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SURGEON GENERAL'S OFFICE

    LIBRARY.

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W. D. S. O. O.
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    ITlXlEl PLATES
          BY
pkqfkssok. of anatomy jek- tjik uHTsnEMsrrr of HE^rsYnMnA
    OJTE OF THE SUTRCSEOECTS TO THE FEBRSTEy^TlIA HDSPHTAI.
        ANB TO THE PHITLAHElLFffinA ALMS HOUSE, KC.

               IN TWO VOLUMES

           SECOKB) EMTION WITH ABMnOFTSo
        VOL.1.             t
          for want of timely care        <
Millions have died of medicable wounds.        -^
                       ARMSTRONG.
l':t!«;ks;ty of ks
        pii i i iAOEiiPniA     ^'7-^

Published In KA'li.Parker \ ttenjamin VVauiier.
s 
 
n&nmssnP!
OF
   SURGERY:

                   FOR

       THE USE OF STUDENTS;

              WITH PLATES.

                    BY    J

        JOHN SYNG DORSEY, M.D.
PROFESSOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA.
   ONE OF THE SURGEONS TO THE PENNSYLVANIA HOSPITAL,
       AND TO THE PHILADELPHIA ALMS HOUSE, &C.

            IN TWO VOLUMES.
SECOND EDITION, WITH ADDITIONS.
<
VOL. I.
......................for want of timely care
Millions have died of medicable wounds.
                      Armstrong.
              PHILADELPHIA :

VLBUSHED BY EDWARD & RICHARD PARKER, No. 178, AND
    BENJAMIN WARNER, No. 171, MARKET STREET.
           JOSEPH R. A. SKERRETT, Pni-XTKR.

                  1818.
 
DISTRICT OF PENNSYLVANIA, to wit:
     Be it remembered, That on the twenty-first day of September, in the
 forty-third year of the independence of the  United States  of America, A. D.
 1818, Edward & Richard Parker, and Benjamin Warner, of the said district,
 have deposited in this office the title of a book, the right whereof they claim
 as proprietors, in the words following, to wit:

   "Elements of Surgery: for the use of Students;  with Plates. By John Syng
     " Dorsey, M. D. Professor of Anatomy in the University of Pennsylvania,
     " one of the Surgeons to the Pennsylvania Hospital, and to the Philadel-
     " phia Alms House, &c. In two volumes. Second Edition, with additions."

  In conformity to the act of the congress of the United States entitled,  "An
Act for the Encouragement of Learning, by securing the copies of Maps, Charts,
and Books, to the authors  and proprietors of  such copies during the times
therein mentioned."  And also to the act, entitled, "An Act supplementary to
an Act, entitled, "An Act for the Encouragement of Learning, by securingthe
copies of Maps, Charts, and Books, to  the authors and  proprietors of such
copies during the times therein mentioned," and extending the benefits thereof
to the arts of designing-,  engraving, and etching historical and other prints."

                                                D. CALDWELL,
Clerk of the District of Pennsylvania. 
               TO THE






     STUDENTS OF SURGERY






THROUGHOUT THE UNITED STATES,






                THIS





           IMPERFECT ATTEMPT





    TO FACILITATE THEIR STUDIES





           IS VERY RESPECTFULLY





             INSCRIBED. 
 
PREFACE.
  NUMEROUS circumstances combine to render neces-
sary an American Epitome of Practical  Surgery; those
members of the medical profession  who, by talent and
experience, are best qualified to compose it,  are fully
occupied by other duties, and indifferent to that  species
of reputation which  might accrue from such a publica-
tion ; the labour has therefore,  in the present instance,
devolved upon one  in many respects inadequate t% the
performance, and fully sensible  of the imperfections of
his work.

  An American, although  he must labour under many
disadvantages in the production of an elementary trea-
tise, is in one respect better qualified for it than an Euro-
pean surgeon.  He is,—at least he ought to be,—strictly
impartial, and  therefore  adopts  from all nations their
respective improvements. Great Britain and France have
been foremost in the cultivation of modern surgery, but
their deficiency in philosophic courtesy and candour has
in some instances greatly retarded its  progress; to illus-
trate this remark, it  will be sufficient to state that the doc-
trines of adhesion so  ably developed in England have been
shamefully neglected in France; and that French  surgery 
IV
PREFACE.
 in fractures finds no advocates  in Britain.   Some of the
 best writings of Desanlt have  never been translated into
 the English language,* and those of John Hunter are un-
 known or disregarded throughout the continent of Europe.
 This spirit of hostile rivalship extending from the field of
 battle to that of science, cannot fail  to exert a pernicious
 influence on practical surgery,—a truth too palpable to es-
 cape  the observation of any foreigner who visits  an Eu-^
 ropean hospital.   An American in  walking their wards,
 sets with surprise, in London, a fractured thigh rudely
 bound in bundles of straw, and the  patient discharged
 limping with  a crooked limb.   In the French capital he
 witnesses an amputation, and is disgusted by the officious
 zeal with which the surgeon crams  a handful of lint be-
 tween the stump and the flap which covers it, with an ex-
 press design  to prevent their adhesion.   It is  difficult to
 reconcile these facts with one equally true, that among
 the most distinguished  men who have ever adorned the
 profession of surgery, are living characters in London and
 Paris.

   As the present work is intended  chiefly for the use of
 students, it is to be considered in the  light of a mere in-
troduction to  other surgical writers, and that ceremony
over, a particular acquaintance with  them is earnestly re-
commended to every one who intends  to practice this im-
portant branch of the healing art.

  * I am happy to state that Air. Dobson is now publishing a translation of two-
very interesting volumes of Desault, for which the public will be indebted to
"he industry of Dr. E. D. Smith, of h-outh Carolina. 
PREFACE.
V
  Before closing these prefatory observations, I take the
opportunity of disclaiming, except in a few instances, all
pretensions to originality.  I have availed myself freely
of the writings of preceding authors,  and my extracts are
in many instances of very unusual length; the only apo-
logy I shall offer for this liberty is, that I have consider-
ed it the most useful and honest method of communicating
information. Having made this acknowledgment, I shall
now state, that I believe there will be found in the follow-
ing  work  many observations  of practical  importance,
which are not contained  in  any other.  These I prin-
cipally owe to my connexion  with Dr. Physick,  and a
careful attention to his practice during a period of fifteen
years.  Whether  my readers will estimate them as I do,
remains to be ascertained.

   In the succeeding pages my chief attention has been
directed to practical precepts, and these I have endea-
voured to deliver with clearness; I am not without a hope
that they will prove useful not only to medical students,
but  also  to country practitioners, and to  the younger
surgeons in the navy and army.

   An apology is due for the manner in which some of the
engravings are  executed,  but I trust they will be foimcl
less deficient in correctness than in elegance.

   It has  been well remarked by Mr. John Bell,  that
" a  book once published is like  a life come to its final
consummation 5—irrevocable ;■—-needins; no  apologies  it' 
Tl
PREFACE.
 generally good, admitting none if it be not so."   If any
 author, however, may justly claim the lenity of criticism,
 it is the medical practitioner, who writes and publishes
 mder circumstances every way hostile to correct compo-
 sition, and  detects in his progress  defects and  errors,
 when the printer's stamp, like that  of  fate,  has fixed
their perpetuity.
Philadelphia, Nov. 1st. 1813. 
CONTENTS OF VOL. I.
                     CHAPTER I.
General remarks on accidental injuries, and their effects,
       Union by the first intention,
       Ecchymosis,  -
                    CHAPTER II.
Of inflammation,   -
                    CHAPTER III.
Of hectic fever,    -
                    CHAPTER IV.
Erysipelatous inflammation,    -
                    CHAPTER V.
Of (edematous inflammation,      -
                    CHAPTER VI.
Of gangrene and mortification,  -
                    CHAPTER VII.
Of bums,     -       -      -
                   CHAPTER VIII.
The effects of cold,      -
       Chilblain,      ^
                        1 1-2 
ii
CONTENTS.
                    CHAPTER IX.
Of wounds,     -
       Of incised wounds,
       Of hemorrhage,

                     CHAPTER X.
Of contused wounds,    -
       Lacerated wounds,
       Punctured wounds,

                    CHAPTER XI.
Of gunshot wounds,

                    CHAPTER XII.
Of poisoned wounds,

                    CHAPTER XIII.
Of particular wounds,    -
       Wounds of the scalp,
       Wounds of the face,
       Wounds of the eye,
       Wounds of the lip,
       Wounds of the tongue,
       Wounds of the throat,  -

                    CHAPTER XIV.
 Of wounds penetrating cavities,
       Wounds  of the thorax,
                     Emphysema,

                     CHAPTER XV.
 Wounds penetrating the abdomen.
        Wounds of the abdominal viscera,
                                    i
                    CHAPTER XVI.
 Wounds of joints, 
CONTENTS.
                   CHAPTER XVII.
Wounds of nerves and tendons,
       Wounds of veins,
                   CHAPTER XVIII.
Of fractures,    -     -      -
       Compound fractures,
                    CHAPTER XIX.
Particular fractures,
       Fractures of the ossa nasi,
                     CHAPTER XX.
Fractures of the lower jaw,
                    CHAPTER XXI.
Fractures of the vertebrae,
                   CHAPTER XXII.
Fractures of the ribs,     -    -
                   CHAPTER XXIII.
Fractures of the bones of the pelvis,
                   CHAPTER XXIV.
Fractures of the scapula,
                    CHAPTER XXV.
Fractures of the clavicle,
                   CHAPTER XXVI.
Fractures of the os humeri,
                  CHAPTER XXVII.
Fractures of the fore-arm,
                  CHAPTER XXVIII.
Fractures of the wrist and hand, 
IV
CONTENTS.
                                                       Page
                    CHAPTER XXIX.
 Fractures of the thigh,         -       -       -       -   169
                     CHAPTER XXX.
 Fractures of the patella,        -       -       -       -   191
                    CHAPTER XXXI.
 Fractures of the leg,      -    -       -       -       -195
                    CHAPTER XXXII.
 Fractures of tlie bones of the foot,       -                  201
                   CHAPTER XXXIII.
 Of wounds of bones,    -----   203
        Exfoliation,    -----   207
                    CHAPTER XXXIV.
 Of dislocations,        -                                 209
                   CHAPTER XXXVI.
 Of particular dislocations,      -                         220
        Dislocation of the lower jaw,   -       -       -    ib.
                  CHAPTER XXXVII.
Dislocations  of the vertebra,    -       -       _       -   223
                  CHAPTER XXXVIII.
Dislocations  of the bones of the pelvis and thorax,     -   229
                  CHAPTER XXXIX.
Dislocation of the clavicle,      -       _       .       -   231
                     CHAPTER XL.
Dislocations  of the os  humeri,           .       _           «<,,•,
                     CHAPTER XLI.
Dislocations  of the fore-arm,     -      „       _       -   241 
                       CONTENTS.                     V

                    CHAPTER XLII.
Dislocations of the hand,        -                        246
        Luxations of the bones of the carpus and meta-
          carpus,      -----  248
        Luxations of the fingers,       -                249

                    CHAPTER XLIII.

Dislocations of the thigh,       -                        253

                    CHAPTER XLIV.
Dislocations of the patella,      -                        265

                    CHAPTER XLV.
« Of internal derangement of the knee joint,*9   -      -   267

                    CHAPTER XLVI.

Dislocations of the bones of the  leg,     -      -      -   271

                    CHAPTER XLVII.

 Of Dislocations of the foot,    -                        274

                    CHAPTER XLVIII.

 Injuries of the head,     -----   280

                    CHAPTER XLIX.

 Of concussion of the brain,     -       -       -       -   282

                      CHAPTER L.

 Of compression of the brain,    -                        286
                    from effused blood,       -       -    ih.
                    from depressed bone,     -       -   294
         Of inflammation of the brain and its membranes
           from external violence,     -                297
         Operation of trepanning,      -      -       -   304
         Hernia cerebri,        -       -      -       -   308 
VI                     CONTENTS.
                                                    Page
                     CHAPTER LI.
Diseases of the eye and its appendages,        -       -    3l5
       Inflammation of  the eye-lids—psorophthalmy—
          lippitudo—hordeolum,     -      -         315—6
       Ectropium,  -      -       -      -       -    317
       Entropium,         -       -      -       -    318
       Lagophthalmy,     -       -      -       -    321

                     CHAPTER LII.
Of ophthalmia,       ...      -       -    322

                   CHAPTER LIII.
Unguis or pterygium,        -                         328

                    CHAPTER LIV.
Opacity of the cornea and artificial pupil,      -       -    331
       Ulcers of the cornea,        -                  333

                    CHAPTKR LV.
Fistula lachrymalis,  -      -       -      -            334

                    CHAPTER LVI.
Of cataract,     -          -       -      -       -    340

                   CHAPTER LVII.
Of extraction,       -      -       -      -       -    351

                   CHAPTER LVIII.
Of couching,         -----    358

                    CHAPTER LIX.
Of congenital cataract,       -       -      _       -    365
       Hypopion,   -      -       -      „       -    371
       Staphyloma,        -       -      _       -     ib.

                     CHAPTER LX.
Extirpation of the eye,       -       .      .       -    388
         Tapping the eye,   -       -      _       -    389 
CONTENTS.
vii
                                                    Page
                    CHAPTER LXI.
Of polypus,   ------     393
                    CHAPTER LXII.
Of ranula,    ------     396
                   CHAPTER LXIII.
Of salivary jistulce,   -----     398
                    CHAPTER LXIV.
Of abscess of the antrum maxillare,    -    -      -    400
                    CHAPTER LXV.
Diseases of the tongue,       -                         402
                    CHAPTER LXVI.
Diseases of the uvula and tonsils,     -                  404
                   CHAPTER LXVII.
Of foreign bodies in the oesophagus,   -      -      -    406
                   CHAPTER LXVIII.
 Of strictures of the oesophagus,       -      -      -    410
                    CHAPTER LXIX.
 Of obstructions in the glottis and trachea,      -      -    412
        Operation of laryngotomy,     -           -    417
                    CHAPTER LXX.
 Accidents and diseases of the ear,     -       -      -    419 
 
ELEMENTS
           OF


SURGERY-
                    CHAPTER I.

 General Remarks  on Accidental Injuries,  and  their
                       Effects.

 XT is the business  of the surgeon to provide remedies
 for the  various accidents to which the human body is
 liable; the treatment of many of its diseases is also com-
 mitted to his care.   As accidental injuries are more sim-
 ple and  intelligible  than diseases, it  will be proper to
 commence an elementary work on surgery  with some
 general explanations of their nature and effects.
   The most simple  accident, which can possibly occur,
 appears  to be that degree of concussion, " in which the
 only effect produced, is a debility of the actions or func-
 tions of  a whole or part, similar to that occasioned by a
 bruise, in which the continuity of the substance is not
interrupted; in such a state, the parts  have little to do,
but to expand and reinstate themselves in their  natural
position,  actions, and feelings; and this is what happens
in the concussion of the brain."
VOL. I.
 
 2               ELEMENTS OF SURGERY.
   The rupture of a small blood-vessel is perhaps the
 next in order of simplicity; when the continuity of the
 part is broken, extravasation takes place,  and the blood
 is effused into  the  common cellular  membrane, into the
 interstices of some part, or into a circumscribed cavity.*
 But should the vessel be either very large, or essential
 to life, such as the femoral, bracheal, or coronary arteries;
 or should the  rupture  take place in a vital part, as the
 brain,  in such cases the injury may  kill from the extra-
 vasation alone, however inconsiderable may be  the ori-
 ginal mischief.
   Another species of injury is that in which the ruptured
 parts  have an external opening,  constituting a  wound.
 The nature and circumstances of wounds will be consi-
 dered in another place. The operation of restoration in
 this case consists, first  in the coagulation of the extrava-
sated blood between the ruptured parts, laying as it were
 the foundation  of union, next in closing the ruptured ves-
 sel, or in promoting its inosculation,  and afterwards in
bringing about an absorption of the superfluous coagulat-
 ed blood. Whether in  these cases a new portion of ves-
 sel is  formed, or whether the original vessel re-unites
without the intervention of a new cylinder is not easily
 determined.
   This mode  of restoration is called  union by the first
intention;  it is evident that it can only happen in cases
 where  the extent of the divided parts is small, and their
 surfaces nearly in contact.  In this case, the blood effused
 by the accident is the bond of union,  and it evidently be-
 comes  living flesh.
   When the quantity of blood poured out is very great,
 even in parts not essential to life,  considerable inconve-

  * Fractures of tendons, simple fractures of bones, and many other injuries,
 in which there is no external communication, are considered by Mr. Hunter as
 similar in nature to this accident. 
                ELEMENTS OF SURGERY.               g
nience results from  the inability of the absorbents to re-
move it. An effusion of blood under the skin,  or in the
interstices of any part of the body, is called Ecchymosis,
and in some cases calls for surgical treatment.   As the
subject will not be resumed, I shall state here the proper
remedies.  They are rest, moderate pressure, and cold
applications; as cold lead water, cold vinegar and water,
§*c. by  the use of these means the blood will generally
be absorbed, during which process the skin, which had
been of a dark purple  colour, becomes blue, green, yel-
low, and assumes a variety of hues. The blood most fre-
quently in  Ecchymosis coagulates, but  it sometimes re-
mains fluid; and in this latter case, is apt to inflame and
suppurate;  to prevent which, a puncture should be made
with a lancet into the cavity containing the blood, which
must  be emptied by gentle pressure.  After which care
should be taken to approximate the sides of the puncture,
that they may speedily unite.  If, notwithstanding these
remedies, the parts inflame and suppurate, the case is to be
treated like any other abscess. If, from this, or any other
cause, union by the first intention  is prevented, another
mode of restoration is effected by means of inflammation; 
4               ELEMENTS OF SURGERY.
                  CHAPTER  II.

                  Of Inflammation.

  A complete acquaintance with this subject is essential
to every practitioner of surgery. In the following remarks
I shall endeavour to describe its  phenomena without at-
tempting to investigate the theories which have been
formed to explain them.
  Inflammation  generally commences with  an increased
sensibility of the part; pain is soon perceived, attended
with heat, redness, and tumefaction; the pulsation of the
arteries in the inflamed parts occasions a throbbing, which
in some situations is  very distressing  to  the patient, as
when the inflammation is seated in one of the fingers.
The pain is attributed by Mr. Hunter to a  spasm of the
vessel, analogous to cramp, tetanus, &c. The tumefaction.
is owing to the enlarged diameters of the vessels,  and to
the  effusion of serum  and  coagulating lymph in their in-
terstices.  The heat of an inflamed part never transcends
the  heat of the animal at the source of circulation, though
the  sensation would lead to a contrary belief.*
  Inflammation  is divided by surgeons into healthy and
diseased.  By healthy is understood, that which has for
its object  the restoration  of injured parts; by diseased,
that in which some morbid peculiarity is superadded to
the simple act of inflammation, as  in erysipelas, carbun-
cle, &c.
                                                    *
  The remote causes of healthy  or phlegmonous inflam-
mation, are varions irritations of a mechanical or  chemi-
cal nature; wounds, bruises, acrid substances, &c.  Some-

  * The heat and redness are probably owing to the increased rapidity of cir-
culation; but in what particular manner is nfct clearly understood. 
ELEMENTS OF SURGERY.                  5
times inflammation appears to arise as a consequence  of
febrile  diseases, forming what has  been  called, critical
abscess ; and in other instances no  evident cause can  be
assigned,  these  cases  are  very  improperly  considered
spontaneous, as they  have certainly a  remote cause, al-
though it be not obvious.
   The proximate cause of inflammation has been a source
of much theoretical discussion. Mr. Hunter considered it
as an increased action of the blood vessels, and this at
the  present time is a generally received opinion.*
   A variety in the exciting cause seems to have no effect
 in varying  the nature of healthy inflammation; though
 different circumstances of the constitution or part, affect
 its progress very materially.  Strength of  constitution; a
 vigorous  circulation  of the blood; and  vicinity  to  the
 source of  circulation, are circumstances highly favoura-
 ble to its progress,  and under   opposite circumstances,
 inflammation  frequently terminates unfavourably.   The
 legs, when  inflamed, heal much  less readily than the  su-
 perior parts of the body. The colour  also of an inflamed
 part, depends on similar circumstances. An inflamed leg

   *  On  this subject see Hunter on the blood, &c. and also Dr. Wilson's Es»ays
 on Febrile Diseases, in which the doctrines of Mr. Hunter are ingeniously, though
 I think, unsuccessfully opposed.  Mr. John Pearson, with his usual accuracy,
 remarks, " by proximate cause is to be understood a real physical cause, so inse-
 parably connected with the disease, that the presence of the one implies the
 agency  of the other: upon the existence and duration of the proximate cause,
 depends the existence and duration of the disease; and if the former be changed,
 there is a correspondent change in the latter." This is precisely what Dr. Rush
 means when he declares, in the language of Gaubius, the proximate cause of a
 disease to be "ipse morbus." Tha,tmere increased action is not the proximate
 cause of inflammation, can easily be proved.  Now since the action of inflamma-
 tion is altered from healthy  action, and since we cannot tell in what this altera-
 tion consists, it appears to me best to confess, that in the present state of our
 knowledge, the proximate cause of inflammation is not distinctly known.  The
 degree of action in inflammation varies very greatly;  sometimes it is feeble, and
 sometimes violent. The nature of the altered action of vessels in inflammation,
 is not more likely to be discovered, than the nature of those actions which in the
 liver form4>ile, in the kidneys urine, &c. The mere alternate contraction and
  dilatation of blood-vessels offer no explanation on any of these subjects. 
6               ELEMENTS OF SURGERY.
is  darker than an inflamed arm.  When seated in very
vascular parts, as skin, cellular membrane, muscle,—it is
more rapid in its progress and more favourable in its ter-
mination, than in those which are less so; as bone, ten-
don, or ligament. As an exception to this remark, how-
ever, we must state, that when inflammation attacks vital
parts, notwithstanding their great vascularity, it does not
proceed so favourably as in those of a similar structure,
which are less essential to life.
  Healthy inflammation is always greatest at the part
nearest the external surface of the body. When it attacks
the socket of a tooth, it affects the external part next the
cheek;  when it  occurs  in  the vicinity of the rectum, it
affects the skin and  cellular texture, leaving the intestine
sound.
  The effects of local inflammations upon the constitu-
tion, depend much on their extent and situation.  Where
they are small, very little  inconvenience results;  where
they are extensive, or seated in vital parts, greater irrita-
tion, and  considerable fever,  are  the consequences.  In-
flammation occurring under a tendinous fascia, produces
more effect on the  constitution  than the same degree of
inflammatory action in other parts. The fever produced
is called symptomatic, and  is generally attended with a
quick tense, full pulse, and sizy blood.
  Healthy inflammation is always attended by one or
more of the following effects—an adhesion of the inflam-
ed parts, one to  another; the formation of pus, and the
removal of portions of the body by the absorbent vessels.
The uniform occurrence  of  these effects induced Mr.
John Hunter to describe inflammation in three different
stages; the adhesive, suppurative, and ulcerative. The
various parts of  the body differ in their  susceptibility of
adhesion,  suppuration,  and ulceration.  The cellular
membrane; the  circumscribed  cavities, as the abdomen, 
                elements of SURGERY.               y
thorax, tunica vaginalis, very readily form adhesions:—
Mucous membranes, on the contrary, as the nose, mouth,
alimentary canal, the air  cells of the lungs, the trachea,
&c. very  seldom adhere, but readily suppurate.  It  is
generally  found that deep-seated parts  suppurate less
readily than superficial: hence, if a musket-ball be lodg-
ed at any  considerable depth in the body, it excites adhe-
sive inflammation, and a  cyst forms  round it; but if it
be lodged nearer the surface, it produces suppuration, an
abscess forms, and it is discharged.
   The symptoms of inflammation which  have been des-
cribed,  exist  very evidently  in the adhesive  stage, but
when suppuration is  about to commence, they are greatly
aggravated;  the pain and throbbing become more violent,
the heat is augmented, the swelling is more prominent,
the colour more intense, and approaching to a pale scar-
let.  Shivering  fits come on, the swelling  grows softer,
and matter is formed, fluctuation may be perceived by ex-
amination with  the  fingers: an  immediate abatement of
the symptoms now takes place.
   If the inflammation be seated in the cellular membrane,
the process of ulceration now commences, and  the absor-
bent vessels remove  the solid parts of the body to make
room for the lodgment of the pus secreted, and also to pre-
pare a way for its escape.  In this manner an  Abscess is
formed, which may  be defined  a circumscribed cavity,
containing pus.   In  a common phlegmonous abscess, we
have a good  example of the three effects of inflammation
which have  been briefly noticed.  At its margin, where
the inflammation is least violent, the inflamed vessels se-
crete  coagulating lymph, which agglutinates and firmly
unites the cells of the cellular texture, circumscribing the
cavity,  and preventing the escape of  the matter into the
surrounding  parts.   Towards the centre of the abscess
inflammation has transcended the adhesive stage, and the 
g               ELEMENTS OF SURGERY.
blood-vessels have relieved themselves by a secretion of
pus.  This process immediately excites the action of the
absorbing vessels, which remove the solid matter to form
a cavity to contain this pus.
   The  natural cure of an abscess consists in the absorp-
tion of all the solid matter intervening between the pus
and the cuticle, by  the  rupture or bursting of which, an
outlet is made for the evacuation of the cavity, after which
small projecting vascular spots appear, in  every part of
it, called granulations, which are formed of the coagu-
lating lymph of the blood, which fill up gradually the
cavity,  and unite one with another, forming solid flesh—
a formation of cuticle takes place on the surface, and thus
the parts are restored nearly to their pristine state.*
   The  terminations of inflammation are various.  In some
instances it terminates by what is called resolution.  In
this case all the symptoms gradually subside,  and the
parts are restored to their natural colour and appearance.
   The  secretion of pus, already noticed, is to be consi-
dered one of the terminations of inflammation. A secre-
tion of  serum frequently puts a stop to the inflammatory
process. The inflammation from cantharides  terminates in
this way.   Instances of this we see also in  inflammation
in the  brain, ending in hydrocephalus.  In the thorax,
terminating in hydrothorax, &c.
   Hemorrhage  has  occurred  in  some cases, and put an
immediate  stop to inflammation.
   Hard tumours occasionally form by the secretion of
coagulating lymph  in the  interstices of parts, and this
has been called a termination of inflammation in scirrhus.
   In other instances the violence of action or the kind of
action exhausts the vital powers of the  inflamed part and
the inflammation terminates in mortification.
  * For a particular account of the process by which cavities are filled
refer to Mr. Hunter, and a paper by Mr. James Moore. 
ELEMENTS OF SURGERY.
9
            TREATMENT OF INFLAMMATION.

   In the  treatment of inflammation the first object is, to
remove if possible the remote causes, if they continue to
act. The next is to lessen the inflammatory action. The
remedies to effect this latter object are general, or consti-
tutional, and  local.  Those which  act on the constitu-
tion are,
   1st. Blood-letting. This is a  powerful remedy in
the treatment of inflammation. The  quantity of blood to
be drawn, and the frequency of its repetition, can only
be estimated by the violence of the  inflammatory symp-
toms. Whenever parts essential to  life are inflamed, as
the  brain, or  the  contents of the thorax, or abdomen,
repeated and copious bleedings become necessary.
   2d.  Low Diet—Tends not only  to diminish the full-
ness of the vessels, but also to  lessen  irritation,  and
should be strictly enjoined.
   3d.  Purging is often  necessary  in the  treatment of
inflammation.  But in many cases it is inconvenient on
account of the necessity which it occasions for moving the
patient, as in cases of fractured bones. Blood-letting must
therefore be substituted.
   4th. Certain Neutral Salts—Sulphate  of  Soda,
Sulphate  of Magnesia, Nitrate of Potash,  &c. are use-
ful,  by promoting the secretions, and are generally com-
bined with preparations of antimony ; in which case they
occasion nausea,  and diminsh the action  of the  blood-
vessels.
   5th. Rest is essential, for motion occasions irritation
and many inflammatory affections are found difficult of
cure, because  the  inflamed parts cannot be kept at rest:
fistula in ano affords an illustration of this remark.
  VOL. 1.         3 
|0               ELEMENTS of surgery.
  6th. Position.  The posture of the body should be
such as to favour the return  of blood  from the inflamed
part. In many local inflammations, posture is of extreme
importance. The elevation of the feet in cases of inflam-
mation on the lower extremities, is found highly useful.
It forms indeed one of the methods of depleting by emp-
tying the blood vessels of the affected  part.
  7th. Opium may be given to  relieve pain in some cases.
  The local remedies, are, 1st.  Bleeding from the inflam-
ed part by cupping, leeches,  and scarifications.  Local
blood-letting is most effectual after general bleeding has
been premised.
  2d.  Cold  Applications are  sometimes of service,
but they should only be carried so far as to be pleasant
to the feelings of the patient. A very common application
which is intended to reduce the temperature of inflamed
parts, is a solution of sugar of lead, with or without the
addition of vinegar. 9j of acetate of lead, to giv of water,
answers the purpose as well as any  other preparation.
It is to be applied on linen rags; and, as it soon acquires
the temperature of the part, these rags should be often
changed.
  3d.  Blisters are, in certain cases, of great use in dimi-
nishing inflammation.  They  must be applied directly
over the inflamed part;  and  in  many cases, produce a
speedy cure.
  All these remedies tend, by  diminishing the violence of
inflammation in its adhesive stage, to prevent suppura-
tion, which is generally to be attempted:  but cases oc-
cur in which this event is desirable, and others in which
it is inevitable. The  best application in such cases is
a soft poultice of bread and milk, with the addition of a
little sweet oil,  or fresh  lard; or ground linseed and
water. 
                ELEMENTS OF SURGERY.               ^
 ,  Wlien  suppuration has taken place, and a fluctuation
of matter can  be perceived, if it  be not soon evacuated
by absorption,  it becomes necessary  to expedite the cure
by an artificial  opening.
   Abscesses should be opened early, when situated near
the larger cavities of the  body, as  the tliofax  or  abdo-
men, instances having occurred in which they have dis-
charged their  contents into these cavities,  occasioning
fatal consequences.  In paronychia,  or other very  paiu-
ful collections  of matter, especially where the pus is con-
fined under a tendinous fascia, an early opening should be
made;—when  situated  near large  joints;—when they
impede respiration or deglutition;—when  they  occasion
nervous fever, or other constitutional affections,  they
should  be opened early. The best  application  after the
cavity of an abscess is evacuated is a  soft linseed or  bread
and milk poultice.*
   There are two ways of opening abscesses; by incision
or puncture, and caustic.  The lancet is to be preferred
whenever we can choose; if the patient, however, from
great fear  of a cutting instrument obstinately refuses to
submit, caustic may  be  substituted—a piece of caustic
vegetable alkali rubbed over the part eight or ten  min-
utes, will occasion a slough, and give vent to the pus.
   The  properties of  pus  have been well described by
Mr. Home.  It is a light straw-coloured fluid of the con-
sistence of cream, composed of globules swimming in a
fluid, which fluid is coagulable by muriate of ammonia—
a property which distinguishes pus from all other animal
fluids.  Healthy pus is perfectly bland, free from all acri-

 * A very ready mode of preparing the linseed poultice, is to mix the  linseed
,neal with warm water until it accuiires-a proper consistence.  If the  linseed
meal be not at hand,it is easily prepared by passing common flaxseed through
a eoffee-mill. 
.s»              ELEMENTS OF SURGERY.
mony.  It is heavier than water,  and sinks in it without
mixing.  Pure pus does not readily putrefy; but when
mixed  with blood or extraneous matter it ferments and
becomes putrid, acquiring a fetid smell, and is now acrid
and irritating. It is evidently a secreted fluid poured out
by the inflamed vessels which assume  the  nature of a
gland. 
ELEMENTS QF SURGERY.
13
                  CHAPTER III.

                  Of Hectic  Fever.

  Fever results from every  extensive local inflamma-
tion.   This fever is called symptomatic, but if the  local
disease continue for a great length of time, and until the
system is weakened,  febrile symptoms of a  very differ-
ent character ensue and constitute  what is called hectic
fever.
   The symptoms of hectic, are, great weakness; a fre-
quent small pulse, a moist skin, copious flow of urine,
moist tongue, loss of appetite, nausea, occasional vomit-
ing,  night sweats, diarrhoea,  frequent  chills succeeded
by flushes of heat; watchfulness to a distressing degree,
and flatulency together with the several symptoms of in-
digestion.
   Hectic fever has been ascribed by Dr.  Cullen and many
others to the absorption of pus. This opinion is however
without foundation, and many facts concur to prove that
copious absorption of matter may take place without hec-
tic fever, and many cases of hectic fever occur unattended
by an absorption of pus.  Of  the former we  have exam-
ples  in  the absorption of  matter from buboes and  other
abscesses, which are not followed by symptoms of hectic,
and of the latter we have instances in those cases of scro-
fulous joints in which hectic fever precedes suppuration,
an occurrence by no means unusual.
   The cure of hectic fever will in vain be  attempted,
whilst the local  disease which gives rise to it continues.
If the local inflammation be absolutely incurable, and in
such  a situation as to admit removal by  a surgical opera-
tion,  this  ought  always to be done.  The effects of re- 
14             ELEMENTS OF SURGERY.
moving even a small local irritation, are in some instances
truly astonishing.  Patients  apparently on  the brink of
the grave, become convalescent in a few hours.
   If however the part can neither be cured nor removed,
the strength of the patient must be supported by an in-
vigorating diet and tonic remedies.  The Peruvian bark
and opium are here valuable medicines, and must be ad-
ministered according to the exigency of the case. 
ELEMENTS OF SURGERY.
15
                  CHAPTER IV.

             Erysipelatous Inflammation.

  This has been considered a disease of the cutis vera;
it differs from healthy inflammation in many circumstan-
ces.  It commences at a particular  spot and very rapidly
extends itself, sometimes over a large portion of the body.
In some cases it is preceded by a chill and general fever,
in other cases the local affection is first observed.
  The colour of the skin when affected with erysipelas
is  a bright scarlet.  There is  less tumefaction than in
phlegmon, but yet some elevation of the inflamed part,
and  a decided  line  of  distinction where it  terminates.
Pressure  on the skin causes the redness to disappear,
but on removing it, the colour quickly returns. The pain
differs from that of phlegmonous inflammation;  it is of a
burning kind and attended  in many instances with intol-
erable itching, especially when seated on the uates and
perineum.  When it occurs in the face, it is attended with
greater tumefaction than in any other part, and is more
dangerous.  The cellular membrane around the eyes are
much swollen and appear as if distended  with a fluid
having a semi-pellucid  appearance.  In some cases it is
attended with vesications,  which  contain  a fluid some-
what acrid, when these burst,  scabs are formed and a
sore beneath them.
  In erysipelas  there is never a secretion  of coagulating
lymph. It either  terminates in resolution, or in a kind
of suppuration, or else in gangrene.  When  suppuration
takes place, as there is no secretion of coagulating lymph
to circumscribe the abscess, the pus travels through  the
cells  of the cellular membrane, occasioning  violent in- 
16               ELEMENTS OF SURGERY.
flammation and gangrene, the parts slough out, and have
a very strong resemblance to wet tow.  I have seen death
occasioned in such a case by the very extensive diffusion
of the matter through the cellular texture producing mor-
tification wherever it went.
  Where the affection is limited in extent and moderate
in degree, it generally  gets well in a week or ten days,
the skin casting off  its cuticle in small flakes like bran.
  The constitutional symptoms  are in  many cases very
severe,  great debility,  head-ache,  nausea,  vomiting fol-
lowed by violent fever  and delirium.
  The remote causes of erysipelas cannot be distinguish-
ed from those of common inflammation.  The state of con-
stitution, appears to influence them in  producing phleg-
mon in some cases and erysipelas in others.

                    TREATMENT.
  The remedies are  the  same as for common inflamma-
tion.  Bleeding is  generally  indicated;  purging—low
diet—neutral salts and antimonials, are to be  adminis-
tered according to the exigency of the case.   In London,
bark and tonics are very frequently exhibited with ad-
vantage, but an opposite plan of treatment is required iu
America. As a  local application, rye meal or wheat flour
is found pleasant and useful; poultices and all  unctuous
substances  do mischief. Cold lotions are sometimes used
with advantage; a solution of acetate of lead is the best.
Blisters are a remedy of great efficacy;  in some instances
they occasion an immediate cessation of the disease. The
late Dr. Pfeiffer, of this city was in the habit of employ-
ing them for many years with advantage in cases of ery-
sipelas.  When suppuration takes place large  openings
must be made for the evacuation of the pus and sloughs. 
ELEMENTS OF SURGERY.
                   CHAPTER V.

            Of (Edematous Inflammation.

   The following remarks of Mr. Hunter contain a very
accurate account of this affection.  " What I would call
the cedematous inflammation is, when the extravasated
fluid is water.   It has very much the appearance of the
adhesive, and comes probably the nearest to it of any, be-
ing of a scarlet colour, but much more diffused. The fluid
extravasated, being principally the  serum,  renders  the
swelling more diffused than even the inflammation itself.
It is very painful, or rather sore, but there is not so much
of the throbbing sensation as in the adhesive inflamma-
tion;  it appears to be only the surface, but most probably
goes much deeper:  for in such cases the extravasated
fluid is in too large quantity to  be furnished by the cells
of the  cutis alone, but in this we have not the same guide
as in the adhesive, namely, the swelling and inflamma-
tion corresponding with each other.
   " The difference  between this inflammation and the ad-
hesive arises, I conceive, from the principle of inflamma-
tion acting upon a dropsical disposition, which is always
attended  with  weakness,  whereas  a greater degree of
strength would have produced the adhesive inflamma-
tion under the same cause or irritation, and what makes
me conceive this is, that in many cases of anasarcous  legs
we have exactly this inflammation, come on from disten-
tion, which adds to the extravasation of the serum, as
well as in most cases of scarifications of cedematous parts
to evacuate the water. When inflammation takes place it
is much  more lasting than  the adhesive, and, I believe,
seldom or ever produces suppuration; but if it should
  vol. i.         4' 
1§              ELEMENTS OF SURGERY.
run into this stage it is more general, and the whole cel-
lular membrane, in the interstices of parts, is apt to mor-
tify  and slough,  producing  very  extensive abscesses,
which are not circumscribed."
  The remedies before the secretion of water takes place,
are the same as for common inflammation. We shall add
a few words on this subject in the chapter on ulcers. 
ELEMENTS OF SURGERY.
19
                  CHAPTER  VI.

           Of Gangrene and Mortification.

  Mortification is the  entire death  of  a part of the
body, gangrene is that  state or condition which immedi-
ately precedes it.  It is gangrenous so long as it retains
sensibility, motion, and warmth, when these cease and it
acquires a livid, brown, or black colour, it is mortified, or
in a state of sphacelus.
  Mortification is of two kinds: the one is not preceded
by inflammation, the other is.
  I. Mortification,  not  preceded by  inflammation, may
be occasioned by a  variety of circumstances.  Interrup-
tions to the circulation of the blood, as the  application of
a ligature to the arterial trunk supplying the part, or pres-
sure on the large veins  by which the return of blood is
prevented, as in strangulated hernia.  Continued pres-
sure on a part of the body, occasions mortification:  this
is seen in the hips and backs of patients who have been
long confined to one posture in bed.  Disorganization by
external violence, intense heat or cold, also  produce mor-
tification which i-s not preceded by inflammation.  When
mortification from  any of these causes commences, the
parts become  livid, cold, purple, black, lose all sensibi-
lity, become covered with vesications, containing a bloody
dark serum,  and at length putrefy, and  emit a foetid
smell.*  These cases admit of no remedy.  A soft bread
and milk poultice is to be applied to prevent the dead
parts from becoming hard and dry, and thereby adding
to the irritation.  If the part mortified be very extensive,

  "The process of "sloughing," in surgical language, signifies the separation
of dead and living parts. 
20              ELFMENTS OF SURGERY.
the constitution sinks, and death takes place. The use of
tonics and  stimulant medicines,  are  necessary in these
cases.  Peruvian bark, elixir of vitriol, and opium, are
among the  most useful.
  When a part has been exposed to intense cold, the
greatest care should be  taken to raise its temperature
gradually, as it is found invariably to mortify when heat
is  suddenly applied.  It  should first be placed in ice or
snow,  afterwards  in  cold  water, and  very  gradually
warmed.
  In some  rare instances, mortification comes on without
any evident  cause, except  extreme  debility.  I  have
known an instance of this after a severe attack of yellow
fever. This is, probably, not preceded by inflammation.
  II. Mortification in many instances is preceded by in-
flammation.  1. It may arise from the violence of the in-
flammatory action exhausting the vital  powers of the
part; or, Sdly, from some peculiarity in the nature of the
inflammation.
  1. "Inflammation is an increased action of that power
which a part naturally possesses, and in healthy inflam-
mations at least, it is probably attended with an  increase
of power.  In cases however which  are to  terminate in
mortification, there is  no increase of power, but on the
contrary a diminution of  it.  This when joined to an in-
creased action, becomes a cause  of mortification, by de-
stroying the balance which ought to  subsist between the
power and action of every part."  (Hunter.)
  When inflammation has, either  not  been  properly
treated, or  has resisted the  remedies usually successful,
and is about to terminate in mortification, the pain and
fever suddenly ceases, the  heat is diminished,  the red
colour is changed  to a  dark purple, and  the  swelling
which was tense and hard, becomes softer.  The cuticle
is elevated in various places and vesications form,  filled 
                ELEMENTS OF SURGERY.              g|
with a darkish and sometimes a transparent fluid.  This
gangrenous  condition rapidly progresses  to  a complete
mortification, attended with putrefaction.
  The constitutional remedies for it are  all such as by
lessening inflammatory action,  have a tendency to pro-
duce  resolution or suppuration.  These  have been al-
ready mentioned in the chapter on inflammation.  Where-
cver the violence  of the symptoms lead to an apprehen-
sion of gangrene,  the evacuations by bleeding, purging,
&c. are to be increased, and carried as far as the state of
the system will warrant.
   The indiscriminate use of evacuating remedies, is how-
ever  by no means  proper.  The sudden diminution of
strength  which frequently precedes  mortification,  de-
mands a very opposite mode of  treatment, and here tonic
remedies are  strongly indicated.  Wherever the inflam-
matory action suddenly subsides, and with it the  symp
tomatic fever, and a great diminution of vigour is per-
ceived in the patient's constitution, the use of tonics and  a
generous diet, with fermented  liquors, especially wine,
are to be directed.  These remedies have no effect cer-
tainly on parts already mortified, but  they fortify those
which are not,  and thereby prevent  the  progress of the
gangrene.
   The Peruvian  bark  has long been  celebrated for its
virtues in this particular  case.   It  is  a  valuable tonic,
but has probably  no specific virtues, and has done great
mischief when administered during an inflammatory state
of the system. The encomiums lavished  on it at the be-
ginning of the last century, appear to have been extrava-
gant, and surgeons no  longer recommend its indiscrimi-
nate exhibition in cases of gangrene.  When  the stomach
rejects it in substance,  it may be administered in decoc-
tion,  but it often produces so much nausea, that its exhi-
bition is necessarily precluded. 
gg              ELEMENTS OF SURGERY.
  The local remedies which have been used in cases of
mortification, are various.  In the first place, if there
exist any local irritation which has  a tendency to keep
up the inflammatory action, and thus extend the mischief,
these are to be  removed.  The application of cataplasms
and poultices can have  no effect on the mortified parts
except by keeping them  moist,  or  correcting the foetor
which  exhales, but these are important objects and should
not be  neglected.   A poultice of bread  and milk mixed
with landannm; of linseed, or  of scraped  carrots well
boiled in milk answers  in general every purpose, and if
renewed once in three or four hours keeps the parts suf-
ficiently  clean, but in warm weather when the smell is
very foetid, the addition of  finely powdered charcoal  to
the poultice of linseed, gij. to the pound, has some effect
in rendering it  more tolerable.  A poultice consisting of
oatmeal and beer,  stirred  together until they have a pro-
per consistence, is  much used by surgeons with a similar
intention.  The fermenting cataplasm, with or without
the addition of charcoal, is  also a useful application.   It
is made in several ways;  the easiest  and therefore  the
best,  is by mixing equal parts of yeast, flour  and honey
—if requisite, powdered charcoal may be added.
   Certain stimulating applications have been much used;
the various balsams, resins, aromatics,  alkohol,  &c.
They are in general laid aside.  The temperature of the
local applications  should  be attended  to; if they be  ap-
plied too hot, they increase inflammation, and if too cold,
they  weaken the parts. The temperature should be near-
ly that of the part to which they are applied, and they
 must always be light, so as not to offend by pressure.
   Scarifications,  if  ever,  are  very  rarely  necessary.
 There can be however no doubt of the propriety  of mak-
 ing punctures through  mortified parts whenever there is
 confined acrid matter beneath them, irritating the living 
                 ELEMENTS OF SURGERY.              go
 parts; they should  never extend into sound flesh.  In
 cases of gangrene from erysipelas, this practice is particu-
 larly necessary.  Wherever  extensive  sloughing of the
 cellular membrane from any  other cause, as extravasated
 urine, &c. takes place,  they are equally proper, but they
 should never be used with a view to expose the  sound
 parts, in order to apply local remedies to these.  When
 performed with this view, they occasion great pain and
 inflammation, and must therefore add to the danger and
 spread the mortification.
   The knife should not in general be  used with a view
 to separate the dead from the  living parts; this separa-
 tion will be readily effected by a natural process institut-
 ed by the absorbent vessels, and to them it should be com-
 mitted.
   When  gangrene  is situated in one of the extremities,
 it has been the practice of some surgeons to amputate the
 member.  The dangers attending this practice, and the
 fatal result of a great number of cases,  have induced
 modern surgeons to  lay it aside.
   When the limb is completely mortified and putrid, and
 the absorbents have  begun to separate the dead from the
 living parts, portions of the  putrid flesh may be cut off
 to diminish the smell, but this should be done with great
 care, so as in no  instance to injure the living parts.  After
 the whole of the  soft parts are  separated  by the absor-
 bents, the bones may be sawed through ; but it commonly
 happens that the bone has mortified higher than the flesh,
 and  therefore, the same process  of separation by the ab-
 sorbents must be  waited for,  so  that the only advantage
 arising from the operation is a removal of the inconveni-
 ence of a putrid and  offensive mass, the cure not  being at
all expedited by the operation.
   I  shall conclude  this account of the local  treatment
of mortification consequent to inflammation, by recom- 
24              ELEMENTS OF SURGERY.
mending in every instance  the application  of  a blister,
large enough to cover all the  sound parts in contact with
the diseased.  This remedy  was introduced into  prac-
tice by Dr. Physick, who was  led to apply it from the
success  of blisters  in cases of erysipelas.  He first em-
ployed it in January 1803, and from that time until the
present, has had the greatest reason to be  pleased with
its effects.  A great number  of  cases have occurred in
various parts of the United States, in which an immedi-
ate cessation of the progress of the gangrene has been the
result of its application.  I have witnessed its  effects in
a variety of instances, and have no  hesitation in recom-
mending it, in preference to all other local  remedies.
After the first dressing of the  blister, it will generally be
found that the mortification has ceased to progress, and in a
very short time the separation  of the sloughs commences.
  2. Mortification it was observed appears  in some cases
to arise from  something peculiar in the nature of the in-
flammation which precedes it, independently of its  appa-
rent violence.  The pustule  of small-pox and carbuncle
are specimens of this.
  The inflammation of the small-pox pustule terminates
by occasioning the death  of that portion of cutis vera in
which the inflammation was situated.
   Carbuncle.  This is  a tumour beginning on different
parts of the body, most frequently  on the back;  the pain
attending it is very great, and of a burning kind;  the skin
itches, and under it is found a very hard circumscribed
tumour, which becomes of a  dark red colour.  A kind of
imperfect suppuration takes place under the skin, attend-
ed with gangrene of the cellular membrane, and skin;
sloughs form, and  several openings are thus  made into
the cavity of the tumour, which discharges a fetid pus.
   The size of these tumours varies  greatly, in some in-
stances, they are small, in others many inches in diame- 
                 ELEMENTS OF SURGERY.              g?j
ter—I have seen them extending  quite across the back.
In general they occur in advanced life, and in those who
have lived well.  When they are very large they often
terminate fatally; in  those instances where several occur
at once, they are also  fatal.  Carbuncle occasionally forms
on the head, or high on the neck, and these cases gene-
rally terminate unfavourably when  they  are large.  In
sound constitutions and in patients not very far advanced
in life, a cure may commonly be expected.
   The cure depends  greatly upon the state of the consti-
tution, and this must influence  our prescriptions: in ge-
neral great debility attends,  and  demands a cordial in-
vigorating diet.  Opium must be  given to relieve pain, and
the bark and elixir of vitriol may  often be used with ad-
vantage.
   As a local remedy, the application of a blister is to b«
preferred to all others;  I have known it produce imme-
diate relief of the  distressing buruing sensation which
invariably attends this complaint,  and occasion a speedy
separation of the sloughs.  As  soon as matter fluctuates
under the  skin, an incision must be made to discharge
it, and a free passage is to be kept open for the evacua-
tion of pus and sloughs.  A plaster  of common basilicon
after the blister has been cut is to be applied,  and if poul-
tices are used, they should be very light  and frequently
ohanged.
  Besides the cases of mortification which have been de-
scribed,  there is a species of mortification which takes
place in the toes and  feet of old persons, w hether or not
it  is  preceded  by  inflammation is  undetermined;  Mr.
Hunter thinks it is.
  The  following account  of this singular  affection is
taken from the  writings of Mr.  Pott.
  " It is very unlike  to the mortification from inflamma-
tion, to that from external cold, from ligature, or ban-
  voi.. i.         d 
26              ELEMENTS OF SURGERY.
dage, or to that which proceeds from any known and vi-
sible cause, and this as well in its attack  as in its pro-
gress.  In some few instances, it makes its  appearance
with little  or no pain; but in by much the majority of
these cases,  the patients  feel great uneasiness through
the whole foot and joint of the ankle, particularly in the
night,  even  before these  parts show  any mark of dis-
temper, or before  there  is any other than  a small dis-
coloured spot on the end of one of the little toes.
   It generally makes its  first appearance on the inside,
or at the extremity of one of the smaller toes, by a small
black, or bluish spot:  from this  spot the cuticle  is al-
ways found to be detached, and the skin under it to be of
a dark red colour.
   If the patient  has lately cut his nails,  or corn; it is
most frequently, though very unjustly set to the account
of such operation.
   Its progress  in different subjects and under different
circumstances,  is different; in some it is slow and long
in passing from toe to toe, and from thence to the foot
and ankle; in  others its  progress is rapid and horribly
painful: it generally begins on the inside of each  small
toe, before it is visible either on its under or upper part,
and when it  makes its attack on the foot, the upper part
of it first  shows its distempered state,  by  tumefaction,
change of colour,  and  sometimes by vesication, but
wherever it is, one of the first marks of it is  a  separation
or detachment of the cuticle.
   Each sex  is, liable to  it; but for one female in whom
I have met with it,  I think I  may say, that I have seen
it in at least twenty males.   I think also  that I  have
much more often found it in the rich and voluptuous, than
in the labouring poor:  more  frequently in  great eaters,
than  free  drinkers.  It frequently happens to persons
advanced in  life, but it is by no means  peculiar to old 
                ELEMENTS OF SURGERY.               «>•*
age.  It is not,  in general,  preceded or accompanied
by apparent distemperature either of the part, or of the
habit.   I do not know any particular kind of constitution
which is more liable to it than another; but as far as my
observation goes, I think that I have most frequently ob-
served it to attack those, who have been subject to flying
uncertain pains in their feet, which they have called
gouts, and but seldom  in those who have been accus-
tomed to have the gout regularly and fairlv.   It has, by
some been supposed to arise from an ossification of ves-
sels; but for this opinion I never could find any founda-
tion but mere conjecture.
   The  common method  of treating this distemper is, by
spirituous  fomentations,  cataplasms actually  and poten-
tially warm, by dressings of the digestive kind, as they
are called, animated with warm, pungent oil and balsams,
&c.  and, internally, by the Peruvian bark.
   I wish I could say that this, which, with little altera-
tion, has been  the  general practice, had  been most fre-
quently successful; but  I am,  from long and  repeated
experience, obliged to say that it has not.
   I am sensible,  that many of my readers will be sur-
prised at my affirming, that the Peruvian bark will not
stop a mortification, a distemper in which for some years,
it has been regarded as specific; but I  must beg not to be
misunderstood; I mean  to confine  my observation  and
my objection to this particular species of mortification,
which I regard as  being sui generis :  and under this re-
striction I  must repeat, that 1 have seldom, if ever seen
the bark successful: in all other cases, wherein it is used
or recommended, no man has  a  higher opinion of it; but
in this I cannot give it a praise which it does not deserve.
   " I believe I may venture to say, that I have tried it as
fairly, as fully, and as variously as any mau has or can:
I have  given it in  the largest quantities, at the shortest 
28               ELEMENTS OF SURGERY.
intervals, and for the longest possible space; that is, as
long as the  patients life would permit.   I have given it
by itself in decoction, extract,  and substance: I have
combined all these together:  I have joined it with nitre,
sal. absynth. w ith snake-root, with confect. cardiac, with
volatile salts, and with musk, as different circumstances
seemed to require, or admit:  I  have used it as  fomenta-
tion, as poultice, as  dressing:  I have assisted it with
every thing  which has  been  usually thought capable of
procuring, or assisting  digestion; still the distemper has
continued  its course, perhaps a  little more  slowly,  but
still it  has ended in death.
  " I  am  sorry  to rob  one of our great medicines of any
part of its supposed merit,  but as on the one  hand, its
claim,  in this instance, is unjust, and as on the other, I
hope to add as much to the character of another, the res
medica will be no sufferer.
  " Some time  ago, I  had a  patient labouring under this
complaint, who  from antipathy,  obstinacy, or some other
cause, could not be prevailed on to take bark in any form
whatever.   I made use of every argument but to no pur-
pose:   fomentation, poultice, and  the  usual  dressings
were applied in the usual manner;  the disease advanced
some days  more, some days less,  and at the end  of a
fortnight, the small toes were all  completely mortified;
the great one became  blackish, the foot  much  swollen,
altered in colour, and the disease  seeming to advance
with such hasty strides, that I supposed  a very few days
would determine the  event.  The  pain  in  the  foot and
ankle  was  so great, and  so continual, as totally to de-
prive  the  patient of sleep.   On this account, and merely
to procure some remission,  I gave two  grains of  opium
at night,  which not having the desired effect, I repeated
it in the morning.  Finding, during the following  day,
 some  advantage, I repeated the same  dose  night  and 
                ELEMENTS OF SURGERY.               gg
morning, for three days;  at  the end of which time  the
patient became  quite easy, and the appearances on  the
foot and ankle were visibly more favourable. Encouraged
by this, I increased  the quantity of the medicine, giving
one grain every three or four hours, taking care to watch
its narcotic effect, and to keep the belly empty by glys-
ters.  In  nine  days from  the first administration of  the
opium, all the tumefaction of the  foot and ankle totally
subsided,  the skin recovered its  natural colour, and all
the mortified parts plainly began to separate; in another
week they were all loose, and casting off, the matter was
good, and the incarnation florid.  During the whole of this
time I continued the use of the opium, varying its quan-
tity as circumstances required,  but never gave less than
three or four grains in twenty-four hours.
   " When the sloughs were all cast off, the bones sepa-
rated, and I had only a clean sore  to  dress and heal, I
gradually left off the medicine.
   " To relate cases which are nearly, or at least materi-
ally similar, is  of no use : I shall therefore only say, that
every opportunity, which I have had since of making the
experiment, has still more and more convinced me of the
value and utility of this medicine,  and of its power of res-
cuing from destruction, persons under this affliction.
   " I cannot say that it has never failed me : it certainly
has;  but  then it has been under  such circumstances, as
I think would  fairly account for the failure/'
   In addition to Mr. Potts' account of this species of mor-
tification, I shall just add, that in the only case of  it I
have ever seen, the application  of a blister produced an
immediate termination of the mortification. 
30
ELEMENTS OF SURGERY.
                  CHAPTER VII.

                      Of Burns.

   The application of  excessive heat to the body, occa*
sions severe pain, and inflammation.  Its  consequences
are more or less serious in  proportion to the degree of
heat applied and the time of its continuance.
   When the degree of heat is not very great it produces
pain, redness and slight inflammation which subsides
spontaneously when the heat is removed.  A greater de-
gree of heat occasions more severe pain; vesications form
filled with serum and the true skin under these vesicles, is
much inflamed.  If the burn be extensive, fever attends
and suppuration takes  place. If the heat be still more in-
tense, the life of the part  is destroyed.
   As a general remark  it may be stated that burns are
dangerous  in proportion to their extent. A burn which
destroys the life of a small part of the body, will produce
but little effect on  the constitution, whilst  an extensive
burn, even if very slight in degree, will occasion death.
I once saw a child scalded on the back, from the neck to
the hips, by falling into a tub of water in which her mo-
ther was washing clothes; the heat occasioned a few ve-
sications, but the inflammation appeared slight, and yet
on th» fifth day the child expired.
  WThen the heat is so intense as to destroy the life of the
part, less pain is  experienced than in  light burns, but
when the eschar begins to be separated by the absorbents
the pain is  augmented; very little pain appears to be suf-
fered by those who are scalded, and die a few hours  after
the accident.  In one  such  instance, I have known the
patient to complain of  nothing but extreme coldness.  In 
                ELEMENTS OF SURGERY.              gj
these cases,  drowsiness  and  coma  frequently  attend.
Burns which affect parts essential to life, generally termi-
nate unfavourably.  Burns on  the head often occasion
death, by affecting the brain. When the larger joints  are
burned, there is great danger from the violent inflamma-
tion which follows.
  Treatment. There is no branch of surgery on which
a greater diversity of opinion and of practice exists than
in the treatment of burns ; remedies apparently opposite
in their nature succeed in the hands of  different  practi-
tioners, and whilst one surgeon strenuously recommends
the use of ice and cold water, another proposes an appli-
cation of hot spirit of turpentine.
   A late  writer on this  subject, Mr. Kentish, who has
had very extensive opportunities of applying his princi-
ples, declares that the stimulating^ plan of treatment is
most successful, and he advises the constitution to be sti-
mulated with opium and ardent  spirits,  and the  part af-
fected to be dressed with a liniment composed of spirits of
turpentine and  basilicon. The  theories  which have led
Mr. Kentish to this practice, are by no means satisfac-
tory, though the local application he has recommended is
extremely valuable.
   The method which is found to succeed best by  the sur-
geons of  this country, is to attend as in all other cases
to the state of  the constitution, and  to accommodate the
general remedies to it. If there be  great pain, opium is
to  be administered.  If considerable fever arise, blood-
letting  and evacuating means are to be used.  If on the
contrary, weakness and want of action appear to require
them, stimulating remedies must be resorted to.
   As a local application to a  bum 1 have found  nothing
so generally successful as the ointment recommended by
Mr. Kentish.  The common  basilicon thinned by being
mixed w ith the oil of turpentine, forms a liniment, which 
 32              elements of surgery.
 when spread  on rags and applied to the burned surface,
 occasions great  relief from pain, and hastens the forma-
 tion of new parts.   Mr. Kentish premises to this dress-
 ing, a lotion with brandy, or hot oil of turpentine, or hot
 alkohol.  This is in general unnecessary, and the liniment
 may be applied without delay, and at any period within a
 few days after the accident.
   It is not to be denied that cases occur in which this ap-
 plication so generally successful produces  pain and in-
 creases  inflammation. In some  instances, however, this
 has arisen from a want of caution in the application.  The
 surgeon, or his nurse, has been careless enough to apply
 the stimulating ointment to the sound skin, where it inevi-
 tably occasions much inflammation and pain. To obviate
 this inconvenience  tlje plasters should be cut into small
 portions and applied to the burned surface only.
   If, notwithstanding  this caution,  the  liniment  excites
 pain and inflammation,  it must be removed and another
 application substituted.  A great variety have been used.
 Vinegar in many cases  affords great relief; lime-water
 mixed with oil is a very soothing application; scraped
 potatoes, a linseed poultice, lead water, are all useful in
 different instances, and if one should not afford relief, the
 others may be tried.*
   The  ulcers left  by  burns  have  some  peculiarities.
 They shoot  out fungous graduations which do not rea-
 dily cicatrize, and  when these ulcers do heal,  they con-
- tract so much, as in many cases to occasion great distor-
 tions.
    To  arrest  the  growth of  fungus,  prepared  chalk
 should be sprinkled over the sore, and if this be not suf-
 ficiently powerful,  burnt alum, or the common escharotic
 applications may be used.
  * Ice has been strongly recommended by Sir James Earl; it alleviates pain
and may be applied in bladders over the other dressings. 
                elements of surgery.              33
  To prevent  deformity from the union of parts which
ought not to adhere, we  should be extremely cautious
whilst the sores are healing, to interpose plasters between
them, and by applying splints and bandages to preserve
them  in a proper posture.   From neglect of this caution
great  mischief  has often  arisen.  I have seen the chin
of a  boy  adhering firmly to  his  breast;  by  which
his mouth was  kept constantly open, and his whole ap-
pearance  was greatly deformed. The fingers when se-
verely burned, are particularly apt to adhere together.
When this unfortunately happens,  w7e must cautiously
dissect them loose, and prevent  their re-union by proper
dressings.
VOL. I.         6 
34               elements of surgery.
                  CHAPTER VIII.

                  The Effects of Cold.

   The power of resisting the effects of cold by preserv-
ing a temperature nearly similar in all changes of the at-
mosphere, is one  of the characteristics  of living matter.
   The human body possesses this power in a  very great
degree, and like all its other faculties, it is augmented by
habit. The inhabitants of northern countries are subject-
ed occasionally to degrees of cold which would unques-
tionably destroy the natives of the torrid zone. The de-
gree of cold which may be endared without loss of life,
cannot in the human subject be ascertained.*
   In hospital practice and among the poor, the surgeon
frequently finds toes and fingers, feet and hands, slough-
ing off in consequence of exposure to cold. He is not often
called until it is too late  to prevent this effect.  When he
is, the great object is  to  restore the warmth  of the parts
very gradually.  A limb  has been frozen perfectly stiff,
and  by being  rubbed in snow,  afterwards immersed in
cold water, and then very gradually warmed, its life has
been preserved.  The sudden application  of  heat never
fails to  occasion inflammation,  and  mortification  very
quickly follows. After the temperature has been gradual-
ly raised, and action and sensation are perceived, frictions

  * A woman in a fit of intoxication was overtaken in a snow storm.  " The
snow accumulated over her to the height of about six feet, a sort of hollow
cone being left from her head to the surface, through which breathing was
performed; from this situation she was removed, after having laid eight days
in the snow." - Her life was preserved, though she lost great part of her feet
Other instances are recorded of long exposure to intense cold, without fatal
consequences. Our present subject is more particularly the effects of its local
application. 
                 elements of surgery.               35
with flannel wet with ardent spirit are to be used.  The
patient should then  be placed in bed and kept warm;
perspiration is to be produced by warm drinks, and by
"keeping him perfectly at rest, the ill effects will speedily
subside.
   When mortification occurs, it has been my practice for
several years to apply blisters, with a view to hasten the
separation of the dead parts, and the  ulcers left  I have
found to heal very soon when treated with basilicon ren-
dered stimulating by the addition of a little spirits of tur-
pentine.*
   Chilblain,  is a local inflammation situated generally
upon the heels,  toes and fingers, but sometimes upon the
nose and ears, resulting from exposure to cold.  This in-
flammation varies in degree;  when moderate, a redness
is observed upon the skin, attended with heat and itch-
ing,  which after a  time, spontaneously subsides.  In a
greater degree the swelling is larger, of a  deeper red co-
lour,  and  sometimes  purple,  or dark  blue;  the  heat,
itching, and pain are very great.  Sometimes small vesi-
 cles arise,  which burst and occasion very obstinate ulcers.
 In the most violent  cases mortification occurs,  preceded
 by the usual vesications containing a dark coloured fluid.
   Chilblains arise most frequently from exposure of the
 parts to sudden and great vicissitudes of temperature.
 They occur oftenest in persons accustomed to indulgence,
 in women and children.
   They generally make  their appearance in the winter,
 disappear  during the summer, and return  the succeeding
 winter. Some persons  suffer most from them during the
 autumn, others not until spring;  sometimes they continue

   * In cases of suspended animation from cold, there is no necessity for the
 very gradual application of heat; on the contrary, it is recommended to bring
 the patient into a warm room and rub him with flannels.  His feet and legs are
 to be immersed in tepid water, and bladders filled with it are to be applied to
 the thorax 
3.6              elements of surgery.
a few days, or weeks, and sometimes during  the whole
winter.   When violent the patient  is unable to  move
about, and is  affected with considerable fever.  When
suppuration occurs, the bone becomes carious, and  even
death has followed the irritation of a chilblain.
  To prevent  the formation of  chilblains in young per-
sons, they should be  accustomed to  wash in cold water,
and  not to be much  in  very  warm rooms,  especially
avoiding sudden changes from cold to heat, or the reverse.
  The remedies for chilblains vary according to the de-
gree of inflammation;  the several remedies for inflamma-
tion  however,  do not relieve the pain and itching which
attend this complaint,  and one thing it is important to
know, which is, that the remedies most successful in one
case, produce no  effect upon another;  when  inefficient
therefore, they must  be  varied.   In some cases great
relief is obtained from lotions  of a spirituous nature,
alkohol, laudanum, brandy, and the like, and in others
poultices afford most  relief.   Leeches  are often useful
where the inflammation is so violent as to produce fever;
cold water or  snow applied  to the part, sometimes pro-
duces great relief; it should be  repeated several times in
the course of  the day, and continued until the pain and
itching abates. A bath of quicklime prepared by throw-
ing a piece of fresh  burnt lime as large as a man's fist
into a quart of water, is recommended by Richter as a
valuable remedy; the affected part is to be immersed in
this  bath, and kept in it half  an hour every morning and
evening.
   Oil  of turpentine affords in many cases  great  relief.
Balsam  copaiva, basilicon ointment, tar  ointment,  and
various other  resinous applications are found useful.
   When chilblains ulcerate, they are  to be  treated as
ulcers from other causes. When mortification takes place,
poultices are to be applied until the sloughs separate, and
then the sore  is to be dressed in the usual manner. 
elements of surgery
37
                 CHAPTER IX.

                     Of Wounds.

  A wound may be defined, a recent solution in the con-
tinuity of a part communicating externally, and produced
by mechanical violence.
  Wounds  differ in  their  nature and appearances from
an endless variety of  circumstances.  They admit, how-
ever of a  general division into Incised, and Contused,
the latter  including punctured, lacerated, and gun-shot
wounds.  Incised wounds are made with a sharp cutting
instrument, and the neighbouring parts sustain no injury.
Contused  wounds are those in which  the surrounding
parts are bruised and  injured.

                 of incised wounds.
  When these are  of small extent,  and made in fleshy
parts, unaccompanied by a division of  any considerable
blood-vessel, the surgeon by approximating the sides of
the wound and retaining them in contact, enables them to
unite, and they very speedily heal.  All incised wounds,
however,  are attended with some  loss of blood, and  this
is in many cases so great, as to form the chief danger of
the case; as there is no subject of more importance to the
surgeon than that of hemorrhage, it w ill be proper in  this
place to offer some remarks upon  it.

                   OF HEMORRHAGE.
  In order to ascertain the  natural process by which the
bleeding from a wound is  arrested,  it is requisite to at-
tend to the phenomena which follow the opening of large
blood-vessels.  It is  now  nearly a century  since Mr. 
38                 ELEMENTS OF SURGERY.

Petit commenced the investigation of the present subject,
and since his  time a variety of theories have been advanc-
ed, to explain the natural  means by which  the bleeding
from  divided  arteries is stopped.   Dr. Jones  in a late
publication  has collected into one view  these various and
discordant doctrines;  has  selected  from  each  what  ap-
peared  founded upon fact,  and by very numerous and in-
teresting experiments, seems to have gone far in develop-
ing the truth.
   If the vessel opened  be  a large  artery, an immediate
jet or stream of blood is  perceived; this blood is of bright
scarlet  colour, and issues, not in a regular current, but per
saltum, every contraction and  dilatation of the vessel pro-
pelling it with alternately  greater and lesser velocity.*
   " An impetuous  flow of blood, a sudden and forcible


  * To comprehend this subject  fully, it is necessary to recollect some circum-
stances connected with the anatomy of arteries, which we shall here very briefly
state.
  " The coats of an artery are three; the internal is extremely thin and smooth,
it is elastic and firm in the longitudinal direction, but so weak in the circular as
to be very easily torn by the slightest force applied in that direction.  It is vascular
and capable of inflaming."
  The middle coat is composed chiefly of muscular fibres, arranged in a circu-
lar manner; they differ from common muscular fibres in being more elastic
As this middle coat has no longitudinal fibres, the circular fibres are held together
by a slender connexion, which yields readily to any force applied in tine circumference
of the artery.
   " The  external coat is remarkable for its whiteness, density, and great elasti-
 city.   When an artery  is surrounded by a tight ligature, its middle and internal
 coats are as completely divided by it as they could be by a knife, wfulst the external
 coat remains entire."
   " Besides these proper coats all the arteries in their natural situations are
 connected by means of the fine cellular substance with surrounding membrane-
 ous sheaths. If an artery be divided, the divided parts, owing to their elasticity, re-
 cede from each otlier, and the length of the celhdar substance, connecting the artery
 ■with the sheath, admits of its retracting a certain way -within the sheath."
   " Arteries are furnished with, arteries, veins, absorbents, and nervea, a struc-
 ture which makes  them susceptible of every change to  which living parts are sub-
 jected in common; enables them to inflame when injured, and to pour out coagulating
 lymph by ivltich the injury is repaired, or the tube permanently closed."—(Joins.) 
                 ELEMENTS OF SURGERY.               gg
retraction of the artery within its sheath, and a slight con-
traction 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 mea-
sure counteracts  the  retraction and resists the  contract-
tion,* of the artery, the blood is effused into the cellular
substance between the artery and  its sheath, and passing
through the canal of the sheath which  had been formed
by the retraction of the artery, flows freely externally, or
is extravasated into the surrounding cellular membrane,
in proportion to the open or confined state of the 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 thus the foundation is laid for the forma-
tion of a coagulum at the mouth of the artery, and which
appears to be completed by the blood as it passes through
this canal of  the sheath, gradually adhering and coagu-
lating around its internal surface, until it completely fills
it up from the circumference to the centre."  (Jones.)
   The diminished force of  the circulation of the blood,
its speedy coagulation, and its extravasation into the sur-
rounding cellular texture, are circumstances which con-
tribute greatly to put a stop to the hemorrhage.   The co-
agulum which acts  as a plug to the open orifice, is situ-
ated not actually within this orifice, but  within its  sur-
rounding sheath, and as it  is  outside of the vessel,  Dr.
Jones has called it external; a  coagulum  however, is
found within the arterial tube, as high as  the nearest col-
lateral branch, this is not sufficient in volume to fill up the
vessel and adheres to the artery  no where except at the
divided extremity;  this clot is called the internal coa-
gulum.
  • The retraction refers to the diminished length, and the contraction to the
diminished volume or diameter of the artery. 
%0              ELEMENTS OF SURGERY.
  The wounded artery  afterwards inflames and  its ves-
sels  (like those  of  any other inflamed part) secrete  co-
agulating lymph in sufficient  quantity to fill up the  ex-
tremity of the artery  between the external and  internal
coagula. This lymph appears to unite these coagula to-
gether, and adheres firmly all round to the internal coat
of the vessel. It is this secreted lymph which constitutes
the permanent barrier to the flow of blood, and this bar-
rier is rendered stronger by a contraction of the wounded
extremity of the vessel,  and by an effusion of lymph  be-
tween  its coats, and into the surrounding cellular sub-
stance,  by which these parts become incorporated  to-
gether very firmly.  If the wound iu the integuments re-
mains open, the  effused lymph connects the artery  to the
subjacent and lateral parts, and gives it a new covering
which  entirely excludes it from the outward wound.
  The  same circumstances  are  also remarkable in  the
portion of the vessel most remote from the heart. Its  ori-
fice is usually more contracted and its external coagulum
smaller than the one which attaches itself to the other cut
end of the artery.
   The impervious  extremity of the  artery no longer al-
lowing blood to circulate through it, the portion  which
lies between it  and the first lateral branch, gradually
contracts till its cavity is completely obliterated, and its
tunics  assume a ligamentous appearance; the  external
coagulum which in  the first instance had stopped the he-
morrhage is absorbed in a few days, and the coagulating
lymph effused around it, by which the parts  were  thick-
ened is gradually removed,so that they resume their cel-
lular structure.
   At a still later period  the ligamentous portion  is re-
duced to a filamentous  state, so that the artery is as  it
were completely annihilated from its cut end to the  first
lateral branch;  long however before this final change is 
                ELEMENTS OF SURGERY.                4^
accomplished, the inosculating branches have become con-
siderably enlarged, so as to establish a free communica-
tion between the disunited  parts of the main artery.
  When an artery has  been divided at some  distance
from a lateral branch, three coagula are formed :  one of
blood  externally,  which shuts  up  its  mouth;  one of
lymph, just within the extremity of its canal, and one of
blood, within its cavity, and contiguous to that of lymph.
But, when  the  artery has been divided near a  lateral
branch, no internal coagulum of blood is formed.
  The external coagulum is always  formed, when  the
divided  artery is  left to nature; not  so however, if  art
interferes, for under the  application of the ligature it can
never  form.  If agaric,  lycoperdon, or sponge  be used,
its formation is  doubtful, depending entirely upon the  de-
gree of pressure that is used ; but, the internal coagulum
of blood will be  equally formed, whether the treatment
be left to art or nature, if no collateral branch is near the
truncated extremity of  the artery; and lastly, efl'used
lymph, which,  when in  sufficient quantity, forms a dis-
tinct coagulum, just at the mouth of the artery, will be
always found, if  the  hemorrhage is  permanently sup-
pressed.
  When, instead  of a complete division of an artery, it is
only  partially divided  or punctured, the cessation of
bleeding is not so easily effected by natural means; hence
it was the custom of the ancients in such instances to di-
vide completely a punctured artery.
  Mr. Petit appears to have given the best  account of the
process by which  the bleeding from arteries partially di-
vided  are stopped. Dr.  Jones, after a great  number of
experiments performed with a view to elucidate this sub-
ject, confesses that he has  little to add to Mr.  Petit's  ac
count.
  The blood is effused into the cellular substance,  be-
   vol. i.         7 
4)2              Er.F.MENT^ OF SURGERY.
tw en the artery and its sheath, for some distance, both
above and below the wounded part;  and when the parts
are examined,  a short  time  after the hemorrhage has
completely stopped, we find a stratum of coagulated blood
between the artery and its sheath, extending from a few
inches below the wounded  part, to  two or three inches
above it, and somewhat thicker, or more prominent over
the wounded part than elsewhere.
  Hence, rather than say the hemorrhage is stopped by
a coagulum, it is more correct to say, that it is stopped
by a  thick  lamina  of coagulated blood, which, though
somewhat thicker at the wounded part, is perfectly con-
tinuous with the coagulated blood lying between the ar-
tery and its  sheath.
  When an artery  is punctured, the hemorrhage imme-
diately following, by filling  up  the  space, between the
artery and its sheath, with blood, and consequently dis-
tending the sheath, alters the relative situation of the
puncture in  the sheath to that in the artery, so that they
are not exactly opposite to each other; and by that means
a layer of blood is confined by the sheath over the punc-
ture in the artery, and, by coagulating there, prevents any
further effusion of blood.
  But this coagulated blood, like the external coagulum
of a divided artery, affords  only a temporary barrier to
the hemorrhage; its permanent suppression is effected by
a process of reparation, or of obliteration.
  It has been  doubted by  many  respectable surgeons
whether arteries when wounded, can heal without an ob-
literation of the cavity of the vessel, in such a  manner
as to carry on the circulation of blood. The experiments
of Dr. Jones upon a number of animals prove that  in
brutes this  very generally happens, when the artery is
wounded only to a small extent; the cicatrization in these
cases  is so complete, that no vestige of the wound can  be 
                 ELEMENTS OF SURGERY.                4,3
perceived, either on the external or internal surface of the
artery, and  that even  oblique  and  transverse  wounds
when they do not exceed one-fourth of the circumference
of the vessel, are filled up, and healed by an effusion of
coagulating lymph  from their inflamed lips,  so as to oc-
casion little or  no obstruction to the  canal of the artery.
It may still be questioned whether in the human body the
same mode of union is effected.
   When an artery of considerable magnitude is punctur-
ed, even by a sharp lancet, the circular fibres of the artery
in most cases contract so much, as to  separate the sides of
the wound  to a  considerable distance from each other, it
appears as  if a piece of the vessel had been actually re-
moved.* To effect the reparation here, a coagulum forms
as explained by Mr.  Petit, inside of the artery, and ex-
tends through the wound, to a coagulum situated on the
outside of the vessel,! in this manner the aperture is tem-
porarily closed, and  the  permanent  closure depends on
the secretion of coagulating lymph, which is  poured out
in considerable quantity, and  in many cases (probably a
large majority of cases) obliterates the arterial tube, but
in some instances the artery heals as in  the experiments
upon brutes related by Dr. Jones, and then the cicatriza-
tion is completed without a destruction of the1  arterial
cavity.  Mr. Petit  records  an instance of this,  and in
professor Scarpa's  learned treatise on Aneurism, I  find
another  very decided instance  in which this  mode of
union was  effected in the  brachial artery  of  a man.
Scarpa denies that when the artery heals in this manner
the cure is radical.   He supposes the vessel  weaker at

  • Such is the common opinion., but I have seen several cases of punctured
arteries, in which no  gaping was evident, the wound being  a mere slit, the
sides of which were nearly or closely in contact, though they  had not united.
As this has been the case in all the punctured arteries I have seen, I cannot
doubt that it very often happens.
  ■j- The inner clot he calls " bouchon/' a cork, or plug, the external is called
" couvercle." 
44               ELEMENTS OF SURGERY.
the cicatrix than  at any other part.  A case of wounded
brachial  artery which healed  without an obliteration of
its canal  may be found in the New York Med. and Phil.
Journal,  No. 4.
  Having  thus  stated the natural process by which  a
wounded artery  is repaired, we may next mention that
these powers of reparation appear to exist  in an inverse
ratio to the size of the vessel, small vessels healing much
more readily than large ones.
  In incised wounds the flow of blood is always much
greater than in contused wounds of similar parts.   The
effect which laceration  has  in preventing hemorrhagy
may be estimated from a case related by Cheselden, in
which a miller's arm  was torn off, together with the
scapula  from  the chest, of course some of the  largest
arteries of the  body were divided, and  yet no fatal he-
morrhagy ensued.  I  have known a  boy's arm ground
off in a mill within a few inches of the shoulder, and so
little bleeding resulted,  as scarcely to stain his clothes.
Dr. Physick has attributed this effect of contusion,  1st,
To the diminished power of the vessels to carry on the
circulation.   In an incised wound the vessels are only
injured at the divided  surfaces;  in a  contused  wTound
they are  injured  to a considerable distance  and therefore
circulate the blood less rapidly.  2dly, In a contused
wound the blood escapes less readily  by the external
opening, and becomes extravasated into the cellular tex-
ture making lateral  pressure  upon the blood-vessels.*
3djy, The blood  coagulates much more promptly in con-
tused than in incised wounds, and this coagulation is a
powerful barrier to the escape of the  blood.   The ex-
tremities of divided vessels  are often actually killed by
the  contusion, and blood, when in contact  with  dead
  * The lateral pressure is increased by ecchymosis, from  a number of rup-
tured blood-vessels which have no external communication, and bleed into the
interstices of the neighbouring parts. 
                 ELEMENTS OF SURGERY.              <jg
matter speedily coagulates.  The coagulation of blood
in the divided extremities  of the vessels, forms another
obstacle to hemorrhage.

