56
WILLIAM M'LANE
No. 27





Hic libeo pvetinet ad editorem
Gulielmo Madane



Memoranda
From a 
Course of Lectures
on 
Surgery.
Delivered in the University of Pennsylvania
By Philip S. Physick M.D. Professor, & 
John S. Dorsey, M.D. Adjunct Professor
of Surgery in that University
By Wm M Lane
Vol II.
1811 & 1812



Memoranda &c
Lecture 20.
Fractures of the lower end of the humerus
are generally transverse, and these are 
sometimes complicated with a separation of 
the condyles of the bone.
Either one condyle is separated from the bone 
alone, or they both are. They are easily detected,
in their superficial situation, by the 
fingers. If we take hold of the condyle or 
condyles, we can move them very easily in 
any direction, and a crepitas will be heard.
A bandage is to be aplied from the hand to 
the elbow, and, extension and counter extension,
used; the condyles are now to be brought 
into place, and the bandage continued up
the arm. The arm is now to be brought to 
right angles, and the rectangular splints 
applied laterally, and straight ones, bent at 

4
the middle, applied before and behind,
and the bandage carried over the splints, down 
to the hand. In 8 or 10 days, the apparatus is 
to be removed, and the parts examined, & 
if any derangement is found, it can be 
rectified.
Fractures communicating with the cavity 
of a joint are longer in uniting than others:
in general, this will unite in 5 or 6 
weeks. When treated in this way alone, we 
always find a deformity: the natural an 
angle which the arm and forearm form 
with one another, the point whereof is downwards
when the arm is extended, is reversed
and the point is now upwards. To avoid
this, after having kept the cubit an right 
angles for about 20 days (as above) it is 
to be extended, and, splints having a 
downward angle, such as the arm naturally 
forms are to applied before and behind,
and the roller carried over them as above,
and this apparatus kept on for 4 or 
5 weeks longer. In this ways I have preserved

5
one arm in perfect shape. The only hazard 
which attends this apparatus, it that anchylosing 
is not a rare accident in such fractures,
and, if it were not for this, the arm ought
be kept extended from the beginning; but 
it being well known that if anchylosis occur
in a straight posture, the limb will be
useless, whereas, in the [cross out] flexed, it will be 
be very serviceable. After the arm is extended 
the state of the joint is to examined every 4
or 5 days, and if anchylosis is found to begin,
we must bend the arm again. When
the bony opised to the humerus are both injured,
we may expect to presever the joint
in most cases, but if either the radius or 
ulna is injured, as well as the humerus
bony union may be expected in the joint.
Fractures of the Bones of the Fore-arm
A. Of both the bones. This generally happens in
the middle of the bones. The seldom pass one another
much, and the [cross out] the derangements
they are most subject to is the angular, and this is 

6)
mostly inwards Counter extension is to be made by 
one assistant, holding the humerus just 
above the condyles, while another makes 
extension holding the hand just as we do
in shaking hands. The surgeon can now
place the ends of the bones in place with his 
fingers, and applies a roller from the 
hand up to the elbow. The arm is to be in 
a flexed posture while this is a doing. A pair
of splints broader than the forearm is drop
are now to be applied one on the front & 
the other behind, and secured by the reflecting
of the roller. The splints are best made
of stiff (not wet) pastboard, or wood. The 
arm is to be suspended by a sling. The thumb
may be left out, that it may shew us the
state of the arm, as to rotary derangement
and if the roller is too tight, this will swell,
and teach us to slacken it. The first roller
must be slacker than usual, lest the fragments 
be pressed together, and thus destroy 
the rotary motion of the radius on the ulna

7)
whereas the second roller, may be pretty tight,
to press the splints tight against the arm, and 
impact the muscles between the bones, and 
keep the latter asunder. In 8 or 10 days, the state
of the parts may be examined, as in other cases
L. Fractures of the Radius. This bone may be
broken at any part, but the most usual place 
of the fracture is about one inch above the 
lower head of the bone. The hand moves with 
difficulty in these cases, an angle inwards is
generally formed. The luxation of the wrist
may be confounded with this, but when the 
fractured parts are examined closely, certain
information may be had. The wrist may be 
bent freely without any motion at the part.
Extension and counter extension, as above
being applied, and the bone reduced, the same 
apparatus as that used when both bones are 
fractured is required. The splint must reach 
beyond the fingers as in the above case, to keep
the arm and hand quiet. This is very important
in both cases.

8)
Fractures of the Ulna. This is by far the 
least common of these accidents. I have never
seen any but two cases of this. One was produced 
by warding off the blow of a club, and 
the other by a fall on the bone itself. This 
bone is very thinly covered, and therefore, this 
accident is very easily detected, by feeling,
moving, and hearing the crepitus of, the fragments
The treatment is the same as in the 
former instance of the fractures of the 
forearm. In 3 weeks the bone will unite,
but it is best to wait 4 or 6 before removing 
the apparatus.
Stiffness of the wrist and fingers is very 
apt to occur especially in old persons; but 
this goes off naturally in some time. The 
splints may be taken off every 4 or 6 days, to 
bend and extend the fingers gradually.
Fractures of the Olecranon. These are produced
by direct falls on the elbow. They are 
very easily discovered. The power of extending 
the arm is lost, as the biceps extensor cubiti

(9
is now unable to act on the forearm. The olecranon
may be easily felt, and if the arm be extended,
the olecranon may be moved in all directions.
The treatment is as follows. The forearm 
is to be extended for the purpose of relaxing the 
triceps, and to let the point of the olecranon
occupy the pit on the posterior side of the humerus,
which it naturally occupies. A roller is 
now to be applied from the hand, and as soon 
as we arrive at the elbow, the skin is to be tightened
over the fracture, by pulling it up, lest 
it should fold between the fragments. (In 18 
or 20 days, the arm may be gently bent and 
extended.) On the front of the arm, one long splint
is to be applied over the first roller, and 
is to apply itself round the arm a little. If any 
considerable inflamation follow, the bandage
may be made slacker, and and the diet reduced 
very slow, and blood may be taken from 
the other arm
c. Fracture of the coronoid process of the
Ulna. I have never heard or read of a case of 
this kind, and I never met a case of it but

10)
one. This was mistaken for a luxation,
as the humerus was thrown forwards, and 
the olecranon felt above the pit for recieving
it. The parts were very easily reduced,
and while I was preparing a bandage, &c. I 
was astonished to see it stontanously luxated 
again. This was soon reduced, and 
perceived the crepitus. The coronoid process
being the only obstacle which keeps the 
triceps from luxating the arm, this effect
may easily be explained when the 
process is broken. I secured the arm at 
right angles, and allowed the humerus 
to rest in the hook like process of the [illegible]
for 15 or 20 days and then the splints
angular downwards, and the childs arm 
grow without deformity. This case first
suggested these splints with the angle 
downwards, which I have used very much
since.
Fractures of the Ossa Metacarpiaria
from direct violence, and are very easily

(11
discovered. The extension and counter extension 
are to be made from the [cross out] wrist and 
fingers, and retained by a broad pasteboard, 
applied in front and secured by a roller, the hollow
having been filled up by the introduction 
of some flannel or to betwixt the splint &
palm of the hand. A wooden splint, which 
will reach from the middle of the cubit, and
in which there is an excavation exactly in
shape of the arm, hand, thumb and fingers,
(if at hand) will answer rather better.
Fractures of the Fingers are very easily 
detected, and reduced. They require only one
small pasteboard splint in front. These 
fractures will unite in two or three weeks.
Decemb 23rd     P.S. Physic.

12)
Lecture 21.
Fractures of the Femur. This bone 
may be fractured in any part of its length,
but is very frequently fractured in its middle.
The upper end, even so high as within the 
capsular ligament is sometimes broken & 
then, the upper fragment is within the cavity 
of the joints. The lower end, just above 
the condyles is sometimes separated, in some 
of these, the condyles are separated; and there
are cases wherein one condyle is removed from 
the body of the bone.
This accident may be very easily detected, the 
motion of the limb is nearly lost, yet there
remains some power of moving the ancles and
toes, so as to deceive the patient, but if he attempt 
to raise the leg, the fails, and convulsive
twitches follow. The limb on comparison 
with the other will be found shorter, and 
on holding the leg, and moving it a crepitus is 
heard.

(13
This fracture is sometimes transverse, but it 
is generally oblicque, downwards and forwards
The lower portion in such cases slides above and 
behind the lower one.
Many means have been proposed, for keeping
this fracture in place. The object of all of them is
to keep the ends of the bones in relative opposition,
and prevend displacement and shortening
till the bones unite. They are as follows.
I. It has been proposed to treat this with simple
bandage and splints as other long bones
but this will by no means answer.
II. To place the limb in a position calculated
to relax the muscles of the limb.
III To maintain permanent extension and counter
extension, and keep the ends of the bones in 
contact.
The first practice was to apply a bandage and 
splints, and this bandage, tho so tight as to 
cause swelling of the limb did not prevent displacement, 
as I have, my self seen. The only 
use of the bandage is to prevent contraction in the 
muscles, and to give support to the veins and 


14)
lymphatics: They can answer no other good purpose.
The femur is so thickly covered with soft 
parts, that unless the fracture be transverse
or the fragments interlock, the bandage cannot 
prevent overlapping.
Mr. Pott, using the sweep of the straight position 
to be such, proposed to lay the patient 
on one side, to bend the thigh on the trunk
and the leg on the thigh to right angles, so 
that by relaxing the muscles of the limb,
he would take off the irritation which induces 
the muscles to contract, and pleasing 
as his proposal is, practice teaches us the 
following inconveniences arise from it.
1. The position is irksome and fatiguing, & 
and if the patient be so resolute as to maintain 
it thro' the day, he is sure to sleep on 
his back at night, and the bones must 
be set every morning, and inflamation will 
be thus produced.
2. We lose the advantage of measuring this 
with the sound limb, which is indeed the only

(15
only true way by which we can judge of the state of 
the bone, it being so deeply covered, that our faling 
quite deciptious.
To join the benefit of the flexed posture with the 
position on the back, a bone had been contrived,
consisting of two boards, joined together at right
angles at the end, and secured be angular stay 
this was introduced under the hough, and the leg
lay on the one square, while the thigh lay on 
the other. I have given this a fair trial 10 or 12
years ago, but I always found one side of the 
pelvis to shift forward, and allow the bone to 
over lap. By supporting the other limb in the 
same way, no benefit was obtained.
I have been led to prefer the extended posture. The 
objections to have been mentioned. Tho a very 
irksome irritation and fatigue occurs, the muscles
accomodate themselves to it in 2 or 3 days,
The heel sometimes inflames and sloughs by 
the continued pressure, but a little attention to 
this will prevent it. As soon as it is found to 
become sore, it may be rubbed with brandy and 
defended with sticking plaster spread on leather

16)
or a compress of 10 or 15 folds of flannel, and 
with a hole in the middle for the heel will 
answer completely.
The last method is permanent extensions
Many means for this purpose have been tried.
The foot being secured to the foot of the bed,
and another roller round the axilla, and 
secured to the head of the bed, extension had 
been kept up; but they produces unsupportable 
irritation and cannot be borne.
It is much better to apply the apparatus
to the bone itself. Weights have been suspended
from the [cross out] thigh over a pully near
the bedside, and extension thus produced,
but I have seen this tried, and no good
effect whatever followed. It only drew the patient
to the foot of the bed. Many other 
apparatus have been proposed, but most
of them are too complicated for as [cross out]
prompt an accident.
But the most certain and the most simple
apparatus, is that of Desault. I have

(17
used it for 12 or 14 years in my private practice and 
in the Penn Hospital, and in most, if not all 
cases, preserved the length of the bone. I shall 
now demonstrate this apparatus.
The bed is to be bottomed with tight-braced sacking
or boards, and to be without a foot board,
An oval hole is to be left in the bottom of the bed
as well as in the matrass for a close stool. They 
may be occupied by an oval cushion, and supported
by a stool under the bed. The sheet it to
be without a wrinkle, and no more than one 
pillow used to support the head, else the body
will press on the limb, and derange the bones
The apparatus is to be laid on the bed in 
the following order. 1. Four or five tapes in 
the length of the thigh 2. The junk-cloth,
or piece of linen or muslin, as long as the thigh,
and it may be broader, (with the convey 
corresponding to the groin folded in). 3 a splint
of pasteboard for the back of the thigh. 4 The 
bandage of strips, each 2 or 3 inches broad and long 
enough to overlap over the thighs and sufficiently 
numerous to reach from the

18)
knee to the groin overlapping over one another
a little 5. The bandage for counter 
extension is to the laid down. This may be
made of silk, or of leather, sewed up into a 
tube and covered with oil cloth. 6. The bandage
for extension is to be laid at hand.
7 The post-board splint for the anterior part 
of the thigh is to be prepared. 8 Two bags of 
chaff as long as the limb, or flannel folded 
8 or 10 times would answer. 9. Two wooden 
splints, one for the outside of the thigh,
and the other for the inner. They are to 
reach from the six inches below the foot, 
and the outside one reaches to the crest 
of the ilium according to Desault, but 2
have extended it to the axileau, and then 
made a head like that of a crutch on it. There are
two holes near the head of this splint,
for the bandage for counter extension.
The limb is now to be laied on the apparatus,
and the latter applied as follows. Each 
of the long splints is to be rolled in the 

(19
junk-cloth from the edge, so as to apply to the 
side of the thigh, and the bags are to be laid 
on the inside of the splits, and they thus applied.
The bandage for counter extension is now 
applied in the groin and carried before and behind,
and carried thro' the holes in the long splint 
and tied. The bandage for extension is next applied 
on the back of the small of the leg, crossed 
on the [cross out] instep, knotted on the sole &
carrid over the block near the end of the outer
splint and tied in the hole on the splint.
Extension is now to be made, and the limb 
is to be compared (at the ancles) with the other,
and we must observe that the anterior 
superior spinous process of the ossa ilia
are not out of their place, and consequently 
that the pelvis is not aslant.
The proper extension having been made, the 
bandage for extension is to be secured. The 
bandage of [cross out] strips is next applied, beginning 
at the knee, and reaching to the groin,
the splint of pasteboard is to be applied on

20)
The fore part of the thigh and the tapes are 
now to be tied over all. It is obvious that 
after the bandage for counter extension is 
applied the surgeon himself can make 
extension merely by pulling the bandage
for extension, and pushing the splints.
Decemd 27th            P.S. Physic
1811
Lecture 22.
Fractures of the Neck of the Femur.
This may happen either within the cavity of 
the capsular ligaments or entirely without 
this. In all these cases, the limb is rendered 
shorter;- in a very few cases, the fragments 
interlock one another so that no immediate 
shortening occur, yet in all these,
the shortening occurs before two or three 
days. The limb is always turned outwards,
and if any attempt is made by the patient

(21
patient to raise the leg or foot, he fails and nothing 
but pain and convulsive twitches follows.
If extension and counter extension be made, the 
limb can be brought to its full length, and as 
soon as this is quit, the limb relapses to its 
former shortness. If the hand be applied over the 
trochanter major, and the limb rotated, the
trochanter will not make any great sweep, especially 
if the fracture be near the body of the 
bone: whereas, if the neck be not broken, there 
will be a considerable arc described, the radius
whereof is as long as from the bottom of the 
acetabulum to the outside of the trochanter.
This accident may be confounded with 
a contusion, or a dislocation; but the diagnosis
is very certain. 1. In contusion, the pelvis 
will be tilted up on that side, and I have seen
this prove very deceitful. In an hospital at 
York, a patient was supposed to have a dislocation,
and a consultation of surgeons was 
held on the occasion, and they were not convinced 
till (6 days after) the patient walked freely

22)
freely. But if we place a stick on the superior 
anterior spinous processes of the ossa ilia,
we immediately detect the shifting of the 
pelvis and know that it is only a contusion
2. For dislocation upwards and backwards
the limb is shortened, but we cannot so easily
bring it to its length, and if we do,
the bone will not return, but be in place 
&c. I have endeavoured to explain this minutely
because accidents of this joint and the elbow
are often very obscure.
The treatment is the same as in oblique
fractures of the body of the bone. The hole in 
the matrass is particularly proper, as there 
cannot be any motion in the pelvis without
deranging the bone, and inflamation 
may be excited, which, as I have seen, may 
suppurate if rest be not maintained. If any
inflamation appear, bleeding and low diet 
may be enjoined.
When the injury is without the capsular 
ligament, the bone may unite well, but if

(23
it be within this, nothing but a ligamentous
union can be expected. In a case of this kind,
which I dissected long after the fracture, a very curious
process of nature is to be seen: the neck of the 
bone was absorbed, the body came nearly under the acetabulum,
and sort of ginglimus joint, with cartilage,
&c was formed
I am now to specify the improvements which I 
have made to the apparatus of Desault for fractures
of the thigh. His external splint only reaches 
from the crest of the ileum, and the bandage 
for counterextension goes obliquely from the groin
to this, and this tends to derange the upper fragment 
outwards. So avoid this, I have extended it 
to the axilla, and after the bandage is on, a strip
of [cross out] bandage is tied to this, midway betwixt 
the groin and splint before and behind*, just so 
tight as to make the bandage act in the line of 
the thigh. The upper end of the splint is made 
like a common crutch and covered with flannel
as a square head would tend to hurt the arm
In
*going over the other side of the abdomen 

24)
In Desaults apparatus, the foot is forcibly 
drawn against the [cross out] splint, and very considerable 
inconvenience follows from this.
I have adapted an innovation of the late Dr. J
Hutchison, to avoid this. It consists in a block 
of wood, which being placed near the lower 
end of the external splint, has a notch
to receive the bandage for extension; so that 
the extension as well as the counterextension
are is thrown in the line of the leg and thigh.
Having applied the apparatus, an inexperienced
surgeon may draw the bandage too 
tight, and produce pain, exoriation, and 
even sloughing, having ulcers over the 
tendo achilles and instep; and the apparatus 
must then be removed, therefore, this 
is to be avoided. When the muscles contract 
strongly, very little force is proper, as by 
doing so, more irritation is induced. After
some days, the force may be gradually increased.
If tenderness or excoriation come 
on, (which is very common, especially in

(25
children) spirits, as brandy may be applied, the 
parts may be covered with adhesive plaster on 
leather, soap plaster, or what is best of all, a 
small buck skin gater, cut away at the heel,
and laced up the instep (with a strip of the same 
material to guard the instep from the whang
strips of buck skin may be fastened to the under 
part of this, thro' holes, and used as the band for 
extension.- Any bandage will soon fold together
like a rope and act very severely, therefore, this 
method is peculiarly proper to defend the skin.
Mr John Bell, in his book, represents the 
apparatus of which I have spoken, as cruel
and useless, and the error he has committed
is truly astonishing. In reading his book, you 
will reflect that he has never seen Desaults
apparatus applied by one who understood it.
He also says that when the femur is broken
in the middle, the lower portion is never displaced"!!!
The lower end of the thigh bone, just above 
the condyles is not unfrequently fractured.

26)
These fractures are generally oblicque,
forwards and downwards, and in these cases,
the upper fragment projects just above
the patella, and the lower is drawn backwards
by the gastroenemic muscles, and 
the bones are laterally deranged by the leg.
Having applied a roller from the ancle up 
and reduced the fracture, a pillow is to be 
applied in the hand, a compress on the hand
over the lower portion, and a splint is to be
applied in the hand, reaching from the 
middle of the thigh down to the middle of the 
leg, and Desaults apparatus may be also 
applied with a moderate of tightness, and 
the rest of the fragments is sure.
When the condyles are separated from 
one another, the treatment is the same as 
above, except that there is no use for the 
compress in the hand, unless the under portion 
be displaced backwards. Any fracture 
of the thigh requires the apparatus for 6 or 8 
weeks, while that within the capsular ligament
of the acetabulum, requires at least

(27
three monts. If it be removed before this, there 
is danger of the callous of ielding, and producing 
deformity, specially in fractures of the neck of 
the bone. P.S. Physic
December 30th
Lecture 23.
Fracture of the Patella. It is very seldom
that these happen in any other direction there 
transversely: however, I have seen then longitudinal
and also oblicque. Transverse fractures
generally happen by the violent contraction 
of the extensor muscles on the anterior 
part of the thigh. Oblicque and longitudinal 
fractures happen mostly from external 
violence directly applied, as in falls, blows, &c.
When the patella is transversely fractured,
the power of extending the leg is lost, also the 
power of walking, and if walking, he falls.
He may however walk sideways, or backwards.


28)
backwards. The transverse fracture produces very 
great displacement of the fragments. The 
separation is very easily felt. The upper
portion may be brought down by our exertions,
and rubbed against the face of the 
lower. The separation arises from three
causes: 1. The extension of the thigh, 2. the
flexion of the leg, 3 the contraction of the extensor
muscles of the thigh. When these causes 
unite, the fractured portions may separate 
5 or 6 inches. The only cause in which 
the parts are obscured, is when after great 
external violence, blood is extravasated &
forms ecchymosis over the part. The cellular 
substance is so lax, that the blood
may be pressed aside by the fingers.
The bones can only be approximated by 
opposing all the causes of displacement.
The thigh is to be bent on the pelvis, and 
the leg extended. After this, the fragments may
be brought nearly, or altogether into contact
The apparatus is designed 1 to keep the upper


(29
upper fragment down, by acting directly on this 
and the lower 2. To maintain the limb in the 
position mentioned. The apparatus always requires 
to be extemporaneous, and therefore simple.
A bandage is to be applied from the ancle to 
the knee, to support the vessels, the body being in 
a horizontal posture, the whole limb is to be raised
so as to relax the thigh on the pelvis, and the leg
is to be supported with pillows, or what is better,
a board reclining, and cover'd with a bolster. This 
posture is preferable to raising the body, in as much,
as it takes off the determination of blood. The 
above posture, tho' irksome, is supportable after 
some time. The fragments being pressed together,
a compress is to be applied above the upper, and below 
the lower, and to be secured by the bandages
turned in the figure of $, meeting on the hand,
the skin over the patella is also to be supported
by a turn of the roller, and it is then to be carried
as high as the groin, for the purpose of 
of suspending muscular contraction in the extensor
muscles.- It is also worthy of attention 
to draw up the skin over the patella, so that

30)
it will not insinuate itself between the fragments.
A long splint is now to be applied to 
the posterior part of the leg and thigh,
(covered with flannel) and the same roller is to 
be carrid down again over the splint to the 
ancle. The limb is to be supported with the 
pillow and board, as above described. If pain 
supervene, bleeding is proper. [See note J. p. 35.
If we are not called in till some inflamation 
has come on, the drawing down the muscles,
would only irritate them, but we must 
wait till by bleeding, elevated posture, lead-water 
poultices, &c we have removed this, &
then apply our apparatus. If put on before 
violent inflamation, is over or even anchylosis may 
follow.
As the roller which accury the compress
is found to press on, and impede the vessels,
Dr. Dorsey has contrived a splint, on the midde
of which two bandage are nailed, 4 or 5 
inched asunder, which being applied on the 
back of the limb, the bandages are brought 
over the compreses, and pinned or sewed

(31
over the compress. The lower bandage goes over the
upper compress, it visce versa, and below this is 
applied, a roller goes simply from the ancle to 
the groin, and the compress are applied. This 
I find very convenient.
In two weeks, (or less in case of inflamation) the 
bandage is to be removed to rectify any derangement;
but the weight of the body is not to be 
rested on before less than 3 months.
The union in all these cases is ligamentous, and 
not bony, tho' it is said that if the bones be kept
in perfect contact, they will unite by bone
I have seen the ligament two or even four inches
long. If bony union took place, the joint might
be lost by anchylosis, and in cases when the
under bones are injured this may be expected,
and in this case, after 16 or 20 days, the limb
may be gradually moved to prevent anchylosis;
which, however, I have never seen in this 
case.*- When no means are used to keep the 
fragments together, they will go 5 or 6 inches
as under and the power of extension will be
*see note H.p.35.

32)
lost. But by seating the patient on a table,
with the legs hanging down and making 
attempts toward extension every day
Dr Hunter succeeded in the case of a lady &
this practice deserves imitation.
Fractures of the Leg. These are mostly
transverse, but in some cases they are oblicque
In the first instance, no shortening of the 
leg occurs, but the leg is bent angularly
forward, if both bones are broken by the 
action of the strong muscles on the posterior 
of the leg. This accident is easily detected 
also, by the feel, and by the grating.
In cases of oblicque fractures, unless the 
fragments interlock, the leg will be shortened
from 1/2 to 1 inch, as will be found on
comparing it with the other leg.
Extension, and counter extension are to
be applied, and the bones are very easily 
replaced. They are to be retained by splints &
bandage till the bones have united. Permanent 
extension is not required in this case

(33
The apparatus is to laid in order on the bed,
as in fractures of the thigh. The leg is suported 
by a board, with a pillow: On this is laid the
bandage of strips, as long as the limb, from 
the knee. On this, two pasteboard splints,
soaked in warm water, and rolled in soft linen
is next applied, and lastly, a bandage of 
strips, similar to the former is laid over this.
The patient is now to be conducted to bed, and the 
surgeon is to preserve the posture of the limb, he 
is to carry it by the knee and ancle, and he is 
to keep it extended while carrying. It being 
laid on the bed, the first bandage of strips
is to be applied from the ancle. If the limb 
has been deranged, as soon as laid on the dressings,
extension and counter extension are 
to be applied and the bones reduced. The bandage
of strips is then put on, next the splint
which are to reach at least from one inch 
below the sole of the foot, to prevent lateral
displacement by securing the lower fragment
and they are to be applied over the sides of the 
leg, and secured by the bandage of strips,

34)
first laid down. This I prefer to tapes which 
are use'd by some, but they press very unevenly.
The foot is best supported by by a 
a bandage put round the toes and carried
up on the leg. The pillows are now to be 
supported by two pieces of shingle, and 
secured by pices of tape passed around the 
shingle, bolster and limb. The state of 
the parts, as in other cases is to be examined 
in eight or ten days.
January 1, 1811          P.
Notes on Lecture 23.
H. p. When after fracture of the patella, if
from external violence, it is required to bend
the leg on the thigh, before the union is perfect,
to prevent anchylosis, this precaution
is very necessary, viz. while very gentle and
limited motion is made, the fragments of 
the bone must be pressed together with
the fingers, lest the new formed parts should
give way.


(35
I. p.30 In all cases of fractured patella, particularly
in those from external violence, it 
is nescesary not to apply the bandage too tight
as this would be very injurious.
Lecture 24
In the subject of fractures of the leg,
one circumstance remains to be explined.
When the fracture of the bones of the leg 
is so oblicque that they pass one another
after reduction and the application of splints,
it is nescessary to apply permanent
extension, else shortness and deformity will
follow. [cross out]
Desault has described an apparatus for the 
purpose in question; and Doctor James Hutchison
has improved it very much, so as to 
make it fully answer our purpose. Two 
splints of boards are to be provided. In the upper
end of these, is a [cross out] number of gimblet
holes, and the lower ends of the splints are 


36)
joined by a cross bar.
1. A pillow is laid on the bed, and on it a bandage 
of strips. 2 The leg is to be laid on this, & 
and a bandage for extension passed around 
the leg, crossed on the instep and tied in a 
knot on the pole. 3. Two tapes are to be applied 
on each side of the leg, and secured by
a roller passed around the leg just below 
the knee. 4. The tapes are now to be put thro'
four holes in the splint, on each side and 
tied. 5. Extension and counter extension are 
applied, the bones reduced, and the bandage 
of strips applied on the leg. 6. There is to be 
a bag of chaff applied on each side of the 
leg, and the splints appied close along 
these. 7. The bar to join the end of the splint 
is to be introduced thro' the mortines in 
them, and the bandage for [cross out] extension 
is to be tied over this with whatever 
degree of force is required.
Thus, whatever degree of force is required,
may be applied, and all causes of displacement
counteracted.

(37
In all fractures of the leg, the weight of the 
bed clothes has a tendency to displace the bones.
This may be kept off, either by three nail-rods
bent into a semicircle, and the points driven 
into two pieces of wood, which serve as basis,
and lie parallel to the limb, or by a more extemporaneous,
tho less steady machine viz
two segments of the hoops of a flour barrel,
each two thirds of a circle, and tied together at
the middle, this sit up is a cross over the leg
will support the clothes.
In compound fractures of the leg, this apparatus 
is very serviceable, as it allows, to dress the 
sore, without undoing the apparatus which 
keeps the bones in place.
It will not be required to apply this apparatus
during much inflamation. If the 
pressure of the roller below the knee causes 
swelling, which it sometimes, tho' seldom, does 
Desaults apparatus for the thigh, which makes 
extension on the tuberosity of the ischium may
be used.- The action of the four tapes on the roller
below the knee, keeps the pressure in some

38)
measure off the lateral vessels.
In women the short apparatus will be 
very convenient, as the long apparatus reaching 
to the pelvis is not very suitable to 
their taste. The fracture box, with a thin 
pillow introduced into it, is very well adapted
to keep the leg steady. Tapes are tied around 
it after the limb is introduced. It has 
a double bottom, and when it is required to 
raise the leg, any body may be introduced
under one end of the bottom for this purpose.
The bottom is excavated for the leg.
It is very common for wet applications
to be used to reduce inflamation of the 
leg as a solution of sugar of lead, this with 
vinegar and a little spirit, vinegar and spirits
alone, vinegar and sweet oil; but these 
remedies are of little consequence, and bleeding 
is the best means to reduce inflamation
In cases of ecchymosis, vinegar and spirits
on the principle of coldness are the best means
to promote absorption.

(39
Ruptures of the tendo achilles are generally
produced by great bodily exertions, in which 
the gastrocnemii muscles are exerted, as in dancing,
going up stairs, &c
The patient feels as if his heel has sunk 
into the floor, a crack is heard, and the patient 
falls down. The powers of the gastrocnemii muscles 
is quite lost, yet by some other muscles 
he can extend the foot a little. * [Sec Note Th p. 43
The leg is to be bent on the thigh, and the foot
extended on the leg, so as to bring the ends of the 
ruptured tendon nearly into contact, and to 
retain them so till union has taken place.
Doctor Monro describes the following means 
to maintain this posture. A piece of Russian 
sheeting is secured round the leg, long enough 
to reach half way down the leg. A slipper is 
next put on the foot, and a strap fastened
to the heel is to be carried up the back of the 
leg, and secured to a buckle on the back and 
inferior part of the sheeting. Thus, the belly 
*See wounds of the Tendo Achillis V.I p.116

40)
of the muscle is compressed, and prevented 
from acting, the lower portion is drawn up, &
the upper down, and the ends are tolerably well
kept together.
Dr. Monro met this accident himself, & 
succeeded in covering it by the above apparatus.
You will perceive on reading his account, 
the great difficulty experienced, and 
a very considerable lump was left on it.
One very great difficulty attends this mode 
of practice. The foot being at liberty to 
move laterally is very apt to derange the
lower fragment. To remedy this, I prefer the 
following apparatus.
A splint of wood is carved in such a 
manner as to adapt itself to the anterior
part of the leg and foot.
1. A roller is to be applied under the knee 
and after being carried half way down the 
leg, is carried up as high as it began.
2. The splint, lined with soft linen or flannel
is applied on the anterior part of the  

(41
leg and foot. 3. The roller is now reflected halfway 
down the leg, carried the same height, and pinned 
4. Another bandage is applied on the lower part
of the bandage* and foot; some turns of it may 
surround the heel, but not make any pressure
on the tendon, as this would derange it very much,
5 The vessels of the finall of the leg may be supported 
by a few turns of the roller, but these 
must be very slack, and it is best to support 
the tendon by compress of tow or lint.
The limb is now to be supported on a pillow 
for 6 weeks when the union will be but soft,
but no weight of the body is to be intrusted
to it before ten or twelve weeks.- Doctor Monro
was not able to use his leg completely before 
four or five months.
Having complated the history of the ruptured
tendo achilles, I shall now introduce
some observations on an accident little understood.
Persons after carrying a heavy burden 
on the shoulders, leaping, &c hear a crack
*splint

42)
referred to the calf of the leg, they are not 
able to raise themselves on the toes, yet
it is possible still to walk in a hobling manner
without raising the heels. I have never 
had an opportunity of dissecting a leg, after
this accident, but it appears to arise 
from the separation of the muscular fibres
of the gastroctemic muscles from the 
tendon to which they are united. In one 
case, I have felt an evident pit at the seat 
of the injury. From the pain and uneasiness 
in walking, patients will keep themselves
quiet for 8 or 10 days, they then walk 
about and a complete separation again
recurs. He confines himself for far a similar
line till easy, and again walks, &
after this many such courses, I have seen
patients miserably perplexed. One man 
was nine months in this way, the leg was 
swelled, and his health very bad!
The carved splints will answer very well
here. The foot part must be so deep as to restrain

43
restrain the lateral motions of the foot completely.
A bandage is to reach from the ancle to the 
knee.
In course of 5 or 6 weeks, a confined motion 
may be allowed, as the tendon will be tolerably
strong.      P.SP.
Jan 3. 1812
Note on Lecture 24.
K. p 39 Rupture of the tendon of Achilles
are very easily detected also by the fingers.
A very great vacuity is felt in the tendon.
However in cases of great swelling this 
may be obscured.
Lecture 25.
Fractures of the Tibia alone. As the fibula
is entire, the length of the limb is unaltered.
When the fracture is transverse, it is often
very difficult to discover the presence of the 
injury. There is generally sharp pain, and unevenness

44)
unevenness at the part, by trying to bend 
the tibia, an angular projection, and a 
chinck may be felt. It is of importance to 
know the presence of this injury in all cases
as it will be very dangerous to treat 
it only as a contusion. A patient of mine,
after I had reduced an accident of this kind
was not satisfied that his leg was broken
and removed the bandage and splints. On 
making somewhat an oblicue step, the 
leg yielded, and very severe distress was the 
consequence. Therefore cases of this sort
ought to be very carefully examined
The treatment is the same as in transverse
fractures of both bones. Two splints,
are required as in that case, and the leg 
is to rest on a pillow. In some cases this 
fracture will not unite, and in this case,
after about 6 weeks, considerable motion 
may be allowed, so that the fragments may 
inflame on their surfaces, and form a bony 
union. I have successfully treated several 

45
several cases in this way; and the union was nearly 
as speedy as usual.
Fractures of the Fibula. This is generally
complicated with a fracture* of the ancle joint. The 
fracture happens mostly at two thirds of the length
of the leg from the knee the leg is much distorted,
the astragalus faces the [cross out] outer ancle, the 
inside of the foot is turned down, and the sole, out.
A considerable hollow is felt over the seat of the 
fracture, the patient complains of pain there 
and if the foot be flexed and extended, a grating 
may be heard.
The first thing to be done is to reduce the 
foot, and the fibula will be drawn into its
place by this alone. The limb is now to be secured
by splints and bandages. The patient may
be laid on his back, and the many tailed bandage
applied, beginning at the ancle. The bandage
must be so slack as not to derange the 
fragments of the fibula.- Perhaps it may be
supposed that splints are unnescessary, as the 
*dislocation

46
tibia remains entire, but this is very far 
from being the case. The splints are to be 
so long as to reach below the foot, and by 
so doing the foot is kept steady, otherwise,
it will be very apt to produce displacement
of the lower fragment inwards. This is
the principal use of the splints, and one 
to which you ought to attend, as you will 
not find it in any book which we have.
By neglecting this, caries of the bone has been
produced, and I have seen amputations resorted 
to, on account of the diseased state of 
the leg produced by the irritation of the parts 
thus neglected till caries came on. In five
or six weeks, union will have formed such 
as to allow of considerable excercise of the leg.
Of Dislocations. A dislocation consists in 
the derangement of a bone out of its natural 
situation. It is attended with a loss of motion
with pain and deformity.
If surgical assistance be at hand, it is generally

47
generally easy to reduce the bone to its place, but
if much time elapse, considerable difficulty is 
commonly experienced. This arises from the contraction 
of the mucles by the irritation of the bone
displaced. The rupture of the capsular ligament
is not the cause of very much trouble, except in
a few cases, to be specified hereafter.
In such cases, many means have been devised 
for moderating the action of the muscles. Bloodletting, 
warm bath, low diet, &c have been used.
The first of these remedies, bloodletting from one
or both arms, ad delinquim animi, I have found
the best remedy; by this means, a temporary 
suspension is put to muscular motion, and 
the principal obstacle being removed, the reduction
is very easy. This remedy was first used 
in the Pennsylvania Hospital by me, and 
it was first proposed by Dr. Alexander Monro in
his lectures.
For the same purpose other means have also 
been used, but with less effect. Nausea produced 
by tartar emetic, or by tobacco injections
and these means may be used when bleeding

48)
is objected to. Intoxication has a similar 
effect. The muscles may be overcome by 
being fatigued. How after do we see reduction 
happen by weak efforts, after resisting 
for hours!
When a dislocation cannot be reduced, the muscles 
accomodate themselves to their new 
functions, adhesiong form round the head
of the bone, and these causes conspire against
reduction. This is particularly the 
case in old dislocating. The natural cavity
becomes less, and presents another obstacle.
Considerable force is required in these cases
Pullies have been much used but I have 
relinquished their use of late, and now, I 
use a number of assistants. Pullies are 
very unmanagable, and their action is 
not easily attend, whereas, by a word, you 
can vary the force and direction at pleasure
by using a proper number of assistants.-
Care must be taken to confine

(49
the force applied, to the joint dislocated.
When a bone remains long out of place, a 
sort of new joint is formed. This is not unusual in 
some joints, particularly the shoulder and hip.
A joiner had his arm dislocated into the axilla and 
remained irreducible. He began to use it a little
when the pain and inflamation had subsided.
The power of moving it returned gradually, he
has able to use the saw as well as before, but one
muscle seemed to have lost its power, (the deltoid)
as he could not raise the arm upwards. In all 
such cases, the cellular membrane is so condensed,
as to serve as a new capsular ligament, and 
even new cartilage is formed.
In irreducible dislocations of the hip, the acitabulum
is very readily and completely absorbed
and a new one, with capsular ligament as well
as cartilage is formed. A girl by receiving a fall
had her femur luxated backwards and upwards
and lost the power of motion for some time,
and nothing could be done to reduce it; after some
confinement, on beginning to walk about,

50)
and received a second-fall, whereby the other 
femur was reduced to the same state as the 
first. The limbs were now of one length,
and she could walk a little, when at the end 
of a year, she took a fever, which proved fatal,
Her pelvis was shown to me by Mr Cruickshank,
and in both sides, the bone was dislocated upwards
and backwards. The natural acitabula 
were completely absorbed, new cavities
were formed on the dorsa of the ossa ilia,
surrounded by bony margins, covered
with cartilages, and furnished with new
capsular ligaments. Dr. S.
January 6th,
1812

(51
Lecture 26.
Dislocation of the Lower Jaw. The only direction
in which this can happen is by the condyle 
being carried before the tuberosity at the 
root of the zygomatic process. The mouth always
stands open, speaking is impracticable,
the saliva flows from the mouth, and considerable 
pain attends.
It is produced by yawning, or any other cause 
of opening the mouth wide, by which the 
condyle mounts upon the tuberosity before 
the pit, and in shutting the mouth the 
condyle cannot get back again. A woman 
in market, in scolding [cross out], husband furiously,
found she could not shut her mouth again,
and came to me, and I found her jaw dislocated 
on both sides.
Some recommend strikeing the chin upward
to reduce this, but by this, the condyles may be
broken. In recent cases the reduction is very

52)
easy. The thumbs are to be introduced into 
mouth, applied to the molar teeth, and the
middle fingers applied under the chin. The 
thumb may be guarded with a soft linen,
lest after reduction, by the spasmodic action,
it should be injured. The patient is to be 
seated on a low chair. The surgeon is to depress 
the angle of the jaw with the thumb,
while with the fingers, he raises the chin,
and as soon as it is dislodged; he is to push 
it backwards. In this way, all the cases
I have ever seen were easily reduced.
No bandage is required after reduction, but 
the mouth is not to be opened freely for 
some time. Both sides of the jaw are 
generally dislocated at once. I have seen
only one case, in which only one condyle
was dislocated. In these cases, the force is 
to be applied to the injured side only.
Dislocation of the Clavicle. This bone 
much oftener fractured than dislocated.
a. I have seen one case of dislocation in

53
the sternal extremity, which was forwards. It 
may also happen upwards or inwards. Dislocation 
forwards always happens from the shoulder being 
driven forcibly backwards. It is very easily known 
by the projection anteriorly, and easily reduced.
A cushion is placed in the axilla, the elbow pressed 
toward the trunk, and the end of the bone
pressed down with the thumb. After reduction 
the apparatus of Desault for fractured clavicle
is to be applied, and kept on for four or five weeks,
till the ligaments resume their tone again,
b. Dislocation of the scapular end from the 
acromion scapulae is very easily discovered. 
The clavicle is found raised above the acromion 
a considerable way; and the ligaments 
are torn. On raising the arm, you reduce 
the fracture. This is always produced by a fall 
on the shoulder. To reduce it, it is only necesary
to raise the arm upwards and outwards, 
and secure it so by the same apparatus 
as in fractures of the clavicle. This is to 
be persevered in for ten or twelve weeks, as 
the ligaments are long in uniting. 

54
Dislocation of the humerus is the 
most usual accident of this kind which is 
met with. This occurs, 1, from the large 
motion which this joint performs, 2, from 
the shallowness of the glenoid cavity, 3, 
the great weaknes of of the joint in some 
directions.
The head of the bone in most cases is 
thrown downwards, into the axilla. It is 
sometimes carried forward, between the 
coracoid process, and glenoid cavity, but 
this is very rare. It is also sometimes dislocated 
back, so as to lie betwixt the glenoid 
cavity, and the spine of the scapula.
The second is very rare, one case of it, being,
all I ever saw. Of the latter sort, or backwards,
very few cases occur: about two 
weeks ago, a case of it occurred to me.
This accident is very easily discovered in every 
situation. 1. In the axilla Considerable pain
attends this. The arm cannot be raised up, 
neither can it be brought to the body, but

55
the elbow will hang about a span from the 
side. There is instead of the round form of the shoulder
a great hollow under the acromion, and a 
large tumor is felt in the axilla. The body of 
the humerus cannot be felt above half way,
from the tension of the deltoid muscle.
This is easily distinguished from a fracture 
of the head of the bone, by the hollow under the 
acromion and the sharpness of this.
2. Inwards. In this case, the motion of the arm 
is greatly impeded. It cannot be raised to the 
head, but can be brought close to the body.
The coracoid process cannot be felt, and the projecting
acromion is felt far behind the 
head of the humerus.
3. Backwards. This is easily known. The acromion 
and clavicle may be felt far before 
the head of the bone, the head projects just 
over the dorsum of the scapula
In old cases, the head of the bone is often
drawn from its situation in the axilla, forwards,
by the action of the pectoral muscle.

56
It can never happen upwards, the acromion 
as scapula here forming an insurmountable 
barrier.
In recent cases of downward luxation,
the reduction is generally easy. I have succeeded 
by extension and counter extension 
without any assistant, holding the humerus 
just above the elbow in one hand, and 
pressing upon the spine of the scapula 
with the other. The force is always to act 
on the joint of the shoulder alone. This is 
a fact of the first importance: it accounts 
for the frequent failures of ignorant, tho'
bold operators, who make counter extension
from the thorax, and spend all their 
force on the connections of the scapula
to the trunk of the body! Have we not read
of a miller, whose arm was torn from the body
by violence, and not the shoulder joint,
but the connections of the scapula to the 
body which gave way.
The forearm is to be bent on the arm and as
* A low chair is the best seat for the patient

(57
handkerchief tied round the arm just above 
the elbow, and given to one two or more assistants.
The surgeon is to press with his hand on the 
spine and acromion scapulae, and an assistant 
may also apply his hand over the surgeons,
and increase the counter extension. The forearm
may be raised up and down to assist its 
going into place. If the reduction do not happen
by these means, the surgeon may entrust the 
assistants with the counter extension and by 
pressing up the upper end of the bone with one 
hand, and the elbow down with the other, he 
may use the bone as a lever to reduce itself.
Some use a pad, put under the axilla for this 
purpose, but the hand is as good, and appears 
more simple to the patient: however, very 
little violence is to be used in this way.
But if it be found that the contraction of 
the muscles will be so violent as to resist
moderate force, Bleeding ad delinquim animi
is to be used rather than great violence, producing 
painful excoriations, &c. This remedy was 
found nescesary in a case in the P. Hospital, in

58
a robust man, and after losing near a 
quart of blood, he fell down, and the bone
was reduced with the greatest ease. Since
this, many other cases have occurred, with 
similar result. This remedy is never to be 
used unnescarily, but confined to all cases
in which we know great force will otherwise 
be required.
But if after several weeks continuance,
there have been adhesions formed, and the 
capsular ligament has closed, it would 
be unnesecary, and improper to spill the 
vital fluid. Force must now be applied.
Either a number of assistants, or pullies may 
be used. It is nescesary to vary the direction 
of the force at the period when the bone is 
just returning to its place, and as this 
cannot be done when we use pullies, I
prefer as many assistants as may be requisite,
probably five or even ten.
In some cases, I have distinctly heard the capsular 
ligament lacerating at the moment 
of reduction 

59
To avoid excoriation, the lower end of the arm, above
the elbow may be defended by stiff buckskin.
A strong roller is applied round this, and given 
to the assistants, or a handkerchief, with a 
rope fastened to it. A strong band, with the middle 
stuffed, so as to be very soft, is applied on the 
acromion, and fastened by the ends to a hook,
as high as the patients groin if he is standing 
or on the floor if he sits. When extension is 
made, this band is apt to slip and excoriate 
the skin, therefore it is to be held in place 
by the hand of an assistant, or secured from
slipping up by a roller passed under it, and 
held. This has been introduced by Dr. Dorsey
and is very convenient. Or strips of leather
may be fastened to the under edge of the band,
for the same purpose.
Any force whatever may now be commanded,
and the arm may be rotated, so as 
to break whatever adhesions may have formed.
If the body should yield, a band of great 
breadth may be put round the body, and held
by assistants, merely to secure the body, or the

60
patient may lie horizontally, but the 
best position is sitting on a low stool.
By the above means, luxations of nine,
eleven and even of thirteen week have 
be reduced under my observation. I also 
have the account of a case in Baltimore
in which it succeeded after five months.
I do not think that  any bone can be put
out of place which cannot be returned by 
art again, and therefore no case is to be 
despaired of.
I may mention some of the other means
which have been used for this reduction.
1. The body has been suspended by the arm
over a door or ladder-but the humerus is 
liable to fracture from this violence.
2. The body has been raised by the arm,
with a pulley,-but no counter extension 
is provided for in this way, and it does not 
succeed well.
3. By placing the patient on the floor,
putting the heel in his axilla, and making 
extension by the wrist, I have seen

61
Mr.J Hunter succeed in a case of this kind of 4 weeks and 
you may have this method in reserve for obstinate 
cases.
4. The various machinery, as the ambe of Hippocrates
&c act violently, yet fail because they 
do not fix the scapula.
Dislocation of the Elbow. This is in most 
cases backwards and upwards. The hook like 
process of the olecrannon may be felt above,
and considerably behind the naturan bid in
the humerus which receives it; the forearm 
is bent at right angles, and cannot be moved
either way. It may also be carried outwards,
or inwards but these forms are raw.
In the former, the olecranon may be felt
on the outside of the humerus, and in the 
latter, at the inside, and also, the hollow
of the radius may assist us in the diagnosis.
It is very easy to ascertain this accident, &
also easy to be reduced. In old cases it was however
very difficult. Boyer says that in four weeks
it is impossible, but in this he is mistaken

62)
as I have reduced one of four, as well as 
one of two weeks standing.
The reduction is performed in the following way
one assistant takes hold of the arm a
above the elbow, and the other just above
the wrist. The surgeon takes hold 
of the arm, by clasping the hands in front
over the lower part of the humerus, and 
he draws this backward, while the assistants 
are extending, so that the three forces
act at once, The fore arm is now bent,
and the bones are very easily reduced. The
use of the Surgeon's making extension
backwards is to dislodge the the coronoid process
of the ulna, from the condyles of the 
humerus, on which it is as it were locked.
The arm may be kept bent for some
time, at least for two or three weeks, and 
the joint may be kept moist by vinegar,
and spirits.
Dislocation of the Wrist may happen
either forward or backwards but cannot happen 
laterally.


(63
When the wrist is carried backward, the hand 
inclines forward, and when forwards, the hand 
turns backward. Nothing but extension and 
counter extension are required, and the reduction 
is very easy. The hand is to be made 
steady, by splints applied to the hand & 
forearm, and continued for some weeks 
at least.
Dislocations of the Fingers. These happen 
either anteriorly and posteriorly, and are 
very easily discovered, their bones being so 
thinly covered. They are quite immoveable
when out of place. They are very easily
reduced, and may be secured by splints.
The first and second joints of the thumb,
when dislocated are very difficult to reduce.
The knobs on the heads of the bones interlock
each other, and the more extension is made,
the more fast the ligaments tie the bones,
and even the last joint has been pulled off.
I have met with but one case of this, and 
succeed with tolerable case.

64)
Mr. Charles Bell has a very ingenuous proposal
on this subject. He proposes to introduce 
a cataract needle through the skin,
and to divide the lateral ligaments of one 
side, and then it is very probable the reduction 
would be very easy. B.P
January 8th,
1812
Lecture 27.
Dislocation of the Thigh. The older surgeons,
reflecting that the head of this bone was 
lodged in a very deep and strong cavity, and 
moved by very strong muscles, asserted that 
the neck of the bone was very frequently fractured,
and that dislocation of the hip joint,
never, or very seldom occurred. But they were 
mistaken in this. Four cases of dislocation 
generally happen as often as one case of 
fracture in the neck of the femur.


(65
This bone may be dislocated in any direction.
The most usual direction however is upwards, & 
backwards, so as to rest on the dorsum of the 
ilium. The next direction in frequency is in an
opposite direction, so that after passing downwards
and forward, the head of the bone rests 
on the foramen ovale. It may also happen
either upwards annd forwards, or downwards and 
backwards.
First, when upwards and backwards, the head
of the bone rests on the dorsum of the ilium.
The limb is shortened, generally two or three
inches, the toes are turned inwards, and the 
case is very easily detected. I have already
explained how this case is distinguished from 
fracture of the neck of the bone. The limb 
cannot be brought to its length, without reducing 
the dislocation; the trochanter major
may be felt nearer the spine of the ilium, and 
sometimes, the head of the bone may be felt 
on the ilium.
Second, the head of the bone is carried downwards,
and forwards into the foramen ovale,

66)
the limb is very considerably elongated,
the toes are turned outwards, and sometimes
the head of the bone may be distinctly felt.
Thirdly, the head of the bone is sometimes
carried forwards, or forwards and a little upwards.
The limb is shortened in proportion 
as the head is upward, and a large tumor
may be felt in the groin.
In the fourth order, the head is carried backwards 
and a little downward, the toes are turned
inward, and the case is easily discovered.
The two last orders are raw; I have never 
met with more than one case of each. For all
there dislocations, the capsular ligaments is
much ruptured. It was common for the older 
surgeons to say that the notch on the inferior
and anterior of the acetabulum caused
most of these dislocations to happen in this 
place, but the very reverse is true. The most 
usual direction, we have seen, is upwards, 
and backwards. This notch is secured by a 
ligamentous bridge, and is as strong as any 
part.

(67
From the great strength of the muscles, and 
also the great depth of the acetabulum, and the 
situations where the bone rests, very great force
is commonly required in this reduction. This is 
best applied by compound pullies.
In one case, I bled ad delinquim animi, and 
by my own exertions, with two assistants, I
reduced it again. But much more force is commonly 
required.
The patient is to be laid on the sound side,
with the thigh flexed on the pelvis, and the leg
flexed on the thigh. A strong band, (the middle 
of which is stuffed, is introduced into the groin
on the injured side, so as to rest on the tuberosity
of the ischeum and on the pubis, and 
secured to a hook opposite to the patients
head. This is to make counter extension.
The extension may be made just above the 
knee [in very corpulent patients, it can only be 
made below the knee] by a towel secured by 
a circular bandage*, to this towel, the pulley is
*To avoid excoriation, the skin is to be defended by
a piece of buckskin, round above the knee.

68)
fastened, and this secured to hook in the opposite 
of the room. Any degree of force may 
thus be applied. The limb may be rotated
to dislodge the head of the bone. In this way,
I have seen several cases succeed the head 
of the bone returned with an audible snap.
But if this do not succeed, it will next 
be required to raise up the head of the bone.
A bandage is put under the thigh near 
the groin, and tied over an assistants neck,
who kneels on the table, and puts one knee
on the pelvis below the rest of this 
ilium. While the assistant raises up the 
head of the bone, the surgeon uses the os femoris
as a lever, pressing down the knee,
This is the best way to make extension at
right angles.- Sometimes a band may 
be put over the pelvis, thro' two holes in 
the table, and secured to a hook in the floor.
By the above means, two extending forces are 
applied: one in the longitudinal, and the other 
at right angles. This is for luxations 
upwards and backwards.

(69
For dislocation into the foramen ovale, viz, downwards
and forwards. The longitudinal extension 
is applied in the same way, and with the same 
intention. The rectangular extension is also 
to be used in the same way, but the longitudinal is not so much
with the intention of lengthening the limb,
(this being already too long) but to dislodge it 
out of its seat on the foramen ovale.
The dislocation forwards, and a little upwards,
may also be treated in the same way. Mr. Heys
(whose/observations on this accident deserve per 
usal) directs in this case, to seat the patient 
on a bed, to apply the pubis to a post of the 
bed, and to make extension by assistants
at the leg. As this is not always convenient 
Dr. Wistar has made a subistitue for the 
bed post in our Hospital. It consists of a 
strong shaft, 3 or 4 yards long, inserted
to a head of about 30 inches long in the 
middle, and secured by stay pieces, thus 
resembling a rake. The end of this shaft 
props against the wall, and the head covered
[illustration]

70)
covered with flannel, makes counter extension 
against the pubis, the [cross out] leg may 
be bent, and extension made by assistants 
or pullies, the limb rotated, and the 
head brought outwards by a band or (what 
is better as it interferes less with the muscles)
a rolling pin. But this method is 
not preferable to this above one.
When the dislocation takes place forwards
and upwards into the groins There is 
some variation required. The longitudinal 
extension is made as usual, but the difference 
is this. The patient is laid on the 
back, a bandage is put round the pelvis
on the injured side, and fastened to a hook
opposite to the other side. Another bandage 
put round the injured thigh near 
the groin, and fastened to a pulley on the 
same side. The leg is bent, the thigh rotated,
as usual. The only case I have seen 
was treated in this way. See Dr. Cox's Med.
Museum. Desault met with a case of 

71
this sort. He differed from the operation described,
only in putting the band for counter
extension on the sound side of the scrotum;
while I put it on the injured side._ This apparatus 
may be used for luxation in any direction
whatever.
Lastly, in the dislocation downwards and 
backwards, I have had only one case. In this 
the usual means failed. The head of the femur
protruded through a rent in the capsular 
ligament, just as a button thro'
a button hole, and extension served only 
to make it faster. At length, I succeeded
by a violent abduction of the thigh. I applied 
my left hand on the trochanter,
and embracing the flexed knee in my 
right arm, I made a violent abduction,
using the thigh as a lever at the same
time. The thigh was bent on the pelvis. Abduction 
is the best means to dislodge the 
head of the bone out of the capsular ligament._
By these means, if the capsular ligament,
&c, have not formed strong adhesion


72
have not found any dislocation may 
be reduced. The only precaution nescesary 
after reduction, is to keep the 
limb quiet for a week or ten days.
In cases when the reduction has been 
delayed for some time, the cavity will
have so closed as to prevent the limb
resuming its usual length, and it remains 
1/2, 3/4 or 1 inch longer than [cross out]
usual. But a few weeks rest will overcome 
this.
Dislocations of the knee. The only direction
in which this joint is dislocated is outwards.
This however is very raw. Two cases of 
this sort have fallen within my observation.
In both, they arose from violent abduction:
the patient going up a ladder, this fell 
when they were 6 or 10 feet from the ground;
they fell thus with the legs asunder. In one 
of them both, but in the second only one 
knee was dislocated.
The leg rests upon the outer condyle of the os

73
femoris, the inner condyle may be easily felt,
a great angle is formed by the leg upon the 
the thigh, so that the injury produces effects 
very easily known,-and the leg is very easily 
restored to its place again, but such is the 
destruction of the capsular ligaments, that 
the leg will fall off again just as before.
The limb must be kept steady: either two 
common splints, or what is better Desaults
long splints must be worn at least four months
before the ligaments have united. The knee 
may be wet with lead-water, vinegar and oil,
vinegar and spirits, or any such liquid.
Dislocation of the Patella. The patella,
or kneepan may be luxated either outwards
or inwards. The former is the most usual direction,
the condyle of the femur being the 
highest on the outside, not allowing the patella 
to return. The pulley like surface of 
the femur being very easily felt, and the motion 
of the leg being lost, the case is very 
easily recognized. Further, the patella, on

74
the outside being very easily felt, its internal 
side is now posterior, its anterior 
surface is now exterior. Considerable pain 
is felt, and the powers of the extensors 
of the leg are lost.
The reduction is very easy. The thigh is 
flexed on the pelvis by the patients sitting 
on a bed, and the leg is to be extended. 
By pushing the patella on the side,
it will now fall into its place very easily.
The only case I have ever seen of this,
was in a lady, in whom it was caused by 
an irregular step in dancing. It was 
seated on the outside as I have described
and very easily reduced. After resting 
for fifteen days, she was perfectly restored,
and able to dance again!
Dislocations of the Ancle. I have
already explained how this accident was 
often complicated with a fracture of the
fibula, at one third of its length from the 
external ancle: however dislocation may

75
happen without this. This may be either anteriorly
or posteriorly. In the former case, the 
foot appears shorter than natural, and the 
bones of the leg lie in front of the astragalis
and the os calcis projects behind. When 
the foot is luxated posteriorly, the reverse 
of all this happens. This is very easily reduced.
An assistant holds the leg fast about its 
middle, while another extends the foot, and 
draws it into place.
One case only has fallen under my observation,
occured in a lady; She was hastily 
running down stairs, when she fell, and 
the heel of the shoe took hold on one of the 
steps, and the whole weight of the body 
resting oblicquely on the joint, this gave 
way. It was reduced as above described, and 
after a month, the function of the ancle
were completely restored again.
Jan 10th 1812     P.S.Physic.

76) Lect 25
Of Injuries of the Head. A. Contusion
Blows upon the head frequently produce a rupture
of a number of vessels, whereby blood is shed under
the scalp, which gives the part a soft pappy feel,
and round this is a hard ring, with a very abrupt
edge, which may deceive for a fracture with depression 
of a piece of the cranium. This has induced 
induced unwary surgeons to incise the part
and prepare for operation, and they were always 
much dissapointed to find the scull whole.
To avoid this unnescesary step of incision, it 
is nescesary in all cases, before we incise, to 
to see the symptoms of injured brain exist.
The incision is a very painful step and even exfoliation
of the bone may follow it.
Nothing but clothes wet with vinegar and water
is required as a local remedy, the antiphlogistic 
regimen, and if the injury be severe, bleeding,
and purging are required. If after several days,
the blood be not absorbed, a small puncture may 
be made into the tumor, the blood pressed out and 
dry lint applied, and secured by adhesive plaster.

(77
2. Wounds. Incised wounds in the scalp require the
some treatment as they as in other parts of the 
body. The hair having been removed, the lips of the 
wound may be approximated by adhesive plaster.
Contused wounds also have nothing peculiar
in them here. A soft poultice is the best application.
It may be continued till the sloughs are
separated, supuration is free, and granulation
goes on well. The sides of the cavity may be either
brought into contact, or at least approximated 
by adhesive plaster
The scalp is sometimes torn off: I have even 
seen one half of the scull laid bare in this way.
The old surgeons in such cases were in the habit
of cutting off all the separated parts, because, they 
said if left on, matter would form under it and injure 
the bones of the head. But their practice 
was as absurd as the reason for it was untrue.
The scalp is to be cleaned of any foreign matter,
replaced, and retained by interrupted sutures,
adhesive plaster, Sutures I do not recommend,
as they are an additional injury, increase the 
constitutional irritation, and if much swelling


78)
swelling come on, they are not (like plasters) easily removed.
If sutures are used, the edges are not to be 
drawn tight, nor nearer than 1/2 inch asunder. But
when inflamation is over, they may be brought
together. Adhesion generally takes place:- if pus
form in any part, it may be evacuated by an 
incision as in any abscess. If an early opening
is made, the bone will very seldom slough. The 
constitutional treatment must be antiphlogistic,
and if headache and fever follow, blood letting 
and purging may be used freely, as in cases 
of contusion.
In those cases in which the bone sloughs off
it is very important to remove the slough as 
soon as possible. Whenever any looseness is evident,
the slough may removed: as the granulations
round the rough edge of the bone will 
soon make it fast if left. We are never to wait 
for the bone to become looser, but pull out
the slough with forceps, and if incision be nescesary,
it may be made freely.
3. Acute pain often remains after the wound of 

79
of the scalp has heated. It also follows simple contusions,
as well as contused wounds. It lasts after the 
inflamation is over: I have seen it last for months,
nay even 3 or 5 years after.
The first case I have met with, was in a lady,
whose head was struck, in looking out at the 
window, by the shutter, which was blown by 
the wind. The pain was very acute, and increased 
as the inflamation subsided. This happened
at Trenton; and after 5 months continuance,
she came to town. I could feel a roughness and 
inequality in the bone. Dr Rush had tried every 
means he could devise, but all failed to afford 
any relief. I was consulted, and made 
a crucial incision through the scalp, and after 
this her complaint subsided entirely.
The second case was in a lady of a full habit
and the pain was very severe. Numerous remedies
were used, but to no purpose. Bleeding, purging,
low diet, low diet, leeches, blizters, issues,
the crucial incision, opium, cicuta, oxymuriate
of potash, solutions of arsenic & mercury, were all
used without benefit. 

80)
At the end of two years, she took a journey in
to the country, and by this she was suddenly 
benefited, but it was five years before she was 
quite well.
The third case was produced in a young lady 
by falling from a gig, and alighting with 
her head on a stone. The pain continued severe 
for 18 months, when by a second fall, the 
complaint was greatly augmented. On taking 
a walk to the Yohenulkylon, and being 
much heated, she went into the cold bath,
and on this, the pain became excruciating.
Mercury was given, but a salivation could not 
be produced. The crucial incision was made,
and from that evening for four weeks, she 
was well, but then relapsed. On the idea of 
retained perspiration, I made an issue as 
large as a dollar, with caustic, on the head,
but no relief followed. After 18 months, she went 
into the country, and on feeling oppression 
at the stomach, a vomit was taken, and brought 
off much mucus, and in six weeks, she 
was perfectly well.

81.
In the fourth case, a man fell from a house
and received a small wound on one side of the 
head. The pain came on, as in the other cases.
Bleeding, purging, &c failed, and the crucial incision, 
as soon as I had made it relieved him
but seized the other side as ill as the first side
and I next operated on this side also, and he 
soon recovered completely. I have seen one case
in which, it ended in fatuity.
In all cases, a complete recovery came on 
in course of time. Indeed I know of no [cross out]
remedy for this disease which is certain. The 
crucial incision is the best remedy I know. 
4. Injuries of the brain a. Compression
This state of the brain is marked by sleepiness,
drowsiness, insensibility, loss of speech and 
voluntary motion, sickness at the stomach,
vomiting and either dilation or contraction
of the pupils of the eyes, and no variation in 
these when exposed to light.
It may arise from either of the following
causes. 1. The fracture and depression of a 

82
piece of the cranium, or 2. by blood extravasated 
out of ruptured vessels, or by both 
causes taken together. The blood may be under
the scull, under the dura mater, or in the 
substance of the brain. Both depression, & 
blood may unite, as they very often do, but 
she may exist perfectly separately.
The symptoms of depression, from fracture 
are immediate, but that from blood generally 
allows a few minutes of sense and 
motion, before there is enough of blood to 
compress the brain.
But fracture of the scull with depressions 
may exist, without constitutional symptoms 
denoting it....A boy received a blow
by a brick thrown from the opposite side
of the street. I was called, and arrived in ten 
minutes, and could feel a considerable depression 
of bone, yet the boy was sensible, and 
told me the circumstances of the accident,
and then fell from his chair, cold, senseless,
and motionless. I trepanned him immediately

(83
immediately. A large quantity of fluid blood flowed from 
the orifice, and the boy recovered even before I 
had raised the depressed bone. There was a union 
of causes; the blood was the cause of the stupor
and it is often so; even without any external 
wound.
Sometimes the dura mater is wounded,
and even portions of the brain prolapsed.
Extravasated blood may be lodged in the cavity 
of the brain.
When compression is known to exist, the 
depressed [cross out] bone must be lodged* in the brain
and brought on a level with the rest of the scull,
or the extravasated fluid must be evacuated. 
If there be many fractured portions,
there may in general be a perforation made
with the trephine, and the blood if there be 
any may escape, and the fragments may 
be elevated. The perforation may be in the 
vicinity of the fracture.
In all cases if after the receipt of a blow, the 
symptoms of compression exist, perforation
*removed out of 

84
perforation is to be made. The inferior, anterior angle
of the parietal bone is the best place 
to open, because there, the artery of the dura
mater exist, which is the Source of extravasation.
If one opening do not succeed, the
other side may be opened.
On this subject, Mr. Abernethy makes a very 
ingenious remark. The scull is supplied with 
blood from the teguments and also by the 
dura mater. Now if these two sources of blood
be removed, the external by incision, and the 
internal by blood, we will not find any 
blood oozing from the bone on laing it 
bare. This may not always be depended on, as 
anastomosing arteries may keep up the circulation.
Even after the perforation is made, the symptoms
of pressure sometimes continue. It is 
then importance to tell whether the blood is 
extravasated under the dura matter or not?
If instead of the level, white, glistening appearance
of the dura mater, we find it pushed 
up into a convexity in the trepan. hole, fluctuation

85)
fluctuation in some degree perceptible, and a livid appearance,
by the presence of blood, we may be 
pretty certain of the nature of the injury. Further,
There is (especially in children) a motion in 
the dura mater corresponding to respiration,
raising with expiration, it visce versa,- and 
also a motion at every stroke of the heart,
but these are absent if blood be extravasated 
under the dura mater.
But even if we are certain of its presence, it
is very doubtful whether or not the dura mater
may be perforated? Rather than let our 
patient die, we might do it, but tho' cases 
are reported of patients recovering after such 
a puncture, yet I have always seen them 
prove fatal...... Indeed the dura mater is often 
wounded by spiculae of bone, and otherwise,
and yet the patient recover, but the above 
case is widely different: in it, we are never 
able to evacuate all the blood, and the part 
remaining becomes acrid by the air, and 
produces inflammation and suppuration in 
the pia mater and death!!

86)
Now, the progress of this injury is as follows:
first, the dura mater at the place of puncture,
becomes enlarged, till as wide as the hole 
in the bone, the brain arises on a level with 
the bone, (I have seen it arise one inch) then 
constituting fungus cerebrix, which is the brain 
itself pressed out. This has been tied with a 
ligature, destroyed with causte, &c, but is 
all cases is has proven fatal, and pus was 
found in the hemispheres of the brain, and 
therefore, this case is hopeless.
Our circumstance is very remarkable in 
this accident: sense remains till near death
unaffected.
In a case of extravasation which occurred 
to me under the dura mater, the membrane 
was pushed up on a level with the bone,
and all the symptoms of compression existed.
I bled the man four times a day, for 
five days, and each time, ad delinquim animi,
purged him freely, blistered him, and
confined him to barley water, and he was 
saved by these means from death.

87)
I therefore condemn the puncture in all 
cases....The dura mater is sometimes wounded
by accident, without death following: Sabatier 
relates the case of a man whose scull & 
dura mater were very widely discovered by a 
saber, and the wound heald just as easily as 
as in any other part of the body; nay, we 
read in the memoirs of the Academy of Surgery 
of a ball going perpendicularly, and of 
cin other going transversely thro the brain,
yet life not being lost, but a happy recovery!!!-
I have however seen one case of a 
wound of the membrane recovered from. The 
child was bled and purged freely, and confined 
to rest and a low diet, and recovered, tho'
dangerous convulsions supervened.
One circumstance more will conclude
this lecture. Patients recover better in the 
country than in a large city or town, and 
particularly better in succh a situation 
than in a crowded hospital.
D.P
January 13th, 1812

88)
Lecture 29.
We continue to speak of injuries of the head.
b. Sloughing of the dura mater. I am now to describe
a form of disease, not spoken of by any 
author; and of which I have met with only
one case. Last summer, I was called to a child,
which had received a kick of a horse on the os 
frontis. I found a very considerable piece of the bone
depressed by the fracture. The senses 
were perfect, but as as I always trepan 
in cases of depression, that I always proceeded
to do it in this. After the removal of 
the piece, I remarked an unusual appearance.
The dura mater was of a very dark colour,
without any convexity, or any other circumstance 
of effusion. In the course of 7 or 8 
days, the piece of the dura mater sloughed 
off, and left the pia mater bare. The child
still retained his senses, but fungus cerebri 
came on, the brain was protruded and the 
child died.

89)
Thus, the dura mater may die and slough off by 
a blow, just as a bone or any other part whose 
life is weak. I know of no remedy for this disorder.
In the case mentioned, the remedies for 
inflamation were used, particularly bleeding 
and purging, and the result was unfortunate.
C. Hamorrhage from the brain and dura
maters. Very considerable bleeding sometimes 
occurs when the brain or dura mater, especially 
the latter, are wounded. This is especially 
the case if one of the large sinuses, as
the longitudinal, or the lateral, is wounded.
This may arise by speculae of bone, or it may 
arise from wounds in our operations. Alarming
as this bleeding is, it is very easily commanded.
A dossil of lint, secured by pressure 
with the finger is always sufficient
to put a permanent stop to the disease.
Of arterial hamorrhage from the dura mater,
more must be said. The only vessel from 
which this can occur in any alarming degree
is the median artery of the dura mater,
which lies under the parietal bones. 

90)
A long quantity of blood may flow out
of this vessel, but in general, a piece of lint,
pressed down with the finger will stop 
this, in ten minutes. But sometimes, from
unusual size of the artery, &c, the blood continues
to flow. In this case, if the dura mater 
is wounded as well as the artery, the latter 
may be secured by a ligature, by a needle, 
or tenaculum, but if the dura mater be
whole, this would be unadviseable, as wounds 
of the dura mater are so seldom recovered from 
even if the puncture be very small, as by 
a spicula of bone, it is best to omit the ligature.
When the artery runs thro' a canal 
of bone, the treatment mentioned in compound
fractures, of stopping the hole by 
a plug of soft wood, put beside the artery,
and not into it is nescessary. But this structure is rare.
We might in some cases introduce a dossil
of lint between the scull and dura mater,
and thus press on the artery, and this 
lint, if not large could not in commode

(91
the brain by its pressure. This I have never yet
used. Might we not in obstinate cases, order pressure 
by an assistant for 30 minutes or more?
I have never seen the bleeding in any of these 
cases prove troublesome; and rather than use 
the ligature when there was no wound,
I would try astringents, as agaric, alum, blue 
vitriol, &c and by these means, there will be 
no difficulty in succeeding.
Before I quit the subject of compression, I 
will warn you of a very usual error into 
which both physicians and surgeons have 
fallen. From the identity of the the symptoms 
of intoxication and compression, they 
may be confounded together. The agree exactly 
in the loss of voluntary motion, puking, dullness,
sleepiness and every other symptom. But 
by an inquiry into the previous conduct, you 
may draw the line of distinction.
I say 'physicians', as apoplexy has been also 
confounded with drunkenness. Dr. Gregory
related a case of a man who had drank to excess
and was treated as an apoplectic by

92)
bleeding, blistering, stimulants, sinapisms,
&c and the man was cured!
An hostler who was intoxicated, fell among
a horses feet and received a wound
of the scalp. One of his companions save 
him, and took him to an infirmary. The 
surgeon shaved his head and enlarged the
wound by a crucial incision, but was 
astonished to find no fracture! It being at 
night, the head was dressed, and a consultation
determined an trepanning early next morning.
But when morning came, and the 
man awoke, he saw himself queerly situated:
an old nurse standing by,- his head 
felt very strangely tied up- and he in the 
infirmary! He demanded what was the 
matter? The nurse told him "hush, my 
man, you must be trepanned today."!!
The smell of the breath may be a very safe 
criterion; also the following. When I was the 
house surgeon in St George's Hospital, a woman
was brought in for a supposed injury

(93
injury of the head. Suspecting another cause, I 
poured a stream of cold water on the upper lip
for some time: the head began to rotate from 
side to side, and at last she got up, and demanded 
the reason of such insolent treatment 
as was used with her!
d. Inflamation of the brain. The symptoms 
of inflamation never follows immediateley 
after the cause which produced them.
They are all of the febrile kind. The face becomes
hot, and is overspread with a blush, headache 
follows, nausea and often vomiting supervene,
the pulse becomes hard and full, delirium,
coma, and restlessness soon follow.
These symptoms seldom come on before a week
or ten days after the injury. Indeed I have known
12 months supervene before the inflamation
come on. This was the case with Captain B.
Turner, who in escaping from a sinking vessel
into a boat, received a contusion on the head
and which was followed by a swelling on the 
occiput. He arrived in a town in Holland, and 
a german physician gave him a wash of 

94)
brandy, and the blue pill, (suposing the case
venereal, he having had the lues 4 years before)
after three months, no relief occurring, but headache
coming on, he came to England and Mr
Blizard continued the blue pill, but no alleviation,
nor salivation could be produced. 
and he was advised to go to a warm climate.
In June 1809 he arrived in Philad. and aplied 
to D Rush. Three weeks before arrival, he 
had the aura epileptica, commencing in the 
hand, and terminating in violent fits, and 
the arm becoming paralytic, and the leg
on the same (left) side becoming numbed. The 
Doctor bled and purged him freely, confining 
him to a very low diet.
No relief being found, I was consulted, the 
fits still continuing. I laid the bone bare
by a free incision. I found it very rough on 
its surface and wasted. I did not hesitate to 
apply the trepan, and on removing a piece
of the bone, I found the dura mater adhering 
strongly to the bone, and much indurated. 

(95
Four days after, it proved fatal, and on dissection,
pus was found both on the dura mater 
and also in the pia mater. Here was inflamation 
in the membranes a full year after the 
blow was received.
The causes of inflamation of the brain may
be either a contusion without any wound,
a fissure without depressure, or a fracture
with depression of a piece of the scull.
1. After concussion, the teguments become puffy
and flaccid, and on laying them open, they 
will be found detached from the bone, and 
if a perforation be made, the internal surface
of the bone will also be found detached.
The pericranium, instead of its florid colour
is found pale and in fact dead, and within,
mucus [cross out] or pus will be found on the dura 
mater.
2. and 3. Fissures or fractures with depression 
are very apt to produce inflamation, with 
them, there is generally a wound of the scalp.
Instead of healthy granulations, there are pale 
and flaccid ones, and they become so as soon

96)
as the inflamation commences. Instead of 
healthy pus, a thin bloody ichor only is discharged,
and the pericranium will separate 
from the bone, round the perforation in 
it. At the same time, the dura mater will separate 
in the same way.
Mr. Pott supposed this to arise from the vessels 
which carry on the circulation thro the 
bone becoming destroyed, but I have reason
to doubt of this explanation. It appears that 
the life of the bone is completely destroyed.
In all injuries of the brain, whether simple
contusion, fissure, or fracture with depression,
inflamation may therefore be expected.
The scalp may indeed be largely separated 
from the scull, and no symptoms of inflamation 
or suppuration follow, but union 
by healthy granulation follow, especially if 
the wound be produced by simple incision. 
Thus, the injury in communicated no deeper than 
to the external membranes of the head, but 
when a great concussion is received, the effects

(97
effects of it are communicated to the internal parts
of the head, not only to the membranes but to 
the brain itself; and inflamation and suppuration 
may come on as far as the parts are 
injured.
This is not merely a speculative point,
but one of great practical importance.
When pus is formed under the dura mater, I 
believe it is always fatal. Pus on the surface
of the dura mater may if let off prove 
of little injury. Therefore in all cases of inflamation,
a perforation with the trephine 
is always to be made, and this as soon as the 
symptoms of cerebral inflamation run 
high. By this timely measure, if suppuration 
is confined to the dura mater alone,
it may be prevented from doing any injury,
as all the pus will escape; and if 
any sloughs form in the dura mater, then 
also will find a free exit.
It is a question of some importance,
whether in the first instance of fractures
without depression, or with it, the perforation

98)
ought to be made, or to wait till symptoms 
of inflamation come on? Mr Pott was in 
the habit of trepanning in all cases of fracture,
immediately, but modern surgeons, having 
seen many recoveries from fractures, w.t
out trepaning have rejected this aphorism.
When the bone is depressed, indeed it is best 
to operate immediately, as the rough bone 
may irritate the dura mater, producing 
inflamation, suppuration and even ulceration.
But I would never trepan for simple 
fracture. Depression, or symptoms of inflamation 
must be apparent before I undertake
the operation of trepanning.
Even after evident depression of the bone, recoveries 
have occurred without trepanning,
but I would not deduce any rule from this.
Therefore, simple fracture, without any symptoms
of compression needs not to be trepaned.
But when depression has occurred, it is 
best to take out the piece of the bone. 

(99
When any other causes of inflamation, which 
I have mentioned occurs, the means to prevent 
and moderate inflamation must be used.
After a blow on the head, the patient must be 
confined to a very low diet, and bleeding and 
purging must be employed. If symptoms of 
inflamation appear, we are to bleed again,
and again, to apply the trepan, and to apply 
a blister over the head: a remedy well calculated
to reduce inflamation in the brain.
Cold applications are very serviseable. Clothes
wet in cold water, or in vinegar and water
are very useful.
e. Of concussion of the brain. Concussion of the 
brain is a certain deranged state of the brain
following blows on the head, which proves 
fatal often in a few minutes, and on dissection,
no marks of injury are found. It appears 
however, that a larger number of the 
minute vessels are ruptured. If the patient survive
some hours, the brain will be found
be set with drops of blood shed from these

100)
vessels, and if he survive for a day or two, the whole 
brain will have a bruised appearance.
Just in the same way do we often see blows 
on the reigion of the heart produce sudden 
death, and yet no symptoms appearances 
of derangement can be found on dissection.
If perfect rest be observed, the effusion of 
blood may be in many cases prevented.
Mr. Abernethy exceeds all authors in the description
of this state. Its progress according 
to him is as follows. 1st stage. The functions
of the brain are quite deranged, the stupor 
is complete, the patient is insensible, his breathing 
is difficult, tho not stertorious, and his 
extremities are cold and this state of stupor 
does not last long. 2nd stage. In this, the pulse 
and respiration are better, heat and sensibility 
increase, the patient will answer to 
a loud question, especially if it concern his 
own feelings, otherwise his answer is incoherent,
and he seems employed about something 
else. There are few symptoms of inflamation;
soon this state is followed by

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the 3rd or inflamatory stage, which is the 
most important of all.
Some surgeons recommend stimuli, as wine,
and if they succeed, they do very serious mischief.
If the establish the pulse and face 
respiration, inflamation and extravasation 
soon follow. I enjoin perfect rest, and keep 
the head elevated, and as the action recovers,
cold clothes with water & vinegar are applied
to the head. As the pulse rises, I bleed freely,
and thus inflamation and suppuration 
of the brain may be prevented.- Cases are 
repoted in which the patient recovered in whom
stimuli were used from the beginning, but 
the practice is very dangerous. The first 
case of contusion I have seen, I treated wt.
success by bleeding, while in St. Georges Hospital.
f. Inflamation of the brain, after it has 
subsided sometimes leaves a state of stupor
or idiotism. This was first treated with 
success by Dr Rush, who gave mercury 
so as to excite a salivation. He made 

102)
this discovery as early as the year 1795 or '6,
and it has been since spoken of by Mr Abernethy,
whose book was published in the year
since this. The plan adopted by Dr. Rush is 
found very successful.  Dr.P.
January 15th 
1812
Lecture 30.
It remains for me to explain the operation of 
perforation of the scull, for the purpose of elevating 
a depressed portion of bone, and for giving 
an exit to extravasated fluids, compressing the brain
The most common instrument for this purpose 
is the trephine, or circular saw, with a centre pin
for fixing the instrument. This pin is moveable 
in the handle, and by a pin in this, it may be 
protruded to any distance, and screwed fast so.
In the trephines of the older surgeons, this pin 
was fixed, and at a certain period of the operation,
this was removed by a key but this is of no service,
and protracts the operation. Thus, their

(103
center pin being always alike long, was very apt 
to wound the dura mater, as in thin sculls, especially 
in children. But the pin which easily 
is slipt up is very convenient.
The older surgeons used conical trephines,
and this, with a view of avoiding wounding the 
dura mater by a sudden plunge of the instrument,
after going thro' the scull. But this is very 
inconvenient, and tedious shape is quite superceded 
by proper care, and all danger of wounding 
the dura mater is avoided by the precautions
I am shortly to describe.
Before this instrument is used, the integuments
must be divided and dissected off. A common 
scalpel will answer this purpose. The iron 
is to continue to the end of the handle of 
this instrument, and to project in a square
form, to raise the pericranium from the 
bone. This quite supercedes a raspatory, which 
is an instrument for this puropse, used by 
some surgeons.
The elevator, which is a simple lever, a little bent

104
must also be at hand. This instrument is 
often made too convex.*
In most cases of trepanning instruments,
a lenticulator (which is a knife with a thick 
ede and a spoon-like point) is found, but the 
purpose for which this instrument is made
viz. cutting off rough edges and spicula after
the piece of bone is removed, is fully, and wt 
more convenience answered by the elevator.
The circular saw of Mr Hey should also be 
at hand. This is used when the depressed bone
is capable of being raised, except on account of 
one neck of bone, or one of these on each side.
This prevents in many cases, the dura mater
being stripped by the circular perforation, and 
is found very convenient.
It will also be proper to have sponge, lint;
needles, tenaculum, a ligature, and a soft poultice 
at hand.
The hair may be shaved off, to shew the extent 
and situation of the wound, before the 
scalp is further removed.
*The tripod is also useless, and superceded by the 
common elevator

(105
The incision may be made, or the wound,
(if there be any,) enlarged. The older surgeons
made a circular incision, and removed a 
large portion of the scalp, and repeated this 
if nescessary, and thus destroyed the covering
of a large portion of the cranium. I have 
see one half of the scalp removed in this way
Even Mr Pott advised this plan, but it is never 
nesccesary. A simple incision down to the bone 
is generally sufficient, and the pericranium 
is to be removed as we have described. If 
nescesary, an incision at right angles, or even 
a crucial incision may be made and the 
corners dissected away, but not removed.
When the cranium is fractured into many
pieces, there is considerable danger of wounding 
the dura mater with the scalpel, and 
therefore the incision is best made in this case
on the firm part of the scull, and from this,
we can dissect to the injured parts.
If an artery should be cut in the scalp, and 
bleed much, rather than trust to pressure, I 
would secure it with a needle, or tenaculum, 

106)
otherwise, it may bleed in the night. Some advise 
to deplete, by leaving such vessels open,
but this is much more conveniently done at 
the jugular vein or arm.
Some surgeons perforate the scull with a 
perforation, but the centre pin of the trephine
does this much more expeditiously.
The pin is to be applied on the sound bone,
but so near the fissure, as to include as much 
of the depressed portion as may be. This is done 
to avoid pressing the portion deeper, as our
efforts with the trephine might have this 
effect, if the pin rested not on the sound, but on 
the depressed bone.
The sawdust may be wiped from the teeth of 
the saw, and from the groove with a towel, which
answers better than the brush commonly used
As soon as the groove in the bone becomes deep
enough to retain the saw, the centre pin may be 
removed, as if left, it might wound the dura-
mater, which we have seen is very dangerous. 
Even before the grove is compleat, the pin 
must be shifted up in cases of thin sculls.

(107
We must very frequently examine the groove
with a tooth pick, to feell if any point of the 
circle is cut through, in which case, you must 
bear obliquely on the uncut part.
It was the ancient mode to mount the trephine
on a large handle, with a crank in 
the middle; this was applied to the surgeon's
breast, and thus their labour was lessened!
but the pressure thus applied was very dangerous
and unjustifiable.
It is common for this instrument to be made
too thin in its edge, and thus the groove will
not admit the levator, and when we want 
to work obliquely, we are unable to do so.
As soon as a considerable groove is made,
tho' no part of the bone be cut though, we may
try with the elevator to raise it, by breaking 
the vitreous table, thus avoiding most completely,
wounding, the dura mater, and if 
the bone be thicken at one side than the other,
this will particularly answer. The 
spiculae may be broken out with the levator,
and thus, the operation is completed.

108
Forceps are of no use in raising the circle.
This operation is considered by some to be 
easily performed and simple: but to perforate 
the scull; [cross out] and to avoid the dura mater requires
considerable attention, and I have seen errors
committed in this, twice prove fatal; inflammation 
of the brain having followed. We ought 
therefore always when one portion of the circle
is through, to avoid it very carefully.
Mr. Heys saw, in the circumstances we 
have mentioned is a very convenient instrument.
In the use of it, the dura mater is 
also to be carefully avoided.
After raising the depressed fragments, if this 
was the cause of compression, the symptoms
will cease, but if much blood is extravasated 
under the scull, more holes may be 
required to evacuate it, and if the symptoms
of pressure continue, the dura mater may
be separated from the scull for some way.
If blood be extravasated through the cavity 
under the dura mater, it is doubtful

(109
as we have shewn, [how dangerous it is] whether it is proper to 
puncture the dura mater with a lancet, but 
if in any case it is chosen to do so, which in 
general is improper, the puncture must be 
very small.
Having raised the depressed fragment or extracted
it, with the levator, the scull is to be 
dressed. A soft, light poultice is the best dressing.
Lint, which is generally used adheres
to the dura mater, and is not easily removed
in a future dressing; while the poultice separates 
very easily.
When the dura mater is pierced by spicular
or punctured by the surgeon, the scalp is 
to be brought over it, so that it may directly 
adhere, and prevent inflammation of the brain
In this way I treated a fracture of the squamous
part of the temporal bone, in which 
there were many fragments, and the dura
mater perforated; yet the patient recovered.
This may be done in cases of depression &
may prevent exfolian of the scull, but when


110)
extravasation has happened under the dura 
mater, and especially if a coagulum remains,
the orifice is by no means to be closed,
but simply a soft poultice applied.
The ancient surgeons forbid our operating 
on particular parts of the scull.
1. We are cautioned never to trepan the frontal
sinus. Here the tables of the scull are 
not paralel, and if it should be required
to trepan this part, the perforation may
be made in the usual way thro' the outer
table, but on the inner, the trepan may
be applied also perpendicular to the surface
of this plate also. If a ridge remains which 
the saw will not cut safely, it may be broken
with the levator.
2. They deem it improper to perforate over 
the longitudinal or lateral sinuses. Haemorhage
from this vessel is easily stopped by a 
little lint. But this vessel may generally 
avoided, unless it lie in a deep groove in the 

(111
bone, and even then, by working obliquely on one 
side, and then on the other. But there is little
hazard in the haemorrhage; the only danger being
that of wounding the dura mater beside
the artery sinus. This may be prevented by 
prizing out the piece of bone before quite cut
through, and breaking the remaining ridges 
with the levator, guarding the dura mater with 
an iron spatula.- If blood be shed under the 
bone, there can be no hazard; but we cannot 
depend on or judge of this before the operation is over.
3. It is deemed unsafe to trepan over the anterior 
inferior angle of of the parietal bone,
for here the median artery of the dura mater 
lieg, but tho' there is some degree of danger
here, by care, the vessel may be avoided. If it 
be wounded, it may however be stoped in most 
cases by a dossil of lint put into the groove it
lig in, or if the artery be inclosed in a bony
channel, the plug of soft wood as we have 
mentioned may be pushed in.
4 The occiput is deemed unfit for the operation,
but, with the precautions for others

112)
cases of unevenness on the scull, this objection 
like all the others is of no Value, and the 
scull may be trepanned in any place where
a fracture can reach, excepting the basis 
of the scull itself. So that all these rules,
so carefully held inviolate by our ancestors
are of no consequence whatever.P
Jan. 17
Lecture 31.
Of Diseases of the eyes, and first, of inflamation.
This may be seated in the eyelids, conjuctiva, 
cornea, or globe of the eye.
Inflamation of the eyelids is acompanied
with a serous discharge, and with a burning 
pain, and after comes on suddenly. It 
is produced by extraneous bodies, mechanical 
violence, &c.
If much pain and fever attend, bleeding, low 
diet and a mercurial purge may be prescribed, 
and the parts may be kept moist with 
diluted brandy, &c and may be expected soon 
to subside. 


113
Inflamation in the edges produces effusion 
and ulceration, and the discharge is so purulent
and viscid as to glue the eyelids together, and 
they cannot be opened without difficulty in 
the morning. The seat of this disease is said
to be the Meibomian glands, but I suppose 
it to arise from inflamation and ulceration 
round the roots of the hairs, thus resembling
tinea capitis, and if the hairs be 
extracted, just as in that disease, the sore will
heal up. The treatment of these two diseases 
is the same. Sperma ceti oil had succeeded 
well. It is recommended to touch the 
eyelid with lapis infernalis, and in this way
I once succeeded. lung Citrinum, [spermaciti]
If strong mercurial ointment, are powerful remedies I have extracted 
the hairs with twizers, and thus succeeded 
after the ointments have been tried 
to no puropse.
When the conjunctiva and cornea are the seat 
of the inflamation, the white membranes 
become red by the admission of anusual. 


114)
quantity of blood. The eye waters, light becomes
offensive, the eye feels hot and burning, and 
the pain is communicated to the temple and 
and fore head. The inflamation is sometimes confined
to a spot near the edge of the cornea. The 
eyes when thus inflamed are very irritable to 
light, we cannot easily get a view of the eye,
and the patient guards off the [inflam] light 
with his hand.
If the inflamation be over the cornea, there
is danger of opacity in this, and on the conjunctiva,
the speck mentioned leaves a film,
which, if near the inner canthus, it forms
what is called unguis.
The causes of this are, mechanical injuries,
viz blows, &c also the inversion of the cilia,
called trichiasis; acrid substances, as lime,
acids, smoke, violent excercise of the eyes,
too much light: and I have known it produced 
by the eye being wit with urine, in 
a young man having gonorrhoea.

(115
The globe of the eye may be inflamed in the anterior 
chamber, or the posterior, behind the lens.
When in the former situation, the pain is of a shooting 
kind, and varies much according to the violence 
of the causes. It sometimes proceeds to 
suppuration, and then, the pus may be seen
in the anterior chamber of the eye.
Inflamation in the posterior part is more
severe, the pain and fever run high, and vision 
is lost, yet the conjunctiva appears not 
much inflamed.
In all cases, the mechanical causes, if 
they continue to act must be removed. To 
remove sand or pieces of iron which stick in 
the coats of the eye, the ball is to be fixed by 
a speculum, and the body removed by a lancet.
Substances under the eye lid may be 
removed by a wet rag, or by syringing 
them with warm milk and water. If this 
fail, the inner surface of the lid may be examined 
by raising the lid.
When the eyelashes are inverted, constituting 
trichiasis, the cause of irritation must

116
be removed. This may depend either on the 
hairs growing inwards, or contraction of the 
eyelid. In the former case, the hairs must be 
pulled out, and St Yves says if destroyed by lunar 
caustic, they will not grow again
In case of contraction, an operation is required.
The tarsi, at the inner and outer ends have 
been cut thro', and, no success has followed in
any case I have heard of. Some assert that 
by cutting the skin lining the lid, they have
removed the stricture, but I have never seen 
any success from this mode.
A late author describes an operation, which 
consists in separating the tarsi from the skin 
without, and the conjunctiva within, thus 
separating its lateral connections; but I 
never tried this mode.
A few years ago, Dr. Dorsey had a case of this 
sort in the Alms House, and after trying to 
cure it by various operations, was obliqed to 
extirpate the whole edge of the cartilage, and 
the sore healed, and the eye was still very well 
defended by the eyelid. This is a mode which

(117
deserves imitation in all similar cases.
In all cases of opthalmia, bleeding is to be used
freely, according to the pain and fever. When 
enough of blood is evacuated in this way, cups 
may be applied to the temples, [and] or 30 or 40 
leechs may be applied to the same part. The vessels 
on the surface may be cut by the shoulder of a 
lancet, or they may be raised with fine forcepts,
and divided with scissars, but I prefer the 
lancet. Purging is also required. Mercurial 
purges are by far the best. The antimonial 
powder, of the P. Hospital answers very well.
The applications are to be mild. Poultices
of bread and milk are very good. The pith 
of sassafras may form one of the best remedies.
It may be applied in form of a poultice,
or as a fomentation dissolved in water.
Blisters may be applied behind the ears, on 
the nape of the neck, or on the shaven head.
After the inflamation is considerably subsided,
laudanum is a valuable remedy. Sugar
of lead, white vitriol and laudanum 
may be united in a collyreum.

118)
But stimuli must never be applied before 
the inflamation is much subdued, else the 
inflamation will be increased. Vinegar is a 
valuable remedy in such cases; the rotten-
apple-poultice is particularly serviceable after 
evacuations have been used.
If matter form in the anterior chamber of 
the eye, certain measures must be used to produce
absorption, but if the eye be made very 
tense by the matter, an incision, such as 
used for the extraction of the cataract, must 
be made, to prevent opacity in the cornea.
When opthalmia is of long duration, a 
salivation is one of the best remedies.
In all cases of opthalmia, particular care
should be taken to avoid light. The chamber 
must be dark, and excercise of the organ 
avoided. The diet must be vegetable, & 
animal food, and spirits avoided.
After severe cases, a sition may be made in the 
neck to prevent a relapse.
In many cases of protracted opthalmia,

119
the action seems to have something peculiar
in it. A gentleman, who had had a tender state 
of the eyes from his youth, had a severe [atta??]
which lasted 3 months; he was bled during 
that time, to ℥ iso, purged very freely, blistered 
had issues almost constantly, and was often 
scarified, and all to no good purpose. I directed
tar water to be applied, first to one eye, & 
after some time to the other. It brought him 
from a state of blindness, to free use of the 
organ, and tho' the application was very stimulating,
it produced no pain, but suddenly 
subdued the inflamation.
Various stimuli have been used. In one 
case, after bleeding, blistering and purging
had been used to no purpose, a solution of 
blue vitriol (in proportion of gr ij to ℥ water)
succeded buy and conception. In a week, the 
man was nearly cured.
Surgeons fear the use of stimuli in these 
cases from the tenderness of the organ, and 
indeed, the evacuating remedies, as bleeding, purging
and blistering must have been used before any 

120
stimuli are proper, but in protracted cases 
they are required. Solution of soap in spirits 
of wine have been of service in some cases.
Specks on the eyes have been cured by a mixture 
of sugar, alum and nitro! A solution 
of salt in water and vinegar, and sea water 
have been well borne in some cases. Red
precipitate, with a little camphor has been 
well endured, and succeeded in some cases, after 
the evacuating plan had failed.
Unguis. This, as we have mentioned, is an enlargement 
of the coates of the eye by inflamation.
When the thickening extends
along the conjunctiva over the cornea, vision 
is obstructed. The whole enlarged membrane 
must be dissected off. That part over 
the cornea, after being raised by fine forcepts
must be carefully dissected away with 
a knife, and the part over the schtonica may 
be cut away with scissars. It must be dissected 
very closely from the caruncular lachrymalis,
else it will return again. This is of 
much importance. 

(121
Specks. The best remedy for small opaque specks
on the eye after inflamation, is mercury. Locally,
gentle stimuli are proper, as corrosive 
sublimate one grain, water four ounces, but 
if there be inflamation produced by stimuli, 
they increase the opacity. But a ptyalism,
with low diet is the best, and most 
certain remedy.
When the part of the cornea, over the pupil
is rendered opacque by inflamation, an artificial 
pupil has been made by opening 
the iris with the needle, opposite to the 
transparent cornea. When the pupil is closed 
by adhesion, an operation [??lour] can cure 
it, by making an artificial pupil.
of Fistula Lachrymalis. To understand
this affection, the anatomy of the 
lachrymal sac and duct, the puncta lachrymalia,
and the adjacent bones must be 
well learned.
Stricture, or obstruction in this tube produces
a swelling in the inner canthus of the 

122)
eye, and if pressure be made on this, water and 
pus escape by the punctae. In this state, the 
eyelids will be glued together in the morning, &
opened with difficulty. If the sac be ostructed 
by disease, or by cold, pain and fever come on,
the part becomes very tender. In this state,
bleeding, purging, and low diet may sometimes
suceed, but generally, the tumor bursts 
externally. Before this can occur, it is the best 
practice to open the external part of the tumor,
give vent to the contents, and then introduce 
a probe into the duct toward the nose, & 
try to overcome the stricture. In this simple
way, I have succeeded in curing the complaint
But the nasal end of the tube is often so 
completely obliterated, as to preclude the fesibility 
of this. It is then nescesary to make 
an artificial opening into the nostril, for 
the future passage of the tears, by puncturing
the of unguis, which is the only division 
between the nose & eye in this place.
Mr. Pott performed this with a bent trochar,
after which, fragments of bone surrounded

(123
surrounded the opening, and were united by membrane.
It was nescesary to wear a bogie in the passage
for 2 or 3 weeks, to prevent its healing up, and 
even after this, it sometimes did heal up.
Mr. Hunter, seeing the imprefeations and in
conveniences of this plan, introduced a mode of 
striking out a circular piece of the bone, by 
an instrument resembling a punch, the 
bone being supported by a flat piece of horn 
introduced up the nostril.
This plan produces immediate relief, and 
after it no bogie is required.
This disease is sometimes complicated
with caries of the bones. In this case, the 
detached piece of bone is to be extracted, and 
the sore treated as another carious ulcer.
At the next lecture, the operation will be
performed on the dead subject, and the minutiae
of it explained.   Dr. P.
January 20.1812,

Lecture 32.
Fistula lachrymalis continued. Stricture in the 
ductus ad nasi, producing accumulation of 
tears, and swelling, may be divided into several 
stages, well distinguished from one another.
1. In the first, no inflamation has appeared, & 
pressure on the sac produces a regurgetation of a 
[mucus] water, and then mucus. Very little is to be 
done in this case. By pressing the fluid out of 
the sac regularly, the distension will be prevented,
part of the tears will return to the eye,
and some will flow into the nose. The eye may
be washed with a weak vitriolic collyeyum, as
white vitriol gr 1 or 2 to water ℥i, and I have seen 
the complaint disappear by this simple plan.
The French recommend injecting the sac with 
warm water by a fine syringe, but pressure 
is sufficient to cleanse the canal. Sir Wm Blizard
recommends injecting mercury, but no 
particular benefit results from this.
2. If by carelessness the sac be suffered to distend 
itself, and the patient expose himself to cold, inflamation

125
inflamation comes on, and parts appear just as 
a common boil. By the use of bleeding, purging, low 
diet and blisters, with a lead water poultice, we 
may prevent suppuration, and reduce the complaint
to the first stage; when it may be treated 
in the same way
3. In the third stage, pus has formed in the sac,
and generally escapes by an ulcerous opening 
in front of the middle of the sac, and the 
true fistula lachrymalis now is formed.
It is nescesary to remove the stricture, and establish
the evacuation of the tears into the 
nose, else the sore will never heal, and from 
inattention, patients have been teased by caustic
&c when the cause of the ulcer was not suspected.
The plate of bone (os unguis) which separates 
the sac from the nostril must often be
perforated, but before this is done, every measure 
must be tried to establish the natural passage
The external opening (if small) may 
be dilated with a bistoury, to introduce the 
probe. 

126
We may be called to operate before the duct is 
much distended, and not easily felt, and also,
the fistula may be so small and circuitous 
that we do not find it possible to introduce a
probe along it; therefore we ouht to know the 
true situation of the sac, and the place to cut
so as to find it. The incisions must commence
just below the inner canthus, and continue
parallel to the edge of the bony orbit. Thus, by 
beginning always below the canthus, we avoid the 
tendon of the orbicularis muscle
A probe is now to be introduced into the duct,
and carried down to the nose. In so doing, we feel 
the stricture, and overcome it. The probe may 
be withdrawn, and a bagie introduced, or what 
is much better, Mr Naru's silver probe. This consists
of a silver wire, the end of which is a little 
bent, and mounted with a flat head set on 
oblicquely, and the face of this after being heated,
covered with black sealing wax, so as to 
appear just like a black patch.
This may be left in. It does not produce 
much pain, and the tears pass along it to

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the nose, tho' this might not be expected.
This stilette has been borne for months, and 
is to be left in till the stricture is overcome. It 
may be removed and cleaned occasionally, and 
is then easily reduced to its place again. When 
the stilette is prematurely with drawn, the stricture 
will recur, and renew the disease where
as, if left in the due time, the canal will 
remain pervous, and the sore will heal very 
well after the stilette is removed. Thus the 
disease is generally easily cured.
But in some cases, the natural canal is 
not capable of yielding, and even the bony 
canal is found closed. Then, the artificial 
passage is the only resource.
When the os unguis is punctured by Mr.
Potts trachar, the fragments suspended together
by membranes are ready to reinstate
themselves again. To operate with Mr Hunters
punch, which is the best way, a piece of 
horn is to be introduced up the nostril, so as
to support the os unguis; the bottom of 
the sac laid bare, and the punch applied,

128)
and the bone may easily be perforated by 
few rotatory turns of the punch, and there 
will be a circular piece of bone neatly cut out.
The external wound may be immediately 
healed. The lips of the sore are to be brought 
together by adhesive plaster, and will soon 
heal up. The bone having no loose fragments,
will not heal up and the sac remains 
pervious, and conducts the tears into 
the nose without any inconvenience.
Of the Cataract. This consists in an opacity 
of the chrystaline lens and its capsule,
whereby the rays of light are prevented from 
passing to the retina.
It appears in an uniform whiteness of the lens,
or only in a speck. It first causes a dimness
of sight, as if gause was hung before the eye,
or threads, spots &c.
It often comes on spontaneously, and may 
in other cases be referred to mechanical violence.
Many remind us have been used to disperse the

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opacity. Mercury stands at the head of these.
Setons, purges, blisters, low diet, &c are also useful
Those cases which proceed from external violence 
may generally be removed by medicine.
They very commonly yield to a salivation.
A lady received a wound in the eye, by a puncture
with a needle, which reached the lens, considerable 
inflamation and finally opacity followed,
and she lost the sight in that eye. Bleeding,
blistering, purging and low diet were tried, but 
had no effect on the opacque lens. I pursuaded 
her to submit to a salivation, and as soon 
as the mouth became sore, the opacity began
to lessen, and before the salivation ceased 
the eye was perfectly restored. But she was 
still obliged to use a convex glass, and it therefore
appeared that the lens had been quite absorbed,
and the eye left in the same state as 
after extraction.
Spontaneous cataracts, I have never seen 
removed by medicine, and only once relieved.
As medicines fail, an operation alone can be 
of decided service. This consists in removing

130)
the opaque lens from the axis of vision 
Several means have been used for this purpose:
two operations continue still in use.
1. Couching, wherein the lens is pushed aside,
or to the bottom of the eye, so as to leave the 
passage for the light penetrable [the?ts] and,
2. Extraction, wherein a transverse incision 
is made thro' the transparent cornea, and 
the lens extracted thro' the iris and cornea,
so as to leave the eye in a transparent state.
Couching is the easiest as well as the oldest 
of these modes of operating, and is still 
strongly advocated by some surgeons, particularly 
Percival Pott, and Mr Hey of Leeds,
but I give a decided preference to extraction,
for the following reasons.
1. Couching is by far the most painful operation.
When extraction is performed by making 
the incision with a single stroke of the knife
it produces almost no pain, whereas, introducing 
the kneedle through the adnata and 
scletoric coat and the subsequent motions 
are very severe.

