected and become tense,
there is a deep and strong throbbing in every  part of the mass:
in this particular case, there is much accumulation of solid mat-
ter, i. e. of thickened  vessels and cellular substance, besides
the mass of circulating blood: the proportion of both  can be
distinctly  perceived, for, by  handling,  and squeezing the tu-
mour, and  repressing the blood, it  can be so much of it re-
pressed into the veins, as to diminish its size by two thirds;
but no force can  repress it entirely, as in smaller  tumours, or
in varicose  aneurisms.  When the blood is repressed, the loose
doughy feeling of cellular substance and dilated veins  is more
sensibly felt, and  is perceived to form the chief mass, and es-
pecially the basis of the  tumour:  when the  blood is thus re-
pressed, you can distinguish, by pinching strongly, a thick and
solid sac within the skin, and quite unconnected with it.   Be-
sides the other  intimations of its connection with the thyroid
gland, and  the whole vessels  and substance of the throat, 1 can
plainly distinguish the thyroid arteries running long  and tortu-
ous over the sides of the  tumour* as if they descended from
under the chin, and then spread over the sac, (so far are these
arteries displaced from their natural  course)  they divide, upon
the surface of the  tumour,  into lesser, yet very  perceptible
twigs, then dive into its substance, and lose themselves; while

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

   * The thyroid gland has been fuccefsfully extirpated by Deffault.   In doing it,
which is exceedingly difficult, and fhould not be attempted, except by a moft ac-
curate anatomift, and dextrous and intrepid operator, the four thyroideal arteries
muft be tied before they are cut, and the principal part of the diffection muft
be done with the  handle of the fcalpel.  S. 
336                Of Salivary  Tumours.
 ing cutaneous, or  almost so, in having thin walk, and  a red
 colour, deepening into a purple at those  points irom which the
 blood bursts out: large dilated  veins, two or  three especially
 like venous  trunks, descended  from the central parts of the
 tumour, into the veins of the neck, while the  thick and fleshy-
 basis of this tumour so encircles the jaw-bone, enters so deeply
 into the substance of the cheek, and joins so solidly the neck
 to the jaw-bone, that, though this girl's  life were the most va-
 luable, (she  is like many I  have observed who have these im-
 perfections, an idiot) and her circumstances the  most despe-
 rate, I hardly know how it could be extirpated, since there is
 no way of effectually extirpating such tumours  but  by leaving
 not the slightest part of the  diseased substance behind.
   But pulsation is not  an essential, nor inseparable character-
 istic of such tumours, and it is  my duty both to give  you no-
 tice of this fact, and to acknowledge, with that generous tem-
 per which becomes one discoursing on matters of life and death,
 whatever errors or mistakes I  recollect in my own opinions or
 practice.   I was consulted for a tumour of this  kind in a young
 woman (also an idiot) about 24 years  of age,  big, lusty, and
 otherwise  in perfect health;   but  being accompanied  by no
 friends, I could learn nothing  of the history ot  her disease.
 Her  neck was fleshy and fat, her cheek round and full, her
 features large and masculine, and, behind the angle of the jaw,
 was seated a tumour of this singular character: the skin was
 thick and sound, and altogether unconnected with  the tumour;
 the tumour was conical, and occupied exactly  the triangular
 hollow behind the corner of the jaw, but  it was a tumour which
 we could not say it was either very soft, or very elastic, reced-
 ed like a loose, puffy, and unconstricted hernia, upon the slightest
 pressure:  when it receded,  you could pinch up a distinct and
 thick sac,  which held  not  the  slightest communion with the
 skin, or its system  of vessels :  the contents of  this sac  could
 be almost dissipated by pressure, and no solid nor spongy basis
 could be felt at the deepest part of this sac, nor could the slight-
 est degree of pulsation, or whizzing noise be perceived,  when
 the fluid returned into the sac.   The case so entirely resembled
 that of Peggy Hall, viz.  a  seemingly thin and serous matter,
 contained within a large and flaccid sac, that I entirely believed
 so.  Although the characteristic of the almost total receding of
 the fluid was too marked, and  particular, not to have excited
 strong suspicions;  yet,  in opposition to Mr. Russel, and  seve-
 ral respectable and  judicious  surgeons,  I believed that it con-
tained matter, and was confident, at all events, that there was
 no shadow of danger in making the experiment of puncturing
the tumour;  in opposition to their better judgment, I made a 
Of Salivary Tumours.                537
flight incision through the skin,  and, with the point of a bleed-
ing-lancet, punctured the sac, and found that it contained  actu-
ally blood,  which seemed to ooze out into the sac,  from innu-
merable small vessels, had no  arterial pulsation,  and  no dis-
tinct character by colour or otherwise of being venous or arte-
