C. Redfield.
Abstracts
From Lectures
On
Surgery
By
Philip Syng Physick M.D.
Delivered in
The University of Pennsylvania
AD. 1818 - 1819.


Surgery.
The word Surgery or Chirurgia
has its derivation from the Greek
Χεερ, the hand, and εργον, work.
It is not to be concluded from this
etymology, that the surgeon has merely
the treatment of those diseases which
require manuel dexterity. To his prooence 
also belong the management
of numerous diseases as well as
accidental injuries: though the treatment
of the last more peculiarly
interest him in a professional
point of view.
The most simple accident that
can possibly occur, is that degree
of concussion in which the only effect
produced, is a debility of the actions
or functions of a part, similar to
that occasioned by a bruise, in


Surgery. 2
which the continuity of the substance
is not interrupted; in such a state the
parts have little to do, but to expand &
reinstate themselves in their natural
position, actions & feelings; and this is
what happens in the concussion of the
brain.
The rupture of a small blood vessel
is perhaps the next in order of simplicity:
though if the vessel be large, or essential
to life, or if the extravasation take
place in a vital part, as the brain, the 
injury may kill from the effusion
alone, however inconsiderable may be
the original mischief.
Another species of injury is where
the ruptured parts have an external
opening constituting a wound. In this
case the coagulation of the effused blood
between the ruptured parts constitutes the
natural bond of union, the ruptured


3 Surgery.
vessels closing up, their inosculation
being promoted, and an absorption
of the superfluous coagulum takes
place. This mode of restoration is
denominated union by the first
intention, and is not attended with
any pain on inflammation.
Whether in these cases a new portion
of the vessel is formed, or whether
the original vessel unites again
without the intervention of a new
cylinder, is not easily determined.


Inflammation. 4
Inflammation generally commences 
with an increased sensibility of the part;
to which succeed pain, heat, redness &
tumefaction: to which may be added impaired
functions of the part affected.
When the inflammation is very severe,
the functions of the part are totally destroyed.
Inflammation is divided into healthy
and diseased. By healthy is understood,
that which has for its object the
restoration of injured parts; by diseased,
that in which some morbid peculiarity
is superadded to the simple
act of inflammation, as in erysipelas,
carauncle &c.
The Remote Causes of inflammation
are various irritations of a mechanical,
or chemical nature, such as wounds,
bruises, acrid substances &c.


5 Inflammation.
The effects which these remote causes
have are different in different constitutions,
and even in the same constitution
at different times. What will produce
the slightest imaginable inflammation
in one, will produce a
most malignant & even fatal inflammation
in another; and even
in the same person at another time.
It is necessary to keep in mind this 
difference of effect in the different constitutions. 
When I am asked by a patient
who is about to submit to an operation,
whether there is danger to be apprehended
from its effects, I answer
yes, there is danger in every thing;
from the scratch of a pin, or the
prick of a needle. I however assure
them that the probability is much
in their favor. For I have seen a
person not complain of pain in


Inflammation. 6
the operation for lithotomy, nor did the
parts assume any bad aspect after the
operation, but healed without any
difficulty. But I have also seen it terminate
in violent inflammation gangrene
& death in a few days in another
person apparently similarly situated,
and where the operation had been performed
with the same skill & dexterity.
In such cases it is not the surgeon 
who is to blame, but the constitution.
In inflammation the motion of the
blood in the vessels of the affected part is
increased. The heat of the part is also
increased when the inflammation is
external, but never transcends that
of the centre of the arterial system.
Inflammation is divided into adhesive,
suppurative, & ulcerative.


7 Inflammation
Inflammation terminates
1. In Resolution: where all the symptoms
gradually subside, and the parts
are restored to their natural color &
appearance.
2. In Suppuration, or Abscess; which
is a circumscribed cavity containing
pus.
3. In a secretion of Serum; as in the
inflammation produced by cantharides.
A termination of inflammation
in the secretion of serum in the brain
produces hydrocephalus, in the chest
hydrothorax, in the abdomen ascitis &c.
4. Hemorage, This is not a very frequent
termination of inflam. But I
have seen the inflam. of an eye terminate by
spontaneous hemorage, & I have seen
the same termination in the throat &
back of the nose (posterior naries])
5. Scirrhus. When the coagulating
lymph remains unabsorbed in the interstices


Inflammation 8
interstices of the part it becomes hard &
the inflammation ends in hand tumors.
Cautions to be observed in the
treatment of inflammations,
1. Some inflammations should be attempted
to be resolved without large
evacuations; as where there is danger
of tetanus supervening.
2. When fever has preceded we are to
be cautious. But I have seen an opacity
of the eye from ophthalmia, &
a fistula in ano, because the patients
were judged too weak to admit the necessary
degree of depletion, for the resolution
of the inflammation.


9 Inflammation.
Treatment.
The first object is to remove the remote
causes if possible, provided they continue
to act. The next, to lessen or entirely subdue
the inflammatory action.
The latter object is accomplished by
§1. General; and §2. by Local
remedies. Of the former are
1. Venaesection. 2. Low-Diet: that is total
abstinence from fish, flesh & fowl,
broth, butter & eggs.
Vs. is useful in 2 ways. 1. by erupting
the distended vessels, & 2nd. by causing them 
to contract. 3. Purging. This probably
acts by reducing the contents of the
blood vessels. When nausea is produced
it acts sympathetically: for when the
stomach is sickened, the circulation is
rendered slower. This effect is produced
by neutral salts combined with antimony


Inflammation. 10
4. Rest: quiet & undisturbed.
5. Proper Position. Such as that
the flow of blood in the arteries to the
inflamed parts shall be retarded, and
that from it by the veins facilitated,
Or oppose the gravity of the blood to the
arteries, & add it to the veins; which is
done by elevating the limb. This is sometimes
of great use when we fear the accession
of tetanus.
6. Opium may sometimes be given to relieve
pain.
Local Remedies.
1. Bleading from the inflamed parts 
by cupping, leeches & scarifications.
But bleeding from the general system
should precede local depletion.
Without attending to this, & to the proper
position, all your local remedies will be
unavailing.


11 Inflammation.
2nd. Cold Applications. I believe
cold acts by diminishing the temperature
of the parts, thereby diminishing the
irritation produced by the temperature.
They should never be employed if they
prove disagreeable to the feelings of the
patient. Lead water, alcohol, laudanum,
poultices &c. are sometimes beneficial.
3rd. Blisters. These should generally
be used after the other methods have been
tried, or where depletion is contra-indicated.
All these remedies tend, by diminishing
the violence of inflammation in its adhesive
stage to prevent suppuration:
though sometimes that event is deniable, &
at others, inevitable. In such cases the
best application is a soft bread & milks,
or linseed poultice.


Inflammation 12
The good effects of Adhesive
Inflammation.
1. When the exposed surface of wounds
cannot be brought into contact, an effusion
of coagulating lymph takes place &
adhesive inflammation follows. In this
way the injury is repaired.
2nd. Adhesive inflam. prevents suppuration
as in the adhesion of the pleura (lining
the thorax) to the lungs.
3. Adhesive inflammation unites the
cells of the cellular substance surrounding
an abscess when suppuration commences
& thus prevents the escape of the
matter into the surrounding parts,
4. Cysts are formed by adhesive inflam.
around bodies, which have proved irritating
to the parts in which they
have been lodged, but not sufficiently
so to cause suppuration.


13 Inflammation.
Suppurative Stage. When suppuration
is about to commence the pain is
increased, and becomes of a shooting, or
throbbing nature, till an abscess forms.
Suppuration is sometimes attended by rigors.
These are often relieve by a discharge of
pus. But sometimes Hectic fever occurs
which is attended with debility, a frequent
small pulse, sharp to the feel; loss of appetite;
a copious flow of pale urine; night sweats;
watchfulness, & frequently a diarrhaea.
Hectic fever constantly attends the suppuration
of vital parts, and of bones,
ligaments & tendons. But it sometimes takes
place before suppuration, as in white
swelling. From the formation of issues
hectic is often relieved & sometimes cured;
though the quantity of pus discharged is
thereby increased. The presence of hectic is
not occasioned by the absorption of pus.
Abscesses should be opened early when
situated near the large cavities


Inflammation. 14
as the throax, abdomen; over a large joint,
or on the cranium. Abscesses are sometimes
attended with very great pain;
as in paronychia. This is instantly relieved
by an early opening.
I saw a case where a tumour seated
upon the external oblique muscle was so
painful that nothing would relieve, and
the patient died. This tumor was found
by Dr. Rush & myself to be an abscess.
A second occurred to me since, which
I opened and the patient got well.
Abscesses are opened by the lancet or by
caustic. Sometimes a puncture is sufficient;
at others a free incision should
be made. Sometimes the pus is absorbed
and the part is reduced to its natural
state. It would be a desideratum
to find some substance capable of doing
this at all times. Nausea & vomiting
sometimes produces that effect; & so does
venaesect. & purging.


15 Inflammation.
Pus. This is of a light straw color, of
the consistence of cream, composed of
globules swimming in a fluid; coagulable
by muriate of ammonia.
Pure pus is not corrosive; if so the
granulations in contact with it would
be destroyed. But like the tears, urine &c.
in an unnatural position it may be
made to excoriate.
Mr. Hunter excited suppuration by a
bogie in the urethra in 6 hours time:
which shows its greater facility in
forming in mucus canals.
Ulceration generally succeeds suppuration:
though it sometimes precedes
it. The process of ulceration is
always attended with a degree of inflammation
which is probably of the adhesive
kind.


Inflammation. 16
Erysipelatous Inflam..
This is often preceded by shivering, succeeded
by fever and a redness & burning
heat at a particular spot. It is generally
situate on the cutis vena & often spreads 
extensively on the skin. The pain is not
acute but burning. I have known it attended
with a distressing itching. It
differs very essentially from adhesive inflammation,
in that it never secretes
coagulating lymph, but serum. As adhesion
of the cellular substance does not
take place when the disease is situated
below the skin, the matter travels from
place to place through the cellular membrane,
the latter becoming gangrenous
and sloughing out like wads of wet toes.
This more generally happens about the
margin of the anus.
A deposition of serum on the cutis vena
causes a vesication.
The disease seldom, seldom terminates before
the 8th or 12th day.


17 Erysipelatous
Treatment. The constitutional remedies
are the same as in phlegmonous
inflammation. Locally, different applications
have been made. Poultices &
oily applications generally do no good;
though I have seen the inside bark of
the elder stewed in cream useful in
relieving pain & quieting irritation.
The best application for the most part
are meal, flour, powdered chalk &c.
I learnt some years ago from a physician
in this city that the application
of a blister had the happiest effect in
erysipelas. I thought this practice had
originated with him, but I find that
Ambrose Paré recommended it in
the same instances & he relates a very
obstinate case thus cured, by himself.
When matter forms under the skin,
large openings should be made to
facilitate its escape, & to prevent it from
spreading the disease from cell to cell.


Inflammation. 18
In the treatment of erysipelas we are
to bleed, purge & confine the patient to
a low diet. Sometimes when the patient
is very low and the pulse such as indicates
languor & depression, yet paying
attention to the appearance of inflammation
vs. though the patient should
faint under the evacuation of blood,
should be employed. The appearance of
the inflammation must regulate our
remedies. Twenty years ago, in London
they were in the habit of giving bark in
erysipelatous inflammation: but I have
seen mortification frequently the effect
of this mode of treatment.


19 Of Gangrene and
Mortification is the entire death of
a part. Gangrene: that state immediately
preceding it, while it yet retains a
degree of sensibility motion & warmth.
Mortification is of two kinds. The
first is preceded by inflammation; the
second is not. Interrupted circulation,
disorganization by external violence, intense
heat or cold, produce mortification
without inflammation.
When mortification commences in a
part the color changes to a livid, purple,
or dark purple; from the coagulation
of the blood in the dead vessels. The
part also becomes cold, is covered with
vesication and emits a foetid smell. 
The best application is a soft bread &
mild poultice. A moderate inflammation
in the surrounding part is
salutary. The use of tonics, opium, bark
and wine becomes necessary.
When a limb has been exposed to intense
cold, numbness or a sensation
of pain is produced; the color alters;


Mortification. 20
and should heat be suddenly applied the
part will invaribly mortify. I have seen
mortification occur in a man recovering
from yellow fever, without inflammation
and without any obvious cause.
2. Mortification preceded
by Inflammation. Violent inflammation
may end in the death of
the part. Sometimes a cause which
produces healthy inflammation in one, 
produces mortification in another.
I knew a woman aged 40, who had a
mortification from the application of
a mustard poultice in a fever. And
Boerhave relates a case of mortification
from the use of volatile liniment to a
paralytic limb. I once saw it happen
from a blundering operator injecting
wine into the cellular texture of the scrotum,
instead of injecting it into the tunica
vaginalis testes, in the operation for hydrocele.


21 Mortification.
A mortification of the toe in old people
sometimes occurs & as I think
is preceded by inflammation, Mr.
Pott recommends opium in this affection
& a soft poultice, Cheselden says
he has known it do well where the
person was left to the salutary operations
of nature.
Pressure long continued will cause inflammation
& mortification. This we
often see in patients confined to bed in
fever, paralysis &c.
When violent inflammation arises and
we have reason to apprehend mortification,
it used to be thought advisable to
employ cordial stimulants, bark, elixer
vitriol &c. But where the constitution is
not impaired, the antiphlogistic treatment
is not to be neglected.


Mortification. 22
Peculiarity of Inflammation
terminating in mortification.
Mr. Hunter thought mortification
originated from some peculiar action
of the constitution independent of the simple
act of inflammation as in small pox,
carbuncle &c. I agree with him here. I
have even gone so far as to believe that
in all cases of mort. preced by inflam.
this peculiar action exists. I have great
doubts whether simple inflammation has
a tendency to produce mortification.
If there was nothing peculiar in inflammations
terminating in the death of the
part, but simple increased action,
then the application of a blister would
spread the disease. But it is only from
reflecting on the subject in the above
light that I was induced many years ago
to employ blisters; nor can they be of benefit
any farther than they have a tendency
to change the nature of that action


23 Mortification.
to one that has a tendency to terminate
in health. But genl. it is only in that
species of mort. preceded by inflam. that
blisters can be beneficial. In that of the
toes of old people & that from obstructed circulation
they would even do harm. I am
exceedingly anxious that you should attend
to this for so many mistakes have already
taken place that I would not wish to add
to them by recommending to you an improper
remedy. From what has been
said you will discern those cases in which
they should be applied & act accordingly.
A mortified leg or arm, should be placed
upon a pillow of carded wool & changed
twice a day. A box, or some contrivance
should be used to prevent the pressure
of the bed cloths.
In order to judge of the state of the parts
in the vicinity of the mortification, press
on them with the fingers for a time which
will force out the blood & the color will
be lighter on raising them. If the circulation


Mortification. 24
circulation be very languid the color will not
be restored for sometime; perheps for a minute.
If at some distance from the mortified
part the blood returns very slow you
will have reason to suppose that, too,
in a condition nearly approaching to
mortification & v.u.


25 Mammary
We seldom see this in its first stage because
nurses think themselves altogether adequate
to its treatment. The inflammation commences
with pain, hardness & tumefaction.
The secretion of milk is often diminished & 
sometimes totally suspended. On examination
a hardness like scirrhus is observed &
extreme pain is caused at the time of suckling
the child, or whenever pressure is applied.
Suppuration generally takes place in 3
or 4 days time. Sometimes are aedematous 
swelling forms, & the nipple is buried below
the level of the skin, In other cases the
inflammation occasions an extravasation
of coagulating lymph and produces distinct
hard tumors.
The remote causes of mammary abscess
are 1. Tight dresses. 2. Exposures to
cold. 3. Accumulations of milk. Sometimes
it takes place without any obvious
cause.


Abscess. 26
Treatment. vs. purging, a soft poultice,
low diet, confinement to bed, suspension of
the breast & proper position. The patient
should rest on the sound side so that the
affected breast may be uppermost.
mercurial ointment is sometimes used
with the poultice, as also lead water,
I have often known a blister do much
good. Stimulating applications are not
to be used. Justamond recommends sal
ammoniac & vinegar. I have tried it &
sometimes with benefit.
When matter is formed it should be discharged
by an opening with the lancet,
In one woman whose breast was oedematous
I tried vs. purging, cold application, &c.
without any benefit. It struck me that
a blister might be proper. I applied it &
the tumefaction went completely away.
In another case where there was a hard tumour
like a scirrhus as big as my fist, a
blister resolved it.


27 Mammary
When the suppuration is deeply seated as
perhaps between the glands of the breast
and the pectoral muscle, or in the cellular
substance between the two, several
sciruses appear communicating with the
same abscess. Mr. Hey says it is the duty
of the surgeon to lay open all these sciruses.
But it cannot be done without cutting
the parts very extensively & dividing one or
more arteries. There is no doubt of its success
however when it can be done. But I
have sometimes effected a cure by introducing
a bogie into the cavity which has
allowed the discharge to take place. And
when that has failed I have introduced
a seton which has never failed. This
reduces all the suppurating cavities to a
mere channel. The way this operates is by
keeping it constantly open, so that no lodgment
being left for the matter the cavities are
all filled up with granulations to the
seton from which the pus is constantly


Abscess 28
oozing out. When thus filled up your seton
may be withdrawn and soon the cure
is affected. This however generally occupies
about 8 weeks.


29 Paronychia.
Paronychia is a very painful & distressing
inflammation, usually seated at the end
of the finger, and generally ending in suppuration;
from παρα, about, & ονυξ, the nail,
It is usually divided into 4 species.
1. That seated near the root or side of the nail.
2. That in the adipose membrane under the 
skin.
3. That, where the inflammation is seated
within the theca covering the flexor tendons.
In this the matter extends sometimes, up to
the wrist, or even to the elbow along the
tendons.
4. In this species, the periosteum, & sometimes
the bone inflame.
The causes of whitlow are not always
obvious. Punctures, irritants applied to the
finger, & vicissitudes of temperature are
among the number.
In the first species which is often
called a run-round, little is necessary
but to open it & if the inflammation
still continues to progress, cut off the cuticle
with the scissors and dress it with


Paronychia. 30
basilicon or lead ointments
In the other species the early application
of a blister frequently puts a stop to all
the mischief. Dr. Perkins employs the
caustic potash. It acts like the blister &
I think a good deal of it. When matter
points in the hand, or above the annular
ligaments of the wrist, make a free incision
& let it out. A free & an early
opening into the primary affects part
when the inflammation is not arrested will
prevent the matter from passing up the arm.
When neglectd I have sometimes seen the
finger become stiff. This may arise from
anchylosis, or from a sloughing of the tendons,
by which motion is prevented.
When anchylosis is expected, bend the
finger if possible; for it is less troublesome
& more useful than if it were suffered
to remain strait. This is of great
consequence to the patient, & should never
be neglected by the surgeon.


31 Onychia
There is another affection of the finger
which has deservedly received the appellation
of onychia maligna. It is a most
dreadful & painful complaint, exceedingly
malignant in appearance, & very obstinate
and difficult to cure.
Till within a few years I considered
amputation as the only remedy. About
two years ago, I observed in looking into
the 3rd Vol. of the medica Chirurgical
Transactions of London that mercury
so as to excite a salivation was recommended
by Mr. Ward as very efficacious.
Rejoiced to find a remedy for so
distressing a complaint, I resolved to try
it the first opportunity. I did so, but
without any benefit whatever.
Not long since Dr. Perkins told me of a
German physician in this city by the
name of Williams who is peculiarly successful
in treating onychia maligna. He
used equal parts of corosive sublumate &
sulph. zinc in powder applied on lint
to the end of the finger, keeping it covered


Maligna. 32
covered with a rag & wet with ꝶ. Myrrh.
So irritating and corrosive an application
I did not choose to hazard till I had
seen it used. Having a case of this nature,
I told Dr. Perkins that as he was
acquainted with Williams' method of
using the remedy, he should make the
application himself. He did so, and
to my utter astonishment it had the
desired effect. I have used it since in a
number of cases, in all of which it has
proved successful.
In a case which occurred to me
in the Pennsylvania Hospital which I
treated for 4 months by the soothing
plan without any benefit, was cured
by applying red precipitate. It
had the effect of allaying the pain &
inflammation & of effecting a speedy
cure.
There is another; similar affection
of the toe to this to which the above treatment
is adapted.


33 Psoas
The matter constituting psoas as lumbar abscess
is seated in the cellular texture exterior
to the peritoneum, surrounding the
psoae muscles. The disease may originate,
from bruises, strains, lifting heavy weights.
Often no cause can be assigned.
The symptoms often commence with difficulty
in walking & weakness about the loins,
but without acute pain. The patient generally
is unable to walk strait & upright &
therefore bends the body. Though generally
attended with a mere sensation of weight &
weakness, yet sometimes there is symptoms
of inflammation & pain.
The matter not being circumscribed by
adhesive inflam. is liable to point at various
places as it travels along the cellular
membrane. It frequently shows itself
by a tumor just under Poupart's ligament,
or even at the middle of the thigh. It
occasionally points about the anus. In
the case of a gentleman who supposed
himself affected with fistula in ano, I passed
a probe 13 inches long up a passage to


Abscess. 34
the lumbar region to the seat of the abscess.
I have almost always found this affection
complicated with caries of the vertebrae.
If the tumor appears in the groin it
has some of the characteristics of hernia
& has actually been mistaken for it the
surgeon applying a tress &c. The discrimination
is very important, & happily
not very difficult. If you place the patient
on the back and press on the tumor
it immediately recedes and the abdomen
rises up. Press on the latter & the tumor
appears again. This together with the fluctuation
renders the case obvious.
In the treatment of lumbar abscess, the
patient should be kept at rest and put
upon a low diet. If fever attend it is
necessary to bleed & purge. Where there is
no pain nor inflammation I believe vs.
is not proper, but purging may be.
Hitherto it has been considered very dangerous
to evacuate the matter in psoas
abscess on account of the violent inflammation


35 Psoas
inflammation & fever which generally supervene.
Mr. Hunter considers this as a
scrofulous affection as well as all abscesses
without inflam. to circumscribe
them. Those collections confined to the
original seat of the disease he calls
abscesses of a part; & those where the pus
passes along the cellular membrane and
points in another place abscesses in a
part. He contends that the inflammation subsequent 
to the opening of the abscess is from
the extent & imperfection of the cavity no
adhesion having taken place to circumscribe 
the matter.
Mr. Abernethy profiting no doubt from
Mr. Hunter's remarks, proposed to open the
abscess by a small puncture, & by a valvular
orifice to let out the matter & close
it again in such a way as that union by
the first intention shall take place in the
orifice & thus preserve the integrity of
the cavity. He directs the opening to be made
by first pushing the lancet longitudinally
upwards with respect to the thigh, & then


Abscess. 36
inwards to the cavity. When a part, or the whole
of the matter is evacuated, the opening is
to be closed with adhesive plaster.
I have used Mr. Hey's method with a good
deal of benefit, but unfortunatily I have
not been able to effect a cure, it having
been in every instance complicated with
caries of the vertebrae.
Sometimes the valvular opening does not close
by the first intention, in which case inflammation
of the cavity will succeed.
Whenever this occurs, however weak the patient
may be vs. purging, & the antiphlogistic
treatment is equally necessary as in
other cases of inflammation.
I opened a lumber abscess in a genl. 27 years
of age & evacuated several pints of matter. But
the opening did not close & inflam. & fever
were the consequence. Vs. & purging produced
an abatement of the symptoms & he was
much relieved. He however languished along
for 8 months & then died. Having
obtained leave to open the body I found


37 Psoas Abscess.
that there had been an extensive caries of
the vertebrae; that the first lumbar vertebra
was so completely destroyed at its anterior part
and the second so disposed as to form an
angle of about 85° degrees, as you see here
exhibited. The inter-articular cartilages were
removed & the bodies of the bone left naked.
As the natural line of support to the trunk
was thus lost, nature formed another line
of support by absorbing the cartilages of all
the oblique processes of the lumbar verterbrae
and by uniting them by anchylosis.
It might be said that inflammation
produced this anchylosis; but these processes
were 3/4 of an inch from the original
seat of the abscess & besides there was
no inflammation attending it when the
curviture took place. I consider this as 
one of the most happy cases to show the
wonderful skill & admirable contrivance
of nature that can possibly be contemplated.