           TREATMENT OF INCISED WOUNDS.
   In the treatment of an incised wound, the first object
is to stop  the bleeding.  In  many cases a wound bleeds
profusely at first, and gradually stops without any atten-
tion from  the surgeon.  In some cases moderate pressure
upon the  wound  by holding its sides  in contact, puts a
stop to the flow of blood, and this, if  no large artery be
obvious, should always be tried.  If, upon removing the
pressure the wound continues to bleed, or if previously
to trying  this, a bleeding artery is observed, it must be
taken up  upon the point of  a tenaculum, and a ligature
applied round it.
   If the bleeding is so great as to  prevent an accurate
inspection of the wound, so that the artery cannot be per-
ceived,  pressure must be  made upon  the  trunk of the
main artery which supplies the parts with blood.   This
pressure may be made with a finger, or if the  wound be
seated in  an extremity, with a tourniquet; that of Petit
is to be preferred  for simplicity and facility of applica-
tion to all others.*  When  the tourniquet is to be ap-
plied,  it must  be placed  above the knee or  elbow, be-
cause, as  there is only one bone in these parts, a circular
bandage will compress all the vessels of  the limb.  After
the tourniquet  is applied and screwed so tight as to in-
terrupt the circulation, the surgeon is to wash the wound
with a sponge and warm water, and then, whilst his eye
is fixed on it, the screw is gradually loosened, and the
divided vessels  may  be seen by  the stream of blood
escaping from their extremities.
  * I mean the tourniquet in common  use, invented by Petit, and improved
by Freke. 
46                ELEMENTS OF SURGERY.
  It is to be recollected, that if the wound be too high up
on an extremity for the application of  a tourniquet, the
compression of the vessel may still  be effected. The sub-
clavian artery may be compressed as it lies over the first
rib, and the circulation in the arm may thus be complete-
ly prevented, and from pressure in the groin, the trunk of
the femoral artery ceases to pulsate.   In every instance
where the bleeding does not speedily cease, and the ori-
fice of the bleeding artery can be seen,  it is to be tied up.
And whenever large  arteries  are  wounded, there is no
other mode of stopping the hemorrhage  to be confided in.
  Dr. Jones having made a number of experiments to as-
certain the effects  of the ligature upon an artery included
in it, and properly tied, states, that the  internal and mid-
dle coats of the artery are cut through  and kept in close
contact  by the ligature; inflammation supervening  they
adhere and unite firmly.
  There are however some situations in which it is ex-
tremely difficult to tie  up  a wounded artery.  If a vessel
be opened in a deep wound of  small extent,  it becomes
sometimes necessary to dilate the wound, in order to ex-
pose it.  Sometimes  we are able by enclosing  in the li-
gature a  portion of flesh through which  the arlery passes,
to put a stop to hemorrhage. In other cases the applica-
tion  of  lint and moderate pressure effects the  purpose
(but this can  only be trusted when the bleeding is from
small vessels.) The application of stiptics and escharo-
tics, is  nearly out of use  among  surgeons;  and  yet
cases sometimes occur, in which they may be employed
with advantage, as when  the bleeding vessel is beyond
the reach of the  ligature, and in such a situation, as to
preclude compression.*  I have once   known  the  hot
  * Powdered agaric. Flour sprinkled over the surface,by exciting coagulation
often stops the bleeding, Sp. turpentine, alum, blue vitriol, the mineral acids,
lunar caustic, &c. &c. &c. 
                ELEMENTS OF SURGERY.               a&
 iron necessary to put a stop to a most alarming hemorr-
 hage from  a large artery in the posterior fauces, which
 had been wounded  in  extirpating a tumour  from  the
 mouth.  It sometimes happens that a proper posture of a
 limb restrains hemorrhagy.  The posture should be one
 in  which gravity favours the descent of blood through
 the veins, and retards its motion-in the arteries.
   The form of the ligatures used by surgeons  is not an
 object of much consequence  when the vessels are small;
 when a large artery however is to be secured, Dr. Jones
 recommends them to  be round and very firm; he states,
 that though a slight force only is necessary to cut through
 the internal and middle coats of an artery, it is better to
 tie the vessel more tightly than is necessary, merely to cut
 through  its inner coats, because the cut surfaces will be
 more certainly kept in contact, the separation of the liga-
 ture expedited, and the danger of ulceration spreading to
 the newly cicatrized part diminished.  This direction of
 Dr. Jones,  I believe useless, and except in the larger
 arteries,  it is quite sufficient to tie the ligature with force
 enough to command  the  hemorrhage, and even in the
 largest arteries, I believe the direction has frequently in-
 duced  surgeons to break their ligatures by unnecessary
 force.
   I would here state, that round bobbin forms an excel-
 lent ligature  for the larger arteries, and for smaller ves-
 sels, a number of sewing threads waxed together of a pro-
 per thickness may be  used.
   Shortly after the  first edition of this work was pub-
 lished, Dr.  Physick  suggested to the author the  pro-
 priety of testing by experiment, the value of an improve-
ment he had long contemplated in the formation of liga-
tures—this was accordingly done, and has resulted in the
substitution of certain animal substances for the materials
formerly employed. 
48                ELEMENTS OF SURGERY.
  It has long been a desideratum among surgeons, to be
able to remove the ligature from a wound after the blood-
vessel on which it has  been applied is healed.   Many
weeks, and in some cases months,  have been found to
elapse before the ligature is detached,  during all which
time the sore is prevented  from healing, and  in some
cases hectic fever and a fatal termination have resulted.
There can  be no reasonable doubt entertained, that all
the processes requisite for the complete obliteration of a
blood-vessel, secured by ligature, are completed in a very
short space of time, probably  in two or three days.*  It
follows that if the ligature applied, be made  of materials
capable of  securing the  vessel during this space of time,
and liable to decomposition and solution in the  animal
fluids afterwards,  the  requisite  advantages  will  be ob-
tained. Dr. Physick was induced to believe that leather
would  be found to possess  these properties; he had re-
marked that the strips  of adhesive  plaster applied over
ulcers, retained their strength  of texture a few hours and
then became dissolved in the pus discharged from the sore;
should the  leather be found to dissolve too rapidly, there
were other  animal matters which he proposed to substitute.
  The first experiment made to ascertain the correctness
of these opinions, was the application of a buckskin liga-
ture to a large artery in a horse. It restrained the bleeding
and was discharged in a liquid state in two or three days.
   Sometime after this  experiment,  Dr. Hartshorne em-
ployed  ligatures  of animal  matter  for securing the
blood-vessels in the human  subject.  He amputated a leg
at the Pennsylvania Hospital, and tied up the vessels with
strips  of parchment, which were found  to  answer ex-
tremely well.  At the first  dressing the  ligatures  were
found dissolved, and never occasioned any inconvenience.
* Vide Travers' Experiments, in the 6th vol. Medico-Chir. Transactions. 
                ELEMENTS OF SURGERY.             4^
  Pursuing the enquiry, I performed a number of expe-
riments with various animal substances, as catgut, parch-
ment, various kinds of leather, &c.  The best method of
constructing ligatures which I have been able to devise,
is by cutting French kid leather into strips, from a fourth
of an inch  to half an inch in width, peeling off what is
called the grain,  or coloured,  polished  surface:  the
strips are then wet  and stretched—they gain greatly in
length and are diminished in breadth  by  this process;
and ligatures may be prepared of any requisite strength
by  varyiug the width of the strips.  I have employed
them^n amputations, and in a number of the capital ope-
rations, and never have seen any occasion to regret their
use, but on the contrary, to consider it one of the most va-
luable improvements in modern surgery.
  I have not  thought it requisite to leave the ligatures
hanging out of the wound, after accidents or operations,
but have cut them very close to the knot and treated the
case as if no ligature were employed.  In some instances
union by the  first intention has taken place, the ligature
probably being dissolved and absorbed, at least  it has
never afterwards appeared, but in others suppuration and
 abscess have been produced.
   Since the experiments above cited have been made, I
find that Mr. Lawrence has proposed to cut off the liga-
tures after operations, close to the divided vessels.  How
wrell the practice may succeed where they are composed
of durable materials, future experience  may decide, but I
cannot  forbear the expression of a belief, that the animal
ligatures will supplant all others except in a few particu-
lar cases which will readily suggest themselves to the
surgeon.   For example, in closing wounds of the abdo-
men, when they can be taken out at pleasure—in  cases
of hare-lip, &c.
  The leather ligatures are rather more bulky than those
  vol. 1.         8 
§0              ELEMENTS OF SURGERY.
made of thread or silk: a little practice, however,  will
enable the surgeon to make them very neatly, and to em-
ploy them in arming his needles, as conveniently as any
others.  In several  cases in  which I have  amputated
scirrhus breasts, and have necessarily removed much skin,
I have from the heat of the  weather, been induced to
dress the  patient on the third day, and at this period not
a vestige  of ligature  has been  observed, except at the up-
per part of the wound, when this has been dry, in which
case the leather is not destroyed so rapidly.
  The  femoral is the largest artery I have as yet secured
with  a  leather ligature; I should not, however,  ^sitate
to employ one for tying any other vessel in  the* body
when necessary. It would  be easy by soaking the liga-
tures in linseed  oil;  or in certain resinous substances, to
render them more  durable, but I have not found  this ex-
pedient necessary.*
  When  the bleeding from an incised wound is arrested,
the next thing demanding the  attention of the surgeon, is
the removal of all extraneous matter; the clotted blood,
dirt, &c. must be  carefully  washed away, and the sides
of the wound are then to be  approximated  and kept in
contact.  The measures to be employed for this  purpose
are  strips of adhesive plaster, compresses,  bandages,
and a proper position of the part, rest, and lastly sutures.
  The  adhesive plasters  are in most  cases  sufficient,
when aided by bandages and a proper posture, without
the use of the  needle.  The sides of the wound being
placed  in contact, are to be held so by an assistant,  and
the surgeon is to apply strips of plaster spread  on linen
or leather across the wound.  These strips should be of
considerable length,  so as to act on a large surface  of sound
skin, and from  half an inch to an inch  in width.  They
  * The first publication  on this subject was made by Dr. Physick, in the Eclec-
tic Repertory, dated July 9tb, 1816. 
                 ELEMENTS OF SURGERY.              g|
should be placed at a small distance one from the other,
so as  to  allow  the  escape of any extravasated  fluid
through the interstices.  If this caution be neglected, and
the plasters placed so as to cover the whole wound, they
often convert it into an  abscess,  by preventing an outlet
for superfluous blood or serum, and in case of suppura-
tion the pus is confined, the parts already united are torn
asunder, and the inflammation is extended.
   If,  from the small extent of the wound and other cir-
cumstances, there is reason to expect its union by the first
intention, or by  the adhesive inflammation, nothing  more
is necessary than to apply a compress of folded linen, or
a pledgit of dry lint over the adhesive strips, and secure
them  by a few turns of  a roller.
   Should there  be no good prospect of so speedy a  cure,
and reason to expect suppuration, a pledgit of lint spread
with simple cerate, and covered with a pledgit of tow or
folded linen, may be placed over the adhesive strips and
confined by the  many-tailed  bandage,  or roller; but it is
of no importance to make any difference of treatment  on
account of the uncertainty respecting the manner in which
the wound is to heal, and it is best to treat incised wounds
generally as if the union by the first intention were cer-
tain.  The pledgit of tow or linen  which adds somewhat
to the pressure, and is calculated to absorb any fluid which
may escape from the wound, may readily be superadded
if found necessary.
   lu  all incised  wounds the sides should be placed and
kept as much as  possible in contact.   There  can be  no
application to wounded  flesh  more  natural or proper than
the flesh from which it  has just been violently separated,
and if it do  not ad hereto it entirely, yet in all proba-
bility a very considerable part will, and thus the extent
of the wound will be lessened.
   The rapidity with which incised  wounds  sometimes 
52              ELEMENTS OF SURGERY.
unite, is really  astonishing to any one  not conversant
with these wonderful powers of nature.   I have  seen
a considerable tumour cut out from  the  breast, and in
forty-eight hours a complete union of the wound had
taken place.   The wound may be examined  in warm
weather in forty-eight  hours, in winter it is best not to
disturb the dressings for three or four days.
  If fever  and inflammation attend,  the usual depleting
remedies are  to be used; if on the contrary, there be rea-
son to apprehend tetanus, wine, opium, and a generous
diet are to be prescribed.
  The blood effused from the wound is in many cases
the bond of union in incised wounds,  but very often this
is  lost and adhesive inflammation supervenes; in this
case the secreted coagulating lymph becomes the uniting
medium, and this is soon assimilated to the wounded
part, becoming bone, tendon, muscle, or skin, according
as the wound has been in any of these parts.  The  cica-
trix  however, differs considerably from  the  originally
formed parts.
  Posture is  of great  consequence in the treatment  of
wounds.  The sides of a wound  on the anterior part of
the thigh cannot be kept in  contact,  unless the leg  be
kept extended upon the  thigh; to aid the surgeon stjll
more in relaxing the parts, the thigh should be flexed on
the pelvis.   A wound through the tendo achillis should
be treated by extending the foot upon the le<^, &c.
  Sutures by attending to these preceding directions are
very rarely necessary: and if possible they ought  to be
dispensed with, as they produce considerable  pain, oc-
casion great and permanent irritation by creating a num-
ber of punctured  wounds, whici#are  kept from healing
by the ligature left in them; this ligature passes through
a part of the original wound, and never fails  to excite 
 
/
PLATE  I.
^T   <t
        v. '■...■  ■
V-.V: -;-.--' .■■■:•■;■;  ,■■■--.

42§g|
'■->t~:±.j  I i.

. />/ /,///>/ -/■ /^W' fy */"&'<
'/naiMa/>ce<  J£kl Aovnl:
Ji\.Portiy >''-<* 
                ELEMENTS OF SURGERY.               53
suppuration in that part,  in addition to these objections,
sutures occasion deformity by increasing  the extent and
irregularity of the cicatrix.
  Notwithstanding  these objections, sutures are  some-
times necessary in  wounds  of projecting parts,  as the
ears, nose, tongue, lips, scrotum, &c. Sometimes the pe-
ritoneum is wounded, and in these cases ligatures are ne-
cessary to keep its edges in contact.  In all these instances
the interrupted, or  twisted suture  are to be used.  The
interrupted suture  consists in making the necessary
number of stitches with an armed needle, and tying them
in  such  a manner  as to keep the sides of the wound to-
gether.*  The twisted  suture  is chiefly  used in wounds
of the lip ; in the annexed plate these sutures are repre-
sented.  In the  twisted sutures ^two or more pins of sil-
ver with moveable  steel points are passed through the
flesh, and a  ligature twisted  round them,  so as to con-
fine the  sides of the wound in contact. In treating hare-
lip, this suture is generally employed.  The pins  ought
 to  be made  of smooth silver  wire,  the extremities  of
 which fit  into steel points which are taken  off when the
 ligature is applied.  If these  be not at  hand, a  piece of
 wire filed sharp at  the end will answer, but after the liga-
 ture is bound on, the point must be cut off with a pair of
 scissors, or a file.
   When  ligatures have been applied upon bleeding ar-
 teries, the ends of them are to be left long enough to pro-
ject  a short  distance out of the wound, they are to  be
 left out  of one of its angles, (the most  depending if prac-
 ticable) and the  wound treated as we  have already di-
 rected.
    When  in  cases  of incised  wounds it becomes evident
   * The knots should be on one side of the wound.  It is right to have, the
 needle shaped so as to form a regular segment of a circle, and to have two
 rutting edges continued from the point 
54              ELEMENTS OF SURGERY.
that union cannot be effected without  suppuration, the
adhesive plasters, and  every pressure, every irritation
are  to  be removed, and a  soft  poultice substituted.
When suppuration is fairly established and granulations
begin to form, the means already recommended for re-
taining the sides of the wound in contact, are  to be re-
sumed and a cure will generally be soon effected. 
ELEMENTS OF SURGERY.
55
                  CHAPTER X.

                Of Contused Wounds.

  In  contused wounds, besides the simple solution of
continuity, there is an injury of the adjacent flesh, great-
er or less according to the nature and violence of the
force applied.
  Contused wounds are produced  by blunt instruments.
It has already been remarked, that these wounds bleed
less  profusely  than simple  incisions, and the reasons of
this difference have been explained.
  The indications of cure are to  prevent excessive in-
flammation,  to wait for the separation of the bruised and
dead flesh, and when suppuration is established and gra-
nulations form, to approximate and retain in contact the
sides of the  wound.
  The best  local application is a boiled bread and milk
poultice. If inflammatory symptoms run high, blood-let-
ting is to be directed. If great pain or irritation come on,
opiates may be given;  should gangrene  result, a blister
is to be applied.
   Lacerated wounds partake of the  nature of con-
tusion, but there is a difference, as their  mode of union
proves. A severely contused wound never heals  by the
first intention,  because there is an interposition of clot-
ted blood and injured  flesh, between the sound parts,
whereas I have known half the scalp torn off  in a lace-
rated wound, and the whole of it has reunited  by the
first intention, except  the  edges  which were greatly
bruised.
   Punctured wounds have considerable depth,  aud 
56              ELEMENTS OF SURGERY.
very little external opening: they are made by pointed
instruments, as a  small sword, bayonet, nails, needles.
They are attended with various consequences, according
to the nature of  the parts injured.  In other wounds the
nature of the mischief is generally apparent; in punctur-
ed wounds, the surgeon is unable to ascertain with accu-
racy  the  parts  which  are injured;  important nerves,
blood-vessels or tendinous fasciae are sometimes wounded;
very violent inflammation  often follows a small  punc-
tured wound, and  collections of matters are  sometimes
formed, great irritation occasionally occurs, the consti-
tution  suiters  and fever comes on.  Tetanus is a frequent
occurrence after  punctured wounds, though I have as
often seen it  a consequence of other contused wounds.
Convulsions, tremour, and nervous affections, are also oc-
casioned.
  In the treatment of punctured wounds, the  first thing
demanding attention is  hemorrhage.  If any blood-vessel
of considerable size have been opened, it must be sought
for by dilating the orifice of the wound  with a probe and
scalpel; the vessel being exposed in this manner, should
be  tied up with a ligature. In some cases, the bleeding,
at  first profuse,  gradually ceases, and although from the
rapidity with which it flowed, there may be reason to ap-
prehend the puncture of a large artery,  yet the patient is
unwilling to suffer his wound to be dilated in order to se-
cure the vessel; and it is  a fact that such vessels have
sometimes healed without the interference of art. I have
been informed of a case in which a very large artery in
the thigh, probably the femoral,*  was opened by a small

  * I speak thus cautiously because there was no dissection, but I have no
 doubt that the wounded vessel was the femoral artery, because the stream  of
 blood was so copious at first as to lead the surgeons present to that opinion 
                 ELEMENTS OF SURGERY.               gy
sword, and although the stream of blood at first was very
alarming, yet it soon ceased, and did not recur, until the
tenth day, when an officious surgeon forced his probe into
the vessel and the patient died in consequence of the bleed-
ing; there is  great reason  to believe that this patient
would have recovered  but for the improper interference
of his  surgeon. Whenever therefore the bleeding ceases
spontaneously, or after the wound is dressed, the patient
should be kept still and watched carefully, as a return of
hemorrhage is to be appn hended. If the puncture be on
a limb, a tourniquet may be applied and left loose, so that
an assistant may have  it in his power in a moment to put
a  stop to the effusion of blood, until the artery is finally
secured by a ligature.
   The healing of a large artery, however, is an event sel-
dom to be trusted to,  and there is no surgical maxim of
greater importance than the  necessity of  tying  up all
wounded  arteries when it is  practicable.  It  is only in
cases where this cannot be done that the surgeon is to
avail himself of other means for suppressing the hemorr-
hage. As all such  means furnish important resources to
the surgeon, I shall mention a plan which I have known
successful in stopping the flow of blood from an artery in
the foot.  The patient  was a child in whom several una-
vailing attempts  to tie up the divided vessel had been
previously made, and  the wound was in a  state of great
inflammation.  A compress was  applied over the trunk
of the anterior,  and another  over that  of the  posterior
tibial arteries  about two  inches  above the ancle:  over
these a strip of sheet copper was passed round the leg,
and  a  tourniquet was  applied over the copper; in this
way, when the tourniquet was tightened, the tibial arte-
ries were compressed,  and the bleeding ceased, the cop-
per prevented the tourniquet from compressing any other
vessel, so that the circulation  in the foot was not inter-
   vol. r.         9 
58               ELEMENTS OF SURGERY.
rupted.  In a few days the  wound healed without any
recurrence  of hemorrhage. Probably  in some analogous
cases similar measures may be found successful.
  When punctured wounds contain  foreign substances
which are easily felt, they may be dilated sufficiently to
allow the extraction of these substances, but in most in-
stances it is best to permit them to be discharged by sup-
puration.
  When convulsions, or great nervous irritation follow,
the dilatation of a punctured wound frequently puts an im-
mediate  stop to these symptoms;  a small incision upon
a probe passed into the puncture, will suffice for this pur-
pose.
  When punctured wounds occur in extremely hot wea-
ther, it is safest to enlarge them by the scalpel, or to apply
stimulating substances to excite inflammation; there is
reason to believe that tetanus has in this way been often
prevented.
  Erysipelatous inflammation in some instances follows
punctured  wounds, especially of the scalp ;  an enlarge-
ment of the wound has been found useful in these cases,
and a blister should be applied over the inflamed parts.
   These are the  principal circumstances in punctured
wounds, which call for dilatation; when suppuration is
established, if matter  be formed and confined, an outlet
must be made for it as in any other case. The practice of
dilating indiscriminately all punctured wounds is highly
reprehensible.   A soft poultice is the best local applica-
tion.  If the pain be great, opium may be administered,
and if  fever or inflammation run high, bleeding and  de-
pleting remedies may become necessary. They are al-
ways, however, and particularly  in hot weather, to be
prescribed with caution, as they certainly render the sys-
tem more liable to  tetanus; punctured wounds some-
times unite by  adhesive inflammation, but  if  extensive
they generally suppurate. 
ELEMENTS OF SURGERY.
J*9
                   CHAPTER XI.

                 Of Gunshot Wounds.

   Since the application of gunpowder to the purposes of
 war, a new class of wounds has attracted the attention of
 surgeons, the nature and peculiarities of which have only
 within a few years been well understood.
   " Gunshot wounds are  made by the forcible projection
 of hard obtuse  bodies, the greatest number of which  are
 musket balls.
   " They vary according to the kind of body projected,
 the velocity of the body, and the nature and peculiarities
 of the parts injured.  The  kind of body projected, is prin-
 cipally musket  balls, sometimes cannon balls, sometimes
 pieces of broken shells, and very often on board of ship,
 splinters of wood.  The effects of cannon balls on different
 parts of the ship, are the principal causes of wounds in the
 sailor, for a cannon ball must generally pass through  the
 timbers of the ship before  it reaches him;  a greater num-
 ber will be wounded by the splinters thus torn off, than
 by the ball itself. The wounds occasioned by these splin-
 ters, differ  in  no  respect from contused  and lacerated
 wounds from other causes.
   " Gunshot wounds are  in  general contused wounds,
 from which contusion there is most commonly a part of the
 solids surrounding the wound deadened, as the projecting
 body forced its way through these  solids, which is after-
 wards thrown off in form of a slough, and which prevents
such wounds from healing by the first intention, or  by
means of the adhesive inflammation, from which circum-
stance most of them must be allowed  to suppurate. This
does not  always  take place equally in every  gunshot 
gQ              ELEMENTS OF SURGERY.
wound, nor  in every part of the  same wound; and the
difference commonly arises from the variety in the velo-
city of the body projected;  for we find in many cases,
where the ball has passed with little velocity, which is
often  the case with balls, even at their entrance,but most
commonly at the \*H last wounded by the ball, that the
wounds are often healed by the first intention.
  66 Gunshot wounds, from the circumstance of commonly
having a part killed, do not generally inflame so readily
as those from other  accidents; this backwardness to  in-
flame, will be in the proportion that the quantity of dead-
ened  parts bear to the extent of the wound.
  "From the circumstance of a part being deadened, a
gunshot wound is often not completely understood at first;
for it is at first, in many cases, impossible to know what
parts are killed, whether  bone, tendon, or soft part, until
the deadened part has separated, which makes it a much
more complicated wound than at first was known or imagin-
ed ; for it very often  happens, that some viscus, or a part of
some viscus, or apart of a large artery, or even a bone, has
been killed by the blow, which does not show itself till the
slough comes away. If for instance, it is a part of an intes-
tine that has received a contusion, so as to kill it, and which
is to  slough, a new  symptom will most probably appear
from the sloughs being separated, the contents of the in-
testine will most probably come through the wound; and
probably the same thing will happen when any other con-
taining viscus is in part deadened; but those cases will
not  be so dangerous, as if the same loss had been pro-
duced at first, for by this time all communication will be
cut off between the containing and contained parts;  nor
will it be so dangerous as when a considerable blood-ves-
sel is deadened;  for in this case, when the slough comes
 off, the  blood, getting a free passage into the wound, as
 also  out of it, probably death will immediately follow. If 
                 ELEMENTS OF SURGERY.              (ft
this artery is internal, nothing can be done;  if in an ex-
tremity, the vessel may generally be taken up. When the
bone  is  deadened,  an  exfoliation  must  take place."
(Hunter.)
  The  velocity with which  the ball passes has a great
influence on the circumstances of these accidents.  If  the
velocity be small, there is not so great a chance of their
being compounded with fractured bones;  but if the  ve-
locity be sufficient to break the bone it hits, the bone will
be  much  more splintered than  if the velocity had been
very considerable, for where the velocity is very great,
the ball as it  were, takes  a piece out.  In a very hard
bone the splinters will be most  numerous. The direction
of a ball is influenced by the celerity of its motion. If it
move with but little force, it is easily altered from its
straight direction, by a bone; where the velocity is great-
est, the course is most direct.
   The greater the velocity  of a bullet, the greater will
be the extent of the deadened parts, consequently  the
 slough is always  greater at the entrance than at the-exit
 of a ball, and in  some cases the part at which it passes
 out, heals by the first intention  or by suppurative inflam-
 mation without casting off any slough.
   Gunshot wounds like all other coutused wounds, bleed
 less than simple incisions, the explanation of this  has
 already been offered.   If,  however, large vessels  are
 killed by the ball, when the sloughs separate there  will
 be great danger of hemorrhage from  the opening formed
 in the artery.
    There is very frequently  extraneous  matter  contained
 in gunshot wounds, as the  bullet carries in with it all
 the  clothing  which had been on the wounded part,  and
 often remains itself  in the wound, much altered in form
 from the effects of  bones upon it. 1 have seen a bullet
 beat out nearly as  thin  as paper, by passing through a
 rib and lodging in one of the vertebrae. These extraneous 
g^              ELEMENTS OF SURGERY.
substances however do less  mischief than in  any other
kind of wounds, because as they are  in contact with
dead parts, they occasion no irritation, and as these dead
parts are themselves  foreign matter and must be dis-
charged by suppuration, the  wound is not much delayed
in healing by their presence.

           TREATMENT OF GUNSHOT WOUNDS.
  The various phenomena of gunshot wounds, being of
a nature not very readily explained by the older surgeons,
induced some to believe that they were poisoned,  others
imagined the ball to be  intensely hot, and supposed the
peculiarities of these accidents to depend on  the burning
of the sides of the wound.  The essential difference, and
the only difference between  gunshot and other contused
wounds, is found to consist in the death of  those parts
through which the ball has passed, and  the necessity for
the separation of these parts before union can be effected.
  It was formerly the  custom  to  dilate  all gunshot
wounds, and much mischief has  resulted from the prac-
tice. There is nothing in the nature of this kind of ac-
cident  that calls for dilatation in every case,  nor is there
any thing forbidding the practice when particular cir-
cumstances render it proper.  If an artery be opened by
a gunshot wound, and the enlargement of the wound by
a knife will enable the  surgeon  to  tie  it up, he ought
surely  to perform the  operation.   In general it is unne-
cessary to dilate a gunshot wound for the purpose of ex-
tracting a bullet or other extraneous matter, because sup-
puration must come on, and  this process will generally
effect the object.  If extraneous matter is perceived, and
can easily be removed, it may be done; but it is wrong
to enlarge the wound  or take much pains to effect, what
will be more readily done at a future period.  The same
reasons which would  induce a surgeon to dilate a punc- 
                ELEMENTS OF SURGERY.              63
tured wound, or any other kind of wound, should lead
him to dilate a gunshot wound, these reasons have been
already stated.
  When a  ball can be  found without difficulty, it is
right  to extract it by means  of forceps, the course of a
ball however is so extremely irregular, that we are  not
always able to  find it.  The glancing of balls is in many
cases very  surprising.  Mr. Hunter  has seen a bullet
enter the skin over the tibia, and pass round the leg  un-
der the skin without injuring either the bone or the skin.
Wiseman relates cases where balls have passed through
joints without occasioning an injury to the bones or car-
tilages.  When the velocity of a ball is nearly spent, a
slight resistance will turn it from its course; balls have
been  known to pass  round half the  skull between  the
cranium and scalp, and then pass out opposite the part
at which it entered.  In the same way they have passed
round the thorax, and glancing from a rib and kept from
passing out by the resistance of the skin.  Mistakes have
been  occasioned by these irregularities,  and bullets are
said to have passed through the head  and chest in many
cases where no such thing has happened.  The posture
of the  body when the wound was received,  should be
attended to when the course of a bullet is searched for;
a ball has entered the arm and been found on the  oppo-
site side of the body, owing to the horizontal posture of
the limb when wounded.
   In many instances balls  pass immediately under the
skin to a considerable distance, their course being mark-
ed by a red line extending from the spot where it  enter-
ed, to that at  which it escaped or is lodged.  Where
bullets are  lodged superficially under the skin, they may
with great safety and propriety be cut out, and no mis-
chief in general arise from this new  opening.  The
propriety however of extracting balls thus  situated  has 
64              ELEMENTS OF SURGERY.
been questioned, and  Mr. Hunter  remarks, that  if the
skin over it be quite sound, he would " in  that case ad-
vise letting it alone, until  the wound made  by the en-
trance of the ball had  inflamed and was suppurating."
His reasons for this direction are, " 1st. We find that
most wounds get well  when the ball is left in (except-
ing  it has done other  mischief than  simply passing
through the soft parts) and that very  little  inflammation
attends  the wound where  the  ball  lodges, only  that
where it enters, the  inflammation  not arising  so much
from the injury done by the ball, as from the parts being
there exposed to the suppurative  inflammation, if it  is
immediately removed. There is always a greater chance
of a slough where the  ball enters than  where it rests,
arising from the greater velocity  of the ball, for beyond
where  the  slough is, the  parts unite by  the first in-
tention."
  " 2dly. In those cases where the ball passes through
and through, we have  two inflammations, one at each
orifice, instead of the one at the entrance, or a continued
inflammation through and through, if the ball has pass-
ed with great velocity.  Where  the ball makes its exit,
the inflammation passes  further along  the passage ol the
ball, than when the wound has been healed up to the
ball and then cut out afterwards, so that by opening im-
mediately the irritation will be extended further, and  of
course the disposition for healing will be prevented.   If
this is the case, I think that two wounds should not be
made at the same time, and what  convinces me more  of
it  is, that I have  seen  cases where  the balls were not
found at first, nor even till after  the patients had got
well of  their wounds, and these  balls were found very
near the skin.  They gave no trouble (or else they would
have been found sooner) no inflammation came upon the
parts,  and afterwards  they were extracted  and did
well." 
                ELEMENTS OF SURGERY.              65
  ({ Again I have seen cases where the balls were found
at first, and cut out immediately, which were similar to
balls passing through and through: the  same inflamma-
tion came on the cut wounds that came on the wounds
made by the entrance of the ball."
  On these remarks of Mr. Hunter, I beg leave to offer
a few observations.  A musket or pistol bullet will doubt-
less in a majority of  cases excite no unpleasant symp-
toms, the parts will  heal around  it forming a sac; but
a bullet is always extraneous matter, and in a majority of
cases carries with it other extraneous matter, cloth, linen,
&c. which cannot fail to irritate the flesh in which they
lodge; they act like setons in keeping up suppuration
and preventing the  union of the wound, effects which I
have witnessed in several cases; in one  a very large ab-
scess  was formed on the back in consequence of a ball
being suffered  to remain  nineteen days under  the skin
near the angle of the scapula.
  It is  with great diffidence that I would venture to op-
pose on a practical point, the authority  of  Mr. Hunter,
but I cannot but believe it right whenever a ball presents
itself in such a situation, as that it may be extracted with
facility,  and without risque  of injuring any important
part to remove it immediately, without waiting  for sup-
puration.  The wound made by the knife may common-
ly  be healed by the first intention.  The ball should be
suffered to remain whenever it is  deeply  buried in the
flesh.  All other extraneous matter if  easily  removed
should be extracted, but probing or other violence must
be  avoided; the finger is to be preferred  to all instru-
ments in examining gunshot wounds.
  Sometimes bullets  are lodged in the substance of the
bones, all violent attempts to remove them are wrong; the
bone will exfoliate,  and when suppuration  takes place,
the ball will be discharged. In some cases balls and other
  vol.  i.        10 " 
    t>.>
 66            ELEMENTS OF SURGERY.
 extraneous matter have remained in bones  or in the soft
 parts during life, without exciting any unpleasant effects,
 but sometimes they produce suppuration and are evacu-
 ated long after the wound has healed.   A very remarka-
 ble instance of this kind, I shall quote from a letter with
 which I have been favoured by Mr. John Randolph, of
 Roanoke. Major S. was wounded in the arm at the bat-
 tle of Germantown: " the wound healed, but was  occa-
 sionally painful and once or twice suppurated and healed
 again. At length, about twenty-five years after the injury
 had been received, the wound broke out for  the last time,
 when a small shred of woollen cloth, recognized by the
 patient as a portion of his coat, and another of linen, were
 discharged; they seemed to have undergone no sensible
 alteration except saturation with the  pus and sanies in
 which they were immersed."
   For the removal of musket balls, a variety of forceps
 have been constructed. A prize was given by the French
 Academy of Surgery to Mr. Percy for one which appears
 to answer extremely well. The instrument is represented
 in PL II.  When a leaden  ball is lodged in a  bone, the
 screw which is contained in one of the handles  may be
 easily made to enter it, and it can be extracted.   This
 screw, however, is so seldom needed, that it is omitted in
the bullet forceps used in the service of the United States.
  When an extremity has been shattered  by  a cannon
ball, the extent of injury is  in some instances so great as
to require the immediate removal of the member, we shall
mention the circumstances which call for this operation,
when we treat of amputation.
  The best local application to a gunshot wound, is a soft
poultice of bread  and milk, or linseed, to be continued
until the sloughs separate and suppuration is established.
The treatment is to be similar to that of  any other con-
tused wound. The state of  the constitution must be very
carefully attended to. 
tWty's  />////</  fonrps
VI. V.
;» 
 
               ELEMENTS OF SURGERY.               67
  When there is reason to apprehend that the parietes of
any considerable blood-vessel has been killed by the ball,
great care should be taken to attend to the separation of
the sloughs, as  serious and fatal hemorrhages have some-
times resulted from neglecting this caution.
  When bones are injured, the  soft parts in some cases
heal up, and when the injured bone exfoliates, an abscess
forms,  and the wound must be opened afresh. 
68               ELEMENTS OF SURGERY.
                  CHAPTER XII.

                 Of Poisoned Wounds.

  Poisoned wounds are those attended with an  intro-
duction of certain healthy or morbid secretions of animals
or vegetables capable of producing disease and death; as
the bite of a venomous reptile, of  a rabid animal, or a
wound with a poisoned arrow.*
  The sting of a bee, wasp, or hornet, the bite of a mus-
quitoe, and certain other insects, although in degree very
moderate, probably partake somewhat  of the nature of
poisoned wounds. It is unnecessary  to say much of these.
Although frequent in their occurrence, they are generally
not so  severe as to require medical aid. The sting of a
bee, wasp or hornet, is always extremely painful,  and is
followed by inflammation,  and sometimes by great tume-
faction.  Cold  applications  afford  great relief.   Cold
water or lead water may be used.  When the  patient has
been attacked by a swarm of these insects, and his head
and face (which generally  in these cases suffer) are much
swelled, bleeding and a purge become necessary.
   The bite of the musquitoe is in  some parts of our coun-
try extremely annoying, and excites considerable inflam-
mation, attended with intolerable  itching.  In some rare
instances, owing probably to peculiarity of constitution,
gangrene has resulted from the bite  of this insect. I once
knew a case of it fatal in a lady of this city, whose health
previously was very good.  Camphorated spirits, brandy,

  • With respect to the manner in which poisons act in producing death, the
reader is referred to Fontana; the late experiments ofMr. Magendie upon the
» upas tieute," and also to the interesting experiments of my friend Mr. Brodie,
related in the Transactions of the Royal Society  of London, 
                ELEMENTS OF SURGERY.               69
or vinegar, generally afford relief of the itching, and the
inflammation in a few hours commonly subsides. Violent
rubbing to allay the itching should be avoided.
  The rattlesnake, one of the most venomous reptiles in
the world, is found in many  parts of our country.* Like
the cobra de capello in India, the bite proves speedily
fatal, and wre have very few histories of the effects of the
poison.
  Professor  Barton,  whose  indefatigable labours have
thrown light on every branch  of physical  science, has
published  in the 3d  vol. of  American  Philosophical
Transactions, a  valuable paper on the subject, to which
the reader is referred for much interesting information.
  It  appears from Dr. Barton's  remarks, and from the
observation of others, that " in the season of supervening
languor and  torpidity, the rattlesnake  in particular bites
with  seeming reluctance,  and  without any or with but
little ill  consequence  arising  from the  wound;"  and
"even in those seasons when  the sun powerfully exerts
its  influence, at which times these  animals are best quali-
fied to strike and to  injure, individuals  of the species
must be  often  found, the cavities  of  whose venomous
fangs are entirely or nearly destitute of their active poi-
son, from the introduction of which into their body those
alarming  symptoms  which  characterise  the successful
bite of this animal arise." Three chickens were bit by a
rattlesnake kept in a cage, on three  successive  days.
The first died  in a few hours;  the second survived much
longer than the first;  the third swelled much, but never-
theless recovered.  On the fourth day several chickens
were bitten, without receiving any injury.   These cir-
cumstances are mentioned by  Dr. Barton, to shew  that
the various  supposed vegetable  specifics for the bite of

  * There are several species of crotalus.  I refer to the " crotalus horridus,"
which is the most common species. 
yO               ELEMENTS OF SURGERY.
the rattlesnake owe their reputation to their having been
used in cases where no bad effects would have resulted.
  As the poison of the rattlesnake  " exerts its principal
effects  on  the sanguiferous  system,"  immediate care
should be taken to cut off the circulation of blood through
the wounded part. When the poison enters a considera-
ble vein or artery, death  in general speedily ensues;
often in the space of two minutes.   Of this Dr. Barton
has been assured from  a variety of sources, although he
is  unwilling to  believe the wound  necessarily mortal.
The wound being generally in the lower extremities, he
recommends the immediate application of a tight ligature
round the limb, to prevent the access of the poison to the
circulation  either by the veins or absorbents.  " As poi-
sons of various  kinds  are liable to be detained for some
time in the glandular appendages of the absorbent system,
it would perhaps be of use to scarify these parts, and ap-
ply a blister to them, in order to promote the discharge
of the poison." When the glands in the groin swell, as
they speedily do after a bite in the foot, the scarifications
are to be made there, and a prompt vesication  excited by
the bark of the Daphne Gnidium.
   I think there can be no doubt of the propriety of ex-
tirpating immediately the wounded part,  as this will ef-
fectually cut off all communication with the  circulating
blood.  The use  of the  numerous  vegetable remedies
which have been employed  in  these cases appears en-
titled to but little attention. The internal administration
of volatile  alkali has been very often employed, but pro-
bably its virtues are much overrated.
   "When the  poison of the  rattlesnake has actually
been introduced into the general mass of blood, it begins
to exert its most alarming and characteristic effects.   A
considerable degree of nausea is a very  common symp-
tom. We now discover an evident alteration in the pulse;
it becomes  full, strong and greatly agitated;   the whole 
                ELEMENTS OF SURGERY.              yj
body begins to swell;  the  eyes become so entirely suf-
fused, that it is difficult to discover the smallest portion
of the adnata that is not painted with blood.   In many
instances there is an hemorrhage from the eyes, and like-
wise from the nose and ears; and so great is the change
induced in the mass of blood,  that large quantities of it
are sometimes thrown out on the surface of the body in
form  of  sweat.   The teeth  vaccillate in their  sockets,
whilst the pains and groans of the unhappy sufferer too
plainly inform us  that the extinction of life is near at
hand."  •
   " In this stage of its action, and even before it has in-
duced the most alarming of the symptoms which I have
mentioned, the powers of medicine can do little to  check
the rapid and violent progress of this poison.   The em-
ployment of the ligature, the use of the blister, and of the
other modes  of treatment which I recommended  in the
local stage, it is obvious to remark, will be of little,  if any
benefit here." (Barton.)
   Perhaps the same remarks will be found applicable in
cases of bites from the other venomous serpents of  Ame-
rica, but my own experience does not warrant me  in of-
fering any thing on this subject.
   The bite of rabid animals is in all instances to be treat-
ed by extirpation with the knife, and when  any  doubt
exists as to the removal of all  the injured parts, caustic
should be applied, so as to render  their separation abso-
lutely  certain.  This is to be done even if months have
elapsed after the healing of the wound,  upon the prin-
ciple  of leaving nothing undone which can possibly be
instrumental in preventing so terrible a disease as hydro-
phobia.
  Inoculation with morbid poisons is foreign from our pre-
sent subject, and with respect to poisoned arrows, and the
effects of the " upas tieute," I refer to the experiments
of Mr. Magendie. 
7^
ELEMENTS OF SURGERY.
                 CHAPTER XIII.

               Of Particular  Wounds.

  The Scalp is liable to all the varieties of incised and
contused wounds; they are often accompanied with in-
juries of the brain.   A mere w ound of the scalp is to be
treated as a similar wound in any other part.  The hair
is to be carefully shaved, the extraneous mattef removed,
the divided parts replaced in contact, and secured so by
adhesive plaster, or if necessary, by stitches. The vessels
of the scalp  seldom  bleed so as to require the use of a
ligature.  When a large artery, however, is opened, as
the occipital,  or one of the principal branches of the tem-
poral,  it must  be taken up:  the needle is found more
convenient for tying up arteries in the scalp than the te-
naculum.
  Punctured wounds of the scalp often occasion  violent
inflammations, in consequence of the parts underneath the
tendon of the occipito frontalis muscle being injured.  The
usual remedies for inflammation relieve it.
  In extensive  lacerated  wounds great portions of the
scalp are separated, leaving the pericranium, and in
some places, the bone bare.   It was the practice  for-
merly  to remove all such detached portions by the knife,
than which nothing can be more absurd.   The doctrines
of  adhesion, taught by Mr. Hunter, have in this, as in
many other important instances, triumphed over the bar-
barisms of former ages, and demonstrated the propriety
of  preserving,  in every instance, the separated scalp.
The parts are to be cleansed and placed in contact, and
they will generally unite by adhesive inflammation;  and
if suppuration  should even take place, granulations will 
                ELEMENTS OF SURGERY.             78
form, and the union, though more tardy, will be equally
certain.  I have seen  nearly one half the scalp torn off,
and  covered  with dirt and splinters  of wood, which,
when carefully cleansed and replaced, united in  a few
days with very little suppuration.

                 WOUNDS OF THE FACE.
  The face is liable  to  the various kinds of wounds
which have been described, and they require no particu-
lar mode of treatment  from their situation, except that it
is of peculiar importance to make the  cicatrix as small
and  as smooth as possible, to prevent deformity. Sutures
are of course  to be  avoided,  and sticking plaster to be
used.  In wounds of  the eyelid, however, it  sometimes
happens that  a stitch  or  two is  necessary.   In these
cases care must be taken not to pass the ligature through
the adnata, as in that case great  irritation  will be the
consequence.
   In the treatment of wounds of the eye,  the great
objects are to extract all foreign matter and to make use
of very powerful  measures to prevent  and relieve the
inflammation of this important organ. The various reme-
dies for inflammation  of  the eye will be detailed when
we speak of ophthalmia.
   Where the  lip is cut through, if the wound be small,
sticking plaster will be found sufficient to keep its  sides
together; but if it be half an inch  or more in extent, the
interrupted or twisted suture will be necessary.  When
the tongue is cut,  stitches must be used.  In children
we often find the tongue wounded by the teeth in conse-
quence of falls.   A hook is in  these cases generally ne-
cessary to keep the tongue sufficiently  forward to enable
the surgeon to perform the operation.   A piece of soft
wood should be placed between the teeth to prevent the
child from biting the  surgeon.  Tn the course of six or
   VOL. 1.         II 
7^               ELEMENTS OF SURGERY.
eight days the stitches may be removed.  During the
cure the child  should not be allowed to chew any solid
food, but must be nourished entirely on fluids.
  When the ears  are wounded, if a portion is nearly
detached, stitches are necessary; but in many cases the
adhesive plaster  is found equally  effectual, and should
therefore be preferred.
  Contused wounds of the face are to be poulticed until
suppuration commences and granulations form, and then
the adhesive strips are to be applied.

               wounds of the throat.
  From the important parts which are here situated, and
from  the magnitude of the blood-vessels generally divi-
ded, wounds of the  throat are among the most dangerous
to which the surgeon is called.
  Superficial wounds of the throat require no particular
treatment,  but  generally  heal as readily as wounds  of
other parts. Sometimes, however, the trachea is divided,
together with large  veins and arteries, even the oesopha-
gus,  and carotid artery, without  immediate death.—
Whenever the carotid artery is opened freely by a sharp
instrument, fatal hemorrhage very promptly takes place:
but Mr. Abernethy  has recorded an  instance in which a
lacerated wound  of this vessel  was occasioned by the
horn of a cow, and the bleeding was not attended with
fatal consequences.  Wounds of the throat most frequent-
ly occur  in attempts to commit suicide;  and as the in-
strument is commonly a razor or  very sharp knife  the
hemorrhage is profuse, and is always the first thin°- de-
manding attention.
  Every bleeding vessel should be immediately secured
by a ligature.   The external jugular veins are generally
opened, and these, as well as the divided arteries, are
to be tied.  The carotid itself  should be tied up, if the 
                ELEMENTS OF SURGERY.               75
surgeon arrive in time to effect it. Mr. Abernethy, in the
instance just noticed, secured this vessel by a ligature,
and his patient survived thirty hours.  He remarks that,
" should it become necessary at any time to tie the carotid
artery, it may be done without much difficulty or danger,
even without  an accurate dissection of the part.   If the
incision be made on that side of the artery which is next
the trachea where  no important parts can be injured as
was done  in the present instance, the finger can then be
passed behind the  artery so as to compress it.  The ves-
sel being sufficiently bulky and firm to make its form and
outline distinctly perceptible, a needle may then be pass-
ed behind the artery as near as  possible  to that edge of
it which is next to the  internal jugular vein; there can
be little risk of wounding that vessel, or of including in
the ligature the eighth pair of nerves  which lies between
them. In attempting to secure the  carotid artery, I passed
behind it in the manner described, a blunt hook with  an
eye in  the point,  and  having previously introduced  a
ligature into it, I drew back the instrument and thus en-
closed the artery.
   In an incised wound of the carotid artery a  very dif-
ferent  and much more expeditious method would be ne-
cessary.   The operation has  hitherto never been done,
but a case may possibly occur in  which the surgeon may
be present.  In such a case I can see no  impropriety in
passing a  sharp armed needle  round the carotid without
attending  to  nerves  or  any thing  else.   This ligature
being given to an assistant, a second should be instantly
passed in  the same manner round the upper orifice. The
hemorrhagy could  now be restrained until the wounded
vessel could be  drawn out separately with a tenaculum
or forceps, and both its cut extremities tied;  after which
the first ligatures  which  had been used  as tourniquets
should be removed. 
76              ELEMENTS OF SURGERY.
  The hemorrhage being stopped, the sides of the wound
are to be brought together, if possible without the use of
stitches.   Where  the trachea is only partially  divided,
adhesive plaster may always be used; if it be cut com-
pletely through, it is generally recommended to make
use of the interrupted  suture;  but in some  cases  the
stitches occasion great irritation, and are  ulcerated out
before the union of  the  wound, leaving it in the same
state  in which  it had been before  the use of the needle.
The interrupted suture is, however to be used, whenever
the wound of the trachea cannot be approximated without
it; and whenever it  is used, great care must be  taken to
pass the  needle merely through the cellular texture sur-
rounding the trachea, as  the thread, if allowed to pass
through  the  inner membrane of this canal, would add
greatly to the irritation.   In  addition to  this the head
must  be  bent forward so as to favour the approximation
of the sides of the wound, and it is to be kept so by
bolsters and  bandages: care, however, is necessary  in
all such cases,  to  guard against a collection of blood or
mucus in the trachea, as death has been occasioned by a
neglect of this caution.   Whenever blood flows in this
way into the trachea, and is not readily coughed up, the
wound should  be  opened, in order that it may be dis-
charged.
  Where the cesophagus is  also opened,  it is  difficult,
unless the external wound be very extensive,  to make
any application to it. Desault in these cases recommends
the introduction of  an elastic  catheter of large, size,
through which the necessary food  may be  injected into
the stomach,  and this practice has been found extremely
useful in a number  of cases.   It  should be suffered to
remain during the cure, and will produce  no ill effect,
but on the contrary will preclude all that irritation which 
                ELEMENTS OF SURGERY.              77
would arise from  the action  of the muscles in attempts
to swallow.   The tube may be passed either through the
mouth or nostril, according to circumstances.  The oeso-
phagus is sometimes punctured by a sword, bayonet, or
knife,  without any wound of the trachea.   In this case,
if the  blood-vessels  escape,  the wound generally heals
readily.
  The great contraction of the parts in large wounds of
the throat produces a very unpleasant appearance of loss
of substance. I have seen several cases in which scarcely
any soft parts intervened between  the lower jaw and the
sternum; the throat seemed to have sunk into the thorax,
or to have been cut away and removed. In the Medical
Commentaries  a case is related by Mr. Stark, in which
this retraction was so great that " between the clavicles
and os hyoides there was only one continued gash, which
looked as if the windpipe and gullet had been cut  out en-
tirely."  In these cases great attention must be paid to
keeping the head close to the top of the chest.
  Longitudinal wounds of the trachea heal  in general
without difficulty by the application of sticking plaster. •
  It has been doubted  by some surgeons, " whether the
oesophagus  can ever be wounded without destroying at
the same time the large blood-vessels and  nerves, so that
the patient must instantly die."*  There is no  doubt that
the escape of food and liquids through the  external open-
ing has been considered a proof of a wound in the oeso-
phagus in cases where the knife or  razor  has passed
above the os  hyoides  and entered the mouth; but it is
equally certain, that in many cases the trachea has been
completely divided, and the oesophagus not merely open-
ed, but cut  nearly asunder, the wound extending almost
to the cervical vertebrae, without injuring  the carotid ar-
* Latta, Vol. UT. p. 131 
78               ELEMENTS OF SURGERY.
teries.  Mr. Stark's case was of this kind.  " The pha-
rynx was cut through, except about a finger's  breadth of
the back part."  I have seen a case  nearly  similar, in
which the trachea was cut  completely  asunder,  and the
oesophagus opened, without any wound of the  carotid ar-
teries. 
ELEMENTS OF SURGERY               79
                 CHAPTER XIV

          Of Wounds penetrating Cavities.

  The thorax and abdomen are sometimes opened, and
very dangerous  consequences often result, especially if
any of the viscera contained in these cavities be injured.

              WOUNDS OF THE THORAX.
  When  the thorax is  wounded to a depth sufficient to
open the cavity  of the pleura,  the admission of air pro-
duces an  immediate collapse of the lung, and breathing
is performed with great difficulty. The lung so completely
fills the cavity of the chest that it is generally injured in
gunshot wounds and in stabs with a dirk or sword. When
this is the case blood is coughed up.  If a considerable
blood-vessel is opened either in the parietes of the thorax
or in  the  lung, blood collects in the cavity of the chest,
produces  great oppression, and increases the difficulty of
breathing.
   When  the wound is a simple incision through  the pa-
rietes of the thorax, it should be dressed with adhesive
plaster, its sides being accurately brought in contact.  A
compress  should be next applied, and over this a roller
moderately tight round the chest.  The patient should he
kept at rest, and observe a strict antiphlogistic regimen,
and be bled  to prevent the accession of inflammation.
Treated in this  way, incised wounds of the thorax very
generally heal  without  difficulty.   The great object of
the surgeon in every such case is to effect as speedily as
possible  the union of the wound, because whenever the
cavity of the thorax is opened, unless union by the first
intention  or by adhesive inflammation takes place, violent 
80              ELEMENTS OF SURGERY.
inflammation comes on, frequently followed by fatal con-
sequences.
  The practice of closing the external wound after a vio-
lent effort to force out the air from the pleura, and  in-
deed all  attempts to draw the air out from it, are unne-
cessary; the wound  may be closed without attending to
the state of respiration, and the air left in the cavity of the
chest will be absorbed without occasioning any ill effects.
  The  great anxiety which  has been shewn to evacuate
the air, originated in an  opinion that  the air of the at-
mosphere is a violent irritant, capable of exciting great
inflammation: an opinion not at all founded in truth.  In
the year 1790, Dr. Physick injected air into one side of
the thorax of a kitten, through a small puncture between
the ribs.   The  wound healed by the first intention, and
appeared to occasion  very little inconvenience to the ani-
mal.  On the fourth day the  kitten was killed, and not a
vestige  of inflammation was observable.  Many  cases
have occurred in the human  subject in which the cavity
of the pleura has been filled with air in consequence of a
wound, and the wound  being speedily healed, no inflam-
mation has resulted.  I  once saw an officer who had been
wounded with a dirk;  the air entered and passed out of
the  wound freely during respiration;  this wound uni-
ted by  the first intention, and in a  week  he was com-
pletely  well,  not having experienced a single  symp-
tom of thoracic inflammation.*
  It happens in many cases  that the existence of pulmo-
nary disease occasions adhesions between the pleura cos-
talis and pleura pulmonalis, in  such a  manner as par-
tially or even totally to  obliterate the cavity of the pleura,
When a wound is received in the chest under these cir-
  * It is remarkable that the French surgeons, and indeed many others, retain
this strange notion of the irritating nature of atmospheric air.  The principal
case in which it irritates, is when it occasions fermentation in the cavity of an
abscess. 
               ELEMENTS OF SURGERY.               g£
cumstances the danger of inflammation is  much dimi-
nished.
  Whenever inflammation comes on in consequence of a
wound in the ehest, bleedings, copious and repeated, must
be employed; all the remedies for inflammation are to be
vigorously  administered, and  in general they are suc-
cessful.
  When the  lung is wounded, the patient will cough up
blood, and if a large vessel be opened, (and a great num-
ber exist in the thorax of the largest size) fatal hemorr-
hagy will in general quickly ensue, and yet the heart itself
has  in some cases been wounded, and also the aorta,
without immediate death.
  There is reason to  believe  that the  heart has often
been slightly wounded without fatal  consequences, and
Dr. Babington has related a very interesting case in which
the heart was wounded by a bayonet  without immediate
death. The patient was a marine on board a ship of war,
and acting  as sentinel at the gangway, fell through to the
lower deck, and caught upon the point  of  his bayonet.
" It entered  his side a little below the false ribs, nearly
in a perpendicular  direction, and had penetrated to its
hilt, having sustained the weight of his whole body. The
poor man at  the time did not feel himself much wounded.
He drew out the bayonet without assistance, rose, lifted
his musket, said  he was not  much hurt, and, as if he
thought himself still fit to continue sentinel, walked eight
or ten steps,  then dropt down  suddenly in a faint.  On
being laid in a horizontal posture he soon recovered, and
was brought  to the  hospital (at Haslar) about 7 o'clock in
the evening, which was about two hours after the accident.
He then made very little complaint of pain,  but lay con-
stantly on the side opposite to that which was wounded,
was inclined to sleep, and when asked a question, spoke
  vol.  i.          13 
g&              ELEMENTS OF SURGERY.
slowly, as if in great distress. The wound was in the left
side, about two inches above the hip bone, and penetrated
into the  cavity of the belly, but neither its direction nor
depth could be ascertained. He did not seem to have bled
much, but  was very faint, his  body cold, and the pulse
scarcely  perceptible.  The circulation was  so  languid,
that, though  a vein was  opened in both arms,  no blood
could  be obtained."  He soon after his admission into
the hospital  began  to breathe  with difficulty, (which at
first he had not clone.)  A great sense of weight was ex-
perienced  about  the chest.  He felt some  pain in the
breast.  A swelling next took place, proceeding from
the breast all over the body. A little after two o'clock in
the morning, (nine hours after the wound was received,)
a sudden strangulation in the  throat put a period to his
life.
   Upon dissection  it  was found that the  bayonet had
penetrated through the integuments, the abdominal mus-
cles and peritoneum, had pierced the colon, the stomach,
the left lobe  of the liver, the diaphragm, and entered the
thorax at its centre.  Immediately within the breast the
pericardium  had  presented and yielded the instrument a
ready passage to the heart.   The right ventricle there
received it.  The point was thrust in at the lower part
of the ventricle,  and  had forced  its way out near the
valve.   From the heart,  again passing the pericardium,
it pierced  through both the upper  and middle lobes of
the lungs, but even these were insufficient to  detain  it.
It forced a  passage on the right side near the sternum,
between the  cartilages of the second and third ribs, and
had  sheathed its  point beneath  the pectoral muscle.
 That  muscle was slightly wounded, but the integuments
 above it were unhurt.  A little bloody serum was found
 in the cavity of the belly, but scarcely any pure  blood.
 The pericardium  contained a little blood.  The ri°-ht 
                 ELEMENTS OF SURGERY.              33
 side of the breast contained above two quarts of blood,
 partly in a fluid and partly in a coagulated state.
   I have quoted this abridgment of the case, because,
 although so terrible a wound as that here described must
 be considered necessarily fatal, yet, during the time the
 patient lived, a simple puncture of one of the cavities of
 the heart might have united.
   Mr. Pelletan, has lately published a case in which the
 aorta was punctured by a small sword  in  a duel.  The
 weapon entered above the right  pap, and from his bent
 posture, passed through his body and out of the left side
 near  the lumbar region.   The young man declared  the
 wounds to have been made by the same thrust, (which
 was doubted at first from the strange course of the sword)
 and said he had  himself pulled it out.   The most dan-
 gerous  consequences  were expected,  but  many  days
 passed  without any.  He complained  of pain in  the
 lumbar region, but the warm bath, two  bleedings, and a
 low diet relieved this, and he lived two months  after  the
 accident, at which time he expired in great pain, a  tu-
 mour having formed opposite  to the eighth dorsal verte-
 bra.  Upon  dissection the right side of the  chest was
 found filled with blood coagulated  in different  degrees.
 This  blood led to an opening as large as a writing quill,
 with which the aorta was pierced, above the crura of the
 diaphragm.  These  crura  and the  surrounding cellular
 texture  were injected with extravasated blood. No viscus
 of the abdomen or thorax had any  mark  of injury (the
 sword having probably passed behind  them) and there
 was no  reason to expect a priori a wound of the aorta.*
   Hemorrhage  from wounds of the chest cannot be com-
manded by ligature, unless it proceeds from an intercostal

  • Chiniquc Cliirurgicale, torn. i. p- 92.
  A case of ruptured aorta is described by Mr. Linn, jun. in which the patient
•urvivcd two weeks.  .Medical Records. 
g4<              ELEMENTS OF SURGERY
artery.  The intercostal arteries are sometimes wound-
ed, and although not very large, bleed freely.   It  has
been proposed to secure the vessel by passing a ligature
round the rib,  and tying a  piece of lint  upon it.  As
this operation, however, would leave a foreign substance
in the cavity of the thorax  (a portion of the ligature)
much inflammation would result from it; and although I
have never seen such a case, I cannot but express my
opinion that a safer measure would be to make a free ex-
ternal  incision,  and secure the vessel in the usual way,
pulling it out with a tenaculum which could with com-
mon dexterity be performed.
  Wounds of the  larger vessels of the lungs  generally
terminate the existence of the patient in a few minutes.
If the  lungs  be wounded, without injury to  any of the
great vessels, abscesses frequently form in the  chest, at-
tended with hectic fever, night  sweats, great exhaustion,
diarrhoea, and  eventually death.  In some cases, how-
ever, bullets and also small swords, have passed through
the chest, and still the patients have recovered.
   Mr.  Hunter remarks, " it is pretty well known  that
wounds of the lungs (abstracted from other mischief) are
not mortal.   I have seen several cases where the patient
has got well after being shot quite through the body and
lungs, while from  a very small wound made by a sword
or bayonet  into the lungs the patients have  died, from
which  I should readily suppose that  a  wound  in the
lungs  from a ball would in general do  better than a
wound in the  same part with a pointed instrument, and
this difference  in effects  would  in many cases  appear to
arise from the difference in the quantity of blood extra-
vasated, because the bleeding from a ball is very incon-
siderable in comparison with that from a cut, and there
is therefore a less chance of extravasated blood, either in 
                ELEMENTS OF SURGERY.               g£
the cavity of the thorax or the cells of the lungs. Another
circumstance  that favours the gunshot wounds in these
parts is, that  they seldom heal up externally by the first
intention,  on  account  of the  slough, especially at  the
wound made  by the entrance of the ball,  so that  the
external  wound remains open a considerable time, by
which  means any extravasated  matter may escape; but
even this has  often its  disadvantages, for by  keeping
open the external wound which leads into the cavity, we
give a chance  to produce the suppurative inflammation
through the whole  surface of that  cavity, which would
most probably prove fatal."
   When the  quantity of blood poured out into the cavity
of the pleura  is small, if it  do not readily escape at the
external  wound, the absorbents  take  it  up; but if the
wounded  lung continue to  bleed into the cavity of the
pleura, symptoms  of an alarming kind  are  produced.
Great prostration of strength, which proceeds from the
nature of the parts  wounded, and perhaps a fainting from
the quantity  of blood  lost to the circulation.  A great
heaviness will be  felt in  the breast,  and  considerable
difficulty of breathing.   The causes of this difficult res-
piration will be the pain which the patient will have in
expanding the lungs in inspiration; the injury of some of
those muscles which move the ribs; and also the dimi-
nution of the capacity  of the thorax, from the effusion of
blood into the cavity of the pleura  which prevents the
complete expansion of the lungs.
   The patient will not be able to lie down, but must sit
upright,  because this  posture throws the weight of the
effused blood upon the diaphragm and forcing this down-
wards, somewhat  enlarges  the  thorax.   Wherever  a
large extravasation of blood into the cavity of the pleura
exists, an opening for its evacuation must be made, and
this should be done if  possible  before it coagulates, in 
g6              ELEMENTS OF SURGERY.
order that it may  the  more  readily escape through  a
small wound.
  In  some cases it may be convenient to enlarge the
original wound, but it is often necessary to make a new
opening, which may be  done with a scalpel, just  above
the upper edge of any of the  ribs.   If  a small opening
suffice to evacuate all the blood, it  will be more  apt to
heal by the  first intention, but if the  blood be  found
coagulated, a larger aperture will be necessary.   When
the contents are evacuated the wound must be accurately
closed with adhesive plaster.
  Sabatier takes notice that  many writers recommend
this operation, but that very few have performed it.  He
relates,  however, one case in which  it became necessary
from a bleeding from the internal mammary artery after
a gunshot wound.   Mr.  Saucerotte performed it, and his
patient recovered.*
  The treatment of gunshot wounds penetrating the tho-
rax, is to be extremely simple; superficial dressings are
to be applied, a soft poultice enclosed in a  bag of  gauze
or muslin, or a pledgit  of linen rag spread with simple
cerate may be used.  Great care is necessary to  prevent
the dressing from being drawn into the chest during inspi-
ration, as much irritation would  be the consequence of
any foreign substance being introduced into the cavity of
the chest.
  Gunshot wrounds  through the chest, when the  sloughs
separate, leave very considerable openings into the  cavity
of the pleura, and although it is a fact that these wounds
are less generally fatal than stabs with sharp instruments,
from their bleeding less freely, yet  they are much more
complicated,  and often attended w ith fractures of the ribs,
and with extraneous matter in the thorax, as the clothing
of the patient and the ball. They are followed by tedious

                   * Medicine Obern^nif' 
                ELEMENTS OF SURGERY.              g7
exfoliations of the ribs ; by long continued suppurations
and hectic fever, which however are not always fatal. In
some  instances  the  suppuration takes place from  the
whole cavity of the pleura, and immense quantities of pus
are discharged.   In some the lung gradually wastes
away, and nothing remains  of  it but a hard diminutive
tubercle at its root.
   "When a man is shot through the lungs, if death be
very near, it must be from suffocation, and you will find
him with a bloody foam at his mouth, his face pale at the
cheeks, and livid round the lips and eyes, heaving the
breast with intolerable anguish, tossing from side to side
in bed, the bloody foam increasing, the breathing becom-
ing more difficult, and the blood and air  rattling in  the
throat;  then the pulse flutters, and  the extremities con-
tinually grow  colder, till  struggling in something like a
convulsion he expires." John Bell.
   In this manner soldiers frequently perish on the field
of battle, their cases admitting of no relief.   But many
cases, as we have already stated, do admit of relief, and
as the primary danger depends on  suffocation from the
air cells of the lungs being filled with blood, the remedy
must be an immediate evacuation  of blood by venaesec-
tion, and this is to be carried to a greater length than in
almost any other accident or  disease, first w ith a view to
unload the lungs and prevent suffocation, and afterwards
to prevent and cure the succeeding  inflammation.  The
French  surgeons have been famous  for the quantities of
blood  which they  direct  to be drawn in such  cases.
They have been censured for it, but I believe with Mr.
John Bell, that it is hardly possible to carry the practice
too far.   Sabatier relates  a successful case in which the
patient  was bled twenty-six times,  and I have  myself
known  a young man  to  lose one hundred and eighty
ounces of blood in twelve  days, in consequence of a gun- 
gg              ELEMENTS OF SURGERY.
shot wound in the chest. He recovered rapidly, although
a very large opening had been made by a load of small
shot.
  In some cases emphysema occurs from wounds of the
lungs.   It commonly happens from the wound being of
small size, and not entering in a direct line.  " It is less
frequent in  large wounds with  a knife or broad sword,
because there the air has an open and unimpeded issue;"
and  " more  frequent in deep stabs with the bayonet or
small sword;"  and  " it is peculiarly frequent in gunshot
wounds, because the orifice in  the skin  inflames and
swells while the wound is wider within."
  This singular affection consists in an escape of air from
the lung into the cavity of the pleura,  and from thence
into the cellular texture over the wound, its escape being
prevented by a closure  of the external  opening,  the
wound through the  skin not corresponding with that in
the pleura;  sometimes it occurs  without the lung being
wounded from  the  air which entered the thorax by the
external wound.  In common it confines itself to  the
vicinity of the wound,  but sometimes it  extends very
rapidly, swells the whole  figure, closes the eyelids, ob-
literates every appearance of the neck, which  has  the
same diameter as the trunk.  The  extent to  which the
body swells in emphysema may be  judged of from a case
related  by Mr. Littre in the Memoirs of the  French
Academy, in which  the skin over the chest was distend-
ed to the distance of eleven inches from the ribs.  The
palms of the hand and soles of the feet are the  only parts
which do not partake of the tumefaction.
  The treatment consists  in making punctures through
the skin with a lancet opposite  to the wound  in the  tho-
rax, by which the air may be allowed to escape.  If small
punctures through the skin be  found  ineffectual, a  free
incision is to be made into the thorax, through the skin 
                 ELEMENTS OF SURGERY.              gg
 and muscles,  which puts an  immediate stop to the pro-
 gress of the complaint, care being taken to  avoid the in-
 tercostal artery.
   In many instances  it is not easy to ascertain whether
 the difficulty of respiration depends upon  air or blood
 confined in the pleura.   The incision is equally effectual
 in both cases.  It is  not by compressing the lung of the
 wounded  side that the oppression is occasioned, for this
 lung must be in a collapsed state from the moment when
 the air was admitted into the thorax, and of course res-
 piration is entirely performed  by the opposite lung.  The
 oppression proceeds  from  the pressure  of  air or blood
 upon this sound lung, its freedom of motion being there-
 by impeded.
   A protrusion of a portion of the lung through a wound
 of the chest is an accident which has sometimes occurred.
 Sabatier recites several cases, and in some  the surgeons
 appear to have treated the patient very roughly, having
 cut off the protruded lung with a hot iron in  one instance,
 and  applied  stiptic powders after cutting it off,  in  ano-
 ther.*  Notwithstanding  these  harsh proceedings the
 patients got well.
   The proper  plan, if we are called  before the pro-
 truded piece  of lung  is  mortified, will be  to replace it
 without delay; and if necessary  the wound may be en-
 larged to facilitate its reduction.  After this the usual
 dressings  are to be applied.  If mortification have taken
 place, Sabatier recommends the application  of a ligature
 rouud the  part to prevent hemorrhage, and  the excision
 of the mortified portion,  a practice which I  think ought
 never to be followed,  because, if the ligature be applied
tight enough to command the hemorrhage, it will infalli-
bly produce gangrene and slough off; now the mortified

              • .HJdicine Optratoire, torn. ii. p. 272.
  vol.  i.          13
     I 
yO               ELEMENTS OF SURGERY.
part will  as certainly separate without the ligature, and
ought therefore in every case to be left.  Until this sepa-
ration  happens, it will be safest to  leave the mortified
portion outside, because  adhesions will form connecting
the lung to the margin of the wound, so that when the
separation of  the slough  takes place, the cavity of th«
thorax will not be exposed,  whereas if a portion of mor-
tified lung be returned into this cavity and there separate,
it  will undoubtedly  occasion  as great inflammation as
other foreign  matter,  and render it  necessary to  keep
open the external wound.
  When  foreign substances, as fractured bone, pieces of
cloth, &c.  are lodged in the  thorax, they must if practi-
cable,  be  immediately removed.   Pieces of the rib are
frequently broken off in such a manner as to project in-
ward and irritate the lungs.  In this case a pair of forceps
must be introduced, and the splinter separated.  A mus-
ket ball sometimes*lodges in  or about the thorax, and, in
general, it is  " irrecoverably lost;" but the clothing car-
ried in with it may commonly be found, and should be
then carefully extracted, for every thing of this kind has a
tendency, like the setons of the French surgeons, to keep
up inflammation and suppuration.  I was called to visit a
carpenter wounded in the back  by falling on a chisel;
the wound penetrated into the chest, and as the muscular
flesh through which  the  chisel had  passed  bled freely,
an old lady emptied  her snuff box into the wound.  At
every  inspiration some of the snuff entered into the tho-
rax, and the  consequence  was  a general  suppuration
from the cavity of the pleura, exposing the life of the pa-
tient to great hazard.
   Care should be  taken to  extract every foreign body
within our reach, and to prevent  our dressings, &c.  from
being drawn into the  chest. 
ELEMENTS OF SURGERY.              *)[
                  CHAPTER  XV.

          Wounds penetrating the Abdomen.

  In consequence of the great variety and importance of
the viscera contained within the abdomen, wounds pene-
trating this cavity must differ essentially in their nature
and consequences according to the parts injured.
  In a wound through the parietes of the  abdomen, in
which none of these viscera are implicated, the great ob-
ject of the surgeon is to produce a speedy union of the
wound, in order to prevent the inflammation of the peri-
toneum.   There is no  reason for believing that  this in-
flammation  arises from  the admission  of air into the ca-
vity,* neither  is the diminution of its temperature the
cause,f as the application  of ice in cases of  hernia fre-
quently reduces the heat of the abdomen much below that
of the atmosphere, without any such effect, and peritoneal
inflammation  is  as apt to  occur in the hottest summer
weather when  the thermometer rises nearly to the heat of
the blood, as in the depth of winter.  The real cause of this
inflammation in wounded cavities, it is by no means  easy
to ascertain, it  is much easier to ascertain that  none of the
alleged  causes can explain it.  The fact is all we  have
to state.   Whenever a large cavity, as the thorax, abdo-
men, or  a large joint, is cut open, unless the  wound be
promptly healed, violent inflammation occurs  throughout
the surface of  that cavity.  The imperfection of the cavity

  • The cavity of the abdomen is a  plenum, every part of it  occupied with
something, and no space exists for the admission of air.  Into the thorax, when
wounded, air finds a ready entrance, but not so in wounds of the abdomen.
  fThis opinion has been maintained by Dr. James Cocke in his Inaugural
Essay, published in this city in 1804. 
92                ELEMENTS OF SURGERY.
appears to be the only circumstance necessary to the pro-
duction of this inflammation, but how it effects it I am not
prepared to say.
  If the wound be made by a sharp instrument, it is to
be closed by the interrupted suture, care being taken to
pass the needle from within outwards, about half an inch
from the wound ;  it is most readily effected by having a
needle at each  end of the ligature; none of the strings
are to be tied until all the stitches are  made.*   In this
case I  should not use leather ligatures.  The various an-
tiphlogistic remedies are to be used in  order to prevent
inflammation, and also to relieve it, if it  supervene.
  It is always of extreme importance to ascertain whether
any of the viscera of the abdomen be injured, because the
danger of the case, and the remedies to be employed, de-
pend greatly upon this circumstance.  If any part of the
bowels protrude, it should be examined carefully before
it is replaced.   If the  wound be a small incision or a
puncture, it is more  difficult to ascertain the extent and
nature  of the mischief.   Some information is to be gain-
ed by examining the instrument with which the wound
was inflicted, and by observing how much of it had en-
tered, and in what direction.  If a large  quantity of blood
escape at the wound, there is reason to apprehend the
injury  of some  of the viscera (unless the wound be in the
course  of the epigastric artery.)  If bile, foeces,  or any of
the usual contents of the viscera, make their appearance,
there can be no doubt of a wound in an  intestine.  Very
little is to be learned by examinations with probes, or
even by passing the finger into the wound, and therefore
unless  some real  good can result from  it,  it should  be
omitted.
  When  a large blood-vessel is opened, and  the blood
does not find a ready exit through the  external wound,
  * Adhesive plaster is also to be used, and over it a compress and bandage. 
                ELEMENTS OF SURGERY.               93
 great debility comes on, fainting, a weak faultering pulse,
 cold sweats, swelling of the abdomen, and, if the bleed-
 ing should not stop, death.
   Gunshot  wounds of the abdomen in  general occasion
 complicated  mischief, the ball passing through the visce-
 ra, and wounding them in several places. If the ball pass
 with considerable velocity, sloughs must take place, and
 greatly enlarge the various openings it has made.   " If
 the ball pass with less velocity, there will be less slough-
 ing, and the parts will in some degree heal by the first
 intention  similar to those made by a cutting instrument;
 but although the ball has passed with such velocity as to
 produce a slough, yet that wound shall do well, for the
 adhesive inflammation will take place on the peritoneum
 all round the wound, which will exclude the general ca-
 vity from taking part in the inflammation, although the
 ball  has  not only penetrated, but  has  wounded  parts
 which are not immediately essential to  life, such as the
 epiploon, mesentery, &c. and perhaps gone quite through
 the body; yet it is to be observed  that wherever there is
 a wound, and whatever  solid  viscus may be penetrated,
 the  surfaces in  contact, surrounding every orifice, will
 unite by the  adhesive inflammation,  so as to exclude en-
 tirely the general cavity,  by  which means there is one
 continued canal, wherever the ball or  instrument has
passed; or if any extraneous body should have been car-
 ried in, such  as clothes, &c. they will be included in these
 adhesions, and both these  and the slough will  be con-
 ducted to the external surface by either orifice."
  This quotation from  Mr. Hunter explains the reason
why so many patients get well of wounds in the viscera,
and  affords a wonderful proof of the  resources  of nature,
in providing against danger and death.  Unless adhesive
inflammation  arise and agglutinate the injured bowels to-
gether, at  the circumference of every aperture made into 
9$              ELEMENTS OF SURGERY.
them, death must inevitably result, from the escape of
the contents of these viscera  into the general cavity of the
abdomen.
  From this view of the subject, and from repeated ex-
perience, we learn that most of the viscera of the abdo-
men may be wounded without fatal consequences.  The
gall bladder is perhaps an exception, because the acrid
nature of its contents, and the facility with which the bile
escapes whenever this viscus is punctured,  cannot fail to
occasion  peritoneal inflammation;  and we find no  case
recorded of a recovery after  a wound penetrating the
gall bladder.   If any acrid substance  escape from the
stomach into the general cavity of the belly,  as  ardent
spirit, &c.  the same fatal consequences  will result, of
which I once saw a striking  instance in a'man whose sto-
mach was  wounded after drinking porter.   The  wound
of the stomach was found on dissection completely heal-
ed ;  the patient died on the fourth day of peritoneal in-
flammation/'
  The inflammation of the cavity of the belly which oc-
curs whether the viscera be  wounded or not, (unless the
external wound be promptly united) calls for copious and
active measures; bleeding, purging, low diet and blisters,
over the  abdomen.  In general these remedies,  if  com-
menced early, and pursued actively, are found successful,
and the inflammatory  symptoms  subside.   In others it
terminates  in adhesions, connecting together the different
viscera, coagulating lymph  being poured out, on  various
parts of the peritoneal surface.  In others suppuration
takes place, and large quantities of matter  are formed in
the abdomen.   Mortification also sometimes occurs, and
consequently death.
   If the remedies for inflammation do not succeed in re-
ducing it,  and  suppuration  takes  place, when its exist-
ence is clearly  ascertained, a lancet may be introduced, 
                ELEMENTS OF SURGERY.              95
and afterwards a canula through which this matter may
be  evacuated.  If  no particular spot  appear elevated
more  than  the rest, the puncture may be made  at  the
usual place where tapping for dropsy is performed, about
two inches  below the umbilicus.
  In  some  wounds of the abdomen  a protrusion of some
of the abdominal viscera takes place; where the protru-
ded parts are uninjured, it is always best to replace them
as speedily as possible  within  the cavity.   If they be
wounded, or if from long exposure and the stricture made
upon them by the  wound, they are in  a mortified state,
other measures are necessary.   Previously to replacing
them all extraneous matter should be carefully removed.
Dirt, clots  of blood, and every foreign substance, must be
washed off with warm water. I have seen a large portion
of the colon,  together with the omentum covered with
sand and dirt mixed with blood, protruding  from a large
wound in the abdomen; great care  was  in this instance
necessary to prevent the  introduction of these irritating
matters into the abdomen.
   It  often  happens that a considerable stricture is made
upon the protruded parts, and of course difficulty is ex-
perienced in reducing them.  To facilitate it, the patient
should be placed in such a posture as to  relax the muscles
of the  abdomen.   If the difficulty arise from distention
with foeces or flatus, the contents may often be squeezed
out, and the bulk of the intestine thus reduced.  If, how-
ever, the reduction be still difficult,  it is highly improper
to use any  violence in attempting it;  it is better to enlarge
very carefully the wound with a bistoury.
   The  treatment of the case when a portion of the intes-  ^
tine is mortified, will be described in the chapter on her-
nia,  as  it  forms a very important  variety of that com-
plaint.
   Blood is sometimes poured out in considerable quanti- 
 96              ELEMENTS OF SURGERY.
 ties by some large vessel within  the  abdomen.  If  the
 quantity be very great, swooning,  and the usual debilita-
 ting effects of hemorrhage quickly  ensue.  If the patient
 survive these symptoms, the collection of blood is easily
 perceived forming a tumour in some part of the abdomen.
 The abdominal viscera are  so  closely in contact that a
 general diffusion of this  blood among them seldom hap-
 pens ; it is found, on the  contrary,  collected  into one
 spot;  and  this, according  to Sabatier, is in the lower
 and anterior part of the abdomen,  just above the pubis.*
 He  remarks that,  in  general, upon opening  bodies in
 which these extravasations  have happened, the blood is
 found in every part of the cavity, but that this is entirely
 owing to carelessness  in the dissection,  and that a cau-
 tious proceeding discovers  that it  is  collected in one
 mass, and  that after a  time it becomes  firmly surrounded
 by the matter of adhesions, in consequence of inflamma-
 tion, forming a kind of sac or pouch.
   The changes which  the extravasated blood undergoes,
 coagulating and irritating the surrounding parts, occasion
 very distressing symptoms.   In the first place  pain, and
 tension of  the  part, followed by  hiccough, costiveness,
 vomiting, and sometimes suppression  of urine.  Some-
 times by great weakness, a small feeble pulse, and cold
 sweats.
   To  relieve these symptoms,  it  becomes necessary to
 make an opening for  the discharge of the blood.  A
 puncture is to be made with a  lancet, or trochar, and
 a canula introduced; if the blood be fluid it will readily
flow through it;  when it is found coagulated, it has been
recommended to inject warm water into the wound, in
order to wash it out; from the fact that injections of warm
water in cases of hydrocele, effect  a radical cure by ex-

              *  .Mcdecine Operatoire, torn. i. p. 35. 
                 ELEMENTS OF SURGERY.              ny
 citing inflammation, I  have strong doubts of the pro?
 priety of this practice.
   When the contents of the viscera are extravasated, the
 only remedies  which can be employed are the remedies
 for inflammation; rest, a  low diet,  bleeding, purging,
 &c.  They sometimes form abscesses, and are discharged
 externally.  I have known a piece of cheese which escap-
 ed from  a wounded stomach, discharged after the wound
 had healed, by an abscess in the groin.