rial blood;  it had so little impulse, as to make not the slightest
sugillation  of the neck, at  the  place where the puncture  was
made, and healed like a vein opened  in bleeding.  I take a
pleasure in mentioning this, both as it ascertains that often the
sac is of great extent, and the  transit of the blood  from the
arteries to the  veins through the cells very slow; that the tu-
mour may be large, and truly an aneurism from anastomosis,
without being characterized by pulsation; and  also as  this liti
de narrative may prove a warning to you, for the blood might
have been difficult to  restrain, and the wound difficult to heal.
   As I always reckon a case more useful in proportion as it
approaches the more ordinary occurrences of practice, and
sacculated tumours on  the  throat containing blood  are so fre-
quent,  and require such careful treatment, that I  will occupy
a small portion  of your time in laying an example before you.
   Miss A-----came from a distant part of the country, with
a tumour encircling the whole throat, from ear  to ear almost,
and extending  from the chin to  the sternum.  This tumour,
the growth of several years, could not be a suppuration of the
thyroid gland,  for there had been  from the first no induration
nor inflammation, but  a  sac  containing a secreted fluid,  in-
creasing slowly in quantity, till the tumour covered all the
trachea.   This, like every other great sac, was far from being
 tense,  it could  be pinched up with the finger and thumb,  so as
 to make the uncommon thickness of the sac very sensible to
 the feeling,  and the fluid so distinctly fluctuated,  and  so easily
 from side to side of the tumour, as to convey the  impression
 of its being like that of Peggy Hall, of a thin and  serous na-
 ture ; nor was there  any other reason, except the  peculiar seat
 of the tumour, to doubt of its being serum,  or to apprehend
 that a tumour so old,  and forming  so  slowly, could contain
 blood.
    In the choice of means for obliterating  so large a sac, occu-
 pying in a young lady the whole circle of the throat, it is most
 natural to incline to those methods, which, if successful,  are
 least liable to produce either a scar, or unsightly thickening,  or
 am other deformity: but, in the present case, I could not  but
 prefer the most decisive method of proceeding, to those which
  seemed milder, for the following reasons.  The flaccid state
  of the tumour was  such  as permitted  me  easily to  pinch  up
  the sac, and feel most sensibly that  its  walls  w re peculiarly 
■>^8                Of Salivary Tumours.
thick  and fleshy: I foresaw that if such means only were re
sorted to as tend to obliterate the sac slowly, and by successive
paroxysms of inflammation, the muscular fascia of the neck,
the platysma-myoides, would be  united  by adhesion  to this
thick  and fleshy sac:  I feared that if the walls thus constituted
were  kept long in an  inflamed state, irritated,  and thickening,
the thyroid gland would not entirely  escape,  but  become  in-
flamed  and hard, so as to form a solid basis  for the tumour;
and I could  not but  recollect how much more apt the  thyroid
gland is to swell in the female sex: for these and  various rea-
sons,  especially from my patient's intention of returning home,
I proposed that method which, though it may be blamed as the
most  cruel, is often in truth the most lenient, by being the most
effectual;  I mean the passing a seton or syndon across the sac :
but, from that timidity which carries with it such strong apolo-
gies,  the  method I  proposed  was unfortunately declined, and
that of a simple puncture preferred.
   Having called Dr.  Monro into consultation,  the  propriety of
opening the sac was decided on, from these motives;  first, the
certainty of the sac  continually increasing in  size, deforming
the neck more and more,  and,  perhaps in  the  end, corrupting
the cartilages of the larynx, and making its way  into the tra-
chea, and forming there such irregular suppurations, and incu-
rable  fistulas, as often prove fatal.  Secondly, that there is no
kind  of motive for refraining  from this very  necessary act of
duty, since the fluctuation  is distinct, the sire circumscribed,
the fluid not repressible;  no varicose veins occupying its sur-
face,  no pulsation felt from within its substance,  to make us
fear its being supplied by any remarkable arteries.
   It  appeared to us that, if  there was blood in the tumour, or
hsemorrhagy in the operation,  it could be only such as might
distil gradually from the surface of so firm a  sac, not such ac-
tive haemorrhagy as might endanger life, or prevent the suppu-
ration of the cavity.*
   Upon making an  incision through the  skin and  fascia of the
lower part of the neck, and striking the lancet directly into the
tumour, a thin bloody serum ran out, or rather pure blood, for
it coagulated in the  saucers,  even before it  could be turned
from them into the  basin : it expressly resembled that  thin
bloody secretion, which  I have so often seen run out upon
making openings round the knee-joint, or in  swellings when,
in consequence of a shock or  rude below,  blood of this dilute