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I performed extraction on a man who had 
had couching performed on the other eye, and 
he could not believe that the operation was 
over till seeing a watch, he was convinced,
and he reflected with horror on the operation 
which had caused his eye to suppurate and 
waste away in the socket. I have even been 
requested to operate on the second eye immediately,
so trifling was the pain after 
extraction in many cases.
2. The lens after depression may, and after
does rise to its place, after which patients, 
will not (as some say) submit to the repetition 
without reluctance. When extraction 
is performed, the operation is complete.
3. When the cataract is fluid, the anterior 
chamber after become muddy, and the 
kneedle is in danger of tearing the iris. It 
is indeed said that the fluid will be absorbed 
again, but still, it is nesceray to repeat
the operation, to depress the nucleus 
of the lens.

132
4. When the capsule of the lens is also opacque,
the operation must be repeated on this if depression 
be performed, but in extraction, the capsule is 
easily removed either entire, as I have often had 
it, which could be seen by suspending it in water,
or piecemeal. When the capsule adheres very 
strongly to the ciliary process, it will be raised 
to its site very soon after couching, and appear 
behind the iris again.
5. Ahesions frequently form between the iris &
lens, and in extraction, I have found it very easy 
to separate them with a gold kneedle, whereas
in couching these adhesions remain, and the lens
will soon be reinstated again, and the repetition 
of the operation is required. Mr. Hey performed 
couching in such a case, no less than 
five times.
Therefore extraction ought to be always prefered.
Indeed objections have been raised against extraction,
but we shall soon see how far these 
result from awkwardness in the operator,
1. The incision in the cornea is said to leave the 
cornea opacque, but this is not the case; if the 

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operation be done well, the eye remains clear.
But if a dull knife be used, or the operation finished
with scissars, the eye may inflame, and becomes 
opacque; but the incision should not be 
near the pupil in any part, and therefore the 
passage of light remains unaltered.
2. The force in extracting the lens is said to 
make the pupil irregular, and so injure vision 
and I have more than once seen the pupil made 
irregular by extracting a hard chrystaline,
but this never injures vision in any degree.
Yet this is very rare, and may be avoided by 
proper care in the force applied.
3. The iris sometimes doubles under the knife
and may be injured if neglected, but if the incision 
be stopped, and the surgeon press and rub
gently on the cornea with the fore finger of 
the hand which is at liberty, the iris goes back
and the operation is easily finished.
4. The vitreous humor is said to escape sometimes
in couching, and this has actually 
been the case, but, it is always the effect of 
awkward pressure made on the eye, after



134
the incision is made. Moderate pressure is 
to be made on the eye during the incision
for the sole purpose of steadying the eye, and 
as soon as the cornea is cut, the pressure is 
to be entirely removed, and the vitreous humor
is in no danger of being moved. These objections 
are therefore of no importance. and extraction 
is the only proper operation. Dr. P.
Jan, 22d.
Lecture 33.
Cataract Continued. Before operating for the 
cataract, we ought to ascertain the probable
effect of the operation, whether or not success is 
to be expected. This is of great importance, as 
our character, as well as our patients ease may 
be sacraficed in a useless operation. The principal 
circumstances to be attended to are these.
1. That the eye in every respect (besides the 
state of the lens) be natural. That the cornea 
be clear, the eyelids, and thin edges free from 
inflamation and oedema. That there be no
tendency to inflamation, as in some cases

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the least injury will cause much inflamation 
2. That there be no pain in the fore head.
This circumstance is often met with especially 
in women. If this symptom exist, we can 
moderate it by bleeding, low diet, purging 2ce
or 3ce a week. In a case in which there was 
considerable head-ache, I gave purge twice a 
week, for nine months, and then operated 
with success.
3. That the iris retain the power of contracting
on the application of objects.
But if the power of distinguishing objects 
continue, we may not be deterred.
This iris may be fixed by adhesions to the capsule
of the chrystaline lens, and unable to 
move, yet if light can be distinguished from 
darkness, of telling the number of windows
in the room, of telling when a hand, a hat, 
&c is interposed between the eye and window,
&c the operation may be successful; but in 
such cases as do not bear these marks, you 
should never operate, as the retina will be in 
a state of torpor, the state called amourosis

136.
Even the pupil may retain its nobility,
and yet the retina be paralytic. An old
lady applied to me for a cataract, which 
was in this state. I extracted the lens, which 
was as hard as a stone, but to my surprise,
no power of vision remained. I then operated 
on the other eye, and in this, vision was 
restored. Now the pupils in both eyes moved alike 
by the light, tho' they were in an opposite 
state.
If the eye be in any of its coats inflamed or 
swelled, these symptoms may be removed by 
bleeding, purging, low diet, and blisters to the 
nape of the neck. The last remedy is particularly 
recommended by Baron Wenzel.
The operation is never to be poured on an 
eye in any degree inflamed, and measures are 
to be taken to prevent inflamation. In all 
cases, except when the patient is very weak, the 
diet should be low, entirely vegetable, and 
if the habit be full, blood should be drawn 
from the arm. 

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The most suitable seasons for the opertion
are spring and fall. In summer, the patient 
cannot lie still in bed the requsite time 
and in winter, the cold may produce inflamation,
and therefore mild weather is to 
be chosen.
The instruments used in extracting the cataract 
are the following.
It is common to fin the eye with a speculum,
by separating the eye lids, and applying it 
round the eye under the eyelids, it having 
a groove to receive the tarsi, but this is an unnescesary 
instrument. The eye[s] being opened
and held for a minute or two becomes steady
and the operation is to commence at this moment,
and it will be easy to keep it steady 
during the incision, without this painful 
and alarming instrument. This instrument 
occupies one hand, and if the iris folds
under the knife, we cannot make the nescessary 
friction on the cornea to press that back. I 
have performend this operation frequently, and 
never found it nescesary to use the speculum,


138)
speculum, but if it is used in any case, it 
will be found very convenient to have 
a ring in the end of the handle to put on 
the little finger, and then we can hold it 
with this, the mid-finger and thumb, and 
so have the fore finger at liberty; and these 
obviate this objection of Baron Wenzel. But 
still, the instrument is inconvenient.
The knife is then, the first instrument. Its 
blade may be 1 1/4 inch long 1/4 inch broad at 
the broadest part, and the sides straight lines
from this to the point. The edge is to extend 
to the broadest part in front, and to 1/10 inch 
on the back so as to make an exquisite point
I have said 1/4 inch broad: but it may be broader 
than [illegible] the diameter of the cornea, so 
as to cut its own way out by a simple push 
and must be very sharp, so as not to push
the eye obliquely, and so as to cut the cornea
without irritating it to inflame, and become 
opaque. See the description of this instrument,
in Wenzel.

(139
The second instrument is a kneedle for tearing 
the capsule on the anterior part of the lens
which may be a little bent, sit in a handle
and having on the end of the hand, a scoop 
for removing portions of the capsule which
may remain after the chrystaline is evacuated.
A small hook is also to be provided, with 
which the lens, may be extracted in case 
it should fall down into the vitreous humor
and only its edge be seen. This is often of great 
use.
Small forcepts are also nescessary, for extracting 
the opacque capsule, from behind the 
chrystaline, either piecemeal or entire. They 
are to touch not only at the points of their blades
but also to touch by flat surfaces, at least 1/10
of an inch. These instruments are of the 
first importance in completing the operation.
Before proceeding to operate, a bandage is 
to be put round the forehead, and to it, two 
compresses are to be pinned

140)
The compress which covers the eye to be operated 
on is to be pinned up. These render 
the eye steady. The patient is to be seated on 
a low seat and the surgeon on one much 
higher. All the windows in the room except 
one are to be closed, and the patient is to be 
set with one side of the head to that window.
Thus alone, the pupil can be seen distinctly.
The assistant is to stand behind the patient,
and support the head on his breast.
He is also to support the upper eyelid, by
holding the skin of it double over the sperciliary 
ridges, and make moderate pressure 
on the eye. The surgeon keeps down 
the lower lid, and makes moderate pressure 
also.
He is to apply the point of the knife to the 
eye, and not puncture it till the involuntary 
motion is over, else the knife may start,
and make a second puncture, and the aqueous 
humor will ooze out by the first,
the cornea will shrink and the iris fall in 
the way of the knife!

(141
The knife being applied at 1/12 inch from the 
junction of the iris and sclerotic coat, and 
the eye steady, the point of the knife is to be 
carried horizontally, and parallel to the iris
is to be brought out at the same situation
in the cornea at which it entered, and carried 
thro' with a single push; and never drawn back
but if the iris fold under the knife, pressure 
may be made on the cornea till this falls into
its place. As the knife fills up all the 
incision, none of the water can escape, but 
if it were withdrawn in any degree, or if 
the knife were not broad enough to cut 
itself out without being moved out of a direct 
line, the aqueous humor would escape.
As soon as the cornea is transfixed, all 
pressure must be removed; we having only 
to support the eyelids, and the knife being 
sufficient to fix the eye, which is as 
[cross out] it were hooked on it. Thus no pressure 
being made after the cornea is open, there is
no danger of evacuating the vitreous humor.

142)
Next, tear the capsule, with the kneedle in 
as complete a manner as posible, and with 
moderate pressure, the chrystaline lens will 
escape by the pupil an cut in the cornea. If the 
lens do not pass the pupil easily, the eye
may be exposed to darkness for some time,
that the iris may be relaxed, and thus, all 
danger of tearing the iris will be averted.
Gentle pressure may be made on the globe
to facilitate the exit of the lens, and if this 
does not follow very freely, the needle may 
again be introduced thro' the cornea and 
iris, the point fixed into the chrystaline,
and this extracted. This supercedes improper
pressure.
After the extraction of the lens, if filaments 
of membrane remain, they are to removed 
by the scoop, and if an opaque membrane
is seen behind the site of the lens, it may 
be removed by the forcepts.
When the operation is over, the compress is
be brought down, a piece of soft linen applied
over the eye, and secured by a bandage passed

(143
passed round the head, and the patient put to 
bed. His hands are to be secured with tapes fastened
to the bed cords, so that the cannot be 
lifted higher than the breast. This is of great 
importance. In one case, after the operation
was performed well, the patient on waking 
out of sleep, forgetting the cause of irritation 
in his eye, rubbed this, so as to evacuate 
the greater part of the vitreous humor
and so destroyed the organs.
In ten days, the eye will have united again.
Low diet, rest and perfect darkness 
are to be observed.-
We might have observ'd that after the incision 
is made in the cornea, we may rest 
a minute or two as in that time, the irritation 
of the incisison will be over, and 
the kneedle will be better borne than if 
this were neglected.   Dr. P.
Jan 24, 1812

144)
Lecture 34.
Cataract continued. Of Couching. And first 
of the instruments. It is common for operators 
in couching to use a speculum, and there is 
no objection to it, if the operator choses however,
it is unnescesary. The eye may be opened, the 
eyelids fixed, considerable pressure may be made
on the eye, this will then become steady, and 
now the operation may be performed. After the 
kneedle is introduced, it fixes the eye.
The kneedle used by Mr. Pott, was spearpointed,
but ingenious men have made many improvements 
in it. They have reduced its length to 
1 1/2 inches, and thus, rendered it very manageable.
The spear point, making too large a hole [prevent] permit 
the escape of some of the vitreous humor, but 
the round instrument now used makes no larger 
an orifice than the rest of it occupies.
It is made flat toward the point, as Mr. Hey has
directed, and I have also adopted, from Scarpa, the 
method of having it bent toward the point, 
1. becuase it is less entangled in the iris, 2, because

145
because after pushing the lens back, we can very easily
carry this crooked kneedle before it and fix it
very easily, 3, because with this it is very easy 
to depress loose, remaining pieces of capsule with
the bent kneedle.
This operation is very simple. The patent being 
seated on a low chair, and the supported by an
assistant, and him facing a window, and the eyes
opened as in extraction. The kneedle being applied 
at 1/6 of an inch from the edge of the transparent 
cornea, it to be pushed thro' the scletorica
to the chrystaline lens, the point is then to 
be applied to the lens so as to push it back,
and the kneedle insinuated between the iris and
the lens, the point is now to be fixed into the 
lens, and, and by elevating the handle of the 
kneedle, you depress the lens down to the bottom
of the eye, and immediately, the pupil will 
be seen black behind the iris, instead of the opacque
chrystaline. If this first motion do not 
perfectly succeed, it is very easily repeated.
It is nescessary for the kneedle to be very 
sharp, and even so, considerable force is required

146)
required in piercing the coats of the eye, and in so 
doing, an indentation is made. To remedy this inconvenience,
I puncture the eye with the point 
of the extracting knife, and then, use the kneedle
as usual. To depressing the lens, it may always 
be observed to keep the concave surface of 
the kneedle downward.
The operation being finished, the eye is to be covered
with a compress, this secured by a bandage
and the patient put to bed. In 10 or 12 days,
after the inflamation is over, the eye may be
examined, to see the effect of the operation.
The cataract is sometimes soft, and cannot 
be depressed. The advocates of couching break the
anterior part of the capsule, and all which escapes
into the anterior chamber will be absorbed,
and probably the posterior also; but if any 
remain, the operation is to be repeated again and 
again, till all the opaque matter is absorbed.
There are also cases of fluid or milky cataract,
in which also, the anterior part of the lens is 
to be ruptured, that the fluid may be absorbed.

(147
Thus, couching is a very easy operation; only one 
or two instruments being used. The principal 
danger consist in the liability of the iris to be 
wounded. Steadiness and skill are required to overcome 
this difficulty. But this operation seldom 
succeeds in restoring vision. I have frequently performed
it, and only in one case, I never restored the 
sense of sight. In all cases but that one great
inflamation followed the operation, and in two 
of them, the symptoms of gutta serena came on 
I was obliged to use depleting means, as purging,
blistering in these cases. From the above reasoning,
I have determined never to perform this 
operation, but to extract all, except in children, in 
whom the eye cannot be easily managed, and 
especially when the cataract is milky, in which 
case, couching may at least be tried on one eye
before extraction.
Artificial pupil. When the part of the cornea opposite
to the iris obscured by an opacity of the cornea, which 
cannot be removed, and another part remained 
transparent, we may make a hole in the iris opposite 
to the transparent part.

148)
The pupil is sometimes closed by inflamation.
This also, the iris may be opened.
I once succeeded in a case in which only one eighth
part of the cornea remained transparent, which 
was in the upper edge.
The patient being seated, and the eye opened
is in extraction, and pressed upon considerably,
the cornea is to be divided as in extraction,
with this difference, that before the opposite side 
of the cornea is punctured, the knife is to be so 
far retracted that a great part of the aqueous humor
may escape, and a flap of the iris fall before 
the knife, and now by finishing the operation 
by one cut, a round portion of the iris is cut
out. This is the simplist way of operating, and 
may prevent the introduction of forcepts and 
scissars which may injure the lens. Thus I
have operated with success several times
But when the pupil is closed, the iris cannot 
be brought afloat before the knife, and consequently 
we cannot succeed in this way; but as 
as soon as the knife is within the cornea,
the point of it is to be carried down, and the 

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pupil cut to about 1/10 inch, and the open incision at 
in the usual way thro' the cornea. The flap 
this iris may now be cut with fine scissars, which 
may be curved near the point, or what is [illegible]
slender forcepts, on one side whereof, there is a
curved edge. But as the causes of the closure of 
the pupil are violent ones, the operation may 
readily renew this, and therefore, before operating,
the patients should be told that the success 
of [of] it but a mere chance; and we 
only operate in uncertainty.
Hydrocele. This is a collection of water in 
the scrotum. The situation of the water produces
essential difference in it.
1. The anasarcous hydrocele, in which, this 
water is contained in the cellular substances
of the scrotum,
2. The hydrocele of the tunica vaginalis teses,
and
3. The encysted hydrocele of the spermatic
cord. As the treatment of these is essentially
different, we ought to distinguish them wt.

150
accuracy.
1. The first species presents an equal tumor,
whhich includes the whole scrotum, on both 
sides, and the raphe divides it into two in the 
middle. The tumor is of its natural colour,
and the finger makes an impression which 
lasts some time. The spermatic cord can easily
be felt in its natural situation. Thus the case
is readily discriminated.
2. The collection in the vaginal coat is supposed
to arise from the increase of the natural secretion
the torpor of the absorbents or the rupture of the 
lymphatic vessels. It commences near the testicle,
is generally confined to one side, is not lessened 
by pressure, is firm, and in the beginning,
the testicle can be felt but in the end cannot
be felt. It may be distinguished from.....
Hernia, by beginning at the bottom of the scrotum,
by being firmer, by being irreducible by 
pressure, by the spermatic cord being distinctly
felt, whereas the hernia presents all the opposites 
of these phenomena. Fluctuation, and 

(151
transparency may often be perceived.
Schirrus testicle, it is easily distinguished by 
cord being generally enlarged and irregular in 
the former, from the tumor being in this also 
heavier and more opaque than in hydroclele
From Hernia humoralis by its having no connection 
with gonorrhoea, by the tumor not 
being so firm in hydrocele, and by other symptoms
of water.
3. When one or more cysts of water are lodged in 
the spermatic cord, the testicle is always felt at 
the bottom of the sac, fluctuation is evident,
and the tumor is diaphanous. This tumor extends
to, or even beyond the abdominal ring,
and may be well distinguished. In a case of 
this kind, I saw some difficulty in distinguishing 
it from hernia. The tumor could be pressed
up (and as it were reduced) but immediately
returned, but fluctuation and transparency,
were evident, the testicle could be felt at the 
bottom of the scrotum, a puncture evacuated 
the water, and the wine injection competed 
the cure.

152)
Method of Cure. The bulk and weight of the 
tumor is often so slight, that patents are 
unwilling to submit to the operation.
The pain, either in the part or in the loins
is much alleviated by a suspensary bandage.
1. In the anasarcous species, tho' the case is 
not connected with surgery, we are often called 
to evacuate the water. Punctures are to 
be preferred to scarifications or setons, as 
the latter may produce mortification.
Five or six punctures will evacuate the water,
and the dressing may be dry lint.
I have seen the tunica vaginalis when 
distended with water, suffer a rupture, and produce 
one of the 1st species. An old gentleman
while setting in his room felt some thing give
way in the scrotum, and the tense tumor of
the vaginal coat was exchanged for a soft
diffused, lived one, and mortification was feared.
I was consulted 3 days after, and prognosticated 
that the breach would heal up, the water 
be absorbed, and the disease resume its
former state, and just such was the result

(153
2. In the second species, little can be done by 
medicine. I have seen it cured by the affusion of 
cold water. Temporary ease may be procured by
evacuating the water with the trocar or lancet
and then introducing a canula and insetor
till the water is carried off, and then covering
the puncture with adhesive plaster.
Simple as this is, I have seen three surgeons
puzled by a simple case in London. The first 
who was called, plunged in the trochar at the 
usual place, the inferior, anterior part, but 
no water followed the stilette. The wound 
was suffered to heal, and then a second was 
called, who also failed in the same manner.
Such also was the fate of the 3rd who could procure
nothing but drops of blood. Mr. Hunter
was now called in. On a very close examination,
he found that the testicle lay just 
at the place where the surgeons had chosen to 
operate, and that they plunged their trochars
into the substance of it. He operated on 
the inferior posterior part of the tumor, just 
where we usually find the testicle, and with

154
complete success. This teaches us always to 
feel the testicle, before operating.
The radical cure can be affected by exciting 
inflamation in the sac, so as to obliterate it
I have cured it by repeated tapings, in one 
case in which, the testicle was so inflamed and 
enlarged that I feared to inject wine. Tevacecated 
the water as soon as the coat was distended
enough to keep the instrument off the 
testicle. Low diet, and mercurial purges were
used. The water was let off every fortnight.
Several ways have been used to obliterate the sac.
1t. Incision is the most ancient. It consists of 
in dividing the skin and vaginal coat, and 
filling the cavity with lint. Great inflamation 
and suppuration came on, the lint was separated 
gradually, and the cavity united.
But this remedy is very severe, attended sometimes 
with haemorrhage, and shreds of lint
remaining often produced abscesses several 
weeks after the sore was healed.
2d. As the tunic is sometimes thickened, the 
removal of it has been proposed by Douglas

(155
but this is quite unnecessary.
3d. Caustic. The whole tumor, from top to 
bottom has been laid open by a caustic, which 
on the separating of the eschar, produced very 
great pain and inflamation, followed by 
the obliteration of the sac. Mr Else has confined
the caustic to a shillings breadth, and this is 
found sufficient. But the caustic is a very 
uncertain remedy; often faling to reach the 
sac, often causing violent inflamation, fever
and supuration, and when the water is 
contained in sacs this does not succeed.
4th Tent. A skein of silk was carried from 
the bottom to the top of the tumor. This often 
answers, but often causes only the tract betwixt
the tunic and testicle in which it lies
to be united, and the disese returns on the 
sides of this.
5. Monro left the canula in the sac, until it
produced the nescesary inflamation, but according 
to Cheselden, this mode is very painful,
and he prefered the tent. 

156)
6. Injection. Lately, the ancient mode of injecting
stimulating fluid into the tenica vaginalasis
has be revived. Wine, or wine and
water have been particularly recommended by 
Sir James Earle. This he has shewn to be perfectly 
safe and easy. In a few cases, indeed
this remedy will fail.
I once succeeded in curing a case with warm 
water alone, in the Penn Hospital, contrary
to my expectations; and I have since read 
Mr. Whateleys report, to the same import.
But wine, or wine and water are found very 
convenient, safe and not painful. If no inflamation
follow, it may soon be repeated
The patient is to be seated opposite to a window,
and the surgeon kneeling before him, makes the 
evacuation either with a trochar and or with a 
small lancet and then introduce a canula.
As soon as the fluid has escaped by the canula,
the injection of wine or wine & water, (being 
prepared in a bladder with a stop cock) is to 
be thrown thro' the canula into the tunica


(157
tunica vaginalis, and as soon as pain is felt in 
the scrotum or loins, which is in general four 
or five minutes, the liquor may be allowed to flow 
back again, the canula with drawn, the orifice 
closed with plaster, and the scrotum supported 
with a roller, which prevents inflamation.
In four or five days, the scrotum becomes red, tender
and covered with a blush, and in four or five 
more this goes off, with the disposition to renew 
the disease. If the inflamation run high, 
the patient may be confined to bed, and to low
diet, evacuating measures used, and a leadwater-
poultice applied. But if the inflamation 
be defective, the patient may walk about his 
room and use stimulating food.
To avoid the canula's escaping from the orifice 
in the tunica vaginales, which would cause 
the injection to pass between the skin and cellular
substance, and mortification, the canula
may be introduced full 2 inches and laid on 
one side. This never happened to me, but I 
saw it in the practice of another.
Jan.28.1812.  Dr. P.

158
Lecture 35.
In speaking of the treatment of the hydrocele
by injection, I observed that in a few cases, that 
operation will fail. I am to describe a late 
and successful operation for these cases, described 
by Mr. Hunter.
It consists in making an incision of 1/2 inches
long on the anterior inferior part of the scrotum,
thro' the skin and cellular substance, and piercing 
the cellular membrane, so as to lay bare the 
testicle. The state of the testicle may be seen.
The scrotum must now be filled, not with lint,
but with flour, or rather dough, made into balls 
of 1/2 diameter, holding the lips of the scrotum
asunder by two hooks, one in the left hand, and the 
other given to an assistant. After the tunica vagnalis
is moderately distended with these balls, a
piece of patent lint is put into the mouth of 
the sore, and the whole suspended in a bag-truss.
In case of much fever or inflamation, blood may be 
drawn, &c. In 2 or three days, a poultice may be applied
over it, the cavity will suppurate the dough

(159
will come away melted in the pus, the cavity appears
just as a large abscess, and the whole will 
very uniformly unite. I have performed this operation 
several times with perfect success.
Of Herniæ. Herniae, or ruptures are among the 
most important surgical diseases, from their 
frequency and their great dangers and inconvenience.
They consist of tumors, caused by the protrusion 
of the natural contents of the abdomen 
through its parieties.
They occur most frequently at the upper and 
fore part of the thigh, at the navel, and the groin.
The twin rupture is improper, as they consist of a 
sac of the peretonuem, pushed thro' some natural opening.
Thus, at the navel the navel, there sometimes
remains an opening in the foetus, imperfectly
closed, which admits of these accidents, and 
in the groin, the ring of the external oblique muscle,
thro' which the spermatic cord in the male and 
the round ligaments in the female pass, is the 
aperture at which the inguinal or scrotal 
hernia, or oschocele pass out, and in the upper,

160
and fore part of the thigh where the crural or 
femoral hernia is seated, the hernial aperture
consists of the cavity under Pouparts ligament.
All the contents of the abdomen have been occasionally
found in hernial sacs, except the 
duodenum and pancreas; but the colon and 
mesentery, and omentum are the most usual.
Hernia are named from their contents, as 
enteracele, epiplocele, gastrocele, &c.
The congenital hernia or that in which,
the protruded parts lie in the tunica vaginalis
testes, arises from that aperture in which the 
testicle [cross out] descends, not being closed before 
birth, and there is still a communication between
the peritoneum and tunica vaginalis.
In such cases, when the child coughs cries, &c the contents
of the abdomen may descend, but when pressure 
is made on it, it easily returns again. By frequent
repetitions, the communication remains open, and 
subject to rupture through life._ We shall treat 
of the bubonocele at length, and then treat of 
the peculiarities of the others.

(161
The bubonal or inguinal hernia is characterised by a tumor
at the abdominal ring. Astley Cooper says it begins 
at the distance of 1 1/2 inch from the external opening,
on the external side of it and higher up. It is 
easy to press the tumor up again; by lying horizontally,
also, it may be reduced, but on rising, or on 
making any pressure with the abdominal muscles,
diaphragm, &c, it is returned again. We see 
the progress of the tumor from the upper to the 
lower part of the scrotum. I have seen it descend
as low as the knee, and suspended by bandages
round the patients neck.
On dissection, we find the tumor to consist of 
1. (After laying aside the skin of the scrotum)
a number of tendinous bands united together
by fascia, which is derived from the obliquies externus
above the abdominal ring
2. The fibres of the cremaster muscle
3 The hernial sac. See A. Cooper. But these 
are sometimes so blended together as to appear 
many more in some instances, yet the above
ordor is universal.
Behind the upper part of the sac is found the

162
spermatic cord. At the bottom and posterior pt 
of the tumor is the testicle, the abdominal 
ring is the mouth or aperture of the rupture and 
and between this and the symphysis pubis,
is found the epigastric artery. In a few cases 
the spermatic cord is found on the anterior side
of the sac. This teaches us always to proceed wt
caution in operating.
Symptoms. 1. The tumor commences at, and 
proceeds from the abdominal ring in the groin.
2. The tumor is increased by the erect posture, 
et. v.v.
3. Is increased by coughing, straining the diaphragm,
abdominal muscles, &c.
4. When intestine is returning we hear a gurglinng 
noise, and
5. When intestine is down, the functions of 
the bowels are interfered with. Nausea, vomiting,
colic pains, costiveness &c are produced.
Diagnosis. 1. From hydrocele. a. by beginning above,
whereas hydrocele begins from the bottom of 
the scrotum, by the abscence of fluctuation
and the cord not being felt in hernia.


163
b. by being increased by the erect posture, pressure
with the muscles, of the abdomen, diaphragm
Thus, we can easily avoid mistakes in these cases
2 From swelled testicle. a. by the causes of this 
as suppressed gonorrhea, external violence, & 
being known. b. by the swelled testicle being 
hot and painful. c. by the swelled testicles
going off suddenly at any time like herniae,
d. by most of the diagnosis betwixt herniae & 
hydrocele.
3. From bubo a. by the connection of this with 
chancre, and being painful. b. by the bowels 
not being interfered with in buboes. c. by bubo
tending to suppuration.
4. From cysts on the spermatic cord. a Tho'
this and inguinal hernia have many features 
in common, when the cysts lie along the cord,
yet this one circumstance is a certain diagnosis,
vizt that if pressure is mad on the tumor,
if it be hernia, it will be lessened, but 
if an encysted tumor, it will not be lessened
in size, but go up in a mass and descend 
just as it went up, immediately. b. By the

164
effects of a puncture in evacuating the water
of the cysts, and so curing the disease.
5. From Varicocele, or a varicose state of the 
veins of the cord, it is considered difficult to distinguish
hernia. When the patient lies, the tumor 
is lessened, and when he stands, the pressure
of the column of blood enlarges it again, such 
also is the effect of coughing, straining, &c.
a. But in varicocele, we can feell, and even see 
the convoluted form of the veins under the skin,
b. A. Cooper proposes to lay the patient horizontally,
to take hold of the cord, and let the patient 
rise again. In hernia, a considerable 
pressure will be made against the fingers, but 
in variococele, this will not be considerable. But 
the first method is preferable, and even tho motion
of the blood in the veins gives a sensation
which prevents any deception when we feel it.
Causes. The causes are 1. Such as weaken the 
parceters of the abdomen. 2. Such as increase the 
pressure of the intestines. &c against them.
3 Both causes united. General debility, as after 
a fever, in old age, &c disposed to hernia.

165
Blows on the abdomen, pregnancy, strains of 
the diaphragm or abdominal muscles, [cross out],
great corpulence, violent coughing, straining
to stool, violent exercise jumping, lifting great 
weights, &c are causes of the second order. When they
act, the contents of the abdomen may be more or 
less forced thro' any weak parts in the parieteis
Thus I have twice seen herniae produced in young
men by carrying in a back leg.
Of the Treatment. For convenience in practice,
herniae may be divided into the following 
orders.
I. Such as are of easy reduction.
II. Such as can only be reduced by particular
management.
III. Such as tho' unattended with stricture, are 
irreducible.
IV. Such as are attended with stricture.
Of the first, it may be obseved that as long 
as intestine or omentum remain down, there
is always danger, even when there is no pain.
Stricture may occur, the contents of the bowel

166
may be stopped, and after frequent descents of 
the omentum, the passages [to be] kept open 
so that the gut may pass down, and this is 
liable to be the case as long as any omentum
is down. While any part remains down, the 
whole may be enlarged by the causes of herniae,
and stricture may follow this second descent.
Therefore the contents of the sac are always
to be reduced, and prevented from returning
by proper compression made on the mouth, or 
neck of the sac, after reduction.
This indication is answered by a truss, or 
slender steel spring, which goes more than 
half round the body, and the circle completed by 
a strap. On the end of this is a pad. A bandage
is applied in the groin, reaching from before 
backwards, to prevent the truss slipping up.
In applying the truss, let us recollect why it is 
used? That it may effectually keep the gut up
it must act on the ruing accurately. This part
presents a pit to the finger after the reduction 
of the intestine &c.
Instrument makes generally err by applying

167
the truss too low, thus pressing on the cord, testicle,
&c and allowing the mouth of the ring to be kept
open, which is the case when the truss acts over the 
pubis. The lower edge of the pad should act just 
over the upper edge of the pubis. The head of the 
truss is sometimes made of silver or ivory, and 
made so as to turn olbi[c]quely at pleasure so 
as to accomodate corpulent persons. The metal 
mentioned is chosen for not rusting. The part 
may be defended by a muslin compress, when this 
instrument is made of these materials.
The truss is to be worn night and day. I have 
known it affect a cure in nine months in a person 
of a good constitution, but the truss ought
never to be laid aside before two years. Aged persons 
must wear the truss always, as in them 
the cure cannot be expected. I know, however, 1 
exception to this, in a man of 50, in whom,
the ring united perfectly.
The exciting causes are to be avoided during the 
use of the truss, as costiveness, lifting weighty bodies,
riding a rough-going horse, violent excercise
&c. And when any exertion is made, the

168
patient should assist the truss, by pressure
with his hand, particularly if costive, or if 
he has a stricture in the urethra. These directions 
are essential to his safety.
Second order. The protrusion is sometimes so 
large that tho there be no stricture, the reduction 
cannot be affected. In this case the patient
must be put to bed, confined to a low diet,
to loose blood and to use purgative medicine.
Thus, the tumor may be lessened, as reduced,
and then the truss is to be applied. I have
often succeeded in this way, in these cases.
Third order. Tho' there be no stricture, the reduction 
may be impracticable, either from 
the shape of the tumor, adhesions betwixt 
the guts, or betwixt the gut and sac, or by ligamentous 
bands. In this case the tumor is to 
be carefully suspended by a suspensary bandage
and the patient often enjoys comfort, yet is 
not freefrom the danger of stricture. [See M.
As in hydrocele the sac has sometimes burst,
so has the hernial sac. In this case the gut

(169
will be found under the skin, and the gut must 
be reduced first through the ruptured aperture, & 
then into the mouth of the sac, into the abdomen 
But this case is very rare. [See N,D. Dr. Ph
Jan.29.
Notes on Lecture 35.
L. Page 165... After the hernia has been lessened 
in size by these remedies, we may by taking hold 
of the remaining tumor, in most cases reduce 
it, if it has not gone up spontaneously.
M. Page 168.... This order is only known by its 
not yielding to the remedies mentioned above (168) 
& cold applications
No above... The suspensary bandage not only 
prevents pain and great inconvenience, but 
by warding off the dragging of the tumor, prevents 
more of the contents of the abdomen being 
displaced. It is to be lined with soft materials.
A. idem... During the use of the suspensary, the 
state of the bowels requires attention. Costiveness,
and the use of flatulent food are to be 
particularly avoided.
Jan 31

170)
Lecture 36.
Hernia continued... Fourth order. We now come 
to speak of herniae, with stricture. Stricture in 
hernia consists of a tightness at the orrifice as
neck of the rupture, which injures the functions 
in the gut, or vessels of the protruded parts.
The tumour becomes hard, the patient becomes 
unable to stand, nausea and vomiting sooner 
or later come on, an antiperistaltic motion 
of the bowels is established, fœcal matter 
is vomited and if the gut be strangulated, no fœces 
can escape per anum, but what may happen
to lie beyond the stricture.
If the tightness be such as to injure the circulation,
and injure the venous circulation, inflamation,
with considerable swelling and 
fever comes on the colour of the tumor is not 
red, but of a dark leaden colour, just as in 
phlegmon before mortification.
The stricture may even be such as to stop the
circulation altogether, and produce mortification.

(171
When that is the case, the belly swells, becomes
very tender, the pulse becomes small and very 
weak, elilliness in may cases, which is followed 
by great restlessness &c occur, and death 
soon follows. But before the fatal hour, (which 
may be protracted from one to several days) it 
is common that a delusive interval occurs. The 
tumor becomes soft, and returns into the abdomen,
and the patient fancies himself nearly 
well, when death is just at hand.
On dissection, the bowels at the seat of the 
stricture are found of a chocolate colour, tender,
and easily torn with the fingers, and even
holes are often found it in.
When the omentum only is strangulated,
all the symptoms are much milder.
All these effects are produced by the pressure 
of the tendons thro' which the spermatic
cord and hernia pass. The ring of the obliquus
externus is the most usual seat of this. But Mr. A
Cooper has shown that the cause of the stricture
is frequently higher seated, viz in the obliquus
internus and transversalis. 

172
This is particularly the case in old and in 
large ruptures. The stricture is said to be spasmodic,
but no muscular fibres are concerned
When this is the case, cutting the ring will not 
relieve the stricture, but we must operate 1 1/4
inches higher up. This is the distance intervening 
betwixt the internal and external orifices,
but in old ruptures, these orifices are 
approximated, so that the internal one is just 
behind the ring.
In all cases of strangulation, effectual measures
must be taken to remove the stricture.
As soon as a patient is the subject of one of 
these accidents, he places himself on the ground 
horizontally, and makes pressure on the tumor.
If he fails, the surgeon is called upon. He 
places the patient in a bed, with the foot of 
it raised, and relaxes the muscles on the anterior
of the thigh and abdomen, by flexing the 
former on the pelvis, and by bending the pelvis
upward. He then takes hold of the tumor,
and presses it upward and outward, but not with 
any violence, which might irritate and even


(173
burst the tumor. If this remedy, viz position 
with tanis fail, other remedies are to be tried 
in the following order.
1. Bloodletting. This may be performed and delinquim
animi, and then, the termis will very 
often succeed very easily.
2. Warm bath. The whole body should be 
introduced into a bath at or near 100 and continued 
till faintness comes on. It may very 
often be practicable to reduce the rupture 
now, by the taxis.
3. Purges. I have found mild purges, particularly
rum, tart, and jalap in small doeses often 
repeated, given with some essence of peppermint,
of great service. Glysters at the same 
time being given. Mr Hey condemns purges 
entirely, but when the intestine is not in 
the strangulation, and in old cases, they answer
very well. But in case of strangulated 
gut, the only increase the vomiting.
4. Tobacco in form of infusion or smoke is 
a well known resource. The smoke is the most 
active, the infusion the milder remedy. 

174)
Tobacco ʒi infused in water [illegible] forms an infusion,
of which, one half may be thrown up 
every half hour, till the desired langor is produced,
and the reduction may generally be affected. 
Dangerous symptoms sometimes follow 
this remedy. In one man last summer, the 
powers life had nearly vanquished by the usual 
quantity, and Astley Cooper mentions a 
case in which the infusion of ℥i produced pain,
and vomiting, followed by death in 25 minutes 
in a girl. Care is therefore requiste in the 
use of this remedy. Perhaps ℥i of the infusion 
would be enough to begin with. Of all other 
remedies, this is the most effectual, and the quickest
in manifesting its result.
5. Cold. A bladder filled with pounded ice may 
be applied to the tumor, or if this cannot be 
had a solution of salts in vinegar & water, or 
crude sal ammonia ℥v nitre ℥v water [illegible]
be put into a bladder, and applied. These remedies
are very effectual. But they are not to be 
too long continued [in], as the part has actually
been frozen. 

(175
6. Opium. This remedy is indispensible in allaying
the sickness and vomiting and to be effectual,
must be given in large doses. 2 grs may 
be given by the mouth, and ʒi of laudanum injected.
In case of a man who had suffered strangulation 
for 3 days, I gave 3 grs of opium at 
night, and put him to rest. He slept well 
all night, and in the morning, the intestines
was found reduced.
But if these remedies fail, the operation for 
removing the stricture must be performed.
As to the time of operating; it is better to operate 
too early than too late. In the latter case
mortification or peritoneal inflamation will
have supervened. The most celebrated men are 
in the habit of operating early, even as soon 
as 24 hours.
We may make it a rule, in all cases after bleeding,
warm bath, purges, tobacco and cold, with a proper posture, taxis
and opium have failed after a fair trial to operate immediately.
By doing so many will be saved.
It is very difficult to ascertain the state of 
the hernia by the symptoms. Langor, hiccup,

176
hiccup, coldness of the extremities, small and weak
pulse &c are said to denote mortification, but 
I have seen the operation successfully performed
with perfect success, and the parts found 
to be sound. The duration of the stricture is 
no rule: patients have died in 8 hours, and they 
have survived 17 days. The fever is also uncertain 
When the countenance is sunk, the pulse weak
and the extremities cold, I have seen the operation 
performed with success.
Hernia are more dangerous in the middle 
aged than in the young or old, in small
than in large, and in recent than in old cases.
When the circulation is stopped, death is 
certain.
One symptom may be regarded as certainly 
fatal, viz coldness of the extremities, [This]
and a cold and moist state of the skin. This is
always a forerunner of death, and if the operation 
be performed under such circumstances,
it will always fail.
Of the Operation. The patient is to be laid on 
a table covered with a blanket. The pubis shaven

(177
An incision is to be made with a scalpel from 
1 1/2 inches above the ring to the bottom of the sac
unless this be very large, the skin and cellular 
substance are to be cut and the tendon of 
the external oblicque exposed. The tendinous 
fibres on the surface of the tumor are to be divided,
and the sac punctured by several very 
delicate strokes* of the knife, trying if the probe
will enter it. As soon as a puncture is made 
the director is to be so far introduced and the sac out on this as to allow
the finger to be introduced. On the finger 
the bistoury is to be applied, and the sac
divided as far as to near the ring but no farther.
By introducing the finger through the 
ring into the abdomen, the stricture can 
very easily be divided by passing the probe pointed
bistoury along the finger. The incision 
may be made upward, or upwards and a little 
outwards. If done inwards, the epigastric artery 
will certainly be wounded, and as the 
artery in a few cases lies on the outside, it is 
best to convey the bistoury directly upwards,
*No water being contained in the sac.

178)
as Mr Cooper advises, and then the artery cannot 
be wounded.
Mr. Cooper advises us for the purpose of preventing 
peritonial inflamation to carry 
the bistoury through the tendon only introducing 
it not within the sac, but betwixt 
this and the tendon.
The above is the way in which the operation 
is generally performed, but some late surgeons,
particularly Monro make no incision 
into the sac atale, but after dissecting 
down to the sac, cut some fibres of the 
tendon of the muscle in muscle with the scalpel,
and then introduce the bistoury.
After dividing the stricture, the part protruded 
may be easily reduced by the taxis.
This operation is exceeding by simple and easy,
and attended with no hazard whatever in
the hand of a careful operator. Dr. P.
Jan. 31.

179
Lecture 37.
Crural hernia continued. When the sac can 
be returned thro' the enlarged ring without being 
divided, this ought always to be done, this 
operation being the most simple, and tends to avoid
pertioneal inflamation; but when the strictured
gut is mortified, the sac must always be opened.
Also if we cannot reduce the sac after dividing
the tendon, the cavity of it must be open'd
and the cause examined, which may be 1. Adhesion
2 alterations in the shape of the parts protruded or
3 stricture at the neck of the sac.
1. Adhesions betwixt the gut and sac, if they be 
long may be divided, but if very short, the portion 
of the sac connected to the bowel may be cut
off and returned with the bowel. Dissecting adhesions 
near the mouth of the sac is difficult
and can only be done by laying the tendon
bare all round the adhesion.
2. When a large mass of omentum is low 
down, and is not retracted, it may be cut off
and the vessels tied, leaving the end of the

180)
ligature out at the wound.
3. Stricture of the neck of the sac is not a frequent 
occurrence: I met with a case of it in July,
1798. A man of 38 years of age was attacked with 
a severe colic which had continued several days.
He had been subject to a tumor in the groin for 
two years, which went off as soon as pressed upon
or the patient lay. A few days before I was called
this tumor had come down in consequence
of his lifting a heavy piece of wood. When I was 
called. I found the wrists cold, the pulse small and 
trembling, the belly tumid, the scrotum swollen, 
vomiting obstinate and no passage by stool
tho' the pain and swelling in tumor were much less than
before my arrival.
I advised an immediate operation, as the symptoms
of mortification were present. I made an incision 
through the skin and cellular substances
from above the ring to the bottom of the tumor,
dissected the sac free from the tendon and laid
the former open, but to my astonishment found 
nothing but bloody serum therein; no gut, no stricture

181
stricture and therefore there could not be in the tumor,
any cause capapable of producing the above
symptoms! Is the case produced by inters [sersc??]?
In these obscure circumstances, no remedy was 
applied except warm bath and purges of jalap & 
cremor tartar; but the man died in 36 hours.
On opening the body, a portion of bowel was 
found closely embraced by the mouth of the sac
which was retracted into the abdom a considerable 
way above the ring, and not at all in contact
with the fascia which usually embraces
it. What ought to have been done, had the true
cause of the disease been known? Ought the sac
to have been pulled down and divided? or ought 
the tendon to have been opened, and the neck 
of the sac cut within the abdomen?
The bowels are never to be returned in a mortified 
state into the abdomen. However, the symptoms
may seem to indicate mortification 
and yet the bowels be found sound. When a
sudden mitigation of the pain comes on, the 
tumor becomes purple, creptus is heard on

182
handling the scrotum, the belly becomes tense
the patient very restless, his skin hot, his pulse
weak and quick, and the hernia easily reduced, 
little doubt need remain.
Yet such a set of [set of] symptoms are not
always fatal. I have seen a negro who was 
in this situation recover, but with an artificial
anus at the groin, where the upper portion 
of intestine terminated after the slough 
separated.
After opening the sac, we can judge of the 
state of the gut. But the dark red, or chocolate
colour of the intestine, produced by impeded circulation
is not to be mistaken for mortification. 
The mortification is generally confined 
to spots, the texture is so altered that the gut
tears under our finger and has an offensive
smell. If the dead spot be small the bowel may 
be [small] returned, as adhesion will fix the surrounding 
parts to the peritoneum &c and the 
slough pass by the forces, but if there be a hole
in the bowel, it will require a stitch. 

(183
When the whole cylinder of the intestine is destroyed,
we are advised by Mrs. Cooper and Thompson
to cut away the slough and secure the tendons 
of the bowel together by four sutures, leaving 
the end of the ligature out that we can [dia??]
out and at any time examine the bowel. But 
the accumulation of fœces in the upper porton 
of the bowel is commonly such as to rupture 
the stitches, or at least to cause the escape 
of fœces from the gut into the general cavity.
I perceive that Mr. Cooper himself failed in two 
cases of this kind.
I should not ever try Mr. Cooper's way. I would 
leave the intestine out, and if the slough were not 
separated, I would open the bowel at the dead part
with the scalpel, to give evacuation to the feces, which 
is always profuse for the first 24 or 30 hours. The 
ends of the intestine would be gradually appoximated,
they would as gradually retract within 
the abdomen and the external wound heal up.
In July, 1798 a woman was attacked with a violent
colic and tumor in the groin, which continued 
several days. The physicians bled, blistered,

184)
and purged her, but the vomiting increased, the 
extremities became cold, the pulse small and feeble,
hiccough and swelling and hardness of the abdomen,
the tumor became hard, the colour of 
it dusky red. She had had a tumor in the groin
after severe parturition 2 years before, and it was 
plain that the hernia, which was femoral in this 
case was mortified. I made an incision through 
the skin and cellular substance, fœtid serum
and air passed from it, the tumor hung like 
an egg by a small neck; I next laid bare the tendon
and cut Pouparts ligament at right angles.
I next cut a hole in the gut, and introduced
my finger to the place of stricture.* The passage
through the bowels was [slow] by artificial means for four days. 
[cross out], the external 
coat of the bowel only, sloughed. On the 23d July
she was able to leave bed, and the bowel having 
retracted, the wound heald. Thus, an artificial 
anus was made, the gangrene was not complete,
neither were there two oricifices, but even
*This was followed by a copious discharge of fœces 
air by the orifice made in the gut. 

(185
if there had, they would probably have united.
When all the protruded intestine does not [in??tify],
and adhesions form round it a permanent
discharge of foeces may be established. I had one 
case of this kind in the P. Hospital some years
ago. I tried to accellerate the rectraction of both 
ends of the bowel by introducing a piece of bogie 
3 inches long bent up, one end being introduced 
into the two orifices, and gentle pressure was thus 
applied, but I found this not to succeed, as pain 
followed its use, and I performed a new operation,
which consisted in establishing a lateral communication
betwixt the ends of the bowel. I brought
the ends of the bowel in contact to the external
wound, and introducing the fore finger into one
and the thumb into the other, I found that the 
two coats moved on one another betwixt my finger
and thumb, so that I feared the adhesion 
was not extensive enough to permit an incision 
to be made betwixt the two bowels. To produce 
adhesion between them, I introduced a ligature
by means of a kneedle through the side 
of the two portions and brought them with

186)
some tightness together, such as might even 
have produced ulceration tho the space I
intended to divide, but the ligature caused so 
much pain that I was content with its producing 
adhesion as far as it reached. I next 
made a slit with the knife betwixt the two 
bowels which I had thus made to adhere, as large 
as the calibre of the bowel. The cavity of the sac
was dressed with a compress, and next day some 
griping was felt, and wind escaped per anum.
In 3 days more foeces passed freely. I next tried 
to heal the external wound by paring its lips, 
and introducing the twisted suture, but in 
this I fail'd, and a truss was the only inconvenience 
he had to submit to, as the natural 
route of the bowels was established; however, if 
the external wound had closed the truss would 
also have been nescessary. This operation being 
successful, that of Cooper is quite unnescessary.
The bowels may be allowed to adhere to 
the ring and lateral parts.
The omentum which forms a part in these hernia

187
is also to be reduced, but if it have mortified, the 
dead parts are to be surrounded by an incision 
through the living and removed. Any large vessels
which bleed may be tied, the end of the ligature 
being kept out. Mr Pott has thought this 
precaution unnesecssary, but alarming haemorrhagies 
have followed the neglect of it.
It sometimes difficult to tell whether or no the 
omentum be dead, and fatal consequences might 
follow the reduction of a mortified portion. It is 
said to feel crisp when dead, but the following 
marks may be depended on 1. The blood is coagulated 
in the veins of the dead portion. 2. The vessels 
of it do not bleed on being punctured.
Some have advised the adhesion securing 
the omentum in a string to prevent haemorrhage,
and even Pott recommended this, but it 
had produced nausea, vomiting, fever, pain & 
death, and therefore this plan must be exploded.
After the operation the wound is to be united by sutures.
The patient is to be confined to a horizontal 
posture, and cough is to be allayed by demulcents 
and opium, but the latter is to be 

188)
avoided as much as possible, as it retards the 
functions of the bowels. If nescessary, the bowels
may be opened with castor oil or salts,
and in some cases the bowels are so torpid & 
paralytic by the pressure they have suffered,
that they are not easily moved. In one case,
a swelling was produced by the accumulation
of the foecis above the wound, and went off by 
pressure again. This returned occasionally for 
three days and then subsided.
In some cases pain and swelling follow the 
operation. Bleeding, low diet, purging, blistering,
&c may be used as circumstances may indicate.
After the wound is healed the part must be 
supported by the use of a truss.
Femoral Herniae. This hernia we have observed, appears
on the upper and anterior part of the thighs
The contents of it pass under Pauparts ligaments,
and the tumor is small and moveable, and 
may be mistaken for a bubo or enlarged lymphatic 
gland. This mistake is very dangerous, and 

(189
yet has fallen out in the hand of every expert 
men. If a hernia were left to suppurate, or boldly 
opened as a suppurated bubo, how serious a 
mistake would be made! We read of men having 
died of ileus and a bubo!
In all doubtful cases of the kind, we ought to 
lay bare and examine the part. 1. The hernia is generally 
the lower, 2 in bubo, the edge of Paupurts ligament
cannot be felt, 3, neither can the pubis.
It is nescessary to know the true situation of 
the sac, as without this knowledge, we could 
not perform the taxis aright.
The bowels pass into the theca for the femoral 
vessels. They lie in the vicinty of of the pectineus
muscle, just over the fascia lata. The epigastric 
artery lies on the outside and the spermatic 
cord lies on the superior and anterior part
These two vessels cross one another. The obturata
artery sometimes arises in common with the epigastric.
The bowels descend first downwards, and then,
forwards at right angles with its neck. The taxis 
must therefore act inward and then upward, whereas

190
whereas in the inguinal hernia, the taxis acts upward
and outwards. This of great importance.
In this tumor we find 1. the skin, 2 the fascia,
3 the proper sac, or that derived from the peritoneum.
The inner edge of Pouparts ligament leaves 
a small aperture only, and the stricture in 
this place is very dangerous, and early open action 
is requisite. Cooper says if he were attacked 
with this hernia he would try the tobacco injection 
and if this failed, the operation!
The integuments are sometimes very thin, so that 
we are to proceed very cautiously thro these 3 membranes 
lest the gut be wounded. After this, the 
stricture is to be divided. In doing this caution
is required. If we cut inward the spermatic cord is 
wounded, If outwards, the epigastric artery, and in 
an upward direction, there is also some danger
of cutting the cord also, but let it be kept inward
that it lies 1/2 inch off, and this Ipace answers every 
purpose. Pinbuuat reccommended to cut the 
internal edge of the crural arch or Pouparts ligament,
but 1. the deep situation renders this difficult 
2, a director is required and the gut must be	

191
pulled with some violence aside 3. In some patients,
the obturator artery winds round the neck
of the Sac, and if wounded here it cannot be
secured as it can be if wounded over the middle
of the tendon. [See notes P and Q below Page 191.
I prefer operating on the middle of Pouparts 
ligament, on its anterior part, and at right 
angles with the ligament.
If the operator is fearful of cutting the spermatic
cord he may as A. Cooper advises dissect 
the cord loose ad have it drawn aside by a
hook before dividing the crucial arch.
February 2nd, 1812 Dr Physic
Notes on Lecture 37.
P. page 191... For nine out of ten cases of femoral 
hernia the patients are women, and in this 
there is not so much danger, as the cord in 
them is absent.
2. Page 191... When the epigastric artery lies 
in the way and is wounded, we can feel the 
pulsation of the vessel, pass a kneedle under
it and tie it. Feb 5th Recapitulations

192
Lecture 38.
Umbilical Herniae. We meet with it both in the 
child and in the adult.
In the infant the bowel often passes through the 
funis umbilicus. In such cases, it is to pressed up 
again, and the cord secured by a ligature. The edges
of the aperture may be approximated by adhesive
plasters, and they will often unite in a few days.
But sometimes it does not close for 3 or 4 months,
and the child by crying, straining, &c may cause a 
protrusion. I have met with 2 or 3 instances of this.
I have seen umbilical hernia in seven children in 
one family, yet in all the parts retracted and united 
well. This is the natural tendency of the parts, and 
can only be prevented by the presence of the gut, and 
this keeps the hole open, so that more gut may descend.
When the natural process fails, we are to treat 
it by an operation. 1. Compresses have been applied,
with a view of making union take place. They are 
secured by a roller passed round the body, but in 
this way the cure is detained for months; very incovenient 
pressure is made on the abdomen, the bowels

(193
bowels are even in danger of being protruded, the operation 
is very imperfect and difficult.
2. The ligature, which is the older method is recommended
by Desault. It is certain and expeditious
The patient being laid on his back with the thighs
and neck bent forward, the contents being reduced,
the sides of the funis are to be rubbed together to 
ascertain that all the contents are reduced. An assistant
now applies a waxed ligature several times
round the funis, making each time a double 
knot, and with such tightness as to produce moderate 
pain. Next day, the cord will be swelled 
just as a polypus after a ligature. 3rd day, it becomes
shrunk and livid. A second ligature is 
to be applied tighter than the former, producing
some pain, and a day after, a 3rd ligature
will compleat the mortification of the cord. The 
union of the mouth may be accelerated by adhesive 
plaster, and the circular bandage may be continued
for 3 or 4 months. This is found a very successful 
operation, and succeeds on young children
uniformly, best in those advanced nearer maturity,
it does not prove so fortunate.

194
This will best appear by the following cases,
which as well as the above operation are from Desault
1. A girl of 18 months old was operated on 
as above. The cord was shut in 7 days. Six months
after, there could be no vestige of the disease found.
2. A boy of 4 years old was operated on as above, the 
funis closed, but afterwards, the impulse of the bowels
could be perceived.
3. The latest period at which Desault operated was 
at the age of 9 years in a girl who had had it from 
birth. The the union was complete to appear and
in 3 mo. the swelling was apparent, and not 
withstanding the use of the bandage, in 6 mo. the 
relapse was complete. Therefore the operation is 
always to be performed early.
In Adults, according to Desault, the ligature
does not succeed. Having reduced the tumor by 
the taxis, pressure is to be made on the navel by 
Hey's truss. This is preferable to compress & bandage
as well as every other sort of truss. After this is 
applied, where any exertion is made the effect of the 
truss must be assisted by the hand.
[See note Pr. Vol. III p.3

(195
The other varieties of hernia woud require too long
time to explain them. They may be learned from 
books; it being my only to design to give a description 
of the nature of the most important kind
and the history of hernia in general. See Cooper
on hernia, and Lawrence.
Observations on the stone, perparatory to the 
demonstration of Lithotomy.
Stony concretions form in many parts of the 
body, as the salivary glands, the gall-bladder,
&c, but they are most usual in the organs for secreting,
containing and excreting the urine. This 
matter is often deposited on the sides of the pots in 
which urine is contained out of the body.
The quantity differs greatly in persons, some showing 
almost none of it, while others abound with 
it. I have seen the urine in a bowl incrust the 
bowl to 1/10 inch all round, in a scrofulous patient.
Now in such cases, it appears that a stone
will form at any time, when a solid body is introduced
into the bladder, serving as a nuclus 
for the matter to adhere to.

196)
A piece of lint, a bullet, a kneedle, &c have been found 
in the stone, and large masses of stone have formed round 
the end of a catheter. In the kidney, a coagulum of 
blood has had a similar effect. In sawing into a 
stone, it is generally found laminated, some stones
are very [hard] soft, and others are very hard, some are of a 
white, others gray, or brown colour.
The form commonly in the kidney and pass thence to 
the bladder, but they sometimes form in the bladder.
When after pain in the loins ceasing, the symptoms
of stone in the bladder commence, no doubt is 
left of the origin of the stone. A gentleman who 
had been troubl'd for some time with pain in 
the loins, on taking a ride from Germantown
to Phila. the pain ceased and the symptoms of calculus
in the bladder came on.
From a stone in the kidney, a dull pain in the loins
is produced. This, on stooping becomes acute. The urine
is often bloody. Inflamation with fever, costiveness 
and diminished urine with vomiting come 
on. If much dilution has been made, there is a copious 
flow of urine; or colic fever and suppression 
come on.

197
The efforts to vomit often press the stone into the 
ureter, which obstructing the passage of the urine, produces
great irritation. In fits of the gravel so produced, bleeding,
opium, blistering, warm bath and diluting liquors
are proper. The patient may stand, leaning forward, so 
as to bring the neck of the bladder immediately down
and pass his urine in a full stream and by this, the 
small stone may escape from the bladder. This is 
of great importance, and ought to be repeated, as it 
may prevent the formation of the stone.
A stone in the bladder produces pain heat and itching 
in the bladder, obstruction of urine frequently,
mucus or even puss will appear in the urine, sometimes
in large quantity. Bloody urine, especially after
excercise is very usual, and in some, the first symptom.
An uneasiness through out the urethra, especially 
at the glans, causing the patient to pull the prepuce
out, causing it to be elongated, prolapsus ani, &c are
common symptoms. By the suppression of urine, irritation,
distress and loss of sleep, the patient is soon 
exhausted of strength.
Other causes of irritation may deceive. Inflamation,
abscesses, ulceration in the bladder, tumors and

198
haemorrhoids in the rectum also have the same symptoms
as the stone in many cases. A woman laboured
under the symptoms of stone, and found no relief 
from the usual remedies. Suspecting an ulcer in 
the neck of the bladder, I ordered mercury till the 
mouth became sore, and all the symptoms vanished.
In another person all the usual symptoms existed,
and continued till death, when a tumor was 
found in the rectum. This, if it had been known could 
have been cured by an operation.
Stone may exist in the bladder and produce little 
or no uneasiness. A man who had a stricture in 
the urethra, and had not suppression, only a diminished 
stream of urine, and no other symptom referrable 
to stone, being prejudiced that he had a stone, 
underwent experiments such as jumping off a 
table, riding of a a rough-going horse, &c and no irritation 
or bloody urine being produced, but the stricture 
prevented sounding. After his death a rough stone 
as large as a walnut was found loose in the bladder!
The only certain criterion is sounding, or the introduction 
of a bent, iron instrument into the bladder,
which when it comes in contact with the stone

(199
produces a tingling fell, and may be heard. This 
operation may be repeated in various ways, through we
do not feel the stone at the first trial. First, let the 
patient stand, if this fail he may lie down. The finger introduced
into the anus may bring the stone into the way
of the sound. A man in this city had symptoms of the 
stone, and no stone could be felt on sounding. He 
went to London and was sounded by Mr. Hunter, but 
without any success. He returned, and applied to me. I 
succeeded by putting him to bed, raising the buttock
so as to throw the stone into the fundus of the bladder.
Having ascertained that a stone exist, no remedy 
can be depended on except lithotomy. Medicines introduced
into the stomach or injected into the bladder
have long been tried. From the effects of akalis on
a stone out of the body, they have been introduced in 
to use. Soap, aqua nephritica alcalina, carbonated
soda &c lessen the pain for a time only. In one case
they seemed to have succeeded. Unequivocal symptoms
of stone existed in a child. Sounding ascertained it 
beyond all doubt. The weather being warm, the operation 
was defferred, and the aqua mephritica alcalina

200)
alcalina was given, and to my utter astonishment, the 
symptoms of stone disappeared, and never returned
again. What became of this stone, it if were not 
dissolved, I do not know. Some other remedies besides
the above give temporary relief, such as lime water,
and uva ursi. But while these are used, the symptoms
will always return unless the stone become encysted,
which effect cannot be attributed to medicine.
Injections, capable of dissolving the stone in the 
bladder have be keenly sought after. But they are 
incapable of affecting the stone unless of such activity
as to cause inflamation and sloughing in 
the bladder.
The best palliatives are small bleedings, warm 
bath, demulcents and opium, which must be 
diligently used when the irritation of a stone become
at any time aggravated, constituting a paroxysm 
of the stone.
Dr. Physic
University of Pennsylvania
February 5th 1812.
END OF VOLUME II.







56
WILLIAM M'LANE
No. 27





Hic libeo pvetinet ad editorem
Gulielmo Madane



Memoranda
From a 
Course of Lectures
on 
Surgery.
Delivered in the University of Pennsylvania
By Philip S. Physick M.D. Professor, & 
John S. Dorsey, M.D. Adjunct Professor
of Surgery in that University
By Wm M Lane
Vol II.
1811 & 1812



Memoranda &c
Lecture 20.
Fractures of the lower end of the humerus
are generally transverse, and these are 
sometimes complicated with a separation of 
the condyles of the bone.
Either one condyle is separated from the bone 
alone, or they both are. They are easily detected,
in their superficial situation, by the 
fingers. If we take hold of the condyle or 
condyles, we can move them very easily in 
any direction, and a crepitas will be heard.
A bandage is to be aplied from the hand to 
the elbow, and, extension and counter extension,
used; the condyles are now to be brought 
into place, and the bandage continued up
the arm. The arm is now to be brought to 
right angles, and the rectangular splints 
applied laterally, and straight ones, bent at 

4
the middle, applied before and behind,
and the bandage carried over the splints, down 
to the hand. In 8 or 10 days, the apparatus is 
to be removed, and the parts examined, & 
if any derangement is found, it can be 
rectified.
Fractures communicating with the cavity 
of a joint are longer in uniting than others:
in general, this will unite in 5 or 6 
weeks. When treated in this way alone, we 
always find a deformity: the natural an 
angle which the arm and forearm form 
with one another, the point whereof is downwards
when the arm is extended, is reversed
and the point is now upwards. To avoid
this, after having kept the cubit an right 
angles for about 20 days (as above) it is 
to be extended, and, splints having a 
downward angle, such as the arm naturally 
forms are to applied before and behind,
and the roller carried over them as above,
and this apparatus kept on for 4 or 
5 weeks longer. In this ways I have preserved

5
one arm in perfect shape. The only hazard 
which attends this apparatus, it that anchylosing 
is not a rare accident in such fractures,
and, if it were not for this, the arm ought
be kept extended from the beginning; but 
it being well known that if anchylosis occur
in a straight posture, the limb will be
useless, whereas, in the [cross out] flexed, it will be 
be very serviceable. After the arm is extended 
the state of the joint is to examined every 4
or 5 days, and if anchylosis is found to begin,
we must bend the arm again. When
the bony opised to the humerus are both injured,
we may expect to presever the joint
in most cases, but if either the radius or 
ulna is injured, as well as the humerus
bony union may be expected in the joint.
Fractures of the Bones of the Fore-arm
A. Of both the bones. This generally happens in
the middle of the bones. The seldom pass one another
much, and the [cross out] the derangements
they are most subject to is the angular, and this is 

6)
mostly inwards Counter extension is to be made by 
one assistant, holding the humerus just 
above the condyles, while another makes 
extension holding the hand just as we do
in shaking hands. The surgeon can now
place the ends of the bones in place with his 
fingers, and applies a roller from the 
hand up to the elbow. The arm is to be in 
a flexed posture while this is a doing. A pair
of splints broader than the forearm is drop
are now to be applied one on the front & 
the other behind, and secured by the reflecting
of the roller. The splints are best made
of stiff (not wet) pastboard, or wood. The 
arm is to be suspended by a sling. The thumb
may be left out, that it may shew us the
state of the arm, as to rotary derangement
and if the roller is too tight, this will swell,
and teach us to slacken it. The first roller
must be slacker than usual, lest the fragments 
be pressed together, and thus destroy 
the rotary motion of the radius on the ulna

7)
whereas the second roller, may be pretty tight,
to press the splints tight against the arm, and 
impact the muscles between the bones, and 
keep the latter asunder. In 8 or 10 days, the state
of the parts may be examined, as in other cases
L. Fractures of the Radius. This bone may be
broken at any part, but the most usual place 
of the fracture is about one inch above the 
lower head of the bone. The hand moves with 
difficulty in these cases, an angle inwards is
generally formed. The luxation of the wrist
may be confounded with this, but when the 
fractured parts are examined closely, certain
information may be had. The wrist may be 
bent freely without any motion at the part.
Extension and counter extension, as above
being applied, and the bone reduced, the same 
apparatus as that used when both bones are 
fractured is required. The splint must reach 
beyond the fingers as in the above case, to keep
the arm and hand quiet. This is very important
in both cases.

8)
Fractures of the Ulna. This is by far the 
least common of these accidents. I have never
seen any but two cases of this. One was produced 
by warding off the blow of a club, and 
the other by a fall on the bone itself. This 
bone is very thinly covered, and therefore, this 
accident is very easily detected, by feeling,
moving, and hearing the crepitus of, the fragments
The treatment is the same as in the 
former instance of the fractures of the 
forearm. In 3 weeks the bone will unite,
but it is best to wait 4 or 6 before removing 
the apparatus.
Stiffness of the wrist and fingers is very 
apt to occur especially in old persons; but 
this goes off naturally in some time. The 
splints may be taken off every 4 or 6 days, to 
bend and extend the fingers gradually.
Fractures of the Olecranon. These are produced
by direct falls on the elbow. They are 
very easily discovered. The power of extending 
the arm is lost, as the biceps extensor cubiti

(9
is now unable to act on the forearm. The olecranon
may be easily felt, and if the arm be extended,
the olecranon may be moved in all directions.
The treatment is as follows. The forearm 
is to be extended for the purpose of relaxing the 
triceps, and to let the point of the olecranon
occupy the pit on the posterior side of the humerus,
which it naturally occupies. A roller is 
now to be applied from the hand, and as soon 
as we arrive at the elbow, the skin is to be tightened
over the fracture, by pulling it up, lest 
it should fold between the fragments. (In 18 
or 20 days, the arm may be gently bent and 
extended.) On the front of the arm, one long splint
is to be applied over the first roller, and 
is to apply itself round the arm a little. If any 
considerable inflamation follow, the bandage
may be made slacker, and and the diet reduced 
very slow, and blood may be taken from 
the other arm
c. Fracture of the coronoid process of the
Ulna. I have never heard or read of a case of 
this kind, and I never met a case of it but

10)
one. This was mistaken for a luxation,
as the humerus was thrown forwards, and 
the olecranon felt above the pit for recieving
it. The parts were very easily reduced,
and while I was preparing a bandage, &c. I 
was astonished to see it stontanously luxated 
again. This was soon reduced, and 
perceived the crepitus. The coronoid process
being the only obstacle which keeps the 
triceps from luxating the arm, this effect
may easily be explained when the 
process is broken. I secured the arm at 
right angles, and allowed the humerus 
to rest in the hook like process of the [illegible]
for 15 or 20 days and then the splints
angular downwards, and the childs arm 
grow without deformity. This case first
suggested these splints with the angle 
downwards, which I have used very much
since.
Fractures of the Ossa Metacarpiaria
from direct violence, and are very easily

(11
discovered. The extension and counter extension 
are to be made from the [cross out] wrist and 
fingers, and retained by a broad pasteboard, 
applied in front and secured by a roller, the hollow
having been filled up by the introduction 
of some flannel or to betwixt the splint &
palm of the hand. A wooden splint, which 
will reach from the middle of the cubit, and
in which there is an excavation exactly in
shape of the arm, hand, thumb and fingers,
(if at hand) will answer rather better.
Fractures of the Fingers are very easily 
detected, and reduced. They require only one
small pasteboard splint in front. These 
fractures will unite in two or three weeks.
Decemb 23rd     P.S. Physic.

12)
Lecture 21.
Fractures of the Femur. This bone 
may be fractured in any part of its length,
but is very frequently fractured in its middle.
The upper end, even so high as within the 
capsular ligament is sometimes broken & 
then, the upper fragment is within the cavity 
of the joints. The lower end, just above 
the condyles is sometimes separated, in some 
of these, the condyles are separated; and there
are cases wherein one condyle is removed from 
the body of the bone.
This accident may be very easily detected, the 
motion of the limb is nearly lost, yet there
remains some power of moving the ancles and
toes, so as to deceive the patient, but if he attempt 
to raise the leg, the fails, and convulsive
twitches follow. The limb on comparison 
with the other will be found shorter, and 
on holding the leg, and moving it a crepitus is 
heard.

(13
This fracture is sometimes transverse, but it 
is generally oblicque, downwards and forwards
The lower portion in such cases slides above and 
behind the lower one.
Many means have been proposed, for keeping
this fracture in place. The object of all of them is
to keep the ends of the bones in relative opposition,
and prevend displacement and shortening
till the bones unite. They are as follows.
I. It has been proposed to treat this with simple
bandage and splints as other long bones
but this will by no means answer.
II. To place the limb in a position calculated
to relax the muscles of the limb.
III To maintain permanent extension and counter
extension, and keep the ends of the bones in 
contact.
The first practice was to apply a bandage and 
splints, and this bandage, tho so tight as to 
cause swelling of the limb did not prevent displacement, 
as I have, my self seen. The only 
use of the bandage is to prevent contraction in the 
muscles, and to give support to the veins and 


14)
lymphatics: They can answer no other good purpose.
The femur is so thickly covered with soft 
parts, that unless the fracture be transverse
or the fragments interlock, the bandage cannot 
prevent overlapping.
Mr. Pott, using the sweep of the straight position 
to be such, proposed to lay the patient 
on one side, to bend the thigh on the trunk
and the leg on the thigh to right angles, so 
that by relaxing the muscles of the limb,
he would take off the irritation which induces 
the muscles to contract, and pleasing 
as his proposal is, practice teaches us the 
following inconveniences arise from it.
1. The position is irksome and fatiguing, & 
and if the patient be so resolute as to maintain 
it thro' the day, he is sure to sleep on 
his back at night, and the bones must 
be set every morning, and inflamation will 
be thus produced.
2. We lose the advantage of measuring this 
with the sound limb, which is indeed the only

(15
only true way by which we can judge of the state of 
the bone, it being so deeply covered, that our faling 
quite deciptious.
To join the benefit of the flexed posture with the 
position on the back, a bone had been contrived,
consisting of two boards, joined together at right
angles at the end, and secured be angular stay 
this was introduced under the hough, and the leg
lay on the one square, while the thigh lay on 
the other. I have given this a fair trial 10 or 12
years ago, but I always found one side of the 
pelvis to shift forward, and allow the bone to 
over lap. By supporting the other limb in the 
same way, no benefit was obtained.
I have been led to prefer the extended posture. The 
objections to have been mentioned. Tho a very 
irksome irritation and fatigue occurs, the muscles
accomodate themselves to it in 2 or 3 days,
The heel sometimes inflames and sloughs by 
the continued pressure, but a little attention to 
this will prevent it. As soon as it is found to 
become sore, it may be rubbed with brandy and 
defended with sticking plaster spread on leather

16)
or a compress of 10 or 15 folds of flannel, and 
with a hole in the middle for the heel will 
answer completely.
The last method is permanent extensions
Many means for this purpose have been tried.
The foot being secured to the foot of the bed,
and another roller round the axilla, and 
secured to the head of the bed, extension had 
been kept up; but they produces unsupportable 
irritation and cannot be borne.
It is much better to apply the apparatus
to the bone itself. Weights have been suspended
from the [cross out] thigh over a pully near
the bedside, and extension thus produced,
but I have seen this tried, and no good
effect whatever followed. It only drew the patient
to the foot of the bed. Many other 
apparatus have been proposed, but most
of them are too complicated for as [cross out]
prompt an accident.
But the most certain and the most simple
apparatus, is that of Desault. I have

(17
used it for 12 or 14 years in my private practice and 
in the Penn Hospital, and in most, if not all 
cases, preserved the length of the bone. I shall 
now demonstrate this apparatus.
The bed is to be bottomed with tight-braced sacking
or boards, and to be without a foot board,
An oval hole is to be left in the bottom of the bed
as well as in the matrass for a close stool. They 
may be occupied by an oval cushion, and supported
by a stool under the bed. The sheet it to
be without a wrinkle, and no more than one 
pillow used to support the head, else the body
will press on the limb, and derange the bones
The apparatus is to be laid on the bed in 
the following order. 1. Four or five tapes in 
the length of the thigh 2. The junk-cloth,
or piece of linen or muslin, as long as the thigh,
and it may be broader, (with the convey 
corresponding to the groin folded in). 3 a splint
of pasteboard for the back of the thigh. 4 The 
bandage of strips, each 2 or 3 inches broad and long 
enough to overlap over the thighs and sufficiently 
numerous to reach from the

18)
knee to the groin overlapping over one another
a little 5. The bandage for counter 
extension is to the laid down. This may be
made of silk, or of leather, sewed up into a 
tube and covered with oil cloth. 6. The bandage
for extension is to be laid at hand.
7 The post-board splint for the anterior part 
of the thigh is to be prepared. 8 Two bags of 
chaff as long as the limb, or flannel folded 
8 or 10 times would answer. 9. Two wooden 
splints, one for the outside of the thigh,
and the other for the inner. They are to 
reach from the six inches below the foot, 
and the outside one reaches to the crest 
of the ilium according to Desault, but 2
have extended it to the axileau, and then 
made a head like that of a crutch on it. There are
two holes near the head of this splint,
for the bandage for counter extension.
The limb is now to be laied on the apparatus,
and the latter applied as follows. Each 
of the long splints is to be rolled in the 

(19
junk-cloth from the edge, so as to apply to the 
side of the thigh, and the bags are to be laid 
on the inside of the splits, and they thus applied.
The bandage for counter extension is now 
applied in the groin and carried before and behind,
and carried thro' the holes in the long splint 
and tied. The bandage for extension is next applied 
on the back of the small of the leg, crossed 
on the [cross out] instep, knotted on the sole &
carrid over the block near the end of the outer
splint and tied in the hole on the splint.
Extension is now to be made, and the limb 
is to be compared (at the ancles) with the other,
and we must observe that the anterior 
superior spinous process of the ossa ilia
are not out of their place, and consequently 
that the pelvis is not aslant.
The proper extension having been made, the 
bandage for extension is to be secured. The 
bandage of [cross out] strips is next applied, beginning 
at the knee, and reaching to the groin,
the splint of pasteboard is to be applied on

20)
The fore part of the thigh and the tapes are 
now to be tied over all. It is obvious that 
after the bandage for counter extension is 
applied the surgeon himself can make 
extension merely by pulling the bandage
for extension, and pushing the splints.
Decemd 27th            P.S. Physic
1811
Lecture 22.
Fractures of the Neck of the Femur.
This may happen either within the cavity of 
the capsular ligaments or entirely without 
this. In all these cases, the limb is rendered 
shorter;- in a very few cases, the fragments 
interlock one another so that no immediate 
shortening occur, yet in all these,
the shortening occurs before two or three 
days. The limb is always turned outwards,
and if any attempt is made by the patient

(21
patient to raise the leg or foot, he fails and nothing 
but pain and convulsive twitches follows.
If extension and counter extension be made, the 
limb can be brought to its full length, and as 
soon as this is quit, the limb relapses to its 
former shortness. If the hand be applied over the 
trochanter major, and the limb rotated, the
trochanter will not make any great sweep, especially 
if the fracture be near the body of the 
bone: whereas, if the neck be not broken, there 
will be a considerable arc described, the radius
whereof is as long as from the bottom of the 
acetabulum to the outside of the trochanter.
This accident may be confounded with 
a contusion, or a dislocation; but the diagnosis
is very certain. 1. In contusion, the pelvis 
will be tilted up on that side, and I have seen
this prove very deceitful. In an hospital at 
York, a patient was supposed to have a dislocation,
and a consultation of surgeons was 
held on the occasion, and they were not convinced 
till (6 days after) the patient walked freely

22)
freely. But if we place a stick on the superior 
anterior spinous processes of the ossa ilia,
we immediately detect the shifting of the 
pelvis and know that it is only a contusion
2. For dislocation upwards and backwards
the limb is shortened, but we cannot so easily
bring it to its length, and if we do,
the bone will not return, but be in place 
&c. I have endeavoured to explain this minutely
because accidents of this joint and the elbow
are often very obscure.
The treatment is the same as in oblique
fractures of the body of the bone. The hole in 
the matrass is particularly proper, as there 
cannot be any motion in the pelvis without
deranging the bone, and inflamation 
may be excited, which, as I have seen, may 
suppurate if rest be not maintained. If any
inflamation appear, bleeding and low diet 
may be enjoined.
When the injury is without the capsular 
ligament, the bone may unite well, but if

(23
it be within this, nothing but a ligamentous
union can be expected. In a case of this kind,
which I dissected long after the fracture, a very curious
process of nature is to be seen: the neck of the 
bone was absorbed, the body came nearly under the acetabulum,
and sort of ginglimus joint, with cartilage,
&c was formed
I am now to specify the improvements which I 
have made to the apparatus of Desault for fractures
of the thigh. His external splint only reaches 
from the crest of the ileum, and the bandage 
for counterextension goes obliquely from the groin
to this, and this tends to derange the upper fragment 
outwards. So avoid this, I have extended it 
to the axilla, and after the bandage is on, a strip
of [cross out] bandage is tied to this, midway betwixt 
the groin and splint before and behind*, just so 
tight as to make the bandage act in the line of 
the thigh. The upper end of the splint is made 
like a common crutch and covered with flannel
as a square head would tend to hurt the arm
In
*going over the other side of the abdomen 

24)
In Desaults apparatus, the foot is forcibly 
drawn against the [cross out] splint, and very considerable 
inconvenience follows from this.
I have adapted an innovation of the late Dr. J
Hutchison, to avoid this. It consists in a block 
of wood, which being placed near the lower 
end of the external splint, has a notch
to receive the bandage for extension; so that 
the extension as well as the counterextension
are is thrown in the line of the leg and thigh.
Having applied the apparatus, an inexperienced
surgeon may draw the bandage too 
tight, and produce pain, exoriation, and 
even sloughing, having ulcers over the 
tendo achilles and instep; and the apparatus 
must then be removed, therefore, this 
is to be avoided. When the muscles contract 
strongly, very little force is proper, as by 
doing so, more irritation is induced. After
some days, the force may be gradually increased.
If tenderness or excoriation come 
on, (which is very common, especially in

(25
children) spirits, as brandy may be applied, the 
parts may be covered with adhesive plaster on 
leather, soap plaster, or what is best of all, a 
small buck skin gater, cut away at the heel,
and laced up the instep (with a strip of the same 
material to guard the instep from the whang
strips of buck skin may be fastened to the under 
part of this, thro' holes, and used as the band for 
extension.- Any bandage will soon fold together
like a rope and act very severely, therefore, this 
method is peculiarly proper to defend the skin.
Mr John Bell, in his book, represents the 
apparatus of which I have spoken, as cruel
and useless, and the error he has committed
is truly astonishing. In reading his book, you 
will reflect that he has never seen Desaults
apparatus applied by one who understood it.
He also says that when the femur is broken
in the middle, the lower portion is never displaced"!!!
The lower end of the thigh bone, just above 
the condyles is not unfrequently fractured.

26)
These fractures are generally oblicque,
forwards and downwards, and in these cases,
the upper fragment projects just above
the patella, and the lower is drawn backwards
by the gastroenemic muscles, and 
the bones are laterally deranged by the leg.
Having applied a roller from the ancle up 
and reduced the fracture, a pillow is to be 
applied in the hand, a compress on the hand
over the lower portion, and a splint is to be
applied in the hand, reaching from the 
middle of the thigh down to the middle of the 
leg, and Desaults apparatus may be also 
applied with a moderate of tightness, and 
the rest of the fragments is sure.
When the condyles are separated from 
one another, the treatment is the same as 
above, except that there is no use for the 
compress in the hand, unless the under portion 
be displaced backwards. Any fracture 
of the thigh requires the apparatus for 6 or 8 
weeks, while that within the capsular ligament
of the acetabulum, requires at least

(27
three monts. If it be removed before this, there 
is danger of the callous of ielding, and producing 
deformity, specially in fractures of the neck of 
the bone. P.S. Physic
December 30th
Lecture 23.
Fracture of the Patella. It is very seldom
that these happen in any other direction there 
transversely: however, I have seen then longitudinal
and also oblicque. Transverse fractures
generally happen by the violent contraction 
of the extensor muscles on the anterior 
part of the thigh. Oblicque and longitudinal 
fractures happen mostly from external 
violence directly applied, as in falls, blows, &c.
When the patella is transversely fractured,
the power of extending the leg is lost, also the 
power of walking, and if walking, he falls.
He may however walk sideways, or backwards.


28)
backwards. The transverse fracture produces very 
great displacement of the fragments. The 
separation is very easily felt. The upper
portion may be brought down by our exertions,
and rubbed against the face of the 
lower. The separation arises from three
causes: 1. The extension of the thigh, 2. the
flexion of the leg, 3 the contraction of the extensor
muscles of the thigh. When these causes 
unite, the fractured portions may separate 
5 or 6 inches. The only cause in which 
the parts are obscured, is when after great 
external violence, blood is extravasated &
forms ecchymosis over the part. The cellular 
substance is so lax, that the blood
may be pressed aside by the fingers.
The bones can only be approximated by 
opposing all the causes of displacement.
The thigh is to be bent on the pelvis, and 
the leg extended. After this, the fragments may
be brought nearly, or altogether into contact
The apparatus is designed 1 to keep the upper


(29
upper fragment down, by acting directly on this 
and the lower 2. To maintain the limb in the 
position mentioned. The apparatus always requires 
to be extemporaneous, and therefore simple.
A bandage is to be applied from the ancle to 
the knee, to support the vessels, the body being in 
a horizontal posture, the whole limb is to be raised
so as to relax the thigh on the pelvis, and the leg
is to be supported with pillows, or what is better,
a board reclining, and cover'd with a bolster. This 
posture is preferable to raising the body, in as much,
as it takes off the determination of blood. The 
above posture, tho' irksome, is supportable after 
some time. The fragments being pressed together,
a compress is to be applied above the upper, and below 
the lower, and to be secured by the bandages
turned in the figure of $, meeting on the hand,
the skin over the patella is also to be supported
by a turn of the roller, and it is then to be carried
as high as the groin, for the purpose of 
of suspending muscular contraction in the extensor
muscles.- It is also worthy of attention 
to draw up the skin over the patella, so that

30)
it will not insinuate itself between the fragments.
A long splint is now to be applied to 
the posterior part of the leg and thigh,
(covered with flannel) and the same roller is to 
be carrid down again over the splint to the 
ancle. The limb is to be supported with the 
pillow and board, as above described. If pain 
supervene, bleeding is proper. [See note J. p. 35.
If we are not called in till some inflamation 
has come on, the drawing down the muscles,
would only irritate them, but we must 
wait till by bleeding, elevated posture, lead-water 
poultices, &c we have removed this, &
then apply our apparatus. If put on before 
violent inflamation, is over or even anchylosis may 
follow.
As the roller which accury the compress
is found to press on, and impede the vessels,
Dr. Dorsey has contrived a splint, on the midde
of which two bandage are nailed, 4 or 5 
inched asunder, which being applied on the 
back of the limb, the bandages are brought 
over the compreses, and pinned or sewed

(31
over the compress. The lower bandage goes over the
upper compress, it visce versa, and below this is 
applied, a roller goes simply from the ancle to 
the groin, and the compress are applied. This 
I find very convenient.
In two weeks, (or less in case of inflamation) the 
bandage is to be removed to rectify any derangement;
but the weight of the body is not to be 
rested on before less than 3 months.
The union in all these cases is ligamentous, and 
not bony, tho' it is said that if the bones be kept
in perfect contact, they will unite by bone
I have seen the ligament two or even four inches
long. If bony union took place, the joint might
be lost by anchylosis, and in cases when the
under bones are injured this may be expected,
and in this case, after 16 or 20 days, the limb
may be gradually moved to prevent anchylosis;
which, however, I have never seen in this 
case.*- When no means are used to keep the 
fragments together, they will go 5 or 6 inches
as under and the power of extension will be
*see note H.p.35.

32)
lost. But by seating the patient on a table,
with the legs hanging down and making 
attempts toward extension every day
Dr Hunter succeeded in the case of a lady &
this practice deserves imitation.
Fractures of the Leg. These are mostly
transverse, but in some cases they are oblicque
In the first instance, no shortening of the 
leg occurs, but the leg is bent angularly
forward, if both bones are broken by the 
action of the strong muscles on the posterior 
of the leg. This accident is easily detected 
also, by the feel, and by the grating.
In cases of oblicque fractures, unless the 
fragments interlock, the leg will be shortened
from 1/2 to 1 inch, as will be found on
comparing it with the other leg.
Extension, and counter extension are to
be applied, and the bones are very easily 
replaced. They are to be retained by splints &
bandage till the bones have united. Permanent 
extension is not required in this case

(33
The apparatus is to laid in order on the bed,
as in fractures of the thigh. The leg is suported 
by a board, with a pillow: On this is laid the
bandage of strips, as long as the limb, from 
the knee. On this, two pasteboard splints,
soaked in warm water, and rolled in soft linen
is next applied, and lastly, a bandage of 
strips, similar to the former is laid over this.
The patient is now to be conducted to bed, and the 
surgeon is to preserve the posture of the limb, he 
is to carry it by the knee and ancle, and he is 
to keep it extended while carrying. It being 
laid on the bed, the first bandage of strips
is to be applied from the ancle. If the limb 
has been deranged, as soon as laid on the dressings,
extension and counter extension are 
to be applied and the bones reduced. The bandage
of strips is then put on, next the splint
which are to reach at least from one inch 
below the sole of the foot, to prevent lateral
displacement by securing the lower fragment
and they are to be applied over the sides of the 
leg, and secured by the bandage of strips,

34)
first laid down. This I prefer to tapes which 
are use'd by some, but they press very unevenly.
The foot is best supported by by a 
a bandage put round the toes and carried
up on the leg. The pillows are now to be 
supported by two pieces of shingle, and 
secured by pices of tape passed around the 
shingle, bolster and limb. The state of 
the parts, as in other cases is to be examined 
in eight or ten days.
January 1, 1811          P.
Notes on Lecture 23.
H. p. When after fracture of the patella, if
from external violence, it is required to bend
the leg on the thigh, before the union is perfect,
to prevent anchylosis, this precaution
is very necessary, viz. while very gentle and
limited motion is made, the fragments of 
the bone must be pressed together with
the fingers, lest the new formed parts should
give way.


(35
I. p.30 In all cases of fractured patella, particularly
in those from external violence, it 
is nescesary not to apply the bandage too tight
as this would be very injurious.
Lecture 24
In the subject of fractures of the leg,
one circumstance remains to be explined.
When the fracture of the bones of the leg 
is so oblicque that they pass one another
after reduction and the application of splints,
it is nescessary to apply permanent
extension, else shortness and deformity will
follow. [cross out]
Desault has described an apparatus for the 
purpose in question; and Doctor James Hutchison
has improved it very much, so as to 
make it fully answer our purpose. Two 
splints of boards are to be provided. In the upper
end of these, is a [cross out] number of gimblet
holes, and the lower ends of the splints are 


36)
joined by a cross bar.
1. A pillow is laid on the bed, and on it a bandage 
of strips. 2 The leg is to be laid on this, & 
and a bandage for extension passed around 
the leg, crossed on the instep and tied in a 
knot on the pole. 3. Two tapes are to be applied 
on each side of the leg, and secured by
a roller passed around the leg just below 
the knee. 4. The tapes are now to be put thro'
four holes in the splint, on each side and 
tied. 5. Extension and counter extension are 
applied, the bones reduced, and the bandage 
of strips applied on the leg. 6. There is to be 
a bag of chaff applied on each side of the 
leg, and the splints appied close along 
these. 7. The bar to join the end of the splint 
is to be introduced thro' the mortines in 
them, and the bandage for [cross out] extension 
is to be tied over this with whatever 
degree of force is required.
Thus, whatever degree of force is required,
may be applied, and all causes of displacement
counteracted.

(37
In all fractures of the leg, the weight of the 
bed clothes has a tendency to displace the bones.
This may be kept off, either by three nail-rods
bent into a semicircle, and the points driven 
into two pieces of wood, which serve as basis,
and lie parallel to the limb, or by a more extemporaneous,
tho less steady machine viz
two segments of the hoops of a flour barrel,
each two thirds of a circle, and tied together at
the middle, this sit up is a cross over the leg
will support the clothes.
In compound fractures of the leg, this apparatus 
is very serviceable, as it allows, to dress the 
sore, without undoing the apparatus which 
keeps the bones in place.
It will not be required to apply this apparatus
during much inflamation. If the 
pressure of the roller below the knee causes 
swelling, which it sometimes, tho' seldom, does 
Desaults apparatus for the thigh, which makes 
extension on the tuberosity of the ischium may
be used.- The action of the four tapes on the roller
below the knee, keeps the pressure in some

38)
measure off the lateral vessels.
In women the short apparatus will be 
very convenient, as the long apparatus reaching 
to the pelvis is not very suitable to 
their taste. The fracture box, with a thin 
pillow introduced into it, is very well adapted
to keep the leg steady. Tapes are tied around 
it after the limb is introduced. It has 
a double bottom, and when it is required to 
raise the leg, any body may be introduced
under one end of the bottom for this purpose.
The bottom is excavated for the leg.
It is very common for wet applications
to be used to reduce inflamation of the 
leg as a solution of sugar of lead, this with 
vinegar and a little spirit, vinegar and spirits
alone, vinegar and sweet oil; but these 
remedies are of little consequence, and bleeding 
is the best means to reduce inflamation
In cases of ecchymosis, vinegar and spirits
on the principle of coldness are the best means
to promote absorption.

(39
Ruptures of the tendo achilles are generally
produced by great bodily exertions, in which 
the gastrocnemii muscles are exerted, as in dancing,
going up stairs, &c
The patient feels as if his heel has sunk 
into the floor, a crack is heard, and the patient 
falls down. The powers of the gastrocnemii muscles 
is quite lost, yet by some other muscles 
he can extend the foot a little. * [Sec Note Th p. 43
The leg is to be bent on the thigh, and the foot
extended on the leg, so as to bring the ends of the 
ruptured tendon nearly into contact, and to 
retain them so till union has taken place.
Doctor Monro describes the following means 
to maintain this posture. A piece of Russian 
sheeting is secured round the leg, long enough 
to reach half way down the leg. A slipper is 
next put on the foot, and a strap fastened
to the heel is to be carried up the back of the 
leg, and secured to a buckle on the back and 
inferior part of the sheeting. Thus, the belly 
*See wounds of the Tendo Achillis V.I p.116

40)
of the muscle is compressed, and prevented 
from acting, the lower portion is drawn up, &
the upper down, and the ends are tolerably well
kept together.
Dr. Monro met this accident himself, & 
succeeded in covering it by the above apparatus.
You will perceive on reading his account, 
the great difficulty experienced, and 
a very considerable lump was left on it.
One very great difficulty attends this mode 
of practice. The foot being at liberty to 
move laterally is very apt to derange the
lower fragment. To remedy this, I prefer the 
following apparatus.
A splint of wood is carved in such a 
manner as to adapt itself to the anterior
part of the leg and foot.
1. A roller is to be applied under the knee 
and after being carried half way down the 
leg, is carried up as high as it began.
2. The splint, lined with soft linen or flannel
is applied on the anterior part of the  

(41
leg and foot. 3. The roller is now reflected halfway 
down the leg, carried the same height, and pinned 
4. Another bandage is applied on the lower part
of the bandage* and foot; some turns of it may 
surround the heel, but not make any pressure
on the tendon, as this would derange it very much,
5 The vessels of the finall of the leg may be supported 
by a few turns of the roller, but these 
must be very slack, and it is best to support 
the tendon by compress of tow or lint.
The limb is now to be supported on a pillow 
for 6 weeks when the union will be but soft,
but no weight of the body is to be intrusted
to it before ten or twelve weeks.- Doctor Monro
was not able to use his leg completely before 
four or five months.
Having complated the history of the ruptured
tendo achilles, I shall now introduce
some observations on an accident little understood.
Persons after carrying a heavy burden 
on the shoulders, leaping, &c hear a crack
*splint

42)
referred to the calf of the leg, they are not 
able to raise themselves on the toes, yet
it is possible still to walk in a hobling manner
without raising the heels. I have never 
had an opportunity of dissecting a leg, after
this accident, but it appears to arise 
from the separation of the muscular fibres
of the gastroctemic muscles from the 
tendon to which they are united. In one 
case, I have felt an evident pit at the seat 
of the injury. From the pain and uneasiness 
in walking, patients will keep themselves
quiet for 8 or 10 days, they then walk 
about and a complete separation again
recurs. He confines himself for far a similar
line till easy, and again walks, &
after this many such courses, I have seen
patients miserably perplexed. One man 
was nine months in this way, the leg was 
swelled, and his health very bad!
The carved splints will answer very well
here. The foot part must be so deep as to restrain

43
restrain the lateral motions of the foot completely.
A bandage is to reach from the ancle to the 
knee.
In course of 5 or 6 weeks, a confined motion 
may be allowed, as the tendon will be tolerably
strong.      P.SP.
Jan 3. 1812
Note on Lecture 24.
K. p 39 Rupture of the tendon of Achilles
are very easily detected also by the fingers.
A very great vacuity is felt in the tendon.
However in cases of great swelling this 
may be obscured.
Lecture 25.
Fractures of the Tibia alone. As the fibula
is entire, the length of the limb is unaltered.
When the fracture is transverse, it is often
very difficult to discover the presence of the 
injury. There is generally sharp pain, and unevenness

44)
unevenness at the part, by trying to bend 
the tibia, an angular projection, and a 
chinck may be felt. It is of importance to 
know the presence of this injury in all cases
as it will be very dangerous to treat 
it only as a contusion. A patient of mine,
after I had reduced an accident of this kind
was not satisfied that his leg was broken
and removed the bandage and splints. On 
making somewhat an oblicue step, the 
leg yielded, and very severe distress was the 
consequence. Therefore cases of this sort
ought to be very carefully examined
The treatment is the same as in transverse
fractures of both bones. Two splints,
are required as in that case, and the leg 
is to rest on a pillow. In some cases this 
fracture will not unite, and in this case,
after about 6 weeks, considerable motion 
may be allowed, so that the fragments may 
inflame on their surfaces, and form a bony 
union. I have successfully treated several 

45
several cases in this way; and the union was nearly 
as speedy as usual.
Fractures of the Fibula. This is generally
complicated with a fracture* of the ancle joint. The 
fracture happens mostly at two thirds of the length
of the leg from the knee the leg is much distorted,
the astragalus faces the [cross out] outer ancle, the 
inside of the foot is turned down, and the sole, out.
A considerable hollow is felt over the seat of the 
fracture, the patient complains of pain there 
and if the foot be flexed and extended, a grating 
may be heard.
The first thing to be done is to reduce the 
foot, and the fibula will be drawn into its
place by this alone. The limb is now to be secured
by splints and bandages. The patient may
be laid on his back, and the many tailed bandage
applied, beginning at the ancle. The bandage
must be so slack as not to derange the 
fragments of the fibula.- Perhaps it may be
supposed that splints are unnescessary, as the 
*dislocation

46
tibia remains entire, but this is very far 
from being the case. The splints are to be 
so long as to reach below the foot, and by 
so doing the foot is kept steady, otherwise,
it will be very apt to produce displacement
of the lower fragment inwards. This is
the principal use of the splints, and one 
to which you ought to attend, as you will 
not find it in any book which we have.
By neglecting this, caries of the bone has been
produced, and I have seen amputations resorted 
to, on account of the diseased state of 
the leg produced by the irritation of the parts 
thus neglected till caries came on. In five
or six weeks, union will have formed such 
as to allow of considerable excercise of the leg.
Of Dislocations. A dislocation consists in 
the derangement of a bone out of its natural 
situation. It is attended with a loss of motion
with pain and deformity.
If surgical assistance be at hand, it is generally

47
generally easy to reduce the bone to its place, but
if much time elapse, considerable difficulty is 
commonly experienced. This arises from the contraction 
of the mucles by the irritation of the bone
displaced. The rupture of the capsular ligament
is not the cause of very much trouble, except in
a few cases, to be specified hereafter.
In such cases, many means have been devised 
for moderating the action of the muscles. Bloodletting, 
warm bath, low diet, &c have been used.
The first of these remedies, bloodletting from one
or both arms, ad delinquim animi, I have found
the best remedy; by this means, a temporary 
suspension is put to muscular motion, and 
the principal obstacle being removed, the reduction
is very easy. This remedy was first used 
in the Pennsylvania Hospital by me, and 
it was first proposed by Dr. Alexander Monro in
his lectures.
For the same purpose other means have also 
been used, but with less effect. Nausea produced 
by tartar emetic, or by tobacco injections
and these means may be used when bleeding

48)
is objected to. Intoxication has a similar 
effect. The muscles may be overcome by 
being fatigued. How after do we see reduction 
happen by weak efforts, after resisting 
for hours!
When a dislocation cannot be reduced, the muscles 
accomodate themselves to their new 
functions, adhesiong form round the head
of the bone, and these causes conspire against
reduction. This is particularly the 
case in old dislocating. The natural cavity
becomes less, and presents another obstacle.
Considerable force is required in these cases
Pullies have been much used but I have 
relinquished their use of late, and now, I 
use a number of assistants. Pullies are 
very unmanagable, and their action is 
not easily attend, whereas, by a word, you 
can vary the force and direction at pleasure
by using a proper number of assistants.-
Care must be taken to confine

(49
the force applied, to the joint dislocated.
When a bone remains long out of place, a 
sort of new joint is formed. This is not unusual in 
some joints, particularly the shoulder and hip.
A joiner had his arm dislocated into the axilla and 
remained irreducible. He began to use it a little
when the pain and inflamation had subsided.
The power of moving it returned gradually, he
has able to use the saw as well as before, but one
muscle seemed to have lost its power, (the deltoid)
as he could not raise the arm upwards. In all 
such cases, the cellular membrane is so condensed,
as to serve as a new capsular ligament, and 
even new cartilage is formed.
In irreducible dislocations of the hip, the acitabulum
is very readily and completely absorbed
and a new one, with capsular ligament as well
as cartilage is formed. A girl by receiving a fall
had her femur luxated backwards and upwards
and lost the power of motion for some time,
and nothing could be done to reduce it; after some
confinement, on beginning to walk about,

50)
and received a second-fall, whereby the other 
femur was reduced to the same state as the 
first. The limbs were now of one length,
and she could walk a little, when at the end 
of a year, she took a fever, which proved fatal,
Her pelvis was shown to me by Mr Cruickshank,
and in both sides, the bone was dislocated upwards
and backwards. The natural acitabula 
were completely absorbed, new cavities
were formed on the dorsa of the ossa ilia,
surrounded by bony margins, covered
with cartilages, and furnished with new
capsular ligaments. Dr. S.
January 6th,
1812

(51
Lecture 26.
Dislocation of the Lower Jaw. The only direction
in which this can happen is by the condyle 
being carried before the tuberosity at the 
root of the zygomatic process. The mouth always
stands open, speaking is impracticable,
the saliva flows from the mouth, and considerable 
pain attends.
It is produced by yawning, or any other cause 
of opening the mouth wide, by which the 
condyle mounts upon the tuberosity before 
the pit, and in shutting the mouth the 
condyle cannot get back again. A woman 
in market, in scolding [cross out], husband furiously,
found she could not shut her mouth again,
and came to me, and I found her jaw dislocated 
on both sides.
Some recommend strikeing the chin upward
to reduce this, but by this, the condyles may be
broken. In recent cases the reduction is very

52)
easy. The thumbs are to be introduced into 
mouth, applied to the molar teeth, and the
middle fingers applied under the chin. The 
thumb may be guarded with a soft linen,
lest after reduction, by the spasmodic action,
it should be injured. The patient is to be 
seated on a low chair. The surgeon is to depress 
the angle of the jaw with the thumb,
while with the fingers, he raises the chin,
and as soon as it is dislodged; he is to push 
it backwards. In this way, all the cases
I have ever seen were easily reduced.
No bandage is required after reduction, but 
the mouth is not to be opened freely for 
some time. Both sides of the jaw are 
generally dislocated at once. I have seen
only one case, in which only one condyle
was dislocated. In these cases, the force is 
to be applied to the injured side only.
Dislocation of the Clavicle. This bone 
much oftener fractured than dislocated.
a. I have seen one case of dislocation in

53
the sternal extremity, which was forwards. It 
may also happen upwards or inwards. Dislocation 
forwards always happens from the shoulder being 
driven forcibly backwards. It is very easily known 
by the projection anteriorly, and easily reduced.
A cushion is placed in the axilla, the elbow pressed 
toward the trunk, and the end of the bone
pressed down with the thumb. After reduction 
the apparatus of Desault for fractured clavicle
is to be applied, and kept on for four or five weeks,
till the ligaments resume their tone again,
b. Dislocation of the scapular end from the 
acromion scapulae is very easily discovered. 
The clavicle is found raised above the acromion 
a considerable way; and the ligaments 
are torn. On raising the arm, you reduce 
the fracture. This is always produced by a fall 
on the shoulder. To reduce it, it is only necesary
to raise the arm upwards and outwards, 
and secure it so by the same apparatus 
as in fractures of the clavicle. This is to 
be persevered in for ten or twelve weeks, as 
the ligaments are long in uniting. 