Burns and Scalds. 38
When heat is applied to a living part
various effects are produced according
to its intensity and extent.
When the degree of heat is not very
great it produces pain, redness & slight
inflammation, which subside spontaneously
when the heat is removed. A greater
degree occasions more severe pain;
vessications appear filled with serum
& the true skin under the vesicles, is
much inflamed. Where the burn is
extensive fever attends, & suppuration
ensues. If the heat be still more intense,
the life of the part is destroyed.
A burn small in extent, though it completely
destroy the vitality of the part
will be unattended with any constitutional
derangement; while a very extensive 
one very slight in degree,
is often productive of much mischief.


39 Burns and
When the heat is very intense so as to
destroy the life of the part, or is very
extensive so as to produce much constitutional
derangement, less pain
is experienced than in slight burns.
This is strikingly exemplified in the
case of a boy who fell into a caldron
of boiling water. He appeared not to be
in pain, said he felt none, neither when
he fell in nor afterwards. But death
soon followed. This has reconciled
me to the practice of putting animals
to death by immersing them in boiling
water.


Scalds. 40
Treatment. In the treatment of burns
it may be laid down as a general rule,
that where no inflammatory symptoms
appear, but on the contrary, those of
weakness & want of reaction, stimulants
must be employed. When inflammation
& fever succeed we bleed, purge & confine
the patient to the antiphlogistic
regimen.
Locally there have been a great variety
of applications, both stimulant &
sedative, such as alcohol; lead water, ice,
oil, lime water, &c. and when the skin is
denuded some have recommended vinegar,
cold water, carded cotton &c. Of late the
stimulating applications are most used.
Nature of Burns. Eccessive heat
appears to me to produce a peculiar kind of
inflammation. 1. The pain differs from
that of common inflammation. 2. It has
no disposition to heal like c. inf. but runs


41 Burns and
into ulceration. The ulcer also has a tendency
to form a fungus. 3. It cicatrizes
different from common soars.
Hence we see the necessity of having an
application which has a tendency to counteract
this peculiar species of inflammation.
And such are those which have the effect
of inducing common inflam. in sound
parts. Of this class none seem better
adapted to the purpose than the Sp. Tar.
It certainly is very curious that such a
heating & acrid substance, which produces
inflam. should cure that produced
by fire. The liniment of Mr. Keutish
made by diluting the basilicon ointment
with the Sp. of turpentine I think the best.
But it should not be applied to the
contiguous parts, for in that case the 
same substance that would be best adapted
to cure the burn, would produce inflammation
of the sound parts. I have
often known gentlemen not aware of this


Scalds. 42
apply Sp. turp. on cloths to a burnt leg.
But I have generally found at my next
visit that the patient had suffered severely
from the improper method of applying
the remedy. The best way is to cut
strips of linen just large enough to
cover the parts affected, spread them
with the above mentioned liniment &
be careful that they do not touch the
sound skin. Upon the whole this is
the very best application that I am
acquainted with when the accident is recent.
But if not called in at first, or
till the accession of inflammation, the
basilicon alone, or some milder ointment
must be subsituted. The stimulant applications
can seldom be continud more
than two or three days. If ulceration
succeed & fungus spring up, it must be
destroyed with burnt alum, or some other
escharotic. When the cutis vena is destroyed
the parts beneath become


43 Burns and
diseased & are bound down by an
eschar. To relieve the tension consequent
to this, you are to cut through
this hard eschar, but not through the
living flesh.
When the whole hand has been scalded
care must be taken to interpose dressings
between all the fingers otherwise
they will unite; which is a very deplorable
event, & cannot be separated
so completely as to restore to
the fingers their use. When thus dressed
the hand should be found on a splint.
When the chin & neck are scalded
by suffering them to remain in contact,
a most dreadful deformity
takes place.
In one case where the chin & lip, were
united to the neck, the head bowed forwards,
the mouth kept constantly opened,
& the saliva running down, with a great


Scalds 44
deal of difficulty, I dissected up a flap
of skin from the breast, raised the head
and placed it under the chin. Unfortunately
a part of the skin being
diseased sloughed off: but the deformity
was in a great measure removed
& he was enabled to keep the head erect
& the mouth closed.
When the parts of generation are scalded
it is particularly necessary to prevent such
bad effects: because in the female the labia
may unite by adhesion, and in the male
the penis & scrotum become one confused
mass. When I was in London, such a
case was presented to Mr. Hunter. A
little boy happened unfortunately to
overturn a vessel of hot water on his belly
which scalded the private parts very
much. His mother dressed it - I dont'
know with what - something that she
supposed would draw out the fire, as she
termed it, paying no attention to penis,
scrotum or anything else.


45 Burns and
The boy got well & could make his water
as usual, and was satisfied enough.
But when he arrived at the age of 18, he
was not so well pleased with the manner
in which this accident had been
treated, and applied to Mr. Hunter to
know if something could not be done
for him. Mr. Hunter examined the case
and found that the penis had grown to
the scrotum the whole length. He thought
it hard to do any thing, but was willing
to undertake it. With a great deal
of trouble & difficulty, he succeeded in
liberating a little piece of the penis,
(about 2 inches) and the young man went
away apparently very well satisfied.
When a burn happens in the vicinity of
a joint & the fire has communicated with
the cavity of the joint, it produces a
kind of sub-luxation, & is attended with
a subsultus tendinum. This is not like


Scalds. 46
tetanus: there is not the same spastic rigidity,
but if not relieved the patient may
die: how an opiate will not remove this.
But it is prevented by binding on a
splint so as to prevent the motion of the joints,
& the system from being drawn into
sympathy with the local irritation.
One circumstance is particularly to be
attended to in the treatment of burns or
scalds of the hand, When the back of the
hand only is burnt, if you allow it to be
extended the cicatrization so contracts the
skin of the hand, that it cannot be shut.
On the contrary, if the palm of the hand
be burned & the fingers are not extended
the hand cannot after cicatrization be
opened. Thus then, when the back of the
hand is burned, the finger, should be
flexed, or the hand shut. When it is the
palm of the hand, the fingers should be extended,
or the hand opened; and when the
whole hand is affected, a semi-flexed posion 
should be preserved.


47 Wounds.
A wound may be defined, a solution
of the continuity of a part communicating
externally, produced by mechanical
violence.
Wounds may be comprehended under
two divisions: Incised and Contused.
The latter includes punctured,
lacerated, & gun-shot wounds.
Incised wounds are made with a sharp 
cutting instruments, which divides the part
that comes in contact with the edge, but
the neighboring parts sustain no injury.
Contused wounds are those in which
the surrounding parts are much
bruised at the same time that
the injury is inflicted.
A wound with a sharp instrument is
always attended with profuse hemorhage.
But a lacerated or contused


Wounds. 48
contused wound is not. This is frequently
the case even where large blood vessels
are torn asunder. Cheselden relates
the case of a miller who got caught
in some machinery & had his
arm & scapula completely torn off
from the body without scarcely
any effusion of blood; & he very
happily recovered. And I have, myself,
seen a boy whose arm was ground off
where the hemorrhage was so trifling
as not to stain the dressings.
I have learned from butchers that a
knife immediately off from the stone
does not occasion so great an effusion
of blood as one used for sometime,
an account of its roughness, &
perhaps also from some particles of the
stone adhering to the edge.


49 Wounds.
Hemorrhage. It is now nearly a
century since M. Petit commenced
the investication of the natural process
by which the bleeding from a
wound is arrested; and since his time
a variety of theories have been advanced
on the subject. Mr. Morand, in
1733 thought that the suppression of
hemorrhage was occasioned by the contraction
or corrugation of the divided
artery.
Dr. Jones has lately published a very
excellent treatise on hemorrhage; to
which I shall have very little to add.
The effusion of blood into the cellular
sheath of an artery when divided making
compression on its parieties is
one way in which hemorrhage is 
stopped. But I believe that the muscular
power of the artery is often sufficient
to contract the divided extremity


Wounds. 50
extremity and prevent any further effusion
of blood. That by this contraction
a small vessel can be closed independent
of external or lateral pressure is very
certain. But when the artery is large, we
see that the idea of Petit, that it is stopped
by the formation of a clot in its
divided extremity is correct.
But the permanent closure of divided
vessels depends on the natural process
of inflammation & adhesion.
Incised Wounds.
In the treatments of these the first object
is to command the hemorrhage. To effect
this the tourniquet, if possible, is
to be applied. The wound is next to be
washed out with a sponge & warm water,
and the ends of the divided vessel
drawn out with the tenaculum, a ligature
passed round it & tied.
It becomes a question what kind of


51 Incised.
ligatures is best. Thread or silk ligatures
have generally been employed to take
up arteries but they often remain in
a very long time & produce great irritation.
I saw a case of popliteal aneurism
operated on by Mr. Hunter where
the ligature remained on the aretry 6
weeks; and the patient nearly lost his
life in consequence of the hectic fever
which followed. And a silk ligature applyed
by Dr. Hartshorn remained on 6
months. This disagreeable attendant on
the use of the common lig. led me to
the consideration of some other substances.
It occurred to me that if ligatures
of animal substances which would dissolve
in the suppurative fluid were used,
all the mischief above noticed would
be prevented. Catgut, common fiddle
strings or French kid answer for these
ligatures. I first requested one of my friends
to try it on the spermatic artery of
a horse & it completely succeeded.


Wounds. 52
It was then tryed with equal success in
the human subject. I have now used the
animal ligatures for some time on
arteries of different magnitudes & have
known others to use them and in no
case has a secondary hemorrhage
occurred so far as I have seen or
heard of.
Mr. Lawrence proposed to use a fine
silk thread and to cut it close to the knot,
Now this will not answer as I have ascertained
by experience. Neither should
we expect it when we consider that the
least shred of lint among granulations
keeps up a continual irritation. I
was surprized to find from Mr. Astly
Coopers Surgical Essays that he used animal
ligatures in operations for aneurisms
and claimed it as his own discovery.
It is more than two years before
the appearance of his work that
I employed them. So you see I can
fairly claim the discovery as mine.


53 Incised
The wounded poplitcal artery has been
known to heal without an operation.
I have known the divided brachial artery
close up in this way. Dr. Mease
of this city in the operation of venesect.
had this artery opened and a varicose 
aneurism was the consequence. But
it afterwards spontaneously disappeared.
After a hemorrhage is stopped, never leave
a patient a single moment without
a tourniquet loosely bound on the limb,
and a watch always on the guard ready
to tighten if should the effusion
recur.
When these steps have been taken
the lips of the wound are to be brought
together & retained in situ by adhesive
straps; and to secure these still more
a compress bandage is to be applied.
The reason why hemorrhage in contused
wounds is less profuse than in incised
ones, is, that in the former there


Wounds. 54
is considerable effusion which makes 
lateral pressure on the vessels while
the death of the mouths of the ruptured
vessels is exceedingly favorable to the
formation of a firm coagulum.
I think it is not necessary to tye the artery
very tight in cases of incised wounds,
for by this means the artery might
be cut entirely through. It strikes
me that Dr. Jones has committed an
error by directing arteries to be tied so
tight as to cut through their interior
coats. This I am confident he speaks of,
mearly from theory. I have been in the
habit of applying ligatures in the way
I recommend for this 30 years, and
have never seen secondary hemorrhage
the consequence. If a ligature be applied 
tight enough to bring the sides
of the artery completely in contact &
keep them so for 24 hours, no hemorrhage
will occur unless, some unusual


Incised Wounds.
55.
unusual circumstance attends.
When a wound is deep it is always
necessary to leave a small space unapproximated,
for the escape of blood,
serum, extraneous matter &c.
Wounds produced by glass constitute
an exception to the common mode
of dressing. We should not attempt to heal
them by the first intention, but by suppuration.
Here we apply a poultice as
in contused wounds.
Adhesive plaster in general will answer
to retain the lips of wounds in apposition,
with proper bandages & position.
The soft parts suffer no injury from
adhesive straps, but stitches excite dreadful
inflammation from the irritation
of the punctures & the presence of
a foreign substance in the wound.
But stitches are necessary in some pendulous
parts, as the nose, ears, lips, scrotum
&c. also in wounds of the peritoneum


Contused Wounds
56
are those made by blunt instruments
which besides the simple solution of
continuity, produce an injury of
the adjacent flesh, greater or less,
according to the nature & violence
of the force applied.
In the treatment of these we apply a
soft poultice obviate excessive inflammation
& wait for the separation
of the bruised & dead flesh, and
when suppuration is established and
granulations form, we approximate
& retain in contact the sides of the wound
by means of adhesive plaster.


Punctured
57
Punctured wounds are made
by pointed instruments & the injury
is more obscure than in the other
species
A moderate diet, an emolient poultice
is to be prescribed. If inflammation
succeed vs. & purging together with
sudorific medicine become necessary.
The constitution sometimes suffers
from a punctured wound and convulsions
arise. In the case of a lady
which came under my notice, dilatation
of the wound put an immediate
stop to the convulsions. Also in
a boy who fell from the fence and
struck upon a nail. He was affected
with a variety of disagreeable symptoms,
such as pain in the back & head,
sickness at the stomach &c. Dilation of the
wound immediately relieved them all.
When such accidents occur in warm
weather, it is important to prevent


Wounds.
58
them from healing too quickly, as
tetanus is apt to supervene. In such
cases I order something stimulating
to be applied to the
wound to excite suppuration, and
a generous diet. I have known
tetanus occur from the puncture
of a pin in the great toe. I think tetanus
is less apt to occur from wounds
of the head & upper extremeties,
than from the lower extremeties,
But I knew it happen not long
since in a boy from a wound of
the uvula. I touch the parts with
something irritating when tetanus
is apprehended, which in most instances
has prevented it. I have often
seen it occur where this had
not been done, & therefore I have
great confidence in the remedy.


Wounds of the Eye
59
When the eye lids are wounded, adhesive
plaster is generally sufficient to keep
the parts in contact. But it occasionally
happens that this cannot be used
and we have to resort to stitches. One
caution is necessary never to pass
them through the tunica conjunctiva,
which always excites inflammation.
Sometimes the eye ball & interior parts
of the eye are wounded. The humours
also are sometimes effused; and occasionally
the iris suffers much.
In all such accidents extraneous
bodies must be removed, the eye shut,
vs, cupping, leeches, blisters &c, employed
together with rest in a dark room to
diminish inflammation. Caution the
patient not to rub the eye. The best
collyrium if any is necessary is made
of the pith of the young twigs of the
sassafras.
A child of Dr. Coxe, aged 6 years,
playing with a whip having a


and its Appendages. 60
tinseled hat band for a lash, had
the misfortune to cut himself across
the eye. A piece of the tinsel was observed
the next day and removed by making
a small nich of the cornea with
the cornea-knife and raising it up.
But inflammation had become violent
and a slight opacity succeeded. This
however was nearly removed by the
use of mercury.
I knew a woman who in pulling
a large darning needle thro'
a quill, stuck it into the eye, passing
through the cornea & crystaline
lens. An opacity succeeded, but a
mercurial course & the antiphlogistic
regimen removed the opacity.
I have never known any other
remedy successful.


61 Wounds of the Face.
In uniting these it was formerly the custom
to employ stitches; and I have seen
a lady's beauty spoiled by this means.
They never forgive you for it; and besides
there is not occasion for them in
contused wounds: and in incised wounds
they may mostly be dispersed with. 
Even where the lip is cut through the
adhesive plaster is sufficient. But if
a part of its substance be lost the utmost
caution must be used to bring the lips
together. Here the hare lip suture will
be necessary,
The Tongue is sometimes cut. Here
we have to use the interrupted suture,
In cases of children it is necessary to
interpose some thing between the teeth
to prevent them from biting the surgeon,
or from shutting the mouth, you will
find it necessary to watch your opportunity
& when you have the tongue
within your reach to plunge the needle


Wounds of the Throat. 62
needle into it by which you will be able
to secure it and to pass your stitches.
Now this is of a great deal of importance
to the practitioner. For if the child
finds you are a going to hurt him,
he will not open the mouth.
Wounds of the Throat are generally
the effect of attempts made to commit
suicide. When the trachea is not entirely
cut through, adhesive plaster will
answer. When completely divided, or
even partially cut stitches have usually
been recommended; observing
however to pass them only through
The cellular substance on the outside,
But I beg leave to dyssent from this advise.
I believe it will rarely be necessary
if a proper position be observed.
The chin must be brought down to
the breast & there confined by a bandage.


63 Wounds of the Throat.
If cough occur opiates & demulcents
must be employed. It is better not to approximate
the lips of the wound entirely
that space may be left for the discharge
of any blood or mucus which may be
effused or coughed up. By neglecting
this precaution suffocation has occurred.
It is however necessary to tye up all the
divided vessels before closing the wound
for I have known an effusion of blood
into the trachea produce instant death.
Nothing can more strikingly exhibit
the exceeding impropriety of using
stitches than a case related by Mr. Stark
in the Medical Commentaries.
In this man the whole of the larynx, &
the greatest part of the pharynx was
divided. The pharynx & trachea were
attached by stitches & the wound dressed
in the usual manner. On the 6th day
the patient had symtomatic fever &
the antiphlogistic treatment, with warm
dressings were ordered. 


Wounds of the Throat. 64
On the 9th day when the surgeon expected
to find him dead his fever had abated
and he had new hopes. On the next day
the stitches gave way and the whole wound
opened & appeared as if the windpipe &
gullet had been cut out entirely, leaving
one continued gash from the chin to
the sternum. At last the surgeon did
exactly what should been done in the
first instance. He brought down the
head and rested the chin upon the
breast by means of pillows placed under
the head and straps placed under the
axilla & made fast to a night cap.
This man under this treatment very
happily recovered though the wound
in the trachea had not entirely healed
up at the expiration of 2 months; when
unfortunately, getting intoxicated and
vomiting into the larynx, he expired
in a moment.
The pharynx is sometimes wounded
without the carotids, sustaining any injury.
I knew a woman to stick a knife
through the trach. into the phar. She recovered.


65 Penetrating Wounds,
are such as divide the parieties of the
cavities of the body.
Wounds of the Thorax.
When the thorax is opened by as penetrating
instrument, the lungs, or the lobe
injured, instantly collapse. Sometimes
one of the intercostal arteries is divided:
and it has been suggested to take it up.
I have never done it but think it practicable.
When the wound is small as that made
by a wire or small sword, the blood collects
in the thorax, and the respiration
becomes so laborious & difficult that
the patient soon expires.
Under such circumstances I believe life
might be saved by making an incision
between two ribs & letting out the effused
fluid. We should never inject any
thing in to wash out coagula, or introduce


Wounds of the Thorax. 66
introduce scoops, probes &c. If coagula
exist in the cavity of the thorax, suppuration
of the pleura must take
place. In order to exemplify this I will
mention the case of a boy who carelessly
discharged the contents of his fowling
piece through the left side of the
chest. A piece of gauze was first laid
over the external orifice & then an
emolient poultice applied & secured
by a bandage round the breast. On
the next day I visited him & found
his respiration very apprehensive, though
he complained of no pain. I bled him
examined the wound and reapplied the
poultice. In examining wounds of the
great cavities great caution is necessary
for the careless surgeon has sometimes
let his probe drop in; a very serious
accident indeed. In this case the pleura
inflamed and secreted a water which
flowed out of the wound & nearly subdued
the inflammation. In the space of
12 days it was necessary to take considerable


67 Wounds of the Thorax.
considerable blood & to use purgatives low
diet &c. At the end of 30 days he had
entirely recovered. No attempt was
made to draw out air, - none as necessary.
I have proved by experiment
that air is absorbed when admitted into
the chest, & of itself produces no inflammation.
There is in the Medico-Chirurgical
Journal of London an account of a
case, well attested, where the shaft of a
schaise passed through both cavities
of the thorax without proving 
fatal.
This case was not credited at first,
but Sir. Wm. Blizard, the attending surgeon
called in Mr. Home & A. Coper before
the wound had entirely healed &
all agreed that the above is a just account
of the case. The depositions of those which
came to the assistance of the man was also
taken to prove that the shaft had actually
passed completely through from one


Wounds of the Abdomen, 68
side to the other. That one cavity of the
chest may be laid open without proving
fatal we all know: but that both should
be without inducing death is hard to
reconcile with our views of the circulation.
When the abdomen is wounded
we are to bring the parts together & retain
them by stitches. In doing this begin with
the needle from within the abdomen,
pass it through the peritoneum first and
then through the integuments. After
all are passed commence tying.
If any of the viscera are wounded we are
previously to attend to them. The chief cause
of mischief in such cases is the discharge
of their contents into the cavity of the
abdomen: as is demonstrated by the case 
of the man who was stabbed through the
stomach with a bayonet. The third


69 Wounds of the
day he died; but the wound in the stomach
had entirely healed. In this instance
a quantity of porter he had drunk shortly
before the accident was discharged
into the abdomen & caused a fatal inflammation
of the peritoneum, and
not the wound abstractly considered.
That wounds of the stomach are not necessarily
fatal is abundantly proved by
a case related by Dr. Archer of Maryland.
A man in attempting to apprehend
a black man, was stabbed thro'
the stomach. The wound was 3 inches
long & all his dinner, cabbage, bacon, &c.
escaped into the cavity of the abdomen.
On the 3rd day the Dr. saw him. An old
soldier immediately after the accident had
sewed up the wound with a shoe maker's
awl. The Dr. immediately cut the stitches &
applied mild dressings, and in a short
time it healed up. But suppuration in
the groin took place an opening formed
through which some of the leaves of the
cabbage were discharged & he entirely
recovered.


Abdomen. 70
Had I been called to a case like this, I
would have sewed up the wound in the
stomach with the interrupted suture and
cut off the ligatures close to the knot, and
closed the external orifice with the same
suture. Closed in this way there is a deposition
of coagulating lymph over the external
part of the stitches, ulceration takes
place & they are discharged into the cavity
of the stomach & pass off with the foeces.
In this way the injury is repared. That
wounds of the viscera heal in this manner is abundantly
proved by the experiments of Dr. Smith
and A. Cooper, Longitudinal wounds of the
stomach & intestines heal more difficultly
than those that are transverse.
But if the omentum be wounded, the
vessels must be tyed and the ends of the ligatures
brough without the external wound;
because not being a hollow viscus the
ligature would be discharged into the cavity
of the abdomen & produce an abscess.
When the wound of the external parieties of the
abdomen is small, & yet we have reason to
suppose that some of the bowels are wounded,


71 Wounds of the
if we cannot examine the nature of the accident
without, I believe it right to dilate the
wound a little so as to protrude some of
them; but I am averse to opening largely, 
As adhesion soon occurs; what is done in
this way should be performed early. If not
it is better to trust to the soothing treatments;
bleeding, no diet but water, emolient
poultices &c.
In judging of the nature of wounds penetrating
the cavity of the abdomen, we must
pay attention to their direction. When passing
into the right hypochondrium, we
shall have reason to expect a wound of
the liver; and so of the other viscera according
to their respective situation.
A small wound of the liver if none of
the large vessels are opened heals very
readily; if extensive, they generally prove
rapidly fatal.
Wounds of the gall bladder are
fatal in consequence of the inflammation
produced by the effusion of its
contents.