  • The opinion and defcriptions are extracted fron. my cafe-book; the other cir-
ortnftances ofthe cafe are not from recollection, which  I never truft to, but from
letters and memorandum. 
Of Salivary Tumours.                539
and serous nature is effused, as from the shock of riding against
the pole of a carriage, &c. or in consequence ot high and sud-
den inflammation ; even after strains of the muscles without
any external injury,  I have  seen such effusions of blood, and
shall have occasion to relate some fatal cases of this nature.
   In the evening when the plug was withdrawn, the same thin
bloody serum, instantaneously  coagulating,  flowed  from  the
sac ; and at each dressing, during the first four days, the fluid
which was discharged seemed little different  from pure blood ;
it was plainly a sort of secretion from the thick walls of the tu-
mour, it gradually became less coagulable, then very thin and
whitish, and ripened before  the tenth day into pure and well
conditioned pus, importing, that  the  internal surface of the
sac was in a state of suppuration, and inclined to heal.
   Now the time of my  patient's  departure approached, and the
seton or long  skein of cotton by  which the sac was to be kept
inflamed till obliterated, and the  sponge with  which the opening
was to be preserved, had been long used, and those who were
in future to manage them made familiar with their use.   The
former was lodged deep, and within the sac by the long probe;
and the latter had been gradually enlarged so as rather to dilate
the opening in proportion as the  cavity of the sac lessened ; the
Gentleman who was to be intrusted with this  part of the pro-
cess was a party at each dressing,  and I had no fear that all
 would go well: but my first letter from the country announced
 that the matter was foul, bloody,  and fetid ; the flow of it ob-
structed by fungus, almost  closing the  orifice; that the intro-
 duction of the sponge was become difficult, or almost impossi-
 ble ; and  that advice was expected of me,  which really could
 be of no avail without  either my personal presence, or my pa-
 tient returning to town. I  was sensible that now the means I
 recommended must be resorted to, for, (although it was not
 included in the description of all that was wrong,) I was sensi-
 ble that there must be a great thickening ofthe neck and throat,
 from the induration of  the sac : I found that  much pressure and
 thumbing of  the parts  was  necessary to discharge the matter.
 and that she had suffered from attacks of fever, accompanied
 with pain and swelling of the tumour.
    By good fortune I was called into that part of the country,
 and found when I visited this lady, the whole tumour condens-
 ed into a thick spongy  mass, inflamed over the whole surface,
 and spongy in its substance,  in consequence of continual tortur-
 ing and squeezing, while pieces of the sponge tent were sus-
 pected to lie buried  in it: I actually encountered these lost pie-
 ces of  sponge with the probe, and hocked them out : enlarged
 the lower opening,  passed the long iron probe obliquely across 
540              Cf Salivary Tumours.