54
Dislocation of the humerus is the 
most usual accident of this kind which is 
met with. This occurs, 1, from the large 
motion which this joint performs, 2, from 
the shallowness of the glenoid cavity, 3, 
the great weaknes of of the joint in some 
directions.
The head of the bone in most cases is 
thrown downwards, into the axilla. It is 
sometimes carried forward, between the 
coracoid process, and glenoid cavity, but 
this is very rare. It is also sometimes dislocated 
back, so as to lie betwixt the glenoid 
cavity, and the spine of the scapula.
The second is very rare, one case of it, being,
all I ever saw. Of the latter sort, or backwards,
very few cases occur: about two 
weeks ago, a case of it occurred to me.
This accident is very easily discovered in every 
situation. 1. In the axilla Considerable pain
attends this. The arm cannot be raised up, 
neither can it be brought to the body, but

55
the elbow will hang about a span from the 
side. There is instead of the round form of the shoulder
a great hollow under the acromion, and a 
large tumor is felt in the axilla. The body of 
the humerus cannot be felt above half way,
from the tension of the deltoid muscle.
This is easily distinguished from a fracture 
of the head of the bone, by the hollow under the 
acromion and the sharpness of this.
2. Inwards. In this case, the motion of the arm 
is greatly impeded. It cannot be raised to the 
head, but can be brought close to the body.
The coracoid process cannot be felt, and the projecting
acromion is felt far behind the 
head of the humerus.
3. Backwards. This is easily known. The acromion 
and clavicle may be felt far before 
the head of the bone, the head projects just 
over the dorsum of the scapula
In old cases, the head of the bone is often
drawn from its situation in the axilla, forwards,
by the action of the pectoral muscle.

56
It can never happen upwards, the acromion 
as scapula here forming an insurmountable 
barrier.
In recent cases of downward luxation,
the reduction is generally easy. I have succeeded 
by extension and counter extension 
without any assistant, holding the humerus 
just above the elbow in one hand, and 
pressing upon the spine of the scapula 
with the other. The force is always to act 
on the joint of the shoulder alone. This is 
a fact of the first importance: it accounts 
for the frequent failures of ignorant, tho'
bold operators, who make counter extension
from the thorax, and spend all their 
force on the connections of the scapula
to the trunk of the body! Have we not read
of a miller, whose arm was torn from the body
by violence, and not the shoulder joint,
but the connections of the scapula to the 
body which gave way.
The forearm is to be bent on the arm and as
* A low chair is the best seat for the patient

(57
handkerchief tied round the arm just above 
the elbow, and given to one two or more assistants.
The surgeon is to press with his hand on the 
spine and acromion scapulae, and an assistant 
may also apply his hand over the surgeons,
and increase the counter extension. The forearm
may be raised up and down to assist its 
going into place. If the reduction do not happen
by these means, the surgeon may entrust the 
assistants with the counter extension and by 
pressing up the upper end of the bone with one 
hand, and the elbow down with the other, he 
may use the bone as a lever to reduce itself.
Some use a pad, put under the axilla for this 
purpose, but the hand is as good, and appears 
more simple to the patient: however, very 
little violence is to be used in this way.
But if it be found that the contraction of 
the muscles will be so violent as to resist
moderate force, Bleeding ad delinquim animi
is to be used rather than great violence, producing 
painful excoriations, &c. This remedy was 
found nescesary in a case in the P. Hospital, in

58
a robust man, and after losing near a 
quart of blood, he fell down, and the bone
was reduced with the greatest ease. Since
this, many other cases have occurred, with 
similar result. This remedy is never to be 
used unnescarily, but confined to all cases
in which we know great force will otherwise 
be required.
But if after several weeks continuance,
there have been adhesions formed, and the 
capsular ligament has closed, it would 
be unnesecary, and improper to spill the 
vital fluid. Force must now be applied.
Either a number of assistants, or pullies may 
be used. It is nescesary to vary the direction 
of the force at the period when the bone is 
just returning to its place, and as this 
cannot be done when we use pullies, I
prefer as many assistants as may be requisite,
probably five or even ten.
In some cases, I have distinctly heard the capsular 
ligament lacerating at the moment 
of reduction 

59
To avoid excoriation, the lower end of the arm, above
the elbow may be defended by stiff buckskin.
A strong roller is applied round this, and given 
to the assistants, or a handkerchief, with a 
rope fastened to it. A strong band, with the middle 
stuffed, so as to be very soft, is applied on the 
acromion, and fastened by the ends to a hook,
as high as the patients groin if he is standing 
or on the floor if he sits. When extension is 
made, this band is apt to slip and excoriate 
the skin, therefore it is to be held in place 
by the hand of an assistant, or secured from
slipping up by a roller passed under it, and 
held. This has been introduced by Dr. Dorsey
and is very convenient. Or strips of leather
may be fastened to the under edge of the band,
for the same purpose.
Any force whatever may now be commanded,
and the arm may be rotated, so as 
to break whatever adhesions may have formed.
If the body should yield, a band of great 
breadth may be put round the body, and held
by assistants, merely to secure the body, or the

60
patient may lie horizontally, but the 
best position is sitting on a low stool.
By the above means, luxations of nine,
eleven and even of thirteen week have 
be reduced under my observation. I also 
have the account of a case in Baltimore
in which it succeeded after five months.
I do not think that  any bone can be put
out of place which cannot be returned by 
art again, and therefore no case is to be 
despaired of.
I may mention some of the other means
which have been used for this reduction.
1. The body has been suspended by the arm
over a door or ladder-but the humerus is 
liable to fracture from this violence.
2. The body has been raised by the arm,
with a pulley,-but no counter extension 
is provided for in this way, and it does not 
succeed well.
3. By placing the patient on the floor,
putting the heel in his axilla, and making 
extension by the wrist, I have seen

61
Mr.J Hunter succeed in a case of this kind of 4 weeks and 
you may have this method in reserve for obstinate 
cases.
4. The various machinery, as the ambe of Hippocrates
&c act violently, yet fail because they 
do not fix the scapula.
Dislocation of the Elbow. This is in most 
cases backwards and upwards. The hook like 
process of the olecrannon may be felt above,
and considerably behind the naturan bid in
the humerus which receives it; the forearm 
is bent at right angles, and cannot be moved
either way. It may also be carried outwards,
or inwards but these forms are raw.
In the former, the olecranon may be felt
on the outside of the humerus, and in the 
latter, at the inside, and also, the hollow
of the radius may assist us in the diagnosis.
It is very easy to ascertain this accident, &
also easy to be reduced. In old cases it was however
very difficult. Boyer says that in four weeks
it is impossible, but in this he is mistaken

62)
as I have reduced one of four, as well as 
one of two weeks standing.
The reduction is performed in the following way
one assistant takes hold of the arm a
above the elbow, and the other just above
the wrist. The surgeon takes hold 
of the arm, by clasping the hands in front
over the lower part of the humerus, and 
he draws this backward, while the assistants 
are extending, so that the three forces
act at once, The fore arm is now bent,
and the bones are very easily reduced. The
use of the Surgeon's making extension
backwards is to dislodge the the coronoid process
of the ulna, from the condyles of the 
humerus, on which it is as it were locked.
The arm may be kept bent for some
time, at least for two or three weeks, and 
the joint may be kept moist by vinegar,
and spirits.
Dislocation of the Wrist may happen
either forward or backwards but cannot happen 
laterally.


(63
When the wrist is carried backward, the hand 
inclines forward, and when forwards, the hand 
turns backward. Nothing but extension and 
counter extension are required, and the reduction 
is very easy. The hand is to be made 
steady, by splints applied to the hand & 
forearm, and continued for some weeks 
at least.
Dislocations of the Fingers. These happen 
either anteriorly and posteriorly, and are 
very easily discovered, their bones being so 
thinly covered. They are quite immoveable
when out of place. They are very easily
reduced, and may be secured by splints.
The first and second joints of the thumb,
when dislocated are very difficult to reduce.
The knobs on the heads of the bones interlock
each other, and the more extension is made,
the more fast the ligaments tie the bones,
and even the last joint has been pulled off.
I have met with but one case of this, and 
succeed with tolerable case.

64)
Mr. Charles Bell has a very ingenuous proposal
on this subject. He proposes to introduce 
a cataract needle through the skin,
and to divide the lateral ligaments of one 
side, and then it is very probable the reduction 
would be very easy. B.P
January 8th,
1812
Lecture 27.
Dislocation of the Thigh. The older surgeons,
reflecting that the head of this bone was 
lodged in a very deep and strong cavity, and 
moved by very strong muscles, asserted that 
the neck of the bone was very frequently fractured,
and that dislocation of the hip joint,
never, or very seldom occurred. But they were 
mistaken in this. Four cases of dislocation 
generally happen as often as one case of 
fracture in the neck of the femur.


(65
This bone may be dislocated in any direction.
The most usual direction however is upwards, & 
backwards, so as to rest on the dorsum of the 
ilium. The next direction in frequency is in an
opposite direction, so that after passing downwards
and forward, the head of the bone rests 
on the foramen ovale. It may also happen
either upwards annd forwards, or downwards and 
backwards.
First, when upwards and backwards, the head
of the bone rests on the dorsum of the ilium.
The limb is shortened, generally two or three
inches, the toes are turned inwards, and the 
case is very easily detected. I have already
explained how this case is distinguished from 
fracture of the neck of the bone. The limb 
cannot be brought to its length, without reducing 
the dislocation; the trochanter major
may be felt nearer the spine of the ilium, and 
sometimes, the head of the bone may be felt 
on the ilium.
Second, the head of the bone is carried downwards,
and forwards into the foramen ovale,

66)
the limb is very considerably elongated,
the toes are turned outwards, and sometimes
the head of the bone may be distinctly felt.
Thirdly, the head of the bone is sometimes
carried forwards, or forwards and a little upwards.
The limb is shortened in proportion 
as the head is upward, and a large tumor
may be felt in the groin.
In the fourth order, the head is carried backwards 
and a little downward, the toes are turned
inward, and the case is easily discovered.
The two last orders are raw; I have never 
met with more than one case of each. For all
there dislocations, the capsular ligaments is
much ruptured. It was common for the older 
surgeons to say that the notch on the inferior
and anterior of the acetabulum caused
most of these dislocations to happen in this 
place, but the very reverse is true. The most 
usual direction, we have seen, is upwards, 
and backwards. This notch is secured by a 
ligamentous bridge, and is as strong as any 
part.

(67
From the great strength of the muscles, and 
also the great depth of the acetabulum, and the 
situations where the bone rests, very great force
is commonly required in this reduction. This is 
best applied by compound pullies.
In one case, I bled ad delinquim animi, and 
by my own exertions, with two assistants, I
reduced it again. But much more force is commonly 
required.
The patient is to be laid on the sound side,
with the thigh flexed on the pelvis, and the leg
flexed on the thigh. A strong band, (the middle 
of which is stuffed, is introduced into the groin
on the injured side, so as to rest on the tuberosity
of the ischeum and on the pubis, and 
secured to a hook opposite to the patients
head. This is to make counter extension.
The extension may be made just above the 
knee [in very corpulent patients, it can only be 
made below the knee] by a towel secured by 
a circular bandage*, to this towel, the pulley is
*To avoid excoriation, the skin is to be defended by
a piece of buckskin, round above the knee.

68)
fastened, and this secured to hook in the opposite 
of the room. Any degree of force may 
thus be applied. The limb may be rotated
to dislodge the head of the bone. In this way,
I have seen several cases succeed the head 
of the bone returned with an audible snap.
But if this do not succeed, it will next 
be required to raise up the head of the bone.
A bandage is put under the thigh near 
the groin, and tied over an assistants neck,
who kneels on the table, and puts one knee
on the pelvis below the rest of this 
ilium. While the assistant raises up the 
head of the bone, the surgeon uses the os femoris
as a lever, pressing down the knee,
This is the best way to make extension at
right angles.- Sometimes a band may 
be put over the pelvis, thro' two holes in 
the table, and secured to a hook in the floor.
By the above means, two extending forces are 
applied: one in the longitudinal, and the other 
at right angles. This is for luxations 
upwards and backwards.

(69
For dislocation into the foramen ovale, viz, downwards
and forwards. The longitudinal extension 
is applied in the same way, and with the same 
intention. The rectangular extension is also 
to be used in the same way, but the longitudinal is not so much
with the intention of lengthening the limb,
(this being already too long) but to dislodge it 
out of its seat on the foramen ovale.
The dislocation forwards, and a little upwards,
may also be treated in the same way. Mr. Heys
(whose/observations on this accident deserve per 
usal) directs in this case, to seat the patient 
on a bed, to apply the pubis to a post of the 
bed, and to make extension by assistants
at the leg. As this is not always convenient 
Dr. Wistar has made a subistitue for the 
bed post in our Hospital. It consists of a 
strong shaft, 3 or 4 yards long, inserted
to a head of about 30 inches long in the 
middle, and secured by stay pieces, thus 
resembling a rake. The end of this shaft 
props against the wall, and the head covered
[illustration]

70)
covered with flannel, makes counter extension 
against the pubis, the [cross out] leg may 
be bent, and extension made by assistants 
or pullies, the limb rotated, and the 
head brought outwards by a band or (what 
is better as it interferes less with the muscles)
a rolling pin. But this method is 
not preferable to this above one.
When the dislocation takes place forwards
and upwards into the groins There is 
some variation required. The longitudinal 
extension is made as usual, but the difference 
is this. The patient is laid on the 
back, a bandage is put round the pelvis
on the injured side, and fastened to a hook
opposite to the other side. Another bandage 
put round the injured thigh near 
the groin, and fastened to a pulley on the 
same side. The leg is bent, the thigh rotated,
as usual. The only case I have seen 
was treated in this way. See Dr. Cox's Med.
Museum. Desault met with a case of 

71
this sort. He differed from the operation described,
only in putting the band for counter
extension on the sound side of the scrotum;
while I put it on the injured side._ This apparatus 
may be used for luxation in any direction
whatever.
Lastly, in the dislocation downwards and 
backwards, I have had only one case. In this 
the usual means failed. The head of the femur
protruded through a rent in the capsular 
ligament, just as a button thro'
a button hole, and extension served only 
to make it faster. At length, I succeeded
by a violent abduction of the thigh. I applied 
my left hand on the trochanter,
and embracing the flexed knee in my 
right arm, I made a violent abduction,
using the thigh as a lever at the same
time. The thigh was bent on the pelvis. Abduction 
is the best means to dislodge the 
head of the bone out of the capsular ligament._
By these means, if the capsular ligament,
&c, have not formed strong adhesion


72
have not found any dislocation may 
be reduced. The only precaution nescesary 
after reduction, is to keep the 
limb quiet for a week or ten days.
In cases when the reduction has been 
delayed for some time, the cavity will
have so closed as to prevent the limb
resuming its usual length, and it remains 
1/2, 3/4 or 1 inch longer than [cross out]
usual. But a few weeks rest will overcome 
this.
Dislocations of the knee. The only direction
in which this joint is dislocated is outwards.
This however is very raw. Two cases of 
this sort have fallen within my observation.
In both, they arose from violent abduction:
the patient going up a ladder, this fell 
when they were 6 or 10 feet from the ground;
they fell thus with the legs asunder. In one 
of them both, but in the second only one 
knee was dislocated.
The leg rests upon the outer condyle of the os

73
femoris, the inner condyle may be easily felt,
a great angle is formed by the leg upon the 
the thigh, so that the injury produces effects 
very easily known,-and the leg is very easily 
restored to its place again, but such is the 
destruction of the capsular ligaments, that 
the leg will fall off again just as before.
The limb must be kept steady: either two 
common splints, or what is better Desaults
long splints must be worn at least four months
before the ligaments have united. The knee 
may be wet with lead-water, vinegar and oil,
vinegar and spirits, or any such liquid.
Dislocation of the Patella. The patella,
or kneepan may be luxated either outwards
or inwards. The former is the most usual direction,
the condyle of the femur being the 
highest on the outside, not allowing the patella 
to return. The pulley like surface of 
the femur being very easily felt, and the motion 
of the leg being lost, the case is very 
easily recognized. Further, the patella, on

74
the outside being very easily felt, its internal 
side is now posterior, its anterior 
surface is now exterior. Considerable pain 
is felt, and the powers of the extensors 
of the leg are lost.
The reduction is very easy. The thigh is 
flexed on the pelvis by the patients sitting 
on a bed, and the leg is to be extended. 
By pushing the patella on the side,
it will now fall into its place very easily.
The only case I have ever seen of this,
was in a lady, in whom it was caused by 
an irregular step in dancing. It was 
seated on the outside as I have described
and very easily reduced. After resting 
for fifteen days, she was perfectly restored,
and able to dance again!
Dislocations of the Ancle. I have
already explained how this accident was 
often complicated with a fracture of the
fibula, at one third of its length from the 
external ancle: however dislocation may

75
happen without this. This may be either anteriorly
or posteriorly. In the former case, the 
foot appears shorter than natural, and the 
bones of the leg lie in front of the astragalis
and the os calcis projects behind. When 
the foot is luxated posteriorly, the reverse 
of all this happens. This is very easily reduced.
An assistant holds the leg fast about its 
middle, while another extends the foot, and 
draws it into place.
One case only has fallen under my observation,
occured in a lady; She was hastily 
running down stairs, when she fell, and 
the heel of the shoe took hold on one of the 
steps, and the whole weight of the body 
resting oblicquely on the joint, this gave 
way. It was reduced as above described, and 
after a month, the function of the ancle
were completely restored again.
Jan 10th 1812     P.S.Physic.

76) Lect 25
Of Injuries of the Head. A. Contusion
Blows upon the head frequently produce a rupture
of a number of vessels, whereby blood is shed under
the scalp, which gives the part a soft pappy feel,
and round this is a hard ring, with a very abrupt
edge, which may deceive for a fracture with depression 
of a piece of the cranium. This has induced 
induced unwary surgeons to incise the part
and prepare for operation, and they were always 
much dissapointed to find the scull whole.
To avoid this unnescesary step of incision, it 
is nescesary in all cases, before we incise, to 
to see the symptoms of injured brain exist.
The incision is a very painful step and even exfoliation
of the bone may follow it.
Nothing but clothes wet with vinegar and water
is required as a local remedy, the antiphlogistic 
regimen, and if the injury be severe, bleeding,
and purging are required. If after several days,
the blood be not absorbed, a small puncture may 
be made into the tumor, the blood pressed out and 
dry lint applied, and secured by adhesive plaster.

(77
2. Wounds. Incised wounds in the scalp require the
some treatment as they as in other parts of the 
body. The hair having been removed, the lips of the 
wound may be approximated by adhesive plaster.
Contused wounds also have nothing peculiar
in them here. A soft poultice is the best application.
It may be continued till the sloughs are
separated, supuration is free, and granulation
goes on well. The sides of the cavity may be either
brought into contact, or at least approximated 
by adhesive plaster
The scalp is sometimes torn off: I have even 
seen one half of the scull laid bare in this way.
The old surgeons in such cases were in the habit
of cutting off all the separated parts, because, they 
said if left on, matter would form under it and injure 
the bones of the head. But their practice 
was as absurd as the reason for it was untrue.
The scalp is to be cleaned of any foreign matter,
replaced, and retained by interrupted sutures,
adhesive plaster, Sutures I do not recommend,
as they are an additional injury, increase the 
constitutional irritation, and if much swelling


78)
swelling come on, they are not (like plasters) easily removed.
If sutures are used, the edges are not to be 
drawn tight, nor nearer than 1/2 inch asunder. But
when inflamation is over, they may be brought
together. Adhesion generally takes place:- if pus
form in any part, it may be evacuated by an 
incision as in any abscess. If an early opening
is made, the bone will very seldom slough. The 
constitutional treatment must be antiphlogistic,
and if headache and fever follow, blood letting 
and purging may be used freely, as in cases 
of contusion.
In those cases in which the bone sloughs off
it is very important to remove the slough as 
soon as possible. Whenever any looseness is evident,
the slough may removed: as the granulations
round the rough edge of the bone will 
soon make it fast if left. We are never to wait 
for the bone to become looser, but pull out
the slough with forceps, and if incision be nescesary,
it may be made freely.
3. Acute pain often remains after the wound of 

79
of the scalp has heated. It also follows simple contusions,
as well as contused wounds. It lasts after the 
inflamation is over: I have seen it last for months,
nay even 3 or 5 years after.
The first case I have met with, was in a lady,
whose head was struck, in looking out at the 
window, by the shutter, which was blown by 
the wind. The pain was very acute, and increased 
as the inflamation subsided. This happened
at Trenton; and after 5 months continuance,
she came to town. I could feel a roughness and 
inequality in the bone. Dr Rush had tried every 
means he could devise, but all failed to afford 
any relief. I was consulted, and made 
a crucial incision through the scalp, and after 
this her complaint subsided entirely.
The second case was in a lady of a full habit
and the pain was very severe. Numerous remedies
were used, but to no purpose. Bleeding, purging,
low diet, low diet, leeches, blizters, issues,
the crucial incision, opium, cicuta, oxymuriate
of potash, solutions of arsenic & mercury, were all
used without benefit. 

80)
At the end of two years, she took a journey in
to the country, and by this she was suddenly 
benefited, but it was five years before she was 
quite well.
The third case was produced in a young lady 
by falling from a gig, and alighting with 
her head on a stone. The pain continued severe 
for 18 months, when by a second fall, the 
complaint was greatly augmented. On taking 
a walk to the Yohenulkylon, and being 
much heated, she went into the cold bath,
and on this, the pain became excruciating.
Mercury was given, but a salivation could not 
be produced. The crucial incision was made,
and from that evening for four weeks, she 
was well, but then relapsed. On the idea of 
retained perspiration, I made an issue as 
large as a dollar, with caustic, on the head,
but no relief followed. After 18 months, she went 
into the country, and on feeling oppression 
at the stomach, a vomit was taken, and brought 
off much mucus, and in six weeks, she 
was perfectly well.

81.
In the fourth case, a man fell from a house
and received a small wound on one side of the 
head. The pain came on, as in the other cases.
Bleeding, purging, &c failed, and the crucial incision, 
as soon as I had made it relieved him
but seized the other side as ill as the first side
and I next operated on this side also, and he 
soon recovered completely. I have seen one case
in which, it ended in fatuity.
In all cases, a complete recovery came on 
in course of time. Indeed I know of no [cross out]
remedy for this disease which is certain. The 
crucial incision is the best remedy I know. 
4. Injuries of the brain a. Compression
This state of the brain is marked by sleepiness,
drowsiness, insensibility, loss of speech and 
voluntary motion, sickness at the stomach,
vomiting and either dilation or contraction
of the pupils of the eyes, and no variation in 
these when exposed to light.
It may arise from either of the following
causes. 1. The fracture and depression of a 

82
piece of the cranium, or 2. by blood extravasated 
out of ruptured vessels, or by both 
causes taken together. The blood may be under
the scull, under the dura mater, or in the 
substance of the brain. Both depression, & 
blood may unite, as they very often do, but 
she may exist perfectly separately.
The symptoms of depression, from fracture 
are immediate, but that from blood generally 
allows a few minutes of sense and 
motion, before there is enough of blood to 
compress the brain.
But fracture of the scull with depressions 
may exist, without constitutional symptoms 
denoting it....A boy received a blow
by a brick thrown from the opposite side
of the street. I was called, and arrived in ten 
minutes, and could feel a considerable depression 
of bone, yet the boy was sensible, and 
told me the circumstances of the accident,
and then fell from his chair, cold, senseless,
and motionless. I trepanned him immediately

(83
immediately. A large quantity of fluid blood flowed from 
the orifice, and the boy recovered even before I 
had raised the depressed bone. There was a union 
of causes; the blood was the cause of the stupor
and it is often so; even without any external 
wound.
Sometimes the dura mater is wounded,
and even portions of the brain prolapsed.
Extravasated blood may be lodged in the cavity 
of the brain.
When compression is known to exist, the 
depressed [cross out] bone must be lodged* in the brain
and brought on a level with the rest of the scull,
or the extravasated fluid must be evacuated. 
If there be many fractured portions,
there may in general be a perforation made
with the trephine, and the blood if there be 
any may escape, and the fragments may 
be elevated. The perforation may be in the 
vicinity of the fracture.
In all cases if after the receipt of a blow, the 
symptoms of compression exist, perforation
*removed out of 

84
perforation is to be made. The inferior, anterior angle
of the parietal bone is the best place 
to open, because there, the artery of the dura
mater exist, which is the Source of extravasation.
If one opening do not succeed, the
other side may be opened.
On this subject, Mr. Abernethy makes a very 
ingenious remark. The scull is supplied with 
blood from the teguments and also by the 
dura mater. Now if these two sources of blood
be removed, the external by incision, and the 
internal by blood, we will not find any 
blood oozing from the bone on laing it 
bare. This may not always be depended on, as 
anastomosing arteries may keep up the circulation.
Even after the perforation is made, the symptoms
of pressure sometimes continue. It is 
then importance to tell whether the blood is 
extravasated under the dura matter or not?
If instead of the level, white, glistening appearance
of the dura mater, we find it pushed 
up into a convexity in the trepan. hole, fluctuation

85)
fluctuation in some degree perceptible, and a livid appearance,
by the presence of blood, we may be 
pretty certain of the nature of the injury. Further,
There is (especially in children) a motion in 
the dura mater corresponding to respiration,
raising with expiration, it visce versa,- and 
also a motion at every stroke of the heart,
but these are absent if blood be extravasated 
under the dura mater.
But even if we are certain of its presence, it
is very doubtful whether or not the dura mater
may be perforated? Rather than let our 
patient die, we might do it, but tho' cases 
are reported of patients recovering after such 
a puncture, yet I have always seen them 
prove fatal...... Indeed the dura mater is often 
wounded by spiculae of bone, and otherwise,
and yet the patient recover, but the above 
case is widely different: in it, we are never 
able to evacuate all the blood, and the part 
remaining becomes acrid by the air, and 
produces inflammation and suppuration in 
the pia mater and death!!

86)
Now, the progress of this injury is as follows:
first, the dura mater at the place of puncture,
becomes enlarged, till as wide as the hole 
in the bone, the brain arises on a level with 
the bone, (I have seen it arise one inch) then 
constituting fungus cerebrix, which is the brain 
itself pressed out. This has been tied with a 
ligature, destroyed with causte, &c, but is 
all cases is has proven fatal, and pus was 
found in the hemispheres of the brain, and 
therefore, this case is hopeless.
Our circumstance is very remarkable in 
this accident: sense remains till near death
unaffected.
In a case of extravasation which occurred 
to me under the dura mater, the membrane 
was pushed up on a level with the bone,
and all the symptoms of compression existed.
I bled the man four times a day, for 
five days, and each time, ad delinquim animi,
purged him freely, blistered him, and
confined him to barley water, and he was 
saved by these means from death.

87)
I therefore condemn the puncture in all 
cases....The dura mater is sometimes wounded
by accident, without death following: Sabatier 
relates the case of a man whose scull & 
dura mater were very widely discovered by a 
saber, and the wound heald just as easily as 
as in any other part of the body; nay, we 
read in the memoirs of the Academy of Surgery 
of a ball going perpendicularly, and of 
cin other going transversely thro the brain,
yet life not being lost, but a happy recovery!!!-
I have however seen one case of a 
wound of the membrane recovered from. The 
child was bled and purged freely, and confined 
to rest and a low diet, and recovered, tho'
dangerous convulsions supervened.
One circumstance more will conclude
this lecture. Patients recover better in the 
country than in a large city or town, and 
particularly better in succh a situation 
than in a crowded hospital.
D.P
January 13th, 1812

88)
Lecture 29.
We continue to speak of injuries of the head.
b. Sloughing of the dura mater. I am now to describe
a form of disease, not spoken of by any 
author; and of which I have met with only
one case. Last summer, I was called to a child,
which had received a kick of a horse on the os 
frontis. I found a very considerable piece of the bone
depressed by the fracture. The senses 
were perfect, but as as I always trepan 
in cases of depression, that I always proceeded
to do it in this. After the removal of 
the piece, I remarked an unusual appearance.
The dura mater was of a very dark colour,
without any convexity, or any other circumstance 
of effusion. In the course of 7 or 8 
days, the piece of the dura mater sloughed 
off, and left the pia mater bare. The child
still retained his senses, but fungus cerebri 
came on, the brain was protruded and the 
child died.

89)
Thus, the dura mater may die and slough off by 
a blow, just as a bone or any other part whose 
life is weak. I know of no remedy for this disorder.
In the case mentioned, the remedies for 
inflamation were used, particularly bleeding 
and purging, and the result was unfortunate.
C. Hamorrhage from the brain and dura
maters. Very considerable bleeding sometimes 
occurs when the brain or dura mater, especially 
the latter, are wounded. This is especially 
the case if one of the large sinuses, as
the longitudinal, or the lateral, is wounded.
This may arise by speculae of bone, or it may 
arise from wounds in our operations. Alarming
as this bleeding is, it is very easily commanded.
A dossil of lint, secured by pressure 
with the finger is always sufficient
to put a permanent stop to the disease.
Of arterial hamorrhage from the dura mater,
more must be said. The only vessel from 
which this can occur in any alarming degree
is the median artery of the dura mater,
which lies under the parietal bones. 

90)
A long quantity of blood may flow out
of this vessel, but in general, a piece of lint,
pressed down with the finger will stop 
this, in ten minutes. But sometimes, from
unusual size of the artery, &c, the blood continues
to flow. In this case, if the dura mater 
is wounded as well as the artery, the latter 
may be secured by a ligature, by a needle, 
or tenaculum, but if the dura mater be
whole, this would be unadviseable, as wounds 
of the dura mater are so seldom recovered from 
even if the puncture be very small, as by 
a spicula of bone, it is best to omit the ligature.
When the artery runs thro' a canal 
of bone, the treatment mentioned in compound
fractures, of stopping the hole by 
a plug of soft wood, put beside the artery,
and not into it is nescessary. But this structure is rare.
We might in some cases introduce a dossil
of lint between the scull and dura mater,
and thus press on the artery, and this 
lint, if not large could not in commode

(91
the brain by its pressure. This I have never yet
used. Might we not in obstinate cases, order pressure 
by an assistant for 30 minutes or more?
I have never seen the bleeding in any of these 
cases prove troublesome; and rather than use 
the ligature when there was no wound,
I would try astringents, as agaric, alum, blue 
vitriol, &c and by these means, there will be 
no difficulty in succeeding.
Before I quit the subject of compression, I 
will warn you of a very usual error into 
which both physicians and surgeons have 
fallen. From the identity of the the symptoms 
of intoxication and compression, they 
may be confounded together. The agree exactly 
in the loss of voluntary motion, puking, dullness,
sleepiness and every other symptom. But 
by an inquiry into the previous conduct, you 
may draw the line of distinction.
I say 'physicians', as apoplexy has been also 
confounded with drunkenness. Dr. Gregory
related a case of a man who had drank to excess
and was treated as an apoplectic by

92)
bleeding, blistering, stimulants, sinapisms,
&c and the man was cured!
An hostler who was intoxicated, fell among
a horses feet and received a wound
of the scalp. One of his companions save 
him, and took him to an infirmary. The 
surgeon shaved his head and enlarged the
wound by a crucial incision, but was 
astonished to find no fracture! It being at 
night, the head was dressed, and a consultation
determined an trepanning early next morning.
But when morning came, and the 
man awoke, he saw himself queerly situated:
an old nurse standing by,- his head 
felt very strangely tied up- and he in the 
infirmary! He demanded what was the 
matter? The nurse told him "hush, my 
man, you must be trepanned today."!!
The smell of the breath may be a very safe 
criterion; also the following. When I was the 
house surgeon in St George's Hospital, a woman
was brought in for a supposed injury

(93
injury of the head. Suspecting another cause, I 
poured a stream of cold water on the upper lip
for some time: the head began to rotate from 
side to side, and at last she got up, and demanded 
the reason of such insolent treatment 
as was used with her!
d. Inflamation of the brain. The symptoms 
of inflamation never follows immediateley 
after the cause which produced them.
They are all of the febrile kind. The face becomes
hot, and is overspread with a blush, headache 
follows, nausea and often vomiting supervene,
the pulse becomes hard and full, delirium,
coma, and restlessness soon follow.
These symptoms seldom come on before a week
or ten days after the injury. Indeed I have known
12 months supervene before the inflamation
come on. This was the case with Captain B.
Turner, who in escaping from a sinking vessel
into a boat, received a contusion on the head
and which was followed by a swelling on the 
occiput. He arrived in a town in Holland, and 
a german physician gave him a wash of 

94)
brandy, and the blue pill, (suposing the case
venereal, he having had the lues 4 years before)
after three months, no relief occurring, but headache
coming on, he came to England and Mr
Blizard continued the blue pill, but no alleviation,
nor salivation could be produced. 
and he was advised to go to a warm climate.
In June 1809 he arrived in Philad. and aplied 
to D Rush. Three weeks before arrival, he 
had the aura epileptica, commencing in the 
hand, and terminating in violent fits, and 
the arm becoming paralytic, and the leg
on the same (left) side becoming numbed. The 
Doctor bled and purged him freely, confining 
him to a very low diet.
No relief being found, I was consulted, the 
fits still continuing. I laid the bone bare
by a free incision. I found it very rough on 
its surface and wasted. I did not hesitate to 
apply the trepan, and on removing a piece
of the bone, I found the dura mater adhering 
strongly to the bone, and much indurated. 

(95
Four days after, it proved fatal, and on dissection,
pus was found both on the dura mater 
and also in the pia mater. Here was inflamation 
in the membranes a full year after the 
blow was received.
The causes of inflamation of the brain may
be either a contusion without any wound,
a fissure without depressure, or a fracture
with depression of a piece of the scull.
1. After concussion, the teguments become puffy
and flaccid, and on laying them open, they 
will be found detached from the bone, and 
if a perforation be made, the internal surface
of the bone will also be found detached.
The pericranium, instead of its florid colour
is found pale and in fact dead, and within,
mucus [cross out] or pus will be found on the dura 
mater.
2. and 3. Fissures or fractures with depression 
are very apt to produce inflamation, with 
them, there is generally a wound of the scalp.
Instead of healthy granulations, there are pale 
and flaccid ones, and they become so as soon

96)
as the inflamation commences. Instead of 
healthy pus, a thin bloody ichor only is discharged,
and the pericranium will separate 
from the bone, round the perforation in 
it. At the same time, the dura mater will separate 
in the same way.
Mr. Pott supposed this to arise from the vessels 
which carry on the circulation thro the 
bone becoming destroyed, but I have reason
to doubt of this explanation. It appears that 
the life of the bone is completely destroyed.
In all injuries of the brain, whether simple
contusion, fissure, or fracture with depression,
inflamation may therefore be expected.
The scalp may indeed be largely separated 
from the scull, and no symptoms of inflamation 
or suppuration follow, but union 
by healthy granulation follow, especially if 
the wound be produced by simple incision. 
Thus, the injury in communicated no deeper than 
to the external membranes of the head, but 
when a great concussion is received, the effects

(97
effects of it are communicated to the internal parts
of the head, not only to the membranes but to 
the brain itself; and inflamation and suppuration 
may come on as far as the parts are 
injured.
This is not merely a speculative point,
but one of great practical importance.
When pus is formed under the dura mater, I 
believe it is always fatal. Pus on the surface
of the dura mater may if let off prove 
of little injury. Therefore in all cases of inflamation,
a perforation with the trephine 
is always to be made, and this as soon as the 
symptoms of cerebral inflamation run 
high. By this timely measure, if suppuration 
is confined to the dura mater alone,
it may be prevented from doing any injury,
as all the pus will escape; and if 
any sloughs form in the dura mater, then 
also will find a free exit.
It is a question of some importance,
whether in the first instance of fractures
without depression, or with it, the perforation

98)
ought to be made, or to wait till symptoms 
of inflamation come on? Mr Pott was in 
the habit of trepanning in all cases of fracture,
immediately, but modern surgeons, having 
seen many recoveries from fractures, w.t
out trepaning have rejected this aphorism.
When the bone is depressed, indeed it is best 
to operate immediately, as the rough bone 
may irritate the dura mater, producing 
inflamation, suppuration and even ulceration.
But I would never trepan for simple 
fracture. Depression, or symptoms of inflamation 
must be apparent before I undertake
the operation of trepanning.
Even after evident depression of the bone, recoveries 
have occurred without trepanning,
but I would not deduce any rule from this.
Therefore, simple fracture, without any symptoms
of compression needs not to be trepaned.
But when depression has occurred, it is 
best to take out the piece of the bone. 

(99
When any other causes of inflamation, which 
I have mentioned occurs, the means to prevent 
and moderate inflamation must be used.
After a blow on the head, the patient must be 
confined to a very low diet, and bleeding and 
purging must be employed. If symptoms of 
inflamation appear, we are to bleed again,
and again, to apply the trepan, and to apply 
a blister over the head: a remedy well calculated
to reduce inflamation in the brain.
Cold applications are very serviseable. Clothes
wet in cold water, or in vinegar and water
are very useful.
e. Of concussion of the brain. Concussion of the 
brain is a certain deranged state of the brain
following blows on the head, which proves 
fatal often in a few minutes, and on dissection,
no marks of injury are found. It appears 
however, that a larger number of the 
minute vessels are ruptured. If the patient survive
some hours, the brain will be found
be set with drops of blood shed from these

100)
vessels, and if he survive for a day or two, the whole 
brain will have a bruised appearance.
Just in the same way do we often see blows 
on the reigion of the heart produce sudden 
death, and yet no symptoms appearances 
of derangement can be found on dissection.
If perfect rest be observed, the effusion of 
blood may be in many cases prevented.
Mr. Abernethy exceeds all authors in the description
of this state. Its progress according 
to him is as follows. 1st stage. The functions
of the brain are quite deranged, the stupor 
is complete, the patient is insensible, his breathing 
is difficult, tho not stertorious, and his 
extremities are cold and this state of stupor 
does not last long. 2nd stage. In this, the pulse 
and respiration are better, heat and sensibility 
increase, the patient will answer to 
a loud question, especially if it concern his 
own feelings, otherwise his answer is incoherent,
and he seems employed about something 
else. There are few symptoms of inflamation;
soon this state is followed by

(101
the 3rd or inflamatory stage, which is the 
most important of all.
Some surgeons recommend stimuli, as wine,
and if they succeed, they do very serious mischief.
If the establish the pulse and face 
respiration, inflamation and extravasation 
soon follow. I enjoin perfect rest, and keep 
the head elevated, and as the action recovers,
cold clothes with water & vinegar are applied
to the head. As the pulse rises, I bleed freely,
and thus inflamation and suppuration 
of the brain may be prevented.- Cases are 
repoted in which the patient recovered in whom
stimuli were used from the beginning, but 
the practice is very dangerous. The first 
case of contusion I have seen, I treated wt.
success by bleeding, while in St. Georges Hospital.
f. Inflamation of the brain, after it has 
subsided sometimes leaves a state of stupor
or idiotism. This was first treated with 
success by Dr Rush, who gave mercury 
so as to excite a salivation. He made 

102)
this discovery as early as the year 1795 or '6,
and it has been since spoken of by Mr Abernethy,
whose book was published in the year
since this. The plan adopted by Dr. Rush is 
found very successful.  Dr.P.
January 15th 
1812
Lecture 30.
It remains for me to explain the operation of 
perforation of the scull, for the purpose of elevating 
a depressed portion of bone, and for giving 
an exit to extravasated fluids, compressing the brain
The most common instrument for this purpose 
is the trephine, or circular saw, with a centre pin
for fixing the instrument. This pin is moveable 
in the handle, and by a pin in this, it may be 
protruded to any distance, and screwed fast so.
In the trephines of the older surgeons, this pin 
was fixed, and at a certain period of the operation,
this was removed by a key but this is of no service,
and protracts the operation. Thus, their

(103
center pin being always alike long, was very apt 
to wound the dura mater, as in thin sculls, especially 
in children. But the pin which easily 
is slipt up is very convenient.
The older surgeons used conical trephines,
and this, with a view of avoiding wounding the 
dura mater by a sudden plunge of the instrument,
after going thro' the scull. But this is very 
inconvenient, and tedious shape is quite superceded 
by proper care, and all danger of wounding 
the dura mater is avoided by the precautions
I am shortly to describe.
Before this instrument is used, the integuments
must be divided and dissected off. A common 
scalpel will answer this purpose. The iron 
is to continue to the end of the handle of 
this instrument, and to project in a square
form, to raise the pericranium from the 
bone. This quite supercedes a raspatory, which 
is an instrument for this puropse, used by 
some surgeons.
The elevator, which is a simple lever, a little bent

104
must also be at hand. This instrument is 
often made too convex.*
In most cases of trepanning instruments,
a lenticulator (which is a knife with a thick 
ede and a spoon-like point) is found, but the 
purpose for which this instrument is made
viz. cutting off rough edges and spicula after
the piece of bone is removed, is fully, and wt 
more convenience answered by the elevator.
The circular saw of Mr Hey should also be 
at hand. This is used when the depressed bone
is capable of being raised, except on account of 
one neck of bone, or one of these on each side.
This prevents in many cases, the dura mater
being stripped by the circular perforation, and 
is found very convenient.
It will also be proper to have sponge, lint;
needles, tenaculum, a ligature, and a soft poultice 
at hand.
The hair may be shaved off, to shew the extent 
and situation of the wound, before the 
scalp is further removed.
*The tripod is also useless, and superceded by the 
common elevator

(105
The incision may be made, or the wound,
(if there be any,) enlarged. The older surgeons
made a circular incision, and removed a 
large portion of the scalp, and repeated this 
if nescessary, and thus destroyed the covering
of a large portion of the cranium. I have 
see one half of the scalp removed in this way
Even Mr Pott advised this plan, but it is never 
nesccesary. A simple incision down to the bone 
is generally sufficient, and the pericranium 
is to be removed as we have described. If 
nescesary, an incision at right angles, or even 
a crucial incision may be made and the 
corners dissected away, but not removed.
When the cranium is fractured into many
pieces, there is considerable danger of wounding 
the dura mater with the scalpel, and 
therefore the incision is best made in this case
on the firm part of the scull, and from this,
we can dissect to the injured parts.
If an artery should be cut in the scalp, and 
bleed much, rather than trust to pressure, I 
would secure it with a needle, or tenaculum, 

106)
otherwise, it may bleed in the night. Some advise 
to deplete, by leaving such vessels open,
but this is much more conveniently done at 
the jugular vein or arm.
Some surgeons perforate the scull with a 
perforation, but the centre pin of the trephine
does this much more expeditiously.
The pin is to be applied on the sound bone,
but so near the fissure, as to include as much 
of the depressed portion as may be. This is done 
to avoid pressing the portion deeper, as our
efforts with the trephine might have this 
effect, if the pin rested not on the sound, but on 
the depressed bone.
The sawdust may be wiped from the teeth of 
the saw, and from the groove with a towel, which
answers better than the brush commonly used
As soon as the groove in the bone becomes deep
enough to retain the saw, the centre pin may be 
removed, as if left, it might wound the dura-
mater, which we have seen is very dangerous. 
Even before the grove is compleat, the pin 
must be shifted up in cases of thin sculls.

(107
We must very frequently examine the groove
with a tooth pick, to feell if any point of the 
circle is cut through, in which case, you must 
bear obliquely on the uncut part.
It was the ancient mode to mount the trephine
on a large handle, with a crank in 
the middle; this was applied to the surgeon's
breast, and thus their labour was lessened!
but the pressure thus applied was very dangerous
and unjustifiable.
It is common for this instrument to be made
too thin in its edge, and thus the groove will
not admit the levator, and when we want 
to work obliquely, we are unable to do so.
As soon as a considerable groove is made,
tho' no part of the bone be cut though, we may
try with the elevator to raise it, by breaking 
the vitreous table, thus avoiding most completely,
wounding, the dura mater, and if 
the bone be thicken at one side than the other,
this will particularly answer. The 
spiculae may be broken out with the levator,
and thus, the operation is completed.

108
Forceps are of no use in raising the circle.
This operation is considered by some to be 
easily performed and simple: but to perforate 
the scull; [cross out] and to avoid the dura mater requires
considerable attention, and I have seen errors
committed in this, twice prove fatal; inflammation 
of the brain having followed. We ought 
therefore always when one portion of the circle
is through, to avoid it very carefully.
Mr. Heys saw, in the circumstances we 
have mentioned is a very convenient instrument.
In the use of it, the dura mater is 
also to be carefully avoided.
After raising the depressed fragments, if this 
was the cause of compression, the symptoms
will cease, but if much blood is extravasated 
under the scull, more holes may be 
required to evacuate it, and if the symptoms
of pressure continue, the dura mater may
be separated from the scull for some way.
If blood be extravasated through the cavity 
under the dura mater, it is doubtful

(109
as we have shewn, [how dangerous it is] whether it is proper to 
puncture the dura mater with a lancet, but 
if in any case it is chosen to do so, which in 
general is improper, the puncture must be 
very small.
Having raised the depressed fragment or extracted
it, with the levator, the scull is to be 
dressed. A soft, light poultice is the best dressing.
Lint, which is generally used adheres
to the dura mater, and is not easily removed
in a future dressing; while the poultice separates 
very easily.
When the dura mater is pierced by spicular
or punctured by the surgeon, the scalp is 
to be brought over it, so that it may directly 
adhere, and prevent inflammation of the brain
In this way I treated a fracture of the squamous
part of the temporal bone, in which 
there were many fragments, and the dura
mater perforated; yet the patient recovered.
This may be done in cases of depression &
may prevent exfolian of the scull, but when


110)
extravasation has happened under the dura 
mater, and especially if a coagulum remains,
the orifice is by no means to be closed,
but simply a soft poultice applied.
The ancient surgeons forbid our operating 
on particular parts of the scull.
1. We are cautioned never to trepan the frontal
sinus. Here the tables of the scull are 
not paralel, and if it should be required
to trepan this part, the perforation may
be made in the usual way thro' the outer
table, but on the inner, the trepan may
be applied also perpendicular to the surface
of this plate also. If a ridge remains which 
the saw will not cut safely, it may be broken
with the levator.
2. They deem it improper to perforate over 
the longitudinal or lateral sinuses. Haemorhage
from this vessel is easily stopped by a 
little lint. But this vessel may generally 
avoided, unless it lie in a deep groove in the 

(111
bone, and even then, by working obliquely on one 
side, and then on the other. But there is little
hazard in the haemorrhage; the only danger being
that of wounding the dura mater beside
the artery sinus. This may be prevented by 
prizing out the piece of bone before quite cut
through, and breaking the remaining ridges 
with the levator, guarding the dura mater with 
an iron spatula.- If blood be shed under the 
bone, there can be no hazard; but we cannot 
depend on or judge of this before the operation is over.
3. It is deemed unsafe to trepan over the anterior 
inferior angle of of the parietal bone,
for here the median artery of the dura mater 
lieg, but tho' there is some degree of danger
here, by care, the vessel may be avoided. If it 
be wounded, it may however be stoped in most 
cases by a dossil of lint put into the groove it
lig in, or if the artery be inclosed in a bony
channel, the plug of soft wood as we have 
mentioned may be pushed in.
4 The occiput is deemed unfit for the operation,
but, with the precautions for others

112)
cases of unevenness on the scull, this objection 
like all the others is of no Value, and the 
scull may be trepanned in any place where
a fracture can reach, excepting the basis 
of the scull itself. So that all these rules,
so carefully held inviolate by our ancestors
are of no consequence whatever.P
Jan. 17
Lecture 31.
Of Diseases of the eyes, and first, of inflamation.
This may be seated in the eyelids, conjuctiva, 
cornea, or globe of the eye.
Inflamation of the eyelids is acompanied
with a serous discharge, and with a burning 
pain, and after comes on suddenly. It 
is produced by extraneous bodies, mechanical 
violence, &c.
If much pain and fever attend, bleeding, low 
diet and a mercurial purge may be prescribed, 
and the parts may be kept moist with 
diluted brandy, &c and may be expected soon 
to subside. 


113
Inflamation in the edges produces effusion 
and ulceration, and the discharge is so purulent
and viscid as to glue the eyelids together, and 
they cannot be opened without difficulty in 
the morning. The seat of this disease is said
to be the Meibomian glands, but I suppose 
it to arise from inflamation and ulceration 
round the roots of the hairs, thus resembling
tinea capitis, and if the hairs be 
extracted, just as in that disease, the sore will
heal up. The treatment of these two diseases 
is the same. Sperma ceti oil had succeeded 
well. It is recommended to touch the 
eyelid with lapis infernalis, and in this way
I once succeeded. lung Citrinum, [spermaciti]
If strong mercurial ointment, are powerful remedies I have extracted 
the hairs with twizers, and thus succeeded 
after the ointments have been tried 
to no puropse.
When the conjunctiva and cornea are the seat 
of the inflamation, the white membranes 
become red by the admission of anusual. 


114)
quantity of blood. The eye waters, light becomes
offensive, the eye feels hot and burning, and 
the pain is communicated to the temple and 
and fore head. The inflamation is sometimes confined
to a spot near the edge of the cornea. The 
eyes when thus inflamed are very irritable to 
light, we cannot easily get a view of the eye,
and the patient guards off the [inflam] light 
with his hand.
If the inflamation be over the cornea, there
is danger of opacity in this, and on the conjunctiva,
the speck mentioned leaves a film,
which, if near the inner canthus, it forms
what is called unguis.
The causes of this are, mechanical injuries,
viz blows, &c also the inversion of the cilia,
called trichiasis; acrid substances, as lime,
acids, smoke, violent excercise of the eyes,
too much light: and I have known it produced 
by the eye being wit with urine, in 
a young man having gonorrhoea.

(115
The globe of the eye may be inflamed in the anterior 
chamber, or the posterior, behind the lens.
When in the former situation, the pain is of a shooting 
kind, and varies much according to the violence 
of the causes. It sometimes proceeds to 
suppuration, and then, the pus may be seen
in the anterior chamber of the eye.
Inflamation in the posterior part is more
severe, the pain and fever run high, and vision 
is lost, yet the conjunctiva appears not 
much inflamed.
In all cases, the mechanical causes, if 
they continue to act must be removed. To 
remove sand or pieces of iron which stick in 
the coats of the eye, the ball is to be fixed by 
a speculum, and the body removed by a lancet.
Substances under the eye lid may be 
removed by a wet rag, or by syringing 
them with warm milk and water. If this 
fail, the inner surface of the lid may be examined 
by raising the lid.
When the eyelashes are inverted, constituting 
trichiasis, the cause of irritation must

116
be removed. This may depend either on the 
hairs growing inwards, or contraction of the 
eyelid. In the former case, the hairs must be 
pulled out, and St Yves says if destroyed by lunar 
caustic, they will not grow again
In case of contraction, an operation is required.
The tarsi, at the inner and outer ends have 
been cut thro', and, no success has followed in
any case I have heard of. Some assert that 
by cutting the skin lining the lid, they have
removed the stricture, but I have never seen 
any success from this mode.
A late author describes an operation, which 
consists in separating the tarsi from the skin 
without, and the conjunctiva within, thus 
separating its lateral connections; but I 
never tried this mode.
A few years ago, Dr. Dorsey had a case of this 
sort in the Alms House, and after trying to 
cure it by various operations, was obliqed to 
extirpate the whole edge of the cartilage, and 
the sore healed, and the eye was still very well 
defended by the eyelid. This is a mode which

(117
deserves imitation in all similar cases.
In all cases of opthalmia, bleeding is to be used
freely, according to the pain and fever. When 
enough of blood is evacuated in this way, cups 
may be applied to the temples, [and] or 30 or 40 
leechs may be applied to the same part. The vessels 
on the surface may be cut by the shoulder of a 
lancet, or they may be raised with fine forcepts,
and divided with scissars, but I prefer the 
lancet. Purging is also required. Mercurial 
purges are by far the best. The antimonial 
powder, of the P. Hospital answers very well.
The applications are to be mild. Poultices
of bread and milk are very good. The pith 
of sassafras may form one of the best remedies.
It may be applied in form of a poultice,
or as a fomentation dissolved in water.
Blisters may be applied behind the ears, on 
the nape of the neck, or on the shaven head.
After the inflamation is considerably subsided,
laudanum is a valuable remedy. Sugar
of lead, white vitriol and laudanum 
may be united in a collyreum.

118)
But stimuli must never be applied before 
the inflamation is much subdued, else the 
inflamation will be increased. Vinegar is a 
valuable remedy in such cases; the rotten-
apple-poultice is particularly serviceable after 
evacuations have been used.
If matter form in the anterior chamber of 
the eye, certain measures must be used to produce
absorption, but if the eye be made very 
tense by the matter, an incision, such as 
used for the extraction of the cataract, must 
be made, to prevent opacity in the cornea.
When opthalmia is of long duration, a 
salivation is one of the best remedies.
In all cases of opthalmia, particular care
should be taken to avoid light. The chamber 
must be dark, and excercise of the organ 
avoided. The diet must be vegetable, & 
animal food, and spirits avoided.
After severe cases, a sition may be made in the 
neck to prevent a relapse.
In many cases of protracted opthalmia,

119
the action seems to have something peculiar
in it. A gentleman, who had had a tender state 
of the eyes from his youth, had a severe [atta??]
which lasted 3 months; he was bled during 
that time, to ℥ iso, purged very freely, blistered 
had issues almost constantly, and was often 
scarified, and all to no good purpose. I directed
tar water to be applied, first to one eye, & 
after some time to the other. It brought him 
from a state of blindness, to free use of the 
organ, and tho' the application was very stimulating,
it produced no pain, but suddenly 
subdued the inflamation.
Various stimuli have been used. In one 
case, after bleeding, blistering and purging
had been used to no purpose, a solution of 
blue vitriol (in proportion of gr ij to ℥ water)
succeded buy and conception. In a week, the 
man was nearly cured.
Surgeons fear the use of stimuli in these 
cases from the tenderness of the organ, and 
indeed, the evacuating remedies, as bleeding, purging
and blistering must have been used before any 

120
stimuli are proper, but in protracted cases 
they are required. Solution of soap in spirits 
of wine have been of service in some cases.
Specks on the eyes have been cured by a mixture 
of sugar, alum and nitro! A solution 
of salt in water and vinegar, and sea water 
have been well borne in some cases. Red
precipitate, with a little camphor has been 
well endured, and succeeded in some cases, after 
the evacuating plan had failed.
Unguis. This, as we have mentioned, is an enlargement 
of the coates of the eye by inflamation.
When the thickening extends
along the conjunctiva over the cornea, vision 
is obstructed. The whole enlarged membrane 
must be dissected off. That part over 
the cornea, after being raised by fine forcepts
must be carefully dissected away with 
a knife, and the part over the schtonica may 
be cut away with scissars. It must be dissected 
very closely from the caruncular lachrymalis,
else it will return again. This is of 
much importance. 

(121
Specks. The best remedy for small opaque specks
on the eye after inflamation, is mercury. Locally,
gentle stimuli are proper, as corrosive 
sublimate one grain, water four ounces, but 
if there be inflamation produced by stimuli, 
they increase the opacity. But a ptyalism,
with low diet is the best, and most 
certain remedy.
When the part of the cornea, over the pupil
is rendered opacque by inflamation, an artificial 
pupil has been made by opening 
the iris with the needle, opposite to the 
transparent cornea. When the pupil is closed 
by adhesion, an operation [??lour] can cure 
it, by making an artificial pupil.
of Fistula Lachrymalis. To understand
this affection, the anatomy of the 
lachrymal sac and duct, the puncta lachrymalia,
and the adjacent bones must be 
well learned.
Stricture, or obstruction in this tube produces
a swelling in the inner canthus of the 

122)
eye, and if pressure be made on this, water and 
pus escape by the punctae. In this state, the 
eyelids will be glued together in the morning, &
opened with difficulty. If the sac be ostructed 
by disease, or by cold, pain and fever come on,
the part becomes very tender. In this state,
bleeding, purging, and low diet may sometimes
suceed, but generally, the tumor bursts 
externally. Before this can occur, it is the best 
practice to open the external part of the tumor,
give vent to the contents, and then introduce 
a probe into the duct toward the nose, & 
try to overcome the stricture. In this simple
way, I have succeeded in curing the complaint
But the nasal end of the tube is often so 
completely obliterated, as to preclude the fesibility 
of this. It is then nescesary to make 
an artificial opening into the nostril, for 
the future passage of the tears, by puncturing
the of unguis, which is the only division 
between the nose & eye in this place.
Mr. Pott performed this with a bent trochar,
after which, fragments of bone surrounded

(123
surrounded the opening, and were united by membrane.
It was nescesary to wear a bogie in the passage
for 2 or 3 weeks, to prevent its healing up, and 
even after this, it sometimes did heal up.
Mr. Hunter, seeing the imprefeations and in
conveniences of this plan, introduced a mode of 
striking out a circular piece of the bone, by 
an instrument resembling a punch, the 
bone being supported by a flat piece of horn 
introduced up the nostril.
This plan produces immediate relief, and 
after it no bogie is required.
This disease is sometimes complicated
with caries of the bones. In this case, the 
detached piece of bone is to be extracted, and 
the sore treated as another carious ulcer.
At the next lecture, the operation will be
performed on the dead subject, and the minutiae
of it explained.   Dr. P.
January 20.1812,

Lecture 32.
Fistula lachrymalis continued. Stricture in the 
ductus ad nasi, producing accumulation of 
tears, and swelling, may be divided into several 
stages, well distinguished from one another.
1. In the first, no inflamation has appeared, & 
pressure on the sac produces a regurgetation of a 
[mucus] water, and then mucus. Very little is to be 
done in this case. By pressing the fluid out of 
the sac regularly, the distension will be prevented,
part of the tears will return to the eye,
and some will flow into the nose. The eye may
be washed with a weak vitriolic collyeyum, as
white vitriol gr 1 or 2 to water ℥i, and I have seen 
the complaint disappear by this simple plan.
The French recommend injecting the sac with 
warm water by a fine syringe, but pressure 
is sufficient to cleanse the canal. Sir Wm Blizard
recommends injecting mercury, but no 
particular benefit results from this.
2. If by carelessness the sac be suffered to distend 
itself, and the patient expose himself to cold, inflamation

125
inflamation comes on, and parts appear just as 
a common boil. By the use of bleeding, purging, low 
diet and blisters, with a lead water poultice, we 
may prevent suppuration, and reduce the complaint
to the first stage; when it may be treated 
in the same way
3. In the third stage, pus has formed in the sac,
and generally escapes by an ulcerous opening 
in front of the middle of the sac, and the 
true fistula lachrymalis now is formed.
It is nescesary to remove the stricture, and establish
the evacuation of the tears into the 
nose, else the sore will never heal, and from 
inattention, patients have been teased by caustic
&c when the cause of the ulcer was not suspected.
The plate of bone (os unguis) which separates 
the sac from the nostril must often be
perforated, but before this is done, every measure 
must be tried to establish the natural passage
The external opening (if small) may 
be dilated with a bistoury, to introduce the 
probe. 

126
We may be called to operate before the duct is 
much distended, and not easily felt, and also,
the fistula may be so small and circuitous 
that we do not find it possible to introduce a
probe along it; therefore we ouht to know the 
true situation of the sac, and the place to cut
so as to find it. The incisions must commence
just below the inner canthus, and continue
parallel to the edge of the bony orbit. Thus, by 
beginning always below the canthus, we avoid the 
tendon of the orbicularis muscle
A probe is now to be introduced into the duct,
and carried down to the nose. In so doing, we feel 
the stricture, and overcome it. The probe may 
be withdrawn, and a bagie introduced, or what 
is much better, Mr Naru's silver probe. This consists
of a silver wire, the end of which is a little 
bent, and mounted with a flat head set on 
oblicquely, and the face of this after being heated,
covered with black sealing wax, so as to 
appear just like a black patch.
This may be left in. It does not produce 
much pain, and the tears pass along it to

(127
the nose, tho' this might not be expected.
This stilette has been borne for months, and 
is to be left in till the stricture is overcome. It 
may be removed and cleaned occasionally, and 
is then easily reduced to its place again. When 
the stilette is prematurely with drawn, the stricture 
will recur, and renew the disease where
as, if left in the due time, the canal will 
remain pervous, and the sore will heal very 
well after the stilette is removed. Thus the 
disease is generally easily cured.
But in some cases, the natural canal is 
not capable of yielding, and even the bony 
canal is found closed. Then, the artificial 
passage is the only resource.
When the os unguis is punctured by Mr.
Potts trachar, the fragments suspended together
by membranes are ready to reinstate
themselves again. To operate with Mr Hunters
punch, which is the best way, a piece of 
horn is to be introduced up the nostril, so as
to support the os unguis; the bottom of 
the sac laid bare, and the punch applied,

128)
and the bone may easily be perforated by 
few rotatory turns of the punch, and there 
will be a circular piece of bone neatly cut out.
The external wound may be immediately 
healed. The lips of the sore are to be brought 
together by adhesive plaster, and will soon 
heal up. The bone having no loose fragments,
will not heal up and the sac remains 
pervious, and conducts the tears into 
the nose without any inconvenience.
Of the Cataract. This consists in an opacity 
of the chrystaline lens and its capsule,
whereby the rays of light are prevented from 
passing to the retina.
It appears in an uniform whiteness of the lens,
or only in a speck. It first causes a dimness
of sight, as if gause was hung before the eye,
or threads, spots &c.
It often comes on spontaneously, and may 
in other cases be referred to mechanical violence.
Many remind us have been used to disperse the

(129
opacity. Mercury stands at the head of these.
Setons, purges, blisters, low diet, &c are also useful
Those cases which proceed from external violence 
may generally be removed by medicine.
They very commonly yield to a salivation.
A lady received a wound in the eye, by a puncture
with a needle, which reached the lens, considerable 
inflamation and finally opacity followed,
and she lost the sight in that eye. Bleeding,
blistering, purging and low diet were tried, but 
had no effect on the opacque lens. I pursuaded 
her to submit to a salivation, and as soon 
as the mouth became sore, the opacity began
to lessen, and before the salivation ceased 
the eye was perfectly restored. But she was 
still obliged to use a convex glass, and it therefore
appeared that the lens had been quite absorbed,
and the eye left in the same state as 
after extraction.
Spontaneous cataracts, I have never seen 
removed by medicine, and only once relieved.
As medicines fail, an operation alone can be 
of decided service. This consists in removing

130)
the opaque lens from the axis of vision 
Several means have been used for this purpose:
two operations continue still in use.
1. Couching, wherein the lens is pushed aside,
or to the bottom of the eye, so as to leave the 
passage for the light penetrable [the?ts] and,
2. Extraction, wherein a transverse incision 
is made thro' the transparent cornea, and 
the lens extracted thro' the iris and cornea,
so as to leave the eye in a transparent state.
Couching is the easiest as well as the oldest 
of these modes of operating, and is still 
strongly advocated by some surgeons, particularly 
Percival Pott, and Mr Hey of Leeds,
but I give a decided preference to extraction,
for the following reasons.
1. Couching is by far the most painful operation.
When extraction is performed by making 
the incision with a single stroke of the knife
it produces almost no pain, whereas, introducing 
the kneedle through the adnata and 
scletoric coat and the subsequent motions 
are very severe.

(131
I performed extraction on a man who had 
had couching performed on the other eye, and 
he could not believe that the operation was 
over till seeing a watch, he was convinced,
and he reflected with horror on the operation 
which had caused his eye to suppurate and 
waste away in the socket. I have even been 
requested to operate on the second eye immediately,
so trifling was the pain after 
extraction in many cases.
2. The lens after depression may, and after
does rise to its place, after which patients, 
will not (as some say) submit to the repetition 
without reluctance. When extraction 
is performed, the operation is complete.
3. When the cataract is fluid, the anterior 
chamber after become muddy, and the 
kneedle is in danger of tearing the iris. It 
is indeed said that the fluid will be absorbed 
again, but still, it is nesceray to repeat
the operation, to depress the nucleus 
of the lens.

132
4. When the capsule of the lens is also opacque,
the operation must be repeated on this if depression 
be performed, but in extraction, the capsule is 
easily removed either entire, as I have often had 
it, which could be seen by suspending it in water,
or piecemeal. When the capsule adheres very 
strongly to the ciliary process, it will be raised 
to its site very soon after couching, and appear 
behind the iris again.
5. Ahesions frequently form between the iris &
lens, and in extraction, I have found it very easy 
to separate them with a gold kneedle, whereas
in couching these adhesions remain, and the lens
will soon be reinstated again, and the repetition 
of the operation is required. Mr. Hey performed 
couching in such a case, no less than 
five times.
Therefore extraction ought to be always prefered.
Indeed objections have been raised against extraction,
but we shall soon see how far these 
result from awkwardness in the operator,
1. The incision in the cornea is said to leave the 
cornea opacque, but this is not the case; if the 

(133
operation be done well, the eye remains clear.
But if a dull knife be used, or the operation finished
with scissars, the eye may inflame, and becomes 
opacque; but the incision should not be 
near the pupil in any part, and therefore the 
passage of light remains unaltered.
2. The force in extracting the lens is said to 
make the pupil irregular, and so injure vision 
and I have more than once seen the pupil made 
irregular by extracting a hard chrystaline,
but this never injures vision in any degree.
Yet this is very rare, and may be avoided by 
proper care in the force applied.
3. The iris sometimes doubles under the knife
and may be injured if neglected, but if the incision 
be stopped, and the surgeon press and rub
gently on the cornea with the fore finger of 
the hand which is at liberty, the iris goes back
and the operation is easily finished.
4. The vitreous humor is said to escape sometimes
in couching, and this has actually 
been the case, but, it is always the effect of 
awkward pressure made on the eye, after



134
the incision is made. Moderate pressure is 
to be made on the eye during the incision
for the sole purpose of steadying the eye, and 
as soon as the cornea is cut, the pressure is 
to be entirely removed, and the vitreous humor
is in no danger of being moved. These objections 
are therefore of no importance. and extraction 
is the only proper operation. Dr. P.
Jan, 22d.
Lecture 33.
Cataract Continued. Before operating for the 
cataract, we ought to ascertain the probable
effect of the operation, whether or not success is 
to be expected. This is of great importance, as 
our character, as well as our patients ease may 
be sacraficed in a useless operation. The principal 
circumstances to be attended to are these.
1. That the eye in every respect (besides the 
state of the lens) be natural. That the cornea 
be clear, the eyelids, and thin edges free from 
inflamation and oedema. That there be no
tendency to inflamation, as in some cases

(135
the least injury will cause much inflamation 
2. That there be no pain in the fore head.
This circumstance is often met with especially 
in women. If this symptom exist, we can 
moderate it by bleeding, low diet, purging 2ce
or 3ce a week. In a case in which there was 
considerable head-ache, I gave purge twice a 
week, for nine months, and then operated 
with success.
3. That the iris retain the power of contracting
on the application of objects.
But if the power of distinguishing objects 
continue, we may not be deterred.
This iris may be fixed by adhesions to the capsule
of the chrystaline lens, and unable to 
move, yet if light can be distinguished from 
darkness, of telling the number of windows
in the room, of telling when a hand, a hat, 
&c is interposed between the eye and window,
&c the operation may be successful; but in 
such cases as do not bear these marks, you 
should never operate, as the retina will be in 
a state of torpor, the state called amourosis

136.
Even the pupil may retain its nobility,
and yet the retina be paralytic. An old
lady applied to me for a cataract, which 
was in this state. I extracted the lens, which 
was as hard as a stone, but to my surprise,
no power of vision remained. I then operated 
on the other eye, and in this, vision was 
restored. Now the pupils in both eyes moved alike 
by the light, tho' they were in an opposite 
state.
If the eye be in any of its coats inflamed or 
swelled, these symptoms may be removed by 
bleeding, purging, low diet, and blisters to the 
nape of the neck. The last remedy is particularly 
recommended by Baron Wenzel.
The operation is never to be poured on an 
eye in any degree inflamed, and measures are 
to be taken to prevent inflamation. In all 
cases, except when the patient is very weak, the 
diet should be low, entirely vegetable, and 
if the habit be full, blood should be drawn 
from the arm. 

(137
The most suitable seasons for the opertion
are spring and fall. In summer, the patient 
cannot lie still in bed the requsite time 
and in winter, the cold may produce inflamation,
and therefore mild weather is to 
be chosen.
The instruments used in extracting the cataract 
are the following.
It is common to fin the eye with a speculum,
by separating the eye lids, and applying it 
round the eye under the eyelids, it having 
a groove to receive the tarsi, but this is an unnescesary 
instrument. The eye[s] being opened
and held for a minute or two becomes steady
and the operation is to commence at this moment,
and it will be easy to keep it steady 
during the incision, without this painful 
and alarming instrument. This instrument 
occupies one hand, and if the iris folds
under the knife, we cannot make the nescessary 
friction on the cornea to press that back. I 
have performend this operation frequently, and 
never found it nescesary to use the speculum,


138)
speculum, but if it is used in any case, it 
will be found very convenient to have 
a ring in the end of the handle to put on 
the little finger, and then we can hold it 
with this, the mid-finger and thumb, and 
so have the fore finger at liberty; and these 
obviate this objection of Baron Wenzel. But 
still, the instrument is inconvenient.
The knife is then, the first instrument. Its 
blade may be 1 1/4 inch long 1/4 inch broad at 
the broadest part, and the sides straight lines
from this to the point. The edge is to extend 
to the broadest part in front, and to 1/10 inch 
on the back so as to make an exquisite point
I have said 1/4 inch broad: but it may be broader 
than [illegible] the diameter of the cornea, so 
as to cut its own way out by a simple push 
and must be very sharp, so as not to push
the eye obliquely, and so as to cut the cornea
without irritating it to inflame, and become 
opaque. See the description of this instrument,
in Wenzel.

(139
The second instrument is a kneedle for tearing 
the capsule on the anterior part of the lens
which may be a little bent, sit in a handle
and having on the end of the hand, a scoop 
for removing portions of the capsule which
may remain after the chrystaline is evacuated.
A small hook is also to be provided, with 
which the lens, may be extracted in case 
it should fall down into the vitreous humor
and only its edge be seen. This is often of great 
use.
Small forcepts are also nescessary, for extracting 
the opacque capsule, from behind the 
chrystaline, either piecemeal or entire. They 
are to touch not only at the points of their blades
but also to touch by flat surfaces, at least 1/10
of an inch. These instruments are of the 
first importance in completing the operation.
Before proceeding to operate, a bandage is 
to be put round the forehead, and to it, two 
compresses are to be pinned

140)
The compress which covers the eye to be operated 
on is to be pinned up. These render 
the eye steady. The patient is to be seated on 
a low seat and the surgeon on one much 
higher. All the windows in the room except 
one are to be closed, and the patient is to be 
set with one side of the head to that window.
Thus alone, the pupil can be seen distinctly.
The assistant is to stand behind the patient,
and support the head on his breast.
He is also to support the upper eyelid, by
holding the skin of it double over the sperciliary 
ridges, and make moderate pressure 
on the eye. The surgeon keeps down 
the lower lid, and makes moderate pressure 
also.
He is to apply the point of the knife to the 
eye, and not puncture it till the involuntary 
motion is over, else the knife may start,
and make a second puncture, and the aqueous 
humor will ooze out by the first,
the cornea will shrink and the iris fall in 
the way of the knife!

(141
The knife being applied at 1/12 inch from the 
junction of the iris and sclerotic coat, and 
the eye steady, the point of the knife is to be 
carried horizontally, and parallel to the iris
is to be brought out at the same situation
in the cornea at which it entered, and carried 
thro' with a single push; and never drawn back
but if the iris fold under the knife, pressure 
may be made on the cornea till this falls into
its place. As the knife fills up all the 
incision, none of the water can escape, but 
if it were withdrawn in any degree, or if 
the knife were not broad enough to cut 
itself out without being moved out of a direct 
line, the aqueous humor would escape.
As soon as the cornea is transfixed, all 
pressure must be removed; we having only 
to support the eyelids, and the knife being 
sufficient to fix the eye, which is as 
[cross out] it were hooked on it. Thus no pressure 
being made after the cornea is open, there is
no danger of evacuating the vitreous humor.

142)
Next, tear the capsule, with the kneedle in 
as complete a manner as posible, and with 
moderate pressure, the chrystaline lens will 
escape by the pupil an cut in the cornea. If the 
lens do not pass the pupil easily, the eye
may be exposed to darkness for some time,
that the iris may be relaxed, and thus, all 
danger of tearing the iris will be averted.
Gentle pressure may be made on the globe
to facilitate the exit of the lens, and if this 
does not follow very freely, the needle may 
again be introduced thro' the cornea and 
iris, the point fixed into the chrystaline,
and this extracted. This supercedes improper
pressure.
After the extraction of the lens, if filaments 
of membrane remain, they are to removed 
by the scoop, and if an opaque membrane
is seen behind the site of the lens, it may 
be removed by the forcepts.
When the operation is over, the compress is
be brought down, a piece of soft linen applied
over the eye, and secured by a bandage passed

(143
passed round the head, and the patient put to 
bed. His hands are to be secured with tapes fastened
to the bed cords, so that the cannot be 
lifted higher than the breast. This is of great 
importance. In one case, after the operation
was performed well, the patient on waking 
out of sleep, forgetting the cause of irritation 
in his eye, rubbed this, so as to evacuate 
the greater part of the vitreous humor
and so destroyed the organs.
In ten days, the eye will have united again.
Low diet, rest and perfect darkness 
are to be observed.-
We might have observ'd that after the incision 
is made in the cornea, we may rest 
a minute or two as in that time, the irritation 
of the incisison will be over, and 
the kneedle will be better borne than if 
this were neglected.   Dr. P.
Jan 24, 1812

144)
Lecture 34.
Cataract continued. Of Couching. And first 
of the instruments. It is common for operators 
in couching to use a speculum, and there is 
no objection to it, if the operator choses however,
it is unnescesary. The eye may be opened, the 
eyelids fixed, considerable pressure may be made
on the eye, this will then become steady, and 
now the operation may be performed. After the 
kneedle is introduced, it fixes the eye.
The kneedle used by Mr. Pott, was spearpointed,
but ingenious men have made many improvements 
in it. They have reduced its length to 
1 1/2 inches, and thus, rendered it very manageable.
The spear point, making too large a hole [prevent] permit 
the escape of some of the vitreous humor, but 
the round instrument now used makes no larger 
an orifice than the rest of it occupies.
It is made flat toward the point, as Mr. Hey has
directed, and I have also adopted, from Scarpa, the 
method of having it bent toward the point, 
1. becuase it is less entangled in the iris, 2, because

145
because after pushing the lens back, we can very easily
carry this crooked kneedle before it and fix it
very easily, 3, because with this it is very easy 
to depress loose, remaining pieces of capsule with
the bent kneedle.
This operation is very simple. The patent being 
seated on a low chair, and the supported by an
assistant, and him facing a window, and the eyes
opened as in extraction. The kneedle being applied 
at 1/6 of an inch from the edge of the transparent 
cornea, it to be pushed thro' the scletorica
to the chrystaline lens, the point is then to 
be applied to the lens so as to push it back,
and the kneedle insinuated between the iris and
the lens, the point is now to be fixed into the 
lens, and, and by elevating the handle of the 
kneedle, you depress the lens down to the bottom
of the eye, and immediately, the pupil will 
be seen black behind the iris, instead of the opacque
chrystaline. If this first motion do not 
perfectly succeed, it is very easily repeated.
It is nescessary for the kneedle to be very 
sharp, and even so, considerable force is required

146)
required in piercing the coats of the eye, and in so 
doing, an indentation is made. To remedy this inconvenience,
I puncture the eye with the point 
of the extracting knife, and then, use the kneedle
as usual. To depressing the lens, it may always 
be observed to keep the concave surface of 
the kneedle downward.
The operation being finished, the eye is to be covered
with a compress, this secured by a bandage
and the patient put to bed. In 10 or 12 days,
after the inflamation is over, the eye may be
examined, to see the effect of the operation.
The cataract is sometimes soft, and cannot 
be depressed. The advocates of couching break the
anterior part of the capsule, and all which escapes
into the anterior chamber will be absorbed,
and probably the posterior also; but if any 
remain, the operation is to be repeated again and 
again, till all the opaque matter is absorbed.
There are also cases of fluid or milky cataract,
in which also, the anterior part of the lens is 
to be ruptured, that the fluid may be absorbed.

(147
Thus, couching is a very easy operation; only one 
or two instruments being used. The principal 
danger consist in the liability of the iris to be 
wounded. Steadiness and skill are required to overcome 
this difficulty. But this operation seldom 
succeeds in restoring vision. I have frequently performed
it, and only in one case, I never restored the 
sense of sight. In all cases but that one great
inflamation followed the operation, and in two 
of them, the symptoms of gutta serena came on 
I was obliged to use depleting means, as purging,
blistering in these cases. From the above reasoning,
I have determined never to perform this 
operation, but to extract all, except in children, in 
whom the eye cannot be easily managed, and 
especially when the cataract is milky, in which 
case, couching may at least be tried on one eye
before extraction.
Artificial pupil. When the part of the cornea opposite
to the iris obscured by an opacity of the cornea, which 
cannot be removed, and another part remained 
transparent, we may make a hole in the iris opposite 
to the transparent part.

148)
The pupil is sometimes closed by inflamation.
This also, the iris may be opened.
I once succeeded in a case in which only one eighth
part of the cornea remained transparent, which 
was in the upper edge.
The patient being seated, and the eye opened
is in extraction, and pressed upon considerably,
the cornea is to be divided as in extraction,
with this difference, that before the opposite side 
of the cornea is punctured, the knife is to be so 
far retracted that a great part of the aqueous humor
may escape, and a flap of the iris fall before 
the knife, and now by finishing the operation 
by one cut, a round portion of the iris is cut
out. This is the simplist way of operating, and 
may prevent the introduction of forcepts and 
scissars which may injure the lens. Thus I
have operated with success several times
But when the pupil is closed, the iris cannot 
be brought afloat before the knife, and consequently 
we cannot succeed in this way; but as 
as soon as the knife is within the cornea,
the point of it is to be carried down, and the 

(149
pupil cut to about 1/10 inch, and the open incision at 
in the usual way thro' the cornea. The flap 
this iris may now be cut with fine scissars, which 
may be curved near the point, or what is [illegible]
slender forcepts, on one side whereof, there is a
curved edge. But as the causes of the closure of 
the pupil are violent ones, the operation may 
readily renew this, and therefore, before operating,
the patients should be told that the success 
of [of] it but a mere chance; and we 
only operate in uncertainty.
Hydrocele. This is a collection of water in 
the scrotum. The situation of the water produces
essential difference in it.
1. The anasarcous hydrocele, in which, this 
water is contained in the cellular substances
of the scrotum,
2. The hydrocele of the tunica vaginalis teses,
and
3. The encysted hydrocele of the spermatic
cord. As the treatment of these is essentially
different, we ought to distinguish them wt.

150
accuracy.
1. The first species presents an equal tumor,
whhich includes the whole scrotum, on both 
sides, and the raphe divides it into two in the 
middle. The tumor is of its natural colour,
and the finger makes an impression which 
lasts some time. The spermatic cord can easily
be felt in its natural situation. Thus the case
is readily discriminated.
2. The collection in the vaginal coat is supposed
to arise from the increase of the natural secretion
the torpor of the absorbents or the rupture of the 
lymphatic vessels. It commences near the testicle,
is generally confined to one side, is not lessened 
by pressure, is firm, and in the beginning,
the testicle can be felt but in the end cannot
be felt. It may be distinguished from.....
Hernia, by beginning at the bottom of the scrotum,
by being firmer, by being irreducible by 
pressure, by the spermatic cord being distinctly
felt, whereas the hernia presents all the opposites 
of these phenomena. Fluctuation, and 

(151
transparency may often be perceived.
Schirrus testicle, it is easily distinguished by 
cord being generally enlarged and irregular in 
the former, from the tumor being in this also 
heavier and more opaque than in hydroclele
From Hernia humoralis by its having no connection 
with gonorrhoea, by the tumor not 
being so firm in hydrocele, and by other symptoms
of water.
3. When one or more cysts of water are lodged in 
the spermatic cord, the testicle is always felt at 
the bottom of the sac, fluctuation is evident,
and the tumor is diaphanous. This tumor extends
to, or even beyond the abdominal ring,
and may be well distinguished. In a case of 
this kind, I saw some difficulty in distinguishing 
it from hernia. The tumor could be pressed
up (and as it were reduced) but immediately
returned, but fluctuation and transparency,
were evident, the testicle could be felt at the 
bottom of the scrotum, a puncture evacuated 
the water, and the wine injection competed 
the cure.

152)
Method of Cure. The bulk and weight of the 
tumor is often so slight, that patents are 
unwilling to submit to the operation.
The pain, either in the part or in the loins
is much alleviated by a suspensary bandage.
1. In the anasarcous species, tho' the case is 
not connected with surgery, we are often called 
to evacuate the water. Punctures are to 
be preferred to scarifications or setons, as 
the latter may produce mortification.
Five or six punctures will evacuate the water,
and the dressing may be dry lint.
I have seen the tunica vaginalis when 
distended with water, suffer a rupture, and produce 
one of the 1st species. An old gentleman
while setting in his room felt some thing give
way in the scrotum, and the tense tumor of
the vaginal coat was exchanged for a soft
diffused, lived one, and mortification was feared.
I was consulted 3 days after, and prognosticated 
that the breach would heal up, the water 
be absorbed, and the disease resume its
former state, and just such was the result

(153
2. In the second species, little can be done by 
medicine. I have seen it cured by the affusion of 
cold water. Temporary ease may be procured by
evacuating the water with the trocar or lancet
and then introducing a canula and insetor
till the water is carried off, and then covering
the puncture with adhesive plaster.
Simple as this is, I have seen three surgeons
puzled by a simple case in London. The first 
who was called, plunged in the trochar at the 
usual place, the inferior, anterior part, but 
no water followed the stilette. The wound 
was suffered to heal, and then a second was 
called, who also failed in the same manner.
Such also was the fate of the 3rd who could procure
nothing but drops of blood. Mr. Hunter
was now called in. On a very close examination,
he found that the testicle lay just 
at the place where the surgeons had chosen to 
operate, and that they plunged their trochars
into the substance of it. He operated on 
the inferior posterior part of the tumor, just 
where we usually find the testicle, and with

154
complete success. This teaches us always to 
feel the testicle, before operating.
The radical cure can be affected by exciting 
inflamation in the sac, so as to obliterate it
I have cured it by repeated tapings, in one 
case in which, the testicle was so inflamed and 
enlarged that I feared to inject wine. Tevacecated 
the water as soon as the coat was distended
enough to keep the instrument off the 
testicle. Low diet, and mercurial purges were
used. The water was let off every fortnight.
Several ways have been used to obliterate the sac.
1t. Incision is the most ancient. It consists of 
in dividing the skin and vaginal coat, and 
filling the cavity with lint. Great inflamation 
and suppuration came on, the lint was separated 
gradually, and the cavity united.
But this remedy is very severe, attended sometimes 
with haemorrhage, and shreds of lint
remaining often produced abscesses several 
weeks after the sore was healed.
2d. As the tunic is sometimes thickened, the 
removal of it has been proposed by Douglas

(155
but this is quite unnecessary.
3d. Caustic. The whole tumor, from top to 
bottom has been laid open by a caustic, which 
on the separating of the eschar, produced very 
great pain and inflamation, followed by 
the obliteration of the sac. Mr Else has confined
the caustic to a shillings breadth, and this is 
found sufficient. But the caustic is a very 
uncertain remedy; often faling to reach the 
sac, often causing violent inflamation, fever
and supuration, and when the water is 
contained in sacs this does not succeed.
4th Tent. A skein of silk was carried from 
the bottom to the top of the tumor. This often 
answers, but often causes only the tract betwixt
the tunic and testicle in which it lies
to be united, and the disese returns on the 
sides of this.
5. Monro left the canula in the sac, until it
produced the nescesary inflamation, but according 
to Cheselden, this mode is very painful,
and he prefered the tent. 

156)
6. Injection. Lately, the ancient mode of injecting
stimulating fluid into the tenica vaginalasis
has be revived. Wine, or wine and
water have been particularly recommended by 
Sir James Earle. This he has shewn to be perfectly 
safe and easy. In a few cases, indeed
this remedy will fail.
I once succeeded in curing a case with warm 
water alone, in the Penn Hospital, contrary
to my expectations; and I have since read 
Mr. Whateleys report, to the same import.
But wine, or wine and water are found very 
convenient, safe and not painful. If no inflamation
follow, it may soon be repeated
The patient is to be seated opposite to a window,
and the surgeon kneeling before him, makes the 
evacuation either with a trochar and or with a 
small lancet and then introduce a canula.
As soon as the fluid has escaped by the canula,
the injection of wine or wine & water, (being 
prepared in a bladder with a stop cock) is to 
be thrown thro' the canula into the tunica


(157
tunica vaginalis, and as soon as pain is felt in 
the scrotum or loins, which is in general four 
or five minutes, the liquor may be allowed to flow 
back again, the canula with drawn, the orifice 
closed with plaster, and the scrotum supported 
with a roller, which prevents inflamation.
In four or five days, the scrotum becomes red, tender
and covered with a blush, and in four or five 
more this goes off, with the disposition to renew 
the disease. If the inflamation run high, 
the patient may be confined to bed, and to low
diet, evacuating measures used, and a leadwater-
poultice applied. But if the inflamation 
be defective, the patient may walk about his 
room and use stimulating food.
To avoid the canula's escaping from the orifice 
in the tunica vaginales, which would cause 
the injection to pass between the skin and cellular
substance, and mortification, the canula
may be introduced full 2 inches and laid on 
one side. This never happened to me, but I 
saw it in the practice of another.
Jan.28.1812.  Dr. P.

158
Lecture 35.
In speaking of the treatment of the hydrocele
by injection, I observed that in a few cases, that 
operation will fail. I am to describe a late 
and successful operation for these cases, described 
by Mr. Hunter.
It consists in making an incision of 1/2 inches
long on the anterior inferior part of the scrotum,
thro' the skin and cellular substance, and piercing 
the cellular membrane, so as to lay bare the 
testicle. The state of the testicle may be seen.
The scrotum must now be filled, not with lint,
but with flour, or rather dough, made into balls 
of 1/2 diameter, holding the lips of the scrotum
asunder by two hooks, one in the left hand, and the 
other given to an assistant. After the tunica vagnalis
is moderately distended with these balls, a
piece of patent lint is put into the mouth of 
the sore, and the whole suspended in a bag-truss.
In case of much fever or inflamation, blood may be 
drawn, &c. In 2 or three days, a poultice may be applied
over it, the cavity will suppurate the dough

(159
will come away melted in the pus, the cavity appears
just as a large abscess, and the whole will 
very uniformly unite. I have performed this operation 
several times with perfect success.
Of Herniæ. Herniae, or ruptures are among the 
most important surgical diseases, from their 
frequency and their great dangers and inconvenience.
They consist of tumors, caused by the protrusion 
of the natural contents of the abdomen 
through its parieties.
They occur most frequently at the upper and 
fore part of the thigh, at the navel, and the groin.
The twin rupture is improper, as they consist of a 
sac of the peretonuem, pushed thro' some natural opening.
Thus, at the navel the navel, there sometimes
remains an opening in the foetus, imperfectly
closed, which admits of these accidents, and 
in the groin, the ring of the external oblique muscle,
thro' which the spermatic cord in the male and 
the round ligaments in the female pass, is the 
aperture at which the inguinal or scrotal 
hernia, or oschocele pass out, and in the upper,

160
and fore part of the thigh where the crural or 
femoral hernia is seated, the hernial aperture
consists of the cavity under Pouparts ligament.
All the contents of the abdomen have been occasionally
found in hernial sacs, except the 
duodenum and pancreas; but the colon and 
mesentery, and omentum are the most usual.
Hernia are named from their contents, as 
enteracele, epiplocele, gastrocele, &c.
The congenital hernia or that in which,
the protruded parts lie in the tunica vaginalis
testes, arises from that aperture in which the 
testicle [cross out] descends, not being closed before 
birth, and there is still a communication between
the peritoneum and tunica vaginalis.
In such cases, when the child coughs cries, &c the contents
of the abdomen may descend, but when pressure 
is made on it, it easily returns again. By frequent
repetitions, the communication remains open, and 
subject to rupture through life._ We shall treat 
of the bubonocele at length, and then treat of 
the peculiarities of the others.

(161
The bubonal or inguinal hernia is characterised by a tumor
at the abdominal ring. Astley Cooper says it begins 
at the distance of 1 1/2 inch from the external opening,
on the external side of it and higher up. It is 
easy to press the tumor up again; by lying horizontally,
also, it may be reduced, but on rising, or on 
making any pressure with the abdominal muscles,
diaphragm, &c, it is returned again. We see 
the progress of the tumor from the upper to the 
lower part of the scrotum. I have seen it descend
as low as the knee, and suspended by bandages
round the patients neck.
On dissection, we find the tumor to consist of 
1. (After laying aside the skin of the scrotum)
a number of tendinous bands united together
by fascia, which is derived from the obliquies externus
above the abdominal ring
2. The fibres of the cremaster muscle
3 The hernial sac. See A. Cooper. But these 
are sometimes so blended together as to appear 
many more in some instances, yet the above
ordor is universal.
Behind the upper part of the sac is found the

162
spermatic cord. At the bottom and posterior pt 
of the tumor is the testicle, the abdominal 
ring is the mouth or aperture of the rupture and 
and between this and the symphysis pubis,
is found the epigastric artery. In a few cases 
the spermatic cord is found on the anterior side
of the sac. This teaches us always to proceed wt
caution in operating.
Symptoms. 1. The tumor commences at, and 
proceeds from the abdominal ring in the groin.
2. The tumor is increased by the erect posture, 
et. v.v.
3. Is increased by coughing, straining the diaphragm,
abdominal muscles, &c.
4. When intestine is returning we hear a gurglinng 
noise, and
5. When intestine is down, the functions of 
the bowels are interfered with. Nausea, vomiting,
colic pains, costiveness &c are produced.
Diagnosis. 1. From hydrocele. a. by beginning above,
whereas hydrocele begins from the bottom of 
the scrotum, by the abscence of fluctuation
and the cord not being felt in hernia.


163
b. by being increased by the erect posture, pressure
with the muscles, of the abdomen, diaphragm
Thus, we can easily avoid mistakes in these cases
2 From swelled testicle. a. by the causes of this 
as suppressed gonorrhea, external violence, & 
being known. b. by the swelled testicle being 
hot and painful. c. by the swelled testicles
going off suddenly at any time like herniae,
d. by most of the diagnosis betwixt herniae & 
hydrocele.
3. From bubo a. by the connection of this with 
chancre, and being painful. b. by the bowels 
not being interfered with in buboes. c. by bubo
tending to suppuration.
4. From cysts on the spermatic cord. a Tho'
this and inguinal hernia have many features 
in common, when the cysts lie along the cord,
yet this one circumstance is a certain diagnosis,
vizt that if pressure is mad on the tumor,
if it be hernia, it will be lessened, but 
if an encysted tumor, it will not be lessened
in size, but go up in a mass and descend 
just as it went up, immediately. b. By the

164
effects of a puncture in evacuating the water
of the cysts, and so curing the disease.
5. From Varicocele, or a varicose state of the 
veins of the cord, it is considered difficult to distinguish
hernia. When the patient lies, the tumor 
is lessened, and when he stands, the pressure
of the column of blood enlarges it again, such 
also is the effect of coughing, straining, &c.
a. But in varicocele, we can feell, and even see 
the convoluted form of the veins under the skin,
b. A. Cooper proposes to lay the patient horizontally,
to take hold of the cord, and let the patient 
rise again. In hernia, a considerable 
pressure will be made against the fingers, but 
in variococele, this will not be considerable. But 
the first method is preferable, and even tho motion
of the blood in the veins gives a sensation
which prevents any deception when we feel it.
Causes. The causes are 1. Such as weaken the 
parceters of the abdomen. 2. Such as increase the 
pressure of the intestines. &c against them.
3 Both causes united. General debility, as after 
a fever, in old age, &c disposed to hernia.

165
Blows on the abdomen, pregnancy, strains of 
the diaphragm or abdominal muscles, [cross out],
great corpulence, violent coughing, straining
to stool, violent exercise jumping, lifting great 
weights, &c are causes of the second order. When they
act, the contents of the abdomen may be more or 
less forced thro' any weak parts in the parieteis
Thus I have twice seen herniae produced in young
men by carrying in a back leg.
Of the Treatment. For convenience in practice,
herniae may be divided into the following 
orders.
I. Such as are of easy reduction.
II. Such as can only be reduced by particular
management.
III. Such as tho' unattended with stricture, are 
irreducible.
IV. Such as are attended with stricture.
Of the first, it may be obseved that as long 
as intestine or omentum remain down, there
is always danger, even when there is no pain.
Stricture may occur, the contents of the bowel

166
may be stopped, and after frequent descents of 
the omentum, the passages [to be] kept open 
so that the gut may pass down, and this is 
liable to be the case as long as any omentum
is down. While any part remains down, the 
whole may be enlarged by the causes of herniae,
and stricture may follow this second descent.
Therefore the contents of the sac are always
to be reduced, and prevented from returning
by proper compression made on the mouth, or 
neck of the sac, after reduction.
This indication is answered by a truss, or 
slender steel spring, which goes more than 
half round the body, and the circle completed by 
a strap. On the end of this is a pad. A bandage
is applied in the groin, reaching from before 
backwards, to prevent the truss slipping up.
In applying the truss, let us recollect why it is 
used? That it may effectually keep the gut up
it must act on the ruing accurately. This part
presents a pit to the finger after the reduction 
of the intestine &c.
Instrument makes generally err by applying

167
the truss too low, thus pressing on the cord, testicle,
&c and allowing the mouth of the ring to be kept
open, which is the case when the truss acts over the 
pubis. The lower edge of the pad should act just 
over the upper edge of the pubis. The head of the 
truss is sometimes made of silver or ivory, and 
made so as to turn olbi[c]quely at pleasure so 
as to accomodate corpulent persons. The metal 
mentioned is chosen for not rusting. The part 
may be defended by a muslin compress, when this 
instrument is made of these materials.
The truss is to be worn night and day. I have 
known it affect a cure in nine months in a person 
of a good constitution, but the truss ought
never to be laid aside before two years. Aged persons 
must wear the truss always, as in them 
the cure cannot be expected. I know, however, 1 
exception to this, in a man of 50, in whom,
the ring united perfectly.
The exciting causes are to be avoided during the 
use of the truss, as costiveness, lifting weighty bodies,
riding a rough-going horse, violent excercise
&c. And when any exertion is made, the

168
patient should assist the truss, by pressure
with his hand, particularly if costive, or if 
he has a stricture in the urethra. These directions 
are essential to his safety.
Second order. The protrusion is sometimes so 
large that tho there be no stricture, the reduction 
cannot be affected. In this case the patient
must be put to bed, confined to a low diet,
to loose blood and to use purgative medicine.
Thus, the tumor may be lessened, as reduced,
and then the truss is to be applied. I have
often succeeded in this way, in these cases.
Third order. Tho' there be no stricture, the reduction 
may be impracticable, either from 
the shape of the tumor, adhesions betwixt 
the guts, or betwixt the gut and sac, or by ligamentous 
bands. In this case the tumor is to 
be carefully suspended by a suspensary bandage
and the patient often enjoys comfort, yet is 
not freefrom the danger of stricture. [See M.
As in hydrocele the sac has sometimes burst,
so has the hernial sac. In this case the gut

(169
will be found under the skin, and the gut must 
be reduced first through the ruptured aperture, & 
then into the mouth of the sac, into the abdomen 
But this case is very rare. [See N,D. Dr. Ph
Jan.29.
Notes on Lecture 35.
L. Page 165... After the hernia has been lessened 
in size by these remedies, we may by taking hold 
of the remaining tumor, in most cases reduce 
it, if it has not gone up spontaneously.
M. Page 168.... This order is only known by its 
not yielding to the remedies mentioned above (168) 
& cold applications
No above... The suspensary bandage not only 
prevents pain and great inconvenience, but 
by warding off the dragging of the tumor, prevents 
more of the contents of the abdomen being 
displaced. It is to be lined with soft materials.
A. idem... During the use of the suspensary, the 
state of the bowels requires attention. Costiveness,
and the use of flatulent food are to be 
particularly avoided.
Jan 31

170)
Lecture 36.
Hernia continued... Fourth order. We now come 
to speak of herniae, with stricture. Stricture in 
hernia consists of a tightness at the orrifice as
neck of the rupture, which injures the functions 
in the gut, or vessels of the protruded parts.
The tumour becomes hard, the patient becomes 
unable to stand, nausea and vomiting sooner 
or later come on, an antiperistaltic motion 
of the bowels is established, fœcal matter 
is vomited and if the gut be strangulated, no fœces 
can escape per anum, but what may happen
to lie beyond the stricture.
If the tightness be such as to injure the circulation,
and injure the venous circulation, inflamation,
with considerable swelling and 
fever comes on the colour of the tumor is not 
red, but of a dark leaden colour, just as in 
phlegmon before mortification.
The stricture may even be such as to stop the
circulation altogether, and produce mortification.

(171
When that is the case, the belly swells, becomes
very tender, the pulse becomes small and very 
weak, elilliness in may cases, which is followed 
by great restlessness &c occur, and death 
soon follows. But before the fatal hour, (which 
may be protracted from one to several days) it 
is common that a delusive interval occurs. The 
tumor becomes soft, and returns into the abdomen,
and the patient fancies himself nearly 
well, when death is just at hand.
On dissection, the bowels at the seat of the 
stricture are found of a chocolate colour, tender,
and easily torn with the fingers, and even
holes are often found it in.
When the omentum only is strangulated,
all the symptoms are much milder.
All these effects are produced by the pressure 
of the tendons thro' which the spermatic
cord and hernia pass. The ring of the obliquus
externus is the most usual seat of this. But Mr. A
Cooper has shown that the cause of the stricture
is frequently higher seated, viz in the obliquus
internus and transversalis. 

172
This is particularly the case in old and in 
large ruptures. The stricture is said to be spasmodic,
but no muscular fibres are concerned
When this is the case, cutting the ring will not 
relieve the stricture, but we must operate 1 1/4
inches higher up. This is the distance intervening 
betwixt the internal and external orifices,
but in old ruptures, these orifices are 
approximated, so that the internal one is just 
behind the ring.
In all cases of strangulation, effectual measures
must be taken to remove the stricture.
As soon as a patient is the subject of one of 
these accidents, he places himself on the ground 
horizontally, and makes pressure on the tumor.
If he fails, the surgeon is called upon. He 
places the patient in a bed, with the foot of 
it raised, and relaxes the muscles on the anterior
of the thigh and abdomen, by flexing the 
former on the pelvis, and by bending the pelvis
upward. He then takes hold of the tumor,
and presses it upward and outward, but not with 
any violence, which might irritate and even


(173
burst the tumor. If this remedy, viz position 
with tanis fail, other remedies are to be tried 
in the following order.
1. Bloodletting. This may be performed and delinquim
animi, and then, the termis will very 
often succeed very easily.
2. Warm bath. The whole body should be 
introduced into a bath at or near 100 and continued 
till faintness comes on. It may very 
often be practicable to reduce the rupture 
now, by the taxis.
3. Purges. I have found mild purges, particularly
rum, tart, and jalap in small doeses often 
repeated, given with some essence of peppermint,
of great service. Glysters at the same 
time being given. Mr Hey condemns purges 
entirely, but when the intestine is not in 
the strangulation, and in old cases, they answer
very well. But in case of strangulated 
gut, the only increase the vomiting.
4. Tobacco in form of infusion or smoke is 
a well known resource. The smoke is the most 
active, the infusion the milder remedy. 

174)
Tobacco ʒi infused in water [illegible] forms an infusion,
of which, one half may be thrown up 
every half hour, till the desired langor is produced,
and the reduction may generally be affected. 
Dangerous symptoms sometimes follow 
this remedy. In one man last summer, the 
powers life had nearly vanquished by the usual 
quantity, and Astley Cooper mentions a 
case in which the infusion of ℥i produced pain,
and vomiting, followed by death in 25 minutes 
in a girl. Care is therefore requiste in the 
use of this remedy. Perhaps ℥i of the infusion 
would be enough to begin with. Of all other 
remedies, this is the most effectual, and the quickest
in manifesting its result.
5. Cold. A bladder filled with pounded ice may 
be applied to the tumor, or if this cannot be 
had a solution of salts in vinegar & water, or 
crude sal ammonia ℥v nitre ℥v water [illegible]
be put into a bladder, and applied. These remedies
are very effectual. But they are not to be 
too long continued [in], as the part has actually
been frozen. 

(175
6. Opium. This remedy is indispensible in allaying
the sickness and vomiting and to be effectual,
must be given in large doses. 2 grs may 
be given by the mouth, and ʒi of laudanum injected.
In case of a man who had suffered strangulation 
for 3 days, I gave 3 grs of opium at 
night, and put him to rest. He slept well 
all night, and in the morning, the intestines
was found reduced.
But if these remedies fail, the operation for 
removing the stricture must be performed.
As to the time of operating; it is better to operate 
too early than too late. In the latter case
mortification or peritoneal inflamation will
have supervened. The most celebrated men are 
in the habit of operating early, even as soon 
as 24 hours.
We may make it a rule, in all cases after bleeding,
warm bath, purges, tobacco and cold, with a proper posture, taxis
and opium have failed after a fair trial to operate immediately.
By doing so many will be saved.
It is very difficult to ascertain the state of 
the hernia by the symptoms. Langor, hiccup,

176
hiccup, coldness of the extremities, small and weak
pulse &c are said to denote mortification, but 
I have seen the operation successfully performed
with perfect success, and the parts found 
to be sound. The duration of the stricture is 
no rule: patients have died in 8 hours, and they 
have survived 17 days. The fever is also uncertain 
When the countenance is sunk, the pulse weak
and the extremities cold, I have seen the operation 
performed with success.
Hernia are more dangerous in the middle 
aged than in the young or old, in small
than in large, and in recent than in old cases.
When the circulation is stopped, death is 
certain.
One symptom may be regarded as certainly 
fatal, viz coldness of the extremities, [This]
and a cold and moist state of the skin. This is
always a forerunner of death, and if the operation 
be performed under such circumstances,
it will always fail.
Of the Operation. The patient is to be laid on 
a table covered with a blanket. The pubis shaven

(177
An incision is to be made with a scalpel from 
1 1/2 inches above the ring to the bottom of the sac
unless this be very large, the skin and cellular 
substance are to be cut and the tendon of 
the external oblicque exposed. The tendinous 
fibres on the surface of the tumor are to be divided,
and the sac punctured by several very 
delicate strokes* of the knife, trying if the probe
will enter it. As soon as a puncture is made 
the director is to be so far introduced and the sac out on this as to allow
the finger to be introduced. On the finger 
the bistoury is to be applied, and the sac
divided as far as to near the ring but no farther.
By introducing the finger through the 
ring into the abdomen, the stricture can 
very easily be divided by passing the probe pointed
bistoury along the finger. The incision 
may be made upward, or upwards and a little 
outwards. If done inwards, the epigastric artery 
will certainly be wounded, and as the 
artery in a few cases lies on the outside, it is 
best to convey the bistoury directly upwards,
*No water being contained in the sac.