Abdomen. 72
In cases of this kind the patient should
be bled & kept perfectly at rest.
Wounds of the kidneys are not necessarily
fatal unless they communicate with
the sack of the peritoneum so as to admit
of the discharge of the urine into the
cav. of the ab. The same may be said
of the bladder.


73 Wounds Of
When these occur it is important to
place the limb in such a position as to
allow the parts to be brought neatly
together; means being taken to prevent
the accession of inflammation.
Mr. Hey uses sutures. I do not believe
them necessary; but if you choose to employ
them, you must be careful not to pass
the needle through the capsular ligament
of the joint; for should this be done, violent
inflammation will inevitably take
place.
When inflammation however induced
supervenes, the constitution suffers severely:
fever carries on, with nausea, &
violent pain in the joint, an increased secretion
of synovia thinner & more watery
than usual, the ligaments swell & become
thickened by effusions of coagulating lymph.
At length suppuration takes place & pus
is secreted from the whole surface of the
capsular ligament; ulceration comes on,


The Joints. 74 
and openings are formed in various
parts of the skin about the joint. This together
with hectic fever undermine the
constitution & frequently end in death.
A turner in this city divided the capsular
ligament of the knee with a chisel.
By dressing it with adhesive plaster, and
observing a proper position & regimen, it
healed by the first intention.
And Mr. Hey relates cases where the ends
of the cartilage of the knee & elbow joints
which had been divided, united in the
same manner.
By all means prevent the inflammation
& suppuration of the joints. For I was
called sometime a go to a case of wounded knee-
joint where an ignorant physician had
dressed the wound to the bottom as he called
it, with lint dipped in Sp. of turpentine. Violent
inflam. suppuration, & a variety of
distressing symptoms took place. He also
suffered severely from convulsive twitches


75 Wounds Of
during the continuance of the suppuration.
He however recovered: but with a stiff knee
after suffering for the space of 4 months.
In addition to the common means, it is necessary
to apply a splint. It prevents convulsive
twitches & keeps the limb at rest. It
may be applied on the side, or behind.
In all cases of inflamed joints I would
recommend it to you.
In cases of contused wounds the parts cannot
be brought in opposition. When this is
the case apply a splint to prevent motion;
then put on a poultice of bread & milk, employ
vs. (cupping) & leeching, & purging to keep
down inflammation & attend to the symptoms
of the case. When the dead surface is
separated by the ulcerative process, and
granulations form, bring the parts
together with adhesive strips.
When the wound is complicated with
luxation, it has been a question whether
any attempts should be made to


The Joints ~ 76
save the limb.
I once knew a man who had a contusion
of the elbow joint from a cart wheel
passing over it. The limb was extended,
was stitched at the wound, & adhesive
plaster put over, & this confined by a bandage.
He died, - I believe in consequence of
the treatment. For if it had been dressed
by applying a right angled splint so as to
relax the parts & keep the limb at rest, and
a soft poultice put on, I think he would
have recovered.
But the danger from such a wound
is greater in summer than in winter;
in the intemperate then in the contrary


77 How the Injury of 
I believe that stiffness is often the effect
of ligamentous union between the ends
of the bones.
But when anchylosis takes place
the union is by bone: and before
this can be effected the cartilage must
be removed, out of the way, Now I
have told you that this substance neither
inflames, suppurates nor ulcerates.
I have been confirmed in this opinion
by the case of a young man who
received a wound from a load of small
shot passing through the ancle joint.
Inflammation & suppuration supervened
& produced such a violent irritation
& fever that it was thought advisable
to amputate the leg a little below
the knee, which was done accordingly.
On dissecting the joint it was
found that nearly one half of the cartilage
tipping the lower extremity of the
tibia, & the upper surface of the os astragalus


Joints is Repaired. 78
astragalus was completely removed & the two
surfaces were covered with florid granulations,
the commencement of bony
union. In the other portion it was obvious
that the same process was going
on, though a part of the cartilage still
remained: and had the limb remained
on, and could his constitution withstood
the shock of the disease, there can be no
doubt but that the remaining thin
plate of cartilage would have been removed
by the absorbents on the surfaces
of the granulations which were
seen sprouting out between the cartilage
& the bone to which it was attached:
and then anchylosis would
have been effected.
Perhaps the removal of the cartilage with a
knife, by scraping it off might greatly facilitate
the process of anchylosis. I wish
however to inform you that I have no
experience in the matter.


79 Wounds of the Nerves.
When any of the nerves are wounded
there arises pain immediately after
the accident numbness of the part to
which they are distributed, or at least
diminished sensation. It is said to occur
often in the operation of venaesect, 
But scarcely any operation can be
performed without dividing some
of the nerves.
Sometimes when the soft parts below the
tendonous fascia on the arm, the thigh &
the scalp, are wounded, the symptoms
are very violent.
The application of a splint when seated
on a limb will generally relieve, and
when it does not, the fascia is to be
divided.
- These symptoms frequently arise
from motion separating the wounded
extremeties of the nerves. Even tetanus
sometimes happens from this cause,
Now all this may generally be prevented
by applying a splint which
stops the motion of the parts.


Wounds of the Nerves 80
This affection however is not generally
a spastic rigidity of the whole body
as in tetanus, but it is more partial;
and this is the way we distinguish them.
A lady received a wound of the parts below
the tendonous fascia in the operation
of os. The symptoms became very violent
and continued until the 90th day. Blisters
were applied which in some degree relieved
the symptoms. When 60 had been
applied she was so far recovered as to be
about: though at the end of 10 months it
remained stiff. I recommended the splint
which completely cured her.
I have since had frequent opportunities
of witnessing its complete success in many
other cases.


81: Wounds Of
The tendons are sometimes entirely cut through.
They require the same treatment as wounds
of other parts. The limb is to be placed in
such a position as to relax the muscles to
which they are attached, and bring the
extremety of the tendon together, and to
keep them in opposition by a proper apparatus.
When the tendo achilles is divided,
a splint so curved as to cover a good
deal of the side of the foot to prevent any
lateral motion ought to be used. When the
tendo Aclil. is ruptured the same mode
of treatment is requisite.
But there is still another accident much
more severe: and this is the rupture of
some of the fibres of the gastroenemii muscle.
The perception is that of a severe blow
on the leg, and there is considerable difficulty
in walking. Sometimes you can
feel the pit or depression where the fibres
are ruptured. At other times we are led
to it by ecchymosis. The remedy consists


The Tendons. 82
consists in extending the foot & applying the
curved splint, and keeping the limb at
rest.
I knew a gentleman in whom inflammation,
swelling & pain occurred, one day,
after a long walk. He then lay still awhile
when it entirely subsided. Thinking
himself well enough, he went out again,
And he again had a repetition of
the symptoms. He at length, after a
frequent repetition & subsidence of the complaint,
called on me for advise. I immediately
discovered the nature of the
case, applied the splint, & in a few weeks
his leg had recovered its usual strength. 


83 Wounds of the
Wounds of the veins seldom cause any
bad effects. But occasionally they prove
both troublesome & dangerous.
Mr. Hunter says that the inside of veins
are subject to inflammation as well as
other cavities. Likewise to adhesion, suppuration
and ulceration. The cause of inflammation
in the veins has been imputed to
a bad constitution, to the wound of a nerve
&c. But this inflammation occurs frequently
where no nerve nor fascia could
be wounded: and that it does not occur
in consequence of a bad habit of body
is proved by the fact that the same patient
if bled in the other arm has no
such occurrence take place.
Mr. Hunter imagines that the inflammation
of the veins consequent to venaesect.
& other wounds, arises from the wound
not healing by the first intention.
Sometimes when the inflam. has progressed
to the suppuration stage, a small abscess


Veins. 84
only forms immediately within the orifice
of the vein & is confined by adhesion above
and below. But sometimes this does not
happen & the pus passes along the circulation
to the heart & occasions death.
He conceives the inflam. arises from the
imperfection of the cavity of the vein
the consequence of neglect to close accurately
the lips of the orifice, When the orifice
is not longitudinal with respect to 
the vein & the arm is much used inflammation
may occur from the gaping
of the orifice.
To prevent this accident it is recommended
to apply a thick compress of linen
which has received a little of the blood,
which is more in harmony with the
wounds than any other substance, &
which has a tendency to form a scab,
taking care at the same time to bring
the lips of the orifice neatly in apposition.


85 Wounds of the Veins.
Mr. Hunter supposed that applying a compress
above the abscess of the vein would
obliterate the cavity of the trunk and thereby
prevent the pus from passing along
the circulation, But this plan will not
answer for there are other various branches
which would receive it. It is suprizing
that Mr. Hunter did not think of
this. Besides it is found in practice to be
inadequate.
The operation of cutting down to the
bone, as recommended by Bell, in inflamed
veins can do no good. I saw a patient who
actually died from the violent effects of 
dividing the inflamed parts down to the bone:
and though a second escaped with his life
yet he suffered an immense deal.
I am happy in being able to inform you
that the application of a blister has almost
always cured this affection; all the symptoms
speedily ceasing under its impression. I have
not failed in curing any case where I
have tried it.


Gun-Shot Wounds. 86
Gun-shot wounds are made by the forcible
projection of hard obtuse bodies, the
greatest number of which are musket balls.
The livid color of the parts & the tendency
they have to become gangrenous induced
the old surgeons to suppose that they were either
poisoned or burnt. There seems however
to be no mystery at all in the case; the
only essential difference between gun-shot &
other contused wounds, is found to consist,
in the death of the parts through which the
obtuse body passes, and the necessity for the
separation of these before union can be
effected. The separation of the slough seldom
takes place before the tenth or twelvth
day. At this time it should be carefully watched
for fear of hemorrhage.
Gun-shot wounds for the reason mentioned
do not generally bleed much.
Sometimes when a ball has nearly spent
its force, as when it passes out of a part, it
produces a lacerated instead of a contused
wound, which will heal by the first intention.


87 Gun-Shot
When in consequence of the lodgment of
balls there is a compression of the brain,
the trephine may be used. In some cases
I have seen a patient die for the want 
of it.
Extraneous matter which can easily be
come at should be extracted, and sometimes
dilitation for this purpose may be
proper. But where it is lodged deep, this
should not be done.
In the treatment of gun-shot wounds
we must attend to the direction of the ball
in order to tell the precise parts injured
if possible. The position the person was in,
when the accident took place, must also
be taken into consideration.
The best application to the wound itself
is a soft bread & milk poultice.
It has been recommended to bleed in
every case of gun-shot wound. But
it is better to postpone this till fever supervene
for fear of tetanus. I saw it occur
in a man I believe from copious evacuations.


Wounds. 88 
To prevent violent inflammation & gangrene
position; elevation of the limb &c. is safer
than bleeding. As soon as suppuration
is established it will be useful to administer
the Cinchon. & allow an invigorating
diet.
When the wound penetrates into the thorax,
then as the parts cannot be united
by the first intention we are sure of a
violent inflammation. And here vs.
and a low diet must be prescribed.
Tetanus seldom occurs from wounds of
the internal parts. It oftener occurs from
wounds of the extremeties. We must incur
the risk of it in cases of the above description.
Wounds of the spine when below
the phrenic nerves are not immediately
fatal & sometimes life is prolonged many
days. When above their origin, death is the
immediate consequence.


89 Gun-Shots 
If the liver is wounded there will be pain
in the part of a sickly or depressing kind;
and if it is in the right lobe there will
be a delusive pain in the right shoulder,
or in the left shoulder from a wound
in the left lobe. A wound of the
stomach will produce great sickness
& vomiting of blood, & some times a
delirium. In wounds of the stomach
if any of its contents escape, externally,
the nature of the case
will be immediately discovered.
Here little can be done but to keep
the patient quiet, & allow nothing
but the mildest fluids, and in as
small quantity as possible.
If the intestines be wounded there
will be bloody stools, more or less
pure according as the part wounded
is more or less distant from the anus.
If the blood come from a high
portion, it will be mixed with


Wounds. 90
foeces, & of a dark color. The pain
will be more or less acute according
to the intestine wounded; more of
a sickly kind the higher it is up, &
more acute the lower. There will 
be bloody urine from a wound of
the kidneys or bladder. The sensation
will be trifling. A wound of
the spleen will produce no particular
symptoms except probably
nausea, from its connection by
nerves with the stomach.
Balls lodging in the bladder may give
rise to calculus.
After gun-shot wounds of the abdomen if
foeces escape it shows that the intestines
have been shot through, But they may be
injured and this effect not take place
immediately, or till sloughing occurs.
Bullets sometimes pass through joints


91 Gun_Shot Wounds. 
which is a serious accident. The inflammation,
suppuration & hectic sometimes
waste & destroy the patient. But when
it has only lacerated the joint, from its
force being nearly spent, the wound may
be healed by the first intention. When the
ligament of large joints are much contused
& lacerated, it is best to amputate,
& immediately too, before the subsequent &
disagreeable symptoms I have mentioned appear;
for I have seen death occur merely 
from the irritation induced by the
inflam. & suppur. of the joint. I wish however
to caution you against amputating
when inflammation has supervened.
Here it ought to be deferred till
suppuration is established, & the inflammatory
symptoms have subsided.


Ulcers. 92 
Having treated of inflammation and
wounds, I go on to the consideration of
ulcers, their consequences.
Too much attention cannot be paid
to the treatment of ulcers, as they are
so frequent in their occurence, and
sometimes so obstinate in their nature.
An ulcer is the solution of continuity
in a soft part discharging pus.
Treatment.
In the treatment of a simple healthy
ulcer, nothing more seems necessary
than to apply a bit of lint to absorb 
the moisture from its surface,
and over this a pledgit spread with
simple cerate to prevent it from
drying up.
But Mr. Bagnton recommends
the application of adhesive plaster
to facilitate the healing process,
He however applies them over all
the surface of the ulcer which is


93 Simple
wrong. I apply them at the distance of 1/4
of an inch from each other: for I
have seen the ulcer enlarge when this
precaution had been neglected.
The dressings are to be retained by
means of a calico roller neatly applied
commencing at the foot. By this, the
edges of the old skin are brought together
and the contraction of the
sore facilitated.
I do not find as the rationale
for the utility of adhesive straps in
the healing of ulcers has been given,
I consider that they are useful by
bringing the originally formed skin
together, & by assisting the granulations
in adhering to each other.
This is one way. But another way is
by fixing the edges of the ulcer & keeping
them in one situation.
Another circumstance demands attention.
Some surgeons are in the


Ulcers. 94
habit of washing the surface of ulcers 
with a sponge, and of rubbing it round
from centre to circumference, by
which the edges are separated and
the granulations torn apart. Now
this is entirely wrong. It ought always
to be from the circumference
to the centre. Pulling away the adhesive
straps by taking hold of one
end tears the granulations a part
& should carefully be avoided.
It is sometimes necessary to strengthen
the granulation by constitutional
remedies & by certain astringent applications;
and when these fail exposing
them to the air causes them to dry
scab & heal.
I must not overlook to mention
that when the ulcer is situated on a
tendon, as the tendo Achill. or on
that of the tibiales anticus &c. it is
apt to be extremely difficulty to cure.


95 Simple
I was called sometime since to see a
very obstinate ulcer seated on the tendon
of the tibialis antimus. This case
had baffled the practitioner for a long
time. He had used a great variety of applications
but without success. At one
time it appeared to be doing well, but
it soon relapsed into its former condition
and now looked blue & livid.
I immediately saw the cause of failure
and told him that the reason why the
ulcer would not heal was because
it was seated on this tendon: and
that if he would apply a curved splint
so as to relax the parts & keep the muscles
from motion and thereby tearing
asunder the granulations, it would
heal in a few days. He did so; and
it immediately got well. I have seen
a great many similar cases which
yielded to the same plan of treatment;
and are which resembled the spongoid
ulcer.


Ulcers. 96
My observations apply principally to
ulcers of the legs; for here they are the
most difficult to heal.
The arteries and veins of the leg are
fine in their texture, and the parts are
too weak to carry on a vigorous circulation.
In consequence of this the blood
stagnates and the granulations upon
ulcers are livid, and have a disposition
to bleed when touched.
Place the patient in a horizontal position.
By this means the circul. of the blood in
the arteries is not augmented, nor obstructed
in the veins.
In cases of this sort bandages should
never be omitted. These are of 3 sorts,
1. The Laced Stocking
2. The Roller
3. The Adhesive Straps.


97 Simple Ulcers.
When water is effused into the cells of the
tela cellulosa, the part becomes oedematous.
Confinement of the patient to bed
will enable the ulcer to heal. When this 
cannot be done a fine bandage must
be employed and neatly applied early
in the morning. Lint, powders and
salves sometimes do harm and we shall
find that their removal alone will
give the ulcer a disposition to heal.
Intemperate drinking & other excesses is
very unfavorable to the restoration of
ulcers. In hot weather ulcers heal less
readily. And I have seen the healing
process quickened in consequence of the
patient becoming attacked with pleurisy.


Unhealthy Ulcers. 98
Those ulcers which have no disposition
to heal are called unhealthy.
These I shall divide into 8 species.
1. The Inflamed Ulcer,
2. The Fungous Ulcer,
3. The Oedematous Ulcer: or ulcers
situated on oedematous limbs.
4. The Sloughing Ulcer,
5. The Indolent Ulcer,
6. The Carious Ulcer,
7. The Varicose Ulcer,
8. Ulcers Attended with Specific
diseased action.
1. The Inflamed Ulcer.
This has the following appearances. The
surrounding parts are red, tumified, &
very tender; the margin of the sore ragged,
the skin terminating in an elevated ridge;
the bottom of the ulcer made up of concavities
& no appearance of granulations; the discharge
is thin & serous; the surface of the sore


Fungous Ulcer.
99
acutely sensible & bleeds when touched.
The pain is sometimes very great, though in
general not constant.
The remedies are rest & confinement in
a horizontal posture, low diet, vs. &c,
The best application is a bread & milk, or
linseed poultice till the inflammatory
symptoms subside; then dress like the simple
healthy ulcer.
2. Fungous Ulcer.
This ulcer is covered with large round
granulations, rising above the level of the
surrounding parts; less compact in texture
than usual, & having no disposition
to cicatrize.
Treatment. Compression, bandaging,
escharotics, as calcined alum, red precipitate,
lunar caustic &c. In cancerous
ulcers where the fungus can almost be
seen to spring up, the old surgeons used
to tye on wooden cups to repress the fungus


Oedamatous Ulcer 100
A limb oedamatous is usually cold, tumefied,
& of a pale color; retaining
the mark or pit made by the pressure 
of the finger for sometime.
An ulcer seated in such a limb is generally
somewhat inflamed & tender to the
touch if not painful. The granulations
appear purple & in spots appear
gangrenous or sloughy.
When fever attend bleed, & purge
repeatedly. Where the patients strength
will not admit of it, subsitute the elevation
of the feet of the bed-stead; bandage
the limb, previously approximating
the edges of the ulcer with adhesive
straps.


101 The Sloughing Ulcer.
In consequence of deficiency of strength
in the constitution, or the part affected,
or change of diet, air &c. the granulations
of an ulcer very frequently mortify, &
sloughs fall off from various parts of
the sore, & sometimes from its whole
surface. In some cases this takes place
after the process of skinning, the new
skin becoming, purple, livid & black.
In the treatment of the sloughing ulcer
we must direct our remedies to
the constitution. Bark, wine, porter
and a generous diet are generally indicated:
as opium to relieve pain.
Locally applications of a moderately
stimulating kind. A soft carrot poultice
is sometimes employed with advantage.
Washing the ulcer with diluted laudanum
or an infusion of galls is beneficial
The two last remedies, I have known successful
for some time. It was so in the


The Indolent Ulcer. 102
case of the door-keeper at the Hospital
some years since, after the ulcer had
covered almost all the the leg from
the ham to the ancle.
5. The Indolent Ulcer has its
edges hard, round & tumefied; the granulations
being smooth and glossy on the
surface. It is sometimes inflamed.
If we happen to be called to see the ulcer
while in a state of inflammation; this is
to be subdued by the antiphlogistic treatments.
We are next to destroy the whole
surface of the sore either with the knife
or the caustic potash, and thereby to
change it into the nature of a sore
from accident. Pressure answers exceedingly
well after the inflammation is
brought under, & may sometimes be
had recourse to. Mercury is very useful
even when there is no venereal contamination


103


104


105 Carious
contamination. A slight salivation often
cures. Gastric juice, alcohol, green & blue
& white vitriol, diluted acids, powdered
rhubarb, galls &c. may often be applied
with advantage to stimulate the granulations
6. Carious Ulcers. In the carious
ulcer a portion of dead bone gives the
stimulus of dead matter, keeps up a constant
irritation, & prevents the sore from
healing.
Here we must wait for the dead bone
to loosen; as soon as that takes place it is
to be extracted.
It is impossible for the healing process
to be completed as long as this remains
in the sore. There is sometimes considerable
difficulty in ascertaining whether
the bone be loose or not. When moveable we 
may dilate the orifice if necessary.
To ascertain whether the portion of bone
be loose or not, I have been in the habit


Ulcers. 106
of attending to two circumstances. 1.
Pass down a probe upon the carious bone,
and 2nly press hard upon it. If this causes
pain, and if the granulations bleed in
consequence of the bone being pushed
against them, you will infer that it is
loose. When you have ascertained this
pass down a director & dilate the orifice.
I have sometimes dilated the orifice with
a sponge tent where the blood vessels of
the limb were too contiguous to admit
of dilatation by means of the knife.
Sometimes the bone is easily extracted. But
if large the difficulty will be greater.
I have employed a pair of gold forceps for
the purpose of extracting a long piece of
bone when it has been deeply situated.


107 7. Varicose Ulcers
These are a species of indolent ulcer attended
with a varicose state of the venae
saphenae & its branches. The ulcer is usually
oval in shape, of a purple color, more or less
painful & has a sanious or bloody discharge,
The veins are enlarged their valves do not
support the gravity of the blood because
their edges do not meet. Thus the great
weight of the whole column of blood ruptures
the small vessels & the ulcers frequently
bleeds & sometimes very freely too. This
then is the reason why they do not heal.
In the treatment of the varicose ulcer
it is best to cause cicatrization by common
dressings; horizontal posture; & then
to apply a bandage or laced stocking to
support the parts and prevent it from
opening again. The effect caused by
tying up the vena saphena has not
been so flattering as to induce me
to repeat the operation very often.


Specific Ulcers. 108
In the first case that I tried the operation
I took up not only the large
trunk of the ven. seph. but all the cutaneous
branches which were enlarged.
The patient recovered very happily,
But still I cannot recommend the
operation very strongly to you; because
it is dangerous. The veins may inflame
and produce death, The safest way of treating
this ulcer has been mentioned.
8. Ulcers Continued by some
specific diseased Action.
This division will include venereal, Scrofulous,
cancerous, and all ulcers from
a local or constitutional action of a
morbid nature.
Treatment. As a general rule it may
be laid down that when the constitution
is affected we are to apply those remedies
which may be indicated by the nature
of the disease: and when the morbid action
is local, we must destroy the diseased parts


1.09. Ulcers Continued by
if possible. Sometimes the disease is seated in
a part where it may be removed with the
knife.
There is a kind of ulcer left after the
ravages of the venereal disease which is
cured by removing its edges or the whole
surface. The disease is very often situated
merely on the surface & is kept up by the
irritation produced on the edges of the ulcer.
The bottom of such an ulcer frequently
appears to be healing very kindly, while the
edges look livid & wormeaten; & all at once
slough off.
Very often the patient & practitioner
are harrassed with an idea that the venereal
virus is not entirely exterminated &
mercury is again resorted to under the supposition
that it has not been continued long
enough.
Some years ago on being called to such
a case I gave it as my opinion that it
was only continued by the local irritation


Specific Diseased Action 110 
on the surface of the ulcer. Much against the 
will of the consulting physician & the patient
I applied the caustic potash. It produced
an eschar which soon separated &
the parts underneath healed up very kindly.
But as the caustic is very painful when extensively
applied, I have generally taken off
the ragged edges of the ulcer, & then applied
powdered chatechu. By this means I have
cured very many completely.
But in men, & women too, where there is
no venereal contamination, there is an
internal ulcer of the leg & arm which goes
on separating the muscles from the bone.
This you must lay open & apply caustic to
its parieties. All the applications in the
world without this will do no good.
A woman lately came to me with such
an ulcer of the cheek of 18 months standing
which she supposed cancerous. I assured
her I would cure it in a few weeks
which tended greatly to quiet her fears.
I applied the caustic & it got well in a little
time.