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

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

  * Where  the catheter is to be paffed into the cefophagus for the  purpofe  of
 conveying food into the ftomach, it had better be introduced through one of th?
noftrils,  as pra<5tifed by Deffault.  S. 
Of Salivary Tumours.               549
their tendency, by affecting respiration  and deglutition, and is
which we must often decline operating, from their roots being
entangled writh the  great arteries  and nerves.   Often when I
have seen a patient dying in  a miserable and lingering manner,
I have wondered that no other means of extirpation has ever
been proposed, than that which the  knife affords, nor any de-
sign invented, by which tumours might be forced to suppurate.
To express such a thought implies that a scheme of  this nature
has presented itself to  my imagination, such as, I think, may
be successful:  it is so, but being yet untried I am bound to sub-
mit the following suggestion to you with diffidence, and to men-
tion it without much detail, and with becoming modesty and
reserve.
 ' Tumours refuse to suppurate when their substance is pecu-
liarly solid, disease  having  obliterated the cellular substance of
the part: tumours also are difficult to  extirpate ; and often, in
consequence of a hurried, bloody, and imperfect dissection, much
of the disease is left behind, because successive inflammations
have  hardened  or  filled up the  cellular substance which sur-
rounds the gland, and consolidated it as it were into one mass
with the surrounding skin and flesh: but could we  venture to
inject the more solid tumours, so as to restore by moderate vio-
lence the cellular interstices, among its integral  parts ; or could
we surround  and insulate  an  apparently  immovable tumour
from its manifold adhesions, by an injection which  would pur-
sue whatever remained of the tela cellulosa from cell to cell, we
 should perhaps attain this desirable end, of forcing the one spe-
 cies of tumour into a state of  suppuration, and disengaging the
 other from the surrounding parts.
    What is it  peculiar in the texture of a tumour that prevents
 suppuration ?  what is the character which implies that it is ca-
 pable of being resolved ? a stony hardness, and  extreme specific
 gravity, indicating that the cellular substance is quite oblitera-
 ted, that there is no interstitial substance  to receive those secre-
 tions, which  are by time matured into pus : thence it is that in
 glands indurated to this degree, schirrous  as  they are named,
 vascular action being excited  by a blow  or fall, and  accompa-
 nied or relieved by no secretion, occasions only pain, ulceration,
 partial gangrene in each bursting part, and a  thin and watery
 ichor, which is itself an animal poison.  The blow-pipe  forced
 into any tumour would, by successive attempts, form those in-
 terstices, and injecting the  part with oily and  camphorated so-
 lutions, would force suppuration in the diseases of the salivary.
 or thvroid, or lymphatic glands,  where no  operation could be
 attempted; and, in tumours even of the mamma, it might be
 advantageous to disengage the part by such injections, as would 
550
Of Salivary Tumours.
throw all the surrounding cellular substance into suppuration,
the part itself, incapable  of suppuration, would thus be insu-
lated and might be  turned out like  a kernel  from  its husk.
Such  spontaneous  suppurations  of the surrounding  cellular
substance, and such  happy deliveries from a desperate  dis-
ease, we have witnessed  many times ; and what I have  now
proposed,  though not without  many difficulties  and  objec-
tions,  is too strong in analogies  not to be worthy of  some de-
gree of notice.   1 know not how any tumour could  resist this
practice:   what dangerous  consequences could  ensue?  none
worse than such suppuration.  Gangrene, or sloughing, as it is
called, when thus local, would be limited to the  cellular sub-
stance and skin, and the operations of inflating or injecting a
tumour for the purpose of suppurating or of unrooting it, could
be conducted with such prudence, and,  being  of the nature of
an experiment, would be attempted by such gentle degrees, as
would save us from self-reproach, or the misery of doing harm
where we intended good.
  I  have read  somewhere of an expression, which  often re-
turns upon my ear,  " Examples  are  eloquent;"  I have ever
found them the most precious lessons, and been at pains through
all my life to record them with care  and precision: our reason-
ing on every professional question, and our proceedings in every
new case, must be regulated by precedents,  and I have laid be-
fore  you such examples,  and deduced from them such lessons,
as you will not despise,  for they are the fruits of experience.
Of all professional questions, that concerning the nature,  ten-
dency, and future consequences of a tumour, seems to me the
most solemn:  the  physician  or surgeon may but too  easily
rid  themselves of the importunity of a patient afflicted with
a dangerous tumour, for if they will but pronounce any projec-
ted operation fatal, the patient will retire  from  public view,
mourn over his helpless and miserable state in solitude, and die
a willing martyr to  their opinion, and to the too natural abhor-
rence of  pain, and the fear of expiring  at  once from loss of
blood. 
APPENDIX.
<©*»—
                              A