           WOUNDS OF THE ABDOMINAL VISCERA.
   The symptoms denoting wounds of the particular vis-
 cera of the abdomen are not always  strongly marked,
 but in general we are able, from  a careful investigation
 to ascertain with some degree of accuracy the parts in-
jured.
   " From a wound in the liver there will be a  pain in
 the part of  the sickly or depressing kind ; and if it is in
 the right lobe there will be a delusive pain in the right
 shoulder, or in  the left shoulder from a wound  in the
 left lobe.
   " A wound in the stomach will produce great sickness
 and vomiting of blood, and sometimes a delirium.
   " Blood in the stools will arise from a wound in the
intestine, and according to the intestine wounded it will
be more or less pure; if the blood is from a high part of
an intestine, it will be mixed with  foeces and of a dark
colour; if low as the colon, the blood will be less mixed
and give the tinge  of blood;  and the pain or sensation
will be more or less acute,  according  to the intestine
wounded, more of  the sickly pain the higher the intes-
tine, and more acute the lower.
  " There will be bloody urine  from a wound of the
kidneys or bladder, and if made by  a shot or ball and a
  VOL. I.         14; 
9§              ELEMENTS OF SLRGEItY.
lodgment made, these bodies will sometimes become the
cause of a stone. The sensation will be trifling.
  " A wound  of the spleen will produce no  particular
symptoms, excepting probably sickness, from its connex-
ion  with the nerves of the stomach."  (Hunter.)
  In  the  treatment of wounds  in the stomach or intes-
tines it must be evident that many cases occur  where the-
part wounded cannot be exposed, or indeed known, and
here nothing is  to be done but to combat the inflammatory
symptoms.* When a wound in the stomach can be seen,
a number of stitches proportioned to  its extent must he
used,  the ligatures cut off close, and the parts returned.
In transverse wounds of the intestine, in which the great-
er part of the  canal remains entire,  the experiments of
Mr. Astly Cooper and  other surgeons have proved the
safety of closing the wound by the  interrupted  suture,
and returning the gut  into  the  belly.  The stitches are
separated by the  actions  of the absorbents,  and  pass
readily through the intestinal canal,  a coating of coagu-
lating lymph being formed over them, which prevents
their falling into the cavity of  the peritoneum, and ex-
citing inflammation there.   A  siugle  stitch  is generally
sufficient to close a wound not extending more than half
round the intestine,  and it should be made with  a com-
mon  round  sewing  needle armed with waxed thread.
Longitudinal wounds of the intestine,  it has been be-
lieved,  do not heal so readily as those which are trans-
verse.  There  is probably more danger of the escape of
foeces from  them, and  they are not  so readily  closed.
From some experiments of Dr.  T. Smith, performed in
this city,  and published in his inaugural thesis in 1805,

  •  The propriety of dilating the external  wound to search for the wounded
intestine is very doubtful; i*t, from the danger attending an enlargement of
the  wound, and 2dly, from the uncertainty of finding the injured viscus 
                  ELEMENTS OF SURGERY.               gg
  it appears that in dogs even extensive longitudinal wounds
  may be reunited.
    It is  proper in many such  cases to cut out completely
  the wounded  portion  and unite the cut extremities to-
  gether,  because the longitudinal is thus converted into a
»  transverse wound.
    When the intestine is cut completely through, either by
  a removal of a mortified portion,  or by the original wound,
  the divided  extremities are to be secured by four stitches;
  the li-atures are to be left out at the external wound, and
  in a short time they unite, and  an adhesion  takes place
  connecting the intestine to the peritoneum at  the wound-
  ed part.   After five or six days,  the  threads, if loose,
  may be  removed, as they become useless after adhesions
  take place.  The practice of Mr. John  Bell in these
 cases, of trusting to a single stitch, is full of danger, and
 ought never  to be adopted.   Mr. Cooper's  remarks on
 the treatment of mortified intestine in his work on hernia
 are entirely applicable to the present subject.
   In most instances of wounded  intestine the  canal is
 diminished at  the injured  part, and cholicky pains are
 an occasional consequence.   A great degree of constric-
 tion has in some cases  resulted  and terminated fatally,
 but in general the bowel regains its usual volume, and
 performs its  functions as well as before the injury.
   In all cases where there  is  reason to believe that the
 bowels are wounded, it is important to prohibit the use
 of solid food, and  confine the patient to  barley water ex-
 clusively, or  some mild drink.
   Wounds of the omentum or mesentery seldom occa-
 sion trouble,  except from their bleeding; when practica-
 ble, the  bleeding vessels are to be secured by ligature
and the  ligature in every instance left out at the external
wound.
  Wounds of the  gall bladder are, in the  opinion of 
100            elements of surgery.
most surgeons, necessarily fatal.   A  case  is related in
the Edinburgh Medical Essays,  in  which the  patient
survived this accident a week.  Before death the abdo-
men became extremely tense;  a rumbling noise  was
heard in it.   The patient had no stools, notwithstanding
the use of purgatives and glisters.  Sleep could not be
procured, although anodynes were exhibited.   No fever
appeared.  The pulse was natural till the last day, when
it became intermittent.   Upon dissection  the  intestines
were found much distended, the gall bladder quite empty,
and a large quantity of bile, extravasated in the abdomen.
Sabatier relates a case in which bile was  drawn off by a
trochar from the cavity of the belly; but no  advantage
resulted, and the patient died a  few hours after it was
performed, viz. on the third day.
   Wounds of the liver call for no particular treatment.
They are generally, when extensive, fatal from hemorr-
hage, owing to its great vascularity;  and if any of the
branches of its excretory duct are punctured, the bile es-
capes  and  occasions  inflammation  of the peritoneum.
Small incised wounds of the liver often heal without dif-
ficulty.
   Wounds of the kidneys are not fatal unless the urine
escapes into the cavity of the abdomen. They call for no
particular treatment.  The patient  generally voids bloody
urine at first, but the part soon heals. 
ELEMENTS OF SURGERY.
101
                 CHAPTER XVI.

                  Wounds of Joints.

  In these, as in other wounds penetrating cavities, it is
of great importance to guard against inflammation, as the
effects of violent inflammation in the larger joints, upon
the constitution are very serious.
  In all cases of wounded joints it is important to place
the limb in such a posture as to favour the approximation
of the sides of the wound.  Absolute rest is to be enjoin-
ed, and a rigid adherence to the antiphlogistic treatment.
Sutures are  never to be used in these cases, if it be  pos-
sible to  dispense with them,  and when it is not,  they
must never be passed into the cavity of the joint, but only
through  the cellular membrane on the outside of it, for
very obvious reasons.  Treated in this manner, incised
wounds of the larger joints very readily heal by the first
intention, even when the articulating  extremity  of the
bones are injured.
  When inflammation supervenes in consequence  of  a
wound in a large joint, the constitution suffers severely:
fever comes on, generally ushered in with a great degree
of nausea.  Violent pain takes place in the joint, and an
increased secretion  of synovia, which is thinner and more
watery  than usual.   The ligaments swell and become
thickened by effusions of coagulating lymph.  At length
suppuration takes  place, and pus is  secreted from  the
whole surface of the synovial membrane; ulceration comes
on, and openings are formed in various parts of the  skin
covering the joint.
  The formation of an abscess in a large joint, as the
knee or  hip, never takes place  without great danger to 
 102            ELEMENTS OF SURGERY.
 the life of the patient.  I have seen death occur in a very
 few days from inflammation of the knee, terminating in
 suppuration.  Extreme  pain, fever and delirium, gene-
 rally precede the fatal event.
   In those cases where the symptoms of inflammation do
 not terminate so speedily, ulceration of the ligaments is
 followed by inflammation of the bone; the cartilage is ab-
 sorbed, and the whole joint destroyed; granulations arise
 from  the inflamed bones;  they unite, and anchylosis is
 effected ; but these processes require a great length of
 time, and during this time the patient is affected with
 hectic fever, and great exhaustion from the continued dis-
 charge.  Abscesses also  form  in the vicinity of the joint,
 and portions of carious bone  or  detached cartilage, are
 evacuated through them.   Before anchylosis  can in this
 manner be accomplished, the patient must inevitably suf-
 fer a tedious, painful  confinement, under which the con-
 stitution often sinks,  and a lingering death  eventually
 concludes his sufferings.
  These terrible consequences sometimes  result  from
simple incisions or punctures into joints, as well as from
the more aggravated mischief of lacerated or gunshot
wounds.  They are only to be prevented by  a most ac-
tive employment of the remedies for inflammation already
enumerated.
  On the first  approach of inflammation, bleeding is to
be performed, and  carried to as great  an extent as the
patient's strength will warrant.  Topical bleeding, by
cupping or leeches, is next to be employed, and after this
a blister should be applied large enough to  cover the
skin over the joint.  The blister in these cases should be
 applied earlier than is recommended by authors. I have
 seen the best effects from a speedy application of  this
 remedy.
  In chronic inflammations of joints, either from wounds 
                ELEMENTS OF SURGERY.             103
or other causes, the repeated use of blisters is never to be
omitted.   Purging is also to be actively employed.
  In order more effectually to  procure absolute rest of
the joints, it is advantageous  in  some cases to apply
carved splints to fit the parts, and these being lined with
soft materials, occasion no inconvenience.   In wounds of
the knee, ankle or elbow, these splints are particularly
useful.
  When in consequence  of the violence and continuance
of the inflammation, there is reason to apprehend  a stiff
joint  from anchylosis, it  is necessary to choose the posi-
tion of the limb, in which  this  stiffness will  be least in-
convenient to the  patient,  and  to  preserve that posture
during the cure. If, for example, the elbow were to heal
with  the arm  permanently extended, the limb would be
almost useless, whereas an arm flexed at the elbow, even
when the joint allows no motion, is extremely useful. In
the lower extremity on  the  contrary, a flexed  posture
would preclude the patient from walking, while an ex-
tended leg, with  a stiff knee, would be attended w ith
comparatively little inconvenience.
   Lacerated and gunshot wounds of the joints are always
attended  with more danger than simple incised wounds,
because in them the parts  cannot unite so speedily, and
the cavity remains longer imperfect.   So great is  the
danger to the life of the patient, that it always becomes
a serious question with  his  surgeon in such wounds of
the elbow, knee, or ankle, whether an amputation  ought
not to be immediately performed. In addition to the dan-
gers already enumerated, gangrene from the disorganiza-
tion of the parts may occur, or life may be destroyed by
tetanus.
   It is  not easy to give any general rules by which to
guide our decision of the momentous question of ampu-
tation in wounds of joints.  Undoubtedly many cases oc- 
 104?             ELEMENTS OF SURGERY.
 cur, in which the destruction of the surrounding  parts,
 arteries, nerves, tendons, &c. together with the shattered
 state of the bones forming the articulation,  especially
 when  this complicated injury has  occurred  in the hot
 weather of summer, leaves no doubt of the propriety of
 immediately removing the limb; but other cases occur in
 which the main artery of the limb is not destroyed, and
 in which there is a prospect of saving the limb, provided
 the patient escape the dangers of gangrene, of tetanus,
 of inflammatory fever, of extensive suppurations, of hec-
 tic  fever, &c.  In cases of this  kind the surgeon feels
 his responsibility to be great, and it requires an attentive
 consideration of every circumstance connected with  the
 particular case to confirm his decision. All these circum-
 stances should be stated to the patient and his friends,
 and they should assume the responsibility and conclude
 whether to attempt the saving of a limb, by incurring the
 dangers which must be encountered, or by an amputation
 to avoid  them.
  The cartilages of a joint never either inflame, suppu-
rate or ulcerate; they are  incapable of restoring  them-
 selves  when  injured,  and  although flesh in some  cases
 grows  over them, they never adhere to it.  Mr. John Bell
observes, " we amputate a toe at the joint, and the flaps
unite in two days, but still they have united with each
other only, and not with the cartilage at the joint; and
in a luxated limb  we find  that the bone  continues dis-
placed, the cartilage never inflames, nor ever unites with
the lacerated parts." 
ELEMENTS OF SURGERY.
105
                CHAPTER XVII.

           Wounds of Nerves and Tendons.

  In most of the systems of surgery which have been
published, wounds of the nerves have been consider-
ed as a  subject of great importance,  and many terrible
consequences are attributed to punctures or partial divi-
sions of them.
  The first symptom indicating a wound of a considera-
ble nerve is severe pain,  and afterwards a numbness, or
diminution  in the  sensation and powers of the part to
which the injured nerve was distributed. These symp-
toms in  general  gradually subside, and no particularly
bad consequence results from the wound.
  The inflammatory symptoms sometimes consequent to
the operation of phlebotomy have been ascribed by many
surgeons to punctures of  a nerve or tendon.  The  true
explanation of these effects we shall presently offer.
  The operation of cutting down to the  nerve and divid-
ing it  entirely,  is very seldom to  be performed.  The
only case in which it is to be recommended is when after
venaesection, the patient experiences violent  pain, follow-
ed by numbness of the ai m, and where these symptoms,
instead of subsiding after a few days, increase in severity.
Under such circumstances an iucision should be made
through  the wound, and carried a little below  it,  by
which in all probability any partially divided nerve would
be completely cut through, and the symptoms, if derived
from this source, would speedily cease.
  The necessity for this operation is,  however, extreme-
ly rare.   I have never seen  or heard of a case in this
city (where blood-letting is a very frequent  operation) in
  vol. i.         15 
 106             elements of surgery.
 which the symptoms  have been such as to warrant any
 surgical operation for the division of a nerve.
   Tendons, when wounded, occasion no pain.  There
 are many proofs that  tendons in a healthy state possess
 little or no sensibility; when inflamed, they are often ex-
 quisitely sensible.  It occasionally happens, however, in
 punctured  wounds, that  certain tendinous  fasciae  are
 pierced, and the  soft parts below the expansion are also
 injured; when these inflame, the stricture formed by the
 tendon occasions very severe pain, and greatly aggravates
 the inflammatory symptoms. In these cases a division of
 the tendinous fasciae  procures immediate relief.   As the
 fasciae attached to the  tendon of the  biceps flexor cubiti
 is situated in the  vicinity of  those veins from  which
 blood is generally drawn,  there is reason to believe that
 in some rare cases this accident has happened in phlebo-
 tomy ;  in such cases a small incision through the fascia
 could very readily be made.
   Wounds of tendons are to be treated as wounds in other
parts, by keeping them at rest with their divided surfaces
in contact.  It happens to carpenters and ship joiners, oc-
casionally to divide with a foot  adze the  tendo Achillis.
 When this accident happens, the foot is to be kept extend-
ed by a splint secured by means of a roller in front of the
leg, extending from just below the knee to the point of the
toe;  compresses being applied to fill up the inequalities of
the limb, the  divided surfaces of the tendon are to be ac-
 curately placed in contact, and kept so six or eight weeks,
when union  will be effected; but several months must
 elapse before the patient attempts to support  the weight
 of the body upon this tendon.   The same mode of treat-
ment is to be used in ruptures of the tendon. In wounds,
however, the skin is apt to fall into folds, and  insinuate
itself between the cut surfaces of the tendon. To prevent
this inconvenience, adhesive plaster should be applied in
 such a manner as to keep it pulled back from the wound. 
                  ELEMENTS OF SURGERY.              IQ^
   Dr. Monro's plan  of dressing such an  accident is
equally successful.  It consists in having a strap fastened
to the heel of a slipper, and this  strap buckled to a ban-
dage fixed round the leg just below the knee. The roller
on the leg prevents the action of the gastrocnemii muscles,
by which the superior portion of the tendon  would be
pulled up, and the  strap on the slipper keeps the foot in
an extended position, by which the lower portion is pre-
vented from being drawn down.*

                    WOUNDS OF VEINS .f
   These generally  occasion very little trouble; the he-
morrhage may be commonly stopped by compression.  In
some cases,  however, the cavities of veins, like the other
cavities of the body, take on inflammation, in consequence
of the external  opening not being united by the first in-
tention.  Mr. Hunter has published a very valuable paper
on the inflammation of veins in the Medico-Chirurgical
Transactions; from this paper it appears that the swelling
of the  arm  consequent to venisection is generally occa-
sioned by the inflammation of the inner  coat of the vein.
He has  dissected the arm  in some cases where patients
have died from this disease, and,has found in some parts
of the vein adhesion, in others suppuration, and in other
cases ulceration.
   In most cases when pus  forms in a vein thus circum-
stanced, adhesive inflammation having preceded the sup-
  • An accident of frequent occurrence, is a rupture of some muscular or ten-
dinous fibres of the gastrocnemius  muscle, attended with severe pain, ec-
chymosis and subsequent inflammation; the treatment is the same, but patients
rarely submit to the confinement, in which case a tight roller applied so as to
cover the leg affords great relief, and generally effects a cure.  A paper on
this subject may be seen in the 7th vol. of the Medico-Chirurgical Transactions
by Mr. Wardrop.—The airthor having tried  his plan of treatment was com-
pelled to lay it aside as inefficient; the roller being the only useful part of it.
  fThc principal circumstances demanding attention  in cases of wounds of
tub aiiteiues have been already noticed in the chapter on hemorrhage. 
IQg             ELEMENTS OF SURGERY
purative stage, is found to have cut off all communication
between the general circulation and the inflamed vein. In
other cases, however, the pus is not  thus excluded from
the mass of blood, but is carried along with it to the heart,
and occasions death.
  After an abscess  is formed by adhesions closing up a
portion of the vein,  absorption takes place, and the coats
of the vein are removed.  The  abscess then points, and
matter appears under the cuticle.  Mr. Hunter has seen
instances of pus contained in  the cavities of veins in many
patients who have died after  amputation, compound frac-
ture,  and  mortification.   It  happens as frequently in
healthy constitutions as in others, a proof of which is that
if a patient with an inflamed vein be bled in the other
arm, the wound heals without any such consequence.
   In some cases a considerable portion of the vein takes
on inflammation;   generally that portion  between the
wound and the heart, but sometimes the portion next the
extremity; a string of abscesses existing throughout its
extent.  When the parts get well, it is found that the ca-
vity of the vein at the inflamed part has been obliterated,
and the patient can never  afterwards be  bled in that
place.
   Inflammation of a vein is sometimes an effect after
bleeding  horses, which is  usually done  in the neck.
 " The operator on  this animal does not always  take suf-
 ficient care to close up the external wound, for although
 the method usually employed would at first sight appeal
 a good one, that is by a pin passed through the wound
from side to side,  as  in the hare-lip, and  overtied by a
 thread or hair; yet if not executed with sufficient atten-
 tion, I am inclined to believe that it is the very worst, as
 it very readily promotes inflammation in the cavity of the
 vein, either of the adhesive or suppurative kind, according
 as the ligature does or does  not communicate with the ca-
 vity." (Hunter.) 
                ELEMENTS OF SURGERY.             109
  Mr. Hunter has seen in some of these inflammations of
horses the jugular vein inflamed through its whole length,
the head greatly swelled, and the  inflammation carried
along the vein quite into  the chest.   Many horses  die of
this  disease, but  what  is the  particular circumstance
which occasions their death is not ascertained.   " It may
be either that the inflammation extends itself to 'the heart
or that the matter secreted  from the inside of the vein
passes along that tube in  considerable quantity to the
heart, and mixes with the blood."
   In many instances  the constitution is affected with vio-
lent fever, and in some cases in the human subject death
has resulted.   Pus passing into the circulation  adds, in
Mr. Hunter's opinion, to the general disorder, and ren-
ders it fatal.
   " Although the  operation, which is the most frequent
cause of this complaint, is in appearance  trifling, yet, as
it is very often of  serious consequence both to the  life of
the patient and the character of the surgeon,  it requires
particular attention in the operator to prevent as much as
possible an evil of such magnitude; with this view he
will be particularly  attentive to the mode of closing the
wound and binding  up  the arm:  this is to be done by
bringing the two sides of the wound together, that they
may unite by the first intention.  To accomplish this let
the surgeon with the thumb of that hand which holds the
arm push the skin towards the orifice, while he draws it
on the other side  to the  same point with the  compress ;
thus the skin will be thrown into folds at the wound, over
which he is immediately to apply  the compress, which
should be broad to  keep the skin better together, and
thick to make the compression more  certain."
   Mr. Hunter recommends a " compress of linen or lint,
in preference to sticking plaster, for the blood dryin^ over
the  orifice is a kind of bond of union more natural and 
HO             ELEMENTS OF SURGERY.
effectual than any other application, and this  conclusion
is drawn from practice," more sore arms being a conse-
quence of bleeding  where plasters have been used than
when the arm has been dressed in any other way.
   " When inflammation takes place beyond the orifice,
so as to alarm the surgeon, he should immediately make
a compress upon  the vein at the inflamed part, to make
the two sides adhere together; or if they do not adhere,
yet simple contact will be sufficient to prevent suppura-
tion in this part;  or if inflammation has gone so far as to
make the surgeon  suspect that suppuration has taken
place, then the compress must be put upon that part of
the vein just above the suppuration."
  The remedy  for inflammation of the veins consequent
to venaesection, which answers best, is the application of
a blister over the  inflamed part.  As soon as  the inflam-
mation  commences, a  small plaster  of  simple cerate,
spread on linen, should be applied on the orifice,  and
over this a blister large enough to cover the whole inflam-
ed part, extending three or four inches from the orifice in
every direction. This remedy, I believe, was first intro-
duced by Dr. Physick. It has been used by him for many
years with constant success, and I have myself employed
it repeatedly, and  never without advantage.
   Should fever attend, purging and low diet should be
ordered, and bleeding, if the inflammatory symptoms run
high.  A splint is sometimes useful to keep  the arm at
rest.
   The inflammation of a vein consequent to venaesection
sometimes assumes a chronic form, and continues with a
hard swelling and some pain for many weeks. Repeated
blisters have been found  extremely serviceable in these
cases. 
                ELEMENTS OF SURGERY.              111
  It is unnecessary particularly to  describe the appear-
ance of the inflamed  arm consequent to venaesection, be-
cause it is generally known to medical men.  In its com-
mencement it resembles somewhat an erysipelatous affec-
tion, extending above and below the orifice made by the
lancet, a tumor existing, however, at the part which  is
hard and painful;  the arm  cannot  be bent or extended
without great  pain.  In this state the blister very ge-
nerally prevents the further  progress of the inflamma-
tion. 
lis
ELEMENTS OF SURGERY.
                CHAPTER XVIII.

                    Of Fractures.

   A fracture is a breach in a bone, (or as it is gene-
rally defined, a solution of continuity) produced by ex-
ternal violence, or by muscular action, or by the conjoint
operation of both.
   The  bones most frequently broken are  those of the
extremities.  Bones are  broken in  one or in  several
places;  when broken  in  more than one place, the frac-
ture is said to be comminuted.
   Fractures may occur in the vicinity of joints, or in the
middle of the bones of an extremity. In the fore arm and
leg, one or both bones  may be fractured.  The fracture
may be directly across  the bone in a transverse direction,
or it may be oblique, and the degree of obliquity may
vary very much.
   Fractures differ in relation to the form of the bone, its
importance, and  uses.  The broad  flat bones,  as the
scapula or ilium, are rarely fractured.  The bones of the
scull, however,  are more frequently  broken than any
other flat bones,  and  the importance of  this  accident
transcends that of most others, from the effects of the in-
jury upon the brain.  The  long bones are by far the most
frequently fractured.
   When the long bones are broken, the place of fracture
is a subject of some importance to be attended to  in judg-
ing of the effects of the accident and of the mode of treat-
ment. In a fracture of  the middle of a bone, the broken
surfaces are less extensive, and therefore they move  more
widely one from the other, yet this kind of fracture is the
least dangerous, because in such cases the cause is sel- 
                ELEMENTS OF SURGERY.              H3
dom applied to  the  part fractured,  and for that reason
the surrounding soft parts are injured equally seldom. A
less force suffices to break the bone in its middle than at
any other part.   It is also certain that inflammation, stiff-
ness, and anchylosis are less likely to happen than when
the bone is fractured near the articulation.
  Bones are sometimes broken within a joint; the frac-
tured patella is always an example of this.   I have seen
a fracture through  the  head of  the thigh bone, and also
through the head of the humerus.
   The relative situation of the fractured extremities it is
of great importance to ascertain.  In some cases of trans-
verse fracture no derangement at all takes place, the parts
supporting each other as though they were not fractured.
I had one patient with a transverse fracture  of the tibia,
who could stand up and bear some of the weight of his
body upon the injured leg; and Dr. Physick had a pa-
tient who, although the grating of the bones was distinct-
ly heard, before his limb  was dressed, took off all the
bandages and splints, under an idea  that the doctor was
mistaken.   After walking, however, once or twice over
the floor, and being confirmed in his  opinion, an unwary
motion  of  his leg occasioned a twist, and it bent under
him at the place of fracture.   Sometimes the fragments
in a transverse fracture  are  partially separated, and in
the tibia we » rten find one fragment  projecting a quarter
of an inch or mu  • above the other, and yet a  great part of
the fractured surfaces remain  in contact.  This is less^pt
to happen  when both  bones of the  leg or fore  arm are
broken, as  in these cases a total  separation and distortion
of the limb generally  takes  place.  In fractures of the
thigh and arm the muscles generally  draw up the inferior
fragment, ;.«d thus shorten the limb,  even when the frac-
ture is tran**' rse.
  VOL. p.         16 
114             ELEMENTS OF SURGERY.
  In some cases a bone is broken in such a manner as to
form an angle at the place of fracture.
  The principal causes of the derangement of the frag-
ments  are the force which produced the fracture, the
weight of the body, or of the fractured limb,  and the ac-
tion of muscles.   The  force which produced  the fracture
will often occasion great derangement of the limb, as the
kick of a horse.  The weight of the arm in  fractures of
the humerus, and of the leg in fractures of the thigh bone,
occasion a separation of the fragments.  The weight of
the foot, when the patient lies on his back, will occasion
a rotation in a broken thigh or leg;  but the most power-
ful of these causes is muscular action.
  " Of the muscles which surround a fractured bone some
are attached to that bone in a great part of its length, and
therefore in many cases to both portions of the fractured
bone.  Others extend from the bone which is superior to
that fractured, to that  which articulates with the lower
portion, or to the lower fragment  itself; there are still
others  which terminate in the upper fragment, the other
extremity of which may be more  or less distant:  The
muscles of the thigh offer examples of these  three differ-
ent dispositions.   The triceps is attached to the whole
length of the femur; the  biceps, semimembranosus and
semitendinosus, descend from  the  pelvis to the leg, to
which  the lower part of the femur is articulated, and all
the movements of  which it obeys;  the great  adductor
muscle has its insertion in the lower part of the femur it-
self;  finally the psoas, iliacus, pectineus,  &c. descend
from the loins and  the pelvis, and have their  insertion
near the superior extremity of the femur.
   " The muscles which are attached to both portions of
the fractured bone,  contribute very little to their change of
situation, but may, however, draw  them both to the°side 
                 ELEMENTS OF SURGERY.             115
on which they are inserted, and thus change the direction
of the limb.  The triceps, and more particularly its mid-
dle part, acts thus on the fractured femur, and renders
the thigh convex anteriorly. The brachialis anterior tends
to produce the same effect when the humerus is broken
below  its middle part, but the change from the natural
situation is principally owing to the muscles which are
inserted  into the lower portion of the fractured bone, or
the limb with which it articulates.  Let us suppose the
fracture of the humerus between its superior extremity,
and the insertion of the great pectoral muscle, this muscle
aided  by the latissimus dorsi and teres major, draws the
inferior portion inward and upward, and causes it to as-
cend on the interior side  of the  upper fragment which
rests motionless, on account of its shortness, and because
the muscles which are inserted  into it are not acted on by
any cause that excites them to action.   In the fracture of
the neck of the femur, the superior fragment has no mus-
cles inserted into it, and remains motionless in the articu-
lating cavity; those muscles which, on the contrary, are
attached to the lower portion, draw it upward and back-
ward, and render its being displaced in that direction ine-
vitable.
   "The lower portion being  acted on by the limb to
which it is articulated, follows  all its motions, and is lia-
ble to be displaced by the action of the muscles which
 are inserted into it. Thus, in fractures of the body of the
femur, the biceps, semitendinosus, and other  muscles,
 draw  the leg, and with it the  inferior portion, upward,
 inward, and backward, and cause it to ascend on the in-
 ternal, and a little on the  posterior side of the superior
 portion, the inferior extremity of which projects, in that
case,  on the anterior and external side.
   " In the fracture of the leg,  the gastrocnemii  muscles,
 tec draw the inferior portion upward and backward, with 
H6             ELEMENTS OF SURGERY.
the foot; for in this, as in every similar case, the strong-
er muscles  displace  the lower  portion of  the  fractured
bone, and draw it in their direction :  hence it is, that in
this case the portion is drawn  backward as well as up-
ward, because the muscles are more numerous and larger
on the back part of the leg than on any other. Therefore,
when a fracture takes place in any part of a bone, it is
easy to  determine,  from a knowledge  of the  muscles,
what species of derangement will follow,  if there be no
counteracting cause.  Finally, the muscles which  have
their insertion  in a superior fragment, may produce its
separation from the  inferior. When the femur is fractur-
ed immediately below the small trochanter, the iliac and
psoas muscles draw forward the inferior extremity of the
superior fragment, which raises the skin, and projects
more or  less. It is to be observed, however, that the dis-
placing of this fragment is very rare, whilst the inferior
fragment is  displaced in almost every case."—(Boyer.)
   Fractures are more or less accompanied with laceration
and  injury of the surrounding soft parts.   When the in-
teguments  covering  the fractured bone remain entire,
even although there be a great degree of  laceration un-
derneath it, the fracture is called simple.  A compound
fracture  is that in which an external opening is formed,
communicating with the space between the broken extre-
mities of the bone, or as it is commonly called, the cavity
of the fracture.  Mr. Hunter has applied the appellation
of compound simple fractures to those in which a frac-
ture originally compound becomes simple by the immedi-
ate healing of  the external wound.
   It sometimes happens  that fractures are accompanied
with dislocation, the dislocation  probably in every case
preceding the fracture.
   The causes of fracture  are the endless varieties of
 accidental  force applied to bones. Certain circumstances 
                elements of surgery.             Hy
of constitution, however, may be considered  as predis-
posing causes, such as old age,  in which the bones are
more brittle than in youth.  Any morbid state of the sys-
tem which occasions  absorption  of parts  of the bony
structure.   The French surgeons*  have recorded cases
where  bones have been  broken by simply turning in
bed.  Cold weather has been supposed to predispose to
fractures.   Boyer  observes,  that  if these accidents  are
more  frequent in  winter than in  summer, it is because
persons are then more liable to injuries from falling. Dr.
Physick has offered a much more plausible explanation
of the fact, which  is,  that in walking over frozen pave-
ments and other slippery places, great exertions are often
made to prevent falling, and this muscular exertion, add-
ed  to the  force of  the fall, occasions the fracture. The
bones are too well covered to feel much influence from
the cold.
   The symptoms  of fractures it is  very important to be
acquainted with.  They  are severe sudden pain—an
alteration in the form of the part—sometimes a shorten-
ing of the limb, if the fracture be in an extremity—an in-
ability to move the limb without severe pain at  the in-
jured part—an inequality of the skin covering the bone;
which renders a fracture of the clavicle, or of the tibia,
generally easy to  be  discovered; crepitation is the most
certain of all the symptoms—a grating noise, not to be
mistaken  for any other sound,  which is  sometimes very
audible.  The surgeon should take hold of the limb above
and below the fracture, and by moving the fractured ex-
tremities of the bone, he produces this noise and decides
beyond doubt the  existence of the fracture.
   If, however, the surgeon be not called till swelling
from ecchymosis,  and inflammation  have come on, it is
• Louis and Saviard. 
1 £8 *          ELEMENTS OF SURGERY.
not easy always to judge whether a fracture exists; in
this case he must wait until these symptoms subside.
  In judging of the probable event of a fracture, a great
variety  of circumstances  influence  the  surgeon.  The
age of the patient is of great consequence;  in young per-
sons they heal much more speedily and certainly than in
the aged.  I have seen several fatal cases of simple frac-
ture in old persons.   A healthy constitution, not debili-
tated  by intemperance, is  favourable for  the healing of
broken  bones.   Drunkards often become  delirious and
die, in  consequence of fractures and other severe acci-
dents.  The nature of the accident, the degree of vio-
lence applied,  and the mode of its application, greatly
influence the  prognosis.   Fractures from gunshot are
always  dangerous, a portion of  bone being destroyed hy
the force of the ball, which must exfoliate  (be  separated
by the absorbents)  before the sound bone  can  granulate
and unite:  a compound is always more dangerous than a
simple fracture.  A fracture attended with great  ecchy-
mosis, and extensive injury of the adjacent flesh, is more
dangerous than one unattended with these circumstances.
An oblique is more difficult to manage than a transverse
fracture.   Fracture of the lower extremities have more
serious  consequences than those of the upper. In general
those of superficial bones are less important than those in
which the fracture is  covered by large strong muscles.
Fractures in the middle of a bone are less dangerous than
r* its extremities in the vicinity  of joints.  The season of
the year, and  many  other  circumstances,  will no doubt
affect the healing of broken bones.
   The  reunion of fractured bones is  effected  nearly in
the same manner as the restoration of soft parts.  The
inflamed vessels pouring out coagulating  lymph, which
becomes  vascular,  and is  gradually by a deposition of 
                ELEMENTS OF SURGERY.              Hg
bony matter and an absorption of the unnecessary parts,
converted into a bone.
  The uniting medium is called callus;  it is at first soft,
but gradually becomes firmer, and  at length completely
ossifies.
  In some cases the bond of union  is very slow in form-
ing, and then the inflammatory action must be increased
by  stimulating remedies.  In other cases too much inflam-
mation exists, and then  unless prevented by depletion,
suppuration takes place.

            OF THE TREATMENT OF FRACTURES.
   To place the fragments as nearly as possible in their
original position, and to keep them so until union is effect-
ed, are the important indications in  the treatment of frac-
tures.
   To effect the replacement of the  fragments, extension
and counter-extension are generally necessary, though in
some cases, as in fractures of the olecranon and patella,
the fragments are to be pushed together. After the parts
are placed in  their proper  position, the  application of
bandages and  splints becomes necessary to retain them
so.  Extension signifies the force exeued on the fragment
of a limb most remote from the body. Counter-extension
is the power by  which the opposite  fragment is prevented
from moving with it. The  various  modes of applying
these forces will  be most properly  considered, when the
treatment of particular fractures is  described.
   The constitutional treatment must be regulated by va-
rious circumstances.   Inflammation frequently attends a
fracture, and is  an essential part of the process of resto-
ration.  If it be  too violent, the surgeon must restrain it
by the usual remedies.  Purging in many cases of frac-
ture is extremely  inconvenient in consequence of the mo-
tion to which it  gives occasion.   Blood-letting is to be 
1^0             ELEMENTS OF SURGERY.
preferred, as this mode of evacuation is not liable to any
objection, and the bowels are to  be kept from costiveness,
but no cathartics should be administered, unless in those
fractures  in which absolute rest is not enjoined,  and the
patient on the contrary is permitted to  walk, as fractures
of the arm, clavicle, &c.  A low diet should be observed.
  When the soft parts  are much injured, the antiphlo-
gistic measures are to  be carried  further than  where the
only injury is the broken bone.  In many cases, by their
powerful application, we prevent ulceration which would
convert a simple into a  compound fracture.  In cases of
extensive ecchymosis, where no large artery is wounded,
cold applications and copious depletion are generally suc-
cessful in preventing the formation  of an abscess.
  If any particular  artery of considerable magnitude is
wounded, it becomes necessary to cut down to it and tie
it up; and if possible without  cutting into the cavity of
fracture.
  In every case of fracture in which  it  is  necessary for
the patient to remain in bed during the cure (and there
are very few  in which it is not)  a proper bed is an ob-
ject of great convenience.  Sir James Earle has publish-
ed  an account of a bedstead and mattress invented by his
son, which in  fractures  and various other accidents and
diseases, adds so greatly to the comforts of the patient, that
I think the medical  world are under great obligations to
the inventor.*  In private practice, however, and espe-
cially in the country, it is extremely  difficult to procure
such a convenience,  and then a firm common mattress of
hair is to be substituted, or if this cannot be obtained, a
few blankets folded  and applied over boards.  A feather

  *  In the Pennsylvania Hospital, I have constantly used this bed in cases of
fracture for several years, and have found it extremely convenient in the treat-
ment of a variety of other accidents. An improvement on this apparatus by Df
J. R. Barton, is described in the 4th voL of the Eclectic Repertory. 
AV//7/'.v  /it>d.
 
 
                 ELEMENTS OF SURGERY.              £21
  bed and sacking bottom afford so very unequal and un-
  steady a surface, that it is extremely difficult to keep the
  patient who lies on them in a proper posture.

                 OF COMPOUND FRACTURES.
   These have an external  wound communicating with
 the cavity of the fracture. Mr. Pott very judiciously re-
 marks that, « In this kind  of case the first object of con-
 sideration is,  whether the  preservation of the fractured
 limb can, with safety to the patient's life, be attempted;
 or,  in other words,  whether the probable chance of de-
 struction, from the nature and circumstances of the acci-
 dent, is  not greater than it would  be from the operation
 of amputation.  Many things may occur to make this the
 case; the bone or bones being broken into many different
 pieces, and  that for  a  considerable extent,  as  happens
 from broad wheels or other heavy bodies passing over,
 or falling on such limbs, the skin, tendons, muscles, &c.
 being so torn, lacerated and  destroyed,  as to  render gan-
 grene and mortification the  most probable and most im-
 mediate consequence; the extremities of the bones form-
 ing a joint being crushed, or  as it were,  comminuted, and
 the ligaments connecting such bones being torn and spoil-
 ed, are, among others, sufficient reasons for proposing and
 for performing immediate amputation; reasons which, not-
 withstanding any thing that may have  been  said to the
 contrary,  long and reiterated experience has  approved."
   "  When a  surgeon says  that a limb  which  has just
 suffered a particular kind of compound fracture ought
 rather to  be  immediately cut off than  that any attempt
 should be made for its preservation, he does not mean by
so saying that it is absolutely impossible for such a limb
to be saved  at  all events; he is not to  be supposed to
mean so much  in general, though sometimes even  that
will be obvious; all that he can truly and justly mean is,
  VOL. I.          17 
i&!$              ELEMENTS OF SURGERY.
that  from the experience of time it has been  found that
the attempts to preserve limbs so circumstanced have most
frequently been frustrated by the death of the patients in
consequence of such injury, and  that from the same ex-
perience it has been found that the chance of death from
amputation is by no means equal to that arising from such
kind of fracture.
   "  Every  man knows that apparently desperate cases
are  sometimes  cured, and that  limbs so  shattered and
wounded as  to  render amputation  the only probable
means, are sometimes saved.   This is an uncontroverted
fact, but a fact which proves very little against the com-
mon opinion, because every man of experience also knows
that such escapes are very rare, much too rare to admit
of being made precedents, and that the majority  of  such
attempts fail.  This consideration relative to amputation
is of the more importance, because it requires immediate
determination; every minute of delay is in many instan-
ces to the patient's disadvantage, and a very short space
of time indeed makes all the difference between probable
safety and  fatality."
   It is not easy to give general rules  for practice  in these
eases, or else Mr.  Pott, and other writers of great prac-
tical experience, would certainly have expressed them-
selves  with more  precision.   One evades the question,
another gives it very little attention,  and Boyer  (inferior
to none in a knowledge of the subject) says, " It is im-
possible  to establish any general rule for cases of this
 kind.  The surgeon must be directed by his own talents
 and sagacity in each particular case." There are,  how-
 ever, some cases of compound fracture which so  evident*
 ly call for amputation that no doubt need exist  as to the
 propriety of performing it immediately, if the surgeon h
 called within a few hours after the accident has  happen-
 ed, and before inflammation has commenced. These are, 
               ELEMENTS OF SURGERY.               Igg
when a  luxation of a large joint, as the knee, ankle,
elbow or wrist, accompany the fracture, forming what
has been called a compound dislocation; when the prin-
cipal blood-vessels of the part are destroyed, and thus
the danger of gangrene augmented; when a large lace-
rated wound exists, the bone being greatly comminuted,
part of its  substance  destroyed, aud the weather very
hot. In such cases, the dangers are to be stated, and the
patient and his friends advised to submit to the operation;
a mere compound fracture never calls for it; it is the ad-
ditional  injuries which may  require so  terrible  a re-
source.
   Mr. John Bell remarks, " I am sorry to observe this
the most important  question perhaps in surgery, treated
as if it  were no question,  but rather a rule of practice,
which might be established on the most absolute grounds.
When a surgeon condemns a limb, he does not say that
if amputation be not instantly performed the patient will
die, nor  is he  disappointed if the  limb be  saved; he
thinks both more sensibly and more humanely; he knows
that there is great danger of losing the patient's life in
attempting to save his limb, and reckons it his appointed
duty to  advise  amputation;  but he is still sensible that
the limb may possibly be saved, and often after his honest
opinion is rejected, contributes, by his attention and kind-
ness,  to that most desirable object.   Sometimes he feels
it his duty to advise amputation,  and to represent very
strongly the manifold dangers of attempting to save the
limb, while yet he rejoices  to find his patient willing to
hazard all those dangers in favour of an object which it
must be the chief honour of the surgeon to accomplish."
   The wound communicating  with the fracture is some-
times made by the protrusion of the bone, at other times •
by the same force which caused the fracture; the latter
cases  are generally accompanied with the greatest mis- 
124             ELEMENTS OF SURGERY.
chief.  If, however, the injury be not so great as to in-
duce amputation, the  bone is to be reduced,  and proper
dressings are to be applied.
  Sometimes  a  considerable portion of  bone protrudes
through the external  wound, and cannot readily be re-
duced.  It has been the custom in these cases to cut off
the sharp ends and projecting pieces of bone, but this is
almost in  every instance unnecessary, and therefore im-
proper.  By carefully attending to the posture of the
limb, and  by dilating the wound when the bone becomes
girded in  it, and embraced tightly, we may  always suc-
ceed in the reduction.  The  enlargement of the wound
thus occasioned does much less mischief than violent at-
tempts to reduce the bone, which always occasion bruis-
ing and great  pain; an incision down upon the bone with
a scalpel,  or from the bone outward with a narrow bis-
toury  (whichever may in the  particular case be found
easiest) is to  be performed;  this incision readily heals,
and  leaves the wound no larger than it would have been
if this had been omitted.  Any loose splinters  of bone
may be removed, and the fragments carefully placed in
contact.   The wound, if an incision, may be closed with
adhesive plaster.  Mr. Hunter prefers, however, the ap-
plication of a superficial dry compress, in order to allow
the blood to coagulate and form a kind of scab, shutting
up the cavity of the fracture.  I have found both methods
successful, and prefer the latter in all cases except where
the wound  of the integuments is somewhat extensive, in
which case a  strip of adhesive plaster should be applied
over the middle of the wound, leaving an opening at each
end for the evacuation of effused fluids.  We are always
to keep in mind the  great importance of uniting the
wound by the first intention, and thereby converting the
accident to the state of a simple fracture, by which much
danger and suffering will  be prevented.  Whatever cir- 
                 ELEMENTS OF SURGERY.              125
cumstances, therefore, can keep the parts in a situation
favourable for union by the first intention, are to be strict-
ly observed, of course whatever can prevent  the inflam-
matory action  from  transcending  the  adhesive grade;
copious blood-letting  is often necessary in these cases.
   In fractures occasioned by  gunshot, and in  others
where union by the first intention is impracticable, and
suppuration must take place, from the extensive contu-
sion and injury of the surrounding flesh, a soft poultice
of bread and milk should be applied.
   The wound being dressed, the accident is to be treated
as a simple fracture, and of the proper dressings we shall
speak after describing the  fractures of particular bones.
   When  extensive suppurations come  on, and exfolia-
tions of bone, the  state of  the patient's  constitution  will
direct the  general remedies.  If debility be  occasioned,
bark and  tonics must be administered, and a generous
diet with fermented liquors allowed.
  The length  of time necessary for the reunion of a  bro-
ken bone  varies at different ages and in different bones.
In a healthy adult a broken leg will generally heal in six
weeks, a broken rib or clavicle in four.  In children they
heal in a shorter time.  In old persons not so soon.
  Notwithstanding the use of the proper remedies, cases
sometimes occur in which fractures do not heal by form-
ing bone, but by a ligamentous union. The patella gene-
rally heals in  this  manner, and no inconvenience results
from  a deficiency of bone between the fragments  in  that
particular instance; but whenever this happens in one of
tfie long bones, motion is allowed at the place of fracture
and a joint is formed,  which destroys in a great measure
the use of the limb, and  exposes the patieut to great in-
convenience.  In order to obviate this inconvenience,  and
to occasion bony union, a variety of measures have been
resorted to. 
126              ELEMENTS OF SURGERY.
  The physiological account of the formation of callus
is a subject foreign from our present purpose;  it is still,
however, necessary to keep in view, that inflammation is
essential to the restoration of a fractured bone, as well as
of a wounded muscle.  Whenever, therefore, two months
or more have elapsed, without solid union being effected,
it becomes necessary  to excite inflammation by rubbing
forcibly the fractured ends against each other; after which
the dressings are to be re-applied, and the part kept still.
If this fail of procuring the desired event (and it some-
times does fail)  other measures of a much more active
nature become necessary.  Mr. Boyer, and other writers
who have preceded him, recommend the cutting off of the
extremities of the bone, and placing them again in con-
tact.  " This operation," he observes, " is painful, terri-
fying, and of dubious event.   Its success, however, has
been frequent enough to warrant the trial.  It would be
impracticable in fractures of the leg or fore arm, on ac-
count of the difficulty of separating from the integuments
the two bones of which each  of these parts is formed, and
on account of the numerous nerves aud  arteries which
would be in danger of being wounded by the large  in-
eisions,  it is therefore practicable only in the femur and
humerus, especially in the latter."
  Mr. Boyer describes an operation of this kind which
he once performed in the middle of the humerus; the limb
mortified, and the patient died on the sixth day! In many
other cases amputation has  been performed.   I saw  an
arm cut off in one of the largest hospitals in Europe in
consequence of an " artificial joint" in the middle of the
radius.   It  must  be  stated, however, that in this case
there was a great deal of pain experienced in the part,
but I do not consider this by  any means  an excuse  for
such an operation, because there is every reason to be-
lieve  that had  the firm reunion  of  the fragments been
effected, this pain would have subsided. 
                ELEMENTS OF SURGERY.             Igy
  Mr. John Hunter suggested the propriety of exposing
the cavity by an incision, under an idea that the " stimu-
lus of imperfection" would excite a sufficiency of inflam-
mation to effect a union of the fragments.
  Dr. Physick has the credit of having proposed and
practiced a mode of cure in these cases more eligible and
successful than any heretofore  in  use,  and one which
promises to supersede the  cruel and  fatal operations
which  have been mentioned.  It consists in passing a
seton between  the  fragments, and suffering it to remain
until bony union commences. The first case in which this
plan was carried into  effect, occurred in the year 1802.
The os humeri had been  fractured many months before,
and a joint was formed in its middle, which rendered the
arm useless.  A seton needle armed with a skein of silk
was passed through the limb (extension being made at
the time by two assistants) between the fractured ends of
the bone,  a pledgit was applied on each orifice made by
the needle, which was cut  off,  leaving the silk in the
wound.  The operation occasioned very little pain, and
the subsequent inflammation was by no means violent,
and  was followed by moderate suppuration; the arm was
in a few days after the operation placed in  splints; the
dressings were renewed daily for twelve Weeks, during
which time no amendment was perceived; but soon after,
the  bending of the arm  at the fracture was observed to
be more difficult, and the  patient complained of more pain
when  it was  moved.   From this time  the bony union
went on gradually, and  in  about five  months  the cure
was completed,  leaving the arm as well and strong as
it ever had been.
   Several cures of the os humeri and  tibia have since
been made in the same mauner. It is  important to  be
recollected that a long continued inflammation  must  be
kept up in these cases, and therefore the seton should not 
128              ELEMENTS OF SURGERY.
be withdrawn for four or  five months unless bony union
is found commencing.  I am sorry to state that the reme-
dy has been applied to two cases of fractured os femoris
without effect; the occasion of the failure was, however,
very  obvious in both cases: it was found impossible to
place the fractured  extremities  nearly together.  They
had passed each other to a considerable distance, and
the adjacent lacerated flesh had  healed  around them in
such  a manner, that a great intervention of soft parts ex-
isted,  and precluded completely all contact of the frag-
ments.*  My friend Mr. Brodie  of  London, has  suc-
ceeded completely in a  case of  fractured os  femoris, by
means of the seton, and believes it applicable to that as
to other cases.  Mr. Wardrop found  it useful in dimin-
ishing the mobility of the artificial joint, but the ill health
of his patient prevented it from effecting a complete cure.
(See Medico-Chirurgical Transactions, vols. 5 and 70
  It  is probable that the remedy will be found effectual
in most other cases  of  artificial  joints, but not often in
those situated in the os femoris.
  Much of the substance of the bone is absorbed in cases
of artificial joints, so that the  fragments are rounded, or
rather pointed,  and terminate in a kind  of  cartilage or
ligament, f

  *  See plate VI. fig. 6.
  f  In a thesis published at Paris, by J. B. La Roche, in 1805, the seton, as
proposed by Dr.  P. S. Physick, is  recommended  as preferable to all other
means heretofore used in such cases; but the writer being unacquainted with
the English language, has supposed the family name of Dr. Physick to be that
of his  profession, and consequently ascribes the honour of the invention to
Monsieur P. S.--------, Physician. The writer of the thesis alluded to, hav-
ing seen setons used after gunshot fractures to facilitate the discharge of dead
bone, wonders that the thought never occurred to himself nor his master, of
applying the remedy to cure artificial joints. 
ELEMENTS OF SURGERY.
129
                 CHAPTER XIX.

                Particular Fractures.

              FRACTURES OF THE OSSA NASI.

  The ossa nasi, in consequence of their exposed situa-
tion, are often fractured.  " The cause of the fracture is
always applied to that part immediately where the solu-
tion of continuity takes place, and  the fracture may be
oblique, longitudinal, or transverse, without derangement
of the  fragments; but it  more frequently happens that
the bones are splintered and crushed into the cavity of
the nostril: the nose  loses  its natural form, and  the
neighbouring soft parts are much bruised by being crush-
ed between the bones and  the cause of the fracture, whe-
ther this be a body against which the nose has been for-
cibly struck,  or  one which  may  have been strongly im-
pelled against it.
   " If the soft parts have suffered no solution of conti-
nuity,  and if the fragments have  not been displaced, the
fracture may  not be discovered, because the form of  the
nose does not change.   An  oversight in this case is not
dangerous, as the use of emollients and resolvents is all
that is  required.  If the fracture be comminutive, not only
the inflammatory symptoms ought to be combatted by
blood-letting and other antiphlogistic means, but further,
the fragments ought to be replaced,  as they strain and
irritate the soft parts, already contused, by their unnatu-
ral  situation.  For that purpose the  surgeon takes a
grooved sound, a female catheter, a ringhaudled forceps,
or any such instrument, introduces it into the nostrils, and
by using it as a lever, pushes the fragments outwards; at
  vol. i.         18 
130            ELEMENTS OF SURGERY.
the same time with the index  of the left hand applied to
the ringe of the nose, he prevents them from being push-
ed  out too far, and from lacerating the integuments.
Sometimes the bones continue in the situation in which
they have  been thus placed; but it may happen,  that
from being much fractured, and badly supported by the
soft parts, they fall again inwards : in  which case a ca-
nula of elastic gum should be directed along the inferior
surface of  each nostril, which ought then to be stuffed
with lint, and gently thrust  in, lest the pituitary mem-
brane should be hurt.
  " In cases of comminuted fracture, with depression of
the splinters, it would be imprudent to wait the disap-
pearance of the inflammatory symptoms,  before  making
an attempt to raise  and adjust the fragments;  because,
during the interval,  the portions of bone might reunite
in an unnatural  situation, and produce  deformity of the
nose.
  " Fracture of the nasal bones is sometimes  attended
with very  dangerous symptoms,  whether produced by
a violent commotion given to the head, by the cause
of the fracture,  or by a co-existing fracture of the bones
of the skull; or, as some authors think by the concus-
sion communicated to the perpendicular part  of the  eth-
moidal bone, and thence  to  its cribriform part, which
would, in that case, be fractured, on account of its great
tenuity.  The laceration of the dura mater  and its  ves-
sels, caused by the fracture  of the cribriform lamella of
the ethmoidal bone, would produce  effusion, and  thus
give rise to  all the symptoms.   It is certain that cases
have occurred where blows on the root of the nose have
produced coma,  convulsions and death; particularly when
the nasal bones  were not fractured." (Boyer.)
  A piece of leather  spread with adhesive  plaster as-
sists,  by gentle compression, in preventing the displace- 
                elements of surgery.             131
ment of the fragments, and as there is no danger of dis-
placement from muscular action, no  other dressing is
necessary.  I  have seen  a  fracture  of these bones in
which  one of the fragments punctured  the  facial ar-
tery as it passes over the nose.  The hemorrhage at first
was very profuse,  but ceased after the fragments  were
reduced. 
132
ELEMENTS OF SURGERY
                 CHAPTER XX.

            Fractures of the Lower Jaw.

  This bone from  its moving freely when struck, and
also from its strength of texture  is  not very often frac-
tured.   It sometimes however is broken, and no part of
it is secure from fracture.   Mr.  Boyer declares that its
" symphysis at the  chin is very rarely fractured though
it is not impossible."  I once saw an instance of fracture
at this place.   Sometimes it is broken in several places.
I have known the jaw bone broken by a fall, into five
different fragments.   The middle piece in these cases is
most difficult to be kept fixed, because of the muscles in-
serted into it which tend  to draw  it downwards.
  It is liable to fracture in every part, from the condyles
to the chin.  The coronoid process is not often fractured
except by gunshot  wounds.   The condyles are oftener
broken.  The fracture may vary greatly in its direction;
it is sometimes transverse, sometimes oblique, sometimes
in the direction of the bone, or longitudinal,  separating
the alveolar portion from the basis.  It is generally sim-
ple, but sometimes  compound.
  The symptoms of a fractured jaw are very obvious; a
severe pain at the part is felt at the time of the accident,
and an inequality  is perceived  on passing the fingers
along  the basis  of the jaw; upon examining the teeth
they  are found unequal, those situated upon  one frag-
ment being elevated above those of the other; when the
two sides are  taken in  the hands  it is easy to reduce
the teeth to their proper  level,  and in doing so crepita-
tion is perceived.   These symptoms exist when the frac-
ture is situated anteriorly to the angle of the jaw, when 
               ELEMENTS OF SURGERY.              133
the condyles are broken, the fracture is not so very ob-
vious, but may be ascertained by pain near the ear when
the jaw is moved, and by crepitation occasioned by these
motions.   If considerable swelling occur before the  sur-
geon is called, greater difficulty is experienced in deter-
mining the nature of the accident, and in these cases it
becomes  necessary to wait until the inflammatory symp-
toms subside.
   The greatest danger attending a simple  fracture of the
lower  jaw is that of consequent  deformity, and this is
very readily obviated by proper arrangement. Compound
fractures, however, are  more dangerous  and are often
followed  by tedious exfoliations, and in some instances
do not unite.
   To reduce the fracture, nothing more is necessary  than
to shut the mouth, and forcibly push upwards  the  infe-
rior fragment, until the teeth contained in it come in  con-
tact with those in the upper jaw. When all the teeth are
upon a level, the fragments are to be supposed in appo-
sition.   It is not easy in all cases to keep  them at rest in
this position:—A variety of  means have been contrived
to effect  this purpose,  such as fastening the pieces to-
gether by passing wire around some  of the teeth in  each
—forming a mould of moistened pasteboard to fit the  chin,
and binding this fast upon  it.  The simplest  and best
plan is to avail  ourselves of the support given by the
teeth in the upper jaw, by binding the fragments firmly
against them,  and this can be very conveniently done hj
means of a simple roller of  muslin passed repeatedly
round  the top of the  head and under the chin.   It may
be further secured by passing a few  turns of it round
the back of the neck and in front of  the chin. The  four-
headed  and double-headed  bandages formerly used for
this purpose, have no advantage over  the roller, and it
is by no  means so easy to apply them neatly.
   The patient should be nourished fifteen or twenty days 
134             ELEMENTS OF SURGERY.
on spoon victuals, sucked between the teeth, for which
there is generally space enough, and this space is  often
augmented by the want of a tooth at some part of one of
the jaws.—It  has  been proposed in comminuted and
compound fractures, where the  slightest motion is pro-
ductive of great  pain, to pass  a catheter  through thi
nostril, and inject the fluid aliment through it.  If a case
requiring such treatment should occur, no difficulty would
be found in effecting it.
  In fractures of the condyles of the jaw, that process is
drawn forwards  by the pterigoideus externus muscle;
as it is very  short  there  is no means of obviating this,
and it becomes necessary therefore to push forward and
keep  in that  situation the inferior fragment; in order to
effect which, before applying the bandage  as  has  been
directed, a compress is to be applied behind the angle of
the jaw extending nearly up to the  ear, this compress
when the roller presses tightly on it  will keep the  infe-
rior  fragment advanced sufficiently to come and remain
in contact with the upper.  In fractures of  the condyles
it is particularly necessary for the parts to remain at rest,
as motion  has sometimes  prevented the reunion of the
fragments and the condyle has exfoliated. Boyer relates
a case in which this unpleasant event occurred: he ex-
tracted the condyle seven months  after  the  accident
through a fistulous ulcer.
  Compound fractures  of the lower jaw,  are very fre-
quently attended with exfoliation, by which the cure is
much protracted.
  It  often happens  that  one  or more of the teeth are
loosened at the fractured part; it has  been advised to
extract all loosened  teeth, as extraneous matter.  It is  *
fact, however,  that the teeth  under these circumstances
very  readily  become fixed, and  it is extremely improper
to remove them, because the accident is  thus converted
into a compound  fracture. 
ELEMENTS OF SURGERY.
1-35
                  CHAPTER, XXI.

              Fractures of the  Vertebrae.

   The spinal column moves readily in every direction,
and being composed of a great number of separate pieces,
of small size, is not very liable to fracture.  The spinous
processes are sometimes  broken, because they are more
slender and brittle than the other parts of the bone, pro-
ject considerably backwards and  are more superficial.
Whenever the  vertebrae are fractured,  the force  which
produces this effect occasions also concussion of the spi-
nal  marrow,  which is the only circumstance rendering
the  accident important, for the mere fracture of the ver-
tebra would heal as readily as that of any other bone. A
palsy of all  those  parts which  derive their nerves from
below the fractured spot is the immediate consequence
of every fracture of the spine which produces compres-
sion on the spinal marrow,  whether this be by the pres-
sure of bone or  effused fluids.  When this happens,
therefore,  in  either of the  three superior cervical verte-
brae, immediate death ensues, from  palsy of the  fourth
and fifth pair of cervical nerves, which chiefly supply
the  diaphragm, and which originate in the spinal mar-
row, a little higher than the place of their exit. Although
death does not instantaneously follow the fracture of the
fourth cervical vertebra, yet it very soon occurs.*
   " The variety of causes which may give rise to symp-
toms analogous to those of fracture  of the vertebra reii-

  * A very remarkable case occurred in January 1816, which seems to form
an exception to this general rule-a gentleman was shot by a pistol presented
close  to his face-the ball entered his mouth and shattered the atlas vertebra
notwithstanding which he survived the accident three weeks, and no symptoms
of paralysis occurred, though the pus and the ball were in contact with the
uura mater. 
136             ELEMENTS OF SURGERY.
der it difficult to establish a diagnosis.  Yet when a per-
son has fallen on his back from an  elevated situation, or
when a  body very forcibly  impelled, as a  bullet dis-
charged from a musket, has struck that part, if a fracture
has taken place, some derangement of the spinal process
of the.fractured vertebrae may be observe^, by an atten-
tive  examination of  the  part affected.   Much  pain is
caused by pressing on that process; the inferior extremi-
ties are paralyzed, as also the rectum and bladder; the
patient is afflicted with a retention of urine and faeces, or
with an involuntary discharge of the latter.
   " This paralysis of the inferior extremities, the neces-
sary concomitant of the fracture of the vertebrae is not in
itself a mortal affection; but the patient losing the power
of locomotion, and being obliged to lie perpetually on his
back, soon  feels a troublesome  itching in the region of
the sacrum  on which the pressure of the body is princi-
pally concentrated.   The skin of this part becomes in-
flamed and  gangrene to a greater or  less degree ensues,
because the pressure  on that part intercepts the course of
the humours.  The bone  is quickly  denuded, the ulcer
extends rapidly and  consumes the patient's strength, the
dissolution is accelerated by the retention of excrements,
from the paralysis of the rectum and  bladder.  The ca-
theter which must be introduced into this latter organ for
the purpose  of evacuating the urine gives admission to
the air."* "Its mucus secretion becomes  more abundant
and its substance thickened.  A slimy matter flows out
with the urine, and the penis and scrotum become cede-
matous, a slow fever succeeds these  symptoms,  and the
patient however robust he may be, falls in a few weeks.

  * The inflammation thus occasioned,  is probably not excited, as Mr. Boyer
supposes, by the admission of air, since there is no reason for supposing this
fluid a powerful irritant, except when it produces fermentation, in the contents
of a cavity. 
                 ELEMENTS OF SURGERY.             13*r
 We have known, however, a man of very vigorous con-
 stitution to have  survived for six months an accident of
 this nature.  Examples of  recovery  are recorded, but
 they are extremely rare, and to be ascribed to the secret
 operations of nature rather than to the efforts of art, and
 we repeat that scarcely one in thirty recovers; almost all
 die from the exhaustion of their strength, by slow fever,
 colliquative diarrhoea, &c.
   " Any attempt at settiug these fractures would be not
 only useless but dangerous, by the  straining -which it
 would occasion.   General treatment  alone can  be had
 recourse to.*' (Boyer.)
   In all cases of injury of the  spine it is of extreme im-
 portance to introduce  a catheter into the bladder, and
 to leave it in with a cork in the orifice, or to introduce it
 and evacuate the  urine  three  or four times every twenty-
 four hours.  As the patient in  these cases feels no pain
 and is  not conscious of the distention of his bladder, it is
 necessary for the surgeon to  be aware of the importance
 of attending to this circumstance. A patient was brought
 into the Pennsylvania  hospital in  the summer of 1812,
 who had  been wounded in  the spine, by a musket-ball
 two weeks before in a  naval engagement.   He had re-
 ceived very little  attention after the accident; immediate-
 ly on  his admission I  ordered the catheter to be intro-
 duced, when nearly three quarts of urine were drawn off;
 he had voided none for  two weeks.
  It has been recommended to  trepan  the spine in cases
 of paralysis from fracture, and to remove the depressed
 bone or effused fluids, as in cases of fractured  cranium.
 This operation could not be  performed without extreme
 difficulty, and the  greatest  uncertainty of relieving the
compression. The inflammation likely  to  follow the- ope-
ration,  would probably occasion a repetition of the pres-
sure from distention of the vessels within the spinal cavity.
  vol. i.         19 
138             ELEMENTS OF SURGERY.
   Dr. Physick has  attempted to relieve  the effects of
fractures of the vertebrae, by making extension and coun-
ter-extension  from the head and feet of the patient, the
head  being secured to the upper and the feet to the lower
part of the bedstead.  In the first case  in which it was
used, the fracture was situated  in the fifth and sixth cer-
vical  vertebrae ; the patient regained after the extension,
the use of his arms which had been paralytic, but expir-
ed shortly after,  apparently from a collection  of mucus
in the trachea which  he was  unable to cough up, from
palsy of the expiratory muscles.  Perhaps  as some relief
was in this case experienced the remedy may be worthy
of trial.*
   In  examining patients with fractures  of the spine it is
of extreme importance not to turn them on their  faces,
but to conduct the examination whilst  they lie on one
side—suffocation has resulted and instant death from ne-
glecting this caution.

  * An account of this case may be seen in Dr. Hartshorne's edition of Boyer 
ELEMENTS OF SURGERY
139
                 CHAPTER XXII.

                Fractures of the Ribs.

  The  ribs in consequence  of the  elastic cartilages in
which they terminate, and of the strength derived from
their  arched fprm, are not very often fractured.  The
first rib is very  seldom broken, as the shoulder and cla-
vicle  protect it  greatly from  accidental violence.  The
ribs are. most commonly broken by falls from a conside-
rable height, and sometimes  by violent  blows.  They
are generally broken near their middle, by a transverse
fracture; sometimes the fracture is oblique, and inconve-
niences  result from  the sharp extremities of  the  frag-
ments;  sometimes these penetrate  the  external integu-
ments, forming a compound fracture, and sometimes they
pierce the pleura and lung, and thus occasion emphysema.
  The fracture is ascertained by an acute pain in breath-
ing and by  careful examination with the hand, and by
pressing the rib in different parts a crepitus may some-
times be felt.  To assist in the investigation the patient
should be desired to cough whilst the surgeon's hand is
kept on the part injured, if any fracture exist the act of
coughing will generally produce crepitation.
  In many cases, especially in very corpulent subjects,
there  is great difficulty iu ascertaining the existence of
the accident, and in all these cases the dressings should
be applied as if a rib actually  were fractured.
  From the  articulation of the ribs to the sternum before,
and the  vertebrae behind, no diminution  of length can
lake place;  no lateral derangement of the fragments can
happen, because the intercostal muscles act  equally  on
both fragments, and tie them to the uninjured ribs above 
140             ELEMENTS OF SURGERY.
and below.  The only derangement which can happen,
is  by an angular  projection internally at  the place of
fracture.
  The only  treatment  necessary in  simple fractures of
the ribs whether one or several be broken, is to keep the
parts at  rest as much as possible  during their reunion,
and this  is done by counteracting in  great measure their
motions in respiration.  To effect this, a  bandage six
inches wide is  to  be passed repeatedly round the chest
as tight as  the patient cau suffer it to  be drawn.  Its de-
scent may be prevented by a shoulder-strap. When this
is done respiration is performed, principally  by the ac
tion of the diaphragm, and the ribs remain, comparative-
ly at rest.  Instead of the roller, a jacket of strong linen
may be used  capable of being laced very tight by means
of tapes.
  When the lungs have been wounded  by a fragment
of the bone, the patient generally spits blood and coughs
violently—the  lungs  inflame, and violent fever comes
on, attended with difficult respiration  and other symp-
toms of pneumonia.  Copious blood-letting, and the usual
remedies for inflammation  must in  such  cases  be em-
ployed.
  When emphysema occurs from  a  fractured rib, it is
to  be treated in the  same  manner as has been recom-
mended when this affection is consequent to a wound of
the thorax. If the  complaint proceed  to any considerable
extent an incision is to be made  into the thorax; it is,
however, a very rare occurrence:  to prevent it, it has
been recommended to bind a compress very firmly over
the fracture.
  When the cartilages of the ribs  become ossified, as
they often do in advanced life,  they are also liable to
fracture, the  accident is to be  treated just as a broken
rib. 
ELEMENTS OF SURGERY.
141
                CHAPTER XXIII.

         Fractures of the bones of the Pelvis.

  The  os sacrum  is not often fractured—a carriage
passing over it, or a  heavy weight falling on it, may oc-
casion a fracture: no muscles are inserted  into it which
have any agency in moving the fragments,  and the only
remedy is rest in a horizontal posture.   If extensive in-
flammation result from  the  contusion accompanying the
fracture, it is to be treated as usual.  If suppuration take
place, and abscesses  form, they must be opened as soon
as possible, to prevent the formation of fistulous ulcers.
When large extravasation takes place within the pelvis,
bleeding and low diet are to be ordered, with a view to
prevent suppuration, which in this situation would  prove
a very serious evil.
  The os coccygis  is sometimes broken,  though  very
rarely—the existence of this fracture is ascertained by
pain in the part, and in every attempt to walk this pain
is augmented:  by introducing  the finger into the  anus,
the fragments may be felt.  The only remedy necessary
is rest and gentle compression, by means of a compress
supported by a T bandage.
  The ossa innominata  are occasionally broken  by a
variety of accidents;  the fracture occurs in different  situa-
tions.   Mr. S.  Cooper has seen instances of fracture  in
the ilium, the ischium, and the  os pubis.  I have seen
the acetabulum fractured in such a manner as to occasion
incurable lameness.  The ilium, however,  is  more fre-
quently broken than  either the ischium or pubis.   The
fracture of these bones,  is in itself of less  consequence
than  the  mischief occasioned by the force which  pro- 
14S             ELEMENTS of surgery.
duced it.^ The contents  of the pelvis must be contused
severely by any force great enough to fracture the bones
which form it, and generally extravasations of blood take
place into the cellular texture, which intervenes between
the viscera of the pelvis.
  A fracture of  the os innominatum,  is to be known by
the usual symptoms of pain and crepitation upon moving
the fragments; an inability to walk also occurs,  but any
severe injury to the pelvis  produces this:  fractures of
these bones have often been found after death, when their
existence has been unsuspected.
  The treatment consists  chiefly in obviating inflamma-
tion by the usual  remedies,  as no displacement of the
fragments is likely to occur.  The inconveniences of dis-
charging the urine and fasces,  are sometimes very great
in these accidents, but they are much diminished by the
use of sir James Earle's bed.  In some cases  suppuration
takes place, notwithstanding the free use  of evacuatiug
remedies, and large abscesses form:  splinters  of bone
have been found to occasion these collections of matter.
" Desault in giving an exit to a collection of urine which
had taken place from a fracture of the pelvis, found a
splinter which he extracted from the bottom of the wound.
If the bladder be perforated by a splinter, this should be
extracted, and a catheter introduced, in order to  prevent
the accumulation of urine and its consequent effusion into
the cavity of the abdomen;" an  accident which  has oc
curred. 
ELEMENTS OF SURGERY.
143
                CHAPTER XXIV.

              Fractures of the Scapula.

  The mass of muscular flesh which surrounds the sca-
pula, and its great mobility, protect it in great measure
from fracture; some  parts of it,  however, are more  ex-
posed than others. The accromion process forms the most
projecting part of the shoulder, and is oftener  fractured
than any other part of the scapula; the inferior angle is
the part  next in frequency found broken.  The coracoid
process  has seldom  been known fractured: a gunshot
wound, and the falling of a heavy body directly upon it,
have sometimes,  however, occasioned this accident.
  The force which produces the fracture  generally occa-
sions much contusion of the adjacent flesh.   When the
scapula is broken longitudinally,  the muscles on its sur-
faces prevent a displacement of the fragments, transverse
fractures are more apt to be accompanied with a  derange-
ment of them. The serratus  major anticus muscle, draws
forward the lower portion to which it is principally at-
tached.   The inequality is evidently perceived  by  pass-
ing the fingers along the base of the scapula.
  To ascertain the existence of the fracture, it  is neces-
sary to examine particularly whether any derangement
is evident, and whether any crepitation can be  produced
by  pressing the bone in different places.  The only frac-
tures which are not easily discoverable in this  way  are
the longitudinal.  The lower  angle when broken  off
moves easily  under  the fingers,  whilst the rest  of  the
bone is stationary.
    When  the  fracture is longitudinal, or  transverse
through  the scapula, a roller is to be applied round the 
144             elements of surgery
chest and arm, so as to confine the arm close to the side;
this roller should cover the arm down to the elbow.
   " As the inferior angle when separated by fracture
from the rest of the bone, is like the condyloid process
of the jaw, little susceptible of being acted on by any
means in  our  power, it  will be necessary to act on the
scapula  itself, to push it downwards and forwards, to-
wards the inferior fragment which the  serratus major
anticus  has drawn in that direction.   In  this case too,
it is on  the arm that it will be necessary to act, in order
to move the scapula.   The arm is to be pushed inward,
forward, and  downward, the  fore arm being half bent.
It must  be kept  in this  position by a circular bandage
seven yards long. It will be proper at the same time to
act on  the angular detached portion by  means of com-
presses, which may be pressed backward by some rounds
of a bandage,  and thus brought in  contact with the rest
of the bone.   The arm may be supported in a sling tied
on the  opposite  shoulder."  (Boyer.)
   " The  accromion when fractured is drawn outward
and downward by the action of the deltoid muscle, at the
same  time that the rest of the bone is drawn upward and
backward by the trapezius and levator scapulas.  This
fracture is set, by raising the  arm in such  a manner as
that the head  of the humerus may push upward the ac-
cromion,  which  has descended,  and which  naturally
covers it like an arched roof, at the same time an assistant
pushes  the scapula forward and downward, in a direc-
tion  opposed to that which  is given to the arm"-—in
order that the parts may remain in this situation, band-
ages  are to be applied—" a circular bandage is to be ap>
plied round the  trunk and arm, and afterwards made to
ascend  from the elbow to the shoulder, and vice versa/
 « This bandage like all  those of the thorax is very liable
 to be displaced, and therefore to be frequently reapplied, 
                elements of surgery.               145
never forgetting on these occasions to have the elbow
raised and the shoulder pressed down,"  (Boyer.)
  Although fractures  of the  scapula  consolidate in the
ordinary time of thirty-five or forty days, yet in those  of
the accromion it will be necessary to continue the band-
age a little longer;  not that the generation of  callus is
slower in that part than in  auy other, but  because the
accromion  is acted on by strong muscles, which might
rupture the callus if exposed to their action before it had
acquired a great degree of solidity.
VOL. I.
20 
146
ELEMENTS OF SURGERY.
                CHAPTER  XXIV.

              Fractures of the Clavicle.

  The clavicle is perhaps  as often broken as any bone
of the body.  Its exposed situation at the upper part of
the trunk,  its long  slender shape,  and its being covered
only by the common  integuments,  expose it  to frequent
accidents.
  The fracture commonly occurs near the middle of the
bone, as it is here most prominent,  it is also occasionally
broken near the sternal, and humeral extremities.  When
fractured by the falling upon  it of a heavy body, the
nerves of the arm become paralyzed by the contusion.
  In general the fragments are displaced, unless it is
broken near the shoulder, in which case its firm connex-
ion by ligaments with  the  scapula  prevent the displace-
ment. The external fragment, or that nearest the shoul-
der, is drawn downwards by the weight of the arm, and
the action  of those fibres of the deltoid muscle, which are
inserted into it, and also by the pectoralis  major, which
when it  is  depressed draws it forwards, or  inwards to-
wards the sternum; so that the sternal portion is always
found riding over the humeral; the arm of the affected
side falls over upon the breast, and the patient is unable
to rotate the humerus,  so that it is impossible for him to
raise his hand upon his head.   He leans to the fractured
side, and the attitude is so remarkable, that the celebrat-
ed Desault it is said,  was never  deceived  in deciding
from this circumstance  alone,  the existence of the frac-
ture.  Crepitation may easily be produced by  moving the
arm,  and the finger passed over the  clavicle  readily de-
tects the place of fracture. 
                 ELEMENTS OF SURGERY.             l^W
  This accident in itself is not dangerous, but becomes
so when accompanied with great contusion or laceration
of the neighbouring soft parts.
  The treatment of this  fracture has  been the source of
much difficulty among surgeons, a vast variety of machi-
nery has been contrived  for  the purpose of keeping the
fragments together, and lately a surgeon of great and de-
served celebrity* has renounced  all applications  and
trusts to rest in a horizontal  posture,  as the only neces-
sary remedy.  I refer to Mr.  Boyer for a concise account
of the discarded apparatus of  the  older surgeons.   Mr.,
Desault was the first who properly contemplatedTOe dif-
ficulties to be  surmounted, and constructed an apparatus,
which better than any before in use, removes them.  His
plan with different modifications has been very generally
used in this country, and continues to be preferred to all
others, I shall therefore describe it. It is not the smallest
advantage of his dressings that they are  always at hand.
  " The pieces of which this apparatus is composed are,
1st, Three rollers  three inches broad; the two first six,
the other eight ells long, each one rolled up separately.
  2d, A bolster or pad (Fig. 1. a b) made in the form of
a wedge, out of pieces of old linen.  Its length should be
equal to  that of the  humerus, its breadth four or five
inches, and its thickness at the base about three inches.
  3d, Two or three long compresses.
  4th, A small sling  for the arm.
  5th, A piece of linen large enough to  cover the whole
bandage.
  Every thing being  properly arranged, the following is
the mode of applying the  apparatus,  which of itself re-
duces the fracture.
  The patient being placed in a standing position, or if
* Mr. Pelletan, surgeon in chief to the Hotel Lieu, &c. &c. &c. 
148             ELEMENTS OF SURGERY.
his case  render that impracticable on a  seat w ithout a
back, an assistant elevates the arm of the affected side,
and  supports it at nearly a right angle  with the body,
(Fig. 2.) whilst the surgeon places under the arm-pit the
head of the bolster, which descends along the side of the
thorax, and which another assistant situated at the pa-
tient's sound side holds by two upper corners.
   The surgeon now takes one of the first rollers, applies
the end of it on the middle of the bolster, fixes it there by
two  circular turns  round the body, and passes a turn ob-
liquely (a a) along the fore part of the thorax ascending
to thdttound shoulder. The roller then descends behind,
passes under the arm, and returning in front of the tho-
rax,  makes a circular turn and a half horizontally.  Hav-
ing reached the hind part of the thorax  it reascends ob-
liquely by the  cast (b) as it had done before, and passes
over, before, and under the sound shoulder; having thus
crossed the turn (a a)  the roller again passes across the
hind part of the thorax,  and finishes by circular  turns
which completely cover the bolster.  A pin is now to be
fixed in the  place  of crossing of the roller on the sound
shoulder, to prevent the  turn (a) from  slipping down-
ward.
   The application  of this first  roller is intended for no
other purpose than firmly  to fix the bolster, which is held
up by  the two oblique turns before and behind, and se-
cured against the body by the subsequent circular turns.
   The bolster  being fixed, the surgeon applying one
hand to its external surface pushes it upwards, and with
the other, taking  hold of the elbow,  after having half
bent the  fore arm,  lowers  the arm till it is laid along the
bolster.  He then presses its  lower extremity forcibly
against the side of the thorax, pushing it upwards at the
same time and  directing its upper extremity a little back-
wards. 
                ELEMENTS OF SURGERY.              14,1)
  The application of the bandage constitutes a part of
the  process of reduction.  The humerus, now converted
into a lever of the first kind, is drawn at its upper end
from the shoulder, in  proportion as its lower end is ap-
proximated to  the thorax. The scapulary fragment being
drawn along with it, and directed at the same time up-
wards and backward, comes into contact with the sternal
fragment, and  in an instant the deformity of the part dis-
appears.
  The arm  being  thus situated is given in charge to  an
assistant, who retains it in the same position in which he
received  it from  the surgeon, by pressing on  it with one
hand, and with the other supporting the  fore arm half
bent, and placed horizontally across the breast.
  The second roller is next to be applied.   The end of
this is carried  under the arm-pit of the sound side.   It is
then brought across the breast, over the superior part of
the diseased arm, and  extends  across the thorax behind
till  it passes under the  arm-pit. Two circular turns cover
the first.  The roller must then ascend to the lower part
of the  shoulder  by oblique turns (c c Fig. 3.) each of
which  must be overlapped by the succeeding one to the
extent of about  the third part of its breadth.   It is ne-
cessary that these turns  be  applied in such a way as to
bind but very  gently above, and to increase in tightness,
as they descend  nearer to the lower extremity of the hu-
merus.
  The use of  the  second roller is to supply the place of
the hand of the assistant in pressing the arm against the
side of the thorax, its effect evidently is to  draw the up-
per extremity  of the arm outwards, and as it is already
directed  backwards, to retain  it in that position.   The
compression of the circular  turns on the arm, being thus
gradually augmented,  becomes on the one hand more  ef-
ficacious, because it acts on a -renter surface: and on the 
 150             ELEMENTS OF SURGERY.
 other less troublesome, because being more divided it is
 less felt at the lower extremity of the arm, where it bears
 with most force.
   A third indication remains to be fulfilled, namely, to
 retain  the  shoulder in its elevated position, and by that
 means to assist in the extension of the fragments, which
 already has some effect in preventing a depression.
   To fulfil  this indication,  an assistant sustains  the
 elbow  in its elevated position with one hand,  and with
 the  other supports the patient's hand  before his breast,
 whilst the surgeon fills with lint the hollow spaces around
 the clavicle.  He then applies on the clavicle at  the place
 where  it is fractured, the two long compresses,  wet with
 vegeto mineral water, a solution of sugar of lead, or some
 other cooling liquid.  Taking now the last roller, he
 fixes the end of it under the  sound shoulder, from thence
 he  brings  it obliquely across the breast, over  the long
 compresses,  and carries it  down  behind the  shoulder
 along the posterior part of the arm, till it  passes under
 the elbow.  From this point he again carries it obliquely
 upwards across the breast to the arm-pit, then across the
 back over the compresses,  and brings it down again be-
fore  the shoulder along the front  of the humerus, till it
 again reaches the elbow.  From thence the roller again
 ascends obliquely behind the thorax,  passing under the
 arm-pit where the first coat of the roller is  covered, and
from whence it  again starts to ruu the same course  we
have just described.  This constitutes  a second round,
which covens in part the first, and forms a kind  of double
triangle, e, /, d, situated before the breast, and over the
circular turns of the other rollers (c c Fig. 4.)   The  re-
maining part of  the roller brought from behind forward,
is employed  in circular  turns over the arm,  and round
the thorax  for the  purpose  of preventing the  displace-
 ment of the first part.  To make it the more secure it is 
                 ELEMENTS OF SURGERY.             151
fastened with pins or stitches at its different places of
crossing.
  The sling (Fig. 4.), is next passed under the hand,
and fastened above to the ascending turns (d) and not to
the circular (c c),  which the weight of the  hand would
be likely to draw downward.
  It is  only necessary to examine the  course of this
third roller to see that united to the sling; it is well cal-
culated  to support the  external  fragment,  which  the
weight of the shoulder,  has a tendency  to depress on a
level with the internal one.  It supplies  the place of the
assistant who raises the elbow, and supports the hand of
the patient, in like manner as the second roller performs
the office of the assistant  who presses the lower part of
the humerus against the side of the thorax.
   On the other hand,  the  circular turns by which the
application of the third roller is finished, being  directed
from before backwards, push  in the  same direction the
arm and shoulder, which have  been already carried that
way, by the process of  reduction,  and thus retain them
in their proper places."  (Desault.)
   By this apparatus the shoulder is kept, upward, back-
trurd, and outtvard; the weight of the arm and the action
of the muscles, are thus effectually prevented from draw-
ing the humeral fragment inward, and downwards.
   " The coats  of the rollers  thus surrounding the tho-
rax, however well they may be secured,  are yet liable to
be displaced,  particularly when the  patient is in  bed.
This inconvenience may be obviated by  surrounding the
w hole with a piece of linen, leaving nothing uncovered
but the sound  arm,  which  is at liberty to perform its
usual motions."
   It is better,  however,  to add to the  firmness of the
dressings by connecting them  together with several rows
of stitches in different places. 
152            ELEMENTS OF SURGERY.
  This mode of treating fractured clavicle has been found
extremely successful, but it has  its inconveniences; the
principal  one  that I have experienced in its use, is the
numbness of the arm, and  stoppage of the circulation,
which occur in consequence of the pressure of the bolster
in the axilla, upon the vessels  and nerves of the arm.
Great attention is necessary to obviate this by diminish-
ing when it occurs,  the tightness of the bandage, which
passes round the arm near the elbow; to judge whether
the pressure be  too great, the  pulsations of the radial
artery at the wrist should be attended to; if they be in-
terrupted the bandage must be loosened. Another incon-
venience results from the slipping down of the pad in the
axilla;  I have in some cases, with advantage, attached
a piece  of tape to it, and tied this on the opposite shoul-
der.  Whenever the dressings  become slack they must
be tightened; without attending to this circumstance they
are useless.
  Mr. Boyer,  availing himself of the principles of De-
sault, has constructed a very simple apparatus which acts
in the same manner, and is very easily applied.
  It consists of a girdle of linen cloth quilted, and six
inches broad,  which passes round the trunk on a level £
with the elbow.  It is fixed on by three straps, and as
many buckles  fastened to its extremities.  At an equal
distance from its extremities, on each  side, are placed
two buckles, that is, two anterior,  and two posterior to
the arm.  A bracelet of quilted linen cloth five or six fin- ■
gers broad, is placed on the lower part of the arm of the i.
side affected, and laced on the outside of the arm; four
straps fixed to this bracelet, that is, two behind and two
before,  correspond to the buckles  on the outside of the
girdle  already described,  and  answer the  purpose of
drawing the lower part of the arm close to the trunk, the
more so, as the straps by being two before,  and two be- 
'LATE. IV.
 