111 Fracture of the Bones.
I had another case which had continued
fifteen years. The practitioner had applied
the caustic freely to the middle of the ulcer,
but it did no good because the ulceration
was continued by specific diseased action
situated in the edges of the sore.
But when these were destroyed it all healed
up.
Fracture of the Bones.
A fracture is the solution of continuity
in a bone produced by external violence,
by muscular action, or by the
conjoint operation of both.
That muscular action has considerable
agency in the fracture of bones
is evident: and some are fractured by
the action of the muscles alone, as the
patella.
It is a notorious fact that drunken
men seldom break their bones by
falling; probably because they use


Fracture of Bones. 112 
no exertion to recover themselves when falling.
The reason why fractures are more
common in slippery wether than at other
times is that the muscular exertion used
to prevent falling superadded to the fall
occasions the fracture.
When a bone is fractured, there is a
sudden & severe pain; the limb is more or
less distorted or bent from its natural
position; and there is an inability to move
it without considerable pain. There is also
crepitus when the ends of the broken fragments
are grated together.
Fractures are either simple or compound.
Simple, when the integuments
are not punctured: Compound
when there is an external opening
communicating with the cavity of
the fracture; and Compound-Simple,
when the external opening of a compound
fracture is of such a nature as to
heal by the first intention.


113 Fracture Of
Treatment. In the treatment of fractures
there are 2 indications.
1. To Place the fragments in contact,
or as nearly so as possible, and
retain there in situ: and
2. To obviate those circumstances which
interfere with the healing process
in the fractured extremities.
The principal resistance to the replacements
of the broken extremeties is,
the action of the muscles.
A fractured bone should always be
set immediately after the occurrence
of the accident. By this means
we avoid the difficulty in overcoming
the force of the muscles where
they have contracted in consequence
of the irritation produced by the
fractured ends. We also avoid the
effusion of blood which takes place, and


Bones. 114
which so distends the limb as to make the
nature of the accident obscure, and
its immediate reduction difficult or
totally impracticable.
There are some conditions in which
the bones do not unite, and a kind of
artificial joint is formed. This has
been imagined to depend on the constitution.
But I do not believe this; for
I have seen a case where the thigh &
tibia were broken at the same time;
the former united, while the latter
never did.
It has been advised in such cases to
cut down & saw off the extreme fragments
under an expectation that ossification
would take place between the
ends & form the bony union which
was wanted. I have actually seen it
done with a fatal termination; &


115 Fracture Of
Mr. Bayer related a case where it was
performed on the arm. The ends of
the bone were sawed off & the vacuity
was 2 1/2 inches. Inflammation & gangrene
put a period to the patients life
the 7th day. Mr. B. says it is one of the
most difficult & dangerous operation
that is performed, and yet, he says it
ought to be done if the patient desires
it.
A great number of years ago it
was performed by a surgeon in the
country but without any advantage,
The patient after finding that his arm
was entirely useless came to the Penn.
hospital & had it amputated.
In several cases of artificial joint
I have caused the bone to unite by
making the patient move the limb about,
or walk on crutches bearing
as much weight on the affected
leg as possible. After several weeks


Bones. 116 
have elapsed & still the ends of the bone
are loose, we must resort to some other
mode of treatment.
I find it has been recommended to
pass the electric shocks through the
parts, and it is said to have succeeded
in some cases. In one case I tried it,
but it did no good.
But when we have made all these
trials without success, it becomes a
serious question, what shall be done.
For if it be the thigh or leg, the person
cannot walk; if the arm, it cannot
be used.
In 1802 a patient applied at the
Hospital with this state of the os humeri.
I proposed to the consulting surgeons
in preference to any other operation
to pass a seton between the ends of
the bones.


117 Fracture Of
As I had seen a case where the other operation
had proved fatal it had made
a strong impression on my mind
against cutting down. This case had
been 20 weeks standing. After passing the
seton inflammation & suppuration
succeeded; but at the end of 12 weeks
no perceptible alteration was obvious
in the artificial joint. But soon after
this it began to stiffen, & pain was
induced whenever it was bended. From
this time bony union went on gradually
& his arm became as strong as
before the accident. This operation
has since been often performed
in the U.S. & in Europe with success


Bones 118
Union of Fractured Bones.
When a bone is broken an effusion of
blood takes place between the fragments
which coagulates. This coagulum soon
became vascular & forms a uniting
medium called callus. This is soft &
vascular at first, but it shortly becomes
cartilaginous & is finally changed into
complete bone.
But there is another way for bones
to unite & that is by granulations.
In compound fractures they always
unite in this way. The ends of the bone
inflame, suppurate, granulate & fill
up the cavity; & the granulations are
gradually changed to bone by the deposition
of the earthy particles to which
bone owes its solidity.
Sometimes the ends of the fragments are
prevented from uniting in either of these
ways in consequence of becoming
dead.


119 Fracture Of
Now under such circumstances the
union is completely in this way:
[image]
At the place where the line of distinction
commences between the living
and dead bone, adhesion of the soft
parts takes place & a bony bridge is
formed round the vacuity on each
side, forming a cylinder of bone over
the gap but with space sufficient for
the dead bone to be discharged through
the same. I here show you a clavicle
where the bony bridge I speak of
is actually to be seen, & a hollow
space left for the discharge of the bone
within by the process of exfoliation.


Bones. 120
Compound fractures are sometimes accompanied
with profuse hemorrhage,
In these cases where practicable we are
to apply the torniquet & secure the bleeding
vessels, if the parts are not so much
contused & comminuted as to render
amputation necessary. If such should
be the case, it ought to be performed
immediately.
Sometimes the medullary artery
causes the hemorrhage in which
case Mr. Gooch recommends amputation.
I have never had such a
case but were it to occur to me, I
would attempt to plug up the orifice
with a wooden plug. I used
this pan with success in a case of amputation
of the leg.
But if the bleeding be in such a place
that the hemorrhage cannot be commanded
the principal artery may


121 Fracture Of
be taken up; as for instance the popliteal.
The posterior tibial artery is sometimes
divided in compound fractures. In this
case it has been recommended to amputate:
& Dr. Wistar actually saw it done
at Paris. But I have taken up this artery
where it is very deeply seated.
In this case it occurred to me that
an artery might be taken up merely
by feeling its [illegible] with a small pair of forceps
which answer the purpose of
slim fingers & a crooked needle I passed
a ligature under the artery.
Sometimes a splinter of bone projects 
through the wound and it is often
difficult to replace it. Sawing
off these fragments may be done when
we cannot reduce them without, I have
never seen a case where dilalation of the
wound was necessary for this purpose,
Having reduced the bony fragments,


Bones. 122
we attempt to close the wound so that
union by the first intention shall take
place, where the state of the parts induce
as to believe it practicable.
To prevent inflammation repeated vs
& a low diet is necessary. The best application
where suppuration must happen
is a bread & milk poultice,
Bark & wine are improperly given
while the inflammatory symptoms
continue. But after they subside &
suppuration is established they are
of use.
Position in cases of compound
fracture is a very important in preventing
inflammation. Elevate the limb.


123 Particular Fractures.
Of the Ossa Nasi. These bones are
occasionally fractured by blows on the nose &c.
The lower part of them is most exposed to
this accident. The broken fragments are
depressed or beaten in. If you see the patient
immediately after the accident, you
can see & feel the depression.
The depressed fragments are to be elevated
by a blunt instrument introduced
into the nostril & at the same time apply
the thumb & finger to the nose on the
outside to assist in adjusting the fragments. 
Then apply adhesive straps to keep
them in situ. There is at first considerable
ecchymosis which however soon
subsides. I have never seen a case where
the broken bones were so loose as
to need any support from within:
nor do I think it likely to happen for
there is no muscles to draw them
out of the place they are put,


Fracture of the Ossa Nasi. 124
When the fracture is very comminuted,
suppuration from loose spicula of
bone comes on . . . . . . . . & an abscess is
the consequence. In this case I would advise
an opening to be made & the spicula to
be extracted. You must however, be certain
that you are cutting into an abscess used
not into an ecchymosis.
I have never seen a case where this violence
was such as to drive the nasal
process of the ethmoid bone upwards,
& push the cresta galli into the brain
producing compression.


125 Fracture Of the Maxil. Inf.
The Lower Jaw is not often broken at
the chin; more frequently between that
and the angles.
But I have seen a jaw broken into
several pieces: at the chin perpendicular,
& just before the angle in the same direction;
& then transversely across those. The
person in whom this happened fell down
several stories where goods are drawn up.
When a fracture of the jaw takes place,
anterior to the angles the symptoms are,
severe pain in the part at the time of
the accident, inequality, perceptible by
passing the fingers along the base of the
jaw, & unevenness of the teeth.
Sometimes the bone is broken without
producing any displacement;
and to examine this you should take
hold of the sides of the jaw & attempt
to move them in opposite directions.
By this means the nature of the accident
will be determined & you will


Continued 126
be sensible of crepitation.
When the condyles are broken, the
fracture is not very obvious, but may
be ascertained by pain in the vicinity
of the ear on moving the jaw, and by
the crepitus which attends it.
If considerable swelling occur before
the surgeon is called great difficulty
is experienced in determining the nature
of the case & it becomes necessary to
wait for the inflammation to subside,
Teeth when loosened by the fracture
ought not to be extracted in any case,
For by so doing you convert a simple,
into a compound fracture, I have
twice seen this produce death. In the
one, there was an extensive fungus, &
in the other, caries.
Splint. The upper jaw is the one prepared
by nature & we need no better.,
The bandage must be so applied as to prevent
all motion of the jaw & the patient


127 patient is not to attempt to open the
mouth nor to talk. His nourishment
must all be fluid.
The bandage used by Dr. R. Basten
is a very good one.
When the condyle is fractured it is
drawn forwards by the pterygoid, ext,
muscle. It here becomes necessary to
push the inferior fragment forwards,
apply a compress behind the angle
of the jaw & a bandage to confine
all in situ.
It is necessary to examine the bandage
every day to see that it does not become
loose. Inflammation must be
guarded against by confining the patient
to the antiphlogistic regimen.
In some cases of fracture near the
condyles, I have been totally unable
to apply any bandage which would
prevent the lower fragment from
being drawn back.


Fracture Of the Vertebrae. 128
The vertebral column is sometimes fractured
though not often. The connical vertebrae
I have seen fractured from the person
falling head long.
The only circumstance which renders
this accident more dangerous than
other fractures is the concussion of the
spinal marrow by the force producing
the fracture, & the compression
produced by the separation of the fragments
constituting the bony bridge
over the spinal marrow.
The consequence of this pressure is a
paralysis in every part deriving its
nerves from the medulla spinalis below
the part fractured.
If the injury is seated above the origin
of the phrenic & intercostal nerves, the patient
dies instantly.
I have never known a patient recover
where a palsy has occurred in consequence
of the fracture of the cere. vert,. They always died
the 3rd, 5th, 6,or 7th day.


129 Fracture Of
A patient in the Hospital survived a
fracture of one of the dorsal vertebrae
nearly 6 months. The body of the vertebrae
was fractured & pressed inwards,
forming an angular point which
pressed on the spinal marrow. He died
in consequence of the extensive ulceration
of the back from lying.
But paralysis from contusion of the
spinal marrow in consequence of
external violence is not always fatal.
I knew a gentleman, in whom it occurred
in consequence of a wound received
by a bullet, who recovered. These
cases however are very tedious, and the
cure sometimes does not take place
for several years.
Sometimes we are called to children in
which a loss of suction occurs in the
lower extremities after a fever. This I
believe is the consequence of the inflammation
attending the fever, terminating in
an effusion of water in the vertebral


The Vertebræ 130
canal so as to compress the spinal marrow.
Low diet, purging every 2nd day, cups
applied to the place of compression appears
to me best at the first; afterwards dry-cupping 
is useful. After evacuating the
child completely (& waiting a reasonable
time) I apply a blister over the part
& keep it running for a great while.
By these means I am happy to say I
have relieved every case I have had,
If this treatment did fail I should
give mercury notwithstanding the
danger attending its administration to
children.
A patient who has received such an injury 
as gives us reason to suppose there is
a fracture of the spine,
is to be placed on the side; but not on
the belly which position might prevent
the action of the diaphragm, and the


131 Fract. Of the Vertebræ.
patient might die before you have
done examining the nature of the
accident.
I have never found any advantage
from machinery; no adjustment
of the fragments can be made. The
bladder must be emptied 2ce or 3times
a day; for the patient has no feeling &
cannot tell whether the bladder is
full or not.
Mortification is apt to occur from
the pressure incident to lying and
is only to be preventing by turning
the patient first on one side, then a
little towards the back, & finaly on
the other side.


Fract. Of the Pelvis. 132
I have seen two cases where the ilium was
broken off transversely. By taking hold of
the anterior superior spinous process & making
an attempt to move it, the crepitus was
perceived.
I have never seen a fracture of the os
ischium: but I have seen the pubis fractured
transversely near its symphysis.
This Patient experienced a great deal of
Pain in raising the leg. By taking hold
of the thigh & moving it, I could discover
a grating noise.
There is no better way of treating
these cases than to pass a broad bandage
round the pelvis & keep the leg &
thigh perfectly at rest. The patient in
general will not attempt to move much
because it occasions pain. He must
be moved very little; just enough to prevent
gangrene from pressure,
Fever must be subdued by vs. & strict diet;
no meat nor spirits.


133. Fracture Of the Pelvis.
I never have seen a fracture of the os
sacrum.
The os coccygis is said to be fractured
when ossified, by falls on the buttocks.
This accident ought to be attended to especially
in females lest it produce a
deformity & be inconvenient in parturition.
Introduce the finger in ano & replace
the fragments, no bandage is
necessary. Diet: laxative,- rye-mush,


Fract. Of the Sternum. 134
I have never seen but one case of fracture
of the sternum & this occurred to me in
St. Bartholomew's Hospital. I could not
at first distinguish it. But I placed the
patients hands on my shoulders & then
told him to press on them; at the same
time I had my hands on the sternum,
In this way I could discover the accident.
I took this hint from seeing the
pectoralis major muscle demonstrated.


135 Fracture Of
The ribs are not often fractured; but
when the accident occurs it is generally
near the angles. I have seen a case where
5 ribs were broken at the same time.
There is no deformity or displacement;
for the connexion of the ribs, liking to the
vertebrae, the sternum before, and the intercostal
muscles prevent it.
The only derangement which can happen
is an angular projection internally
at the place of fracture.
When the ribs are broken the patient 
always experiences considerable
pain in the part & if several are broken
respiration is very painful. By causing
the patients to cough, you will be
sensible of the jar & decide on the crepitus.
Sometimes the patient immediately
after the accident is fainty, & the pulse
is very low. There is however no danger if
respiration goes on.
Fracture of the ribs is often attended


The Ribs. 136
with cough & sometimes the mucus that
is thrown up is tinged with blood from
a wound in the lung produced by the
broken fragments.
Sometimes you discover a degree of
tumefaction which on pressing produce
a crackling noise; which is an
indication of emphysema. When not
extensive, it requires no attention. But
when it is general there is but one
way of relieving the symptoms; that
of making a puncture between two
of the ribs.
In fractures of the ribs, the indication
of cure is to keep the ribs still by applying
a broad bandage tight round the
thorax. Respiration under such circumstance
will be carried on by
the diaphragm alone.
The bandage should be broad enough


137 Fracture Of
to extend all the way from the axilla
to the lower true ribs & scapulary
applied to prevent it from slipping
down.
The cough is generally considerable;
& sometimes distressing. Now I
have succeeded completely in allaying
this, by demulcent remedies.
The Spermaciti mixture is the article.
Why this should be so efficacious
I cannot imagine; but such is the
fact.


The Scapula. 138
The scapula I have seen broken off transversely
& in a perpendicular direction
with respect to the body: i.e. the lower
or inferior angle fractured, & the spine
broken off.
When the inferior fragment is broken
off the lower fragment is pulled
forwards by the serratus major
anticus.
The inequality attendant on the
fracture is perceived by passing the
fingers along the basis of the scapula.
In the treatment of this accident,
you must place the arm in such a
position as to bring the upper part
down to the lower & retain it in
situ by a proper bandage.
In the cases I have seen, there was
a vast deal of pain and inflammation
which required bleeding & purging.


139 T. Of the Scapula.
Sometimes the Acromion scapula
is fractured; in which case it is
drawn downwards by the deltoid
muscle.
Apply one hand to the shoulder
& then push up the os humeri. In
this way you reduce the fracture &
are sensible of the crepitus.
To keep it in its situation is very difficult.
It is to be attempted by applying
the same bandage as for the broken
clavicula. I have never seen a
fracture of the Coronois process
of the scapula. If it should happen
the plan would be to apply a bandage
to keep the arm still.


Fract. Of the Clavicula. 140
This bone is very frequently broken; generally
about the middle; or rather nearer
the shoulder.
When it is fractured near the middle
the accident is very obvious. The 
patient always holds up the arm with
the other hand, & the fragment next the
scapula is depressed. By passing the finger
along the clavicle an unevenness will
be discovered; and by lifting the arm &
leaning it backwards crepitation will
be distinguished,
But when the fracture happens
near the scapular extremety & within the
ligament which joins the clavicula to
the coronoid process of the scapula, no
displacement takes place. If the pain
be great at that place, & if on raising
the arm crepitation occurs, the nature
of the accident will be obvious.
To reduce the fracture you have only


141 Fract. Of the Clavicula.
to raise the arm & bring the scapula backwards.
But to retain it in its place is more
difficult. The English Surgeons attempt it
by employing the figure 8 bandage;
but it does not answer well. That of Desseault
is more scientific & useful, though
it is far from being perfect.
The wedge-shaped pad used in this
instance encounters the action of the
Pectoral muscles which bring the scapular
fragment downwards & inwards.
A piece of soft linen should be interposed
between the hand, arm & belly to prevent
the disagreeable consequence of contact,
before applying the bandage.
When the fracture is oblique, I have
never seen it heal without some deformity.
When fractured between the ligaments
of the clavicula, why then of cours no displacement
happen; & no deformity
succeeds.


Fract. Of The Os Humeri. 142
The os humeri is most generally fractured
near the middle, though sometimes quite at
the end of the bone, or the neck. Besides the
bone is sometimes fractured near the condyles.
Occasionally the condyles are separated
from each other by a longitudinal fracture.
To reduce & dress the fracture when
near the middle of the bone, flex the fore
arm so as to form a right angle with
the humerus. An assistant then fixes the
scapula, while another places one hand
round the fore-arm just below the elbow,
& with the other he takes hold of the condyles
to make extension.
Sometimes an assistant takes hold above
the elbow with both hands & pulls with
all his might, but it does no good: he
stretches the skin a good deal, but does
not move the bone. This therefore


143 Fracture Of
should be avoided. Having adjusted the
fragments, the surgeon applies a roller
beginning just below the elbow, and continues
it up as far as the scapula. He then
applies a pasteboard splint on the posterior
or outer, another on the anterior or inner,
and a third on the external or upper
part of the arm; and then continues
the roller down over the whole of them
moderately tight. It has been usual to
swing the arm in a sling; but this permits
too much motion, and I have seen
the motion thus produced cause an immense
deal of irritation to the patient.
It is best to swing the arm, interpose
soft linen between the arm & the body
& then apply a bandage round the thorax,
from just below the place where
the arm lies up to the axilla,
About the 8th or 10th day remove the


The Os Humeri. 144
dressings & examine the state of the fragments;
and if any deformity is likely to
happen, remedy it while the uniting medicine
is soft; & there reapply the dressings.
When the Neck of the bone is
fractured, it is sometimes a little difficult
to distinguish it from a luxation.
But the head of the bone always remains
in situ; and when you come to examine you
will find the space under the acromion scapulae
will be less considerable than what occurs
in the dislocation of the head of the
bone; and you will feel the sharp or rough
fragments of the os humeri in the axilla,
Now this is of a good deal of importance,
for year before last a case of this nature
occurred in the country where the surgeon
actually mistook the fracture for
a dislocation. The consequence was that
they made numerous attempts to reduce
the dislocation, put the patient to a great


145. Fracture Of
deal of pain, & not only did no good, but
neglected what ought to have been done
by mistaking the nature of the accident.
About 3 weeks after he came to the Pennsylvania
Hospital & put himself under
the care of Dr. Wistan & myself. On examining
we readily discovered that it was a
fracture; for not only was the shoulder rounder
than in a dislocation, but we could
actually feel the fractured ends of the
bone under the pectoral muscles. The union
however was now such that nothing
could be done & he remained lame.
The fractured bone will always be
beat in, in the direction of the force
applied. If externally, as where a man is
thrown out of a carriage on frozen
ground on the arm near the joint, the
lower fragment will be beat in towards
the side of the thorax; or further forwards
when the force is more posterior, & further
backwards when it is more anterior.


The Os Humeri. 146
This fracture must be dressed nearly in the
same manner as the fracture of the clavicula,
after it is reduced; only the pad need
not be so large.
Sometimes the fracture is so completely in
contact with the head of the bone, & so transverse,
that no displacement can be discovered.
By moving the arm backwards
while the scapula is fixed, the bones will
generally grate against each other. Even
this I have known to fail. In one such
case I discovered it in this manner. I
directed an assistant to pull the forearm
downwards, while I pressed the arm
backwards. By this means I was sensible
of the crepitus.
Where there is a severe contusion
in the parts, and the patient complains
of a good deal of pain, you will have reason
to expect a fracture, & will examine
very thoroughly.
After having reduced the fracture it is
necessary to apply the bandage.


147 Fracture Of
you would suppose that fixing the thorax and
pulling the arm would separate the fragments
enough to admit of their reduction. But
the case mentioned above shows that pulling
alone will not do. In order to make
proper counter-extension, we must fix
the scapula, For you may pull the fore
arm ever so much without this, and
not reduce it.
Splints are necessary in this case. One
on the anterior, one on the posterior part,
& one between these.
Begin the application of the roller just
above the elbow & carry it up to the
shoulder, & as the lower fragment will
have a great tendency to be displaced
into the axilla a compress must be fixed
there by a bandage round the thorax.
The splints are to extend one inch or more
above the shoulder. Bring the bandage
above the shoulder, under the opposite
axilla 2 or 3 times, & then bring it round
the body & arm as far as the elbow &


The Os Humeri. 148
suspend it by a sling. A good deal of inflammation
is apt to occur & is to be combatted
by the usual remedies.
When the os humeri is fractured at the
lower end the forearm must be fixed in
order to prevent the separation of the fragments 
& the irritation attending it. And to
do this the angular splint must be used.
Commence the bandage at the wrist, carry
it up to the shoulder. Having applied
the bandage, place the broken ends carefully
in apposition. An assistant supports
the arm while the surgeon applies a splint
on each side, & it is well enough to have
one of the inside. Then bring down
the roller as far as the hand to fix the
splints completely. Next place the arm
in a sling.
Besides these there occur cases sometimes
where the condyles are broken off
longitudinally, or one is broken off.