 JL HE following explanation of the process employed by nature in
arresting the hemorrhage from divided arteries, appears to me to be
much more  satisfactory than Mr. Bell's.   For the experiments and
facts, which  prove it, the reader is referred to the work from which it
is  extracted, " Jones on Hemorrhage.''
   " The results of the experiments related in the last section will not
allow us to give so concise and simple an account of the process, as
has hitherto  been done ; but they  afford us one more  satisfactory,
because it accords better with the operations ofthe animal ceconomy,
in which we are accustomed to observe the most important changes
gradually produced by  the co-operation  of several means,  rather
than by the sole influence of any one in particular.
   " They accordingly shew, that the blood, the action and even the
structure of arteries, their sheath, and the cellular substance connec-
ting them with it—in short, that all  the parts concerned in or affect-
ed by haemorrhage, contribute to arrest its fatal progress, by operating,
in the  case of  a divided artery  of moderate size,  in the following
manner.
   " An impetuous flow of blood, a sudden and forcible retraction of
the artery within its sheath, and a slight contraction of its extremity,
are the immediate  and almost  simultaneous effects of  its division.
The natural impulse, however,  with  which the blood is driven on,
in some measure counteracts the retraction, and resists  the contrac-
tion ofthe artery.   The blood is effused into, the cellular substance
between the  artery and its sheath,  and passing  through that canal of
the sheath which  had been formed by the retraction of the artery,
flows freely externally, or is extravasated into the surrounding cellu-
lar membrane,  in  proportion to the open or confined state of the ex-
ternal wound   The retracting artery  leaves the internal surface of
the sheath uneven by lacerating or  stretching the cellular fibres that
connected them.  These fibres entangle the blood as it flows, and 
552
Appendix.
thus the foundation is laid for the formation of a coagulum  at tin
mouth ofthe artery, and which appears to be completed by the bloodj
as it passes through this canal ofthe sheath, gradually adhering and
coagulating around its internal surface, till it completely fills it up
from the circumference to the centre.
   " A certain degree of obstruction to the hemorrhage, which re-
sults from the effusion of blood into the surrounding cellular mem-
brane, and between the artery and its sheath, but particularly the
diminished force and velocity of the circulation, occasioned by the
hemorrhage,  and  the speedy coagulation of the blood, which is a
well known constquence of such diminished action of  the vascular
system, most essentially contribute to  the accomplishment of this
important  and desirable effect.
   " A coagulum then, formed at the mouth ofthe artery, and with-
in its sheath, and which I have distinguished in the experiments by
the name of the external coagulum, presents the first  complete bar-
rier to the effusion of blood.  This coagulum, viewed externally,
appears like a continuation of the artery,  but on cutting open the
artery, its termination can be distinctly seen with the coagulum com-
pletely shutting up its mouth, and inclosed in its sheath.
   " The mouth of the artery being no longer pervious, nor a colla-
teral branch very near it, the blood just within it  is at  rest, coagu-
lates, and  forms, in general, a slender conical coagulum,  which
neither fills up the canal of the artery, nor adheres to its sides, ex-
cept by a small portion of the circumference of its base, which lies
near the extremity  of the vessel.   This coagulum  is  distinct  from
the former, and I have called it the internal coagulum.
   " In the mean time the cut extremity of  the artery inflames, and
the vasa vasorum pour out lymph, which is prevented  from escaping
by the external coagulum.   This lymph fills up the extremity of the
artery, is situated  between the internal and external  coagula of
blood,  is somewhat intermingled  with them, or  adheres to them,
and is firmly  united all round to the internal coat ofthe artery.
  " The permanent suppression of the hemorrhage chiefly depends
on this coagulum of lymph ; but while it is forming within, the ex-
tremity of the artery is farther secured by a gradual  contraction
which it undergoes, and by an effusion of lymph between its tunics,
and into  the cellular membrane  surrounding it ; in consequence of
which these parts become thickened, and so completely incorporated
with each  other, that it is impossible  to distinguish one from the
other:  thus, not only is the canal  of  the artery obliterated, but its
extremity  also is completely effaced, and blended with the surroun-
ding parts.
  " From this view ofthe subject we can no longer consider the sup-
pression of hemorrhage as a simple or mere mechanical effect, but
as a process performed by  the concurrent and successive operation
of many causes :  these  may  briefly be stated to consist in the re-
traction and contraction ofthe artery ;  the formation of a coagulum 
Appendix.                      £53
  at its mouth ; the inflammation and consolidation of its extremity by
  an effusion of coagulating lymph within its canal,  between its tunics
  and in the cellular substance surrounding it."

                                B

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

                                 c

    Dr. Jones has  fully proved  that there  is not so much danger to
  be apprehended from drawing the ligature upon the artery with con-
  siderable firmness ;  if, however, the surgeon should be afraid ©t the
                            4  A 
554
Appendix.
ligature's  being thrown off by  the force of the circulation, he may
absolutely prevent  it by passing the needle through the coats of the
artery, between its mouth and the former ligature and tying another
knot.  After doing this, the ligature cannot be pulled away without
great force is used.
   In addition to what Mr. Bell has said upon the subject of seconda-
ry hemorrhage, the following observations are extracted from Dr.
Jones's work p. I81,andseq.
   "  There is yet another cause of secondary hemorrhage,  which,
although I have hinted at it  once or twice  in the preceding parts of
this  treatise, I have  not yet represented it in the important point of
view which it ought to be.  I allude to the sudden separation or la-
ceration of the recently united parts of an  artery by  premature and
extraordinary exertions ofthe patient.
   "  That newly cicatrized wounds may easily be torn asunder, for a
certain time after their union, a sufficient number of proofs might be
adduced,  if any were required, from the operation for the hare lip ;
but in these, and other instances of disunited wounds in fleshy parts,
the united  surfaces  had been  more or less broad,  and, of course,
their adhesion  proportionably strong ; whereas in the case of a re-
cently united artery, the cicatrized part is  a mere line, and,  conse-
quently,  weak, and easily torn through : it is, therefore, ofthe ut-
most importance to  keep the limb,  a large artery of  which has been
tied, in a state of  the most perfect rest, and to prohibit and guard,
as much as possible, against the patient's making  any  sudden or
great exertion.  In the case of amputation which gave rise to Petit's
invention for compressing divided  arteries,  secondary hemorrhage
was  brought on, on the twenty-first day after the operation,  by the
patient's raising himself suddenly and sitting up  in  bed.  On this
subject Petit makes the following observation : " But  in every case
it is absolutely necessary  that the patient and  the wounded part
should remain in  a complete state of rest :"* in which, however, he
seems rather to have had in  view the  perfect formation  of the clot,
for he afterwards  adds: " because the formation of  the clot is  dis-
turbed by a change  of  position."f   But the remark is not  the less
valuable  and worthy of attention:  nor does this allusion to the  clot
prove that he was ignorant ofthe state ofthe extremity ofthe artery;
for in a former memoir, after describing how he conceived the par-
ticular figure of the clot, formed in an artery that  had  been  tied,
would prevent hemorrhage, even though the extremity of the artery
should ulcerate ;  he adds :  " It is not  the  same thing when some
convulsion or some  other violent motion on the part of  the  patient
causes a separation of the ligature ; because this separation happens
before the vessel is perfectly closed, and moreover, the coagulum,
notwithstanding its figure, is pushed with  such violence that it not
only escapes, but in its passage destroys whatever re-union may have