 
                ELEMENTS OF SURGERY.             I53
hind, prevent the arm from moving either backwards or
forwards.  With this apparatus,  as well as the preceding,
the cushion must be applied under the arm.
  I have never seen this plan used, but have no doubt it
would  answer very well.   It cannot, however,  be free
from those inconveniences of Desault's which result from
pressure in the axilla, and the weight of the arm, appears
to be less completely supported.
  In about four or five weeks the fracture will generally
unite, and no particular  attention is necessary to diet or
regimen; the patient may be allowed to walk about dur-
ing the cure.
vol. r.
%\ 
154
ELEMENTS OF SURGERY.
                CHAPTER XXVI.

            Fractures of the Os Humeri.

  The os humeri is fractured most frequently near its
middle; occasionally, however, in all its parts.  1 have
known it fractured in one case within the capsular liga-
ment, the fracture extending through the head of the
bone.  Fractures above the insertion of the pectoral and
latissimus dorsi muscles, are called fractures of the neck
of the bone.  The lower extremity is also broken, and in
some instances  the condyles are detached from the rest
of the bone, and from each  other.
  When the fracture is transverse, and is situated near
the middle of the bone, no great derangement takes place,
the fragments  supporting each other,  and the limb  pre-
serving its length, and unless moved, its form.  In ob-
lique fractures, the limb is shortened by the action of the
muscles, and considerable alteration in its shape is per-
ceived.
   When the bone is fractured at its upper end, or neck,
there is some difficulty in distinguishing the accident from
a dislocation of the head of the bone into the axilla.  It
can always, however,  be known, by a depression at the
upper and external side of the  arm, very different from
that depression which occurs in dislocations, and which
is situated immediately under the accromion scapulas. In
the present instance,  the  shoulder retains its natural ro-
tundity,  and no depression exists directly under the ac-
cromion.  The axilla  being  examined with the fingers,
the fractured unequal surface is readily felt; whereas, in
dislocations, the round head  of the bone is felt high up
in the arm-pit.  By moving the arm  the  grating of the 
                elements of surgery.             155
fractured surfaces can be distinctly perceived.  The best
manner of treating this accident, is  that described by
Desault.
  " The patient is to be seated on a chair, or on the side
of a bed, the arm is slightly separated from the body and
carried a little forward.  One assistant is directed to fix
and secure the trunk in a proper manner; this he  does
by pulling the arm of the sound side, taking hold of it
near to the hand, and extending it in  a direction perpen-
dicular to the axis of the body.   This mode of counter-
extension, is  preferable  to  that commonly employed,
which consists in applying the hands to the upper part
of the patient's shoulder; because  on the one hand, the
power being further removed from  the  resisting force
need  not be so great, and on the other, the body being
entirely unincumbered renders it easy for the surgeon to
apply the roller, w ithout discontinuing,  or in any way
disturbing the extension.  Another assistant makes ex-
tension on the fore arm,  which serves  him as a  lever,
where one hand  being placed behind, or on the back of
the wrist, forms the point of support, or fulcrum,  while
the other applied to the anterior and  middle part of the
fore arm, on which it makes pressure from above down-
ward, constitutes the power; and  the  fragments  to  be
brought into contact, the resistance.
   The relaxation of the muscles produced by this semi-
flexion of the fore arm,  and the separation of the arm
from the trunk,  greatly favours this mode of extension;
a mode, recommended by the  ancients, adhered to by the
English, and which possesses the advantage of leaving
uncovered all that portion of  the limb on which the ap-
paratus is to be  applied, and by that means of allowing
the hands of the assistant to keep the same position dur-
ing the whole time of the application.   A small degree
of force directed according as the displacement is inward 
156              elements of surgery.
or outward, is  sufficient to effect the  reduction, which
even  takes place of its own accord under this  process.
If the surgeon lays his hands  on the  place of fracture,
it is rather to examine the state of the fragments, than to
assist in bringing them into apposition."
   In  order to keep  the parts  in this state of reduction,
the surgeon takes a roller, fixes one  end of it by two  cir-
cular turns, on the upper part of the fore arm, and carries
it  up  along the arm  by oblique  turns  moderately tight,
and  overlapping each other about two  thirds  of their
breadth.  Having reached the upper part of the limb, he
makes  some reversed turns  to  prevent  the wrinkles,
which would otherwise be caused  by  the unevenness at
this place.  He then passes two casts of the roller under
the opposite arm-pit, and brings  it to the  top of the
shoulder again;  a  splint* is then placed before,  which
reaches from the fold of the arm to a level with the ac-
cromion;  another on the outside reaching  from the ex-
ternal condyle to the same level;  a third reaching from the
olecranon to the  fold of the arm-pit.f  These splints are
to be secured in their situation by the roller brought down
over them and secured at the  elbow.  A bolster is now
applied between the  arm and side;  Desault advises this
bolster " to be made of linen from three to four inches
thick at one end, tapering like a wedge to the other, and
of a sufficient length to reach from the arm-pit to the el-
bow."  If the displacement be  in  an  inward direction,
the thick  end is to be placed uppermost, and if outward,
which is commonly the case, the thin end.   This bolster
is to  be pinned to the roller, and the arm then secured
against it, by a roller passed round  the arm  and  body,
(as  in cases  of fractured clavicle), sufficiently tight to

  * Firm pasteboard answers very well for this purpose.
  t Two splints, each two inches wide, are generally sufficient in this fracture 
                ELEMENTS OF SURGERY.             Ifl^
keep the arm firmly fixed against the bolster.  Instead of
the cushion  or bolster recommended by Desault, com-
presses of folded flannel or linen maybe substituted, and
they can be  made thicker at one place than another, ac-
cording as the displacement inward or outward, may re-
quire.  The  fore arm is to be suspended in a sling. From
twenty-six to thirty days are required for the reunion of
the fragments.  It is  of consequence in this  accident,
from the vicinity to  the joint,  to prevent any  displace-
ment of the  fragments, as their  union under such circum-
stances would greatly impede  the motions of  the limb.
The apparatus  just described, which varies in nothing
important from that  of Desault, will effectually prevent
this inconvenience.
   Fractures occurring in the middle of the bone, or in
any situation  between the immediate  vicinity of the el-
bow and shoulder joints, are very easily dressed.  Coun-
ter-extension is to be made by an assistant with his arms
round the chest; extension  is to be made by another as-
sistant who draws down the arm, taking hold below the
elbow.  The surgeon readily places the fragments in
contact, when the arm will be found to have its proper
length and shape;  the external condyle corresponding
with the most prominent part of the shoulder.  A roller
is now to be applied, extending from the  wrist to the
shoulder (to prevent tumefaction of the fore arm); the
fore arm is  to be bent to a right angle with the arm; when
the roller reaches the elbow, three or four splints accord-
ing to the bulk of the arm, (I have never, however, seen
more than three necessary,) are to be applied to the outer,
inner, and back part of the arm,  and secured by bring-
ing down the roller over  them:  these splints should be
two and a half inches broad, long enough to extend from
the shoulder  to the elbow,  the inner one will be several
inches shorter than the two others, to allow the  flexion of 
158             ELEMENTS OF SURGERY.
the fore arm, and  to  prevent excoriation at the axilla.
They may be made of thin wood, or strips of wood glued
upon leather, or tin, or what I have always  preferred to
every other material, thick pasteboard, such as is em-
ployed for the  covers of books.  When pasteboard is
used in this case,  it  need not be soaked in water, but
bent so as  to fit the arm.  The roller must never be
bound  so tight as to cause pain.  The arm must be sup.
ported in a sling, and the patient, in general walks about
during the cure, which is commonly completed in four
weeks.   At the expiration of a week (and in most other
fractures the same thing  should be done) the dressings
are to be removed  and the part examined, and any dis-
placement rectified before they are reapplied.
  When the fracture  is situated near the  condyles, or at
the condyles, a very different mode of treatment is to be
adopted. A deformity is extremely apt to occur after this
accident, and the motion of the elbow is much impeded.
To obviate this, Dr. Physick has for many years been in
the habit of applying two angular splints,  which keep
the fore arm flexed at a right angle upon the arm.   The
fracture being reduced, and the parts placed in their pro-
per situation, a roller  is to be applied as usual, from the
wrist to the shoulder, and brought down over the angular
splints: these splints are made of pasteboard or wood, an
inch and a half wdde % the part applied to the arm, ex-
tends from near the shoulder to the elbow, and the part
applied to  the fore arm, should be long enough to reach
to the  ends of the fingers, to obviate the motions of the
hand;  a handkerchief passed round  the  neck, supports
the weight of the arm.
  After a week has elapsed, the dressings are to be re-
moved, aud the joint carefully and gently flexed, and ex-
tended several times  to prevent stiffness;  after which
they are to be carefully reapplied, and this is to be re- 
 
Plate v.
"#*y
■%/\.
±m
&

*$$•;. 
                 ELEMENTS OF SURGERY.             I59
peated once in every forty-eight  hours, increasing as the
cure advances,  the motion  of the joint.  At the end of
three weeks the mode of dressing is to be altered, and
splints forming an obtuse angle are to be substituted for
the rectangular,* which  had been first employed.   The
object  of this change is to prevent a kind of deformity,
which  though not very important in  man, as it does not
interfere with the motions  of the joint, is,  however, of
more consequence to females.  The deformity alluded to,
consists, in an angular projection of the elbow, outwards.
It is most evident when  the whole arm is placed at  right
angles to the body, with the thumb upwards, the patient
standing erect.   In that case, instead of a  gentle curve
downwards at the elbow,  which is natural, the curve is
directly reversed.   I have attempted to represent it in
the annexed sketch, in which the natural and the deform-
ed appearances, are  contrasted.  The effect is particu-
larly apt to  occur, when  the  condyles  are broken off
directly at the joint, and when in addition to this trans-
verse fracture they are  also separated from each other,
which  sometimes happens,  from the  extreme thinness of
the bone between  the two condyles, occasioned by the
space for receiving the olecranon behind, and the coronoid
process of  the ulna before.   The mode of treatment just
described,  has in several instances, been completely suc-
cessful in preventing deformity,  and preserving the per-
fect motions of the elbow.
   Dr.  Physick has since ascertained that  the  same end
may be answered by keeping the patient in bed, with the
arm flexed  at the elbow, and lying on its outside,  with
rectangular splints, supported by a pillow. 
160             ELEMENTS OF SURGERY.
                CHAPTER XXVII.

             Fractures of the Fore Arm.

  These  are very frequent accidents, and are produced
by a variety of  causes.  Sometimes both bones are bro-
ken, sometimes the radius only, and sometimes the ulna.
When both bones of the fore arm are fractured,  by the
same force, the  fracture in each bone is generally on the
same level; but sometimes one bone is broken higher up
than the other.  The interosseous ligament which connects
the bones  of the fore arm  together,  generally prevents a
separation of the fragments in the longitudinal direction;
the derangement is most commonly in a transverse direc-
tion, the  four fragments  approaching each other at the
injured part, and a considerable change in the  shape of
the arm is perceived.
  The symptoms of the fracture are very obvious; great
pain at the time of the accident, which is augmented by
every motion of the hand; an inability  to pronate or supi-
nate the hand;  mobility at the place of fracture; crepi-
tus when  the fragments are moved, and deformity of the
member.  These symptoms are not so obvious when the
fracture occurs  near the wrist; the accident has in such
cases, been mistaken for a dislocation.   Boyer mentions
as  the best diagnostic symptom that, when  the fracture
exists, the styloid processes  of the radius  and  ulna fol-
low the motion of the  hand when the wrist is  flexed;
whereas in cases of dislocation they remain fixed.  The
dislocation is  a very rare accident,  and the fracture  a
very frequent  one; in most cases, the crepitus when the
fragments are moved decides the nature of the injury.
   To reduce the fracture, the fore arm is bent to  a right- 
                 ELEMENTS OF SURGERY.              16 f
 angle with the os humeri.  An assistant takes firm hold
 of the arm just above the elbow, another grasps the pa-
 tient's hand, and the necessary extension is then  made.
 The surgeon very readily adjusts the fragments.
   To dress the fracture a roller is applied, commencing
 at the hand and extending a  little above the elbow;  two
 firm splints of pasteboard (not soaked in water), are to be
 next applied; compresses of  linen, flannel, or tow, being
 interposed,  to fill up the spaces between the splint and
 arm: the roller being brought down over these  splints
 secures them in their situation;  the thumb being upper-
 most may be left projecting  out between the  splints, as
 an indication that no rotatory motion has displaced the
 fragments.  The splints used  in dressing all fractures
 of the fore arm, should be long enough to  extend from
 the elbow to the extremities of the fingers,  and a little
 wider than the broadest part of the arm.  They should
 be long, in order to confine the  fingers  from moving, by
 which irritation would be occasioned, and possibly a dis-
 placement of the fragments, because the  muscles moving
 the fingers, are situated on the fore arm; and they  should
 be broad, because the roller passed round narrow splints
 would press the fragments together, and thus  by  dimin-
 ishing the interosseous space, greatly impede the motions
 of the limb: for the same reason the roller first passed
 round the arm should not be  drawn tight over the place
 of fracture. The compresses placed on each side of the arm,
 being pressed by the splints  upon  the soft parts  situat-
 ed between the bones, force them between the  two bones
 and thus obviate the inconvenience alluded to: all that
remains, is to place the arm in a sling.   After a week or
ten days, the dressings  should be removed and the part
examined; any deviation from the proper position can at
this period be remedied.   In thirty or forty days the cure
will  generally  be completed.  Whenever the fracture
   vol. i.         23 
162             ELEMENTS OF SURGERY.
occurs near the elbow or wrist, the dressings should be
removed every forty-eight hours after the tenth day, and
the joint gently flexed and extended before they are re-
applied.
  If much contusion  be occasioned  by the cause of the
accident, the patient is to be confined to his bed, and the
inflammation combatted by the usual remedies.
  A compound fracture requires the confinement of the
arm upon a  pillow, and instead of the roller a bandage of
strips is to be applied (called Scultets, from its inventor
Scultetus ;) the wound is to be dressed in such a manner
as to  promote its speedy union: if it be small  and not
greatly  contused, it may be allowed to scab, and dry lint
is to be applied over it: if great laceration exist, a poul-
tice will be found necessary.
  2.  When the Radius only,  is broken, which is  most
frequently the case in fractures of the fore arm, the mem-
ber cannot be bent at the place of  fracture, as the ulna
being uninjured,  preserves its firmness.  The existence
of the accident is discovered by drawing the hand along
the edge of  the radius firmly,  when the fracture can be
felt by the angle of one of the fragments;  great pain is
experienced in attempts to rotate the hand, and the cre-
pitus can generally be heard.  When the radius is broken
near its upper extremity, the depth of muscle  in which it
is imbedded,  renders the  diagnosis  more difficult.  In
these cases  Mr. Boyer  recommends  that " the thumb be
placed under the  external condyle of the os humeri, and
on the superior extremity of the radius, and at the same
time, the hand is to be brought to the prone  and supine
positions.  If in these trials, always painful, the head of
the bone rests motionless, there can be no doubt  of its
being fractured."  There can be no derangement of the
fragments in  fractures of the radius,  except what the
muscles occasion  by  drawing  one or both fragments to- 
                 ELEMENTS OF SURGERY.             ^gg
 wards the ulna;  and  the  pronators principally  effect
 this.
   The treatment of this accident is similar to that recom-
 mended when both bones are broken; the ulna, however,
 acts as a splint in the present case, and aids  in keeping
 the fragments at rest; but it has no effect in  preventing
 their lateral  displacement,  and therefore  compresses
 must be applied between the splints and the fote arm, to
 keep up pressure  upon the interosseous muscles, and
 thereby preclude the approximation of the fragments, to
 the ulna.
   3. When the ulna is alone broken, the fracture is easi-
 ly discovered  by passing the hand  along it,  as it is su-
perficial, and easily felt  from the olecranon to the wrist.
 The treatment is the  same as in fracture of both bones,
 unless the fracture  happens high up, near the joint.
   When the olecranon is fractured, no difficulty is expe-
 rienced in detecting it.   The fracture is generally trans-
 verse, and as the triceps extensor cubiti, is inserted into
 it, the upper fragment is generally separated consider-
 ably from the  lower,  and the patient loses the power  of
 extending the fore arm: a  wide  space is generally felt
 and seen between the fragments,  and they readily  move
 upon each other producing crepitus.  The proper treat-
ment of the accident is well described by Boyer.  " The
 divided  parts, are brought  into contact by  extending
the fere arm, and pushing down the olecranon from the
place to which it had been drawn  up by the action of the
triceps.   The principal object is to counteract the action
of this muscle, w hich tends  incessantly to separate the
detached olecranon from the ulna.  To effect this  pur-
pose, a circular bandage moderately broad, is  passed on
the fore  arm fully extended, this  being  done the olecra-
non is pushed down into contact  with the ulna, and the
middle part of a long compress placed behind  it, the ex- 
164             ELEMENTS OF SURGERV.
tremities of which are brought downward, and crossed on
the anterior part of the fore arm, after which several turns
of the bandage made so as to cross one another, are car-
ried round the articulation  of  the elbow;  the bandage
should then be  rolled up on the humerus, in order to
diminish by pressure the irritability of the triceps, which
is  relaxed by extension of the fore arm.  This bandage
being applied, the bend of the fore arm is filled with lint,
and a long splint applied on it anteriorly, by which the
flexion of the arm is prevented.  The splint is fixed by
the same bandage, rolled on downward from the shoulder
to the wrist.  The oblique casts of the roller which cross
one another on the articulation,  forming a kind of figure
of 8, ought to be nicely applied and drawn very tight;
because if but slightly braced, their action,  which is ob-
lique, will not be sufficient  to confine the olecranon in its
situation.  Previous to the application  of  these oblique
casts, the skin of the  olecranon should be  drawn up by
an assistant, for if this precaution be not taken, it may
sink between the divided portions and prevent their con-
tact.
   Though the contact be  exact, immediately after the
application of the bandage, yet if, as is apt to happen,
the bandage become relaxed, or if the patient inadver-
tently contract the  triceps,  the  olecranon  ascends; be-
cause the bandage acting  perpendicularly to its direction,
can but feebly oppose the ascent of this process : an in-
terval will therefore exist between the ulna, and olecra-
non, which will be filled  up by granulations, and by the
thickening of the periosteum, or tendinous expansion of
triceps which covers  that bone, and the reunion of the
parts will be effected by  means of an intermediate liga-
mentous substance, the length  of which will depend on
the careful application, and frequent renewal of the band-
age.  In forty or forty-five days  the  ligamentous sub- 
                ELEMENTS OF SURGERY.             Igg
stance acquires its greatest consistence, but the articula-
tion should not be kept motionless so long; gentle mo-
tion may be commenced  on the twenty-fifth or thirtieth
day.  The object of these  motions is  to prevent a false
anchylosis of the articulation.
  In cases of recovery obtained by these means, the ole-
cranon adheres to the ulna firmly enough to transmit to
it the action of the triceps  muscle, and to  moderate the
extension of the fore arm.
   Compound  fracture of the  olecranon is an accident
of the most grievous nature, on account  of the great
number of nerves  which pass  in the  neighbourhood of
that part.  It should therefore  be treated with the great-
est care.   The inflammatory  symptoms are to  be treat-
ed by copious and  repeated bleedings; the arm is to
be placed half bent on a pillow and dressed with Scul-
tets bandage.   Iu  these  cases the intermediate ligamen-
tous  substance is  always  greater than in simple  frac-
ture, and consequently the force of the arm is  much di-
minished.  If a false  anchylosis be prevented by judi-
ciously exercising  the  articulation as  soon  as  the  state
of the parts will permit, the patient may  think himself
fortunate.
  Ff the  inflammatory swelling, &c,  be not dissipated
before the twenty-fifth or  twenty-sixth day, the appli-
cation of  the apparatus we have  just  described will be
useless, because it will be  necessary at that time to be-
gin to exercise  the articulation, the formation of the li-
gamentous substance  being  then considerably advanced."
(Boyer.)
  The coronoid process  of the ulna,  Dr.  Physick  has
once seen broken.  The  symptoms resembled a disloca-
tion of the humerus forward, or rather a luxation of the
fore arm  backward, except  that when the reduction was
affected,  the dislocation  was repeated, and by  careful 
166             ELEMENTS OF SURGERY.
examination, the crepitation was discovered.  The fore
arm was kept flexed at a right angle with the humerus.
The tendency of the  brachieus  internus to draw up the
superior fragment,  was counteracted  in  some measure,
by the pressure of the roller above the elbow.  A perfect
cure was readily obtained. 
ELEMENTS OF SURGERY.
167
               CHAPTER XXVni.

          Fractures of the Wrist and Hand.

  Fractures of the bones of the carpus very rarely occur,
except in gunshot wounds, or by a heavy body falling
upon them.  In every case of this accident which I have
seen, the fracture has been an object of secondary import-
ance, and amputation has in general been necessary from
the nature of the injury.  Where the limb is to be pre-
served, the hand is to  be  placed in a straight position
and kept at rest by splints and bandages.
   The bones of the metacarpus are sometimes broken. I
have known them fractured in pugilistic contests.  The
accident is  readily known from the crepitation perceived
at the place of fracture by careful examination. The treat-
ment consists in filling the palm of the hand  with a com-
press, and applying a straight splint in front, extending
from just below the elbow to the  ends of the  fingers.
   The bones of the fingers are also sometimes broken.
All the different phalanges are liable to fracture.  The
accident is  known  by the change of shape in the finger,
and by the motion at the fractured part, which is attend-
ed with evident crepitation.   The reduction  is easily ef-
fected, and is to be maintained by a narrow roller passed
round the finger, and by two firm pasteboard splints, one
before, and one behind wider than the finger and  bent a
little round it, which are to be secured  by the same  rol-
ler.  I have found it useful to prevent the motion of the
fingers and hand by a firm splint, long enough to reach
from the middle of the fore arm  to  the finger ends.   In
about four  weeks the union is generally completed.
   " When a very heavy body has crushed the  extremi- 
168            ELEMENTS OF SURGERY.
ties of the fingers,  or when they have  been bruised by a
folding door, the soft parts are generally lacerated, the
nail torn off,  and the last phalanx fractured and denu-
dated.  If in such cases, the  parts  hold together by a
shred of a certain thickness, and which contains vessels
enough for the nourishment of  the  phalanx,  the reunion
of the parts should be attempted.   The prospect of suc-
cess it is true, is not great in most cases, but if our en-
deavours to  save  the finger fail,  amputation  is still as
much in our power, as in the commencement.
   " If the last phalanx alone is crushed, it will be better
to, amputate at once, than attempt to save the joint. The
cure would be difficult and tedious,  on account of the ex-
foliation that would take  place.  Besides the part being
deformed, instead of being useful, would be troublesome.
By amputating at the articulation with the second pha-
lanx, a simple wound is  substituted to the ragged and
lacerated  wound,  produced by the cause of fracture.
This will heal in a very short  time, if care be taken to
preserve a sufficiency of skin to cover the surface of the
articulation."  (Boyer.) 
ELEMENTS OF SURGERY.
169
                CHAPTER XXIX.

               Fractures of the Thigh.

   The os femoris is very frequently broken, and it is of
 great importance to  treat the  accident in such a manner
 as to prevent deformity and lameness, which are often
 its consequences.
   The  thigh bone may be broken at the head, even with-
 in the acetabulum; at the neck, at the condyles, and at
 any  part between the neck and condyles.  The  great
 trochanter is in some cases, knocked off from the rest of
 the bone.  The fracture  is  sometimes transverse, some-
 times oblique, sometimes comminuted, sometimes com-
 pound ; but most commonly we find it, a simple oblique
 fracture.
   A fracture of the os femoris is attended with a mobility
 at the fractured part, an inability to stand on the limb, or
 to move it without extreme pain at the fracture;  generally
 With  a  very distinct  crepitation when the fragments  are
 moved against each  other,  and almost in every instance
 with deformity and shortening of the member.
  Mr. Boyer observes, that " the numerous muscles of
 the thigh by means of which derangement may  be effect-
 ed, are  divisible into three classes, relative to the  man-
 ner in which they tend  to effect it. The three portions of
the triceps femoris are  attached to both pieces, and tend
to produce the angular derangement by drawing the two
fractured portions to a salient angle on the outside, where
their fibres are strongest and most numerous. The biceps
femoris,  semiteudinosus,  semimembranosus,  sartorius,
rectus internus, and  third  adductor, all those  in short,
  vol. i.         23 
l^Q             ELEMENTS of SURGERV
which extend from the pelvis to the inferior portion, or
to the leg with which it articulates, tend to draw the in-
ferior portion  upward, on the  internal side of the supe-
rior, the extremity of which forms a tumour on the exter-
nal side of the thigh.  The inferior portion is that which
is always displaced, except when the fracture takes place
immediately under the small trochanter, to which process
are attached, by a common insertion, the psoas and iliacus
muscles; which muscles  would, in such a case, draw the
superior portion upward and forward,  producing by that
means a tumour in the groin.
  When the  femur is fractured immediately  above the
condyles, the inferior  piece is  drawn  backward, and its
superior surface turned downward by the action of the
gastrocnemius externus, plantaris, and popliteus muscles.
When the great trochanter is  detached from the rest of
the bone, it is drawn upward by the  muscles which are
inserted into it, but  without producing any change in the
direction or form of the thigh.
   The angular derangement in which the foot inclines,
either inward or outward, is the effect of the weight of the
foot or of the bed-clothes,  rather than of muscular con-
traction."
   Transverse fractures are less liable to displacement,
 and  are more easily  retained  in their natural  position
 than oblique, for very obvious reasons, the opposing sur-
 faces supporting each other to a certain extent.
   Fractures of the os femoris are  more  difficult of cure
 than those  of any other limb;  and such was formerly the
 want of success in preventing  deformity that the ancients
 considered it impossible to cure them without shortening
 of the thigh, and Mr. John Bell, notwithstanding his high
 notions of modern surgery declares, that " the machine is
 not yet invented, by which a fractured thigh bone can be 
                 ELEMENTS OF SURGERY.             1^1
 perfectly secured."   A position which,  though entirely
 false, proves that surgeons consider the fracture of a very
 serious nature.
   Before proceeding  to detail  the practice I wish to re-
 commend in the treatment of fractures"of the os femoris,
 it may not be amiss to premise, that surgeons have been
 greatly divided in their opinions respecting the posture in
 which the patient should be placed during the cure.
   The celebrated Mr. Percival Pott, was a warm advo-
 cate for a bent position, and recommended the thigh to be
 bent upon the pelvis, and the leg upon the thigh, and the
 patient to be  laid upon his side, under an idea, that in this
 manner the muscles would be most completely relaxed, and
 thus the great cause of deformity obviated.  The British
 surgeons have pretty generally followed this practice.
   The late French writers, and particularly Desault and
 Boyer, have strenuously  recommended a contrary prac-
 tice, placing  the patient on the back and extending the
 lower extremity; the  reasons which induced them to re-
ject Mr. Pott's plan, Desault states to be " the difficulty
 of making extension  and  counter-extension,  with the
 limb thus situated; the necessity of making them on the
 fractured bone  itself,  and not on a part remote from the
 fracture, such as the lower part of the leg; the impossi-
 bility of comparing the broken with the sound limb; the
 uneasiness occasioned by this position if long continued,
 though at first it  may appear most natural; the trouble-
 some and painful pressure on the great trochanter of the
 affected side; the derangements to which the fragments are
 exposed when the patient goes to stool; the difficulty of
 fixing the leg with sufficient steadiness, to prevent it from
 affecting the os femoris by its motions; the evident  im-
practicability of this method when both thighs are broken,
 and finally experience, which in France has been by no
 means favourable to the position recommended by Pott." 
lyg             ELEMENTS OF SURGERY.
  Mr. John Bell, with all  that copia verborum which
characterizes his truly peculiar style, and with all that
violence, with which he opposes every thing he  fancies
wrong, has devoted several quarto pages of his  Princi-
ples of Surgery  to an abusive opposition of the practice
of Desault, whose theory he pronounces " unworthy his
high character," and asserts that " his intentions,  and in-
deed his very words, are anticipated not merely by old
surgeons whose works he might have neglected to read,
but  by his immediate  predecessors  and cotemporaries,
Petit, Sabatier,  and Duverney."   Mr. Bell declares,
that Desault's plan " is neither original nor successful,"
and that " the napkin round the thorax produces oppres-
sion and insufferable distress which no one can possibly
bear." Mr. Bell in this and many other passages proves
incontestibly that he never  saw Desault's apparatus ap-
plied ; that he is entirely ignorant of it, and  that in this,
as in several other instances, he writes and rails on a sub-
ject he does not comprehend.   In proof of this,  I  shall
quote the following passage, which strongly evinces his
want of candour, and his want of correct information.
   " To judge of the  merits of these methods, imagine to
yourselves the condition of a patient under Desault's dis-
cipline ; first laid down on one side and bound to the long
splint of Duverney that the  body and the limb were as one
piece; next a great napkin  put round the thorax with all
the firmness of  a bandage; straps going round the thorax,
passing under the arm-pits  fixed to this circular, and the
patient drawn up by these  straps to the head of the bed.
Next imagine, two lacs or long bandages, fixed one round
 the knee the other round the ankle, one tightened when
 the other  had  caused excoriation; imagine the patient,
 extended  like  a malefactor drawn by horses, bound so
 down to the bed, that even a cloth or flat dish could not
 be slipped in undojr him; the bands assiduously tightened 
                ELEMENTS OF SURGERY.             |yg
the moment they seemed to relax, and the thorax so hound
and compressed that he could not breathe; think of all this
apparatus of bandage if you can, without holding in  your
breath, as if trying whether such oppression could be en-
dured.  I think for my share, I could as well undertake
to live under water, as in Desault's, I might say Damien's
bed."  When the reader has finished this rhapsody, let
him imagine something precisely opposite to what Mr.
Bell has imagined,  and he will have some idea of De-
sault's apparatus.
   How far  Desault or Damien,  are to be considered as
authors of this imaginary apparatus of Mr. Bell, a peru-
sal of their writings will show;  but it is truly  astonishing
that after such gross perversions, Mr. Bell should  have
the effrontery to add, that he has quoted  his  histories of
the various  machines " in the very words of the inven-
tors, because it is the only fair and impartial  representa-
tion."* Mr. Bell knew what would have been impartial;
and yet far  from quoting Desault's " very words," his
whole object has been to misrepresent them.
   I should owe an apology for this digression if the ob-
ject were less important, but I am solicitous that students
of surgery  should  not consider  the sophistries  of Mr.
John Bell as logical arguments.
   I should  next proceed  to state the advantages of the
straight position in fractured  thigh,  but having quoted
them from  Desault, I shall simply detail the  mode of
treatment which I  consider best  adapted  to the accident,
and which is a  modification of that proposed  by Desault,
 just premising that although volumes have been  written
 on the action of the muscles in occasioning derangements
 of the fragments, it is a certain truth which has been too
much overlooked by all  writers, that  the muscles very
• John Bell—Principles of Surgery, Vol. T. 
 174             ELEMENTS OF SURGERY
 speedily accommodate  themselves to any posture, and
 that therefore, that one should be chosen, which is most
 favourable to the healing of the fracture and the conve-
 nience of the patient, and this for many reasons which I
 shall not detail  in  this place (but the chief of which is
 the experience of the surgeons in the Pennsylvania hos-
 pital and in the French hospitals,) I believe to be the
 straight position.
   The bed should  be prepared and the dressings dispos-
 ed on it before the patient is  placed upon it.  If sir James
 Earle's bed, cannot be  procured, a hair mattress may be
 placed upon  a common bedstead, but boards or strips of
 wood should be substituted for the sacking bottom; across
 this  mattress, five  or six pieces  of tape should be laid;
 over the tapes a piece of muslin a yard in width, and a
 yard and a half long (if the patient be an adult;) over
 this  " splint cloth" a splint  of  pasteboard  nine inches
 long and two wide is to be  placed at its upper end, and
 a bandage of strips long enough to extend from the knee
 to the groin, is  to  be  laid over this splint; each strip
 should  be  of muslin, two inches  wide, and long enough
 to pass round the thigh, and overlap several inches.  In
 arranging these  strips, the one which is to be last applied
 to the thigh,  must be the first laid down, and this will be
 the upper one, which should be rather longer than the
 rest, because the thigh is thickest at its upper part; each
 succeeding strip is to cover one-third part or half of that
 which preceded  it.   The next things to be provided, are
two bags of chaff, or finely cut straw, four  inches wide
 and  long enough to extend  from the hip to the foot; if
these cannot  be obtained, flannel  or tow may be used as
compresses, in lieu of them.   A  silk handkerchief, or a
 strong band of soft  linen, is to be  placed at the top of the
 splint cloth for counter-extension, and a similar one is to
be provided for making extension at the ankle.  Two long 
                ELEMENTS OF SURGERY.             I75
splints are to be procured, made of light wood; the first,
which is that of Desault, improved  by Dr. Physick ant!
Dr. Hutcliinson, snould be so long as to extend from the
axilla six inches below the foot; it is formed like a crutch
at its upper extremity, and a block projects from near its
lower end,  the use of which will be presently noticed;
two holes are formed  near the upper extremity, and one
near the lower, through which the counter-extending and
extending bands are  passed; the second  long  splint is
three inches  wide  above, and tapers to two and a half
below, and long enough to reach from the perineum to the
end of the longest splint;  a fourth splint, of the same di-
mensions and materials as the first, completes the appa-
ratus.
  The patient  is now to be placed carefully on his back
on the mattress, in such a manner that the injured thigh
may be situated upon the  bandage of  strips.  The band
for counter-extension is now passed along  the perineum,
and  between  the  scrotum (or labium pudendi) and the
affected thigh, and is delivered to an assistant. The band
for extension is passed round the ankle,  tied under the
foot and delivered to another assistant; by pulling these
bands extension is made,  and the surgeon replaces care-
fully the fragments in apposition, and then applies  the
bandage  of strips, beginning at the  knee and proceeding
upward to the groin. The two long splints are now fold-
ed up in the  splint cloth so that both splints may apply
neatly to the sides of the limb; the bags of chaff, or com-
presses are interposed to till up the spaces  occasioned by
the inequalities of the leg and thigh, and the two extremi-
ties of the bands for counter-extension are passed through
the two holes near the upper end of the splint  and tied
firmly; care being taken not to permit the displacement
of the fragments whilst this is done.  The band for ex-
tension is next passed through the hole at the lower end 
176             ELEMENTS OF SURGERY
of the splint, and  tied; but great caution is to be used
in this stage of the business, to avoid, on the one hand,
drawing the bandage too tight, and  on the other, relax-
ing it so as  to  suffer the  fragments  to pass each other.
All  that now remains is  to  apply the fourth  splint on
top of the thigh, and secure it by three tapes, which will
bind all four  of the splints  moderately tight upon the
thigh, and to secure the lower extremities of the two long
splints by two or three tapes between the knee and ankle.
A bandage or  handkerchief may now be passed round
the pelvis, to assist in fixing the patient at rest, and this
bandage will certainly be found to exert no mischievous
effects on the organs of respiration.
   The use of the posterior pasteboard splint, is chiefly to
prevent the tape passed round the thigh from irritating
the  skin,  and  also  to assist in gently compressing the
muscles of the  thigh and supporting equably the frag
ments of the bone  behind.
   The principal difference between the mode of dressing
a fractured thigh, just described, and  that recommended
by Desault, consists in the increased length of the splint
by which the permanent  extension  is kept up;  an im-
provement which was first made by  Dr. Physick.
   In the first of the annexed engravings, Desault's appa-
ratus is represented, and in the second the improvements
that have been introduced by Dr. Physick, which cer-
tainly give to the  apparatus some important advantages.
In the first place, the  splint of Desault being but little
longer than the limb, the strap  or band for  counter-ex-
tension passes  over  the  upper part  of the os  femoris  at
an oblique angle,  and has a strong tendency to draw the
superior fragment  of the bone outwards; whereas in the
splint contrived by Dr. Physick,  the  mortise hole being
cut high up near the axilla,  the band for counter-exten-
sion acts upon the pelvis, in a line nearly parallel with 
                ELEMENTS OF SURGERY.              ^yy
the natural direction of the limb, and has no tendency to
any lateral displacement of either fragment.  In the next
place, by extending  the splint as high as the axilla, the
pressure of the end of the splint does not injure the pa-
tient's hip. The crutch-like form is  intended to prevent
the extremity from rubbing against the patient's side, and
it is to be covered w ith  soft flannel or linen, to defend
the axilla.
  Dr. Physick having in some cases  found that when
considerable force was applied to the extending band, the
foot was pulled outward and pressed against the splint
bo as to occasion excoriation, and finding the use of com-
presses  and the chaff bags inefficient in preventing this
inconvenience, suggested to Dr. Hutchinson, then a stu-
dent at the Pennsylvania hospital, the advantage of some
contrivance to obviate it. He accordingly attached to the
lower end of the splint a block, projecting  two or three
inches  from the inside of  the  splint, across which  the
band for extension is carried to the mortise hole at the
lower end of the splint. The splint being thus construct-
ed, the  extension is  also made more completely in the
direction of the limb.
  By the  use of this  apparatus there can  be  no doubt
that " permanent extension" of the thigh bone, notwith-
standing the cavils of Mr. J. Bell, may be kept up, and
that a perfect cure may in  most cases be effected, with-
out the slightest evident deformity, or shortening of the
limb.   I have for twelve or fourteen years witnessed the
effect of this mode of treatment in the Pennsylvania hos-
pital, where  more accidents are admitted than in any
other institution in America,  and I am safe in asserting,
that the success of the  practice has been surpassed by
that of no other hospital in  the world. I have never seen
a crooked limb, or a shortened limb, the consequence of
a simple fracture of the thigh, unattended by comminu-
  vol.  i.          24. 
178              ELEMENTS OF SURGERY.
tion, where Desault's apparatus, modified as above, has
been fairly applied.
  It is proper, however, to remark, that some practition-
ers have become dissatisfied with this mode of treatment
in consequence of the excoriation which they have found
to take place at the perineum and at the top of the foot.
In answer to this objection it must be stated, that the use
of "permanent extension" does not imply violent exten-
sion, nor sudden extension, but simply a  long continued
resistance to the contraction  of muscles which would if
unresisted, shorten the limb.  In order to effect this, after
the dressings are applied, it is proper in every instance, if
any pain is  experienced,  either at  the foot or perineum,
to loosen the extending band. Most of the inconveniences
attributed to the method of Desault have arisen from its
improper application, and nothing is more improper, than
to make violent extension during  the  existence of the
irritation and inflammatory symptoms which succeed to a
fracture  of  the os femoris.  The  extending  bandages
ought  always to be  very moderately tense,  during the
first three or four days after the accident,  and afterwards
they should be gradually tightened, the limb being exa-
mined from day to day,  and its comparative length with
its uninjured fellow, distinctly ascertained.  If the patient
experience any difficulty in bearing pressure upon the top
of the  foot, a piece of buckskin with holes in front may
be laced  round the ankle, and  straps attached to this
afford  a very convenient substitute for the  handkerchief
with which the extension is made. In warm weather, and
in emaciated persons this gaiter of buckskin is extremely
useful.
   By  observing these precautions, very little difficulty
will be experienced iu the treatment of fractures of the
thigh bone near its middle. Six or eight weeks are gene-
rally necessary for the reunion of a fractured thigh bone. 
                ELEMENTS OF SURGERY.             17Q
  Compound fractures of the body of  the os femoris re-
quire no difference of treatment from other  compound
fractures,  but the dressings necessary for the external
wound may be very conveniently applied, without inter-
fering with the long splints.
  When both thighs are broken,  or when one thigh  is
fractured in several parts, no plan  of treatment is compa-
rable with that by permanent extension.  I have had oc-
casion to apply it in the case of a  miller's wife who was
caught in  some machinery; which fractured both her
thighs and one leg below the knee.  She was placed on
her back, and the dressings which  have been recommend-
ed, were applied;  she recovered as happily as  if only one
fracture had existed, experiencing  very little more  pain,
fever or inconvenience, than is usual in simple fractures
of the thigh or leg.
  It has been  proposed among other methods of preserv-
ing a bent position, to  place the patient on his back with
an angular box under the knee.  I have known this plan
used, and much difficulty was experienced in  preventing
the rotation of the limb, every motion of the pelvis,  occa-
sioned motion at the fracture,  and the surgeon who at-
tempted it, laid it  aside.*
  Fractures of  the great trochanter are the  effect
either of falls on that protuberance, or of the action of bo-
dies striking against it. They are either oblique, or trans-
verse, situated sometimes at its summit, and  sometimes
at its base.
  This accident  may be distinguished, by a facility  of
moving the great trochanter in every direction, while the
pelvis and  the thigh remain without motion; by a crepita-
tion, arisingfrom the friction of the divided surfaces against

  * Something of this kind has been recommended by Mr. Charles Bell. Ope-
rative Surgery, Vol. U. page 190. 
180             ELEMENTS OF SURGERY.
each  other; by their being  no shortening of the  limb,
when the fracture  exists alone: by the fragments  being
brought  together in abduction, and separated  in adduc-
tion;  by the position of the great trochanter being  high-
er and  more anterior than  natural.   The presence of
these  signs are more readily perceived, because,  being
superficially  situated, this protuberance  can be easily
felt, and yields to the  motions impressed on  it.
  The  reduction  is  effected, by pushing  the  separated
fragment in the direction opposite to that of its displace-
ment, by bringing it to its natural level, and, in certain
cases, by moving the thigh a little outwards; it is retain-
ed by means of some compresses placed by its sides, and
secured by a  roller directed obliquely  from  the sound
hip towards that part of the thigh corresponding to the
fracture.
  Fractures  of  the neck  of the os femoris are not
so frequent as those of the body of the bone, but they do
occasionally occur; the fracture is generally  transverse,
occurs at every part of  the neck of the bone, sometimes
completely within the capsular ligament, so that the
round ligament,  constitutes  the only connexion which
the upper fragment has with the body.  As this accident
has some symptoms in  common with certain dislocations
of the os femoris, it is of great importance to discriminate
this accident from  all others.   Desault states the follow-
ing as the  best diagnostic symptoms.  " At the time of
the fall a sharp pain is felt, sometimes a noise is distinct-
ly heard, a sudden inability to move the limb occurs, and
in general the patient cannot rise,  this last circumstance,
however, is not uniform; a case is recorded in  the fourth
volume of the Mem. Acad.  Surg,  where  the patient
walked home after the fall, and even  rose  up the follow-
ing day.  Desault also saw examples of this peculiarity.
The interlocking of the fragments is the cause of it. 
                ELEMENTS OF SURGERY.              181
  A shortening  of the limb almost always occurs, more
or less perceptible, according as the extremity of the frag-
ments are retained by the capsule, or as the division,
being without the cavity, no resistance is made to their
displacement.   The muscular  action drawing the lower
fragment upwards, and the weight of the trunk, pushing
the  pelvis and  superior  fragment downward,  are  the
causes of this shortening.   A slight  effort is  in general
sufficient to remove this shortening, which, however,
soon returns when the effort ceases.   A tumefaction ap-
pears in the anterior and upper part of the thigh, almost
always proportioned to its  shortening, of w hicb it  ap-
pears to be the effect.
  The projection of the great trochanter is almost entire-
ly removed.   That protuberance being directed upward
and backward, is approximated to the spine of the ilium.
But if it be  pushed in  the  opposite  direction, it readily
yields, and then returning to its proper level, allows the
patient to move the thigh.
  " The knee is a little bent.  A severe pain always ac-
companies the motions of abduction, when they are com-
municated to the limb.   If,  while the hand is  applied to
the  great trochanter, the limb  be made to rotate on  its
axis, this bony protuberance is perceived to turn on itself
as on a pivot, instead of describing, as it does in its natu-
ral state, the arch of a circle, of which the neck of the os
femoris is the radius.  This sign, which was first  ob-
served by Desault, is very perceptible, when the fracture
is at the root of the neck; less, when it is in the middle,
and very little, when it exists  towards the head of the
bone: these are circumstances the cause of which it is
unnecessary to unfold.  In  rotatory motions,  the lower
fragment, rubbing against the upper one, produces a dis-
tinct crepitation, a phenomenon  which does not always
occur. 
182              ELEMENTS OF SURGERY.
  " The point of the foot is usually turned outwards; a
position which Sabatier, Bruninghausen, and most other
practitioners, regard as a necessary effect of the fracture;
although Ambrose Parey and Petit have borne witness
that it does not always  exist.   Two cases, reported on
this subject, by celebrated surgeons, have been thought
unfounded by Louis, who has  attributed them either to
an error in language, or  a mistake of the transcriber. But
the practice of Desault  has fully confirmed their possi-
bility. The first patient whom he had under his care, at
the hospital of Charity,  after he was appointed surgeon
in chief, laboured under a fracture  which presented this
phenomenon.  Many other examples occurred to him after-
wards, and he believed it might be laid down as an estab-
lished principle,  that, in fractures of the neck of the os
femoris, the direction of the foot outwards is to that in-
wards as eight to two.
  " The common opinion is, that this direction outwards,
is to be attributed to  the muscles that  perform rotation.
But, were  that the case, 1st, it is evident that it would
always exist: 2dly, all the muscles running from the pel-
vis towards the trochanter,  except the quadratus, are in
a state of relaxation, in consequence of the approximation
of the os femoris to their points of insertion: 3dly, mus-
cles in a state of contraction would not allow the point of
the foot to be drawn so  easily inwards.  Is it not more
probable, that the weight of the part draws it in the direc-
tion in which it is usually found.
  " From  the foregoing considerations, it follows, that
none of the signs of a fracture of the neck of the os femo-
ris, is exclusively characteristic, that the whole of them,
taken separately, would  be insufficient, and that it is their
assemblage alone, which can throw on the diagnosis that
light which is oftentimes wanting to it,  even in the view
of able practitioners.  But  after all, in the present case, 
                ELEMENTS OF SURGERY.             183
as in every other one, should any doubt exist, it is right
to take the safe side, and apply the apparatus,  which is
indeed useless, but not dangerous, if the fracture does not
exist, but indispensably necessary if it does." (Desault.)
   A concise  abstract of the  symptoms enumerated by
Boyer will aid  the student  in distinguishing this frac-
ture.  A fall  or  blow on the trochanter or feet,  is gene-
rally the cause;  it is followed by pain in the articulation,
an impossibility to bend the thigh; shortness of the limb,
which is easily removed, but returns when the extension
is discontinued; an inclination of the  foot and knee out-
ward, with great facility of  moving  these parts to their
natural situation; crepitation produced in different move-
ments ; and the smallness of the circle in which the great
trochanter moves in a rotatory motion.  We can seldom be
mistaken  as to the existence of this fracture, if we attend
to all these circumstances.
   Of all fractures of the os femoris, those of the neck are
most tedious  in  healing, and attended with most danger
of lameness and deformity.  Some surgeons  imagine, that
bony union never forms between the fragments; but many
proofs exist that this opinion is erroneous,  and prepara-
tions in different anatomical collections  shew  instances
of bony reunion of the  neck of the thigh bone.  It is al-
ways, however, slower in its formation, and in  many in-
stances does  not at all  take  place, the patient remaining
incurably lame.
   Instances  of recovery in old persons are not  frequent,
 and Boyer considers  the fracture " after a certain age"
incurable; but he adds " it is not in our power to mark
precisely  the period beyond which a cure is not to be
hoped for.   To be able to settle this, it would be neces-
sary that the effects of old age were  uniform in  every in-
dividual,  and that the degree of senility  were always
commensurate with the number of years. Lesne shewed 
184*              ELEMENTS OF SURGERY.
at the Academy of Surgery, the femur of a woman aged
eighty-nine, with evident marks of a consolidated frac-
ture of its neck." Boyer himself, saw a patient in which
the consolidation of a  double fracture was considerably
advanced in a  man  eighty-three years old.   Numerous
facts of this nature, authorize and require the application
of the apparatus in  all cases, except where the patient
reduced to the last stage of decrepitude and debility can-
not support its weight, or is attacked  by some mortal
disease.  But at the same time the surgeon should for his
own sake, acquaint  the patient and his  friends with the
uncertainty of the cure, in order to ward off any imputa-
tion that might be made in case of failure.
   Many respectable surgeons have positively  asserted
that a recovery without lameness and shortening is im-
possible.  Desault and Boyer on the contrary, both relate
instances in which they were completely successful.
   The fracture is easily reduced by making counter-ex-
tension at the  arm-pits, an assistant holding the patient
under the arms, and extension by drawing down the foot
until the limb resumes  its natural length  and appearance,
it is not easy, however, to secure the fragments in con-
tact, but the apparatus of Desault promises to be more
successful than any other plan heretofore in  use for that
purpose.  The  long splints are to be applied precisely
as in fractures of the body of the os femoris, but no band-
ages of strips,  or pasteboard  splints are required in this
case, as the permanent extension is alone necessary, and
they would be useless  as they would act only on the in-
ferior fragment.
   The fracture healed in one case recorded by Desault,
in sixty days,  but generally three  months are  required
for the consolidation.  During  this time the apparatus
should be examined daily, and tightened from  time  to
time,  if any shortening of the limb is observed.   Stiff- 
                ELEMENTS OF SURGERY.             4 85
ness of the joint is not a frequent consequence of this
accident.
  When  the permanent extension cannot be  applied,
from the extreme age of the patient, or any other cause,
great care should be taken to prevent the motions of the
fragments, by long stiff splints bound firmly on the pel-
vis, and extending below the foot.  In  this manner a cure
will be effected, but probably the detached neck of the
bone will adhere to a  portion, considerably  below the
trochanter, and thus the limb will be shortened.
  In a case of fracture of the  head  of the  os femoris
which occurred in a gentleman of Philadelphia, perma-
nent lameness ensued, and no  union of the fragments
took place, he  died some years  after,  and upon examin-
ing the hip joint,  a singular instance of the resources of
nature was presented to view. ,A ledge of bone was ob-
served projecting from  the trochanter, and upon this the
acetabulum rested, and thus some weight was sustained
by the os femoris—it was in fact,  an attempt to regenerate
a neck and head  for  the bone  in  a  situation where it
would have been useful, and have enabled the patient to
walk, had he lived until it was completed.    He never
was able after the accident to bear much weight on the
affected side.  The bone is now in Dr. Physick's pos-
session.
  Fractures of the lower extremity  of the os femoris un-
less they are situated within the joint, call for uo pecu-
liarity of treatment, but are to be managed just as when
they occur higher up in the bone.
  Sometimes,  however, the fracture detaches a portion of
one condyle from  the  rest of the  bone (Fig. 5.) Some-
times a fracture separates the condyles from  each  other,
and both from the rest  of the bone  by a double fracture,
analogous to that which occurs in  the lower  end  of the
humerus, as in Fig. 4.
  Vol. i.         25 
186             ELEMENTS OF SURGERY.
  The fracture in which the condyles  are thus separated
from the os  femoris may be known, by a perceptible se-
paration, increasing the width of the knee.   The patella
sinking into the chasm between the condyles, renders the
part flatter than natural: if the patella be pressed  back-
wards the condyles are still further separated : if on the
coutrary, pressure be made on the sides of the knee, the
knee resumes its usual breadth and appearance: by mov-
ing the fragments, crepitation may be heard.  Where only
one condyle is detached, it can be felt moving under the
fingers, and producing crepitus when rubbed against its
fellow.
   Sometimes this accident is complicated with a lace-
rated  wound,  from  the bone  being forced through the
skin, or from the cause of the accident penetrating  to the
cavity of the fracture,  and of the joint, thus producing a
compound fracture, with an exposure  of the joint:  a ter-
rible accident, attended with all the dangers resulting
from lacerated wounds of the larger joints, and demand-
ing the same mode of treatment, with the additional mea-
sures necessary for maintaining in contact the fragments
of the bone.
   The treatment necessary in these cases, varies accord-
ing  to their circumstances.   If a  fracture exist an inch
above the knee joint,  and this  fracture be attended with
a shortening of the limb, (which will  be the case if it be
an oblique  fracture,) and if in addition to this, a second
fracture separates the condyles extending to the first, as
in Fig. 4.   In this case the permanent extension is to be
applied, as  iu fractures of the body of the thigh bone with
the omission of the pasteboard splints, this will prevent
the  upper  fracture from displacement, and  in  order to
keep the condyles in contact at their fractured surfaces  a
roller or bandage of strips  must be applied, reaching from 
               ELEMENTS OF SURGERY.               487
the ankle to the middle  or upper part of the thigh, and
applied pretty tight at the knee.
  If the upper fracture be transverse, no necessity exists
for permanent extension,  and therefore simple pasteboard
splints may be applied, or the long splints as in the pre-
ceding case, omitting to apply the extending force.   The
lateral pressure is in these cases the chief indication, and
to prevent the foot and leg from swelling, a roller should
be applied from the foot  to the knee.  The  usual  anti- '
phlogistic remedies  are to be employed  if inflammation
run high, and the apparatus must be kept on eight weeks
before any motion  is attempted;  as soon as the parts
have united firmly, the limb must be gently and repeat-
edly moved, to prevent false anchylosis, or stiffness of the
joint.   The patella  should be moved frequently, and the
posture of the leg whilst  at rest, often varied. 
188              ELEMENTS OF SURGERY.
              EXPLANATION OF THE PLATE.

Fig. 1.  Represents a fracture of the head of  the os fe-
        moris.
Fig. 2.  A fracture of its neck.
Fig. 3.  A common oblique fracture near the middle of
        the bone.
Fig. 4.  A fracture at the lower extremity of the bone, in
        which the condyles  are detached from the body
        of the os femoris and from each other.
Fig. 5.  Shews several directions a, b, c, d, in which the
        different condyles are occasionally fractured.
Fig. 6.  Represents the relative situation of the fractured
        ends of the bone in the cases mentioned in page
        128, in which the seton was unsuccessfully tried
        for the cure of an  artificial joint.  The dotted
        line shews the course of the seton, which passed
        through an indurated mass  of flesh, and did not
        come in contact with the bone.   From this view
        it is evident, that in such cases, the seton cannot
        be successfully used. 
f$f*-*
r.s.flm-s't .m 
■»t
• 
• 
PL A TJE . VJI.
 
ELEMENTS OF SURGERY.
189
              EXPLANATION OF THE PLATE.

The opposite engraving represents the apparatus for per-
  manent extension, employed  by Desault  in oblique
  fractures of the os femoris.

AA. The external splint, with a notch and a mortise at
  the lower end to fix the inferior extending roller.
BB. A bandage passing round the body, intended to se-
  cure this splint against the pelvis.
CC. The anterior splint, reaching only to the knee.
d. d. d. d. The anterior bolster,  extending along  the
  whole limb, and secured by pieces of strong tape.
EE. A portion of the bandage of strips, seen between the
  anterior and the external lateral bolsters.
FF. The junk-cloth intended to be folded round"the two
  lateral splints.
g. g. The superior extending roller, passing round the
  end of the external splint, and fixed underneath on the
  tuberosity of the ischium.
H.  The sub-femoral roller or strap, intended to prevent
  the bandage BB, which passes round the  body, from
  slipping upwards.
KA\ A roller usually passed round the foot, to prevent it
  from turning.
L. The inferior extending roller, fixed in the mortise and
  the notch of the external splint. 
190              ELEMENTS OF SURGERY.
              EXPLANATION OF THE PLATE

Representing  Dr. Physick's  modification of Desault's
  apparatus.

AA. Dr. Physick's long splint.
B. A block  fastened near its  lower end, projecting  at
  right angles from the splint, over which the extending
  band passes and is tied at the mortise C.
D. The crutch-like extremity fitted to the axilla.
E. The edge of the inner splint which extends from the
  perineum below the foot.
F. The splint cloth wrapped round the external and in-
  ternal splints.
Gr. The counter-extending band passing under the tube-
  rosity of the ischium, and secured at the mortise, at the
  upper end of the splint.
H.  The anterior splint of pasteboard (a  similar one is
  placed on the back part of the thigh.)
The bandage round the pelvis is omitted to prevent con-
  fusion. 
i \\ %\
W.z
i 
 
ELEMENTS OF SURGERY.
191
                 CHAPTER XXX.

              Fractures of the Patella.

  These  may be longitudinal, transverse, or oblique;
but in general they are transverse.  They are occasioned
by falls, blows, and accidental violence, and also in some
cases by the exclusive action of the extensor muscles of
the leg:  of this  many instances are recorded.  I have
myself met with two, one of which occurred in a rider at
the circus, who in vaulting into his saddle from the ground
whilst his horse was in full speed, suddenly fell, without
knowing the cause; a  sharp pain at the knee informed
him  of the seat  of the  injury.  Upon  examination, I
found the  patella fractured transversely, and the upper
half, drawn to a considerable distance from the lower.
  It sometimes, though  very  rarely  happens, that  the
tendon above or below the patella is fractured, and not
the bone.   The mode of  treatment are in both  cases pre-
cisely similar.
  A fracture of the patella  is readily distinguished.   If
it  be  transverse  the patient cannot extend the leg, he
generally  falls and is  unable#to rise; though  sometimes
he gets up, and by dragging the  limb sideways, is even
able to walk,  taking great care not to beud the knee. A
depression at the place of fracture is perceived, and com-
monly, the superior fragment is found at a considerable
distance from the  inferior, which being tied firmly to the
tibia, cannot move upwards.  The longitudinal and ob-
lique fractures can be known  by examination with  the
fingers, as the bone is very thinly covered.
   It has been a matter of doubt among surgeons whether
bony reunion  ever takes  place between the fragments of 
192             ELEMENTS OF SURGERY.
a broken patella.   When the distance  between them is
considerable, a firm ligamentous or tendinous matter con-
nects them, and the motion of the joint after a time is re-
gained.  When, on the contrary, they are kept in close
contact, the union is hard, firm, and unyielding; whether
it is bone, tendon, cartilage  or ligament, is  an object of
more curiosity than utility.
  The great object  to be attended to in the treatment of
fractures of the patella, is to preserve the fragments as
nearly as possible,  in apposition,  so that the  substance
connecting them may be  rendered as short as possible,
and the motions of the joint  be perfectly preserved.
  Whenever the fracture is occasioned by a violent blow,
and great contusion is produced by it, there is  reason to
apprehend inflammation and swelling of the knee, in
which case bleeding and the usual remedies for  inflam-
mation are to be employed.  The  local treatment consists
in keeping the limb at rest in an  extended posture, and
by a splint and bandages  preserving  the  contact of the
fragments.  The chief obstacle to be encountered, is the
action  of the extensor muscles; and this is easily  over-
come, by the application of a stiff splint behind the limb
secured by a roller.
  A variety of machines have been constructed for the
purpose of preserving the permanent extension of the leg,
and most of them answer very well.   I have always em-
ployed a very simple one. It consists of a piece of wood
half an inch thick,  two or three inches wide, and long
enough to extend from the buttock to the heel; near the
middle of this splint, two bands of strong doubled muslin  }
a yard long, are nailed, at a distance of six  inches from
each other. Upon this splint, covered with compresses of
soft flannel or linen, so as to fill up the inequalities of the
limb, the patient's leg and thigh are placed.  An assistant
now raises the heel, and the surgeon applies a bandage1 
                ELEMENTS OF SURGERY.             I93
(a common muslin roller, two inches wide, and eight or
ten yards long,) commencing at the ankle, and proceed-
ing to the knee; he carefully draws down the upper frag-
ment of the bone as nearly as possible to the lower one,
and places a compress of  folded linen above it; several
turns of the bandage are now made  over this  compress
and obliquely under the knee,  in such a manner as to
cross below the lower and above the upper fragment al-
ternately, in the form of the figure 8; the bandage is then
carried on to the top of the thigh and brought down over
the splint, leaving the band attached to it,  free.   Care
must be taken to cover every part of the skin  with the
roller, because any part  which is not thus supported will
swell and inflame.   After the  dressing has proceeded
thus far, the bands of muslin are to be used  for the pur-
pose of more completely fixing the fragments;  the lower
one is to be passed round the thigh above the upper frag-
ment, and vice versa, the  upper strap passed below the
lower and secured by a  pin or knot.   These bands will
thus  enable the  surgeon to exert any requisite compres-
sion  upon the fragments  without the inconvenience of
moving the bandage or splint.
  It is evident that this  apparatus  is in principle the
same as Boyer's.   I claim no merit  for its construction,
but one advantage it certainly possesses; it may always
be procured in a few minutes, as a shingle or strip of
wood and  a couple of nails are the only materials neces-
sary for its formation; aud this  in country practice is an
object of no small importance.   I have never  employed
any other mode of treatment, in the cases of this accident
which have fallen under my care, and in all these, it has
completely answered  my expectations; the union of the
fragments has taken place very quickly and in two cases
without any perceptible  interval or motion between them.
The patient must be kept lying on his back on a mattress
  vol. i.         26 
194*             ELEMENTS OF SURGERY.
and from day to day the bands are to be examined, and
tightened  if necessary.  Boyer directs the joint to be
moved after the  twenty-fifth day, to  prevent stiffness,
These motions, if commenced so  early, should be very
gentle, but they may safely be  delayed until the fourth
or fifth week.   In six or seven weeks  the union is gene-
rally completed. 
ELEMENTS OF SURGERY.
195
                 CHAPTER XXXI.

                 Fractures of the Leg.

   The tibia and fibula are sometimes broken singly and
 sometimes both are fractured.  The fracture may happen
 at any part between the knee and ankle.  The fracture of
 both bones is most frequent; it may be transverse or ob-
 lique,  simple or compound, comminuted or single.  The
 fragments  are occasionally displaced in every  direction.
 In transverse fractures, there is generally no shortening
 of the limb, but  in those  which are oblique, the leg is
 generally shortened :  patients have been known to walk
 many  steps  without  great  inconvenience, after  having
 fractured  the tibia transversely, in consequence of the
 want of derangement.
   Fractures  of the leg are characterized by the general
 symptoms of fracture. Deformity of the member; loss of
 power to move the limb; great pain at the time of frac-
 ture, and on every motion of the part, crepitation, &c.
  The higher up the fracture is situated, in general, the
 more favourably does it terminate: very little danger of
 derangement exists when the upper extremity of the bones
 are broken, as the bulk of the tibia at this part,  affords
 large opposing  surfaces, which support  each other, and
 prevent displacement.   Oblique fractures of  both  bones
 of the leg it is sometimes very difficult to manage; they
 are attended with great inflammation from the  irritation
 of the sharp fragments.
   The treatment varies  according as  the  fracture is
 transverse  or oblique.  A transverse fracture,  is very
easily reduced and maintained in its proper situation.
One assistant grasps the knee,  and another the  foot, ex- 
196             ELEMENTS OF SURGERY.
tension  and counter-extension being made, the surgeon
replaces the fragments, and judges of this by the de-
formity  ceasing, and by the regularity of the anterior
edge of the tibia,  which  is so thinly covered as to be
easily felt.
  A roller is now  to be applied, (or a bandage of strips,)
very neatly from the ankle to the knee: two pasteboard
splints soaked  in  water, are placed one on each side of
the leg, they should extend from the knee to the sole of
the foot, in order  to confine and prevent the lateral mo-
tions of the foot at the ankle joint.   Over these splints a
second  roller or bandage of strips  is  to be applied; the
splints  soon  become  dry and form a solid case for the
limb which supports sufficiently the fractured  bones. It
is necessary  to avoid bandaging too tight, and to loosen
the dressings if inflammation render them so, by augment-
ing the volume of the limb:  an observation which is ap-
plicable to most fractures and should never be  neglected.
The limb is now laid on a pillow, the patient being plac-
ed on a mattress on his back, two strips of wood as long
as the pillow, and three or  four inches wide, may be tied
with tapes on the outside  of the pillow and answer the
purpose of a fracture box; the weight of the foot should
be  supported by a bandage passed round the toes, and
fastened to the boards on the outside of the pillow. The
weight of the bed clothes  should  be sustained by some
simple  contrivance, as the segments of two hoops tied
together.  At the end of six or seven weeks the fracture
generally unites.
   When instead  of a transverse  direction, th& fracture
has taken a very  oblique one, the mode of treatment is
very different, and permanent extension becomes  neces-
sary: a very convenient mode of applying this was con-
trived  by the late Dr. James Hutcliinson.   Two splints
 of wood are made, long enough to extend from the knee 
 
PLA TE. IX.
 
                ELEMENTS OF SURGERY.             197
six or eight inches below  the sole of the foot; a mortise
hole is cut near the lower end of both  these splints, and
the upper extremity of each  is perforated with four small
holes. A piece of wood fitted to the mortise holes of the
splints, eight inches long, is to be provided.
   In applying this simple apparatus, the patient is to be
laid  on  his back, and extension and  counter-extension
made as usual;  a pillow is placed under the leg upon
which is arranged a bandage of strips; two pieces of tape
are next to be secured by numerous turns of a roller,  on
each side of the leg below the knee:  these tapes are to
be passed through the four holes in the upper end of the
splint, and tied, a silk handkerchief is next to be passed
round the ankle, crossed on  top of the foot, and tied
under the sole. The fracture being reduced, the bandage
of strips is applied neatly to the leg, and the silk hand-
kerchief next tied over the cross piece connecting the two
splints; by which any necessary degree of extension may
be permanently applied.
   The annexed plate  represents the apparatus and  its
mode of application, very intelligibly.   It is particularly
convenient in compound fractures, because the external
wound  can be dressed daily, without disturbing in  the
slightest degree, the fragments of the bone ; but it cannot
be used in fractures  near the knee or ankle joints,  be-
cause the bands for extension and  counter-extension
would irritate the inflamed parts and could not be borne.
Excoriation must be guarded  against by applying soft
compresses wherever  the skin is irritated by the extend-
ing forces;  it is convenient  to interpose a small compress
of folded liuen with this view, between the tapes and skin,
or what is equally effectual, to pass the roller once or
twice round the limb  before they are applied.
   In some cases the  irritation at the knee is very great,
and the leg swells from the pressure of the circular band- 
198            ELEMENTS OF SURGERY.
age below it:  when this happens in oblique fractures of
the leg,  the long splint of Desault must be substituted,
and the counter-extension made against the pelvis.  It is
to be applied in the same manner as to a fractured thigh,
excepting that the leg must be dressed with the bandage
of strips; the two long splints are all that will be found
necessary.
  It is of great consequence in all oblique fractures of the
leg to attend particularly from day to day, to the form of
the limb, and the position of the foot, which should be
supported by a bandage, as before directed, or by a prop
of wood attached to the splints or bedstead.  If the heel
sinks too low, so as to cause the lower fragment to fall
downwards, a piece of folded linen or flannel must be
placed under it.
  The general treatment of the patient is of great import-
ance in these  cases, and blood-letting is to be performed
as often as the degree of fever and inflammation may in-
dicate.   It is  by far the most convenient mode of deple-
tion, and the most efficacious.
  Compound  fractures of the leg, are from the thin
covering of the tibia, and its exposure to accidents, more
frequent than  any other compound fracture.  The general
directions for  their treatment have already been detailed.
But it  may  not be improper to remark in this place, that
the permanent extension kept up, either by Desault's or
Hutchinson's splints, enable the practitioner to dress the
fracture,  as  often as necessary, without any pain,  or in-
convenience to the patient, and without retarding the pro^
gress of the cure by moving the fragments of bone—circum-
stances of great importance at all times, but particularly
in warm  weather when the dressings must be very fre-*
quently changed.  Should the discharge be very copious
from a compound fracture of the  leg, the  pillow  upon
which it rests should be covered with thin oiled silk, to 
                ELEMENTS OF SURGERY.             |gg
prevent its imbibing the offensive matter, and great clean-
liness should be observed.
  Fractures  of  the tibia alone, sometimes happen:
the fracture is generally transverse and attended with but
little  derangement of the fragments.   The fibula being
uninjured, prevents the shortening of the limb,  and as no
great pain or  inconvenience is  experienced, the case is
sometimes not discovered until  a considerable time has
elapsed.   A careful examination with the fingers will in
general, from the thinness of the covering over the tibia,
enable the surgeon to detect an inequality at the place of
fracture.   Crepitation may also in general, be occasion-
ed, by forcibly pressing the fragments in  opposite di-
rections.
  The treatment of the case is extremely simple;  rest on
a pillow,  is  all that is essential,  but it is most prudent to
apply the dressings recommended for transverse fractures
of both bones of the leg, and to  keep the patient in bed
until the cure is effected, viz. forty or  forty-five days.
  Fractures  of  the fibula  are less frequent  than
those of the  tibia, notwithstanding its slender size, owing
in great measure to the circumstance  that it is not con-
cerned in supporting the weight  of the body.
  The chief causes of fractures of the fibula,  are a violent
blow on the outside of the leg, or a forcible  abduction of
the foot.   There is reason to believe  that in many cases
of sprained ankle this fracture  exists  without being
known.   No shortening of the limb takes place, and the
only displacement  observed, is the fragments being push-
ed inwards  towards the tibia.
  To  ascertain the existence of the accident, the bone
should be pressed  inwards, and crepitation will generally
be perceived, or at least a motion of the bone at the place
of fracture.
  The mode of treatment; consists, in an attempt to force 
200             ELEMENTS OF SURGERY.
the fragments outward by abduction of the foot, and by
pressure upon the interosseous muscles  after which two
pasteboard splints  are to be applied,  as in transverse
fractures of both bones of the leg, and the patient must be
kept at rest thirty or forty days.  The splints are chiefly
useful by keeping the ankle  joint at rest.
   The approximation of the fibula to the tibia, is not so
important as that of the radius and ulna, because no rota-
tory motion  exists  between the  bones of the leg.  A
slight stiffness  of  the ankle joint is commonly a conse-
quence of fractures of the fibula, but it soon subsides with-
out any remedy but exercise. 
ELEMENTS OF SURGERY.
201
               CHAPTER XXXII.

          Fractures of the bones of the Foot.

  Fractures of the os calcis are very rare, but occa-
sionally happen.  The  accident may be  detected by a
crack at  the moment attended with severe pain at the
part, and great difficulty in standing upright,  a swelling
of the heel and mobility of the fragments  attended with
crepitation.
  To reduce the fracture, the leg must be flexed upon the
thigh, and the foot extended on the leg.   In which situa-
tion  the fragments can readily  be reduced.   Boyer di-
rects in order to retain  the fragments, the  slipper in-
vented by Petit, for a rupture of the tendo achillis, or if
that  cannot  be procured, the uniting bandage used for
transverse wounds, modified as follows.    The end of a
bandage  is placed on the superior  surface of the foot,
whence the bandage is reverted on the sole, and the end
is made fast by circular casts around the  foot; this band-
age is then drawn along the posterior side of the leg  to
the ham, the foot  being previously extended, on which
part it is fixed by other circular casts, it is thence brought
downward forcibly,  and  the  application terminated by
rolling along the leg what remains.  To this bandage
may be added a long compress, the middle part of which
should be applied  above  the posterior portion of the  os
calcis, and the extremities crossed on the superior sur-
face of the foot, and turned under the sole; this compress
may be fixed by a bandage rolled on the foot in the shape
of the figure 8.  The union of the fracture is effected  in
thirty or forty days, at the end of which time the patient
may be allowed to bend his foot.   He must, however, for
  vol. i.         27 
202              ELEMENTS OF SURGERY.
some days, avoid any forced flexion of the foot, as also
any excessive extension by rising on his toes."
   "  The other bones  of the tarsus, as the  astragalus, cu-
boides,  scaphoides, and three ossa cuneiformia, are sus-
ceptible only of comminutive fracture.  The same may be
said  of the bones of the metatarsus and phalanges of the
toes."   The treatment of these fractures can be very suf-
ficiently understood from what has been said of fractures
of the bones of the hand, to which they are analogous. 
ELEMENTS OF SURGERY.
203
                CHAPTER XXXIII.

                Of  Wounds  of Bones.

   In the following observations on  the  denudation and
 wounds of bones, I shall avail myself chiefly of the la-
 bours of Boyer and Hunter.
   The bones may be  stripped, not  only of the integu-
 ments, muscles, &c. by which they are naturally covered,
 but also of the periosteum, which is their intimate and ap-
 propriate covering.
   Cutting  or contunding instruments may produce this
 denudation of the bone, without injuring its substance, or
 they may cut or contuse  its external fibres.   These two
 cases must be carefully distinguished, as the contusion of
 the bone is attended with consequences much more seri-
 ous than those of a simple denudation.
   If the bone  has been  merely stripped of its perios-
 teum  and  integuments, and those  parts are immediately
 replaced, so as to exclude the contact of the air and band-
 ages, the  reunion of  the  periosteum is found  to  take
 place in a  very short time.  But if the external lamina of
 the bone has been contused, or if its surface has  been
 left a long time exposed to the action of the air,  or to the
 friction of bandages, exfoliation becomes a natural conse-
 quence.  All the external lamina must separate;  and be-
 fore this separation is effected,  the  cicatrization of the
 external wound would be rather injurious.   Should the
 wound in  the integuments be prematurely closed, puru-
 lent matter will continue to form  underneath, the  con-
 tused lamina will exfoliate, an abscess will point exter-
nally  and  burst spontaneously,  and the matter  that
escapes  from  it will  contain small  splinters of bone. 
^04             ELEMENTS OF SURGERY.
Old  age is unfavourable to the healing of wounds and
contusion of the bones; because  as the cure can be ef-
fected only by  means of the vascular texture of the bone
and  periosteum, the turgescence and expansion of this
must be slow and difficult in  proportion to the person's
age.   The treatment adapted  to the different cases is as
follows.
  If the bone be simply laid bare, the integuments, if not
completely separated, should be instantly replaced. This
precept holds good in  all cases, whatever may  be the
patient's age, if the bone has  not been already exposed
to the contact of the air.   At the  same time it must be
allowed, that it is very difficult to know by mere inspec-
tion,  whether the bone be contused  or  not;  but  should
that be the case, and even should suppuration and exfo-
liation be inevitable,  no bad consequences can result
from the attempt to produce  an immediate cicatrization;
whereas,  in the contrary event, the duration of the treat-
ment will be much abridged.  If it be possible to unite
the wound by the first intention, its lips are to be kept
separate by lint interposed, and the whole is to be lightly
covered.  In a short time granulations appear,  and the
external lamina of the bone exfoliates.  Sometimes, how-
ever, and particularly in young person, the bone becomes
soft  and red, and granulations arise from it, which bleed
from the  slightest cause.  It has been said that the bone
exfoliates insensibly in this case; but this observation is
not  found to be true:  the lamina: of  the bone  are not
broken down,  dissolved, and carried off by suppuration.
The change consists of a softening of the bone, and con-
version of it into a fleshy substance, which unites with
the soft parts.
   In this last mentioned case, the cure is  much more
prompt than when  a real  exfoliation takes place.  The
process of exfoliation resembles that of the separation of 
                ELEMENTS OF SURGERY.             gns
gangrenous eschars:  the mode in which the separation
is effected, is equally unknown in both cases.*  In exfo-
liation,  it  is merely known  that the  subjacent vessels
grow turgid, expand, and pullulate, and that a line of
separation  is observed between the contused laminae and
the sound part of the bone.  The former are undetermin-
ed, as it were,  and their connexion  shaken by the puru-
lent matter formed under them, and at length are entirely
detached, and may be easily removed by the fingers or a
forceps. When the bottom of the wound is entirely freed,
the granulations  that arise from it, unite  with the soft
parts, and  in a short time the wound is cicatrized.
  Various  processes have been employed for expediting
the exfoliation.  Thus the ancients covered the bone with
pledgits of lint impregnated with spirits, or with a tincture
of myrrh and aloes; but it is found, that these applications
retard the exfoliation by  opposing the expansion of the
vessels; for which reason they have been laid aside, and
oily relaxing applications have been substituted for them.
  It has been proposed to perforate  in different parts the
laminae which are to exfoliate, on  the supposition that
this practice facilitates the growth of the  granulations.
The perforations certainly have this effect, but the granu-
lations by shooting up through them,  retain the  laminae
rather than aid their exfoliation: each vessel spreading
as it rises,  and assuming in some respect the  shape of a
broad-headed nail.  It will then be more prudent to limit
the treatment to the use of unctuous  or emollient applica-
tions.  By means  of these remedies, the texture of the
part will be sufficiently relaxed, and the developement of
the vessels facilitated.  But if the portion of the bone to
be exfoliated be very considerable and deep seated, these

 • Mr. Hunter has fully explained this formerly unintelligible process. See
nage 207 of the present volume. 
206            ELEMENTS OF SURGERY.
applications are nearly useless, at least their effect must
be  very trifling; then we must content ourselves with
covering the part with lint, and trusting to time and na-
ture for effecting the separation.
  Though the  exfoliation be complete, as may be known
by  the motion  of the piece, it may still happen that the
circumference of the detached portion may be encroached
on  by the growth of the soft parts, and thus prevented
from separating. In this case it will be necessary to dis-
engage it by  making an incision in some point of the cir-
cumference of the wound, after which it may be drawn
out by the fingers or a forceps.   In general  there is but
very little difficulty in removing it.
  The action of cutting instruments is not  always limit-
ed  to the  mere denudation of the bone; they sometimes
completely divide it: this, however, is but a rare occur
rence.   It sometimes happens that  a  part of the bone is
cut off, of which there are numerous instances in wounds
of the head, where a part of the  parietal bone, with its
pericranium,  a  portion of the occipito-frontalis muscle
and hairy scalp, have been entirely separated by a blow
of a sword.
  When  a wound of the soft  parts is accompanied by a
similar affection of the subjacent bone, an immediate re-
union of the soft parts must not be attempted.  Lint is to
be gently introduced into the fissure, and the wound heal-
ed from the bottom; for a solid cicatrix of the soft parts
cannot be expected until the wound  in the bone is first
cicatrized.
  If the  bone in one of our limbs be cut quite through,
as in the cases  mentioned by La Peyronie, Warner, and
others; and if  a piece of flesh remain undivided, which
contains the principal vessels of the limb, it will be pru-
dent to reunite  the parts, and place  the limb in the appa-
ratus used in cases of fracture of the part. 
                ELEMENTS OF SURGERY.             2qv
  The time necessary for the reunion of the parts in cases
of this  nature, is full as long as that in those  of fracture,
and the consolidation is effected in the same manner as
in the former case.
  In the preceding remarks, Mr. Boyer has not attempt-
ed to explain the manner, in which bone  that has been
contused  and  suffers death, in consequence  of  a blow,
separates from the living bone with which it is in contact.
I shall  therefore state in this place the opinion on the sub-
ject, taught by Mr. Hunter, and now generally adopted.
  Exfoliation is the separation of  dead from living
bone, as sloughing is the separation of dead  from living
flesh, and the process in  both  cases,  is effected in the
same manner,  by the action of the  absorbent  vessels.
There  is  nothing like a  melting down of the bone; no
solution takes place; the  bone  separated is solid and in
texture unchanged, and the term exfoliation was derived
from the  scales or leaves of bone thus  detached.   In
bones  which are most solid,  and have fewest cells,  the
separation takes  place most rapidly.  I have known a
portion of the radius exfoliate in a few days, and I have
known the os  calcis, several years  in  casting off a por-
tion of dead bone. The entire death of a portion of bone,
is necessary to its exfoliation, and hence, in some cases,
the hot iron may be used with  advantage in expediting
the process,  by destroying the life  of  diseased bone.
According to  Mr. Hunter, caustics and hot irons  may ex-
pedite  exfoliation in  two ways,  first by killing the bone,
and secondly by inflaming the  adjacent bone, and  thus
increasing its vascularity and  its actions.  Dead bone
like all other extraneous  matter, stimulates  the  adja-
cent parts, in consequence of which they  become more
vascular.  The bone is composed of animal gluten, and
earth;  the earthy portion of the living bone, is removed
by the  action of the  absorbents; just  as in health these 
«>08              ELEMENTS OF SURGERY.
vessels perform the process of interstitial absorption, re-
moving from time to time the solid parts of the body. The
consequence of this  absorption of the earthy particles from
the bone, must necessarily be, that the bone is converted
into a soft matter, which is interposed between the living
solid bone, and the dead solid bone.  The soft substance
thus interposed, is last of all absorbed, and the dead bone
left  without any connection with  the living.   We are,
therefore,  to  consider the living  bone as effecting the
whole business of exfoliation, through the  agency of its
absorbing vessels, and  these  vessels act on  the living
matter, and perhaps  also, on the dead part immediately
in contact with it.
   The process of exfoliation begins at the surface of the
bone, and proceeds irregularly, not progressing uniform-
ly, in the same direction, or with the same celerity in
every part; circumstances not easy of explanation. Dur-
ing  the continuance of this absorption of the bone, granula-
tions of a fungous nature,  shoot out from the surrounding
parts, and by pressing on the loosened bone, push it out-
wards towards the surface of the body, in the same man-
ner as any other  loose  extraneous matter would be cast
off, by the ulcerative process.
   The edge  of dead bone, presents an unequal ragged
surface,  " a  groove  or worm eaten canal"  being inter-
posed between it and the sound bone.
   The  highly  interesting physiology  of the  absorbent
 vessels, aud their agency in this process, have been most
 ably developed by the late John Hunter, the first writer
 who threw any light on the subject. 
ELEMENTS OF SURGERY.
209
               CHAPTER XXXIV.

                   Of Dislocations.