149 Fracture Of
Here a great deal of attention is
necessary: for the natural angle of
the elbow is very apt to be reversed
& its apex to project upwards. I was in
hopes of preventing this deformity by
the use of the obtuse angular splints.
But in two cases I was disappointed
notwithstanding every attempt. I expected
that by applying the angular
splints at first & then while the uniting
medium was soft I should be able
to bend it as I was minded to. Then
putting on the obtuse angular splint
that is to say about the 14th, or 15th day
I imagined in every case the deformity
mentioned would be prevented.
This sometimes answered very well,
but it likewise sometimes failed.
It struck me afterwards, that
I should succeed by placing the patient
on his back in bed, bending
the arm & laying it supinely on a


The Os Humeri. 150
pillow. The weight of the hand in
this position has the effect of forcing
the head of the radius against the os humeri
pushing up the broken condyle &
thereby preventing the angular derangements
& preserving the angle.
But in the other way the position is
such that in every attempt to move the
os humeri, the radius is separated from
the humerus & a cavity is left between
them, which allows the condyles to descend
& deform the joint.
Two cases have succeeded in my hands
by the new method and I have lately
recommended it in a third which is
healing without deformity.
I would therefore recommend it to
you by all means to apply the rectangular
splint, put the patient to bed,
and incline the arm backwards and
place it upon a pillow. It is necessary


151 Fracture Of
to retain the dressings thus applied for
3 or 4 weeks till union be firm.
The accidents that occur about the
elbow joint are very complex, and
I know of no part of the skeleton
which requires more study & attention.
For the mistakes here have, I think, been
ten to one in any other place, the hip
not excepted.
The Fore-Arm is generally
broken at the middle or a little below.
There are two ways in which
the deformity may occur. One
where there is an angular projection;
and the other where the
broken ends are depressed into
the interosseous space.
In dressing the fracture, the
patient is to be seated; one assistant


The Fore _ Arm. 152 
takes hold, as if to shake hands &
a second one takes hold of the arm
just above the elbow with one
hand & with the other, hold of the
condyles. In this way extension and
counter-extension is made with
the arm at right angles. The fragments
being reduced commence with
the bandage at the wrists and carry
it up to the elbow, (taking care not
to apply the bandage too tight so as
to press the fragments into the interosseous
space & produce deformity)
or a little above. Then apply a pasteboard
splint on each side, the thumb
projecting upward, between. These
should be so broad as not to permit
the roller which passes down
over them to press the bones inwards
towards each other, Then
bring down the roller to the very end
of the splints, which must reach below


153 Fracture Of 
below the ends of the fingers, so as to
prevent all motion of the hand & 
fingers. For if the hand were allowed
to move, the derangement, &
irritation would be great. And,
added to this if ossification were to
take place with the hand prone,
the power of supination would be
entirely lost. The arm is then to
be suspended in a sling & to prevent
deformity in consequence of the perspiration
softening the splints, a thin
splint of wood ought to be interposed
between the arm and the body against
which it rests.
In people subject to rheumastism 
by keeping on the splint, and the
fingers extended for a long time, the
ability to bend the fingers, or use
the joint is much impared or totally
lost for many months. The person
thus situated applies a great variety



The Fore _ Arm. 154
washes, & liniments, but to us manner
of advantage. Time alone can remove
this affection & rigidity.
But being aware of this, we shall
be able to avoid the affection altogether,
my practice is to remove the splints
at the end of the first week & every
day, or every 2nd day after, and flex
the wrists and fingers; & then reapply
them again.
But there is one case in which
nothing of this kind will do any
good. That is where the sharp end
of the bone sticks in a muscle making
nearly a compound fracture.


155 Fracture Of 
I think this bone is oftenest broken
at about 1/3 of its length from the
lower end. But it is frequently fractured
at a place where we should little
expect it, i.e. just above its articulation
with the hand. When it is broken in
the former place no great deal of difficulty
occurs in distinguishing it.
But when it happens at the lower end of 
the bone it is is exceedingly difficult & obscure,
& is often mistaken for a luxation. A
case lately happened in the country of this
description. A boy has the radius fractured,
and mistaken for a luxation,
Of course nothing was done & it healed
with a great projection, a good deal of
deformity, & interruption to the motion
of the wrist. Now this accident occurs
often but the luxation is very rare indeed.
I have never seen but one case
in my life. It therefore requires a good
deal of attention, more especially as it


The Radius. 156 
involves so deeply the character of the
surgeon.
In all the cases of fracture of the radius
that I have seen, it has been in consequence
of falling on the palm of the
hand or the ball of the thumb. The
fragments are frequently so interlaced
with each other, that even by rotating
the hand we cannot render the accident
obvious.
I have distinguished, & reduced it
too, in the following manner. Bend
the arm, let one assistant take hold of
the hand & make extension, & a 2nd,,
take hold of the arm & make counter-extension;
by pulling & placing your 
(fingers) hand against the angular projection
at the lower end of the external
part of the radius, you will bring
out the depressed portion & reduce
it. At the same time crepitation
will be perceived.
It requires the same dressings as
for the fracture of the fore arm.


157 Fract. Of the Ulna.
The ulna alone is not often broken,
and when it is, it generally happens
in consequence of a severe
blow on that bone; or from some
projectile force acting exclusively
on it. Deformity is obvious
at the place of fracture. And
by passing the hand along its
external edge, you will discover
the exact place of the fracture;
or if this be obscure, it will be
evident on rotating the arm.
It is to be managed in the way already
mentioned.


The Metacarpal bones 158
are not often broken. But to ascertain
the accident when suspected, take hold
of the lower end of the metacarpal bone
with one hand & with the other grasp
the upper part of the hand. In this way
motion and crepitus will be made evident.
A compress & carved splints adapted
to the hand must be applied,
The Fingers are sometimes broken
by heavy bodies falling on them. I knew
a boy to break them by boxing at school.
And a lady fractured the index finger
in attempting to raise a window.
The treatment consists in applying a
narrow roller & a splint adapted to the
finger, & then to put on a large one
fitted to the whole hand so as to prevent
any motion in the fingers. This is very
necessary; for by undertaking to treat


159 The lady merely by adapting the splint 
to the finger, expecting no difficulty as
she did not want to use the hand, I
found after some time that the motion
of the other finger caused a corresponding
one in the fractured finger,
producing swelling & inflammation
& I believe suppuration would have
happened if I had not put on the
hand splint.
Compound Fracture of
These occasionally happen in consequence
of bruises or comminution by a great
force; or when the flesh is so much injured
that it gives away leaving a
communication with the cavity of
the fracture. Sometimes the finger is so
nearly dissevered that it adheres only
by a thin slip of flesh which you would
almost be tempted to cut off.


160
But I would dissuade you from this
by all means. Replace the fragments
of bone & the soft parts, and apply
adhesive straps lengthways to keep
them in their situation; & then a
broad splint to the whole hand.
It is surprizing to see how small a
quantity of blood is sufficient to preserve
the vitality of a part, I have
seen a finger cut off, all excepting
a quarter of an inch of skin, grow together
very well.
We are even told by authors
(which we cannot very well disbelieve)
that parts even after being removed
if replaced immediately, have united.
This is analogous to what happens when
a tooth is extracted from the jaw and
engrafted into a cocks-comb, and almost
gives us reason to believe the story of
a man's nose having been bitten off, &


161 Fract. Of the Olecranon. 
even stampted upon, uniting again.
At least there can be no harm in trying
the experiment.
When lecturing of fractures of the fore
arm I forgot to mention that of the
Olecranon Process of the Ulna.
This process is sometimes broken off, in
which case the patient will be unable
to extend the arm; and you will
generally [illegible] see the chink between
the fragments. If you take hold of the
olecranon under such circumstances you
can readily move it.
Extend the arm & the fracture is
reduced. Then apply a roller from the
wrist up to the axilla. Then apply a
graduated splint made by pasting on
muslin narrow bits of shindle, on
the inside of the arm, & bring down


162 
the bandage over it to the wrist.
You will find in reading authors, that
they say a good deal about a fold of
skin which is apt to get between the
fragments. I have had a great many
of these cases but I never saw one where
there was danger of this happening.
To prevent anchylosis it is supposed
necessary to remove the dressings
after a week & flex the elbow gently.
I have never had a case myself
where this did happen; but I have
seen a case in a lady. I suspect however,
that the motion incident to flexing
the joint augments the swelling and
inflammation. In one case where
it was attended with these symptoms
by flexing the arm at right angles &
putting on a bandage and splint
to keep it so (thinking that anchylosis
might happen) the motion of the


163. Fract. Of the
joint was happily preserved.
The Coracoid Process of
the Ulna is not often broken; & it
is actually attended with luxation
backwards.
I had one case which I supposed
was a luxation. On extending the arm
I reduced it very readily. But before
I could apply the bandage I found
it out again. I then examined the
inside of the arm at the bend of the
elbow and I could feel the loose
fragment. By this I was convinced
at once, that in the attempt of luxation
the coracoid process had been
broken off. I then bent the arm &
put on the angular splints which
preserved its position. But on examining
it after sometime I found that
the deformity of the apex was likely
to take place.


Coracoid Process. 164
By applying the other splints I mentioned
I succeeded in preventing it to acertain
degree.
Important.
When in consequence of any of these accidents,
inflammation & tumefaction
arise, elevate the arm & hand. This obviates
or reduces inflammation, prevents suppuration,
& it may even prevent caries
& gangrene, This practice is successful
where very copious depletion
would otherwise be necessary.


"165. Fracture Of 
Fractures of the thigh bone happen
most frequently near the middle, or
a little below. But the fracture sometimes
happens very high up, the head
itself being broken off, or it occurs at
the neck of the bone: and the trochanter 
major is occasionally broken off.
I have never seen such a case, but I
have seen a fracture extend obliquely
through it. It sometimes happens
very low down,
The fracture is most generally
very oblique.
The person experiences a severe
pain at the time of the accident, and
is sometimes sensible of a cracking
(noise.) in the part, There is generally
some displacement, & the limb is 2
inches shorter than the other,
There is another deformity which
is occasioned by the lower fragment
rotating outward, or inward.


The Os Femoris 166 
I have never seen the foot turn inwards
when the fracture was in the middle of
the bone. But to one it happened higher
up, I have known it to fall inward.
It is in general, very easy by extension
& counter-extension to bring
the fragments in contact. But to
keep them so is much more difficult
and can only be done by counteracting
the muscles of the thigh which
are inserted into the lower fragment. 
Most of the Brittish Surgeons believe
a shortening of the limb in oblique
fracture of the thigh bone, a necessary
consequence of the accident,
Mr. Pott attributes this to the improper
manner of treating them, which was
by placing the patient on the back &
extenting the legs. He recommends the
flexed position of the thigh & leg, and
that the patient should be placed on


167 Fracture Of 
the affected side. In reading Mr. Pott's
remarks you would be inclined to believe
that the best position, But the
moment you put it to the test you
will find it full of inconvenience;
and the angular deformity is always
geneater than when treated by the
old way, And besides the position is
a very uneasy one, requiring great
muscular exertion to preserve it &
the patient always gets out of it
during sleep.
I have tried Charles Bell's
apparatus and I found that the patient
twisted the pelvis so that the
fragments overlapped. It is not
effectual.
The best plan which experience
supports is that of Desault. I shall
apply his, & then show you how I
would have it modified.


The Os Femoris. 168
Before we dress the fracture, we must
provide a hair mattress with a circular
hole in the middle in which a cushion
can be placed.
Support the head with only
one, or at the most with two pillows,
The patient often calls for pillows
to raise the head & the consequence
is, he slides down so that the foot projects
over the foot of the bed and
produces displacement.
Having provided the bed, next put
down 4 tapes, then the splint cloth
turning in the corner next the inside
of the thigh. Then 1 splint of pasteboard,
and on this the bandage of strips.
Common silk handkerchiefs answer exceedingly
well for the extending & counter-extending
bandages
Two long lays of chaff, or 2 flannel compresses;
the outer longer than the inner


169 Fracture Of 
one must be provided. This being
done place the patient on the mat.
& let one assistant take hold of the
counter-extending bandage, while
another takes hold of the ancle just
above the foot & extend till you
perceive that the leg is of the same
length as the sound one, - taking care
at the same time that the pelvis
be strait. Next apply the strip bandage,
roll up the splints & fix all 
the long splint. Finally interpose the
bags of chaff and secure all with the
tapes. It is customary to place a
pillow under the foot to give some
support, and also to pass a bandage
round the upper part of the splint
& round the pelvis; and as it is apt
to slip, I always tack it to the splint.
Some contrivance is also necessary
to prevent the pressure of the clothes on the foot,


The Os Femoris 170 
This is the apparatus of Default, the only
modification which I would suggest is to
make the splint long enough to reach
up to the axilla instead of the pelvis, &
to fix a small block to the lower end of
it as you see, over which to pass
the extending bandage.
So great has been the success
of the long splints modified as above,
that not a case of shortened by has
gone from the Pennsylvania Hospital
(except one who would not submit to
the treatment) since it has been adopted
so far as I know,


171 Fracture Of The Neck
Where the Neck of the thigh bone
is fractured, the soft parts are so
thick that you cannot feel the part
but the patient will have been sensible
of a crack, the limb will incline
outwards, and it will generally be
shortened,
Sometimes the accident resembles
a luxation, But in luxation
the foot is turned inwards, and
it is impossible to turn it outwards
without reducing the luxations
when the symptoms ceases,
The bone is sometimes broken
within the capsular ligament;
and in this case there is no displacement,
the part being so firmly
embraced, but there is a great
deal of pain.
Sometime ago I was called to see
an old lady who had received a


Of Th Os Femoris 172 
a violent contusion on the trochanter 
major. As I could feel
no fracture I desired her to stand
up and make an attempt to walk,
This produced pain but did not
disclose the nature of the accident,
I told them I could not tell, but
I really believed the the head of
the bone was fractured & I applied
the apparatus accordingly.
And at my second or third visit
I found the limb 2 or 3 inches shorter
than the other, Thus the action
of the muscles had at length drawn
up the lower fragment.
There is no dressing so good as
the long splint to keep up the permanent
extension,
When the fracture is within
the capsular ligament, I cannot
promise that the union will


17.3 Fracture Of The 
be by bone: but it will unite by
ligament: This is long of becoming
firm so as to afford sufficient support.
I show you an example where
nature, in the course of ten years
removed the neck of the bone, brought
the body under the pelvis, and the
trochanter major in contact with
the tuber ischii, and formed a smoth 
surface, or a kind of ginglimus joint
affording such support that the
patient contemplated laying
aside his crutches when he died
with fever. This specimen shows
in a most striking & admirable
manner the wonderful
resources of nature.
I show you another specimen
where the head of the bone was


Os Femoris 174 
broken off; and a vast knob of
of bone you see is formed on the
neck, making a complete bed for
the head of the bone.
Thus it appears that by a law
of nature no union by bone can
take place in joints where the bone
is broken within. the capsular ligament.
Let us suppose for instance
that this mass of bone had been
thrown into the acetabulum;
the use of the joint would have
been entirely lost.
I exhibit a specimen where
the fracture was from a gun-shot
wound. In this instance the fragments
passed each other, so that
no union could have taken
place. Nature in this case made
an attempt to throw out a kind


175 Fracture Of 
of fennall to inclose the lower fragment,
& had not the suppuration
& hectic rendered amputation necessary,
would have effected the
purpose and the leg would have
been strong.
The Patella is often fractured by
the violent action of the muscles inserted
into it. When this is the case
it is broken transversely. But it is
also broken occasionally by external
violence in which case the fracture
may be longitudinal, or diagonal.
In transverse fracture of the patella,
something is necessary to keep the fragments
in contact. It unites by ligament
When the accident happens there
is an inability of extending the
leg; sometimes it breaks with an


The Patella. 176
audible noise & the person falls down:
& the cleft can readily be felt. The
upper fragment is the one which is drawn
up; the lower one is only connected by
ligament, and is incapable of being drawn
down excepting a very little when the
knee is bent. By drawing up the
lower fragment & pressing down the
upper one, the leg being extended there
will be crepitus. But sometimes the
ecchymosis is such that this cannot be
perceived. Here we must not give an
opinion till it subsides, when the nature
of the accident will be obvious,
To dress it commence a bandage at
the ancle & continue it up to the upper
part of the thigh, to prevent the swelling
of the limbs & to diminish the tendency
to contraction in the muscles
of the thigh. Next apply a splint to
the inside of the leg, bring the bandage


177 Fracture Of
down & pass it in the form of a figure
8, & then carry it down to the ancle.
Or employ the apparatus recommended
in Dr. Dorsey's Surgery.
Sometimes owing to the retraction of
the muscles the upper fragment is kept
at some distance from the lower, no
attention being paid to prevent it, the
ligament between the two fragments is
so long that the leg cannot be extended.
In the case of a lady thus situated
which had baffled all the practitioners
in her neighborhood (near Lander)
who had applied a great many
articles in order to stimulate the muscles
into action without effect, Mr.
Hunter knowing the power of the
muscles is increased by motion, recommended
to the lady to set on the
bed beside a wall & them endeavor


The Patella. 178 
to extend the leg & kick against the
wall. This was done with difficulty
at first & the extent of motion was
very trifling. After a while however it
became more manifest by the adaptation
of the muscles to the new purchase;
and the practitioner was surprized
to find how much higher she
could kick on the wall from day
to day. Simple as this may appear,
by continuing the practice for a
long time, the lady acquired the motion
of the extensors completely,


179 Fracture Of 
When the tibia is broken transversely,
little deformity occurs & the accident is
easily treated
To dress it 1. Put down a pillow,
2. A bandage of strips. 3. Then over this
2 pasteboard splints soaked in water.
4. Then another bandage of strips. The
principal part of the feathers in the
pillow must be pressed to the lower 
part of it so as to be adapted to the
shape of the leg. 5. This done put on
the leg, make extension & counter-extension,
adjust the fragments; and
6. Then apply the bandage of strips,
beginning at the ancle. 7. Then the
pasteboard splints. 8. Then the second
bandage of strips over the splints.
9. Then bring up the sides of the pillow;
and to support them more readily
apply to piece of shingle on
each side & til all layethed with two


The Tibia 180
pieces of tape. To give a little support
to the foot pass a bandage round the
instep & pin the ends to the pillow.
But cases now and then occur in
which the fracture is oblique and
the muscles of the back part of the
leg pull up the lower fragment sometimes
one or 2 inches. You would suppose 
that there would be a great angular
deformity anteriorly. But
this is not the case, & you will be deceived
unless you measure, or compare
the length of the leg with the other,
In general all we have to avoid is angular
(deformity) projection forwards
making what is called a bow-shin.
I have seen the tibia broken low 
down, while the fibula was fractured
high up near its head.


181. Fracture Of
Now it is absolutely necessary to recollect
this, for I have seen the permanent
extension by bandages applied.
to the upper part of the leg do a
great deal of injury by depressing
the fibula & bringing it too near
the tibia.
In the oblique fracture of the leg
permanent extension is necessary
& for this purpose we use Dr,
Hutchinsons splint. However you
see that when the counter-extending
bandage is passed tight it
causes swelling of the parts below;
and when the fibula is broken
high up, it presses in the fragments,
produces inflammation, suppuration,
ulceration & a simple fracture
is converted into a compound
one. Such cases I have seen.


The Tibia 182
One patient did not get over it for
near a year. Now to prevent all this,
I have for a long time used the long
splint of Desault, making the counter
extension on the pelvis.
When both bones are broken no
difficulty occurs in distinguishing
the accident. But when only one of
them is broken, the extension is so kept
up by the other, that no displacement
happens. We can generally discover
it if we are aware of the deception.
We however must examine very
carefully: there is no angular deformity
or derangement.
I was once called to a youngster
with this fracture in which there was
no derangement whatever. I applied
the bandages &c, & left him. But
seeing the length of time I employed


183 Fracture Of
in examining the case, supposed I had
mistaken its nature altogether. He
accordingly, as seen as my back was
turned, in spite of the persuasions of
his relations took off the whole of the
apparatus, got out of bed, sprung
about the room, exclaiming, with exaltation
that his leg was not broken
that the Dr. was mistaken, and he
would laugh at him when he returned.
Making however, an oblique step, it
bent under him, and I was immediately
sent for. He was now well
enough convinced of the nature of
his case and I applied the bandages
again & forgave him; as you will
have to do in similar cases.
But I shall mention another
fracture which is that of the tibia


The Tibia. 184
near its top. Now if you do not put
a boulster between the knee and the
splint, you will produce a disagreeable
deformity; the thigh and leg
being in the same line. The consequence
of this is, that the person
in walking always describes a considerable
part of a circle.


185 Fracture Of
The fibula may be broken in almost
any part of it by external violence.
It is sometimes fractured near the
lower part. It is true this cannot happen
immediately at the ancle, it being
so strongly connected by ligaments.
When it happens it is a little above,
& is attended with luxation of the astragalus.
Now this is not an unfrequent
accident. I was this day called
to see a lady which had sprained
her ancle (as she supposed, by
slipping off from a step obliquely,
producing a violent abduction
of the foot. This was several days ago,
Upon examination I found it was
a fracture of the lower part of the
fibula & dislocation of the astragalus:
which has been mistaken for
a sprain.


The Fibula. 186
By passing the fingers along the fibula
you will easily discover the place of
fracture. To reduce it an assistant
grasps the leg just below the knee another
takes hold of the instep with the
left hand, & the heel with the right.
By making extension in this way, &
pressing the foot inwards, we reduce
both the fracture & luxation at the
same time. It is necessary to apply
splints to the leg sufficiently broad
to extend up more than half the foot
so as to prevent any motion or displacement


187 Dislocations.
When the articulating extremity of one
bone is separated from the other, it is
said to be luxated, or dislocated.
In luxation the motion of the limb is
much impaired, or entirely lost, there is
a shortening or elongation; pain & more
or less visible derangement.
The difficulty we have to encounter
in reducing a dislocation arises from
the violent action of the muscles#.
To relax them moderate vs. & hanging
have been recommended.
The best way of overcoming muscular resistance
is by bleeding ad deliquium animi.
This remedy was first employed by me
in the Pennsylvania Hospital. The idea was
first suggested by Dr. Monroe in his 
lectures.
# This offers the chief resistance. It has been
thought that the rupture of the capsular ligament
produces considerable resistance.
It sometimes does, though in general I believe
it does not.


Dislocations 188
Emetics, opium &c. have been recommended
when bleeding cannot be resorted to
in consequence of weakness. I have been in
the habit of recommending & using
them too, for this 20 years. Yet Mr,
Cooper in a work published last year
recommeds as his own, the same remedies
namely emetics & the warm bath.
After sometime, if unreduced, the involuntary
contraction of the muscles cease,
and the parts are accommodated to the
preternatural state of the luxation.
When the bone remains long in the new
situation, adhesion takes place & reduction
is impracticable unless this
adhesion is broken up. The surgeon will
feel the tearing of the adhesion when sufficient
force is applied. I have always
been sensible of it in reducing such luxations.
In these cases, where the luxation
cannot be reduced, nature forms a new


189 Luxation Of
joint which I have repeatedly seen in
the arm & thigh.
The Jaw can only be dislocated in
one way i.e. forward.
Both of the condyles are generally
dislocated, though sometimes only
one. The accident generally occurs
in consequence of opening the mouth
very wide: sometimes in yawning.
It is sometimes luxated in consequence
of moving very fast & opening
the mouth very wide to vociferate.
A woman in the market
thus circumstanced found she
could not shut her mouth any
more. In this state she was brought
to me in the Hospital with the


The Lower Jaw. 190
saliva dribbling down.
Last year a lady becoming sleepy
yawned so that so that her jaw fell down &
she could not raise it again, and
in this condition she was brought
to my house at 11 or 12 o'clock at
night.
When the dislocation is recent
there is no difficulty in reducing
it. But when it has been out for
some time the adhesion & muscular
force is so great that it is reduced
with great difficulty.
Some years ago a lady was brought
to me from the country whose jaw
had been dislocated in consequence
of a violent salivation in a dropsy.
The accident was not discovered till
it had been out a long time.