178)
as Mr Cooper advises, and then the artery cannot 
be wounded.
Mr. Cooper advises us for the purpose of preventing 
peritonial inflamation to carry 
the bistoury through the tendon only introducing 
it not within the sac, but betwixt 
this and the tendon.
The above is the way in which the operation 
is generally performed, but some late surgeons,
particularly Monro make no incision 
into the sac atale, but after dissecting 
down to the sac, cut some fibres of the 
tendon of the muscle in muscle with the scalpel,
and then introduce the bistoury.
After dividing the stricture, the part protruded 
may be easily reduced by the taxis.
This operation is exceeding by simple and easy,
and attended with no hazard whatever in
the hand of a careful operator. Dr. P.
Jan. 31.

179
Lecture 37.
Crural hernia continued. When the sac can 
be returned thro' the enlarged ring without being 
divided, this ought always to be done, this 
operation being the most simple, and tends to avoid
pertioneal inflamation; but when the strictured
gut is mortified, the sac must always be opened.
Also if we cannot reduce the sac after dividing
the tendon, the cavity of it must be open'd
and the cause examined, which may be 1. Adhesion
2 alterations in the shape of the parts protruded or
3 stricture at the neck of the sac.
1. Adhesions betwixt the gut and sac, if they be 
long may be divided, but if very short, the portion 
of the sac connected to the bowel may be cut
off and returned with the bowel. Dissecting adhesions 
near the mouth of the sac is difficult
and can only be done by laying the tendon
bare all round the adhesion.
2. When a large mass of omentum is low 
down, and is not retracted, it may be cut off
and the vessels tied, leaving the end of the

180)
ligature out at the wound.
3. Stricture of the neck of the sac is not a frequent 
occurrence: I met with a case of it in July,
1798. A man of 38 years of age was attacked with 
a severe colic which had continued several days.
He had been subject to a tumor in the groin for 
two years, which went off as soon as pressed upon
or the patient lay. A few days before I was called
this tumor had come down in consequence
of his lifting a heavy piece of wood. When I was 
called. I found the wrists cold, the pulse small and 
trembling, the belly tumid, the scrotum swollen, 
vomiting obstinate and no passage by stool
tho' the pain and swelling in tumor were much less than
before my arrival.
I advised an immediate operation, as the symptoms
of mortification were present. I made an incision 
through the skin and cellular substances
from above the ring to the bottom of the tumor,
dissected the sac free from the tendon and laid
the former open, but to my astonishment found 
nothing but bloody serum therein; no gut, no stricture

181
stricture and therefore there could not be in the tumor,
any cause capapable of producing the above
symptoms! Is the case produced by inters [sersc??]?
In these obscure circumstances, no remedy was 
applied except warm bath and purges of jalap & 
cremor tartar; but the man died in 36 hours.
On opening the body, a portion of bowel was 
found closely embraced by the mouth of the sac
which was retracted into the abdom a considerable 
way above the ring, and not at all in contact
with the fascia which usually embraces
it. What ought to have been done, had the true
cause of the disease been known? Ought the sac
to have been pulled down and divided? or ought 
the tendon to have been opened, and the neck 
of the sac cut within the abdomen?
The bowels are never to be returned in a mortified 
state into the abdomen. However, the symptoms
may seem to indicate mortification 
and yet the bowels be found sound. When a
sudden mitigation of the pain comes on, the 
tumor becomes purple, creptus is heard on

182
handling the scrotum, the belly becomes tense
the patient very restless, his skin hot, his pulse
weak and quick, and the hernia easily reduced, 
little doubt need remain.
Yet such a set of [set of] symptoms are not
always fatal. I have seen a negro who was 
in this situation recover, but with an artificial
anus at the groin, where the upper portion 
of intestine terminated after the slough 
separated.
After opening the sac, we can judge of the 
state of the gut. But the dark red, or chocolate
colour of the intestine, produced by impeded circulation
is not to be mistaken for mortification. 
The mortification is generally confined 
to spots, the texture is so altered that the gut
tears under our finger and has an offensive
smell. If the dead spot be small the bowel may 
be [small] returned, as adhesion will fix the surrounding 
parts to the peritoneum &c and the 
slough pass by the forces, but if there be a hole
in the bowel, it will require a stitch. 

(183
When the whole cylinder of the intestine is destroyed,
we are advised by Mrs. Cooper and Thompson
to cut away the slough and secure the tendons 
of the bowel together by four sutures, leaving 
the end of the ligature out that we can [dia??]
out and at any time examine the bowel. But 
the accumulation of fœces in the upper porton 
of the bowel is commonly such as to rupture 
the stitches, or at least to cause the escape 
of fœces from the gut into the general cavity.
I perceive that Mr. Cooper himself failed in two 
cases of this kind.
I should not ever try Mr. Cooper's way. I would 
leave the intestine out, and if the slough were not 
separated, I would open the bowel at the dead part
with the scalpel, to give evacuation to the feces, which 
is always profuse for the first 24 or 30 hours. The 
ends of the intestine would be gradually appoximated,
they would as gradually retract within 
the abdomen and the external wound heal up.
In July, 1798 a woman was attacked with a violent
colic and tumor in the groin, which continued 
several days. The physicians bled, blistered,

184)
and purged her, but the vomiting increased, the 
extremities became cold, the pulse small and feeble,
hiccough and swelling and hardness of the abdomen,
the tumor became hard, the colour of 
it dusky red. She had had a tumor in the groin
after severe parturition 2 years before, and it was 
plain that the hernia, which was femoral in this 
case was mortified. I made an incision through 
the skin and cellular substance, fœtid serum
and air passed from it, the tumor hung like 
an egg by a small neck; I next laid bare the tendon
and cut Pouparts ligament at right angles.
I next cut a hole in the gut, and introduced
my finger to the place of stricture.* The passage
through the bowels was [slow] by artificial means for four days. 
[cross out], the external 
coat of the bowel only, sloughed. On the 23d July
she was able to leave bed, and the bowel having 
retracted, the wound heald. Thus, an artificial 
anus was made, the gangrene was not complete,
neither were there two oricifices, but even
*This was followed by a copious discharge of fœces 
air by the orifice made in the gut. 

(185
if there had, they would probably have united.
When all the protruded intestine does not [in??tify],
and adhesions form round it a permanent
discharge of foeces may be established. I had one 
case of this kind in the P. Hospital some years
ago. I tried to accellerate the rectraction of both 
ends of the bowel by introducing a piece of bogie 
3 inches long bent up, one end being introduced 
into the two orifices, and gentle pressure was thus 
applied, but I found this not to succeed, as pain 
followed its use, and I performed a new operation,
which consisted in establishing a lateral communication
betwixt the ends of the bowel. I brought
the ends of the bowel in contact to the external
wound, and introducing the fore finger into one
and the thumb into the other, I found that the 
two coats moved on one another betwixt my finger
and thumb, so that I feared the adhesion 
was not extensive enough to permit an incision 
to be made betwixt the two bowels. To produce 
adhesion between them, I introduced a ligature
by means of a kneedle through the side 
of the two portions and brought them with

186)
some tightness together, such as might even 
have produced ulceration tho the space I
intended to divide, but the ligature caused so 
much pain that I was content with its producing 
adhesion as far as it reached. I next 
made a slit with the knife betwixt the two 
bowels which I had thus made to adhere, as large 
as the calibre of the bowel. The cavity of the sac
was dressed with a compress, and next day some 
griping was felt, and wind escaped per anum.
In 3 days more foeces passed freely. I next tried 
to heal the external wound by paring its lips, 
and introducing the twisted suture, but in 
this I fail'd, and a truss was the only inconvenience 
he had to submit to, as the natural 
route of the bowels was established; however, if 
the external wound had closed the truss would 
also have been nescessary. This operation being 
successful, that of Cooper is quite unnescessary.
The bowels may be allowed to adhere to 
the ring and lateral parts.
The omentum which forms a part in these hernia

187
is also to be reduced, but if it have mortified, the 
dead parts are to be surrounded by an incision 
through the living and removed. Any large vessels
which bleed may be tied, the end of the ligature 
being kept out. Mr Pott has thought this 
precaution unnesecssary, but alarming haemorrhagies 
have followed the neglect of it.
It sometimes difficult to tell whether or no the 
omentum be dead, and fatal consequences might 
follow the reduction of a mortified portion. It is 
said to feel crisp when dead, but the following 
marks may be depended on 1. The blood is coagulated 
in the veins of the dead portion. 2. The vessels 
of it do not bleed on being punctured.
Some have advised the adhesion securing 
the omentum in a string to prevent haemorrhage,
and even Pott recommended this, but it 
had produced nausea, vomiting, fever, pain & 
death, and therefore this plan must be exploded.
After the operation the wound is to be united by sutures.
The patient is to be confined to a horizontal 
posture, and cough is to be allayed by demulcents 
and opium, but the latter is to be 

188)
avoided as much as possible, as it retards the 
functions of the bowels. If nescessary, the bowels
may be opened with castor oil or salts,
and in some cases the bowels are so torpid & 
paralytic by the pressure they have suffered,
that they are not easily moved. In one case,
a swelling was produced by the accumulation
of the foecis above the wound, and went off by 
pressure again. This returned occasionally for 
three days and then subsided.
In some cases pain and swelling follow the 
operation. Bleeding, low diet, purging, blistering,
&c may be used as circumstances may indicate.
After the wound is healed the part must be 
supported by the use of a truss.
Femoral Herniae. This hernia we have observed, appears
on the upper and anterior part of the thighs
The contents of it pass under Pauparts ligaments,
and the tumor is small and moveable, and 
may be mistaken for a bubo or enlarged lymphatic 
gland. This mistake is very dangerous, and 

(189
yet has fallen out in the hand of every expert 
men. If a hernia were left to suppurate, or boldly 
opened as a suppurated bubo, how serious a 
mistake would be made! We read of men having 
died of ileus and a bubo!
In all doubtful cases of the kind, we ought to 
lay bare and examine the part. 1. The hernia is generally 
the lower, 2 in bubo, the edge of Paupurts ligament
cannot be felt, 3, neither can the pubis.
It is nescessary to know the true situation of 
the sac, as without this knowledge, we could 
not perform the taxis aright.
The bowels pass into the theca for the femoral 
vessels. They lie in the vicinty of of the pectineus
muscle, just over the fascia lata. The epigastric 
artery lies on the outside and the spermatic 
cord lies on the superior and anterior part
These two vessels cross one another. The obturata
artery sometimes arises in common with the epigastric.
The bowels descend first downwards, and then,
forwards at right angles with its neck. The taxis 
must therefore act inward and then upward, whereas

190
whereas in the inguinal hernia, the taxis acts upward
and outwards. This of great importance.
In this tumor we find 1. the skin, 2 the fascia,
3 the proper sac, or that derived from the peritoneum.
The inner edge of Pouparts ligament leaves 
a small aperture only, and the stricture in 
this place is very dangerous, and early open action 
is requisite. Cooper says if he were attacked 
with this hernia he would try the tobacco injection 
and if this failed, the operation!
The integuments are sometimes very thin, so that 
we are to proceed very cautiously thro these 3 membranes 
lest the gut be wounded. After this, the 
stricture is to be divided. In doing this caution
is required. If we cut inward the spermatic cord is 
wounded, If outwards, the epigastric artery, and in 
an upward direction, there is also some danger
of cutting the cord also, but let it be kept inward
that it lies 1/2 inch off, and this Ipace answers every 
purpose. Pinbuuat reccommended to cut the 
internal edge of the crural arch or Pouparts ligament,
but 1. the deep situation renders this difficult 
2, a director is required and the gut must be	

191
pulled with some violence aside 3. In some patients,
the obturator artery winds round the neck
of the Sac, and if wounded here it cannot be
secured as it can be if wounded over the middle
of the tendon. [See notes P and Q below Page 191.
I prefer operating on the middle of Pouparts 
ligament, on its anterior part, and at right 
angles with the ligament.
If the operator is fearful of cutting the spermatic
cord he may as A. Cooper advises dissect 
the cord loose ad have it drawn aside by a
hook before dividing the crucial arch.
February 2nd, 1812 Dr Physic
Notes on Lecture 37.
P. page 191... For nine out of ten cases of femoral 
hernia the patients are women, and in this 
there is not so much danger, as the cord in 
them is absent.
2. Page 191... When the epigastric artery lies 
in the way and is wounded, we can feel the 
pulsation of the vessel, pass a kneedle under
it and tie it. Feb 5th Recapitulations

192
Lecture 38.
Umbilical Herniae. We meet with it both in the 
child and in the adult.
In the infant the bowel often passes through the 
funis umbilicus. In such cases, it is to pressed up 
again, and the cord secured by a ligature. The edges
of the aperture may be approximated by adhesive
plasters, and they will often unite in a few days.
But sometimes it does not close for 3 or 4 months,
and the child by crying, straining, &c may cause a 
protrusion. I have met with 2 or 3 instances of this.
I have seen umbilical hernia in seven children in 
one family, yet in all the parts retracted and united 
well. This is the natural tendency of the parts, and 
can only be prevented by the presence of the gut, and 
this keeps the hole open, so that more gut may descend.
When the natural process fails, we are to treat 
it by an operation. 1. Compresses have been applied,
with a view of making union take place. They are 
secured by a roller passed round the body, but in 
this way the cure is detained for months; very incovenient 
pressure is made on the abdomen, the bowels

(193
bowels are even in danger of being protruded, the operation 
is very imperfect and difficult.
2. The ligature, which is the older method is recommended
by Desault. It is certain and expeditious
The patient being laid on his back with the thighs
and neck bent forward, the contents being reduced,
the sides of the funis are to be rubbed together to 
ascertain that all the contents are reduced. An assistant
now applies a waxed ligature several times
round the funis, making each time a double 
knot, and with such tightness as to produce moderate 
pain. Next day, the cord will be swelled 
just as a polypus after a ligature. 3rd day, it becomes
shrunk and livid. A second ligature is 
to be applied tighter than the former, producing
some pain, and a day after, a 3rd ligature
will compleat the mortification of the cord. The 
union of the mouth may be accelerated by adhesive 
plaster, and the circular bandage may be continued
for 3 or 4 months. This is found a very successful 
operation, and succeeds on young children
uniformly, best in those advanced nearer maturity,
it does not prove so fortunate.

194
This will best appear by the following cases,
which as well as the above operation are from Desault
1. A girl of 18 months old was operated on 
as above. The cord was shut in 7 days. Six months
after, there could be no vestige of the disease found.
2. A boy of 4 years old was operated on as above, the 
funis closed, but afterwards, the impulse of the bowels
could be perceived.
3. The latest period at which Desault operated was 
at the age of 9 years in a girl who had had it from 
birth. The the union was complete to appear and
in 3 mo. the swelling was apparent, and not 
withstanding the use of the bandage, in 6 mo. the 
relapse was complete. Therefore the operation is 
always to be performed early.
In Adults, according to Desault, the ligature
does not succeed. Having reduced the tumor by 
the taxis, pressure is to be made on the navel by 
Hey's truss. This is preferable to compress & bandage
as well as every other sort of truss. After this is 
applied, where any exertion is made the effect of the 
truss must be assisted by the hand.
[See note Pr. Vol. III p.3

(195
The other varieties of hernia woud require too long
time to explain them. They may be learned from 
books; it being my only to design to give a description 
of the nature of the most important kind
and the history of hernia in general. See Cooper
on hernia, and Lawrence.
Observations on the stone, perparatory to the 
demonstration of Lithotomy.
Stony concretions form in many parts of the 
body, as the salivary glands, the gall-bladder,
&c, but they are most usual in the organs for secreting,
containing and excreting the urine. This 
matter is often deposited on the sides of the pots in 
which urine is contained out of the body.
The quantity differs greatly in persons, some showing 
almost none of it, while others abound with 
it. I have seen the urine in a bowl incrust the 
bowl to 1/10 inch all round, in a scrofulous patient.
Now in such cases, it appears that a stone
will form at any time, when a solid body is introduced
into the bladder, serving as a nuclus 
for the matter to adhere to.

196)
A piece of lint, a bullet, a kneedle, &c have been found 
in the stone, and large masses of stone have formed round 
the end of a catheter. In the kidney, a coagulum of 
blood has had a similar effect. In sawing into a 
stone, it is generally found laminated, some stones
are very [hard] soft, and others are very hard, some are of a 
white, others gray, or brown colour.
The form commonly in the kidney and pass thence to 
the bladder, but they sometimes form in the bladder.
When after pain in the loins ceasing, the symptoms
of stone in the bladder commence, no doubt is 
left of the origin of the stone. A gentleman who 
had been troubl'd for some time with pain in 
the loins, on taking a ride from Germantown
to Phila. the pain ceased and the symptoms of calculus
in the bladder came on.
From a stone in the kidney, a dull pain in the loins
is produced. This, on stooping becomes acute. The urine
is often bloody. Inflamation with fever, costiveness 
and diminished urine with vomiting come 
on. If much dilution has been made, there is a copious 
flow of urine; or colic fever and suppression 
come on.

197
The efforts to vomit often press the stone into the 
ureter, which obstructing the passage of the urine, produces
great irritation. In fits of the gravel so produced, bleeding,
opium, blistering, warm bath and diluting liquors
are proper. The patient may stand, leaning forward, so 
as to bring the neck of the bladder immediately down
and pass his urine in a full stream and by this, the 
small stone may escape from the bladder. This is 
of great importance, and ought to be repeated, as it 
may prevent the formation of the stone.
A stone in the bladder produces pain heat and itching 
in the bladder, obstruction of urine frequently,
mucus or even puss will appear in the urine, sometimes
in large quantity. Bloody urine, especially after
excercise is very usual, and in some, the first symptom.
An uneasiness through out the urethra, especially 
at the glans, causing the patient to pull the prepuce
out, causing it to be elongated, prolapsus ani, &c are
common symptoms. By the suppression of urine, irritation,
distress and loss of sleep, the patient is soon 
exhausted of strength.
Other causes of irritation may deceive. Inflamation,
abscesses, ulceration in the bladder, tumors and

198
haemorrhoids in the rectum also have the same symptoms
as the stone in many cases. A woman laboured
under the symptoms of stone, and found no relief 
from the usual remedies. Suspecting an ulcer in 
the neck of the bladder, I ordered mercury till the 
mouth became sore, and all the symptoms vanished.
In another person all the usual symptoms existed,
and continued till death, when a tumor was 
found in the rectum. This, if it had been known could 
have been cured by an operation.
Stone may exist in the bladder and produce little 
or no uneasiness. A man who had a stricture in 
the urethra, and had not suppression, only a diminished 
stream of urine, and no other symptom referrable 
to stone, being prejudiced that he had a stone, 
underwent experiments such as jumping off a 
table, riding of a a rough-going horse, &c and no irritation 
or bloody urine being produced, but the stricture 
prevented sounding. After his death a rough stone 
as large as a walnut was found loose in the bladder!
The only certain criterion is sounding, or the introduction 
of a bent, iron instrument into the bladder,
which when it comes in contact with the stone

(199
produces a tingling fell, and may be heard. This 
operation may be repeated in various ways, through we
do not feel the stone at the first trial. First, let the 
patient stand, if this fail he may lie down. The finger introduced
into the anus may bring the stone into the way
of the sound. A man in this city had symptoms of the 
stone, and no stone could be felt on sounding. He 
went to London and was sounded by Mr. Hunter, but 
without any success. He returned, and applied to me. I 
succeeded by putting him to bed, raising the buttock
so as to throw the stone into the fundus of the bladder.
Having ascertained that a stone exist, no remedy 
can be depended on except lithotomy. Medicines introduced
into the stomach or injected into the bladder
have long been tried. From the effects of akalis on
a stone out of the body, they have been introduced in 
to use. Soap, aqua nephritica alcalina, carbonated
soda &c lessen the pain for a time only. In one case
they seemed to have succeeded. Unequivocal symptoms
of stone existed in a child. Sounding ascertained it 
beyond all doubt. The weather being warm, the operation 
was defferred, and the aqua mephritica alcalina

200)
alcalina was given, and to my utter astonishment, the 
symptoms of stone disappeared, and never returned
again. What became of this stone, it if were not 
dissolved, I do not know. Some other remedies besides
the above give temporary relief, such as lime water,
and uva ursi. But while these are used, the symptoms
will always return unless the stone become encysted,
which effect cannot be attributed to medicine.
Injections, capable of dissolving the stone in the 
bladder have be keenly sought after. But they are 
incapable of affecting the stone unless of such activity
as to cause inflamation and sloughing in 
the bladder.
The best palliatives are small bleedings, warm 
bath, demulcents and opium, which must be 
diligently used when the irritation of a stone become
at any time aggravated, constituting a paroxysm 
of the stone.
Dr. Physic
University of Pennsylvania
February 5th 1812.
END OF VOLUME II.







56
WILLIAM M'LANE
No. 27





Hic libeo pvetinet ad editorem
Gulielmo Madane



Memoranda
From a 
Course of Lectures
on 
Surgery.
Delivered in the University of Pennsylvania
By Philip S. Physick M.D. Professor, & 
John S. Dorsey, M.D. Adjunct Professor
of Surgery in that University
By Wm M Lane
Vol II.
1811 & 1812



Memoranda &c
Lecture 20.
Fractures of the lower end of the humerus
are generally transverse, and these are 
sometimes complicated with a separation of 
the condyles of the bone.
Either one condyle is separated from the bone 
alone, or they both are. They are easily detected,
in their superficial situation, by the 
fingers. If we take hold of the condyle or 
condyles, we can move them very easily in 
any direction, and a crepitas will be heard.
A bandage is to be aplied from the hand to 
the elbow, and, extension and counter extension,
used; the condyles are now to be brought 
into place, and the bandage continued up
the arm. The arm is now to be brought to 
right angles, and the rectangular splints 
applied laterally, and straight ones, bent at 

4
the middle, applied before and behind,
and the bandage carried over the splints, down 
to the hand. In 8 or 10 days, the apparatus is 
to be removed, and the parts examined, & 
if any derangement is found, it can be 
rectified.
Fractures communicating with the cavity 
of a joint are longer in uniting than others:
in general, this will unite in 5 or 6 
weeks. When treated in this way alone, we 
always find a deformity: the natural an 
angle which the arm and forearm form 
with one another, the point whereof is downwards
when the arm is extended, is reversed
and the point is now upwards. To avoid
this, after having kept the cubit an right 
angles for about 20 days (as above) it is 
to be extended, and, splints having a 
downward angle, such as the arm naturally 
forms are to applied before and behind,
and the roller carried over them as above,
and this apparatus kept on for 4 or 
5 weeks longer. In this ways I have preserved

5
one arm in perfect shape. The only hazard 
which attends this apparatus, it that anchylosing 
is not a rare accident in such fractures,
and, if it were not for this, the arm ought
be kept extended from the beginning; but 
it being well known that if anchylosis occur
in a straight posture, the limb will be
useless, whereas, in the [cross out] flexed, it will be 
be very serviceable. After the arm is extended 
the state of the joint is to examined every 4
or 5 days, and if anchylosis is found to begin,
we must bend the arm again. When
the bony opised to the humerus are both injured,
we may expect to presever the joint
in most cases, but if either the radius or 
ulna is injured, as well as the humerus
bony union may be expected in the joint.
Fractures of the Bones of the Fore-arm
A. Of both the bones. This generally happens in
the middle of the bones. The seldom pass one another
much, and the [cross out] the derangements
they are most subject to is the angular, and this is 

6)
mostly inwards Counter extension is to be made by 
one assistant, holding the humerus just 
above the condyles, while another makes 
extension holding the hand just as we do
in shaking hands. The surgeon can now
place the ends of the bones in place with his 
fingers, and applies a roller from the 
hand up to the elbow. The arm is to be in 
a flexed posture while this is a doing. A pair
of splints broader than the forearm is drop
are now to be applied one on the front & 
the other behind, and secured by the reflecting
of the roller. The splints are best made
of stiff (not wet) pastboard, or wood. The 
arm is to be suspended by a sling. The thumb
may be left out, that it may shew us the
state of the arm, as to rotary derangement
and if the roller is too tight, this will swell,
and teach us to slacken it. The first roller
must be slacker than usual, lest the fragments 
be pressed together, and thus destroy 
the rotary motion of the radius on the ulna

7)
whereas the second roller, may be pretty tight,
to press the splints tight against the arm, and 
impact the muscles between the bones, and 
keep the latter asunder. In 8 or 10 days, the state
of the parts may be examined, as in other cases
L. Fractures of the Radius. This bone may be
broken at any part, but the most usual place 
of the fracture is about one inch above the 
lower head of the bone. The hand moves with 
difficulty in these cases, an angle inwards is
generally formed. The luxation of the wrist
may be confounded with this, but when the 
fractured parts are examined closely, certain
information may be had. The wrist may be 
bent freely without any motion at the part.
Extension and counter extension, as above
being applied, and the bone reduced, the same 
apparatus as that used when both bones are 
fractured is required. The splint must reach 
beyond the fingers as in the above case, to keep
the arm and hand quiet. This is very important
in both cases.

8)
Fractures of the Ulna. This is by far the 
least common of these accidents. I have never
seen any but two cases of this. One was produced 
by warding off the blow of a club, and 
the other by a fall on the bone itself. This 
bone is very thinly covered, and therefore, this 
accident is very easily detected, by feeling,
moving, and hearing the crepitus of, the fragments
The treatment is the same as in the 
former instance of the fractures of the 
forearm. In 3 weeks the bone will unite,
but it is best to wait 4 or 6 before removing 
the apparatus.
Stiffness of the wrist and fingers is very 
apt to occur especially in old persons; but 
this goes off naturally in some time. The 
splints may be taken off every 4 or 6 days, to 
bend and extend the fingers gradually.
Fractures of the Olecranon. These are produced
by direct falls on the elbow. They are 
very easily discovered. The power of extending 
the arm is lost, as the biceps extensor cubiti

(9
is now unable to act on the forearm. The olecranon
may be easily felt, and if the arm be extended,
the olecranon may be moved in all directions.
The treatment is as follows. The forearm 
is to be extended for the purpose of relaxing the 
triceps, and to let the point of the olecranon
occupy the pit on the posterior side of the humerus,
which it naturally occupies. A roller is 
now to be applied from the hand, and as soon 
as we arrive at the elbow, the skin is to be tightened
over the fracture, by pulling it up, lest 
it should fold between the fragments. (In 18 
or 20 days, the arm may be gently bent and 
extended.) On the front of the arm, one long splint
is to be applied over the first roller, and 
is to apply itself round the arm a little. If any 
considerable inflamation follow, the bandage
may be made slacker, and and the diet reduced 
very slow, and blood may be taken from 
the other arm
c. Fracture of the coronoid process of the
Ulna. I have never heard or read of a case of 
this kind, and I never met a case of it but

10)
one. This was mistaken for a luxation,
as the humerus was thrown forwards, and 
the olecranon felt above the pit for recieving
it. The parts were very easily reduced,
and while I was preparing a bandage, &c. I 
was astonished to see it stontanously luxated 
again. This was soon reduced, and 
perceived the crepitus. The coronoid process
being the only obstacle which keeps the 
triceps from luxating the arm, this effect
may easily be explained when the 
process is broken. I secured the arm at 
right angles, and allowed the humerus 
to rest in the hook like process of the [illegible]
for 15 or 20 days and then the splints
angular downwards, and the childs arm 
grow without deformity. This case first
suggested these splints with the angle 
downwards, which I have used very much
since.
Fractures of the Ossa Metacarpiaria
from direct violence, and are very easily

(11
discovered. The extension and counter extension 
are to be made from the [cross out] wrist and 
fingers, and retained by a broad pasteboard, 
applied in front and secured by a roller, the hollow
having been filled up by the introduction 
of some flannel or to betwixt the splint &
palm of the hand. A wooden splint, which 
will reach from the middle of the cubit, and
in which there is an excavation exactly in
shape of the arm, hand, thumb and fingers,
(if at hand) will answer rather better.
Fractures of the Fingers are very easily 
detected, and reduced. They require only one
small pasteboard splint in front. These 
fractures will unite in two or three weeks.
Decemb 23rd     P.S. Physic.

12)
Lecture 21.
Fractures of the Femur. This bone 
may be fractured in any part of its length,
but is very frequently fractured in its middle.
The upper end, even so high as within the 
capsular ligament is sometimes broken & 
then, the upper fragment is within the cavity 
of the joints. The lower end, just above 
the condyles is sometimes separated, in some 
of these, the condyles are separated; and there
are cases wherein one condyle is removed from 
the body of the bone.
This accident may be very easily detected, the 
motion of the limb is nearly lost, yet there
remains some power of moving the ancles and
toes, so as to deceive the patient, but if he attempt 
to raise the leg, the fails, and convulsive
twitches follow. The limb on comparison 
with the other will be found shorter, and 
on holding the leg, and moving it a crepitus is 
heard.

(13
This fracture is sometimes transverse, but it 
is generally oblicque, downwards and forwards
The lower portion in such cases slides above and 
behind the lower one.
Many means have been proposed, for keeping
this fracture in place. The object of all of them is
to keep the ends of the bones in relative opposition,
and prevend displacement and shortening
till the bones unite. They are as follows.
I. It has been proposed to treat this with simple
bandage and splints as other long bones
but this will by no means answer.
II. To place the limb in a position calculated
to relax the muscles of the limb.
III To maintain permanent extension and counter
extension, and keep the ends of the bones in 
contact.
The first practice was to apply a bandage and 
splints, and this bandage, tho so tight as to 
cause swelling of the limb did not prevent displacement, 
as I have, my self seen. The only 
use of the bandage is to prevent contraction in the 
muscles, and to give support to the veins and 


14)
lymphatics: They can answer no other good purpose.
The femur is so thickly covered with soft 
parts, that unless the fracture be transverse
or the fragments interlock, the bandage cannot 
prevent overlapping.
Mr. Pott, using the sweep of the straight position 
to be such, proposed to lay the patient 
on one side, to bend the thigh on the trunk
and the leg on the thigh to right angles, so 
that by relaxing the muscles of the limb,
he would take off the irritation which induces 
the muscles to contract, and pleasing 
as his proposal is, practice teaches us the 
following inconveniences arise from it.
1. The position is irksome and fatiguing, & 
and if the patient be so resolute as to maintain 
it thro' the day, he is sure to sleep on 
his back at night, and the bones must 
be set every morning, and inflamation will 
be thus produced.
2. We lose the advantage of measuring this 
with the sound limb, which is indeed the only

(15
only true way by which we can judge of the state of 
the bone, it being so deeply covered, that our faling 
quite deciptious.
To join the benefit of the flexed posture with the 
position on the back, a bone had been contrived,
consisting of two boards, joined together at right
angles at the end, and secured be angular stay 
this was introduced under the hough, and the leg
lay on the one square, while the thigh lay on 
the other. I have given this a fair trial 10 or 12
years ago, but I always found one side of the 
pelvis to shift forward, and allow the bone to 
over lap. By supporting the other limb in the 
same way, no benefit was obtained.
I have been led to prefer the extended posture. The 
objections to have been mentioned. Tho a very 
irksome irritation and fatigue occurs, the muscles
accomodate themselves to it in 2 or 3 days,
The heel sometimes inflames and sloughs by 
the continued pressure, but a little attention to 
this will prevent it. As soon as it is found to 
become sore, it may be rubbed with brandy and 
defended with sticking plaster spread on leather

16)
or a compress of 10 or 15 folds of flannel, and 
with a hole in the middle for the heel will 
answer completely.
The last method is permanent extensions
Many means for this purpose have been tried.
The foot being secured to the foot of the bed,
and another roller round the axilla, and 
secured to the head of the bed, extension had 
been kept up; but they produces unsupportable 
irritation and cannot be borne.
It is much better to apply the apparatus
to the bone itself. Weights have been suspended
from the [cross out] thigh over a pully near
the bedside, and extension thus produced,
but I have seen this tried, and no good
effect whatever followed. It only drew the patient
to the foot of the bed. Many other 
apparatus have been proposed, but most
of them are too complicated for as [cross out]
prompt an accident.
But the most certain and the most simple
apparatus, is that of Desault. I have

(17
used it for 12 or 14 years in my private practice and 
in the Penn Hospital, and in most, if not all 
cases, preserved the length of the bone. I shall 
now demonstrate this apparatus.
The bed is to be bottomed with tight-braced sacking
or boards, and to be without a foot board,
An oval hole is to be left in the bottom of the bed
as well as in the matrass for a close stool. They 
may be occupied by an oval cushion, and supported
by a stool under the bed. The sheet it to
be without a wrinkle, and no more than one 
pillow used to support the head, else the body
will press on the limb, and derange the bones
The apparatus is to be laid on the bed in 
the following order. 1. Four or five tapes in 
the length of the thigh 2. The junk-cloth,
or piece of linen or muslin, as long as the thigh,
and it may be broader, (with the convey 
corresponding to the groin folded in). 3 a splint
of pasteboard for the back of the thigh. 4 The 
bandage of strips, each 2 or 3 inches broad and long 
enough to overlap over the thighs and sufficiently 
numerous to reach from the

18)
knee to the groin overlapping over one another
a little 5. The bandage for counter 
extension is to the laid down. This may be
made of silk, or of leather, sewed up into a 
tube and covered with oil cloth. 6. The bandage
for extension is to be laid at hand.
7 The post-board splint for the anterior part 
of the thigh is to be prepared. 8 Two bags of 
chaff as long as the limb, or flannel folded 
8 or 10 times would answer. 9. Two wooden 
splints, one for the outside of the thigh,
and the other for the inner. They are to 
reach from the six inches below the foot, 
and the outside one reaches to the crest 
of the ilium according to Desault, but 2
have extended it to the axileau, and then 
made a head like that of a crutch on it. There are
two holes near the head of this splint,
for the bandage for counter extension.
The limb is now to be laied on the apparatus,
and the latter applied as follows. Each 
of the long splints is to be rolled in the 

(19
junk-cloth from the edge, so as to apply to the 
side of the thigh, and the bags are to be laid 
on the inside of the splits, and they thus applied.
The bandage for counter extension is now 
applied in the groin and carried before and behind,
and carried thro' the holes in the long splint 
and tied. The bandage for extension is next applied 
on the back of the small of the leg, crossed 
on the [cross out] instep, knotted on the sole &
carrid over the block near the end of the outer
splint and tied in the hole on the splint.
Extension is now to be made, and the limb 
is to be compared (at the ancles) with the other,
and we must observe that the anterior 
superior spinous process of the ossa ilia
are not out of their place, and consequently 
that the pelvis is not aslant.
The proper extension having been made, the 
bandage for extension is to be secured. The 
bandage of [cross out] strips is next applied, beginning 
at the knee, and reaching to the groin,
the splint of pasteboard is to be applied on

20)
The fore part of the thigh and the tapes are 
now to be tied over all. It is obvious that 
after the bandage for counter extension is 
applied the surgeon himself can make 
extension merely by pulling the bandage
for extension, and pushing the splints.
Decemd 27th            P.S. Physic
1811
Lecture 22.
Fractures of the Neck of the Femur.
This may happen either within the cavity of 
the capsular ligaments or entirely without 
this. In all these cases, the limb is rendered 
shorter;- in a very few cases, the fragments 
interlock one another so that no immediate 
shortening occur, yet in all these,
the shortening occurs before two or three 
days. The limb is always turned outwards,
and if any attempt is made by the patient

(21
patient to raise the leg or foot, he fails and nothing 
but pain and convulsive twitches follows.
If extension and counter extension be made, the 
limb can be brought to its full length, and as 
soon as this is quit, the limb relapses to its 
former shortness. If the hand be applied over the 
trochanter major, and the limb rotated, the
trochanter will not make any great sweep, especially 
if the fracture be near the body of the 
bone: whereas, if the neck be not broken, there 
will be a considerable arc described, the radius
whereof is as long as from the bottom of the 
acetabulum to the outside of the trochanter.
This accident may be confounded with 
a contusion, or a dislocation; but the diagnosis
is very certain. 1. In contusion, the pelvis 
will be tilted up on that side, and I have seen
this prove very deceitful. In an hospital at 
York, a patient was supposed to have a dislocation,
and a consultation of surgeons was 
held on the occasion, and they were not convinced 
till (6 days after) the patient walked freely

22)
freely. But if we place a stick on the superior 
anterior spinous processes of the ossa ilia,
we immediately detect the shifting of the 
pelvis and know that it is only a contusion
2. For dislocation upwards and backwards
the limb is shortened, but we cannot so easily
bring it to its length, and if we do,
the bone will not return, but be in place 
&c. I have endeavoured to explain this minutely
because accidents of this joint and the elbow
are often very obscure.
The treatment is the same as in oblique
fractures of the body of the bone. The hole in 
the matrass is particularly proper, as there 
cannot be any motion in the pelvis without
deranging the bone, and inflamation 
may be excited, which, as I have seen, may 
suppurate if rest be not maintained. If any
inflamation appear, bleeding and low diet 
may be enjoined.
When the injury is without the capsular 
ligament, the bone may unite well, but if

(23
it be within this, nothing but a ligamentous
union can be expected. In a case of this kind,
which I dissected long after the fracture, a very curious
process of nature is to be seen: the neck of the 
bone was absorbed, the body came nearly under the acetabulum,
and sort of ginglimus joint, with cartilage,
&c was formed
I am now to specify the improvements which I 
have made to the apparatus of Desault for fractures
of the thigh. His external splint only reaches 
from the crest of the ileum, and the bandage 
for counterextension goes obliquely from the groin
to this, and this tends to derange the upper fragment 
outwards. So avoid this, I have extended it 
to the axilla, and after the bandage is on, a strip
of [cross out] bandage is tied to this, midway betwixt 
the groin and splint before and behind*, just so 
tight as to make the bandage act in the line of 
the thigh. The upper end of the splint is made 
like a common crutch and covered with flannel
as a square head would tend to hurt the arm
In
*going over the other side of the abdomen 

24)
In Desaults apparatus, the foot is forcibly 
drawn against the [cross out] splint, and very considerable 
inconvenience follows from this.
I have adapted an innovation of the late Dr. J
Hutchison, to avoid this. It consists in a block 
of wood, which being placed near the lower 
end of the external splint, has a notch
to receive the bandage for extension; so that 
the extension as well as the counterextension
are is thrown in the line of the leg and thigh.
Having applied the apparatus, an inexperienced
surgeon may draw the bandage too 
tight, and produce pain, exoriation, and 
even sloughing, having ulcers over the 
tendo achilles and instep; and the apparatus 
must then be removed, therefore, this 
is to be avoided. When the muscles contract 
strongly, very little force is proper, as by 
doing so, more irritation is induced. After
some days, the force may be gradually increased.
If tenderness or excoriation come 
on, (which is very common, especially in

(25
children) spirits, as brandy may be applied, the 
parts may be covered with adhesive plaster on 
leather, soap plaster, or what is best of all, a 
small buck skin gater, cut away at the heel,
and laced up the instep (with a strip of the same 
material to guard the instep from the whang
strips of buck skin may be fastened to the under 
part of this, thro' holes, and used as the band for 
extension.- Any bandage will soon fold together
like a rope and act very severely, therefore, this 
method is peculiarly proper to defend the skin.
Mr John Bell, in his book, represents the 
apparatus of which I have spoken, as cruel
and useless, and the error he has committed
is truly astonishing. In reading his book, you 
will reflect that he has never seen Desaults
apparatus applied by one who understood it.
He also says that when the femur is broken
in the middle, the lower portion is never displaced"!!!
The lower end of the thigh bone, just above 
the condyles is not unfrequently fractured.

26)
These fractures are generally oblicque,
forwards and downwards, and in these cases,
the upper fragment projects just above
the patella, and the lower is drawn backwards
by the gastroenemic muscles, and 
the bones are laterally deranged by the leg.
Having applied a roller from the ancle up 
and reduced the fracture, a pillow is to be 
applied in the hand, a compress on the hand
over the lower portion, and a splint is to be
applied in the hand, reaching from the 
middle of the thigh down to the middle of the 
leg, and Desaults apparatus may be also 
applied with a moderate of tightness, and 
the rest of the fragments is sure.
When the condyles are separated from 
one another, the treatment is the same as 
above, except that there is no use for the 
compress in the hand, unless the under portion 
be displaced backwards. Any fracture 
of the thigh requires the apparatus for 6 or 8 
weeks, while that within the capsular ligament
of the acetabulum, requires at least

(27
three monts. If it be removed before this, there 
is danger of the callous of ielding, and producing 
deformity, specially in fractures of the neck of 
the bone. P.S. Physic
December 30th
Lecture 23.
Fracture of the Patella. It is very seldom
that these happen in any other direction there 
transversely: however, I have seen then longitudinal
and also oblicque. Transverse fractures
generally happen by the violent contraction 
of the extensor muscles on the anterior 
part of the thigh. Oblicque and longitudinal 
fractures happen mostly from external 
violence directly applied, as in falls, blows, &c.
When the patella is transversely fractured,
the power of extending the leg is lost, also the 
power of walking, and if walking, he falls.
He may however walk sideways, or backwards.


28)
backwards. The transverse fracture produces very 
great displacement of the fragments. The 
separation is very easily felt. The upper
portion may be brought down by our exertions,
and rubbed against the face of the 
lower. The separation arises from three
causes: 1. The extension of the thigh, 2. the
flexion of the leg, 3 the contraction of the extensor
muscles of the thigh. When these causes 
unite, the fractured portions may separate 
5 or 6 inches. The only cause in which 
the parts are obscured, is when after great 
external violence, blood is extravasated &
forms ecchymosis over the part. The cellular 
substance is so lax, that the blood
may be pressed aside by the fingers.
The bones can only be approximated by 
opposing all the causes of displacement.
The thigh is to be bent on the pelvis, and 
the leg extended. After this, the fragments may
be brought nearly, or altogether into contact
The apparatus is designed 1 to keep the upper


(29
upper fragment down, by acting directly on this 
and the lower 2. To maintain the limb in the 
position mentioned. The apparatus always requires 
to be extemporaneous, and therefore simple.
A bandage is to be applied from the ancle to 
the knee, to support the vessels, the body being in 
a horizontal posture, the whole limb is to be raised
so as to relax the thigh on the pelvis, and the leg
is to be supported with pillows, or what is better,
a board reclining, and cover'd with a bolster. This 
posture is preferable to raising the body, in as much,
as it takes off the determination of blood. The 
above posture, tho' irksome, is supportable after 
some time. The fragments being pressed together,
a compress is to be applied above the upper, and below 
the lower, and to be secured by the bandages
turned in the figure of $, meeting on the hand,
the skin over the patella is also to be supported
by a turn of the roller, and it is then to be carried
as high as the groin, for the purpose of 
of suspending muscular contraction in the extensor
muscles.- It is also worthy of attention 
to draw up the skin over the patella, so that

30)
it will not insinuate itself between the fragments.
A long splint is now to be applied to 
the posterior part of the leg and thigh,
(covered with flannel) and the same roller is to 
be carrid down again over the splint to the 
ancle. The limb is to be supported with the 
pillow and board, as above described. If pain 
supervene, bleeding is proper. [See note J. p. 35.
If we are not called in till some inflamation 
has come on, the drawing down the muscles,
would only irritate them, but we must 
wait till by bleeding, elevated posture, lead-water 
poultices, &c we have removed this, &
then apply our apparatus. If put on before 
violent inflamation, is over or even anchylosis may 
follow.
As the roller which accury the compress
is found to press on, and impede the vessels,
Dr. Dorsey has contrived a splint, on the midde
of which two bandage are nailed, 4 or 5 
inched asunder, which being applied on the 
back of the limb, the bandages are brought 
over the compreses, and pinned or sewed

(31
over the compress. The lower bandage goes over the
upper compress, it visce versa, and below this is 
applied, a roller goes simply from the ancle to 
the groin, and the compress are applied. This 
I find very convenient.
In two weeks, (or less in case of inflamation) the 
bandage is to be removed to rectify any derangement;
but the weight of the body is not to be 
rested on before less than 3 months.
The union in all these cases is ligamentous, and 
not bony, tho' it is said that if the bones be kept
in perfect contact, they will unite by bone
I have seen the ligament two or even four inches
long. If bony union took place, the joint might
be lost by anchylosis, and in cases when the
under bones are injured this may be expected,
and in this case, after 16 or 20 days, the limb
may be gradually moved to prevent anchylosis;
which, however, I have never seen in this 
case.*- When no means are used to keep the 
fragments together, they will go 5 or 6 inches
as under and the power of extension will be
*see note H.p.35.

32)
lost. But by seating the patient on a table,
with the legs hanging down and making 
attempts toward extension every day
Dr Hunter succeeded in the case of a lady &
this practice deserves imitation.
Fractures of the Leg. These are mostly
transverse, but in some cases they are oblicque
In the first instance, no shortening of the 
leg occurs, but the leg is bent angularly
forward, if both bones are broken by the 
action of the strong muscles on the posterior 
of the leg. This accident is easily detected 
also, by the feel, and by the grating.
In cases of oblicque fractures, unless the 
fragments interlock, the leg will be shortened
from 1/2 to 1 inch, as will be found on
comparing it with the other leg.
Extension, and counter extension are to
be applied, and the bones are very easily 
replaced. They are to be retained by splints &
bandage till the bones have united. Permanent 
extension is not required in this case

(33
The apparatus is to laid in order on the bed,
as in fractures of the thigh. The leg is suported 
by a board, with a pillow: On this is laid the
bandage of strips, as long as the limb, from 
the knee. On this, two pasteboard splints,
soaked in warm water, and rolled in soft linen
is next applied, and lastly, a bandage of 
strips, similar to the former is laid over this.
The patient is now to be conducted to bed, and the 
surgeon is to preserve the posture of the limb, he 
is to carry it by the knee and ancle, and he is 
to keep it extended while carrying. It being 
laid on the bed, the first bandage of strips
is to be applied from the ancle. If the limb 
has been deranged, as soon as laid on the dressings,
extension and counter extension are 
to be applied and the bones reduced. The bandage
of strips is then put on, next the splint
which are to reach at least from one inch 
below the sole of the foot, to prevent lateral
displacement by securing the lower fragment
and they are to be applied over the sides of the 
leg, and secured by the bandage of strips,

34)
first laid down. This I prefer to tapes which 
are use'd by some, but they press very unevenly.
The foot is best supported by by a 
a bandage put round the toes and carried
up on the leg. The pillows are now to be 
supported by two pieces of shingle, and 
secured by pices of tape passed around the 
shingle, bolster and limb. The state of 
the parts, as in other cases is to be examined 
in eight or ten days.
January 1, 1811          P.
Notes on Lecture 23.
H. p. When after fracture of the patella, if
from external violence, it is required to bend
the leg on the thigh, before the union is perfect,
to prevent anchylosis, this precaution
is very necessary, viz. while very gentle and
limited motion is made, the fragments of 
the bone must be pressed together with
the fingers, lest the new formed parts should
give way.


(35
I. p.30 In all cases of fractured patella, particularly
in those from external violence, it 
is nescesary not to apply the bandage too tight
as this would be very injurious.
Lecture 24
In the subject of fractures of the leg,
one circumstance remains to be explined.
When the fracture of the bones of the leg 
is so oblicque that they pass one another
after reduction and the application of splints,
it is nescessary to apply permanent
extension, else shortness and deformity will
follow. [cross out]
Desault has described an apparatus for the 
purpose in question; and Doctor James Hutchison
has improved it very much, so as to 
make it fully answer our purpose. Two 
splints of boards are to be provided. In the upper
end of these, is a [cross out] number of gimblet
holes, and the lower ends of the splints are 


36)
joined by a cross bar.
1. A pillow is laid on the bed, and on it a bandage 
of strips. 2 The leg is to be laid on this, & 
and a bandage for extension passed around 
the leg, crossed on the instep and tied in a 
knot on the pole. 3. Two tapes are to be applied 
on each side of the leg, and secured by
a roller passed around the leg just below 
the knee. 4. The tapes are now to be put thro'
four holes in the splint, on each side and 
tied. 5. Extension and counter extension are 
applied, the bones reduced, and the bandage 
of strips applied on the leg. 6. There is to be 
a bag of chaff applied on each side of the 
leg, and the splints appied close along 
these. 7. The bar to join the end of the splint 
is to be introduced thro' the mortines in 
them, and the bandage for [cross out] extension 
is to be tied over this with whatever 
degree of force is required.
Thus, whatever degree of force is required,
may be applied, and all causes of displacement
counteracted.

(37
In all fractures of the leg, the weight of the 
bed clothes has a tendency to displace the bones.
This may be kept off, either by three nail-rods
bent into a semicircle, and the points driven 
into two pieces of wood, which serve as basis,
and lie parallel to the limb, or by a more extemporaneous,
tho less steady machine viz
two segments of the hoops of a flour barrel,
each two thirds of a circle, and tied together at
the middle, this sit up is a cross over the leg
will support the clothes.
In compound fractures of the leg, this apparatus 
is very serviceable, as it allows, to dress the 
sore, without undoing the apparatus which 
keeps the bones in place.
It will not be required to apply this apparatus
during much inflamation. If the 
pressure of the roller below the knee causes 
swelling, which it sometimes, tho' seldom, does 
Desaults apparatus for the thigh, which makes 
extension on the tuberosity of the ischium may
be used.- The action of the four tapes on the roller
below the knee, keeps the pressure in some

38)
measure off the lateral vessels.
In women the short apparatus will be 
very convenient, as the long apparatus reaching 
to the pelvis is not very suitable to 
their taste. The fracture box, with a thin 
pillow introduced into it, is very well adapted
to keep the leg steady. Tapes are tied around 
it after the limb is introduced. It has 
a double bottom, and when it is required to 
raise the leg, any body may be introduced
under one end of the bottom for this purpose.
The bottom is excavated for the leg.
It is very common for wet applications
to be used to reduce inflamation of the 
leg as a solution of sugar of lead, this with 
vinegar and a little spirit, vinegar and spirits
alone, vinegar and sweet oil; but these 
remedies are of little consequence, and bleeding 
is the best means to reduce inflamation
In cases of ecchymosis, vinegar and spirits
on the principle of coldness are the best means
to promote absorption.

(39
Ruptures of the tendo achilles are generally
produced by great bodily exertions, in which 
the gastrocnemii muscles are exerted, as in dancing,
going up stairs, &c
The patient feels as if his heel has sunk 
into the floor, a crack is heard, and the patient 
falls down. The powers of the gastrocnemii muscles 
is quite lost, yet by some other muscles 
he can extend the foot a little. * [Sec Note Th p. 43
The leg is to be bent on the thigh, and the foot
extended on the leg, so as to bring the ends of the 
ruptured tendon nearly into contact, and to 
retain them so till union has taken place.
Doctor Monro describes the following means 
to maintain this posture. A piece of Russian 
sheeting is secured round the leg, long enough 
to reach half way down the leg. A slipper is 
next put on the foot, and a strap fastened
to the heel is to be carried up the back of the 
leg, and secured to a buckle on the back and 
inferior part of the sheeting. Thus, the belly 
*See wounds of the Tendo Achillis V.I p.116

40)
of the muscle is compressed, and prevented 
from acting, the lower portion is drawn up, &
the upper down, and the ends are tolerably well
kept together.
Dr. Monro met this accident himself, & 
succeeded in covering it by the above apparatus.
You will perceive on reading his account, 
the great difficulty experienced, and 
a very considerable lump was left on it.
One very great difficulty attends this mode 
of practice. The foot being at liberty to 
move laterally is very apt to derange the
lower fragment. To remedy this, I prefer the 
following apparatus.
A splint of wood is carved in such a 
manner as to adapt itself to the anterior
part of the leg and foot.
1. A roller is to be applied under the knee 
and after being carried half way down the 
leg, is carried up as high as it began.
2. The splint, lined with soft linen or flannel
is applied on the anterior part of the  

(41
leg and foot. 3. The roller is now reflected halfway 
down the leg, carried the same height, and pinned 
4. Another bandage is applied on the lower part
of the bandage* and foot; some turns of it may 
surround the heel, but not make any pressure
on the tendon, as this would derange it very much,
5 The vessels of the finall of the leg may be supported 
by a few turns of the roller, but these 
must be very slack, and it is best to support 
the tendon by compress of tow or lint.
The limb is now to be supported on a pillow 
for 6 weeks when the union will be but soft,
but no weight of the body is to be intrusted
to it before ten or twelve weeks.- Doctor Monro
was not able to use his leg completely before 
four or five months.
Having complated the history of the ruptured
tendo achilles, I shall now introduce
some observations on an accident little understood.
Persons after carrying a heavy burden 
on the shoulders, leaping, &c hear a crack
*splint

42)
referred to the calf of the leg, they are not 
able to raise themselves on the toes, yet
it is possible still to walk in a hobling manner
without raising the heels. I have never 
had an opportunity of dissecting a leg, after
this accident, but it appears to arise 
from the separation of the muscular fibres
of the gastroctemic muscles from the 
tendon to which they are united. In one 
case, I have felt an evident pit at the seat 
of the injury. From the pain and uneasiness 
in walking, patients will keep themselves
quiet for 8 or 10 days, they then walk 
about and a complete separation again
recurs. He confines himself for far a similar
line till easy, and again walks, &
after this many such courses, I have seen
patients miserably perplexed. One man 
was nine months in this way, the leg was 
swelled, and his health very bad!
The carved splints will answer very well
here. The foot part must be so deep as to restrain

43
restrain the lateral motions of the foot completely.
A bandage is to reach from the ancle to the 
knee.
In course of 5 or 6 weeks, a confined motion 
may be allowed, as the tendon will be tolerably
strong.      P.SP.
Jan 3. 1812
Note on Lecture 24.
K. p 39 Rupture of the tendon of Achilles
are very easily detected also by the fingers.
A very great vacuity is felt in the tendon.
However in cases of great swelling this 
may be obscured.
Lecture 25.
Fractures of the Tibia alone. As the fibula
is entire, the length of the limb is unaltered.
When the fracture is transverse, it is often
very difficult to discover the presence of the 
injury. There is generally sharp pain, and unevenness

44)
unevenness at the part, by trying to bend 
the tibia, an angular projection, and a 
chinck may be felt. It is of importance to 
know the presence of this injury in all cases
as it will be very dangerous to treat 
it only as a contusion. A patient of mine,
after I had reduced an accident of this kind
was not satisfied that his leg was broken
and removed the bandage and splints. On 
making somewhat an oblicue step, the 
leg yielded, and very severe distress was the 
consequence. Therefore cases of this sort
ought to be very carefully examined
The treatment is the same as in transverse
fractures of both bones. Two splints,
are required as in that case, and the leg 
is to rest on a pillow. In some cases this 
fracture will not unite, and in this case,
after about 6 weeks, considerable motion 
may be allowed, so that the fragments may 
inflame on their surfaces, and form a bony 
union. I have successfully treated several 

45
several cases in this way; and the union was nearly 
as speedy as usual.
Fractures of the Fibula. This is generally
complicated with a fracture* of the ancle joint. The 
fracture happens mostly at two thirds of the length
of the leg from the knee the leg is much distorted,
the astragalus faces the [cross out] outer ancle, the 
inside of the foot is turned down, and the sole, out.
A considerable hollow is felt over the seat of the 
fracture, the patient complains of pain there 
and if the foot be flexed and extended, a grating 
may be heard.
The first thing to be done is to reduce the 
foot, and the fibula will be drawn into its
place by this alone. The limb is now to be secured
by splints and bandages. The patient may
be laid on his back, and the many tailed bandage
applied, beginning at the ancle. The bandage
must be so slack as not to derange the 
fragments of the fibula.- Perhaps it may be
supposed that splints are unnescessary, as the 
*dislocation

46
tibia remains entire, but this is very far 
from being the case. The splints are to be 
so long as to reach below the foot, and by 
so doing the foot is kept steady, otherwise,
it will be very apt to produce displacement
of the lower fragment inwards. This is
the principal use of the splints, and one 
to which you ought to attend, as you will 
not find it in any book which we have.
By neglecting this, caries of the bone has been
produced, and I have seen amputations resorted 
to, on account of the diseased state of 
the leg produced by the irritation of the parts 
thus neglected till caries came on. In five
or six weeks, union will have formed such 
as to allow of considerable excercise of the leg.
Of Dislocations. A dislocation consists in 
the derangement of a bone out of its natural 
situation. It is attended with a loss of motion
with pain and deformity.
If surgical assistance be at hand, it is generally

47
generally easy to reduce the bone to its place, but
if much time elapse, considerable difficulty is 
commonly experienced. This arises from the contraction 
of the mucles by the irritation of the bone
displaced. The rupture of the capsular ligament
is not the cause of very much trouble, except in
a few cases, to be specified hereafter.
In such cases, many means have been devised 
for moderating the action of the muscles. Bloodletting, 
warm bath, low diet, &c have been used.
The first of these remedies, bloodletting from one
or both arms, ad delinquim animi, I have found
the best remedy; by this means, a temporary 
suspension is put to muscular motion, and 
the principal obstacle being removed, the reduction
is very easy. This remedy was first used 
in the Pennsylvania Hospital by me, and 
it was first proposed by Dr. Alexander Monro in
his lectures.
For the same purpose other means have also 
been used, but with less effect. Nausea produced 
by tartar emetic, or by tobacco injections
and these means may be used when bleeding

48)
is objected to. Intoxication has a similar 
effect. The muscles may be overcome by 
being fatigued. How after do we see reduction 
happen by weak efforts, after resisting 
for hours!
When a dislocation cannot be reduced, the muscles 
accomodate themselves to their new 
functions, adhesiong form round the head
of the bone, and these causes conspire against
reduction. This is particularly the 
case in old dislocating. The natural cavity
becomes less, and presents another obstacle.
Considerable force is required in these cases
Pullies have been much used but I have 
relinquished their use of late, and now, I 
use a number of assistants. Pullies are 
very unmanagable, and their action is 
not easily attend, whereas, by a word, you 
can vary the force and direction at pleasure
by using a proper number of assistants.-
Care must be taken to confine

(49
the force applied, to the joint dislocated.
When a bone remains long out of place, a 
sort of new joint is formed. This is not unusual in 
some joints, particularly the shoulder and hip.
A joiner had his arm dislocated into the axilla and 
remained irreducible. He began to use it a little
when the pain and inflamation had subsided.
The power of moving it returned gradually, he
has able to use the saw as well as before, but one
muscle seemed to have lost its power, (the deltoid)
as he could not raise the arm upwards. In all 
such cases, the cellular membrane is so condensed,
as to serve as a new capsular ligament, and 
even new cartilage is formed.
In irreducible dislocations of the hip, the acitabulum
is very readily and completely absorbed
and a new one, with capsular ligament as well
as cartilage is formed. A girl by receiving a fall
had her femur luxated backwards and upwards
and lost the power of motion for some time,
and nothing could be done to reduce it; after some
confinement, on beginning to walk about,

50)
and received a second-fall, whereby the other 
femur was reduced to the same state as the 
first. The limbs were now of one length,
and she could walk a little, when at the end 
of a year, she took a fever, which proved fatal,
Her pelvis was shown to me by Mr Cruickshank,
and in both sides, the bone was dislocated upwards
and backwards. The natural acitabula 
were completely absorbed, new cavities
were formed on the dorsa of the ossa ilia,
surrounded by bony margins, covered
with cartilages, and furnished with new
capsular ligaments. Dr. S.
January 6th,
1812

(51
Lecture 26.
Dislocation of the Lower Jaw. The only direction
in which this can happen is by the condyle 
being carried before the tuberosity at the 
root of the zygomatic process. The mouth always
stands open, speaking is impracticable,
the saliva flows from the mouth, and considerable 
pain attends.
It is produced by yawning, or any other cause 
of opening the mouth wide, by which the 
condyle mounts upon the tuberosity before 
the pit, and in shutting the mouth the 
condyle cannot get back again. A woman 
in market, in scolding [cross out], husband furiously,
found she could not shut her mouth again,
and came to me, and I found her jaw dislocated 
on both sides.
Some recommend strikeing the chin upward
to reduce this, but by this, the condyles may be
broken. In recent cases the reduction is very

52)
easy. The thumbs are to be introduced into 
mouth, applied to the molar teeth, and the
middle fingers applied under the chin. The 
thumb may be guarded with a soft linen,
lest after reduction, by the spasmodic action,
it should be injured. The patient is to be 
seated on a low chair. The surgeon is to depress 
the angle of the jaw with the thumb,
while with the fingers, he raises the chin,
and as soon as it is dislodged; he is to push 
it backwards. In this way, all the cases
I have ever seen were easily reduced.
No bandage is required after reduction, but 
the mouth is not to be opened freely for 
some time. Both sides of the jaw are 
generally dislocated at once. I have seen
only one case, in which only one condyle
was dislocated. In these cases, the force is 
to be applied to the injured side only.
Dislocation of the Clavicle. This bone 
much oftener fractured than dislocated.
a. I have seen one case of dislocation in

53
the sternal extremity, which was forwards. It 
may also happen upwards or inwards. Dislocation 
forwards always happens from the shoulder being 
driven forcibly backwards. It is very easily known 
by the projection anteriorly, and easily reduced.
A cushion is placed in the axilla, the elbow pressed 
toward the trunk, and the end of the bone
pressed down with the thumb. After reduction 
the apparatus of Desault for fractured clavicle
is to be applied, and kept on for four or five weeks,
till the ligaments resume their tone again,
b. Dislocation of the scapular end from the 
acromion scapulae is very easily discovered. 
The clavicle is found raised above the acromion 
a considerable way; and the ligaments 
are torn. On raising the arm, you reduce 
the fracture. This is always produced by a fall 
on the shoulder. To reduce it, it is only necesary
to raise the arm upwards and outwards, 
and secure it so by the same apparatus 
as in fractures of the clavicle. This is to 
be persevered in for ten or twelve weeks, as 
the ligaments are long in uniting. 

54
Dislocation of the humerus is the 
most usual accident of this kind which is 
met with. This occurs, 1, from the large 
motion which this joint performs, 2, from 
the shallowness of the glenoid cavity, 3, 
the great weaknes of of the joint in some 
directions.
The head of the bone in most cases is 
thrown downwards, into the axilla. It is 
sometimes carried forward, between the 
coracoid process, and glenoid cavity, but 
this is very rare. It is also sometimes dislocated 
back, so as to lie betwixt the glenoid 
cavity, and the spine of the scapula.
The second is very rare, one case of it, being,
all I ever saw. Of the latter sort, or backwards,
very few cases occur: about two 
weeks ago, a case of it occurred to me.
This accident is very easily discovered in every 
situation. 1. In the axilla Considerable pain
attends this. The arm cannot be raised up, 
neither can it be brought to the body, but

55
the elbow will hang about a span from the 
side. There is instead of the round form of the shoulder
a great hollow under the acromion, and a 
large tumor is felt in the axilla. The body of 
the humerus cannot be felt above half way,
from the tension of the deltoid muscle.
This is easily distinguished from a fracture 
of the head of the bone, by the hollow under the 
acromion and the sharpness of this.
2. Inwards. In this case, the motion of the arm 
is greatly impeded. It cannot be raised to the 
head, but can be brought close to the body.
The coracoid process cannot be felt, and the projecting
acromion is felt far behind the 
head of the humerus.
3. Backwards. This is easily known. The acromion 
and clavicle may be felt far before 
the head of the bone, the head projects just 
over the dorsum of the scapula
In old cases, the head of the bone is often
drawn from its situation in the axilla, forwards,
by the action of the pectoral muscle.

56
It can never happen upwards, the acromion 
as scapula here forming an insurmountable 
barrier.
In recent cases of downward luxation,
the reduction is generally easy. I have succeeded 
by extension and counter extension 
without any assistant, holding the humerus 
just above the elbow in one hand, and 
pressing upon the spine of the scapula 
with the other. The force is always to act 
on the joint of the shoulder alone. This is 
a fact of the first importance: it accounts 
for the frequent failures of ignorant, tho'
bold operators, who make counter extension
from the thorax, and spend all their 
force on the connections of the scapula
to the trunk of the body! Have we not read
of a miller, whose arm was torn from the body
by violence, and not the shoulder joint,
but the connections of the scapula to the 
body which gave way.
The forearm is to be bent on the arm and as
* A low chair is the best seat for the patient

(57
handkerchief tied round the arm just above 
the elbow, and given to one two or more assistants.
The surgeon is to press with his hand on the 
spine and acromion scapulae, and an assistant 
may also apply his hand over the surgeons,
and increase the counter extension. The forearm
may be raised up and down to assist its 
going into place. If the reduction do not happen
by these means, the surgeon may entrust the 
assistants with the counter extension and by 
pressing up the upper end of the bone with one 
hand, and the elbow down with the other, he 
may use the bone as a lever to reduce itself.
Some use a pad, put under the axilla for this 
purpose, but the hand is as good, and appears 
more simple to the patient: however, very 
little violence is to be used in this way.
But if it be found that the contraction of 
the muscles will be so violent as to resist
moderate force, Bleeding ad delinquim animi
is to be used rather than great violence, producing 
painful excoriations, &c. This remedy was 
found nescesary in a case in the P. Hospital, in

58
a robust man, and after losing near a 
quart of blood, he fell down, and the bone
was reduced with the greatest ease. Since
this, many other cases have occurred, with 
similar result. This remedy is never to be 
used unnescarily, but confined to all cases
in which we know great force will otherwise 
be required.
But if after several weeks continuance,
there have been adhesions formed, and the 
capsular ligament has closed, it would 
be unnesecary, and improper to spill the 
vital fluid. Force must now be applied.
Either a number of assistants, or pullies may 
be used. It is nescesary to vary the direction 
of the force at the period when the bone is 
just returning to its place, and as this 
cannot be done when we use pullies, I
prefer as many assistants as may be requisite,
probably five or even ten.
In some cases, I have distinctly heard the capsular 
ligament lacerating at the moment 
of reduction 

59
To avoid excoriation, the lower end of the arm, above
the elbow may be defended by stiff buckskin.
A strong roller is applied round this, and given 
to the assistants, or a handkerchief, with a 
rope fastened to it. A strong band, with the middle 
stuffed, so as to be very soft, is applied on the 
acromion, and fastened by the ends to a hook,
as high as the patients groin if he is standing 
or on the floor if he sits. When extension is 
made, this band is apt to slip and excoriate 
the skin, therefore it is to be held in place 
by the hand of an assistant, or secured from
slipping up by a roller passed under it, and 
held. This has been introduced by Dr. Dorsey
and is very convenient. Or strips of leather
may be fastened to the under edge of the band,
for the same purpose.
Any force whatever may now be commanded,
and the arm may be rotated, so as 
to break whatever adhesions may have formed.
If the body should yield, a band of great 
breadth may be put round the body, and held
by assistants, merely to secure the body, or the

60
patient may lie horizontally, but the 
best position is sitting on a low stool.
By the above means, luxations of nine,
eleven and even of thirteen week have 
be reduced under my observation. I also 
have the account of a case in Baltimore
in which it succeeded after five months.
I do not think that  any bone can be put
out of place which cannot be returned by 
art again, and therefore no case is to be 
despaired of.
I may mention some of the other means
which have been used for this reduction.
1. The body has been suspended by the arm
over a door or ladder-but the humerus is 
liable to fracture from this violence.
2. The body has been raised by the arm,
with a pulley,-but no counter extension 
is provided for in this way, and it does not 
succeed well.
3. By placing the patient on the floor,
putting the heel in his axilla, and making 
extension by the wrist, I have seen

61
Mr.J Hunter succeed in a case of this kind of 4 weeks and 
you may have this method in reserve for obstinate 
cases.
4. The various machinery, as the ambe of Hippocrates
&c act violently, yet fail because they 
do not fix the scapula.
Dislocation of the Elbow. This is in most 
cases backwards and upwards. The hook like 
process of the olecrannon may be felt above,
and considerably behind the naturan bid in
the humerus which receives it; the forearm 
is bent at right angles, and cannot be moved
either way. It may also be carried outwards,
or inwards but these forms are raw.
In the former, the olecranon may be felt
on the outside of the humerus, and in the 
latter, at the inside, and also, the hollow
of the radius may assist us in the diagnosis.
It is very easy to ascertain this accident, &
also easy to be reduced. In old cases it was however
very difficult. Boyer says that in four weeks
it is impossible, but in this he is mistaken

62)
as I have reduced one of four, as well as 
one of two weeks standing.
The reduction is performed in the following way
one assistant takes hold of the arm a
above the elbow, and the other just above
the wrist. The surgeon takes hold 
of the arm, by clasping the hands in front
over the lower part of the humerus, and 
he draws this backward, while the assistants 
are extending, so that the three forces
act at once, The fore arm is now bent,
and the bones are very easily reduced. The
use of the Surgeon's making extension
backwards is to dislodge the the coronoid process
of the ulna, from the condyles of the 
humerus, on which it is as it were locked.
The arm may be kept bent for some
time, at least for two or three weeks, and 
the joint may be kept moist by vinegar,
and spirits.
Dislocation of the Wrist may happen
either forward or backwards but cannot happen 
laterally.


(63
When the wrist is carried backward, the hand 
inclines forward, and when forwards, the hand 
turns backward. Nothing but extension and 
counter extension are required, and the reduction 
is very easy. The hand is to be made 
steady, by splints applied to the hand & 
forearm, and continued for some weeks 
at least.
Dislocations of the Fingers. These happen 
either anteriorly and posteriorly, and are 
very easily discovered, their bones being so 
thinly covered. They are quite immoveable
when out of place. They are very easily
reduced, and may be secured by splints.
The first and second joints of the thumb,
when dislocated are very difficult to reduce.
The knobs on the heads of the bones interlock
each other, and the more extension is made,
the more fast the ligaments tie the bones,
and even the last joint has been pulled off.
I have met with but one case of this, and 
succeed with tolerable case.

64)
Mr. Charles Bell has a very ingenuous proposal
on this subject. He proposes to introduce 
a cataract needle through the skin,
and to divide the lateral ligaments of one 
side, and then it is very probable the reduction 
would be very easy. B.P
January 8th,
1812
Lecture 27.
Dislocation of the Thigh. The older surgeons,
reflecting that the head of this bone was 
lodged in a very deep and strong cavity, and 
moved by very strong muscles, asserted that 
the neck of the bone was very frequently fractured,
and that dislocation of the hip joint,
never, or very seldom occurred. But they were 
mistaken in this. Four cases of dislocation 
generally happen as often as one case of 
fracture in the neck of the femur.


(65
This bone may be dislocated in any direction.
The most usual direction however is upwards, & 
backwards, so as to rest on the dorsum of the 
ilium. The next direction in frequency is in an
opposite direction, so that after passing downwards
and forward, the head of the bone rests 
on the foramen ovale. It may also happen
either upwards annd forwards, or downwards and 
backwards.
First, when upwards and backwards, the head
of the bone rests on the dorsum of the ilium.
The limb is shortened, generally two or three
inches, the toes are turned inwards, and the 
case is very easily detected. I have already
explained how this case is distinguished from 
fracture of the neck of the bone. The limb 
cannot be brought to its length, without reducing 
the dislocation; the trochanter major
may be felt nearer the spine of the ilium, and 
sometimes, the head of the bone may be felt 
on the ilium.
Second, the head of the bone is carried downwards,
and forwards into the foramen ovale,

66)
the limb is very considerably elongated,
the toes are turned outwards, and sometimes
the head of the bone may be distinctly felt.
Thirdly, the head of the bone is sometimes
carried forwards, or forwards and a little upwards.
The limb is shortened in proportion 
as the head is upward, and a large tumor
may be felt in the groin.
In the fourth order, the head is carried backwards 
and a little downward, the toes are turned
inward, and the case is easily discovered.
The two last orders are raw; I have never 
met with more than one case of each. For all
there dislocations, the capsular ligaments is
much ruptured. It was common for the older 
surgeons to say that the notch on the inferior
and anterior of the acetabulum caused
most of these dislocations to happen in this 
place, but the very reverse is true. The most 
usual direction, we have seen, is upwards, 
and backwards. This notch is secured by a 
ligamentous bridge, and is as strong as any 
part.

(67
From the great strength of the muscles, and 
also the great depth of the acetabulum, and the 
situations where the bone rests, very great force
is commonly required in this reduction. This is 
best applied by compound pullies.
In one case, I bled ad delinquim animi, and 
by my own exertions, with two assistants, I
reduced it again. But much more force is commonly 
required.
The patient is to be laid on the sound side,
with the thigh flexed on the pelvis, and the leg
flexed on the thigh. A strong band, (the middle 
of which is stuffed, is introduced into the groin
on the injured side, so as to rest on the tuberosity
of the ischeum and on the pubis, and 
secured to a hook opposite to the patients
head. This is to make counter extension.
The extension may be made just above the 
knee [in very corpulent patients, it can only be 
made below the knee] by a towel secured by 
a circular bandage*, to this towel, the pulley is
*To avoid excoriation, the skin is to be defended by
a piece of buckskin, round above the knee.

68)
fastened, and this secured to hook in the opposite 
of the room. Any degree of force may 
thus be applied. The limb may be rotated
to dislodge the head of the bone. In this way,
I have seen several cases succeed the head 
of the bone returned with an audible snap.
But if this do not succeed, it will next 
be required to raise up the head of the bone.
A bandage is put under the thigh near 
the groin, and tied over an assistants neck,
who kneels on the table, and puts one knee
on the pelvis below the rest of this 
ilium. While the assistant raises up the 
head of the bone, the surgeon uses the os femoris
as a lever, pressing down the knee,
This is the best way to make extension at
right angles.- Sometimes a band may 
be put over the pelvis, thro' two holes in 
the table, and secured to a hook in the floor.
By the above means, two extending forces are 
applied: one in the longitudinal, and the other 
at right angles. This is for luxations 
upwards and backwards.

(69
For dislocation into the foramen ovale, viz, downwards
and forwards. The longitudinal extension 
is applied in the same way, and with the same 
intention. The rectangular extension is also 
to be used in the same way, but the longitudinal is not so much
with the intention of lengthening the limb,
(this being already too long) but to dislodge it 
out of its seat on the foramen ovale.
The dislocation forwards, and a little upwards,
may also be treated in the same way. Mr. Heys
(whose/observations on this accident deserve per 
usal) directs in this case, to seat the patient 
on a bed, to apply the pubis to a post of the 
bed, and to make extension by assistants
at the leg. As this is not always convenient 
Dr. Wistar has made a subistitue for the 
bed post in our Hospital. It consists of a 
strong shaft, 3 or 4 yards long, inserted
to a head of about 30 inches long in the 
middle, and secured by stay pieces, thus 
resembling a rake. The end of this shaft 
props against the wall, and the head covered
[illustration]

70)
covered with flannel, makes counter extension 
against the pubis, the [cross out] leg may 
be bent, and extension made by assistants 
or pullies, the limb rotated, and the 
head brought outwards by a band or (what 
is better as it interferes less with the muscles)
a rolling pin. But this method is 
not preferable to this above one.
When the dislocation takes place forwards
and upwards into the groins There is 
some variation required. The longitudinal 
extension is made as usual, but the difference 
is this. The patient is laid on the 
back, a bandage is put round the pelvis
on the injured side, and fastened to a hook
opposite to the other side. Another bandage 
put round the injured thigh near 
the groin, and fastened to a pulley on the 
same side. The leg is bent, the thigh rotated,
as usual. The only case I have seen 
was treated in this way. See Dr. Cox's Med.
Museum. Desault met with a case of 

71
this sort. He differed from the operation described,
only in putting the band for counter
extension on the sound side of the scrotum;
while I put it on the injured side._ This apparatus 
may be used for luxation in any direction
whatever.
Lastly, in the dislocation downwards and 
backwards, I have had only one case. In this 
the usual means failed. The head of the femur
protruded through a rent in the capsular 
ligament, just as a button thro'
a button hole, and extension served only 
to make it faster. At length, I succeeded
by a violent abduction of the thigh. I applied 
my left hand on the trochanter,
and embracing the flexed knee in my 
right arm, I made a violent abduction,
using the thigh as a lever at the same
time. The thigh was bent on the pelvis. Abduction 
is the best means to dislodge the 
head of the bone out of the capsular ligament._
By these means, if the capsular ligament,
&c, have not formed strong adhesion


72
have not found any dislocation may 
be reduced. The only precaution nescesary 
after reduction, is to keep the 
limb quiet for a week or ten days.
In cases when the reduction has been 
delayed for some time, the cavity will
have so closed as to prevent the limb
resuming its usual length, and it remains 
1/2, 3/4 or 1 inch longer than [cross out]
usual. But a few weeks rest will overcome 
this.
Dislocations of the knee. The only direction
in which this joint is dislocated is outwards.
This however is very raw. Two cases of 
this sort have fallen within my observation.
In both, they arose from violent abduction:
the patient going up a ladder, this fell 
when they were 6 or 10 feet from the ground;
they fell thus with the legs asunder. In one 
of them both, but in the second only one 
knee was dislocated.
The leg rests upon the outer condyle of the os

73
femoris, the inner condyle may be easily felt,
a great angle is formed by the leg upon the 
the thigh, so that the injury produces effects 
very easily known,-and the leg is very easily 
restored to its place again, but such is the 
destruction of the capsular ligaments, that 
the leg will fall off again just as before.
The limb must be kept steady: either two 
common splints, or what is better Desaults
long splints must be worn at least four months
before the ligaments have united. The knee 
may be wet with lead-water, vinegar and oil,
vinegar and spirits, or any such liquid.
Dislocation of the Patella. The patella,
or kneepan may be luxated either outwards
or inwards. The former is the most usual direction,
the condyle of the femur being the 
highest on the outside, not allowing the patella 
to return. The pulley like surface of 
the femur being very easily felt, and the motion 
of the leg being lost, the case is very 
easily recognized. Further, the patella, on

74
the outside being very easily felt, its internal 
side is now posterior, its anterior 
surface is now exterior. Considerable pain 
is felt, and the powers of the extensors 
of the leg are lost.
The reduction is very easy. The thigh is 
flexed on the pelvis by the patients sitting 
on a bed, and the leg is to be extended. 
By pushing the patella on the side,
it will now fall into its place very easily.
The only case I have ever seen of this,
was in a lady, in whom it was caused by 
an irregular step in dancing. It was 
seated on the outside as I have described
and very easily reduced. After resting 
for fifteen days, she was perfectly restored,
and able to dance again!
Dislocations of the Ancle. I have
already explained how this accident was 
often complicated with a fracture of the
fibula, at one third of its length from the 
external ancle: however dislocation may

75
happen without this. This may be either anteriorly
or posteriorly. In the former case, the 
foot appears shorter than natural, and the 
bones of the leg lie in front of the astragalis
and the os calcis projects behind. When 
the foot is luxated posteriorly, the reverse 
of all this happens. This is very easily reduced.
An assistant holds the leg fast about its 
middle, while another extends the foot, and 
draws it into place.
One case only has fallen under my observation,
occured in a lady; She was hastily 
running down stairs, when she fell, and 
the heel of the shoe took hold on one of the 
steps, and the whole weight of the body 
resting oblicquely on the joint, this gave 
way. It was reduced as above described, and 
after a month, the function of the ancle
were completely restored again.
Jan 10th 1812     P.S.Physic.

76) Lect 25
Of Injuries of the Head. A. Contusion
Blows upon the head frequently produce a rupture
of a number of vessels, whereby blood is shed under
the scalp, which gives the part a soft pappy feel,
and round this is a hard ring, with a very abrupt
edge, which may deceive for a fracture with depression 
of a piece of the cranium. This has induced 
induced unwary surgeons to incise the part
and prepare for operation, and they were always 
much dissapointed to find the scull whole.
To avoid this unnescesary step of incision, it 
is nescesary in all cases, before we incise, to 
to see the symptoms of injured brain exist.
The incision is a very painful step and even exfoliation
of the bone may follow it.
Nothing but clothes wet with vinegar and water
is required as a local remedy, the antiphlogistic 
regimen, and if the injury be severe, bleeding,
and purging are required. If after several days,
the blood be not absorbed, a small puncture may 
be made into the tumor, the blood pressed out and 
dry lint applied, and secured by adhesive plaster.

(77
2. Wounds. Incised wounds in the scalp require the
some treatment as they as in other parts of the 
body. The hair having been removed, the lips of the 
wound may be approximated by adhesive plaster.
Contused wounds also have nothing peculiar
in them here. A soft poultice is the best application.
It may be continued till the sloughs are
separated, supuration is free, and granulation
goes on well. The sides of the cavity may be either
brought into contact, or at least approximated 
by adhesive plaster
The scalp is sometimes torn off: I have even 
seen one half of the scull laid bare in this way.
The old surgeons in such cases were in the habit
of cutting off all the separated parts, because, they 
said if left on, matter would form under it and injure 
the bones of the head. But their practice 
was as absurd as the reason for it was untrue.
The scalp is to be cleaned of any foreign matter,
replaced, and retained by interrupted sutures,
adhesive plaster, Sutures I do not recommend,
as they are an additional injury, increase the 
constitutional irritation, and if much swelling


78)
swelling come on, they are not (like plasters) easily removed.
If sutures are used, the edges are not to be 
drawn tight, nor nearer than 1/2 inch asunder. But
when inflamation is over, they may be brought
together. Adhesion generally takes place:- if pus
form in any part, it may be evacuated by an 
incision as in any abscess. If an early opening
is made, the bone will very seldom slough. The 
constitutional treatment must be antiphlogistic,
and if headache and fever follow, blood letting 
and purging may be used freely, as in cases 
of contusion.
In those cases in which the bone sloughs off
it is very important to remove the slough as 
soon as possible. Whenever any looseness is evident,
the slough may removed: as the granulations
round the rough edge of the bone will 
soon make it fast if left. We are never to wait 
for the bone to become looser, but pull out
the slough with forceps, and if incision be nescesary,
it may be made freely.
3. Acute pain often remains after the wound of 

79
of the scalp has heated. It also follows simple contusions,
as well as contused wounds. It lasts after the 
inflamation is over: I have seen it last for months,
nay even 3 or 5 years after.
The first case I have met with, was in a lady,
whose head was struck, in looking out at the 
window, by the shutter, which was blown by 
the wind. The pain was very acute, and increased 
as the inflamation subsided. This happened
at Trenton; and after 5 months continuance,
she came to town. I could feel a roughness and 
inequality in the bone. Dr Rush had tried every 
means he could devise, but all failed to afford 
any relief. I was consulted, and made 
a crucial incision through the scalp, and after 
this her complaint subsided entirely.
The second case was in a lady of a full habit
and the pain was very severe. Numerous remedies
were used, but to no purpose. Bleeding, purging,
low diet, low diet, leeches, blizters, issues,
the crucial incision, opium, cicuta, oxymuriate
of potash, solutions of arsenic & mercury, were all
used without benefit. 

80)
At the end of two years, she took a journey in
to the country, and by this she was suddenly 
benefited, but it was five years before she was 
quite well.
The third case was produced in a young lady 
by falling from a gig, and alighting with 
her head on a stone. The pain continued severe 
for 18 months, when by a second fall, the 
complaint was greatly augmented. On taking 
a walk to the Yohenulkylon, and being 
much heated, she went into the cold bath,
and on this, the pain became excruciating.
Mercury was given, but a salivation could not 
be produced. The crucial incision was made,
and from that evening for four weeks, she 
was well, but then relapsed. On the idea of 
retained perspiration, I made an issue as 
large as a dollar, with caustic, on the head,
but no relief followed. After 18 months, she went 
into the country, and on feeling oppression 
at the stomach, a vomit was taken, and brought 
off much mucus, and in six weeks, she 
was perfectly well.

81.
In the fourth case, a man fell from a house
and received a small wound on one side of the 
head. The pain came on, as in the other cases.
Bleeding, purging, &c failed, and the crucial incision, 
as soon as I had made it relieved him
but seized the other side as ill as the first side
and I next operated on this side also, and he 
soon recovered completely. I have seen one case
in which, it ended in fatuity.
In all cases, a complete recovery came on 
in course of time. Indeed I know of no [cross out]
remedy for this disease which is certain. The 
crucial incision is the best remedy I know. 
4. Injuries of the brain a. Compression
This state of the brain is marked by sleepiness,
drowsiness, insensibility, loss of speech and 
voluntary motion, sickness at the stomach,
vomiting and either dilation or contraction
of the pupils of the eyes, and no variation in 
these when exposed to light.
It may arise from either of the following
causes. 1. The fracture and depression of a 

82
piece of the cranium, or 2. by blood extravasated 
out of ruptured vessels, or by both 
causes taken together. The blood may be under
the scull, under the dura mater, or in the 
substance of the brain. Both depression, & 
blood may unite, as they very often do, but 
she may exist perfectly separately.
The symptoms of depression, from fracture 
are immediate, but that from blood generally 
allows a few minutes of sense and 
motion, before there is enough of blood to 
compress the brain.
But fracture of the scull with depressions 
may exist, without constitutional symptoms 
denoting it....A boy received a blow
by a brick thrown from the opposite side
of the street. I was called, and arrived in ten 
minutes, and could feel a considerable depression 
of bone, yet the boy was sensible, and 
told me the circumstances of the accident,
and then fell from his chair, cold, senseless,
and motionless. I trepanned him immediately

(83
immediately. A large quantity of fluid blood flowed from 
the orifice, and the boy recovered even before I 
had raised the depressed bone. There was a union 
of causes; the blood was the cause of the stupor
and it is often so; even without any external 
wound.
Sometimes the dura mater is wounded,
and even portions of the brain prolapsed.
Extravasated blood may be lodged in the cavity 
of the brain.
When compression is known to exist, the 
depressed [cross out] bone must be lodged* in the brain
and brought on a level with the rest of the scull,
or the extravasated fluid must be evacuated. 
If there be many fractured portions,
there may in general be a perforation made
with the trephine, and the blood if there be 
any may escape, and the fragments may 
be elevated. The perforation may be in the 
vicinity of the fracture.
In all cases if after the receipt of a blow, the 
symptoms of compression exist, perforation
*removed out of 

84
perforation is to be made. The inferior, anterior angle
of the parietal bone is the best place 
to open, because there, the artery of the dura
mater exist, which is the Source of extravasation.
If one opening do not succeed, the
other side may be opened.
On this subject, Mr. Abernethy makes a very 
ingenious remark. The scull is supplied with 
blood from the teguments and also by the 
dura mater. Now if these two sources of blood
be removed, the external by incision, and the 
internal by blood, we will not find any 
blood oozing from the bone on laing it 
bare. This may not always be depended on, as 
anastomosing arteries may keep up the circulation.
Even after the perforation is made, the symptoms
of pressure sometimes continue. It is 
then importance to tell whether the blood is 
extravasated under the dura matter or not?
If instead of the level, white, glistening appearance
of the dura mater, we find it pushed 
up into a convexity in the trepan. hole, fluctuation

85)
fluctuation in some degree perceptible, and a livid appearance,
by the presence of blood, we may be 
pretty certain of the nature of the injury. Further,
There is (especially in children) a motion in 
the dura mater corresponding to respiration,
raising with expiration, it visce versa,- and 
also a motion at every stroke of the heart,
but these are absent if blood be extravasated 
under the dura mater.
But even if we are certain of its presence, it
is very doubtful whether or not the dura mater
may be perforated? Rather than let our 
patient die, we might do it, but tho' cases 
are reported of patients recovering after such 
a puncture, yet I have always seen them 
prove fatal...... Indeed the dura mater is often 
wounded by spiculae of bone, and otherwise,
and yet the patient recover, but the above 
case is widely different: in it, we are never 
able to evacuate all the blood, and the part 
remaining becomes acrid by the air, and 
produces inflammation and suppuration in 
the pia mater and death!!

86)
Now, the progress of this injury is as follows:
first, the dura mater at the place of puncture,
becomes enlarged, till as wide as the hole 
in the bone, the brain arises on a level with 
the bone, (I have seen it arise one inch) then 
constituting fungus cerebrix, which is the brain 
itself pressed out. This has been tied with a 
ligature, destroyed with causte, &c, but is 
all cases is has proven fatal, and pus was 
found in the hemispheres of the brain, and 
therefore, this case is hopeless.
Our circumstance is very remarkable in 
this accident: sense remains till near death
unaffected.
In a case of extravasation which occurred 
to me under the dura mater, the membrane 
was pushed up on a level with the bone,
and all the symptoms of compression existed.
I bled the man four times a day, for 
five days, and each time, ad delinquim animi,
purged him freely, blistered him, and
confined him to barley water, and he was 
saved by these means from death.

87)
I therefore condemn the puncture in all 
cases....The dura mater is sometimes wounded
by accident, without death following: Sabatier 
relates the case of a man whose scull & 
dura mater were very widely discovered by a 
saber, and the wound heald just as easily as 
as in any other part of the body; nay, we 
read in the memoirs of the Academy of Surgery 
of a ball going perpendicularly, and of 
cin other going transversely thro the brain,
yet life not being lost, but a happy recovery!!!-
I have however seen one case of a 
wound of the membrane recovered from. The 
child was bled and purged freely, and confined 
to rest and a low diet, and recovered, tho'
dangerous convulsions supervened.
One circumstance more will conclude
this lecture. Patients recover better in the 
country than in a large city or town, and 
particularly better in succh a situation 
than in a crowded hospital.
D.P
January 13th, 1812

88)
Lecture 29.
We continue to speak of injuries of the head.
b. Sloughing of the dura mater. I am now to describe
a form of disease, not spoken of by any 
author; and of which I have met with only
one case. Last summer, I was called to a child,
which had received a kick of a horse on the os 
frontis. I found a very considerable piece of the bone
depressed by the fracture. The senses 
were perfect, but as as I always trepan 
in cases of depression, that I always proceeded
to do it in this. After the removal of 
the piece, I remarked an unusual appearance.
The dura mater was of a very dark colour,
without any convexity, or any other circumstance 
of effusion. In the course of 7 or 8 
days, the piece of the dura mater sloughed 
off, and left the pia mater bare. The child
still retained his senses, but fungus cerebri 
came on, the brain was protruded and the 
child died.

89)
Thus, the dura mater may die and slough off by 
a blow, just as a bone or any other part whose 
life is weak. I know of no remedy for this disorder.
In the case mentioned, the remedies for 
inflamation were used, particularly bleeding 
and purging, and the result was unfortunate.
C. Hamorrhage from the brain and dura
maters. Very considerable bleeding sometimes 
occurs when the brain or dura mater, especially 
the latter, are wounded. This is especially 
the case if one of the large sinuses, as
the longitudinal, or the lateral, is wounded.
This may arise by speculae of bone, or it may 
arise from wounds in our operations. Alarming
as this bleeding is, it is very easily commanded.
A dossil of lint, secured by pressure 
with the finger is always sufficient
to put a permanent stop to the disease.
Of arterial hamorrhage from the dura mater,
more must be said. The only vessel from 
which this can occur in any alarming degree
is the median artery of the dura mater,
which lies under the parietal bones. 

90)
A long quantity of blood may flow out
of this vessel, but in general, a piece of lint,
pressed down with the finger will stop 
this, in ten minutes. But sometimes, from
unusual size of the artery, &c, the blood continues
to flow. In this case, if the dura mater 
is wounded as well as the artery, the latter 
may be secured by a ligature, by a needle, 
or tenaculum, but if the dura mater be
whole, this would be unadviseable, as wounds 
of the dura mater are so seldom recovered from 
even if the puncture be very small, as by 
a spicula of bone, it is best to omit the ligature.
When the artery runs thro' a canal 
of bone, the treatment mentioned in compound
fractures, of stopping the hole by 
a plug of soft wood, put beside the artery,
and not into it is nescessary. But this structure is rare.
We might in some cases introduce a dossil
of lint between the scull and dura mater,
and thus press on the artery, and this 
lint, if not large could not in commode

(91
the brain by its pressure. This I have never yet
used. Might we not in obstinate cases, order pressure 
by an assistant for 30 minutes or more?
I have never seen the bleeding in any of these 
cases prove troublesome; and rather than use 
the ligature when there was no wound,
I would try astringents, as agaric, alum, blue 
vitriol, &c and by these means, there will be 
no difficulty in succeeding.
Before I quit the subject of compression, I 
will warn you of a very usual error into 
which both physicians and surgeons have 
fallen. From the identity of the the symptoms 
of intoxication and compression, they 
may be confounded together. The agree exactly 
in the loss of voluntary motion, puking, dullness,
sleepiness and every other symptom. But 
by an inquiry into the previous conduct, you 
may draw the line of distinction.
I say 'physicians', as apoplexy has been also 
confounded with drunkenness. Dr. Gregory
related a case of a man who had drank to excess
and was treated as an apoplectic by

92)
bleeding, blistering, stimulants, sinapisms,
&c and the man was cured!
An hostler who was intoxicated, fell among
a horses feet and received a wound
of the scalp. One of his companions save 
him, and took him to an infirmary. The 
surgeon shaved his head and enlarged the
wound by a crucial incision, but was 
astonished to find no fracture! It being at 
night, the head was dressed, and a consultation
determined an trepanning early next morning.
But when morning came, and the 
man awoke, he saw himself queerly situated:
an old nurse standing by,- his head 
felt very strangely tied up- and he in the 
infirmary! He demanded what was the 
matter? The nurse told him "hush, my 
man, you must be trepanned today."!!
The smell of the breath may be a very safe 
criterion; also the following. When I was the 
house surgeon in St George's Hospital, a woman
was brought in for a supposed injury

(93
injury of the head. Suspecting another cause, I 
poured a stream of cold water on the upper lip
for some time: the head began to rotate from 
side to side, and at last she got up, and demanded 
the reason of such insolent treatment 
as was used with her!
d. Inflamation of the brain. The symptoms 
of inflamation never follows immediateley 
after the cause which produced them.
They are all of the febrile kind. The face becomes
hot, and is overspread with a blush, headache 
follows, nausea and often vomiting supervene,
the pulse becomes hard and full, delirium,
coma, and restlessness soon follow.
These symptoms seldom come on before a week
or ten days after the injury. Indeed I have known
12 months supervene before the inflamation
come on. This was the case with Captain B.
Turner, who in escaping from a sinking vessel
into a boat, received a contusion on the head
and which was followed by a swelling on the 
occiput. He arrived in a town in Holland, and 
a german physician gave him a wash of 

94)
brandy, and the blue pill, (suposing the case
venereal, he having had the lues 4 years before)
after three months, no relief occurring, but headache
coming on, he came to England and Mr
Blizard continued the blue pill, but no alleviation,
nor salivation could be produced. 
and he was advised to go to a warm climate.
In June 1809 he arrived in Philad. and aplied 
to D Rush. Three weeks before arrival, he 
had the aura epileptica, commencing in the 
hand, and terminating in violent fits, and 
the arm becoming paralytic, and the leg
on the same (left) side becoming numbed. The 
Doctor bled and purged him freely, confining 
him to a very low diet.
No relief being found, I was consulted, the 
fits still continuing. I laid the bone bare
by a free incision. I found it very rough on 
its surface and wasted. I did not hesitate to 
apply the trepan, and on removing a piece
of the bone, I found the dura mater adhering 
strongly to the bone, and much indurated. 

(95
Four days after, it proved fatal, and on dissection,
pus was found both on the dura mater 
and also in the pia mater. Here was inflamation 
in the membranes a full year after the 
blow was received.
The causes of inflamation of the brain may
be either a contusion without any wound,
a fissure without depressure, or a fracture
with depression of a piece of the scull.
1. After concussion, the teguments become puffy
and flaccid, and on laying them open, they 
will be found detached from the bone, and 
if a perforation be made, the internal surface
of the bone will also be found detached.
The pericranium, instead of its florid colour
is found pale and in fact dead, and within,
mucus [cross out] or pus will be found on the dura 
mater.
2. and 3. Fissures or fractures with depression 
are very apt to produce inflamation, with 
them, there is generally a wound of the scalp.
Instead of healthy granulations, there are pale 
and flaccid ones, and they become so as soon

96)
as the inflamation commences. Instead of 
healthy pus, a thin bloody ichor only is discharged,
and the pericranium will separate 
from the bone, round the perforation in 
it. At the same time, the dura mater will separate 
in the same way.
Mr. Pott supposed this to arise from the vessels 
which carry on the circulation thro the 
bone becoming destroyed, but I have reason
to doubt of this explanation. It appears that 
the life of the bone is completely destroyed.
In all injuries of the brain, whether simple
contusion, fissure, or fracture with depression,
inflamation may therefore be expected.
The scalp may indeed be largely separated 
from the scull, and no symptoms of inflamation 
or suppuration follow, but union 
by healthy granulation follow, especially if 
the wound be produced by simple incision. 
Thus, the injury in communicated no deeper than 
to the external membranes of the head, but 
when a great concussion is received, the effects

(97
effects of it are communicated to the internal parts
of the head, not only to the membranes but to 
the brain itself; and inflamation and suppuration 
may come on as far as the parts are 
injured.
This is not merely a speculative point,
but one of great practical importance.
When pus is formed under the dura mater, I 
believe it is always fatal. Pus on the surface
of the dura mater may if let off prove 
of little injury. Therefore in all cases of inflamation,
a perforation with the trephine 
is always to be made, and this as soon as the 
symptoms of cerebral inflamation run 
high. By this timely measure, if suppuration 
is confined to the dura mater alone,
it may be prevented from doing any injury,
as all the pus will escape; and if 
any sloughs form in the dura mater, then 
also will find a free exit.
It is a question of some importance,
whether in the first instance of fractures
without depression, or with it, the perforation

98)
ought to be made, or to wait till symptoms 
of inflamation come on? Mr Pott was in 
the habit of trepanning in all cases of fracture,
immediately, but modern surgeons, having 
seen many recoveries from fractures, w.t
out trepaning have rejected this aphorism.
When the bone is depressed, indeed it is best 
to operate immediately, as the rough bone 
may irritate the dura mater, producing 
inflamation, suppuration and even ulceration.
But I would never trepan for simple 
fracture. Depression, or symptoms of inflamation 
must be apparent before I undertake
the operation of trepanning.
Even after evident depression of the bone, recoveries 
have occurred without trepanning,
but I would not deduce any rule from this.
Therefore, simple fracture, without any symptoms
of compression needs not to be trepaned.
But when depression has occurred, it is 
best to take out the piece of the bone. 

(99
When any other causes of inflamation, which 
I have mentioned occurs, the means to prevent 
and moderate inflamation must be used.
After a blow on the head, the patient must be 
confined to a very low diet, and bleeding and 
purging must be employed. If symptoms of 
inflamation appear, we are to bleed again,
and again, to apply the trepan, and to apply 
a blister over the head: a remedy well calculated
to reduce inflamation in the brain.
Cold applications are very serviseable. Clothes
wet in cold water, or in vinegar and water
are very useful.
e. Of concussion of the brain. Concussion of the 
brain is a certain deranged state of the brain
following blows on the head, which proves 
fatal often in a few minutes, and on dissection,
no marks of injury are found. It appears 
however, that a larger number of the 
minute vessels are ruptured. If the patient survive
some hours, the brain will be found
be set with drops of blood shed from these

100)
vessels, and if he survive for a day or two, the whole 
brain will have a bruised appearance.
Just in the same way do we often see blows 
on the reigion of the heart produce sudden 
death, and yet no symptoms appearances 
of derangement can be found on dissection.
If perfect rest be observed, the effusion of 
blood may be in many cases prevented.
Mr. Abernethy exceeds all authors in the description
of this state. Its progress according 
to him is as follows. 1st stage. The functions
of the brain are quite deranged, the stupor 
is complete, the patient is insensible, his breathing 
is difficult, tho not stertorious, and his 
extremities are cold and this state of stupor 
does not last long. 2nd stage. In this, the pulse 
and respiration are better, heat and sensibility 
increase, the patient will answer to 
a loud question, especially if it concern his 
own feelings, otherwise his answer is incoherent,
and he seems employed about something 
else. There are few symptoms of inflamation;
soon this state is followed by

(101
the 3rd or inflamatory stage, which is the 
most important of all.
Some surgeons recommend stimuli, as wine,
and if they succeed, they do very serious mischief.
If the establish the pulse and face 
respiration, inflamation and extravasation 
soon follow. I enjoin perfect rest, and keep 
the head elevated, and as the action recovers,
cold clothes with water & vinegar are applied
to the head. As the pulse rises, I bleed freely,
and thus inflamation and suppuration 
of the brain may be prevented.- Cases are 
repoted in which the patient recovered in whom
stimuli were used from the beginning, but 
the practice is very dangerous. The first 
case of contusion I have seen, I treated wt.
success by bleeding, while in St. Georges Hospital.
f. Inflamation of the brain, after it has 
subsided sometimes leaves a state of stupor
or idiotism. This was first treated with 
success by Dr Rush, who gave mercury 
so as to excite a salivation. He made 

102)
this discovery as early as the year 1795 or '6,
and it has been since spoken of by Mr Abernethy,
whose book was published in the year
since this. The plan adopted by Dr. Rush is 
found very successful.  Dr.P.
January 15th 
1812
Lecture 30.
It remains for me to explain the operation of 
perforation of the scull, for the purpose of elevating 
a depressed portion of bone, and for giving 
an exit to extravasated fluids, compressing the brain
The most common instrument for this purpose 
is the trephine, or circular saw, with a centre pin
for fixing the instrument. This pin is moveable 
in the handle, and by a pin in this, it may be 
protruded to any distance, and screwed fast so.
In the trephines of the older surgeons, this pin 
was fixed, and at a certain period of the operation,
this was removed by a key but this is of no service,
and protracts the operation. Thus, their

(103
center pin being always alike long, was very apt 
to wound the dura mater, as in thin sculls, especially 
in children. But the pin which easily 
is slipt up is very convenient.
The older surgeons used conical trephines,
and this, with a view of avoiding wounding the 
dura mater by a sudden plunge of the instrument,
after going thro' the scull. But this is very 
inconvenient, and tedious shape is quite superceded 
by proper care, and all danger of wounding 
the dura mater is avoided by the precautions
I am shortly to describe.
Before this instrument is used, the integuments
must be divided and dissected off. A common 
scalpel will answer this purpose. The iron 
is to continue to the end of the handle of 
this instrument, and to project in a square
form, to raise the pericranium from the 
bone. This quite supercedes a raspatory, which 
is an instrument for this puropse, used by 
some surgeons.
The elevator, which is a simple lever, a little bent

104
must also be at hand. This instrument is 
often made too convex.*
In most cases of trepanning instruments,
a lenticulator (which is a knife with a thick 
ede and a spoon-like point) is found, but the 
purpose for which this instrument is made
viz. cutting off rough edges and spicula after
the piece of bone is removed, is fully, and wt 
more convenience answered by the elevator.
The circular saw of Mr Hey should also be 
at hand. This is used when the depressed bone
is capable of being raised, except on account of 
one neck of bone, or one of these on each side.
This prevents in many cases, the dura mater
being stripped by the circular perforation, and 
is found very convenient.
It will also be proper to have sponge, lint;
needles, tenaculum, a ligature, and a soft poultice 
at hand.
The hair may be shaved off, to shew the extent 
and situation of the wound, before the 
scalp is further removed.
*The tripod is also useless, and superceded by the 
common elevator

(105
The incision may be made, or the wound,
(if there be any,) enlarged. The older surgeons
made a circular incision, and removed a 
large portion of the scalp, and repeated this 
if nescessary, and thus destroyed the covering
of a large portion of the cranium. I have 
see one half of the scalp removed in this way
Even Mr Pott advised this plan, but it is never 
nesccesary. A simple incision down to the bone 
is generally sufficient, and the pericranium 
is to be removed as we have described. If 
nescesary, an incision at right angles, or even 
a crucial incision may be made and the 
corners dissected away, but not removed.
When the cranium is fractured into many
pieces, there is considerable danger of wounding 
the dura mater with the scalpel, and 
therefore the incision is best made in this case
on the firm part of the scull, and from this,
we can dissect to the injured parts.
If an artery should be cut in the scalp, and 
bleed much, rather than trust to pressure, I 
would secure it with a needle, or tenaculum, 

106)
otherwise, it may bleed in the night. Some advise 
to deplete, by leaving such vessels open,
but this is much more conveniently done at 
the jugular vein or arm.
Some surgeons perforate the scull with a 
perforation, but the centre pin of the trephine
does this much more expeditiously.
The pin is to be applied on the sound bone,
but so near the fissure, as to include as much 
of the depressed portion as may be. This is done 
to avoid pressing the portion deeper, as our
efforts with the trephine might have this 
effect, if the pin rested not on the sound, but on 
the depressed bone.
The sawdust may be wiped from the teeth of 
the saw, and from the groove with a towel, which
answers better than the brush commonly used
As soon as the groove in the bone becomes deep
enough to retain the saw, the centre pin may be 
removed, as if left, it might wound the dura-
mater, which we have seen is very dangerous. 
Even before the grove is compleat, the pin 
must be shifted up in cases of thin sculls.