  A Dislocation or Luxation signifies the  escape of
the  articulating surface of a bone, from its natural situa-
tion ; as  of the head of  the thigh  bone from the  aceta-
bulum.
  A knowledge of  anatomy is essential to the compre<-
hension of all surgical cases, but the reduction of dislo-
cated bones in some instances  occasions great difficulty,
and calls for a complete  and accurate knowledge of  the
parts concerned informing the joints, and of the effects of
the  muscles  acting upon the displaced bone;  a kind of
knowledge not to be obtained simply from osteology or
a study of the skeleton, but demanding a frequent inspec-
tion of the fresh joints, covered with cartilage and sur-
rounded with ligaments, &c.
  Some  bones in  consequence of the structure of their
joints and their exposure to accidental violence, are very
frequently luxated, as the  os humeri at the shoulder;
others from opposite circumstances, are very  rarely dis-
located, as the vertebra.  In general the liability to luxa-
tion is  proportionate to the degree of motion which  the
joint possesses, and hence  the ball and socket  joint  al-
lowing motion in all directions, is the seat of dislocation
most frequently.   In the joints possessing a hinge-like,
or ginglimus motion, the accident is proportionally rare,
in consequence of the greater extent of the opposiug sur-
faces forming the joint, and of the  strength of the liga-
ments which surround them,  added to which, they are
less frequently exposed to force in a direction proper  for
separating their articulating  extremities.
  v m.  t.          28 
210              ELEMENTS 01 SURGERY
  Luxations are said to be complete, when the bones of
the joint are entirely separated ; incomplete, when some
portion of the articulating bones remain in contact.   The
only instances of incomplete luxation occur in the articu-
lations by ginglimus;  as  the knee, elbow, or foot; and
here a complete luxation is very rare, from circumstances
obvious to every one who is conversant with the struc-
ture  of these joints.
  The longer a bone is  suffered to remain in the new
situation into which it has been forced, the more difficult
will  it be found to reduce it to its  natural place.   The
soft  parts having  accommodated themselves to the new
position;  the muscles  being shortened;  after a longer
time, adhesions forming;  and lastly, actual concretion of
the dislocated bones in a situation remote from the joint,
or the formation  of a new  moveable joint; these are cir-
cumstances which increase the difficulty of replacing the
luxated bone, in proportion  to the length of time which
has elapsed after the accident.
  Luxations like fractures,  have been divided into sim-
ple and compound.   The  simple being accompanied
with no external  wound, the compound having a wound
communicating with the cavity of the joint, formed either
by the protrusion of the  bone through the integuments, 01
by the cause of the luxation dividing them at the time of
the accident.   Luxations  may be complicated with vari-
ous  other  mischief,  by  the injury of  blood-vessels,
nerves, &c.
  The immediate causes of the luxation of a bone are vio-
lence applied to  the joint, and the action of muscles.  In
an enarthrosis joint (ball and socket) if the direction be
not oblique, it is impossible for the bone to be dislocated.
Boyer has illustrated this by the example of the os hu-
meri.  If this bone " hang exactly along side of the body,
or perpendicularly with respect to the  glenoid cavity of 
                 ELEMENTS OF SURGERY.             ^U
 the scapula, no force is capable of luxating it.   If a per-
 son fall on the elbow while the fore-arm is in this posi-
 tion, the  head of the humerus will be forced against the
 cavity formed to receive it;  but if the arm be  removed
 from the body,  the  axis  of  the os humeri will fall ob-
 liquely on the surface of the  glenoid cavity, which will
 favour its passing out of the socket; and this disposition
 to luxate, will be encreased  in  proportion as the angle
 formed by the axis of the bone  with  the  surface of the
 cavity deviates from a right angle.
   The  action  of muscles probably very often assists in
 dislocating  bones;  sometimes no other cause exists.  I
 have known the patella dislocated laterally, by a lady in
 dancing, and in convulsions different bones are occasion-
 ally luxated.
   Some joints we have already noticed, are more liable
 to dislocations than others.  This predisposition  may de-
 pend on great latitude of motion; on the small extent of
 articulating  surfaces  in  contact;  the laxity and small
 number of the  ligaments uniting them ; paralysis of the
 muscles surrounding  a joint;   and whatever has  a ten-
 dency to weaken the different connections  between the
 bones.
  In some instances the soft parts connecting the bones,
 are so relaxed that a very slight force suffices to dislocate
 them. I have known a woman whose shoulder was liable
 to luxation from  exertions of the most trifling force, and
 Boyer relates the case of a patient who could  not yawn
 even  moderately  without dislocating  her  jaw.   These
 luxations are, from the same relaxation which gives rise
 to them, very readily reduced, unless this process be too
 long delayed.
  Boyer declares, that " whatever may be the manner in
which the causes  act,  luxations are always accompanied
with more or less laceration of the ligaments surround- 
312             ELEMENTS OF SURGERY.
ing the joint;  and in  the round articulations, as those of
the shoulder and  hip, the fibrous capsules are always
torn."   He ought to have excepted cases similar to those
noticed in the last paragraph.
  The  symptoms  which  distinguish luxations, are pain
and  inability  to move the member, a change in  the ap-
pearance of the joint, an  elongation or shortening of the
limb, an  impossibility  of performing certain  motions.
By careful examination the displaced bones may often he
felt in their new situations; producing eminences where
there are naturally depressions, and vice versa; but a
more explicit account of these  symptoms will be deli-
vered when the different luxations arc particularly de-
scribed.
  The  treatment of dislocations consists in replac-
ing the  bones, and retaining them in their natural situa-
tion.  The reduction  is to be effected as in fractures, by
extension aud counter-extension.  There is in general no
difficulty in keeping the  bones in their natural position
when they have once  regained it.
  The  principal  obstacle to the replacement of  a bone,
recently dislocated, is the action of muscles drawing its
articulating surface into  a situation  remote  from that,
which it  ought to  occupy.   It frequently happens,  that
after the head of a bone has been forced out of its nat/ral
place, it passes over  certain bony prominences, and then
takes a situation  in a depression of bone, from which it
must be forcibly  raised  before  its reduction can be ef-
fected.   Instances of  these bony resistances to the reduc-
tion are found in luxations of the thigh bone ; the head of
the femur passing over the high  margin of the acetabu-
lum lodges in the foramen thyroideum, or on the dorsum
ilii,  and before it can be replaced in its natural socket,
it must  reascend  the prominences  over which it has
passed. 
                 ELEMENTS OF SURGERY.             213
  For the purpose of applying extension and counter-ex-
tension for the reduction  of luxated bones, a variety of
machines have been contrived, which  it is unnecessary
to detail in  this place.  The only means  at present in
use,  are  the hands of assistants, and compound pullies.
Whenever we can avail ourselves of the aid of a suffi-
cient number of assistants, this mode of applying force is
to be preferred, because its direction and degree may be
altered instantly by a word.
  The parts to which force should be  applied  in reduc-
ing luxations, can be  better explained by describing the
different  dislocations,  than by any general rules.   In
most cases  the force should be made to act  as directly as
possible  upon the affected joint.   Boyer and the gene-
rality of French  surgeons direct,  on  the contrary,  that
" the extending force should be applied not on the luxat-
ed bone,  but  on that with which it is articulated, and as
far as possible from it."   A rule  which can be applied
with advantage to very few cases.*
  The degree of force to  be employed  can  only be esti-
mated by the difficulty of the reduction, it should always
be sufficient to accomplish that end.  Although it is to be
constantly recollected,  that force alone is never to be re-
lied on, but skill in the direction of it is ever to  be exert-
ed.   A force  sufficient to tear oft'  a limb  has been ap-
plied without reducing a dislocation.  In estimating the
force to  be employed, the obstacles to be encountered
should be carefully kept  in view, and when these  are
clearly understood, the direction of the extending powers
and the degree of their violence will be the more easily
judged of.   It should in every instance be gradually
applied : Mr. Pott remarks, that " whatever kiud or de-
gree  of force may be found necessary for the reduction of
a luxated joint, that such force be employed gradually;

  • Mr. Pott advocates the principle I have recommended, and  most of the
Uritish surgeons, as usual, oppose the F: jji- I 
214            ELEMENTS OF SURGERY.
that the lessep degree be first tried, and that it be in-
creased gradatim."   This  important rule  if carefully
observed will prevent all serious mischief from the use of
the force necessary even in the most chronic luxations.
  Napkins and strong bands or girths, fastened upon the
limb by means of cotton rollers, enable the requisite num-
ber of assistants to act at the same time.  To prevent ex-
coriation of the skin where  great force is necessary,  Dr.
Physick has  applied a piece of buckskin with advantage,
between the cuticle and the  extending bands.
  Counter-extension  applied to the bone with which the
luxated one  was articulated,  should always be made at
least equal to the extension.  If for example, three as-
sistants are employed in extending a luxated arm, a force
equal to three should be employed in fixing the scapula.
Counter-extension may often be made by securing a band
to a staple in a wall, or some secure position.
  In  attempting the reduction of difficult luxations the
position of the patient should be changed.  After an erect
posture has been tried,  a recumbent one should  be sub-
stituted ; if this fail, the patient may sometimes with ad-
vantage be seated  in a chair.
  " Great advantage is derived  in the reduction of  dis-
locations from attending to the patient's mind; the mus-
cles opposing the  efforts  of the  surgeon, by acting in
obedience to the will, may have that action suspended by
directing the mind to  other muscles.  Several years  ago,
a surgeon in Blackfriar's Road asked me to  see a patient
of his with a dislocated shoulder, which had resisted the
various attempts he had made at reduction.   I found the
patient in bed with his right arm  dislocated; I sat down
on the bed by his side, placed my heel in the  axilla, and
drew his arm at the wrist;  the dislocated bone remained
unmoved.  I said,  "  Rise from your bed sir;" he made
an effort to do so,  whilst I  continued my extension,  and
the bone snapped into its socket; for the same reason, a 
                 ELEMENTS OF SURGERY.             ^i5
slight effort, when the muscles are unprepared, will suc-
ceed in reduction of dislocation after  violent measures
have failed."*   (Astley Cooper,)
  In recent luxations it has been already noticed that the
principal difficulty experienced, is in overcoming the con
traction of the muscles. The fatigue of the muscles occa-
sioned  by long contiuued efforts at reduction, often pro-
duces a relaxation which permits the bone to return to its
natural place.  Dr.  Physick many years ago employed
copious blood-letting with this  view. He bled the patient
until fainting was produced,  and  during his continuance
in a state of syncope all muscular action being suspend-
ed,  the reduction was readily accomplished.  In a great
sumber of instances  which have since occurred, the prac-
tice has been  found completely successful.   There are
several writers who  recommend bleeding to diminish the
action  of the  muscles in obstinate luxations, but none
(so far  as  I know) who propose bleeding  ad deliquium
animi,  except Dr. A. Monro, sen. who suggested in his
lectures on surgery copious blood-letting from one or both
arms in an  erect posture, as a probable means of facilitat-
ing the reduction  of dislocations ; but Dr. Physick I be-
lieve was the first who had the  boldness  to  carry the
practice to the extent necessary  for  complete success.
The "first case in which it succeeded, was a luxated hu-
merus,  which had baffled every mode of applying force,
and a very great degree of force had been used.  During
the fainty state, the  hands of the operator were the only
means  employed, and in a single moment, without the
slightest difficulty he replaced the head of the bone in its
socket.
  In cases  where blood-letting to the necessary extent is
inadmissible, other means of suspending the action of the

  • This fact, and the practice deduced from it, have been long since pointed
out by Dr. Physick, in his Surgical Lectures, and exemplified at the Pennsyl-
'■ini.i hospital. 
&16               ELEMENTS OF SURGERY.

muscles  are  to be used.   Perhaps nauseating doses  of
emetics,  or the tobacco glyster,  might be employed with
advantage.*  Intoxication has been recommended.  I once
saw it succeed completely in a  case  of dislocated jaw,
which no previous efforts were effectual in reducing.   It
was resorted to by Dr.  Physick,  on  account of the ex-
treme  debility of  his patient who was dropsical,  and
whom blood-letting would probably have destroyed.
   The effects of blood-letting ad deliquium animi in faci-
litating the reduction of dislocated bones,  has  been very
strikingly exemplified in several chronic luxations, which
have  occurred in  different  parts  of  the United  States.
Dr. Physick  reduced a luxated humerus which had been
out of place  forty-five  days, with very great facility;
and in a case Which occurred  at Baltimore, the arm had
been dislocated five or  six months and was replaced by
Dr. M'Kenzie by the aid of the same remedy, f

  ♦From the surgical essays of Mr. Astley Cooper and Mr. Travers, published
in this present year, 1818, it appears  that blood-letting, the warm bath, and
nauseating doses of emetics, have been freely employed to diminish muscular
action, by various British surgeons, and with great success.
  -j- The following extract of a letter to Dr. Physick, contains the history of this
truly remarkable case, of the success  of which I believe no parallel is to be
found in the records of surgery.
  " B. J. a seaman aged about thirty-five years, was admitted into the Baltimore
hospital in the month of September 1805, with a luxation of the os humeri. The
account he gave of his case was, that while  on a voyage to Liverpool, and two
weeks after leaving this port, he  fell from a considerable height  and dislocated
his shoulder, and that an attempt was made by the captain of the ship to re-
duce it, but without success; that upon his arrival at Liverpool repeated trials
were made  to effect reduction of the bone, but to no purpose, and he had now
remained in this situation between five and six months.
  " Upon examining the shoulder, 1 found the head of the humerus under the
pectoral muscles, where it had imbedded itself, and appeared to Iiave formed
considerable connexions with the surrounding parts.
   "In this state of things I deferred any attempt to reduce the bone till the fol-
lowing day, when in consultation with my friend Dr Smyth, it was determined
at once, to have recourse to bleeding ad deliquium, as the only plan in our view
likely to succeed; and having secured  our patient in the usual manner,  a vein
;vas opened, ™&nzzr\y five pounds of blood were  drawn before fainting could be 
                ELEMENTS OF SURGERY.               g^y
   An erect posture, as being most favourable to the pro.
duction of syncope, should be preferred.
   It is proper to remark, however, that after a bone has
continued  several mouths dislocated, it forms adhesions
in its new situation;  probably the  rent in the capsular
ligament contracts, or even heals up.  Inflammation pro-
duces great changes in the structure of the parts and in-
creases greatly the  difficulty of reduction.  Rotating the
bone  and moving the joint in all  possible directions, are
necessary to destroy these adhesions, and long continued
efforts sometimes succeed when the surgeon had nearly
despaired  of accomplishing his  object.   Perseverance,
therefore, is to be strongly  recommended in all recent
luxations, and even in* those which have existed several
months.
   To preserve the bone  in  its proper place  nothing but
rest is necessary.   Very  little bandaging is required for
this purpose, but it should  be remembered  that  a joint
which has been dislocated has suffered necessarily a great
deal of contusion and that it will probably inflame very
considerably.  The usual means of combatting this in-
flammation  when it occurs,  among which rest is indis-
pensable, are to be employed. It is proper in most cases,
to bathe a joint  which has  been dislocated with  a solu-
tion of sugar of lead or with some cooling lotion.
  Luxated  bones which are not reduced, sometimes re-
i
produced; this, however, was at length completely effected, and with (compa-
ratively speaking) very little efFort the bone was reduced.
  "It is worthy of remark in this case, that neither swelling nor inflammation
succeeded the reduction of the bone, and the poor man was dismissed well in
the course of two weeks.
                          " I am, &c
                                    "COLIN M'KENZIE."

  Desault's most chronic case was of three months duration, and I believe Dr.
M'Kenzie has accomplished what no other surgeon of this or former ages can
boast of having performed.
  vol. i.         29 
218              ELEMENTS OF SURGERY.
main in the situation into which they had been at first
forced;  more commonly, however, they change their si-
tuation, being drawn by the action of muscles further and
further from the cavity of the joint.   In its new situation
it excites inflammation and a thickening of the surround-
ing soft parts ;  if in contact with bone, this bone becomes
inflamed,  and  after  a time a  depression is  formed  in
it which receives the head of the dislocated  bone, and
a kind of imperfect joint is  formed;  the  muscular  flesh
and cellular texture are changed into a ligamentous mat-
ter which assist in supporting and strengthening the new
articulation.   In various anatomical collections are pre-
served curious  specimens of these newly formed joints,
affording wonderful  proofs of the resources of  the animal
ceconomy.   The socket of the joint from which the bone
had been displaced,  sometimes fills up wi:h a  thickeuiug
of the ligaments, and  the  usual matter of  adhesions,
though in  other cases it remains very little changed in
structure.
   The muscles of a limb permanently dislocated shrink
and lose  their  strength, and although in some  cases a
power of motion is regained after a time, yet it is always
very limited and imperfect.
   Of compound dislocations.  These are  among the
most dangerous accidents to which the bones  are liable;
all the dangers of wounded joints, and of compound frac-
tures,  are  to be dreaded from them.   The question of
amputating a limb in which a compound dislocation has
happened, is  attended  with  all the difficulties,  already
noticed when speaking of wounded joints.  The various
circumstances of the patient in each particular case must
be taken into view, and  no general rules  for deciding it,
can be laid down.
   The principal object in the treatment of compound dis-
locations is, after reducing the bone, to procure as speedi- 
                ELEMENTS OF SURGERY.              g^g
ly as possible the union of the  external wound, thereby
precluding the dangers  of an  exposed joint.   For this
purpose its edges should  be brought as nearly as possible
into contact,  and retained so by adhesive plaister, and
the joint kept perfectly at rest by bandages, splints, and
a proper posture. 
220
ELEMENTS OF SURGERY.
               CHAPTER XXXVI.

             Of Particular Dislocations.

            DISLOCATION OF THE LOWER JAW.

  This accident happens generally in adults and never
in young infants, because in the latter the angle of the
jaw is obtuse, in consequence  of which the condyles by
which it is articulated with the temporal bones  have the
same direction as the basis of the jaw, and from  this
structure the mouth cannot be opened wide enough in in-
fancy to separate the articulating surfaces.
  Sometimes one and sometimes both condyles are dis-
located.   The  only direction in which the displacement
can happen is forwards.  In  most cases the accident is
produced by yawning, or opening the mouth excessively
wide.   A woman in scolding her husband, in a very vo-
ciferous tone, found herself unable to close her mouth,
and  applied to  Dr. Physick  who found both condyles
of the lower  jaw dislocated.  A blow upon the  chin
whilst the mouth is opened may also occasion the same
effect.
  The symptoms which denote this luxation, are an in-
ability to close the mouth, which is kept considerably
open; immediately before the  ears  where the condyles
naturally occasion a fulness, an empty  hollow  space is
perceived;  the coronoid process is felt projecting more
anteriorly than natural;  the cheeks and temples are flat-
tened;  the saliva flows from the mouth; the patient
speaks and swallows  with great difficulty ; the chin pro-
jects  forward.   When the jaw continues dislocated se- 
                ELEMENTS OF SURGERY.             £21
veral  days these symptoms are not so strongly marked,
but they still exist, to a greater or lesser degree.
  To effect the reduction the patient is to be seated on a
low chair, his head supported against the breast of an as-
sistant ; the surgeon defending his thumbs with a piece
of leather, or linen, places them as  far back  upon the
molar teeth of the lower jaw as possible, the fingers are
then placed under the chin, and whilst he presses down
the back teeth with his thumbs, he at the same time ele-
vates the chin;  by this manoeuvre he uses the base of the
jaw as a lever of which his thumbs represent the fulcrum,
and disengages the condyles from the  zygomatic foss« in
which they had been  lodged;  when the condyles  are
found moving, the chin is to be pushed backwards, and
the reduction is effected.   At this moment it behoves the
operator to be careful in removing his thumbs from be-
tween the teeth, for the condyles regain their situation
very  suddenly, and the jaws are spasmodically closed,
with great force.  To prevent their being bruised he slips
them very  quickly  outwards between  the  cheeks and
teeth, where they are safe.
   After the reduction  the jaws  should be kept at rest a
few days by a bandage passed round the head and chin,
the patient being nourished with spoon victuals.
   It has been proposed to reduce this luxation by a sud-
 den blow on the chin, knocking it upwards and back-
 wards.  This  plan has sometimes succeeded but it is al-
 ways attended with great danger of breaking off the con-
 dyles of the jaw.
   When only one condyle is dislocated the reduction is
 effected in the same manner as when both are displaced,
 except that only one hand is necessary.
   Le Cat succeeded in reducing an obstinate dislocation
 of the jaw by introducing a stick betw een the back  teeth
 and usin°" it as a lever continually prizing the teeth of the 
222             ELEMENTS OF SURGERY.
upper and lowrer jaw apart, until the muscles which were
spasmodically contracted, became fatigued and  then the
reduction was easily effected.
  Dr. Physick was consulted a short time ago by a young
woman who had been salivated for the cure of a dropsy,
the inflammation and swelling of the jaws in consequence
of the use of mercury were very great, and during the
continuance  of  these  symptoms she dislocated  (without
knowing how or when) both condyles of the lower jaw.
When the effects of the mercury had somewhat subsided,
she perceived her inability to close her mouth, and her
physician soon discovered that the jaw was luxated. She
came to Philadelphia, and Dr. Physick attempted its re-
duction in the usual manner, but not succeeding,  the plan
proposed by Le Cat was tried without effect, her molar
teeth being almost all carious prevented any violent efforts
upon them, with the wooden lever.  Her extreme debility
and dropsical habit, precluded blood-letting and I sug-
gested to  Dr. Physick the propriety  of trying  the nau-
seating effects of tobacco.  She refused this however, and
the Dr. next proposed to  give her as much ardent spirit,
as should occasion intoxication.  She consented and be-
came perfectly inebriated, and whilst inebriated was pre-
vailed on to smoke a segar, great nausea ensued, during
which time the measures  which had been before  unavail-
ing, very promptly succeeded in effecting the reduction. 
ELEMENTS OF SURGERY.
22B
              CHAPTER XXXVII.

            Dislocations of the Vertebrce.

  The excellent work of Boyer will furnish the follow-
ing Chapter.
  " The large surfaces by which these bones correspond,
the number and thickness of their ligaments, the strength
of the  muscles lying on the column formed by them, the
small motion  of  which  each  vertebra is capable, and
lastly,  the vertical direction of their articulating apophy-
ses,  render a luxation of them in the dorsal and lumbar
part of the  column,  entirely  impossible.   A  violence,
though ever so considerable, cannot displace them with-
out first fracturing them.   The same is not the case with
the cervical vertebrae:  the extent  of their articulating
surfaces  is  less,  the ligamento-cartilaginous  substance
which  unites their bodies has more pliability, the motion
of their articulations is greater, and their articulating
surfaces  have an  oblique  direction,  which allows them
to have an obscure rotatory motion; consequently luxa-
tions of them are sometimes  met with.   I have seen a
case in which the neck was  luxated by a  violent rota-
tory motion of the cervical vertebrae, and the luxation re-
sisted  all  means that  were  employed to reduce  it.  The
cause of impediment  was felt  towards the middle of  the
column formed  by the  cervical vertebra; from  which
circumstance  we may conclude that  the  dislocation did
not consist of a separation of the first vertebra from  the
second, which is admitted to  be possible by all authors,
but that it took  place lower down iu the cervical part of
the column.
   It appears from  well attested facts, that luxations may 
ggj,             ELEMENTS OF SURGERY.
take place in the vertebral column; such as those of the
head from the first vertebra, and of the first vertebra from
the second.  These,  and especially  the latter,  are the
most frequent; but others, though much rarer and more
difficult, may, however, take place.
  The  articulation of the occipital  bone with  the first
vertebra of the neck is strengthened by means of many
ligaments, and  admits of  only very limited motions.  It
is well  known, that the motions of inclination of the head
to the right and left,  and of flexion and extension, take
place along the whole length of  the cervical vertebrae.
We have no instance of luxation of the head  from the
first vertebrae by an external cause; such  a dislocation,
if possible,  would instantly destroy the  individual to
whom it happened, by the compression and disorganiza-
tion  of  the  spinal marrow.   But nature  which  cannot
bear so  sudden a change, is habituated to it when it takes
place gradually and insensibly; and the spinal marrow,
which a sudden though inconsiderable  derangement of
the spine would totally disorganize, is not sensibly in-
jured when it takes place by degrees; cases of rachitis
furnish  us many proofs of this.   It is only in  this way
that we can explain how the individual from whom the
preparation in the Museum of Natural History was taken,
could exist  until such very great deformity took place in
his spine.
  It is  principally in the triple articulation of these two
vertebrae, that  the motion of rotation of the head to the
right or left takes place; for the union of the first vete-
bra  to the occipital bone  is so close, that the motion of
both is  the same.   This  rotation  of the first vertebra on
the  second,  which the laxity and weakness of  the liga-
ments that go from one to the other, and the direction of
their articulating apophyses, render easy,  would  be fre-
quently carried beyond its natural bounds; and luxation 
                 ELEMENTS OF SURGERY.             gas
would take place  every time we turn our  head with
force, if the motion were not confined by two very thick
ligaments,  which go from the sides and summit  of  the
toothlike process of the second vertebra to the edges of
the great  occipital  hole.  When this  motion is  forced
beyond its proper limits, the  ligaments are torn, and  the
lateral parts of the  body of the first vertebra glide along
on the articulating horizontal processes of the second.  If
the head is turned from the left to the right, the left side
of the body of the  vertebra  is carried before its corres-
ponding articulating surface,  whilst the right side falls
behind its corresponding surface.  In this luxation, some-
times the toothlike  process,  the ligaments of which  are
broken,  leaves the  ring formed for it  by the transverse
ligament and the anterior arch of the first vertebra, and
presses on the spinal marrow, the substance  of which it
destroys; at  other  times  it remains  on its ring, but  the
diameter of the vertebral canal is always diminished  at
this place, and the spinal marrow experiences a compres-
sion, and at the same time a contortion, by which it is la-
cerated.  It is easily conceived  that  the patient cannot
survive a derangement of this nature : every lesion of the
spinal marrow at this height  is quickly fatal.  Louis,  in
making researches  on  the manner of dying  of hanged
persons, found that  those  despatched  by the  executioner
of Lyons, perished by the luxation of the first vertebra
from the second; whilst those hanged at Paris were suf-
focated by strangulation. He  discovered the cause of this
difference in a rotatory motion given to the body  of the
culprit by the executioner of  Lyons, at the moment that
the ladder was taken from under  his feet.  We ought  to
attend to this observation, when we examine in a judicial
capacity the body of a person found hanged.  We should
carefully examine the second vertebra, and  see if it  be
luxated.  If so the individual has not been guilty of sui-
  vol. i.         30 
226             ELEMENTS OF SURGERY.
cide,  for the luxation must have resulted from a violent
motion communicated to the body by the assassin.
  The following case by J. L.  Petit, furnishes an in-
stance of luxation produced by the person  himself; the
circumstances  of it are so extraordinary, that we  shall
relate them  at full length.
  " The only son of a tradesman, aged between six and
seven years, went into a neighbouring shop, the proprie-
tor  of which was  a friend  of his father's.  This person
playing with the child, put one hand under his chin and
the other oil the back of his head, and then raised him up
in the air,  telling him he  was going to shew  him his
grandfather, a  common expression  among the vulgar.
Scarcely was  the child raised from the ground, when he
began to struggle, and by his efforts dislocated his neck,
and died on the spot.  The father on hearing of the death
of his child, ran in a  fit of passion after his  neighbour,
who fled before him, but not being able to catch him, he
threw  at him  a saddler's  hammer which he had in his
hand,  and buried the cutting part of  it in the depression
of his neck.  The weapon  cut  all the muscles,  pene-
trated into the space between the first and  second cervi-
cal vertebra, divided the spinal marrow and  occasioned
almost instantaneous death.  Thus both perished nearly
in a similar  manner."   J. L.  Petit,  who  quotes no
authority to support this fact, avails himself of the op-
portunity of censuring this dangerous kind  of play, and
observes with  justice,  that  the  motion which the  child
gave himself was the cause of his death.
  The relaxation of the ligaments of the toothlike pro-
cess  may favour this luxation.   Such probably was the
case of a young man,  who  found a difficulty to bring his
head back to its natural posture, each  time that he turned
it to the right  or left.  There are many cases of  luxation
of the neck, in which death does not succeed the acci- 
                 ELEMENTS OF SURGERY.              ga~
 dent;  but  in  these the  luxation  takes place  in  the
 third,  fourth, fifth,  or sixth vertebrae, and only one arti-
 culating process is luxated:  in these cases, the diameter
 of the vertebral canal is  not so much diminished as to
 compress the spinal  marrow, and destroy life; but a wry-
 neck remains, which becomes incurable, unless the real
 cause be found out.
   A child,  playing  on his mother's bed, suddenly  felt
 pain in his neck, accompanied with a distortion which he
 could  not remove.   Desault,  to  whom the  child  was
 brought, discovered a luxation of the vertebrae  of  the
 neck;  but before trying to  reduce  it, he informed  the
 mother that  the child might die in the attempt. This in-
 formation terrified the mother so much, that she took  the
 child away without having any thing done to relieve it.
   A lawyer writing at his desk, heard the door behind
 him open; he quickly turned round  his head to see who
 was  coming in, but  could not bring it back  again to its
 natural direction.  Many surgeons  of Paris  have seen
 this patient: his head was turned to the right, and slight-
 ly inclined to the shoulder of the same side.  This  in-
 clination was  much  less  than it would have  been in a
 spasmodic contraction of  the sterno-cleido-mastoideus
 muscle.
  Thus when in consequence of a sudden and violent  ef-
 fort, the head is found  turned to one side, either right or
 left, with inability to bring it back, the ear  a little inclin-
 ed to one side, and the sterno-cleido-mastoideus in a state
 of relaxation, there can be no  doubt but that a luxation of
 one of the cervical vertebrae has taken place.
  If the luxation produce no  symptom which indicates a
compression  of the spinal  marrow, it is prudent to abstain
from  all attempts to reduce it.  However, if the patient
absolutely insist on our interfering, we are  to proceed in
this way :  we begin by inclining the head to the side 
ggg              ELEMENTS OF SURGERY.
towards  which it is directed, in order to disengage the
articulating process of the upper vertebra: this part of
the operation is extremely dangerous, as it may kill the
patient by causing  a compression of the spinal  marrow.
When the process  is disengaged, the head  and  neck are
brought  to their right direction, by making them perform
a rotatory motion the contrary of that which had taken
place  in the luxation.   A relapse is prevented  by keep-
ing the  head free from motion.   This is done by means
of bandages  which are attached to the head and shoul-
 ders."  (Boyer—Vol. 2.) 
ELEMENTS OF SURGERY.
229
              CHAPTER XXXVIII.

  Dislocations of the Bones of the Pelvis and Thorax.

  The nature of the articulation connecting the sacrum
and ossa innominata,  and their great strength  at  the
places of their juucture, prevent them from dislocation
except by great violence applied immediately at the spot
where the  synchondrosis  exists.   The accident in  one
instance occurred by a heavy body falling on the back of
a labourer, who died  twenty days after,  and upon dis-
section a luxation of the  sacrum was discovered.   The
right os  ilium passed nearly three inches behind the sa-
crum and the luxated bones moved freely on each other.
Great inflammation existed in the parts contained in the
pelvis, and pus  was found in the abdomen. • This case
being very analogous  in its symptoms and effects  to a
fracture of  the ossa innominata, calls for the same treat-
ment;  rest and the antiphlogistic  measures,  to guard
against inflammation.  Boyer who relates this case, states
further, that in pregnant women the symphysis pubis be-
comes in some cases so much relaxed that the ossa inno-
minata may be  separated, and supposes that something
similar may take place to a smaller  extent at the sacro-
iliac symphysis.  These cases  call  for no surgical treat-
ment.
   Dislocations of the os coccygis, may be occasioned in
early life by the same  accidents which at a more advanc-
ed age,  would occasion a fracture.   The circumstances
of the cases  being similar, no  difference of treatment is
required.  It is evident that luxations  of the bones form-
ing the pelvis have nothing in common with other dislo-
cations ;  they are in fact fractures of the cartilage connect- 
g30              ELEMENTS OF SURGERY.
ing these bones ; are produced by the same causes, and
are to be treated by the same remedies as fractures of the
bones.  They are extremely rare, as the bdnes generally
yield and are broken by a force capable of producing the
dislocation.
  The ribs likewise, are not capable of dislocation, be-
cause no force can be applied to their articulation with the
vertebrae which will not occasion a fracture.
  The starting of the cartilages of the ribs in front is an
accident which is not  unfrequent; it occurs in certain
motions  of the arm.  Mr.  Charles  Bell observes, " a
young man playing the dumb bells and throwing his arms
behind him, feels something give way on the chest; and
one of  the cartilages of the ribs has  started and stands
prominent.   To reduce it,  we make  the patient draw a
full inspiration and with the fingers knead the projecting
cartilage into its place. We apply a compress, and band-
age, but the luxation is with difficulty retained." 
ELE>reNTS OF SURGERY.
231
               CHAPTER XXXIX.

             Dislocation of the Clavicle.

  This is a rare accident compared with the fracture of
the bone.  It occurs at the sternal and also at the hume-
ral extremity.
  At the sternal extremity the sternum and the car-
tilage of the first rib prevent the dislocation downwards,
but in every other direction it is occasionally dislocated,
viz. forwards, backwards, and upwards.  In general, the.
displacement is forwards.   It is effected by violent mo-
tions of the clavicle backwards.  In consequence of this
motion the sternal extremity is carried forwards, the liga-
ments are broken, and the end of the bone is found before
the upper end of the sternum, forming a hard projecting
tumour, which moves whenever the arm and shoulder are
moved.
  The  treatment of all dislocations of the sternal extre-
mity, consists in the same  dressings  as  those used for
fractured clavicle; they reduce the luxation and main-
tain the proper situation of  the bone.  The dressings
should  be continued a greater length of time than  in a
case of fracture ;  and in general, some deformity exists,
the clavicle being more salient than natural at the place of
dislocation.
  The humeral  extremity of the clavicle is not so
often dislocated as the sternal.  It is generally dislocated
upward, but it may take place downward, being lodged
under the accromion.   The dislocation upwards is the
only one  demanding attention, because the only one in
which any difficulty is experienced in maintaining the re-
duction. 
23S             ELEMENTS OF SURGERY.
   The accident is generally occasioned by falling on the
shoulder, and is ascertained by examination with the fin-
gers ;  the extremity of the clavicle being found under the
skin covering the accromion, causing a considerable pro-
jection there.  The patient  inclines his head to the af-
fected  side, and moves as little as possible the arm and
shoulder, because he  cannot move these parts without
calling into action the deltoid or some other muscle, which
would consequently extend  the motion to the  diseased
part, and cause pain.
   The treatment of the accident is to be the same as that
recommended for fractures of the clavicle, viz.  the ap-
paratus of Desault, which effects  and maintains, better
than any other, the reduction. That part of the bandage
which  ascends from the elbow to the shoulder, should in
the present case be made as tight as can be borne, in order
to press  down the clavicle, and  keep  it in  its proper
place.
   The inconveniences resulting from this accident when
improperly treated are very considerable;  the motions of
the arm being for a long time greatly impeded; they are,
however, after a lapse of years gradually recovered. 
ELEMENTS OF SURGERY
233
                CHAPTER  XL.

           Dislocations of the Os Humeri.

  These are by  far the most common dislocations, and
have been supposed to equal in  frequency, all others
which  occur.*   The structure of  the shoulder joint, in
which a spherical surface is articulated with a  very su-
perficial cavity, and  in contact with it in a very few
points, together with the weakness of the ligaments of the
joint, and  its exposure  to violence  in performing a great
variety of motions, are circumstances which sufficiently
explain the frequency of the accident;  and it would be
still more frequent, were it not for the admirable provi-
sion by which the scapula moves with it, thus preventing
in a variety of instances the force of percussion from act-
ing solely on the os humeri.   Were the scapula fixed as
is the pelvis, almost every violent motion of the arm would
be attended with dislocation.
  The head  of the os humeri  may escape  from the gle-
noid cavity of the scapula in  any direction except up-
wards, where the acromion and coracoid processes and
the ligament connecting them together, prevent its ascent.
Mr. Boyer observes, that there is " one species of luxa-
tion of the humerus of which though it has been described,
and the possibility made evident, we are not acquainted
with a single instance, it is the luxation outwards or back-
wards."   Such a case occurred to Dr. Physick in De-
cember, 1811, and  I have seen a luxation directly for-
wards, the head of the bone being lodged before the co-
racoid  process, both of which will be noticed hereafter.
  The situation of the bone after it has been dislocated
  • At the Hotel Dieu, of the total number of luxations, admitted during a long
period of time, a majority were luxations of the  os humeri.   (Bichat.)
  VOL. I.          31 
234             ELEMENTS OF SURGERY.
is often changed very considerably by the action of mus-
cles.
  The  dislocation downwards into the axilla, is by far
the most frequent; the anatomical structure of the joint
has furnished the French surgeons with some ingenious
reasons for this, but they are of no importance in a prac-
tical point of view.   It is probable that in every case
where the head of the bone is found in the axilla, a con-
siderable laceration of the capsular ligament must have
taken place.
  The symptoms of  a dislocation of the os humeri down-
wards, are very easily distinguished.  The principal dif-
ference  observed between  the luxated and sound shoul-
der, are the natural  rotundity  of the latter,  and in  the
injured one  a very remarkable  depression under  the
acromion which of course appears very prominent; this
symptom which was noticed by Hippocrates is never ab-
sent.   The arm is longer than the sound one.  Its direc-
tion  is changed, and instead of hanging parallel to the
side, it  stands off at an acute angle from  the body, and no
effort of the patient can draw the elbow  close to the side.
Great pain is perceived in attempting to move the arm in
any direction, but the motion outwards is less painful than
any other. The head of the os humeri is  felt in the axilla,
forming a hard round tumour.
  To reduce the bone, a vast variety of means have been
employed; the ambe of Hippocrates is  perhaps the old-
est apparatus upon record: to  recount  the different in-
ventions which have been contrived since his time would
be a very useless and fatiguing task.   I shall therefore
very briefly describe  the  method which  I believe best
adapted to the case.  It consists  in  making  counter-ex-
tension  against the acromion process of  the scapula, and
extension by  the arm above the  elbow, the fore-arm being
flexed.
..._ 
                ELEMENTS OF SURGERY.             335
  If the surgeon is  called soon after  the  accident has
happened,  he is to  press  firmly with one  hand against
the acromion, and with his other grasping the arm above
the elbow, forcibly to extend it, the patient  being seated.
In a great number of instances I have known this simple
manoeuvre to succeed instantly in reducing the bone, the
strength of an individual being sufficient for the purpose.
  If a greater tength of time have elapsed, the extension
and counter-extension are  to be made in the same  man-
ner, but with additional power. Several assistants being
employed, to make counter-extension against the  acro-
mion,  by placing one hand over another, and an equal
number to make extension.
  When the force required  is  greater than can  be thus
applied, a girth or strong band covered with soft buck-
skin may be passed over the shoulder for counter-exten-
sion, and this can be held by  assistants, or secured to a
staple fastened in a wall; in order to prevent it from slip-
ping, I have made use of two strips of muslin, one on
each side of the  shoulder, which are passed round the
band, and held down by an assistant.   To make exten-
sion, a piece of soft  buckskin is applied round the arm
above the elbow, and a strong towel is fastened upon this
by very  numerous turns of a muslin roller passed round
and round the arm ;  to this towel,  cords or bands  may
be attached, and any number of assistants can act upon
them, or if pullies be necessary these can be affixed.
  The  advantage derived from the mode  of applying
force which has just been recommended is that it  acts al-
most exclusively upon the shoulder joint.  When  the pa-
tient is secured by straps, bandages, or jackets about the
thorax, the scapula moves with the  humerus when this is
pulled, and it would probably be possible to drag off the
scapula ?nd  clavicle  together with  the arm,  without re-
ducing the luxation.  T» e mode of treating the accident, 
236              ELEMENTS OF SURGERY.
by placing the heel in the axilla, and pulling at the arm,
is a better plan, for in this case some of the counter-exten-
sion is borne by the scapula, and this has often been suc-
cessful, but  among the  numerous methods  which inge-
nuity has devised  to aid in the reduction of a  luxated
humerus, I know  of none which so completely and exclu-
sively operates upon the affected part, and none which can
succeed more happily than that which I have described.*
   In general, the extension has not been long continued
in this  manner before the head of the bone in the axilla
is found to move, and very often without any other effort,
slips  into its socket; if this, however, should not be the
case, the surgeon is to take the fore-arm bent to a right
angle with the arm, and with some force, rotate it repeat-
edly inward and outward.  If the luxation be not reduced
thus, pressure against the head of  the  bone,  is  to be
made, directing it towards the glenoid cavity ;  if it can
not now be pushed into its situation,  the extensions may
be suddenly  suspended,  and the surgeon having his left
hand under the arm near the axilla, as suddenly depres-
ses the  patient's elbow towards his side  and thus uses
the os humeri as a lever and brings out the head of the
bone to a level  with the glenoid cavity which it conse-
quently enters.  By these means aided if necessary by
copious blood-letting, the luxation has in  every case I
have  yet seen been reduced.
   Among the causes impeding the reduction  of this luxa-
tion, Desault mentions « a narrowness in the opening of
the capsular ligament," to enlarge  which,  he  advises
moving the arm very  freely and forcibly  in every direc-
tion.  The same measure is useful also by tearing asun-
der any adhesions  which may have formed  in the new
situation of the bone.

  * Mr. Freke, Benjamin Bell, Charles Bell, and other writers, recommeiul
securing the scapula, but not in the manner here directed. 
                ELEMENTS OF SURGERY.             <gm
  In all these efforts perseverance is an important rule.
If the  first attempts fail,  they should be repeated, and
varied  again and  again,  and according to Desault even
when success is not completely obtained, something will
be gained if the head of the bone be brought nearer to the
glenoid cavity, for  " the motions of the bone will be the
freer in proportion  to its proximity to the natural  situa-
tion."
  At what period after its luxation  should we consider
it  impracticable  to reduce a dislocated bone ?  Did we
believe B. Bell and other writers of  the last  century, a
week or a fortnight having elapsed,  all efforts should be
considered  as hopeless.   Desault succeeded after three
months.  In a variety of instances Dr. Physick has suc-
ceeded after two and three months, and Dr. M'Kenzie of
Baltimore, has replaced a dislocated os humeri nearly
six months  after  its  luxation.   Before answering  the
question therefore,  it may be well  to consider  another
which I shall state in the language of Dr. Physick, quot-
ed from his lecture on this subject.   " If force  applied
can remove a bone from its natural  to an unnatural situa-
tion, why may not force be so directed as to remove it
from this new, to its former position ?" If the time could
be ascertained at which the socket is certainly filled  up,
and its texture completely altered, that would be the time
to give over all attempts at reduction.
  The plan we have recommended  is proper in most
cases of dislocated os humeri.  In  the dislocation back-
ward,  (a very rare accident, which neither Desault nor
Boyer ever saw,) in addition to the extensions and coun-
ter-extensions, some pressure should be made upon the
head of the bone,  and  an attempt to push it towards its
socket  whilst  the  extension  is made.  Dr. Physick  in
this manner succeeded  in reducing  a case of the kind,
without difficulty.   It was distinguished by a great de- 
£38             ELEMENTS OF SURGERY.
pression  under the acromion,  as  in  all other disloca-
tions ; by a hard tumour  on the dorsum of the scapula
which was evidently formed by the head of the bone ; by
an inability to move the arm, in any direction ; and by an
absence of the  head of the bone  from the  axilla.  No
doubt could exist as to the nature of the accident, and no
difficulty was experienced in its reduction.
  It is astonishing that Mr. Charles Bell should deny
positively the possibility of this accident. "No force can
be applied in a direction to dislocate the humerus  and
push its head behind the scapula,  for this  very evident
reason that the chest prevents  the necessary position of
the humerus."*   Mr. Bell's accurate anatomical know-
ledge should have taught him that  the chest is no defence
to the shoulder, and  that a blow on the  shoulder  can
luxate the humerus, as readily  as  a twist of the arm. In
the case  recited  the patient fell through a hatchvvay  and
struck the fore part of the shoulder which was thus push-
ed directly backwards.
  A case of dislocation inwards and forwards occurred
to Dr. Physick in 1812; there  is no reason for believing
this  to have been consecutive, for the head of the bone
continued unmoved after  the accident, and assumed the
situation in which he found it,  immediately after escap-
ing from the glenoid cavity.  As the head of the bone iu
this  case, was fixed between the glenoid cavity and the
coracoid process,  extension was made by drawing the
elbow backwards and  downwards, and counter-exten-
sion,  by pressing the acromion  scapulae forwards  and
inwards  towards the head of the bone, at the same time
a band was passed under  the arm by which  the upper
end  of the  os humeri was dragged  outwards so as to
unhitch it from the coracoid process.   By these  means,

                 * Operative Surgery, Vol. H.
4 
                ELEMENTS OF SURGERY.              5^39
after  in  vain trying extension in the usual way,  the
reduction was effected.
  In another instance of luxation forwards and inwards,
the head of the bone passed completely over the coracoid
process, and was situated directly under the clavicle.  In
this case by bleeding  ad deliquium,  and extending the
arm at a right angle from the body,  the reduction was
easily effected.
   After the reduction of a dislocated  os humeri the arm
should be kept at  rest, and if inflammatory symptoms
occur, they  are to be treated by the usual remedies.
   Many of the preceding remarks are  taken from  Dr.
Physick's MS. lectures.  I am well aware that the idea
of making some counter-extension against the  acromion
is to be found in several writers.  Mr. Charles Bell  and
Boyer,  appear  to come nearer the plan above proposed
than any others, but their methods are different  in many
particulars:  Mr. Hey  in his practical observations  has
some excellent  remarks on this luxation,  but they are
 detailed with less than his usual perspicacity.  The great
object to be kept iu view,  is to act as effectually as pos-
 sible on the shoulder joint, and this can best be done by
 making the  counter-extension as nearly as possible to the
 glenoid cavity, and this can certainly  be accomplished by
making counter-extension exclusively upon the acromion
 process.
   An accidental  circumstance  which occasioned some
 alarm to Desault iu attempting a difficult reduction, it
may not be improper to notice  in this place ; the sudden
 formation of a very considerable tumour  at the upper
part of the  arm, occasioned probably by the rupture of a
 vein,  as it subsided  in a fortnight,  leaving  a large
 ecchymosis : no particular injury resulted from it, though
 at first it  was mistaken by  some,   for an effusion  of 
g40            ELEMENTS OF SURGERY.
air from the thorax,  and by others,  for a rupture of an
artery.
   The stiffness of the joint which follows a luxation of
the os humeri is generally of short continuance,  and its
motions are soon perfectly restored.  The arm should be
gently moved after a  few days have elapsed, and these
motions are to be gradually increased. 
ELEMENTS OF SURGERY.
241
                  CHAPTER XLI.

            Dislocations of the Fore-arm.

  The radius and ulna may be dislocated from the hu-
merus ;  or secondly, The superior extremity of the ra-
dius may be separated from the  ulna;  or thirdly,  The
ulna may be luxated at its inferior extremity from the
radius.
  1. The articulating  surfaces which  form the elbow
joint are very extensive, and the joint consequently  pos-
sesses considerable strength, which is augmented by the
muscles passing over it arid connected with the bones  in
its vicinity.  The  elbow  joint possesses the true hinge-
like motion, and is  a pure specimen of the articulation
denominated ginglimus.  From these circumstances it is
not frequently dislocated.  The luxation may take place,
however, backwards, and laterally. The luxation back-
wards is most frequent.  A complete dislocation laterally
cannot take place, from the great extent of the articulating
surfaces in this direction, and the  strength of the  muscles
and ligaments around the joint.
  " In the luxation backwards the  radius  and ulna  may
ascend more or less  behind the humerus, but  the coro-
noid process of  the ulna is always carried above the ar-
ticular pulley, and is  found lodged in the cavity destined
to receive the olecranon.  The head of the radius is placed
behiud and above the external condyle  of the humerus.
The annular  ligament  which  confines  the superior ex-
tremity of the radius  to  the  ulna may be lacerated, in
which case even when the bones are reduced, it is  difficult
to keep them in their proper places, as the radius tends
constantly to separate from the ulna.
  vol. i.          32 
242              ELEMENTS OF SURGERY.
  " This luxation always takes place from a fall on the
hand; for when we are falling we are led by involuntary
instinct to bring our hands forwards to protect the body.
If in this case the superior extremity instead of resting
vertically on the ground, be placed obliquely, with the
hand nearly in  a state of supination, the repulsion which
it receives from the ground will cause the two bones of
the fore-arm to ascend behind  the humerus, whilst the
weight of the body pressing the humerus obliquely down-
wards forces its extremity to pass down before the coro-
noid process of the ulna.
  u The  fore-arm in this luxation  is in  a  state of demi-
flexion, and every attempt to  extend it, occasions smart
pain.    The situation of the olecranon with respect to the
condyles  of the humerus is  changed.  The olecranon
which in the natural state is  placed on a  level with the
external condyle, which is itself situated lower than the
internal, is higher than it.
  " This luxation may be mistaken for a  fracture of the
olecranon, of the head of the radius, or even of the lower
end  of the humerus:  such  a  mistake is attended with
Very bad consequences; for if the reduction be not effect-
ed before the end of fifteen or twenty days,  it is impossible
to accomplish  it afterwards.*   The swelling  more or
less considerable which supervenes in twenty-four hours
after the accident, renders a diagnosis difficult; the bony
prominences are so covered by it, that it is impossible to
examine  their  respective situations.  Besides,  the rub-
bing  of the coronoid process and olecranon against the
humerus, causes a grating noise  similar to that in frac-
ture.   From these  circumstances  it  must appear,  that
much  attention  is requisite  to establish a diagnosis be-
tween the fracture of the head of the radius, and a dislo-
cation of the fore-arm backwards."   (Boyer.)
  * This is a great mistake of Mr. Boyer. I have seen a case of this luxatio-.
which had continued longer than a month, very promptly  reduce^. 
                 ELEMENTS OF SURGERY.             g^g
  The reduction is effected by  seating the  patient in a
chair, and  making  extension  and counter-extension by
two assistants, one  of  whom  grasps the wrist and the
other the arm near the shoulder.   The surgeon now in-
terlocks his fingers in front of the arm just above the el-
bow and draws it backwards.  If greater force be neces-
sary it is to  be applied in the same directions.   Boyer
recommends that the olecranon be pressed forwards and
the humerus pulled backwards by the surgeon, who is to
place the four fingers of each hand on the fore part of the
humerus, and his thumbs on the olecranon.   The only
objection to the plan is, that  the surgeon unless a Her-
cules, could not in this way  act with sufficient power,
 and if the humerus be forcibly  drawn backwards, there
 will be no  necessity for pushing the olecranon forwards.
 When the  reduction is effected, the form  and  motions of
 the elbow will be restored and a very evident noise will
 be heard at the moment when it takes place.  Rest and a
 low diet should be observed for a few days after the ac-
 cident, the fore-arm being preserved in a state  between
 flexion and  extension by  a  roller and  compresses or
 splints.  A  week  after the  accident the arm should be
 gently and repeatedly moved to prevent anchylosis; these
 motions are to be daily increased, until they are per-
 formed perfectly and without pain.
   " In a luxation of the fore-arm backwards the annular
 ligament which confines the head of the radius to  the ex-
 tremity  of the  ulna, is sometimes torn, and  the  radius
 passes before  the  ulna.   In such  cases, the motions of
 pronation and supination, are difficult and painful,  though
 the principal luxation has been reduced."  The head of
 the radius may be easily replaced by pressing it from be-
 fore backwards, and it is kept in its place by compresses
 bound on  the superior and external part of the fore-arm
 by  a roller passed  round  the elbow  in  form  of  the
 figure 8. 
g44            ELEMENTS OF SURGERY".
   When the luxation has not been reduced, the superior
extremities of the bones, grow to the posterior part of the
os humeri, and flexion and extension are thus precluded.
In young subjects a slight degree of motion is sometimes
regained.
   The lateral luxation,  either inwards  or outwards, is
easily detected  and easily  reduced,  the reduction is ef-
fected by moderate extension, and whilst this is made, by
pressing laterally the projecting parts of the humerus and
fore-arm.  If no great degree of contusion exists the arm
requires no dressing, but to be supported in a sling.
   Besides these dislocations the fore-arm may be luxated
forwards, but in that case, the olecranon  process must be
fractured, and the case,  therefore,  is to be treated as a
fracture of the olecranon.   The reduction is readily ef-
fected.
   In  all these accidents  to the elbow, inflammation su-
pervenes, and must be remedied by  bleeding and a low
diet.
   2. The head  of the radius is in some cases dislo-
cated from its articulation with the ulna.   In general the
luxation takes place backwards.  The hand is found in
a state of pronation, and  cannot be moved out of it with-
out great pain.  The head of the radius is found project-
ing at the external side of the olecranon.  There  is a con-
siderable depression felt at the part where the head of the
bone is naturally situated.
   To replace the luxated bone,  the head of the radius is
to be  pushed from behind forwards, and the hand of the
patient is at the same time to be brought to a state of su-
pination.  The reduction is thus effected, and an audible
noise  is produced  by the re-entrance of the head  of the
radius into the sigmoid cavity of the ulna.   The  hand re-
gains the power of rotation ; the ligament in this instance
being ruptured, it will be some  time  before the joint re- 
                 ELEMENTS OF SURGERY.             &ar
 covers its motions perfectly, and gentle motion is to be
 frequently made, after the lapse of a few days from the
 accident.   The limb may be surrounded at the joint by a
 few turns of a roller, and this may be wet with a saturnine
 lotion.
   3. The  inferior extremity of the ulna is occasionally
 dislocated  from its connection with the radius.   It may
 be pushed either forwards or backwards, most commonly
 backwards.  This  dislocation  is easily distinguished.
 The hand is kept continually in a state of pronation, and
 this position cannot be changed ; a tumour is felt behind
 the lower extremity of the radius; the hand is turned a
 little inwards, and there is an evident depression where
 the lower end of the ulna ought to be situated.  The re-
 duction is easily effected, by pulling the arm and turning
 it a little inwards, whilst the lower end of the ulna is
 pushed backwards, and that of  the radius forwards, the
 hand being at the same time placed in a state of supina-
 tion.   A roller wet with a solution of sugar of lead is to
 be applied after the reduction, and the hand supported at
 rest in  a sling.
   The dislocation anteriorly is more rare.  It is known
 by the  hand being in a continued state of supination and
 it cannot be placed in a state  of pronation : a tumour is
 felt before the radius, and there is an empty space where
 the lower end of the ulna should be.  The ulna crosses
 the radius obliquely instead of being parallel with it.  The
 reduction is effected as  the preceding luxation, except
 that the hand must be moved in a contrary direction.
  If the parts be much swollen before the surgeon  is
called,  in this as in all similar cases, he should  wait un-
til the  inflammation is somewhat abated before making
any attempt to reduce  the bone. 
246
ELEMENTS OF SURGERY.
                 CHAPTER XLI1.

              Dislocations of the Hand.

  « Four kinds of luxations may take place in the articu-
lations of the bones of the carpus  with the inferior extre-
mities  of those of  the fore-arm,  viz. luxation forwards,
backwards, inwards, and outwards.  But the two first,
especially that backwards, are the most frequent, because
the motions of flexion and extension are much more ex-
tensive than those of adduction and abduction,  and be-
cause the extent of the articulating surfaces is greater from
within to the outside, than from before backwards; be-
sides,  the styloid  apophyses of the radius and ulna,
strengthen the external and internal sides of the  articu-
lation, and render  dislocation in the transverse direction
still more difficult.
   " The articulation of the hand  with the fore-arm is re-
markable in this, that it admits of flexion  and extension
nearly to the same extent; whilst these two motions, in
all the other articulations, have rarely the same latitude,
that of flexion being always the most considerable.
   " Luxation backwards is facilitated by the direction of
the convex articulating surfaces of the scaphoides,  lunare,
and cuneiforme, which, inclined more backwards  than
anteriorly, must be more disposed to slide in this direc-
tion than in any other.  It is caused by a fall on the back
of the hand  while much bent;  in which case the first
range of bones of the wrist slides backwards into the ob-
long cavity of the two bones of the fore-arm, extends and
lacerates the posterior ligament, and forms  an eminence
 behind  the ends of the radius and ulna.   This  tumour,
 the depression at th.* anterior part of the wrist, and the 
                ELEMENTS OF SURGERY.             24<7
extraordinary flexion of the hand which cannot be ex-
tended, are the distinguishing marks of this luxation.  It
is reduced by fixing the fore-arm, and drawing the hand,
whilst pressure  is  made on the eminence formed by the
displaced carpus to force it back into its cavity.  An as-
sistant fixes  the arm, and the surgeon  makes extension
and adjusts the bones.
  Luxation forwards is occasioned by a fall on the palm
of the hands, the fingers  being extended and more force
being applied to the inferior part of the palm than to the
superior.   It is rarely complete; the hand remains pain-
fully  extended,  and cannot be restored to its natural di-
rection without  some difficulty.   The numerous tendons
which pass before the wrist, and the annular ligament
which confines them, being pushed forwards, render it so
 difficult to discover the eminence formed by the bones of
 the wrist before the ends of those of the fore-arm, that this
 affection may be easily mistaken for a sprain.   Conse-
 quently, in all doubtful cases, we should proceed as if the
 luxation had really taken place, and  bring the hand into
 its proper direction.
   " Luxations backwards, but especially those forwards,
 are always accompanied with a more  or less considerable
 laceration of the ligaments, and are followed by an in
 flammatory swelling difficult to subdue; hence, the full
 use of the wrist is  not recovered for a considerable time.
 When the bones are reduced, the remainder of the treat-
 ment is the same as in cases of sprain :  refrigerants and
 repellents  are to be first  used, and  then emollients and
 resolvents. The patient must not fatigue the hand much,
 even for some time  after complete recovery, lest he excite
 inflammation, and lay the foundation  of a white swelling.
   « Luxations inwards,  and tho.e outwards, are never
 eomplete   The laceratiou of the ligaments, a tumour at
 the internal or external side of the joint and distortion of 
sj48             ELEMENTS OF SURGERY.
the hand, are the concomitant symptoms of these luxa-
tions, and mark them out Sufficiently. They are reduced
by making gentle extension, and causing the two sur-
faces  of the joint  to slide on one another in a direction
contrary to what they took in luxating, and by bringing
the hand into its natural  situation.   The danger of these
luxations depends  less  on  the dislocation  than on the
straining or laceration of the  soft parts, which are always
followed by more or less  tumefaction, a symptom difficult
to subdue, and  often the  cause of anchylosis or even of
caries."

 LUXATIONS OF THE BONLS OF THE CARPUS AND MKTACAKPUS.

   " The motions of the bones of the carpus and their ar-
ticulations with one another  are so limited, and the con-
nection is so  strong, that a dislocation of them appears
entirely impossible.   However, the head of the os mag-
num,  which is received in a deep cavity formed for it by
the scaphoides and lunarenaris, may  escape from this ca-
vity,  be luxated backwards  by too great a flexion of the
bdnes of the first range on those of the second, and form
a tumour on  the superior part of the back of the hand.
Boyer and Desault have both seen cases  of this accident
   " As to the bones of the metacarpus, they are connect-
ed so  closely and strongly,  and support one another so
firmly in efforts made against the palm of the hand, that
they are never luxated.  The ligaments of their articu: •<
lations  may,  however, be overstretched and torn, and a
painful diastasis produced, which will require the use of
emollients and  resolvents, with immobility of the hand as
long as the affection continues.
  " Notwithstanding the mobility of the articulation of
the trapezium with the first bone of the metacarpus, the
latter  is  luxated but very rarely.   Efforts  made in the 
                ELEMENTS OF SURGERY.             g^g
thumb  which is supported by this bone, would produce
rather  a luxation of the first phalanx, than that of the
metacarpal bone.  The second and third bones  are  so
firmly  articulated with one another, and with the bones
of the second row of the carpus, that  they are not  sus-
ceptible of any luxation whatever.   As to the fourth and
fifth, a little more moveable, and supported by the os un-
ciforme, their articulations are more susceptible of sprains
than true luxations."

              LUXATIONS OF THE FINGERS.

  " The first phalanges  may be luxated backwards  at
 their articulations with the bones of the metacarpus.  A
 luxation of them forwards would be very difficult, if not
 altogether impossible, on account of the disposition of the
 articulating surfaces  of the  metacarpal bones,  which are
 much elongated forwards,  and allow  a great extent of
 motion to the phalanges in this direction, without losing
 contact with them; and on account of the resistance made
 by  the palm of the hand,  which would  restrain the
 flexion carried beyond what the inclination of the articu-
 lating  surfaces would admit of.   Luxations  inwards can
 take place only in the first phalanges of the thumb and
 little finger:  as to that outwards, the first phalanx of the
 thumb alone  is susceptible of it.  This phalanx  is also
 the most  exposed to luxations backwards.  When a vio-
 lent effort is made on the thumb from before backwards,
 its  first phalanx slips behind the head of the first meta-
. carpal bone,  and remains extended, while the second is
 bent, its flexor-muscle being thrown  into action  by the
 irritation.  The distortion of  the thumb, the impossibility
 of bending the first phalanx, and the pain, render this
 luxation  sufficiently  evident.
   "The  more violent  the effort  necessary to produce
r    vol. i.          33 
g50             ELEMENTS OF SURGERY.
these luxations,  the more  grievous  are  their  conse-
quences.  In some persons in whom  the ligaments are
excessively relaxed, they produce no inconvenience. In
such, the first phalanx  of the thumb may  be luxated at
will; but then it is as easily reduced as displaced.
  " These luxations should be quickly reduced, for, at
the end of eight or ten  days, they are irreducible.  De-
sault in a case of this kind, proposed making an incision
behind  the  superior extremity of the  phalanx, and by
means of it to introduce a spatula,  in order to push the
phalanx into its  place;  but the patient frightened at the
operation,  would  not submit to it.  Citizen Boyer has
also  observed in a hair-dresser,  a luxation backwards
irreducible from having continued too long.
  " The reduction  is not as easy as one might imagine.
The number and force of the muscles which are inserted
into the first phalanx of  the thumb, and the little hold we
can take of this part in order to make extension,  render
the reduction  difficult.  Luxations of the first phalanges
of the thumb and little finger inwards, that of the thumb
outwards, and luxations of the first phalanges of the other
finger backwards, are all reduced by  making  extension
on the inferior  extremity of the affected  finger, round
which a fillet is  to  be passed if there be occasion for
much force.  The  wrist  is fixed by an assistant,  who
makes counter-extension,  and the surgeon replaces the
bone.  The first and second phalanges are also suscepti-
ble of  luxation backwards, which only differs from the
former by being more easily reduced.  After the reduc-
tion  is accomplished a roller is put round  the finger to
prevent a return of the luxation."  (Boyer.)
   To  the preceding remarks from Boyer I shall add a
very  few respecting the dislocation of the thumb :  Mr.
Hey observes, that " a peculiar difficulty attends the re-
duction, when the head of the metacarpal  bone which is 
                 ELEMENTS OF SURGERY.             g^|
joined to the first phalanx of the thumb, is luxated com-
pletely and depressed towards the palm of the hand.  A
dislocation in the opposite direction,  is easily reduced."
Mr. Hey attempts an explanation of  the difficulty, from
the manner  in which the lateral ligaments are connected
with the extremities  of the bones concerned in this luxa-
tion ; these ligaments are connected with the two  tuber-
cles,  which  are  situated on  each side of the  anterior
extremity of the  metacarpal  bone  ; upon measuring the
distance of  these tubercles from  each other, Mr. Hey
found "those two,  which are nearest the palm of the
hand, to be  three-eighths of an inch from each  other,
while those on the posterior part are distant five-eighths:
supposing, therefore, the head of the  metacarpal bone to
be pressed forcibly between the lateral ligaments towards
the palm of the  hand, the extremity of the metacarpal
bone passes like a wedge between the lateral ligaments,
and having passed through them, it cannot return,  as the
posterior broad  part of  the  bone  presents itself to the
more contracted  aperture between the ligaments.   From
an anatomical consideration of this joint, it seems impos-
sible that  the metacarpal bone should pass in this  direc-
tion to  a  complete dislocation without tearing off some
part of the lateral ligaments ;  yet  so  much of the liga-
ments remains, as to prevent the return of the bone to its
natural  situation."
  Mr. Hey himself,  experienced great difficulty and was
foiled in an attempt to reduce this dislocation.  He wit-
nessed also  the want of success in other celebrated sur-
geons, and states  on  the authority of Broomfield that the
thumb was actually  torn off at the second joint without
effecting the reduction.   Under these circumstances, the
plan suggested  by  Desault  of cutting open  the  joint,
would surely be warrantable,  since we know that incised
wounds of  these joints  when properly treated seldom 
25S              ELEMENTS OF SURGERY.
occasion any  ill consequences.  Mr. Charles Bell has,
however,  proposed a plan to which I conceive there can
be no valid objection in these obstinate cases; the intro-
duction of a couching needle obliquely under the skin, so
as to cut  one  of the lateral  ligaments, this would in all
probability very quickly liberate the confined hone and
permit its  easy reduction.
  The  first case of this  accident I ever saw,  although
attended with great difficulty, was eventually reduced by
Dr. Physick.   I have, since the publication of the first
edition  of this work, met  with two other instances.  The
first I reduced with great difficulty, the second (in a child)
very readily. 
ELEMENTS OF SURGERY.             gjg
                CHAPTER XLIII.

             Dislocations of the Thigh.

  From a consideration of the structure of the hip-joint,
in a skeleton, it would appear extremely difficult to effect
a dislocation of the os femoris, and this  difficulty is
greatly augmented  by the cartilages  and ligaments  con-
nected with the articulation;  notwithstanding, however,
these  powerful obstacles,  the accident not unfrequently
happens.   Mr. Boyer is of opinion,  that it is more rare
than has been supposed, and believes that authors have
frequently mistaken fractures  of the neck of the os femo-
ris for dislocations.   The experience of many practition-
ers  is, however, opposed  to the opinion of Boyer,  con-
cerning the comparative frequency of the two accidents.
So  far as my own limited observation has extended,  I
have witnessed about three luxations at the hip, for one
fracture of the neck of the os  femoris.*   Mr.  Hey  says
he  has  seen but six  cases in a practice of forty-three
years, during thirty-four of which he attended a large
infirmary; this, however, is what few surgeons of equal
-experience can declare.
  The  dislocation  may take  place,  upwards   and
backwards (or upwards  and outwards)  on  the dorsum
ilii; secondly,  upwards and forwards on the os pubis;
thirdly, downwards and inwards into the foramen thy-
roideum; fourthly, downwards  and backwards  on the
os ischium.  Some variety exists in the situations of the

  * I have had now  (1818,) occasion to see this proportion altered, but stiU
have witnessed many more luxations than fractures. Mr. AsUey Cooper states
the proportion of fractures of the neck of the thigh bone which he has seen
to be at least four, to one of dislocation. 
 £54            ELEMENTS OF SURGERY.
 bone in these four kinds of luxation generally described;
 I have seen a luxation directly forwards, differing some-
 what from the second species, but yet not in any very
 important respect.   1 have also seen a luxation directly
 backwards.
   The most frequent of these  accidents are the first and
 third, and of these it is not easy to  ascertain the most
 common.   The luxation  outwards and  upwards I have
 met with  much more frequently than any other, though I
 have seen all except the fourth species  which is extreme-
 ly uncommon, and perhaps never occurs directly, but is
 owing to  a subsequent change in the position of the head
 of the bone from the action of muscles  drawing it down-
 wards.
   A luxation  upwards and backwards is described
 very accurately  by Boyer.
   " When by a fall from a place more or less elevated,
 on the  soles  of  the feet,  or  on the knees, the thigh is
 pushed forwards and inwards, the head of the femur,
 forced towards the superior and external part of the ace-
 tabulum, breaks the internal and orbicular ligaments, es-
 capes through the laceration in the latter, and ascends on
 the external face of the os ilium ; but as the part of the
 os ilium  immediately above and at the external side of
 the cavity, is very convex, the head of the femur  soon
 abandons  its first position, and slides backwards and up-
 wards into the external fossa of the os ilium, following
 the inclination of the plane towards this fossa, and obey-
 ing the action of the glutsei  muscles which draws it in
 this direction.  The head of the femur, in ascending thus
 on the external face of the os ilium, pushes upwards the
 glutaeus minimus, which forms a sort of cap for it; and
 the glutseus maximus and medius are relaxed by the ap-
proximation of the points into  which they  are inserted.
The pyriformis is nearly in its natural  state, the gemini, 
               ELEMENTS OF SURGERY.              gg^
obturatores, and quadratus femoris, are a little elongated.
The psoas magnus and  iliacus  internus are relaxed, as
are also the  other  muscles inserted into the trochanter
minor.  If to this description it be added, that the orbi-
cular ligament, torn at its superior part, is stretched over
the acetabulum and  covers  it,  an exact idea may  be
formed of the change occasioned  in the surrounding parts
by this  luxation of the  femur.   The  affected thigh is
shorter than the sound one : it is a little bent, and carried
inwards.  The knee inclines more forwards and inwards
than the opposite one ; the leg and thigh are turned in-
wards,  and the foot  points in this direction.  The tro-
chanter  major is brought  nearer the anterior and superior
spinous  process of the os ilium, and is  at the same time
elevated and  carried a little forwards ; the latter circum-
stance may be considered as the necessary consequence of
the rotation inwards of the thigh.  The natural length of
the limb cannot be restored without reducing the luxation:
the foot cannot be turned outwards, and any attempt to
do so causes pain ;  but the inclination of the foot inwards
may be increased.   If the patient endeavours to walk, he
extends the foot to  put the top of it on the ground ; and
though he is  raised,  he  is still  lame;  for  the diseased
limb remains always shorter than the other, and the pain
occasioned by the attempt to walk renders progression
still more difficult.
  " Luxation of the  femur upwards and outwards has
nothing in common with  the fracture of the neck of this
bone but the shortness of the limb.  The easy rotation of
the member outwards and inwards, &"c. &c. preclude all
possibility of confounding  them, unless the surgeon  be
remarkably inattentive.
  " It is difficult to assign the cause of the foot and re-
mainder of the limb being turned inwards  in this luxa-
tion.  It may  be established as a general rule,, that luxat- 
£06              ELEMENTS OF SURGERY.
ed members always  take  a  direction determined by the
elongation of the muscles of the  side  opposite that to
which the luxated bone is carried:  thus in  luxation of
the arm downwards and inwards, the deltoides and infra-
spinatus muscles, lengthened  by the separation of their
points of insertion, move  the  elbow out from the body,
and give the  arm an oblique direction.  In this case, the
obturatores, gemini, and quadratus  femoris,  being elon-
gated, the point of the foot ought to be turned outwards.
This  phenomenon depends perhaps  on the external por-
tion of the orbicular ligament which comes from the an-
terior and inferior spine  of the os  ilium; this portion,
which is very thick,  being elongated in the luxation out-
wards, draws the great trochanter forwards, and conse-
quently turns inwards the entire limb."
  Luxations  of the thigh bone are generally extremely
difficult of reduction, from  the powerful action of the
muscles surrounding the joint, and from the peculiar con-
struction of the articulation  itself.   To effect the reduc-
tion of the first species of dislocation (upwards and back-
wards) the patient is to be  placed on his back upon a
table  covered with a mattress, or  with folded blankets.
A strong band is to be passed between the pudendum
and the luxated thigh in such  a manner as to press upon
the ischium,  and this band is to  be secured firmly to a
post or staple, or it may be held  by a sufficient num-
ber of assistants; in this manner counter-extension is
made by fixing the pelvis. The extending force is to be
made by securing a folded sheet or strong band  above the
knee  by  means of a roller passed tight round the limb at
this place; this  band  is  to be delivered to  a sufficient
number of strong assistants. The surgeon directs the ex-
tension to be made, and with his hands presses upon the
trochanter and endeavours to direct the head  of the bone
towards  the  acetabulum.  In  recent cases  this simple 
                   ELEMENTS OF SURGERY.             ggw
  plan  is often completely  successful.   The head  slips
  into its cavity with a very audible noise, and the symp-
  toms of dislocation immediately cease.
     If this measure, however, should  fail, as it sometimes
  does, the  head of the bone must be pulled outwards,
  (that is, more remote from the centre of the body.)  The
  object of this motion outwards  is to raise the head of the
  bone  to a level with the  high margin of the acetabulum,
  over which it must  pass in order to regain its  natural
  situation.   The means of effecting it are to place the pa-
  tient upon his side, and to pass a band under the thigh;
  an assistant  places  his knee upon  the crista of the os
  ilium and thus prevents the pelvis from moving in a late-
  ral direction  ; the band may be tied over his shoulder by
  which he will be enabled very conveniently to draw the
  thigh outwards;  or  he may place one  foot (without a
  shoe) upon the pelvis, and draw with his hands the late-
  ral band; the extension and counter-extension,  as  pre-
  viously directed,  are to be continued, and the surgeon is
  to bend the leg to a  right angle with the thigh,  and ro-
  tate the limb backwards and forwards. This plan is gene-
  rally successful.   A variety of measures have been devis-
  ed by which extension in the  directions just described
  may be made, pullies may be substituted for assistants;
  bed-posts may be used for counter-extension, &c.  Nume-
  rous plans  suggested by the circumstances of each  par-
  ticular patient have been found  successful.
     A low diet should be enjoined for several days  after
  the reduction of the  bone, and the patient should remain
  at rest for a considerable time.   The round ligament
,  probably never completely unites after this  accident, and
  consequently  the joint remains always weak.
    The luxation downwards and  inwards into the
  foramen thyroideum,  is the next in point of frequency.  I
  shall quote the description of this accident from  Boyer.
[    vol. i.          34 
 258             elements of surgery
 " It is favoured by the great extent of the motion of ab-
 duction of the thigh; by the notch at the inferior and in-
 ternal part of the acetabulum ;  by the* weakness of the or-
 bicular ligament at this side ; and lastly, by the situation
 of the round ligament,  the rupture of which is not a ne-
 cessary  consequence of it.  It is occasioned by a fall on
 the feet or knees considerably separated from each other.
 The  head of the femur slides from without inwards on
 the bottom of the acetabulum, and comes against the in-
 ferior and internal portion of the orbicular ligament, which
 it lacerates and passes on to the  foramen ovale between
 the ligament and the obturator externus.
   "In this species of luxation of the femur, the state of
 the soft  parts surrounding the  articulation is as follows:
 the glutaei, gemini, obturatores, quadratus femoris, psoas
 magnus, and iliacus internus, are elongated by the sepa-
 ration of their points of insertion.   The rotation of the
 limb  outwards  is produced by the elongation of these
 muscles.  The adductors, elongated, form at the interior
 part of the thigh a tense cord, which is felt from the pubis
 to below the middle of the thigh.
   " The affected thigh  is longer than the  sound one; the
 head  of  the femur  being placed  lower than the acetabu-
 lum, the great trochanter is removed to a greater distance
 from the anterior and superior spinous process of the os
 ilium,  and the thigh is flattened in consequence  of the
 elongation of the muscles.  The adductors, extended ob-
 liquely from  the pubis  to  the femur, form a cord which
 elevates  the  skin  of the internal part of the* thigh.  A
 hard round tumour  is felt at the  inner and superior part
 of the thigh, formed by  the head of the femur, which ele-
 vates  the soft parts situated before the foramen ovale.
 1 he leg  is slightly  bent; the knee and foot turned out-
 wards, cannot be brought back to their proper  direction.
If the patient attempts to walk a  few steps, he make, a 
                elements of surgery.             259
semicircular motion with the foot, and places at once the
entire sole on the ground; and though he keep the knee
bent, still the limb is  too  long, and occasions lameness.
The mode of progression of persons whose thigh is luxat-
ed in this direction may be compared to that of a mow-
er:—the elongated extremity,  like  the  leg which the
mower keeps forwards, describes a semicircular motion
outwards.
  " All these symptoms taken together form a combina-
tion too striking to admit of error in our diagnosis, or to
allow us to confound this luxation with any other, or even
with fracture of the neck of the femur.
  " The prognosis is somewhat less favourable in this
than in luxation upwards and outwards.   The muscles,
which  might oppose  the  reduction, being all elongated
by the very circumstance  of luxation itself, renders the
reduction easier; besides the contusion of the soft parts is
less considerable, and  the round ligament is stretched,
but not broken."
  The  reduction is to  be effected in the same manner as
that of the luxation last described.
  The luxation upwards and forwards is very rare;
Desault describes a case of it, and I  had myself an op-
portunity of seeing a  case which Dr. Physick has pub-
lished.   In the latter the luxation was not precisely simi-
lar to Desault's, the head  of  the bone being not at all
higher than the acetabulum.   I shall  relate this case as
illustrative of the nature and treatment of the accident.
  " In  February 1805, a man was brought to the Penn-
sylvania Hospital, in consequence of a dislocation of the
thigh bone at  the hip-joint, which had taken place the
day before in the following manner.   As he was riding
on a sled, which was drawn rapidly along, with his legs
extended over its side, the  foot of his left  leg became en-
tangled  in the gears of a team of horses standing in the 
260             elements of slrglr\.
road.  A great abduction of the leg and thigh was thus
suddenly made, by which the head of the bone was forced
out of its socket, and  lodged on the os pubis, directly
before the acetabulum.   In this situation it formed a tu-
mour, plainly to be seen and felt in  the  groin,  under
Poupart's ligament.  The foot and knee were turned
outward, the thigh was extended with the leg bent back-
ward.   By  a very  particular examination it  appeared
that the dislocated limb was a little longer than the other,
though  the difference in  length was very inconsiderable.
   "  After an unsuccessful attempt, which is unnecessary
to describe, the head of the bone was replaced by the fol-
lowing means.
   " The patient being laid on his back on  a table cover-
ed with a mattress,  a firm  strap  was placed behind his
thighs,  and the ends of it being carried upwards,  before
and  behind his body, were fastened to a staple opposite
his left shoulder,  for the purpose of  fixing the pelvis,
and  making the counter-extension.  This  strap was ap-
plied in such a manner  as  to act as much as  possible
against the injured side  of the pelvis, and was carried,
therefore, between the dislocated thigh and scrotum, and
then over the tuberosity  of the ischium of the same side.
A strong towel was then fastened with a roller upon the
leg just below the knee, and the leg was bent  to a right
angle with the thigh.  The ends of this towel  were tied
together, and a pulley was hooked to  it for the purpose
of making the extension.
   " In order to draw the head of the bone directly out-
wards,  a firm strap was passed over the pelvis  below the
crista of the ilium of the injured side,  and the ends of it
fastened to  a staple opposite the sound side  of the pa-
tient's body.  Another strap was applied over the upper
part of the dislocated thigh, the ends of which  were fast-
ened to a pulley opposite the injured side  of the patient. 
Plate x
 
 
                ELEMENTS OF SURGERY.              ggf
  " After the application of this apparatus, before com-
mencing the extensions,  the  man  was copiously  bled,
with the intention of causing him to faint, an effect, how-
ever,  which was not fully produced,  though he  lost a
considerable quantity of blood,  by which he was much
weakened.  In this state of debility the extensions were
repeated, and at the same time the leg being bent, was
moved inwards and outwards, so as to rotate the  thigh
bone as  much as  possible and  thereby to  assist in dis-
lodging its head.  To prevent the abduction of the thigh
by  the strap over its upper part, the  knee was pressed
inwards by the hand of an assistant  applied on its outside.
  u In this manner several attempts were unsuccessfully
made, biify added to the bleeding, they exhausted the
f patient's strength so much, that his body became  cover-
ed  with a cold sweat.  In this state of weakness the ex-
tensions were directed to be  again  repeated with greater
force than  had been before employed, and by these the
head  of the bone was  suddenly reduced  to its natural
situation.  The  patient in a few minutes recovered suffi-
ciently to move his thigh in every direction, suffered very
little pain afterwards, and was discharged from the hos-
pital, cured, in three weeks."*
  In Desault's case  the following  were the symptoms :
"the limb  was nearly an inch shorter than natural.  The
point of the foot was turned outwards, the thigh being in
a state  of painful extension  could  not be  flexed on the
body;  adduction and abduction were alike painful; the
great trochanter being   more approximated than  usual
to the anterior superior spinous  process of the ilium, was
also too far forwards;  finally, the  projecting  head of
the bone could be  felt iu  the  groin."  The mode of
reduction which succeeded differed but little from that

                  * Medical Mr.^:< in— vol. 1. 
 26^             ELEMENTS OF SURGERY.
 employed by Dr. Physick,  the chief circumstances  in
 which the plan  of Desault differs from  that which we
 would recommend,  are  that Desault applied extension
 at the ankle, and counter-extension  on the sound side of
 the pelvis, and not on the side where the dislocation ex-
 isted.  Dr. Physick's plan appears calculated to act more
 directly and powerfully on the luxated joint.  If the one,
 however, should fail, the other ought unquestionably to bo
 tried.
   The luxation downwards  and  backwards I have
 never seen, and shall quote Boyer's history of it.*
   " Luxation of the femur, downwards and backwards
 may  be either  primary  or secondary.   It is primary,
 when in consequence of some effort, the  head of the fe-
 mur is forced from the acetabulum at its inferior and pos-
 tt 'or part, and is placed at the  junction  of the os ilium
 and ischium; it is  secondary,  when it  succeeds to the
 luxation upwards and outwards, the head of the femur,
 which was placed at first in the  external iliac fossa, slid-
 ing downwards and backwards,  its passage in this direc-
tion being favoured by the binding  of the thigh on the
pelvis.
   66 In these two cases, the head of the femur rests upon
that part of the ossa innominata, where the os ilium and
 ischium  join.   The muscles which cover the posterior
 part of the  articulation, such as the  pyriformis,  gemini,
 obturatores, and quadratus femoris, are  raised  up and
 stretched; the psoas magnus  and iliacus  internus are in
a great state of  tension, and  this explains the turning of
the limb outwards.  When this luxation  is primary, the
 extremity is lengthened;  a hard tumour is felt at the pos-
terior and inferior part of the thigh,  the great trochanter,

  * Mr. Astley Cooper states, that he has never seen it, and supposes mistakes
to have arisen on the subject, though he does not positively deny its possibility.
 Surgical Essays, 1818. 
                ELEMENTS OF SURGERY.             ago
by descending, is removed further from the spine of the
os ilium, and the knee and sole of the foot are turned out-
wards ;  but if it be secondary,  the thigh is much bent
against the pelvis; the knee and sole of the foot are turn-
ed inwards, because the primary luxation has been up-
wards and outwards.   Secondary luxation in this direc-
tion is much more frequent than the primary: in reduc-
ing it, the  same rules are to be observed as in other spe-
cies of luxations."
  A primary luxation  directly backwards was  brought
into the  Pennsylvania hospital last winter, and after va-
rious attempts to reduce it by powerful extension, in the
different directions before described, Dr. Physick thought
it probable that the head of the bone had slipped through
a slit or longitudinal rent in the capsular ligament, and
that this rent embraced it at the  neck,  as a button ht^
does a button ; under this impression after the extensions
had ceased, he made an abduction of the thigh, bent to
a right angle with the body, pushing at the same time the
head of the bone forwards towards the acetabulum; this
manoeuvre in a moment succeeded without any more force
than the Dr. was himself able to  exert—a strong confir-
mation of his opinion respecting the nature of the obstacle
previously existing. In all difficult cases  it will be proper
to try every possible motion of the limb,  before abandon-
ing the case as hopeless; very often after great force has
failed, a gentle effort in some new direction is found suc-
cessful.
  When a luxated thigh bone remains long unreduced a
new joint is formed in the situation where the head of the
bone is lodged, and a considerable degree of motion is
regained.  The acetabulum lessens in size and is even-
tually obliterated.  When the luxation is upwards and
backwards an imperfect joint forms on  the dorsum ilii,
and of course the limb is considerably shortened and the 
264             ELEMENTS OF SURGERY.
patient is very lame, walking principally on the toes and
anterior part of the foot, sometimes he avails himself of a
high, heeled shoe.  If the luxation be forward and down-
ward the foramen thyroideum forms part of the new articu-
lating cavity and the limb  is rather longer, the patient
walks much better than in the preceding case.  Dr.  Wis-
tar has preserved in his collection very interesting speci-
mens of new  joints formed in consequence of unreduced
luxations of the os femoris.
   Spontaneous dislocations of  the  os  femoris are those
in which the head of the bone has been protruded by pus,
granulations, or tumefaction, in the acetabulum.   It can
occur only in cases of extensive disease of the hip-joint,
and is of little  moment compared with  the disease of
which it is a symptom—this we shall describe more par-
ticularly hereafter. 
ELEMENTS OF SURGERY.
265
                   CHAPTER XLIV.