191 Dislocation Of
The practitioner who attended this attempted
to reduce it, but without effect.
I made an attempt but found
I could not move it. As Dr. Dorsey
an a Gent. Dentist who were at hand
had more strength than myself,
I proposed that they should try
what they could do. Each of them
made several attempts but they
could no more move it than myself.
As she was in such a state of debility,
I did not think it prudent
to employ vs. and therefore proposed
that she should drink till intoxication
was induced. This I was led to
believe would have the same effect
as blood-letting - I frequently having
had occasion to see that drunkards
in a state of intoxication have
their muscles completely relaxed.


The Lower Jaw 192
The project meeting has approbation,
she chose gin. When she was pretty completely
under its effect Dr. Dorsey proposed
that she should smoke a cigar.
This she did with a good deal of difficulty,
making only a few whiffs.
The two, however, accomplished every
thing I wanted. She now began to reel
every way & could no longer sustain
the head. In this condition I reduced
the jaw as easily as I could put
the one I have before me into its
place


193 Dislocation Of
The clavical is prevented from being luxated 
downwards at its sternal extremety, by
the sternum and the cartilage of the first
rib. But forwards, backwards & upwards
it is liable to be luxated. In general the 
displacement is forwards. This is produced
by violent motions of the clavicle backward.
In consequence of this motion the sternal
extremety is carried forwards, the ligaments
broken, & the end of the bone forced before
the upper end of the sternum, making a
hard projecting tumor, which moves whenever
the arm & shoulder are moved
The bandage & dressing used for fractured
clavicle are proper here. They reduce the
dislocation, & maintain the proper situation
of the bone.


The Clavicula. 194
The scapulary extremety is sometimes luxated
upwards from falls on the shoulder.
The reduction is effected by raising the arm.
I believe the dressing, foe fractured clavicle 
are best. Take care to examine frequently
that the bandage does not slip.
It is impossible to cure it without deformity;
and it is a long time before the
lacerated ligaments are healed. The bandages
ought to be kept on ten or twelve weeks.


195 Luxation Of
The Dislocation of the shoulder joint happens
most frequently of any in the body. It
can take place in every direction excepting
directly upwards. Forwards, backwards,
& downwards, I have seen it luxated. The
most common is that where the head
of the bone passes into the axilla. The
pain is considerable, the arm forms an
angle with the body standing out from
it & the patient cannot bring the forearm
to the body. You will perceive a
hollow under the acromion scapula, & the
round head is readily felt in the axilla.
By this you will distinguish it from
a fracture of the neck of the bone.
When it is luxated forwards, there is a
large tumor on the coracoid process 
which prevents you from feeling
that process. when the head is backwards
it will be perceived, unless there is considerable


The Os Humeri. 196
considerable ecchymosis on the dorsum scapulae. 
In reducing dislocation a great deal of art
consists in taking the patient unawares.
We should not let him know that we are
going to reduce the luxation. For if you let
him know it he will imagine he is a going to
be put to pain & this idea will produce
such contraction of the muscles that it will
be reduced with difficulty.
The idea of taking by surprize, or tripping
the muscles, first occurred to me when I
was house-surgeon in St. George's Hospital in
London in 1789. A person was brought in
who had a luxation of the humerus. I told
him I only wanted to examine it taking hold
of the arm just above the condyles with the
left hand & placing the right hand against
the acromion scapulae. Some of the young
gentlemen in the hospital began to laugh &
sneer; & asked me if I intended to reduce the


197 Luxation Of
bone in this way. But before the words
were cleverly out, by one twitching effort,
the bone was instantly reduced.
I have ever since employed this method.
Mr. Cooper, you will perceive has also
recommended this plan in the reduction
of luxated joints in his surgical essays.
But I certainly was before him in this.
When it is necessary to use much force,
place a soft piece of buck-skin round the
arm just above the condyles. On this apply
the extending bandage, and flex the arm.
The number of assistants employed in extension
and counter-extension should be
equal. Having adjusted every thing, give
the extending bandage to the assistants.
Then one places his hand against the acromion
scap. another places his hand
on that of the first &c. till a sufficient
number are employed.


The Os Humeri. 198
The assistants having pulled so as to bring
the head of the bone out even with the glenoid
cavity. (the edge of it.) At this moment desire
them to let go the bandage & then instantly,
using one fist in the axilla as a purchase,
& the arm as a lever bring it down
to the side of the patient. In this way the
reduction will be immediately accomplished.
By purging this plan I have never failed
in a recent case.
But in chronic luxations we must
have a soft pad adapted to the acromion
and attached to a strap. Pullies may be used if
necessary. Sometimes the patient attempts to
elude the extending & counter extending
force (as he is generally seated) by bending
the body & inclining different ways. When
this has been the case, I have found it best to
place him on his back on the table; in
which posture the bandages can be applied
exceedingly well, without any possibility of


199 Luxation Of
his avoiding the force. Vs. ad. deliq.
may be used in all obstinate cases as I shall
have occasion to mention.
I have to mention another method
of managing a luxated humerus when
others have failed. This is to place the patient
on his back on the floor; and then
to take off your shoe, & lying along the
patient place your heel in the axilla, taking
hold of the wrist & making pretty powerful
extension, & bringing the arm to the
side using it as a lever. In this way we can
sometimes dislodge the head of the bone from
the edge of the glenoid cavity & unhitch it
so that the muscles will bring it into the
cavity.
I have never succeeded in reducing
a luxation of the os humeri after the expiration
of 12 weeks. But Dr. McKenzie
of Baltimore has succeeded in one case


The Os Humeri. 200
of 6 months standing.
I do not recommend it to you to
open and cut through the adhesions in
chronic cases; but at the same time, when
we see the joint is sometimes exposed in
consequence of balls passing through their
cavities without serious detriment, that
practice would surely afford some prospect
of success.
It is necessary to unhook the head
of the bone from the coracoid process
of the scapula. In this case the force of
counter-extension must be partly lateral.
Contusions of the Deltoid
Muscle. A person is sometimes thrown
out of a carriage on the shoulder & arm, by
which the deltoid muscle is so contused that
when he recovers, he is unable to throw out
the arm.


201 Luxation Of
After some time has elapsed, by making 
exertions as I mentioned before, the
use of it will be restored.
The common opinion is, & some practitioners
think so, too, that there is a luxation.
(& unless attempts are sometimes made
to reduce it). But you must explain the
nature of the case to the patient & encourage
him to persist in the attempts to
use the arm. A great number of oils and
liniments are used to restore the motion in
the muscles; but they are of no manner of
use. Motion & time alone are the remedies.
The Luxations of the Fore-Arm
may take place laterally (though not complete)
and backwards. The latter is the
most frequent.
In recent cases there occurs no
difficulty in discovering the accident:
and yet you will find it bears a striking
resemblance to the fracture of the


The Fore _ Arm. 202
os humeri near the condyles In the luxation
backwards the radius & ulna may ascend more
or less behind the humerus, but the coracoid
process of the ulna is always carried above
the articular pulley, & is found lodged in the
cavity destined to receive the olecranon.
The head of the radius is placed behind
and above the external condyle of the humerus.
Having ascertained the luxation upwards
& backwards, the reduction can easily be
accomplished by proper extension and
counter-extension. But by simple extension
it is impossible to reduce it for the
coracoid process of the ulna is actually
hitched in the pit destined for the olecranon.
Let one assistant take hold of the arm
just below the axilla, & another hold of the
fore-arm just above the wrist.
The surgeon then places his left hand on
the posterior & lower part of the arm, and


203 Luxation Of
his right hand on the inner part of the
fore-arm just below the elbow. You then
tell your assistants to extend; at the same time
you pull (downwards) towards you with
the left hand and pushing with the right,
Having thus unhooked the process you tell
your assistant to bend the arm suddenly,
when it immediately slips into its place.
I have never failed in this way. But
I have reduced it at the end of 4 weeks,
notwithstanding Boyer says it cannot
be done after the 16th day.
When the Ulna is partially luxated
it is easily reduced. But when the
olecranon hooks on the internal or external
condyle of the humerus, it is embraced
very tenaciously by the ligaments and
muscles.
Here also we must use extension, &


The Fore _ Arm. 204
taking hold as before we give a lateral
direction with the hand, so as to dislodge
the olecranon, when it is easily
reduced
The Luxation of the wrist
is very rare. I have only seen one case,
you should be careful to distinguish
a luxation from the fracture of the fore-(arm)
radius near the wrist, as I told you.


205 Luxation of the Fingers.
The Fingers are sometimes luxated
the hilt passing backwards. In
this case the finger is bent and immovable.
They are easily reduced.
But when the metacarpal bone of the
thumb is dislocated inwards it is with
great difficulty that it is reduced. I
once had a case of this kind. I tried every
method, used a great deal of force, & continued
it so long that I was entirely out
of patience. At length by a fortunate
motion or direction in the extending force,
it was immediately reduced, I know not
how. Before I would continue my efforts
so long, in another case, I would
divide the lateral ligament with the old
couching-needle, as proposed by Mr.
C. Bell.


Luxation Of the Femur 206
This was formerly supposed to be a very rare
occurrence: and the idea was taught in this
school that it hardly ever happened. But
it is notwithstanding, not unfrequently not
with. Mr. Astley Cooper says he has seen more
fractures of the neck, than luxations, of
the bone, in thirty years practice. The reverse
is the case with me.
The luxation upwards & backwards. I
have seen most frequently. It is sometimes
luxated downwards & forwards. I
have never seen a luxation directly
downwards; it was always carried into
the ischiatic notch, the head of the bone
lying on the pyriform muscles.
When the dislocation is upwards &
backwards, the thigh is shorter than
the other, a little bent & carried inwards,
the toes are turned inwards & you cannot
turn them outwards without reducing
the dislocation.


207 Dislocation Of
In the Luxation Downwards, &
Inwards, the affected thigh is longer
than the other; a hard tumor is felt at
the inner & superior part of the thigh; the
leg is slightly bent; the knee & foot turned
outwards
In the Luxation upwards and
forward the head is forced out of
the acetabulum and lodged on the os
pubis. The leg is sometimes lengthened a
little 1/4 or 1/2 an inch. The toes are turned
a little outwards & the head of the
bone can be felt forming a tumor
in the groin. And bends the trochanter
major projects further from the
spine of the ilium than natural.
This species of luxation is very rare; I have
seen but one case: and Desault & Cooper
only once each.


The Os Femoris. 208
The most difficult luxation to discover, is
where the head passes into the ischiatic notch.
In lean subjects the head of the bone may
be felt. But I have never seen but one 
case. The limb is not shortened as in other
luxations.
To examine whether one leg is shorter
than the other, the patient must be laid
on his back; and a line drawn from one
spinous process of the ilium to the other,
should cut the body as right angles. For
if the pelvis be crooked you will be deceived.
You remember in fracture of the neck
of the bone, the lower fragment is drawn
up, but the foot is turned outwards,
which is not the case here. In the fracture 
it can be pulled down to its place,
but in this case it cannot be done without
reducing the luxation.
A power must always be applied to


209 Dislocation Of
the upper part of the bone to lift up the
head from its lodgment let it be luxated
in what way it may; and this force is
to be applied laterally.
In our attempt to reduce the dislocation
of the thigh bone, we must proceed
as follows.
1. Apply a strong girth between the
thigh & pudendum, on the side affected
so as to pass across the ischium & tye it fast
to a post.
2. Put on a strip of soft buck-skin
just above the knee.
3. Then 2 bandages (extending bands) lengthwise
of the thigh, & secure by a roller passed
over the buck-skin.
4. Next, place a second girth in the perineum
for lateral use.
Then fix the counter extending
bandage to the wall, & adapt the extending
bandage to pullies, or give it into


The Os Femoris. 210
the hands of assistants. I like the notion
suggested in Mr. Cooper's book, of wetting the
bandage above the knee; for in fat persons
it will be very apt to slip without.
Mr. Cooper mentions a case in his
Surgical Essays for 1818, reduced at the expiration
of 5 weeks. I reduced a case of 4 weeks, in
the Infirmary, while the extension was performed
only by assistants. And Dr. Wistar
and myself reduced a case at the end of
12 weeks. It was very surprizing that the
leg after reduction was about 2 inches
longer than the other. This circumstance
gave us reason to fear that the acetabulum
was filled up. But in a few days
this appearance subsided & the patient recovered
the use of his leg very happily.


211
A Dislocation directly backwards occurred
to me in the Pennsylvania Hospital
in 1812. After various attempts to
reduce it in the manner I have related
had proved unsuccessful, it occurred to
me that the dent in the capsular ligament
might be in the form of a buttonhole
& that the neck of the bone was embraced
as a button is by a button-hole;
& that contrary to what happens for
common, the capsular ligament might
impede the reduction. Under this view
I bent the thigh to a right angle with
the pelvis, then abducted it so as to remove 
the strictened parts and relax the
ligaments. I then gave the patient a pretty
smart knock with my fist on the trochanter
major, when it instantly snapped
into the acetabulum. It is of great importance
to recollect this.


Dislocation Of the Patella 212
The Patella is so situated that it is impossible
for it to be luxated either upwards
or downwards. But it may be forced
from its situation laterally. The internal
condyle of the os femoris does not
project sufficiently for the patella to be
lodged, but it immediately flies back when
force in an opposite direction is applied.
This is not the case when it is forced
outwards. It is however a very rare occurrence.
I have never seen but two cases:
one occurred in my practice; the other
in that of Dr. Dorsey.
Mine happened to a young lady in dancing.
She felt pain, heard the snap, & was
incapacitated from bending the knee.
By placing her on a sofa & extending
the leg fully it was easily reduced.
The case which occurred to Dr. D. was reduced 
in the same manner.


213 Dislocation of the Tibia.
After the reduction, rest, horizontal position,
& a low diet are necessary for 10 or
12 days to prevent inflammation.
The Tibia is sometimes, though rarely
dislocated. I have never seen it take
place either forwards or backwards.
It did occur I am told by a gentleman
who attended lectures a year or two
a go, in consequence of very great force
applied so as to lacerate the ligaments of
the leg. In this case the displacement was
backwards.
I have never known the luxation
to happen but in one direction, and
that was when it was turned so that
the head of the tibia rested on the outside
of the internal condyle of the
os femoris.
It was produced in both legs in one
case, & in one leg, in another case, by
the person falling from a ladder with


214
the legs & feet projecting outwards.
In luxations of this nature there is
such a tearing of the ligaments, that
there is no difficulty in reducing the
dislocation. But it is not maintained
without the application of the long
splint of Desault carrying up a bandage
above the knee, & interposing a
flannel compress between the splint
& the outside of the leg.


215 Lux. Of the Ancle.
The dislocation of the Ancle# is also a
very rare accident; except when there
is a fracture of the fibula. But it is
sometimes luxated forwards, or backwards.
When forced forwards it projects very
much, the foot is stiff & cannot be
moved.
When forced backwards the heel projects
very much. I have never seen
but one such a case. A lady cometing
down stairs very rapidly at the
cry of fire, hitched the heel of her shoe
by which the ancle joint was violently
forced backwards & dislocated.
But within a few day, I have seen
a case something like it; but it is accompanied
with the fracture of the tibia,
the internal malleolus being broken
off obliquely. In this case, the only one
I have ever had, or seen, I find great
difficulty in keeping the foot in situ.
#laterally,


Sprains. 216
I have contrived a splint which I am
in hopes will succeed.
When in consequence of force applied,
one of the bones is pushed against the capsular
ligament of the joint there is produced
a strain, a rupture, and sometimes
an effusion of blood. Violent pain takes
place at the moment of the accident &
continues for a long time. Between a
sprain & fracture you can always distinguish
by the absence of crepitus; and
from a luxation by the mobility of the
joint.
Treatment. I believe the affusion of
cold water over the part immediately
after the accident is the best remedy.
Afterwards apply flannel dipped in cold
vinegar & water. If it be the ancle joint


217 Sprains.
the patient must be put in a recumbent
position; if the wrists it is to be swung
in a horizontal sling by the side of the
body. This confinement is so disagreeable
that your patient is exceedingly apt to
rebel. I tell them that if it be a simple
sprain (inflammation) the symptoms will subside
in a few days. But if violent inflammation
& fever come on from carelessness, it
requires more of the same treatment to subdue
them: and therefore it will be best for
them to remain quiet till I think proper
for them to walk about.
I knew a lady which sprained her ancle.
She lay still a few days, & then supposing
that nothing but weekness remained
which would be relieved by exercise, got
up & began to walk about. This produced
an immediate swelling. She then lay by
a while under which treatment it grew
better. But getting a pair of crutches she
repeatedly tried this method.


Sprains. 218
After some time I was consulted, when
on examination I found an abscess of the
joint, & a caries of the os astragalus succeeded.
A hectic came on, and in spite of every
thing that Dr. Rush & I could do, so wasted
the lady that she died in about 9 months.
The Wrist is often sprained, especially
in washer-women, by wringing their
clothes.
Cold applications, bleeding with leeches,
rest &c. must be had recover to.
You must be cautious, however, about
applying cold water while a woman
is menstruating, which might suppress
the discharge producing many distressing
affections. Also in pulmonary affections
we should not apply cold water
For instance: if I should sprain my ancle,
I should not like to submit to this treatment
in my state. We must here employ warm vinegar
enveloping the limb in flannel clothes.


219 Morbus
The Hip Disease occurs to
persons of every age, but more especially
to children.
Lameness with loss of appetite, and
averseness to motion are generally the
first symptoms; though sometimes
pain & violent screaming attend,
which are periodical. I have known this
to happen with a child at the tea-table
without any apparent cause, or
when in bed.
A pain in the knee, in general
attends this disease; which is altogether
delusive, the disease being 
seated in the hip joint. Physicians
are sometimes led to believe from this
symptom, that the complaint is confined
to the knee, & have misapplied
their remedies.
Some pain however, is felt in
the hip-joint, and the affected limb
appears longer than the sound one
because the patient supports himself


Coscarius. 220
himself on the other, bending the pelvis.
The pain becomes more & more severe,
the nates lose their convexity, & we
now observe redness & tumefaction.
Fever comes on, suppuration succeeds,
& a projection of matter.
In some instances a dislocation
of the thigh bone takes place in consequence
of the formation of matter
in the acetabulum & accumulating
to such an extent as to push
out the head of the bone from its sockets.#
Now & then openings are discoverable
about the joint out of which is
constantly oozing a kind of matter.
Sometimes there is only one opening.
The bone is sometimes carious & can
be felt when a probe is passed into the
orifices. Hectic fever comes on at the
period & the patient suffers much before
he expires.
# The swelling of the parts within the acetabulum
is supposed to produce it sometimes.


221 Morbus
Sometimes a more favorable termination
happens; the bone being dislocated,
anchylosis takes place & the patient gets
well.
Treatment.
In purging, emetics, sea-bathing & the
various remedies for scrofula have
been used in this disease without effect.
Issues & blisters have been highly recommended
but they do but little good.
The best practice I have ever pursued,
was to purge actively with jalop and
cremor tartar every other day, & to
enjoin rest & a vegetable diet, and to
put on the long splint. Under this
treatment the health & strength of
the patient improve. After suppuration
has come on, little can
be done but to keep the sinuses open
till the dead bone comes out.


Coxarius. 222
I think I have derived some advantage
from issues or blisters applied behind
the trochanter. But upon the whole I
believe the purging & rest, either with the
long splint, or the patient kept on a
sofa constantly; the best remedy.
In the first stage I do not know that
it has ever failed. But when it has
advanced far, it will do less good of
course: But even here the application
of the splint, & the purging will allay
the pain & case the patient very
considerably.


223 Caries Of
Analogous to the preceeding affection
is the caries of the vertebrae.
In this disease Mr. Pott recommends
very strongly issues made with caustic
on each side of the projecting vertebrae.
I have seen them useful in a great
many cases, though not universally
so. For in some it has grown worse
& worse, and suppuration has come
on. I formerly used the steel splint &
issues in this complaint, but I have
found that the purgative plan is
equally successful when used in this
disease as in the morbus coxarius.
I have this day seen a case where
a stop has been put to the progress
of the disease by observing
the same treatment. It cannot
cure the curviture of the back,
for that depends on the absorption
of the bodies of the vertebrae.


The Vertebra. 224
I believe if we could be consulted
in the beginning of the disease, this
treatment would be as successful as
in the hip disease.
These remarks apply equally well
to the disease of the knee called the
White Swelling.


225 Injuries Of
1. Of the Scull. The head is liable
to all the different wounds that
other parts are subject to.
Incised wounds of the scalp require
no peculiar treatment from such elsewhere.
It is however particularly necessary
to remove the hair & extraneous
matter before approximating the sides of
the wound. The old surgeons were in the 
habit of using sutures. I believe that in
simple wounds it is never necessary,
adhesive plaster being far better.
Dr. Washington of the U.S. Navy
says he has avoided shaving off the hair
& has made use of its tufts tied together
to retain the lips of the wound together.
I however should generally prefer
shaving it away.
In Contused wounds you will
find much advantage in applying an
emolient poultice, and when the


The Head. 226
inflammation subsides, or the sloughs separate
& the wound becomes clean and
in a healing condition approximate the
edges of it with adhesive plaster.
In punctured wounds vs. & other evacuations
are necessary. Generally you
can relieve the inflammation from
a puncture by the application of a
blister. But I have known inflammation
take place on the whole surface of the cranium
in consequence of punctured
wounds. Sometimes this is accompanied
with fever, and occasionally with
violent delirium.
I knew a consultation called in
such a case, in a large hospital to
consider whether the inflammation
had not extended to the brain or its
membranes, and had caused all these
symptoms.


227 Injuries Of
They all came to the conclusion that
this was the case, and that the perforation
of the cranium was necessary.
They however deferred it for a little while,
which completely undeceived them.
This gave me reason to believe that
no such thing had happened as they supposed.
For where the integuments of the
head one very much inflamed, you
never have inflammation of the duramater.
When that membrane is inflamed,
the integuments of the head
are never in a similar condition.
On this principle we derive the good
effects of blisters which by causing inflammation
of the integuments, diminish
the inflammation of the brain.
When the intestines are inflamed the
abdomen never is; and when the pleura
is inflamed the external parieties


The Head. 228
are uninflamed. And when you see
such inflammation on the head, you
may be pretty certain that the brain
is not inflamed. By applying a blister,
and by evacuating remedies, I have
always succeeded in removing the
inflammation of the head.
In some cases of punctured wounds, when
in the beginning there was much tension,
I have introduced a director in the track
of the puncture, and enlarged it; thus
converting a punctured into an incised
wound.
Sometimes the whole scalp is torn
off adhering only be the edges. Always
clean the scalp, remove all extraneous
substances, & replace it neatly. If carefully
done in most cases it will adhere. If
an abscess form, open it & granulations
will fill up the cavity.