   * Pitit,  Memoires de l'Acad. &c. de l'annee 1732.
  +  Ibid. ibid.  . 
Appendix.                       555
taken place, and the mouth ofthe vessel as large as ever, discharges
the blood as in the first day of its division."!;
  Scarpa, in his treatise on  aneurism, lays great stress on keeping
the patient in a state of rest, and recommends moderating the force
ofthe circulation,  by bleeding in the first instance, if it should be ne-
cessary, and afterwards keeping the patient on very low diet for some
time.  He mentions several cases in which  secondary hemorrhage
took place several weeks after tying a large artery, apparently and in
all probability, from some exertion on the part of the patient.


                               D


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

   { Petit, Mem. de l'Acad. &c. de l'arraee ijSu
   f See Wiihart, p. 73 & scq. 
556                      Appendix.
wards : and, finally,  the divisions between the interstices ofthe cel-
lular coat being ruptured, converts it into a sac, which is filled with
polypous concretions, and with fluid blood, and at last forms, properly
speaking,  the aneurismal sac; the internal texture of  which,  al-
though apparently composed  of membranes placed one over the
other,  is,  in fact, very different from that of the proper coats ofthe
artery, notwithstanding the injured artery, both in the thorax and in
the abdomen, as well as the aneurismal sac, is  covered externally,
and enclosed within a common smooth membrane.
  " In the very considerable number of aneurisms of the arch, and
of the thoracic and ventral trunk of the aorta, commonly regarded
by medical men as true or incysted, or as formed by a dilatation ofthe
proper coats of the great artery, which I have had an opportunity of
examining, I have not found  a single one, in which the rupture of
the proper coats of the artery was not evident, and  in which, conse-
quently, the aneurismal sac was produced by a substance completely
different from  the internal or muscular coat of the injured artery*
To ascertain the truth, and confirm the  constancy of this fact, it is
not necessary that one should be possessed of uncommon knowledge
in the art of dissection, but only that lie be disposed to see things as
they really  exist, and that he undertake  to examine the aneurism in
the situation in which  it is found, and without  removing the parts
which surround it, or at least that he do this with due circumspec-
tion.   For, as I have asserted above,  very often  the examination
which is made by medical  men, of internal aneurisms in the dead
subject, consists of little more than a simple division of the fundus
of the tumour, without paying attention to the cellular sheath which
surrounds the artery, above  and below the place of the aneurism,
and without examining  the disposition and particular characters of
the proper coats of the aneurismatic artery, and comparing it with
the substance which forms the parietes of the aneurismal sac; and
what is still worse,  the aneurism is examined by some, after being
removed from the body, and filled with some substance, or dried ; in
which preparations, there is nothing to be seen but confusion and
obscurity, in every thing which relates to the true nature and  struc-
ture ofthe parts by which the  tumour is formed.
   " A circumstance very important  to be known relative to this
subject, has been  hinted at  above ;  viz.  that the aneurismal sac
never comprehends  the whole circumference of the injured artery,
but only a portion of the arterial tube, to which the tumour is united
on the one or the other side.   At this place, the aneurismal sac pre-
sents, as it were, a  species of constriction, or neck, beyond  which
the sac of the aneurism is more or less enlarged, or expanded, and
sometimes to an enormous degree.  This circumstance would never
accompany aneurism, or rather, quite the contrary would be found,
if the aneurismal sac were produced by an equable distention of the
tube and of the proper membranes of the aneurismatic artery.   For,
in incipient aneurisms, at least, the greatest effect of the distention
acting upon the tube of the artery, the greatest size ofthe tumour
ought to bean the artery itself, or in the beginning or root ofthe in- 
Appendix.                      551
mour, and the least at its fundus.  But observation demonstrates^
that,  whether the aneurism be recent and small, or of long standing
and large, the passage from the artery  is always narrow, and th»
fundus of the aneurism, the farther  it is removed from the artery,
the more it is enlarged.  Another circumstance worthy of attention
on this head, which I have likewise  pointed out above, is, that the
aneurismal sac is always covered by the same soft distendible cellu-
lar substance, which in the sound state surrounded the artery, and
united it to the adjacent parts ;  which soft cellular substance, sup-
posing it to be an aneurism ofthe arch, or of the thoracic trunk of
the aorta, is covered by the pleura, and if the aneurism is  in the ab-
domen, by the   peritoneum ; which membranes include the aneu-
rismal sac, together with the ruptured artery, and present  exter-
nally, a  continued, smooth, shining surface,  as if the artery alone
was in that way dilated.
   " But if,  instead of dividing,  as is commonly done, the fundus
of the aneurismal sac, the aorta  be divided lengthwise on the other
side,  and opposite  to  the  constriction or  neck of the tumour, the
place of the ulceration, or of the rupture of the proper coats of the
artery, immediately appears within the artery, on the side opposite
to that where the incision was made, and the fissure which has taken
place  is immediately discovered, the edge of which  is sometimes
fringed, often callous and hard, like that of a fistula ; through which
fissure the arterial blood had formed itself  a passage into the cellu-
lar sheath of the artery, afterwards converted into an aneurismal sac.
If, as sometimes happens in the arch ofthe aorta in the vicinity of
the heart, the artery, before being ruptured,  has suffered some de-
gree  of enlargement beyond  its usual diameter,  it appears at first
sight that  there  are two aneurisms ; but the constriction or neck
which the  aneurismal sac next to the artery presents externally,
points out exactly the limits,  beyond which the internal and muscu-
lar coat of the  aorta had not been able to resist the  distention, and