                Dislocations of the  Patella.

    The patella is occasionally forced over one of the con-
  dyles of the os femoris, and is thus luxated laterally.  A
  dislocation upwards  or  downwards  cannot take place
  without a rupture of the extensor tendon of the leg, which
  reduces the accident more nearly to the nature of a frac-
  tured than of a dislocated patella, and is to be treated like
  the former case.
    The lateral dislocation is most frequent outwards. The
  patella is found  to have deserted the anterior part of the
  knee, and a depression is felt at the place where it is usu-
  ally situated.  The internal edge of the patella presents
  anteriorly,  the external, posteriorly ; the anterior flat sur-
  face faces outwards, the posterior smooth articulating sur-
  face inwards,  being thinly covered; all these symptoms
  are very obvious.   I have known this accident  occur in
  dancing: a young lady in attempting some difficult step
  suddenly felt a great pain in her knee, and was unable to
  move it. Dr. Physick was sent for and discovered a luxa-
  tion of the patella characterized by the preceding symp-
  toms ; it was reduced in  a moment by extending the leg,
  flexing the  thigh on the pelvis, and pushing the luxated
  bone back to its natural situation—a plan which generally
  succeeds very speedily in effecting a reduction of a dislo-
  cated patella.
    In some instances much trouble is experienced in effect-
  ing the reduction:  Sabatier was foiled in attempting it,
  and Boyer who was called in, found great difficulty though
  he eventually succeeded.  I have myself experienced much
  difficulty in such a case. A young lady in stepping into
!    vol.  i.          35 
g66             ELEMENTS OF SURGERY.
bed dislocated the patella laterally,  and although T saw
her within five minutes after the occurrence  of the acci-
dent, it occasioned ine no small embarrassment.  After
many fruitless efforts  I at length succeeded, but not by
any particular exertion of force or skill,  and I cannot de-
scribe the motion which effected it.
   Sometimes after the reduction, the bone is not easily
kept in its situation ;  in all such cases rest should be en-
joined, and a bandage, or laced knee cap, should be ap-
plied, with a compress on the outside of the knee to pre-
vent the  escape of the  bone from its central situation.
   When the luxation is inwards the symptoms differ only
in the situation of the bone.  The reduction is effected in
a similar manner; a blow on the outside of the knee ge-
nerally occasions the accident. 
ELEMENTS OF SURGERY.
267
                 CHAPTER XLV.

   te Of internal derangement of the Knee Joint."

  Mr. Hey is the author of some interesting observations
on an accident which may not improperly be considered
a species of  dislocation.  I shall, therefore, quote them
in this place.
  " The knee joint is so firmly supported on all sides4iy
tendinous  and ligamentous substances, that  the bones of
the thigh  and leg are very rarely separated from each
other, so as  to form a dislocation, in the common sense
of the term.   Great violence must take place and a con-
siderable laceration must happen, before the tibia can be
completely separated from the os femoris.  Yet this joint
is not unfrequently affected with an internal derangement
of its component  parts;  and  that sometimes in conse-
quence of trifling accidents.  The disease is, indeed, now
and then removed as suddenly as it is produced, by the
natural motions of the joint, without  surgical assistance:
but it may remain for weeks or months, and will then be.
come a serious misfortune,  as it causes a considerable de-
gree of lameness.  I am not acquainted with any author
who has described the disease or the remedy ;* I shall
therefore give, such  a description as my experience has
furnished me with, and such as will suffice to distinguish
a complaint, which, when  recent, admits  of an  easy
method  of cure.
  " This disorder may happen with or without"contusion.
In the latter case it is readily distinguished.   In the for-
mer  the symptoms are equivocal, till the effects of the

   ♦ 1 shall presently  show that Bromfield was not ignorant of the cue. 
268            ELEMENTS OF SURGERY.
contusion are removed.   When  no contusion has  hap-
pened,  or the  effects  of  it are removed, the joint,  with
respect  to its shape appears to be uninjured.  If there is
any difference  from its usual appearance, it is, that the
ligament of the patella appears rather more relaxed than
in the sound limb.   The  leg is readily bent or extended
by the hands of the surgeon, and  without pain to the pa-
tient :   at most the degree of uneasiness caused by this
flexion  and  extension is trifling.   But the patient  him-
self cannot freely bend nor perfectly extend the limb in
walking;  but is compelled to walk with an invariable
and small degree of flexion.  Though the patient is ob-
liged to keep the leg thus stiff in  walking; yet, in setting
down, the affected joint will move like the other.
   " The  complaint which I have described may be
brought on, I apprehend, by any such  alteration in the
state of the  joint, as will prevent the condyles of the os
femoris  from moving truly in the hollow  formed by the
semilunar cartilages and articular depressions of the tibia.
An  unequal tension of the lateral or cross ligaments of
the joint, or some slight derangement of the semilunar
cartilages, may  probably  be sufficient to bring on the
complaint.  When the disorder is the effect of contusion.
it is most likely that the  lateral ligament on one side pf
the joint  may  be  rendered  somewhat  more rigid  than
usual, and hereby prevent that equable motion of the con-
dyles of the os femoris, which is necessary for walking
with firmness."
  The mode of cure proposed by Mr. Hey and which he
found successful in a variety of cases, consisted in plac-
ing his patient upon an elevated seat having nothing un-
derneath it which could prevent the leg from being push-
ed backwards towards the posterior part of the thigh and
then extending the joint  by the  assistance of one hand 
                ELEMENTS OF SURGERY.             269
placed just above the knee while with the other hand he
grasped the leg.   During the continuance of the exten-
sion he suddenly moved the leg backwards that it might
make as acute an angle with  the thigh as possible.  Im-
mediately after this simple operation his patients were
in general able to walk without much inconvenience and
the joiut soon regained its natural condition.  If one trial
should fail, a repetition of Mr. Hey's method should be
made.  I have seen several cases  of this accident in
which Mr. Hey's plan has been immediately successful,
a dancing master  among others, was twice affected with
this singular and sudden lameness  and was very prompt-
ly cured  by a few extensions and flexions of his limb;
he began  capering immediately after as if nothing had
happened.
  Mr. Bromfield  appears to  have  been acquainted with
the accident.   " I have  seen (he remarks,) a temporary
lameness happen from one of  the semilunar cartilages
within the joint of the knee, having slipped out of its si-
tuation ; the knee immediately became swelled, and very
painful.    This case I first discovered by accident;  for
the assistant having hold  of the leg, and sometimes lightly
extending, at other times gently bending it, while I was
examining the joint of the knee the cartilage slipped into
its place, and the patient  soon became easy.
  " I dare say many surgeons have seen a lameness in
the shoulder from almost a similar  cause, that is, the ten-
don of the bisceps muscle, which  runs in the excavated
groove at  the head of the os brachii, having,  by some
turn of the limb, slipped out of the sulcus, and resting
on one of the little exuberances of the upper part of the
channel, till it returned,  has occasioned not only an im-
mobility of the joint, but, most  violent pain: when the
case is known, the reduction is very  easy: for, the cubit 
gyO              ELEMENTS OF SURGERY.
being bent, the muscle is  relaxed and while an assistant
holding the lower extremity of the  os  brachii, moves the
head thereof, sometimes  inward,  sometimes outward in
the acetabulum scapula, the operator with his fingers will
easily replace it, and the patient presently becomes per-
fectly easy."*

           • Ctururgical Observations and Cases.—Vol. 2. 
ELEMENTS OF SURGERY.
271
                CHAPTER XLVI.

         Dislocations of the bones of the Leg.

  u The tibia, at its articulation with the condyles of the
femur, may be luxated in four different directions; viz.
anteriorly, posteriorly, and laterally to either side of the
knee.  The luxation  backwards is  always incomplete;
it could not be otherwise without a great laceration of the
soft parts.  It is as often secondary as primary, and in
such cases it  is a concomitant of white swelling,  a dis-
ease much more grievous than the dislocation, and almost
always requiring amputation.
  " Luxation forwards is still more rare than that back-
wards ; the ligaments of the  knee and the greater part of
the tendons surrounding it, being placed nearer its pos-
terior than anterior part, prevent the too great extension
of the leg. Luxations  inwards and outwards are the most
frequent. They are  always incomplete, on account of the
extent of the articulating surfaces, and the strength of the
parts surrounding  the  articulation.  They take place
from the femur being  drawn either inwards or outwards,
while the leg is fixed.
  " The luxation backwards is distinguished by attend-
ing to the following circumstances: it is  impossible to
extend the leg; the patella, closely applied to the pulley
of the femur, forms an eminence, under  which there is
an empty space, and  the  inferior ligament is extended
obliquely downwards  and backwards; and a projection
formed by the extremity of the tibia,  is felt in the ham,
&c. &c.
  " Symptoms of an opposite kind accompany the luxa-
tion forwards.  Those inwards and outwards  are easily 
2Jg             ELEMENTS OF SURGERY.
known from the deformity of the joint.  In the first,  the
external condyle of  the femur is lodged in the internal
cavity of the tibia, and the internal condyle projects and
forms a tumour at the internal side of the knee: the con-
trary takes place in the  second.  When they are com-
plete, which  is  extremely rare, the tibia is carried  en-
tirely to the internal or external side of the femur.  In
every  case of luxation the laceration of the ligamentous
parts is  so great, that the  ends of the tibia and femur
may be easily placed in their natural situations; there is
scarcely occasion for even gentle extension and counter-
extension.  It  happens sometimes,  notwithstanding  the
extent of the articulating surfaces, that a return  of  the
luxation takes place from  the great laceration  of  the
parts which should confine the bones.   To prevent this,
an apparatus similar to that used in fractures of the thigh,
is to be applied.  Disagreeable symptoms,  occasioned
by the laceration of  the soft parts, are always to  be  ex-
pected ; our attention should be particularly  directed to
moderate and subdue them.   The antiphlogistic regimen
must be strictly observed, and the other means  of pre-
venting and subduing inflammation had recourse to.   If
the inflammation  terminates in suppuration, the abscesses
are to be opened by  making  a large incision.  In gene-
ral, large openings  are to be made  in abscesses  seated
in the neighbourhood of joints to allow a  free evacuation
of the pus, which by stagnating might become acrid, and
attack  the cartilages  of the joint; but if the abscesses be
formed in  consequence of a caries  of the ends  of  the
bones, a very small  opening is  to be made, in order to
prevent  as  much as  possible  the inflammation  of  the
joint.  If the  inflammation  terminates in gangrene,  we
must wait until  nature has arrested  the progress  of  the
mortification, and then amputate. The separation of  the
living from the dead part, is marked by an inflamed cjr- 
                 ELEMENTS OF SURGERY.             g^3
clft.  The progress of the  mortification is very often so
rapid that it is impossible to save the patient; and per-
haps a complete luxation of the tibia from the femur may
be considered as a case requiring immediate amputation.
However, before  a general precept of this kind can be
established,  it  must  be  founded  on observations  well
made and judiciously compared.
  " The fibula is  difficultly displaced from the tibia, with
which it forms two  articulations; nevertheless  we may
conceive, that in  a violent and sudden turn outwards of
the foot, if its  ligaments  are naturally relaxed, it may
slide from below  upwards, so  as to touch the  external
condyle of the  femur. Citizen  Boyer has seen a luxa-
tion of this kind  in consequence of a dislocation of the
foot outwards.  By putting  the  foot in its natural direc-
tion, the fibula  descended into its  proper place.  Com-
presses soaked in resolvent liquids were placed  over the
part, and a roller was passed round the foot and leg, to
prevent a return  of  the luxations.   The patient had  a
tardy recovery, and some stiffness of the  foot remained,
though the precaution of moving it, when the state of the
parts would admit it, was not neglected."
vol. 1.         36 
274
ELEMENTS OF SURGERY.
               CHAPTER  XLVII.

              Of Dislocations of the Foot.

  " These luxations are but seldom met with; the great
violence necessary to produce them and  the difficulty of
effecting  them, account for their unfrequency.   Before
they can take place, the  astragalus must be partially or
totally forced from the  quadrangular cavity formed for it
by the two bones of the leg, and in which it is received
like a mortise. The sides of the articulation are strength-
ened by very strong ligaments, which go from the tibia
and fibula to the os calcis and astragalus and by the two
malleoli.  An external violence, it is true, may distend
or even break these ligaments;  but its force being al-
most entirely spent in  producing this effect,  will not be
sufficient to force the astragalus from the cavity in which
it is enclosed.
  " The foot  may be luxated inwards or outwards, for-
wards  or backwards,  and the luxation in any of these
directions may be complete or  incomplete.  Luxations
inwards and outwards  are the most frequent; the former,
however, occurs more frequently than the latter:  the  in-
ternal  malleolus not descending so low as the external,
the astragalus has a less space to describe from without
inwards, than in the contrary direction.   It is occasioned
by a violent abduction  of the  foot,  and is easily known
from the derangement of this  part,  the  sole of which is
turned outwards, and the back  inwards; from the pain,
and inability of moving the foot; and lastly,  by the emi-
nence formed below the internal malleolus by the astra-
galus. 
                 ELEMENTS OF SURGERY.            275
  " In the luxation outwards, it is equally impossible to
move the foot; the sole is turned inwards and  the back
outwards, and the astragalus forms an  eminence below
the external malleolus.
  " Luxations of the  foot are always dangerous; their
consequences  may be so dreadful as to occasion death,
and in very many cases  they render  amputation neces-
sary. However the prognosis is not always so unfavoura-
ble, for it is clearly proved,  that many patients have re-
covered without any thing extraordinary having occurred
during their  treatment.   This  invalidates the general
rule laid down by J. L. Petit to amputate before twenty-
four hours after the luxation.  It is also now well ascer-
tained that dislocations likely to produce the most  mis-
chievous consequences, have had a  happy termination,
and  that this  was the case, though the  soft parts  have
been very much injured,  the ligaments nearly quite rup-
tured, and the astragalus completely removed from the
foot.
   " The reduction  should  be  accomplished as soon as
possible in every luxation of the foot; if deferred the in-
flammatory  symptoms and  swelling which supervene,
will  render it difficult and painful.   To effect  this, one
assistant makes counter-extension, by fixing the leg, and
another draws the  foot, whilst the surgeon pushes the
latter part in a direction contrary to that in which it was
luxated.   If the  luxation be inwards, the external  edge
of the foot must  be depressed by elevating the internal,
when it is found  that  the ligaments  yield to the exten-
sion : the contrary is done in luxations outwards.   The
articulation is covered with compresses moistened with re-
solvent liquids;  and splints  which reach below the sole
of the foot, are  applied on the inside and outside of the leg.
  " Consequences more  or less disagreeable are always
to be expected, which may  be moderated  or even  pre- 
276             ELEMENTS OF SURGERY.
vented by copious  and repeated bleedings.   Sometimes,
notwithstanding the  enormous  derangement  and lacera-
tion of the soft parts, no bad symptom succeeds, and the
patient recovers with an unexpected rapidity; but in very
many cases, violent inflammation supervenes and quickly
terminates in gangrene.  In other cases the inflammation
terminates  in suppuration, abscesses form and heal up,
and the patient recovers.  Sometimes, however, there is
a caries of the ends of the bones conjoined with them.
  " The experienced  practitioner is to judge, from the
nature and violence  of the symptoms,  when immediate
amputation is necessary. A great number of observations
posterior to those of J. L. Petit, prove that, by following
his Instructions, we should often amputate a limb which
might be preserved.  It  is  also ascertained by expe-
rience that the astragalus may be extirpated with advan-
tage, when the laceration is such, that it is only attached
by a few shreds of ligament.   The tibia, in consequence
of this extirpation, descends, and rests upon the superior
face of the os calcis, to which it grows, and the patient
recovers  its  use, with  an  anchylosed joint;  but such a
termination is preferable to  losing the  foot by amputa-
tion, or  running the risk  of the dangerous symptoms
arising from preserving the astragalus.   Ferraud per-
formed this operation on an  invalid  soldier,  who was in
the habit of carrying the bone in his pocket.  Desault
performed it  three times with success.   One  of his three
patients (a female) died three months after the operation;
but she evidently fell a victim to an hospital fever,  which
was by no means connected with the complaint for which
she was admitted  into the hospital.  On  dissecting the
foot, the  extremity of the tibia was  found already par-
tially attached  to the os calcis.  There  is no doubt but
that the operation  would have been crowned with com-
plete success, had the person survived the other disease. 
                ELEMENTS OF SURGERY.             gyy
  u Fracture of the fibula  near its inferior extremity, is
a frequent complication of luxation of the foot inwards.
This bone is  to be carefully examined in  all such cases,
and the foot is to  be supported,  whether the fibula be
fractured or not, by means of the  ordinary apparatus for
fractures  of the leg.
  " Luxations  forwards and backwards, less frequent
than those described, are, however, sometimes met with.
The first is  occasioned by a fall backwards, while the
foot  is fixed to the ground; the second by a fall on the
feet, with the body inclined forwards, and the leg much
bent.   The luxation forwards is more difficultly produc-
ed than that backwards, on account of the articular pul-
ley of  the astragalus which inclines forwards the poste-
rior  side, being permitted to slide much on the tibia,
without abandoning it in the extension of the foot. When
the extension is carried too far, luxation forwards is pro-
duced."  (Boyer.)
  I have known this  accident occasioned in the follow-
ing manner:  a lady who wore high  heeled shoes, was
descending rapidly a flight of stairs,  the  heel of one of
her shoes hooked itself upon a step, and her whole weight
was consequently  impelled against the  anterior part of
the ankle joint, the foot being fixed  by the shoe to the
step, the tibia was  forced forwards, ruptured the capsular
ligament and was  luxated anteriorly.
  " In the luxation backwards, the external and poste-
rior  ligaments, and the posterior  part of the capsule, are
torn;  iu that  forward, the anterior and external liga-
ments, the anterior fibres of the internal lateral ligament,
and  the  anterior  part of the capsule  are  torn.   The
symptoms of the first species are, a diminution in length
in that part of the foot between the lower part of the leg
and  the anterior extremity of the toes, elongation of the
heel tension of tbe tendo achilles, and relaxation of the 
278             ELEMENTS OF SURGERY.
entensors of the toes.   It is impossible either to beud or
extend the foot:  this symptom distinguishes luxation from
sprain, in which the foot may be moved, though not with-
out pain, however high the inflammation may be.
   " Contrary symptoms accompany the  luxation for-
wards : the foot is lengthened, the heel is shortened, and
the foot, much extended, cannot be bent, &c.
   (S The reduction of both is  easily effected; after which
it will be necessary to use effectual means to prevent a
relapse.   The  mode  of treatment, to be afterwards  ob-
served, for subduing the unfavourable symptoms that su-
pervene, is the same as that pointed out for luxations in-
wards and outwards.   When gangrene  takes place in
any luxation of the foot, we must defer amputation until
its ravages are arrested.  In cases where the inflamma-
tion is moderate, aud the destruction  of the soft parts  not
considerable, the articulation may be preserved;  and to
prevent stiffness of the joint, the foot is to be moved as
soon as circumstances will admit of it.
  "The very  thick  and  short  ligamentous  substance
which unites  the astragalus to the os calcis, binds them
so strongly together, that they follow  one another in their
motions, and form as it were but one bone.  Hence they
are never completely separated, even in the most  despe-
rate cases of the luxation of the foot; but one or both of
them  may be luxated  from the scaphoides and cuboides.
The transverse  direction of the  articulation formed by
these four bones, suggested to Chopart the  ingenious idea
of amputating only part of the foot. But these luxations,
less dangerous than the others, can be occasioned only by
a violent effort, in which the  anterior part of the  foot is
fixed, as happened in the two cases related by J. L. Petit:
the foot was  fastened in an  iron grate,  whilst the body
was  drawn backwards.  The astragalus  and os  calcis,
may, under these circumstances, be luxated, but particu- 
                ELEMENTS OF SURGERY.             279
larly the former, the head of which slides from below up-
wards, in the cavity of the posterior face of the scaphoides,
and forms a tumour on the back of the foot.  The inflam-
matory swelling renders  it often difficult to ascertain this
luxation.  It is not easily reduced, even shortly after it
has taken place.  Citizen Boyer failed  in a case of this
kind, in which the head of the astragalus was luxated up-
wards  and inwards, by  a fall from a horse;  but after
some time  the person felt no inconvenience- from the af-
fection, he  could walk  without  pain or  lameness, and
nothing remained but the deformity occasioned by the
tumour.
   " The other bones of the tarsus and metatarsus are too
strongly tied together to admit of luxation.  The pha-
langes of the toes cannot be luxated by external violence,
on account of their shortness.  However, the possibility
of luxation of the first phalanx of the great toe from the
first bone of  the metatarsus may be easily conceived.
 It is not necessary to give here the rules to be followed
 in such a case.   They consist in reducing the luxation,
 and amputating the great toe, when the state of the soft
 parts renders it impossible to preserve it."  (Boyer.) 
280             ELEMENTS OF SURGERY.

                CHAPTER XLVIII.

                 Injuries of the Head.

  Among  the  various accidents which call for the sur-
geon's aid, none are more important than those to which
the head is liable;  they in many cases, prove very speedi-
ly fatal, and always require the  greatest attention.
  The scalp  is  liable  to wounds and contusions;—
wounds  of the scalp  have been  already noticed, but it
may be useful to  mention on the present occasion, that,
in addition to the  usual effects of blows in which the
scalp is chiefly concerned, a  severe pain sometimes re-
mains for a great length of time after the accident.
  Dr. Physick describes in his  lectures,  several cases of
this singular affection, in which  a  great variety of means
were employed without any  evident advantage, and in
which after a lapse of time the  pain subsided.   In some
cases, an incision  through the scalp at the injured part
proved immediately successful;  in others, it was found
entirely inefficient.   I know  of  no remedy for this terri-
ble complaint which  happily is of rare occurrence, but
which in severity and obstinacy, is surpassed by no local
pain. Cold-bathing, sea-bathing, mercury, copious bleed-
ing, blisters, issues, purging, emetics,  all the  narcotics,
and numerous  other remedies  have been used in some in-
stances without any effect.  The  incision down to the
bone should be tried, as it has in some cases produced im-
mediate relief.*
  *  I am very happy to add to this edition, that emetics have been tried by
Dr. Physick in several cases of this singular malady, with complete success,
and in two instances I also have found them successful. A dose of ipecacuanha,
or tartar emetic is to be given every day, till three doses are taken, afterwards,
once in two or three days, according to the urgency of the case. This practice
has also effected the cure of several obstinate cases of an analogous disease, the
tic dcloreux. 
                 ELEMENTS OF SURGERY.              gg|
  A blow on the  scalp sometimes occasions  an ecchy-
mosis, in which the  blood forming  the tumour remains
fluid, and the  surrounding scalp feels  unusually hard
and  elevated,  and conveys to the fingers a sensation re-
sembling that of depressed bone.  Mr. Pott has described
this  accident particularly, with a view to caution young
practitioners against opening the tumour under an ex-
pectation of finding depressed bone.  The proper treat-
ment consists in promoting the absorption of  the extra-
vasated blood by cold applications,  and if these  are un-
successful a small puncture may be made with  a sharp
lancet, and  the fluid pressed out.  If suppuration take
place, the abscess must be treated in the  usual manner.
It is prudent in all  injuries of the scalp to enjoin a low
diet and prescribe a  purge.
   The effects of a blow on the head, owe their chief im-
portance to the affections of the brain which result.  Iu
describing these, we shall first notice those cases in which
the brain is injured by concussion  or contusion;  after-
wards,  those cases in  which it is compressed by extra-
vasated blood or a fragment of bone; and  thirdly, pror
 ceed to describe the effects of inflammation.
VOL, I.
37 
282              ELEMENTS OF SURGERY.
                CHAPTER XLIX.

             Of Concussion of the Brain.

  A patient who receives a violent blow on the head is
immediately deprived of sense and voluntary motion—in
popular  language he  is  stunned.   Respiration  is per-
formed slowly, and the pulsations of the heart and arte-
ries  are  diminished in frequency.   In a  lesser  degree
the symptoms are stupidity, drowsiness, imperfect articu-
lation in speech,  diminution in the vigour  of all the ani-
mal functions, nausea,  and vertigo.  The pupil  of the
eye is generally dilated, at  other times contracted, and
often not at all  changed.  These  effects result from
blows on the head which occasion fractures of the skull;
from those  in which an  extravasation of blood takes
place within  the cranium,—and  also from blows which
produce no fracture and no considerable  extravasation.
It is the latter  case which is  denominated  concussion,
but whether the symptoms enumerated do  ever result
from accidents which occasion no extravasation, no rup-
ture of a blood-vessel, no organic lesion in the contents
of the cranium,  I very much doubt.   Dr. Physick many
years ago dissected the brain of a person who died on
the fifth  day after a concussion; it was  found to have
suffered  a contusion;  numerous  extravasations of small
quantities of blood, were observed throughout the sur-
face of the cortical substance of the  brain in the vicinity
of the part stricken, and it  resembled a bruise, in every
resoect.   Probably the state of the  brain after a  concus-
sion is  always  that of a contusion,—numerous  blood-
vessels of a small size  are ruptured, and pour out small
quantities of blood in various places. 
                 ELEMENTS OF SURGERY.             qga
   That we ought to consider concussion as a lesser de-
 gree of compression from extravasated  blood,  in  every
 instance, I am  not  prepared to assert; but  that in all
 cases of violent concussion this bruised state or ecchymo*
 sis of the brain does exist, I have no doubt.   The doc-
 trine is by no means novel—Le Dran  appears to have
 entertained it to a  certain degree, and John Bell also
 advocates it.
   When the brain  has suffered  concussion merely, the
 symptoms  which have been mentioned gradually sub-
 side, the pulse rises to its natural state, the drowsiness
 wears off, sensation  is restored, and  the functions of the
 body are performed as usual.
   The immediate effects of concussion  being over, the
 only ill effects to be dreaded are those which arise from
 inflammation of the brain,  and its consequences; and to
 guard  against these is all that is  necessary in the treat-
 ment of the case.  Cloths wet with  cold  water should
 be applied to the injured part, and the patient should be
 kept at rest with his  head somewhat elevated,  during the
 continuance of the stupor; after this has  gone off, bleed-
 ing, purging, and a low diet are to be directed, and should
 inflammation supervene, these remedies  are to be vigor-
 ously employed according to the exigency of the  case.
 Nothing I conceive can be more improper  than  the use
 of ardent spirits, volatile alkali, and other stimuli which
 have been  recommended  in cases of concussion of the
 brain.   The final cause of the  languid circulation which
 succeeds a blow on the head, is probably the prevention
 of extravasation, and yet the officious surgeon attempts to
 interrupt it by stimuli, and thus urges on the  action of
 vessels, wounded and bruised  by the previous injury
which  consequently  pour out an  increased quantity of
blood and produce all the ill effects of compression of the
brain.
  Mr.  Abernethy has described with so much accuracy 
gg^             ELEMENTS OF SURGERY.
the effects of concussion of the brain,  that I shall tran-
scribe his remarks  in this place.  " The whole  train of
symptoms following  a concussion of the brain, may I
think, be properly divided into three stages.  The first
is that state of insensibility and derangement of the bo-
dily powers, which immediately  succeeds the accident.
While it lasts the patient scarcely feels any injury that
may be inflicted on him.  His breathing is  difficult, but
in general, without stertor; his pulse  intermitting, and
his extremities cold.   But such a state cannot last long;
it goes off gradually, and is succeeded by another, which
I consider as the second  stage of concussion.  In  this
the pulse and respiration become better, and though not
regularly performed, are sufficient to  maintain life, and
to diffuse warmth over the extreme parts of the  body.
The feeling of the patient is now so far restored, that he
is sensible of his skin being pinched; but he lies stupid
and inattentive to  slight external impressions.  As the
effects of concussion diminish, he becomes capable of re-
plying to questions put to him in a loud tone of voice,
especially when they refer to  his chief suffering  at  the
time, as pain in the head, &c. otherwise, he answers in-
 coherently, and as if his attention could not be excited,
 or was occupied by something else; he is in short like a
 man in  a heavy sleep.  The  concussion of the  brain,
 lastly, produces a  state of inflammation of the organ, and
 this constitutes the third stage, which is the most impor-
 tant of the series of effects proceeding from this cause.
   " These several stages vary considerably in  their de-
 gree and duration; but more or less of each will be found
 to take place in every instance where the brain has been
 violently shaken.   Whether they bear  any certain pro-
 portion to each other or not, I  do  not know.  Indeed
 this will depend upon such a variety  of circumstances in
 the constitution, injury, and after-treatment, that it must
  be difficult to determine. 
                 ELEMENTS OF SURGERY.            285
  " With regard to the treatment of concussion, it would
appear,  that  in  the  first stage very little can be done.
From a loose, and, I think, a fallacious analogy between
the insensibility  in  fainting, and  that  which occurs in
concussion, the more powerful stimulants, such as wine,
brandy, and  volatile alkali, are commonly had recourse
to, as soon as the patient can be made to swallow.  The
same reasoning which led to the employment of these re-
medies in the first stage, in order to recal sensibility, has
given a kind  of sanction to their repetition in the second,
with a view to continue and increase it.
   " But here the practice becomes more evidently perni-
cious. The circumstance of the brain having so far re-
covered its powers, as to carry  on the animal functions in
a degree sufficient to maintain life, is surely  a strong ar-
gument that  it will continue to do so, without the aid of
such means;  which  tend to exhaust parts already weak-
ened by the violent action they induce.
   " It seems  probable  that these stimulating liquors will
aggravate that inflammation which must ensue sooner or
later.  The access of it in the cases which I have related,
is sufficiently evident;  and its cure is to be effected by
the common methods.   The great benefit of evacuations
was, in those  cases  very evident.  Indeed, it appears to
me,  that there is no  complaint which requires such means
to be more rigorously  prosecuted, than  an  inflammation
of the brain or its membranes.
   "In  addition  to  the reasoning which I have offered
here, I would observe,  that the surgical books abound
with cases in which suitable evacuations have been free-
ly employed in concussions, with the best effects; while
the advocates for a contrary practice, have rested their ar-
guments upon  vague theory, and communicate no parti-
culars of their success." For the cases referred to in the
preceding quotation the reader is referred to Mr. Aber-
nethy's book. 
286              ELEMENTS OF SURGERY.
                   CHAPTER L.

             Of Compression of the Brain.

  Compression of the brain may be produced by blood
extravasated within the cranium, or  by a portion of the
skull being beat in below its natural level.

           OF COMPRESSION FROM EFFUSED BLOOD.

  Blood may be extravasated between the skull and dura
mater;—immediately beneath the dura mater;—beneath
the pia mater;—into the ventricles;—or into  the sub-
stance of the brain.  The symptoms in all these cases are
similar.  It  has always been an object of interest among
surgeons to  designate the symptoms which attend com-
pression of the brain, and to discriminate them from those
arising from concussion,  and although no subject has been
more carefully investigated than this, yet amidst the mul-
tiplicity of observations  which are to be found  in surgi-
cal writings, no accurately distinctive symptoms  have
ever been pointed out, and this furnishes an argument in
favour of the opinion that in concussion there is  extra-
vasation.* The loss of sense, speech, and voluntary mo-
tion, which attends  severe concussion, is alike common
after extravasations of blood, and depression of the skull.
Mr. Abernethy observes  on this  subject, that  " If we
judge of the symptoms of compression from what occurs
in cases  of apoplexy, or from cases of the rupture  of the
middle artery of the dura mater, we  must be of opinion

  • Le Dran long ago observed, that "in concussion small vessels may be rup-
tured and thereby occasion extravasations in several places." Gataker's trans-
\ifion—P. 377. 
                 ELEMENTS OF SURGERY.             287
that pressure on the brain occasions insensibility partially,
or generally, and in a degree proportionate to its quan-
tity."
   This remark of Mr. Abernethy's is generally, but not
universally correct,  for as Pott observes  " sometimes a
very small quantity of extravasated blood will produce
the most  alarming and most pressing symptoms,  and at
other times a large quantity will occasion none at all."
   " In extreme cases the  insensibility is  manifested by
every circumstance.   The  pupil of the eye is dilated and
cannot be  made to contract, even by a strong light.  The
respiration is slow and stertorous, and the pulse propor-
tionably slow and labouring.  There is no vomiting which
would indicate sensibility of stomach.   The limbs are re-
laxed as in a person just dead.  JVo struggles take place,
nor signs of sensation appear during the operation, but on
the pressure being removed  sensation and  intelligence
are immediately restored.  In concussion the insensible
state is of short duration and during its continuance the
body is generally cold, and the pulse feeble and intermit-
ting. Afterwards the skin is hotter than usual;  the pulse
and respiration more frequent, the former often intermits,
and the latter has not the stertorof apoplexy (but the ab-
sence of stertor must not be relied on as a proof that there
is no  compression, for Morgagni relates  dissections of
apoplectic persons where the effusion was considerable,
yet no  stertor had occurred, and  I have seen cases where
it took place only in a very slight degree.)  The pupil of
the eye is  not dilated, but rather contracted.  The coun-
tenance expresses pain and uneasiness, and vomiting oc-
casionally takes place.   The state of the patient is like
that  of a  heavy and uncomfortable sleep; yet  being
roused, signs  even of intelligence appear."  These re-
marks  of Mr. Abernethy contain the best contrast of the
symptoms resulting from  concussion  and compression 
288             ELEMENTS OF SURGERY.
which are to be found, but in some cases they arc insuf-
ficient to afford an accurate diagnosis.
  In  many instances, however, the  symptoms indicating
extravasation are very clearly marked; of a great num-
ber of cases which I have met with  in books and in prac-
tice, I shall relate the prominent circumstances of one, to
illustrate this observation.

                        CASE.

  On the tenth of May 1811, Michael Schoch, aged
about forty years, in ascending the first step  of a stair-
case fell backwards on the floor;  he  arose, rubbed his
head, and did not suppose himself much hurt.  About
twenty minutes after the accident, he felt sick at the sto-
mach and vomited.   In half an hour he became drowsy
and stupid, his stupor gradually increased, and when I
saw him,  which was several hours  after the accident, he
was perfectly  senseless and could  not be roused.  His
breathing was stertorous, his pulse  about forty, and com-
municated to the fingers the same sensation, as that of a
patient in apoplexy.
  Upon shaving the head, not the slightest vestige of in-
jury could be observed. From these circumstances it was
very obvious that a blood-vessel was ruptured within the
cranium.  His brother said that he had pointed to the
left side of his head above the ear, after his fall; and with
no other direction than this, as to the part injured, I re-
solved to  perforate the parietal bone, and accordingly cut
through the scalp and applied the trephine; immediately
on removing the bone a large quantity of blood escaped
at the opening, and upon passing my finger under the cra-
nium, I was literally unable to feel the dura mater; clots
of blood appeared  to occupy the place of the whole  left
hemisphere of the brain,  the quantity of blood  extra- 
                 ELEMENTS OF SURGERY.             ggg
vasated was very great; far  exceeding any thing I bad
conceived possible.
  Copious extravasations  always happen when  one of
the principal vessels of the dura  mater is ruptured, but
when this membrane is merely separated from the skull
by the accident, and the only vessels divided, are those
which connect the bone and membrane,  then the quan-
tity effused is comparatively  small supposing the middle
artery of the  dura mater to be opened in the present in-
stance.
  I determined to make another perforation  with the
trephine, and then trust the case to copious bleeding and
purges.  I accordingly  enlarged the incision of the scalp,
and now discovered a  small  fissure an inch long  in the
parietal bone, (which  probably was  in itself of no im-
portance)  without  any depression; the  greater part of
this crack was  included in the second portion of bone
which I removed.   In  a few hours the stupor subsided
and the pulse rose.   The patient was  copiously and re-
peatedly bled, and for three weeks nourished exclusively
by  toast and water; the blood for the first week came
away in large  quantities through the openings in the
skull, and afterwards blood and matter came out to-
gether.  This patient  soon recovered and has remained
perfectly well for two years, except that he is afflicted with
a periodical head-ach with  which for many years he has
been troubled, and which has recurred since the accident.
His right  side  was slightly  paralytic for a day or two
after the operation, but no permanent affection of that
nature remained.   Mr. Hill  relates a case very similar
to this, and Mr. Latta  also records one not unlike  it.
  In  the preceding case, as  in many other instances of
■xtravasation, the patient remained well for a considera-
We space of time; this was owing to  the gradual  accu-
mulation of the blood which  did not immediately collect
  vol. i.          38 
290             ELEMENTS OF SURGERY.
in sufficient quantity to occasion stupor.   Patients  often
walk to a considerable distance before any symptoms of
compression appear.   In every case, therefore, when
after the blow, the patient remains a considerable time
free from stupor, we may conclude without much risk of
mistake that extravasation has happened, or if the patient
be stunned by the blow and recover from this first effect
of the violence, and regain his senses, and after this in-
terval of sense, relapse into a stupid comatose state; we
have also great reason to apprehend extravasation.
  It has already  been observed that the situation of the
effused  blood varies.   In general, however,  indeed in a
very large majority of instances, the  extravasated blood
is found between the  dura mater and the skull, owing to
the intimate connection by means of vessels between this
membrane and the bone.  In every case, therefore, where
there is good reason  to believe that extravasated blood
exists under the skull, it is the duty of the surgeon to re-
move a portion of the bone in order to allow its escape.
  In endeavouring to ascertain the part of the head where
this extravasation will probably be found, all the circum-
stances of the accident are to be carefully considered. The
head being shaved, a bruise or wound may generally be
discovered at the injured part, and if so, the crown of the
trephine should be applied at that part. If, however, (as
sometimes happens) no part of the head appears to have
suffered more than another and the witnesses of the acci-
dent can give no account of  the spot which received the
blow, still should the symptoms continue to indicate the
operation, it ought to  be performed, and the part where
extravasations most generally happen, should be select-
ed ; perforations  may in such cases with great propriety
be made in  the course of the middle artery of  the dura
mater, and if the  extravasation be not found here the
operation should be repeated on the  opposite side of the 
                 ELEMENTS OF SURGERY.             291
head, over the same vessel.  If paralysis  of one side  of
the body exist, it affords a presumption that the opposite
side of the head has suffered.
  In attempting  to ascertain the place of extravasation,
Mr. Abernethy recommends  to  scrape the bone where
the mischief is suspected, if it bleed, there will be no rea-
son  to expect an effusion under it, if no blood  escape
from the bone  when scraped, it  is an evidence of extra-
vasation  underneath.   This truly  ingenious idea was
suggested to Mr. Abernethy,  in reflecting on the vascu-
lar connection subsisting  between the dura  mater and
skull;  a great part of the blood of  the skull is derived
from the dura mater, and if the connection be  destroyed,
there is a deficiency in the quantity of blood  which the
bone receives.   Mr. Abernethy  has in two instances by
attending to this rule,  ascertained  the extent  to which
the  dura  mater and skull were separated by extrava-
sation.*
   On removing a portion of bone the blood if fluid imme-
diately escapes ; in most instances, however, a considera-
ble  portion of it will be found  coagulated.   The dura
mater being separated from the cranium to an extent pro-
portioned to the quantity effused, the coagula  if it can
readily be done  should be removed, but  care should be
taken not to injure the dura mater by introducing any in-
struments for the purpose, it  is safer to trust to the ac-
tion of  the brain, which will effectually expel these coa-
gula. In cases where the quantity of blood found under
the cranium is  very great, two perforations may be made,
or perhaps cases may occur where a greater number will
be necessary,  but from what I have seen  of such  cases,

  • I have myself been less fortunate, and Dr. Parrish has recently put the
matter fairly to tiie test in a case of very copious extravasation.  In this in-
stance the parietal bone was detached from all its  membranous connexions
to a considerable distance, and yet bled freely when scraped. 
292              ELEMENTS OF SURGERY.
and  from similar ones contained in the memoirs of the
French academy, I am disposed to believe that an exten-
sive  removal of  bone in cases of extravasation is im-
proper, the brain  does not immediately react, and the pa-
tient expires in some instances before the operation is con-
cluded.  The case I have detailed in the present chap-
ter, is a convincing proof of the power  of  the brain to
evacuate the clotted blood  even when  it exists  in the
largest quantities.
   In some instances  when  a portion of the bone is re-
moved by  the trephine,  the  dura mater is protruded up
into the orifice forming an elevated tumour evidently con-
taining blood ;  in these cases it has been recommended to
puncture the membrane  and evacuate the fluid.  Of the
propriety of this practice I have great doubts.  Dr. Phy-
sick has witnessed the operation in several cases, all of
which terminated fatally, and Mr. Abernethy states that
in those cases which he has seen " where blood was ex-
travasated between the dura and pia mater and a division
of the  former membrane was made for its  discharge, in
some instances the serous part only could be evacuated;
for the coagulum was spread over the hemisphere of the
brain, and had descended as low as possible towards its
inferior part; in others, though a portion of the effused
 blood was discharged in a fluid or grumous state, a con-
 siderable quantity which was coagulated remained behind,
 so that very little relief was obtained by the operation.
 It seems then, that extravasation between the dura mater
 and  the cranium is almost  the only  case of extravasion
 which  admits of being  remedied by the use of the tre-
 phine."   «
   Cases have occurred, and some  such  are recorded,
 where punctures through the dura mater have been made
 for  the evacuation of blood,  and a favourable termination
 has resulted; these cases are, however, extremely rare, 
                ELEMENTS OF SURGERY.             293
and a fatal event in most instances results.   The reco-
veries which happen after wounds of the dura mater, are
by no means  analogous; because, in these the membrane
is not detached  from its usual connexions, and is unin-
jured except at the wounded part;  whereas  in cases
where it is punctured for the purpose of evacuating either
extravasated  blood or pus, it is separated from  every at-
tachment to the skull and pia mater to a very considera-
ble extent; under such circumstances it generally sloughs,
and when this happens, the brain beneath inflames and
suppurates, and death is the consequence.  I believe the
best general practice in  cases of extravasation beneath the
dura mater, whether immediately under it, or in the ven-
tricles, or in  the substance of the brain, will  be to bleed
copiously and as often as the patient's strength can per-
mit.  To administer purges daily, to prohibit all nourish-
ment except bread and water, and to apply blisters over
the head.
   Under this mode of treatment, I have witnessed reco-
veries where there was  every  reason to believe that con-
siderable effusions of blood existed under the dura mater,
 and 1 have never seen  success attend any other method,
 though  I have  full confidence in the testimony  of others
 who  have been more fortunate.  Mr.  Abernethy for in-
 stance, relates a case in which one of his pupils evacuated
 five ounces of blood through a puncture in the dura mater
 and cured the  patient.—Here the case was recent, the
 blood was still flowing from the wounded vessel, and all
 the circumstances of the case  were as favourable as possi-
 ble, and under such circumstances the operation may be,
 and ought to be performed: that is to say, the dura mater,
 should  he punctured whenever fluid, fresh blood, pushes
 it out, so as to form a tumour in the aperture made by
 the trephine, provided the symptoms are also indicative
 of pressure on the brain to a great degree. 
29*
ELEMENTS OF SURGERY.
   OF COMPRESSION OF THE BRAIN FROM DEPRESSED BONE.

  Fractures of the skull as they are produced in a va-
riety of ways, must differ very materially in their nature
and  extent.  The numerous divisions of the ancients,
founded upon these circumstances are, however, of little
importance.  The  chief differences  now regarded, are
the degree of pressure and irritation produced upon the
brain and its membranes.
  Fissures or cracks in  the skull unattended by a de-
pression  of one of the fragments are not dangerous, and
very  readily  heal  without unpleasant symptoms;  but
pressure  from a piece of bone beat down upon the brain
must occasion all the symptoms which are produced by
pressure  from an effused fluid:  accordingly we find that
patients  thus circumstanced are generally affected with
the same apoplectic  symptoms,—a complete  or partial
loss of sense, speech, and voluntary motion—stertorous
breathing, followed  by vomiting, vertigo, hemorrhage
from  the ears, nose, mouth, &c.  Now these symptoms
often  occur  without  a fractured skull,  as has already
been  remarked,  and on the other hand, many cases of
fractured skull, even where the bone is considerably de-
pressed,  are unaccompanied by them.  I once saw a wo-
man who had  been  assaulted by a lunatic, and  struck
forcibly with an iron bar: I found her skull fractured near
the junction of the parietal bones, a depression existed
which in  one part was full  half an inch below the natural
level, and yet none of the usual symptoms of compressed
brain occurred, and  the fracture healed up without any
dressings except a superficial pledgit.  Similar cases are
recorded.
  Fractures of the skull although they occasionally pro-
duce  no  unpleasant  symptoms, are notwithstanding, ac- 
                ELEMENTS OF SURGERY.             295
companied with many dangers.  In addition to the evils
to be dreaded from pressure upon the brain, the irritation
occasioned by the  mechanical action of the sharp and ir-
regular edges of the bone upon the dura mater and brain
is to be feared.   The constant pulsation of the vessels of
the brain, which  produces  motion under the  fracture,
augment  considerably the irritation in consequence  of
which the dura mater sometimes ulcerates.
  In many cases of fracture of the skull the dura mater
is pierced and  the brain wounded,  by the body which
caused the accident,  or by a fragment of the bone being
forced through these parts.  In some instances portions
of the substance of the brain escapes  through the frac-
ture at the time of the accident.   In sabre  wounds, slices
of brain,  together with considerable portions of skull are
sometimes removed.
   To ascertain the existence of a fracture of the skull,
the bone must be  laid bare and examined.  In general,
the part  which received the blow is fractured,  but some-
times the skull suffers in a remote  situation,  in conse-
quence of what the French surgeons have called a contre-
coup; very good proof exists  that fractures have been
thus occasioned by counter-strokes,  on the opposite side
of the skull.  If a wound of the teguments accompanies
the accident, the fracture is often obvious on the first ex-
amination.  If  the wound be too small to afford  a view
of the skull,  or if only a contusion exist,  it is easy with
a scalpel to cut down to the bone and expose it sufficient-
ly. This, however, should never be done unless symp-
toms of  compressed brain exist, because the  exposure
converts  the injury to a compound fracture, and greater
inflammation is therefore to be expected, from which pos-
sibly the dura mater and brain  may suffer.
   Respecting the  treatment of fractured skull,  a variety
of opinions exist among surgeons.  The practice 1 would 
296              ELEMENTS OF SURGERY.
recommend I shall briefly state.  In every instance where
symptoms of compression exist, whether these arise from
fracture or from extravasated fluids  a perforation ought
to be made through the skull by means of  a trephine, at
the spot where such pressure is  reasonably judged to
exist.  The immediate effects of concussion of the brain,
generally subside in  a few  hours, and as  these  may be
supposed to exist  in  all cases  of  injured  brain, it will
(except in  particular instances presently  to be noticed)
be proper  to defer the operation, until  such effects shall
have subsided.  If then it be found after waiting twelve
hours,* that evident symptoms of compression exist with-
out abatement, the operation should be no longer delayed,
but the fracture sought for, and if depressed  bone be found
it should be elevated, and all loose fragments removed.
If a crack  or fissure  only be found, still the symptoms
existing, a perforation should be made  to  discharge the
blood which is probably effused under it.
   The particular cases in which  the operation should
be promptly performed, are those in which the extent of
injury leaves no doubt as to the existence of fracture witfc
depression, and where there can be no probable expec-
tation that  the  symptoms  will subside when  the imme-
diate effects of concussion are over.  A man is  thrown
from his  horse head foremost upon a stump or on  a stone,
and the surgeon  on his arrival finds an extensive frac-
ture, with depression, and all the symptoms of compres-
sed brain—in such a case it is right to  perform  the ope-
ration immediately.
   Should depressed  bone be removed, or the operation
of trephining ever  be  performed to prevent the ill conse-

  » This is  a very general direction, and of course many exceptions will be
made to it, as  the effects of concussion subside in some cases much sooner
than in others,—whenever a doubt exists, postponement is the preferable plan.
Mr. Abernethy and Mr. John Bell, both,sanction this practice. 
                ELEMENTS OF SURGERY.             gn*
quences of inflammation of  the brain? Mr. Pott under
particular circumstances,  recommended the  practice,—
Mr. Abernethy, however opposes it, and Mr. John Bell,
Desault, and many modern surgeons, deny that it is ever
proper, and assert that the trephine is only to be applied
with a view of relieving present symptoms. I have never
seen reason to differ from this opinion, and though cases
may be imagined where  the  trephine would certainly
prevent fatal consequences, yet in practice, such certainty
is seldom evident. It would be improper in a compendi-
ous work like the present to enter into any discussion on
this question: I shall  therefore conclude  this part of the
subject by  recommending to  postpone the operation of
trephining  in all cases where  doubt exists as to its pro-
priety, because in many cases it will be found, that when
inflammation  moderates, the symptoms of compression
will be diminished  by the diminution of fullness in the
vessels, and if the operation be  indicated afterwards it
can still be performed, and perhaps with as good a pros-
pect of success.

OF INFLAMMATION  OF THE BRAIN AND ITS MEMBRANES FROM
                  EXTERNAL VIOLENCE.

  Mr. Abernethy very judiciously remarks, that "in the
generality of cases of injury done to the head, the symp-
toms of concussion, compression, and inflammation, are
so combined  as to  appear inexplicable.   It  is  only by
an attention to those rare cases,  in which  the symptoms
of each appear distinctly,  that we are likely  to increase
our knowledge of their specific effects." Inflammation of
the brain and its membranes  is a consequence of differ-
ent species of violence to  which it is subject, and there-
fore its symptoms will be more or less blended with those
resulting directly from the accident, as stupor, &c.  In 
298            ELEMENTS OF SURGERY.
describing the inflammatory symptoms  which occur, 1
shall principally avail myself of the descriptions given by
Mr. Pott and Mr. Abernethy.  The inflammation or
the dura mater  is well described  by the first of these
writers.
  " If there be neither fissure  nor fracture of the skull,
nor extravasation,  nor commotion underneath it, and the
scalp be  neither considerably bruised, nor wounded,  the
mischief is seldom discovered or  attended  to  for some
few days.  The first attack is generally  pain in the part
which received the blow.   Th»- pain,  though beginning
in that point,  is soon extended all over the head, and is
attended with a langour, or dejection of strength and spi-
rits, which are soon followed by a  nausea and inclina-
tion to vomit,  a vertigo,  or giddiness,  a  quick and hard
pulse,  and an incapacity of sleeping, at least quietly. A
day or two after this attack,  if no means preventative of
inflammation are used, the part stricken generally  swells,
and becomes puffy and tender, but  not painful;  neither
does the  tumour  rise  to  any considerable height,  or
spread to any great extent: if this humid  part of  the
scalp be now divided, the pericranium will be found of a
darkish hue,  and  either quite detached, or very easily
separable from the skull, between which and it, will be
found a small quantity of a dark-coloured ichor.
  " If the disorder has made such progress, that  the
pericranium is quite separated  and detached  from the
skull, the latter will even now be found  to be somewhat
altered  in colour  from a sound healthy bone.  Of  this
alteration it is not  easy to convey an idea by words,  but
it is a very visible  one, and what some very able  writers
have noticed.
  "From this time the  symptoms generally advance
more hastily and  more apparently; the  fever increases,
the  skin  becomes hotter, the pulse quicker and harder, 
                ELEMENTS OF SURGERY.             ggg
the sleep  more disturbed, the anxiety and restlessness
more fatiguing, and to these are generally added irregu-
lar rigors, which are not followed by any critical sweat,
and which instead of relieving the patient, add consider-
ably to his suffering.   If the scalp has not been divided
or removed, until the symptoms are thus far advanced,
the alteration of the colour of the bone will be found to
be more remarkable; it will be found to be whiter and
more dry  than a healthy one, or, as Fallopius has very
justly observed, it will be found to  be more like a dead
bone: the  sanies or fluid, between it and the pericranium,
will also, in this state*,  be found to be more in quantity,
and the said membrane will have a more livid diseased
aspect.
   " In this state of matters, if the dura mater be denuded,
it will be found to  be detached from the inside of the
cranium, to have lost its bright silver hue, and to be, as
it were,  smeared  over with a kind of  mucus, or with
matter, but  not with blood.   Every hour  after this pe-
riod, all the symptoms are exasperated and advance with
hasty strides:  the head-ache and thirst  become intense,
the strength decreases,  the sighs are more frequent, and
at last convulsive motions, attended in some with delirium,
in others  with paralysis or comatose stupidity, finish the
tragedy.
   "If the scalp has not been divided or removed till this
point of time, and it be done now, a very offensive disco-
loured kind of fluid, will be found lying  on the bare cra-
nium, whose appearance will be still more  unlike to the
healthy natural one ;  if the bone be now  perforated, mat-
ter will be found between it and the dura mater, generally
in considerable quantity, but different in different cases
and circumstances. Sometimes it will be in great abund-
ance, and diffused over a very  large part of the mem-
brane : and sometimes the quantity will be less, and con- 
gQQ              ELEMENTS OF SURGERY.
sequently the space  which it occupies smaller.   Some-
times it lies only on the exterior surface of the dura mater;
and  sometimes it is  between it and  the  pia mater,
or also even on the surface of the brain or within the sub-
stance of it.
   " The primary and  original  cause of all this, is the
stroke upon the skull;  by this the vessels  which should
carry  on the circulation between the  scalp, pericranium,
skull,  and meninges, are injured, and  no means being
used to prevent the impending mischief, or such as have
been made use of, proving ineffectual, the necessary and
mutual communication between all these parts ceases, the
pericranium is detached from the skull, by means of a
sanies discharged from the ruptured vessels, the bone be-
ing deprived of its due nourishment and circulation, loses
its healthy appearance, the dura mater (its attaching ves-
sels being destroyed or rendered  unfit for their office) se-
parates from the inside of the cranium, inflames and sup-
purates.
   " Whoever will attend to the appearances, which the
parts concerned make in  every  stage of  the disease, to
the nature of the symptoms, the time of their access, their
progress, and most frequent event, will find them all easi-
ly and  fairly  deducible from the one cause, which has
just been assigned, viz. the contusion.  As the inflamma-
tion and separation of the dura mater, is not an immediate
consequence of the violence, so neither are the symptoms
immediate, seldom  until some  days have passed; the
fever  at first is slight, but increases  gradually; as the
membrane becomes more and more  diseased, all the fe-
brile symptoms are heightened;  the  formation of matter
occasions rigors,  frequent and  irregular,  until such a
quantity is collected,  as brings  on delirium, spasm, and
death.
   " Hitherto  I have  considered this disease,  as  unac- 
                ELEMENTS OF SURGERY.             3Q£
companied by any other, not even by any external mark
of injury, except perhaps a trifling bruise on the scalp;
let us now suppose the scalp to be  wounded at the time
of the accident, by whatever gave  the contusion; or let
us suppose, that the immediate symptoms having been
alarming, a part of the scalp had  been removed, in or-
der to examine the skull; in short, let the injury be con-
sidered as joined with a wounded scalp.
  " In this case, the wound will for some little time have
the same appearance, as a mere simple wound of this part
unattended with other mischief, would have;  it will like
that, at first discharge a thin sanies  or  gleet, and then
begin to  suppurate; it will digest,  begin to incarn, and
look perfectly well; but,  after a few days, all these fa-
vourable appearances will vanish; the sore will lose its
florid complexion, and  granulated surface ;  will become
pale, glassy, and flabby;  instead of good matter, it will
discharge only a thin discoloured sanies;  the lint with
which it is dressed instead of coming off easily (as in a
kindly suppurating sore) will stick to all parts of it; and
the pericranium instead of adhering firmly to the bone,
will separate from it, all round, to some distance from the
edges.
  " The first  appearance of alteration in the wound im-
mediately succeeds  the febrile attack, and as the febrile
symptoms increase, the sore becomes worse and  worse,
that is, degenerates more and more from a healthy, kind-
ly aspect.
  " Through the whole time, from the first attack of the
fever, to the last and fatal period, an attentive observer
will remark the gradual alteration  of the colour of the
bone, if it be bare.  At first it will be found to be whiter,
and more dry, than the natural one; and as the  symp-
toms increase, and either matter is collected, or the dura
mater becomes sloughy, the bone inclines more and more 
3Q2             ELEMENTS OF SURGERY.
to a kind of purulent hue, or whitish yellow; and it may
also be worth while to remark, that if the blow was on
or very near  to a suture, and the subject young, the said
suture will often separate in  such a  manner as to let
through it a loose, painful, ill-natured  fungus;  at which
time also it is no uncommon thing for the patient's head
and face to be attacked with an erysipelas."  (Pott.)
  The pia mater is often attacked with inflammation in
consequence  of blows on the head.  The  free communi-
cation by vessels between this membrane  and the brain,
necessarily occasions an extension of the inflammatory
action to the substance of the cerebrum.   The  degree of
inflammation of the brain varies, in proportion  to the af-
fection of the pia mater.   It differs also in the extent of
the inflamed surface, and in the depth to which it pro-
ceeds ; these circumstances occasion  a difference in the
degree to which the functions  are interrupted.
   Sometimes the inflammation of the brain is attended
with a copious  secretion  of fluid, and at others  a small
quantity only is poured out, of course  a difference in the
subsequent symptoms of compression from this cause will
ensue.
   Mr. Abernethy remarks " If the inflammation be vio-
lent and general, the patient will be irrational and dis-
turbed, having his mind strongly affected by wrong ideas
and endeavouring to act in consequence of them.  If the
inflammation be moderate and affect the surface only, he
will  be  irrational, uneasy,  restless, and perhaps endea-
vour to get out of bed, but without the violence of mania.
Should a moderate inflammation be blended with the ef-
fects of concussion, he will  have less  appearance of irra-
tionality, .will lie pretty quiet, and inattentive to slight
impressipns."  Some variety will occur probably in the
 symptoms in different patients, " but in all there will be
more  or less derangement of the powers both mental and 
               ELEMENTS OF SURGERY.              gQ3
corporeal depending upon the degree of inflammation, &c.
The symptoms which chiefly characterize the complaint,
are those of an increase of sensibility; the pupils of the
eyes arc contracted; the patient often withdraws his arm
on being touched, and his pulse and tongue denote ge-
neral, as well as local inflammation.  It seems of the ut-
most importance that those means which in general cure
inflammation should be prosecuted very vigorously at the
commencement of this complaint, since otherwise although
they will check they will not overcome it.  Large  blood-
lettings, brisk purging, and extensive counter-irritation by
blisters, ought to be employed at the very commencement,
for if omitted, the disease will then become established,
and the powers of the body will soon be too much sunk
to admit of the same active treatment at a later period."
   Suppuration takes  place when the remedies are un-
successful in arresting the progress of the inflammation,
and when this happens the symptoms of compressed brain
are repeated and a deep coma comes on.
   The pus  in this case is very often situated ^directly
under  the  skull, but  sometimes  under the dura  mater,
and at other times an abscess is found in the brain. The
trephine can only be used with success  when the  matter
can  be evacuated, but where the symptoms denote that
pus has been actually  secreted, a perforation through the
bone at the injured part should be made, and the usual
means for   ascertaining this part, are to be employed.
Mr. Abernethy's test  of scraping the bone, will probably
be found useful in this instance, as well as in cases where
the pressure  is caused  by extravasated blood.  When
the perforation has been made, if the pus exist under the
skull it will flow out,  if under the dura mater this mem-
brane  should be punctured with a sharp lancet, though
recoveries  under such circumstances are not to be ex-
pected. 
gO^            ELEMENTS OF SURGERY.
   Although inflammation of the brain generally occurs
within a few days after the accident which causes it, yet
in some cases  months elapse before  its commencement.
I  assisted Dr. Physick to  trepan a  gentleman,  whose
dura mater we found thickened and in a state of suppu-
ration,  one year  after the occurrence  of the  accident
which occasioned the formation of the abscess.

      THE OPERATION OF TREPANNING OR TREPHINING.

   The manner of removing  portions of the  cranium,
when  this becomes necessary is next to be described.
The various obsolete instruments of the ancients, and
many  of the  useless  contrivances of modern  surgeons
may be dispensed  with in proceeding to this operation,
for as Mr. Pott remarks,  " Reduction of the number of
instruments to.be used in an operation, and an extreme
simplicity and plainness in those which may be  required^
are a part of the merit  of modern surgery."  The instru-
ments wanted for removing portions  of the  skull,  are a
scalpel (with the steel projecting through the handle (Fig.
1.), a trephine with a sliding centre-pin. (Fig. 2.),  a saw
(commonly called Hey's saw) (Fig. 3.), an elevator (Fig.
4.) a quill tooth-pick, needles, and ligatures. The lenticular,
the rhaspatory, the brush,  and the other instruments com-
monly found in the trepanning cases,  are quite useless.
  The hair being previously removed, an incision is to
be  made through  the scalp down to the bone, and if a
longitudinal incision should not sufficiently expose the
surface, it may be crossed by another, and extended in
any necessary  direction.   The removal  of a portion of
scalp  as  practised by the  older surgeons  and recom-
mended by  Mr. Pott,  should never be performed.  In
making the incision down to  the bone,  great caution is
in some cases necessary  to avoid  plunging the  knife 
^TLATE TT-
—    M
Fuj.L'
V
C*
il 
 
                 ELEMENTS OF SURGERY.             gQfl
 through the fracture into the brain. After having denud-
 ed the bone of its pericranium,  by means of the end of
 the knife handle,  the centre-pin  of the trephine  is to be
 protruded, and fixed on the part  of the skull which is to
 be removed.   If  in  a  case  of fracture, this centre-pin
 must always be placed upon a piece of firm solid bone,
 not  detached from the  skull, and as near  as possible to
 the fracture, and therefore more  than  half the bone  in-
cluded by the crown  of the instrument will generally be
 uninjured bone.  The  instrument  is  to be  now freely
 turned backwards and forwards, by the  surgeon, who
 presses  it firmly  against the skull, until a groove  is
 formed of sufficient depth to allow the retraction of the
 centre-pin, which  must always be carefully withdrawn
 as soon as this groove is made, to prevent a wound  of
 the dura mater. The action of the circular saw  is to be
 continued and the depth of the  groove very frequently
 examined.  The teeth of the instrument are to be wiped
 from time to  time with a towel, and when they have
 penetrated to the diploe,  less resistance is experienced,
 and now a great degree of care  is necessary on account
 of the inequalities in the  thickness of the inner table  of
 the skull, in consequence of which one part may be com-
 pletely cut through before the other  is nearly divided.
 The  tooth-pick is the most convenient probe for ascer-
 taining the  depth of the  groove, but  when the trephine
 reaches the  tabula vitrea and has made some little im-
 pression upon it, it is safer to attempt to break  out the
 circular portion of bone by means of the elevator, than to
 proceed  completely through  it  with  the  saw.   If any
 part of the bone is entirely divided and the tooth-pick  is
 found to touch the dura mater, considerable force should
 be exerted to separate  the section of bone without fur-
 ther sawing,  as the dangers of a wounded dura mater,
 are very great; if this,  however, be impracticable,  the
   vol. 1/        40 
 306             ELEMENTS OF SURGERY.
 action of the trephine should  be directed  against the
 undivided portion of bone  exclusively until it is  thin
 enough to be broken  off; this can always be done with
 the common trephine without resorting to the old instru-
 ment with a file-like circumference.
   If any inequalities of bone remain round the edge  of
 the foramen, they may be broken off by the end of the
 elevator; the lenticular  which has been constructed for
 this purpose, is by no means a convenient instrument.
   When one perforation has been made, in general the
 depressed bone may be elevated to the proper level, and
 any loosened portions may be entirely removed.  If the
 operation have been performed in order to  evacuate ex-
" travasated  blood or pus, one opening is generally suffi-
 cient, but if necessary the operation may be repeated.
 The ancient surgeons were in the habit of applying the
 trepan very frequently, and in some cases very numerous
 perforations have been made without fatal consequences.
 In  one  instance,  we are assured that twenty-seven per-
 forations were made through the skull of a nobleman  in
 consequence of a fracture, but no one can doubt that the
 removal  of portions of the  skull is  a very  serious evil,
 and that it should be performed as rarely as possible.
   The introduction of the straight saw  into practice has
 diminished  the frequency of using the trephine, and
 although the  instrument is to be  found  in many old
 books of surgery, yet until Mr. Hey of Leeds in a pub-
 lication  a few years ago, recommended its  use in  frac-
 tures  of the skull,  surgeons were ignorant  of  its great
 advantages.  A variety of cases occur  in which it may
 be substituted for the trephine  in removing portions of
 skull, without the additional loss of bone which the lat-
 ter instrument occasions.
    With respect to the parts of the skull where the tre-
 phine may properly  be  applied,  I believe the surgeon 
                 ELEMENTS OF SURGERY.             30*"
 hesitates at none, to which he can get access,  provided
 the urgency  of the symptoms demand the operation.
 The sutures offer no barrier  and the large blood-vessels
 none—indeed  the  basis  of the skull  is the only part
 where the operation cannot be performed, and with safe-
 ty,  by  a  prudent operator.  Should  the  longitudinal
 sinus or  the great arteries of the dura mater be opened
 eitlier by a  fragment of bone, or by the operator, the
 bleeding  is easily arrested by a dossil of lint.   I have
 seen a profuse hemorrhagy from a large  opening in the
 longitudinal  sinus  occasioned  by  a fragment of bone,
 immediately  stopped by  applying  lint over  the orifice.
 The middle artery of the dura mater wounded  in the
 same manner, is as readily secured.   Dr. F. Dorsey of
 Maryland, once tied up  this vessel with a  needle and
 ligature,  and no  ill consequences  resulted.  In  some
 cases which I have seen  this would easily be  effected,
 because the artery could  be separated  to some  distance
 from the dura mater, with which it is  not always inti-
 mately connected.  I have seen it projecting  a quarter of
 an inch from that membrane in an extensive fracture of
 the parietal bone, but if the ligature must pass  through
 the dura  mater in order  to secure it, the operation of
 tying it up ought never to be performed.  If the bleeding
 from the vessels of the scalp should not spontaneously
 cease, the needle and ligature are  most convenient for
 securing them.
  The only dressing in general required after trephining,
 is a light  poultice of bread and milk ;  great care should
 be taken  to  guard against pressure upon the exposed
 brain.   The  remedies proper to prevent and relieve in
 flammation are always to be employed with great activity.
 In some cases it may be proper after removing the bone.
to place  the scalp and dura mater in contact and to allow
them  to unite,  but in a majority of cases  this cannot 
308              ELEMENTS OF SURGERY.
be effected, and when  it is attempted great care should
be taken  to prevent collections of blood and  serum or
pus from being confined under the  scalp, and thus com-
pressing the brain.   Where a small wound of the dura
mater exists,  I believe its adhesion to the scalp  at the
wound and around it,  would greatly diminish the dan-
ger of suppuration in the brain.

                   HERNIA CEREBRI.

  When ulceration takes place in the dura mater a tu-
mour generally rises through it, which  has  been called
hernia cerebri, this tumour in all the cases I have
seen, consisted evidently of the substance of the brain,
and under the pia mater in several places clots of blood
of a dark colour were observed.
  These tumours sometimes acquire a  large  size,  and
if removed,  speedily  return.   Mr.  Abernethy has de-
scribed  some cases  which  have led  him to an opinion
that  " the disease frequently described by the term her-
nia cerebri, consists of a tumour formed by coagulated
blood ;  for an organized fungus could hardly be produc-
ed in so short a time as that in which these tumours are
usually formed."  I have no doubt that the tumour con-
sists partly of coagulated blood, but chiefly of the sub-
stance of the brain,  which is pressed out at the aperture
through  the  dura mater, in consequence of an  abscess
having  formed in the  brain,  or immediately under the
skull, and  in consequence of the increased volume of the
brain which is greatly swelled by inflammation.
  Mr. Abernethy is of opinion that extravasated blood
pushes out the brain, and that what would be  apoplexy,
if the cranium were entire, becomes fungus cerebri,  in
consequence of the deficiency of bone which  allows the
brain and coagulated blood to protrude.  This no doubt 
                ELEMENTS OF SURGERY.              gQQ
occasionally happens, but a considerable quantity of pu§
was found in two cases  which I have dissected, and the
protrusion appeared to be caused by the pressure of this
pus.   Mr. Charles Bell  supposes that though Mr. Aber-
nethy's account be correct, yet two other kinds of tumour
arise from the brain—the  one  a fungus excrescence from
the dura mater,  the other  a  proper organized fungus
of the brain.
   How  far these opinions are correct, I shall not decide,
but I  shall  take a greater liberty with his practice than
with  his opinions, and condemn without hesitation his
proposal to cut off the tumour:  this I conceive could not
answer any good purpose, and would probably be pro-
ductive  of very copious hemorrhagy, which in the ex-
hausted  state of the patient might prove fatal.  The best
application is a light soft poultice, or a pledgit spread
with simple cerate.   Should the tumour however acquire
a  very great  size, portions may be separated  with the
knife, as in some of Mr.  Hill's cases.  Some   rare in-
stances  are  recorded of recoveries from this dangerous
affection, but in general it terminates speedily in death.
   Since writing the preceding sentences, I have witness-
ed in my own  practice,  the  recovery of  a patient in
whom hernia cerebri occurred.   On the 5th of August,
1814, I trepanned  a  girl,  aged between eight and
nine years, and removed  a large portion of the left pa-
rietal  bone.    She had  sustained  an  extensive  fracture
and depression of the skull, from falling through a hatch-
way or trap  door in a sugar refinery.   She was  relieved
by the operation, from stupor,  convulsions, and the usual
symptoms of compressed  brain,  and. continued till  the
twelfth day free from all bad  symptoms:  at this period
a tumour was perceived protruding through a small ul-
ceration  in the dura mater: it gradually  enlarged and
pulsated strongly.  This tumour was unattended by any 
3J[0              ELEMENTS OF SURGERY.
augmentation of fever or stupor, and slowly increased till
the thirty-first day.  My next visit was a few days after
this, and during my absence (the precise time I could not
learn) vomiting occurred, during which a copious flow of
blood took place from some ruptured vessels  in the tu-
mour. From this time I had the pleasure to find the tumour
gradually subsiding;  granulations formed, the  tumour
cicatrized, and afterwards diminished, till  it returned to
the original level of the skull.  The patient has remain-
ed quite well for several years, and bone has  now form-
ed so as nearly to supply the deficiency occasioned by
the original injury.
  Dr. Physick, in his lectures, suggests the propriety of
puncturing the tumour with a lancet, in order, if an ab-
scess can be found, to evacuate the pus.
  I have endeavoured to avoid confusing  the preceding
condensed  history of the affections of the brain from ex-
ternal violence by a detail of opinions,  or  a quotation of
wonderful cases.  I may now, however, not improperly
remark  that although the opinions of our predecessors on
the subject,  are manyr of them fanciful and unimportant,
yet their histories of cases, merit  the greatest attention.
One general  principle I would  inculcate from them,
which is,  that injuries of the head apparently  trifling
should never be neglected ; and on the other hand,  those
which appear most dangerous and alarming should never
be despaired of.   In proof of this I could select instances
of death from a blow  which  scarcely  excited  attention,
and of recovery where the brain had been shot through
by a musket-ball. I  have myself  seen several skulls in
an European collection, in which the bony cicatrices de-
monstrate that large portions of brain and skull had been
cut out, and subsequent cures had been effected.
  I shall now proceed to relate a case, which I think 
               ELEMENTS OF SURGERY.              * » i
illustrates more of the usual circumstances of injury of
the brain than any other I have met with.

                        CASE.
  P. Welch, aged about twenty-four years, received at
midnight, June fifteenth, a violent blow from a brick-bat.
He instantly  fell, and was conveyed  home stunned and
scarcely  breathing;  a quack in the neighbourhood  was
sent for and by the time of his arrival the symptoms of
the first stage of concussion had  subsided, and  the pa-
tient's breathing was much improved,  his pulse rose, he
remained stupid, but moved occasionally,  and when his
head was touched appeared to suffer pain and put up his
hands, as patients generally do in the second stage of
concussion.   He remained in this situation till the after-
noon of the succeeding day, the  doctor having declared
that the skull was not fractured and that he would soon
be well.  His friends becoming uneasy at the continu-
ance of the stupor had him bled, and sent for surgical
aid.  I made my visit about twenty hours  after the acci-
dent, and found him snoring, but if spoken to in a loud
tone of voice, he attempted to answer,  but could not arti-
culate distinctly.  His pulse was full and slow.  Over
the left ear was a contusion and a small  wound which
when touched occasioned pain, and the patient moved his
head and hands to escape from  the examination of it.
I made an incision  down to the bone and discovered  that
a portion of the squamous plate of the temporal bone  was
fractured and  depressed.  During this operation  it  was
with extreme difficulty that the patient could be kept in
bed; he screamed, and moved about  violently.   Under
these circumstances  I postponed  operating and  drew
from the arm eighteen ounces of blood in addition to
several ounces  which had flowed from the branches of
the temporal  artery. 
212             ELEMENTS OF SURGERY.
  The next morning, (June seventeenth) no favourable
change having taken place but on the contrary the stupor
being increased,  I proceeded  to remove the depressed
bone to which the trephine  was applied twice,  and  all
the depressed  bone as  large  as  a half dollar taken
away,  a crack extended  forwards  toward  the  parietal
bone the extent of which appeared considerable, but no
cause for tracing it further existed.   A little extravasated
blood was  found under the skull.  After the  operation
the pulse rose and in the evening gxvi  of  blood  were
drawn   from his arm  after which he appeared  more
sensible.
  On the eighteenth, the day  after that on which the
operation had been performed  he  was evidently better,
was  perfectly  rational though still  somewhat drowsy,
had  no recollection of the accident—was bled  gxii in
the morning and  gviii in the evening, drank toast and
water.
  For several days no particular alteration was observed,
the wound appeared sloughy,  and a portion of the tem-
poral muscle which had been  cut through sloughed off.
He vomited occasionally and was  bled pretty regularly
twice a day till the twenty-third.  A tumour covered bj
the dura mater gradually protruded at the wound; this
membrane was tense and appeared evidently to contain
a fluid.   His stupor was increased.
  On the  twenty-fifth,  ten  days  after the accident,  the
nurse informed me he was greatly better and was more
rational.  I immediately  suspected that  the dura mater
had given way and that pus had been evacuated; upon
inspecting the head this was found to be the case—a large
quantity of  pus had been discharged during the preced-
ing night and a hole was observed in the dura mater
through which it had  issued.  I anticipated now  the
formation of a hernia  cerebri, which  accordingly hap- 
                 ELEMENTS OF SURGERY.            3|g
pencd:  on the twenty-seventh (twelve days after the ac-
cident)  a tumour began to  appear protruding through
the aperture in the dura mater which gradually increased
to the size of a hen's egg and was evideutly covered in
some parts by the pia mater, and in others had ruptured
this membrane and  appeared to consist of brain and clot-
ted blood.  During  the formation of this tumour, and the
discharge of matter which attended it, the patient regained
the entire use of his mental faculties, and appeared to his
friends to be getting well; I assured them that these hopes
were delusive and that he would not survive many days.
He complained of hunger, and his pulse being languid, he
was allowed chicken broth, and a few oysters.
   On the first  of July he had a violent chill, a  slough
came  away from the dura mater, and the tumour  of the
brain enlarged very considerably;—On the second, copi-
ous hemorrhage from the tumour;—On the third at mid-
night eighteen days after the accident  he expired, much
blood having been previously discharged from the tumour.
   On dissection, the crack noticed during the operation
was traced, and 1 found it to extend completely round the
head, having passed through the temporal bone, a small
part of the parietal, and separating the os frontis into two
portions,  by a crack situated  immediately  above  the
frontal sinuses  parallel  to the superciliary ridges. Where
the fungous tumour had existed  clots  of blood only were
seen, and  on  removing these  a considerable  hole was
found in the brain, occasioned by a loss of its substance,
the brain to some distance round this  vacuity was inter-
mixed with coagula, and completely disorganized,  a layer
of pus, thick and viscid, intervened every where between
the dura and pia mater, and at one place under the fis-
sure in the bone, an extravasation of one half an ounce of
blood was found.
   In this case the effects  of concussion  were very evi- 
314             ELEMENTS OF SURGERY.
dent, afterwards those of compression, then the usual ef-
fects of inflammation (not so distinctly marked as in some
cases, because compression still existed) followed by sup-
puration and by hernia cerebri.
   In consequence of gun-shot wounds and other contu-
sions of the skull, exfoliations occasionally happen, some-
times of one and sometimes of both tables of the skull.
When the external table  is killed, and exfoliation com-
mences, the inner table inflames, and the action of the ab-
sorbents as described formerly, removes the earthy mat-
ter of the bone, granulations shoot out from the inner table
and push  off the scale of dead bone, after which, these
granulations probably secrete and deposit osseous matter
and are converted into solid bone.  This process goes on
more rapidly in young than in old subjects.  In some cases
it is performed very slowly in consequence of the granu-
lations shooting up into cavities in the dead bone, and thus
connected  they prevent  for some time the  separation;
where the  delay is evidently owing to this  cause some
force maybe used in removing the dead bone. If both ta-
bles of the  skull are killed as in cases of gun-shot wounds,
the symptoms generally call  for the trephine, but  if this
be not applied, the separation of the dead bone is effected
in the usual manner, and granulations arise from the dura
mater and  fill up the space.   The deficiency of bone after
portions of the skull have been removed, is supplied by
granulations from the surrounding bone and from the dura
mater.  The bone forms first in contact with  the remain-
ing solid bone, and a thin plate afterwards, extends  gra-
dually over the aperture.   Previously to the formation of
this plate of bone, the brain is defended only by a soft
cicatrix of skin under which it may be observed pulsating.
From this exposed  state it is proper to defend it, espe-
cially when large portions of skull are deficient by means
of firm plates of tin, silver, or leather, which may be
worn under a wig, or cap, until the bone is replaced. 
ELEMENTS OF SURGERY.
315
                  CHAPTER LI.

       Diseases of the Eye and its Appendages.

   Having treated of the most usual accidental injuries to
which the body  is exposed and of the remedies to be em-
ployed, we pass on to describe certain morbid affections
submitted to the care of the surgeon.
   The term disease does not convey a precise and accu-
rate notion of many  of these affections; in a qualified
sense, however, it may be retained and cannot mislead,
when the nature of the various cases is understood.
   Inflammation attacks the eye and its appendages as well
as the other parts of the body; it may be excited by acci-
dental irritations, or by diseases of flie constitution.   In
some cases it makes its approach without any obvious re-
mote cause.
   Inflammation of the eye-lids occasions some pain, but
less than when the eye-ball is affected—the lids swell in
consequence of an effusion of serum into the cellular tex-
ture—the skin becomes red and a  burning sensation is
felt.  In some instances,  this inflammatory tumefaction
of the eye-lid  comes on at night, and as only one eye-lid
is generally affected the patient ascribes it to  the bite of
an insect; the cause is not always easily ascertained.
   If fever accompany it, as is sometimes the case, the pa-
tient should lose blood from the arm, if not, a  brisk mer-
curial cathartic  and  low diet  will generally remove the
affection  very promptly. A lotion  of brandy, or cam-
phorated spirit is often found useful.   Should it resist
these remedies, repeated blood-letting, the application of
a dozen leeches, and the usual antiphlogistic measures are
to be employed. 
316            ELEMENTS OF SURGERY.
  A discharge of pus from the edges of the eye-lids, call-
ed psorophthalmy often calls for the aid of the surgeon.
The patient waking in the morning finds  his eye-lids
closed by a secretion of pus which has dried and keeps
them in contact. The glands of Meibomius are generally
considered  as  the seat of this affection.  Dr. Physick
has been led to believe from his own  observations, that
the inflammation is seated at the roots  of the eye-lashes.
The affection of the head called tcenia  capitis is probably
of the same nature, ulceration existing in both cases at the
roots of the hair.  One proof  of  the correctness of this
opinion is, that the hair being pulled out the inflammation
often gets  well, and another, that the  tar ointment and
spermaceti oil, remedies very successful in tcenia capitis,
are advantageous in  the present case.
  The edges of the  eye-lids are sometimes ulcerated in
this complaint.  The most successful  application is the
citrin ointment, applied to the part;  a solution of lunar
caustic has also been used with great  benefit.  Common
mercurial ointment is sometimes successful.   Lamp oil,
and tar ointment I have several times used with advan-
tage.   When  the inflammation is  veryr  great,  leeches
should be applied, and purges administered.
  A chronic inflammation  of  the eye-lids called lippi-
tudo sometimes proves extremely obstinate ; the patient's
eye appears surrounded with a red circle, and the lids are
agglutinated in the morning. The treatment recommend-
ed in the last  case is sometimes  successful  in this; but
in many  cases it is extremely obstinate  and requires great
attention to diet and regimen.  I have known instances
where it has lasted through life, and has appeared in se-
veral members of the same  family.
  The eye-lids are  subject to an  inflammatory  tumour
called hordeolum or stye.  It resembles at first  a small
pimple  situated on the edge of the eye-lid, which aug- 
                ELEMENTS OF SURGERY.             3iy
ments, becomes  painful and suppurates.  It is in fact a
small boil, or  phlegmonous tumour, and in general gets
well without any surgical  aid, occasionally an induration
remains after the inflammatory tumour has subsided.   If
this become troublesome  it may be destroyed by lunar
caustic.
  The eye-lids are subject to two very opposite affections
which become  sources of great trouble and inconvenience,
the one an eversion of the lid, called Ectropium, the other
an inversion called Entropium, or Trichiasis.