229 Injuries Of
But I would recommend it to you
not to place the scalp in a state of tension
in applying adhesive plaster. Allow
an inch in every case for the swelling
from inflammation.
The Scalp when subjected to external
violence, is sometimes affected with
a severe pain which continues a
long time. The pain I speak of does
not take place till the inflammation
attending the accident has entirely
subsided, and the patient supposes himself
entirely well. On examining there
is no swelling nor soreness to the touch.
The pain at first is of a dull obtuse,
or stupefying nature. After continuing
a few weeks it renders the patient 
very miserable, & he experiences
a sensation of fullness in the head as
though it was ready to burst.
I have known it to continue for 5
years before it terminated. The appetite
and digestion are bad, & there is sometimes


The Head. 230
sometimes palpitation & fainty fits: and I
have known a case to terminate in
complete fatuity.
The first case I saw was in consultation
with Dr. Rush. A lady had
received a blow on the head from
which had originated all the mischief.
She was put on a low diet, was
bled, purged, had the hair shaved off
and a blister applied, but without any
benefit. This was all done before I
saw her. I was now desired to examine
if there was any thing wrong about
the head, but I could discover nothing.
I suggested to the Dr. the propriet of
making a crucial incision through
the part that had received the accident,
which was done accordingly.
After the smarting produced by
the incision had ceased, the pain was
put a stop to and never after returned.
I was very much encouraged by the


231 Injuries Of
success of this practice and I employed
it again & again. In several it succeeded,
but it failed in a number of cases.
In one case where the operation relieved,
the pain returned again in a
month. The evacuating plan was then
tried very faithfully but without effect,
Then opium, henbane, bark, arsenic,
mercury &c.
Mercury relieved the affection
for a little while, but was of no
permanent benefit. In a great number
of cases salivation could not be
excited.
Till within a few years I was so 
much discouraged, that I was obliged
to tell my patients that if the
incision did not relieve, I knew no
remedy.
The pain I found sometimes ceased
spontaneously, & always ultimately, though
it sometimes continued very long.


The Head. 232
I now begin to consider whether it was
not of the same nature as the tic
doloreaux. Under this idea I began
a course of experiments with emetics.
I gave them to a lady thus affected &
continued them for some time under
the operation of which she was completely
cured. I have since employed
them with great success in other
similar cases.
I will now mention that in
the tic dolor. The emetic plan is
by far the best. 
You will probably have patients 
consult you in this disease. I
have even cut down & divided the
nerves without benefit.
Within the last year I have had
three cases & have had the pleasure
of curing them all by emetics. I
have given the antimonial medicine
as the best calculated to produce nausea,
& have continued it for some days.


233 Injuries Affecting the
Compression. Symptoms: Stupidity,
loss of sense & voluntary motion, nausea
& vomiting have been enumerated.
The pupils when you open the eyes and
expose them to the light remain in the
state they were at the time of the accident,
- totally immovable. It loses the
power of varying its shape with the variations
of light. There are in addition to
these, slow pulse, slow stertorous respiration,
cold extremeties &c. These symptoms
may take place in two ways: either from
a fracture & depression of the bone, or
from compression produced by extravasation
of blood between the scull and
the dura mater, or in the substance
of the brain. In most cases you will
find that the depression & extravasation
conjointly produce these symptoms.
When it occurs from depression
the symptoms are immediate. But
sometime must elapse before it can


Brain & its Membranes. 234
take place from extravasation. I will
state a case. A boy received a blow on
the head with a brick bat while at
play. He went into the house, told
what had happened & said he was
not hurt much. I was called in to
see him and while he was relating
the circumstances of the case, he became
insensible & stupid, and exhibited
the symptoms of compressed brain.
I immediately applied the trephine &
removed the extravasated blood which
restored his sensibility at once.
I am next to mention to you
that cases do occur where the scull
is fractured and even depressed, so
as to press upon the dura mater
without the symptoms of compression
of the brain. But these are
somewhat uncommon.


235 Compression
Treatment. With respect to the
mode of treatment in accidents of this
kind, I would recommend it to you
when the bone is broken & depressed, &
there are symptoms of compressed brain,
to elevate the depressed portion immediately.
Mr. Pott says that in every instance 
where the scull is broken the
trephine ought to be applied. But
surgeons at this day disagree with
him and I, among the rest. It is
only the symptoms of compression
which can justify the perforation of
the cranium.
That kind of compression where
there is no mark to guide you in the
application of the trephine is the most
difficult.


Of the Brain. 236
In these cases you must be governed
by your knowledge of anatomy. Where
the symptoms are very urgent, but
no marks or bruises to indicate the
seat of the injury. I should recommend
to lay bear the scull & make a perforation
near the anterior inferior angle
of the parietal bone in the direction
of the middle artery of the dura
mater. If the accident be not
now discovered, do the same on the
opposite side, in the same direction.
I know that this may not be successful
for the effusion may be in some
other place, or in the brain. When the
latter is the case, the operation can do
no good. The effusion is however, more
apt to be in the direction above mentioned
than in any other, and the rule is
worth attending to.


237 Compression
To assist us in these cases, Mr Abernethy
has proposed a very ingenious
method of discovering the exact place
of the extravasation. It is to denude the
pericranium & scrape the bone with
the projecting end of the scalpel. If
the bone does not now bleed, it affords
great reason to believe the
extravasation exists under that part
I do not think this conclusive
though it is worth attending
to. If however the bone bleeds, you
then are pretty sure, that the
extravasation does not exist under
that part.
This ingenious idea of Mr. A.
was suggested to him, in reflecting on
the vascular connection subsisting between
the dura mater & the scull; a
great part of the blood, being derived


Of the Brain. 238
derived from the dura mater, so that if
the connection between the scull &
that membrane be destroyed, it is
naturally expected that there will be
a deficiency in the quantity of blood
which the bone receives.
Operation. 1. Cause all the hair
to be removed: first cut it off with scissors
& then shave close; to give an opportunity
of examining it. Sometimes
the nature of the accident is such that
the injured bone is rendered obvious
being fractured & the fragments
beat in. But at other times there is
nothing more than a contusion to be
seen: even this is sometimes wanting.
It is necessary that you should be
able to discriminate between a simple


239 Compression
contusion & a fracture of the bone,
when injuries of the head occur.
When you examine a contusion of
the scalp, you will find it soft & pappy,
& it will be surrounded by a hard ridge
which is liable to be mistaken for the
raggid margin of the broken scull
bone.
Now it is easy under some circumstances
to distinguish the cases, for
if there is no symptoms of compression
you will infer that the bone is not depressed,
that it is a simple contusion
of the scalp, & you will not by any
means cut down to the cranium.
You might think perhaps that cutting
down to the bone could do no hurt
even if no fracture or compression
did exist. But here you will be mistaken;
for you hazzard an exfoliation


Of the Brain. 240
of the bone & a tedious ulceration.
The rule is never to operate even if you
know the bone to be fractured, and
depressed; if there is no symptoms of
compressed brain.
If I were called to such a
case I would not operate. It is the compression
alone, which demands the
operation.
You would suppose from what is
said in books, that the incision down to
the cranium is very simple; for they tell
you to make a free incision. Now this is
never to be done. It is not so simple as
represented. By such boldness the knife
has entered the fissure of the fractured
bone, pierced the dura mater, and has
been attended with fatal consequences.
I always cut down to the cranium


241 Compression
very carefully, and then oppose the back
of the scalpel to the bone & run it along
so as to avoid all danger of entering
the track of the fracture.
The head of the patient must be
placed on something hard & resisting.
The operation cannot be performed
with the head on a pillow, where it
is generally found when the surgeon
is called, but a block must be procured.
You will next find it necissary
to make preparation for the operation
by providing yourselves
with sponges, warm water, needles &
ligatures. Next a good scalpel, with
a projecting end; a rugie to scrape
the bone if necessary. Next a cylindrical
trephine. It is right to have
spaces or interruptions in the saw


Of the Brain. 242
to let out the saw-dust. Also the sliding
centre-pin of Dr. Physick. The old method
was to have a centre pin which was to be
removed by a key. It always projected 1/4 of
an inch, and as it is necessary to continue
it till the teeth of the saw are
steadied in the bone, there was danger of
perforating the scull in some cases before
you could remove it.
Next Mr. Hey's saw with a flat
and circular edge
There is another little instrument
which you must not forget; - a tooth
pick of quill to examine the depth of
the saw track.
Next a lever or elevator. The Lenticulare
of the old instrument case to cut
of the projecting spiculae from the
tabular vitrea, & to receive them in the
cup attached to it is an useful instrument


243 Compression
instrument; as is also a pair of forceps used
to lift up fragments of bone.
2. Make a simple incision four or five
inches long used with the end of the
scalpel scrap away the pericaranum.
3. Apply the centre pin of the trephine
& by a semi-rotatory motion make
a groove large enough to steady the
instrument: then remove the centre-pin.
4. As soon as you have arrived at the
diploë, use the tooth-pick, to examine
whether the bone is perforated; & this examination
should be frequently made.
5. Never be in hurry. It is not
the coursest operation in surgery
by any means; but on the contrary
where a good share of nicety
is requisite. It is one where a puncture


Of the Brain. 244
puncture of the dura mater will prove
fatal.
6. Never think of cutting through
the inner table of the bone. I never
want to do it; but as soon as I come
to the diploë, I try the elevator to
see if the portion enclosed be not
loose, and examine frequently with
the quill if the bone is not perforated
in some places. So far from
sawing the bone out, I only use
the saw to enable me to break a
piece out.
You would think if the bone
were not cute through, there
would be a great many spiculae.
But the projections of the bone
are on the part removed. And if
there should remain any spiculaes you
can easily break them off with the
elevator, & you will be certain


245 Compression
that the dura mater is not injured.
If the blood be fluid it easily escapes
if the perforation be in the right place,
on lifting up the bone, & the symptoms
of compression immediately cease.
If the blood be coagulated the clots
may be removed with a spatula.
In cases where the extravasation is
under the pia mater your operation
will do no good. But sometimes
it is under the dua mater which rises
up in a tumor which you would
be tempted to puncture. Now this ought
not to be done unless the symptoms
are so violent that the patient cannot
survive without.
This tumor will rise during
expiration & fall during inspiration, in
the same manner as the brain.


Of the Brain. 246
I have never seen puncturing the
dura mater to let out either blood
or successful. It has always
proved fatal ultimately, though it
might give temporary relief.
That cases have proved successful we
have the testimony of authors; but
I have never performed the operation.
Cautions.
Never proceed to perforate the
cranium till you have unequivocal
symptoms of compression. Merely
stunning is to be distinguished from
compression.
I once saw a man who fell
& experienced some stunning, and exhibited
considerable stupor. He was
carried into a hospital where the surgeons
seeing an indentation on the


247 Compression
back part of the head which had
previously existed, supposed that the
bone had been fractured & driven in
at the time of the accident. They therefore
applied the trephine; in doing
which they punctured the dura mater,
& he died the 4th day in consequence
of this needness operation. Dr. Dorsey
saw a similar case when he was in
Europe.
Thus we are to keep in mind this
irregularity of the scull in certain cases,
& act accordingly.
I said that puncturing the dura
mater to let out blood had in every
case which came under my
notice proved fatal. But the dura
mater & the brain have both been
wounded without fatal results.


Of the Brain. 248
And Dr. Washington says he has seen
a ball which continued in the substance
of the brain, seven months.
I saw a child which had been
crushed by a beam, the head broken,
the dura mater ruptured; and I distinctly
saw a portion of the brain
which had been squeezed out and
lodged among the hair. Yet remarkable
as it may appear, the
child recovered.
Extraneous matter exists for
some time in the brain before
the fatal result takes place.


249 Inflammation
The brain & its investing membranes
may become inflamed in consequence
of a fracture of the scull, and almost
any injury done to the head.
When it comes on in consequence
of injuries of the head, the symptoms
are not immediate. It generally
does not make its appearance
till 6 or 7 days have elapsed.
I have known a case in which the
inflammation did not occur till
7 or 8 weeks; and in another not till
12 months had supervened the injury.
The symptoms are of a febrile
kind. It comes on with great restlessness;
the patient gets scarcely any
sleep; he experiences nausea, vertigo,
or giddiness; has a quick hard pulse,
much fever & sometimes convulsions.


Of the Brain. 250
When contusion exist, the part is
soft & pappy. If you divide the scalp,
the bone appears a dull white as in the
dead subject.
If there have previously been a
wound of the scalp, it may have been
suppurating, granulating & doing very
well, when all at once the granulations
become flabby, give way &
a sanious discharge takes place.
Upon examining you find that
a separation both between the pericranium
& the scull, & between the later
& the dura mater internally, and
matter is sometimes found under the
scull. These [illegible] idea of Mr. Pott,
That inflammation exists on the scalp
& dura mater & bone at the same
time, is certainly incorrect.


251 Inflammation
For as soon as inflammation of the
brain happens, where there is a
wound of the scalp, I have already
said that the suppuration & granulation
cease.
Inflammation is produced by,
and frequently depends upon the force
of percussion. When this has happened
& the above symptoms occur, we have
no doubt but that inflammation
has actually taken place.
In every injury of the head the patient
should be put on a low diet,
be bled & purged; but in inflammation
of the brain these must be carried
to a great extent. The patient
should be allowed nothing but
bread and water.
You will find that patients


Of the Brain. 252
reluctantly submit to this treatment
in common cases: and it is a fact
that they generally recover from injuries
of the head, though they take
no care to avoid inflammation.
This is more particularly the case
with children, which every now &
then receive knocks & blows on the
head. But even here it often becomes
the foundation of hydrocephalus.
Children after these accidents frequently
have intervals of screaming, and put
their hands to the head. I had myself
a case of this kind a few days since.
I prescribed vs. purging, low diet &c,
& I have had the pleasure of seeing the
symptoms subside. I have no doubt
if this practice had not been pursued,
that the child would have
had hydrocephalus.


253 Injuries Of the
But sometimes in spite of all that we can do
inflammation will take place & matter form
producing the symptoms of compression.
Here we are to apply the trephine immediately
to the injured part.
But sometimes the pus is seated
under the dura mater; and you would be
tempted to open & let it out.
I believe fungus cerebri is a part of the substance
of the brain squeezed out in consequence
of pus deposited in the brain: for
the cranium cannot contain both pus &
brain & hence it protrudes the latter out.
Surgeons do not agree in the treatment
of this disease. Some recommend the cautery,
& others to cut it off.
Now I believe that we ought to evacuate
the pus; and I should not hesitate
to introduce a lancet 3/4 of an inch into the
substance of the brain to open an abscess
& let out the matter. Nothing else


Brain & its Appendges. 254
will do; and if this fails the patient will
die. This is not a new thing, - some of
the French surgeons recommend it.
Of the cases of chronic affections of
the head I will relate one.
A sea captain came to this city in
June 1809 who had received an injury
of the head nearly a year before.
He had convulsive fits & severe headache.
Bleeding & purging was employed: and as
he had fell I cut down & observing a
roughness in the bone, I expected that the
inner table might be in the same condition
as the bone externally. Applying
the trephine & removing a piece of bone
relieved for a while the symptoms, though
in consequence of the induration of the dura
mater it was difficult to separate the
fragment from it. He however died
in a few days; when on examination


255
the dura mater was found nearly 1/2
an inch thick, and the brain in a state
which indicated the speedy formation
of pus
Hemorrhage.
Some times in opening the cranium some
blood vessels are opened and it becomes
necessary to stop the effusion. When the
bleeding is from the sinuses, it is stopped
by lint held on the wounded sinus which
allows the blood to coagulate. The artery
of the dura mater is stopped in general
in the same way. I would never recommend
to take it up with a ligature. I
think a dossil of lint placed in the sulous
in the bone would be successful, & I
would employ a number of assistants to
keep this in for 24 hours before I would
take up the artery.


Of Concussions. 256
Concussion. This is supposed to be a violent
jar communicated to the brain by
external violence, independent of any lesions
of that organ whatever. If the force be so
great as to produce instant death, we,
no doubt shall find little or no injury.
But if the patient survive the accident
a week & then die you will find the case
quite different. Contusion & rupture
of vessels will now be obvious.
The cause of death, then is not seen when
the patient dies immediately from the
instant cessation in the action of the heart
and arteries before an effusion can take
place from the ruptured vessels and
before the symptoms of contusion can
have time to supervene.
The same occurs when a violent blow
on the stomach puts a stop to life in
an instant.


257 Concussion
The symptoms of concussion are so well
described by Mr. Abernethy, that I
would recommend his work to your
notice. Ibid. also Dorsey's Surgery p.284
Vol. 1.
Treatment. The treatment in the first
stage consists in elevating the head and
letting the patient be undisturbed. When
you see the patient pale & ghastly, his
extremeties cold, & his pulse scarcely perceptible,
you would be very apt to
administer stimulants. But this should
not on any account be done. This is
the most favorable state to prevent
effusion.
In the second stage, or when reaction
takes place it becomes necessary to keep
the patient quiet and or a very spare
diet to open the bowels &c. But as soon
as there are any symptoms of inflammation


Of the Brain 258
inflammation, then you are to bleed very copiously.
When I first went to Europe I had
imbibed the opinion of B. Bell in
these cases I thought we ought to
give wine, volatile alkali &c. But seeing
Mr. Hunter's practice put me
out of the notion.
A man was brought into St. George's
Hospital who had received an injury on
the head; Mr. Hunter said it was a case
of concussion and prescribed bleeding.
What: bleed said I, for concussion of the
brain? Yes bleed him, and bleed him again;
bleed him to death if you can.
This copious depletion had a very happy
effect and the man recovered.
But fatuity and paralysis sometimes
came on in consequence of this affection.


259 Diseases of
I had a case of this kind in the Pennsylvania
Hospital. I could hardly get an answer
from him. I mentioned the circumstances
to Dr. Rush who prescribed mercury
supposing it to depend on effusion. I
salivated him & the affection subsided.
Some years after Mr. Abernethy mentioned
mercury in these cases. I think it no
more than just to mention that Dr.
Rush prescribed this remedy long
before Mr. Abernethy wrote
In hydrocephalus, improperly called hydrocephalus
externus, there is an accumulation
of water in the substance of the brain.
In this affection it occurred to me that
if I introduced a trochar obliquely between
the scull & dura mater for some
distance & then carried it into the brain
the seat of the water, so as to make a


The Brain. 260
valvular orifice, inflammation might be
prevented. I performed the operation in
this way several times in one child; drew
off a great deal of water without any
inflammation or any bad consequences
supervening. The water however again
accumulated successively till I became
tired of performing the operation &
the child at length died. A case of this
kind is mentioned by some gentleman
in the class as having been performed
lately. Now I performed it many
years ago. I failed it is true, but
others may be more successful; and
even I, might be so in other cases.
Hydrocele, as I shall tell you had
been cured by letting out the water
and I do not see why dropsy of the
brain may not be cured in some


261 Diseases Of
cases by letting out the water in the
same manner.
It is still necessary for me to mention
that the effects of intoxication and the
symptoms of compression of the brain
are so nearly alike that the perforator
has actually been applied if a slight
scratch or bruise be received by the
person fulling.
Now to distinguish these cases
you must pay particular attention
to the history of the case for some
hours before. The smell of the breath
can generally give you some light on
the subject.
I have even known a physician


The Brain. 262
make the same mistake supposing the
patient to be in a state of apoplexy:
And on recovering from his debauch
the poor unfortunate man has found
his head shaved & blistered, his feet sore
from the application of sinapisms,
& that he has been bled pretty largely.


263 Diseases Of
Inflammation. This may be seated
either in the eye-lids, the tunica conjunctiva,
or in the globe of the eye.
When the eye-lids are inflamed there is
slight pain, tumefaction, redness and a burning
sensation. The disease comes on frequently
in the night and is attributed to the bite
of some insect.
For this complaint, vs. is sometimes
necessary, though generally purging will
answer. Brandy applied as a lotion has
been recommended
When this disease is seated in the edges
of the eye-lids, it is attended with a viscid
purulent discharge which glues the eye-lids
together during the night. This disease
consists of an ulceration around the
roots of the eye-winkers, resembling tinea
capitis.
I judged this to be the case from those


The Eye 264
remedies proving most successful which
are used in that disease, and from this
circumstance that pulling out the hair
cures both cases.
Under this idea I have employed the
same remedies as in tinea.
St. Ives says it is easily cured by applying
to the ulcerated edges the lapis infernalis,
and then washing it with water
taking care to keep it from entering
the eye. I have used this remedy in some
cases with success. But the following
are also applied.
1. Unguent. Citrinum diluted with [illegible]
of lard. 2. Mer. Ointment. They should
be applied to the eye-lids night & morning.
But I have found most advantage
from washing the eye-lids with tar-water,
& applying the tar ointment M. & N.


265 Ophthalmia.
The next part of the eye we find inflamed
is the tunica conjunctiva. It is characterized
by severe pain, redness, & a copious secretion
of tears. The eye waters exceedingly,
the light is offensive; and the pain is of a hot,
burning kind. In some cases the pain is not
entirely confined to the eye, but extends to
the temples. The inflammation is occasionally
confined to one spot.
So great is the intolerance of light in
this disease, that the moment you go to
examine the eye the child (if such you have
for a patient) will close it forcibly & put
his hands over the eye-lids.
Inflammation sometimes extends over the cornea
and an extravasation of lymph takes
place between its lamina, & opacity is
the consequence.
The causes producing ophthalmia
are numerous mechanical & chemical irritants
applied to the eye, the vicissitudes of
heat & cold &c.


Ophthalmia. 266
The causes of ophthalmia may be arranged as
follows:
1. Irritating substances, inversion of the eye-winks
(trich.)
2. Acrid substances introduced into the eye or in
vapor.
3. Cold acting on a predisposition to the
complaint.
4. Strong light.
5. Frequent intoxication.
6. Scrofula, measles, variola &c.
I have seen two cases which were produced
by washing the eyes with urine while
the person labored under gonorrhoea.
Till these obstinate cases occurred, I did not
know that urine was ever used for inflamed
eyes, - a substance exceedingly acrid. What
is most remarkable one of these was a medical
gentleman.
The next seat of inflammation is the 
globe of the eye. The pain here is shooting


267 Ophthalmia.
and very severe.
When it is confined to the anterior chamber
of the eye, or in the anterior part of the
iris, ending in a secretion of pus, it is
termed hypopium. The pupil remains of
the same size in every stage. In general if
not arrested the sight is destroyed.
Treatment. 1. Remove exciting
causes if produced by irritation. Fix
the eye with a speculum & with a lancet
& a pair of forceps remove whatever sticks
in the eye. (such as filings, partials of sand &c.)
A linen rag wet & introduced on the end
of a probe will sometimes be successful.
Trichiasis arises, 1. From hairs turned
inwards & 2. from the ciliary cartilages
turned inwards upon the eye.
Several remedies have been successful
in this last case. The most successful


Ophthalmia. 268
is the one suggested by Dr. Dorsey, and put
to practice for the first time in 1810.
I have performed the operation several times,
and last summer in a gentleman from Virginia,
on both eyes, and where it had nearly
produced blindness, with complete success.
In operating never carry the scissors so as to
remove the puncta lacrymalia.
The best way of doing it is to take hold of
the external canthus of the eye lid with a hook
& then, with a pair of scissors cut off a suitable
portion of the tarsus.
For the treatment of ophthalmia the following
remedies must be employed;
1. Blood-letting. 2. Cups & leeches applied around
the eye-lids & temples, and if the inflammation
is still unarrested divide the vessels of the adnata
with the shoulder of a lancet.
But always subdue the febrile symptoms


269 Treatment Of
before you employ local bleeding.
3. Purging Mercurial cathartics are preferable;
together with nitrous powder & antimony.
External applications should be of the mildest
kind. The best is an infusion of the pith
of the young twigs of the sassafras, in cold
water, and dropped into the eye. It is mucilaginous
& sooths the pain very much.
Blisters applied to the temples or back of the
neck is useful in subduing the inflammation,
but eminently so when applied over
the eye itself.
The general & constitutional symptoms
having subsided but some inflammation
still left in the eye we may employ with
advantage the following Collyrium.
Rx. Acet. Plumb. gr. 5 Sulph Zinci gr. 3 Rx.
Opii Ʒij liquor pur. ℥4 m.