(107
We must very frequently examine the groove
with a tooth pick, to feell if any point of the 
circle is cut through, in which case, you must 
bear obliquely on the uncut part.
It was the ancient mode to mount the trephine
on a large handle, with a crank in 
the middle; this was applied to the surgeon's
breast, and thus their labour was lessened!
but the pressure thus applied was very dangerous
and unjustifiable.
It is common for this instrument to be made
too thin in its edge, and thus the groove will
not admit the levator, and when we want 
to work obliquely, we are unable to do so.
As soon as a considerable groove is made,
tho' no part of the bone be cut though, we may
try with the elevator to raise it, by breaking 
the vitreous table, thus avoiding most completely,
wounding, the dura mater, and if 
the bone be thicken at one side than the other,
this will particularly answer. The 
spiculae may be broken out with the levator,
and thus, the operation is completed.

108
Forceps are of no use in raising the circle.
This operation is considered by some to be 
easily performed and simple: but to perforate 
the scull; [cross out] and to avoid the dura mater requires
considerable attention, and I have seen errors
committed in this, twice prove fatal; inflammation 
of the brain having followed. We ought 
therefore always when one portion of the circle
is through, to avoid it very carefully.
Mr. Heys saw, in the circumstances we 
have mentioned is a very convenient instrument.
In the use of it, the dura mater is 
also to be carefully avoided.
After raising the depressed fragments, if this 
was the cause of compression, the symptoms
will cease, but if much blood is extravasated 
under the scull, more holes may be 
required to evacuate it, and if the symptoms
of pressure continue, the dura mater may
be separated from the scull for some way.
If blood be extravasated through the cavity 
under the dura mater, it is doubtful

(109
as we have shewn, [how dangerous it is] whether it is proper to 
puncture the dura mater with a lancet, but 
if in any case it is chosen to do so, which in 
general is improper, the puncture must be 
very small.
Having raised the depressed fragment or extracted
it, with the levator, the scull is to be 
dressed. A soft, light poultice is the best dressing.
Lint, which is generally used adheres
to the dura mater, and is not easily removed
in a future dressing; while the poultice separates 
very easily.
When the dura mater is pierced by spicular
or punctured by the surgeon, the scalp is 
to be brought over it, so that it may directly 
adhere, and prevent inflammation of the brain
In this way I treated a fracture of the squamous
part of the temporal bone, in which 
there were many fragments, and the dura
mater perforated; yet the patient recovered.
This may be done in cases of depression &
may prevent exfolian of the scull, but when


110)
extravasation has happened under the dura 
mater, and especially if a coagulum remains,
the orifice is by no means to be closed,
but simply a soft poultice applied.
The ancient surgeons forbid our operating 
on particular parts of the scull.
1. We are cautioned never to trepan the frontal
sinus. Here the tables of the scull are 
not paralel, and if it should be required
to trepan this part, the perforation may
be made in the usual way thro' the outer
table, but on the inner, the trepan may
be applied also perpendicular to the surface
of this plate also. If a ridge remains which 
the saw will not cut safely, it may be broken
with the levator.
2. They deem it improper to perforate over 
the longitudinal or lateral sinuses. Haemorhage
from this vessel is easily stopped by a 
little lint. But this vessel may generally 
avoided, unless it lie in a deep groove in the 

(111
bone, and even then, by working obliquely on one 
side, and then on the other. But there is little
hazard in the haemorrhage; the only danger being
that of wounding the dura mater beside
the artery sinus. This may be prevented by 
prizing out the piece of bone before quite cut
through, and breaking the remaining ridges 
with the levator, guarding the dura mater with 
an iron spatula.- If blood be shed under the 
bone, there can be no hazard; but we cannot 
depend on or judge of this before the operation is over.
3. It is deemed unsafe to trepan over the anterior 
inferior angle of of the parietal bone,
for here the median artery of the dura mater 
lieg, but tho' there is some degree of danger
here, by care, the vessel may be avoided. If it 
be wounded, it may however be stoped in most 
cases by a dossil of lint put into the groove it
lig in, or if the artery be inclosed in a bony
channel, the plug of soft wood as we have 
mentioned may be pushed in.
4 The occiput is deemed unfit for the operation,
but, with the precautions for others

112)
cases of unevenness on the scull, this objection 
like all the others is of no Value, and the 
scull may be trepanned in any place where
a fracture can reach, excepting the basis 
of the scull itself. So that all these rules,
so carefully held inviolate by our ancestors
are of no consequence whatever.P
Jan. 17
Lecture 31.
Of Diseases of the eyes, and first, of inflamation.
This may be seated in the eyelids, conjuctiva, 
cornea, or globe of the eye.
Inflamation of the eyelids is acompanied
with a serous discharge, and with a burning 
pain, and after comes on suddenly. It 
is produced by extraneous bodies, mechanical 
violence, &c.
If much pain and fever attend, bleeding, low 
diet and a mercurial purge may be prescribed, 
and the parts may be kept moist with 
diluted brandy, &c and may be expected soon 
to subside. 


113
Inflamation in the edges produces effusion 
and ulceration, and the discharge is so purulent
and viscid as to glue the eyelids together, and 
they cannot be opened without difficulty in 
the morning. The seat of this disease is said
to be the Meibomian glands, but I suppose 
it to arise from inflamation and ulceration 
round the roots of the hairs, thus resembling
tinea capitis, and if the hairs be 
extracted, just as in that disease, the sore will
heal up. The treatment of these two diseases 
is the same. Sperma ceti oil had succeeded 
well. It is recommended to touch the 
eyelid with lapis infernalis, and in this way
I once succeeded. lung Citrinum, [spermaciti]
If strong mercurial ointment, are powerful remedies I have extracted 
the hairs with twizers, and thus succeeded 
after the ointments have been tried 
to no puropse.
When the conjunctiva and cornea are the seat 
of the inflamation, the white membranes 
become red by the admission of anusual. 


114)
quantity of blood. The eye waters, light becomes
offensive, the eye feels hot and burning, and 
the pain is communicated to the temple and 
and fore head. The inflamation is sometimes confined
to a spot near the edge of the cornea. The 
eyes when thus inflamed are very irritable to 
light, we cannot easily get a view of the eye,
and the patient guards off the [inflam] light 
with his hand.
If the inflamation be over the cornea, there
is danger of opacity in this, and on the conjunctiva,
the speck mentioned leaves a film,
which, if near the inner canthus, it forms
what is called unguis.
The causes of this are, mechanical injuries,
viz blows, &c also the inversion of the cilia,
called trichiasis; acrid substances, as lime,
acids, smoke, violent excercise of the eyes,
too much light: and I have known it produced 
by the eye being wit with urine, in 
a young man having gonorrhoea.

(115
The globe of the eye may be inflamed in the anterior 
chamber, or the posterior, behind the lens.
When in the former situation, the pain is of a shooting 
kind, and varies much according to the violence 
of the causes. It sometimes proceeds to 
suppuration, and then, the pus may be seen
in the anterior chamber of the eye.
Inflamation in the posterior part is more
severe, the pain and fever run high, and vision 
is lost, yet the conjunctiva appears not 
much inflamed.
In all cases, the mechanical causes, if 
they continue to act must be removed. To 
remove sand or pieces of iron which stick in 
the coats of the eye, the ball is to be fixed by 
a speculum, and the body removed by a lancet.
Substances under the eye lid may be 
removed by a wet rag, or by syringing 
them with warm milk and water. If this 
fail, the inner surface of the lid may be examined 
by raising the lid.
When the eyelashes are inverted, constituting 
trichiasis, the cause of irritation must

116
be removed. This may depend either on the 
hairs growing inwards, or contraction of the 
eyelid. In the former case, the hairs must be 
pulled out, and St Yves says if destroyed by lunar 
caustic, they will not grow again
In case of contraction, an operation is required.
The tarsi, at the inner and outer ends have 
been cut thro', and, no success has followed in
any case I have heard of. Some assert that 
by cutting the skin lining the lid, they have
removed the stricture, but I have never seen 
any success from this mode.
A late author describes an operation, which 
consists in separating the tarsi from the skin 
without, and the conjunctiva within, thus 
separating its lateral connections; but I 
never tried this mode.
A few years ago, Dr. Dorsey had a case of this 
sort in the Alms House, and after trying to 
cure it by various operations, was obliqed to 
extirpate the whole edge of the cartilage, and 
the sore healed, and the eye was still very well 
defended by the eyelid. This is a mode which

(117
deserves imitation in all similar cases.
In all cases of opthalmia, bleeding is to be used
freely, according to the pain and fever. When 
enough of blood is evacuated in this way, cups 
may be applied to the temples, [and] or 30 or 40 
leechs may be applied to the same part. The vessels 
on the surface may be cut by the shoulder of a 
lancet, or they may be raised with fine forcepts,
and divided with scissars, but I prefer the 
lancet. Purging is also required. Mercurial 
purges are by far the best. The antimonial 
powder, of the P. Hospital answers very well.
The applications are to be mild. Poultices
of bread and milk are very good. The pith 
of sassafras may form one of the best remedies.
It may be applied in form of a poultice,
or as a fomentation dissolved in water.
Blisters may be applied behind the ears, on 
the nape of the neck, or on the shaven head.
After the inflamation is considerably subsided,
laudanum is a valuable remedy. Sugar
of lead, white vitriol and laudanum 
may be united in a collyreum.

118)
But stimuli must never be applied before 
the inflamation is much subdued, else the 
inflamation will be increased. Vinegar is a 
valuable remedy in such cases; the rotten-
apple-poultice is particularly serviceable after 
evacuations have been used.
If matter form in the anterior chamber of 
the eye, certain measures must be used to produce
absorption, but if the eye be made very 
tense by the matter, an incision, such as 
used for the extraction of the cataract, must 
be made, to prevent opacity in the cornea.
When opthalmia is of long duration, a 
salivation is one of the best remedies.
In all cases of opthalmia, particular care
should be taken to avoid light. The chamber 
must be dark, and excercise of the organ 
avoided. The diet must be vegetable, & 
animal food, and spirits avoided.
After severe cases, a sition may be made in the 
neck to prevent a relapse.
In many cases of protracted opthalmia,

119
the action seems to have something peculiar
in it. A gentleman, who had had a tender state 
of the eyes from his youth, had a severe [atta??]
which lasted 3 months; he was bled during 
that time, to ℥ iso, purged very freely, blistered 
had issues almost constantly, and was often 
scarified, and all to no good purpose. I directed
tar water to be applied, first to one eye, & 
after some time to the other. It brought him 
from a state of blindness, to free use of the 
organ, and tho' the application was very stimulating,
it produced no pain, but suddenly 
subdued the inflamation.
Various stimuli have been used. In one 
case, after bleeding, blistering and purging
had been used to no purpose, a solution of 
blue vitriol (in proportion of gr ij to ℥ water)
succeded buy and conception. In a week, the 
man was nearly cured.
Surgeons fear the use of stimuli in these 
cases from the tenderness of the organ, and 
indeed, the evacuating remedies, as bleeding, purging
and blistering must have been used before any 

120
stimuli are proper, but in protracted cases 
they are required. Solution of soap in spirits 
of wine have been of service in some cases.
Specks on the eyes have been cured by a mixture 
of sugar, alum and nitro! A solution 
of salt in water and vinegar, and sea water 
have been well borne in some cases. Red
precipitate, with a little camphor has been 
well endured, and succeeded in some cases, after 
the evacuating plan had failed.
Unguis. This, as we have mentioned, is an enlargement 
of the coates of the eye by inflamation.
When the thickening extends
along the conjunctiva over the cornea, vision 
is obstructed. The whole enlarged membrane 
must be dissected off. That part over 
the cornea, after being raised by fine forcepts
must be carefully dissected away with 
a knife, and the part over the schtonica may 
be cut away with scissars. It must be dissected 
very closely from the caruncular lachrymalis,
else it will return again. This is of 
much importance. 

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Specks. The best remedy for small opaque specks
on the eye after inflamation, is mercury. Locally,
gentle stimuli are proper, as corrosive 
sublimate one grain, water four ounces, but 
if there be inflamation produced by stimuli, 
they increase the opacity. But a ptyalism,
with low diet is the best, and most 
certain remedy.
When the part of the cornea, over the pupil
is rendered opacque by inflamation, an artificial 
pupil has been made by opening 
the iris with the needle, opposite to the 
transparent cornea. When the pupil is closed 
by adhesion, an operation [??lour] can cure 
it, by making an artificial pupil.
of Fistula Lachrymalis. To understand
this affection, the anatomy of the 
lachrymal sac and duct, the puncta lachrymalia,
and the adjacent bones must be 
well learned.
Stricture, or obstruction in this tube produces
a swelling in the inner canthus of the 

122)
eye, and if pressure be made on this, water and 
pus escape by the punctae. In this state, the 
eyelids will be glued together in the morning, &
opened with difficulty. If the sac be ostructed 
by disease, or by cold, pain and fever come on,
the part becomes very tender. In this state,
bleeding, purging, and low diet may sometimes
suceed, but generally, the tumor bursts 
externally. Before this can occur, it is the best 
practice to open the external part of the tumor,
give vent to the contents, and then introduce 
a probe into the duct toward the nose, & 
try to overcome the stricture. In this simple
way, I have succeeded in curing the complaint
But the nasal end of the tube is often so 
completely obliterated, as to preclude the fesibility 
of this. It is then nescesary to make 
an artificial opening into the nostril, for 
the future passage of the tears, by puncturing
the of unguis, which is the only division 
between the nose & eye in this place.
Mr. Pott performed this with a bent trochar,
after which, fragments of bone surrounded

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surrounded the opening, and were united by membrane.
It was nescesary to wear a bogie in the passage
for 2 or 3 weeks, to prevent its healing up, and 
even after this, it sometimes did heal up.
Mr. Hunter, seeing the imprefeations and in
conveniences of this plan, introduced a mode of 
striking out a circular piece of the bone, by 
an instrument resembling a punch, the 
bone being supported by a flat piece of horn 
introduced up the nostril.
This plan produces immediate relief, and 
after it no bogie is required.
This disease is sometimes complicated
with caries of the bones. In this case, the 
detached piece of bone is to be extracted, and 
the sore treated as another carious ulcer.
At the next lecture, the operation will be
performed on the dead subject, and the minutiae
of it explained.   Dr. P.
January 20.1812,

Lecture 32.
Fistula lachrymalis continued. Stricture in the 
ductus ad nasi, producing accumulation of 
tears, and swelling, may be divided into several 
stages, well distinguished from one another.
1. In the first, no inflamation has appeared, & 
pressure on the sac produces a regurgetation of a 
[mucus] water, and then mucus. Very little is to be 
done in this case. By pressing the fluid out of 
the sac regularly, the distension will be prevented,
part of the tears will return to the eye,
and some will flow into the nose. The eye may
be washed with a weak vitriolic collyeyum, as
white vitriol gr 1 or 2 to water ℥i, and I have seen 
the complaint disappear by this simple plan.
The French recommend injecting the sac with 
warm water by a fine syringe, but pressure 
is sufficient to cleanse the canal. Sir Wm Blizard
recommends injecting mercury, but no 
particular benefit results from this.
2. If by carelessness the sac be suffered to distend 
itself, and the patient expose himself to cold, inflamation

125
inflamation comes on, and parts appear just as 
a common boil. By the use of bleeding, purging, low 
diet and blisters, with a lead water poultice, we 
may prevent suppuration, and reduce the complaint
to the first stage; when it may be treated 
in the same way
3. In the third stage, pus has formed in the sac,
and generally escapes by an ulcerous opening 
in front of the middle of the sac, and the 
true fistula lachrymalis now is formed.
It is nescesary to remove the stricture, and establish
the evacuation of the tears into the 
nose, else the sore will never heal, and from 
inattention, patients have been teased by caustic
&c when the cause of the ulcer was not suspected.
The plate of bone (os unguis) which separates 
the sac from the nostril must often be
perforated, but before this is done, every measure 
must be tried to establish the natural passage
The external opening (if small) may 
be dilated with a bistoury, to introduce the 
probe. 

126
We may be called to operate before the duct is 
much distended, and not easily felt, and also,
the fistula may be so small and circuitous 
that we do not find it possible to introduce a
probe along it; therefore we ouht to know the 
true situation of the sac, and the place to cut
so as to find it. The incisions must commence
just below the inner canthus, and continue
parallel to the edge of the bony orbit. Thus, by 
beginning always below the canthus, we avoid the 
tendon of the orbicularis muscle
A probe is now to be introduced into the duct,
and carried down to the nose. In so doing, we feel 
the stricture, and overcome it. The probe may 
be withdrawn, and a bagie introduced, or what 
is much better, Mr Naru's silver probe. This consists
of a silver wire, the end of which is a little 
bent, and mounted with a flat head set on 
oblicquely, and the face of this after being heated,
covered with black sealing wax, so as to 
appear just like a black patch.
This may be left in. It does not produce 
much pain, and the tears pass along it to

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the nose, tho' this might not be expected.
This stilette has been borne for months, and 
is to be left in till the stricture is overcome. It 
may be removed and cleaned occasionally, and 
is then easily reduced to its place again. When 
the stilette is prematurely with drawn, the stricture 
will recur, and renew the disease where
as, if left in the due time, the canal will 
remain pervous, and the sore will heal very 
well after the stilette is removed. Thus the 
disease is generally easily cured.
But in some cases, the natural canal is 
not capable of yielding, and even the bony 
canal is found closed. Then, the artificial 
passage is the only resource.
When the os unguis is punctured by Mr.
Potts trachar, the fragments suspended together
by membranes are ready to reinstate
themselves again. To operate with Mr Hunters
punch, which is the best way, a piece of 
horn is to be introduced up the nostril, so as
to support the os unguis; the bottom of 
the sac laid bare, and the punch applied,

128)
and the bone may easily be perforated by 
few rotatory turns of the punch, and there 
will be a circular piece of bone neatly cut out.
The external wound may be immediately 
healed. The lips of the sore are to be brought 
together by adhesive plaster, and will soon 
heal up. The bone having no loose fragments,
will not heal up and the sac remains 
pervious, and conducts the tears into 
the nose without any inconvenience.
Of the Cataract. This consists in an opacity 
of the chrystaline lens and its capsule,
whereby the rays of light are prevented from 
passing to the retina.
It appears in an uniform whiteness of the lens,
or only in a speck. It first causes a dimness
of sight, as if gause was hung before the eye,
or threads, spots &c.
It often comes on spontaneously, and may 
in other cases be referred to mechanical violence.
Many remind us have been used to disperse the

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opacity. Mercury stands at the head of these.
Setons, purges, blisters, low diet, &c are also useful
Those cases which proceed from external violence 
may generally be removed by medicine.
They very commonly yield to a salivation.
A lady received a wound in the eye, by a puncture
with a needle, which reached the lens, considerable 
inflamation and finally opacity followed,
and she lost the sight in that eye. Bleeding,
blistering, purging and low diet were tried, but 
had no effect on the opacque lens. I pursuaded 
her to submit to a salivation, and as soon 
as the mouth became sore, the opacity began
to lessen, and before the salivation ceased 
the eye was perfectly restored. But she was 
still obliged to use a convex glass, and it therefore
appeared that the lens had been quite absorbed,
and the eye left in the same state as 
after extraction.
Spontaneous cataracts, I have never seen 
removed by medicine, and only once relieved.
As medicines fail, an operation alone can be 
of decided service. This consists in removing

130)
the opaque lens from the axis of vision 
Several means have been used for this purpose:
two operations continue still in use.
1. Couching, wherein the lens is pushed aside,
or to the bottom of the eye, so as to leave the 
passage for the light penetrable [the?ts] and,
2. Extraction, wherein a transverse incision 
is made thro' the transparent cornea, and 
the lens extracted thro' the iris and cornea,
so as to leave the eye in a transparent state.
Couching is the easiest as well as the oldest 
of these modes of operating, and is still 
strongly advocated by some surgeons, particularly 
Percival Pott, and Mr Hey of Leeds,
but I give a decided preference to extraction,
for the following reasons.
1. Couching is by far the most painful operation.
When extraction is performed by making 
the incision with a single stroke of the knife
it produces almost no pain, whereas, introducing 
the kneedle through the adnata and 
scletoric coat and the subsequent motions 
are very severe.

(131
I performed extraction on a man who had 
had couching performed on the other eye, and 
he could not believe that the operation was 
over till seeing a watch, he was convinced,
and he reflected with horror on the operation 
which had caused his eye to suppurate and 
waste away in the socket. I have even been 
requested to operate on the second eye immediately,
so trifling was the pain after 
extraction in many cases.
2. The lens after depression may, and after
does rise to its place, after which patients, 
will not (as some say) submit to the repetition 
without reluctance. When extraction 
is performed, the operation is complete.
3. When the cataract is fluid, the anterior 
chamber after become muddy, and the 
kneedle is in danger of tearing the iris. It 
is indeed said that the fluid will be absorbed 
again, but still, it is nesceray to repeat
the operation, to depress the nucleus 
of the lens.

132
4. When the capsule of the lens is also opacque,
the operation must be repeated on this if depression 
be performed, but in extraction, the capsule is 
easily removed either entire, as I have often had 
it, which could be seen by suspending it in water,
or piecemeal. When the capsule adheres very 
strongly to the ciliary process, it will be raised 
to its site very soon after couching, and appear 
behind the iris again.
5. Ahesions frequently form between the iris &
lens, and in extraction, I have found it very easy 
to separate them with a gold kneedle, whereas
in couching these adhesions remain, and the lens
will soon be reinstated again, and the repetition 
of the operation is required. Mr. Hey performed 
couching in such a case, no less than 
five times.
Therefore extraction ought to be always prefered.
Indeed objections have been raised against extraction,
but we shall soon see how far these 
result from awkwardness in the operator,
1. The incision in the cornea is said to leave the 
cornea opacque, but this is not the case; if the 

(133
operation be done well, the eye remains clear.
But if a dull knife be used, or the operation finished
with scissars, the eye may inflame, and becomes 
opacque; but the incision should not be 
near the pupil in any part, and therefore the 
passage of light remains unaltered.
2. The force in extracting the lens is said to 
make the pupil irregular, and so injure vision 
and I have more than once seen the pupil made 
irregular by extracting a hard chrystaline,
but this never injures vision in any degree.
Yet this is very rare, and may be avoided by 
proper care in the force applied.
3. The iris sometimes doubles under the knife
and may be injured if neglected, but if the incision 
be stopped, and the surgeon press and rub
gently on the cornea with the fore finger of 
the hand which is at liberty, the iris goes back
and the operation is easily finished.
4. The vitreous humor is said to escape sometimes
in couching, and this has actually 
been the case, but, it is always the effect of 
awkward pressure made on the eye, after



134
the incision is made. Moderate pressure is 
to be made on the eye during the incision
for the sole purpose of steadying the eye, and 
as soon as the cornea is cut, the pressure is 
to be entirely removed, and the vitreous humor
is in no danger of being moved. These objections 
are therefore of no importance. and extraction 
is the only proper operation. Dr. P.
Jan, 22d.
Lecture 33.
Cataract Continued. Before operating for the 
cataract, we ought to ascertain the probable
effect of the operation, whether or not success is 
to be expected. This is of great importance, as 
our character, as well as our patients ease may 
be sacraficed in a useless operation. The principal 
circumstances to be attended to are these.
1. That the eye in every respect (besides the 
state of the lens) be natural. That the cornea 
be clear, the eyelids, and thin edges free from 
inflamation and oedema. That there be no
tendency to inflamation, as in some cases

(135
the least injury will cause much inflamation 
2. That there be no pain in the fore head.
This circumstance is often met with especially 
in women. If this symptom exist, we can 
moderate it by bleeding, low diet, purging 2ce
or 3ce a week. In a case in which there was 
considerable head-ache, I gave purge twice a 
week, for nine months, and then operated 
with success.
3. That the iris retain the power of contracting
on the application of objects.
But if the power of distinguishing objects 
continue, we may not be deterred.
This iris may be fixed by adhesions to the capsule
of the chrystaline lens, and unable to 
move, yet if light can be distinguished from 
darkness, of telling the number of windows
in the room, of telling when a hand, a hat, 
&c is interposed between the eye and window,
&c the operation may be successful; but in 
such cases as do not bear these marks, you 
should never operate, as the retina will be in 
a state of torpor, the state called amourosis

136.
Even the pupil may retain its nobility,
and yet the retina be paralytic. An old
lady applied to me for a cataract, which 
was in this state. I extracted the lens, which 
was as hard as a stone, but to my surprise,
no power of vision remained. I then operated 
on the other eye, and in this, vision was 
restored. Now the pupils in both eyes moved alike 
by the light, tho' they were in an opposite 
state.
If the eye be in any of its coats inflamed or 
swelled, these symptoms may be removed by 
bleeding, purging, low diet, and blisters to the 
nape of the neck. The last remedy is particularly 
recommended by Baron Wenzel.
The operation is never to be poured on an 
eye in any degree inflamed, and measures are 
to be taken to prevent inflamation. In all 
cases, except when the patient is very weak, the 
diet should be low, entirely vegetable, and 
if the habit be full, blood should be drawn 
from the arm. 

(137
The most suitable seasons for the opertion
are spring and fall. In summer, the patient 
cannot lie still in bed the requsite time 
and in winter, the cold may produce inflamation,
and therefore mild weather is to 
be chosen.
The instruments used in extracting the cataract 
are the following.
It is common to fin the eye with a speculum,
by separating the eye lids, and applying it 
round the eye under the eyelids, it having 
a groove to receive the tarsi, but this is an unnescesary 
instrument. The eye[s] being opened
and held for a minute or two becomes steady
and the operation is to commence at this moment,
and it will be easy to keep it steady 
during the incision, without this painful 
and alarming instrument. This instrument 
occupies one hand, and if the iris folds
under the knife, we cannot make the nescessary 
friction on the cornea to press that back. I 
have performend this operation frequently, and 
never found it nescesary to use the speculum,


138)
speculum, but if it is used in any case, it 
will be found very convenient to have 
a ring in the end of the handle to put on 
the little finger, and then we can hold it 
with this, the mid-finger and thumb, and 
so have the fore finger at liberty; and these 
obviate this objection of Baron Wenzel. But 
still, the instrument is inconvenient.
The knife is then, the first instrument. Its 
blade may be 1 1/4 inch long 1/4 inch broad at 
the broadest part, and the sides straight lines
from this to the point. The edge is to extend 
to the broadest part in front, and to 1/10 inch 
on the back so as to make an exquisite point
I have said 1/4 inch broad: but it may be broader 
than [illegible] the diameter of the cornea, so 
as to cut its own way out by a simple push 
and must be very sharp, so as not to push
the eye obliquely, and so as to cut the cornea
without irritating it to inflame, and become 
opaque. See the description of this instrument,
in Wenzel.

(139
The second instrument is a kneedle for tearing 
the capsule on the anterior part of the lens
which may be a little bent, sit in a handle
and having on the end of the hand, a scoop 
for removing portions of the capsule which
may remain after the chrystaline is evacuated.
A small hook is also to be provided, with 
which the lens, may be extracted in case 
it should fall down into the vitreous humor
and only its edge be seen. This is often of great 
use.
Small forcepts are also nescessary, for extracting 
the opacque capsule, from behind the 
chrystaline, either piecemeal or entire. They 
are to touch not only at the points of their blades
but also to touch by flat surfaces, at least 1/10
of an inch. These instruments are of the 
first importance in completing the operation.
Before proceeding to operate, a bandage is 
to be put round the forehead, and to it, two 
compresses are to be pinned

140)
The compress which covers the eye to be operated 
on is to be pinned up. These render 
the eye steady. The patient is to be seated on 
a low seat and the surgeon on one much 
higher. All the windows in the room except 
one are to be closed, and the patient is to be 
set with one side of the head to that window.
Thus alone, the pupil can be seen distinctly.
The assistant is to stand behind the patient,
and support the head on his breast.
He is also to support the upper eyelid, by
holding the skin of it double over the sperciliary 
ridges, and make moderate pressure 
on the eye. The surgeon keeps down 
the lower lid, and makes moderate pressure 
also.
He is to apply the point of the knife to the 
eye, and not puncture it till the involuntary 
motion is over, else the knife may start,
and make a second puncture, and the aqueous 
humor will ooze out by the first,
the cornea will shrink and the iris fall in 
the way of the knife!

(141
The knife being applied at 1/12 inch from the 
junction of the iris and sclerotic coat, and 
the eye steady, the point of the knife is to be 
carried horizontally, and parallel to the iris
is to be brought out at the same situation
in the cornea at which it entered, and carried 
thro' with a single push; and never drawn back
but if the iris fold under the knife, pressure 
may be made on the cornea till this falls into
its place. As the knife fills up all the 
incision, none of the water can escape, but 
if it were withdrawn in any degree, or if 
the knife were not broad enough to cut 
itself out without being moved out of a direct 
line, the aqueous humor would escape.
As soon as the cornea is transfixed, all 
pressure must be removed; we having only 
to support the eyelids, and the knife being 
sufficient to fix the eye, which is as 
[cross out] it were hooked on it. Thus no pressure 
being made after the cornea is open, there is
no danger of evacuating the vitreous humor.

142)
Next, tear the capsule, with the kneedle in 
as complete a manner as posible, and with 
moderate pressure, the chrystaline lens will 
escape by the pupil an cut in the cornea. If the 
lens do not pass the pupil easily, the eye
may be exposed to darkness for some time,
that the iris may be relaxed, and thus, all 
danger of tearing the iris will be averted.
Gentle pressure may be made on the globe
to facilitate the exit of the lens, and if this 
does not follow very freely, the needle may 
again be introduced thro' the cornea and 
iris, the point fixed into the chrystaline,
and this extracted. This supercedes improper
pressure.
After the extraction of the lens, if filaments 
of membrane remain, they are to removed 
by the scoop, and if an opaque membrane
is seen behind the site of the lens, it may 
be removed by the forcepts.
When the operation is over, the compress is
be brought down, a piece of soft linen applied
over the eye, and secured by a bandage passed

(143
passed round the head, and the patient put to 
bed. His hands are to be secured with tapes fastened
to the bed cords, so that the cannot be 
lifted higher than the breast. This is of great 
importance. In one case, after the operation
was performed well, the patient on waking 
out of sleep, forgetting the cause of irritation 
in his eye, rubbed this, so as to evacuate 
the greater part of the vitreous humor
and so destroyed the organs.
In ten days, the eye will have united again.
Low diet, rest and perfect darkness 
are to be observed.-
We might have observ'd that after the incision 
is made in the cornea, we may rest 
a minute or two as in that time, the irritation 
of the incisison will be over, and 
the kneedle will be better borne than if 
this were neglected.   Dr. P.
Jan 24, 1812

144)
Lecture 34.
Cataract continued. Of Couching. And first 
of the instruments. It is common for operators 
in couching to use a speculum, and there is 
no objection to it, if the operator choses however,
it is unnescesary. The eye may be opened, the 
eyelids fixed, considerable pressure may be made
on the eye, this will then become steady, and 
now the operation may be performed. After the 
kneedle is introduced, it fixes the eye.
The kneedle used by Mr. Pott, was spearpointed,
but ingenious men have made many improvements 
in it. They have reduced its length to 
1 1/2 inches, and thus, rendered it very manageable.
The spear point, making too large a hole [prevent] permit 
the escape of some of the vitreous humor, but 
the round instrument now used makes no larger 
an orifice than the rest of it occupies.
It is made flat toward the point, as Mr. Hey has
directed, and I have also adopted, from Scarpa, the 
method of having it bent toward the point, 
1. becuase it is less entangled in the iris, 2, because

145
because after pushing the lens back, we can very easily
carry this crooked kneedle before it and fix it
very easily, 3, because with this it is very easy 
to depress loose, remaining pieces of capsule with
the bent kneedle.
This operation is very simple. The patent being 
seated on a low chair, and the supported by an
assistant, and him facing a window, and the eyes
opened as in extraction. The kneedle being applied 
at 1/6 of an inch from the edge of the transparent 
cornea, it to be pushed thro' the scletorica
to the chrystaline lens, the point is then to 
be applied to the lens so as to push it back,
and the kneedle insinuated between the iris and
the lens, the point is now to be fixed into the 
lens, and, and by elevating the handle of the 
kneedle, you depress the lens down to the bottom
of the eye, and immediately, the pupil will 
be seen black behind the iris, instead of the opacque
chrystaline. If this first motion do not 
perfectly succeed, it is very easily repeated.
It is nescessary for the kneedle to be very 
sharp, and even so, considerable force is required

146)
required in piercing the coats of the eye, and in so 
doing, an indentation is made. To remedy this inconvenience,
I puncture the eye with the point 
of the extracting knife, and then, use the kneedle
as usual. To depressing the lens, it may always 
be observed to keep the concave surface of 
the kneedle downward.
The operation being finished, the eye is to be covered
with a compress, this secured by a bandage
and the patient put to bed. In 10 or 12 days,
after the inflamation is over, the eye may be
examined, to see the effect of the operation.
The cataract is sometimes soft, and cannot 
be depressed. The advocates of couching break the
anterior part of the capsule, and all which escapes
into the anterior chamber will be absorbed,
and probably the posterior also; but if any 
remain, the operation is to be repeated again and 
again, till all the opaque matter is absorbed.
There are also cases of fluid or milky cataract,
in which also, the anterior part of the lens is 
to be ruptured, that the fluid may be absorbed.

(147
Thus, couching is a very easy operation; only one 
or two instruments being used. The principal 
danger consist in the liability of the iris to be 
wounded. Steadiness and skill are required to overcome 
this difficulty. But this operation seldom 
succeeds in restoring vision. I have frequently performed
it, and only in one case, I never restored the 
sense of sight. In all cases but that one great
inflamation followed the operation, and in two 
of them, the symptoms of gutta serena came on 
I was obliged to use depleting means, as purging,
blistering in these cases. From the above reasoning,
I have determined never to perform this 
operation, but to extract all, except in children, in 
whom the eye cannot be easily managed, and 
especially when the cataract is milky, in which 
case, couching may at least be tried on one eye
before extraction.
Artificial pupil. When the part of the cornea opposite
to the iris obscured by an opacity of the cornea, which 
cannot be removed, and another part remained 
transparent, we may make a hole in the iris opposite 
to the transparent part.

148)
The pupil is sometimes closed by inflamation.
This also, the iris may be opened.
I once succeeded in a case in which only one eighth
part of the cornea remained transparent, which 
was in the upper edge.
The patient being seated, and the eye opened
is in extraction, and pressed upon considerably,
the cornea is to be divided as in extraction,
with this difference, that before the opposite side 
of the cornea is punctured, the knife is to be so 
far retracted that a great part of the aqueous humor
may escape, and a flap of the iris fall before 
the knife, and now by finishing the operation 
by one cut, a round portion of the iris is cut
out. This is the simplist way of operating, and 
may prevent the introduction of forcepts and 
scissars which may injure the lens. Thus I
have operated with success several times
But when the pupil is closed, the iris cannot 
be brought afloat before the knife, and consequently 
we cannot succeed in this way; but as 
as soon as the knife is within the cornea,
the point of it is to be carried down, and the 

(149
pupil cut to about 1/10 inch, and the open incision at 
in the usual way thro' the cornea. The flap 
this iris may now be cut with fine scissars, which 
may be curved near the point, or what is [illegible]
slender forcepts, on one side whereof, there is a
curved edge. But as the causes of the closure of 
the pupil are violent ones, the operation may 
readily renew this, and therefore, before operating,
the patients should be told that the success 
of [of] it but a mere chance; and we 
only operate in uncertainty.
Hydrocele. This is a collection of water in 
the scrotum. The situation of the water produces
essential difference in it.
1. The anasarcous hydrocele, in which, this 
water is contained in the cellular substances
of the scrotum,
2. The hydrocele of the tunica vaginalis teses,
and
3. The encysted hydrocele of the spermatic
cord. As the treatment of these is essentially
different, we ought to distinguish them wt.

150
accuracy.
1. The first species presents an equal tumor,
whhich includes the whole scrotum, on both 
sides, and the raphe divides it into two in the 
middle. The tumor is of its natural colour,
and the finger makes an impression which 
lasts some time. The spermatic cord can easily
be felt in its natural situation. Thus the case
is readily discriminated.
2. The collection in the vaginal coat is supposed
to arise from the increase of the natural secretion
the torpor of the absorbents or the rupture of the 
lymphatic vessels. It commences near the testicle,
is generally confined to one side, is not lessened 
by pressure, is firm, and in the beginning,
the testicle can be felt but in the end cannot
be felt. It may be distinguished from.....
Hernia, by beginning at the bottom of the scrotum,
by being firmer, by being irreducible by 
pressure, by the spermatic cord being distinctly
felt, whereas the hernia presents all the opposites 
of these phenomena. Fluctuation, and 

(151
transparency may often be perceived.
Schirrus testicle, it is easily distinguished by 
cord being generally enlarged and irregular in 
the former, from the tumor being in this also 
heavier and more opaque than in hydroclele
From Hernia humoralis by its having no connection 
with gonorrhoea, by the tumor not 
being so firm in hydrocele, and by other symptoms
of water.
3. When one or more cysts of water are lodged in 
the spermatic cord, the testicle is always felt at 
the bottom of the sac, fluctuation is evident,
and the tumor is diaphanous. This tumor extends
to, or even beyond the abdominal ring,
and may be well distinguished. In a case of 
this kind, I saw some difficulty in distinguishing 
it from hernia. The tumor could be pressed
up (and as it were reduced) but immediately
returned, but fluctuation and transparency,
were evident, the testicle could be felt at the 
bottom of the scrotum, a puncture evacuated 
the water, and the wine injection competed 
the cure.

152)
Method of Cure. The bulk and weight of the 
tumor is often so slight, that patents are 
unwilling to submit to the operation.
The pain, either in the part or in the loins
is much alleviated by a suspensary bandage.
1. In the anasarcous species, tho' the case is 
not connected with surgery, we are often called 
to evacuate the water. Punctures are to 
be preferred to scarifications or setons, as 
the latter may produce mortification.
Five or six punctures will evacuate the water,
and the dressing may be dry lint.
I have seen the tunica vaginalis when 
distended with water, suffer a rupture, and produce 
one of the 1st species. An old gentleman
while setting in his room felt some thing give
way in the scrotum, and the tense tumor of
the vaginal coat was exchanged for a soft
diffused, lived one, and mortification was feared.
I was consulted 3 days after, and prognosticated 
that the breach would heal up, the water 
be absorbed, and the disease resume its
former state, and just such was the result

(153
2. In the second species, little can be done by 
medicine. I have seen it cured by the affusion of 
cold water. Temporary ease may be procured by
evacuating the water with the trocar or lancet
and then introducing a canula and insetor
till the water is carried off, and then covering
the puncture with adhesive plaster.
Simple as this is, I have seen three surgeons
puzled by a simple case in London. The first 
who was called, plunged in the trochar at the 
usual place, the inferior, anterior part, but 
no water followed the stilette. The wound 
was suffered to heal, and then a second was 
called, who also failed in the same manner.
Such also was the fate of the 3rd who could procure
nothing but drops of blood. Mr. Hunter
was now called in. On a very close examination,
he found that the testicle lay just 
at the place where the surgeons had chosen to 
operate, and that they plunged their trochars
into the substance of it. He operated on 
the inferior posterior part of the tumor, just 
where we usually find the testicle, and with

154
complete success. This teaches us always to 
feel the testicle, before operating.
The radical cure can be affected by exciting 
inflamation in the sac, so as to obliterate it
I have cured it by repeated tapings, in one 
case in which, the testicle was so inflamed and 
enlarged that I feared to inject wine. Tevacecated 
the water as soon as the coat was distended
enough to keep the instrument off the 
testicle. Low diet, and mercurial purges were
used. The water was let off every fortnight.
Several ways have been used to obliterate the sac.
1t. Incision is the most ancient. It consists of 
in dividing the skin and vaginal coat, and 
filling the cavity with lint. Great inflamation 
and suppuration came on, the lint was separated 
gradually, and the cavity united.
But this remedy is very severe, attended sometimes 
with haemorrhage, and shreds of lint
remaining often produced abscesses several 
weeks after the sore was healed.
2d. As the tunic is sometimes thickened, the 
removal of it has been proposed by Douglas

(155
but this is quite unnecessary.
3d. Caustic. The whole tumor, from top to 
bottom has been laid open by a caustic, which 
on the separating of the eschar, produced very 
great pain and inflamation, followed by 
the obliteration of the sac. Mr Else has confined
the caustic to a shillings breadth, and this is 
found sufficient. But the caustic is a very 
uncertain remedy; often faling to reach the 
sac, often causing violent inflamation, fever
and supuration, and when the water is 
contained in sacs this does not succeed.
4th Tent. A skein of silk was carried from 
the bottom to the top of the tumor. This often 
answers, but often causes only the tract betwixt
the tunic and testicle in which it lies
to be united, and the disese returns on the 
sides of this.
5. Monro left the canula in the sac, until it
produced the nescesary inflamation, but according 
to Cheselden, this mode is very painful,
and he prefered the tent. 

156)
6. Injection. Lately, the ancient mode of injecting
stimulating fluid into the tenica vaginalasis
has be revived. Wine, or wine and
water have been particularly recommended by 
Sir James Earle. This he has shewn to be perfectly 
safe and easy. In a few cases, indeed
this remedy will fail.
I once succeeded in curing a case with warm 
water alone, in the Penn Hospital, contrary
to my expectations; and I have since read 
Mr. Whateleys report, to the same import.
But wine, or wine and water are found very 
convenient, safe and not painful. If no inflamation
follow, it may soon be repeated
The patient is to be seated opposite to a window,
and the surgeon kneeling before him, makes the 
evacuation either with a trochar and or with a 
small lancet and then introduce a canula.
As soon as the fluid has escaped by the canula,
the injection of wine or wine & water, (being 
prepared in a bladder with a stop cock) is to 
be thrown thro' the canula into the tunica


(157
tunica vaginalis, and as soon as pain is felt in 
the scrotum or loins, which is in general four 
or five minutes, the liquor may be allowed to flow 
back again, the canula with drawn, the orifice 
closed with plaster, and the scrotum supported 
with a roller, which prevents inflamation.
In four or five days, the scrotum becomes red, tender
and covered with a blush, and in four or five 
more this goes off, with the disposition to renew 
the disease. If the inflamation run high, 
the patient may be confined to bed, and to low
diet, evacuating measures used, and a leadwater-
poultice applied. But if the inflamation 
be defective, the patient may walk about his 
room and use stimulating food.
To avoid the canula's escaping from the orifice 
in the tunica vaginales, which would cause 
the injection to pass between the skin and cellular
substance, and mortification, the canula
may be introduced full 2 inches and laid on 
one side. This never happened to me, but I 
saw it in the practice of another.
Jan.28.1812.  Dr. P.

158
Lecture 35.
In speaking of the treatment of the hydrocele
by injection, I observed that in a few cases, that 
operation will fail. I am to describe a late 
and successful operation for these cases, described 
by Mr. Hunter.
It consists in making an incision of 1/2 inches
long on the anterior inferior part of the scrotum,
thro' the skin and cellular substance, and piercing 
the cellular membrane, so as to lay bare the 
testicle. The state of the testicle may be seen.
The scrotum must now be filled, not with lint,
but with flour, or rather dough, made into balls 
of 1/2 diameter, holding the lips of the scrotum
asunder by two hooks, one in the left hand, and the 
other given to an assistant. After the tunica vagnalis
is moderately distended with these balls, a
piece of patent lint is put into the mouth of 
the sore, and the whole suspended in a bag-truss.
In case of much fever or inflamation, blood may be 
drawn, &c. In 2 or three days, a poultice may be applied
over it, the cavity will suppurate the dough

(159
will come away melted in the pus, the cavity appears
just as a large abscess, and the whole will 
very uniformly unite. I have performed this operation 
several times with perfect success.
Of Herniæ. Herniae, or ruptures are among the 
most important surgical diseases, from their 
frequency and their great dangers and inconvenience.
They consist of tumors, caused by the protrusion 
of the natural contents of the abdomen 
through its parieties.
They occur most frequently at the upper and 
fore part of the thigh, at the navel, and the groin.
The twin rupture is improper, as they consist of a 
sac of the peretonuem, pushed thro' some natural opening.
Thus, at the navel the navel, there sometimes
remains an opening in the foetus, imperfectly
closed, which admits of these accidents, and 
in the groin, the ring of the external oblique muscle,
thro' which the spermatic cord in the male and 
the round ligaments in the female pass, is the 
aperture at which the inguinal or scrotal 
hernia, or oschocele pass out, and in the upper,

160
and fore part of the thigh where the crural or 
femoral hernia is seated, the hernial aperture
consists of the cavity under Pouparts ligament.
All the contents of the abdomen have been occasionally
found in hernial sacs, except the 
duodenum and pancreas; but the colon and 
mesentery, and omentum are the most usual.
Hernia are named from their contents, as 
enteracele, epiplocele, gastrocele, &c.
The congenital hernia or that in which,
the protruded parts lie in the tunica vaginalis
testes, arises from that aperture in which the 
testicle [cross out] descends, not being closed before 
birth, and there is still a communication between
the peritoneum and tunica vaginalis.
In such cases, when the child coughs cries, &c the contents
of the abdomen may descend, but when pressure 
is made on it, it easily returns again. By frequent
repetitions, the communication remains open, and 
subject to rupture through life._ We shall treat 
of the bubonocele at length, and then treat of 
the peculiarities of the others.

(161
The bubonal or inguinal hernia is characterised by a tumor
at the abdominal ring. Astley Cooper says it begins 
at the distance of 1 1/2 inch from the external opening,
on the external side of it and higher up. It is 
easy to press the tumor up again; by lying horizontally,
also, it may be reduced, but on rising, or on 
making any pressure with the abdominal muscles,
diaphragm, &c, it is returned again. We see 
the progress of the tumor from the upper to the 
lower part of the scrotum. I have seen it descend
as low as the knee, and suspended by bandages
round the patients neck.
On dissection, we find the tumor to consist of 
1. (After laying aside the skin of the scrotum)
a number of tendinous bands united together
by fascia, which is derived from the obliquies externus
above the abdominal ring
2. The fibres of the cremaster muscle
3 The hernial sac. See A. Cooper. But these 
are sometimes so blended together as to appear 
many more in some instances, yet the above
ordor is universal.
Behind the upper part of the sac is found the

162
spermatic cord. At the bottom and posterior pt 
of the tumor is the testicle, the abdominal 
ring is the mouth or aperture of the rupture and 
and between this and the symphysis pubis,
is found the epigastric artery. In a few cases 
the spermatic cord is found on the anterior side
of the sac. This teaches us always to proceed wt
caution in operating.
Symptoms. 1. The tumor commences at, and 
proceeds from the abdominal ring in the groin.
2. The tumor is increased by the erect posture, 
et. v.v.
3. Is increased by coughing, straining the diaphragm,
abdominal muscles, &c.
4. When intestine is returning we hear a gurglinng 
noise, and
5. When intestine is down, the functions of 
the bowels are interfered with. Nausea, vomiting,
colic pains, costiveness &c are produced.
Diagnosis. 1. From hydrocele. a. by beginning above,
whereas hydrocele begins from the bottom of 
the scrotum, by the abscence of fluctuation
and the cord not being felt in hernia.


163
b. by being increased by the erect posture, pressure
with the muscles, of the abdomen, diaphragm
Thus, we can easily avoid mistakes in these cases
2 From swelled testicle. a. by the causes of this 
as suppressed gonorrhea, external violence, & 
being known. b. by the swelled testicle being 
hot and painful. c. by the swelled testicles
going off suddenly at any time like herniae,
d. by most of the diagnosis betwixt herniae & 
hydrocele.
3. From bubo a. by the connection of this with 
chancre, and being painful. b. by the bowels 
not being interfered with in buboes. c. by bubo
tending to suppuration.
4. From cysts on the spermatic cord. a Tho'
this and inguinal hernia have many features 
in common, when the cysts lie along the cord,
yet this one circumstance is a certain diagnosis,
vizt that if pressure is mad on the tumor,
if it be hernia, it will be lessened, but 
if an encysted tumor, it will not be lessened
in size, but go up in a mass and descend 
just as it went up, immediately. b. By the

164
effects of a puncture in evacuating the water
of the cysts, and so curing the disease.
5. From Varicocele, or a varicose state of the 
veins of the cord, it is considered difficult to distinguish
hernia. When the patient lies, the tumor 
is lessened, and when he stands, the pressure
of the column of blood enlarges it again, such 
also is the effect of coughing, straining, &c.
a. But in varicocele, we can feell, and even see 
the convoluted form of the veins under the skin,
b. A. Cooper proposes to lay the patient horizontally,
to take hold of the cord, and let the patient 
rise again. In hernia, a considerable 
pressure will be made against the fingers, but 
in variococele, this will not be considerable. But 
the first method is preferable, and even tho motion
of the blood in the veins gives a sensation
which prevents any deception when we feel it.
Causes. The causes are 1. Such as weaken the 
parceters of the abdomen. 2. Such as increase the 
pressure of the intestines. &c against them.
3 Both causes united. General debility, as after 
a fever, in old age, &c disposed to hernia.

165
Blows on the abdomen, pregnancy, strains of 
the diaphragm or abdominal muscles, [cross out],
great corpulence, violent coughing, straining
to stool, violent exercise jumping, lifting great 
weights, &c are causes of the second order. When they
act, the contents of the abdomen may be more or 
less forced thro' any weak parts in the parieteis
Thus I have twice seen herniae produced in young
men by carrying in a back leg.
Of the Treatment. For convenience in practice,
herniae may be divided into the following 
orders.
I. Such as are of easy reduction.
II. Such as can only be reduced by particular
management.
III. Such as tho' unattended with stricture, are 
irreducible.
IV. Such as are attended with stricture.
Of the first, it may be obseved that as long 
as intestine or omentum remain down, there
is always danger, even when there is no pain.
Stricture may occur, the contents of the bowel

166
may be stopped, and after frequent descents of 
the omentum, the passages [to be] kept open 
so that the gut may pass down, and this is 
liable to be the case as long as any omentum
is down. While any part remains down, the 
whole may be enlarged by the causes of herniae,
and stricture may follow this second descent.
Therefore the contents of the sac are always
to be reduced, and prevented from returning
by proper compression made on the mouth, or 
neck of the sac, after reduction.
This indication is answered by a truss, or 
slender steel spring, which goes more than 
half round the body, and the circle completed by 
a strap. On the end of this is a pad. A bandage
is applied in the groin, reaching from before 
backwards, to prevent the truss slipping up.
In applying the truss, let us recollect why it is 
used? That it may effectually keep the gut up
it must act on the ruing accurately. This part
presents a pit to the finger after the reduction 
of the intestine &c.
Instrument makes generally err by applying

167
the truss too low, thus pressing on the cord, testicle,
&c and allowing the mouth of the ring to be kept
open, which is the case when the truss acts over the 
pubis. The lower edge of the pad should act just 
over the upper edge of the pubis. The head of the 
truss is sometimes made of silver or ivory, and 
made so as to turn olbi[c]quely at pleasure so 
as to accomodate corpulent persons. The metal 
mentioned is chosen for not rusting. The part 
may be defended by a muslin compress, when this 
instrument is made of these materials.
The truss is to be worn night and day. I have 
known it affect a cure in nine months in a person 
of a good constitution, but the truss ought
never to be laid aside before two years. Aged persons 
must wear the truss always, as in them 
the cure cannot be expected. I know, however, 1 
exception to this, in a man of 50, in whom,
the ring united perfectly.
The exciting causes are to be avoided during the 
use of the truss, as costiveness, lifting weighty bodies,
riding a rough-going horse, violent excercise
&c. And when any exertion is made, the

168
patient should assist the truss, by pressure
with his hand, particularly if costive, or if 
he has a stricture in the urethra. These directions 
are essential to his safety.
Second order. The protrusion is sometimes so 
large that tho there be no stricture, the reduction 
cannot be affected. In this case the patient
must be put to bed, confined to a low diet,
to loose blood and to use purgative medicine.
Thus, the tumor may be lessened, as reduced,
and then the truss is to be applied. I have
often succeeded in this way, in these cases.
Third order. Tho' there be no stricture, the reduction 
may be impracticable, either from 
the shape of the tumor, adhesions betwixt 
the guts, or betwixt the gut and sac, or by ligamentous 
bands. In this case the tumor is to 
be carefully suspended by a suspensary bandage
and the patient often enjoys comfort, yet is 
not freefrom the danger of stricture. [See M.
As in hydrocele the sac has sometimes burst,
so has the hernial sac. In this case the gut

(169
will be found under the skin, and the gut must 
be reduced first through the ruptured aperture, & 
then into the mouth of the sac, into the abdomen 
But this case is very rare. [See N,D. Dr. Ph
Jan.29.
Notes on Lecture 35.
L. Page 165... After the hernia has been lessened 
in size by these remedies, we may by taking hold 
of the remaining tumor, in most cases reduce 
it, if it has not gone up spontaneously.
M. Page 168.... This order is only known by its 
not yielding to the remedies mentioned above (168) 
& cold applications
No above... The suspensary bandage not only 
prevents pain and great inconvenience, but 
by warding off the dragging of the tumor, prevents 
more of the contents of the abdomen being 
displaced. It is to be lined with soft materials.
A. idem... During the use of the suspensary, the 
state of the bowels requires attention. Costiveness,
and the use of flatulent food are to be 
particularly avoided.
Jan 31

170)
Lecture 36.
Hernia continued... Fourth order. We now come 
to speak of herniae, with stricture. Stricture in 
hernia consists of a tightness at the orrifice as
neck of the rupture, which injures the functions 
in the gut, or vessels of the protruded parts.
The tumour becomes hard, the patient becomes 
unable to stand, nausea and vomiting sooner 
or later come on, an antiperistaltic motion 
of the bowels is established, fœcal matter 
is vomited and if the gut be strangulated, no fœces 
can escape per anum, but what may happen
to lie beyond the stricture.
If the tightness be such as to injure the circulation,
and injure the venous circulation, inflamation,
with considerable swelling and 
fever comes on the colour of the tumor is not 
red, but of a dark leaden colour, just as in 
phlegmon before mortification.
The stricture may even be such as to stop the
circulation altogether, and produce mortification.

(171
When that is the case, the belly swells, becomes
very tender, the pulse becomes small and very 
weak, elilliness in may cases, which is followed 
by great restlessness &c occur, and death 
soon follows. But before the fatal hour, (which 
may be protracted from one to several days) it 
is common that a delusive interval occurs. The 
tumor becomes soft, and returns into the abdomen,
and the patient fancies himself nearly 
well, when death is just at hand.
On dissection, the bowels at the seat of the 
stricture are found of a chocolate colour, tender,
and easily torn with the fingers, and even
holes are often found it in.
When the omentum only is strangulated,
all the symptoms are much milder.
All these effects are produced by the pressure 
of the tendons thro' which the spermatic
cord and hernia pass. The ring of the obliquus
externus is the most usual seat of this. But Mr. A
Cooper has shown that the cause of the stricture
is frequently higher seated, viz in the obliquus
internus and transversalis. 

172
This is particularly the case in old and in 
large ruptures. The stricture is said to be spasmodic,
but no muscular fibres are concerned
When this is the case, cutting the ring will not 
relieve the stricture, but we must operate 1 1/4
inches higher up. This is the distance intervening 
betwixt the internal and external orifices,
but in old ruptures, these orifices are 
approximated, so that the internal one is just 
behind the ring.
In all cases of strangulation, effectual measures
must be taken to remove the stricture.
As soon as a patient is the subject of one of 
these accidents, he places himself on the ground 
horizontally, and makes pressure on the tumor.
If he fails, the surgeon is called upon. He 
places the patient in a bed, with the foot of 
it raised, and relaxes the muscles on the anterior
of the thigh and abdomen, by flexing the 
former on the pelvis, and by bending the pelvis
upward. He then takes hold of the tumor,
and presses it upward and outward, but not with 
any violence, which might irritate and even


(173
burst the tumor. If this remedy, viz position 
with tanis fail, other remedies are to be tried 
in the following order.
1. Bloodletting. This may be performed and delinquim
animi, and then, the termis will very 
often succeed very easily.
2. Warm bath. The whole body should be 
introduced into a bath at or near 100 and continued 
till faintness comes on. It may very 
often be practicable to reduce the rupture 
now, by the taxis.
3. Purges. I have found mild purges, particularly
rum, tart, and jalap in small doeses often 
repeated, given with some essence of peppermint,
of great service. Glysters at the same 
time being given. Mr Hey condemns purges 
entirely, but when the intestine is not in 
the strangulation, and in old cases, they answer
very well. But in case of strangulated 
gut, the only increase the vomiting.
4. Tobacco in form of infusion or smoke is 
a well known resource. The smoke is the most 
active, the infusion the milder remedy. 

174)
Tobacco ʒi infused in water [illegible] forms an infusion,
of which, one half may be thrown up 
every half hour, till the desired langor is produced,
and the reduction may generally be affected. 
Dangerous symptoms sometimes follow 
this remedy. In one man last summer, the 
powers life had nearly vanquished by the usual 
quantity, and Astley Cooper mentions a 
case in which the infusion of ℥i produced pain,
and vomiting, followed by death in 25 minutes 
in a girl. Care is therefore requiste in the 
use of this remedy. Perhaps ℥i of the infusion 
would be enough to begin with. Of all other 
remedies, this is the most effectual, and the quickest
in manifesting its result.
5. Cold. A bladder filled with pounded ice may 
be applied to the tumor, or if this cannot be 
had a solution of salts in vinegar & water, or 
crude sal ammonia ℥v nitre ℥v water [illegible]
be put into a bladder, and applied. These remedies
are very effectual. But they are not to be 
too long continued [in], as the part has actually
been frozen. 

(175
6. Opium. This remedy is indispensible in allaying
the sickness and vomiting and to be effectual,
must be given in large doses. 2 grs may 
be given by the mouth, and ʒi of laudanum injected.
In case of a man who had suffered strangulation 
for 3 days, I gave 3 grs of opium at 
night, and put him to rest. He slept well 
all night, and in the morning, the intestines
was found reduced.
But if these remedies fail, the operation for 
removing the stricture must be performed.
As to the time of operating; it is better to operate 
too early than too late. In the latter case
mortification or peritoneal inflamation will
have supervened. The most celebrated men are 
in the habit of operating early, even as soon 
as 24 hours.
We may make it a rule, in all cases after bleeding,
warm bath, purges, tobacco and cold, with a proper posture, taxis
and opium have failed after a fair trial to operate immediately.
By doing so many will be saved.
It is very difficult to ascertain the state of 
the hernia by the symptoms. Langor, hiccup,

176
hiccup, coldness of the extremities, small and weak
pulse &c are said to denote mortification, but 
I have seen the operation successfully performed
with perfect success, and the parts found 
to be sound. The duration of the stricture is 
no rule: patients have died in 8 hours, and they 
have survived 17 days. The fever is also uncertain 
When the countenance is sunk, the pulse weak
and the extremities cold, I have seen the operation 
performed with success.
Hernia are more dangerous in the middle 
aged than in the young or old, in small
than in large, and in recent than in old cases.
When the circulation is stopped, death is 
certain.
One symptom may be regarded as certainly 
fatal, viz coldness of the extremities, [This]
and a cold and moist state of the skin. This is
always a forerunner of death, and if the operation 
be performed under such circumstances,
it will always fail.
Of the Operation. The patient is to be laid on 
a table covered with a blanket. The pubis shaven

(177
An incision is to be made with a scalpel from 
1 1/2 inches above the ring to the bottom of the sac
unless this be very large, the skin and cellular 
substance are to be cut and the tendon of 
the external oblicque exposed. The tendinous 
fibres on the surface of the tumor are to be divided,
and the sac punctured by several very 
delicate strokes* of the knife, trying if the probe
will enter it. As soon as a puncture is made 
the director is to be so far introduced and the sac out on this as to allow
the finger to be introduced. On the finger 
the bistoury is to be applied, and the sac
divided as far as to near the ring but no farther.
By introducing the finger through the 
ring into the abdomen, the stricture can 
very easily be divided by passing the probe pointed
bistoury along the finger. The incision 
may be made upward, or upwards and a little 
outwards. If done inwards, the epigastric artery 
will certainly be wounded, and as the 
artery in a few cases lies on the outside, it is 
best to convey the bistoury directly upwards,
*No water being contained in the sac.

178)
as Mr Cooper advises, and then the artery cannot 
be wounded.
Mr. Cooper advises us for the purpose of preventing 
peritonial inflamation to carry 
the bistoury through the tendon only introducing 
it not within the sac, but betwixt 
this and the tendon.
The above is the way in which the operation 
is generally performed, but some late surgeons,
particularly Monro make no incision 
into the sac atale, but after dissecting 
down to the sac, cut some fibres of the 
tendon of the muscle in muscle with the scalpel,
and then introduce the bistoury.
After dividing the stricture, the part protruded 
may be easily reduced by the taxis.
This operation is exceeding by simple and easy,
and attended with no hazard whatever in
the hand of a careful operator. Dr. P.
Jan. 31.

179
Lecture 37.
Crural hernia continued. When the sac can 
be returned thro' the enlarged ring without being 
divided, this ought always to be done, this 
operation being the most simple, and tends to avoid
pertioneal inflamation; but when the strictured
gut is mortified, the sac must always be opened.
Also if we cannot reduce the sac after dividing
the tendon, the cavity of it must be open'd
and the cause examined, which may be 1. Adhesion
2 alterations in the shape of the parts protruded or
3 stricture at the neck of the sac.
1. Adhesions betwixt the gut and sac, if they be 
long may be divided, but if very short, the portion 
of the sac connected to the bowel may be cut
off and returned with the bowel. Dissecting adhesions 
near the mouth of the sac is difficult
and can only be done by laying the tendon
bare all round the adhesion.
2. When a large mass of omentum is low 
down, and is not retracted, it may be cut off
and the vessels tied, leaving the end of the

180)
ligature out at the wound.
3. Stricture of the neck of the sac is not a frequent 
occurrence: I met with a case of it in July,
1798. A man of 38 years of age was attacked with 
a severe colic which had continued several days.
He had been subject to a tumor in the groin for 
two years, which went off as soon as pressed upon
or the patient lay. A few days before I was called
this tumor had come down in consequence
of his lifting a heavy piece of wood. When I was 
called. I found the wrists cold, the pulse small and 
trembling, the belly tumid, the scrotum swollen, 
vomiting obstinate and no passage by stool
tho' the pain and swelling in tumor were much less than
before my arrival.
I advised an immediate operation, as the symptoms
of mortification were present. I made an incision 
through the skin and cellular substances
from above the ring to the bottom of the tumor,
dissected the sac free from the tendon and laid
the former open, but to my astonishment found 
nothing but bloody serum therein; no gut, no stricture

181
stricture and therefore there could not be in the tumor,
any cause capapable of producing the above
symptoms! Is the case produced by inters [sersc??]?
In these obscure circumstances, no remedy was 
applied except warm bath and purges of jalap & 
cremor tartar; but the man died in 36 hours.
On opening the body, a portion of bowel was 
found closely embraced by the mouth of the sac
which was retracted into the abdom a considerable 
way above the ring, and not at all in contact
with the fascia which usually embraces
it. What ought to have been done, had the true
cause of the disease been known? Ought the sac
to have been pulled down and divided? or ought 
the tendon to have been opened, and the neck 
of the sac cut within the abdomen?
The bowels are never to be returned in a mortified 
state into the abdomen. However, the symptoms
may seem to indicate mortification 
and yet the bowels be found sound. When a
sudden mitigation of the pain comes on, the 
tumor becomes purple, creptus is heard on

182
handling the scrotum, the belly becomes tense
the patient very restless, his skin hot, his pulse
weak and quick, and the hernia easily reduced, 
little doubt need remain.
Yet such a set of [set of] symptoms are not
always fatal. I have seen a negro who was 
in this situation recover, but with an artificial
anus at the groin, where the upper portion 
of intestine terminated after the slough 
separated.
After opening the sac, we can judge of the 
state of the gut. But the dark red, or chocolate
colour of the intestine, produced by impeded circulation
is not to be mistaken for mortification. 
The mortification is generally confined 
to spots, the texture is so altered that the gut
tears under our finger and has an offensive
smell. If the dead spot be small the bowel may 
be [small] returned, as adhesion will fix the surrounding 
parts to the peritoneum &c and the 
slough pass by the forces, but if there be a hole
in the bowel, it will require a stitch. 

(183
When the whole cylinder of the intestine is destroyed,
we are advised by Mrs. Cooper and Thompson
to cut away the slough and secure the tendons 
of the bowel together by four sutures, leaving 
the end of the ligature out that we can [dia??]
out and at any time examine the bowel. But 
the accumulation of fœces in the upper porton 
of the bowel is commonly such as to rupture 
the stitches, or at least to cause the escape 
of fœces from the gut into the general cavity.
I perceive that Mr. Cooper himself failed in two 
cases of this kind.
I should not ever try Mr. Cooper's way. I would 
leave the intestine out, and if the slough were not 
separated, I would open the bowel at the dead part
with the scalpel, to give evacuation to the feces, which 
is always profuse for the first 24 or 30 hours. The 
ends of the intestine would be gradually appoximated,
they would as gradually retract within 
the abdomen and the external wound heal up.
In July, 1798 a woman was attacked with a violent
colic and tumor in the groin, which continued 
several days. The physicians bled, blistered,

184)
and purged her, but the vomiting increased, the 
extremities became cold, the pulse small and feeble,
hiccough and swelling and hardness of the abdomen,
the tumor became hard, the colour of 
it dusky red. She had had a tumor in the groin
after severe parturition 2 years before, and it was 
plain that the hernia, which was femoral in this 
case was mortified. I made an incision through 
the skin and cellular substance, fœtid serum
and air passed from it, the tumor hung like 
an egg by a small neck; I next laid bare the tendon
and cut Pouparts ligament at right angles.
I next cut a hole in the gut, and introduced
my finger to the place of stricture.* The passage
through the bowels was [slow] by artificial means for four days. 
[cross out], the external 
coat of the bowel only, sloughed. On the 23d July
she was able to leave bed, and the bowel having 
retracted, the wound heald. Thus, an artificial 
anus was made, the gangrene was not complete,
neither were there two oricifices, but even
*This was followed by a copious discharge of fœces 
air by the orifice made in the gut. 

(185
if there had, they would probably have united.
When all the protruded intestine does not [in??tify],
and adhesions form round it a permanent
discharge of foeces may be established. I had one 
case of this kind in the P. Hospital some years
ago. I tried to accellerate the rectraction of both 
ends of the bowel by introducing a piece of bogie 
3 inches long bent up, one end being introduced 
into the two orifices, and gentle pressure was thus 
applied, but I found this not to succeed, as pain 
followed its use, and I performed a new operation,
which consisted in establishing a lateral communication
betwixt the ends of the bowel. I brought
the ends of the bowel in contact to the external
wound, and introducing the fore finger into one
and the thumb into the other, I found that the 
two coats moved on one another betwixt my finger
and thumb, so that I feared the adhesion 
was not extensive enough to permit an incision 
to be made betwixt the two bowels. To produce 
adhesion between them, I introduced a ligature
by means of a kneedle through the side 
of the two portions and brought them with

186)
some tightness together, such as might even 
have produced ulceration tho the space I
intended to divide, but the ligature caused so 
much pain that I was content with its producing 
adhesion as far as it reached. I next 
made a slit with the knife betwixt the two 
bowels which I had thus made to adhere, as large 
as the calibre of the bowel. The cavity of the sac
was dressed with a compress, and next day some 
griping was felt, and wind escaped per anum.
In 3 days more foeces passed freely. I next tried 
to heal the external wound by paring its lips, 
and introducing the twisted suture, but in 
this I fail'd, and a truss was the only inconvenience 
he had to submit to, as the natural 
route of the bowels was established; however, if 
the external wound had closed the truss would 
also have been nescessary. This operation being 
successful, that of Cooper is quite unnescessary.
The bowels may be allowed to adhere to 
the ring and lateral parts.
The omentum which forms a part in these hernia

187
is also to be reduced, but if it have mortified, the 
dead parts are to be surrounded by an incision 
through the living and removed. Any large vessels
which bleed may be tied, the end of the ligature 
being kept out. Mr Pott has thought this 
precaution unnesecssary, but alarming haemorrhagies 
have followed the neglect of it.
It sometimes difficult to tell whether or no the 
omentum be dead, and fatal consequences might 
follow the reduction of a mortified portion. It is 
said to feel crisp when dead, but the following 
marks may be depended on 1. The blood is coagulated 
in the veins of the dead portion. 2. The vessels 
of it do not bleed on being punctured.
Some have advised the adhesion securing 
the omentum in a string to prevent haemorrhage,
and even Pott recommended this, but it 
had produced nausea, vomiting, fever, pain & 
death, and therefore this plan must be exploded.
After the operation the wound is to be united by sutures.
The patient is to be confined to a horizontal 
posture, and cough is to be allayed by demulcents 
and opium, but the latter is to be 

188)
avoided as much as possible, as it retards the 
functions of the bowels. If nescessary, the bowels
may be opened with castor oil or salts,
and in some cases the bowels are so torpid & 
paralytic by the pressure they have suffered,
that they are not easily moved. In one case,
a swelling was produced by the accumulation
of the foecis above the wound, and went off by 
pressure again. This returned occasionally for 
three days and then subsided.
In some cases pain and swelling follow the 
operation. Bleeding, low diet, purging, blistering,
&c may be used as circumstances may indicate.
After the wound is healed the part must be 
supported by the use of a truss.
Femoral Herniae. This hernia we have observed, appears
on the upper and anterior part of the thighs
The contents of it pass under Pauparts ligaments,
and the tumor is small and moveable, and 
may be mistaken for a bubo or enlarged lymphatic 
gland. This mistake is very dangerous, and 

(189
yet has fallen out in the hand of every expert 
men. If a hernia were left to suppurate, or boldly 
opened as a suppurated bubo, how serious a 
mistake would be made! We read of men having 
died of ileus and a bubo!
In all doubtful cases of the kind, we ought to 
lay bare and examine the part. 1. The hernia is generally 
the lower, 2 in bubo, the edge of Paupurts ligament
cannot be felt, 3, neither can the pubis.
It is nescessary to know the true situation of 
the sac, as without this knowledge, we could 
not perform the taxis aright.
The bowels pass into the theca for the femoral 
vessels. They lie in the vicinty of of the pectineus
muscle, just over the fascia lata. The epigastric 
artery lies on the outside and the spermatic 
cord lies on the superior and anterior part
These two vessels cross one another. The obturata
artery sometimes arises in common with the epigastric.
The bowels descend first downwards, and then,
forwards at right angles with its neck. The taxis 
must therefore act inward and then upward, whereas

190
whereas in the inguinal hernia, the taxis acts upward
and outwards. This of great importance.
In this tumor we find 1. the skin, 2 the fascia,
3 the proper sac, or that derived from the peritoneum.
The inner edge of Pouparts ligament leaves 
a small aperture only, and the stricture in 
this place is very dangerous, and early open action 
is requisite. Cooper says if he were attacked 
with this hernia he would try the tobacco injection 
and if this failed, the operation!
The integuments are sometimes very thin, so that 
we are to proceed very cautiously thro these 3 membranes 
lest the gut be wounded. After this, the 
stricture is to be divided. In doing this caution
is required. If we cut inward the spermatic cord is 
wounded, If outwards, the epigastric artery, and in 
an upward direction, there is also some danger
of cutting the cord also, but let it be kept inward
that it lies 1/2 inch off, and this Ipace answers every 
purpose. Pinbuuat reccommended to cut the 
internal edge of the crural arch or Pouparts ligament,
but 1. the deep situation renders this difficult 
2, a director is required and the gut must be	

191
pulled with some violence aside 3. In some patients,
the obturator artery winds round the neck
of the Sac, and if wounded here it cannot be
secured as it can be if wounded over the middle
of the tendon. [See notes P and Q below Page 191.
I prefer operating on the middle of Pouparts 
ligament, on its anterior part, and at right 
angles with the ligament.
If the operator is fearful of cutting the spermatic
cord he may as A. Cooper advises dissect 
the cord loose ad have it drawn aside by a
hook before dividing the crucial arch.
February 2nd, 1812 Dr Physic
Notes on Lecture 37.
P. page 191... For nine out of ten cases of femoral 
hernia the patients are women, and in this 
there is not so much danger, as the cord in 
them is absent.
2. Page 191... When the epigastric artery lies 
in the way and is wounded, we can feel the 
pulsation of the vessel, pass a kneedle under
it and tie it. Feb 5th Recapitulations

192
Lecture 38.
Umbilical Herniae. We meet with it both in the 
child and in the adult.
In the infant the bowel often passes through the 
funis umbilicus. In such cases, it is to pressed up 
again, and the cord secured by a ligature. The edges
of the aperture may be approximated by adhesive
plasters, and they will often unite in a few days.
But sometimes it does not close for 3 or 4 months,
and the child by crying, straining, &c may cause a 
protrusion. I have met with 2 or 3 instances of this.
I have seen umbilical hernia in seven children in 
one family, yet in all the parts retracted and united 
well. This is the natural tendency of the parts, and 
can only be prevented by the presence of the gut, and 
this keeps the hole open, so that more gut may descend.
When the natural process fails, we are to treat 
it by an operation. 1. Compresses have been applied,
with a view of making union take place. They are 
secured by a roller passed round the body, but in 
this way the cure is detained for months; very incovenient 
pressure is made on the abdomen, the bowels

(193
bowels are even in danger of being protruded, the operation 
is very imperfect and difficult.
2. The ligature, which is the older method is recommended
by Desault. It is certain and expeditious
The patient being laid on his back with the thighs
and neck bent forward, the contents being reduced,
the sides of the funis are to be rubbed together to 
ascertain that all the contents are reduced. An assistant
now applies a waxed ligature several times
round the funis, making each time a double 
knot, and with such tightness as to produce moderate 
pain. Next day, the cord will be swelled 
just as a polypus after a ligature. 3rd day, it becomes
shrunk and livid. A second ligature is 
to be applied tighter than the former, producing
some pain, and a day after, a 3rd ligature
will compleat the mortification of the cord. The 
union of the mouth may be accelerated by adhesive 
plaster, and the circular bandage may be continued
for 3 or 4 months. This is found a very successful 
operation, and succeeds on young children
uniformly, best in those advanced nearer maturity,
it does not prove so fortunate.

194
This will best appear by the following cases,
which as well as the above operation are from Desault
1. A girl of 18 months old was operated on 
as above. The cord was shut in 7 days. Six months
after, there could be no vestige of the disease found.
2. A boy of 4 years old was operated on as above, the 
funis closed, but afterwards, the impulse of the bowels
could be perceived.
3. The latest period at which Desault operated was 
at the age of 9 years in a girl who had had it from 
birth. The the union was complete to appear and
in 3 mo. the swelling was apparent, and not 
withstanding the use of the bandage, in 6 mo. the 
relapse was complete. Therefore the operation is 
always to be performed early.
In Adults, according to Desault, the ligature
does not succeed. Having reduced the tumor by 
the taxis, pressure is to be made on the navel by 
Hey's truss. This is preferable to compress & bandage
as well as every other sort of truss. After this is 
applied, where any exertion is made the effect of the 
truss must be assisted by the hand.
[See note Pr. Vol. III p.3

(195
The other varieties of hernia woud require too long
time to explain them. They may be learned from 
books; it being my only to design to give a description 
of the nature of the most important kind
and the history of hernia in general. See Cooper
on hernia, and Lawrence.
Observations on the stone, perparatory to the 
demonstration of Lithotomy.
Stony concretions form in many parts of the 
body, as the salivary glands, the gall-bladder,
&c, but they are most usual in the organs for secreting,
containing and excreting the urine. This 
matter is often deposited on the sides of the pots in 
which urine is contained out of the body.
The quantity differs greatly in persons, some showing 
almost none of it, while others abound with 
it. I have seen the urine in a bowl incrust the 
bowl to 1/10 inch all round, in a scrofulous patient.
Now in such cases, it appears that a stone
will form at any time, when a solid body is introduced
into the bladder, serving as a nuclus 
for the matter to adhere to.

196)
A piece of lint, a bullet, a kneedle, &c have been found 
in the stone, and large masses of stone have formed round 
the end of a catheter. In the kidney, a coagulum of 
blood has had a similar effect. In sawing into a 
stone, it is generally found laminated, some stones
are very [hard] soft, and others are very hard, some are of a 
white, others gray, or brown colour.
The form commonly in the kidney and pass thence to 
the bladder, but they sometimes form in the bladder.
When after pain in the loins ceasing, the symptoms
of stone in the bladder commence, no doubt is 
left of the origin of the stone. A gentleman who 
had been troubl'd for some time with pain in 
the loins, on taking a ride from Germantown
to Phila. the pain ceased and the symptoms of calculus
in the bladder came on.
From a stone in the kidney, a dull pain in the loins
is produced. This, on stooping becomes acute. The urine
is often bloody. Inflamation with fever, costiveness 
and diminished urine with vomiting come 
on. If much dilution has been made, there is a copious 
flow of urine; or colic fever and suppression 
come on.

197
The efforts to vomit often press the stone into the 
ureter, which obstructing the passage of the urine, produces
great irritation. In fits of the gravel so produced, bleeding,
opium, blistering, warm bath and diluting liquors
are proper. The patient may stand, leaning forward, so 
as to bring the neck of the bladder immediately down
and pass his urine in a full stream and by this, the 
small stone may escape from the bladder. This is 
of great importance, and ought to be repeated, as it 
may prevent the formation of the stone.
A stone in the bladder produces pain heat and itching 
in the bladder, obstruction of urine frequently,
mucus or even puss will appear in the urine, sometimes
in large quantity. Bloody urine, especially after
excercise is very usual, and in some, the first symptom.
An uneasiness through out the urethra, especially 
at the glans, causing the patient to pull the prepuce
out, causing it to be elongated, prolapsus ani, &c are
common symptoms. By the suppression of urine, irritation,
distress and loss of sleep, the patient is soon 
exhausted of strength.
Other causes of irritation may deceive. Inflamation,
abscesses, ulceration in the bladder, tumors and

198
haemorrhoids in the rectum also have the same symptoms
as the stone in many cases. A woman laboured
under the symptoms of stone, and found no relief 
from the usual remedies. Suspecting an ulcer in 
the neck of the bladder, I ordered mercury till the 
mouth became sore, and all the symptoms vanished.
In another person all the usual symptoms existed,
and continued till death, when a tumor was 
found in the rectum. This, if it had been known could 
have been cured by an operation.
Stone may exist in the bladder and produce little 
or no uneasiness. A man who had a stricture in 
the urethra, and had not suppression, only a diminished 
stream of urine, and no other symptom referrable 
to stone, being prejudiced that he had a stone, 
underwent experiments such as jumping off a 
table, riding of a a rough-going horse, &c and no irritation 
or bloody urine being produced, but the stricture 
prevented sounding. After his death a rough stone 
as large as a walnut was found loose in the bladder!
The only certain criterion is sounding, or the introduction 
of a bent, iron instrument into the bladder,
which when it comes in contact with the stone

(199
produces a tingling fell, and may be heard. This 
operation may be repeated in various ways, through we
do not feel the stone at the first trial. First, let the 
patient stand, if this fail he may lie down. The finger introduced
into the anus may bring the stone into the way
of the sound. A man in this city had symptoms of the 
stone, and no stone could be felt on sounding. He 
went to London and was sounded by Mr. Hunter, but 
without any success. He returned, and applied to me. I 
succeeded by putting him to bed, raising the buttock
so as to throw the stone into the fundus of the bladder.
Having ascertained that a stone exist, no remedy 
can be depended on except lithotomy. Medicines introduced
into the stomach or injected into the bladder
have long been tried. From the effects of akalis on
a stone out of the body, they have been introduced in 
to use. Soap, aqua nephritica alcalina, carbonated
soda &c lessen the pain for a time only. In one case
they seemed to have succeeded. Unequivocal symptoms
of stone existed in a child. Sounding ascertained it 
beyond all doubt. The weather being warm, the operation 
was defferred, and the aqua mephritica alcalina

200)
alcalina was given, and to my utter astonishment, the 
symptoms of stone disappeared, and never returned
again. What became of this stone, it if were not 
dissolved, I do not know. Some other remedies besides
the above give temporary relief, such as lime water,
and uva ursi. But while these are used, the symptoms
will always return unless the stone become encysted,
which effect cannot be attributed to medicine.
Injections, capable of dissolving the stone in the 
bladder have be keenly sought after. But they are 
incapable of affecting the stone unless of such activity
as to cause inflamation and sloughing in 
the bladder.
The best palliatives are small bleedings, warm 
bath, demulcents and opium, which must be 
diligently used when the irritation of a stone become
at any time aggravated, constituting a paroxysm 
of the stone.
Dr. Physic
University of Pennsylvania
February 5th 1812.
END OF VOLUME II.







56
WILLIAM M'LANE
No. 27





Hic libeo pvetinet ad editorem
Gulielmo Madane



Memoranda
From a 
Course of Lectures
on 
Surgery.
Delivered in the University of Pennsylvania
By Philip S. Physick M.D. Professor, & 
John S. Dorsey, M.D. Adjunct Professor
of Surgery in that University
By Wm M Lane
Vol II.
1811 & 1812



Memoranda &c
Lecture 20.
Fractures of the lower end of the humerus
are generally transverse, and these are 
sometimes complicated with a separation of 
the condyles of the bone.
Either one condyle is separated from the bone 
alone, or they both are. They are easily detected,
in their superficial situation, by the 
fingers. If we take hold of the condyle or 
condyles, we can move them very easily in 
any direction, and a crepitas will be heard.
A bandage is to be aplied from the hand to 
the elbow, and, extension and counter extension,
used; the condyles are now to be brought 
into place, and the bandage continued up
the arm. The arm is now to be brought to 
right angles, and the rectangular splints 
applied laterally, and straight ones, bent at 

4
the middle, applied before and behind,
and the bandage carried over the splints, down 
to the hand. In 8 or 10 days, the apparatus is 
to be removed, and the parts examined, & 
if any derangement is found, it can be 
rectified.
Fractures communicating with the cavity 
of a joint are longer in uniting than others:
in general, this will unite in 5 or 6 
weeks. When treated in this way alone, we 
always find a deformity: the natural an 
angle which the arm and forearm form 
with one another, the point whereof is downwards
when the arm is extended, is reversed
and the point is now upwards. To avoid
this, after having kept the cubit an right 
angles for about 20 days (as above) it is 
to be extended, and, splints having a 
downward angle, such as the arm naturally 
forms are to applied before and behind,
and the roller carried over them as above,
and this apparatus kept on for 4 or 
5 weeks longer. In this ways I have preserved

5
one arm in perfect shape. The only hazard 
which attends this apparatus, it that anchylosing 
is not a rare accident in such fractures,
and, if it were not for this, the arm ought
be kept extended from the beginning; but 
it being well known that if anchylosis occur
in a straight posture, the limb will be
useless, whereas, in the [cross out] flexed, it will be 
be very serviceable. After the arm is extended 
the state of the joint is to examined every 4
or 5 days, and if anchylosis is found to begin,
we must bend the arm again. When
the bony opised to the humerus are both injured,
we may expect to presever the joint
in most cases, but if either the radius or 
ulna is injured, as well as the humerus
bony union may be expected in the joint.
Fractures of the Bones of the Fore-arm
A. Of both the bones. This generally happens in
the middle of the bones. The seldom pass one another
much, and the [cross out] the derangements
they are most subject to is the angular, and this is 

6)
mostly inwards Counter extension is to be made by 
one assistant, holding the humerus just 
above the condyles, while another makes 
extension holding the hand just as we do
in shaking hands. The surgeon can now
place the ends of the bones in place with his 
fingers, and applies a roller from the 
hand up to the elbow. The arm is to be in 
a flexed posture while this is a doing. A pair
of splints broader than the forearm is drop
are now to be applied one on the front & 
the other behind, and secured by the reflecting
of the roller. The splints are best made
of stiff (not wet) pastboard, or wood. The 
arm is to be suspended by a sling. The thumb
may be left out, that it may shew us the
state of the arm, as to rotary derangement
and if the roller is too tight, this will swell,
and teach us to slacken it. The first roller
must be slacker than usual, lest the fragments 
be pressed together, and thus destroy 
the rotary motion of the radius on the ulna

7)
whereas the second roller, may be pretty tight,
to press the splints tight against the arm, and 
impact the muscles between the bones, and 
keep the latter asunder. In 8 or 10 days, the state
of the parts may be examined, as in other cases
L. Fractures of the Radius. This bone may be
broken at any part, but the most usual place 
of the fracture is about one inch above the 
lower head of the bone. The hand moves with 
difficulty in these cases, an angle inwards is
generally formed. The luxation of the wrist
may be confounded with this, but when the 
fractured parts are examined closely, certain
information may be had. The wrist may be 
bent freely without any motion at the part.
Extension and counter extension, as above
being applied, and the bone reduced, the same 
apparatus as that used when both bones are 
fractured is required. The splint must reach 
beyond the fingers as in the above case, to keep
the arm and hand quiet. This is very important
in both cases.

8)
Fractures of the Ulna. This is by far the 
least common of these accidents. I have never
seen any but two cases of this. One was produced 
by warding off the blow of a club, and 
the other by a fall on the bone itself. This 
bone is very thinly covered, and therefore, this 
accident is very easily detected, by feeling,
moving, and hearing the crepitus of, the fragments
The treatment is the same as in the 
former instance of the fractures of the 
forearm. In 3 weeks the bone will unite,
but it is best to wait 4 or 6 before removing 
the apparatus.
Stiffness of the wrist and fingers is very 
apt to occur especially in old persons; but 
this goes off naturally in some time. The 
splints may be taken off every 4 or 6 days, to 
bend and extend the fingers gradually.
Fractures of the Olecranon. These are produced
by direct falls on the elbow. They are 
very easily discovered. The power of extending 
the arm is lost, as the biceps extensor cubiti

(9
is now unable to act on the forearm. The olecranon
may be easily felt, and if the arm be extended,
the olecranon may be moved in all directions.
The treatment is as follows. The forearm 
is to be extended for the purpose of relaxing the 
triceps, and to let the point of the olecranon
occupy the pit on the posterior side of the humerus,
which it naturally occupies. A roller is 
now to be applied from the hand, and as soon 
as we arrive at the elbow, the skin is to be tightened
over the fracture, by pulling it up, lest 
it should fold between the fragments. (In 18 
or 20 days, the arm may be gently bent and 
extended.) On the front of the arm, one long splint
is to be applied over the first roller, and 
is to apply itself round the arm a little. If any 
considerable inflamation follow, the bandage
may be made slacker, and and the diet reduced 
very slow, and blood may be taken from 
the other arm
c. Fracture of the coronoid process of the
Ulna. I have never heard or read of a case of 
this kind, and I never met a case of it but

10)
one. This was mistaken for a luxation,
as the humerus was thrown forwards, and 
the olecranon felt above the pit for recieving
it. The parts were very easily reduced,
and while I was preparing a bandage, &c. I 
was astonished to see it stontanously luxated 
again. This was soon reduced, and 
perceived the crepitus. The coronoid process
being the only obstacle which keeps the 
triceps from luxating the arm, this effect
may easily be explained when the 
process is broken. I secured the arm at 
right angles, and allowed the humerus 
to rest in the hook like process of the [illegible]
for 15 or 20 days and then the splints
angular downwards, and the childs arm 
grow without deformity. This case first
suggested these splints with the angle 
downwards, which I have used very much
since.
Fractures of the Ossa Metacarpiaria
from direct violence, and are very easily

(11
discovered. The extension and counter extension 
are to be made from the [cross out] wrist and 
fingers, and retained by a broad pasteboard, 
applied in front and secured by a roller, the hollow
having been filled up by the introduction 
of some flannel or to betwixt the splint &
palm of the hand. A wooden splint, which 
will reach from the middle of the cubit, and
in which there is an excavation exactly in
shape of the arm, hand, thumb and fingers,
(if at hand) will answer rather better.
Fractures of the Fingers are very easily 
detected, and reduced. They require only one
small pasteboard splint in front. These 
fractures will unite in two or three weeks.
Decemb 23rd     P.S. Physic.

12)
Lecture 21.
Fractures of the Femur. This bone 
may be fractured in any part of its length,
but is very frequently fractured in its middle.
The upper end, even so high as within the 
capsular ligament is sometimes broken & 
then, the upper fragment is within the cavity 
of the joints. The lower end, just above 
the condyles is sometimes separated, in some 
of these, the condyles are separated; and there
are cases wherein one condyle is removed from 
the body of the bone.
This accident may be very easily detected, the 
motion of the limb is nearly lost, yet there
remains some power of moving the ancles and
toes, so as to deceive the patient, but if he attempt 
to raise the leg, the fails, and convulsive
twitches follow. The limb on comparison 
with the other will be found shorter, and 
on holding the leg, and moving it a crepitus is 
heard.

(13
This fracture is sometimes transverse, but it 
is generally oblicque, downwards and forwards
The lower portion in such cases slides above and 
behind the lower one.
Many means have been proposed, for keeping
this fracture in place. The object of all of them is
to keep the ends of the bones in relative opposition,
and prevend displacement and shortening
till the bones unite. They are as follows.
I. It has been proposed to treat this with simple
bandage and splints as other long bones
but this will by no means answer.
II. To place the limb in a position calculated
to relax the muscles of the limb.
III To maintain permanent extension and counter
extension, and keep the ends of the bones in 
contact.
The first practice was to apply a bandage and 
splints, and this bandage, tho so tight as to 
cause swelling of the limb did not prevent displacement, 
as I have, my self seen. The only 
use of the bandage is to prevent contraction in the 
muscles, and to give support to the veins and 


14)
lymphatics: They can answer no other good purpose.
The femur is so thickly covered with soft 
parts, that unless the fracture be transverse
or the fragments interlock, the bandage cannot 
prevent overlapping.
Mr. Pott, using the sweep of the straight position 
to be such, proposed to lay the patient 
on one side, to bend the thigh on the trunk
and the leg on the thigh to right angles, so 
that by relaxing the muscles of the limb,
he would take off the irritation which induces 
the muscles to contract, and pleasing 
as his proposal is, practice teaches us the 
following inconveniences arise from it.
1. The position is irksome and fatiguing, & 
and if the patient be so resolute as to maintain 
it thro' the day, he is sure to sleep on 
his back at night, and the bones must 
be set every morning, and inflamation will 
be thus produced.
2. We lose the advantage of measuring this 
with the sound limb, which is indeed the only

(15
only true way by which we can judge of the state of 
the bone, it being so deeply covered, that our faling 
quite deciptious.
To join the benefit of the flexed posture with the 
position on the back, a bone had been contrived,
consisting of two boards, joined together at right
angles at the end, and secured be angular stay 
this was introduced under the hough, and the leg
lay on the one square, while the thigh lay on 
the other. I have given this a fair trial 10 or 12
years ago, but I always found one side of the 
pelvis to shift forward, and allow the bone to 
over lap. By supporting the other limb in the 
same way, no benefit was obtained.
I have been led to prefer the extended posture. The 
objections to have been mentioned. Tho a very 
irksome irritation and fatigue occurs, the muscles
accomodate themselves to it in 2 or 3 days,
The heel sometimes inflames and sloughs by 
the continued pressure, but a little attention to 
this will prevent it. As soon as it is found to 
become sore, it may be rubbed with brandy and 
defended with sticking plaster spread on leather

16)
or a compress of 10 or 15 folds of flannel, and 
with a hole in the middle for the heel will 
answer completely.
The last method is permanent extensions
Many means for this purpose have been tried.
The foot being secured to the foot of the bed,
and another roller round the axilla, and 
secured to the head of the bed, extension had 
been kept up; but they produces unsupportable 
irritation and cannot be borne.
It is much better to apply the apparatus
to the bone itself. Weights have been suspended
from the [cross out] thigh over a pully near
the bedside, and extension thus produced,
but I have seen this tried, and no good
effect whatever followed. It only drew the patient
to the foot of the bed. Many other 
apparatus have been proposed, but most
of them are too complicated for as [cross out]
prompt an accident.
But the most certain and the most simple
apparatus, is that of Desault. I have

(17
used it for 12 or 14 years in my private practice and 
in the Penn Hospital, and in most, if not all 
cases, preserved the length of the bone. I shall 
now demonstrate this apparatus.
The bed is to be bottomed with tight-braced sacking
or boards, and to be without a foot board,
An oval hole is to be left in the bottom of the bed
as well as in the matrass for a close stool. They 
may be occupied by an oval cushion, and supported
by a stool under the bed. The sheet it to
be without a wrinkle, and no more than one 
pillow used to support the head, else the body
will press on the limb, and derange the bones
The apparatus is to be laid on the bed in 
the following order. 1. Four or five tapes in 
the length of the thigh 2. The junk-cloth,
or piece of linen or muslin, as long as the thigh,
and it may be broader, (with the convey 
corresponding to the groin folded in). 3 a splint
of pasteboard for the back of the thigh. 4 The 
bandage of strips, each 2 or 3 inches broad and long 
enough to overlap over the thighs and sufficiently 
numerous to reach from the

18)
knee to the groin overlapping over one another
a little 5. The bandage for counter 
extension is to the laid down. This may be
made of silk, or of leather, sewed up into a 
tube and covered with oil cloth. 6. The bandage
for extension is to be laid at hand.
7 The post-board splint for the anterior part 
of the thigh is to be prepared. 8 Two bags of 
chaff as long as the limb, or flannel folded 
8 or 10 times would answer. 9. Two wooden 
splints, one for the outside of the thigh,
and the other for the inner. They are to 
reach from the six inches below the foot, 
and the outside one reaches to the crest 
of the ilium according to Desault, but 2
have extended it to the axileau, and then 
made a head like that of a crutch on it. There are
two holes near the head of this splint,
for the bandage for counter extension.
The limb is now to be laied on the apparatus,
and the latter applied as follows. Each 
of the long splints is to be rolled in the 

(19
junk-cloth from the edge, so as to apply to the 
side of the thigh, and the bags are to be laid 
on the inside of the splits, and they thus applied.
The bandage for counter extension is now 
applied in the groin and carried before and behind,
and carried thro' the holes in the long splint 
and tied. The bandage for extension is next applied 
on the back of the small of the leg, crossed 
on the [cross out] instep, knotted on the sole &
carrid over the block near the end of the outer
splint and tied in the hole on the splint.
Extension is now to be made, and the limb 
is to be compared (at the ancles) with the other,
and we must observe that the anterior 
superior spinous process of the ossa ilia
are not out of their place, and consequently 
that the pelvis is not aslant.
The proper extension having been made, the 
bandage for extension is to be secured. The 
bandage of [cross out] strips is next applied, beginning 
at the knee, and reaching to the groin,
the splint of pasteboard is to be applied on

20)
The fore part of the thigh and the tapes are 
now to be tied over all. It is obvious that 
after the bandage for counter extension is 
applied the surgeon himself can make 
extension merely by pulling the bandage
for extension, and pushing the splints.
Decemd 27th            P.S. Physic
1811
Lecture 22.
Fractures of the Neck of the Femur.
This may happen either within the cavity of 
the capsular ligaments or entirely without 
this. In all these cases, the limb is rendered 
shorter;- in a very few cases, the fragments 
interlock one another so that no immediate 
shortening occur, yet in all these,
the shortening occurs before two or three 
days. The limb is always turned outwards,
and if any attempt is made by the patient

(21
patient to raise the leg or foot, he fails and nothing 
but pain and convulsive twitches follows.
If extension and counter extension be made, the 
limb can be brought to its full length, and as 
soon as this is quit, the limb relapses to its 
former shortness. If the hand be applied over the 
trochanter major, and the limb rotated, the
trochanter will not make any great sweep, especially 
if the fracture be near the body of the 
bone: whereas, if the neck be not broken, there 
will be a considerable arc described, the radius
whereof is as long as from the bottom of the 
acetabulum to the outside of the trochanter.
This accident may be confounded with 
a contusion, or a dislocation; but the diagnosis
is very certain. 1. In contusion, the pelvis 
will be tilted up on that side, and I have seen
this prove very deceitful. In an hospital at 
York, a patient was supposed to have a dislocation,
and a consultation of surgeons was 
held on the occasion, and they were not convinced 
till (6 days after) the patient walked freely

22)
freely. But if we place a stick on the superior 
anterior spinous processes of the ossa ilia,
we immediately detect the shifting of the 
pelvis and know that it is only a contusion
2. For dislocation upwards and backwards
the limb is shortened, but we cannot so easily
bring it to its length, and if we do,
the bone will not return, but be in place 
&c. I have endeavoured to explain this minutely
because accidents of this joint and the elbow
are often very obscure.
The treatment is the same as in oblique
fractures of the body of the bone. The hole in 
the matrass is particularly proper, as there 
cannot be any motion in the pelvis without
deranging the bone, and inflamation 
may be excited, which, as I have seen, may 
suppurate if rest be not maintained. If any
inflamation appear, bleeding and low diet 
may be enjoined.
When the injury is without the capsular 
ligament, the bone may unite well, but if

(23
it be within this, nothing but a ligamentous
union can be expected. In a case of this kind,
which I dissected long after the fracture, a very curious
process of nature is to be seen: the neck of the 
bone was absorbed, the body came nearly under the acetabulum,
and sort of ginglimus joint, with cartilage,
&c was formed
I am now to specify the improvements which I 
have made to the apparatus of Desault for fractures
of the thigh. His external splint only reaches 
from the crest of the ileum, and the bandage 
for counterextension goes obliquely from the groin
to this, and this tends to derange the upper fragment 
outwards. So avoid this, I have extended it 
to the axilla, and after the bandage is on, a strip
of [cross out] bandage is tied to this, midway betwixt 
the groin and splint before and behind*, just so 
tight as to make the bandage act in the line of 
the thigh. The upper end of the splint is made 
like a common crutch and covered with flannel
as a square head would tend to hurt the arm
In
*going over the other side of the abdomen 

24)
In Desaults apparatus, the foot is forcibly 
drawn against the [cross out] splint, and very considerable 
inconvenience follows from this.
I have adapted an innovation of the late Dr. J
Hutchison, to avoid this. It consists in a block 
of wood, which being placed near the lower 
end of the external splint, has a notch
to receive the bandage for extension; so that 
the extension as well as the counterextension
are is thrown in the line of the leg and thigh.
Having applied the apparatus, an inexperienced
surgeon may draw the bandage too 
tight, and produce pain, exoriation, and 
even sloughing, having ulcers over the 
tendo achilles and instep; and the apparatus 
must then be removed, therefore, this 
is to be avoided. When the muscles contract 
strongly, very little force is proper, as by 
doing so, more irritation is induced. After
some days, the force may be gradually increased.
If tenderness or excoriation come 
on, (which is very common, especially in

(25
children) spirits, as brandy may be applied, the 
parts may be covered with adhesive plaster on 
leather, soap plaster, or what is best of all, a 
small buck skin gater, cut away at the heel,
and laced up the instep (with a strip of the same 
material to guard the instep from the whang
strips of buck skin may be fastened to the under 
part of this, thro' holes, and used as the band for 
extension.- Any bandage will soon fold together
like a rope and act very severely, therefore, this 
method is peculiarly proper to defend the skin.
Mr John Bell, in his book, represents the 
apparatus of which I have spoken, as cruel
and useless, and the error he has committed
is truly astonishing. In reading his book, you 
will reflect that he has never seen Desaults
apparatus applied by one who understood it.
He also says that when the femur is broken
in the middle, the lower portion is never displaced"!!!
The lower end of the thigh bone, just above 
the condyles is not unfrequently fractured.

26)
These fractures are generally oblicque,
forwards and downwards, and in these cases,
the upper fragment projects just above
the patella, and the lower is drawn backwards
by the gastroenemic muscles, and 
the bones are laterally deranged by the leg.
Having applied a roller from the ancle up 
and reduced the fracture, a pillow is to be 
applied in the hand, a compress on the hand
over the lower portion, and a splint is to be
applied in the hand, reaching from the 
middle of the thigh down to the middle of the 
leg, and Desaults apparatus may be also 
applied with a moderate of tightness, and 
the rest of the fragments is sure.
When the condyles are separated from 
one another, the treatment is the same as 
above, except that there is no use for the 
compress in the hand, unless the under portion 
be displaced backwards. Any fracture 
of the thigh requires the apparatus for 6 or 8 
weeks, while that within the capsular ligament
of the acetabulum, requires at least

(27
three monts. If it be removed before this, there 
is danger of the callous of ielding, and producing 
deformity, specially in fractures of the neck of 
the bone. P.S. Physic
December 30th
Lecture 23.
Fracture of the Patella. It is very seldom
that these happen in any other direction there 
transversely: however, I have seen then longitudinal
and also oblicque. Transverse fractures
generally happen by the violent contraction 
of the extensor muscles on the anterior 
part of the thigh. Oblicque and longitudinal 
fractures happen mostly from external 
violence directly applied, as in falls, blows, &c.
When the patella is transversely fractured,
the power of extending the leg is lost, also the 
power of walking, and if walking, he falls.
He may however walk sideways, or backwards.