                      ECTROPIUM.

  The eversion  of the eye-lid most frequently  occurs in
the lower lid, which is turned outwards towards the cheek
and does not come into contact with the  eye.  Inflamma-
tion results  from the exposure of the eye, and from the
unnatural situation of the puncta lachrymalia, the tears
cannot pass through them and of course  overflow  the
cheeks and a very unpleasant tumour of a red, fungous
appearance forms in consequence of the distension of the
vessels of the conjunctiva.   The complaint is occasioned
sometimes by the contraction of granulations in the heal-
ing of burns, wounds, or ulcers, on the cheek, but oftener
from  a relaxation  and elongation of the eye-lid.  The
only  remedy  hitherto relied on, is  the removal of the
everted lining membrane of the eye-lid, which becomes
indurated and enlarged; when this is done  by a scalpel
or scissars, the lid should be supported in its natural situ-
ation by a compress  carefully applied,  and the  wound in
healin"- generally contracts sufficiently to counteract the
disease.
   A  more ingenious operation, however, is described  by
Sir  William  Adams in  a work published in 1812, at
London for the cure of this affection, it consists in cutting 
318            ELEMENTS OF SURGERY.
out a portion of the lower eye-lid resembling the letter
V—the piece thus removed is one-third of an inch wide
at its upper part, the sides of the wound are approxi-
mated by a stitch, and the diseased conjunctiva cut off—
this effects invariably a complete and speedy cure.

                     ENTROPIUM.

  In the entropium or trichiasis, the eye-lid is invert-
ed  upon the eye, in consequence of which, the cilia irri-
tate excessively the surface of  the  eye,  and keep up  a
constant and violent inflammation.   According to Scarpa
and other writers, two species of this  disease are met
with; in one the  cilia are turned  inwards without the
tarsus having changed its natural position  and direction,
in the other the tarsus is  inverted,  and consequently all
the eye-lashes  are in contact with  the globe of the eye.
The second form is most common, and to this only the
term Entropium is properly applied.
  The causes of Trichiasis are by no means well under-
stood—ulceration and consequent cicatrices are supposed
to have produced it in most cases, but of this there is no
proof.   It seldom occurs in the under eye-lid.
  The consequence of the inversion of the eye-lids is  a
constant irritation  and inflammation of the eye, from
which the cornea becomes opaque;  but the patients from
time to time relieve themselves by pulling out the cilia,
and then the inflammation abates;  it is, however, soon
repeated when  the eye-lashes begin to grow, and blind-
ness sooner or  later results; nor is this  a termination of
the patient's sufferings, for the inflammation goes on,  and
the pain continues.   A callosity and complete change in
the structure of the eye is the only  event which affords a
complete relief to the unhappy  sufferer.
  A great variety  of means have been proposed  and 
                ELEMENTS OF SURGERY.             gig
adopted for the cure of this disease, which it is unneces-
sary here to detail.
  In reflecting on the nature of the  complaint, several
years ago, I was  induced to think that the eye-lid could
very readily be cut half off, without much inconvenience,
because the orbicularis muscle is capable of contracting
in such a degree as to throw the folds of skin into nu-
merous wrinkles, thereby demonstrating  that much of it
could be removed, and the eye still be closed.  A case of
trichiasis came under my care  in the Philadelphia Alms-
house,  in  July 1810, in which several  operations had
been performed,  but without  effecting  a cure:  about
one-third part of the cilia were inverted.   In this case I
made an incision through the tarsus, and cut  out  com-
pletely all  that portion of the eye-lid, from which the
eilia proceeded.  My patient in a few days was perfectly
cured,  was extremely pleased with the operation, and
very little  disfigured; indeed, compared with her  in-
flamed  eye, her appearance was improved.   Encouraged
by the  success of this case, I have twice since  perform-
ed the operation of removing totally the lower half of the
tarsus cartilage, together with the skin covering it and the
inverted cilia; the success has been complete in  both
cases—the  wound healed up very readily, the inflamma-
tion quickly subsided, and the opacity of the cornea was
soon removed.
  By one  of those coincidences which are  often occur-
ring, the late Mr.  Saunders, of London, contrived and
performed  the same operation, and with  equal success.
A small volume on the diseases of the eyes, which for
the first time I saw during the present winter, though it
was published in 1811, contains an account of this  ope-
ration.   Mr. Saunders remarks, " the certainty of its re-
lieving the  patient, is  what I more value  than the credit,
if there be any, of having suggested it;"  and in this 
320             ELEMENTS OF SURGERY
sentiment I heartily joiu him.  I shall therefore proceed
to describe the manner of operating proposed by Mr.
Saunders, aud afterwards relate my own method.
   Mr. Saunders directs  the operation to  be performed
as follows: " a piece of thin horn or a plate of  silver
having a curvature corresponding with that of the eye-
lid, is to be introduced, and its concavity turned towards
the globe  within the eye-lid which  is to be stretched
upon it.   An  incision is to be made through the integu-
ments, and orbicularis palpebrarum, immediately be-
hind the roots of the cilia to  the tarsus,  and should ex-
tend from the punctum lachrymale  to the external an-
gle.  The exterior surface of the tarsus  is then to be
dissected until the orbital margin  is exposed, when the
conjunctiva is to be cut through directly by the side of
the tarsus which must now be disengaged at each extre-
mity ;  the only caution necessary being to  leave the
punctum lachrymale uninjured."
   The manner in which I have performed the operation
is extremely simple.  A hook is passed through the edge
of the eye-lid in order  to gain a secure hold  of it, and
with a pair of sharp scissors the necessary portion of the
eye-lid is removed by two or three  cuts.    " Nothing can
be more simple than this piece of dissection."  A remark
applied by Mr. Saunders to his operation, but which is
much more applicable  to mine.  The punctum  lachry-
male must be carefully avoided.
  The wound generally  heals in a few days ;  no dres-
sings  are necessary, but a soft compress  may be lightly
bound  over the eye.  Mr. Saunders says a fungus arose
from the cicatrix in all his cases,  which required caus-
tic or the knife; all the  cases I have seen, healed imme-
diately without any inconvenience, and  the deformity is
not so great as would be  imagined.*  The appearance
  * The operation  is I believe new, though Hallerinhis Bibliotheca Chirurgica
spates, that Rhazes recommended cutting and burning the eye-lid, in similar 
                  ELEMENTS OF SURGERY.              32^
ef the eye after the cure, is represented in Fig. 2. of the
Plate next succeeding.*
   When the eye-lids are contracted by cicatrices so  as
no longer to cover the eye, systematic  writers  have call-
ed the affection  lagophthalmy,  or hare-eye.   I have
6eenitin consequence of burns and  there is no remedy
but careful dissection of the surrounding parts, by which
the skin may be loosened in  sufficient  quantity to defend
and cover  the  eye;  after the  dissection care must be
taken to prevent by adhesive plaster or even a suture if
requisite, the subsequent retraction of the skin.

cases; the nature of his operation I cannot ascertain, as the only copy of Rhazes
which I have been able to see, contains nothing on the subject.  It is a black
letter edition,  very ancient in barbarous  Latin, belonging to the Loganian
library in this city.
  • Since my first edition  an enlai*ged experience has convinced me ef the
propriety of this operation.
vol.  i.          43 
322
ELEMENTS OF SURGERY.
                  CHAPTER LII.

                   Of Ophthalmia.

  Inflammation of the eye, or in medical language oph-
thalmia, is a frequent, and very distressing complaint.
Its symptoms are very well known; they generally com-
mence with a severe pain in the  eye, redness of the eye-
ball, and a copious secretion of tears—the patient is un-
able  to bear the light,  and keeps his eyes closed—some-
times a violent  burning is perceived in the eye; head-
ache and  in general  fever attend—the inflammation is
either seated in the adnata, or in the globe of the eye,  in
which latter case there is less external evidence of in-
flammation, but the same general symptoms.  In some
cases an effusion of blood takes place into the cellular tex-
ture  under the adnata, and occasions a great tumefaction.
  Coagulating lymph is sometimes poured out by the in-
flamed vessels,  and opacity of the  cornea is  the conse-
quence.   In some cases a pimple or inflamed speck ap-
pears in some part of the adnata, generally in the vici-
nity  of the cornea.  Small red vessels are often seen ra-
mifying over the cornea.
  It is unnecessary to enumerate the various causes of
ophthalmia; they are  numerous mechanical and chemical
irritants, and certain  diseases,  as  small-pox, syphilis,
scrofula, catarrh, &c.
  When the disease occurs in the adnata only, the pain
is tolerable, compared with the sufferings of those patients
in whom  the  internal parts of the  eye are affected with
severe inflammation;  in these  the  pain is excruciating,
and  if it be not soon relieved, blindness is generally the
result, and death sometimes takes place.
  The treatment of ophthalmia, whether  confined to the 
                ELEMENTS OF SURGERY.             323
adnata, or seated more internally, consists in  the active
employment of the usual remedies for inflammation.  Of
course the remote causes, if they continue to act, should
be removed; all extraneous  matters which may irritate
the eye should be wiped off; this may generally be done
by passing a small piece of rag wet with clean water upon
the end of a probe, round the eye between the eye and
lid, or by injecting a stream of milk and water under the
eye-lids  by means of a syringe.   In  many cases, how-
ever, the foreign substance sticks in the cornea or sclero-
tica, and cannot be thus easily removed.  It is  very com-
mon for  blacksmiths, in filing iron, to detach  small por-
tions of the metal with great force,  so  that  when they
strike the eye,  they  penetrate to some depth.   In these
cases  the point of a lancet, or a cataract knife,  must be
used to detach the foreign body.
  The remote causes being removed, blood-letting is to be
performed, as extensively  as the nature of the case may
require.  After this  remedy has  been carried as far as
may be necessary, topical bleeding by leeches, and cup-
ping in the  neighbouring parts is to be next used.   The
European surgeons do not employ blood-letting so exten-
sively in ophthalmia,  as is necessary in the treatment of
the complaint in this country. I have known, in one case,
seventy  bleedings required for the cure  of an obstinate
acute ophthalmia; the quantity of blood lost at each ope-
ration was generally six or eight ounces.  In the Penn-
sylvania hospital, I have  generally directed the patients
afflicted  with acute ophthalmia to be bled every second
day, and on the intermediate day to be purged; to live
upon a very abstemious diet, and to remain constantly in
a dark room.  These  remedies are in almost every re-
cent case very speedily successful, and active measures
ought surely  to  be preferred to tampering with serious
diseases. 
 324?             ELEMENTS OF SURGERY.
   In some cases, after bleeding, and cupping, and leeches
 have been tried, if the inflammation continue,  scarifica-
 tions become necessary;  the vessels of the adnata may
 be conveniently divided by the edge of  a sharp scalpel,
 or the shoulder of a lancet.   A few drops of blood eva-
 cuated  in this way, from  the inflamed part,  will often
 prove extremely serviceable.
   Purges are to be frequently administered, the saline
 cathartics are generally employed, and antimonial prepay
 rations in combination with nitre are also useful.
   Blisters to the back of the  neck, or  behind  the ear,
 or to the forehead, are in many cases extremely benefi-
 cial; but Dr. Physick has introduced a mode of apply-
 ing blisters, in cases of ophthalmia, which is more quickly
 useful than any other; the plaster is to be  spread with
 the epispastic ointment covered with gauze,  and applied  ^
 directly over the eye, the lids being  closed;  in this
 manner the whole surface of the upper and lower eye-
 lid, and a  portion of the cheek, are blistered, a copious
 discharge of serum takes place, and great relief is in ge-
 neral immediately experienced.  I have for several years
 availed myself  of  this  practice,  and have been much
 pleased with its efficacy.  I was  formerly in the habit of
 cutting  off the cilia,  and  applying a strip  of adhesive
 plaster to prevent the flies from  coming in contact with
 the eye, but of this, if the blistering plaster be carefully
 prepared, there is no risk, and I have often omitted the
 precaution; indeed, the copious secretion of tears would
 wash out any extraneous matter which might be insinuat-
 ed between the eye-lids.
   When, notwithstanding a vigorous perseverance in the
use of the preceding remedies, the inflammation  continues
unabated, and great pain is felt in the ball  of the eye,
mercury should  be administered in such a manner as  to
excite a speedy salivation, the ointment should be rubbed 
                 ELEMENTS OF SURGERY.             325
 upon  the thighs,  and calomel administered in doses  of
 two or three grains in the twenty-four hours.
   No collyrium but  of the mildest kind should be em-
 ployed during the acute stage of ophthalmia.   Milk and
 water answers very well.  The pith of sassafras, infused
 in water forms a mild mucilage, which in these cases is a
 very pleasant application to the patient; the young twigs
 of the sassafras split open, afford considerable quantities
 of pith; a  teaspoonful will  render eight ounces of wa-
 ter sufficiently viscid.   A soft light poultice of bread and
 milk sometimes relieves the pain of ophthalmia,  but  in
 general compresses of soft linen, wet with cold water  or
 milk and water often changed, give more ease; the poul-
 tice  keeps the part too hot, and its weight is an inconve-
 nience.
   After the more active symptoms  of inflammation have
 abated, the  employment of gently irritating or astringent
 collyria, becomes useful; the  formula I have found most
 beneficial is the following:

     R. Sacchar: saturn:  (Acetatis plumbi)       gr. v.
        Vitriol: alb :      (Sulphatis zinci)       gr. iij.
        Laud : liquid:                          3.  ij.
        Aq : fluvial:                             3. iv.
     M. f. collyr.

   The addition of sij of vinegar sometimes improves the
medicine.    Dr. Physick employed  tar  water several
years ago in a most obstinate case of ophthalmia, which
had resisted all the usual remedies, it proved  completely
and speedily successful.
  In the employment of an eye-water,  a rag wet with
the fluid should be placed over the eye-lids,  and  occa-
sionally they should be opened so  as to admit it into
contact with the ball of the eye. The tar water should in 
326             ELEMENTS OF SURGERY.
the first instance be diluted, and  afterwards  applied of
the usual strength.  Diluted laudanum, and the  vinous
tincture of opium, are in some cases very useful as colly -
ria.  A great va i iety  of collyria  have been contrived;
I have already named  those  which appear to me most
useful.
  In general by these  measures the inflammation is re-
lieved; but it sometimes terminates in  suppuration, and
pus is  poured out under the cornea, forming the disease
called  iiypopion.  In these cases it is proper to make a
puncture with a cataract knife through the cornea for the
evacuation of the pus; for if this be suffered to  remain
until ulceration takes place, vision will inevitably be de-
stroyed.  It generally happens, however, that brisk purg-
ing, and a continuance of the antiphlogistic measures,
produce an  absorption  of the effused pus, and render it
unnecessary to puncture the cornea.
  Confinement to a dark room, and a very abstemious ve-
getable diet, should be  enjoined during the whole course
of the  disease.   Setons and issues in chronic cases are
sometimes useful; they may be made on the back of the
neck.   When the inflammation abates, light should gra-
dually be admitted to the eye, and a very cautious return
made to the usual habits of diet and  exercise.
  Within a few years much attention has been excited in
England by an epidemic  ophthalmia,  evidently conta-
gious,  accompanied by  a puriform discharge from  the ad-
nata.   To this complaint the British surgeons have af-
fixed the name of Egyptian  ophthalmy, from its resem-
blance  to the disease which occurred among the troops in
Egypt, in the year 1801.
  This malady commences with a sensation of irri^tion,
as if from a mote: the  white  of the eye becomes sudden-
ly red, and the lower eye-lid very vascular. In this stage
it readily yields to active antiphlogistic remedies.  If 
                ELEMENTS OF SURGERY.            3giy
these be not employed, the disease advances;  and in the
second stage the upper lids inflame, and secrete a " scald-
ing fluid," which excoriates the cheeks, and suppuration
soon follows.   The remedies for inflammation  are still
proper, aiid sometimes successful; but if they are uot, the
third stage comes on, the cornea inflames, becomes opaque,
and ulcerates.
   Numerous treatises on  this subject  have appeared in
the medical writings of Great Britain.  An excellent his-
tory of it may  be  seen in Mr. MacGregor's  paper, de-
scribing the disease as it occurred in the military asylum
at Chelsea, in the 3d vol. Medico-Chirurgical Transac-
tions.  Sir William Adams has been  very successful in
the treatment of the Egyptian ophthalmia.  His practice
has been  approved by the  most  respectable surgeons of
London, and consists in  copious depletion in the early
stage; and in the  latter, cutting off with a knife the gra-
nulations which arise from the adnata, and  irritate the
cornea.  For a minute account of this  and other diseases
of the eye, the  reader is referred to his excellent treatises
 written in 1812 and 1817.
   In cases  which I presume to call Egyptian  ophthal-
mia, I have cut off the granulations of the adnata with
 obvious advantage. 
328              ELEMENTS OF SURGERY.
                 CHAPTER LIII.

                Unguis or Pterygium.

   Unguis or Pterygium, is an affection of the eye, not
unfrequently met with; it consists in an enlargement of
the vessels of the adnata proceeding from the inner can-
thus of the eye, and at length forming a dense opaque
red membrane  of  a triangular figure pointing  and pro-
gressing towards the cornea, over  which at length, it
gradually spreads and of course impedes vision, in pro-
portion to its extent.   In  some  rare  cases it  proceeds
from the external can thus of the  eye.   Scarpa observes
that the unguis in some rare instances  proceeds  from
other parts of the globe of the eye, but always maintains
a  triangular shape,—the  apex of  w hich is presented
towards the cornea; occasionally two or  three pterygia
form  upon the same eye;  when these  unite upon the
cornea, a complete obstruction to vision takes place.
   Scarpa considers the vessels  of the eye in chronic
ophthalmia to be in a varicose state, and  in the present
case in addition to the varicose state of the vessels which
are extended over  a certain part of the cornea, there is
a preternatural  thickening of the thin lamina of the con-
junctiva which  covers it, upon which these small vari-
cose veins are situated.
   Hence it seems that the pterygium appears at first, to
be a new membrane formed upon the cornea, while it is
nothing more than  the fine lamina of the  conjunctiva,
forming its natural external covering, which in conse-
quence of chronic  ophthalmia has degenerated from  a
transparent into a thick and opaque tunic interwoven with
varicose vessels. 
                 elements of surgery.             32g
  Scarpa supposes the unguis to be  nothing more than
an increase of the same affection which forms nebulje,
or spots on the cornea.  These nebulae consist of dilated
kuotty vessels upon the  cornea,  which ought in their
forming state to be treated by astringent collyria, and sti-
mulating applications, as the citrin ointment, &c. in order
to prevent their extending  over the lucid cornea and thus
impeding vision.   A peculiarity of unguis  or pterygium
is that it appears very loosely connected with the sclero-
tica; if taken hold of by  a  hook or forceps it moves ea-
sily, and seems connected only by loose cellular texture.
Scarpa remarks that cancer has  sometimes  resulted from
this complaint.
  The remedy consists in seizing the thickened mem-
brane with a  hook or pair of forceps and dissecting  it
carefully  off with a pair of curved  scissors,  (Fig. 3.)
Where it adheres to the cornea the union is more intimate,
and here a sharp  knife is  the  most proper instrument
for the dissection.   It is  most convenient  to commence
the incision near the canthus and proceed towards the
cornea.
  Scarpa remarks that in some cases after the  removal
of the pterygium, the cicatrix  prevents  the  freedom of
motion outwards,  to avoid  which  inconvenience  in the
treatment of pterygia which  have a very extensive base
upon the white of the eye, he has found it  convenient to
divide them from  the  apex, only as far as  the cornea
and sclerotica unite, and  then to separate them at their
base by  a semicircular incision including  about a line
in breadth of the  substance of the conjunctiva, iu a di-
rection concentric to  the margin of the cornea.  By ope-
rating:  in this manner, he has found that the after-treat-
meut is much shorter, than when it is executed after the
common  method,  that the cicatrix does not form a ridge
or fra?num, and that the conjunctiva being  stretched en-
  voi,, r.         -hS 
33O             ELEMENTS OF SURGERY.
cularly and equably upon the white of the eye by the ci-
catrix, loses that relaxation and varicose state of its ves-
sels  which formed the base  of  the pterygium.   This
nicety however, is not necessary where the pterygium is
small, and does not  extend  much upon  the white  of
the eye.
  After the operation no particular dressings are requi-
site, a wet  compress should be loosely bound upon the
eye and the patient for a  few days confined to a low diet.
  A species of disease very analogous to  this is called
Encanthis ; it is a  tumour of the same texture as the
unguis and formed  in the same manner, growing from
the caruncula lachrymalis and semilunar fold of the ad-
nata.  It is  to be extirpated by sharp  scissors. 
ELEMENTS OF SURGERY.
331
                  CHAPTER  LIV.

      Opacity of the Cornea and Artificial Pupil.

  Inflammation of the eye sometimes terminates in opa-
city of the cornea.  Several distinct appellations have.
been given to the various forms  of opacity in the cornea,
as nebula, albugo, leucoma, &c.; for an account of these
I refer to Scarpa.
  In some cases the texture of the whole cornea appears
to be changed, in others opaque spots are visible;  some-
times the opacity depends on increased vascularity and
subsides  when the inflammation is over, in others it re-
mains permanent.
  Some practitioners are in the habit of blowing into the
eye powdered  sugar, molasses,  white vitriol, or pulve-
rized glass, with a view to grind off this film, as they call
it;  the practice is extremely pernicious, and ought never
to be used; the remedies for inflammation already recited
are the only ones in which confidence should be placed.
When a portion of the cornea remains lucid, an artificial
pupil if necessary, may be  made  opposite to  this lucid
spot in the cornea, and thus vision will be restored;  the
operation should  not be performed unless the patient has
lost the sight of both eyes.  The  same operation may also
become necessary,  in cases  where the pupil has become
obliterated, from  an adhesion of  the iris at its margin, in
consequence of inflammation.  In both these  cases Dr.
Physick has for many years been in the habit of making
a section of the cornea, as for the extraction of cateract,
and afterwards of removing a portion of the iris, by means
of a pair of forceps terminating in  narrow extremities upon
one of which is fixed a sharp circular punch (Fig. IS.) 
332            ELEMENTS OF SURGERY.
the iris in cases where the pupil is obliterated, must be
punctured by the point of the knife in making the section
of the cornea, and then the forceps can readily seize it.
A variety of methods have been contrived for effecting this
purpose.
  Baron Wenzel's I think is preferable to all before de-
scribed.  The one I have just noticed is an improvement
of Baron Wenzel's,
  Mr. Charles Bell  remarks that he had thought it pos-
sible  to  restore sight  by making an artificial pupil, in
cases of opaque cornea;  what he considered possible, I
have  seen  accomplished  in a variety of cases.  Indeed
the advantages of the operation would be limited to a very
narrow boundary  if it were only adapted to cases in
which the pupil is obliterated, because this is a very rare
case in comparison with opacities of the cornea.
  A portion of iris ought in most instances to be remov-
ed, because a simple puncture or incision  through it is
apt to contract, and of course it becomes necessary to re-
peat the operation.
  Professor Scarpa has lately contrived a mode of form-
ing artificial pupil which consists, not in making an aper-
ture through  the iris, but in separating the iris from the
ciliary ligament.   The patient being seated, and held as
in the operation for cataract, a couching needle is to be in-
troduced through  the sclerotic coat,  about two lines dis-
tant from the cornea; the needle enters on the side next
to the external canthus, and its point is made to advance
as far as the upper and internal part of  the margin of the
iris, that is, on the side  next the nose.   The instrument
is then made to pierce the upper part of the internal mar-
gin of the iris close to the ciliary  ligament, until its point
is just perceptible in the anterior  chamber of the aqueous
humour.  As soon as the point of the needle can be seen
in the anterior chamber of the aqueous humour, it should 
                  ELEMENTS OF SURGERY.             333
 be pressed upon the iris from above downwards, and from
 the internal  towards the external angle;  by this means a
 separation will be made of the iris at its margin, from the
 ciliary ligament and a black  spot will be observed. The
 light can in this manner be transmitted to the retina.
   I have mentioned the operation, because sometimes the
 only lucid part of the cornea is its margin, and in such
 cases, Scarpa's operation would probably  answer  ex-
 tremely well, but  under common circumstances Dr. Phy-
 bick's is  vastly preferable, because the pupil can be made
 wherever it is requisite, and with as little pain and dif-
 ficulty as possible.*
   Mr. Saunders has recommended the use of Belladon-
 na to prevent the obliteration of the pupil, when the  iris
 is inflamed :   it produces a great dilatation of the pupil.
 Stramonium  has been employed in this country with  the
 view of dilating the pupil in certain cases, and would pro-
 bably be equally effectual in this; indeed most of the nar-
 cotic plants possess the same property.

                ULCERS OF THE CORNEA.
   These  sometimes  form in consequence of inflamma-
 tion, and sometimes an  accidental injury ends in ulcera-
 tion.   The application of lunar caustic is the proper  re-
 medy.  It is to be scraped to a point;  secured in a quill,
 and  then applied to  the  ulcer,  and suddenly removed;
 the slough separates in  a  day or two, and the operation
 is to be repeated;  the pain and  intolerance of light gra-
 dually diminish, and the ulcer generally fills up and  ci-
 catrizes.   For more minute information on ulcers of the
 cornea, I refer to Wardrop's morbid Anatomy of the Hu-
 man Eye.
  * It mav not be improper in this place to ascribe the invention of the artifi-
cial pupil to Cheselden, his publication on the subject is contained in the Phil.
Trans, for 1735.   His mode of operating has lately been revived and modified
by Sir Wm. Adams. See his work*. 
334
ELEMENTS OF SURGERY.
                  CHAPTER LV.

                Fistula Lachrymalis.

  The tears secreted by the lachrymal gland after lubri-
cating the  eye, are taken up by the puncta lachrymalia,
and conveyed to the lachrymal  sac, whence they pass
through the ductus ad nasum into the  nose.   This ductus
ad nasum,  however, is liable like all other canals in the
body to stricture.  Whenever in consequence of a stric-
ture in this duct, the course of the tears into the nose is
interrupted, they accumulate in the sac which becomes tu-
mid, and upon being pressed they regurgitate and flow
partly over the cheek, and partly through the nasal duct.
The tumour is situated on one side of the root of the nose
below the inner canthus of the eye.   The tears are con-
stantly overflowing the eye, because the sac being full the
puncta can receive no more.  To the  disease in this state
the term fistula is improperly applied.  The patient ex-
periences but little  inconvenience from  it, except a con-
stant watery eye; no pain and inflammation exist. Even-
tually, however, the stricture becomes complete,  the sac
inflames and suppurates, and now a fistulous  sore  is form-
ed which discharges tears mixed with mucus and pus. It
is  generally accompanied with inflammation of the eye,
and often with caries of the os unguis.   The puncta, in
this  stage  are often obstructed,  and no  tears find their
way into the sac, but all which are secreted pass over the
eye-lids.
  In the first stage  of the disease which has been called
epiphora,  and by  Scarpa the puriform discharge of
the  eye-lids, while the lachrymal sac is entire, the 
                ELEMENTS OF SURGERY.             335
only remedy necessary is to inject by means of a fine sy-
ringe, called from  its inventor Anel's, a stream of warm
water through the puncta  lachrymalia which will wash
away any thickened  mucus or similar obstruction.   The
sac should be kept empty by  frequent pressure.  Scarpa
recommends in addition to  this  washing out of the " via
lachrymalia" the use of an astringent ointment, to be ap-
plied between the eye-lids  and  upon the ball of the eye.
He prefers the celebrated ophthalmic oiutment of Janin.
It is  composed of the  following ingredients; hogs-lard
half an ounce, prepared tutty and armenian bole of each
two  drams, white precipitate (calx  hydrargyri alba) a
dram.  Scarpa dilutes the ointment at its first application
by adding hogs-lard.  By  the use of these remedies the
disease has in many cases been prevented from ulcerating
and has been completely cured.
   Mr. Pott who condemns  the use of Mr.  Anel's probes
which were  intended  to  pass  through  the  lachrymal
puncta into the nose, recommends the employment of the
syringe;  he found it, however, sometimes unsuccessful.
Mr. Ware's testimony is in favour of the syringe of Anel;
he injects warm water through the lower punctum and
places a finger upon the upper one to prevent its escape.
He repeats the operation four or five days in succession.
If he is unsuccessful in forcing any of  the fluid into the
nose, he makes use of topical blood-letting, from the an-
gular vein, or by a leech applied near the lachrymal sac.
He also varies the injection, and tries the effect of a weak
vitriolic or anodyne lotion.  Mr. Ware has in some cases
passed a fine gold probe through the punctum, when un-
able  to  force the fluid into the nose, and by gently in-
sinuating this, he has overcome the obstruction, and im-
mediately afterwards the injection has  readily found its
way  through the ductus ad  nasum.
   Mr.  Ware remarks  that " when an epiphora is occa- 
336             ELEMENTS OF SURGERY.
sioned by an acrimonious discharge from the sebaceous
glands on  the edges of the eye-lids, it  must be evident,
that  injections into the sac will be very insufficient to
accomplish a cure, because the sac is not the seat of the
disorder.   The remedies that  are employed must be di-
rected, on the contrary, to the ciliary glands themselves,
in order to correct the morbid secretion that is made by
them; and  for this purpose, I do not know any applica-
tion  that is so likely to prove effectual as the unguentum
hydrargyri  nitrati, of the  new London Dispensatory,
which should be used here in the same  manner in which
it is  applied in common cases of the psorophthalmy.  It
will  be  proper  to  cleanse  the eye-lids every  morning,
from the gum that collects on their edges during the night,
with some  soft unctuous application; and I  usually ad-
vise  to apply to them, two or three times in the course of
a day, a lotion composed of three grains of white vitriol,
in two ounces of rose or elder-flower water."  Mr. Ware
recommends  whenever collyria are applied,  to  substitute
for linen compresses, eye-glasses,  or to apply the fluid
by camel's liar pencils.
   In the second stage of the disease, where the fistulous
sore exists, or where  the inflamed state of the parts pre-
cludes the hope  of any other  termination,  a  different
mode of treatment becomes requisite.
   When the abscess of the  sac has actually formed, it is
best to open it with a lancet, because a puncture of this
kind leaves a smaller scar  than the sore formed by the
absorbents.  A probe should now be passed if possible
into the  ductus ad nasum;  if it enter  readily a bougie
should be introduced of a conical form,  so as to dilate the
canal at the  part where the obstruction exists, and this
bougie should  be suffered  to remain,  and a superficial
mild dressing applied to the  sore.  In some cases this
simple plan succeeds effectually.  If, however, a bougie 
                 ELEMENTS OF SURGERY.             337
cannot readily be passed, a silver style or short probe is
to be substituted; the size and form of this instrument is
represented in Fig.  17.   The circular button  on its ex-
tremity may be covered with black sealing wax, or court
plaster; when this instrument is introduced, the patient
must  wear it for several months,  care being taken  to
cleanse it twice or  thrice a week,  and to  inject when-
ever it is removed,  a stream of tepid water through the
canal.  It might be  supposed that  the tears during this
time would  flow entirely over the cheek; but this is not
the case; they pass by the sides of the probe and moisten
the nostril.   Very little  inconvenience is  sustained by
the patient in wearing the style constructed by  Mr.
Ware, and it occasions no more deformity than a small
black patch.   In six weeks sometimes  the obstruction
will be permanently removed, but as it occasionally re-
curs even when  the  style has been continued a greater
length of time, I have been accustomed to  direct its use
for six months.   Some  of Mr. Ware's patients have
worn it for years, all the tears passing by its side into
the nose.   A great advantage is  derived by  gradually
increasing the thickness of the style.  Dr.  Physick em-
ploys three or four  in succession, the last  being double
the thickness of the first.
   Mr. Ware directs, if the disease has not  yet occasion-
ed an aperture in the lachrymal sac,  or if  this aperture
be  not situated in  a right line  with the longitudinal
direction of the nasal duct,  a puncture to be made into
the sac at a small distance from the juncture of the  pal-
pebral, and nearly in a  line drawn  horizontally from
this juucture  towards the  nose,  with  a  very narrow
spear-pointed  lancet.  The orifice thus formed soon be-
comes fistulous round the style,  and no irritation is  ex-
perienced in  the subsequent introductions of  this in-
strument.
  vol. 1.         44 
 338              ELEMENTS OF SURGERY.
   When the ductus ad nasum is completely obliterated,
 instead of any attempt to form a new passage  in the old
 situation,  it is the practice to perforate  the os unguis.
 Mr. Pott used a  trochar for this purpose, but an incon-
 venience occasionally follows the use of the trochar; the
 aperture closes up by the fragments of  bone inflaming
 and reuniting; to obviate this, Mr. Hunter constructed
 an instrument like a  shoemaker's  punch, by which a
 circular piece of bone may be  cut  out completely, and
 then the aperture  cannot again be closed.  It is true that
 a dossil of lint, or a probe of lead,  or a  bougie, kept in
 the passage will prevent its reuniting; but if Mr.  Hun-
 ter's plan be adopted there will be  no need of this trou-
 ble.  Mr. Ware recommends  a nail-headed style  to be
 worn in this case, as well as in those instances  where
 the natural canal  is to be dilated, but for this  practice I
 think there can be no necessity.
   The operation of removing a portion of the  os unguis
 is very readily performed.  The only necessary caution
 says Mr. Pott, " is to  apply whatever instrument is used
 so that it may pierce through that part of the bone which
 lies immediately behind  the sacculus lachrymalis, and
 not to  push too  far up into the nose, for  fear of injuring
 the os spongiosum behind, while it breaks its way." Mr.
 Hunter recommends a piece of thin smooth horn  to be
 passed  up  the  nostril,  to receive  the  circular punch,
which is to be passed into the lachrymal  sac and forced
through the os unguis, till it comes in contact with the
horn.   When the perforation is completed, air passes
out of the nose through the wound,  and blood will flow
through the wound into the nostril.   The external open-
ing may now  be dressed with adhesive plaster and suf-
fered to heal immediately.  If carious bone exist it will
be separated by the absorbents, and should fungus  arise
from the wound it is to be destroyed by caustic.  Mr 
                 ELEMENTS OF SURGERY.             339
Ware's plan of introducing the style through the ductus
ad nasum, and of continuing its use for a great length of
time supersedes the use of this latter operation in all but
a few rare instances in which there is complete  oblitera-
tion of the nasal duct.  He is entitled  to  the  greatest
credit for his improvements in the treatment of  this dis-
ease. 
340
ELEMENTS OF SURGERY.
                 CHAPTER LVI.

                    Of Cataract.

  By this term is designated an opacity of the chrystal-
line lens or its capsule,  or of both.   The  pupil  of the
eye, which is naturally  perfectly black, becomes grey or
white, except  in  some rare cases where it has a dark
colour; the colour, however,  is always distinguishable
from the deep  black of the pupil in a sound eye.  In its
commencement it occasions a weakness or dimness of
sight,  which  increases until vision is totally destroyed.
In general, cataract occurs in advanced life, seldom com-
mencing before the age of forty; in some cases, however,
it begins much sooner, and is in some instances congeni-
tal; in congenital cataract the capsule (according to Wen-
zel and Saunders) is. generally opaque and the lens fluid
and milky.
  The causes of cataract are not very easily ascertained.
Baron Wenzel found it most frequent among persons
exposed to the light of strong fires, as blacksmiths, glass-
blowers, &c.   It now and  then  happens  from external
violence.
  The disease generally  commences without pain; the
first symptom is commonly  an  appearance of  motes,
specks, cobwebs, or  insects floating before the  eye; the
patient attempts to remove them, but without effect. The
pupil  at this time does  not generally evince  any  morbid
appearance, but as  the  disease advances,  a settled mist
or cloud obscures every object—vision is greatly impair-
ed, and a turbid whitish appearance of the pupil begins
to be  observed.   In  some cases these symptoms proceed
very slowly,  and iu others  the entire obfuscation of the 
                ELEMENTS OF SURGERY.              34^
lens takes place in a few weeks.   When the disease is
fully formed the patient is generally able to discern the
situation of a  strong light; can  distinguish day  from
night; or perhaps count the windows  in a room, but is
unable to discern most  objects,  and in some cases even
this faint degree of vision does not exist.
  In the incipient stage of the disease it is proper to em-
ploy certain remedies  which are  occasionally useful in
preventing its  formation.  Bleeding, purging, and a low
diet, are to be recommended; mercury has been supposed
useful; setons,  issues, and blisters, are also to be employ-
ed.  In some cases, more especially where the  disease
has resulted from  external injuries, these remedies have
been found successful, and the opacity  has been removed
by absorption; but in general no such favourable termi-
nation is to be expected, and Wenzel declares that " in-
ternal remedies either of the mercurial or  of any other
kind, are inadequate to the cure of this disorder, and
equally so  whether  opacity be  in the chrystalline or
in the capsule, whether incipient or advanced."  This is
not quite correct; I have seen one patient  in whom the
lens or its capsule was universally opaque, and the pupil
perfectly white; and this opacity subsided in the course
of four or five months;  the chief remedies employed were
bleeding, purges,  and mercury;  how far  they were ser-
viceable I am not able to determine,  for Pott and Hey
both remark that cataract from external violence some-
times subsides spontaneously—the case alluded to was
consequent to a wouud of the eye.
  Mr. Ware believes in the occasional absorption of the
opaque chrystalline, and recommends to expedite it, by the
application of a drop or two  of aether to the ball of the eye
once or twice  a day, together with friction over the eye-
lid with a fin°er smeared with mercurial ointment.   Lit-
tle confidence  is to be placed in such remedies, and it is 
342             ELEMENTS OF SURGERY.
now very  generally conceded  that  the  only method of
restoring sight to persons afflicted  with cataract, is  to
remove the opaque chrystalline from the axis of vision;
this may be done either by extracting it, or by depress
sing it to the bottom of the eye.  Both  of these  opera-
tions are performed by surgeons of the present  day, and
each has powerful advocates among  the most respectable
members of the  medical profession.  Other operations
have recently been invented for the cure of cataract which
shall be described presently.
  Before comparing the merits of the two operations, it
will be proper to enquire what cases of cataract promise
to terminate successfully.   Scarpa observes, " it is easy
to determine whether an operation can be performed with
a prospect  of success or not.  A favourable issue may be
expected whenever the cataract is  simple, or without any
other disease of the eye-ball;  in  a subject not quite un-
healthy or decrepid,  and in whom the opacity of  the
chrystalline humour has been gradually  formed without
having originated from any external  violence, or habitual
ophthalmia, especially the internal; where there has  not
been frequent pain in the head, eye-ball,  and superci-
lium; where the pupil, notwithstanding the cataract, has
preserved its free and  quick  motion, as well as  its circu-
lar  figure in different degrees of light; and  lastly, where
notwithstanding the opacity of the chrystalline lens,  the
patient retains the power, not only of distinguishing light
from darkness, but also of perceiving vivid colours, and
the principal outlines  of bodies which are presented to
him, and where the pupil has that  degree of dilatation
which  it is usually found  to have in a moderate  light."
  When the pupil does not contract  and  dilate in various
degrees of light, there is reason  to apprehend gutta serena
(paralysis  of the  optic nerve  and retina)  but in some
cases of gutta serena, even in both eyes this contractility 
                ELEMENTS OF SURGERY.              34,3
of the iris exists, and on the  other hand, cases have oc-
curred where no motion  could be observed in the pupil,
in which, nevertheless, the operation of extraction has
proved the retina to possess its power of vision as usual;
the  probable cause of the immobility of the pupil in these
cases, is adhesion between the posterior surface of the iris
and the anterior portion of the capsule of the chrystalline
lens.   These are to be considered however very rare ex-
ceptions  to a general rule.
  In distinguishing gutta serena from cataract, the colour
of the pupil is to be considered; it is black in the former
disease, and turbid and lighter coloured in cataract; but
Wenzel  has met with black cataracts, in which scarcely
any change could be detected in the colour of the pupil.
  Both Wenzel and his commentator, Mr. Ware, believe
it possible to distinguish the blackness of a cataract from
the natural  blackness of  the pupil.  De Haen  and Van
Swieten  have been mistaken, yet they were not professing
oculists.    Mr. Ware decides boldly that  " it is a rule
as  certain as almost any in surgery, that when  an  eye in
a state of blindness, is  accompanied with a clear black
pupil which is incapable of varying its size according to
the degree  of light to which the eye is exposed;  this
blindness is produced by a defect of sensibility in the im-
mediate  organ of vision, and removable only by the ap-
plication of proper stimuli to  rouse it again to its natural
 action."
   To ascertain with precision the nature and consistence
 of  a cataract  by  examination  is  perhaps  impossible.
 Scarpa says " all  that  has  been hitherto written  and
 taught upon this subject, has not that degree of certain-
 ty  w hich can serve as a  guide in practice, and the most
 experienced oculist of the present day is not able to de-
 termine  with  precision what the nature  and consistence
 of  the cataract is, upon which he proposes to operate, nor 
344             ELEMENTS OF SURGERY.
whether  the  capsule be yet transparent or not, although
the lens be evidently opaque.   For it is an indisputable
fact, that the capsule  sometimes preserves its transpa-
rency  when  the  lens does not.  The want of accurate
notions however, upon  this subject does  not materially
influence the success  of the operation, as the surgeon
ought in every case to be prepared to employ such means
as the particular species of cataract which presents itself
to him, may require during the performance of the opera-
tion, whether hard or soft, accompanied by opacity of the
capsule which invests it, or not.   The firm chrystalline
cataract undoubtedly admits of being more  easily removed
by the needle from the axis of vision than any other;
and does not rise again to its former place, if the surgeon
in removing it from the pupil, use the precaution of bury-
ing it in the vitreous humour.   The soft, the milky, or
the membranous cataract, however, when met with in the
operation,  may  be also removed from the pupil, effused
or lacerated with the  same needle, without the necessity
of introducing any other instrument into the eye."
   In the next place it will be proper to compare the ad-
vantages of extraction and depression as remedies for
cataract.   Scarpa says truly that " in the warmth of dis-
cussion the advantages of the one, and the disadvantages
of the other,  have been exaggerated by both parties."
   The most  ancient of these operations is depression or
couching.  The extraction  was  not performed till near
the conclusion of the seventeenth  century.  Freytagius
Lotterius, and Wenzel, are the principal surgeons con-
cerned in contriving and perfecting the operation of ex-
traction.   The last named oculist had wonderful success
 in the latter part of his life (though he confesses that he
 spoiled  a " hat full  of eyes" before he  learned how to
 operate) and his son who succeeded him, was also ex-
 tremely  celebrated. He remarks  in his treatise that " the 
                 ELEMENTS OF SURGERY.             34,5
accidents which are charged upon the operation of ex-
traction may be  reduced to the eight following;—-first,
the staphyloma;—-secondly, pain ;—thirdly, the discharge
of the vitreous humour ;—fourthly, the irregularity of the
pupil;—fifthly, the deformity of the cicatrix;—sixthly,
the closure of the pupil;—seventhly, the  secondary cata-
ract; and eighthly, the section of the iris.
   First. With regard  to the  staphyloma; Wenzel re-
marks  " that the mode in which the cornea  is divided
most commonly prevents this accident, by hiudering the
iris from  coming forwards.   But if such an  accident
should at  any time happen, notwithstanding this care to
prevent it, it may be reduced by merely rubbing the eye-
lids ;  and it does  not occasion those ill effects  which
some authors have dreaded.
   Secondly.  The unavoidable pain that attends  the ope-
ration of extraction is to be moderated, as in other opera-
tions by general remedies. It is, however, notwithstand-
ing the assertion  of a late author, less severe than  that
which is produced by depression.
   Much  has been  said  respecting the comparative pain
of the two operations:  I do not consider it an object of
great magnitude to decide this contest, because it must be
conceded on all hands  that if an important advantage is
to be gained by a temporary addition to the  sufferings of
the patient, this slight  evil should not enter into compe-
tition with a permanent benefit; and it is  notorious to all
who are conversant with the subject, that neither couch-
ing or extraction, are to be considered as very painful ope-
rations   Notwithstanding this, from what I have seen,
and I have seen very  numerous cases where  extraction
has been performed, and some cases of  couching, I am
very decidedly of opinion that couching is the more pain-
ful operation.  One patient in particular  I recollect who
had been  couched, and whose cataract had  resumed its
   vol. 1.         45 
34,6             ELEMENTS OF SURGERY.
situation, when the operation of extraction was finished
(which was performed on the other eye) exclaimed, " is
it possible the operation is over? it was not half so severe
as the couching."  I have never heard a single patient
complain of much pain during the extraction of a cataract,
but have often heard them express  great astonishment at
having suffered so little.
   TMrdly.  The escape of the vitreous humour if the ope-
ration be properly performed, will seldom take place. In
some cases, however, notwithstanding every caution, por-
tions of this fluid  will escape.  Wenzel thinks that al-
though this is a slight evil, yet the clear perception of ob-
jects  is  sometimes  diminished  by  this accident;  but I
have known a very considerable quantity of vitreous hu-
mour lost in several instances, in which not the slightest
inconvenience resulted, but the cure was perfected as well
as in the most successful cases.  This is therefore no ob-
jection to the operation  of extraction;  first, because the
escape of vitreous  humour can generally be prevented ;
and secondly, if from its unusual  fluidity, or any other
cause, a portion  of it should escape, no harm results from
its loss.
  Fourthly. An  irregularity of the form of the pupil is
an occasional consequence of the extraction of a cataract,
—but I would observe that it is a very rare accident, and
of little moment when it occurs.  The shape of the pupil
is of no great consequence,  and though I  do not agree
with Wenzel that it becomes au advantage  by enlargm0*
the aperture through which the rays of light are to pass,
yet I do maintain that patients see as well in whom some
irregularity of the pupil exists, as they in whose eyes the
pupil is a perfect circle.
  Fifthly. The  cicatrix  of the cornea.   " If the incision
be made with one instrument and one stroke, if it be near
the margin of the sclerotica and large enough to allow the 
                ELEMENTS OF SURGERY.              34-*
epaque chrystalline to pass through it without violence;
in this case the cicatrix will be scarcely visible and  will
not  at all obstruct the rays of light in their passage to the
retina."  When the incision is made originally too small
and is enlarged by means of scissors, the cicatrix becomes
opaque, but if it be near the sclerotica it does not, even if
opaque, interfere with vision. In general it is impossible  '
to discern a vestige of the wound made in the cornea.
  Sixthly.  A total closure of the pupil.   This I never
saw, and Wenzel asserts that it is  much  more frequent
after couching:  certainly the iris is often scratched and
injured by  the needle used in the latter operation, and of
course is liable to inflammation from which this closure
generally arises.
  Seventhly.  A secondary  cataract,  or  opacity of the
capsule of  the lens.   This happens both after extraction
and couching, and I  knowr net which  it most frequently
succeeds; Wenzel of course says it is most common after
couching.   One  thing is  certain, that if the  capsule be
found opaque it is easily  removed at the same time with
the  lens; if it become opaque afterward, a repetition of
the  section  of the cornea will readily enable the surgeon
to extract it.
  Eighthly.  A wound of the iris by the edge of the knife.
This accident it is generally  in the power of the surgeon
to prevent.  It commonly arises  (except  in awkward
hands) from an escape of a small portion of aqueous hu-
mour  at the puncture made by the knife in passing through
the  cornea  ; whenever the iris is found floating before the
edge of the knife, as in (Fig. 11.) a gentle friction should
be made upon the cornea with one finger  of the hand
which is at liberty, and the iris in this way  becomes  dis-
engaged from the edge of the knife.  Whether the fric-
tion acts by stimulating the iris to contract or whether by
pressure' on the cornea the iris is  stretched at its margin, 
348            ELEMENTS OF SURGERY.
and thus mechanically disengaged, is not easily ascertain-
ed.   Mr. C. Bell (without much experience in the ope-
ration)  recommends pressure, and gives what he calls
" an intelligible reason" for it.  The fact is that friction
succeeds immediately  in reducing the iris to a situation
behind  the knife, and how this is effected is of no sort of
consequence.
  Mr. Hey for whose judgment in common with the me-
dical world, I entertain a very high  respect, differs with
Ware and Wenzel, and prefers the operation of couch-
ing to extraction.   Scarpa who has attended with great
diligence to  the subject, prefers couching; and to such
authority great  deference is  unquestionably to be paid.
Each of these gentlemen has invented a couching needle
different from  that in common use, and never  perform
any other operation than depression.
  Scarpa has offered no defence of couching, but round-
ly asserts  that " observation  and experience, the great
teachers in all  things,  seem  to  have decided  in  fa-
vour of the ancient method of treating the cataract,  or
that by depression."   Mr. Hey on the contrary, enters
into a laboured  vindication of the operation, against the
attack of Baron Wenzel.
  The Baron alleges against couching many evils which
probably in the hands  of Scarpa or Hey,  never have  oc-
curred,  and like most other disputants has urged his  ob-
jections in language too strong and general.
  The  consequences to be dreaded from couching he
states under eight distinct heads ; first, great pain at the
time of the operation and subsequently to  it; second,  vo-
miting from a wound of the ciliary nerves, occasioning
collections of matter; third, pain and suppuration of the
eye from puncturing the retina; fourth, violent long con-
tinued  pain  in  the eye,  sometimes during life; fifth,
bleeding into the cavity of the eye occasioning suppura- 
                 ELEMENTS OF SURGERY.             34g
tion; sixth, the impossibility of depressing fluid or milky
cataracts ; seventh, the rising again of the lens;*  eighth,
wounding the ciliary processes. Enlarging on these ideas
Wenzel very strongly contends in favour of extraction,
and Mr. Hey taking up  each of the arguments very in-
geniously endeavours to  refute them, and  states that the
pain in couching is very trifling;—that the vomiting sel-
dom occurs, and when it does, is removed by an opiate;—
that suppuration of the eye—that the long continued pain
and  bleeding within the eye, he never has  met with in
his practice.
   The milky cataract Mr. Hey declares  " has in some
respects the advantage over a hard one, as the former is
less apt to adhere to the iris, and consequently there is
less risk of deranging the ciliary processes or their invest-
ing membrana nigra, by breaking down a soft cataract
than by removing a hard one."   Mr. Hey confesses, how-
ever, that " the softness of the cataract generally requires
a repetition of the operation but does not prevent the pa-
tient from receiving a cure."  The objection that the ca-
taract if depressed is liable to rise again, Mr. Hey admits
to be " true, but of little consequence.   A repetition of
the operation is not in this case always necessary, as the
chrystalline  will sometimes  spontaneously subside and
disappear, and when it does not, a repetition of the ope-
ration  has never failed within  the  compass of his expe-
rience of being attended  with success."
   The wound of the ciliary processes, Mr. Hey prevents
by a change in the shape of the needle which instead of
being spear-pointed should be square.
   Mr. Hey further states that the opaque capsule though
it  cannot be depressed may be so  lacerated by the nee-
dle  as soon to be absorbed.  Mr. Hey does not believe

   • The lens has been found undissolved seventeen years after couching 
350              ELEMENTS OF SURGERY,
with the Baron that a closure of the pupil or an opacity
of the capsule of the lens, are to be considered as solid
objections against couching.
  Mr. Hey when he quits  his defensive attitude, and at-
tacks the operation of extraction by replying to Baron
Wenzel and Mr.  Ware, in their account of its advan-
tages, appears by no means a powerful opponent.  Unit-
ing with Mr. Hey in the sentiment with which he closes
his chapter upon  cataract, I can declare with truth my
wish " that that mode of operating may prevail which is
most beneficial to  the afflicted."  I have no hesitation in
deciding from what I have  seen and  read, and from hav-
ing myself performed the operation (though not frequent-
ly) that extraction in a great majority of cases, ought to
be performed  in  preference to couching,  and I have no
doubt that its advocates would be much more numerous,
if the operation were as easily performed, for the greatest
advantage which I conceive couching to possess is the fa-
cility with which it is done  ; it is in fact an operation, re-
quiring very little dexterity or science.  I shall describe
both operations. 
ELEMENTS OF SURGERY.
351
                 CHAPTER LVII.

                   Of Extraction.

  It will generally be proper that the patient for a week
before the operation be confined to a low diet—he should
be free from catarrh and other diseases—coughing, sneez-
ing, or vomiting would prove extremely pernicious after
the operation. The seasons to be preferred are the spring
and fall, when the weather is settled and mild.
  The instruments necessary in  the operation of extrac-
tion are a knife for  dividing the cornea;  the one to be
preferred is the instrument invented by the elder Wenzel.
u It resembles the common lancet employed in bleeding,
except that its  blade is a little longer and not  quite so
broad.   Its edges are strait.   The blade is an inch and a
half long and a quarter of an inch  broad, in the widest
part of it, which is at the base.  From hence it gradually
becomes narrower towards the point, so that this breadth
of a quarter of an inch extends only to the space of about
one-third of an inch from  the base,  and for the space of
half an inch from the point, it is no more than one-eighth
of an inch broad."
  One  edge  is sharp  through the  whole length of the
blade, at the  distance of a quarter of  an inch from the
base, this  lower edge  has  a  slight projection.  The up-
per edge is  divided into three portions for the  space of
five-sixths of an inch from the basis ; this edge is blunt,
and very little flattened. For the  space of half an inch or
rather six lines and a half* further towards the  point, it
is blunt and rounded, although very thin. The extremity
of this edge to the extent of one-eighth of an inch from the
             * A line is the twelfth part of an inch. 
  352             ELEMENTS OF SURGERY.
  point, is keen like the lower edge, in order to facilitate
  the conveyance of the  instrument  through the cornea—
  the handle is octangular.  The knife is represented in
  Fig.  14.
    I have described it particularly,  because much of the
  success of  the operation depends upon the perfection of
  the instrument.   Mr. Ware uses a knife very little dif-
  ferent from Wenzel's ;  it is rather wider near the point,
  in order that the  edge may quickly get below the infe-
  rior margin of the pupil  and thus avoid wounding the
  iris.
   It has been customary in operating on the eye to make
  use of a contrivance called a speculum to  keep the eye
  motionless; a variety of specula have been constructed,
 but in the opinion of Baron Wenzel they are useless. In
 addition to  the knife, a curette,  or  small scoop of silver
 or gold, and a curved needle of steel which  are gene-
 rally fixed  to one handle (Fig. 15.);—a small steel hook
 (Fig.  13.);—and a pair of small forceps  (Fig. 16.) are
 all the instruments required for the operation.   Instead
 of the forceps copied from Wenzel, a more convenient
 form is  that delineated (Fig. 4.) the extremities  are to
 be flat, and their surfaces  of contact when closed about
 the fourth of an inch.

                      OPERATION.

   The patient is to be seated in a low chair before a mo-
 derate light which strikes  the  eye obliquely.   Baron
 Wenzel directs the operator to proceed in  the following
 manner.
   " The sound eye being  covered with a compress re-
 tained by a bandage, an assistant, placed behind, must
 hold the patient's head, and support it on his breast.
 With the fore-finger of the hand that is at liberty, he is
then to raise the upper lid of the eye to be operated upon, 
                 ELEMENTS OF SURGERY.             333
and gently to press the tarsus, with the extremity of the
finger, against the upper edge of the orbit.   In order to
assist this arrangement,  and properly  to  fix the upper
lid, the assistant should take care to draw up the  skin
over the orbit, and  strongly  to fold the teguments that
support the eye-brow.  By this method, the eye will be
entirely uncovered,  an undue pressure upon it  will be
avoided, the fingers of the assistant will  not interfere
with those of the operator, and the eye-lid  will  be so
fixed as to be incapable of any motion.
  "The operator is to be seated on  a  chair, a  little
higher than  that df the patient.   The eyes  naturally
turning towards the  light,  he is to place the head of the
patient obliquely to  a window;   so that  the eye  to be
operated upon may be inclined towards the outer  angle
of the orbit.   This  position of the  eye will  enable the
operator to bring out the knife, on the  inner side of the
cornea, opposite to the part where it pierces  this tunic,
more  exactly than he would otherwise be able to do.
The operator is to rest  his right foot on a stool, placed
near the patient, that his knee may be raised high enough
to support the right  elbow, and to  bring the hand  with
which  he holds the knife, to a level  with the  eye on
which he is  to operate:   (this direction I think unne-
cessary if the operator have a steady hand.)  He is then
to take the cornea knife in his right hand, if it be the
left eye on which he is to operate, and, vice versa, in
the left hand, if it be the right eye.  The knife is to be
held like a pen in writing, and his hand is to rest stea-
dily on the outer side of the eye, with the little finger,
separated a little from the  rest, on the edge of the orbit.
In this position he is to wait, without any hurry to begin
the  incision,  until the eye  which is usually very much
agitated by the preparations for the operation, becomes
perfectly still.  This always  takes  place within a  few 
354              ELEMENTS OF SURGERY.
seconds  of time; and, therefore, as I have already fully
expressed  myself on this  subject^ »every instrument in-
vented to fix it is useless.
   " When the eye is still and so turned towards the outer
angle of the orbit, that the inner and inferior part of the
cornea, through which the point of the instrument is to
come out, may be distinctly seen, the operator is to plunge
the knife into the upper and outer part of the tunic,  a
quarter of  a line distant from the sclerotica,  in such a
direction, that it may pass obliquely from above down-
wards, parallel to  the plane of the iris.   At the  same
time, the operator must  depress  the  lower lid  with his
fore and middle fingers, which  are to be kept a  little
distant one from the  other, and must take the greatest care
to avoid all  pressure on the globe,  which is  to be left
perfectly free, as the surest way to diminish its power of
moving.*
   " When the point of  the  knife has  proceeded so far
as to be opposite to the pupil, it is to be dipped into this
aperture, by a slight motion of the hand forward, in order
to puncture the capsule of the chrystalline ;f and then by
another  slight motion, contrary to the former, it must be
withdrawn from the pupil, and, passing through the an-
terior chamber, must be brought out near the inferior part
of the cornea, a little inclined to the inner  angle, and at
the same distance from the sclerotica, as when it pierced
the cornea above.   If the knife has been well-directed,
and the  fore and middle  fingers of the hand opposite to
that which holds the instrument, have been properly ap-
plied, the section  of the  cornea,  thus completed, will be

  * Mr. Ware very properly condemns this direction, and advises the eye at
this time to be moderately pressed, which certainly serves to fix it, and pre-
vent its motion.
  f Baron Wenzel's practice in this particular, is not to be imitated by any but
experienced operators. 
                 ELEMENTS OF SURGERY.             355
found sufficiently large; its  shape will be semi-circular;
and  it will be quite  near enough to the  margin of tire
sclerotica."  (Wenzel.)
  When the iris is unusually convex, and in making the
section of the cornea becomes entangled before the knife,
the cornea  is to  be rubbed downward with  the finger,
Which disengages it.  A fear of wounding the iris, should
never induce the operator to make the section of the cor-
nea at too great a distauce  from the sclerotica, because
the section will in that case be  too small to allow the lens
to escape.
   While the section of the cornea is proceeding, and when
the point of the knife has passed out at the side opposite
to the part at which it entered, the assistant lets the upper
eye-lid drop, and all pressure  is immediately taken off.
   The next part of the operation consists in puncturing
 the capsule of the chrystalline lens, for  I believe few
 surgeons have  dexterity and confidence enough to do  it,
 generally,  with the cornea knife.  The best  mode of ef-
 fecting this will be  to introduce the needle (Fig. 15.)
 through  the wound  in the cornea, into the  pupil, and
 move it gently, but freely and quickly, in all directions;
 by this manoeuvre the anterior portion of the capsule will
 be lacerated, and a gentle degree of pressure  being made
 upon the eye, the pupil is observed gradually to enlarge,
 and one edge of the lens is observed escaping through it;
 all  pressure  is to be  immediately  removed, and the
 opaque chrystalline escapes.
   Sometimes it is necessary to  assist its escape through
 the aperture in the cornea,  by the use of the needle,  or
 scoop, and any portion of opaque glutinous matter which
 remains behind  are to be  carefully removed by the cu-
 rette.  If the capsule be not opaque the pupil will now
 be observed to have regained its natural blackness, and
 the patient will  discover the surrounding objects.  In a 
336             elements of surgery.
majority of the cataracts  which I have  seen extracted,
the centre has been firm and dense, but portions of the
external part have been soft and glutinous, and have re-
mained after the extraction of the central portion.  If it
be inconvenient to remove them all, it will be better to
wait for their  absorption than to augment the danger of
inflammation by protracting the operation too long.
  Sometimes the cataract, according to Wenzel, adheres,
and must be separated by the needle from its adhesions,
this is in general  readily effected by inserting the needle
in the lens, and  moving it gently in different directions.
  If the capsule of the lens be found opaque, it may now
be extracted, by  means of a pair of small forceps; those
recommended by Wenzel, (Fig. 16.) are much too clumsy,
they cannot, from their bulk, be readily opened and shut
in the wound of the cornea, it is more convenient to have
forceps resembling those delineated in Fig. 4.
  The anterior portion of the capsule is  most frequently
opaque, and sometimes considerably thickened and indu-
rated; when this is the case it comes out at once; if it be
torn, however, the fragments are to be removed, and dur-
ing this part of the operation, great  care must be taken to
avoid the escape  of the vitreous humour;  the eye should
not be kept open long at  a time,  and the attempts to ex-
tract the portions of opaque  capsule,  should be repeated
as often as necessary, but not continue more than a minute
at a time, and the eye in the intervals should be covered
with a small compress of fine  linen wet with clear cold
water.
  Dr. Physick has, in some cases where the capsule was
evidently opaque, extracted it first with the forceps; when
this is done the lens descends  below its  usual situation,
but its falling to  the bottom of the eye " does not appear
to be quite correct; it was in the cases alluded  to, very
easily extracted with a  curved needle,  or small hook, 
                ELEMENTS OF SURGERY.              33^
(Fig. 13.) this hook is occasionally useful  in  removing
portions of the capsule as well as of the lens and should
always be at hand.
  The lens  does, however, in  a diseased state of the
vitreous humour, descend in  some cases to the inferior
part of the eye, and in these cases pressure cannot be
used, and it must be extracted with the hook.
  If the capsule though lucid at the time of the opera-
tion should become subsequently opaque, forming what
is called secondary cataract, the section  of the cornea is
to be repeated, and the opaque membraue removed.. The
subsequent treatment consists in  preventing inflammation.
The patient should lie on his  back for eight or ten days,
the room being  somewhat darkened: the eye requires no
dressing but a compress loosely applied:  the hands ought
in every instance to be secured to the sides of the bed by
means of tapes, in such a manner as  to  prevent their
reaching so  high  as the head, persons waking, are very
apt to rub their eyes, and  sight has been destroyed by
 such accidents, the caution  just  given  ought therefore
 never to be neglected; a low diet, and if necessary from
the accession of fever, bleeding  and purging ought to be
 directed.
   For much useful information on the present subject,
 the reader is referred to the writings of Mr. Ware, and
 Baron Wenzel. 
358
ELEMENTS OF SURGERY.
                CHAPTER  LVIII.

                    Of Couching.

   It has already been  mentioned, that this operation
consists in depressing the opaque chrystalline lens, and
removing it  from the  axis  of vision.  The  couching
needles generally employed are those of Saunders,  fig.
5; of Scarpa, fig. 6; and of Hey, fig. 7- No very parti-
cular description need be given.  Scarpa's needle is,  in
my opinion, to be preferred; it possesses firmness enough
to enter the eye without danger of its breaking, and has
a point somewhat curved. The curved extremity is sharp
at the edges,  and polished and  flat upon its convex dor-
sum  ; there is a mark on the side of the handle which
corresponds to the convexity of the point.   It should be
made rather shorter than Scarpa directs.  I shall quote
the description given by this celebrated oculist of his
operation.

                     OPERATION.

   " Every thing being arranged for performing the ope-
ration, the surgeon should place his  patient on a low
seat, on the side of a window which  has a northern as-
pect, so that the light coming from it may only fall upon
the eye which is to be operated on laterally.  The pa-
tient's  other eye being  covered,  although affected with
cataract,  the surgeon ought to place himself directly op-
posite the patient, upon a seat of such a height, that
when he is prepared to operate,  his mouth shall be on a
level with the patient's eye.  And, in order  to give his
hand a greater degree of steadiness in the several mo- 
                ELEMENTS OF SURGERY.             35Q
tions  which the depressions of the cataract require, the
elbow corresponding  to this hand should  be supported
upon  the knee of the  same side, which for this  purpose
he should raise sufficiently  by resting his foot upon a
stool, and according to  circumstances also, by placing a
small hard pillow upon his knee.  An able assistant si-
tuated behind the patient, with one hand fixed upon the
chin, should support the patient's head against his breast,
and with the other placed on the forehead, gently raise
the upper eye-lid  by means of Peltier's elevator,  care-
fully  observing to  gather  the eye-lid  against  the arch
of the orbit, without pressing  upon the  globe of the
eye.
  " Supposing then the eye to be operated on is the left,
the surgeon taking the  curved needle in his  right hand,
as he would  a writing pen, with the  convexity of the
hook forwards,  the point back,  and the handle in a  di-
rection parallel to  the patient's left temple; should rest
his fingers upon the temple,  and boldly perforate the eye-
ball in its external angle, at rather more than a line from
the union of the cornea  and sclerotica, a little below the
transverse diameter of the  pupil, gradually  moving the
extremity of  the handle of  the  needle from behind for-
wards from the patient's left temple,  and consequently
giving the whole instrument a curved motion,  until  its
bent point has entirely penetrated the eye-ball; which is
effected with the greatest readiness and ease.  The ope-
rator  should then conduct  the convexity  of the needle
upon the summitof the opaque chrystalline, and by pressing
upon it from  above downwards, cause it to  descend a lit-
tle, carefully passing the curved point at the  same time
between the corpus ciliare and the capsule of the chrystal-
line lens, until it be visible before the pupil, between the
anterior convexity of the capsule of the lens and the iris.
Having  done this he should cautiously push the  hook 
 360             ELEMENTS OF SURGERY.
 with its  point turned backwards  towards the internal
 angle of the eye, passing it  horizontally between the
 posterior surface of the iris, and the  anterior convexity
 of the capsule, until the point of the needle has arrived
 as near the margin of the chrystalline and capsule as pos-
 sible, which is  next the internal angle  of the eye, and
 consequently beyond the centre of the opaque lens.  The
 operator then inclining the handle of the instrument more
 towards himself,  should press the curved point of it deep-
 ly into the anterior convexity of the capsule, and  sub-
 stance of the opaque chrystalline, and by moving it in the
 arc of a circle, should lacerate the anterior convexity of
 the capsule extensively,  remove the cataract from  the
 axis of vision,  and  lodge it deeply in the vitreous hu-
 mour, leaving the pupil perfectly round, black, and free
 from every obstacle  to the vision.  The  needle being re-
 tained in  this position for a short time,  if no portion  of
 opaque membrane appear behind the pupil, which would
 require the point of  the instrument to be turned towards
 it,  in order to remove such obstacle,  (for with respect to
 the chrystalline,  depressed in the manner now described,
 it never rises again) the surgeon should give the instru-
 ment a small degree of rotatory  motion, in order to dis-
 entangle it easily from the depressed cataract, and should
 withdraw it from the eye in a direction  opposite to that
 in  which it  had been introduced,  that is  greatly  in-
 clining and turning the handle towards the patient's left
 temple.
   " In every species of cataract, with considerable opa-
 city and  density of  the anterior hemisphere of the cap-
 sule of the chrystalline, the surgeon may very easily know
 during the operation, whether the curved  point of the
 needle, insinuated between the corpus ciliare and the cap-
 sule,  is exposed  between the  pupil and  the anterior he-
misphere of that  membrane; or, whether  having pene- 
                  ELEMENTS OF SURGERY.             ggi|
  trated into the membranous sac of the chrystalline, it has
  only advanced between  the  anterior hemisphere of the
  capsule and the opaque lens.  But when the capsule, not-
  withstanding the opacity of  the chrystalline  lens, pre-
  serves in a great measure,  or entirely, its transparency,
  it is  an easy matter for a young surgeon, not sufficiently
  conversant with this operation, to commit an error,  and
  one of great importance, that is,  to remove  the  cataract
  from the axis of vision, and  lodge it in the vitreous hu-
  mour, leaving the anterior convexity of the capsule  un-
  touched, which afterwards gives rise to the  secondary
  membranous cataract.
    " To avoid this serious inconvenience, every operator
  should'  be particularly careful to satisfy himself before
  making any movement with  the point  of the needle for
  depressing the cataract, that  the curved extremity of the
  instrument is really, and not apparently, situated between
  the pupil and the  anterior  portion of the capsule, of
  which he will be convinced by the degree of light which
  the convexity of the hook presents to him,  and the faci-
  lity which he finds  in pushing it forwards  through the
  pupil towards the anterior chamber of the  aqueous hu-
  mour, and in moving it horizontally between the iris and
  anterior hemisphere of the capsule.   In the opposite case
  he may be  certain that the curved point  is within the
  membranous sac of the chrystalline, by observing that the
  extremity of the needle is  obscured and covered by a
  more  or less transparent veil; that he meets with some
  resistance in pushing it through the pupil into the ante-
  rior chamber of the aqueous humour; and that in doing
  it, this membranous veil which covers the hook is ele-
  vated towards the pupil,  and lastly, that the point of the
  needle is with difficulty conducted horizontally between
  the iris  and the cataract,  from the external  towards the
^  internal angle of the eye.
    VOL.  I.         4/ 
362             ELEMENTS OF SURGERY.
  " The  surgeon will remedy this  inconvenience, by
giving a slight rotatory motion to the needle, by which
the point being forwards will pass through the  anterior
convexity of the capsule opposite the pupil; the point of
the instrument being then turned backwards again, should
be passed horizontally between the iris  and the anterior
hemisphere of the capsule towards the internal  angle of
the eye, and having reached this part should be boldly
plunged into the capsule, and the substance of the opaque
lens, in order to lacerate the former extensively, and to
carry the latter deeply into the vitreous  humour out of
the axis of vision, and thus complete the operation.
  " When,  without observing this  precept, the opaque
lens  is removed,  or, more strictly speaking, enucleated
from its capsule and lodged in  the vitreous humour; and
the anterior  convexity of this membrane  being left entire,
is slightly opaque, the pupil will appear black, and  so
free from obstruction to the light as easily to deceive the
young surgeon, and induce  him to believe that the ope-
ration has been properly executed.   But persons expe-
rienced in this part of surgery, will instantly perceive
that the pupil under such circumstances, has not that just
and perfect degree of blackness which it  ought to have,
and that this slight dimness  is  caused by  an imperfectly
transparent membranous veil, placed between the  pupil
and the bottom  of  the  eye, which when  suffered  to re-
main, never fails, in process of time, to give rise to the
secondary membranous cataract. In  this case, the expert
operator having depressed the opaque  lens,  should im-
mediately turn the  curved point of  the needle forward,
and pass it through the pupil into the anterior chamber of
the aqueous humour, in order to perforate this semi-trans-
parent membranous veil with the greatest certainty; then
turning the point of the needle  backwards and making it
pass as far  as possible between the posterior surface of v 
                ELEMENTS OF SURGERY.             3fi3
the iris and this membrane, should press the point of the
instrument into it and lacerate it from before backwards,
making a  movement as if  he had  to depress the lens
again.  In doing this he will have the satisfaction to see
the pupil assume the deep black colour of velvet, and a
degree of clearness which it had not  before, although the
opaque lens had been completely removed  from the axis
of vision.
   " Hitherto I have supposed the cataract to be of a firm
consistence, and to resist the pressure of the needle. But
if the operator should meet with a fluid cataract, the
milky for instance, which is not an unfrequent occurrence,
when he has passed the needle  between the  corpus ci-
liare and the capsule, until it appears uncovered between
the pupil and the anterior hemisphere of the membranous
sac of the chystalline lens, and the curved point has been
cautiously  advanced between the iris and the  margin of
the capsule, nearest  the internal angle of the eye; at the
moment  that the point  of the needle is deeply  pressed
into the  capsule and cataract, a whitish milky fluid will
be seen to issue from the capsule, which extending itself
in the form of a cloud or smoke, will be diffused through
both the  chambers of the aqueous humour, and  obscure
the pupil and the whole of the eye.  The surgeon should
not on this  account lose his confidence, but, guided by
his anatomical  knowledge, should make  the small hook
describe  the arc of a circle from the internal towards the
external angle of the eye, and from before backwards, as if
he were  depressing a solid cataract, with a view of lacerat-
ing as much  as possible, the anterior hemisphere of the
capsule,  upon which the favourable success of the opera-
tion principally depends, not only in this, but in every
other species of cataract.  For as to the effusion of the
milky fluid into the chambers of  the aqueous humour, it
disappears spontaneously a few days after the operation, 
364             ELEMENTS OF SURGERY.
and permits the pupil and the whole of the eye to resume
their former natural brightness.
  " The method of operating which the surgeon should
employ will be little  different from  this,  if, during its
performance, he should meet  with a soft or cheesy  ca-
taract.  The anterior convexity of the capsule should be
lacerated as much as possible  opposite the pupil, so that
the opening may equal the diameter of the  pupil in its or-
dinary dilatation.  And with  respect to the pulpy sub-
stance of the cataract, which, in such cases, remains be-
hind, partly diffused in  the aqueous  humour, and partly
swimming beyond the pupil,  all that is necessary, is to
divide the  most tenacious  parts of that substance, that
they may be more easily  dissolved in the aqueous  hu-
mour, and  to push those moleculae of the caseous sub-
stance of the chrystalline, which cannot be sufficiently di-
vided, through the pupil into the anterior chamber of the
aqueous humour, in order that they may not be carried
opposite the pupil, but being situated at the bottom of the
anterior chamber, may be  gradually  dissolved and  ab
sorbed without obstructing the sight." (Scarpa.) 
ELEMENTS OF SURGERY.
365
                 CHAPTER LIX.

                Of Congenital Cataract.