have  therefore been torn by it, and shows clearly the difference ex-
isting between  an aneurism and a simple enlargement in diameter
of the lube of the aorta in the vicinity of the heart.
   " The rupture in the  artery is always small in proportion to
the large size of the aneurismal  tumour ;  so  that when the arch of
the aorta has suffered some degree of dilatation before bursting, as
sometimes happens near its passage out of the heart, on making an
incision on  one side into the  aneurismal sac,  and on the other into
the tube of the artery lengthwise, two sacs present themselves, se-
parated from each other by means of a partition or diaphragm lace-
rated in its mkldle ; which partition is formed of nothing else than
the remains of the internal and muscular coats of the ruptured arte-
iv.   And as the limits of the proper coats ofthe aorta, and the be-
ginning  of  the  cellular  aneurismal  sac, are  marked  externally by
That kind of constriction or neck which the tumour presents in the
vicinity ofthe artery; in  the same manner, internally,  this partition, 
358
Ajjpcndix.
 torn in its middle, determines the precise point of the rupture ofthe
 proper coats ofthe artery occupied by aneurism.
   " AU  this acquires a  degree of  demonstration and  certainty,
 to which nothing can be opposed, by carefully dissecting the proper
 coats ofthe ruptured aorta in  its situation, and comparing  them at
 the same time with the cellular substance forming the aneurismal
 sac ; for, in the incision made in the direction of the axis of the aor-
 ta, and in its side  opposite to that where the rupture has taken place,
 its proper coats are found either perfectly sound,  or a little weaken-
 ed and intermixed with earthy points, but still capable of being se-
 parated distinctly  into layers from one another ; when, on the con-
 trary, in the opposite side ofthe aorta, where the ulceration or lace-
 ration exists, its  proper coats are met with unusually thin,  blended
 together, and with difficulty, or in no way capable of being separat-
 ed from each other, intermixed very often with heterogeneous sub-
 stances, which render them brittle like  the  shell of an egg ;  and,
 lastly, disorganized and torn at the place where they  form that spe-
 cies of partition, which marks the limits between the ruptured artery
 and  the entrance  of the  aneurismal  sac.  Continuing to  separate
 these  coats from  within outwards,  we come to the cellular sheath
 which surrounds the aorta externally.  Then, on removing the cel-
 lular pulpy sheath  of  the aorta, it is found smooth externally, like
 the  artery,   villous,  cellular,  and irregular  internally, extending
 from the circumference of the tube of the artery over the neck and
 fundus of the aneurismal sac.   This external covering or sheath of
 the artery actually appears, to those who are not sufficiently  skilled
 in such dissections,  as if the  artery were dilated under it to  such a
 degree as to form  the aneurism ; and it  has  still more that appear-
 ance if the aneurism is very large and of long standing, since in this
 ease  the cellular sheath of the  artery becomes unusually thick and
 pulpy, and because it adheres very firmly to the subjacent muscular
 coat of the artery at the stricture or neck ofthe  aneurismal sac.—
 But  even in these  cases,  as well  as in those of recent and small an-
 eurisms of the aorta, by employing care, we may at least succeed in
 separating,  without laceration, this cellular sheath from the tube of
 the  artery, above and below the  injury,  and successively from the
 subjacent muscular coat, as far as the neck or root of the aneurism.
 It is then clearly perceived that  the muscular coat of the aorta does
 not  pass beyond  the partition which  divides  its tube from the en-
 trance of the aneurismal  sac; and it is distinctly observed, that the
 fibres and layers ofthe muscular coat are not prolonged over the  an-
 eurismal sac,  but  terminate like a fringe, or in obtuse points, at the
 edge ofthe rupture of the artery.  On which account, nothing can
 be more evident than that the aueurismal sac does not belong at all
 to the artery, and that,  properly speaking,  it is only  the  cellular
 sheath, which in  the sound state covered and connected the  aitery
to the neighbouring parts, which, being elevated by the effused blood,
at first in the manner of an ccchymuss,  then distended and compress-
ed, has acquired that degree of density,  and of additional hardness 
Appendix.                      55$
and thickness, as if ithad been formed by the proper coats ofthe ar-
tery, prodigiously  relaxed,  distended, and thickened.   'I hese ap-
pearances the more readily lead to error,  as both  the injured artery
and the aneurismal sac, as has been frequently mentioned,  are co-
vered by a common smooth membrane externally, such as the pleura
in the thorax, and  the peritoneum in the abdomen.
   "  From all that has been hitherto said with regard to aneurism
in general, and more particularly of that of the aorta, it appears to
me,  that we may  with certainty conclude,  1st, That this disease is
invariably formed  by the rupture of the proper coats of the artery.
2dly, That the aneurismal sac is never formed by  a dilatation of the
proper coats of the  artery, but undoubtedly by the cellular sheath
which the artery receives in common with the parts contiguous to it j
over which cellular sheath the pleura is placed in the thorax, and the
peritoneum in the  abdomen.  3dly, That if the aorta immediately
above the heart  appears sometimes increased beyond its natural di-
ameter, this is not common to all the rest of the artery ;  and when
the aorta in the  vicinity of the heart yields to a  dilatation greater
than natural, this  dilatation does not constitute, properly speaking,
the essence of aneurism.  4thly, That there are none of those marks
regarded by medical men as characteristic of aneurism from dilata-
tion, which may  not be met with in aneurism from rupture, including
even the circumscribed figure of the tumour.  5thly, That the dis-
tinction of aneurism into true and spurious, adopted in the  schools, is
only the production of a false theory ; since observation shows, that
there is only one form of this disease, or that caused by a rupture of
the proper coats ofthe artery,  and an effusion of arterial blood into
the cellular sheath which surrounds the ruptured artery."