28)
backwards. The transverse fracture produces very 
great displacement of the fragments. The 
separation is very easily felt. The upper
portion may be brought down by our exertions,
and rubbed against the face of the 
lower. The separation arises from three
causes: 1. The extension of the thigh, 2. the
flexion of the leg, 3 the contraction of the extensor
muscles of the thigh. When these causes 
unite, the fractured portions may separate 
5 or 6 inches. The only cause in which 
the parts are obscured, is when after great 
external violence, blood is extravasated &
forms ecchymosis over the part. The cellular 
substance is so lax, that the blood
may be pressed aside by the fingers.
The bones can only be approximated by 
opposing all the causes of displacement.
The thigh is to be bent on the pelvis, and 
the leg extended. After this, the fragments may
be brought nearly, or altogether into contact
The apparatus is designed 1 to keep the upper


(29
upper fragment down, by acting directly on this 
and the lower 2. To maintain the limb in the 
position mentioned. The apparatus always requires 
to be extemporaneous, and therefore simple.
A bandage is to be applied from the ancle to 
the knee, to support the vessels, the body being in 
a horizontal posture, the whole limb is to be raised
so as to relax the thigh on the pelvis, and the leg
is to be supported with pillows, or what is better,
a board reclining, and cover'd with a bolster. This 
posture is preferable to raising the body, in as much,
as it takes off the determination of blood. The 
above posture, tho' irksome, is supportable after 
some time. The fragments being pressed together,
a compress is to be applied above the upper, and below 
the lower, and to be secured by the bandages
turned in the figure of $, meeting on the hand,
the skin over the patella is also to be supported
by a turn of the roller, and it is then to be carried
as high as the groin, for the purpose of 
of suspending muscular contraction in the extensor
muscles.- It is also worthy of attention 
to draw up the skin over the patella, so that

30)
it will not insinuate itself between the fragments.
A long splint is now to be applied to 
the posterior part of the leg and thigh,
(covered with flannel) and the same roller is to 
be carrid down again over the splint to the 
ancle. The limb is to be supported with the 
pillow and board, as above described. If pain 
supervene, bleeding is proper. [See note J. p. 35.
If we are not called in till some inflamation 
has come on, the drawing down the muscles,
would only irritate them, but we must 
wait till by bleeding, elevated posture, lead-water 
poultices, &c we have removed this, &
then apply our apparatus. If put on before 
violent inflamation, is over or even anchylosis may 
follow.
As the roller which accury the compress
is found to press on, and impede the vessels,
Dr. Dorsey has contrived a splint, on the midde
of which two bandage are nailed, 4 or 5 
inched asunder, which being applied on the 
back of the limb, the bandages are brought 
over the compreses, and pinned or sewed

(31
over the compress. The lower bandage goes over the
upper compress, it visce versa, and below this is 
applied, a roller goes simply from the ancle to 
the groin, and the compress are applied. This 
I find very convenient.
In two weeks, (or less in case of inflamation) the 
bandage is to be removed to rectify any derangement;
but the weight of the body is not to be 
rested on before less than 3 months.
The union in all these cases is ligamentous, and 
not bony, tho' it is said that if the bones be kept
in perfect contact, they will unite by bone
I have seen the ligament two or even four inches
long. If bony union took place, the joint might
be lost by anchylosis, and in cases when the
under bones are injured this may be expected,
and in this case, after 16 or 20 days, the limb
may be gradually moved to prevent anchylosis;
which, however, I have never seen in this 
case.*- When no means are used to keep the 
fragments together, they will go 5 or 6 inches
as under and the power of extension will be
*see note H.p.35.

32)
lost. But by seating the patient on a table,
with the legs hanging down and making 
attempts toward extension every day
Dr Hunter succeeded in the case of a lady &
this practice deserves imitation.
Fractures of the Leg. These are mostly
transverse, but in some cases they are oblicque
In the first instance, no shortening of the 
leg occurs, but the leg is bent angularly
forward, if both bones are broken by the 
action of the strong muscles on the posterior 
of the leg. This accident is easily detected 
also, by the feel, and by the grating.
In cases of oblicque fractures, unless the 
fragments interlock, the leg will be shortened
from 1/2 to 1 inch, as will be found on
comparing it with the other leg.
Extension, and counter extension are to
be applied, and the bones are very easily 
replaced. They are to be retained by splints &
bandage till the bones have united. Permanent 
extension is not required in this case

(33
The apparatus is to laid in order on the bed,
as in fractures of the thigh. The leg is suported 
by a board, with a pillow: On this is laid the
bandage of strips, as long as the limb, from 
the knee. On this, two pasteboard splints,
soaked in warm water, and rolled in soft linen
is next applied, and lastly, a bandage of 
strips, similar to the former is laid over this.
The patient is now to be conducted to bed, and the 
surgeon is to preserve the posture of the limb, he 
is to carry it by the knee and ancle, and he is 
to keep it extended while carrying. It being 
laid on the bed, the first bandage of strips
is to be applied from the ancle. If the limb 
has been deranged, as soon as laid on the dressings,
extension and counter extension are 
to be applied and the bones reduced. The bandage
of strips is then put on, next the splint
which are to reach at least from one inch 
below the sole of the foot, to prevent lateral
displacement by securing the lower fragment
and they are to be applied over the sides of the 
leg, and secured by the bandage of strips,

34)
first laid down. This I prefer to tapes which 
are use'd by some, but they press very unevenly.
The foot is best supported by by a 
a bandage put round the toes and carried
up on the leg. The pillows are now to be 
supported by two pieces of shingle, and 
secured by pices of tape passed around the 
shingle, bolster and limb. The state of 
the parts, as in other cases is to be examined 
in eight or ten days.
January 1, 1811          P.
Notes on Lecture 23.
H. p. When after fracture of the patella, if
from external violence, it is required to bend
the leg on the thigh, before the union is perfect,
to prevent anchylosis, this precaution
is very necessary, viz. while very gentle and
limited motion is made, the fragments of 
the bone must be pressed together with
the fingers, lest the new formed parts should
give way.


(35
I. p.30 In all cases of fractured patella, particularly
in those from external violence, it 
is nescesary not to apply the bandage too tight
as this would be very injurious.
Lecture 24
In the subject of fractures of the leg,
one circumstance remains to be explined.
When the fracture of the bones of the leg 
is so oblicque that they pass one another
after reduction and the application of splints,
it is nescessary to apply permanent
extension, else shortness and deformity will
follow. [cross out]
Desault has described an apparatus for the 
purpose in question; and Doctor James Hutchison
has improved it very much, so as to 
make it fully answer our purpose. Two 
splints of boards are to be provided. In the upper
end of these, is a [cross out] number of gimblet
holes, and the lower ends of the splints are 


36)
joined by a cross bar.
1. A pillow is laid on the bed, and on it a bandage 
of strips. 2 The leg is to be laid on this, & 
and a bandage for extension passed around 
the leg, crossed on the instep and tied in a 
knot on the pole. 3. Two tapes are to be applied 
on each side of the leg, and secured by
a roller passed around the leg just below 
the knee. 4. The tapes are now to be put thro'
four holes in the splint, on each side and 
tied. 5. Extension and counter extension are 
applied, the bones reduced, and the bandage 
of strips applied on the leg. 6. There is to be 
a bag of chaff applied on each side of the 
leg, and the splints appied close along 
these. 7. The bar to join the end of the splint 
is to be introduced thro' the mortines in 
them, and the bandage for [cross out] extension 
is to be tied over this with whatever 
degree of force is required.
Thus, whatever degree of force is required,
may be applied, and all causes of displacement
counteracted.

(37
In all fractures of the leg, the weight of the 
bed clothes has a tendency to displace the bones.
This may be kept off, either by three nail-rods
bent into a semicircle, and the points driven 
into two pieces of wood, which serve as basis,
and lie parallel to the limb, or by a more extemporaneous,
tho less steady machine viz
two segments of the hoops of a flour barrel,
each two thirds of a circle, and tied together at
the middle, this sit up is a cross over the leg
will support the clothes.
In compound fractures of the leg, this apparatus 
is very serviceable, as it allows, to dress the 
sore, without undoing the apparatus which 
keeps the bones in place.
It will not be required to apply this apparatus
during much inflamation. If the 
pressure of the roller below the knee causes 
swelling, which it sometimes, tho' seldom, does 
Desaults apparatus for the thigh, which makes 
extension on the tuberosity of the ischium may
be used.- The action of the four tapes on the roller
below the knee, keeps the pressure in some

38)
measure off the lateral vessels.
In women the short apparatus will be 
very convenient, as the long apparatus reaching 
to the pelvis is not very suitable to 
their taste. The fracture box, with a thin 
pillow introduced into it, is very well adapted
to keep the leg steady. Tapes are tied around 
it after the limb is introduced. It has 
a double bottom, and when it is required to 
raise the leg, any body may be introduced
under one end of the bottom for this purpose.
The bottom is excavated for the leg.
It is very common for wet applications
to be used to reduce inflamation of the 
leg as a solution of sugar of lead, this with 
vinegar and a little spirit, vinegar and spirits
alone, vinegar and sweet oil; but these 
remedies are of little consequence, and bleeding 
is the best means to reduce inflamation
In cases of ecchymosis, vinegar and spirits
on the principle of coldness are the best means
to promote absorption.

(39
Ruptures of the tendo achilles are generally
produced by great bodily exertions, in which 
the gastrocnemii muscles are exerted, as in dancing,
going up stairs, &c
The patient feels as if his heel has sunk 
into the floor, a crack is heard, and the patient 
falls down. The powers of the gastrocnemii muscles 
is quite lost, yet by some other muscles 
he can extend the foot a little. * [Sec Note Th p. 43
The leg is to be bent on the thigh, and the foot
extended on the leg, so as to bring the ends of the 
ruptured tendon nearly into contact, and to 
retain them so till union has taken place.
Doctor Monro describes the following means 
to maintain this posture. A piece of Russian 
sheeting is secured round the leg, long enough 
to reach half way down the leg. A slipper is 
next put on the foot, and a strap fastened
to the heel is to be carried up the back of the 
leg, and secured to a buckle on the back and 
inferior part of the sheeting. Thus, the belly 
*See wounds of the Tendo Achillis V.I p.116

40)
of the muscle is compressed, and prevented 
from acting, the lower portion is drawn up, &
the upper down, and the ends are tolerably well
kept together.
Dr. Monro met this accident himself, & 
succeeded in covering it by the above apparatus.
You will perceive on reading his account, 
the great difficulty experienced, and 
a very considerable lump was left on it.
One very great difficulty attends this mode 
of practice. The foot being at liberty to 
move laterally is very apt to derange the
lower fragment. To remedy this, I prefer the 
following apparatus.
A splint of wood is carved in such a 
manner as to adapt itself to the anterior
part of the leg and foot.
1. A roller is to be applied under the knee 
and after being carried half way down the 
leg, is carried up as high as it began.
2. The splint, lined with soft linen or flannel
is applied on the anterior part of the  

(41
leg and foot. 3. The roller is now reflected halfway 
down the leg, carried the same height, and pinned 
4. Another bandage is applied on the lower part
of the bandage* and foot; some turns of it may 
surround the heel, but not make any pressure
on the tendon, as this would derange it very much,
5 The vessels of the finall of the leg may be supported 
by a few turns of the roller, but these 
must be very slack, and it is best to support 
the tendon by compress of tow or lint.
The limb is now to be supported on a pillow 
for 6 weeks when the union will be but soft,
but no weight of the body is to be intrusted
to it before ten or twelve weeks.- Doctor Monro
was not able to use his leg completely before 
four or five months.
Having complated the history of the ruptured
tendo achilles, I shall now introduce
some observations on an accident little understood.
Persons after carrying a heavy burden 
on the shoulders, leaping, &c hear a crack
*splint

42)
referred to the calf of the leg, they are not 
able to raise themselves on the toes, yet
it is possible still to walk in a hobling manner
without raising the heels. I have never 
had an opportunity of dissecting a leg, after
this accident, but it appears to arise 
from the separation of the muscular fibres
of the gastroctemic muscles from the 
tendon to which they are united. In one 
case, I have felt an evident pit at the seat 
of the injury. From the pain and uneasiness 
in walking, patients will keep themselves
quiet for 8 or 10 days, they then walk 
about and a complete separation again
recurs. He confines himself for far a similar
line till easy, and again walks, &
after this many such courses, I have seen
patients miserably perplexed. One man 
was nine months in this way, the leg was 
swelled, and his health very bad!
The carved splints will answer very well
here. The foot part must be so deep as to restrain

43
restrain the lateral motions of the foot completely.
A bandage is to reach from the ancle to the 
knee.
In course of 5 or 6 weeks, a confined motion 
may be allowed, as the tendon will be tolerably
strong.      P.SP.
Jan 3. 1812
Note on Lecture 24.
K. p 39 Rupture of the tendon of Achilles
are very easily detected also by the fingers.
A very great vacuity is felt in the tendon.
However in cases of great swelling this 
may be obscured.
Lecture 25.
Fractures of the Tibia alone. As the fibula
is entire, the length of the limb is unaltered.
When the fracture is transverse, it is often
very difficult to discover the presence of the 
injury. There is generally sharp pain, and unevenness

44)
unevenness at the part, by trying to bend 
the tibia, an angular projection, and a 
chinck may be felt. It is of importance to 
know the presence of this injury in all cases
as it will be very dangerous to treat 
it only as a contusion. A patient of mine,
after I had reduced an accident of this kind
was not satisfied that his leg was broken
and removed the bandage and splints. On 
making somewhat an oblicue step, the 
leg yielded, and very severe distress was the 
consequence. Therefore cases of this sort
ought to be very carefully examined
The treatment is the same as in transverse
fractures of both bones. Two splints,
are required as in that case, and the leg 
is to rest on a pillow. In some cases this 
fracture will not unite, and in this case,
after about 6 weeks, considerable motion 
may be allowed, so that the fragments may 
inflame on their surfaces, and form a bony 
union. I have successfully treated several 

45
several cases in this way; and the union was nearly 
as speedy as usual.
Fractures of the Fibula. This is generally
complicated with a fracture* of the ancle joint. The 
fracture happens mostly at two thirds of the length
of the leg from the knee the leg is much distorted,
the astragalus faces the [cross out] outer ancle, the 
inside of the foot is turned down, and the sole, out.
A considerable hollow is felt over the seat of the 
fracture, the patient complains of pain there 
and if the foot be flexed and extended, a grating 
may be heard.
The first thing to be done is to reduce the 
foot, and the fibula will be drawn into its
place by this alone. The limb is now to be secured
by splints and bandages. The patient may
be laid on his back, and the many tailed bandage
applied, beginning at the ancle. The bandage
must be so slack as not to derange the 
fragments of the fibula.- Perhaps it may be
supposed that splints are unnescessary, as the 
*dislocation

46
tibia remains entire, but this is very far 
from being the case. The splints are to be 
so long as to reach below the foot, and by 
so doing the foot is kept steady, otherwise,
it will be very apt to produce displacement
of the lower fragment inwards. This is
the principal use of the splints, and one 
to which you ought to attend, as you will 
not find it in any book which we have.
By neglecting this, caries of the bone has been
produced, and I have seen amputations resorted 
to, on account of the diseased state of 
the leg produced by the irritation of the parts 
thus neglected till caries came on. In five
or six weeks, union will have formed such 
as to allow of considerable excercise of the leg.
Of Dislocations. A dislocation consists in 
the derangement of a bone out of its natural 
situation. It is attended with a loss of motion
with pain and deformity.
If surgical assistance be at hand, it is generally

47
generally easy to reduce the bone to its place, but
if much time elapse, considerable difficulty is 
commonly experienced. This arises from the contraction 
of the mucles by the irritation of the bone
displaced. The rupture of the capsular ligament
is not the cause of very much trouble, except in
a few cases, to be specified hereafter.
In such cases, many means have been devised 
for moderating the action of the muscles. Bloodletting, 
warm bath, low diet, &c have been used.
The first of these remedies, bloodletting from one
or both arms, ad delinquim animi, I have found
the best remedy; by this means, a temporary 
suspension is put to muscular motion, and 
the principal obstacle being removed, the reduction
is very easy. This remedy was first used 
in the Pennsylvania Hospital by me, and 
it was first proposed by Dr. Alexander Monro in
his lectures.
For the same purpose other means have also 
been used, but with less effect. Nausea produced 
by tartar emetic, or by tobacco injections
and these means may be used when bleeding

48)
is objected to. Intoxication has a similar 
effect. The muscles may be overcome by 
being fatigued. How after do we see reduction 
happen by weak efforts, after resisting 
for hours!
When a dislocation cannot be reduced, the muscles 
accomodate themselves to their new 
functions, adhesiong form round the head
of the bone, and these causes conspire against
reduction. This is particularly the 
case in old dislocating. The natural cavity
becomes less, and presents another obstacle.
Considerable force is required in these cases
Pullies have been much used but I have 
relinquished their use of late, and now, I 
use a number of assistants. Pullies are 
very unmanagable, and their action is 
not easily attend, whereas, by a word, you 
can vary the force and direction at pleasure
by using a proper number of assistants.-
Care must be taken to confine

(49
the force applied, to the joint dislocated.
When a bone remains long out of place, a 
sort of new joint is formed. This is not unusual in 
some joints, particularly the shoulder and hip.
A joiner had his arm dislocated into the axilla and 
remained irreducible. He began to use it a little
when the pain and inflamation had subsided.
The power of moving it returned gradually, he
has able to use the saw as well as before, but one
muscle seemed to have lost its power, (the deltoid)
as he could not raise the arm upwards. In all 
such cases, the cellular membrane is so condensed,
as to serve as a new capsular ligament, and 
even new cartilage is formed.
In irreducible dislocations of the hip, the acitabulum
is very readily and completely absorbed
and a new one, with capsular ligament as well
as cartilage is formed. A girl by receiving a fall
had her femur luxated backwards and upwards
and lost the power of motion for some time,
and nothing could be done to reduce it; after some
confinement, on beginning to walk about,

50)
and received a second-fall, whereby the other 
femur was reduced to the same state as the 
first. The limbs were now of one length,
and she could walk a little, when at the end 
of a year, she took a fever, which proved fatal,
Her pelvis was shown to me by Mr Cruickshank,
and in both sides, the bone was dislocated upwards
and backwards. The natural acitabula 
were completely absorbed, new cavities
were formed on the dorsa of the ossa ilia,
surrounded by bony margins, covered
with cartilages, and furnished with new
capsular ligaments. Dr. S.
January 6th,
1812

(51
Lecture 26.
Dislocation of the Lower Jaw. The only direction
in which this can happen is by the condyle 
being carried before the tuberosity at the 
root of the zygomatic process. The mouth always
stands open, speaking is impracticable,
the saliva flows from the mouth, and considerable 
pain attends.
It is produced by yawning, or any other cause 
of opening the mouth wide, by which the 
condyle mounts upon the tuberosity before 
the pit, and in shutting the mouth the 
condyle cannot get back again. A woman 
in market, in scolding [cross out], husband furiously,
found she could not shut her mouth again,
and came to me, and I found her jaw dislocated 
on both sides.
Some recommend strikeing the chin upward
to reduce this, but by this, the condyles may be
broken. In recent cases the reduction is very

52)
easy. The thumbs are to be introduced into 
mouth, applied to the molar teeth, and the
middle fingers applied under the chin. The 
thumb may be guarded with a soft linen,
lest after reduction, by the spasmodic action,
it should be injured. The patient is to be 
seated on a low chair. The surgeon is to depress 
the angle of the jaw with the thumb,
while with the fingers, he raises the chin,
and as soon as it is dislodged; he is to push 
it backwards. In this way, all the cases
I have ever seen were easily reduced.
No bandage is required after reduction, but 
the mouth is not to be opened freely for 
some time. Both sides of the jaw are 
generally dislocated at once. I have seen
only one case, in which only one condyle
was dislocated. In these cases, the force is 
to be applied to the injured side only.
Dislocation of the Clavicle. This bone 
much oftener fractured than dislocated.
a. I have seen one case of dislocation in

53
the sternal extremity, which was forwards. It 
may also happen upwards or inwards. Dislocation 
forwards always happens from the shoulder being 
driven forcibly backwards. It is very easily known 
by the projection anteriorly, and easily reduced.
A cushion is placed in the axilla, the elbow pressed 
toward the trunk, and the end of the bone
pressed down with the thumb. After reduction 
the apparatus of Desault for fractured clavicle
is to be applied, and kept on for four or five weeks,
till the ligaments resume their tone again,
b. Dislocation of the scapular end from the 
acromion scapulae is very easily discovered. 
The clavicle is found raised above the acromion 
a considerable way; and the ligaments 
are torn. On raising the arm, you reduce 
the fracture. This is always produced by a fall 
on the shoulder. To reduce it, it is only necesary
to raise the arm upwards and outwards, 
and secure it so by the same apparatus 
as in fractures of the clavicle. This is to 
be persevered in for ten or twelve weeks, as 
the ligaments are long in uniting. 

54
Dislocation of the humerus is the 
most usual accident of this kind which is 
met with. This occurs, 1, from the large 
motion which this joint performs, 2, from 
the shallowness of the glenoid cavity, 3, 
the great weaknes of of the joint in some 
directions.
The head of the bone in most cases is 
thrown downwards, into the axilla. It is 
sometimes carried forward, between the 
coracoid process, and glenoid cavity, but 
this is very rare. It is also sometimes dislocated 
back, so as to lie betwixt the glenoid 
cavity, and the spine of the scapula.
The second is very rare, one case of it, being,
all I ever saw. Of the latter sort, or backwards,
very few cases occur: about two 
weeks ago, a case of it occurred to me.
This accident is very easily discovered in every 
situation. 1. In the axilla Considerable pain
attends this. The arm cannot be raised up, 
neither can it be brought to the body, but

55
the elbow will hang about a span from the 
side. There is instead of the round form of the shoulder
a great hollow under the acromion, and a 
large tumor is felt in the axilla. The body of 
the humerus cannot be felt above half way,
from the tension of the deltoid muscle.
This is easily distinguished from a fracture 
of the head of the bone, by the hollow under the 
acromion and the sharpness of this.
2. Inwards. In this case, the motion of the arm 
is greatly impeded. It cannot be raised to the 
head, but can be brought close to the body.
The coracoid process cannot be felt, and the projecting
acromion is felt far behind the 
head of the humerus.
3. Backwards. This is easily known. The acromion 
and clavicle may be felt far before 
the head of the bone, the head projects just 
over the dorsum of the scapula
In old cases, the head of the bone is often
drawn from its situation in the axilla, forwards,
by the action of the pectoral muscle.

56
It can never happen upwards, the acromion 
as scapula here forming an insurmountable 
barrier.
In recent cases of downward luxation,
the reduction is generally easy. I have succeeded 
by extension and counter extension 
without any assistant, holding the humerus 
just above the elbow in one hand, and 
pressing upon the spine of the scapula 
with the other. The force is always to act 
on the joint of the shoulder alone. This is 
a fact of the first importance: it accounts 
for the frequent failures of ignorant, tho'
bold operators, who make counter extension
from the thorax, and spend all their 
force on the connections of the scapula
to the trunk of the body! Have we not read
of a miller, whose arm was torn from the body
by violence, and not the shoulder joint,
but the connections of the scapula to the 
body which gave way.
The forearm is to be bent on the arm and as
* A low chair is the best seat for the patient

(57
handkerchief tied round the arm just above 
the elbow, and given to one two or more assistants.
The surgeon is to press with his hand on the 
spine and acromion scapulae, and an assistant 
may also apply his hand over the surgeons,
and increase the counter extension. The forearm
may be raised up and down to assist its 
going into place. If the reduction do not happen
by these means, the surgeon may entrust the 
assistants with the counter extension and by 
pressing up the upper end of the bone with one 
hand, and the elbow down with the other, he 
may use the bone as a lever to reduce itself.
Some use a pad, put under the axilla for this 
purpose, but the hand is as good, and appears 
more simple to the patient: however, very 
little violence is to be used in this way.
But if it be found that the contraction of 
the muscles will be so violent as to resist
moderate force, Bleeding ad delinquim animi
is to be used rather than great violence, producing 
painful excoriations, &c. This remedy was 
found nescesary in a case in the P. Hospital, in

58
a robust man, and after losing near a 
quart of blood, he fell down, and the bone
was reduced with the greatest ease. Since
this, many other cases have occurred, with 
similar result. This remedy is never to be 
used unnescarily, but confined to all cases
in which we know great force will otherwise 
be required.
But if after several weeks continuance,
there have been adhesions formed, and the 
capsular ligament has closed, it would 
be unnesecary, and improper to spill the 
vital fluid. Force must now be applied.
Either a number of assistants, or pullies may 
be used. It is nescesary to vary the direction 
of the force at the period when the bone is 
just returning to its place, and as this 
cannot be done when we use pullies, I
prefer as many assistants as may be requisite,
probably five or even ten.
In some cases, I have distinctly heard the capsular 
ligament lacerating at the moment 
of reduction 

59
To avoid excoriation, the lower end of the arm, above
the elbow may be defended by stiff buckskin.
A strong roller is applied round this, and given 
to the assistants, or a handkerchief, with a 
rope fastened to it. A strong band, with the middle 
stuffed, so as to be very soft, is applied on the 
acromion, and fastened by the ends to a hook,
as high as the patients groin if he is standing 
or on the floor if he sits. When extension is 
made, this band is apt to slip and excoriate 
the skin, therefore it is to be held in place 
by the hand of an assistant, or secured from
slipping up by a roller passed under it, and 
held. This has been introduced by Dr. Dorsey
and is very convenient. Or strips of leather
may be fastened to the under edge of the band,
for the same purpose.
Any force whatever may now be commanded,
and the arm may be rotated, so as 
to break whatever adhesions may have formed.
If the body should yield, a band of great 
breadth may be put round the body, and held
by assistants, merely to secure the body, or the

60
patient may lie horizontally, but the 
best position is sitting on a low stool.
By the above means, luxations of nine,
eleven and even of thirteen week have 
be reduced under my observation. I also 
have the account of a case in Baltimore
in which it succeeded after five months.
I do not think that  any bone can be put
out of place which cannot be returned by 
art again, and therefore no case is to be 
despaired of.
I may mention some of the other means
which have been used for this reduction.
1. The body has been suspended by the arm
over a door or ladder-but the humerus is 
liable to fracture from this violence.
2. The body has been raised by the arm,
with a pulley,-but no counter extension 
is provided for in this way, and it does not 
succeed well.
3. By placing the patient on the floor,
putting the heel in his axilla, and making 
extension by the wrist, I have seen

61
Mr.J Hunter succeed in a case of this kind of 4 weeks and 
you may have this method in reserve for obstinate 
cases.
4. The various machinery, as the ambe of Hippocrates
&c act violently, yet fail because they 
do not fix the scapula.
Dislocation of the Elbow. This is in most 
cases backwards and upwards. The hook like 
process of the olecrannon may be felt above,
and considerably behind the naturan bid in
the humerus which receives it; the forearm 
is bent at right angles, and cannot be moved
either way. It may also be carried outwards,
or inwards but these forms are raw.
In the former, the olecranon may be felt
on the outside of the humerus, and in the 
latter, at the inside, and also, the hollow
of the radius may assist us in the diagnosis.
It is very easy to ascertain this accident, &
also easy to be reduced. In old cases it was however
very difficult. Boyer says that in four weeks
it is impossible, but in this he is mistaken

62)
as I have reduced one of four, as well as 
one of two weeks standing.
The reduction is performed in the following way
one assistant takes hold of the arm a
above the elbow, and the other just above
the wrist. The surgeon takes hold 
of the arm, by clasping the hands in front
over the lower part of the humerus, and 
he draws this backward, while the assistants 
are extending, so that the three forces
act at once, The fore arm is now bent,
and the bones are very easily reduced. The
use of the Surgeon's making extension
backwards is to dislodge the the coronoid process
of the ulna, from the condyles of the 
humerus, on which it is as it were locked.
The arm may be kept bent for some
time, at least for two or three weeks, and 
the joint may be kept moist by vinegar,
and spirits.
Dislocation of the Wrist may happen
either forward or backwards but cannot happen 
laterally.


(63
When the wrist is carried backward, the hand 
inclines forward, and when forwards, the hand 
turns backward. Nothing but extension and 
counter extension are required, and the reduction 
is very easy. The hand is to be made 
steady, by splints applied to the hand & 
forearm, and continued for some weeks 
at least.
Dislocations of the Fingers. These happen 
either anteriorly and posteriorly, and are 
very easily discovered, their bones being so 
thinly covered. They are quite immoveable
when out of place. They are very easily
reduced, and may be secured by splints.
The first and second joints of the thumb,
when dislocated are very difficult to reduce.
The knobs on the heads of the bones interlock
each other, and the more extension is made,
the more fast the ligaments tie the bones,
and even the last joint has been pulled off.
I have met with but one case of this, and 
succeed with tolerable case.

64)
Mr. Charles Bell has a very ingenuous proposal
on this subject. He proposes to introduce 
a cataract needle through the skin,
and to divide the lateral ligaments of one 
side, and then it is very probable the reduction 
would be very easy. B.P
January 8th,
1812
Lecture 27.
Dislocation of the Thigh. The older surgeons,
reflecting that the head of this bone was 
lodged in a very deep and strong cavity, and 
moved by very strong muscles, asserted that 
the neck of the bone was very frequently fractured,
and that dislocation of the hip joint,
never, or very seldom occurred. But they were 
mistaken in this. Four cases of dislocation 
generally happen as often as one case of 
fracture in the neck of the femur.


(65
This bone may be dislocated in any direction.
The most usual direction however is upwards, & 
backwards, so as to rest on the dorsum of the 
ilium. The next direction in frequency is in an
opposite direction, so that after passing downwards
and forward, the head of the bone rests 
on the foramen ovale. It may also happen
either upwards annd forwards, or downwards and 
backwards.
First, when upwards and backwards, the head
of the bone rests on the dorsum of the ilium.
The limb is shortened, generally two or three
inches, the toes are turned inwards, and the 
case is very easily detected. I have already
explained how this case is distinguished from 
fracture of the neck of the bone. The limb 
cannot be brought to its length, without reducing 
the dislocation; the trochanter major
may be felt nearer the spine of the ilium, and 
sometimes, the head of the bone may be felt 
on the ilium.
Second, the head of the bone is carried downwards,
and forwards into the foramen ovale,

66)
the limb is very considerably elongated,
the toes are turned outwards, and sometimes
the head of the bone may be distinctly felt.
Thirdly, the head of the bone is sometimes
carried forwards, or forwards and a little upwards.
The limb is shortened in proportion 
as the head is upward, and a large tumor
may be felt in the groin.
In the fourth order, the head is carried backwards 
and a little downward, the toes are turned
inward, and the case is easily discovered.
The two last orders are raw; I have never 
met with more than one case of each. For all
there dislocations, the capsular ligaments is
much ruptured. It was common for the older 
surgeons to say that the notch on the inferior
and anterior of the acetabulum caused
most of these dislocations to happen in this 
place, but the very reverse is true. The most 
usual direction, we have seen, is upwards, 
and backwards. This notch is secured by a 
ligamentous bridge, and is as strong as any 
part.

(67
From the great strength of the muscles, and 
also the great depth of the acetabulum, and the 
situations where the bone rests, very great force
is commonly required in this reduction. This is 
best applied by compound pullies.
In one case, I bled ad delinquim animi, and 
by my own exertions, with two assistants, I
reduced it again. But much more force is commonly 
required.
The patient is to be laid on the sound side,
with the thigh flexed on the pelvis, and the leg
flexed on the thigh. A strong band, (the middle 
of which is stuffed, is introduced into the groin
on the injured side, so as to rest on the tuberosity
of the ischeum and on the pubis, and 
secured to a hook opposite to the patients
head. This is to make counter extension.
The extension may be made just above the 
knee [in very corpulent patients, it can only be 
made below the knee] by a towel secured by 
a circular bandage*, to this towel, the pulley is
*To avoid excoriation, the skin is to be defended by
a piece of buckskin, round above the knee.

68)
fastened, and this secured to hook in the opposite 
of the room. Any degree of force may 
thus be applied. The limb may be rotated
to dislodge the head of the bone. In this way,
I have seen several cases succeed the head 
of the bone returned with an audible snap.
But if this do not succeed, it will next 
be required to raise up the head of the bone.
A bandage is put under the thigh near 
the groin, and tied over an assistants neck,
who kneels on the table, and puts one knee
on the pelvis below the rest of this 
ilium. While the assistant raises up the 
head of the bone, the surgeon uses the os femoris
as a lever, pressing down the knee,
This is the best way to make extension at
right angles.- Sometimes a band may 
be put over the pelvis, thro' two holes in 
the table, and secured to a hook in the floor.
By the above means, two extending forces are 
applied: one in the longitudinal, and the other 
at right angles. This is for luxations 
upwards and backwards.

(69
For dislocation into the foramen ovale, viz, downwards
and forwards. The longitudinal extension 
is applied in the same way, and with the same 
intention. The rectangular extension is also 
to be used in the same way, but the longitudinal is not so much
with the intention of lengthening the limb,
(this being already too long) but to dislodge it 
out of its seat on the foramen ovale.
The dislocation forwards, and a little upwards,
may also be treated in the same way. Mr. Heys
(whose/observations on this accident deserve per 
usal) directs in this case, to seat the patient 
on a bed, to apply the pubis to a post of the 
bed, and to make extension by assistants
at the leg. As this is not always convenient 
Dr. Wistar has made a subistitue for the 
bed post in our Hospital. It consists of a 
strong shaft, 3 or 4 yards long, inserted
to a head of about 30 inches long in the 
middle, and secured by stay pieces, thus 
resembling a rake. The end of this shaft 
props against the wall, and the head covered
[illustration]

70)
covered with flannel, makes counter extension 
against the pubis, the [cross out] leg may 
be bent, and extension made by assistants 
or pullies, the limb rotated, and the 
head brought outwards by a band or (what 
is better as it interferes less with the muscles)
a rolling pin. But this method is 
not preferable to this above one.
When the dislocation takes place forwards
and upwards into the groins There is 
some variation required. The longitudinal 
extension is made as usual, but the difference 
is this. The patient is laid on the 
back, a bandage is put round the pelvis
on the injured side, and fastened to a hook
opposite to the other side. Another bandage 
put round the injured thigh near 
the groin, and fastened to a pulley on the 
same side. The leg is bent, the thigh rotated,
as usual. The only case I have seen 
was treated in this way. See Dr. Cox's Med.
Museum. Desault met with a case of 

71
this sort. He differed from the operation described,
only in putting the band for counter
extension on the sound side of the scrotum;
while I put it on the injured side._ This apparatus 
may be used for luxation in any direction
whatever.
Lastly, in the dislocation downwards and 
backwards, I have had only one case. In this 
the usual means failed. The head of the femur
protruded through a rent in the capsular 
ligament, just as a button thro'
a button hole, and extension served only 
to make it faster. At length, I succeeded
by a violent abduction of the thigh. I applied 
my left hand on the trochanter,
and embracing the flexed knee in my 
right arm, I made a violent abduction,
using the thigh as a lever at the same
time. The thigh was bent on the pelvis. Abduction 
is the best means to dislodge the 
head of the bone out of the capsular ligament._
By these means, if the capsular ligament,
&c, have not formed strong adhesion


72
have not found any dislocation may 
be reduced. The only precaution nescesary 
after reduction, is to keep the 
limb quiet for a week or ten days.
In cases when the reduction has been 
delayed for some time, the cavity will
have so closed as to prevent the limb
resuming its usual length, and it remains 
1/2, 3/4 or 1 inch longer than [cross out]
usual. But a few weeks rest will overcome 
this.
Dislocations of the knee. The only direction
in which this joint is dislocated is outwards.
This however is very raw. Two cases of 
this sort have fallen within my observation.
In both, they arose from violent abduction:
the patient going up a ladder, this fell 
when they were 6 or 10 feet from the ground;
they fell thus with the legs asunder. In one 
of them both, but in the second only one 
knee was dislocated.
The leg rests upon the outer condyle of the os

73
femoris, the inner condyle may be easily felt,
a great angle is formed by the leg upon the 
the thigh, so that the injury produces effects 
very easily known,-and the leg is very easily 
restored to its place again, but such is the 
destruction of the capsular ligaments, that 
the leg will fall off again just as before.
The limb must be kept steady: either two 
common splints, or what is better Desaults
long splints must be worn at least four months
before the ligaments have united. The knee 
may be wet with lead-water, vinegar and oil,
vinegar and spirits, or any such liquid.
Dislocation of the Patella. The patella,
or kneepan may be luxated either outwards
or inwards. The former is the most usual direction,
the condyle of the femur being the 
highest on the outside, not allowing the patella 
to return. The pulley like surface of 
the femur being very easily felt, and the motion 
of the leg being lost, the case is very 
easily recognized. Further, the patella, on

74
the outside being very easily felt, its internal 
side is now posterior, its anterior 
surface is now exterior. Considerable pain 
is felt, and the powers of the extensors 
of the leg are lost.
The reduction is very easy. The thigh is 
flexed on the pelvis by the patients sitting 
on a bed, and the leg is to be extended. 
By pushing the patella on the side,
it will now fall into its place very easily.
The only case I have ever seen of this,
was in a lady, in whom it was caused by 
an irregular step in dancing. It was 
seated on the outside as I have described
and very easily reduced. After resting 
for fifteen days, she was perfectly restored,
and able to dance again!
Dislocations of the Ancle. I have
already explained how this accident was 
often complicated with a fracture of the
fibula, at one third of its length from the 
external ancle: however dislocation may

75
happen without this. This may be either anteriorly
or posteriorly. In the former case, the 
foot appears shorter than natural, and the 
bones of the leg lie in front of the astragalis
and the os calcis projects behind. When 
the foot is luxated posteriorly, the reverse 
of all this happens. This is very easily reduced.
An assistant holds the leg fast about its 
middle, while another extends the foot, and 
draws it into place.
One case only has fallen under my observation,
occured in a lady; She was hastily 
running down stairs, when she fell, and 
the heel of the shoe took hold on one of the 
steps, and the whole weight of the body 
resting oblicquely on the joint, this gave 
way. It was reduced as above described, and 
after a month, the function of the ancle
were completely restored again.
Jan 10th 1812     P.S.Physic.

76) Lect 25
Of Injuries of the Head. A. Contusion
Blows upon the head frequently produce a rupture
of a number of vessels, whereby blood is shed under
the scalp, which gives the part a soft pappy feel,
and round this is a hard ring, with a very abrupt
edge, which may deceive for a fracture with depression 
of a piece of the cranium. This has induced 
induced unwary surgeons to incise the part
and prepare for operation, and they were always 
much dissapointed to find the scull whole.
To avoid this unnescesary step of incision, it 
is nescesary in all cases, before we incise, to 
to see the symptoms of injured brain exist.
The incision is a very painful step and even exfoliation
of the bone may follow it.
Nothing but clothes wet with vinegar and water
is required as a local remedy, the antiphlogistic 
regimen, and if the injury be severe, bleeding,
and purging are required. If after several days,
the blood be not absorbed, a small puncture may 
be made into the tumor, the blood pressed out and 
dry lint applied, and secured by adhesive plaster.

(77
2. Wounds. Incised wounds in the scalp require the
some treatment as they as in other parts of the 
body. The hair having been removed, the lips of the 
wound may be approximated by adhesive plaster.
Contused wounds also have nothing peculiar
in them here. A soft poultice is the best application.
It may be continued till the sloughs are
separated, supuration is free, and granulation
goes on well. The sides of the cavity may be either
brought into contact, or at least approximated 
by adhesive plaster
The scalp is sometimes torn off: I have even 
seen one half of the scull laid bare in this way.
The old surgeons in such cases were in the habit
of cutting off all the separated parts, because, they 
said if left on, matter would form under it and injure 
the bones of the head. But their practice 
was as absurd as the reason for it was untrue.
The scalp is to be cleaned of any foreign matter,
replaced, and retained by interrupted sutures,
adhesive plaster, Sutures I do not recommend,
as they are an additional injury, increase the 
constitutional irritation, and if much swelling


78)
swelling come on, they are not (like plasters) easily removed.
If sutures are used, the edges are not to be 
drawn tight, nor nearer than 1/2 inch asunder. But
when inflamation is over, they may be brought
together. Adhesion generally takes place:- if pus
form in any part, it may be evacuated by an 
incision as in any abscess. If an early opening
is made, the bone will very seldom slough. The 
constitutional treatment must be antiphlogistic,
and if headache and fever follow, blood letting 
and purging may be used freely, as in cases 
of contusion.
In those cases in which the bone sloughs off
it is very important to remove the slough as 
soon as possible. Whenever any looseness is evident,
the slough may removed: as the granulations
round the rough edge of the bone will 
soon make it fast if left. We are never to wait 
for the bone to become looser, but pull out
the slough with forceps, and if incision be nescesary,
it may be made freely.
3. Acute pain often remains after the wound of 

79
of the scalp has heated. It also follows simple contusions,
as well as contused wounds. It lasts after the 
inflamation is over: I have seen it last for months,
nay even 3 or 5 years after.
The first case I have met with, was in a lady,
whose head was struck, in looking out at the 
window, by the shutter, which was blown by 
the wind. The pain was very acute, and increased 
as the inflamation subsided. This happened
at Trenton; and after 5 months continuance,
she came to town. I could feel a roughness and 
inequality in the bone. Dr Rush had tried every 
means he could devise, but all failed to afford 
any relief. I was consulted, and made 
a crucial incision through the scalp, and after 
this her complaint subsided entirely.
The second case was in a lady of a full habit
and the pain was very severe. Numerous remedies
were used, but to no purpose. Bleeding, purging,
low diet, low diet, leeches, blizters, issues,
the crucial incision, opium, cicuta, oxymuriate
of potash, solutions of arsenic & mercury, were all
used without benefit. 

80)
At the end of two years, she took a journey in
to the country, and by this she was suddenly 
benefited, but it was five years before she was 
quite well.
The third case was produced in a young lady 
by falling from a gig, and alighting with 
her head on a stone. The pain continued severe 
for 18 months, when by a second fall, the 
complaint was greatly augmented. On taking 
a walk to the Yohenulkylon, and being 
much heated, she went into the cold bath,
and on this, the pain became excruciating.
Mercury was given, but a salivation could not 
be produced. The crucial incision was made,
and from that evening for four weeks, she 
was well, but then relapsed. On the idea of 
retained perspiration, I made an issue as 
large as a dollar, with caustic, on the head,
but no relief followed. After 18 months, she went 
into the country, and on feeling oppression 
at the stomach, a vomit was taken, and brought 
off much mucus, and in six weeks, she 
was perfectly well.

81.
In the fourth case, a man fell from a house
and received a small wound on one side of the 
head. The pain came on, as in the other cases.
Bleeding, purging, &c failed, and the crucial incision, 
as soon as I had made it relieved him
but seized the other side as ill as the first side
and I next operated on this side also, and he 
soon recovered completely. I have seen one case
in which, it ended in fatuity.
In all cases, a complete recovery came on 
in course of time. Indeed I know of no [cross out]
remedy for this disease which is certain. The 
crucial incision is the best remedy I know. 
4. Injuries of the brain a. Compression
This state of the brain is marked by sleepiness,
drowsiness, insensibility, loss of speech and 
voluntary motion, sickness at the stomach,
vomiting and either dilation or contraction
of the pupils of the eyes, and no variation in 
these when exposed to light.
It may arise from either of the following
causes. 1. The fracture and depression of a 

82
piece of the cranium, or 2. by blood extravasated 
out of ruptured vessels, or by both 
causes taken together. The blood may be under
the scull, under the dura mater, or in the 
substance of the brain. Both depression, & 
blood may unite, as they very often do, but 
she may exist perfectly separately.
The symptoms of depression, from fracture 
are immediate, but that from blood generally 
allows a few minutes of sense and 
motion, before there is enough of blood to 
compress the brain.
But fracture of the scull with depressions 
may exist, without constitutional symptoms 
denoting it....A boy received a blow
by a brick thrown from the opposite side
of the street. I was called, and arrived in ten 
minutes, and could feel a considerable depression 
of bone, yet the boy was sensible, and 
told me the circumstances of the accident,
and then fell from his chair, cold, senseless,
and motionless. I trepanned him immediately

(83
immediately. A large quantity of fluid blood flowed from 
the orifice, and the boy recovered even before I 
had raised the depressed bone. There was a union 
of causes; the blood was the cause of the stupor
and it is often so; even without any external 
wound.
Sometimes the dura mater is wounded,
and even portions of the brain prolapsed.
Extravasated blood may be lodged in the cavity 
of the brain.
When compression is known to exist, the 
depressed [cross out] bone must be lodged* in the brain
and brought on a level with the rest of the scull,
or the extravasated fluid must be evacuated. 
If there be many fractured portions,
there may in general be a perforation made
with the trephine, and the blood if there be 
any may escape, and the fragments may 
be elevated. The perforation may be in the 
vicinity of the fracture.
In all cases if after the receipt of a blow, the 
symptoms of compression exist, perforation
*removed out of 

84
perforation is to be made. The inferior, anterior angle
of the parietal bone is the best place 
to open, because there, the artery of the dura
mater exist, which is the Source of extravasation.
If one opening do not succeed, the
other side may be opened.
On this subject, Mr. Abernethy makes a very 
ingenious remark. The scull is supplied with 
blood from the teguments and also by the 
dura mater. Now if these two sources of blood
be removed, the external by incision, and the 
internal by blood, we will not find any 
blood oozing from the bone on laing it 
bare. This may not always be depended on, as 
anastomosing arteries may keep up the circulation.
Even after the perforation is made, the symptoms
of pressure sometimes continue. It is 
then importance to tell whether the blood is 
extravasated under the dura matter or not?
If instead of the level, white, glistening appearance
of the dura mater, we find it pushed 
up into a convexity in the trepan. hole, fluctuation

85)
fluctuation in some degree perceptible, and a livid appearance,
by the presence of blood, we may be 
pretty certain of the nature of the injury. Further,
There is (especially in children) a motion in 
the dura mater corresponding to respiration,
raising with expiration, it visce versa,- and 
also a motion at every stroke of the heart,
but these are absent if blood be extravasated 
under the dura mater.
But even if we are certain of its presence, it
is very doubtful whether or not the dura mater
may be perforated? Rather than let our 
patient die, we might do it, but tho' cases 
are reported of patients recovering after such 
a puncture, yet I have always seen them 
prove fatal...... Indeed the dura mater is often 
wounded by spiculae of bone, and otherwise,
and yet the patient recover, but the above 
case is widely different: in it, we are never 
able to evacuate all the blood, and the part 
remaining becomes acrid by the air, and 
produces inflammation and suppuration in 
the pia mater and death!!

86)
Now, the progress of this injury is as follows:
first, the dura mater at the place of puncture,
becomes enlarged, till as wide as the hole 
in the bone, the brain arises on a level with 
the bone, (I have seen it arise one inch) then 
constituting fungus cerebrix, which is the brain 
itself pressed out. This has been tied with a 
ligature, destroyed with causte, &c, but is 
all cases is has proven fatal, and pus was 
found in the hemispheres of the brain, and 
therefore, this case is hopeless.
Our circumstance is very remarkable in 
this accident: sense remains till near death
unaffected.
In a case of extravasation which occurred 
to me under the dura mater, the membrane 
was pushed up on a level with the bone,
and all the symptoms of compression existed.
I bled the man four times a day, for 
five days, and each time, ad delinquim animi,
purged him freely, blistered him, and
confined him to barley water, and he was 
saved by these means from death.

87)
I therefore condemn the puncture in all 
cases....The dura mater is sometimes wounded
by accident, without death following: Sabatier 
relates the case of a man whose scull & 
dura mater were very widely discovered by a 
saber, and the wound heald just as easily as 
as in any other part of the body; nay, we 
read in the memoirs of the Academy of Surgery 
of a ball going perpendicularly, and of 
cin other going transversely thro the brain,
yet life not being lost, but a happy recovery!!!-
I have however seen one case of a 
wound of the membrane recovered from. The 
child was bled and purged freely, and confined 
to rest and a low diet, and recovered, tho'
dangerous convulsions supervened.
One circumstance more will conclude
this lecture. Patients recover better in the 
country than in a large city or town, and 
particularly better in succh a situation 
than in a crowded hospital.
D.P
January 13th, 1812

88)
Lecture 29.
We continue to speak of injuries of the head.
b. Sloughing of the dura mater. I am now to describe
a form of disease, not spoken of by any 
author; and of which I have met with only
one case. Last summer, I was called to a child,
which had received a kick of a horse on the os 
frontis. I found a very considerable piece of the bone
depressed by the fracture. The senses 
were perfect, but as as I always trepan 
in cases of depression, that I always proceeded
to do it in this. After the removal of 
the piece, I remarked an unusual appearance.
The dura mater was of a very dark colour,
without any convexity, or any other circumstance 
of effusion. In the course of 7 or 8 
days, the piece of the dura mater sloughed 
off, and left the pia mater bare. The child
still retained his senses, but fungus cerebri 
came on, the brain was protruded and the 
child died.

89)
Thus, the dura mater may die and slough off by 
a blow, just as a bone or any other part whose 
life is weak. I know of no remedy for this disorder.
In the case mentioned, the remedies for 
inflamation were used, particularly bleeding 
and purging, and the result was unfortunate.
C. Hamorrhage from the brain and dura
maters. Very considerable bleeding sometimes 
occurs when the brain or dura mater, especially 
the latter, are wounded. This is especially 
the case if one of the large sinuses, as
the longitudinal, or the lateral, is wounded.
This may arise by speculae of bone, or it may 
arise from wounds in our operations. Alarming
as this bleeding is, it is very easily commanded.
A dossil of lint, secured by pressure 
with the finger is always sufficient
to put a permanent stop to the disease.
Of arterial hamorrhage from the dura mater,
more must be said. The only vessel from 
which this can occur in any alarming degree
is the median artery of the dura mater,
which lies under the parietal bones. 

90)
A long quantity of blood may flow out
of this vessel, but in general, a piece of lint,
pressed down with the finger will stop 
this, in ten minutes. But sometimes, from
unusual size of the artery, &c, the blood continues
to flow. In this case, if the dura mater 
is wounded as well as the artery, the latter 
may be secured by a ligature, by a needle, 
or tenaculum, but if the dura mater be
whole, this would be unadviseable, as wounds 
of the dura mater are so seldom recovered from 
even if the puncture be very small, as by 
a spicula of bone, it is best to omit the ligature.
When the artery runs thro' a canal 
of bone, the treatment mentioned in compound
fractures, of stopping the hole by 
a plug of soft wood, put beside the artery,
and not into it is nescessary. But this structure is rare.
We might in some cases introduce a dossil
of lint between the scull and dura mater,
and thus press on the artery, and this 
lint, if not large could not in commode

(91
the brain by its pressure. This I have never yet
used. Might we not in obstinate cases, order pressure 
by an assistant for 30 minutes or more?
I have never seen the bleeding in any of these 
cases prove troublesome; and rather than use 
the ligature when there was no wound,
I would try astringents, as agaric, alum, blue 
vitriol, &c and by these means, there will be 
no difficulty in succeeding.
Before I quit the subject of compression, I 
will warn you of a very usual error into 
which both physicians and surgeons have 
fallen. From the identity of the the symptoms 
of intoxication and compression, they 
may be confounded together. The agree exactly 
in the loss of voluntary motion, puking, dullness,
sleepiness and every other symptom. But 
by an inquiry into the previous conduct, you 
may draw the line of distinction.
I say 'physicians', as apoplexy has been also 
confounded with drunkenness. Dr. Gregory
related a case of a man who had drank to excess
and was treated as an apoplectic by

92)
bleeding, blistering, stimulants, sinapisms,
&c and the man was cured!
An hostler who was intoxicated, fell among
a horses feet and received a wound
of the scalp. One of his companions save 
him, and took him to an infirmary. The 
surgeon shaved his head and enlarged the
wound by a crucial incision, but was 
astonished to find no fracture! It being at 
night, the head was dressed, and a consultation
determined an trepanning early next morning.
But when morning came, and the 
man awoke, he saw himself queerly situated:
an old nurse standing by,- his head 
felt very strangely tied up- and he in the 
infirmary! He demanded what was the 
matter? The nurse told him "hush, my 
man, you must be trepanned today."!!
The smell of the breath may be a very safe 
criterion; also the following. When I was the 
house surgeon in St George's Hospital, a woman
was brought in for a supposed injury

(93
injury of the head. Suspecting another cause, I 
poured a stream of cold water on the upper lip
for some time: the head began to rotate from 
side to side, and at last she got up, and demanded 
the reason of such insolent treatment 
as was used with her!
d. Inflamation of the brain. The symptoms 
of inflamation never follows immediateley 
after the cause which produced them.
They are all of the febrile kind. The face becomes
hot, and is overspread with a blush, headache 
follows, nausea and often vomiting supervene,
the pulse becomes hard and full, delirium,
coma, and restlessness soon follow.
These symptoms seldom come on before a week
or ten days after the injury. Indeed I have known
12 months supervene before the inflamation
come on. This was the case with Captain B.
Turner, who in escaping from a sinking vessel
into a boat, received a contusion on the head
and which was followed by a swelling on the 
occiput. He arrived in a town in Holland, and 
a german physician gave him a wash of 

94)
brandy, and the blue pill, (suposing the case
venereal, he having had the lues 4 years before)
after three months, no relief occurring, but headache
coming on, he came to England and Mr
Blizard continued the blue pill, but no alleviation,
nor salivation could be produced. 
and he was advised to go to a warm climate.
In June 1809 he arrived in Philad. and aplied 
to D Rush. Three weeks before arrival, he 
had the aura epileptica, commencing in the 
hand, and terminating in violent fits, and 
the arm becoming paralytic, and the leg
on the same (left) side becoming numbed. The 
Doctor bled and purged him freely, confining 
him to a very low diet.
No relief being found, I was consulted, the 
fits still continuing. I laid the bone bare
by a free incision. I found it very rough on 
its surface and wasted. I did not hesitate to 
apply the trepan, and on removing a piece
of the bone, I found the dura mater adhering 
strongly to the bone, and much indurated. 

(95
Four days after, it proved fatal, and on dissection,
pus was found both on the dura mater 
and also in the pia mater. Here was inflamation 
in the membranes a full year after the 
blow was received.
The causes of inflamation of the brain may
be either a contusion without any wound,
a fissure without depressure, or a fracture
with depression of a piece of the scull.
1. After concussion, the teguments become puffy
and flaccid, and on laying them open, they 
will be found detached from the bone, and 
if a perforation be made, the internal surface
of the bone will also be found detached.
The pericranium, instead of its florid colour
is found pale and in fact dead, and within,
mucus [cross out] or pus will be found on the dura 
mater.
2. and 3. Fissures or fractures with depression 
are very apt to produce inflamation, with 
them, there is generally a wound of the scalp.
Instead of healthy granulations, there are pale 
and flaccid ones, and they become so as soon

96)
as the inflamation commences. Instead of 
healthy pus, a thin bloody ichor only is discharged,
and the pericranium will separate 
from the bone, round the perforation in 
it. At the same time, the dura mater will separate 
in the same way.
Mr. Pott supposed this to arise from the vessels 
which carry on the circulation thro the 
bone becoming destroyed, but I have reason
to doubt of this explanation. It appears that 
the life of the bone is completely destroyed.
In all injuries of the brain, whether simple
contusion, fissure, or fracture with depression,
inflamation may therefore be expected.
The scalp may indeed be largely separated 
from the scull, and no symptoms of inflamation 
or suppuration follow, but union 
by healthy granulation follow, especially if 
the wound be produced by simple incision. 
Thus, the injury in communicated no deeper than 
to the external membranes of the head, but 
when a great concussion is received, the effects

(97
effects of it are communicated to the internal parts
of the head, not only to the membranes but to 
the brain itself; and inflamation and suppuration 
may come on as far as the parts are 
injured.
This is not merely a speculative point,
but one of great practical importance.
When pus is formed under the dura mater, I 
believe it is always fatal. Pus on the surface
of the dura mater may if let off prove 
of little injury. Therefore in all cases of inflamation,
a perforation with the trephine 
is always to be made, and this as soon as the 
symptoms of cerebral inflamation run 
high. By this timely measure, if suppuration 
is confined to the dura mater alone,
it may be prevented from doing any injury,
as all the pus will escape; and if 
any sloughs form in the dura mater, then 
also will find a free exit.
It is a question of some importance,
whether in the first instance of fractures
without depression, or with it, the perforation

98)
ought to be made, or to wait till symptoms 
of inflamation come on? Mr Pott was in 
the habit of trepanning in all cases of fracture,
immediately, but modern surgeons, having 
seen many recoveries from fractures, w.t
out trepaning have rejected this aphorism.
When the bone is depressed, indeed it is best 
to operate immediately, as the rough bone 
may irritate the dura mater, producing 
inflamation, suppuration and even ulceration.
But I would never trepan for simple 
fracture. Depression, or symptoms of inflamation 
must be apparent before I undertake
the operation of trepanning.
Even after evident depression of the bone, recoveries 
have occurred without trepanning,
but I would not deduce any rule from this.
Therefore, simple fracture, without any symptoms
of compression needs not to be trepaned.
But when depression has occurred, it is 
best to take out the piece of the bone. 

(99
When any other causes of inflamation, which 
I have mentioned occurs, the means to prevent 
and moderate inflamation must be used.
After a blow on the head, the patient must be 
confined to a very low diet, and bleeding and 
purging must be employed. If symptoms of 
inflamation appear, we are to bleed again,
and again, to apply the trepan, and to apply 
a blister over the head: a remedy well calculated
to reduce inflamation in the brain.
Cold applications are very serviseable. Clothes
wet in cold water, or in vinegar and water
are very useful.
e. Of concussion of the brain. Concussion of the 
brain is a certain deranged state of the brain
following blows on the head, which proves 
fatal often in a few minutes, and on dissection,
no marks of injury are found. It appears 
however, that a larger number of the 
minute vessels are ruptured. If the patient survive
some hours, the brain will be found
be set with drops of blood shed from these

100)
vessels, and if he survive for a day or two, the whole 
brain will have a bruised appearance.
Just in the same way do we often see blows 
on the reigion of the heart produce sudden 
death, and yet no symptoms appearances 
of derangement can be found on dissection.
If perfect rest be observed, the effusion of 
blood may be in many cases prevented.
Mr. Abernethy exceeds all authors in the description
of this state. Its progress according 
to him is as follows. 1st stage. The functions
of the brain are quite deranged, the stupor 
is complete, the patient is insensible, his breathing 
is difficult, tho not stertorious, and his 
extremities are cold and this state of stupor 
does not last long. 2nd stage. In this, the pulse 
and respiration are better, heat and sensibility 
increase, the patient will answer to 
a loud question, especially if it concern his 
own feelings, otherwise his answer is incoherent,
and he seems employed about something 
else. There are few symptoms of inflamation;
soon this state is followed by

(101
the 3rd or inflamatory stage, which is the 
most important of all.
Some surgeons recommend stimuli, as wine,
and if they succeed, they do very serious mischief.
If the establish the pulse and face 
respiration, inflamation and extravasation 
soon follow. I enjoin perfect rest, and keep 
the head elevated, and as the action recovers,
cold clothes with water & vinegar are applied
to the head. As the pulse rises, I bleed freely,
and thus inflamation and suppuration 
of the brain may be prevented.- Cases are 
repoted in which the patient recovered in whom
stimuli were used from the beginning, but 
the practice is very dangerous. The first 
case of contusion I have seen, I treated wt.
success by bleeding, while in St. Georges Hospital.
f. Inflamation of the brain, after it has 
subsided sometimes leaves a state of stupor
or idiotism. This was first treated with 
success by Dr Rush, who gave mercury 
so as to excite a salivation. He made 

102)
this discovery as early as the year 1795 or '6,
and it has been since spoken of by Mr Abernethy,
whose book was published in the year
since this. The plan adopted by Dr. Rush is 
found very successful.  Dr.P.
January 15th 
1812
Lecture 30.
It remains for me to explain the operation of 
perforation of the scull, for the purpose of elevating 
a depressed portion of bone, and for giving 
an exit to extravasated fluids, compressing the brain
The most common instrument for this purpose 
is the trephine, or circular saw, with a centre pin
for fixing the instrument. This pin is moveable 
in the handle, and by a pin in this, it may be 
protruded to any distance, and screwed fast so.
In the trephines of the older surgeons, this pin 
was fixed, and at a certain period of the operation,
this was removed by a key but this is of no service,
and protracts the operation. Thus, their

(103
center pin being always alike long, was very apt 
to wound the dura mater, as in thin sculls, especially 
in children. But the pin which easily 
is slipt up is very convenient.
The older surgeons used conical trephines,
and this, with a view of avoiding wounding the 
dura mater by a sudden plunge of the instrument,
after going thro' the scull. But this is very 
inconvenient, and tedious shape is quite superceded 
by proper care, and all danger of wounding 
the dura mater is avoided by the precautions
I am shortly to describe.
Before this instrument is used, the integuments
must be divided and dissected off. A common 
scalpel will answer this purpose. The iron 
is to continue to the end of the handle of 
this instrument, and to project in a square
form, to raise the pericranium from the 
bone. This quite supercedes a raspatory, which 
is an instrument for this puropse, used by 
some surgeons.
The elevator, which is a simple lever, a little bent

104
must also be at hand. This instrument is 
often made too convex.*
In most cases of trepanning instruments,
a lenticulator (which is a knife with a thick 
ede and a spoon-like point) is found, but the 
purpose for which this instrument is made
viz. cutting off rough edges and spicula after
the piece of bone is removed, is fully, and wt 
more convenience answered by the elevator.
The circular saw of Mr Hey should also be 
at hand. This is used when the depressed bone
is capable of being raised, except on account of 
one neck of bone, or one of these on each side.
This prevents in many cases, the dura mater
being stripped by the circular perforation, and 
is found very convenient.
It will also be proper to have sponge, lint;
needles, tenaculum, a ligature, and a soft poultice 
at hand.
The hair may be shaved off, to shew the extent 
and situation of the wound, before the 
scalp is further removed.
*The tripod is also useless, and superceded by the 
common elevator

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The incision may be made, or the wound,
(if there be any,) enlarged. The older surgeons
made a circular incision, and removed a 
large portion of the scalp, and repeated this 
if nescessary, and thus destroyed the covering
of a large portion of the cranium. I have 
see one half of the scalp removed in this way
Even Mr Pott advised this plan, but it is never 
nesccesary. A simple incision down to the bone 
is generally sufficient, and the pericranium 
is to be removed as we have described. If 
nescesary, an incision at right angles, or even 
a crucial incision may be made and the 
corners dissected away, but not removed.
When the cranium is fractured into many
pieces, there is considerable danger of wounding 
the dura mater with the scalpel, and 
therefore the incision is best made in this case
on the firm part of the scull, and from this,
we can dissect to the injured parts.
If an artery should be cut in the scalp, and 
bleed much, rather than trust to pressure, I 
would secure it with a needle, or tenaculum, 

106)
otherwise, it may bleed in the night. Some advise 
to deplete, by leaving such vessels open,
but this is much more conveniently done at 
the jugular vein or arm.
Some surgeons perforate the scull with a 
perforation, but the centre pin of the trephine
does this much more expeditiously.
The pin is to be applied on the sound bone,
but so near the fissure, as to include as much 
of the depressed portion as may be. This is done 
to avoid pressing the portion deeper, as our
efforts with the trephine might have this 
effect, if the pin rested not on the sound, but on 
the depressed bone.
The sawdust may be wiped from the teeth of 
the saw, and from the groove with a towel, which
answers better than the brush commonly used
As soon as the groove in the bone becomes deep
enough to retain the saw, the centre pin may be 
removed, as if left, it might wound the dura-
mater, which we have seen is very dangerous. 
Even before the grove is compleat, the pin 
must be shifted up in cases of thin sculls.

(107
We must very frequently examine the groove
with a tooth pick, to feell if any point of the 
circle is cut through, in which case, you must 
bear obliquely on the uncut part.
It was the ancient mode to mount the trephine
on a large handle, with a crank in 
the middle; this was applied to the surgeon's
breast, and thus their labour was lessened!
but the pressure thus applied was very dangerous
and unjustifiable.
It is common for this instrument to be made
too thin in its edge, and thus the groove will
not admit the levator, and when we want 
to work obliquely, we are unable to do so.
As soon as a considerable groove is made,
tho' no part of the bone be cut though, we may
try with the elevator to raise it, by breaking 
the vitreous table, thus avoiding most completely,
wounding, the dura mater, and if 
the bone be thicken at one side than the other,
this will particularly answer. The 
spiculae may be broken out with the levator,
and thus, the operation is completed.

108
Forceps are of no use in raising the circle.
This operation is considered by some to be 
easily performed and simple: but to perforate 
the scull; [cross out] and to avoid the dura mater requires
considerable attention, and I have seen errors
committed in this, twice prove fatal; inflammation 
of the brain having followed. We ought 
therefore always when one portion of the circle
is through, to avoid it very carefully.
Mr. Heys saw, in the circumstances we 
have mentioned is a very convenient instrument.
In the use of it, the dura mater is 
also to be carefully avoided.
After raising the depressed fragments, if this 
was the cause of compression, the symptoms
will cease, but if much blood is extravasated 
under the scull, more holes may be 
required to evacuate it, and if the symptoms
of pressure continue, the dura mater may
be separated from the scull for some way.
If blood be extravasated through the cavity 
under the dura mater, it is doubtful

(109
as we have shewn, [how dangerous it is] whether it is proper to 
puncture the dura mater with a lancet, but 
if in any case it is chosen to do so, which in 
general is improper, the puncture must be 
very small.
Having raised the depressed fragment or extracted
it, with the levator, the scull is to be 
dressed. A soft, light poultice is the best dressing.
Lint, which is generally used adheres
to the dura mater, and is not easily removed
in a future dressing; while the poultice separates 
very easily.
When the dura mater is pierced by spicular
or punctured by the surgeon, the scalp is 
to be brought over it, so that it may directly 
adhere, and prevent inflammation of the brain
In this way I treated a fracture of the squamous
part of the temporal bone, in which 
there were many fragments, and the dura
mater perforated; yet the patient recovered.
This may be done in cases of depression &
may prevent exfolian of the scull, but when


110)
extravasation has happened under the dura 
mater, and especially if a coagulum remains,
the orifice is by no means to be closed,
but simply a soft poultice applied.
The ancient surgeons forbid our operating 
on particular parts of the scull.
1. We are cautioned never to trepan the frontal
sinus. Here the tables of the scull are 
not paralel, and if it should be required
to trepan this part, the perforation may
be made in the usual way thro' the outer
table, but on the inner, the trepan may
be applied also perpendicular to the surface
of this plate also. If a ridge remains which 
the saw will not cut safely, it may be broken
with the levator.
2. They deem it improper to perforate over 
the longitudinal or lateral sinuses. Haemorhage
from this vessel is easily stopped by a 
little lint. But this vessel may generally 
avoided, unless it lie in a deep groove in the 

(111
bone, and even then, by working obliquely on one 
side, and then on the other. But there is little
hazard in the haemorrhage; the only danger being
that of wounding the dura mater beside
the artery sinus. This may be prevented by 
prizing out the piece of bone before quite cut
through, and breaking the remaining ridges 
with the levator, guarding the dura mater with 
an iron spatula.- If blood be shed under the 
bone, there can be no hazard; but we cannot 
depend on or judge of this before the operation is over.
3. It is deemed unsafe to trepan over the anterior 
inferior angle of of the parietal bone,
for here the median artery of the dura mater 
lieg, but tho' there is some degree of danger
here, by care, the vessel may be avoided. If it 
be wounded, it may however be stoped in most 
cases by a dossil of lint put into the groove it
lig in, or if the artery be inclosed in a bony
channel, the plug of soft wood as we have 
mentioned may be pushed in.
4 The occiput is deemed unfit for the operation,
but, with the precautions for others

112)
cases of unevenness on the scull, this objection 
like all the others is of no Value, and the 
scull may be trepanned in any place where
a fracture can reach, excepting the basis 
of the scull itself. So that all these rules,
so carefully held inviolate by our ancestors
are of no consequence whatever.P
Jan. 17
Lecture 31.
Of Diseases of the eyes, and first, of inflamation.
This may be seated in the eyelids, conjuctiva, 
cornea, or globe of the eye.
Inflamation of the eyelids is acompanied
with a serous discharge, and with a burning 
pain, and after comes on suddenly. It 
is produced by extraneous bodies, mechanical 
violence, &c.
If much pain and fever attend, bleeding, low 
diet and a mercurial purge may be prescribed, 
and the parts may be kept moist with 
diluted brandy, &c and may be expected soon 
to subside. 


113
Inflamation in the edges produces effusion 
and ulceration, and the discharge is so purulent
and viscid as to glue the eyelids together, and 
they cannot be opened without difficulty in 
the morning. The seat of this disease is said
to be the Meibomian glands, but I suppose 
it to arise from inflamation and ulceration 
round the roots of the hairs, thus resembling
tinea capitis, and if the hairs be 
extracted, just as in that disease, the sore will
heal up. The treatment of these two diseases 
is the same. Sperma ceti oil had succeeded 
well. It is recommended to touch the 
eyelid with lapis infernalis, and in this way
I once succeeded. lung Citrinum, [spermaciti]
If strong mercurial ointment, are powerful remedies I have extracted 
the hairs with twizers, and thus succeeded 
after the ointments have been tried 
to no puropse.
When the conjunctiva and cornea are the seat 
of the inflamation, the white membranes 
become red by the admission of anusual. 


114)
quantity of blood. The eye waters, light becomes
offensive, the eye feels hot and burning, and 
the pain is communicated to the temple and 
and fore head. The inflamation is sometimes confined
to a spot near the edge of the cornea. The 
eyes when thus inflamed are very irritable to 
light, we cannot easily get a view of the eye,
and the patient guards off the [inflam] light 
with his hand.
If the inflamation be over the cornea, there
is danger of opacity in this, and on the conjunctiva,
the speck mentioned leaves a film,
which, if near the inner canthus, it forms
what is called unguis.
The causes of this are, mechanical injuries,
viz blows, &c also the inversion of the cilia,
called trichiasis; acrid substances, as lime,
acids, smoke, violent excercise of the eyes,
too much light: and I have known it produced 
by the eye being wit with urine, in 
a young man having gonorrhoea.

(115
The globe of the eye may be inflamed in the anterior 
chamber, or the posterior, behind the lens.
When in the former situation, the pain is of a shooting 
kind, and varies much according to the violence 
of the causes. It sometimes proceeds to 
suppuration, and then, the pus may be seen
in the anterior chamber of the eye.
Inflamation in the posterior part is more
severe, the pain and fever run high, and vision 
is lost, yet the conjunctiva appears not 
much inflamed.
In all cases, the mechanical causes, if 
they continue to act must be removed. To 
remove sand or pieces of iron which stick in 
the coats of the eye, the ball is to be fixed by 
a speculum, and the body removed by a lancet.
Substances under the eye lid may be 
removed by a wet rag, or by syringing 
them with warm milk and water. If this 
fail, the inner surface of the lid may be examined 
by raising the lid.
When the eyelashes are inverted, constituting 
trichiasis, the cause of irritation must

116
be removed. This may depend either on the 
hairs growing inwards, or contraction of the 
eyelid. In the former case, the hairs must be 
pulled out, and St Yves says if destroyed by lunar 
caustic, they will not grow again
In case of contraction, an operation is required.
The tarsi, at the inner and outer ends have 
been cut thro', and, no success has followed in
any case I have heard of. Some assert that 
by cutting the skin lining the lid, they have
removed the stricture, but I have never seen 
any success from this mode.
A late author describes an operation, which 
consists in separating the tarsi from the skin 
without, and the conjunctiva within, thus 
separating its lateral connections; but I 
never tried this mode.
A few years ago, Dr. Dorsey had a case of this 
sort in the Alms House, and after trying to 
cure it by various operations, was obliqed to 
extirpate the whole edge of the cartilage, and 
the sore healed, and the eye was still very well 
defended by the eyelid. This is a mode which

(117
deserves imitation in all similar cases.
In all cases of opthalmia, bleeding is to be used
freely, according to the pain and fever. When 
enough of blood is evacuated in this way, cups 
may be applied to the temples, [and] or 30 or 40 
leechs may be applied to the same part. The vessels 
on the surface may be cut by the shoulder of a 
lancet, or they may be raised with fine forcepts,
and divided with scissars, but I prefer the 
lancet. Purging is also required. Mercurial 
purges are by far the best. The antimonial 
powder, of the P. Hospital answers very well.
The applications are to be mild. Poultices
of bread and milk are very good. The pith 
of sassafras may form one of the best remedies.
It may be applied in form of a poultice,
or as a fomentation dissolved in water.
Blisters may be applied behind the ears, on 
the nape of the neck, or on the shaven head.
After the inflamation is considerably subsided,
laudanum is a valuable remedy. Sugar
of lead, white vitriol and laudanum 
may be united in a collyreum.

118)
But stimuli must never be applied before 
the inflamation is much subdued, else the 
inflamation will be increased. Vinegar is a 
valuable remedy in such cases; the rotten-
apple-poultice is particularly serviceable after 
evacuations have been used.
If matter form in the anterior chamber of 
the eye, certain measures must be used to produce
absorption, but if the eye be made very 
tense by the matter, an incision, such as 
used for the extraction of the cataract, must 
be made, to prevent opacity in the cornea.
When opthalmia is of long duration, a 
salivation is one of the best remedies.
In all cases of opthalmia, particular care
should be taken to avoid light. The chamber 
must be dark, and excercise of the organ 
avoided. The diet must be vegetable, & 
animal food, and spirits avoided.
After severe cases, a sition may be made in the 
neck to prevent a relapse.
In many cases of protracted opthalmia,

119
the action seems to have something peculiar
in it. A gentleman, who had had a tender state 
of the eyes from his youth, had a severe [atta??]
which lasted 3 months; he was bled during 
that time, to ℥ iso, purged very freely, blistered 
had issues almost constantly, and was often 
scarified, and all to no good purpose. I directed
tar water to be applied, first to one eye, & 
after some time to the other. It brought him 
from a state of blindness, to free use of the 
organ, and tho' the application was very stimulating,
it produced no pain, but suddenly 
subdued the inflamation.
Various stimuli have been used. In one 
case, after bleeding, blistering and purging
had been used to no purpose, a solution of 
blue vitriol (in proportion of gr ij to ℥ water)
succeded buy and conception. In a week, the 
man was nearly cured.
Surgeons fear the use of stimuli in these 
cases from the tenderness of the organ, and 
indeed, the evacuating remedies, as bleeding, purging
and blistering must have been used before any 

120
stimuli are proper, but in protracted cases 
they are required. Solution of soap in spirits 
of wine have been of service in some cases.
Specks on the eyes have been cured by a mixture 
of sugar, alum and nitro! A solution 
of salt in water and vinegar, and sea water 
have been well borne in some cases. Red
precipitate, with a little camphor has been 
well endured, and succeeded in some cases, after 
the evacuating plan had failed.
Unguis. This, as we have mentioned, is an enlargement 
of the coates of the eye by inflamation.
When the thickening extends
along the conjunctiva over the cornea, vision 
is obstructed. The whole enlarged membrane 
must be dissected off. That part over 
the cornea, after being raised by fine forcepts
must be carefully dissected away with 
a knife, and the part over the schtonica may 
be cut away with scissars. It must be dissected 
very closely from the caruncular lachrymalis,
else it will return again. This is of 
much importance. 

(121
Specks. The best remedy for small opaque specks
on the eye after inflamation, is mercury. Locally,
gentle stimuli are proper, as corrosive 
sublimate one grain, water four ounces, but 
if there be inflamation produced by stimuli, 
they increase the opacity. But a ptyalism,
with low diet is the best, and most 
certain remedy.
When the part of the cornea, over the pupil
is rendered opacque by inflamation, an artificial 
pupil has been made by opening 
the iris with the needle, opposite to the 
transparent cornea. When the pupil is closed 
by adhesion, an operation [??lour] can cure 
it, by making an artificial pupil.
of Fistula Lachrymalis. To understand
this affection, the anatomy of the 
lachrymal sac and duct, the puncta lachrymalia,
and the adjacent bones must be 
well learned.
Stricture, or obstruction in this tube produces
a swelling in the inner canthus of the 

122)
eye, and if pressure be made on this, water and 
pus escape by the punctae. In this state, the 
eyelids will be glued together in the morning, &
opened with difficulty. If the sac be ostructed 
by disease, or by cold, pain and fever come on,
the part becomes very tender. In this state,
bleeding, purging, and low diet may sometimes
suceed, but generally, the tumor bursts 
externally. Before this can occur, it is the best 
practice to open the external part of the tumor,
give vent to the contents, and then introduce 
a probe into the duct toward the nose, & 
try to overcome the stricture. In this simple
way, I have succeeded in curing the complaint
But the nasal end of the tube is often so 
completely obliterated, as to preclude the fesibility 
of this. It is then nescesary to make 
an artificial opening into the nostril, for 
the future passage of the tears, by puncturing
the of unguis, which is the only division 
between the nose & eye in this place.
Mr. Pott performed this with a bent trochar,
after which, fragments of bone surrounded

(123
surrounded the opening, and were united by membrane.
It was nescesary to wear a bogie in the passage
for 2 or 3 weeks, to prevent its healing up, and 
even after this, it sometimes did heal up.
Mr. Hunter, seeing the imprefeations and in
conveniences of this plan, introduced a mode of 
striking out a circular piece of the bone, by 
an instrument resembling a punch, the 
bone being supported by a flat piece of horn 
introduced up the nostril.
This plan produces immediate relief, and 
after it no bogie is required.
This disease is sometimes complicated
with caries of the bones. In this case, the 
detached piece of bone is to be extracted, and 
the sore treated as another carious ulcer.
At the next lecture, the operation will be
performed on the dead subject, and the minutiae
of it explained.   Dr. P.
January 20.1812,

Lecture 32.
Fistula lachrymalis continued. Stricture in the 
ductus ad nasi, producing accumulation of 
tears, and swelling, may be divided into several 
stages, well distinguished from one another.
1. In the first, no inflamation has appeared, & 
pressure on the sac produces a regurgetation of a 
[mucus] water, and then mucus. Very little is to be 
done in this case. By pressing the fluid out of 
the sac regularly, the distension will be prevented,
part of the tears will return to the eye,
and some will flow into the nose. The eye may
be washed with a weak vitriolic collyeyum, as
white vitriol gr 1 or 2 to water ℥i, and I have seen 
the complaint disappear by this simple plan.
The French recommend injecting the sac with 
warm water by a fine syringe, but pressure 
is sufficient to cleanse the canal. Sir Wm Blizard
recommends injecting mercury, but no 
particular benefit results from this.
2. If by carelessness the sac be suffered to distend 
itself, and the patient expose himself to cold, inflamation

125
inflamation comes on, and parts appear just as 
a common boil. By the use of bleeding, purging, low 
diet and blisters, with a lead water poultice, we 
may prevent suppuration, and reduce the complaint
to the first stage; when it may be treated 
in the same way
3. In the third stage, pus has formed in the sac,
and generally escapes by an ulcerous opening 
in front of the middle of the sac, and the 
true fistula lachrymalis now is formed.
It is nescesary to remove the stricture, and establish
the evacuation of the tears into the 
nose, else the sore will never heal, and from 
inattention, patients have been teased by caustic
&c when the cause of the ulcer was not suspected.
The plate of bone (os unguis) which separates 
the sac from the nostril must often be
perforated, but before this is done, every measure 
must be tried to establish the natural passage
The external opening (if small) may 
be dilated with a bistoury, to introduce the 
probe. 

126
We may be called to operate before the duct is 
much distended, and not easily felt, and also,
the fistula may be so small and circuitous 
that we do not find it possible to introduce a
probe along it; therefore we ouht to know the 
true situation of the sac, and the place to cut
so as to find it. The incisions must commence
just below the inner canthus, and continue
parallel to the edge of the bony orbit. Thus, by 
beginning always below the canthus, we avoid the 
tendon of the orbicularis muscle
A probe is now to be introduced into the duct,
and carried down to the nose. In so doing, we feel 
the stricture, and overcome it. The probe may 
be withdrawn, and a bagie introduced, or what 
is much better, Mr Naru's silver probe. This consists
of a silver wire, the end of which is a little 
bent, and mounted with a flat head set on 
oblicquely, and the face of this after being heated,
covered with black sealing wax, so as to 
appear just like a black patch.
This may be left in. It does not produce 
much pain, and the tears pass along it to

(127
the nose, tho' this might not be expected.
This stilette has been borne for months, and 
is to be left in till the stricture is overcome. It 
may be removed and cleaned occasionally, and 
is then easily reduced to its place again. When 
the stilette is prematurely with drawn, the stricture 
will recur, and renew the disease where
as, if left in the due time, the canal will 
remain pervous, and the sore will heal very 
well after the stilette is removed. Thus the 
disease is generally easily cured.
But in some cases, the natural canal is 
not capable of yielding, and even the bony 
canal is found closed. Then, the artificial 
passage is the only resource.
When the os unguis is punctured by Mr.
Potts trachar, the fragments suspended together
by membranes are ready to reinstate
themselves again. To operate with Mr Hunters
punch, which is the best way, a piece of 
horn is to be introduced up the nostril, so as
to support the os unguis; the bottom of 
the sac laid bare, and the punch applied,

128)
and the bone may easily be perforated by 
few rotatory turns of the punch, and there 
will be a circular piece of bone neatly cut out.
The external wound may be immediately 
healed. The lips of the sore are to be brought 
together by adhesive plaster, and will soon 
heal up. The bone having no loose fragments,
will not heal up and the sac remains 
pervious, and conducts the tears into 
the nose without any inconvenience.
Of the Cataract. This consists in an opacity 
of the chrystaline lens and its capsule,
whereby the rays of light are prevented from 
passing to the retina.
It appears in an uniform whiteness of the lens,
or only in a speck. It first causes a dimness
of sight, as if gause was hung before the eye,
or threads, spots &c.
It often comes on spontaneously, and may 
in other cases be referred to mechanical violence.
Many remind us have been used to disperse the

(129
opacity. Mercury stands at the head of these.
Setons, purges, blisters, low diet, &c are also useful
Those cases which proceed from external violence 
may generally be removed by medicine.
They very commonly yield to a salivation.
A lady received a wound in the eye, by a puncture
with a needle, which reached the lens, considerable 
inflamation and finally opacity followed,
and she lost the sight in that eye. Bleeding,
blistering, purging and low diet were tried, but 
had no effect on the opacque lens. I pursuaded 
her to submit to a salivation, and as soon 
as the mouth became sore, the opacity began
to lessen, and before the salivation ceased 
the eye was perfectly restored. But she was 
still obliged to use a convex glass, and it therefore
appeared that the lens had been quite absorbed,
and the eye left in the same state as 
after extraction.
Spontaneous cataracts, I have never seen 
removed by medicine, and only once relieved.
As medicines fail, an operation alone can be 
of decided service. This consists in removing

130)
the opaque lens from the axis of vision 
Several means have been used for this purpose:
two operations continue still in use.
1. Couching, wherein the lens is pushed aside,
or to the bottom of the eye, so as to leave the 
passage for the light penetrable [the?ts] and,
2. Extraction, wherein a transverse incision 
is made thro' the transparent cornea, and 
the lens extracted thro' the iris and cornea,
so as to leave the eye in a transparent state.
Couching is the easiest as well as the oldest 
of these modes of operating, and is still 
strongly advocated by some surgeons, particularly 
Percival Pott, and Mr Hey of Leeds,
but I give a decided preference to extraction,
for the following reasons.
1. Couching is by far the most painful operation.
When extraction is performed by making 
the incision with a single stroke of the knife
it produces almost no pain, whereas, introducing 
the kneedle through the adnata and 
scletoric coat and the subsequent motions 
are very severe.

(131
I performed extraction on a man who had 
had couching performed on the other eye, and 
he could not believe that the operation was 
over till seeing a watch, he was convinced,
and he reflected with horror on the operation 
which had caused his eye to suppurate and 
waste away in the socket. I have even been 
requested to operate on the second eye immediately,
so trifling was the pain after 
extraction in many cases.
2. The lens after depression may, and after
does rise to its place, after which patients, 
will not (as some say) submit to the repetition 
without reluctance. When extraction 
is performed, the operation is complete.
3. When the cataract is fluid, the anterior 
chamber after become muddy, and the 
kneedle is in danger of tearing the iris. It 
is indeed said that the fluid will be absorbed 
again, but still, it is nesceray to repeat
the operation, to depress the nucleus 
of the lens.

132
4. When the capsule of the lens is also opacque,
the operation must be repeated on this if depression 
be performed, but in extraction, the capsule is 
easily removed either entire, as I have often had 
it, which could be seen by suspending it in water,
or piecemeal. When the capsule adheres very 
strongly to the ciliary process, it will be raised 
to its site very soon after couching, and appear 
behind the iris again.
5. Ahesions frequently form between the iris &
lens, and in extraction, I have found it very easy 
to separate them with a gold kneedle, whereas
in couching these adhesions remain, and the lens
will soon be reinstated again, and the repetition 
of the operation is required. Mr. Hey performed 
couching in such a case, no less than 
five times.
Therefore extraction ought to be always prefered.
Indeed objections have been raised against extraction,
but we shall soon see how far these 
result from awkwardness in the operator,
1. The incision in the cornea is said to leave the 
cornea opacque, but this is not the case; if the 

(133
operation be done well, the eye remains clear.
But if a dull knife be used, or the operation finished
with scissars, the eye may inflame, and becomes 
opacque; but the incision should not be 
near the pupil in any part, and therefore the 
passage of light remains unaltered.
2. The force in extracting the lens is said to 
make the pupil irregular, and so injure vision 
and I have more than once seen the pupil made 
irregular by extracting a hard chrystaline,
but this never injures vision in any degree.
Yet this is very rare, and may be avoided by 
proper care in the force applied.
3. The iris sometimes doubles under the knife
and may be injured if neglected, but if the incision 
be stopped, and the surgeon press and rub
gently on the cornea with the fore finger of 
the hand which is at liberty, the iris goes back
and the operation is easily finished.
4. The vitreous humor is said to escape sometimes
in couching, and this has actually 
been the case, but, it is always the effect of 
awkward pressure made on the eye, after



134
the incision is made. Moderate pressure is 
to be made on the eye during the incision
for the sole purpose of steadying the eye, and 
as soon as the cornea is cut, the pressure is 
to be entirely removed, and the vitreous humor
is in no danger of being moved. These objections 
are therefore of no importance. and extraction 
is the only proper operation. Dr. P.
Jan, 22d.
Lecture 33.
Cataract Continued. Before operating for the 
cataract, we ought to ascertain the probable
effect of the operation, whether or not success is 
to be expected. This is of great importance, as 
our character, as well as our patients ease may 
be sacraficed in a useless operation. The principal 
circumstances to be attended to are these.
1. That the eye in every respect (besides the 
state of the lens) be natural. That the cornea 
be clear, the eyelids, and thin edges free from 
inflamation and oedema. That there be no
tendency to inflamation, as in some cases

(135
the least injury will cause much inflamation 
2. That there be no pain in the fore head.
This circumstance is often met with especially 
in women. If this symptom exist, we can 
moderate it by bleeding, low diet, purging 2ce
or 3ce a week. In a case in which there was 
considerable head-ache, I gave purge twice a 
week, for nine months, and then operated 
with success.
3. That the iris retain the power of contracting
on the application of objects.
But if the power of distinguishing objects 
continue, we may not be deterred.
This iris may be fixed by adhesions to the capsule
of the chrystaline lens, and unable to 
move, yet if light can be distinguished from 
darkness, of telling the number of windows
in the room, of telling when a hand, a hat, 
&c is interposed between the eye and window,
&c the operation may be successful; but in 
such cases as do not bear these marks, you 
should never operate, as the retina will be in 
a state of torpor, the state called amourosis

136.
Even the pupil may retain its nobility,
and yet the retina be paralytic. An old
lady applied to me for a cataract, which 
was in this state. I extracted the lens, which 
was as hard as a stone, but to my surprise,
no power of vision remained. I then operated 
on the other eye, and in this, vision was 
restored. Now the pupils in both eyes moved alike 
by the light, tho' they were in an opposite 
state.
If the eye be in any of its coats inflamed or 
swelled, these symptoms may be removed by 
bleeding, purging, low diet, and blisters to the 
nape of the neck. The last remedy is particularly 
recommended by Baron Wenzel.
The operation is never to be poured on an 
eye in any degree inflamed, and measures are 
to be taken to prevent inflamation. In all 
cases, except when the patient is very weak, the 
diet should be low, entirely vegetable, and 
if the habit be full, blood should be drawn 
from the arm. 

(137
The most suitable seasons for the opertion
are spring and fall. In summer, the patient 
cannot lie still in bed the requsite time 
and in winter, the cold may produce inflamation,
and therefore mild weather is to 
be chosen.
The instruments used in extracting the cataract 
are the following.
It is common to fin the eye with a speculum,
by separating the eye lids, and applying it 
round the eye under the eyelids, it having 
a groove to receive the tarsi, but this is an unnescesary 
instrument. The eye[s] being opened
and held for a minute or two becomes steady
and the operation is to commence at this moment,
and it will be easy to keep it steady 
during the incision, without this painful 
and alarming instrument. This instrument 
occupies one hand, and if the iris folds
under the knife, we cannot make the nescessary 
friction on the cornea to press that back. I 
have performend this operation frequently, and 
never found it nescesary to use the speculum,


138)
speculum, but if it is used in any case, it 
will be found very convenient to have 
a ring in the end of the handle to put on 
the little finger, and then we can hold it 
with this, the mid-finger and thumb, and 
so have the fore finger at liberty; and these 
obviate this objection of Baron Wenzel. But 
still, the instrument is inconvenient.
The knife is then, the first instrument. Its 
blade may be 1 1/4 inch long 1/4 inch broad at 
the broadest part, and the sides straight lines
from this to the point. The edge is to extend 
to the broadest part in front, and to 1/10 inch 
on the back so as to make an exquisite point
I have said 1/4 inch broad: but it may be broader 
than [illegible] the diameter of the cornea, so 
as to cut its own way out by a simple push 
and must be very sharp, so as not to push
the eye obliquely, and so as to cut the cornea
without irritating it to inflame, and become 
opaque. See the description of this instrument,
in Wenzel.

(139
The second instrument is a kneedle for tearing 
the capsule on the anterior part of the lens
which may be a little bent, sit in a handle
and having on the end of the hand, a scoop 
for removing portions of the capsule which
may remain after the chrystaline is evacuated.
A small hook is also to be provided, with 
which the lens, may be extracted in case 
it should fall down into the vitreous humor
and only its edge be seen. This is often of great 
use.
Small forcepts are also nescessary, for extracting 
the opacque capsule, from behind the 
chrystaline, either piecemeal or entire. They 
are to touch not only at the points of their blades
but also to touch by flat surfaces, at least 1/10
of an inch. These instruments are of the 
first importance in completing the operation.
Before proceeding to operate, a bandage is 
to be put round the forehead, and to it, two 
compresses are to be pinned

140)
The compress which covers the eye to be operated 
on is to be pinned up. These render 
the eye steady. The patient is to be seated on 
a low seat and the surgeon on one much 
higher. All the windows in the room except 
one are to be closed, and the patient is to be 
set with one side of the head to that window.
Thus alone, the pupil can be seen distinctly.
The assistant is to stand behind the patient,
and support the head on his breast.
He is also to support the upper eyelid, by
holding the skin of it double over the sperciliary 
ridges, and make moderate pressure 
on the eye. The surgeon keeps down 
the lower lid, and makes moderate pressure 
also.
He is to apply the point of the knife to the 
eye, and not puncture it till the involuntary 
motion is over, else the knife may start,
and make a second puncture, and the aqueous 
humor will ooze out by the first,
the cornea will shrink and the iris fall in 
the way of the knife!

(141
The knife being applied at 1/12 inch from the 
junction of the iris and sclerotic coat, and 
the eye steady, the point of the knife is to be 
carried horizontally, and parallel to the iris
is to be brought out at the same situation
in the cornea at which it entered, and carried 
thro' with a single push; and never drawn back
but if the iris fold under the knife, pressure 
may be made on the cornea till this falls into
its place. As the knife fills up all the 
incision, none of the water can escape, but 
if it were withdrawn in any degree, or if 
the knife were not broad enough to cut 
itself out without being moved out of a direct 
line, the aqueous humor would escape.
As soon as the cornea is transfixed, all 
pressure must be removed; we having only 
to support the eyelids, and the knife being 
sufficient to fix the eye, which is as 
[cross out] it were hooked on it. Thus no pressure 
being made after the cornea is open, there is
no danger of evacuating the vitreous humor.

142)
Next, tear the capsule, with the kneedle in 
as complete a manner as posible, and with 
moderate pressure, the chrystaline lens will 
escape by the pupil an cut in the cornea. If the 
lens do not pass the pupil easily, the eye
may be exposed to darkness for some time,
that the iris may be relaxed, and thus, all 
danger of tearing the iris will be averted.
Gentle pressure may be made on the globe
to facilitate the exit of the lens, and if this 
does not follow very freely, the needle may 
again be introduced thro' the cornea and 
iris, the point fixed into the chrystaline,
and this extracted. This supercedes improper
pressure.
After the extraction of the lens, if filaments 
of membrane remain, they are to removed 
by the scoop, and if an opaque membrane
is seen behind the site of the lens, it may 
be removed by the forcepts.
When the operation is over, the compress is
be brought down, a piece of soft linen applied
over the eye, and secured by a bandage passed

(143
passed round the head, and the patient put to 
bed. His hands are to be secured with tapes fastened
to the bed cords, so that the cannot be 
lifted higher than the breast. This is of great 
importance. In one case, after the operation
was performed well, the patient on waking 
out of sleep, forgetting the cause of irritation 
in his eye, rubbed this, so as to evacuate 
the greater part of the vitreous humor
and so destroyed the organs.
In ten days, the eye will have united again.
Low diet, rest and perfect darkness 
are to be observed.-
We might have observ'd that after the incision 
is made in the cornea, we may rest 
a minute or two as in that time, the irritation 
of the incisison will be over, and 
the kneedle will be better borne than if 
this were neglected.   Dr. P.
Jan 24, 1812

144)
Lecture 34.
Cataract continued. Of Couching. And first 
of the instruments. It is common for operators 
in couching to use a speculum, and there is 
no objection to it, if the operator choses however,
it is unnescesary. The eye may be opened, the 
eyelids fixed, considerable pressure may be made
on the eye, this will then become steady, and 
now the operation may be performed. After the 
kneedle is introduced, it fixes the eye.
The kneedle used by Mr. Pott, was spearpointed,
but ingenious men have made many improvements 
in it. They have reduced its length to 
1 1/2 inches, and thus, rendered it very manageable.
The spear point, making too large a hole [prevent] permit 
the escape of some of the vitreous humor, but 
the round instrument now used makes no larger 
an orifice than the rest of it occupies.
It is made flat toward the point, as Mr. Hey has
directed, and I have also adopted, from Scarpa, the 
method of having it bent toward the point, 
1. becuase it is less entangled in the iris, 2, because

145
because after pushing the lens back, we can very easily
carry this crooked kneedle before it and fix it
very easily, 3, because with this it is very easy 
to depress loose, remaining pieces of capsule with
the bent kneedle.
This operation is very simple. The patent being 
seated on a low chair, and the supported by an
assistant, and him facing a window, and the eyes
opened as in extraction. The kneedle being applied 
at 1/6 of an inch from the edge of the transparent 
cornea, it to be pushed thro' the scletorica
to the chrystaline lens, the point is then to 
be applied to the lens so as to push it back,
and the kneedle insinuated between the iris and
the lens, the point is now to be fixed into the 
lens, and, and by elevating the handle of the 
kneedle, you depress the lens down to the bottom
of the eye, and immediately, the pupil will 
be seen black behind the iris, instead of the opacque
chrystaline. If this first motion do not 
perfectly succeed, it is very easily repeated.
It is nescessary for the kneedle to be very 
sharp, and even so, considerable force is required

146)
required in piercing the coats of the eye, and in so 
doing, an indentation is made. To remedy this inconvenience,
I puncture the eye with the point 
of the extracting knife, and then, use the kneedle
as usual. To depressing the lens, it may always 
be observed to keep the concave surface of 
the kneedle downward.
The operation being finished, the eye is to be covered
with a compress, this secured by a bandage
and the patient put to bed. In 10 or 12 days,
after the inflamation is over, the eye may be
examined, to see the effect of the operation.
The cataract is sometimes soft, and cannot 
be depressed. The advocates of couching break the
anterior part of the capsule, and all which escapes
into the anterior chamber will be absorbed,
and probably the posterior also; but if any 
remain, the operation is to be repeated again and 
again, till all the opaque matter is absorbed.
There are also cases of fluid or milky cataract,
in which also, the anterior part of the lens is 
to be ruptured, that the fluid may be absorbed.

(147
Thus, couching is a very easy operation; only one 
or two instruments being used. The principal 
danger consist in the liability of the iris to be 
wounded. Steadiness and skill are required to overcome 
this difficulty. But this operation seldom 
succeeds in restoring vision. I have frequently performed
it, and only in one case, I never restored the 
sense of sight. In all cases but that one great
inflamation followed the operation, and in two 
of them, the symptoms of gutta serena came on 
I was obliged to use depleting means, as purging,
blistering in these cases. From the above reasoning,
I have determined never to perform this 
operation, but to extract all, except in children, in 
whom the eye cannot be easily managed, and 
especially when the cataract is milky, in which 
case, couching may at least be tried on one eye
before extraction.
Artificial pupil. When the part of the cornea opposite
to the iris obscured by an opacity of the cornea, which 
cannot be removed, and another part remained 
transparent, we may make a hole in the iris opposite 
to the transparent part.

148)
The pupil is sometimes closed by inflamation.
This also, the iris may be opened.
I once succeeded in a case in which only one eighth
part of the cornea remained transparent, which 
was in the upper edge.
The patient being seated, and the eye opened
is in extraction, and pressed upon considerably,
the cornea is to be divided as in extraction,
with this difference, that before the opposite side 
of the cornea is punctured, the knife is to be so 
far retracted that a great part of the aqueous humor
may escape, and a flap of the iris fall before 
the knife, and now by finishing the operation 
by one cut, a round portion of the iris is cut
out. This is the simplist way of operating, and 
may prevent the introduction of forcepts and 
scissars which may injure the lens. Thus I
have operated with success several times
But when the pupil is closed, the iris cannot 
be brought afloat before the knife, and consequently 
we cannot succeed in this way; but as 
as soon as the knife is within the cornea,
the point of it is to be carried down, and the 

(149
pupil cut to about 1/10 inch, and the open incision at 
in the usual way thro' the cornea. The flap 
this iris may now be cut with fine scissars, which 
may be curved near the point, or what is [illegible]
slender forcepts, on one side whereof, there is a
curved edge. But as the causes of the closure of 
the pupil are violent ones, the operation may 
readily renew this, and therefore, before operating,
the patients should be told that the success 
of [of] it but a mere chance; and we 
only operate in uncertainty.
Hydrocele. This is a collection of water in 
the scrotum. The situation of the water produces
essential difference in it.
1. The anasarcous hydrocele, in which, this 
water is contained in the cellular substances
of the scrotum,
2. The hydrocele of the tunica vaginalis teses,
and
3. The encysted hydrocele of the spermatic
cord. As the treatment of these is essentially
different, we ought to distinguish them wt.

150
accuracy.
1. The first species presents an equal tumor,
whhich includes the whole scrotum, on both 
sides, and the raphe divides it into two in the 
middle. The tumor is of its natural colour,
and the finger makes an impression which 
lasts some time. The spermatic cord can easily
be felt in its natural situation. Thus the case
is readily discriminated.
2. The collection in the vaginal coat is supposed
to arise from the increase of the natural secretion
the torpor of the absorbents or the rupture of the 
lymphatic vessels. It commences near the testicle,
is generally confined to one side, is not lessened 
by pressure, is firm, and in the beginning,
the testicle can be felt but in the end cannot
be felt. It may be distinguished from.....
Hernia, by beginning at the bottom of the scrotum,
by being firmer, by being irreducible by 
pressure, by the spermatic cord being distinctly
felt, whereas the hernia presents all the opposites 
of these phenomena. Fluctuation, and 

(151
transparency may often be perceived.
Schirrus testicle, it is easily distinguished by 
cord being generally enlarged and irregular in 
the former, from the tumor being in this also 
heavier and more opaque than in hydroclele
From Hernia humoralis by its having no connection 
with gonorrhoea, by the tumor not 
being so firm in hydrocele, and by other symptoms
of water.
3. When one or more cysts of water are lodged in 
the spermatic cord, the testicle is always felt at 
the bottom of the sac, fluctuation is evident,
and the tumor is diaphanous. This tumor extends
to, or even beyond the abdominal ring,
and may be well distinguished. In a case of 
this kind, I saw some difficulty in distinguishing 
it from hernia. The tumor could be pressed
up (and as it were reduced) but immediately
returned, but fluctuation and transparency,
were evident, the testicle could be felt at the 
bottom of the scrotum, a puncture evacuated 
the water, and the wine injection competed 
the cure.

152)
Method of Cure. The bulk and weight of the 
tumor is often so slight, that patents are 
unwilling to submit to the operation.
The pain, either in the part or in the loins
is much alleviated by a suspensary bandage.
1. In the anasarcous species, tho' the case is 
not connected with surgery, we are often called 
to evacuate the water. Punctures are to 
be preferred to scarifications or setons, as 
the latter may produce mortification.
Five or six punctures will evacuate the water,
and the dressing may be dry lint.
I have seen the tunica vaginalis when 
distended with water, suffer a rupture, and produce 
one of the 1st species. An old gentleman
while setting in his room felt some thing give
way in the scrotum, and the tense tumor of
the vaginal coat was exchanged for a soft
diffused, lived one, and mortification was feared.
I was consulted 3 days after, and prognosticated 
that the breach would heal up, the water 
be absorbed, and the disease resume its
former state, and just such was the result

(153
2. In the second species, little can be done by 
medicine. I have seen it cured by the affusion of 
cold water. Temporary ease may be procured by
evacuating the water with the trocar or lancet
and then introducing a canula and insetor
till the water is carried off, and then covering
the puncture with adhesive plaster.
Simple as this is, I have seen three surgeons
puzled by a simple case in London. The first 
who was called, plunged in the trochar at the 
usual place, the inferior, anterior part, but 
no water followed the stilette. The wound 
was suffered to heal, and then a second was 
called, who also failed in the same manner.
Such also was the fate of the 3rd who could procure
nothing but drops of blood. Mr. Hunter
was now called in. On a very close examination,
he found that the testicle lay just 
at the place where the surgeons had chosen to 
operate, and that they plunged their trochars
into the substance of it. He operated on 
the inferior posterior part of the tumor, just 
where we usually find the testicle, and with

154
complete success. This teaches us always to 
feel the testicle, before operating.
The radical cure can be affected by exciting 
inflamation in the sac, so as to obliterate it
I have cured it by repeated tapings, in one 
case in which, the testicle was so inflamed and 
enlarged that I feared to inject wine. Tevacecated 
the water as soon as the coat was distended
enough to keep the instrument off the 
testicle. Low diet, and mercurial purges were
used. The water was let off every fortnight.
Several ways have been used to obliterate the sac.
1t. Incision is the most ancient. It consists of 
in dividing the skin and vaginal coat, and 
filling the cavity with lint. Great inflamation 
and suppuration came on, the lint was separated 
gradually, and the cavity united.
But this remedy is very severe, attended sometimes 
with haemorrhage, and shreds of lint
remaining often produced abscesses several 
weeks after the sore was healed.
2d. As the tunic is sometimes thickened, the 
removal of it has been proposed by Douglas

(155
but this is quite unnecessary.
3d. Caustic. The whole tumor, from top to 
bottom has been laid open by a caustic, which 
on the separating of the eschar, produced very 
great pain and inflamation, followed by 
the obliteration of the sac. Mr Else has confined
the caustic to a shillings breadth, and this is 
found sufficient. But the caustic is a very 
uncertain remedy; often faling to reach the 
sac, often causing violent inflamation, fever
and supuration, and when the water is 
contained in sacs this does not succeed.
4th Tent. A skein of silk was carried from 
the bottom to the top of the tumor. This often 
answers, but often causes only the tract betwixt
the tunic and testicle in which it lies
to be united, and the disese returns on the 
sides of this.
5. Monro left the canula in the sac, until it
produced the nescesary inflamation, but according 
to Cheselden, this mode is very painful,
and he prefered the tent. 