  The late Mr. Saunders of London, instituted an in-
firmary for the reception of patients afflicted with diseases
of the eyes—he lived but a  few years after its founda-
tion, long enough however, to be very  useful as surgeon
to the  establishment,  and a small  posthumous volume
published in 1811, contains a number of highly interest-
ing remarks on various affections of this important organ.
The following observations on congenital cataract are ex-
tracted principally from his writings.
  The causes of congenital cataract are unknown :  it ap-
pears sometimes in several of the same family. Mr. Saun-
ders saw sixty cases of the disease between June  1806,
and December 1809, so that it is by no means unfrequent.
He relates many cases where several children of the same
parents were born blind.
  The opacity is generally seated in the  capsule;  the
lens  being absorbed.   Sometimes the lens is opaque, and
solid or fluid as in adults.   Mr. Saunders found that the
only treatment necessary, was  to perforate the centre of
the capsule, and if a permanent aperture was made in that
membrane, the  lens if it  existed was  subsequently ab-
sorbed.
  Children affected with the  disease possess various de-
grees of vision.   Some indistinctly see external objects,
others  can only discern bright colours or vivid lights.  If
the privation of vision be nearly complete, volition for
want of an external object to  attract these organs,  is not
exercised over the muscles belonging to them, and their 
 3(56             ELEMENTS OF SURGERY.
 actions are  not  associated, but  the eye rolls here and
 there with rapidity, and trembles as it moves.
   The excessive mobility of the  eye, the unsteadiness of
 the little  patient, the small field for the operation, and
 the flexibility of the opaque capsule, are the difficulties
 with which the surgeon has to contend.   Mr. Saunders
 overcame them  by fixing the  eye-ball with a speculum,
 controlling the patient, dilating the pupil with belladon-
 na, and by using a diminutive needle armed with a cut-
 ting edge  from its shoulders to its point,  and thin enough
 to penetrate with the most perfect facility.   This needle
 is delineated in Fig. 5.
   The extract of belladonna is to be diluted with water
 to the consistence of cream and  dropped  into the eye,
 or the extract undiluted  may  be  smeared over  the eye-
 lid and browr.  In half an hour, or an  hour the pupil  is
 fully dilated, and the application  should  be then washed
 off.  The patient is confined in a proper position and in
 a situation near a window by a sufficient number of as-
 sistants, who take great care to fix the head  motionless,
 and to secure the limbs from  moving.   The operator  is
 seated on  a high chair, behind the patient, takes the spe-
 culum in one hand and the needle in the other.
  Should  the capsule contain an opaque lens, the sur-
 geon gently introduces the  bow of the speculum under
 the upper eye-lid, his assistant at the same time depress-
ing the lower, and at the moment he is about to  pierce
 the cornea, he fixes the eye by resting the speculum w ith
 a moderate pressure upon the eye-ball.   The position  of
 the operator  enables him to  do this with perfect safety,
 and by that consent  which can only exist between the
 hands of the same person, he not only discontinues the
 pressure,  by using  the speculum  merely as an  elevator
 of the lid, as soon as his purpose  is accomplished, but
 he with facility renews or regulates the pressure at  any 
                   ELEMENTS OF SURGERY.             3(W
  moment in which it may be required.  He penetrates the
  cornea  as  near to  its junction with the  sclerotica as it
  will admit the flat surface of the needle to pass, in a di-
  rection  parallel and close to the iris, without injuring this
  membrane.    When  the point of the needle  has arrived
  at the  centre of the dilated  pupil, he does  not boldly
  plunge  it through the capsule into the lens, and perform
  any depressing motion;  it is a material object with him
  not to injure the vitreous humour or  its capsule ; neither
  does he lift the  capsule of the lens on the point of the
  needle, and by forcibly drawing it forward into the an-
  terior chamber, rend it through its whole  extent.   Such
  an operation would dislocate the lens, deliver it into the,
  anterior chamber, or leave it projecting in the  pupil, and
  stretching the iris;  and  although its soft  texture in the
  child should exempt him  from  any disorganizing in-
  flammation, the most favourable result will be a perma-
  nently  dilated iris,  deforming the  eye.   He proceeds
  with a  gentle lateral  motion, working with the point and
  shoulders of the needle only on the surface  and centra
  of the  capsule, in  a circumference  which does not ex-
  ceed the natural  size of  the pupil.  This object is  per-
  manently to  destroy this central position of the capsule:
  merely  to  pierce it would not answer his intention, be-
  cause the adhesive  process will speedily close the wound.
  Having acted upon the centre of the anterior lamella of
  the capsule  to the extent  which he  wishes,  he gently
  sinks the needle into the body of the lens, and mode-
  rately opens its texture.   In doing this he may,  if he
v. pleases, incline the edge of the needle, by which motion
 1 the aqueous  humour will escape, and the lens will ap-
  proach  his instrument; but at the same time his field for
  operating will be diminished  by  the  contraction of the
  pupil.  The needle  and  speculum are now to be with-
  drawn, the  eye is to be lightly covered, and the patient
  put to bed, 
368             ELEMENTS OF SURGERY.
   Inflammation is seldom excited by  this operation on
the child; but its first approach, marked by  pain and
unusual  redness  of  the conjunctiva, or serous effusion
under it, must immediately  be arrested by  the applica-
tion of leeches  on the palpebrae, and, in stouter children,,
by bleeding from the arm, followed by purgatives and a
very low diet.   Soon after the operation the  extract of
belladonna should be applied over the eye-brow, to pre-
vent, by  a dilatation of the iris, the adhesion of  the pupil-
lary margin to the wounded capsule.  Nature  now per-
forms her part of the cure, and the lens, loosened iu its
texture, and  through the aperture in  the  capsule, sub-
jected to  the action of the aqueous humour, is  gradually
dissolved and absorbed.
   A  single operation sometimes suffices,  and the cure
is completed in the space of  a few weeks; but if the
process should  not advance  with sufficient rapidity, the
operation may  be repeated  once or  oftener, interposing
at least a fortnight between each operation.   If the ad-
hesive process has counteracted his  former operation on
the capsule, he will take care now to effect the perma-
nent aperture in  its centre, and  he may use greater li-
berty than at first in opening the texture of the  lens.
   Some  have supposed that  the  fluid cataract is not
only the  most frequent, but  the most manageable  of the
congenital cases.   Both suppositions are erroneous.  It
is not only the least common,  but the fluid, when extra-
vasated sometimes excites a hazardous inflammation.  In
these cases, after puncturing the anterior lamella  of the
capsule,  and discharging its contents  into the anterior
chamber, it wall be prudent  to desist for the time,  and to
guard against inflammation: by this operation the case
will be converted into a capsular cataract.
   Where the lens is nearly or  quite absorbed, and the
capsule only is opaque, the  surgeon may use the needle 
                ELEMENTS OF SURGERY.             369
with more freedom than in the lenticular cataract, but in
other respects he  proceeds in the manner above describ-
ed.  If any portion of the lens remain as a small nucleus
or scale, in the centre of the capsule, his efforts will  be
exclusively directed to detach this  portion,  by which  he
will fulfil the intention of the operation, that of effecting
a permanent aperture in the centre of the capsule.
  Mr. Saunders  in  some cases punctured  the sclerotica
and perforated the capsule from behind :  he  observes,
that in this posterior operation the surgeon has more
power, but that the  anterior operation excites less pain
and inflammation, and inflicts a slighter injury (if any)
on the vitreous  humour;  from the facility with which the
qornea heals I should prefer the anterior operation.
  The number of operations which may  be necessary
to accomplish the cure of a  congenital cataract, will de-
pend much upon the texture of the capsule, and the size
of the lens.   It is frequently cured by a  single opera-
tion; more  frequently  it  requires two;  often three;
sometimes four;  but very rarely five.   In sixty patients
Mr. Saunders, (the author of the operation) succeeded in
giving sight to fifty-two.   In thirteen he operated on sin-
gle eyes.  In forty-seven he operated on both eyes. The
ages were as follows : five, from two to nine months; nine,
from 13 months to two yeavs; four, from two and  a half
to three years ; five, from three and  a half to four years ;
eight, from  four to  six years.   Seven,  at  seven years;
eight, from seven to nine; ten, from nine to fifteen; and
four from twenty to  twenty-eight.  The  greatest suc-
cess attended the operation  when performed between the
ages of 18  months and  four years.   The age  of two
years is perhaps preferable to any  other.  It is extreme-
ly important to operate as early  as possible, because,
the muscles  acquire  an  inveterate habit of  rolling the
eve so that for a long time, no voluntary effort can con- 
g^O              ELEMENTS OF SURGERY.
trol this irregular motion,  nor direct the  eye to objects
with sufficient precision for the purpose of distinct and
useful vision.
  I cannot refrain in this place from expressing my high
sense of the ingenuity of Mr. Saunders, in  the contrivance
of the simple and important operation which has been de-
scribed. When the advantages of education are consider-
ed, and the necessity of sight for this purpose, the magni-
tude of the object will appear very great,  and when the
success of his practice is recollected, (52  cures of 60 pa-
tients) his skill and judgment cannot be too highly rated.
Since Mr. Saunders' publication I have met with but one
case of congenital cataract, (which from all the inquiries
I can make, I believe to be extremely rare in America, as
from Scarpa's account it is in Italy) but in that one case
I succeeded in restoring vision, and my patient, now four
years old, sees very well.
  Before concluding this  subject, I beg leave to suggest
the propriety in cases of cataract where the pupil is great-
ly contracted,  of  using either the belladonna,  as directed
by Mr. Saunders, or  the extract of stramonium, which
operates in the same manner; great difficulty sometimes
attends the extraction of the lens, owing to the contracted
state  of the pupil, the applications just proposed will
probably be found to obviate this difficulty, and perhaps
another, the entangling of the iris  on the point of the
knife, because the dilatation of the pupil, occasioned by
stramonium and  belladonna, is so great, that the iris ac-
tually resembles a narrow ring at the margin of the cornea.
  The effect  of  certain narcotic plants in dilating the
pupil of the eye, both when externally and internally ad-
ministered, has been long known, but it is only a few
years since surgeons have availed themselves of it, in ex-
amining cataracts, and facilitating their extraction.   Mr.
Wishart,  in a paper published in  the Edinburgh  Med.
and  Surg. Journal, for January 1813, recommends very 
                 ELEMENTS OF SURGERY.            %Jl
strongly the hyosciamus, and quotes professor Himly of
Gtittingen, who has made comparative experiments with
belladonna and hyosciamus, and prefers on his authority*
as well as from his own observation,  the  latter article.
The mode of using it is, to dissolve a dram of the extract
in an ounce of water,  of which solution a few drops are
to be let fall into the eye.  It occasions no pain nor red-
ness. The effect on the pupil commences in an hour, and
continues five or six hours.
   There are several advantages which may be gained by
artificially dilating the pupil. I  have known a lady blind
except at  noon; her pupil was no larger than a pin's
head, the  use of stramonium enabled her to see tolerably
in various degrees of light.  In examining cataracts, the
larger the pupil, the more readily we  may ascertain the
circumstances of the case.  It is always in the surgeon's
power to learn whether the iris be adherent, in which
case no dilatation of the pupil will be  occasioned by the
narcotic applications.   In cases of partial opacity in the
cornea, the dilatation of the  pupil enables the patient to
see by withdrawing the iris from behind a lucid part of
the cornea, and thus forming a temporary substitute for
an artificial pupil: the advantages of a  dilated pupil dur-
ing the operation of extracting a cataract, have been al-
ready mentioned; but  an inconvenience has been dreaded
from the escape of the vitreous  humour, in consequence
of a want of that support which the iris afforded.   The
experiments of Himly quoted  by Wishart, appear  to
prove that this fear need not be entertained, and the sur-
geon  may doubtless avail himself safely of the  benefits
which are to be  derived  from  the  application of these
narcotics to the eye.
   Amon°- the consequences of the extraction of cataract,
hypopion and  staphyloma are the  most formidable,
happily they are  of rare occurrence, I have never  seen
either.  Hypopion is a collection of matter in the anterior 
372            ELEMENTS OF SURGERY.
chamber of the eye.  The term empyesis signifies a col-
lection of  pus in the posterior chamber, both  are conse-
quences of violent inflammation, and occasionally occur
after ophthalmia.
  In cases of hypopion the continued use of the reme-
dies for inflammation seldom fails of producing an ab-
sorption of the  pus;—as this absorption  goes on, the
pus being heavier than the aqueous  humour  falls to the
bottom  of the anterior chamber of  the  eye,  forming a
semicircle of a yellow colour, the circumference of which
is formed by the cornea.   It is very seldom necessary to
puncture the cornea for the evacuation of the  pus, active
purges  are  to be repeatedly administered, but, if aided
by  the  usual depleting remedies they are unsuccessful, a
puncture must be made. These remarks apply equally to
hypopion from inflammation of the eye arising from other
causes.
  The  staphyloma is a tumour projecting through the
wound of the cornea, formed generally of the iris, but in
some cases  of a transparent membrane, which Wenzel
calls the capsule  of the  aqueous humour.  When upon
looking at  the eye  for the first time, which is generally
done m six or eight days after the operation, the iris is
observed protruding through the wound, no attempt should
be made to replace it; as the  opening in the natural cornea
closes, the iris generally regains its situation. The tumour
formed by a transparent membrane, is of a very different
nature.  The membrane is  probably an adhesion formed
of coagulating lymph, distended afterwards by an abund-
ant secretion of aqueous humour; if cut off or destroyed, it
generally returns again, which would not be the case if it
were formed of an organized capsule.   Wenzel  recom-
mends  the case to be left to nature, the eye-lids gradually
produce by friction and pressure, an absorption of the
tumour.  Staphyloma sometimes results from ulcers of
 the cornea; in these cases, if it continue obstinate and do 
                ELEMENTS OF SURGERY.             373
not subside spontaneously, the lunar caustic must be ap-
plied.
  Scarpa denominates the staphyloma formed by the iris
" procidentia iridis," which is surely a more proper ap-
pellation, for it is perfectly distinct from the tumour just
described, which is often pellucid, but when opaque  is of
a pearly white colour, and easily distinguishable from the
protruded iris.
  Staphyloma  is sometimes occasioned by small-pox—
in this  case  the tumour is of a  white colour like the
opaque cornea.   In general it ulcerates and occasions in-
flammation of the eye; in these cases the tumour may be
cut off,  and should it reappear lunar caustic is to be ap-
plied.
   The term staphyloma has been vaguely applied  to
many and various  tumours  of the cornea.   It has  been
called total when the whole cornea is morbidly promi-
nent, and partial when the tumour is confined to a portion
only.  For some very interesting remarks on this  sub-
ject the reader  is referred to Wardrop, and Scarpa.

  Since the  first  edition of the Elements  of Surgery,
some very important improvements have been made in the
treatment of cataract, which I shall next relate, having
judged it proper to leave my previous account of extrac-
tion and couching for the  information of those readers
who may not have access to other works  on these sub-
jects.
  Mr. Saunders's operation of lacerating the capsule and
destroying the  texture of the lens, by means of a double-
edged needle introduced through the cornea or sclerotica,
which succeeds so happily in cases of congenital cataract,
has been found also well adapted to a large number  of
cataracts occurring in advanced life.  I have myself em-
ployed  it in  a  great many cases with complete success, 
 374             ELEMENTS OF SURGERY.
 and the facility with which it is performed, together with
 the  little injury which the eye sustains from it, give it
 certainly strong claims to a preference over either couch-
 ing or the former methods of extraction. When I adopted
 this mode of treatment, I commenced a journal of my ope-
 rations and recorded the  results of eighteen cases, which
 were published in the second American edition of Coop-
 er's Surgical Dictionary, in 1816, viz: between the &5th
 of April, 1814, and the 25th of October, 1815, I perform-
 ed Mr. Saunders's operation as improved  by Mr. (now
 sir William) Adams, in eighteen cases; at the  time of
 the  publication  alluded  to, eight of the patients were
 completely cured; in two  of the cases both  eyes were
 cured, in the others only one ;—two of the patients re*
 fused to  wait for absorption, and were cured by extrac-
 tion ;—in two permanent  blindness ensued from violent
 inflammation, and the remaining six were under treat-
 ment.  These have since been operated on  repeatedly,
 and have all  got well,  with one exception; in that case,
 making the third out of eighteen,  inflammation destroyed
 the eye.
  I have continued to employ this operation,  sometimes
 passing  the  needle through the  cornea and  sometimes
 through the sclerotica in a much greater number of cases,
but of these I have not preserved  an entire list: my suc-
cess, however,  has been  such as induces me to declare a
 decided opinion that it is far preferable to the  usual mode
 of extraction, or to couching.  It has succeeded, partially
or totally, in a great majority of cases, since the  publica-
tion alluded to, but by no means so generally as in  sir
William Adams's practice; in some it has proved exceed-
ingly tedious, and my patients, in one or two instances,
have been  twelve months and longer before absorption
has  been completed.    The  gradual improvement  of
vision; however, satisfies them and eventually  success ap. 
                 ELEMENTS OF SURGERY.              Qiyg
pears  as certain as  from any other operation.  I have
now I believo, operated  upon nearly fifty cases,  and in
six of these the eye has been destroyed by inflammation.
In one of these instances the patient was very old, the cata-
ract fluid, and immediately on its escaping from the wound-
ed capsule into the anterior chamber and mixing with the
aqueous humour, he complained of severe pain—this con-
tinued and augmented, and although the operation was
performed with  as little violence to the eye as possible,
suppuration took place.  I  cannot but ascribe this result
to some  irritating quality of the fluid lens. In a few other
cases in which the operation has been very cautiously
performed,  violent inflammation has resulted, but has
been cured by copious evacuations.
  Sir William Adams has just favoured the world with his
anxiously expected volume on cataract, and his success in
treating it seems to exceed any thing which the  most san-
guine hopes could have anticipated. Of thirty-one cases of
cataract, at Greenwich hospital, many of which were
complicated with other diseases of the eye, he  complete-
ly cured twenty-nine ;  one only failed, and one was dis-
missed for irregular conduct.*  The testimonials of accu-
racy in this statement are from the governors of the  hos-
pital,  noblemen and  gentlemen of great respectability,
and are entitled to the fullest confidence.  The treatment
of sir William Adams varies in different cases. I shall
proceed to give an outline of his  practice.
  "I shall commence with the description and considera-
tion of the operation for "solid cataract in children  and in
adults."   It is an operation, perhaps, more  extensively

  • If tins be contrasted with the results of the practice at the Hotel Dieu at
Paris, it will be found that the improvements are very striking.  In that cele-
brated institution one hundred and thirteen cases were operated  on from 18U6
to 1810—and of these ouly  forty-three were completely successful,  and ten
partially so.  And in the very hospital in which Sir W illiam Adams operated,
of twentv-four cases in which extraction was performed by the usual  method,
one only succeeded. 
 376             ELEMENTS OF SURGERY.
 applicable, and which has proved more generally suc-
 cessful, than any other, either ancient or modern.
   Having secured the eye by making a gentle pressure
 with the concave  speculum, introduced  under the  upper
 eye-lid, I pass the two-edged needle through the sclero-
 tic coat, about a line behind the iris, with the flat surface
 parallel to that membrane; it is then carried cautiously
 through the posterior chamber,  without in the  slightest
 degree interfering with the cataract or its capsule. When
 the point has reached the temporal margin of the pupil, I
 direct it into the anterior chamber, and carry it on  as far
 as the nasal margin of the pupil, in a line with the  trans-
 verse diameter of the  chrystalline lens.  1 then turn the
 edge backwards, and with one stroke of the instrument, cut
 in halves both the capsule and cataract. By repeated cuts
 in different directions, the opaque lens  and its capsule,
 are divided in many pieces, and at the same time I take
 particular care, to detach as much of the capsule as pos-
 sible from its ciliary connexion.  As soon as this  is ac-
 complished, I turn the instrument in the same direction
 as when it entered the  eye, and,  with  its  flat  surface,
 bring forward into the anterior chamber, as many of the
 fragments as I am able: by these means, the upper part
 of the pupil is frequently left perfectly free from opacity.
 By cutting in pieces the capsule and lens at the same
 time, not only is  capsular cataract generally prevented,
 but the capsule is also much more easily divided into mi-
 nute portions, than when its contents have been previously
 removed.
   The needle which I employ in this operation, is  eight
 tenths of an inch long, the thirtieth part of an inch broad,
 and has a slight degree of convexity  through its whole
 blade, in order to give it  sufficient  strength to penetrate
 the coats of the eye  without bending. It is spear-pointed,
with both edges made as sharp as possible, to the extent
 of four-tenths of an inch.   Above the cutting part, it gra- 
                 ELEMENTS OF SURCERY.            377
dually thickens, so as to prevent the escape of the vitre-
ous humour.*
  This instrument, it is apparent, is well calculated to
cut  in pieces with facility, any cataract whose nucleus is
not  too solid to admit of division, and from the peculiar
manner in which it is employed, (by making the vitreous
humour and  the attachment of the capsule to the ciliary
processes, a counter-resistance to the cataract, while acted
upon with its edge turned backwards,) is capable of di-
viding the nuclei of lenses of a greater degree of solidity,
than could be effected by any other instrument hitherto
used for  the same  purpose.   Most of  these instruments
are  sharpened, a short way only from their point, and any
attempt to divide with them  a lens of  any considerable
degree of solidity, would, instead of accomplishing the di-
vision, detach the lens from  the ciliary processes, when,
according to the usual practice, no alternative remains but
either to  depress the lens in the vitreous humour,  or to
place it in the anterior chamber for solution and absorp-
tion, whole and  undivided,  which latter practice can
never be done with safety, when its nucleus does not admit
of division.
  The first step of this operation consists in carrying the
needle through the coats of the eye, which, from its spear
point and sharp edges, can be effected with a very slight
degree of force,  as it penetrates the dense sclerotic with
as much facility  as a lancet, while, from its very small
size, it inflicts as little injury upon the organ as it is pos-
sible  for any instrument to  do.   There is reason to be-
lieve, that the degree of  force which is necessary to be
used, in  effecting this step with a needle whose blade is
round, instead of being flat,  is one source of the inflam-
mation  which immediately  succeeds  to  the  operation,

  " An engraving is unnecessary from its resemblance to Saunders' needle.
  vol.  1.          49 
gyg             ELEMENTS OF SURGERY.
while the wound inflicted upon the coats of the eye, par-
taking more of a contused than an incised  wound, is not
only  another  source  of irritation and inflammation, but
also prevents its healing kindly,  which evidently  cannot
be  the case when my sharp-edged needle is employed.
It has, however, been stated, that the eye sustains less
injury from the use of a blunt than of a sharp-cutting in-
strument, but  this opinion I conceive to be entirely erro-
neous ;  where any part is to be divided, it can obviously
be done with less injury and violence,  the sharper the in-
strument employed,  provided it  is used with skill and
judgment.   If this argument applies to operations in ge-
neral, how much more forcibly may it be urged, in regard
to those on the  eye; when any considerable degree of
force is there  employed, either from the nature of the ope-
ration itself, or from the instrument  with which it is  ex-
ecuted, a degree of inflammation is  produced, which too
often baffles the utmost skill of the operator.  On this ac-
count, it is observable, that the most experienced oculists
are the  most  particular in their instructions relative to
the form and condition of their instruments, all agreeing,
that the favourable termination of the section of the cor-
nea,  greatly  depends  upon  the good  condition of the
knife;  and surely, if it is the principle of an operation
 to  divide  the cataract, that object can  be  more expe-
ditiously accomplished, and with less violence to the eye,
with a sharp-cutting needle,  than  with a blunt one, in
which latter case, the cataract is  torn, rather than  cut; so
many movements of  the needle  are also required, as not
 only to prolong the sufferings of the patient, but the con-
 tinued action  of the instrument upon that part of the coats
 of the eye in  which it is inserted, necessarily excites in-
 flammation, and hazards  the total failure of the ope-
 ration.
   From the facility with which  my needle penetrates the
 coats of the eye, the operator (particularly if he lias been 
                ELEMENTS OF SURGERY.             37Q
in the habit qf employing needles  with  round blades)
should be careful  not to use much pressure,  and should
make the puncture at a sufficient distance behind the iris,
and  parallel with  its plane  surface, otherwise the point
may either pass through that membrane before it reaches
the edge of the pupil, or be  carried too far into the eye
towards the nose.   In either case, however, no  serious
mischief is  to  be  apprehended, and these accidents can
only occur to a very inexperienced and unsteady operator,
who would  probably do much more mischief to the eye,
by any other mode of operating;  the eye being rendered
immoveable by the speculum,  and the pupil previously
dilated by the belladonna, the iris is the only part at all
likely to be injured in this step of the operation, unless
indeed the instrument be broken in penetrating the coats
of the eye, an accident which, when the operation is per-
formed, agreeably  to the description of it given at length
in my work on Diseases of the Eye, can only happen from
unskilfulness.
  The second step of the operation  consists  in dividing
both capsule and lens, with the same stroke of the knife.
This may  be always accomplished, when the vitreous
humour is in a healthy state,  in young, and frequently in
old persons, by turning the edge of the knife backwards,
in the manner directed, provided the usual degree of firm-
ness, in the attachment of the capsule to the ciliary pro-
cesses, exists.  In those cases, however,  where the nu-
cleus of the lens is  too solid to admit of division, if an at-
tempt is made immediately to divide the lens, it will be
entirely separated  from its  natural adhesions,  when,
should the vitreous humour be partly or wholly disorga-
nized, the cataract will immediately become spontaneously
depressed, when it cannot be extracted, without hazard-
ing a very dangerous escape of the vitreous fluid.   This
h the only accident to which the second step of the ope-
ration is liable, when properly conducted; as, if the iris 
   3g0             ELEMENTS OF SURGERY.
   be wounded with the point of the needle, it must, as in
   the first, at all times be the fault of the operator. Should
   he not have had sufficient experience to enable him to as-
.  certain with precision, the nature of the cataract by  pre-
   vious examination, he may certainly fall into the error, of
   attempting to divide a lens, which is too solid to admit of
   such division, when,  should the vitreous humour prove to
   be in a disorganized state, he necessarily subjects the pa-
   tient, to the dangers already detailed, from the depression
   of a solid lens, in a fluid vitreous humour. As this know-
   ledge can only be acquired by practice, and observation,
   the young operator, in all doubtful cases, should proceed
   with caution; and, instead of attempting to cut the  cap-
   sule, and cataract in  halves,  with one stroke of  the in-
   strument, it will be prudent in him, to act at the first only
   with its point; by this means, he will be enabled, to as-
   • certain the consistence of the opaque lens, which will di-
   rect  him how to proceed, in  the prosecution of this, the
   most important step of the operation.
      Having effected the division of the nucleus of the ca-
   taract, the operator is then to remove the divided portions
   with the point of the needle, through the aperture of the
   pupil, into  the anterior chamber, which constitutes the
   third, and last step of the operation.
      When the consistence of the cataract is tolerably  firm,
   there is no difficulty  in placing a part, or even  the whole
   of the divided lens in the anterior chamber, should  it be
    adviseable so to do, such is the dilated state of the pupil;
    no impediment is presented to the accomplishing that ob-
   ject; but  when,  as  sometimes happens, the lens is very
    soft, and of a jelly-like  consistence, the flat part of the
    needle, passes through it, with as  much facility, as if  it
    were turned edgeways, in which case, after freely divid-
    ing the capsule, as well as the lens,  it will be better, to
    avoid irritating the coats of the eye considerably, by re-
    peated attempts to  pass the  portions of cataract  through 
                 ELEMENTS OF SURGERY.             381
the pupil, which might probably produce inflammation,
but rather to let it remain in situ, (taking care, however,
to prevent its pressing too much against the posterior part
of the iris,) where it will in a few weeks become lessened
in quantity, and acquire a consistence which admits of its
being removed with great readiness  into the anterior
chamber, if it be necessary to  repeat the operation.  In
this stage, also, the iris may be wounded with the point
of the needle, from a want of  dexterity in  the operator,
but otherwise that  accident will never happen, as, from
the dilated state of the pupil, its circular margin is suf-
ficiently out of the way of the needle, when the operation
is skilfully  performed.
  If the  capsule be partially, and not completely cut in
pieces,  during the  division of  the lens, after placing the
fragments of that body in the anterior chamber, the cap-
sule should  be lacerated to the full extent of the area of
the pupil.   In doing this, the  iris is alone the part sub-
jected to injury;  whatever injury the ciliary processes, or
vitreous humour, have sustained during the posterior ope-
ration,  (as the introduction of the needle behind the iris
has been called,) being of no moment whatever, the uses
of  the  ciliary processes  having ceased, as soon as the
chrystalline lens is removed; and it is evident, from the
very little irritation generally excited  in the eye by the
operation for capsular cataract, that no inflammation is to
be  apprehended  from the laceration of  these processes by
the needle;  experience in  the operation  for couching,
(but especially the circumstance of the patient's vision
not being perceptibly impaired, when the vitreous hu-
mour is in part or wholly disorganized,) renders it equally
certain, that no  injury is occasioned by the needle hav-
ing lacerated the vitreous tunic.
   The next operation to be  considered is that for " cap-
sular and adherent capsular cataract."  The needle used
in  this  operation, although slightly curved, is much less 
ogg             ELEMENTS OF SURGERY.
bent at its point,  than that recommended by Professor
Scarpa, on which account the surgeon can direct the point
of it with greater ease and precision, for the purpose of
separating  minute portions of  capsule, when adherent to
the iris.  In this operation the capsule should be lacerat-
ed very  freely,  as much as its consistence will possibly
admit of; but when that membrane is too  thickened to
enable the  operator  to accomplish this  object,  he must
then detach it, from its ciliary connexion, except at  one
small part, as I  have already described, and afterwards
place it  out  of  the axis of vision.  In effecting these
steps, there is less  likelihood of wounding the  iris even
than in the operation for children  and young persons,
from the point of the needle,  which is introduced at the
same distance behind the iris, being  somewhat curved,
and directed towards the bottom of the eye, the pupil be-
ing dilated by the belladonna.
   When the  capsule adheres  to  the iris, constituting
" adherent capsular cataract," the operator  must pro-
ceed more cautiously, otherwise,  in liberating the adhe-
sions between the cataract and  the iris, the latter mem-
brane may be injured, and thereby give rise  to severe
inflammation; or, should the  adhesions be very firm  and
extensive, a forcible attempt at separation would be like-
ly to detach the iris from the ciliary ligament, and conse-
quently  occasion an obliteration of the natural pupil.   In
this, as in the operation  for capsular cataract without ad-
hesions, care must be taken not entirely  to detach the
capsule  from the ciliary  processes, as it would float about
in the vitreous humour, and probably obstruct the pupil;
but, on the other hand, if not sufficiently detached, it will
be likely, particularly if much thickened,  to  rise again
into its former situation.   Should these accidents occur,
 the evils resulting from them may be avoided; the float-
 ing portions may be extracted  through a small puncture
 in the cornea, and if the capsule should rise, the operator 
                ELEMENTS OF SURGERY.            383
may again introduce  the needle through the same punc-
ture in the eye,  and detach it still further; or, if the re-
turn should not  take place for some time after the opera-
tion, it may be again repeated, and the further detachment
effected, as may be necessary.
  Iu " adherent lenticular cataract,"  when the pupil is
not too much contracted, provided the nucleus of the lens
is sufficiently soft to admit of division,  I employ the same
two-edged needle  as in operating for the solid cataract in
young persons.   Part of the fragments should then be
carried  through the pupil with the point  of the needle
into the anterior  chamber for solution and  absorption.
In this case,  great caution is necessary on the part of the
operator, both from the small size of the pupil, and from
the extensive adhesion of the capsule of the  lens to the
iris, affording a much smaller area for the action of the
needle,  and thereby rendering the iris more liable to be
cut or punctured with the point of the instrument, while
dividing the lens;  in effecting this division, unless the sur-
geon proceed with similar caution, the iris is put so much
upon the stretch  as either to hazard its partial detachment
from the ciliary ligament, or to  produce  a considerable
degree of inflammation.  By proper care and  delicacy in
the use of the needle, these dangers may, however,  be
wholly avoided, and are to be apprehended only, when
an  injudicious degree of force is employed with the in-
strument.  If the pupil be too much  contracted for the
purposes  of  vision, the surgeon, instead of using the
two-edged needle to cut up  the cataract, should, at the
first, proceed to the division of the iris, in order to form
an artificial pupil, in a manner which  will presently, be
minutely  described.
   When the lens  is hard and solid, and the pupil suffi-
ciently large to  admit of its free passage, I at once carry
the lens forwards into the anterior chamber, with the two-
edged needle, ready for extraction, but more  commonly 
384            ELEMENTS OF SURGERY.
the pupil requires enlargement before this can be effect-
ed.  The iris scalpel, should in this case be employed at
first, with which the iris should be divided transversely
full two-thirds of its extent, and the lens afterwards car-
ried through this  newr opening, into  the anterior cham-
ber, with the point of the same instrument.  Should the
lens be soft, and even transparent, both lens and capsule
ought to be cut  through and divided,  the  capsule being
always opaque,  which would intercept the rays of light,
equally as if the lens were in the same state.
  In introducing the iris scalpel at the usual distance be-
hind the  iris, its edge should at the first be turned back-
wards instead of upwards or downwards;  by that means,
the stretching of the aperture in the coats of the eye, which
ensues from subsequently  turning its edge backwards,
(as is recommended in the operation for solid cataract in
young persons,)  and also the  escape of a  portion of the
vitreous humour, when partially or wholly disorganized,
will be prevented.  It is of great importance that  this
escape should not take place in this particular species of
case, for the coats  of the eye being thereby rendered flac-
cid, a sufficient resistance to the action of the knife is not
afforded  in dividing the iris ; whereas, if the operator en-
deavours to accomplish his object by increasing the degree
of pressure upon the instrument, he will detach that mem-
brane from its ciliary ligament, instead of dividing it. It
is necessary not only to  divide the iris, but either to de-
tach, or divide the  capsule of the lens, to   the full extent
of the  opening of  the  iris,  otherwise its radiated fibres
cannot retract the  edges of the divided membrane suffi-
ciently distant from each other, to  prevent their reunion
by the first intention, unless indeed some portions of the
fragments  of  the  divided lens  are interposed between
them.
   For the purpose of dividing the  iris, I introduce the
point of the instrument,  through the coats of the  eye, 
                ELEMENTS OF SURGERY.             385
about a line behind that membrane.   The point is next
brought forward through the iris, somewhat more than a
line from its temporal ciliary attachment, and cautiously
carried  through the  anterior  chamber, until  it nearly
reaches the inner edge of that membrane, when it should
be drawn nearly out of the eye, making gentle pressure
With the curved part of the cutting edge of the instrument,
against the iris in a line with its transverse diameter.  If,
ill the first attempt, the division of the fibres of the iris is
not sufficiently extensive, the point of the knife is to be
again carried forward, and similarly withdrawn, until the
incision is of a proper length.  I take care, however,
very freely at the same time to cut the cataract in pieces.
Some of these pieces I bring into the anterior chamber,
and  leave  the remaining portions in the newly-formed
opening of the iris.  These act as a plug in preventing its
reunion by the  first intention,  and  assist the radiated
fibres,  in keeping  the pupil more extensively open; by
the time these fragments  are dissolved, the iris  has lost
all disposition, or indeed power, of again contracting, its
divided edges having by that time become callous, and be-
ing drawn considerably apart by the permanent contrac-
tion of the radiated fibres." (Adams.)
   In reviewing  the innovations introduced within a few
years in the treatment of  cataract, every intelligent sur-
geon will perceive, that they embrace modifications of every
mode of operating hitherto employed,  and are to be re-
garded more in the light of improvements than inventions,
nor  is this  conclusion derogatory to  the characters of
those by whom these new modes of operating have been
introduced—Since his merit is surely greatest, whose
practice succeeds best.  Mr. Hey has a sentence which
I  shall here transcribe,  as proving  that before Mr.
Saunders or sir William Adams were known in  the
   vol. i.          5® 
386             ELEMENTS OF SURGERY.
medical profession, he had  accidentally performed their
operations.
   "Though I do not  think  it advisable to persist in
pressing an  entire cataract  into  the  anterior chamber,
when the advance of the cataract causes a large dilatation
of the pupil;  yet after the needle has wounded the cap-
sule, a firm cataract, or at least its nucleus, will sometimes
slip through the pupil without the  design of the operator.
This has been considered by some authors, as  a disagreea-
ble  circumstance, and has been ranked amongst the ob-
jections to the operation of. couching.   On the contrary,
it ought to be considered as a favourable event, since the
cataract always dissolves  in  the  aqueous humour, and
finally disappears without any injury to the eye. This, at
least, has been the event in every case of the kind which
I have seen.  I have six or seven times seen the whole
opaque  nucleus fall  into the anterior chamber of the eye,
and very frequently small  opaque  portions.   Indeed, if
the cataract could, in all cases, be brought into the ante-
rior chamber of the eye,  without injury to the iris, it
would be  the  best method  of performing the operation.
But this is not usually practicable ;  the softness, as well
as the bulk  of the cataract  presenting an  obstacle to this
process."
   It is strange that Mr.  Hey  should state, that when the
nucleus of a cataract accidentally escapes into the aqueous
humour it is a favourable circumstance,  and should yet
never have  done by design what succeeded so  well by
accident.
   Sir William Adams's new mode of extraction I have
too recently been acquainted with to decide upon  it.   I
think it  well entitled to trial, and shall try it impartially.
   One remark I  shall make in concluding  this article,
which is, that it is impossible to anticipate the degree of
ioflammation  likely to result from any operation on  the 
                ELEMENTS OF SURGERY.              387
eye.  In some cases when merely punctured, it inflames
very violently, and in others, where the operation is diffi-
cult and protracted,  scarcely any  inflammation results.
This remark must not be construed into  an apology for
violence, or for too much effort to destroy the texture of
the lens, for I believe that the  surgeon  who treats the
organ most tenderly will be most sure of success.
  My own  practice at present is to destroy as much as
possible the texture of the lens and capsule in the manner
described by sir William Adams, and with the same in-
struments, and to push the fragments as much as possible
into the anterior chamber for solution  and  absorption.
When the nucleus remains unabsorbed and very hard, I
propose in future to extract it.  I have in  two cases found
long continued inflammation to result from leaving a large
portion of hard cataract in the  anterior chamber; these
portions are diminishing however daily,  and I trust will
be  ultimately removed.   Some of my patients with very
tough membranous cataracts, have as yet, derived no bene-
fit from the  operation, and are still under treatment.  I
have a gouty patient thus circumstanced, whose eye occa-
sionally inflames severely during his gouty paroxysms. 
388             LLEMEVLS OF SURGERY.
                 CHAPTER LX.

               Extirpation of the Eye.

  This operation, terrible in its nature, is extremely sim-
ple.   The diseases which render it  necessary  are not
very accurately defined.  In general it is performed for
the removal of a disorganization which commences, and
terminates in a fungous  tumour :  in some cases this af-
fection begins without pain, but commonly it is preceded
by head-ache, and itching and watering of the eye.  It is
in some cases truly cancerous, but in others,  probably,
has no cancerous tendency.  It occurs  at all  ages,  but
oftenest in young persons.  More than one-third  of De-
sault's patients were under twelve years of age.   As the
disease advances great pain is perceived—sight is lost—
the cornea inflames, ulcerates, and bursts—a fungous red
tumour projects through it,  discharging a purulent sanies,
fetid  and acrid—the size  of the tumour becomes  very
great.  I extirpated  a fungous tumour of this nature from
the socket of a boy's eye, resembling, except in  colour,
a cauliflower, its size and appearance are represented in
the annexed plate—no return of the disease took place.
The plate affords a tolerable idea of the general  form of
this dreadful malady.
  The operation is to  be  performed, when practicable,
by separating  the lid, from the ball of the eye with a
scalpel:  but in many cases this is  impracticable,  and all
that  can be  done is  to save as much of  the upper lid as
possible, provided it be sound.   A straight bistoury of
sufficient strength is to be  passed as quickly as possible
round the basis of the tumour, the surgeon making  it
revolve upon its point  in such a manner  as to keep the 
/'/./>./■; ju
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Carcinoma   of tit*%ye
IS.1 hrsrr dd. K Scufy 
 
                ELEMENTS OF SURGERY.             3$Q
edge close to the bony orbit.  Having seen Mr. Dubois
at Paris perform the operation in this simple manner, I
have imitated his example,  and in a very short time the
operation is completed.  Any portions  of  the tumour
which  remain  may be  afterwards removed,  but as the
hemorrhagy is  always very profuse, whatever cutting is
done, should be done quickly.   The orbit is to be filled
with lint, and  the bleeding soon ceases.  The antiphlo-
gistic regimen should be adhered to for a few days.
   Sometimes the  fungus returns,  and  although  often
destroyed, as frequently springs up.   In these cases the
event is fatal.  But as death is  inevitable if the disease
be not extirpated,  the attempt ought always  to be made.
I have four times performed the operation,  and three of
the four patients  remain quite free from disease.   The
fourth was attended with disease of the absorbent glands,
and terminated fatally, though life appeared to be pro-
longed by the operation.

                   TAPPING THE EYE.

   Dropsy of the eye, or hydrophthalmy, sometimes ren-
ders it necessary to evacuate the aqueous humour, accu-
mulated in too great quantity.  Scarpa states  that in
the cases of dropsy of  the eye which  he has dissected,
the vitreous humour has been in a morbid state of fluidity,
and he was unable to  distinguish  it from the aqueous
humour.  The proper  internal remedies having  been
in vain administered, if the eye-ball  continue to  aug-
ment  in volume, and protrude from  the socket, it be-
comes necessary to open the eye by a surgical operation.
Nuck used to puncture the centre of the cornea with a
small trochar; other writers  recommend the puncture
to be made through  the  sclerotica.   Scarpa advises a
small circular incision to be made in the upper part or 
 390             ELEMENTS OF SURGERY.
 centre of the cornea, as the best mode of evacuating the
 eye.   Iu several cases I have punctured the cornea by
 inserting the point of a sharp  cataract knife through it,
 the evacuation of the aqueous humour although not sud-
 den, was amply sufficient, but if necessary it is very easy
 to turn the knife  a little, so as to make the incision some-
 what circular, whereby  the fluid  will more readily es-
 cape.
   Dr. Physick from an idea that gutta serena is in some
 cases occasioned by  pressure upon the retina and optic
 nerve  from an over  secretion of aqueous  humour, has
 punctured the  eye with a view to relieve this affection.
 In some  instances the operation has been evidently ad-
 vantageous—in others no benefit whatever  has resulted.
 I have suggested this because I shall not enter into the
 history of this paralytic affection of the eye, as many ex-
 cellent histories of it are in the hands of every medical
 man.   Richter,  Scarpa, and Ware are among the best
writers on the subject, and to them  I refer, only suggest-
ing that in very obstinate cases where other remedies have
failed,  tapping  may be  tried,  as it has been sometimes
useful, and  the repeated application of blisters directly
 over the  eye-lids, are also occasionally beneficial. 
 
Plate xiii
 
 
''LATE XIV.
          Fig.
f5m
I
99451 
                ELEMENTS OF SURGERY.             39 i


             EXPLANATION OF THE PLATES.

Fig. 1. Represents the most usual form of Pterygium or
        Unguis.
     2. The appearance of an eye, after the excision of
        that portion of the palpebra, from which the cilia
        project;  an operation performed for the cure of
        Entropium or Trichiasis.
     3. Curved scissors used in various operations on the
        eye.
     4. Forceps.
     5. Saunders' couching needle.
     6. Scarpa's couching needle.
     7- Hey's couching needle.
     8. Represents the section made in the cornea in the
        operation of extracting a cataract.
     9. An artificial  pupil, near the external margin of
        the iris.
    10. The place of introducing the cornea knife and
        the mode of passing it through the anterior cham-
        ber of the eye.
    11. This figure represents an  accident which some-
        times happens in the operation of Extraction,
        the floating of the iris before the blade  of the
        knife.
    12. The forceps  contrived by Dr. Physick, with a
        circular punch on the extremities of the blades.
    13. A small hook useful in the operation of Extrac-
        tion.
    14. Wenzel's knife for incising the cornea.
    15. Curette and needle.
    16. Wenzel's forceps.
    17. The nail-headed  style  used in  fistula lachry-
        malis. 
292
ELEMENTS OF SURGERY.
                  CHAPTER LXI.

                     Of Polypus.

   A polypus is a fleshy excrescence, of various, density
and colour, originating  from the  lining membrane of a
canal or cavity, as the nose, vagina, rectum, &c.
   The nostrils are the most frequent situation of this com-
plaint. It commences as a small pendulous tumour, void
of pain, accompanied with watering of the eyes, sneezing,
and the usual symptoms of catarrh. The colour of these
tumours is generally a pale red.  They commonly com-
mence from the ossa spongiosa; but occasionally from all
the parts concerned in forming the cavity of the  nostril.
They produce at  first  no other effects  than  have been
noticed,  but as  they enlarge, the defluxion from the
eyes  increases,  sneezing  is  frequent,  and the  tone of
voice is  much altered.   The weather  has  a great in-
fluence on the patient.  In dry weather the tumour ap-
pears to  diminish, and  it increases  in  damp and cola*
weather—augmenting gradually in size, it at  length ob-
structs the passage of air  through the nostril  and in
this stage  produces  a  very  unpleasant  nasal  tone of
voice.  The polypus assumes gradually the shape of the
cavity of the nose,  being formed in it  as  in a mould.  It
becomes visible at the anterior nostril and at  the fauces
behind, where it  maybe  seen situated over the soft palate,
and sometimes hanging down behind the uvula.   In this
state great inconvenience  is  experienced—the eyes are
constantly suffused with tears, from the obstruction to the
ductus ad nasum.  In some instances,  ulceration takes
place, and a fetid matter is  discharged, attended with
great inflammation and severe pain.  In some cases, how-
ever,  it is remarkable that the tumour  acquires  a great 
                 ELEMENTS OF SURGERY.            393
size and the patient suffers no pain.  From the nose be-
ing stopped patients generally sleep with the mouth open,
and inconvenience is sustained from  the dryness of the
mouth and throat.  Hearing  is  often injured, probably
from pressure against the Eustachian tube.  In swallow-
ing, some difficulty is experienced from the weight of the
tumour which presses against the velum pendulum palati.
The appearance  of the face becomes changed from one
nostril being wider than the other, the root of the nose ap-
pears   swelled, and  violent  head-aches  come on—the
bones  eventually  become  carious  and ulcerated—a foul
fetid sanies mixed with blood is discharged—hemorrhage
sometimes ensues—the teeth fall out and a fungus shoots
through the sockets.   These  symptoms in some cases in-
crease and exhaust  the patient's  strength;—frequent
bleedings and an incessant discharge of matter take place,
and during the last stage of the disease, stupor and coma
come on, and eventually death.—Such are sometimes the
dreadful effects of a disease at first trifling, and to all ap-
pearance of very little consequence.
  The causes of this complaint are not well understood.
Some have supposed picking the nose, or violently blow-
ing the nose to have produced it, but for this there is no
foundation.
   Several  species of  nasal polypi are described by au-
thors,  one of which is said to be  of a malignant nature,
disposed to end in cancer. This, however,  I believe is
extremely rare; the most common are a fleshy, red vas-
cular polypus, and a pale tough, firm polypus, neither of
which is of a cancerous nature.

                      TREATMENT.

   The cure of polypi consists in  extracting or destroying
them with caustic. 
394*             ELEMENTS OF SURGERV.
  The extraction may be  performed by forceps,  or by
passing a ligature round the base of the tumour in such
a manner as to destroy the circulation,  after  which the
polypus soon falls off.  The application of a  ligature is
to be preferred in cases where the pedicle by which  it
hangs is very small, or in cases where the patient is too
feeble to bear the loss of blood which is apt to follow the
use of the forceps.   The mode of applying the ligature
must vary in different cases.   Sometimes all that is ne-
cessary is to pull the polypus  forward with a hook and
pass a silver wire over it—or a waxed ligature may be
formed into a noose and passed round the base of the tu-
mour in  the same way.  When the wire is to be used
a double canula  is generally the best instrument for fix-
ing it—it must be drawn very tight,  and in a few days
the polypus will fall  off.   It  is of great  importance to
watch when the polypus becomes loose, as  it has occa-
sionally separated in the night time and endangered suf-
focation by falling over the glottis.   A case of this com-
plaint occurred several years ago in  which Dr. Physick
practised a new mode of extraction that will probably
be found useful  in many other instances.  A gentleman
having suffered many unsuccessful attempts  for the re-
moval of his polypus, came to Philadelphia and consult-
ed Dr. Physick—he found  a large tumour projecting be-
hind the soft palate as low  as the extremity of the uvula,
and filling completely the posterior  nares and cavity  of
the nose, after vain attempts to extract it in the usual
manner with ligature and  forceps, a piece of tape was
made stiff by passing silver wire through it, and this was
fixed on the projecting part of the  tumour by a firm
knot—the tape  was  now pulled forcibly and with it
came away the polypus, which was of prodigious size.
   In using the forceps they must be  applied as  near the
root of the polypus as possible.   Hemorrhage generally 
                ELEMENTS OF SURGERY.             3gg
attends the operation but it is not often alarming—cold
water or brandy injected into  the nose generally checks
it.  If not, a plug of lint may be introduced into the nos-
trils so as to press on the part whence the blood issues.
It necessary the posterior nostrils may be  stopped up
by passing  a  double catgut  through the nose into  the
mouth and  by means  of this  a roll of lint is readily in-
troduced into the posterior  nares which invariably suc-
ceeds in putting a stop to the  hemorrhage.
   The application of caustic is often requisite to prevent
the growth of the tumour after the greater part of  it has
been removed.   This  is  in general easily  effected by
means of a bougie, or a roll of waxed linen in which is
included a piece of caustic alkali.
   The application may be repeated daily until the tu-
mour no longer grows up. 
396
ELEMENTS OF SURGERY
                 CHAPTER LXII.

                     Of Ranula.

  This consists in a tumour under the tongue containing
a glairy fluid,  resembling the white of an  egg.  It is
supposed to proceed from an obstruction in the salivary
duct.   The tumour is  generally on one side of the  frav
num linguae, and varies greatly in size,  sometimes  ex-
tending to the very point of the tongue, and elevating it
considerably.*  The tumour sometimes contains instead
of the viscid fluid which has been mentioned,  a purulent
matter, and, sometimes, a calculous concretion.   When
uninflamed the disease gives no pain, but  from its bulk
is more or less inconvenient; when it inflames considera-
ble pain is experienced.

                      TREATMENT.
  The remedy for  ranula, that is, for a tumour actually
formed by a dilatation of the  salivary duct, consists if
possible in dilating the duct  by  means of a probe, as
recommended  by Desault; but it is not often  in  our
power to effect this, and other measures become neces-
sary.
  The extirpation of the tumour is difficult and danger-
ous on account of the large blood-vessels in the vicinity.
The British surgeons are in the habit of laying open the
cavity of the tumour, by a free incision, after which they
apply caustic to its surface.  This plan does not  always
effect a cure, and is unnecessarily severe;  a simpler and

  * I have never seen these tumours very large, but when suppuration takes
place in them, large abscesses have been formed, and as much as a pint of mat-
ter has been discharged from under the tongue. 
                ELEMENTS OF SURGERY.             397
easier method should therefore have the preference.  In
a majority of cases the disease may be cured,  as recom-
mended by Dr. Physick, by passing a seton through the
cavity of the sac; a common curved needle armed with a
ligature can readily be passed through the tumour, the
needle being cut off, the string is suffered to remain in
the cavity of the tumour where it  excites inflammation
and suppuration,  after which  a fistulous orifice is estab-
lished  through which the  saliva afterwards flows, and
this is  soon followed by a complete obliteration of the
cavity.  I have  known this simple remedy successful in
a great number of cases, and I believe it will be found
to fail in very few.
   If calculous concretions are found in the sac they  must
be removed, and the caustic if necessary  can be applied
for the purpose of destroying the sac.  I  have met with
a very difficult case of ranula  attended with a large cal-
culous concretion, which occasioned an abscess and sali-
vary fistula in the neck.  In this  case the calculus en-
larged, and was found in close contact with  the carotid
artery  and compressing the  oesophagus and trachea.  I
succeeded in rescuing my patient from his dangerous con-
dition by injecting into the cavity containing the calculus,
diluted sulphuric acid,  which  softened  the  stone  and
enabled me to extract  it  with forceps  through an in-
cision  made cautiously down to the stone.   The aper-
ture of the  submaxillary duct being enlarged by probe*
and bougies, the external  wound healed up in a short
space of time.
   It has occasionally happened that a small calculus in
the duct produces the obstruction, in which case all that
is necessary is to remove it, after which the tumour will
subside.
   Mr. B. Bell relates such a case  which terminated in
ulceration of the cavity.  The ulcer could not be healed
until the calcnlus w as removed. 
398             ELEMENTS OF STJRGERY.
                CHAPTER LXIII.

                Of Salivary Fistulce.

  In  consequence of wounds of the cheek or of ulcers,
the duct of the parotid gland is sometimes opened and
discharges  its contents externally.  When the patient is
eating, the  saliva instead of being poured into the mouth,
flows  out upon the cheek. Whether the loss of this fluid
occasions any effect upon the  digestive organs  or not, the
complaint is found extremely inconvenient, two ounces of
saliva are said to have flowed out of such a fistula dur-
ing a  single meal.
  In case of a recent wound which opens the  parotid
duct, great  care should be taken to  unite very accurately
the sides of the wound externally; in this way the proba-
bility  is, that the duct will either reunite or form a fistu-
lous orifice internally, either of which occurrences  will
prevent the formation of an external fistula.
  When the fistula has existed for a considerable time,
and attempts have been made by  pressure,  caustic ap-
plications,  and other means,  to heal up the ulcer  without
effect, more difficulty is to be anticipated.  In these cases
it is necessary in the first place to  establish  an opening
into the mouth, and  afterwards to  heal  up the external
orifice.
  Mr. Charles Bell directs the following measures, which
I believe were contrived by  the celebrated Dr. Monro:
" Our first attempt will be to pass a small silver probe
from the mouth into  the natural opening of the duct, and
enlarge it,  if it shall be found contracted; then to  sub-
stitute a small tube, which  being  introduced from the
mouth shall  also  pass some way into that  part of the 
                ELEMENTS OF SURGERY.             399
duct which discharges the saliva.  Lastly, while the tube
is retained in its place, the outward lips of the wound are
to be made raw, brought together and healed.
  " But the circumstances of the case may be such, that
it will  be better to make  a new duct, from the fistulous
opening  into the mouth.  To do this we  must  push a
straight needle, obliquely from the bottom of the fistula
into the mouth, and draw through a small  seton, which
is to be  worn until the passage is callous.  Then either
with or without introducing the tube, we have to endea-
vour to unite the edges of the outward opening."
  Desault made use  of the seton in the treatment of
salivary  fistulse, but instead of introducing it in the usual
manner,  he complicated his operation by using a trochar
instead of a needle.  His mode of cure  which differs in
several particulars  from the one just described,  appears
to have no advantages over it.
  The patient during the cure, should as much as possi-
ble avoid speaking, and should be nourished principally
upon spoon victuals. 
4QQ             ELEMENTS OF SURGERY.
                 CHAPTER LXIV.

         Of Abscess of the Antrum Maxillare.

   This cavity is sometimes the seat of inflammation and
suppuration.  The  complaint commences like  a fit of
tooth-ache,  a severe darting pain extending through the
jaw, without any external tumefaction: afterwards sup-
puration takes place;  the pus flows into the nostril of
the affected side, especially when  the head is  inclined
in such a position as to favour its escape.   The disease
even after suppuration is  established is not always easily
known, for the mucus of the nostril often resembles pus,
and the pus is mistaken for the common secretion of the
nostril.  In some cases the affection subsides after sup-
puration takes place, but more generally it continues, and
occasions caries  of the bone.  The absorbents remove
portions of bone, and make outlets for the pus in different
places.  In some cases the sockets of the molar teeth are
absorbed, the teeth loosened, and the pus  discharged
through the openings thus formed into the mouth.
   The cause of the disease is often a caries of the upper
molar  teeth and  consequent inflammation of the sockets,
extending gradually to the antrum.
   The treatment of  the abscess  is  to  be  commenced by
extracting any carious teeth which may exist in its vici-
nity ; this removes in many instances the remote cause of
the disease, and also  affords not unfrequently  a ready
outlet  for the pus at the  most depending part of the  ab-
scess,  which is  an object of great importance.   If the
fang of the tooth should  not extend into  the  antrum,
a perforation is  to be  made  cautiously with  the stilette
of a small  trochar, or a common  pointed probe. If, how- 
                 ELEMENTS OF SURGERY.             qfi\
 ever, the teeth be sound, and pus evidently exists in the
 antrum, the third or fourth molar tooth should be remov-
 ed, and  an aperture  made  through  its socket  into the
 abscess.
   The removal of carious bone should never be  attempt-
 ed before it is quite loose; this process may be very safe-
 ly trusted to the absorbent vessels.
   Besides inflammation and  abscess, the antrum is occa-
 sionally the seat of fungous tumours.  These  occasion
 an enlargement of the  bone, and subsequently an absorp-
 tion of it.  The  alveolar sockets are protruded down-
 ward, and the teeth pushed out from their sockets.   The
 nostril  becomes  filled up;   the excrescence  extends in
 every direction;  the eye is pushed upward, and in some
 cases  the skin  ulcerates,  and  the   fungus protrudes
 through it.
t  The only remedy is  an early extirpation of the tumour,
 by removing a portion of the bone, and dissecting out the
 tumour with a knife and destroying  what may remain
 with caustic; if the disease have made much progress be-
fore the operation is performed, its efficacy is very doubt-
 ful.   In one case I extirpated a  very extensive  fungous
 tumour, extending almost to the orbitar plate of the upper
 maxillary bone, in a girl, and after a cure was apparent-
 ly nearly  effected, the tumour  recommenced its growth
 and neither the knife nor caustic had auy effect in arrest-
 ing its progress.  The  disease although not very frequent
is extremely formidable, and often terminates fatally.
  In the collection of Mr. Heaviside at London, there is
a skull exhibiting a very exteusive bony excrescence from
the antrum and upper jaw, an engraving of which may be
seen in Mr. Fox's treatise  on teeth.   The early extir-
pation of  all such tumours is the only remedy in which
confidence can be placed.
  vol.  t.          52 
402             ELEMENTS OF SURGERY.
                CHAPTER  LXV.

               Diseases of the Tongue.

  The frsenum linguae is occasionally too short to allow
the free motion of the tongue, and  it sometimes extends
to the extremity of the tongue and thus confines it. Chil-
dren suck with great difficulty in these  cases, and it be-
comes necessary to divide the  frsenum.  The operation
is extremely easy, and may be performed either with
scissors,  or,  what  is better, a sharp  pointed bistoury.
Care should be taken to avoid the ranina artery.
  It is proper to remark that surgeons are often consult-
ed about children, said to be tongue-tied in whom there
is no confinenient of the tongue, a certain difficulty in
speaking is generally the  reason for the supposition; an
inspection of the mouth will readily  enable the practition-
er to ascertain whether the tongue is preternaturally con-
fined or not.
   Ulcers of the tongue arise from various causes and are
often very difficult of cure.  Sometimes a carious tooth
occasions ulceration of the tongue; this ought certainly
to be removed or filed smooth.  Slits or fissures occasion-
ally form in the tongue which swells and becomes indu-
rated in their vicinity.  The use of caustic is  generally
proper in these cases.  Dr. Physick has employed with
advantage the actnal cautery in a very obstinate case of
this kind, with a view  to change the nature of the sore
into the state of a burn.
   Cancer occasionally forms on the tongue;—extirpa-
tion is the only remedy ; and in performing it, all the dis-
eased parts should be carefully removed.  Mr. Home
advises in these cases to pass a needle  armed with a 
                 ELEMENTS of surgery.             403
strong double ligature through the middle of the tongue
beyond the diseased part, and to tie one ligature on each
side; in this manner the diseased  part being deprived of
its circulation, will mortify and drop off.  The pain is not
very great, and no danger of hemorrhagy exists.  A sa-
livation in some cases follows, but soon subsides.
  It will be obvious to every one that a little attention
and dexterity will enable the surgeon to remove such parts
only as are diseased, leaving the sound parts of the tongue
uninjured;  he should always, however, apply the liga-
ture in sound parts.  If any circumstance should induce
the surgeon to prefer the knife,  he should  be careful to
take up all the bleeding arteries and to have at hand a
heated iron  in case he should be  unable to secure  them
with ligatures.   I particularly urge this precaution upon
the young surgeon, because no one unaccustomed to sur-
gical operations upon the mouth can be aware of the diffi-
culty of securing a bleeding artery in these parts.
  Ulcers of the tongue are not unfrequently occasioned
by diseases  of the digestive organs—here  the remedies
must be  internally administered and different cases call
for very opposite medicines.   In some, alkalies are use-
ful, in others,  acids.  Opium has relieved a number of
these cases.   Tartar emetic, in small doses long continued
has occasionally succeeded.    In addition to these reme-
dies, leeches should be applied in the vicinity of the ulcer,
and various  astringent lotions are to be tried.
  Ulcers from the use of mercury, generally  get  well
when the medicine is discontinued. 
404
elements of surgery.
                CHAPTER LXYI.

          Diseases of the Uvula and Tonsils.

   Inflammation of the throat and fauces produces some-
times a considerable elongation of the uvula.  In gene-
ral it resumes  its usual  length after the  inflammation
subsides,  but in some  cases it  is permanently elongat-
ed, and in these instances should be  removed ;—a hook
may be inserted  into  the uvula to prevent its slipping
backwards, and then with a pair of scissors a portion of
it can be easily  cut off.  There is no danger of hemorr-
hagy.
   The tonsils in  this climate are particularly liable to
inflammation.   In some cases the swelling is very con-
siderable and breathing and deglutition are greatly imped-
ed.  In these cases, in  addition  to the  remedies em-
ployed by the physician,  scarifications become necessary.
A sharp scalpel answers the purpose very well. A num-
ber of small incisions  are to be made,  and the  vessels
suffered to unload themselves;   the mouth and throat
should be  rinsed with warm water to promote bleeding.
In case of suppuration  the abscess may be opened by a
common lancet, and  great  relief will  be immediately
perceived.  A particular instrument has been construct-
ed for the purpose of opening abscesses of the throat,
called pharyngotomus, an engraving of which may be seen
in Brambilla's Instrumentarium.   It  has no advantage
over a common  lancet or scalpel.
   The tonsils are sometimes enlarged  and indurated
from successive inflammations,  and  sometimes  an en-
largement occurs without  any evident cause.   The com-
plaint is usually, but improperly, denominated schirrhus. 
                elements of surgery.              405
 It has no disposition to terminate in cancer, but great in-
 convenience is experienced from the bulk of the tumour.
 A part or the whole of  the  tonsil may be removed by
 means  of a knife, but in this operation the bleeding is
 sometimes troublesome.  Caustic may also be employed,
 but it is the most tedious and painful mode of removing
 the  glands.  The application of a ligature around its
 base, is I believe  the safest and best mode of extirpating
 schirrhus tonsils;  at least I have never seen any incon-
 venience from this method, and I have seen it very fre-
 quently performed.
  When the base of the tumour is small, a silver wire in a
 double canula, is  to be applied round it, in the same man-
 ner  as around the root of a  polypus; this wire is to be
 drawn very tight  and secured to the shoulders of the in-
 strument.   In a great majority of cases this operation is
 very readily performed, and in  a few days the tumour
 drops off.   Great care  is necessary to make the ligature
 sufficiently tight in order to prevent all circulation in the
 tumour,  otherwise a portion of it only will be destroyed,
 the central part remaining after the rest had dropped oft'.
   When the base  of the tumour is large, it is best to  cut
 off at least a considerable portion of the gland with a bis-
 toury;  the bleeding may in  general be restrained  by
 washing the mouth with cold water.  If the whole of the
 tonsil be removed with the knife, it is said  that a great
 discharge of blood takes  place.   I believe that no dan-
 gerous hemorrhagy would be likely to occur, for if the
 bleeding vessels did not speedily contract, it would be
 easy to apply a hot iron and put a check to the discharge.
 The great improvements of modern surgery have almost
 entirely banished the actual cautery from practice, but in
certain hemorrhages from the fauces, it is indispensable. 
406             elements of surgery.
                CHAPTER LXVII.

         Of Foreign bodies in the (Esophagus.

   Substances occasionally become arrested in the oeso-
phagus,  and by pressing forwards the membranous part
of the trachea obstruct  respiration.  I believe with Mr.
Charles  Bell, that the obstruction in these  cases  is not
purely of a mechanical nature, but that spasm is excited
by the irritation produced,  and the muscles of the glottis
diminish very much the aperture through which the air
passes.
  If the  substance be not likely to occasion unpleasant
consequences  in the stomach, it  is generally easier  to
push it down than to extract it through the mouth—pins,
needles,  sharp bones, or any pointed substance which
would probably wound the oesophagus, or any portion of
the alimentary canal, and also  substances  which from
their chemical qualities would be likely to occasion mis-
chief, as copper coins, &c. should if possible be extracted
through the mouth.  This can only be done when they
are situated high up near the fauces.  If near the sto-
mach they must be pushed down, and the  risk of the con-
sequences must be incurred.
  To extract substances from the oesophagus the fingers
and forceps are generally the only instruments which can
be employed, and we are very often able to see the fo-
reign body by pressing  down the tongue with a spoon,
even when the sensations  of the  patient lead  him  to
suppose  that it has  descended  very low;  a hook of
curved wire is also useful in some cases for extracting
foreign matters, especially when they are  of considerable
size.  In two instances I have known the spasm which 
                elements of surgery.             4*07
had arrested a foreign substance, speedily relaxed by a
solution of emetic tartar.  In each of these cases, a large
peach stone had slipped into the oesophagus, and the pa-
tients were of course unable  to swallow, and could not
breathe without great difficulty.  They were directed by
Dr. Physick to hold in their mouths a solution of emetic
tartar, and attempt to swallow it.  Nausea  came on, and
the spasm relaxing,  the  peach stones were readily dis-
charged.
   An ingenious mode of extracting small substances, as
needles, fish-bones,  &c.  is described by Mr. S. Cooper.
" The art  of employing compressed  sponge in the  most
advantageous manner, consists in taking a piece about
the size of a chesnut, and introducing each end of a strong
ligature through it.   The ends of the ligature are then to
be passed through a tube, and fastened to that end of the
instrument which the surgeon holds.  The sponge is then
to be introduced down the oesophagus beyond the foreign
body, and water is to be injected through the tube, in order
to moisten the sponge and make it expand.   After this the
ends of the ligature are to be firmly drawn, for the pur-
pose of pressing the sponge against the extremity of the
canula to make it expand still  more.   Then the  tube is
to be withdrawn, together with the sponge, observing to
twist the instrument to the right and left in this part of the
operation.
   " When the foreign substance cannot be extracted with
this instrument a probang may be tried, to the end of
which a bunch of thread,  doubled  so as to make an im-
mense number of nooses, is fastened.  Little bodies may
frequently  become entangled,  and  be extracted in this
way, when  the other one fails."
   When the foreign matter cannot be extracted, it  be-
comes necessary to push it forcibly into the  stomach, this
is generally done by means of a  probang,  a piece  of 
 408             ELEMENTS OF SURGERY.
 sponge tied on the end of a whalebone, or large firm
 bougie of waxed linen.  In many cases where much in-
 convenience has been anticipated from the nature of the
 foreign substance,  it has  passed through the alimentary
 canal, without occasioning any great  inconvenience.  I
 have known, however, a very extensive  fistula in ano,
 produced by a large fragment of bone accidentally swal-
 lowed.
   When the foreign body cannot be either extracted or
 pushed down into the stomach, it sometimes occasions
 very speedy suffocation. Benjamin Bell relates two cases
 of death from this cause, and Desault mentions one in-
 stance in which a woman swallowed a bone with so much
 voracity that it lodged  in the middle of the pharynx and
 occasioned suffocation; she  died  in three minutes:  nu-
 merous accidents of a like nature  have happened.
  In other instances the foreign matter remains for many
 years, occasioning no inconvenience.  A boy four years
 old, playing with an English farthing, slipped it into the
 oesophagus and was unable to swallow or eject it.  The
 accident  happened  in Dublin; Dr. Dease and  several
 other surgeons of eminence  attempted to  extract it, but
 without success ; the immediate symptoms of suffocation
 soon subsided,  and the coin, although very inconvenient
 to the patient in his attempts to swallow, remained with-
 out occasioning any very alarming symptoms.  He came
 to America, and was attacked in this city with a vomit-
 ing of blood of which  he  died after a few hours illness,
 at the age of seventeen years.  Upon  examination  after
 death, I found the coin lodged vertically in. the oesopha-
 gus opposite the bifurcation of the  trachea, it was so loose
 as easily to  move  upwards, its motion downwards was
 more difficult.  The  copper was encrusted with a thick
 coat of dark greenish matter, which was detached at one
part shewing the metallic surface.  How it was detained 
                ELEMENTS OF SURGERY.              409
thirteen years in this situation I am at a loss to imagine ;
certainly it  would  have been  an easy matter to  have
pushed it into the stomach, and by no means impractica-
ble to have withdrawn it through the mouth.
   Sometimes pins and  needles are swallowed, they oc-
casion abscesses  by sticking  in  the oesophagus, when
they get  into the stomach they are generally evacuated
with the faeces.  In other instances they travel to differ-
ent parts of the body, and ultimately approach the  sur-
face.   A case is related in the Memoirs of the Academy
of Surgery,  in which a needle remained eighteen years
before it made its appearance externally,  during which
time  very little sensation was  occasioned by it.
  The operation  of cutting into the oesophagus in order
to extract foreign bodies, I have never known necessary,
and I believe it ought  very  seldom to be done.  The
memoirs of the French Academy contain, however, two
cases  in which it was successfully performed.
  Whenever suffocation is dreaded, and the  patient  is
unable to  breathe in consequence of a foreign body in
the oesophagus, it  becomes  necessary to maintain the
communication  of air to the  lungs, by artificial meaus
hereafter to  be described.   By these means we have  it
in our power to prevent suffocation, and thus to afford
time for the removal of the foreign body.
VOL. I.
sa 
410
ELEMENTS OF SURGERY
               CHAPTER LXVIII.

          Of Strictures of the (Esophagus.

  The  oesophagus being a muscular canal is capable of
contracting at times and of being again dilated.   Occa-
sionally  spasm takes place at a particular part of the
oesophagus and produces a spasmodic stricture, similar to
the same disease  in the urethra.  Permanent strictures
in the oesophagus also occur, producing a narrowness at
the part,  with thickening   of its  substance,  and at
length if not prevented, an almost total  obliteration of
the canal.  The case in this way proves fatal by cutting
off supplies of food, from the  stomach, unless medical aid
is successful in relieving it.
   The  disease can in no manner be  better  explained,
than by a history of cases in which it has occurred.   Mr.
Home has published  several iu his  second  volume on
strictures to which the reader is  referred.   The com-
plaint generally commences with a  difficulty of degluti-
tion, gradually increasing until fluids  only can be swal-
lowed, and at last every attempt at deglutition  becomes
extremely painful and attended with a sense  of suffoca-
tion, from the substance passing into the glottis.  Ema-
ciation takes place—hunger is extreme, and  the patient
unless relieved, is literally  starved to death.   I have
seen one case  in which  this actually happened—upon
dissection the oesophagus  was  found  so nearly oblite-
rated that a probe could not  without difficulty be forced
through the stricture.
   The  treatment recommended by Mr. Home  is to dilate
the stricture by introducing bougies of  waxed linen, com-
mencing with  such as readily  enter  it  and gradually 
                 ELEMENTS OF SURGERY.            444
enlarging their  diameter so as to dilate it.   In some
cases this method is ineffectual, and the progress made in
dilating the passage is too slow.  Mr. Home has em-
ployed the caustic in such instances with advantage, and
Dr. Andrews of Madeira, has lately published some ca-
ses in which the  same remedy proved successful.  The
lunar caustic is to be  preferred.  It must be fastened se-
curely in the extremity of a bougie, of such a size as to
pass readily down to the stricture ; another bougie of  a
larger diameter is first to be introduced, and when the re-
sistance of the stricture is felt the patient by shutting his
mouth makes  a mark with his teeth, upon the instrument,
by which the precise distance of the stricture is ascertain-
ed.   This bougie being withdrawn, a-mark correspond-
ing to it, is to be made on the bougie, armed with caustic,
which is next  to be introduced, and suffered to remain half
a minute  in contact with the stricture; this may be re-
peated as often as necessary.  In  passing the bougie,  it
will be an advantage to preserve as  accurately as possi-
ble the curve which the first instrument had assumed,  as
this facilitates greatly the operation of introducing it. 
412
ELEMENTS OF SURGERY.
                CHAPTER LXIX.

     Of  Obstructions in the Glottis  and Trachea.

  Whenever respiration becomes interrupted in conse-
quence of obstruction in the trachea either from disease,
or from foreign  substances accidentally  introduced into
it, it becomes necessary to make an artificial  opening into
this  canal, below the obstructed part, in order to preserve
the free  communication of air  to the  lungs.  This has
generally been done by cutting into the trachea,  an ope-
ration which may be performed with great safety and
without risk of any permanent inconvenience—this truth
is established, not only by the frequency  with which the
operation has been performed, but also by the facility
with which even the most extensive wounds  of the wind-
pipe heal up, after unsuccessful attempts to commit sui-
cide.
  Although the operation of cutting into the  trachea may
become necessary  in  a  variety of instances, yet the ne-
cessity for performing it has been greatly diminished by
the introduction of a plan of treatment in which the
knife is dispensed with :  the passage of a  flexible tube
through the glottis into the trachea.
  The causes which may render one of these operations
necessary are numerous.   Inflammatory swellings in the
vicinity of the glottis, as in the tonsils, sometimes occa-
sion great difficulty  in  breathing, and  though I  have
never known tracheotomy performed in this  place in
consequence of an  enlargement of the  tonsils, yet it may
possibly  become necessary.—Tumours sometimes  form
in such situations as to impede respiration  by pressing
on the  trachea.—Substances lodging in the  oesophagus,
by pressing forward the membranous part of the trachea 
                ELEMENTS OF SURGERY".             418
a»d  exciting spasm of the  glottis, lessen the size of its
cavity so as to cut off the free access of air to the lungs.
  In some cases the tongue becomes so much  swelled
from the use  of mercury as  to fill up the mouth,  and ob-
struct respiration.   In most  of the cases which have been
enumerated, we may frequently avail ourselves of the in-
troduction of a large elastic catheter into the trachea, and
thereby avoid the necessity  of tracheotomy.
  The introduction of foreign substances into the glottis
occasions always great uneasiness, violent coughing, and
much irritation; hence  it would appear from theory, a
most imprudent act to force an instrument into this pas-
sage.  Experience, however, proves that no danger re-
sults from it, and many cases have now occurred which
establish the  fact, that an elastic catheter may be left for
many days in the trachea without exciting any other in-
convenience than a convulsive cough at its first introduc-
tion.  Even in cases where  the irritability of the parts is
augmented by inflammation, the introduction of  a canula
into  the glottis is easily tolerated.   The cough  is at first
violent, but it soon subsides  and the patient breathes very
well through the instrument.
  When the  tumour exists in the mouth, and the glottis is
not diseased, the canula may be passed through  the nos-
tril,  and readily finds its way into the windpipe.
  In cases where foreign substances exist in the  oesopha-
gus  pressing forward the membranous part of the trachea,
nothing is easier than to pass a catheter into the glottis
which will prevent the canal from being closed and allow
the patient to respire freely.  In these cases tracheotomy
has often been performed—a surgeon once performed the
operation to  relieve from suffocation a young man, who
for fear of being robbed, had sw allowed his money, tied
in a rag—it  stopped in the pharynx,  and  would have
killed him, had not tracheotomy  been performed—now 
444j             elements of surgery.
in this aud similar cases, the operation recommended by
Desault would certainly have prevented  suffocation  and
afforded time to extract or force through the oesophagus
into the stomach the substance arrested there.
  The advantages of the plan are very considerable. The
operation is not difficult;—there is no danger from bleed-
ing  vessels;—no wound to heal;—no risk of a fistulous
opening;—consequences which sometimes follow the ope-
ration of tracheotomy.
  A tube may with great safety be left a considerable
time in the trachea; this fact is established by the case of
a soldier in the hospital at Lyons, who  cut  his trachea
through, and wounded the oesophagus.   His surgeon
introduced  a  large  flexible  catheter  into  the trachea,
another into  the  oesophagus, by  means  of one he was
nourished, and through the other he breathed during the
cure.  Although  the  operation of opening the trachea
may sometimes be dispensed with and the introduction of
a flexible tube substituted, yet this cannot always be done.
Tracheotomy becomes necessary in certain  cases when
foreign bodies are lodged in the trachea and cannot be
coughed up.  Writers also mention polypi  and other ex-
crescences in the trachea, as causes demanding the ope-
ration ; these are, however, very  rare.
  Foreign substances having entered the glottis sometimes
get fixed in the  ventricles of the larynx, this accident has
often happened, they produce less  disturbance here than
in the trachea or glottis, sometimes remaining many years
without occasioning any unpleasant effects:  they must of
necessity be very small.  If the foreign body  should rest
in the glottis so as to impede respiration,  no time is to be
lost, an opening must be made below it, and  the substance
pushed up with a probe.
  When any substance falls into the windpipe, it occa-
sions violent coughing and difficulty of breathing, attend- 
                 ELEMENTS OF SURGERY.             445
ed with the usual symptoms of suffocation; but if the for-
eign body be not discharged by the efforts of coughing,
and  death be not occasioned by the obstruction  to respi-
ration, then we are to infer that the substance has passed
through the  glottis  into the trachea, the irritation in this
case is greatly diminished and after a short time entirely
subsides.   Heister relates  several  instances in  which
foreign bodies have passed down  to the  bifurcation  of
the trachea, and  there remained for many years.
  In consequence of the facility with which the mem-
branous partition between  the oesophagus and trachea
may be pushed forward, so as to diminish the  cavity  of
the latter canal,  and of the spasmodic action of the mus-
cle of the glottis  excited by any irritation of these parts,
it is occasionally  difficult to  ascertain, whether the for-
eign substance be actually in the oesophagus, or trachea.
Indeed mistakes have  been made,  and  the trachea has
been laid open in cases where nothing has been found in
it, the obstruction having proceeded from pressure in the
oesophagus.  It  is of the utmost importance before  pro-
ceeding to such an operation to ascertain precisely whe-
ther the body be in the oesophagus or not, and this can
readily be  done  by passing a probang or catheter down
the oesophagus, which will remove all doubt.
   When the catheter is to be introduced, it should  be
one of the  largest size in use for  the urethra.  It is to
be held as  a pen,  and passed through the mouth, or if
this be inconvenient  from  the nature  of the disease,
through the nostril, at the fauces it readily passes either
into the larynx or pharynx ;  at the former it produces,
First, A cough and tickling pain,  with desire  to vomit,
and a'spasmodic elevation of the larynx.  Secondly, The
flame  of a candle placed before the end of it is  blown to
 one side.   Thirdly, In passiug it still further, resistance
 is felt at the bronchia*.  In the pharynx and oesophagus 
416             ELEMENTS OF SURGERY.
there is less irritation—no cough—no blast of air—but
if some fluid  is injected through the tube,  the  doubt
ceases :  if it pass into the larynx, violent coughing is oc-
casioned, and it returns; if on the contrary into the oeso-
phagus, no inconvenience results.
  When any difficulty is found in passing the tube into
the glottis, a stilette may be  introduced into it properly
curved;  by this means it acquires sufficient firmness to
be passed through the glottis.  When introduced it is
to be secured to the patient's night cap, and  a piece of
gauze must  be fastened over the orifice of the tube in
order to prevent the dust and floating matter of the air,
from  being  drawn  into the lungs.   The  tube is to be
often removed and cleansed, as the apertures at its extre-
mity are soon filled w ith mucus so as to obstruct the free
passage of air.
  When the operation of bronchotomy becomes neces-
sary there  are two places of performing it, one at the
lower part of the larynx, the other in  the trachea.   Tra-
cheotomy consists  in  making a puncture  between the
rings of the windpipe, or if necessary for the extraction
of foreign matters it may be divided  longitudinally,  for
a considerable length.   But of late the French surgeons
have preferred very much the division of the larynx, and
they state the following advantages which  this operation
possesses.
  In dividing the membrane between the cricoid and thy-
roid cartilages the skin and a very small portion of cellu-
lar membrane are the only substances met with. While in
tracheotomy, the skin, much cellular substance, and gene-
rally a part  of the thyroid gland, are divided.
   There is never any  hemorrhage from the puncture
between the cricoid and thyroid cartilages, whereas  the
other operation  is  almost always followed by more or
le<s hemorrhage, and this is an important  circumstance, 
                  ELEMENTS OF SURGERY.           417
because it occasions delay, or, by falling into the trachea,
produces unpleasant effects.   Desault relates an instance
of a child who died from loss of blood before the opera-
tion could be completed.  The larynx is firmly supported,
and the operation is easily performed; in the trachea, so
much motion is allowed that it is often pushed before the
knife, and in one case the carotid artery was opened owing
to this circumstance; laryngotomy is therefore upon the
whole to be preferred.
OPERATION.
  The patient is to be seated, and the head inclined some-
what backwards, a bistoury and a curved canula adapted
to the larynx are to be provided.   The surgeon placed
before the patient searches for the space between the thy-
roid and cricoid cartilages, and makes an incision with the
bistoury an inch long, through the skin and cellular mem-
brane, from the bottom  of the thyroid to the cricoid car-
tilage—the edges of this wound being separated, the bis-
toury is to be passed through the membrane of the tra-
chea, low down, so as to avoid a small artery sometimes
found on the lower edge of the thyroid cartilage.  If this
be divided however, it is to be taken  up immediately.
The canula is next introduced and secured by tapes, the
angles  of the wound covered Avith lint, and the end of the
canula with gauze.
  When a foreign substance is to be extracted, the aper-
ture may be enlarged, by means of a pair of forceps and a
bistoury; the forceps when introduced  into the wound
maybe opened so as  to stretch the trachea and liberate the
substance, which may then be extracted, or  pushed up-
wards through  the glottis.   The cricoid cartilage, if ne-
cessary, may be cut through in this operation, and a  con-
siderable portion  of the thyroid may be divided.
  vol. i.         5* 
44g             ELEMENTS OF SURGERY.
  Where the object has been to remove a foreign sub-
stance, the wound may be immediately closed, and in ge-
neral it soon unites, but it is sometimes necessary to leave
the canula in the wound, and then  great attention must
be paid to frequently cleansing it, because the collection
of mucus is so great as to impede the passage of air when
this caution is neglected.
  I have sometimes found it necessary to introduce a ca-
nula into the trachea, in cases where it has been opened
by persons attempting to destroy themselves.  In these
cases it is difficult to prevent the collection of blood and
mucus in  the cavity of the canula, and great care is ne-
cessary to change the tube frequently, in order to romove
the obstructions which may be formed within it. 
PLATA'XV.
(.ana/a   for  / arvmwiomv
 
 
ELEMENTS OF SURGERY.
419
                 CHAPTER LXX.

          Accidents and Diseases of the Har.

  The meatus  auoitorius  externus  is  frequently
plugged up in children with foreign substances, as corn,
beads, &c, and  in adults with hardened wax. In these
oases a common eyed probe bent so as to form a hook at
the perforated extremity, is a very convenient instrument
for extracting them.   The wax if necessary may be soft-
ened by injections of warm water.   In general the hear-
ing is immediately restored when the passage is cleared.
  Insects sometimes crawl into the  ear and excite extreme
pain ;—a little olive oil poured into the external meatus
kills them very speedily, and they can be readily extract-
ed.  Worms have occasionally been found in this canal,
their  ova having been previously deposited, probably
during sleep; an infusion of tobacco in these cases may
be poured into the meatus ; it does not irritate the parts,
and is fatal to the insects.
  Abscesses  sometimes form in the vicinity of this canal
and discharge themselves into it—when this is the case,
the hearing is generally unimpaired.   Should the tym-
panum, however,  be affected, the bones of the ear are
sometimes discharged through the membrana tympani
and hearing is  greatly injured or entirely  destroyed.
When the symptoms of inflammation exist in this impor-
tant organ, the usual remedies for it are to be employed,
with a view  to prevent the formation of pus ;—a number
of leeches behind the  ear, and blisters afterwards are to
be  applied.   Mr. Saunders  observes  that when  these
remedies arc unsuccessful and matter has formed,  it is
generally  evacuated,  as far as he has observed, between 
4^0             ELEMENTS OF SURGERY.
the auricle and mastoid process, or into the meatus.  If
it has been evacuated into the meatus, the opening is most
commonly small, and the spongy granulations, squeezed
through a small aperture, assume the appearance of a po-
lypus.  Sometimes the small aperture, by which the mat-
ter is evacuated, is in this manner even closed, and the
patient suffers the inconvenience of frequent returns of
pain from the retention  of the discharge.  When the parts
have fallen into this state, it will be expedient to hasten
the cure by making an incision into the sinus, between the
auricle and mastoid process.
  It occasionally happens  that the bone itself dies, in
consequence of the sinus being neglected, or the original
extent of the suppuration.  The exfoliating parts are the
meatus externus of the os temporis or  the external lami-
na of the mastoid process.
  When polypi are found  in the external meatus they
are to be removed by the knife or forceps.
  The cavity of the tympanum is  sometimes, as has
been  remarked, the seat of abscess;  in these cases the
membrane is destroyed, and air passes through the ear
when the patient closes his mouth and blows forcibly;
these abscesses are sometimes the result of common in-
flammation, and sometimes  follow small-pox and other
diseases.  The usual remedies for inflammation are the
only  means of preventing suppuration, and where pus
is  evidently  formed,  notwithstanding their exhibition,
Mr. Saunders advises a puncture to be made through the
membrana tympani, in preference to allowing the abscess
to burst.   When the discharge of pus continues a great
length of time, astringent injections of white vitriol  and
sugar of  lead dissolved in water, may be used.  Blisters
and setons applied behind the ear are also advantageous.
  The eustachian tube is sometimes obstructed  and
occasions a considerable degree of deafness.   A severe 
                  EI .EM E NTS OF SURGERY.            421
catarrh frequently produces a temporary deafness of this
kind. When this tube is obstructed the patient is unable
to inflate the tympanum as  in health ;  the sensation at-
tending this inflation is more easily felt  than described :
to produce it, is only necessary to make a forcible attempt
at expiration while the nostrils and mouth are closed. Mr.
Astley Cooper has proposed when permanent obstructions
exists in  the Eustachian tube, to perforate the membrane
of the tympanum, an operation which has been repeatedly
performed, and  sometimes with success.   I have tried it
but without any benefit, though I should have no hesita-
tion in repeating it, because it can do no harm  to a deaf
person and  has  in many  cases  proved  beneficial—a
couching needle or sharp pointed probe answers the pur-
pose very well—when inserted through the membrana
tympani  a sharp pain is felt, but it quickly subsides. The
instrument should not  be  pushed so far as to wound the
parts within the membrane.  Air in this manner will be
admitted to the cavity of the tympanum, and if deafness
should have arisen from a want of it, it will be  relieved.
Mr. Saunders in one case by this operation instantaneous-
ly relieved a deafness of thirty years standing—he re-
commends a large aperture to be made, a small  one being
apt to close up.
  Diseases of the labyrinth are very generally beyond
the reach of surgery.  In some cases the parts upon dis-
section evince no morbid alteration, and the want of sen-
sation has probably been owing to the state of the nerve.
In other cases the labyrinth is found filled with  a cheesy
concretion, instead of  the natural fluid which should be
found.
  Mr. Saunders considers most of the diseases  of the in-
ternal ear as depending on the nerve of hearing, the por-
tio mollis of the auditory nerve being probably paralytic.
Various  noises are generally  perceived by patients la- 
43g              ELEMENTS OF SURGERY.
bouring under deafness from the palsy of the nerve, such
as the murmuring  of water, the hissing of a boiling
kettle, &c.
  The remedies  which have oftenest been useful  (and
they have been but very rarely so) are long continued
purging, low diet, and the  use of mercury, with blisters,
issues, and setons applied in the vicinity of the ear.
  Mr. Saunders  has  known  a nervous  deafness, origi-
nating from a syphilitic source, to be relieved completely
by a mercurial course. Deafness, however, is a very rare
consequence of the venereal disease, unless when it arises
from ulcers, or scabs, in  the  external meatus, in which
case  it is temporary, and amounts merely to an external
obstruction readily removable.
END  OF VOL. I. 
 
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