                              E


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


                                F


  DIRECTIONS  FOR  PERFORMING THE OPERATION  FOR POP-
                     LITEAL ANEURISM.

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


                               G


   When the thigh-bone is luxated, and the head of it is  lodged
 either upon the os pubis, or in the foramen thyroideum, it may  be
 reduced in the following manner.
   The patient is to be extended, upon his back, upon a firm table, a
 broad bandage is then to be passed around the pelvis, the two ends of
 which are to be made fast to a pillar, or some other firm object on  the
 side of the patient, opposite to the luxated extremity.  Another
 bandage is to  be passed around the dislocated thigh as high as possi-
 ble, that is in contact with the  perineum which is to be secured in
 the same  manner as the other, but on the opposite side.  The ban-
 dages should  be made of such materials  and drawn so tightly  as not
 to yield, when the attempt to  reduce the luxation is made.   This
 is to be done  by extending  the leg upon the thigh and then using
 the whole limb as a lever, in which the  resistance is at one end, the
 power at the other, and the fulcrum, which is the bandage around the
 luxated limb,  in the middle, which is done by forcing  the luxated
 limb suddenly and smartly across the other.   In this way, if the ban-
 dages are properly fixed and of sufficient strength, any requisite de-
 gree of force may be applied.  This method of reduction I have seen
 practised by Mr. Astley Cooper with success.
   But when  the head of the thigh-bone is lodged in the ischiatic
 notch or upon  the dorsum ofthe ileum, then recourse must be had to
 other and  more effectual means. The first thing to be attended to is
 the fixing ofthe pelvis. If this is attempted with bandages only, the
 table on which the patient is  placed must be very heavy and strong,
and the bandages must be sufficiently longtofa ;*en Ir.m^ecureAy.to'■*■
I  B 
562                       Appendix.
A better plan has,  I think,  been recommended, of making the pa-
tient sit astride a beam wrapped round with cloths sufficient to pre-
vent injury to the perineum. The extension, which must be very pow-
erful and long continued, and more depends upon the length of ti ■{•
than the degree of force, is to be made downwards and outwai :-> .1
the latter direction first, to  detach the bone from its unnatur.: posi-
tion, and enable it when the force acting downwards is appli' .', ''< slip
over the edge ofthe acetabulum into the socket. In order to •    nish
the resistance from the muscles, various remedies have b     ;sed, of
these, bleeding, to as great an extent as the patient can co..  niently
bear, is by far the best. Fainting should be brought  on, if practicable,
without too great a loss of blood.  Tobacco injections have proved
fatal and ought therefore, I think, never to be used.
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