156)
6. Injection. Lately, the ancient mode of injecting
stimulating fluid into the tenica vaginalasis
has be revived. Wine, or wine and
water have been particularly recommended by 
Sir James Earle. This he has shewn to be perfectly 
safe and easy. In a few cases, indeed
this remedy will fail.
I once succeeded in curing a case with warm 
water alone, in the Penn Hospital, contrary
to my expectations; and I have since read 
Mr. Whateleys report, to the same import.
But wine, or wine and water are found very 
convenient, safe and not painful. If no inflamation
follow, it may soon be repeated
The patient is to be seated opposite to a window,
and the surgeon kneeling before him, makes the 
evacuation either with a trochar and or with a 
small lancet and then introduce a canula.
As soon as the fluid has escaped by the canula,
the injection of wine or wine & water, (being 
prepared in a bladder with a stop cock) is to 
be thrown thro' the canula into the tunica


(157
tunica vaginalis, and as soon as pain is felt in 
the scrotum or loins, which is in general four 
or five minutes, the liquor may be allowed to flow 
back again, the canula with drawn, the orifice 
closed with plaster, and the scrotum supported 
with a roller, which prevents inflamation.
In four or five days, the scrotum becomes red, tender
and covered with a blush, and in four or five 
more this goes off, with the disposition to renew 
the disease. If the inflamation run high, 
the patient may be confined to bed, and to low
diet, evacuating measures used, and a leadwater-
poultice applied. But if the inflamation 
be defective, the patient may walk about his 
room and use stimulating food.
To avoid the canula's escaping from the orifice 
in the tunica vaginales, which would cause 
the injection to pass between the skin and cellular
substance, and mortification, the canula
may be introduced full 2 inches and laid on 
one side. This never happened to me, but I 
saw it in the practice of another.
Jan.28.1812.  Dr. P.

158
Lecture 35.
In speaking of the treatment of the hydrocele
by injection, I observed that in a few cases, that 
operation will fail. I am to describe a late 
and successful operation for these cases, described 
by Mr. Hunter.
It consists in making an incision of 1/2 inches
long on the anterior inferior part of the scrotum,
thro' the skin and cellular substance, and piercing 
the cellular membrane, so as to lay bare the 
testicle. The state of the testicle may be seen.
The scrotum must now be filled, not with lint,
but with flour, or rather dough, made into balls 
of 1/2 diameter, holding the lips of the scrotum
asunder by two hooks, one in the left hand, and the 
other given to an assistant. After the tunica vagnalis
is moderately distended with these balls, a
piece of patent lint is put into the mouth of 
the sore, and the whole suspended in a bag-truss.
In case of much fever or inflamation, blood may be 
drawn, &c. In 2 or three days, a poultice may be applied
over it, the cavity will suppurate the dough

(159
will come away melted in the pus, the cavity appears
just as a large abscess, and the whole will 
very uniformly unite. I have performed this operation 
several times with perfect success.
Of Herniæ. Herniae, or ruptures are among the 
most important surgical diseases, from their 
frequency and their great dangers and inconvenience.
They consist of tumors, caused by the protrusion 
of the natural contents of the abdomen 
through its parieties.
They occur most frequently at the upper and 
fore part of the thigh, at the navel, and the groin.
The twin rupture is improper, as they consist of a 
sac of the peretonuem, pushed thro' some natural opening.
Thus, at the navel the navel, there sometimes
remains an opening in the foetus, imperfectly
closed, which admits of these accidents, and 
in the groin, the ring of the external oblique muscle,
thro' which the spermatic cord in the male and 
the round ligaments in the female pass, is the 
aperture at which the inguinal or scrotal 
hernia, or oschocele pass out, and in the upper,

160
and fore part of the thigh where the crural or 
femoral hernia is seated, the hernial aperture
consists of the cavity under Pouparts ligament.
All the contents of the abdomen have been occasionally
found in hernial sacs, except the 
duodenum and pancreas; but the colon and 
mesentery, and omentum are the most usual.
Hernia are named from their contents, as 
enteracele, epiplocele, gastrocele, &c.
The congenital hernia or that in which,
the protruded parts lie in the tunica vaginalis
testes, arises from that aperture in which the 
testicle [cross out] descends, not being closed before 
birth, and there is still a communication between
the peritoneum and tunica vaginalis.
In such cases, when the child coughs cries, &c the contents
of the abdomen may descend, but when pressure 
is made on it, it easily returns again. By frequent
repetitions, the communication remains open, and 
subject to rupture through life._ We shall treat 
of the bubonocele at length, and then treat of 
the peculiarities of the others.

(161
The bubonal or inguinal hernia is characterised by a tumor
at the abdominal ring. Astley Cooper says it begins 
at the distance of 1 1/2 inch from the external opening,
on the external side of it and higher up. It is 
easy to press the tumor up again; by lying horizontally,
also, it may be reduced, but on rising, or on 
making any pressure with the abdominal muscles,
diaphragm, &c, it is returned again. We see 
the progress of the tumor from the upper to the 
lower part of the scrotum. I have seen it descend
as low as the knee, and suspended by bandages
round the patients neck.
On dissection, we find the tumor to consist of 
1. (After laying aside the skin of the scrotum)
a number of tendinous bands united together
by fascia, which is derived from the obliquies externus
above the abdominal ring
2. The fibres of the cremaster muscle
3 The hernial sac. See A. Cooper. But these 
are sometimes so blended together as to appear 
many more in some instances, yet the above
ordor is universal.
Behind the upper part of the sac is found the

162
spermatic cord. At the bottom and posterior pt 
of the tumor is the testicle, the abdominal 
ring is the mouth or aperture of the rupture and 
and between this and the symphysis pubis,
is found the epigastric artery. In a few cases 
the spermatic cord is found on the anterior side
of the sac. This teaches us always to proceed wt
caution in operating.
Symptoms. 1. The tumor commences at, and 
proceeds from the abdominal ring in the groin.
2. The tumor is increased by the erect posture, 
et. v.v.
3. Is increased by coughing, straining the diaphragm,
abdominal muscles, &c.
4. When intestine is returning we hear a gurglinng 
noise, and
5. When intestine is down, the functions of 
the bowels are interfered with. Nausea, vomiting,
colic pains, costiveness &c are produced.
Diagnosis. 1. From hydrocele. a. by beginning above,
whereas hydrocele begins from the bottom of 
the scrotum, by the abscence of fluctuation
and the cord not being felt in hernia.


163
b. by being increased by the erect posture, pressure
with the muscles, of the abdomen, diaphragm
Thus, we can easily avoid mistakes in these cases
2 From swelled testicle. a. by the causes of this 
as suppressed gonorrhea, external violence, & 
being known. b. by the swelled testicle being 
hot and painful. c. by the swelled testicles
going off suddenly at any time like herniae,
d. by most of the diagnosis betwixt herniae & 
hydrocele.
3. From bubo a. by the connection of this with 
chancre, and being painful. b. by the bowels 
not being interfered with in buboes. c. by bubo
tending to suppuration.
4. From cysts on the spermatic cord. a Tho'
this and inguinal hernia have many features 
in common, when the cysts lie along the cord,
yet this one circumstance is a certain diagnosis,
vizt that if pressure is mad on the tumor,
if it be hernia, it will be lessened, but 
if an encysted tumor, it will not be lessened
in size, but go up in a mass and descend 
just as it went up, immediately. b. By the

164
effects of a puncture in evacuating the water
of the cysts, and so curing the disease.
5. From Varicocele, or a varicose state of the 
veins of the cord, it is considered difficult to distinguish
hernia. When the patient lies, the tumor 
is lessened, and when he stands, the pressure
of the column of blood enlarges it again, such 
also is the effect of coughing, straining, &c.
a. But in varicocele, we can feell, and even see 
the convoluted form of the veins under the skin,
b. A. Cooper proposes to lay the patient horizontally,
to take hold of the cord, and let the patient 
rise again. In hernia, a considerable 
pressure will be made against the fingers, but 
in variococele, this will not be considerable. But 
the first method is preferable, and even tho motion
of the blood in the veins gives a sensation
which prevents any deception when we feel it.
Causes. The causes are 1. Such as weaken the 
parceters of the abdomen. 2. Such as increase the 
pressure of the intestines. &c against them.
3 Both causes united. General debility, as after 
a fever, in old age, &c disposed to hernia.

165
Blows on the abdomen, pregnancy, strains of 
the diaphragm or abdominal muscles, [cross out],
great corpulence, violent coughing, straining
to stool, violent exercise jumping, lifting great 
weights, &c are causes of the second order. When they
act, the contents of the abdomen may be more or 
less forced thro' any weak parts in the parieteis
Thus I have twice seen herniae produced in young
men by carrying in a back leg.
Of the Treatment. For convenience in practice,
herniae may be divided into the following 
orders.
I. Such as are of easy reduction.
II. Such as can only be reduced by particular
management.
III. Such as tho' unattended with stricture, are 
irreducible.
IV. Such as are attended with stricture.
Of the first, it may be obseved that as long 
as intestine or omentum remain down, there
is always danger, even when there is no pain.
Stricture may occur, the contents of the bowel

166
may be stopped, and after frequent descents of 
the omentum, the passages [to be] kept open 
so that the gut may pass down, and this is 
liable to be the case as long as any omentum
is down. While any part remains down, the 
whole may be enlarged by the causes of herniae,
and stricture may follow this second descent.
Therefore the contents of the sac are always
to be reduced, and prevented from returning
by proper compression made on the mouth, or 
neck of the sac, after reduction.
This indication is answered by a truss, or 
slender steel spring, which goes more than 
half round the body, and the circle completed by 
a strap. On the end of this is a pad. A bandage
is applied in the groin, reaching from before 
backwards, to prevent the truss slipping up.
In applying the truss, let us recollect why it is 
used? That it may effectually keep the gut up
it must act on the ruing accurately. This part
presents a pit to the finger after the reduction 
of the intestine &c.
Instrument makes generally err by applying

167
the truss too low, thus pressing on the cord, testicle,
&c and allowing the mouth of the ring to be kept
open, which is the case when the truss acts over the 
pubis. The lower edge of the pad should act just 
over the upper edge of the pubis. The head of the 
truss is sometimes made of silver or ivory, and 
made so as to turn olbi[c]quely at pleasure so 
as to accomodate corpulent persons. The metal 
mentioned is chosen for not rusting. The part 
may be defended by a muslin compress, when this 
instrument is made of these materials.
The truss is to be worn night and day. I have 
known it affect a cure in nine months in a person 
of a good constitution, but the truss ought
never to be laid aside before two years. Aged persons 
must wear the truss always, as in them 
the cure cannot be expected. I know, however, 1 
exception to this, in a man of 50, in whom,
the ring united perfectly.
The exciting causes are to be avoided during the 
use of the truss, as costiveness, lifting weighty bodies,
riding a rough-going horse, violent excercise
&c. And when any exertion is made, the

168
patient should assist the truss, by pressure
with his hand, particularly if costive, or if 
he has a stricture in the urethra. These directions 
are essential to his safety.
Second order. The protrusion is sometimes so 
large that tho there be no stricture, the reduction 
cannot be affected. In this case the patient
must be put to bed, confined to a low diet,
to loose blood and to use purgative medicine.
Thus, the tumor may be lessened, as reduced,
and then the truss is to be applied. I have
often succeeded in this way, in these cases.
Third order. Tho' there be no stricture, the reduction 
may be impracticable, either from 
the shape of the tumor, adhesions betwixt 
the guts, or betwixt the gut and sac, or by ligamentous 
bands. In this case the tumor is to 
be carefully suspended by a suspensary bandage
and the patient often enjoys comfort, yet is 
not freefrom the danger of stricture. [See M.
As in hydrocele the sac has sometimes burst,
so has the hernial sac. In this case the gut

(169
will be found under the skin, and the gut must 
be reduced first through the ruptured aperture, & 
then into the mouth of the sac, into the abdomen 
But this case is very rare. [See N,D. Dr. Ph
Jan.29.
Notes on Lecture 35.
L. Page 165... After the hernia has been lessened 
in size by these remedies, we may by taking hold 
of the remaining tumor, in most cases reduce 
it, if it has not gone up spontaneously.
M. Page 168.... This order is only known by its 
not yielding to the remedies mentioned above (168) 
& cold applications
No above... The suspensary bandage not only 
prevents pain and great inconvenience, but 
by warding off the dragging of the tumor, prevents 
more of the contents of the abdomen being 
displaced. It is to be lined with soft materials.
A. idem... During the use of the suspensary, the 
state of the bowels requires attention. Costiveness,
and the use of flatulent food are to be 
particularly avoided.
Jan 31

170)
Lecture 36.
Hernia continued... Fourth order. We now come 
to speak of herniae, with stricture. Stricture in 
hernia consists of a tightness at the orrifice as
neck of the rupture, which injures the functions 
in the gut, or vessels of the protruded parts.
The tumour becomes hard, the patient becomes 
unable to stand, nausea and vomiting sooner 
or later come on, an antiperistaltic motion 
of the bowels is established, fœcal matter 
is vomited and if the gut be strangulated, no fœces 
can escape per anum, but what may happen
to lie beyond the stricture.
If the tightness be such as to injure the circulation,
and injure the venous circulation, inflamation,
with considerable swelling and 
fever comes on the colour of the tumor is not 
red, but of a dark leaden colour, just as in 
phlegmon before mortification.
The stricture may even be such as to stop the
circulation altogether, and produce mortification.

(171
When that is the case, the belly swells, becomes
very tender, the pulse becomes small and very 
weak, elilliness in may cases, which is followed 
by great restlessness &c occur, and death 
soon follows. But before the fatal hour, (which 
may be protracted from one to several days) it 
is common that a delusive interval occurs. The 
tumor becomes soft, and returns into the abdomen,
and the patient fancies himself nearly 
well, when death is just at hand.
On dissection, the bowels at the seat of the 
stricture are found of a chocolate colour, tender,
and easily torn with the fingers, and even
holes are often found it in.
When the omentum only is strangulated,
all the symptoms are much milder.
All these effects are produced by the pressure 
of the tendons thro' which the spermatic
cord and hernia pass. The ring of the obliquus
externus is the most usual seat of this. But Mr. A
Cooper has shown that the cause of the stricture
is frequently higher seated, viz in the obliquus
internus and transversalis. 

172
This is particularly the case in old and in 
large ruptures. The stricture is said to be spasmodic,
but no muscular fibres are concerned
When this is the case, cutting the ring will not 
relieve the stricture, but we must operate 1 1/4
inches higher up. This is the distance intervening 
betwixt the internal and external orifices,
but in old ruptures, these orifices are 
approximated, so that the internal one is just 
behind the ring.
In all cases of strangulation, effectual measures
must be taken to remove the stricture.
As soon as a patient is the subject of one of 
these accidents, he places himself on the ground 
horizontally, and makes pressure on the tumor.
If he fails, the surgeon is called upon. He 
places the patient in a bed, with the foot of 
it raised, and relaxes the muscles on the anterior
of the thigh and abdomen, by flexing the 
former on the pelvis, and by bending the pelvis
upward. He then takes hold of the tumor,
and presses it upward and outward, but not with 
any violence, which might irritate and even


(173
burst the tumor. If this remedy, viz position 
with tanis fail, other remedies are to be tried 
in the following order.
1. Bloodletting. This may be performed and delinquim
animi, and then, the termis will very 
often succeed very easily.
2. Warm bath. The whole body should be 
introduced into a bath at or near 100 and continued 
till faintness comes on. It may very 
often be practicable to reduce the rupture 
now, by the taxis.
3. Purges. I have found mild purges, particularly
rum, tart, and jalap in small doeses often 
repeated, given with some essence of peppermint,
of great service. Glysters at the same 
time being given. Mr Hey condemns purges 
entirely, but when the intestine is not in 
the strangulation, and in old cases, they answer
very well. But in case of strangulated 
gut, the only increase the vomiting.
4. Tobacco in form of infusion or smoke is 
a well known resource. The smoke is the most 
active, the infusion the milder remedy. 

174)
Tobacco ʒi infused in water [illegible] forms an infusion,
of which, one half may be thrown up 
every half hour, till the desired langor is produced,
and the reduction may generally be affected. 
Dangerous symptoms sometimes follow 
this remedy. In one man last summer, the 
powers life had nearly vanquished by the usual 
quantity, and Astley Cooper mentions a 
case in which the infusion of ℥i produced pain,
and vomiting, followed by death in 25 minutes 
in a girl. Care is therefore requiste in the 
use of this remedy. Perhaps ℥i of the infusion 
would be enough to begin with. Of all other 
remedies, this is the most effectual, and the quickest
in manifesting its result.
5. Cold. A bladder filled with pounded ice may 
be applied to the tumor, or if this cannot be 
had a solution of salts in vinegar & water, or 
crude sal ammonia ℥v nitre ℥v water [illegible]
be put into a bladder, and applied. These remedies
are very effectual. But they are not to be 
too long continued [in], as the part has actually
been frozen. 

(175
6. Opium. This remedy is indispensible in allaying
the sickness and vomiting and to be effectual,
must be given in large doses. 2 grs may 
be given by the mouth, and ʒi of laudanum injected.
In case of a man who had suffered strangulation 
for 3 days, I gave 3 grs of opium at 
night, and put him to rest. He slept well 
all night, and in the morning, the intestines
was found reduced.
But if these remedies fail, the operation for 
removing the stricture must be performed.
As to the time of operating; it is better to operate 
too early than too late. In the latter case
mortification or peritoneal inflamation will
have supervened. The most celebrated men are 
in the habit of operating early, even as soon 
as 24 hours.
We may make it a rule, in all cases after bleeding,
warm bath, purges, tobacco and cold, with a proper posture, taxis
and opium have failed after a fair trial to operate immediately.
By doing so many will be saved.
It is very difficult to ascertain the state of 
the hernia by the symptoms. Langor, hiccup,

176
hiccup, coldness of the extremities, small and weak
pulse &c are said to denote mortification, but 
I have seen the operation successfully performed
with perfect success, and the parts found 
to be sound. The duration of the stricture is 
no rule: patients have died in 8 hours, and they 
have survived 17 days. The fever is also uncertain 
When the countenance is sunk, the pulse weak
and the extremities cold, I have seen the operation 
performed with success.
Hernia are more dangerous in the middle 
aged than in the young or old, in small
than in large, and in recent than in old cases.
When the circulation is stopped, death is 
certain.
One symptom may be regarded as certainly 
fatal, viz coldness of the extremities, [This]
and a cold and moist state of the skin. This is
always a forerunner of death, and if the operation 
be performed under such circumstances,
it will always fail.
Of the Operation. The patient is to be laid on 
a table covered with a blanket. The pubis shaven

(177
An incision is to be made with a scalpel from 
1 1/2 inches above the ring to the bottom of the sac
unless this be very large, the skin and cellular 
substance are to be cut and the tendon of 
the external oblicque exposed. The tendinous 
fibres on the surface of the tumor are to be divided,
and the sac punctured by several very 
delicate strokes* of the knife, trying if the probe
will enter it. As soon as a puncture is made 
the director is to be so far introduced and the sac out on this as to allow
the finger to be introduced. On the finger 
the bistoury is to be applied, and the sac
divided as far as to near the ring but no farther.
By introducing the finger through the 
ring into the abdomen, the stricture can 
very easily be divided by passing the probe pointed
bistoury along the finger. The incision 
may be made upward, or upwards and a little 
outwards. If done inwards, the epigastric artery 
will certainly be wounded, and as the 
artery in a few cases lies on the outside, it is 
best to convey the bistoury directly upwards,
*No water being contained in the sac.

178)
as Mr Cooper advises, and then the artery cannot 
be wounded.
Mr. Cooper advises us for the purpose of preventing 
peritonial inflamation to carry 
the bistoury through the tendon only introducing 
it not within the sac, but betwixt 
this and the tendon.
The above is the way in which the operation 
is generally performed, but some late surgeons,
particularly Monro make no incision 
into the sac atale, but after dissecting 
down to the sac, cut some fibres of the 
tendon of the muscle in muscle with the scalpel,
and then introduce the bistoury.
After dividing the stricture, the part protruded 
may be easily reduced by the taxis.
This operation is exceeding by simple and easy,
and attended with no hazard whatever in
the hand of a careful operator. Dr. P.
Jan. 31.

179
Lecture 37.
Crural hernia continued. When the sac can 
be returned thro' the enlarged ring without being 
divided, this ought always to be done, this 
operation being the most simple, and tends to avoid
pertioneal inflamation; but when the strictured
gut is mortified, the sac must always be opened.
Also if we cannot reduce the sac after dividing
the tendon, the cavity of it must be open'd
and the cause examined, which may be 1. Adhesion
2 alterations in the shape of the parts protruded or
3 stricture at the neck of the sac.
1. Adhesions betwixt the gut and sac, if they be 
long may be divided, but if very short, the portion 
of the sac connected to the bowel may be cut
off and returned with the bowel. Dissecting adhesions 
near the mouth of the sac is difficult
and can only be done by laying the tendon
bare all round the adhesion.
2. When a large mass of omentum is low 
down, and is not retracted, it may be cut off
and the vessels tied, leaving the end of the

180)
ligature out at the wound.
3. Stricture of the neck of the sac is not a frequent 
occurrence: I met with a case of it in July,
1798. A man of 38 years of age was attacked with 
a severe colic which had continued several days.
He had been subject to a tumor in the groin for 
two years, which went off as soon as pressed upon
or the patient lay. A few days before I was called
this tumor had come down in consequence
of his lifting a heavy piece of wood. When I was 
called. I found the wrists cold, the pulse small and 
trembling, the belly tumid, the scrotum swollen, 
vomiting obstinate and no passage by stool
tho' the pain and swelling in tumor were much less than
before my arrival.
I advised an immediate operation, as the symptoms
of mortification were present. I made an incision 
through the skin and cellular substances
from above the ring to the bottom of the tumor,
dissected the sac free from the tendon and laid
the former open, but to my astonishment found 
nothing but bloody serum therein; no gut, no stricture

181
stricture and therefore there could not be in the tumor,
any cause capapable of producing the above
symptoms! Is the case produced by inters [sersc??]?
In these obscure circumstances, no remedy was 
applied except warm bath and purges of jalap & 
cremor tartar; but the man died in 36 hours.
On opening the body, a portion of bowel was 
found closely embraced by the mouth of the sac
which was retracted into the abdom a considerable 
way above the ring, and not at all in contact
with the fascia which usually embraces
it. What ought to have been done, had the true
cause of the disease been known? Ought the sac
to have been pulled down and divided? or ought 
the tendon to have been opened, and the neck 
of the sac cut within the abdomen?
The bowels are never to be returned in a mortified 
state into the abdomen. However, the symptoms
may seem to indicate mortification 
and yet the bowels be found sound. When a
sudden mitigation of the pain comes on, the 
tumor becomes purple, creptus is heard on

182
handling the scrotum, the belly becomes tense
the patient very restless, his skin hot, his pulse
weak and quick, and the hernia easily reduced, 
little doubt need remain.
Yet such a set of [set of] symptoms are not
always fatal. I have seen a negro who was 
in this situation recover, but with an artificial
anus at the groin, where the upper portion 
of intestine terminated after the slough 
separated.
After opening the sac, we can judge of the 
state of the gut. But the dark red, or chocolate
colour of the intestine, produced by impeded circulation
is not to be mistaken for mortification. 
The mortification is generally confined 
to spots, the texture is so altered that the gut
tears under our finger and has an offensive
smell. If the dead spot be small the bowel may 
be [small] returned, as adhesion will fix the surrounding 
parts to the peritoneum &c and the 
slough pass by the forces, but if there be a hole
in the bowel, it will require a stitch. 

(183
When the whole cylinder of the intestine is destroyed,
we are advised by Mrs. Cooper and Thompson
to cut away the slough and secure the tendons 
of the bowel together by four sutures, leaving 
the end of the ligature out that we can [dia??]
out and at any time examine the bowel. But 
the accumulation of fœces in the upper porton 
of the bowel is commonly such as to rupture 
the stitches, or at least to cause the escape 
of fœces from the gut into the general cavity.
I perceive that Mr. Cooper himself failed in two 
cases of this kind.
I should not ever try Mr. Cooper's way. I would 
leave the intestine out, and if the slough were not 
separated, I would open the bowel at the dead part
with the scalpel, to give evacuation to the feces, which 
is always profuse for the first 24 or 30 hours. The 
ends of the intestine would be gradually appoximated,
they would as gradually retract within 
the abdomen and the external wound heal up.
In July, 1798 a woman was attacked with a violent
colic and tumor in the groin, which continued 
several days. The physicians bled, blistered,

184)
and purged her, but the vomiting increased, the 
extremities became cold, the pulse small and feeble,
hiccough and swelling and hardness of the abdomen,
the tumor became hard, the colour of 
it dusky red. She had had a tumor in the groin
after severe parturition 2 years before, and it was 
plain that the hernia, which was femoral in this 
case was mortified. I made an incision through 
the skin and cellular substance, fœtid serum
and air passed from it, the tumor hung like 
an egg by a small neck; I next laid bare the tendon
and cut Pouparts ligament at right angles.
I next cut a hole in the gut, and introduced
my finger to the place of stricture.* The passage
through the bowels was [slow] by artificial means for four days. 
[cross out], the external 
coat of the bowel only, sloughed. On the 23d July
she was able to leave bed, and the bowel having 
retracted, the wound heald. Thus, an artificial 
anus was made, the gangrene was not complete,
neither were there two oricifices, but even
*This was followed by a copious discharge of fœces 
air by the orifice made in the gut. 

(185
if there had, they would probably have united.
When all the protruded intestine does not [in??tify],
and adhesions form round it a permanent
discharge of foeces may be established. I had one 
case of this kind in the P. Hospital some years
ago. I tried to accellerate the rectraction of both 
ends of the bowel by introducing a piece of bogie 
3 inches long bent up, one end being introduced 
into the two orifices, and gentle pressure was thus 
applied, but I found this not to succeed, as pain 
followed its use, and I performed a new operation,
which consisted in establishing a lateral communication
betwixt the ends of the bowel. I brought
the ends of the bowel in contact to the external
wound, and introducing the fore finger into one
and the thumb into the other, I found that the 
two coats moved on one another betwixt my finger
and thumb, so that I feared the adhesion 
was not extensive enough to permit an incision 
to be made betwixt the two bowels. To produce 
adhesion between them, I introduced a ligature
by means of a kneedle through the side 
of the two portions and brought them with

186)
some tightness together, such as might even 
have produced ulceration tho the space I
intended to divide, but the ligature caused so 
much pain that I was content with its producing 
adhesion as far as it reached. I next 
made a slit with the knife betwixt the two 
bowels which I had thus made to adhere, as large 
as the calibre of the bowel. The cavity of the sac
was dressed with a compress, and next day some 
griping was felt, and wind escaped per anum.
In 3 days more foeces passed freely. I next tried 
to heal the external wound by paring its lips, 
and introducing the twisted suture, but in 
this I fail'd, and a truss was the only inconvenience 
he had to submit to, as the natural 
route of the bowels was established; however, if 
the external wound had closed the truss would 
also have been nescessary. This operation being 
successful, that of Cooper is quite unnescessary.
The bowels may be allowed to adhere to 
the ring and lateral parts.
The omentum which forms a part in these hernia

187
is also to be reduced, but if it have mortified, the 
dead parts are to be surrounded by an incision 
through the living and removed. Any large vessels
which bleed may be tied, the end of the ligature 
being kept out. Mr Pott has thought this 
precaution unnesecssary, but alarming haemorrhagies 
have followed the neglect of it.
It sometimes difficult to tell whether or no the 
omentum be dead, and fatal consequences might 
follow the reduction of a mortified portion. It is 
said to feel crisp when dead, but the following 
marks may be depended on 1. The blood is coagulated 
in the veins of the dead portion. 2. The vessels 
of it do not bleed on being punctured.
Some have advised the adhesion securing 
the omentum in a string to prevent haemorrhage,
and even Pott recommended this, but it 
had produced nausea, vomiting, fever, pain & 
death, and therefore this plan must be exploded.
After the operation the wound is to be united by sutures.
The patient is to be confined to a horizontal 
posture, and cough is to be allayed by demulcents 
and opium, but the latter is to be 

188)
avoided as much as possible, as it retards the 
functions of the bowels. If nescessary, the bowels
may be opened with castor oil or salts,
and in some cases the bowels are so torpid & 
paralytic by the pressure they have suffered,
that they are not easily moved. In one case,
a swelling was produced by the accumulation
of the foecis above the wound, and went off by 
pressure again. This returned occasionally for 
three days and then subsided.
In some cases pain and swelling follow the 
operation. Bleeding, low diet, purging, blistering,
&c may be used as circumstances may indicate.
After the wound is healed the part must be 
supported by the use of a truss.
Femoral Herniae. This hernia we have observed, appears
on the upper and anterior part of the thighs
The contents of it pass under Pauparts ligaments,
and the tumor is small and moveable, and 
may be mistaken for a bubo or enlarged lymphatic 
gland. This mistake is very dangerous, and 

(189
yet has fallen out in the hand of every expert 
men. If a hernia were left to suppurate, or boldly 
opened as a suppurated bubo, how serious a 
mistake would be made! We read of men having 
died of ileus and a bubo!
In all doubtful cases of the kind, we ought to 
lay bare and examine the part. 1. The hernia is generally 
the lower, 2 in bubo, the edge of Paupurts ligament
cannot be felt, 3, neither can the pubis.
It is nescessary to know the true situation of 
the sac, as without this knowledge, we could 
not perform the taxis aright.
The bowels pass into the theca for the femoral 
vessels. They lie in the vicinty of of the pectineus
muscle, just over the fascia lata. The epigastric 
artery lies on the outside and the spermatic 
cord lies on the superior and anterior part
These two vessels cross one another. The obturata
artery sometimes arises in common with the epigastric.
The bowels descend first downwards, and then,
forwards at right angles with its neck. The taxis 
must therefore act inward and then upward, whereas

190
whereas in the inguinal hernia, the taxis acts upward
and outwards. This of great importance.
In this tumor we find 1. the skin, 2 the fascia,
3 the proper sac, or that derived from the peritoneum.
The inner edge of Pouparts ligament leaves 
a small aperture only, and the stricture in 
this place is very dangerous, and early open action 
is requisite. Cooper says if he were attacked 
with this hernia he would try the tobacco injection 
and if this failed, the operation!
The integuments are sometimes very thin, so that 
we are to proceed very cautiously thro these 3 membranes 
lest the gut be wounded. After this, the 
stricture is to be divided. In doing this caution
is required. If we cut inward the spermatic cord is 
wounded, If outwards, the epigastric artery, and in 
an upward direction, there is also some danger
of cutting the cord also, but let it be kept inward
that it lies 1/2 inch off, and this Ipace answers every 
purpose. Pinbuuat reccommended to cut the 
internal edge of the crural arch or Pouparts ligament,
but 1. the deep situation renders this difficult 
2, a director is required and the gut must be	

191
pulled with some violence aside 3. In some patients,
the obturator artery winds round the neck
of the Sac, and if wounded here it cannot be
secured as it can be if wounded over the middle
of the tendon. [See notes P and Q below Page 191.
I prefer operating on the middle of Pouparts 
ligament, on its anterior part, and at right 
angles with the ligament.
If the operator is fearful of cutting the spermatic
cord he may as A. Cooper advises dissect 
the cord loose ad have it drawn aside by a
hook before dividing the crucial arch.
February 2nd, 1812 Dr Physic
Notes on Lecture 37.
P. page 191... For nine out of ten cases of femoral 
hernia the patients are women, and in this 
there is not so much danger, as the cord in 
them is absent.
2. Page 191... When the epigastric artery lies 
in the way and is wounded, we can feel the 
pulsation of the vessel, pass a kneedle under
it and tie it. Feb 5th Recapitulations

192
Lecture 38.
Umbilical Herniae. We meet with it both in the 
child and in the adult.
In the infant the bowel often passes through the 
funis umbilicus. In such cases, it is to pressed up 
again, and the cord secured by a ligature. The edges
of the aperture may be approximated by adhesive
plasters, and they will often unite in a few days.
But sometimes it does not close for 3 or 4 months,
and the child by crying, straining, &c may cause a 
protrusion. I have met with 2 or 3 instances of this.
I have seen umbilical hernia in seven children in 
one family, yet in all the parts retracted and united 
well. This is the natural tendency of the parts, and 
can only be prevented by the presence of the gut, and 
this keeps the hole open, so that more gut may descend.
When the natural process fails, we are to treat 
it by an operation. 1. Compresses have been applied,
with a view of making union take place. They are 
secured by a roller passed round the body, but in 
this way the cure is detained for months; very incovenient 
pressure is made on the abdomen, the bowels

(193
bowels are even in danger of being protruded, the operation 
is very imperfect and difficult.
2. The ligature, which is the older method is recommended
by Desault. It is certain and expeditious
The patient being laid on his back with the thighs
and neck bent forward, the contents being reduced,
the sides of the funis are to be rubbed together to 
ascertain that all the contents are reduced. An assistant
now applies a waxed ligature several times
round the funis, making each time a double 
knot, and with such tightness as to produce moderate 
pain. Next day, the cord will be swelled 
just as a polypus after a ligature. 3rd day, it becomes
shrunk and livid. A second ligature is 
to be applied tighter than the former, producing
some pain, and a day after, a 3rd ligature
will compleat the mortification of the cord. The 
union of the mouth may be accelerated by adhesive 
plaster, and the circular bandage may be continued
for 3 or 4 months. This is found a very successful 
operation, and succeeds on young children
uniformly, best in those advanced nearer maturity,
it does not prove so fortunate.

194
This will best appear by the following cases,
which as well as the above operation are from Desault
1. A girl of 18 months old was operated on 
as above. The cord was shut in 7 days. Six months
after, there could be no vestige of the disease found.
2. A boy of 4 years old was operated on as above, the 
funis closed, but afterwards, the impulse of the bowels
could be perceived.
3. The latest period at which Desault operated was 
at the age of 9 years in a girl who had had it from 
birth. The the union was complete to appear and
in 3 mo. the swelling was apparent, and not 
withstanding the use of the bandage, in 6 mo. the 
relapse was complete. Therefore the operation is 
always to be performed early.
In Adults, according to Desault, the ligature
does not succeed. Having reduced the tumor by 
the taxis, pressure is to be made on the navel by 
Hey's truss. This is preferable to compress & bandage
as well as every other sort of truss. After this is 
applied, where any exertion is made the effect of the 
truss must be assisted by the hand.
[See note Pr. Vol. III p.3

(195
The other varieties of hernia woud require too long
time to explain them. They may be learned from 
books; it being my only to design to give a description 
of the nature of the most important kind
and the history of hernia in general. See Cooper
on hernia, and Lawrence.
Observations on the stone, perparatory to the 
demonstration of Lithotomy.
Stony concretions form in many parts of the 
body, as the salivary glands, the gall-bladder,
&c, but they are most usual in the organs for secreting,
containing and excreting the urine. This 
matter is often deposited on the sides of the pots in 
which urine is contained out of the body.
The quantity differs greatly in persons, some showing 
almost none of it, while others abound with 
it. I have seen the urine in a bowl incrust the 
bowl to 1/10 inch all round, in a scrofulous patient.
Now in such cases, it appears that a stone
will form at any time, when a solid body is introduced
into the bladder, serving as a nuclus 
for the matter to adhere to.

196)
A piece of lint, a bullet, a kneedle, &c have been found 
in the stone, and large masses of stone have formed round 
the end of a catheter. In the kidney, a coagulum of 
blood has had a similar effect. In sawing into a 
stone, it is generally found laminated, some stones
are very [hard] soft, and others are very hard, some are of a 
white, others gray, or brown colour.
The form commonly in the kidney and pass thence to 
the bladder, but they sometimes form in the bladder.
When after pain in the loins ceasing, the symptoms
of stone in the bladder commence, no doubt is 
left of the origin of the stone. A gentleman who 
had been troubl'd for some time with pain in 
the loins, on taking a ride from Germantown
to Phila. the pain ceased and the symptoms of calculus
in the bladder came on.
From a stone in the kidney, a dull pain in the loins
is produced. This, on stooping becomes acute. The urine
is often bloody. Inflamation with fever, costiveness 
and diminished urine with vomiting come 
on. If much dilution has been made, there is a copious 
flow of urine; or colic fever and suppression 
come on.

197
The efforts to vomit often press the stone into the 
ureter, which obstructing the passage of the urine, produces
great irritation. In fits of the gravel so produced, bleeding,
opium, blistering, warm bath and diluting liquors
are proper. The patient may stand, leaning forward, so 
as to bring the neck of the bladder immediately down
and pass his urine in a full stream and by this, the 
small stone may escape from the bladder. This is 
of great importance, and ought to be repeated, as it 
may prevent the formation of the stone.
A stone in the bladder produces pain heat and itching 
in the bladder, obstruction of urine frequently,
mucus or even puss will appear in the urine, sometimes
in large quantity. Bloody urine, especially after
excercise is very usual, and in some, the first symptom.
An uneasiness through out the urethra, especially 
at the glans, causing the patient to pull the prepuce
out, causing it to be elongated, prolapsus ani, &c are
common symptoms. By the suppression of urine, irritation,
distress and loss of sleep, the patient is soon 
exhausted of strength.
Other causes of irritation may deceive. Inflamation,
abscesses, ulceration in the bladder, tumors and

198
haemorrhoids in the rectum also have the same symptoms
as the stone in many cases. A woman laboured
under the symptoms of stone, and found no relief 
from the usual remedies. Suspecting an ulcer in 
the neck of the bladder, I ordered mercury till the 
mouth became sore, and all the symptoms vanished.
In another person all the usual symptoms existed,
and continued till death, when a tumor was 
found in the rectum. This, if it had been known could 
have been cured by an operation.
Stone may exist in the bladder and produce little 
or no uneasiness. A man who had a stricture in 
the urethra, and had not suppression, only a diminished 
stream of urine, and no other symptom referrable 
to stone, being prejudiced that he had a stone, 
underwent experiments such as jumping off a 
table, riding of a a rough-going horse, &c and no irritation 
or bloody urine being produced, but the stricture 
prevented sounding. After his death a rough stone 
as large as a walnut was found loose in the bladder!
The only certain criterion is sounding, or the introduction 
of a bent, iron instrument into the bladder,
which when it comes in contact with the stone

(199
produces a tingling fell, and may be heard. This 
operation may be repeated in various ways, through we
do not feel the stone at the first trial. First, let the 
patient stand, if this fail he may lie down. The finger introduced
into the anus may bring the stone into the way
of the sound. A man in this city had symptoms of the 
stone, and no stone could be felt on sounding. He 
went to London and was sounded by Mr. Hunter, but 
without any success. He returned, and applied to me. I 
succeeded by putting him to bed, raising the buttock
so as to throw the stone into the fundus of the bladder.
Having ascertained that a stone exist, no remedy 
can be depended on except lithotomy. Medicines introduced
into the stomach or injected into the bladder
have long been tried. From the effects of akalis on
a stone out of the body, they have been introduced in 
to use. Soap, aqua nephritica alcalina, carbonated
soda &c lessen the pain for a time only. In one case
they seemed to have succeeded. Unequivocal symptoms
of stone existed in a child. Sounding ascertained it 
beyond all doubt. The weather being warm, the operation 
was defferred, and the aqua mephritica alcalina

200)
alcalina was given, and to my utter astonishment, the 
symptoms of stone disappeared, and never returned
again. What became of this stone, it if were not 
dissolved, I do not know. Some other remedies besides
the above give temporary relief, such as lime water,
and uva ursi. But while these are used, the symptoms
will always return unless the stone become encysted,
which effect cannot be attributed to medicine.
Injections, capable of dissolving the stone in the 
bladder have be keenly sought after. But they are 
incapable of affecting the stone unless of such activity
as to cause inflamation and sloughing in 
the bladder.
The best palliatives are small bleedings, warm 
bath, demulcents and opium, which must be 
diligently used when the irritation of a stone become
at any time aggravated, constituting a paroxysm 
of the stone.
Dr. Physic
University of Pennsylvania
February 5th 1812.
END OF VOLUME II.







56
WILLIAM M'LANE
No. 27





Hic libeo pvetinet ad editorem
Gulielmo Madane



Memoranda
From a 
Course of Lectures
on 
Surgery.
Delivered in the University of Pennsylvania
By Philip S. Physick M.D. Professor, & 
John S. Dorsey, M.D. Adjunct Professor
of Surgery in that University
By Wm M Lane
Vol II.
1811 & 1812



Memoranda &c
Lecture 20.
Fractures of the lower end of the humerus
are generally transverse, and these are 
sometimes complicated with a separation of 
the condyles of the bone.
Either one condyle is separated from the bone 
alone, or they both are. They are easily detected,
in their superficial situation, by the 
fingers. If we take hold of the condyle or 
condyles, we can move them very easily in 
any direction, and a crepitas will be heard.
A bandage is to be aplied from the hand to 
the elbow, and, extension and counter extension,
used; the condyles are now to be brought 
into place, and the bandage continued up
the arm. The arm is now to be brought to 
right angles, and the rectangular splints 
applied laterally, and straight ones, bent at 

4
the middle, applied before and behind,
and the bandage carried over the splints, down 
to the hand. In 8 or 10 days, the apparatus is 
to be removed, and the parts examined, & 
if any derangement is found, it can be 
rectified.
Fractures communicating with the cavity 
of a joint are longer in uniting than others:
in general, this will unite in 5 or 6 
weeks. When treated in this way alone, we 
always find a deformity: the natural an 
angle which the arm and forearm form 
with one another, the point whereof is downwards
when the arm is extended, is reversed
and the point is now upwards. To avoid
this, after having kept the cubit an right 
angles for about 20 days (as above) it is 
to be extended, and, splints having a 
downward angle, such as the arm naturally 
forms are to applied before and behind,
and the roller carried over them as above,
and this apparatus kept on for 4 or 
5 weeks longer. In this ways I have preserved

5
one arm in perfect shape. The only hazard 
which attends this apparatus, it that anchylosing 
is not a rare accident in such fractures,
and, if it were not for this, the arm ought
be kept extended from the beginning; but 
it being well known that if anchylosis occur
in a straight posture, the limb will be
useless, whereas, in the [cross out] flexed, it will be 
be very serviceable. After the arm is extended 
the state of the joint is to examined every 4
or 5 days, and if anchylosis is found to begin,
we must bend the arm again. When
the bony opised to the humerus are both injured,
we may expect to presever the joint
in most cases, but if either the radius or 
ulna is injured, as well as the humerus
bony union may be expected in the joint.
Fractures of the Bones of the Fore-arm
A. Of both the bones. This generally happens in
the middle of the bones. The seldom pass one another
much, and the [cross out] the derangements
they are most subject to is the angular, and this is 

6)
mostly inwards Counter extension is to be made by 
one assistant, holding the humerus just 
above the condyles, while another makes 
extension holding the hand just as we do
in shaking hands. The surgeon can now
place the ends of the bones in place with his 
fingers, and applies a roller from the 
hand up to the elbow. The arm is to be in 
a flexed posture while this is a doing. A pair
of splints broader than the forearm is drop
are now to be applied one on the front & 
the other behind, and secured by the reflecting
of the roller. The splints are best made
of stiff (not wet) pastboard, or wood. The 
arm is to be suspended by a sling. The thumb
may be left out, that it may shew us the
state of the arm, as to rotary derangement
and if the roller is too tight, this will swell,
and teach us to slacken it. The first roller
must be slacker than usual, lest the fragments 
be pressed together, and thus destroy 
the rotary motion of the radius on the ulna

7)
whereas the second roller, may be pretty tight,
to press the splints tight against the arm, and 
impact the muscles between the bones, and 
keep the latter asunder. In 8 or 10 days, the state
of the parts may be examined, as in other cases
L. Fractures of the Radius. This bone may be
broken at any part, but the most usual place 
of the fracture is about one inch above the 
lower head of the bone. The hand moves with 
difficulty in these cases, an angle inwards is
generally formed. The luxation of the wrist
may be confounded with this, but when the 
fractured parts are examined closely, certain
information may be had. The wrist may be 
bent freely without any motion at the part.
Extension and counter extension, as above
being applied, and the bone reduced, the same 
apparatus as that used when both bones are 
fractured is required. The splint must reach 
beyond the fingers as in the above case, to keep
the arm and hand quiet. This is very important
in both cases.

8)
Fractures of the Ulna. This is by far the 
least common of these accidents. I have never
seen any but two cases of this. One was produced 
by warding off the blow of a club, and 
the other by a fall on the bone itself. This 
bone is very thinly covered, and therefore, this 
accident is very easily detected, by feeling,
moving, and hearing the crepitus of, the fragments
The treatment is the same as in the 
former instance of the fractures of the 
forearm. In 3 weeks the bone will unite,
but it is best to wait 4 or 6 before removing 
the apparatus.
Stiffness of the wrist and fingers is very 
apt to occur especially in old persons; but 
this goes off naturally in some time. The 
splints may be taken off every 4 or 6 days, to 
bend and extend the fingers gradually.
Fractures of the Olecranon. These are produced
by direct falls on the elbow. They are 
very easily discovered. The power of extending 
the arm is lost, as the biceps extensor cubiti

(9
is now unable to act on the forearm. The olecranon
may be easily felt, and if the arm be extended,
the olecranon may be moved in all directions.
The treatment is as follows. The forearm 
is to be extended for the purpose of relaxing the 
triceps, and to let the point of the olecranon
occupy the pit on the posterior side of the humerus,
which it naturally occupies. A roller is 
now to be applied from the hand, and as soon 
as we arrive at the elbow, the skin is to be tightened
over the fracture, by pulling it up, lest 
it should fold between the fragments. (In 18 
or 20 days, the arm may be gently bent and 
extended.) On the front of the arm, one long splint
is to be applied over the first roller, and 
is to apply itself round the arm a little. If any 
considerable inflamation follow, the bandage
may be made slacker, and and the diet reduced 
very slow, and blood may be taken from 
the other arm
c. Fracture of the coronoid process of the
Ulna. I have never heard or read of a case of 
this kind, and I never met a case of it but

10)
one. This was mistaken for a luxation,
as the humerus was thrown forwards, and 
the olecranon felt above the pit for recieving
it. The parts were very easily reduced,
and while I was preparing a bandage, &c. I 
was astonished to see it stontanously luxated 
again. This was soon reduced, and 
perceived the crepitus. The coronoid process
being the only obstacle which keeps the 
triceps from luxating the arm, this effect
may easily be explained when the 
process is broken. I secured the arm at 
right angles, and allowed the humerus 
to rest in the hook like process of the [illegible]
for 15 or 20 days and then the splints
angular downwards, and the childs arm 
grow without deformity. This case first
suggested these splints with the angle 
downwards, which I have used very much
since.
Fractures of the Ossa Metacarpiaria
from direct violence, and are very easily

(11
discovered. The extension and counter extension 
are to be made from the [cross out] wrist and 
fingers, and retained by a broad pasteboard, 
applied in front and secured by a roller, the hollow
having been filled up by the introduction 
of some flannel or to betwixt the splint &
palm of the hand. A wooden splint, which 
will reach from the middle of the cubit, and
in which there is an excavation exactly in
shape of the arm, hand, thumb and fingers,
(if at hand) will answer rather better.
Fractures of the Fingers are very easily 
detected, and reduced. They require only one
small pasteboard splint in front. These 
fractures will unite in two or three weeks.
Decemb 23rd     P.S. Physic.

12)
Lecture 21.
Fractures of the Femur. This bone 
may be fractured in any part of its length,
but is very frequently fractured in its middle.
The upper end, even so high as within the 
capsular ligament is sometimes broken & 
then, the upper fragment is within the cavity 
of the joints. The lower end, just above 
the condyles is sometimes separated, in some 
of these, the condyles are separated; and there
are cases wherein one condyle is removed from 
the body of the bone.
This accident may be very easily detected, the 
motion of the limb is nearly lost, yet there
remains some power of moving the ancles and
toes, so as to deceive the patient, but if he attempt 
to raise the leg, the fails, and convulsive
twitches follow. The limb on comparison 
with the other will be found shorter, and 
on holding the leg, and moving it a crepitus is 
heard.

(13
This fracture is sometimes transverse, but it 
is generally oblicque, downwards and forwards
The lower portion in such cases slides above and 
behind the lower one.
Many means have been proposed, for keeping
this fracture in place. The object of all of them is
to keep the ends of the bones in relative opposition,
and prevend displacement and shortening
till the bones unite. They are as follows.
I. It has been proposed to treat this with simple
bandage and splints as other long bones
but this will by no means answer.
II. To place the limb in a position calculated
to relax the muscles of the limb.
III To maintain permanent extension and counter
extension, and keep the ends of the bones in 
contact.
The first practice was to apply a bandage and 
splints, and this bandage, tho so tight as to 
cause swelling of the limb did not prevent displacement, 
as I have, my self seen. The only 
use of the bandage is to prevent contraction in the 
muscles, and to give support to the veins and 


14)
lymphatics: They can answer no other good purpose.
The femur is so thickly covered with soft 
parts, that unless the fracture be transverse
or the fragments interlock, the bandage cannot 
prevent overlapping.
Mr. Pott, using the sweep of the straight position 
to be such, proposed to lay the patient 
on one side, to bend the thigh on the trunk
and the leg on the thigh to right angles, so 
that by relaxing the muscles of the limb,
he would take off the irritation which induces 
the muscles to contract, and pleasing 
as his proposal is, practice teaches us the 
following inconveniences arise from it.
1. The position is irksome and fatiguing, & 
and if the patient be so resolute as to maintain 
it thro' the day, he is sure to sleep on 
his back at night, and the bones must 
be set every morning, and inflamation will 
be thus produced.
2. We lose the advantage of measuring this 
with the sound limb, which is indeed the only

(15
only true way by which we can judge of the state of 
the bone, it being so deeply covered, that our faling 
quite deciptious.
To join the benefit of the flexed posture with the 
position on the back, a bone had been contrived,
consisting of two boards, joined together at right
angles at the end, and secured be angular stay 
this was introduced under the hough, and the leg
lay on the one square, while the thigh lay on 
the other. I have given this a fair trial 10 or 12
years ago, but I always found one side of the 
pelvis to shift forward, and allow the bone to 
over lap. By supporting the other limb in the 
same way, no benefit was obtained.
I have been led to prefer the extended posture. The 
objections to have been mentioned. Tho a very 
irksome irritation and fatigue occurs, the muscles
accomodate themselves to it in 2 or 3 days,
The heel sometimes inflames and sloughs by 
the continued pressure, but a little attention to 
this will prevent it. As soon as it is found to 
become sore, it may be rubbed with brandy and 
defended with sticking plaster spread on leather

16)
or a compress of 10 or 15 folds of flannel, and 
with a hole in the middle for the heel will 
answer completely.
The last method is permanent extensions
Many means for this purpose have been tried.
The foot being secured to the foot of the bed,
and another roller round the axilla, and 
secured to the head of the bed, extension had 
been kept up; but they produces unsupportable 
irritation and cannot be borne.
It is much better to apply the apparatus
to the bone itself. Weights have been suspended
from the [cross out] thigh over a pully near
the bedside, and extension thus produced,
but I have seen this tried, and no good
effect whatever followed. It only drew the patient
to the foot of the bed. Many other 
apparatus have been proposed, but most
of them are too complicated for as [cross out]
prompt an accident.
But the most certain and the most simple
apparatus, is that of Desault. I have

(17
used it for 12 or 14 years in my private practice and 
in the Penn Hospital, and in most, if not all 
cases, preserved the length of the bone. I shall 
now demonstrate this apparatus.
The bed is to be bottomed with tight-braced sacking
or boards, and to be without a foot board,
An oval hole is to be left in the bottom of the bed
as well as in the matrass for a close stool. They 
may be occupied by an oval cushion, and supported
by a stool under the bed. The sheet it to
be without a wrinkle, and no more than one 
pillow used to support the head, else the body
will press on the limb, and derange the bones
The apparatus is to be laid on the bed in 
the following order. 1. Four or five tapes in 
the length of the thigh 2. The junk-cloth,
or piece of linen or muslin, as long as the thigh,
and it may be broader, (with the convey 
corresponding to the groin folded in). 3 a splint
of pasteboard for the back of the thigh. 4 The 
bandage of strips, each 2 or 3 inches broad and long 
enough to overlap over the thighs and sufficiently 
numerous to reach from the

18)
knee to the groin overlapping over one another
a little 5. The bandage for counter 
extension is to the laid down. This may be
made of silk, or of leather, sewed up into a 
tube and covered with oil cloth. 6. The bandage
for extension is to be laid at hand.
7 The post-board splint for the anterior part 
of the thigh is to be prepared. 8 Two bags of 
chaff as long as the limb, or flannel folded 
8 or 10 times would answer. 9. Two wooden 
splints, one for the outside of the thigh,
and the other for the inner. They are to 
reach from the six inches below the foot, 
and the outside one reaches to the crest 
of the ilium according to Desault, but 2
have extended it to the axileau, and then 
made a head like that of a crutch on it. There are
two holes near the head of this splint,
for the bandage for counter extension.
The limb is now to be laied on the apparatus,
and the latter applied as follows. Each 
of the long splints is to be rolled in the 

(19
junk-cloth from the edge, so as to apply to the 
side of the thigh, and the bags are to be laid 
on the inside of the splits, and they thus applied.
The bandage for counter extension is now 
applied in the groin and carried before and behind,
and carried thro' the holes in the long splint 
and tied. The bandage for extension is next applied 
on the back of the small of the leg, crossed 
on the [cross out] instep, knotted on the sole &
carrid over the block near the end of the outer
splint and tied in the hole on the splint.
Extension is now to be made, and the limb 
is to be compared (at the ancles) with the other,
and we must observe that the anterior 
superior spinous process of the ossa ilia
are not out of their place, and consequently 
that the pelvis is not aslant.
The proper extension having been made, the 
bandage for extension is to be secured. The 
bandage of [cross out] strips is next applied, beginning 
at the knee, and reaching to the groin,
the splint of pasteboard is to be applied on

20)
The fore part of the thigh and the tapes are 
now to be tied over all. It is obvious that 
after the bandage for counter extension is 
applied the surgeon himself can make 
extension merely by pulling the bandage
for extension, and pushing the splints.
Decemd 27th            P.S. Physic
1811
Lecture 22.
Fractures of the Neck of the Femur.
This may happen either within the cavity of 
the capsular ligaments or entirely without 
this. In all these cases, the limb is rendered 
shorter;- in a very few cases, the fragments 
interlock one another so that no immediate 
shortening occur, yet in all these,
the shortening occurs before two or three 
days. The limb is always turned outwards,
and if any attempt is made by the patient

(21
patient to raise the leg or foot, he fails and nothing 
but pain and convulsive twitches follows.
If extension and counter extension be made, the 
limb can be brought to its full length, and as 
soon as this is quit, the limb relapses to its 
former shortness. If the hand be applied over the 
trochanter major, and the limb rotated, the
trochanter will not make any great sweep, especially 
if the fracture be near the body of the 
bone: whereas, if the neck be not broken, there 
will be a considerable arc described, the radius
whereof is as long as from the bottom of the 
acetabulum to the outside of the trochanter.
This accident may be confounded with 
a contusion, or a dislocation; but the diagnosis
is very certain. 1. In contusion, the pelvis 
will be tilted up on that side, and I have seen
this prove very deceitful. In an hospital at 
York, a patient was supposed to have a dislocation,
and a consultation of surgeons was 
held on the occasion, and they were not convinced 
till (6 days after) the patient walked freely

22)
freely. But if we place a stick on the superior 
anterior spinous processes of the ossa ilia,
we immediately detect the shifting of the 
pelvis and know that it is only a contusion
2. For dislocation upwards and backwards
the limb is shortened, but we cannot so easily
bring it to its length, and if we do,
the bone will not return, but be in place 
&c. I have endeavoured to explain this minutely
because accidents of this joint and the elbow
are often very obscure.
The treatment is the same as in oblique
fractures of the body of the bone. The hole in 
the matrass is particularly proper, as there 
cannot be any motion in the pelvis without
deranging the bone, and inflamation 
may be excited, which, as I have seen, may 
suppurate if rest be not maintained. If any
inflamation appear, bleeding and low diet 
may be enjoined.
When the injury is without the capsular 
ligament, the bone may unite well, but if

(23
it be within this, nothing but a ligamentous
union can be expected. In a case of this kind,
which I dissected long after the fracture, a very curious
process of nature is to be seen: the neck of the 
bone was absorbed, the body came nearly under the acetabulum,
and sort of ginglimus joint, with cartilage,
&c was formed
I am now to specify the improvements which I 
have made to the apparatus of Desault for fractures
of the thigh. His external splint only reaches 
from the crest of the ileum, and the bandage 
for counterextension goes obliquely from the groin
to this, and this tends to derange the upper fragment 
outwards. So avoid this, I have extended it 
to the axilla, and after the bandage is on, a strip
of [cross out] bandage is tied to this, midway betwixt 
the groin and splint before and behind*, just so 
tight as to make the bandage act in the line of 
the thigh. The upper end of the splint is made 
like a common crutch and covered with flannel
as a square head would tend to hurt the arm
In
*going over the other side of the abdomen 

24)
In Desaults apparatus, the foot is forcibly 
drawn against the [cross out] splint, and very considerable 
inconvenience follows from this.
I have adapted an innovation of the late Dr. J
Hutchison, to avoid this. It consists in a block 
of wood, which being placed near the lower 
end of the external splint, has a notch
to receive the bandage for extension; so that 
the extension as well as the counterextension
are is thrown in the line of the leg and thigh.
Having applied the apparatus, an inexperienced
surgeon may draw the bandage too 
tight, and produce pain, exoriation, and 
even sloughing, having ulcers over the 
tendo achilles and instep; and the apparatus 
must then be removed, therefore, this 
is to be avoided. When the muscles contract 
strongly, very little force is proper, as by 
doing so, more irritation is induced. After
some days, the force may be gradually increased.
If tenderness or excoriation come 
on, (which is very common, especially in

(25
children) spirits, as brandy may be applied, the 
parts may be covered with adhesive plaster on 
leather, soap plaster, or what is best of all, a 
small buck skin gater, cut away at the heel,
and laced up the instep (with a strip of the same 
material to guard the instep from the whang
strips of buck skin may be fastened to the under 
part of this, thro' holes, and used as the band for 
extension.- Any bandage will soon fold together
like a rope and act very severely, therefore, this 
method is peculiarly proper to defend the skin.
Mr John Bell, in his book, represents the 
apparatus of which I have spoken, as cruel
and useless, and the error he has committed
is truly astonishing. In reading his book, you 
will reflect that he has never seen Desaults
apparatus applied by one who understood it.
He also says that when the femur is broken
in the middle, the lower portion is never displaced"!!!
The lower end of the thigh bone, just above 
the condyles is not unfrequently fractured.

26)
These fractures are generally oblicque,
forwards and downwards, and in these cases,
the upper fragment projects just above
the patella, and the lower is drawn backwards
by the gastroenemic muscles, and 
the bones are laterally deranged by the leg.
Having applied a roller from the ancle up 
and reduced the fracture, a pillow is to be 
applied in the hand, a compress on the hand
over the lower portion, and a splint is to be
applied in the hand, reaching from the 
middle of the thigh down to the middle of the 
leg, and Desaults apparatus may be also 
applied with a moderate of tightness, and 
the rest of the fragments is sure.
When the condyles are separated from 
one another, the treatment is the same as 
above, except that there is no use for the 
compress in the hand, unless the under portion 
be displaced backwards. Any fracture 
of the thigh requires the apparatus for 6 or 8 
weeks, while that within the capsular ligament
of the acetabulum, requires at least

(27
three monts. If it be removed before this, there 
is danger of the callous of ielding, and producing 
deformity, specially in fractures of the neck of 
the bone. P.S. Physic
December 30th
Lecture 23.
Fracture of the Patella. It is very seldom
that these happen in any other direction there 
transversely: however, I have seen then longitudinal
and also oblicque. Transverse fractures
generally happen by the violent contraction 
of the extensor muscles on the anterior 
part of the thigh. Oblicque and longitudinal 
fractures happen mostly from external 
violence directly applied, as in falls, blows, &c.
When the patella is transversely fractured,
the power of extending the leg is lost, also the 
power of walking, and if walking, he falls.
He may however walk sideways, or backwards.


28)
backwards. The transverse fracture produces very 
great displacement of the fragments. The 
separation is very easily felt. The upper
portion may be brought down by our exertions,
and rubbed against the face of the 
lower. The separation arises from three
causes: 1. The extension of the thigh, 2. the
flexion of the leg, 3 the contraction of the extensor
muscles of the thigh. When these causes 
unite, the fractured portions may separate 
5 or 6 inches. The only cause in which 
the parts are obscured, is when after great 
external violence, blood is extravasated &
forms ecchymosis over the part. The cellular 
substance is so lax, that the blood
may be pressed aside by the fingers.
The bones can only be approximated by 
opposing all the causes of displacement.
The thigh is to be bent on the pelvis, and 
the leg extended. After this, the fragments may
be brought nearly, or altogether into contact
The apparatus is designed 1 to keep the upper


(29
upper fragment down, by acting directly on this 
and the lower 2. To maintain the limb in the 
position mentioned. The apparatus always requires 
to be extemporaneous, and therefore simple.
A bandage is to be applied from the ancle to 
the knee, to support the vessels, the body being in 
a horizontal posture, the whole limb is to be raised
so as to relax the thigh on the pelvis, and the leg
is to be supported with pillows, or what is better,
a board reclining, and cover'd with a bolster. This 
posture is preferable to raising the body, in as much,
as it takes off the determination of blood. The 
above posture, tho' irksome, is supportable after 
some time. The fragments being pressed together,
a compress is to be applied above the upper, and below 
the lower, and to be secured by the bandages
turned in the figure of $, meeting on the hand,
the skin over the patella is also to be supported
by a turn of the roller, and it is then to be carried
as high as the groin, for the purpose of 
of suspending muscular contraction in the extensor
muscles.- It is also worthy of attention 
to draw up the skin over the patella, so that

30)
it will not insinuate itself between the fragments.
A long splint is now to be applied to 
the posterior part of the leg and thigh,
(covered with flannel) and the same roller is to 
be carrid down again over the splint to the 
ancle. The limb is to be supported with the 
pillow and board, as above described. If pain 
supervene, bleeding is proper. [See note J. p. 35.
If we are not called in till some inflamation 
has come on, the drawing down the muscles,
would only irritate them, but we must 
wait till by bleeding, elevated posture, lead-water 
poultices, &c we have removed this, &
then apply our apparatus. If put on before 
violent inflamation, is over or even anchylosis may 
follow.
As the roller which accury the compress
is found to press on, and impede the vessels,
Dr. Dorsey has contrived a splint, on the midde
of which two bandage are nailed, 4 or 5 
inched asunder, which being applied on the 
back of the limb, the bandages are brought 
over the compreses, and pinned or sewed

(31
over the compress. The lower bandage goes over the
upper compress, it visce versa, and below this is 
applied, a roller goes simply from the ancle to 
the groin, and the compress are applied. This 
I find very convenient.
In two weeks, (or less in case of inflamation) the 
bandage is to be removed to rectify any derangement;
but the weight of the body is not to be 
rested on before less than 3 months.
The union in all these cases is ligamentous, and 
not bony, tho' it is said that if the bones be kept
in perfect contact, they will unite by bone
I have seen the ligament two or even four inches
long. If bony union took place, the joint might
be lost by anchylosis, and in cases when the
under bones are injured this may be expected,
and in this case, after 16 or 20 days, the limb
may be gradually moved to prevent anchylosis;
which, however, I have never seen in this 
case.*- When no means are used to keep the 
fragments together, they will go 5 or 6 inches
as under and the power of extension will be
*see note H.p.35.

32)
lost. But by seating the patient on a table,
with the legs hanging down and making 
attempts toward extension every day
Dr Hunter succeeded in the case of a lady &
this practice deserves imitation.
Fractures of the Leg. These are mostly
transverse, but in some cases they are oblicque
In the first instance, no shortening of the 
leg occurs, but the leg is bent angularly
forward, if both bones are broken by the 
action of the strong muscles on the posterior 
of the leg. This accident is easily detected 
also, by the feel, and by the grating.
In cases of oblicque fractures, unless the 
fragments interlock, the leg will be shortened
from 1/2 to 1 inch, as will be found on
comparing it with the other leg.
Extension, and counter extension are to
be applied, and the bones are very easily 
replaced. They are to be retained by splints &
bandage till the bones have united. Permanent 
extension is not required in this case

(33
The apparatus is to laid in order on the bed,
as in fractures of the thigh. The leg is suported 
by a board, with a pillow: On this is laid the
bandage of strips, as long as the limb, from 
the knee. On this, two pasteboard splints,
soaked in warm water, and rolled in soft linen
is next applied, and lastly, a bandage of 
strips, similar to the former is laid over this.
The patient is now to be conducted to bed, and the 
surgeon is to preserve the posture of the limb, he 
is to carry it by the knee and ancle, and he is 
to keep it extended while carrying. It being 
laid on the bed, the first bandage of strips
is to be applied from the ancle. If the limb 
has been deranged, as soon as laid on the dressings,
extension and counter extension are 
to be applied and the bones reduced. The bandage
of strips is then put on, next the splint
which are to reach at least from one inch 
below the sole of the foot, to prevent lateral
displacement by securing the lower fragment
and they are to be applied over the sides of the 
leg, and secured by the bandage of strips,

34)
first laid down. This I prefer to tapes which 
are use'd by some, but they press very unevenly.
The foot is best supported by by a 
a bandage put round the toes and carried
up on the leg. The pillows are now to be 
supported by two pieces of shingle, and 
secured by pices of tape passed around the 
shingle, bolster and limb. The state of 
the parts, as in other cases is to be examined 
in eight or ten days.
January 1, 1811          P.
Notes on Lecture 23.
H. p. When after fracture of the patella, if
from external violence, it is required to bend
the leg on the thigh, before the union is perfect,
to prevent anchylosis, this precaution
is very necessary, viz. while very gentle and
limited motion is made, the fragments of 
the bone must be pressed together with
the fingers, lest the new formed parts should
give way.


(35
I. p.30 In all cases of fractured patella, particularly
in those from external violence, it 
is nescesary not to apply the bandage too tight
as this would be very injurious.
Lecture 24
In the subject of fractures of the leg,
one circumstance remains to be explined.
When the fracture of the bones of the leg 
is so oblicque that they pass one another
after reduction and the application of splints,
it is nescessary to apply permanent
extension, else shortness and deformity will
follow. [cross out]
Desault has described an apparatus for the 
purpose in question; and Doctor James Hutchison
has improved it very much, so as to 
make it fully answer our purpose. Two 
splints of boards are to be provided. In the upper
end of these, is a [cross out] number of gimblet
holes, and the lower ends of the splints are 


36)
joined by a cross bar.
1. A pillow is laid on the bed, and on it a bandage 
of strips. 2 The leg is to be laid on this, & 
and a bandage for extension passed around 
the leg, crossed on the instep and tied in a 
knot on the pole. 3. Two tapes are to be applied 
on each side of the leg, and secured by
a roller passed around the leg just below 
the knee. 4. The tapes are now to be put thro'
four holes in the splint, on each side and 
tied. 5. Extension and counter extension are 
applied, the bones reduced, and the bandage 
of strips applied on the leg. 6. There is to be 
a bag of chaff applied on each side of the 
leg, and the splints appied close along 
these. 7. The bar to join the end of the splint 
is to be introduced thro' the mortines in 
them, and the bandage for [cross out] extension 
is to be tied over this with whatever 
degree of force is required.
Thus, whatever degree of force is required,
may be applied, and all causes of displacement
counteracted.

(37
In all fractures of the leg, the weight of the 
bed clothes has a tendency to displace the bones.
This may be kept off, either by three nail-rods
bent into a semicircle, and the points driven 
into two pieces of wood, which serve as basis,
and lie parallel to the limb, or by a more extemporaneous,
tho less steady machine viz
two segments of the hoops of a flour barrel,
each two thirds of a circle, and tied together at
the middle, this sit up is a cross over the leg
will support the clothes.
In compound fractures of the leg, this apparatus 
is very serviceable, as it allows, to dress the 
sore, without undoing the apparatus which 
keeps the bones in place.
It will not be required to apply this apparatus
during much inflamation. If the 
pressure of the roller below the knee causes 
swelling, which it sometimes, tho' seldom, does 
Desaults apparatus for the thigh, which makes 
extension on the tuberosity of the ischium may
be used.- The action of the four tapes on the roller
below the knee, keeps the pressure in some

38)
measure off the lateral vessels.
In women the short apparatus will be 
very convenient, as the long apparatus reaching 
to the pelvis is not very suitable to 
their taste. The fracture box, with a thin 
pillow introduced into it, is very well adapted
to keep the leg steady. Tapes are tied around 
it after the limb is introduced. It has 
a double bottom, and when it is required to 
raise the leg, any body may be introduced
under one end of the bottom for this purpose.
The bottom is excavated for the leg.
It is very common for wet applications
to be used to reduce inflamation of the 
leg as a solution of sugar of lead, this with 
vinegar and a little spirit, vinegar and spirits
alone, vinegar and sweet oil; but these 
remedies are of little consequence, and bleeding 
is the best means to reduce inflamation
In cases of ecchymosis, vinegar and spirits
on the principle of coldness are the best means
to promote absorption.

(39
Ruptures of the tendo achilles are generally
produced by great bodily exertions, in which 
the gastrocnemii muscles are exerted, as in dancing,
going up stairs, &c
The patient feels as if his heel has sunk 
into the floor, a crack is heard, and the patient 
falls down. The powers of the gastrocnemii muscles 
is quite lost, yet by some other muscles 
he can extend the foot a little. * [Sec Note Th p. 43
The leg is to be bent on the thigh, and the foot
extended on the leg, so as to bring the ends of the 
ruptured tendon nearly into contact, and to 
retain them so till union has taken place.
Doctor Monro describes the following means 
to maintain this posture. A piece of Russian 
sheeting is secured round the leg, long enough 
to reach half way down the leg. A slipper is 
next put on the foot, and a strap fastened
to the heel is to be carried up the back of the 
leg, and secured to a buckle on the back and 
inferior part of the sheeting. Thus, the belly 
*See wounds of the Tendo Achillis V.I p.116

40)
of the muscle is compressed, and prevented 
from acting, the lower portion is drawn up, &
the upper down, and the ends are tolerably well
kept together.
Dr. Monro met this accident himself, & 
succeeded in covering it by the above apparatus.
You will perceive on reading his account, 
the great difficulty experienced, and 
a very considerable lump was left on it.
One very great difficulty attends this mode 
of practice. The foot being at liberty to 
move laterally is very apt to derange the
lower fragment. To remedy this, I prefer the 
following apparatus.
A splint of wood is carved in such a 
manner as to adapt itself to the anterior
part of the leg and foot.
1. A roller is to be applied under the knee 
and after being carried half way down the 
leg, is carried up as high as it began.
2. The splint, lined with soft linen or flannel
is applied on the anterior part of the  

(41
leg and foot. 3. The roller is now reflected halfway 
down the leg, carried the same height, and pinned 
4. Another bandage is applied on the lower part
of the bandage* and foot; some turns of it may 
surround the heel, but not make any pressure
on the tendon, as this would derange it very much,
5 The vessels of the finall of the leg may be supported 
by a few turns of the roller, but these 
must be very slack, and it is best to support 
the tendon by compress of tow or lint.
The limb is now to be supported on a pillow 
for 6 weeks when the union will be but soft,
but no weight of the body is to be intrusted
to it before ten or twelve weeks.- Doctor Monro
was not able to use his leg completely before 
four or five months.
Having complated the history of the ruptured
tendo achilles, I shall now introduce
some observations on an accident little understood.
Persons after carrying a heavy burden 
on the shoulders, leaping, &c hear a crack
*splint

42)
referred to the calf of the leg, they are not 
able to raise themselves on the toes, yet
it is possible still to walk in a hobling manner
without raising the heels. I have never 
had an opportunity of dissecting a leg, after
this accident, but it appears to arise 
from the separation of the muscular fibres
of the gastroctemic muscles from the 
tendon to which they are united. In one 
case, I have felt an evident pit at the seat 
of the injury. From the pain and uneasiness 
in walking, patients will keep themselves
quiet for 8 or 10 days, they then walk 
about and a complete separation again
recurs. He confines himself for far a similar
line till easy, and again walks, &
after this many such courses, I have seen
patients miserably perplexed. One man 
was nine months in this way, the leg was 
swelled, and his health very bad!
The carved splints will answer very well
here. The foot part must be so deep as to restrain

43
restrain the lateral motions of the foot completely.
A bandage is to reach from the ancle to the 
knee.
In course of 5 or 6 weeks, a confined motion 
may be allowed, as the tendon will be tolerably
strong.      P.SP.
Jan 3. 1812
Note on Lecture 24.
K. p 39 Rupture of the tendon of Achilles
are very easily detected also by the fingers.
A very great vacuity is felt in the tendon.
However in cases of great swelling this 
may be obscured.
Lecture 25.
Fractures of the Tibia alone. As the fibula
is entire, the length of the limb is unaltered.
When the fracture is transverse, it is often
very difficult to discover the presence of the 
injury. There is generally sharp pain, and unevenness

44)
unevenness at the part, by trying to bend 
the tibia, an angular projection, and a 
chinck may be felt. It is of importance to 
know the presence of this injury in all cases
as it will be very dangerous to treat 
it only as a contusion. A patient of mine,
after I had reduced an accident of this kind
was not satisfied that his leg was broken
and removed the bandage and splints. On 
making somewhat an oblicue step, the 
leg yielded, and very severe distress was the 
consequence. Therefore cases of this sort
ought to be very carefully examined
The treatment is the same as in transverse
fractures of both bones. Two splints,
are required as in that case, and the leg 
is to rest on a pillow. In some cases this 
fracture will not unite, and in this case,
after about 6 weeks, considerable motion 
may be allowed, so that the fragments may 
inflame on their surfaces, and form a bony 
union. I have successfully treated several 

45
several cases in this way; and the union was nearly 
as speedy as usual.
Fractures of the Fibula. This is generally
complicated with a fracture* of the ancle joint. The 
fracture happens mostly at two thirds of the length
of the leg from the knee the leg is much distorted,
the astragalus faces the [cross out] outer ancle, the 
inside of the foot is turned down, and the sole, out.
A considerable hollow is felt over the seat of the 
fracture, the patient complains of pain there 
and if the foot be flexed and extended, a grating 
may be heard.
The first thing to be done is to reduce the 
foot, and the fibula will be drawn into its
place by this alone. The limb is now to be secured
by splints and bandages. The patient may
be laid on his back, and the many tailed bandage
applied, beginning at the ancle. The bandage
must be so slack as not to derange the 
fragments of the fibula.- Perhaps it may be
supposed that splints are unnescessary, as the 
*dislocation

46
tibia remains entire, but this is very far 
from being the case. The splints are to be 
so long as to reach below the foot, and by 
so doing the foot is kept steady, otherwise,
it will be very apt to produce displacement
of the lower fragment inwards. This is
the principal use of the splints, and one 
to which you ought to attend, as you will 
not find it in any book which we have.
By neglecting this, caries of the bone has been
produced, and I have seen amputations resorted 
to, on account of the diseased state of 
the leg produced by the irritation of the parts 
thus neglected till caries came on. In five
or six weeks, union will have formed such 
as to allow of considerable excercise of the leg.
Of Dislocations. A dislocation consists in 
the derangement of a bone out of its natural 
situation. It is attended with a loss of motion
with pain and deformity.
If surgical assistance be at hand, it is generally

47
generally easy to reduce the bone to its place, but
if much time elapse, considerable difficulty is 
commonly experienced. This arises from the contraction 
of the mucles by the irritation of the bone
displaced. The rupture of the capsular ligament
is not the cause of very much trouble, except in
a few cases, to be specified hereafter.
In such cases, many means have been devised 
for moderating the action of the muscles. Bloodletting, 
warm bath, low diet, &c have been used.
The first of these remedies, bloodletting from one
or both arms, ad delinquim animi, I have found
the best remedy; by this means, a temporary 
suspension is put to muscular motion, and 
the principal obstacle being removed, the reduction
is very easy. This remedy was first used 
in the Pennsylvania Hospital by me, and 
it was first proposed by Dr. Alexander Monro in
his lectures.
For the same purpose other means have also 
been used, but with less effect. Nausea produced 
by tartar emetic, or by tobacco injections
and these means may be used when bleeding

48)
is objected to. Intoxication has a similar 
effect. The muscles may be overcome by 
being fatigued. How after do we see reduction 
happen by weak efforts, after resisting 
for hours!
When a dislocation cannot be reduced, the muscles 
accomodate themselves to their new 
functions, adhesiong form round the head
of the bone, and these causes conspire against
reduction. This is particularly the 
case in old dislocating. The natural cavity
becomes less, and presents another obstacle.
Considerable force is required in these cases
Pullies have been much used but I have 
relinquished their use of late, and now, I 
use a number of assistants. Pullies are 
very unmanagable, and their action is 
not easily attend, whereas, by a word, you 
can vary the force and direction at pleasure
by using a proper number of assistants.-
Care must be taken to confine

(49
the force applied, to the joint dislocated.
When a bone remains long out of place, a 
sort of new joint is formed. This is not unusual in 
some joints, particularly the shoulder and hip.
A joiner had his arm dislocated into the axilla and 
remained irreducible. He began to use it a little
when the pain and inflamation had subsided.
The power of moving it returned gradually, he
has able to use the saw as well as before, but one
muscle seemed to have lost its power, (the deltoid)
as he could not raise the arm upwards. In all 
such cases, the cellular membrane is so condensed,
as to serve as a new capsular ligament, and 
even new cartilage is formed.
In irreducible dislocations of the hip, the acitabulum
is very readily and completely absorbed
and a new one, with capsular ligament as well
as cartilage is formed. A girl by receiving a fall
had her femur luxated backwards and upwards
and lost the power of motion for some time,
and nothing could be done to reduce it; after some
confinement, on beginning to walk about,

50)
and received a second-fall, whereby the other 
femur was reduced to the same state as the 
first. The limbs were now of one length,
and she could walk a little, when at the end 
of a year, she took a fever, which proved fatal,
Her pelvis was shown to me by Mr Cruickshank,
and in both sides, the bone was dislocated upwards
and backwards. The natural acitabula 
were completely absorbed, new cavities
were formed on the dorsa of the ossa ilia,
surrounded by bony margins, covered
with cartilages, and furnished with new
capsular ligaments. Dr. S.
January 6th,
1812

(51
Lecture 26.
Dislocation of the Lower Jaw. The only direction
in which this can happen is by the condyle 
being carried before the tuberosity at the 
root of the zygomatic process. The mouth always
stands open, speaking is impracticable,
the saliva flows from the mouth, and considerable 
pain attends.
It is produced by yawning, or any other cause 
of opening the mouth wide, by which the 
condyle mounts upon the tuberosity before 
the pit, and in shutting the mouth the 
condyle cannot get back again. A woman 
in market, in scolding [cross out], husband furiously,
found she could not shut her mouth again,
and came to me, and I found her jaw dislocated 
on both sides.
Some recommend strikeing the chin upward
to reduce this, but by this, the condyles may be
broken. In recent cases the reduction is very

52)
easy. The thumbs are to be introduced into 
mouth, applied to the molar teeth, and the
middle fingers applied under the chin. The 
thumb may be guarded with a soft linen,
lest after reduction, by the spasmodic action,
it should be injured. The patient is to be 
seated on a low chair. The surgeon is to depress 
the angle of the jaw with the thumb,
while with the fingers, he raises the chin,
and as soon as it is dislodged; he is to push 
it backwards. In this way, all the cases
I have ever seen were easily reduced.
No bandage is required after reduction, but 
the mouth is not to be opened freely for 
some time. Both sides of the jaw are 
generally dislocated at once. I have seen
only one case, in which only one condyle
was dislocated. In these cases, the force is 
to be applied to the injured side only.
Dislocation of the Clavicle. This bone 
much oftener fractured than dislocated.
a. I have seen one case of dislocation in

53
the sternal extremity, which was forwards. It 
may also happen upwards or inwards. Dislocation 
forwards always happens from the shoulder being 
driven forcibly backwards. It is very easily known 
by the projection anteriorly, and easily reduced.
A cushion is placed in the axilla, the elbow pressed 
toward the trunk, and the end of the bone
pressed down with the thumb. After reduction 
the apparatus of Desault for fractured clavicle
is to be applied, and kept on for four or five weeks,
till the ligaments resume their tone again,
b. Dislocation of the scapular end from the 
acromion scapulae is very easily discovered. 
The clavicle is found raised above the acromion 
a considerable way; and the ligaments 
are torn. On raising the arm, you reduce 
the fracture. This is always produced by a fall 
on the shoulder. To reduce it, it is only necesary
to raise the arm upwards and outwards, 
and secure it so by the same apparatus 
as in fractures of the clavicle. This is to 
be persevered in for ten or twelve weeks, as 
the ligaments are long in uniting. 

54
Dislocation of the humerus is the 
most usual accident of this kind which is 
met with. This occurs, 1, from the large 
motion which this joint performs, 2, from 
the shallowness of the glenoid cavity, 3, 
the great weaknes of of the joint in some 
directions.
The head of the bone in most cases is 
thrown downwards, into the axilla. It is 
sometimes carried forward, between the 
coracoid process, and glenoid cavity, but 
this is very rare. It is also sometimes dislocated 
back, so as to lie betwixt the glenoid 
cavity, and the spine of the scapula.
The second is very rare, one case of it, being,
all I ever saw. Of the latter sort, or backwards,
very few cases occur: about two 
weeks ago, a case of it occurred to me.
This accident is very easily discovered in every 
situation. 1. In the axilla Considerable pain
attends this. The arm cannot be raised up, 
neither can it be brought to the body, but

55
the elbow will hang about a span from the 
side. There is instead of the round form of the shoulder
a great hollow under the acromion, and a 
large tumor is felt in the axilla. The body of 
the humerus cannot be felt above half way,
from the tension of the deltoid muscle.
This is easily distinguished from a fracture 
of the head of the bone, by the hollow under the 
acromion and the sharpness of this.
2. Inwards. In this case, the motion of the arm 
is greatly impeded. It cannot be raised to the 
head, but can be brought close to the body.
The coracoid process cannot be felt, and the projecting
acromion is felt far behind the 
head of the humerus.
3. Backwards. This is easily known. The acromion 
and clavicle may be felt far before 
the head of the bone, the head projects just 
over the dorsum of the scapula
In old cases, the head of the bone is often
drawn from its situation in the axilla, forwards,
by the action of the pectoral muscle.

56
It can never happen upwards, the acromion 
as scapula here forming an insurmountable 
barrier.
In recent cases of downward luxation,
the reduction is generally easy. I have succeeded 
by extension and counter extension 
without any assistant, holding the humerus 
just above the elbow in one hand, and 
pressing upon the spine of the scapula 
with the other. The force is always to act 
on the joint of the shoulder alone. This is 
a fact of the first importance: it accounts 
for the frequent failures of ignorant, tho'
bold operators, who make counter extension
from the thorax, and spend all their 
force on the connections of the scapula
to the trunk of the body! Have we not read
of a miller, whose arm was torn from the body
by violence, and not the shoulder joint,
but the connections of the scapula to the 
body which gave way.
The forearm is to be bent on the arm and as
* A low chair is the best seat for the patient

(57
handkerchief tied round the arm just above 
the elbow, and given to one two or more assistants.
The surgeon is to press with his hand on the 
spine and acromion scapulae, and an assistant 
may also apply his hand over the surgeons,
and increase the counter extension. The forearm
may be raised up and down to assist its 
going into place. If the reduction do not happen
by these means, the surgeon may entrust the 
assistants with the counter extension and by 
pressing up the upper end of the bone with one 
hand, and the elbow down with the other, he 
may use the bone as a lever to reduce itself.
Some use a pad, put under the axilla for this 
purpose, but the hand is as good, and appears 
more simple to the patient: however, very 
little violence is to be used in this way.
But if it be found that the contraction of 
the muscles will be so violent as to resist
moderate force, Bleeding ad delinquim animi
is to be used rather than great violence, producing 
painful excoriations, &c. This remedy was 
found nescesary in a case in the P. Hospital, in

58
a robust man, and after losing near a 
quart of blood, he fell down, and the bone
was reduced with the greatest ease. Since
this, many other cases have occurred, with 
similar result. This remedy is never to be 
used unnescarily, but confined to all cases
in which we know great force will otherwise 
be required.
But if after several weeks continuance,
there have been adhesions formed, and the 
capsular ligament has closed, it would 
be unnesecary, and improper to spill the 
vital fluid. Force must now be applied.
Either a number of assistants, or pullies may 
be used. It is nescesary to vary the direction 
of the force at the period when the bone is 
just returning to its place, and as this 
cannot be done when we use pullies, I
prefer as many assistants as may be requisite,
probably five or even ten.
In some cases, I have distinctly heard the capsular 
ligament lacerating at the moment 
of reduction 

59
To avoid excoriation, the lower end of the arm, above
the elbow may be defended by stiff buckskin.
A strong roller is applied round this, and given 
to the assistants, or a handkerchief, with a 
rope fastened to it. A strong band, with the middle 
stuffed, so as to be very soft, is applied on the 
acromion, and fastened by the ends to a hook,
as high as the patients groin if he is standing 
or on the floor if he sits. When extension is 
made, this band is apt to slip and excoriate 
the skin, therefore it is to be held in place 
by the hand of an assistant, or secured from
slipping up by a roller passed under it, and 
held. This has been introduced by Dr. Dorsey
and is very convenient. Or strips of leather
may be fastened to the under edge of the band,
for the same purpose.
Any force whatever may now be commanded,
and the arm may be rotated, so as 
to break whatever adhesions may have formed.
If the body should yield, a band of great 
breadth may be put round the body, and held
by assistants, merely to secure the body, or the

60
patient may lie horizontally, but the 
best position is sitting on a low stool.
By the above means, luxations of nine,
eleven and even of thirteen week have 
be reduced under my observation. I also 
have the account of a case in Baltimore
in which it succeeded after five months.
I do not think that  any bone can be put
out of place which cannot be returned by 
art again, and therefore no case is to be 
despaired of.
I may mention some of the other means
which have been used for this reduction.
1. The body has been suspended by the arm
over a door or ladder-but the humerus is 
liable to fracture from this violence.
2. The body has been raised by the arm,
with a pulley,-but no counter extension 
is provided for in this way, and it does not 
succeed well.
3. By placing the patient on the floor,
putting the heel in his axilla, and making 
extension by the wrist, I have seen

61
Mr.J Hunter succeed in a case of this kind of 4 weeks and 
you may have this method in reserve for obstinate 
cases.
4. The various machinery, as the ambe of Hippocrates
&c act violently, yet fail because they 
do not fix the scapula.
Dislocation of the Elbow. This is in most 
cases backwards and upwards. The hook like 
process of the olecrannon may be felt above,
and considerably behind the naturan bid in
the humerus which receives it; the forearm 
is bent at right angles, and cannot be moved
either way. It may also be carried outwards,
or inwards but these forms are raw.
In the former, the olecranon may be felt
on the outside of the humerus, and in the 
latter, at the inside, and also, the hollow
of the radius may assist us in the diagnosis.
It is very easy to ascertain this accident, &
also easy to be reduced. In old cases it was however
very difficult. Boyer says that in four weeks
it is impossible, but in this he is mistaken

62)
as I have reduced one of four, as well as 
one of two weeks standing.
The reduction is performed in the following way
one assistant takes hold of the arm a
above the elbow, and the other just above
the wrist. The surgeon takes hold 
of the arm, by clasping the hands in front
over the lower part of the humerus, and 
he draws this backward, while the assistants 
are extending, so that the three forces
act at once, The fore arm is now bent,
and the bones are very easily reduced. The
use of the Surgeon's making extension
backwards is to dislodge the the coronoid process
of the ulna, from the condyles of the 
humerus, on which it is as it were locked.
The arm may be kept bent for some
time, at least for two or three weeks, and 
the joint may be kept moist by vinegar,
and spirits.
Dislocation of the Wrist may happen
either forward or backwards but cannot happen 
laterally.


(63
When the wrist is carried backward, the hand 
inclines forward, and when forwards, the hand 
turns backward. Nothing but extension and 
counter extension are required, and the reduction 
is very easy. The hand is to be made 
steady, by splints applied to the hand & 
forearm, and continued for some weeks 
at least.
Dislocations of the Fingers. These happen 
either anteriorly and posteriorly, and are 
very easily discovered, their bones being so 
thinly covered. They are quite immoveable
when out of place. They are very easily
reduced, and may be secured by splints.
The first and second joints of the thumb,
when dislocated are very difficult to reduce.
The knobs on the heads of the bones interlock
each other, and the more extension is made,
the more fast the ligaments tie the bones,
and even the last joint has been pulled off.
I have met with but one case of this, and 
succeed with tolerable case.

64)
Mr. Charles Bell has a very ingenuous proposal
on this subject. He proposes to introduce 
a cataract needle through the skin,
and to divide the lateral ligaments of one 
side, and then it is very probable the reduction 
would be very easy. B.P
January 8th,
1812
Lecture 27.
Dislocation of the Thigh. The older surgeons,
reflecting that the head of this bone was 
lodged in a very deep and strong cavity, and 
moved by very strong muscles, asserted that 
the neck of the bone was very frequently fractured,
and that dislocation of the hip joint,
never, or very seldom occurred. But they were 
mistaken in this. Four cases of dislocation 
generally happen as often as one case of 
fracture in the neck of the femur.


(65
This bone may be dislocated in any direction.
The most usual direction however is upwards, & 
backwards, so as to rest on the dorsum of the 
ilium. The next direction in frequency is in an
opposite direction, so that after passing downwards
and forward, the head of the bone rests 
on the foramen ovale. It may also happen
either upwards annd forwards, or downwards and 
backwards.
First, when upwards and backwards, the head
of the bone rests on the dorsum of the ilium.
The limb is shortened, generally two or three
inches, the toes are turned inwards, and the 
case is very easily detected. I have already
explained how this case is distinguished from 
fracture of the neck of the bone. The limb 
cannot be brought to its length, without reducing 
the dislocation; the trochanter major
may be felt nearer the spine of the ilium, and 
sometimes, the head of the bone may be felt 
on the ilium.
Second, the head of the bone is carried downwards,
and forwards into the foramen ovale,

66)
the limb is very considerably elongated,
the toes are turned outwards, and sometimes
the head of the bone may be distinctly felt.
Thirdly, the head of the bone is sometimes
carried forwards, or forwards and a little upwards.
The limb is shortened in proportion 
as the head is upward, and a large tumor
may be felt in the groin.
In the fourth order, the head is carried backwards 
and a little downward, the toes are turned
inward, and the case is easily discovered.
The two last orders are raw; I have never 
met with more than one case of each. For all
there dislocations, the capsular ligaments is
much ruptured. It was common for the older 
surgeons to say that the notch on the inferior
and anterior of the acetabulum caused
most of these dislocations to happen in this 
place, but the very reverse is true. The most 
usual direction, we have seen, is upwards, 
and backwards. This notch is secured by a 
ligamentous bridge, and is as strong as any 
part.

(67
From the great strength of the muscles, and 
also the great depth of the acetabulum, and the 
situations where the bone rests, very great force
is commonly required in this reduction. This is 
best applied by compound pullies.
In one case, I bled ad delinquim animi, and 
by my own exertions, with two assistants, I
reduced it again. But much more force is commonly 
required.
The patient is to be laid on the sound side,
with the thigh flexed on the pelvis, and the leg
flexed on the thigh. A strong band, (the middle 
of which is stuffed, is introduced into the groin
on the injured side, so as to rest on the tuberosity
of the ischeum and on the pubis, and 
secured to a hook opposite to the patients
head. This is to make counter extension.
The extension may be made just above the 
knee [in very corpulent patients, it can only be 
made below the knee] by a towel secured by 
a circular bandage*, to this towel, the pulley is
*To avoid excoriation, the skin is to be defended by
a piece of buckskin, round above the knee.

68)
fastened, and this secured to hook in the opposite 
of the room. Any degree of force may 
thus be applied. The limb may be rotated
to dislodge the head of the bone. In this way,
I have seen several cases succeed the head 
of the bone returned with an audible snap.
But if this do not succeed, it will next 
be required to raise up the head of the bone.
A bandage is put under the thigh near 
the groin, and tied over an assistants neck,
who kneels on the table, and puts one knee
on the pelvis below the rest of this 
ilium. While the assistant raises up the 
head of the bone, the surgeon uses the os femoris
as a lever, pressing down the knee,
This is the best way to make extension at
right angles.- Sometimes a band may 
be put over the pelvis, thro' two holes in 
the table, and secured to a hook in the floor.
By the above means, two extending forces are 
applied: one in the longitudinal, and the other 
at right angles. This is for luxations 
upwards and backwards.

(69
For dislocation into the foramen ovale, viz, downwards
and forwards. The longitudinal extension 
is applied in the same way, and with the same 
intention. The rectangular extension is also 
to be used in the same way, but the longitudinal is not so much
with the intention of lengthening the limb,
(this being already too long) but to dislodge it 
out of its seat on the foramen ovale.
The dislocation forwards, and a little upwards,
may also be treated in the same way. Mr. Heys
(whose/observations on this accident deserve per 
usal) directs in this case, to seat the patient 
on a bed, to apply the pubis to a post of the 
bed, and to make extension by assistants
at the leg. As this is not always convenient 
Dr. Wistar has made a subistitue for the 
bed post in our Hospital. It consists of a 
strong shaft, 3 or 4 yards long, inserted
to a head of about 30 inches long in the 
middle, and secured by stay pieces, thus 
resembling a rake. The end of this shaft 
props against the wall, and the head covered
[illustration]

70)
covered with flannel, makes counter extension 
against the pubis, the [cross out] leg may 
be bent, and extension made by assistants 
or pullies, the limb rotated, and the 
head brought outwards by a band or (what 
is better as it interferes less with the muscles)
a rolling pin. But this method is 
not preferable to this above one.
When the dislocation takes place forwards
and upwards into the groins There is 
some variation required. The longitudinal 
extension is made as usual, but the difference 
is this. The patient is laid on the 
back, a bandage is put round the pelvis
on the injured side, and fastened to a hook
opposite to the other side. Another bandage 
put round the injured thigh near 
the groin, and fastened to a pulley on the 
same side. The leg is bent, the thigh rotated,
as usual. The only case I have seen 
was treated in this way. See Dr. Cox's Med.
Museum. Desault met with a case of 

71
this sort. He differed from the operation described,
only in putting the band for counter
extension on the sound side of the scrotum;
while I put it on the injured side._ This apparatus 
may be used for luxation in any direction
whatever.
Lastly, in the dislocation downwards and 
backwards, I have had only one case. In this 
the usual means failed. The head of the femur
protruded through a rent in the capsular 
ligament, just as a button thro'
a button hole, and extension served only 
to make it faster. At length, I succeeded
by a violent abduction of the thigh. I applied 
my left hand on the trochanter,
and embracing the flexed knee in my 
right arm, I made a violent abduction,
using the thigh as a lever at the same
time. The thigh was bent on the pelvis. Abduction 
is the best means to dislodge the 
head of the bone out of the capsular ligament._
By these means, if the capsular ligament,
&c, have not formed strong adhesion


72
have not found any dislocation may 
be reduced. The only precaution nescesary 
after reduction, is to keep the 
limb quiet for a week or ten days.
In cases when the reduction has been 
delayed for some time, the cavity will
have so closed as to prevent the limb
resuming its usual length, and it remains 
1/2, 3/4 or 1 inch longer than [cross out]
usual. But a few weeks rest will overcome 
this.
Dislocations of the knee. The only direction
in which this joint is dislocated is outwards.
This however is very raw. Two cases of 
this sort have fallen within my observation.
In both, they arose from violent abduction:
the patient going up a ladder, this fell 
when they were 6 or 10 feet from the ground;
they fell thus with the legs asunder. In one 
of them both, but in the second only one 
knee was dislocated.
The leg rests upon the outer condyle of the os

73
femoris, the inner condyle may be easily felt,
a great angle is formed by the leg upon the 
the thigh, so that the injury produces effects 
very easily known,-and the leg is very easily 
restored to its place again, but such is the 
destruction of the capsular ligaments, that 
the leg will fall off again just as before.
The limb must be kept steady: either two 
common splints, or what is better Desaults
long splints must be worn at least four months
before the ligaments have united. The knee 
may be wet with lead-water, vinegar and oil,
vinegar and spirits, or any such liquid.
Dislocation of the Patella. The patella,
or kneepan may be luxated either outwards
or inwards. The former is the most usual direction,
the condyle of the femur being the 
highest on the outside, not allowing the patella 
to return. The pulley like surface of 
the femur being very easily felt, and the motion 
of the leg being lost, the case is very 
easily recognized. Further, the patella, on

74
the outside being very easily felt, its internal 
side is now posterior, its anterior 
surface is now exterior. Considerable pain 
is felt, and the powers of the extensors 
of the leg are lost.
The reduction is very easy. The thigh is 
flexed on the pelvis by the patients sitting 
on a bed, and the leg is to be extended. 
By pushing the patella on the side,
it will now fall into its place very easily.
The only case I have ever seen of this,
was in a lady, in whom it was caused by 
an irregular step in dancing. It was 
seated on the outside as I have described
and very easily reduced. After resting 
for fifteen days, she was perfectly restored,
and able to dance again!
Dislocations of the Ancle. I have
already explained how this accident was 
often complicated with a fracture of the
fibula, at one third of its length from the 
external ancle: however dislocation may

75
happen without this. This may be either anteriorly
or posteriorly. In the former case, the 
foot appears shorter than natural, and the 
bones of the leg lie in front of the astragalis
and the os calcis projects behind. When 
the foot is luxated posteriorly, the reverse 
of all this happens. This is very easily reduced.
An assistant holds the leg fast about its 
middle, while another extends the foot, and 
draws it into place.
One case only has fallen under my observation,
occured in a lady; She was hastily 
running down stairs, when she fell, and 
the heel of the shoe took hold on one of the 
steps, and the whole weight of the body 
resting oblicquely on the joint, this gave 
way. It was reduced as above described, and 
after a month, the function of the ancle
were completely restored again.
Jan 10th 1812     P.S.Physic.

76) Lect 25
Of Injuries of the Head. A. Contusion
Blows upon the head frequently produce a rupture
of a number of vessels, whereby blood is shed under
the scalp, which gives the part a soft pappy feel,
and round this is a hard ring, with a very abrupt
edge, which may deceive for a fracture with depression 
of a piece of the cranium. This has induced 
induced unwary surgeons to incise the part
and prepare for operation, and they were always 
much dissapointed to find the scull whole.
To avoid this unnescesary step of incision, it 
is nescesary in all cases, before we incise, to 
to see the symptoms of injured brain exist.
The incision is a very painful step and even exfoliation
of the bone may follow it.
Nothing but clothes wet with vinegar and water
is required as a local remedy, the antiphlogistic 
regimen, and if the injury be severe, bleeding,
and purging are required. If after several days,
the blood be not absorbed, a small puncture may 
be made into the tumor, the blood pressed out and 
dry lint applied, and secured by adhesive plaster.

(77
2. Wounds. Incised wounds in the scalp require the
some treatment as they as in other parts of the 
body. The hair having been removed, the lips of the 
wound may be approximated by adhesive plaster.
Contused wounds also have nothing peculiar
in them here. A soft poultice is the best application.
It may be continued till the sloughs are
separated, supuration is free, and granulation
goes on well. The sides of the cavity may be either
brought into contact, or at least approximated 
by adhesive plaster
The scalp is sometimes torn off: I have even 
seen one half of the scull laid bare in this way.
The old surgeons in such cases were in the habit
of cutting off all the separated parts, because, they 
said if left on, matter would form under it and injure 
the bones of the head. But their practice 
was as absurd as the reason for it was untrue.
The scalp is to be cleaned of any foreign matter,
replaced, and retained by interrupted sutures,
adhesive plaster, Sutures I do not recommend,
as they are an additional injury, increase the 
constitutional irritation, and if much swelling


78)
swelling come on, they are not (like plasters) easily removed.
If sutures are used, the edges are not to be 
drawn tight, nor nearer than 1/2 inch asunder. But
when inflamation is over, they may be brought
together. Adhesion generally takes place:- if pus
form in any part, it may be evacuated by an 
incision as in any abscess. If an early opening
is made, the bone will very seldom slough. The 
constitutional treatment must be antiphlogistic,
and if headache and fever follow, blood letting 
and purging may be used freely, as in cases 
of contusion.
In those cases in which the bone sloughs off
it is very important to remove the slough as 
soon as possible. Whenever any looseness is evident,
the slough may removed: as the granulations
round the rough edge of the bone will 
soon make it fast if left. We are never to wait 
for the bone to become looser, but pull out
the slough with forceps, and if incision be nescesary,
it may be made freely.
3. Acute pain often remains after the wound of 

79
of the scalp has heated. It also follows simple contusions,
as well as contused wounds. It lasts after the 
inflamation is over: I have seen it last for months,
nay even 3 or 5 years after.
The first case I have met with, was in a lady,
whose head was struck, in looking out at the 
window, by the shutter, which was blown by 
the wind. The pain was very acute, and increased 
as the inflamation subsided. This happened
at Trenton; and after 5 months continuance,
she came to town. I could feel a roughness and 
inequality in the bone. Dr Rush had tried every 
means he could devise, but all failed to afford 
any relief. I was consulted, and made 
a crucial incision through the scalp, and after 
this her complaint subsided entirely.
The second case was in a lady of a full habit
and the pain was very severe. Numerous remedies
were used, but to no purpose. Bleeding, purging,
low diet, low diet, leeches, blizters, issues,
the crucial incision, opium, cicuta, oxymuriate
of potash, solutions of arsenic & mercury, were all
used without benefit. 

80)
At the end of two years, she took a journey in
to the country, and by this she was suddenly 
benefited, but it was five years before she was 
quite well.
The third case was produced in a young lady 
by falling from a gig, and alighting with 
her head on a stone. The pain continued severe 
for 18 months, when by a second fall, the 
complaint was greatly augmented. On taking 
a walk to the Yohenulkylon, and being 
much heated, she went into the cold bath,
and on this, the pain became excruciating.
Mercury was given, but a salivation could not 
be produced. The crucial incision was made,
and from that evening for four weeks, she 
was well, but then relapsed. On the idea of 
retained perspiration, I made an issue as 
large as a dollar, with caustic, on the head,
but no relief followed. After 18 months, she went 
into the country, and on feeling oppression 
at the stomach, a vomit was taken, and brought 
off much mucus, and in six weeks, she 
was perfectly well.

81.
In the fourth case, a man fell from a house
and received a small wound on one side of the 
head. The pain came on, as in the other cases.
Bleeding, purging, &c failed, and the crucial incision, 
as soon as I had made it relieved him
but seized the other side as ill as the first side
and I next operated on this side also, and he 
soon recovered completely. I have seen one case
in which, it ended in fatuity.
In all cases, a complete recovery came on 
in course of time. Indeed I know of no [cross out]
remedy for this disease which is certain. The 
crucial incision is the best remedy I know. 
4. Injuries of the brain a. Compression
This state of the brain is marked by sleepiness,
drowsiness, insensibility, loss of speech and 
voluntary motion, sickness at the stomach,
vomiting and either dilation or contraction
of the pupils of the eyes, and no variation in 
these when exposed to light.
It may arise from either of the following
causes. 1. The fracture and depression of a 

82
piece of the cranium, or 2. by blood extravasated 
out of ruptured vessels, or by both 
causes taken together. The blood may be under
the scull, under the dura mater, or in the 
substance of the brain. Both depression, & 
blood may unite, as they very often do, but 
she may exist perfectly separately.
The symptoms of depression, from fracture 
are immediate, but that from blood generally 
allows a few minutes of sense and 
motion, before there is enough of blood to 
compress the brain.
But fracture of the scull with depressions 
may exist, without constitutional symptoms 
denoting it....A boy received a blow
by a brick thrown from the opposite side
of the street. I was called, and arrived in ten 
minutes, and could feel a considerable depression 
of bone, yet the boy was sensible, and 
told me the circumstances of the accident,
and then fell from his chair, cold, senseless,
and motionless. I trepanned him immediately

(83
immediately. A large quantity of fluid blood flowed from 
the orifice, and the boy recovered even before I 
had raised the depressed bone. There was a union 
of causes; the blood was the cause of the stupor
and it is often so; even without any external 
wound.
Sometimes the dura mater is wounded,
and even portions of the brain prolapsed.
Extravasated blood may be lodged in the cavity 
of the brain.
When compression is known to exist, the 
depressed [cross out] bone must be lodged* in the brain
and brought on a level with the rest of the scull,
or the extravasated fluid must be evacuated. 
If there be many fractured portions,
there may in general be a perforation made
with the trephine, and the blood if there be 
any may escape, and the fragments may 
be elevated. The perforation may be in the 
vicinity of the fracture.
In all cases if after the receipt of a blow, the 
symptoms of compression exist, perforation
*removed out of 

84
perforation is to be made. The inferior, anterior angle
of the parietal bone is the best place 
to open, because there, the artery of the dura
mater exist, which is the Source of extravasation.
If one opening do not succeed, the
other side may be opened.
On this subject, Mr. Abernethy makes a very 
ingenious remark. The scull is supplied with 
blood from the teguments and also by the 
dura mater. Now if these two sources of blood
be removed, the external by incision, and the 
internal by blood, we will not find any 
blood oozing from the bone on laing it 
bare. This may not always be depended on, as 
anastomosing arteries may keep up the circulation.
Even after the perforation is made, the symptoms
of pressure sometimes continue. It is 
then importance to tell whether the blood is 
extravasated under the dura matter or not?
If instead of the level, white, glistening appearance
of the dura mater, we find it pushed 
up into a convexity in the trepan. hole, fluctuation

85)
fluctuation in some degree perceptible, and a livid appearance,
by the presence of blood, we may be 
pretty certain of the nature of the injury. Further,
There is (especially in children) a motion in 
the dura mater corresponding to respiration,
raising with expiration, it visce versa,- and 
also a motion at every stroke of the heart,
but these are absent if blood be extravasated 
under the dura mater.
But even if we are certain of its presence, it
is very doubtful whether or not the dura mater
may be perforated? Rather than let our 
patient die, we might do it, but tho' cases 
are reported of patients recovering after such 
a puncture, yet I have always seen them 
prove fatal...... Indeed the dura mater is often 
wounded by spiculae of bone, and otherwise,
and yet the patient recover, but the above 
case is widely different: in it, we are never 
able to evacuate all the blood, and the part 
remaining becomes acrid by the air, and 
produces inflammation and suppuration in 
the pia mater and death!!

86)
Now, the progress of this injury is as follows:
first, the dura mater at the place of puncture,
becomes enlarged, till as wide as the hole 
in the bone, the brain arises on a level with 
the bone, (I have seen it arise one inch) then 
constituting fungus cerebrix, which is the brain 
itself pressed out. This has been tied with a 
ligature, destroyed with causte, &c, but is 
all cases is has proven fatal, and pus was 
found in the hemispheres of the brain, and 
therefore, this case is hopeless.
Our circumstance is very remarkable in 
this accident: sense remains till near death
unaffected.
In a case of extravasation which occurred 
to me under the dura mater, the membrane 
was pushed up on a level with the bone,
and all the symptoms of compression existed.
I bled the man four times a day, for 
five days, and each time, ad delinquim animi,
purged him freely, blistered him, and
confined him to barley water, and he was 
saved by these means from death.

87)
I therefore condemn the puncture in all 
cases....The dura mater is sometimes wounded
by accident, without death following: Sabatier 
relates the case of a man whose scull & 
dura mater were very widely discovered by a 
saber, and the wound heald just as easily as 
as in any other part of the body; nay, we 
read in the memoirs of the Academy of Surgery 
of a ball going perpendicularly, and of 
cin other going transversely thro the brain,
yet life not being lost, but a happy recovery!!!-
I have however seen one case of a 
wound of the membrane recovered from. The 
child was bled and purged freely, and confined 
to rest and a low diet, and recovered, tho'
dangerous convulsions supervened.
One circumstance more will conclude
this lecture. Patients recover better in the 
country than in a large city or town, and 
particularly better in succh a situation 
than in a crowded hospital.
D.P
January 13th, 1812

88)
Lecture 29.
We continue to speak of injuries of the head.
b. Sloughing of the dura mater. I am now to describe
a form of disease, not spoken of by any 
author; and of which I have met with only
one case. Last summer, I was called to a child,
which had received a kick of a horse on the os 
frontis. I found a very considerable piece of the bone
depressed by the fracture. The senses 
were perfect, but as as I always trepan 
in cases of depression, that I always proceeded
to do it in this. After the removal of 
the piece, I remarked an unusual appearance.
The dura mater was of a very dark colour,
without any convexity, or any other circumstance 
of effusion. In the course of 7 or 8 
days, the piece of the dura mater sloughed 
off, and left the pia mater bare. The child
still retained his senses, but fungus cerebri 
came on, the brain was protruded and the 
child died.

89)
Thus, the dura mater may die and slough off by 
a blow, just as a bone or any other part whose 
life is weak. I know of no remedy for this disorder.
In the case mentioned, the remedies for 
inflamation were used, particularly bleeding 
and purging, and the result was unfortunate.
C. Hamorrhage from the brain and dura
maters. Very considerable bleeding sometimes 
occurs when the brain or dura mater, especially 
the latter, are wounded. This is especially 
the case if one of the large sinuses, as
the longitudinal, or the lateral, is wounded.
This may arise by speculae of bone, or it may 
arise from wounds in our operations. Alarming
as this bleeding is, it is very easily commanded.
A dossil of lint, secured by pressure 
with the finger is always sufficient
to put a permanent stop to the disease.
Of arterial hamorrhage from the dura mater,
more must be said. The only vessel from 
which this can occur in any alarming degree
is the median artery of the dura mater,
which lies under the parietal bones. 

90)
A long quantity of blood may flow out
of this vessel, but in general, a piece of lint,
pressed down with the finger will stop 
this, in ten minutes. But sometimes, from
unusual size of the artery, &c, the blood continues
to flow. In this case, if the dura mater 
is wounded as well as the artery, the latter 
may be secured by a ligature, by a needle, 
or tenaculum, but if the dura mater be
whole, this would be unadviseable, as wounds 
of the dura mater are so seldom recovered from 
even if the puncture be very small, as by 
a spicula of bone, it is best to omit the ligature.
When the artery runs thro' a canal 
of bone, the treatment mentioned in compound
fractures, of stopping the hole by 
a plug of soft wood, put beside the artery,
and not into it is nescessary. But this structure is rare.
We might in some cases introduce a dossil
of lint between the scull and dura mater,
and thus press on the artery, and this 
lint, if not large could not in commode

(91
the brain by its pressure. This I have never yet
used. Might we not in obstinate cases, order pressure 
by an assistant for 30 minutes or more?
I have never seen the bleeding in any of these 
cases prove troublesome; and rather than use 
the ligature when there was no wound,
I would try astringents, as agaric, alum, blue 
vitriol, &c and by these means, there will be 
no difficulty in succeeding.
Before I quit the subject of compression, I 
will warn you of a very usual error into 
which both physicians and surgeons have 
fallen. From the identity of the the symptoms 
of intoxication and compression, they 
may be confounded together. The agree exactly 
in the loss of voluntary motion, puking, dullness,
sleepiness and every other symptom. But 
by an inquiry into the previous conduct, you 
may draw the line of distinction.
I say 'physicians', as apoplexy has been also 
confounded with drunkenness. Dr. Gregory
related a case of a man who had drank to excess
and was treated as an apoplectic by

92)
bleeding, blistering, stimulants, sinapisms,
&c and the man was cured!
An hostler who was intoxicated, fell among
a horses feet and received a wound
of the scalp. One of his companions save 
him, and took him to an infirmary. The 
surgeon shaved his head and enlarged the
wound by a crucial incision, but was 
astonished to find no fracture! It being at 
night, the head was dressed, and a consultation
determined an trepanning early next morning.
But when morning came, and the 
man awoke, he saw himself queerly situated:
an old nurse standing by,- his head 
felt very strangely tied up- and he in the 
infirmary! He demanded what was the 
matter? The nurse told him "hush, my 
man, you must be trepanned today."!!
The smell of the breath may be a very safe 
criterion; also the following. When I was the 
house surgeon in St George's Hospital, a woman
was brought in for a supposed injury

(93
injury of the head. Suspecting another cause, I 
poured a stream of cold water on the upper lip
for some time: the head began to rotate from 
side to side, and at last she got up, and demanded 
the reason of such insolent treatment 
as was used with her!
d. Inflamation of the brain. The symptoms 
of inflamation never follows immediateley 
after the cause which produced them.
They are all of the febrile kind. The face becomes
hot, and is overspread with a blush, headache 
follows, nausea and often vomiting supervene,
the pulse becomes hard and full, delirium,
coma, and restlessness soon follow.
These symptoms seldom come on before a week
or ten days after the injury. Indeed I have known
12 months supervene before the inflamation
come on. This was the case with Captain B.
Turner, who in escaping from a sinking vessel
into a boat, received a contusion on the head
and which was followed by a swelling on the 
occiput. He arrived in a town in Holland, and 
a german physician gave him a wash of 

94)
brandy, and the blue pill, (suposing the case
venereal, he having had the lues 4 years before)
after three months, no relief occurring, but headache
coming on, he came to England and Mr
Blizard continued the blue pill, but no alleviation,
nor salivation could be produced. 
and he was advised to go to a warm climate.
In June 1809 he arrived in Philad. and aplied 
to D Rush. Three weeks before arrival, he 
had the aura epileptica, commencing in the 
hand, and terminating in violent fits, and 
the arm becoming paralytic, and the leg
on the same (left) side becoming numbed. The 
Doctor bled and purged him freely, confining 
him to a very low diet.
No relief being found, I was consulted, the 
fits still continuing. I laid the bone bare
by a free incision. I found it very rough on 
its surface and wasted. I did not hesitate to 
apply the trepan, and on removing a piece
of the bone, I found the dura mater adhering 
strongly to the bone, and much indurated. 

(95
Four days after, it proved fatal, and on dissection,
pus was found both on the dura mater 
and also in the pia mater. Here was inflamation 
in the membranes a full year after the 
blow was received.
The causes of inflamation of the brain may
be either a contusion without any wound,
a fissure without depressure, or a fracture
with depression of a piece of the scull.
1. After concussion, the teguments become puffy
and flaccid, and on laying them open, they 
will be found detached from the bone, and 
if a perforation be made, the internal surface
of the bone will also be found detached.
The pericranium, instead of its florid colour
is found pale and in fact dead, and within,
mucus [cross out] or pus will be found on the dura 
mater.
2. and 3. Fissures or fractures with depression 
are very apt to produce inflamation, with 
them, there is generally a wound of the scalp.
Instead of healthy granulations, there are pale 
and flaccid ones, and they become so as soon

96)
as the inflamation commences. Instead of 
healthy pus, a thin bloody ichor only is discharged,
and the pericranium will separate 
from the bone, round the perforation in 
it. At the same time, the dura mater will separate 
in the same way.
Mr. Pott supposed this to arise from the vessels 
which carry on the circulation thro the 
bone becoming destroyed, but I have reason
to doubt of this explanation. It appears that 
the life of the bone is completely destroyed.
In all injuries of the brain, whether simple
contusion, fissure, or fracture with depression,
inflamation may therefore be expected.
The scalp may indeed be largely separated 
from the scull, and no symptoms of inflamation 
or suppuration follow, but union 
by healthy granulation follow, especially if 
the wound be produced by simple incision. 
Thus, the injury in communicated no deeper than 
to the external membranes of the head, but 
when a great concussion is received, the effects

(97
effects of it are communicated to the internal parts
of the head, not only to the membranes but to 
the brain itself; and inflamation and suppuration 
may come on as far as the parts are 
injured.
This is not merely a speculative point,
but one of great practical importance.
When pus is formed under the dura mater, I 
believe it is always fatal. Pus on the surface
of the dura mater may if let off prove 
of little injury. Therefore in all cases of inflamation,
a perforation with the trephine 
is always to be made, and this as soon as the 
symptoms of cerebral inflamation run 
high. By this timely measure, if suppuration 
is confined to the dura mater alone,
it may be prevented from doing any injury,
as all the pus will escape; and if 
any sloughs form in the dura mater, then 
also will find a free exit.
It is a question of some importance,
whether in the first instance of fractures
without depression, or with it, the perforation

98)
ought to be made, or to wait till symptoms 
of inflamation come on? Mr Pott was in 
the habit of trepanning in all cases of fracture,
immediately, but modern surgeons, having 
seen many recoveries from fractures, w.t
out trepaning have rejected this aphorism.
When the bone is depressed, indeed it is best 
to operate immediately, as the rough bone 
may irritate the dura mater, producing 
inflamation, suppuration and even ulceration.
But I would never trepan for simple 
fracture. Depression, or symptoms of inflamation 
must be apparent before I undertake
the operation of trepanning.
Even after evident depression of the bone, recoveries 
have occurred without trepanning,
but I would not deduce any rule from this.
Therefore, simple fracture, without any symptoms
of compression needs not to be trepaned.
But when depression has occurred, it is 
best to take out the piece of the bone. 

(99
When any other causes of inflamation, which 
I have mentioned occurs, the means to prevent 
and moderate inflamation must be used.
After a blow on the head, the patient must be 
confined to a very low diet, and bleeding and 
purging must be employed. If symptoms of 
inflamation appear, we are to bleed again,
and again, to apply the trepan, and to apply 
a blister over the head: a remedy well calculated
to reduce inflamation in the brain.
Cold applications are very serviseable. Clothes
wet in cold water, or in vinegar and water
are very useful.
e. Of concussion of the brain. Concussion of the 
brain is a certain deranged state of the brain
following blows on the head, which proves 
fatal often in a few minutes, and on dissection,
no marks of injury are found. It appears 
however, that a larger number of the 
minute vessels are ruptured. If the patient survive
some hours, the brain will be found
be set with drops of blood shed from these

100)
vessels, and if he survive for a day or two, the whole 
brain will have a bruised appearance.
Just in the same way do we often see blows 
on the reigion of the heart produce sudden 
death, and yet no symptoms appearances 
of derangement can be found on dissection.
If perfect rest be observed, the effusion of 
blood may be in many cases prevented.
Mr. Abernethy exceeds all authors in the description
of this state. Its progress according 
to him is as follows. 1st stage. The functions
of the brain are quite deranged, the stupor 
is complete, the patient is insensible, his breathing 
is difficult, tho not stertorious, and his 
extremities are cold and this state of stupor 
does not last long. 2nd stage. In this, the pulse 
and respiration are better, heat and sensibility 
increase, the patient will answer to 
a loud question, especially if it concern his 
own feelings, otherwise his answer is incoherent,
and he seems employed about something 
else. There are few symptoms of inflamation;
soon this state is followed by

(101
the 3rd or inflamatory stage, which is the 
most important of all.
Some surgeons recommend stimuli, as wine,
and if they succeed, they do very serious mischief.
If the establish the pulse and face 
respiration, inflamation and extravasation 
soon follow. I enjoin perfect rest, and keep 
the head elevated, and as the action recovers,
cold clothes with water & vinegar are applied
to the head. As the pulse rises, I bleed freely,
and thus inflamation and suppuration 
of the brain may be prevented.- Cases are 
repoted in which the patient recovered in whom
stimuli were used from the beginning, but 
the practice is very dangerous. The first 
case of contusion I have seen, I treated wt.
success by bleeding, while in St. Georges Hospital.
f. Inflamation of the brain, after it has 
subsided sometimes leaves a state of stupor
or idiotism. This was first treated with 
success by Dr Rush, who gave mercury 
so as to excite a salivation. He made 

102)
this discovery as early as the year 1795 or '6,
and it has been since spoken of by Mr Abernethy,
whose book was published in the year
since this. The plan adopted by Dr. Rush is 
found very successful.  Dr.P.
January 15th 
1812
Lecture 30.
It remains for me to explain the operation of 
perforation of the scull, for the purpose of elevating 
a depressed portion of bone, and for giving 
an exit to extravasated fluids, compressing the brain
The most common instrument for this purpose 
is the trephine, or circular saw, with a centre pin
for fixing the instrument. This pin is moveable 
in the handle, and by a pin in this, it may be 
protruded to any distance, and screwed fast so.
In the trephines of the older surgeons, this pin 
was fixed, and at a certain period of the operation,
this was removed by a key but this is of no service,
and protracts the operation. Thus, their

(103
center pin being always alike long, was very apt 
to wound the dura mater, as in thin sculls, especially 
in children. But the pin which easily 
is slipt up is very convenient.
The older surgeons used conical trephines,
and this, with a view of avoiding wounding the 
dura mater by a sudden plunge of the instrument,
after going thro' the scull. But this is very 
inconvenient, and tedious shape is quite superceded 
by proper care, and all danger of wounding 
the dura mater is avoided by the precautions
I am shortly to describe.
Before this instrument is used, the integuments
must be divided and dissected off. A common 
scalpel will answer this purpose. The iron 
is to continue to the end of the handle of 
this instrument, and to project in a square
form, to raise the pericranium from the 
bone. This quite supercedes a raspatory, which 
is an instrument for this puropse, used by 
some surgeons.
The elevator, which is a simple lever, a little bent

104
must also be at hand. This instrument is 
often made too convex.*
In most cases of trepanning instruments,
a lenticulator (which is a knife with a thick 
ede and a spoon-like point) is found, but the 
purpose for which this instrument is made
viz. cutting off rough edges and spicula after
the piece of bone is removed, is fully, and wt 
more convenience answered by the elevator.
The circular saw of Mr Hey should also be 
at hand. This is used when the depressed bone
is capable of being raised, except on account of 
one neck of bone, or one of these on each side.
This prevents in many cases, the dura mater
being stripped by the circular perforation, and 
is found very convenient.
It will also be proper to have sponge, lint;
needles, tenaculum, a ligature, and a soft poultice 
at hand.
The hair may be shaved off, to shew the extent 
and situation of the wound, before the 
scalp is further removed.
*The tripod is also useless, and superceded by the 
common elevator

(105
The incision may be made, or the wound,
(if there be any,) enlarged. The older surgeons
made a circular incision, and removed a 
large portion of the scalp, and repeated this 
if nescessary, and thus destroyed the covering
of a large portion of the cranium. I have 
see one half of the scalp removed in this way
Even Mr Pott advised this plan, but it is never 
nesccesary. A simple incision down to the bone 
is generally sufficient, and the pericranium 
is to be removed as we have described. If 
nescesary, an incision at right angles, or even 
a crucial incision may be made and the 
corners dissected away, but not removed.
When the cranium is fractured into many
pieces, there is considerable danger of wounding 
the dura mater with the scalpel, and 
therefore the incision is best made in this case
on the firm part of the scull, and from this,
we can dissect to the injured parts.
If an artery should be cut in the scalp, and 
bleed much, rather than trust to pressure, I 
would secure it with a needle, or tenaculum, 

106)
otherwise, it may bleed in the night. Some advise 
to deplete, by leaving such vessels open,
but this is much more conveniently done at 
the jugular vein or arm.
Some surgeons perforate the scull with a 
perforation, but the centre pin of the trephine
does this much more expeditiously.
The pin is to be applied on the sound bone,
but so near the fissure, as to include as much 
of the depressed portion as may be. This is done 
to avoid pressing the portion deeper, as our
efforts with the trephine might have this 
effect, if the pin rested not on the sound, but on 
the depressed bone.
The sawdust may be wiped from the teeth of 
the saw, and from the groove with a towel, which
answers better than the brush commonly used
As soon as the groove in the bone becomes deep
enough to retain the saw, the centre pin may be 
removed, as if left, it might wound the dura-
mater, which we have seen is very dangerous. 
Even before the grove is compleat, the pin 
must be shifted up in cases of thin sculls.

(107
We must very frequently examine the groove
with a tooth pick, to feell if any point of the 
circle is cut through, in which case, you must 
bear obliquely on the uncut part.
It was the ancient mode to mount the trephine
on a large handle, with a crank in 
the middle; this was applied to the surgeon's
breast, and thus their labour was lessened!
but the pressure thus applied was very dangerous
and unjustifiable.
It is common for this instrument to be made
too thin in its edge, and thus the groove will
not admit the levator, and when we want 
to work obliquely, we are unable to do so.
As soon as a considerable groove is made,
tho' no part of the bone be cut though, we may
try with the elevator to raise it, by breaking 
the vitreous table, thus avoiding most completely,
wounding, the dura mater, and if 
the bone be thicken at one side than the other,
this will particularly answer. The 
spiculae may be broken out with the levator,
and thus, the operation is completed.

108
Forceps are of no use in raising the circle.
This operation is considered by some to be 
easily performed and simple: but to perforate 
the scull; [cross out] and to avoid the dura mater requires
considerable attention, and I have seen errors
committed in this, twice prove fatal; inflammation 
of the brain having followed. We ought 
therefore always when one portion of the circle
is through, to avoid it very carefully.
Mr. Heys saw, in the circumstances we 
have mentioned is a very convenient instrument.
In the use of it, the dura mater is 
also to be carefully avoided.
After raising the depressed fragments, if this 
was the cause of compression, the symptoms
will cease, but if much blood is extravasated 
under the scull, more holes may be 
required to evacuate it, and if the symptoms
of pressure continue, the dura mater may
be separated from the scull for some way.
If blood be extravasated through the cavity 
under the dura mater, it is doubtful

(109
as we have shewn, [how dangerous it is] whether it is proper to 
puncture the dura mater with a lancet, but 
if in any case it is chosen to do so, which in 
general is improper, the puncture must be 
very small.
Having raised the depressed fragment or extracted
it, with the levator, the scull is to be 
dressed. A soft, light poultice is the best dressing.
Lint, which is generally used adheres
to the dura mater, and is not easily removed
in a future dressing; while the poultice separates 
very easily.
When the dura mater is pierced by spicular
or punctured by the surgeon, the scalp is 
to be brought over it, so that it may directly 
adhere, and prevent inflammation of the brain
In this way I treated a fracture of the squamous
part of the temporal bone, in which 
there were many fragments, and the dura
mater perforated; yet the patient recovered.
This may be done in cases of depression &
may prevent exfolian of the scull, but when


110)
extravasation has happened under the dura 
mater, and especially if a coagulum remains,
the orifice is by no means to be closed,
but simply a soft poultice applied.
The ancient surgeons forbid our operating 
on particular parts of the scull.
1. We are cautioned never to trepan the frontal
sinus. Here the tables of the scull are 
not paralel, and if it should be required
to trepan this part, the perforation may
be made in the usual way thro' the outer
table, but on the inner, the trepan may
be applied also perpendicular to the surface
of this plate also. If a ridge remains which 
the saw will not cut safely, it may be broken
with the levator.
2. They deem it improper to perforate over 
the longitudinal or lateral sinuses. Haemorhage
from this vessel is easily stopped by a 
little lint. But this vessel may generally 
avoided, unless it lie in a deep groove in the 

(111
bone, and even then, by working obliquely on one 
side, and then on the other. But there is little
hazard in the haemorrhage; the only danger being
that of wounding the dura mater beside
the artery sinus. This may be prevented by 
prizing out the piece of bone before quite cut
through, and breaking the remaining ridges 
with the levator, guarding the dura mater with 
an iron spatula.- If blood be shed under the 
bone, there can be no hazard; but we cannot 
depend on or judge of this before the operation is over.
3. It is deemed unsafe to trepan over the anterior 
inferior angle of of the parietal bone,
for here the median artery of the dura mater 
lieg, but tho' there is some degree of danger
here, by care, the vessel may be avoided. If it 
be wounded, it may however be stoped in most 
cases by a dossil of lint put into the groove it
lig in, or if the artery be inclosed in a bony
channel, the plug of soft wood as we have 
mentioned may be pushed in.
4 The occiput is deemed unfit for the operation,
but, with the precautions for others

112)
cases of unevenness on the scull, this objection 
like all the others is of no Value, and the 
scull may be trepanned in any place where
a fracture can reach, excepting the basis 
of the scull itself. So that all these rules,
so carefully held inviolate by our ancestors
are of no consequence whatever.P
Jan. 17
Lecture 31.
Of Diseases of the eyes, and first, of inflamation.
This may be seated in the eyelids, conjuctiva, 
cornea, or globe of the eye.
Inflamation of the eyelids is acompanied
with a serous discharge, and with a burning 
pain, and after comes on suddenly. It 
is produced by extraneous bodies, mechanical 
violence, &c.
If much pain and fever attend, bleeding, low 
diet and a mercurial purge may be prescribed, 
and the parts may be kept moist with 
diluted brandy, &c and may be expected soon 
to subside. 


113
Inflamation in the edges produces effusion 
and ulceration, and the discharge is so purulent
and viscid as to glue the eyelids together, and 
they cannot be opened without difficulty in 
the morning. The seat of this disease is said
to be the Meibomian glands, but I suppose 
it to arise from inflamation and ulceration 
round the roots of the hairs, thus resembling
tinea capitis, and if the hairs be 
extracted, just as in that disease, the sore will
heal up. The treatment of these two diseases 
is the same. Sperma ceti oil had succeeded 
well. It is recommended to touch the 
eyelid with lapis infernalis, and in this way
I once succeeded. lung Citrinum, [spermaciti]
If strong mercurial ointment, are powerful remedies I have extracted 
the hairs with twizers, and thus succeeded 
after the ointments have been tried 
to no puropse.
When the conjunctiva and cornea are the seat 
of the inflamation, the white membranes 
become red by the admission of anusual. 


114)
quantity of blood. The eye waters, light becomes
offensive, the eye feels hot and burning, and 
the pain is communicated to the temple and 
and fore head. The inflamation is sometimes confined
to a spot near the edge of the cornea. The 
eyes when thus inflamed are very irritable to 
light, we cannot easily get a view of the eye,
and the patient guards off the [inflam] light 
with his hand.
If the inflamation be over the cornea, there
is danger of opacity in this, and on the conjunctiva,
the speck mentioned leaves a film,
which, if near the inner canthus, it forms
what is called unguis.
The causes of this are, mechanical injuries,
viz blows, &c also the inversion of the cilia,
called trichiasis; acrid substances, as lime,
acids, smoke, violent excercise of the eyes,
too much light: and I have known it produced 
by the eye being wit with urine, in 
a young man having gonorrhoea.

(115
The globe of the eye may be inflamed in the anterior 
chamber, or the posterior, behind the lens.
When in the former situation, the pain is of a shooting 
kind, and varies much according to the violence 
of the causes. It sometimes proceeds to 
suppuration, and then, the pus may be seen
in the anterior chamber of the eye.
Inflamation in the posterior part is more
severe, the pain and fever run high, and vision 
is lost, yet the conjunctiva appears not 
much inflamed.
In all cases, the mechanical causes, if 
they continue to act must be removed. To 
remove sand or pieces of iron which stick in 
the coats of the eye, the ball is to be fixed by 
a speculum, and the body removed by a lancet.
Substances under the eye lid may be 
removed by a wet rag, or by syringing 
them with warm milk and water. If this 
fail, the inner surface of the lid may be examined 
by raising the lid.
When the eyelashes are inverted, constituting 
trichiasis, the cause of irritation must

116
be removed. This may depend either on the 
hairs growing inwards, or contraction of the 
eyelid. In the former case, the hairs must be 
pulled out, and St Yves says if destroyed by lunar 
caustic, they will not grow again
In case of contraction, an operation is required.
The tarsi, at the inner and outer ends have 
been cut thro', and, no success has followed in
any case I have heard of. Some assert that 
by cutting the skin lining the lid, they have
removed the stricture, but I have never seen 
any success from this mode.
A late author describes an operation, which 
consists in separating the tarsi from the skin 
without, and the conjunctiva within, thus 
separating its lateral connections; but I 
never tried this mode.
A few years ago, Dr. Dorsey had a case of this 
sort in the Alms House, and after trying to 
cure it by various operations, was obliqed to 
extirpate the whole edge of the cartilage, and 
the sore healed, and the eye was still very well 
defended by the eyelid. This is a mode which

(117
deserves imitation in all similar cases.
In all cases of opthalmia, bleeding is to be used
freely, according to the pain and fever. When 
enough of blood is evacuated in this way, cups 
may be applied to the temples, [and] or 30 or 40 
leechs may be applied to the same part. The vessels 
on the surface may be cut by the shoulder of a 
lancet, or they may be raised with fine forcepts,
and divided with scissars, but I prefer the 
lancet. Purging is also required. Mercurial 
purges are by far the best. The antimonial 
powder, of the P. Hospital answers very well.
The applications are to be mild. Poultices
of bread and milk are very good. The pith 
of sassafras may form one of the best remedies.
It may be applied in form of a poultice,
or as a fomentation dissolved in water.
Blisters may be applied behind the ears, on 
the nape of the neck, or on the shaven head.
After the inflamation is considerably subsided,
laudanum is a valuable remedy. Sugar
of lead, white vitriol and laudanum 
may be united in a collyreum.

118)
But stimuli must never be applied before 
the inflamation is much subdued, else the 
inflamation will be increased. Vinegar is a 
valuable remedy in such cases; the rotten-
apple-poultice is particularly serviceable after 
evacuations have been used.
If matter form in the anterior chamber of 
the eye, certain measures must be used to produce
absorption, but if the eye be made very 
tense by the matter, an incision, such as 
used for the extraction of the cataract, must 
be made, to prevent opacity in the cornea.
When opthalmia is of long duration, a 
salivation is one of the best remedies.
In all cases of opthalmia, particular care
should be taken to avoid light. The chamber 
must be dark, and excercise of the organ 
avoided. The diet must be vegetable, & 
animal food, and spirits avoided.
After severe cases, a sition may be made in the 
neck to prevent a relapse.
In many cases of protracted opthalmia,

119
the action seems to have something peculiar
in it. A gentleman, who had had a tender state 
of the eyes from his youth, had a severe [atta??]
which lasted 3 months; he was bled during 
that time, to ℥ iso, purged very freely, blistered 
had issues almost constantly, and was often 
scarified, and all to no good purpose. I directed
tar water to be applied, first to one eye, & 
after some time to the other. It brought him 
from a state of blindness, to free use of the 
organ, and tho' the application was very stimulating,
it produced no pain, but suddenly 
subdued the inflamation.
Various stimuli have been used. In one 
case, after bleeding, blistering and purging
had been used to no purpose, a solution of 
blue vitriol (in proportion of gr ij to ℥ water)
succeded buy and conception. In a week, the 
man was nearly cured.
Surgeons fear the use of stimuli in these 
cases from the tenderness of the organ, and 
indeed, the evacuating remedies, as bleeding, purging
and blistering must have been used before any 

120
stimuli are proper, but in protracted cases 
they are required. Solution of soap in spirits 
of wine have been of service in some cases.
Specks on the eyes have been cured by a mixture 
of sugar, alum and nitro! A solution 
of salt in water and vinegar, and sea water 
have been well borne in some cases. Red
precipitate, with a little camphor has been 
well endured, and succeeded in some cases, after 
the evacuating plan had failed.
Unguis. This, as we have mentioned, is an enlargement 
of the coates of the eye by inflamation.
When the thickening extends
along the conjunctiva over the cornea, vision 
is obstructed. The whole enlarged membrane 
must be dissected off. That part over 
the cornea, after being raised by fine forcepts
must be carefully dissected away with 
a knife, and the part over the schtonica may 
be cut away with scissars. It must be dissected 
very closely from the caruncular lachrymalis,
else it will return again. This is of 
much importance. 

(121
Specks. The best remedy for small opaque specks
on the eye after inflamation, is mercury. Locally,
gentle stimuli are proper, as corrosive 
sublimate one grain, water four ounces, but 
if there be inflamation produced by stimuli, 
they increase the opacity. But a ptyalism,
with low diet is the best, and most 
certain remedy.
When the part of the cornea, over the pupil
is rendered opacque by inflamation, an artificial 
pupil has been made by opening 
the iris with the needle, opposite to the 
transparent cornea. When the pupil is closed 
by adhesion, an operation [??lour] can cure 
it, by making an artificial pupil.
of Fistula Lachrymalis. To understand
this affection, the anatomy of the 
lachrymal sac and duct, the puncta lachrymalia,
and the adjacent bones must be 
well learned.
Stricture, or obstruction in this tube produces
a swelling in the inner canthus of the 

122)
eye, and if pressure be made on this, water and 
pus escape by the punctae. In this state, the 
eyelids will be glued together in the morning, &
opened with difficulty. If the sac be ostructed 
by disease, or by cold, pain and fever come on,
the part becomes very tender. In this state,
bleeding, purging, and low diet may sometimes
suceed, but generally, the tumor bursts 
externally. Before this can occur, it is the best 
practice to open the external part of the tumor,
give vent to the contents, and then introduce 
a probe into the duct toward the nose, & 
try to overcome the stricture. In this simple
way, I have succeeded in curing the complaint
But the nasal end of the tube is often so 
completely obliterated, as to preclude the fesibility 
of this. It is then nescesary to make 
an artificial opening into the nostril, for 
the future passage of the tears, by puncturing
the of unguis, which is the only division 
between the nose & eye in this place.
Mr. Pott performed this with a bent trochar,
after which, fragments of bone surrounded

(123
surrounded the opening, and were united by membrane.
It was nescesary to wear a bogie in the passage
for 2 or 3 weeks, to prevent its healing up, and 
even after this, it sometimes did heal up.
Mr. Hunter, seeing the imprefeations and in
conveniences of this plan, introduced a mode of 
striking out a circular piece of the bone, by 
an instrument resembling a punch, the 
bone being supported by a flat piece of horn 
introduced up the nostril.
This plan produces immediate relief, and 
after it no bogie is required.
This disease is sometimes complicated
with caries of the bones. In this case, the 
detached piece of bone is to be extracted, and 
the sore treated as another carious ulcer.
At the next lecture, the operation will be
performed on the dead subject, and the minutiae
of it explained.   Dr. P.
January 20.1812,

Lecture 32.
Fistula lachrymalis continued. Stricture in the 
ductus ad nasi, producing accumulation of 
tears, and swelling, may be divided into several 
stages, well distinguished from one another.
1. In the first, no inflamation has appeared, & 
pressure on the sac produces a regurgetation of a 
[mucus] water, and then mucus. Very little is to be 
done in this case. By pressing the fluid out of 
the sac regularly, the distension will be prevented,
part of the tears will return to the eye,
and some will flow into the nose. The eye may
be washed with a weak vitriolic collyeyum, as
white vitriol gr 1 or 2 to water ℥i, and I have seen 
the complaint disappear by this simple plan.
The French recommend injecting the sac with 
warm water by a fine syringe, but pressure 
is sufficient to cleanse the canal. Sir Wm Blizard
recommends injecting mercury, but no 
particular benefit results from this.
2. If by carelessness the sac be suffered to distend 
itself, and the patient expose himself to cold, inflamation

125
inflamation comes on, and parts appear just as 
a common boil. By the use of bleeding, purging, low 
diet and blisters, with a lead water poultice, we 
may prevent suppuration, and reduce the complaint
to the first stage; when it may be treated 
in the same way
3. In the third stage, pus has formed in the sac,
and generally escapes by an ulcerous opening 
in front of the middle of the sac, and the 
true fistula lachrymalis now is formed.
It is nescesary to remove the stricture, and establish
the evacuation of the tears into the 
nose, else the sore will never heal, and from 
inattention, patients have been teased by caustic
&c when the cause of the ulcer was not suspected.
The plate of bone (os unguis) which separates 
the sac from the nostril must often be
perforated, but before this is done, every measure 
must be tried to establish the natural passage
The external opening (if small) may 
be dilated with a bistoury, to introduce the 
probe. 

126
We may be called to operate before the duct is 
much distended, and not easily felt, and also,
the fistula may be so small and circuitous 
that we do not find it possible to introduce a
probe along it; therefore we ouht to know the 
true situation of the sac, and the place to cut
so as to find it. The incisions must commence
just below the inner canthus, and continue
parallel to the edge of the bony orbit. Thus, by 
beginning always below the canthus, we avoid the 
tendon of the orbicularis muscle
A probe is now to be introduced into the duct,
and carried down to the nose. In so doing, we feel 
the stricture, and overcome it. The probe may 
be withdrawn, and a bagie introduced, or what 
is much better, Mr Naru's silver probe. This consists
of a silver wire, the end of which is a little 
bent, and mounted with a flat head set on 
oblicquely, and the face of this after being heated,
covered with black sealing wax, so as to 
appear just like a black patch.
This may be left in. It does not produce 
much pain, and the tears pass along it to

(127
the nose, tho' this might not be expected.
This stilette has been borne for months, and 
is to be left in till the stricture is overcome. It 
may be removed and cleaned occasionally, and 
is then easily reduced to its place again. When 
the stilette is prematurely with drawn, the stricture 
will recur, and renew the disease where
as, if left in the due time, the canal will 
remain pervous, and the sore will heal very 
well after the stilette is removed. Thus the 
disease is generally easily cured.
But in some cases, the natural canal is 
not capable of yielding, and even the bony 
canal is found closed. Then, the artificial 
passage is the only resource.
When the os unguis is punctured by Mr.
Potts trachar, the fragments suspended together
by membranes are ready to reinstate
themselves again. To operate with Mr Hunters
punch, which is the best way, a piece of 
horn is to be introduced up the nostril, so as
to support the os unguis; the bottom of 
the sac laid bare, and the punch applied,

128)
and the bone may easily be perforated by 
few rotatory turns of the punch, and there 
will be a circular piece of bone neatly cut out.
The external wound may be immediately 
healed. The lips of the sore are to be brought 
together by adhesive plaster, and will soon 
heal up. The bone having no loose fragments,
will not heal up and the sac remains 
pervious, and conducts the tears into 
the nose without any inconvenience.
Of the Cataract. This consists in an opacity 
of the chrystaline lens and its capsule,
whereby the rays of light are prevented from 
passing to the retina.
It appears in an uniform whiteness of the lens,
or only in a speck. It first causes a dimness
of sight, as if gause was hung before the eye,
or threads, spots &c.
It often comes on spontaneously, and may 
in other cases be referred to mechanical violence.
Many remind us have been used to disperse the

(129
opacity. Mercury stands at the head of these.
Setons, purges, blisters, low diet, &c are also useful
Those cases which proceed from external violence 
may generally be removed by medicine.
They very commonly yield to a salivation.
A lady received a wound in the eye, by a puncture
with a needle, which reached the lens, considerable 
inflamation and finally opacity followed,
and she lost the sight in that eye. Bleeding,
blistering, purging and low diet were tried, but 
had no effect on the opacque lens. I pursuaded 
her to submit to a salivation, and as soon 
as the mouth became sore, the opacity began
to lessen, and before the salivation ceased 
the eye was perfectly restored. But she was 
still obliged to use a convex glass, and it therefore
appeared that the lens had been quite absorbed,
and the eye left in the same state as 
after extraction.
Spontaneous cataracts, I have never seen 
removed by medicine, and only once relieved.
As medicines fail, an operation alone can be 
of decided service. This consists in removing

130)
the opaque lens from the axis of vision 
Several means have been used for this purpose:
two operations continue still in use.
1. Couching, wherein the lens is pushed aside,
or to the bottom of the eye, so as to leave the 
passage for the light penetrable [the?ts] and,
2. Extraction, wherein a transverse incision 
is made thro' the transparent cornea, and 
the lens extracted thro' the iris and cornea,
so as to leave the eye in a transparent state.
Couching is the easiest as well as the oldest 
of these modes of operating, and is still 
strongly advocated by some surgeons, particularly 
Percival Pott, and Mr Hey of Leeds,
but I give a decided preference to extraction,
for the following reasons.
1. Couching is by far the most painful operation.
When extraction is performed by making 
the incision with a single stroke of the knife
it produces almost no pain, whereas, introducing 
the kneedle through the adnata and 
scletoric coat and the subsequent motions 
are very severe.

(131
I performed extraction on a man who had 
had couching performed on the other eye, and 
he could not believe that the operation was 
over till seeing a watch, he was convinced,
and he reflected with horror on the operation 
which had caused his eye to suppurate and 
waste away in the socket. I have even been 
requested to operate on the second eye immediately,
so trifling was the pain after 
extraction in many cases.
2. The lens after depression may, and after
does rise to its place, after which patients, 
will not (as some say) submit to the repetition 
without reluctance. When extraction 
is performed, the operation is complete.
3. When the cataract is fluid, the anterior 
chamber after become muddy, and the 
kneedle is in danger of tearing the iris. It 
is indeed said that the fluid will be absorbed 
again, but still, it is nesceray to repeat
the operation, to depress the nucleus 
of the lens.

132
4. When the capsule of the lens is also opacque,
the operation must be repeated on this if depression 
be performed, but in extraction, the capsule is 
easily removed either entire, as I have often had 
it, which could be seen by suspending it in water,
or piecemeal. When the capsule adheres very 
strongly to the ciliary process, it will be raised 
to its site very soon after couching, and appear 
behind the iris again.
5. Ahesions frequently form between the iris &
lens, and in extraction, I have found it very easy 
to separate them with a gold kneedle, whereas
in couching these adhesions remain, and the lens
will soon be reinstated again, and the repetition 
of the operation is required. Mr. Hey performed 
couching in such a case, no less than 
five times.
Therefore extraction ought to be always prefered.
Indeed objections have been raised against extraction,
but we shall soon see how far these 
result from awkwardness in the operator,
1. The incision in the cornea is said to leave the 
cornea opacque, but this is not the case; if the 

(133
operation be done well, the eye remains clear.
But if a dull knife be used, or the operation finished
with scissars, the eye may inflame, and becomes 
opacque; but the incision should not be 
near the pupil in any part, and therefore the 
passage of light remains unaltered.
2. The force in extracting the lens is said to 
make the pupil irregular, and so injure vision 
and I have more than once seen the pupil made 
irregular by extracting a hard chrystaline,
but this never injures vision in any degree.
Yet this is very rare, and may be avoided by 
proper care in the force applied.
3. The iris sometimes doubles under the knife
and may be injured if neglected, but if the incision 
be stopped, and the surgeon press and rub
gently on the cornea with the fore finger of 
the hand which is at liberty, the iris goes back
and the operation is easily finished.
4. The vitreous humor is said to escape sometimes
in couching, and this has actually 
been the case, but, it is always the effect of 
awkward pressure made on the eye, after



134
the incision is made. Moderate pressure is 
to be made on the eye during the incision
for the sole purpose of steadying the eye, and 
as soon as the cornea is cut, the pressure is 
to be entirely removed, and the vitreous humor
is in no danger of being moved. These objections 
are therefore of no importance. and extraction 
is the only proper operation. Dr. P.
Jan, 22d.
Lecture 33.
Cataract Continued. Before operating for the 
cataract, we ought to ascertain the probable
effect of the operation, whether or not success is 
to be expected. This is of great importance, as 
our character, as well as our patients ease may 
be sacraficed in a useless operation. The principal 
circumstances to be attended to are these.
1. That the eye in every respect (besides the 
state of the lens) be natural. That the cornea 
be clear, the eyelids, and thin edges free from 
inflamation and oedema. That there be no
tendency to inflamation, as in some cases

(135
the least injury will cause much inflamation 
2. That there be no pain in the fore head.
This circumstance is often met with especially 
in women. If this symptom exist, we can 
moderate it by bleeding, low diet, purging 2ce
or 3ce a week. In a case in which there was 
considerable head-ache, I gave purge twice a 
week, for nine months, and then operated 
with success.
3. That the iris retain the power of contracting
on the application of objects.
But if the power of distinguishing objects 
continue, we may not be deterred.
This iris may be fixed by adhesions to the capsule
of the chrystaline lens, and unable to 
move, yet if light can be distinguished from 
darkness, of telling the number of windows
in the room, of telling when a hand, a hat, 
&c is interposed between the eye and window,
&c the operation may be successful; but in 
such cases as do not bear these marks, you 
should never operate, as the retina will be in 
a state of torpor, the state called amourosis

136.
Even the pupil may retain its nobility,
and yet the retina be paralytic. An old
lady applied to me for a cataract, which 
was in this state. I extracted the lens, which 
was as hard as a stone, but to my surprise,
no power of vision remained. I then operated 
on the other eye, and in this, vision was 
restored. Now the pupils in both eyes moved alike 
by the light, tho' they were in an opposite 
state.
If the eye be in any of its coats inflamed or 
swelled, these symptoms may be removed by 
bleeding, purging, low diet, and blisters to the 
nape of the neck. The last remedy is particularly 
recommended by Baron Wenzel.
The operation is never to be poured on an 
eye in any degree inflamed, and measures are 
to be taken to prevent inflamation. In all 
cases, except when the patient is very weak, the 
diet should be low, entirely vegetable, and 
if the habit be full, blood should be drawn 
from the arm. 

(137
The most suitable seasons for the opertion
are spring and fall. In summer, the patient 
cannot lie still in bed the requsite time 
and in winter, the cold may produce inflamation,
and therefore mild weather is to 
be chosen.
The instruments used in extracting the cataract 
are the following.
It is common to fin the eye with a speculum,
by separating the eye lids, and applying it 
round the eye under the eyelids, it having 
a groove to receive the tarsi, but this is an unnescesary 
instrument. The eye[s] being opened
and held for a minute or two becomes steady
and the operation is to commence at this moment,
and it will be easy to keep it steady 
during the incision, without this painful 
and alarming instrument. This instrument 
occupies one hand, and if the iris folds
under the knife, we cannot make the nescessary 
friction on the cornea to press that back. I 
have performend this operation frequently, and 
never found it nescesary to use the speculum,


138)
speculum, but if it is used in any case, it 
will be found very convenient to have 
a ring in the end of the handle to put on 
the little finger, and then we can hold it 
with this, the mid-finger and thumb, and 
so have the fore finger at liberty; and these 
obviate this objection of Baron Wenzel. But 
still, the instrument is inconvenient.
The knife is then, the first instrument. Its 
blade may be 1 1/4 inch long 1/4 inch broad at 
the broadest part, and the sides straight lines
from this to the point. The edge is to extend 
to the broadest part in front, and to 1/10 inch 
on the back so as to make an exquisite point
I have said 1/4 inch broad: but it may be broader 
than [illegible] the diameter of the cornea, so 
as to cut its own way out by a simple push 
and must be very sharp, so as not to push
the eye obliquely, and so as to cut the cornea
without irritating it to inflame, and become 
opaque. See the description of this instrument,
in Wenzel.

(139
The second instrument is a kneedle for tearing 
the capsule on the anterior part of the lens
which may be a little bent, sit in a handle
and having on the end of the hand, a scoop 
for removing portions of the capsule which
may remain after the chrystaline is evacuated.
A small hook is also to be provided, with 
which the lens, may be extracted in case 
it should fall down into the vitreous humor
and only its edge be seen. This is often of great 
use.
Small forcepts are also nescessary, for extracting 
the opacque capsule, from behind the 
chrystaline, either piecemeal or entire. They 
are to touch not only at the points of their blades
but also to touch by flat surfaces, at least 1/10
of an inch. These instruments are of the 
first importance in completing the operation.
Before proceeding to operate, a bandage is 
to be put round the forehead, and to it, two 
compresses are to be pinned

140)
The compress which covers the eye to be operated 
on is to be pinned up. These render 
the eye steady. The patient is to be seated on 
a low seat and the surgeon on one much 
higher. All the windows in the room except 
one are to be closed, and the patient is to be 
set with one side of the head to that window.
Thus alone, the pupil can be seen distinctly.
The assistant is to stand behind the patient,
and support the head on his breast.
He is also to support the upper eyelid, by
holding the skin of it double over the sperciliary 
ridges, and make moderate pressure 
on the eye. The surgeon keeps down 
the lower lid, and makes moderate pressure 
also.
He is to apply the point of the knife to the 
eye, and not puncture it till the involuntary 
motion is over, else the knife may start,
and make a second puncture, and the aqueous 
humor will ooze out by the first,
the cornea will shrink and the iris fall in 
the way of the knife!

(141
The knife being applied at 1/12 inch from the 
junction of the iris and sclerotic coat, and 
the eye steady, the point of the knife is to be 
carried horizontally, and parallel to the iris
is to be brought out at the same situation
in the cornea at which it entered, and carried 
thro' with a single push; and never drawn back
but if the iris fold under the knife, pressure 
may be made on the cornea till this falls into
its place. As the knife fills up all the 
incision, none of the water can escape, but 
if it were withdrawn in any degree, or if 
the knife were not broad enough to cut 
itself out without being moved out of a direct 
line, the aqueous humor would escape.
As soon as the cornea is transfixed, all 
pressure must be removed; we having only 
to support the eyelids, and the knife being 
sufficient to fix the eye, which is as 
[cross out] it were hooked on it. Thus no pressure 
being made after the cornea is open, there is
no danger of evacuating the vitreous humor.

142)
Next, tear the capsule, with the kneedle in 
as complete a manner as posible, and with 
moderate pressure, the chrystaline lens will 
escape by the pupil an cut in the cornea. If the 
lens do not pass the pupil easily, the eye
may be exposed to darkness for some time,
that the iris may be relaxed, and thus, all 
danger of tearing the iris will be averted.
Gentle pressure may be made on the globe
to facilitate the exit of the lens, and if this 
does not follow very freely, the needle may 
again be introduced thro' the cornea and 
iris, the point fixed into the chrystaline,
and this extracted. This supercedes improper
pressure.
After the extraction of the lens, if filaments 
of membrane remain, they are to removed 
by the scoop, and if an opaque membrane
is seen behind the site of the lens, it may 
be removed by the forcepts.
When the operation is over, the compress is
be brought down, a piece of soft linen applied
over the eye, and secured by a bandage passed

(143
passed round the head, and the patient put to 
bed. His hands are to be secured with tapes fastened
to the bed cords, so that the cannot be 
lifted higher than the breast. This is of great 
importance. In one case, after the operation
was performed well, the patient on waking 
out of sleep, forgetting the cause of irritation 
in his eye, rubbed this, so as to evacuate 
the greater part of the vitreous humor
and so destroyed the organs.
In ten days, the eye will have united again.
Low diet, rest and perfect darkness 
are to be observed.-
We might have observ'd that after the incision 
is made in the cornea, we may rest 
a minute or two as in that time, the irritation 
of the incisison will be over, and 
the kneedle will be better borne than if 
this were neglected.   Dr. P.
Jan 24, 1812

144)
Lecture 34.
Cataract continued. Of Couching. And first 
of the instruments. It is common for operators 
in couching to use a speculum, and there is 
no objection to it, if the operator choses however,
it is unnescesary. The eye may be opened, the 
eyelids fixed, considerable pressure may be made
on the eye, this will then become steady, and 
now the operation may be performed. After the 
kneedle is introduced, it fixes the eye.
The kneedle used by Mr. Pott, was spearpointed,
but ingenious men have made many improvements 
in it. They have reduced its length to 
1 1/2 inches, and thus, rendered it very manageable.
The spear point, making too large a hole [prevent] permit 
the escape of some of the vitreous humor, but 
the round instrument now used makes no larger 
an orifice than the rest of it occupies.
It is made flat toward the point, as Mr. Hey has
directed, and I have also adopted, from Scarpa, the 
method of having it bent toward the point, 
1. becuase it is less entangled in the iris, 2, because

145
because after pushing the lens back, we can very easily
carry this crooked kneedle before it and fix it
very easily, 3, because with this it is very easy 
to depress loose, remaining pieces of capsule with
the bent kneedle.
This operation is very simple. The patent being 
seated on a low chair, and the supported by an
assistant, and him facing a window, and the eyes
opened as in extraction. The kneedle being applied 
at 1/6 of an inch from the edge of the transparent 
cornea, it to be pushed thro' the scletorica
to the chrystaline lens, the point is then to 
be applied to the lens so as to push it back,
and the kneedle insinuated between the iris and
the lens, the point is now to be fixed into the 
lens, and, and by elevating the handle of the 
kneedle, you depress the lens down to the bottom
of the eye, and immediately, the pupil will 
be seen black behind the iris, instead of the opacque
chrystaline. If this first motion do not 
perfectly succeed, it is very easily repeated.
It is nescessary for the kneedle to be very 
sharp, and even so, considerable force is required

146)
required in piercing the coats of the eye, and in so 
doing, an indentation is made. To remedy this inconvenience,
I puncture the eye with the point 
of the extracting knife, and then, use the kneedle
as usual. To depressing the lens, it may always 
be observed to keep the concave surface of 
the kneedle downward.
The operation being finished, the eye is to be covered
with a compress, this secured by a bandage
and the patient put to bed. In 10 or 12 days,
after the inflamation is over, the eye may be
examined, to see the effect of the operation.
The cataract is sometimes soft, and cannot 
be depressed. The advocates of couching break the
anterior part of the capsule, and all which escapes
into the anterior chamber will be absorbed,
and probably the posterior also; but if any 
remain, the operation is to be repeated again and 
again, till all the opaque matter is absorbed.
There are also cases of fluid or milky cataract,
in which also, the anterior part of the lens is 
to be ruptured, that the fluid may be absorbed.

(147
Thus, couching is a very easy operation; only one 
or two instruments being used. The principal 
danger consist in the liability of the iris to be 
wounded. Steadiness and skill are required to overcome 
this difficulty. But this operation seldom 
succeeds in restoring vision. I have frequently performed
it, and only in one case, I never restored the 
sense of sight. In all cases but that one great
inflamation followed the operation, and in two 
of them, the symptoms of gutta serena came on 
I was obliged to use depleting means, as purging,
blistering in these cases. From the above reasoning,
I have determined never to perform this 
operation, but to extract all, except in children, in 
whom the eye cannot be easily managed, and 
especially when the cataract is milky, in which 
case, couching may at least be tried on one eye
before extraction.
Artificial pupil. When the part of the cornea opposite
to the iris obscured by an opacity of the cornea, which 
cannot be removed, and another part remained 
transparent, we may make a hole in the iris opposite 
to the transparent part.

148)
The pupil is sometimes closed by inflamation.
This also, the iris may be opened.
I once succeeded in a case in which only one eighth
part of the cornea remained transparent, which 
was in the upper edge.
The patient being seated, and the eye opened
is in extraction, and pressed upon considerably,
the cornea is to be divided as in extraction,
with this difference, that before the opposite side 
of the cornea is punctured, the knife is to be so 
far retracted that a great part of the aqueous humor
may escape, and a flap of the iris fall before 
the knife, and now by finishing the operation 
by one cut, a round portion of the iris is cut
out. This is the simplist way of operating, and 
may prevent the introduction of forcepts and 
scissars which may injure the lens. Thus I
have operated with success several times
But when the pupil is closed, the iris cannot 
be brought afloat before the knife, and consequently 
we cannot succeed in this way; but as 
as soon as the knife is within the cornea,
the point of it is to be carried down, and the 

(149
pupil cut to about 1/10 inch, and the open incision at 
in the usual way thro' the cornea. The flap 
this iris may now be cut with fine scissars, which 
may be curved near the point, or what is [illegible]
slender forcepts, on one side whereof, there is a
curved edge. But as the causes of the closure of 
the pupil are violent ones, the operation may 
readily renew this, and therefore, before operating,
the patients should be told that the success 
of [of] it but a mere chance; and we 
only operate in uncertainty.
Hydrocele. This is a collection of water in 
the scrotum. The situation of the water produces
essential difference in it.
1. The anasarcous hydrocele, in which, this 
water is contained in the cellular substances
of the scrotum,
2. The hydrocele of the tunica vaginalis teses,
and
3. The encysted hydrocele of the spermatic
cord. As the treatment of these is essentially
different, we ought to distinguish them wt.

150
accuracy.
1. The first species presents an equal tumor,
whhich includes the whole scrotum, on both 
sides, and the raphe divides it into two in the 
middle. The tumor is of its natural colour,
and the finger makes an impression which 
lasts some time. The spermatic cord can easily
be felt in its natural situation. Thus the case
is readily discriminated.
2. The collection in the vaginal coat is supposed
to arise from the increase of the natural secretion
the torpor of the absorbents or the rupture of the 
lymphatic vessels. It commences near the testicle,
is generally confined to one side, is not lessened 
by pressure, is firm, and in the beginning,
the testicle can be felt but in the end cannot
be felt. It may be distinguished from.....
Hernia, by beginning at the bottom of the scrotum,
by being firmer, by being irreducible by 
pressure, by the spermatic cord being distinctly
felt, whereas the hernia presents all the opposites 
of these phenomena. Fluctuation, and 

(151
transparency may often be perceived.
Schirrus testicle, it is easily distinguished by 
cord being generally enlarged and irregular in 
the former, from the tumor being in this also 
heavier and more opaque than in hydroclele
From Hernia humoralis by its having no connection 
with gonorrhoea, by the tumor not 
being so firm in hydrocele, and by other symptoms
of water.
3. When one or more cysts of water are lodged in 
the spermatic cord, the testicle is always felt at 
the bottom of the sac, fluctuation is evident,
and the tumor is diaphanous. This tumor extends
to, or even beyond the abdominal ring,
and may be well distinguished. In a case of 
this kind, I saw some difficulty in distinguishing 
it from hernia. The tumor could be pressed
up (and as it were reduced) but immediately
returned, but fluctuation and transparency,
were evident, the testicle could be felt at the 
bottom of the scrotum, a puncture evacuated 
the water, and the wine injection competed 
the cure.

152)
Method of Cure. The bulk and weight of the 
tumor is often so slight, that patents are 
unwilling to submit to the operation.
The pain, either in the part or in the loins
is much alleviated by a suspensary bandage.
1. In the anasarcous species, tho' the case is 
not connected with surgery, we are often called 
to evacuate the water. Punctures are to 
be preferred to scarifications or setons, as 
the latter may produce mortification.
Five or six punctures will evacuate the water,
and the dressing may be dry lint.
I have seen the tunica vaginalis when 
distended with water, suffer a rupture, and produce 
one of the 1st species. An old gentleman
while setting in his room felt some thing give
way in the scrotum, and the tense tumor of
the vaginal coat was exchanged for a soft
diffused, lived one, and mortification was feared.
I was consulted 3 days after, and prognosticated 
that the breach would heal up, the water 
be absorbed, and the disease resume its
former state, and just such was the result

(153
2. In the second species, little can be done by 
medicine. I have seen it cured by the affusion of 
cold water. Temporary ease may be procured by
evacuating the water with the trocar or lancet
and then introducing a canula and insetor
till the water is carried off, and then covering
the puncture with adhesive plaster.
Simple as this is, I have seen three surgeons
puzled by a simple case in London. The first 
who was called, plunged in the trochar at the 
usual place, the inferior, anterior part, but 
no water followed the stilette. The wound 
was suffered to heal, and then a second was 
called, who also failed in the same manner.
Such also was the fate of the 3rd who could procure
nothing but drops of blood. Mr. Hunter
was now called in. On a very close examination,
he found that the testicle lay just 
at the place where the surgeons had chosen to 
operate, and that they plunged their trochars
into the substance of it. He operated on 
the inferior posterior part of the tumor, just 
where we usually find the testicle, and with

154
complete success. This teaches us always to 
feel the testicle, before operating.
The radical cure can be affected by exciting 
inflamation in the sac, so as to obliterate it
I have cured it by repeated tapings, in one 
case in which, the testicle was so inflamed and 
enlarged that I feared to inject wine. Tevacecated 
the water as soon as the coat was distended
enough to keep the instrument off the 
testicle. Low diet, and mercurial purges were
used. The water was let off every fortnight.
Several ways have been used to obliterate the sac.
1t. Incision is the most ancient. It consists of 
in dividing the skin and vaginal coat, and 
filling the cavity with lint. Great inflamation 
and suppuration came on, the lint was separated 
gradually, and the cavity united.
But this remedy is very severe, attended sometimes 
with haemorrhage, and shreds of lint
remaining often produced abscesses several 
weeks after the sore was healed.
2d. As the tunic is sometimes thickened, the 
removal of it has been proposed by Douglas

(155
but this is quite unnecessary.
3d. Caustic. The whole tumor, from top to 
bottom has been laid open by a caustic, which 
on the separating of the eschar, produced very 
great pain and inflamation, followed by 
the obliteration of the sac. Mr Else has confined
the caustic to a shillings breadth, and this is 
found sufficient. But the caustic is a very 
uncertain remedy; often faling to reach the 
sac, often causing violent inflamation, fever
and supuration, and when the water is 
contained in sacs this does not succeed.
4th Tent. A skein of silk was carried from 
the bottom to the top of the tumor. This often 
answers, but often causes only the tract betwixt
the tunic and testicle in which it lies
to be united, and the disese returns on the 
sides of this.
5. Monro left the canula in the sac, until it
produced the nescesary inflamation, but according 
to Cheselden, this mode is very painful,
and he prefered the tent. 

156)
6. Injection. Lately, the ancient mode of injecting
stimulating fluid into the tenica vaginalasis
has be revived. Wine, or wine and
water have been particularly recommended by 
Sir James Earle. This he has shewn to be perfectly 
safe and easy. In a few cases, indeed
this remedy will fail.
I once succeeded in curing a case with warm 
water alone, in the Penn Hospital, contrary
to my expectations; and I have since read 
Mr. Whateleys report, to the same import.
But wine, or wine and water are found very 
convenient, safe and not painful. If no inflamation
follow, it may soon be repeated
The patient is to be seated opposite to a window,
and the surgeon kneeling before him, makes the 
evacuation either with a trochar and or with a 
small lancet and then introduce a canula.
As soon as the fluid has escaped by the canula,
the injection of wine or wine & water, (being 
prepared in a bladder with a stop cock) is to 
be thrown thro' the canula into the tunica


(157
tunica vaginalis, and as soon as pain is felt in 
the scrotum or loins, which is in general four 
or five minutes, the liquor may be allowed to flow 
back again, the canula with drawn, the orifice 
closed with plaster, and the scrotum supported 
with a roller, which prevents inflamation.
In four or five days, the scrotum becomes red, tender
and covered with a blush, and in four or five 
more this goes off, with the disposition to renew 
the disease. If the inflamation run high, 
the patient may be confined to bed, and to low
diet, evacuating measures used, and a leadwater-
poultice applied. But if the inflamation 
be defective, the patient may walk about his 
room and use stimulating food.
To avoid the canula's escaping from the orifice 
in the tunica vaginales, which would cause 
the injection to pass between the skin and cellular
substance, and mortification, the canula
may be introduced full 2 inches and laid on 
one side. This never happened to me, but I 
saw it in the practice of another.
Jan.28.1812.  Dr. P.

158
Lecture 35.
In speaking of the treatment of the hydrocele
by injection, I observed that in a few cases, that 
operation will fail. I am to describe a late 
and successful operation for these cases, described 
by Mr. Hunter.
It consists in making an incision of 1/2 inches
long on the anterior inferior part of the scrotum,
thro' the skin and cellular substance, and piercing 
the cellular membrane, so as to lay bare the 
testicle. The state of the testicle may be seen.
The scrotum must now be filled, not with lint,
but with flour, or rather dough, made into balls 
of 1/2 diameter, holding the lips of the scrotum
asunder by two hooks, one in the left hand, and the 
other given to an assistant. After the tunica vagnalis
is moderately distended with these balls, a
piece of patent lint is put into the mouth of 
the sore, and the whole suspended in a bag-truss.
In case of much fever or inflamation, blood may be 
drawn, &c. In 2 or three days, a poultice may be applied
over it, the cavity will suppurate the dough

(159
will come away melted in the pus, the cavity appears
just as a large abscess, and the whole will 
very uniformly unite. I have performed this operation 
several times with perfect success.
Of Herniæ. Herniae, or ruptures are among the 
most important surgical diseases, from their 
frequency and their great dangers and inconvenience.
They consist of tumors, caused by the protrusion 
of the natural contents of the abdomen 
through its parieties.
They occur most frequently at the upper and 
fore part of the thigh, at the navel, and the groin.
The twin rupture is improper, as they consist of a 
sac of the peretonuem, pushed thro' some natural opening.
Thus, at the navel the navel, there sometimes
remains an opening in the foetus, imperfectly
closed, which admits of these accidents, and 
in the groin, the ring of the external oblique muscle,
thro' which the spermatic cord in the male and 
the round ligaments in the female pass, is the 
aperture at which the inguinal or scrotal 
hernia, or oschocele pass out, and in the upper,

160
and fore part of the thigh where the crural or 
femoral hernia is seated, the hernial aperture
consists of the cavity under Pouparts ligament.
All the contents of the abdomen have been occasionally
found in hernial sacs, except the 
duodenum and pancreas; but the colon and 
mesentery, and omentum are the most usual.
Hernia are named from their contents, as 
enteracele, epiplocele, gastrocele, &c.
The congenital hernia or that in which,
the protruded parts lie in the tunica vaginalis
testes, arises from that aperture in which the 
testicle [cross out] descends, not being closed before 
birth, and there is still a communication between
the peritoneum and tunica vaginalis.
In such cases, when the child coughs cries, &c the contents
of the abdomen may descend, but when pressure 
is made on it, it easily returns again. By frequent
repetitions, the communication remains open, and 
subject to rupture through life._ We shall treat 
of the bubonocele at length, and then treat of 
the peculiarities of the others.

(161
The bubonal or inguinal hernia is characterised by a tumor
at the abdominal ring. Astley Cooper says it begins 
at the distance of 1 1/2 inch from the external opening,
on the external side of it and higher up. It is 
easy to press the tumor up again; by lying horizontally,
also, it may be reduced, but on rising, or on 
making any pressure with the abdominal muscles,
diaphragm, &c, it is returned again. We see 
the progress of the tumor from the upper to the 
lower part of the scrotum. I have seen it descend
as low as the knee, and suspended by bandages
round the patients neck.
On dissection, we find the tumor to consist of 
1. (After laying aside the skin of the scrotum)
a number of tendinous bands united together
by fascia, which is derived from the obliquies externus
above the abdominal ring
2. The fibres of the cremaster muscle
3 The hernial sac. See A. Cooper. But these 
are sometimes so blended together as to appear 
many more in some instances, yet the above
ordor is universal.
Behind the upper part of the sac is found the

162
spermatic cord. At the bottom and posterior pt 
of the tumor is the testicle, the abdominal 
ring is the mouth or aperture of the rupture and 
and between this and the symphysis pubis,
is found the epigastric artery. In a few cases 
the spermatic cord is found on the anterior side
of the sac. This teaches us always to proceed wt
caution in operating.
Symptoms. 1. The tumor commences at, and 
proceeds from the abdominal ring in the groin.
2. The tumor is increased by the erect posture, 
et. v.v.
3. Is increased by coughing, straining the diaphragm,
abdominal muscles, &c.
4. When intestine is returning we hear a gurglinng 
noise, and
5. When intestine is down, the functions of 
the bowels are interfered with. Nausea, vomiting,
colic pains, costiveness &c are produced.
Diagnosis. 1. From hydrocele. a. by beginning above,
whereas hydrocele begins from the bottom of 
the scrotum, by the abscence of fluctuation
and the cord not being felt in hernia.


163
b. by being increased by the erect posture, pressure
with the muscles, of the abdomen, diaphragm
Thus, we can easily avoid mistakes in these cases
2 From swelled testicle. a. by the causes of this 
as suppressed gonorrhea, external violence, & 
being known. b. by the swelled testicle being 
hot and painful. c. by the swelled testicles
going off suddenly at any time like herniae,
d. by most of the diagnosis betwixt herniae & 
hydrocele.
3. From bubo a. by the connection of this with 
chancre, and being painful. b. by the bowels 
not being interfered with in buboes. c. by bubo
tending to suppuration.
4. From cysts on the spermatic cord. a Tho'
this and inguinal hernia have many features 
in common, when the cysts lie along the cord,
yet this one circumstance is a certain diagnosis,
vizt that if pressure is mad on the tumor,
if it be hernia, it will be lessened, but 
if an encysted tumor, it will not be lessened
in size, but go up in a mass and descend 
just as it went up, immediately. b. By the

164
effects of a puncture in evacuating the water
of the cysts, and so curing the disease.
5. From Varicocele, or a varicose state of the 
veins of the cord, it is considered difficult to distinguish
hernia. When the patient lies, the tumor 
is lessened, and when he stands, the pressure
of the column of blood enlarges it again, such 
also is the effect of coughing, straining, &c.
a. But in varicocele, we can feell, and even see 
the convoluted form of the veins under the skin,
b. A. Cooper proposes to lay the patient horizontally,
to take hold of the cord, and let the patient 
rise again. In hernia, a considerable 
pressure will be made against the fingers, but 
in variococele, this will not be considerable. But 
the first method is preferable, and even tho motion
of the blood in the veins gives a sensation
which prevents any deception when we feel it.
Causes. The causes are 1. Such as weaken the 
parceters of the abdomen. 2. Such as increase the 
pressure of the intestines. &c against them.
3 Both causes united. General debility, as after 
a fever, in old age, &c disposed to hernia.

165
Blows on the abdomen, pregnancy, strains of 
the diaphragm or abdominal muscles, [cross out],
great corpulence, violent coughing, straining
to stool, violent exercise jumping, lifting great 
weights, &c are causes of the second order. When they
act, the contents of the abdomen may be more or 
less forced thro' any weak parts in the parieteis
Thus I have twice seen herniae produced in young
men by carrying in a back leg.
Of the Treatment. For convenience in practice,
herniae may be divided into the following 
orders.
I. Such as are of easy reduction.
II. Such as can only be reduced by particular
management.
III. Such as tho' unattended with stricture, are 
irreducible.
IV. Such as are attended with stricture.
Of the first, it may be obseved that as long 
as intestine or omentum remain down, there
is always danger, even when there is no pain.
Stricture may occur, the contents of the bowel

166
may be stopped, and after frequent descents of 
the omentum, the passages [to be] kept open 
so that the gut may pass down, and this is 
liable to be the case as long as any omentum
is down. While any part remains down, the 
whole may be enlarged by the causes of herniae,
and stricture may follow this second descent.
Therefore the contents of the sac are always
to be reduced, and prevented from returning
by proper compression made on the mouth, or 
neck of the sac, after reduction.
This indication is answered by a truss, or 
slender steel spring, which goes more than 
half round the body, and the circle completed by 
a strap. On the end of this is a pad. A bandage
is applied in the groin, reaching from before 
backwards, to prevent the truss slipping up.
In applying the truss, let us recollect why it is 
used? That it may effectually keep the gut up
it must act on the ruing accurately. This part
presents a pit to the finger after the reduction 
of the intestine &c.
Instrument makes generally err by applying

167
the truss too low, thus pressing on the cord, testicle,
&c and allowing the mouth of the ring to be kept
open, which is the case when the truss acts over the 
pubis. The lower edge of the pad should act just 
over the upper edge of the pubis. The head of the 
truss is sometimes made of silver or ivory, and 
made so as to turn olbi[c]quely at pleasure so 
as to accomodate corpulent persons. The metal 
mentioned is chosen for not rusting. The part 
may be defended by a muslin compress, when this 
instrument is made of these materials.
The truss is to be worn night and day. I have 
known it affect a cure in nine months in a person 
of a good constitution, but the truss ought
never to be laid aside before two years. Aged persons 
must wear the truss always, as in them 
the cure cannot be expected. I know, however, 1 
exception to this, in a man of 50, in whom,
the ring united perfectly.
The exciting causes are to be avoided during the 
use of the truss, as costiveness, lifting weighty bodies,
riding a rough-going horse, violent excercise
&c. And when any exertion is made, the

168
patient should assist the truss, by pressure
with his hand, particularly if costive, or if 
he has a stricture in the urethra. These directions 
are essential to his safety.
Second order. The protrusion is sometimes so 
large that tho there be no stricture, the reduction 
cannot be affected. In this case the patient
must be put to bed, confined to a low diet,
to loose blood and to use purgative medicine.
Thus, the tumor may be lessened, as reduced,
and then the truss is to be applied. I have
often succeeded in this way, in these cases.
Third order. Tho' there be no stricture, the reduction 
may be impracticable, either from 
the shape of the tumor, adhesions betwixt 
the guts, or betwixt the gut and sac, or by ligamentous 
bands. In this case the tumor is to 
be carefully suspended by a suspensary bandage
and the patient often enjoys comfort, yet is 
not freefrom the danger of stricture. [See M.
As in hydrocele the sac has sometimes burst,
so has the hernial sac. In this case the gut

(169
will be found under the skin, and the gut must 
be reduced first through the ruptured aperture, & 
then into the mouth of the sac, into the abdomen 
But this case is very rare. [See N,D. Dr. Ph
Jan.29.
Notes on Lecture 35.
L. Page 165... After the hernia has been lessened 
in size by these remedies, we may by taking hold 
of the remaining tumor, in most cases reduce 
it, if it has not gone up spontaneously.
M. Page 168.... This order is only known by its 
not yielding to the remedies mentioned above (168) 
& cold applications
No above... The suspensary bandage not only 
prevents pain and great inconvenience, but 
by warding off the dragging of the tumor, prevents 
more of the contents of the abdomen being 
displaced. It is to be lined with soft materials.
A. idem... During the use of the suspensary, the 
state of the bowels requires attention. Costiveness,
and the use of flatulent food are to be 
particularly avoided.
Jan 31

170)
Lecture 36.
Hernia continued... Fourth order. We now come 
to speak of herniae, with stricture. Stricture in 
hernia consists of a tightness at the orrifice as
neck of the rupture, which injures the functions 
in the gut, or vessels of the protruded parts.
The tumour becomes hard, the patient becomes 
unable to stand, nausea and vomiting sooner 
or later come on, an antiperistaltic motion 
of the bowels is established, fœcal matter 
is vomited and if the gut be strangulated, no fœces 
can escape per anum, but what may happen
to lie beyond the stricture.
If the tightness be such as to injure the circulation,
and injure the venous circulation, inflamation,
with considerable swelling and 
fever comes on the colour of the tumor is not 
red, but of a dark leaden colour, just as in 
phlegmon before mortification.
The stricture may even be such as to stop the
circulation altogether, and produce mortification.

(171
When that is the case, the belly swells, becomes
very tender, the pulse becomes small and very 
weak, elilliness in may cases, which is followed 
by great restlessness &c occur, and death 
soon follows. But before the fatal hour, (which 
may be protracted from one to several days) it 
is common that a delusive interval occurs. The 
tumor becomes soft, and returns into the abdomen,
and the patient fancies himself nearly 
well, when death is just at hand.
On dissection, the bowels at the seat of the 
stricture are found of a chocolate colour, tender,
and easily torn with the fingers, and even
holes are often found it in.
When the omentum only is strangulated,
all the symptoms are much milder.
All these effects are produced by the pressure 
of the tendons thro' which the spermatic
cord and hernia pass. The ring of the obliquus
externus is the most usual seat of this. But Mr. A
Cooper has shown that the cause of the stricture
is frequently higher seated, viz in the obliquus
internus and transversalis. 

172
This is particularly the case in old and in 
large ruptures. The stricture is said to be spasmodic,
but no muscular fibres are concerned
When this is the case, cutting the ring will not 
relieve the stricture, but we must operate 1 1/4
inches higher up. This is the distance intervening 
betwixt the internal and external orifices,
but in old ruptures, these orifices are 
approximated, so that the internal one is just 
behind the ring.
In all cases of strangulation, effectual measures
must be taken to remove the stricture.
As soon as a patient is the subject of one of 
these accidents, he places himself on the ground 
horizontally, and makes pressure on the tumor.
If he fails, the surgeon is called upon. He 
places the patient in a bed, with the foot of 
it raised, and relaxes the muscles on the anterior
of the thigh and abdomen, by flexing the 
former on the pelvis, and by bending the pelvis
upward. He then takes hold of the tumor,
and presses it upward and outward, but not with 
any violence, which might irritate and even


(173
burst the tumor. If this remedy, viz position 
with tanis fail, other remedies are to be tried 
in the following order.
1. Bloodletting. This may be performed and delinquim
animi, and then, the termis will very 
often succeed very easily.
2. Warm bath. The whole body should be 
introduced into a bath at or near 100 and continued 
till faintness comes on. It may very 
often be practicable to reduce the rupture 
now, by the taxis.
3. Purges. I have found mild purges, particularly
rum, tart, and jalap in small doeses often 
repeated, given with some essence of peppermint,
of great service. Glysters at the same 
time being given. Mr Hey condemns purges 
entirely, but when the intestine is not in 
the strangulation, and in old cases, they answer
very well. But in case of strangulated 
gut, the only increase the vomiting.
4. Tobacco in form of infusion or smoke is 
a well known resource. The smoke is the most 
active, the infusion the milder remedy. 

174)
Tobacco ʒi infused in water [illegible] forms an infusion,
of which, one half may be thrown up 
every half hour, till the desired langor is produced,
and the reduction may generally be affected. 
Dangerous symptoms sometimes follow 
this remedy. In one man last summer, the 
powers life had nearly vanquished by the usual 
quantity, and Astley Cooper mentions a 
case in which the infusion of ℥i produced pain,
and vomiting, followed by death in 25 minutes 
in a girl. Care is therefore requiste in the 
use of this remedy. Perhaps ℥i of the infusion 
would be enough to begin with. Of all other 
remedies, this is the most effectual, and the quickest
in manifesting its result.
5. Cold. A bladder filled with pounded ice may 
be applied to the tumor, or if this cannot be 
had a solution of salts in vinegar & water, or 
crude sal ammonia ℥v nitre ℥v water [illegible]
be put into a bladder, and applied. These remedies
are very effectual. But they are not to be 
too long continued [in], as the part has actually
been frozen. 

(175
6. Opium. This remedy is indispensible in allaying
the sickness and vomiting and to be effectual,
must be given in large doses. 2 grs may 
be given by the mouth, and ʒi of laudanum injected.
In case of a man who had suffered strangulation 
for 3 days, I gave 3 grs of opium at 
night, and put him to rest. He slept well 
all night, and in the morning, the intestines
was found reduced.
But if these remedies fail, the operation for 
removing the stricture must be performed.
As to the time of operating; it is better to operate 
too early than too late. In the latter case
mortification or peritoneal inflamation will
have supervened. The most celebrated men are 
in the habit of operating early, even as soon 
as 24 hours.
We may make it a rule, in all cases after bleeding,
warm bath, purges, tobacco and cold, with a proper posture, taxis
and opium have failed after a fair trial to operate immediately.
By doing so many will be saved.
It is very difficult to ascertain the state of 
the hernia by the symptoms. Langor, hiccup,

176
hiccup, coldness of the extremities, small and weak
pulse &c are said to denote mortification, but 
I have seen the operation successfully performed
with perfect success, and the parts found 
to be sound. The duration of the stricture is 
no rule: patients have died in 8 hours, and they 
have survived 17 days. The fever is also uncertain 
When the countenance is sunk, the pulse weak
and the extremities cold, I have seen the operation 
performed with success.
Hernia are more dangerous in the middle 
aged than in the young or old, in small
than in large, and in recent than in old cases.
When the circulation is stopped, death is 
certain.
One symptom may be regarded as certainly 
fatal, viz coldness of the extremities, [This]
and a cold and moist state of the skin. This is
always a forerunner of death, and if the operation 
be performed under such circumstances,
it will always fail.
Of the Operation. The patient is to be laid on 
a table covered with a blanket. The pubis shaven

(177
An incision is to be made with a scalpel from 
1 1/2 inches above the ring to the bottom of the sac
unless this be very large, the skin and cellular 
substance are to be cut and the tendon of 
the external oblicque exposed. The tendinous 
fibres on the surface of the tumor are to be divided,
and the sac punctured by several very 
delicate strokes* of the knife, trying if the probe
will enter it. As soon as a puncture is made 
the director is to be so far introduced and the sac out on this as to allow
the finger to be introduced. On the finger 
the bistoury is to be applied, and the sac
divided as far as to near the ring but no farther.
By introducing the finger through the 
ring into the abdomen, the stricture can 
very easily be divided by passing the probe pointed
bistoury along the finger. The incision 
may be made upward, or upwards and a little 
outwards. If done inwards, the epigastric artery 
will certainly be wounded, and as the 
artery in a few cases lies on the outside, it is 
best to convey the bistoury directly upwards,
*No water being contained in the sac.

178)
as Mr Cooper advises, and then the artery cannot 
be wounded.
Mr. Cooper advises us for the purpose of preventing 
peritonial inflamation to carry 
the bistoury through the tendon only introducing 
it not within the sac, but betwixt 
this and the tendon.
The above is the way in which the operation 
is generally performed, but some late surgeons,
particularly Monro make no incision 
into the sac atale, but after dissecting 
down to the sac, cut some fibres of the 
tendon of the muscle in muscle with the scalpel,
and then introduce the bistoury.
After dividing the stricture, the part protruded 
may be easily reduced by the taxis.
This operation is exceeding by simple and easy,
and attended with no hazard whatever in
the hand of a careful operator. Dr. P.
Jan. 31.

179
Lecture 37.
Crural hernia continued. When the sac can 
be returned thro' the enlarged ring without being 
divided, this ought always to be done, this 
operation being the most simple, and tends to avoid
pertioneal inflamation; but when the strictured
gut is mortified, the sac must always be opened.
Also if we cannot reduce the sac after dividing
the tendon, the cavity of it must be open'd
and the cause examined, which may be 1. Adhesion
2 alterations in the shape of the parts protruded or
3 stricture at the neck of the sac.
1. Adhesions betwixt the gut and sac, if they be 
long may be divided, but if very short, the portion 
of the sac connected to the bowel may be cut
off and returned with the bowel. Dissecting adhesions 
near the mouth of the sac is difficult
and can only be done by laying the tendon
bare all round the adhesion.
2. When a large mass of omentum is low 
down, and is not retracted, it may be cut off
and the vessels tied, leaving the end of the

180)
ligature out at the wound.
3. Stricture of the neck of the sac is not a frequent 
occurrence: I met with a case of it in July,
1798. A man of 38 years of age was attacked with 
a severe colic which had continued several days.
He had been subject to a tumor in the groin for 
two years, which went off as soon as pressed upon
or the patient lay. A few days before I was called
this tumor had come down in consequence
of his lifting a heavy piece of wood. When I was 
called. I found the wrists cold, the pulse small and 
trembling, the belly tumid, the scrotum swollen, 
vomiting obstinate and no passage by stool
tho' the pain and swelling in tumor were much less than
before my arrival.
I advised an immediate operation, as the symptoms
of mortification were present. I made an incision 
through the skin and cellular substances
from above the ring to the bottom of the tumor,
dissected the sac free from the tendon and laid
the former open, but to my astonishment found 
nothing but bloody serum therein; no gut, no stricture

181
stricture and therefore there could not be in the tumor,
any cause capapable of producing the above
symptoms! Is the case produced by inters [sersc??]?
In these obscure circumstances, no remedy was 
applied except warm bath and purges of jalap & 
cremor tartar; but the man died in 36 hours.
On opening the body, a portion of bowel was 
found closely embraced by the mouth of the sac
which was retracted into the abdom a considerable 
way above the ring, and not at all in contact
with the fascia which usually embraces
it. What ought to have been done, had the true
cause of the disease been known? Ought the sac
to have been pulled down and divided? or ought 
the tendon to have been opened, and the neck 
of the sac cut within the abdomen?
The bowels are never to be returned in a mortified 
state into the abdomen. However, the symptoms
may seem to indicate mortification 
and yet the bowels be found sound. When a
sudden mitigation of the pain comes on, the 
tumor becomes purple, creptus is heard on

182
handling the scrotum, the belly becomes tense
the patient very restless, his skin hot, his pulse
weak and quick, and the hernia easily reduced, 
little doubt need remain.
Yet such a set of [set of] symptoms are not
always fatal. I have seen a negro who was 
in this situation recover, but with an artificial
anus at the groin, where the upper portion 
of intestine terminated after the slough 
separated.
After opening the sac, we can judge of the 
state of the gut. But the dark red, or chocolate
colour of the intestine, produced by impeded circulation
is not to be mistaken for mortification. 
The mortification is generally confined 
to spots, the texture is so altered that the gut
tears under our finger and has an offensive
smell. If the dead spot be small the bowel may 
be [small] returned, as adhesion will fix the surrounding 
parts to the peritoneum &c and the 
slough pass by the forces, but if there be a hole
in the bowel, it will require a stitch. 

(183
When the whole cylinder of the intestine is destroyed,
we are advised by Mrs. Cooper and Thompson
to cut away the slough and secure the tendons 
of the bowel together by four sutures, leaving 
the end of the ligature out that we can [dia??]
out and at any time examine the bowel. But 
the accumulation of fœces in the upper porton 
of the bowel is commonly such as to rupture 
the stitches, or at least to cause the escape 
of fœces from the gut into the general cavity.
I perceive that Mr. Cooper himself failed in two 
cases of this kind.
I should not ever try Mr. Cooper's way. I would 
leave the intestine out, and if the slough were not 
separated, I would open the bowel at the dead part
with the scalpel, to give evacuation to the feces, which 
is always profuse for the first 24 or 30 hours. The 
ends of the intestine would be gradually appoximated,
they would as gradually retract within 
the abdomen and the external wound heal up.
In July, 1798 a woman was attacked with a violent
colic and tumor in the groin, which continued 
several days. The physicians bled, blistered,

184)
and purged her, but the vomiting increased, the 
extremities became cold, the pulse small and feeble,
hiccough and swelling and hardness of the abdomen,
the tumor became hard, the colour of 
it dusky red. She had had a tumor in the groin
after severe parturition 2 years before, and it was 
plain that the hernia, which was femoral in this 
case was mortified. I made an incision through 
the skin and cellular substance, fœtid serum
and air passed from it, the tumor hung like 
an egg by a small neck; I next laid bare the tendon
and cut Pouparts ligament at right angles.
I next cut a hole in the gut, and introduced
my finger to the place of stricture.* The passage
through the bowels was [slow] by artificial means for four days. 
[cross out], the external 
coat of the bowel only, sloughed. On the 23d July
she was able to leave bed, and the bowel having 
retracted, the wound heald. Thus, an artificial 
anus was made, the gangrene was not complete,
neither were there two oricifices, but even
*This was followed by a copious discharge of fœces 
air by the orifice made in the gut. 

(185
if there had, they would probably have united.
When all the protruded intestine does not [in??tify],
and adhesions form round it a permanent
discharge of foeces may be established. I had one 
case of this kind in the P. Hospital some years
ago. I tried to accellerate the rectraction of both 
ends of the bowel by introducing a piece of bogie 
3 inches long bent up, one end being introduced 
into the two orifices, and gentle pressure was thus 
applied, but I found this not to succeed, as pain 
followed its use, and I performed a new operation,
which consisted in establishing a lateral communication
betwixt the ends of the bowel. I brought
the ends of the bowel in contact to the external
wound, and introducing the fore finger into one
and the thumb into the other, I found that the 
two coats moved on one another betwixt my finger
and thumb, so that I feared the adhesion 
was not extensive enough to permit an incision 
to be made betwixt the two bowels. To produce 
adhesion between them, I introduced a ligature
by means of a kneedle through the side 
of the two portions and brought them with

186)
some tightness together, such as might even 
have produced ulceration tho the space I
intended to divide, but the ligature caused so 
much pain that I was content with its producing 
adhesion as far as it reached. I next 
made a slit with the knife betwixt the two 
bowels which I had thus made to adhere, as large 
as the calibre of the bowel. The cavity of the sac
was dressed with a compress, and next day some 
griping was felt, and wind escaped per anum.
In 3 days more foeces passed freely. I next tried 
to heal the external wound by paring its lips, 
and introducing the twisted suture, but in 
this I fail'd, and a truss was the only inconvenience 
he had to submit to, as the natural 
route of the bowels was established; however, if 
the external wound had closed the truss would 
also have been nescessary. This operation being 
successful, that of Cooper is quite unnescessary.
The bowels may be allowed to adhere to 
the ring and lateral parts.
The omentum which forms a part in these hernia

187
is also to be reduced, but if it have mortified, the 
dead parts are to be surrounded by an incision 
through the living and removed. Any large vessels
which bleed may be tied, the end of the ligature 
being kept out. Mr Pott has thought this 
precaution unnesecssary, but alarming haemorrhagies 
have followed the neglect of it.
It sometimes difficult to tell whether or no the 
omentum be dead, and fatal consequences might 
follow the reduction of a mortified portion. It is 
said to feel crisp when dead, but the following 
marks may be depended on 1. The blood is coagulated 
in the veins of the dead portion. 2. The vessels 
of it do not bleed on being punctured.
Some have advised the adhesion securing 
the omentum in a string to prevent haemorrhage,
and even Pott recommended this, but it 
had produced nausea, vomiting, fever, pain & 
death, and therefore this plan must be exploded.
After the operation the wound is to be united by sutures.
The patient is to be confined to a horizontal 
posture, and cough is to be allayed by demulcents 
and opium, but the latter is to be 

188)
avoided as much as possible, as it retards the 
functions of the bowels. If nescessary, the bowels
may be opened with castor oil or salts,
and in some cases the bowels are so torpid & 
paralytic by the pressure they have suffered,
that they are not easily moved. In one case,
a swelling was produced by the accumulation
of the foecis above the wound, and went off by 
pressure again. This returned occasionally for 
three days and then subsided.
In some cases pain and swelling follow the 
operation. Bleeding, low diet, purging, blistering,
&c may be used as circumstances may indicate.
After the wound is healed the part must be 
supported by the use of a truss.
Femoral Herniae. This hernia we have observed, appears
on the upper and anterior part of the thighs
The contents of it pass under Pauparts ligaments,
and the tumor is small and moveable, and 
may be mistaken for a bubo or enlarged lymphatic 
gland. This mistake is very dangerous, and 

(189
yet has fallen out in the hand of every expert 
men. If a hernia were left to suppurate, or boldly 
opened as a suppurated bubo, how serious a 
mistake would be made! We read of men having 
died of ileus and a bubo!
In all doubtful cases of the kind, we ought to 
lay bare and examine the part. 1. The hernia is generally 
the lower, 2 in bubo, the edge of Paupurts ligament
cannot be felt, 3, neither can the pubis.
It is nescessary to know the true situation of 
the sac, as without this knowledge, we could 
not perform the taxis aright.
The bowels pass into the theca for the femoral 
vessels. They lie in the vicinty of of the pectineus
muscle, just over the fascia lata. The epigastric 
artery lies on the outside and the spermatic 
cord lies on the superior and anterior part
These two vessels cross one another. The obturata
artery sometimes arises in common with the epigastric.
The bowels descend first downwards, and then,
forwards at right angles with its neck. The taxis 
must therefore act inward and then upward, whereas

190
whereas in the inguinal hernia, the taxis acts upward
and outwards. This of great importance.
In this tumor we find 1. the skin, 2 the fascia,
3 the proper sac, or that derived from the peritoneum.
The inner edge of Pouparts ligament leaves 
a small aperture only, and the stricture in 
this place is very dangerous, and early open action 
is requisite. Cooper says if he were attacked 
with this hernia he would try the tobacco injection 
and if this failed, the operation!
The integuments are sometimes very thin, so that 
we are to proceed very cautiously thro these 3 membranes 
lest the gut be wounded. After this, the 
stricture is to be divided. In doing this caution
is required. If we cut inward the spermatic cord is 
wounded, If outwards, the epigastric artery, and in 
an upward direction, there is also some danger
of cutting the cord also, but let it be kept inward
that it lies 1/2 inch off, and this Ipace answers every 
purpose. Pinbuuat reccommended to cut the 
internal edge of the crural arch or Pouparts ligament,
but 1. the deep situation renders this difficult 
2, a director is required and the gut must be	

191
pulled with some violence aside 3. In some patients,
the obturator artery winds round the neck
of the Sac, and if wounded here it cannot be
secured as it can be if wounded over the middle
of the tendon. [See notes P and Q below Page 191.
I prefer operating on the middle of Pouparts 
ligament, on its anterior part, and at right 
angles with the ligament.
If the operator is fearful of cutting the spermatic
cord he may as A. Cooper advises dissect 
the cord loose ad have it drawn aside by a
hook before dividing the crucial arch.
February 2nd, 1812 Dr Physic
Notes on Lecture 37.
P. page 191... For nine out of ten cases of femoral 
hernia the patients are women, and in this 
there is not so much danger, as the cord in 
them is absent.
2. Page 191... When the epigastric artery lies 
in the way and is wounded, we can feel the 
pulsation of the vessel, pass a kneedle under
it and tie it. Feb 5th Recapitulations

192
Lecture 38.
Umbilical Herniae. We meet with it both in the 
child and in the adult.
In the infant the bowel often passes through the 
funis umbilicus. In such cases, it is to pressed up 
again, and the cord secured by a ligature. The edges
of the aperture may be approximated by adhesive
plasters, and they will often unite in a few days.
But sometimes it does not close for 3 or 4 months,
and the child by crying, straining, &c may cause a 
protrusion. I have met with 2 or 3 instances of this.
I have seen umbilical hernia in seven children in 
one family, yet in all the parts retracted and united 
well. This is the natural tendency of the parts, and 
can only be prevented by the presence of the gut, and 
this keeps the hole open, so that more gut may descend.
When the natural process fails, we are to treat 
it by an operation. 1. Compresses have been applied,
with a view of making union take place. They are 
secured by a roller passed round the body, but in 
this way the cure is detained for months; very incovenient 
pressure is made on the abdomen, the bowels

(193
bowels are even in danger of being protruded, the operation 
is very imperfect and difficult.
2. The ligature, which is the older method is recommended
by Desault. It is certain and expeditious
The patient being laid on his back with the thighs
and neck bent forward, the contents being reduced,
the sides of the funis are to be rubbed together to 
ascertain that all the contents are reduced. An assistant
now applies a waxed ligature several times
round the funis, making each time a double 
knot, and with such tightness as to produce moderate 
pain. Next day, the cord will be swelled 
just as a polypus after a ligature. 3rd day, it becomes
shrunk and livid. A second ligature is 
to be applied tighter than the former, producing
some pain, and a day after, a 3rd ligature
will compleat the mortification of the cord. The 
union of the mouth may be accelerated by adhesive 
plaster, and the circular bandage may be continued
for 3 or 4 months. This is found a very successful 
operation, and succeeds on young children
uniformly, best in those advanced nearer maturity,
it does not prove so fortunate.

194
This will best appear by the following cases,
which as well as the above operation are from Desault
1. A girl of 18 months old was operated on 
as above. The cord was shut in 7 days. Six months
after, there could be no vestige of the disease found.
2. A boy of 4 years old was operated on as above, the 
funis closed, but afterwards, the impulse of the bowels
could be perceived.
3. The latest period at which Desault operated was 
at the age of 9 years in a girl who had had it from 
birth. The the union was complete to appear and
in 3 mo. the swelling was apparent, and not 
withstanding the use of the bandage, in 6 mo. the 
relapse was complete. Therefore the operation is 
always to be performed early.
In Adults, according to Desault, the ligature
does not succeed. Having reduced the tumor by 
the taxis, pressure is to be made on the navel by 
Hey's truss. This is preferable to compress & bandage
as well as every other sort of truss. After this is 
applied, where any exertion is made the effect of the 
truss must be assisted by the hand.
[See note Pr. Vol. III p.3

(195
The other varieties of hernia woud require too long
time to explain them. They may be learned from 
books; it being my only to design to give a description 
of the nature of the most important kind
and the history of hernia in general. See Cooper
on hernia, and Lawrence.
Observations on the stone, perparatory to the 
demonstration of Lithotomy.
Stony concretions form in many parts of the 
body, as the salivary glands, the gall-bladder,
&c, but they are most usual in the organs for secreting,
containing and excreting the urine. This 
matter is often deposited on the sides of the pots in 
which urine is contained out of the body.
The quantity differs greatly in persons, some showing 
almost none of it, while others abound with 
it. I have seen the urine in a bowl incrust the 
bowl to 1/10 inch all round, in a scrofulous patient.
Now in such cases, it appears that a stone
will form at any time, when a solid body is introduced
into the bladder, serving as a nuclus 
for the matter to adhere to.

196)
A piece of lint, a bullet, a kneedle, &c have been found 
in the stone, and large masses of stone have formed round 
the end of a catheter. In the kidney, a coagulum of 
blood has had a similar effect. In sawing into a 
stone, it is generally found laminated, some stones
are very [hard] soft, and others are very hard, some are of a 
white, others gray, or brown colour.
The form commonly in the kidney and pass thence to 
the bladder, but they sometimes form in the bladder.
When after pain in the loins ceasing, the symptoms
of stone in the bladder commence, no doubt is 
left of the origin of the stone. A gentleman who 
had been troubl'd for some time with pain in 
the loins, on taking a ride from Germantown
to Phila. the pain ceased and the symptoms of calculus
in the bladder came on.
From a stone in the kidney, a dull pain in the loins
is produced. This, on stooping becomes acute. The urine
is often bloody. Inflamation with fever, costiveness 
and diminished urine with vomiting come 
on. If much dilution has been made, there is a copious 
flow of urine; or colic fever and suppression 
come on.

197
The efforts to vomit often press the stone into the 
ureter, which obstructing the passage of the urine, produces
great irritation. In fits of the gravel so produced, bleeding,
opium, blistering, warm bath and diluting liquors
are proper. The patient may stand, leaning forward, so 
as to bring the neck of the bladder immediately down
and pass his urine in a full stream and by this, the 
small stone may escape from the bladder. This is 
of great importance, and ought to be repeated, as it 
may prevent the formation of the stone.
A stone in the bladder produces pain heat and itching 
in the bladder, obstruction of urine frequently,
mucus or even puss will appear in the urine, sometimes
in large quantity. Bloody urine, especially after
excercise is very usual, and in some, the first symptom.
An uneasiness through out the urethra, especially 
at the glans, causing the patient to pull the prepuce
out, causing it to be elongated, prolapsus ani, &c are
common symptoms. By the suppression of urine, irritation,
distress and loss of sleep, the patient is soon 
exhausted of strength.
Other causes of irritation may deceive. Inflamation,
abscesses, ulceration in the bladder, tumors and

198
haemorrhoids in the rectum also have the same symptoms
as the stone in many cases. A woman laboured
under the symptoms of stone, and found no relief 
from the usual remedies. Suspecting an ulcer in 
the neck of the bladder, I ordered mercury till the 
mouth became sore, and all the symptoms vanished.
In another person all the usual symptoms existed,
and continued till death, when a tumor was 
found in the rectum. This, if it had been known could 
have been cured by an operation.
Stone may exist in the bladder and produce little 
or no uneasiness. A man who had a stricture in 
the urethra, and had not suppression, only a diminished 
stream of urine, and no other symptom referrable 
to stone, being prejudiced that he had a stone, 
underwent experiments such as jumping off a 
table, riding of a a rough-going horse, &c and no irritation 
or bloody urine being produced, but the stricture 
prevented sounding. After his death a rough stone 
as large as a walnut was found loose in the bladder!
The only certain criterion is sounding, or the introduction 
of a bent, iron instrument into the bladder,
which when it comes in contact with the stone

(199
produces a tingling fell, and may be heard. This 
operation may be repeated in various ways, through we
do not feel the stone at the first trial. First, let the 
patient stand, if this fail he may lie down. The finger introduced
into the anus may bring the stone into the way
of the sound. A man in this city had symptoms of the 
stone, and no stone could be felt on sounding. He 
went to London and was sounded by Mr. Hunter, but 
without any success. He returned, and applied to me. I 
succeeded by putting him to bed, raising the buttock
so as to throw the stone into the fundus of the bladder.
Having ascertained that a stone exist, no remedy 
can be depended on except lithotomy. Medicines introduced
into the stomach or injected into the bladder
have long been tried. From the effects of akalis on
a stone out of the body, they have been introduced in 
to use. Soap, aqua nephritica alcalina, carbonated
soda &c lessen the pain for a time only. In one case
they seemed to have succeeded. Unequivocal symptoms
of stone existed in a child. Sounding ascertained it 
beyond all doubt. The weather being warm, the operation 
was defferred, and the aqua mephritica alcalina

200)
alcalina was given, and to my utter astonishment, the 
symptoms of stone disappeared, and never returned
again. What became of this stone, it if were not 
dissolved, I do not know. Some other remedies besides
the above give temporary relief, such as lime water,
and uva ursi. But while these are used, the symptoms
will always return unless the stone become encysted,
which effect cannot be attributed to medicine.
Injections, capable of dissolving the stone in the 
bladder have be keenly sought after. But they are 
incapable of affecting the stone unless of such activity
as to cause inflamation and sloughing in 
the bladder.
The best palliatives are small bleedings, warm 
bath, demulcents and opium, which must be 
diligently used when the irritation of a stone become
at any time aggravated, constituting a paroxysm 
of the stone.
Dr. Physic
University of Pennsylvania
February 5th 1812.
END OF VOLUME II.