Opthalmia. 270
Mr. Ware recommends a watery solution
of opium to be dropped into the eye.
In some cases I think Ʒij of vinegar
a useful addition.
When matter forms in the eye the
evacuation produced by purging will generally
cause an absorption of it.
If it does not and ulceration must
take place make an opening through the
cornea with a cornea knife. But I
have always been able to cause absorption
by the above means. Should they
not, mercury is next to be resorted to.
Rules to be observed in the management 
of ophthalmia
1. Place the patient in a dark room
2. Restrict his diet to vegetables. All spirits
& fermented liquors are inadmissible.
It is customary to form an issue in the arm.


271 Ophthalmia.
Some cases of ophthalmia are of a peculiar
nature, as is evinced by their not yielding
to the common remedies, but to such as
would augment the inflammation in common
cases.
To illustrate this I will mention
the case of a gentleman who had been
bleed to the extent of 200 ounces, purged
frequently, blistered, scarrified &c. without
effect, the inflammation still remaining
obstinate. In this condition I gave him
for a collyrium the common tar-water.
On my next visit I found him much
better. I only applied it to one eye, but this
being attended with such good effects it was
used on the other, and it cured both in
a few days. Now this application in
a common case would have inflamed it
still more.
I believe these remedies cure by the strong
impression their counter irritation makes.


Unguis. 272
Unguis or ptergium is an enlargement
of the vessels of the adnata proceeding,
from the inner canthus of the eye.
The only remedy is to dissect it off; which
may be done by transfixing it with
a hook before using the knife
Opacity. 
In this complaint it has been usual
to prescribe acrid & stimulating applications.
Some have even blowed into
the eye pounded glass with a view of
grinding off the film as they term it
Now I consider all such applications
dangerous; for as the opacity
is the iffect of inflammation, it
follows that the opacity would be
increased by exciting it again by the
irritants intended to relieve the disease.


273 Opacity Of
It is a common idea that the matter is
on the outside, & can be cut, or scoured
off. But I have already told you that in
opacity there is always an effusion
of coagulating lymph between the lamina
of the cornea.
When there is considerable inflammation
remaining, I have seen
great advantage from puncturing &
unloading the enlarged vessels of the
adnata. You are then to give mercury
till a salivation is produced. Then
remit it, & when the action on the mouth
stops, administer it again so as to keep
up a gentle ptyalism for three months.
In one such case where the opacity
was so complete that no object could
be distinguished, this remedy was entirely
successful.
This was a lady whom I attended


The Cornea. 274
with Dr. Wistar. Thus you see that by
keeping the mouth tender for three months,
the cornea became as pellucid as ever.
I have always known it beneficial,
though I never saw it so completely
successful before the above case.


275 Fistula
The ductus ad nasum is liable to obstruction,
in consequence of which the tears
accumulate in the lacrymal sac.
By pressing with the fingers the tears
will regurgitate together with some mucus.
This is the beginning of the disease
and the patient suffers rather from inconvenience
than from pain. - the
eye being constantly watery especially
when much exposed to cold air.
In some instances however inflammation
is excited either from distention or from
exposures to cold; the obstruction then
becomes more complete & the tears are
prevented from passing per vius naturales.
Most generally vs. & purging will
subdue the symptoms: but sometimes
suppuration takes place & an abscess is
formed in the sack. It is here necessary
to make an opening into the abscess
with a lancet: and to examine


Lacrymalis. 276
the state of the ductus ad nasum with a
probe. If it can pass we remove the obstruction
as much as convenient & introduce
a stile to dilate the stricture.
In some cases the duct becomes
impervious and it is necessary to make
an artificial opening into the nose.
Mr. Pott recommended for this purpose
a curved trochar. But this breaks
the bone so much that it is not to be
employed.
Mr. Hunter used an instrument by
which he could cut out a piece of the
bone & make an opening which would
be permanent: - that of Mr. Pott frequently
closing up again.
Mr. Anel's probes I have used without
effect.
If carious bone exist after the operation


277 Fistula
operation it ought to be extracted.
Its the disease consists in a stricture
of the duct it must some way be
overcome.
For this purpose Mr. Weare's stile
must be introduced. You would be
apt to think that the stem of the stile
would prevent the flow of tears into
the nose; - and some physicians afraid
of this have ordered a groove to be
made to admit the tears to flow
freely.
Now this is a mistaken notion, &
I know by experience that they pass
along the stile perfectly well.
But Mr. Weare has omitted one very
important direction, and that is to
increase the size of the stile so as to
dilate the canal ultimately to its


Lachrymalis. 278
natural size which cannot be done
by employing the one first introduced.
To obtain the exact shape of the passage
I introduce a bagie of waxen materials
and drawing it out suffer it to cool &
carry it to the instrument makers to
get one of the same pattern. When this
has been worn a while a larger sized
one must be substituted in its place.
Never introduce the lancet so as to
cut the tendon of the orbicularis palpebrarum 
in your operation; but
carry it outwards & downwards.
If the sac is distended with pus it
is very easy & can hardly be mistaken.
But every now & then the patient
comes to you with a sore in the angle of


279 Fistula
the eye; and some operators attempt to
cut upon the side of the ulcer in this
instance they miss the sac altogether.
But you should carry the lancet just
within the lower edge of the orbit of the
eye & below the junction of the eye-lids.
Having opened the sac, and introduced
the probe put in the stile; - and as it is
apt to excite the curiosity of people to see
the head of the stile, & give occasion for
them to ask questions, it is best to cover
it with a small piece of court plaster;
or what is better dip it in black
sealing wax.
So long as the patient can empty the sac
with his fingers, it is best not to operate.
But when this cannot be done it ought
not to be long delayed.
But when the duct is completely obliterated,
the operation as performed by
Mr. Hunter must be had recourse to,


Lachrymalis. 280
the object of which is to make an opening
into the nose with a punch.
Operation. 1. Lay open the lachrymal sac,
2. Introduce a wooden spatula into the nose.
Then introduce the punch in a proper direction
and with a boring motion cut out
a piece of the os unguis. The punch then
comes upon the wooden spatula, which
defends the tender structure of the nose.
A saddler's punch if sharp will do as well
as any. Next bring the sides of the wound
together with adhesive plaster. It is an
operation however not frequently necessary.


281 Cataract.
This disease consists in an opacity of the crystaline
lens or its capsule obstructing the rays
of light in their passage to the retina.
A great many medicines have been introduced
in the treatment of cataract: at
the head of which is mercury.
Venesection, cupping & blisters have often
been employed. I wish I could say they
were effectual. 
In some recent cases originating from
injuries of the eye, mercury has proved
successful.
This remedy must be given till the
mouth becomes sore then suspend it till
it begins to get well, & then give it again &c.
for a long time.
But though we cannot often cure cataract,
there are several operations for removing
the opaque lens.
The oldest of these operations is couching.


Cataract. 282
In some cases however, the old operation produced
inflammation of the eye, gutta serena &c.
I believe the depression of the cataract the
very worst operation which can be performed.
It certainly causes gutta serena,
& almost always fails, notwithstanding what
Mr. Pott, Hey, Scarpa, &c. say in its favor.
The operation I have most generally performed
and which I prefer to every other, is
extraction.
To this I have now to except the operation
of Mr. Saunders as improved by Sir. 
Wm.. Adams.
The idea however was suggested by Mr.
Pott who observed that the lens was often
absorbed when broken down in the old
operation.
As soon as this mode of operation came
to be known Dr. Dorsey commenced with
it which at first was not so successful &


283 Cataract.
I began to think the operation inferior
to mine. But after a while he was much
more successful.
Sir Wm.. Adams has materially
improved the operation of Mr. Saunders
& I would advice you all to study
his work.
Operation. Before either the operation
of Saunders' or Adam's be performed
it is necessary to dilate the pupil to
prevent the iris from being injured
by the needle. The belladonna is used
in Europe, but the juice of the fresh
leaves of stramonium is employed here
with equal advantage. A solution of
the extract is also efficient. Neither of them
in some cases produces dilatation
of the pupil: and it sometimes takes
place in five minutes.


Cataract. 284
Adams introduces his needle posterior to the
cornea about two lines, and carries
it between the uvea & the lens, with the 
flat side before & behind. Then turning
the needle round so as to oppose its edge
to the lens, he moves it gently so as to
cut it in half. This requires a good deal
of nice management; for if you use
much force, you will depress the lens
without dividing it. If you find it
sufficiently soft you cut it up in shreds &
with the flat side of the needle push
the fragments into the aqueous humor in
the anterior chamber of the eye where it
will be speedily absorbed.
I have performed the operation several
times, and am very well pleased with it.
Where the lens is so hard that it cannot
be divided, push the whole of it into
the anterior chamber through the pupil,
and when you have got it there


285 Cataract
make an incision through the cornea &
extract it.
This he conceives is far better than the usual
method of extraction as performed
by Wenzel. In this instance the lens
being anterior to the iris, there is no
danger of its floating before the knife.
Sir Wm Adams makes the incision of
the cornea with a knife of peculiar
construction, and if not large enough
he uses another still broader at the
shoulders. And if this fails he employs
the scissors. I object to the use of the
latter instrument, because I have observed
the inflammation is always
greater than when a keen knife is used.
After making the incision through the
cornea, he has a delicate hook to draw
out the lens.


Closure Of the Pupil. 286
By this operation there is no danger of
wounding the iris & none of the vitreous
humor escaping. He places
the patient on the back when he operates 
and uses the bent wringed speculum
to keep up the upper eye-lid, &
to fix the eye, whilst the lower is held
down by an assistant.
Cheselden was the first who performed
the operation for an artificial pupil
The one now performed is an improvement
on his. Adams advises to make
the section larger than Cheselden. He
uses a very small, delicate scalpel.
It is to be introduced with the flat side
next to the lens: then bring it towards
you so as to divide 3/4 of the width of the
iris. If you fail in this divide it fibre after


287 Of Artificial
fibre, till of the proper size. He then
recommends to push the lens whether opaque
or not into the anterior chamber through
the artificial pupil. By this means it
is prevented from uniting.
I have never done this, but I have
used a circular punch-shaped forceps
which I have introduced after making
the incision through the cornea, with
complete success.
But when the cornea is opaque except
in some one part, as the side, or
above, or below, I have employed
an operation which I claim as my
own invention. It consists in introducing
the cornea knife in the
transparent part then, retracting it
a little to let the aqueous humor
escape, and then carrying it through
so as to complete the section of the cornea.
But this means a fold of the


Pupil. 288
iris which floats before the knife will
be divided & the artificial pupil formed.


289 Hydrocele.
This term is used to designate a collection of
water within the scrotum.
Of this disease there are several species
1. Hydrocele of the tunica vaginals testis
2. " Of the tunica communis, or cellular
membrane, envelloping & connecting the
spermatic vessels.
3. Encysted Hydrocele of the tunica communis.
4. Encystes Hydrocele of the spermatic
cord.
The hydrocele of the tunica vaginalis
testis generally increases very gradually.
When it appears suddenly it has been
imputed to the rupture of a lymphatic.
The encysted Hydrocele of the spermatic
cord might be mistaken for hernia.
But in the latter case the cord cannot


Hydrocele. 290
be felt all all; & besides if the tumor were
to be pressed above the abdominal ring, it
would instantly return on removing the
pressure. The water in some cases in this
species, extends as high as the abdominal ring,
& in one case I had reason to believe that
it extended within the ring along the cord.
I tapped & discharged the water without
injury. He was afterwards cured by a
mercurial course.
When anasarcous, small punctures may
be made if medical means are not successful.
The tunica vaginalis is sometimes ruptured
in hydrocel of that kind, & a rapid distention
of the whole cellular structure takes
place. And as blood is also effused from
some ruptured vessels, it gives to the scrotum
a purple appearance as if mortification


291 Hydrocele.
were coming on.
Dr. Shippen used to tell us, when I was
a pupil that he had cured a hydrocele
with a purge of calomel. I have never
seen calomel of any use when given as a
purge.
The usual & most successful method
of treating this disease, is to draw off the
water; and if it again accumulates, to
inject it some stimulating fluid to excite
inflammation, & thereby cause an obliteration
of the cavity.
Slight as this operation is, I have seen
mortification occur from it. This was
propably in consequence of the constitution
not being able to bear the least
irritation; as where this effect follows


Hydrocele. 292
the prick of a pin, or the scratch of an oystershell.
The patient should always keep
quiet & at rest for a day or two after
the operation of tapping to prevent the
inflammation from rising too high.
This though not absolutely necessary in
every case, is still the safest.
The testicle I have told you is generally
found in the inferior and posterior part
of the scrotum. But it may be in the
anterior & inferior part or in the lateral
part. In some recent cases I have
succeeded in bringing about an absorption
of the fluid by pouring cold water
several times a day, over the scrotum,
for the space of several weeks.
The old surgeons used caustic in hydrocele,
so as to cause a slough of the srotum
and the tunica vaginalis testis.


293 Hydrocele.
It was recommended by others to cut
into the tunic, & if thickened as it frequently
is in some old hydroceles, to cut
out a piece. In either of these cases the
operation was exceedingly severe.
Old Dr. Monroe recommended to tap
with a trochar and to leave the canula
in for a time, so that the introduction
of the air might excite the necessary
inflammation as he supposed.
Mr. Else about fifty years ago proposed
to apply the caustic in one spot so as to
penetrate through the srotum & into the
tunica vaginalis.
I never saw but one case treated in
this way, & that was in the Pennsylvania
hospital, by Dr. Rush. It produced the
usual burning pain of caustic at the time;
but it brought on such inflammation
& swelling of the scrotum as to render


Hydrocele. 294
his life very miserable. It likewise produced
a discharge of coagulating lymph, which
Mr. Else mistook for the tunica vaginalis
which he supposed to be eaten out. This
plan was not found to answered.
Pott's plan was to pass a seton through
the tunica vag. In a great many cases
this proved successful. But I once
saw it produce gangrene and death.
Sir Wm Earle about 30 years ago employed
injections into the cavity of the
tun. vag. test. by which it was obliterated.
Fluids were injected long ago by
a French surgeon; but they were so corrosive
as to produce too violent inflammation


295 Operation For
Provide yourselves with a good trochar,
a syringe adapted to its canula, Portwine
undiluted, sponges, adhesive plaster
and lint.
The patient is then to be seated with his
hands under the nates to prevent him
from dabbling them in your way.
Then with the left hand hold of the
upper part of the scrotum so as to render
it steady & tense, introduce the trochar
into the tunica vaginalis testis, carrying
it in so far as to be sure that it will
not slip out. Then withdraw the stilette
and suffer the water to run off.
which it will readily do by the Protraction
of the parts. When about one
half has run out, with the left hand
grasp the scrotum & pinch up a fold
of it, & of the tun. vag. and hold them
firmly so as to prevent the canula from
slipping out. After the water is evacuated


Hydrocele. 296
evacuated, the assistants holding the scrotum
as above directed, you proceed to inject 
into the tunica vaginalis, a sufficient
quantity of wine to distend it moderately.
The wine generally causes some pain in the
loins, sometimes nausea, and I have seen it
produce fainting; but no pain is felt in the
part itself. I leave the explanation of this
to your ingenuity. When it has been in
sufficiently long, suffer the wine to run
out through the canula, put a piece of
lint on the puncture, and an adhesive
strap over this, and put the patient to bed
directing him to lie on his back, with
the scrotum raised & kept up by a cloth or
cushion to prevent it from being stretched.
In a few days it will generally swell, become
red & painful: this is a very sure sign that
the operation will be successful. It rarely
ever fails indeed, so that I generally tell


297 Extirpation Of
my patients that it is the easiest & safest remedy
that can be. I have cured a case by
affusions of cold water over the parts
when the operation has failed. If both
of these remedies should fail, then employ
the operation of Mr. Hunter, which I never
knew to fail.
In speaking of inflammation of the mamma,
and mammary abscess, I mentioned
that schirrous tumors frequently continued
after the inflammation had subsided.
I stated that vs. purging, blisters,
mercury & mercurial frictions generally
succeeded in curing it. But when
we cannot get rid of the tumor by these
discutient remedies, as no one can tell
its latent tendency, the best & safest
practice is to extirpate it.
I have known a tumor of this kind


Schirious Breast. 298
continue harmless for twenty years, and
then all at once inflammation took place
and a fatal termination succeeded in six
weeks.
Sometimes young ladies have tumors
of the breast which cause no inconvenience,
therefore they pay no attention
to them. But about the time of the cessation
of the menses they become cancerous.
I always recommend their extirpation
and I have never known a cancer
follow when the tumor was confined to
the breast alone. But when the glands
in the arm-pit become affected we are
not so sure that the extirpation of the
tumor of the breast and axilla will be
successful: because contamination may
have taken place further than we can
feel or cut.
I always tell them that I cannot
promise certainty of success.


299 Extirpation Of
This to be sure is terrible to the mind
of a lady; but you cannot retain your
reputation without.
On the propriety of operating I would
observe, that if you cannot pass your fingers
above the indurated parts in the axilla,
decline the operation altogether. Never touch
it. They will ask you why cannot it be
extirpated? You had better tell them the whole
truth than to persuade them with false hopes
and gain the discredit of performing what
would be called a very cruel operation
without removing the seeds of the disease.
A lady once said to me, why will
you not operate? I will suffer you to
cut off one side, but only extirpate the
disease.
The answer is contained in the above
sentence.


Schirrous Breast. 300
Rules to be observed in performing
the operation.
If the external skin be hard, or adhere
at all to the tumor, cut it entirely
away.
We generally are to save skin enough
to cover the part after the operation.
But if discolored, purple, or adherent,
never let the saving of skin influence
you to leave it. Carry the
knife at least one half an inch beyond
the diseased part of the skin, so as to remove
all tincture, or disposition of the
disease to return.
The same is to be the rule in dissecting
out the breast also. After extirpation
in this way I do not, know that
I have ever seen cancer follow. But


301 Extirpation Of
I have seen a surgeon pride himself in
dissecting it out neatly, in saving the
skin &c. but this very neatness of dissection
has again given rise to the disease
which has proved fatal.
Operation. The patient is to be seated, the
arm raised, and the hair shaved from the
axilla. Then commence in the axilla and
carry the knife down the lower part of
the breast. Then make a second incision
to meet the first, so as to include an oval
space between. Next dissect off the adipose
matter from the tumor, and carry down
the incision anterior so as to expose some
fibres of the pectoral muscles. Then dissect
off the tumor from the pectoral muscles.
You would now be very much tempted
to cut off the tumor and dissect from
the axilla afterwards. But by doing


Schirrous Breast. 302
so you would commit a very gross mistake.
Instead of doing this, you will dissect
the skin open in the axilla so as to expose
the glands there, and reach the upper parts
of them. Be extremely careful in cutting
all away in the axilla.
By leaving the tumor adherent by
its vessels to the axilla, you have a handle
to take hold of, by which you can draw
down, the smaller ones situated in the armpit.
Never remove the breast till you have
tyed up the large artery which runs up
into the axilla, till you have tyed a very
strong silk or thread ligature above all
the indurated axillary glanys; (not an animal
ligature) then cut it off below leaving
the ligatures hanging out of the axilla. Then
bring the lower part together.


303 Hernia.
By the term hernia, in the limited
sense I want to apply it, is meant a
protrusion of some of the viscera which
ought to be included within the cavity
of the abdomen. 
The term rupture was improper because
there is always a sac of the peritoneum
inclosing the protruded viscus.
Hernia has been divided into several
species. Inguinal hernia, or Bubanocele, denote
a protrusion at the abdominal ring.
In the male it is called oscheocele or
Scrotal hernia, when the tumor descends
into the scrotum. Femoral hernia, Merocele,
or Crural hernia is used to designate
a protrusion under the crural arch or
Pouparts' ligament. When the protrusion
happens at the naval it is called exomphalos,
or Umbilical hernia: at any other part
of the abdomen Ventral hernia.
Hernia Cangenita is that where the


Anatomy of Bubonocele. 304
tunica vaginalis testis forms the hernial sac,
the testicle & intestine being in contact.
After removing the integuments, make a semilunar
incision through the tendon of the external
oblique muscle, extending exterior to,
and in the direction of the spermatic cord.
By dissecting, and turning the tendinous
flap inwards & downwards, you expose the
fleshy part of the internal oblique, which
goes down to be inserted into the lower part
of the linea alba. Dissecting this up, you expose
a triangular part of the transversalis:
which last being very cautiously dissected
and raised, we then have a view of the fascia
transversalis. Through this passes the spermatic
vessels, and constitutes the upper aperture of
the abdominal canal. From this aperture to
the opening of the abdominal ring is about
1 1/4 inch.


305 Anat. Of the Femoral Hernia.
As you see, the fascia of the thigh, where the
vena saphena enters, has a semilunar
appearance, and in the internal part there
is a space occupied by a lymphatic gland.
Internally between the iliac vein & the posterior
edge of the Pouparts' ligament there is
a weakened spot, through which the intestine
protrudes; over the neck of the sac,
from without, in a direction inwards
runs the epigastric artery; and from
within outwards, the spermatic cord.


Of Bubonocele. 306
A Tumor is observed to protrude for the most part
at the abdominal ring. Mr. Cooper has taught
us that it commences an inch and a quarter
above. The swelling is variable in size, being
smaller in a recumbent, than in an erect position.
Coughing & sneezing vary its size, and generally
except when strangulated it returns of
itself or with a slight effort when the patient
lies down.
The diseases likely to be confounded with
Bubonocele are, hydrocele, varicocel, swelled
testicle, venereal bubo, abscess, & Cysts upon the
spermatic cord.
The varicocele has the strongest resemblance
but you can feel the nervous tubes and with
your finger can cause the blood to pass up,
and when the finger is removed it will return
& distend them as before which is not
the case in hernia. Besides in varicocele
the convoluted appearance is evident.
If you grasp the tumor & desire the patient
to lie down, the hernia will not return into
the abdomen; but the tumor of varicocele will.


307 Causes of Bubonocele.
These are such as weaken the abdominal parieties,
or such as by violence force down
the contents of the abdomen. The abdominal
canal being larger in some than in others
gives them a greater predisposition to the
complaint.
The most frequent exciting cause is violent straining,
by which the diaphragm and abdominal 
muscles are brought into increased action,
as in lifting heavy weights, coughing, vomiting
straining at stool &c.
Treatment. 1. The first indication is
fulfilled by reducing the hernia, & the
2. by preventing its occurrence by wearing
a truss.
Bubonocele, as well as other species of
hernia may be divided into four different
kinds.
1. Such as is of easy reduction.


Treatment of Bubonocele. 308
2. Such as requires manual efforts.
3. Irreducible. 4. Strangulated.
So long as the intestine is allowed to remain
down strangulation will be endangered.
But great neglect takes place in this disease
and so long as it can be returned, especially if
the patient be a woman, the complaint
is not revealed.
In every case we ought to return the protruded
parts & apply a truss, if the case will
admit of it. This can only be done where
the hernia is reducible.
Retaining Bandages are of two
kinds Elastic & Non-Elastic. The elastic
are made of leather, the non-elastic of linen.
The best of the elastic bandages is a steel spring
covered with leather, to which is attached a
leathern strap by which it can be attached


309 Treatment Of
to the body. Thus constructed it is called a
truss.
After reducing the bubonocele, feel
first for the aperture at the abdominal
ring, and then place the pad of the truss
directly over it. If the truss is apt to rise
up, confine it by a bandage passed round
the thigh: and if it slip down confine
it with a scapulary. Never put the pad
of the truss below the abdominal ring.
For if it be applied to the os pubis, the
spermatic cord will be compressed, and
the protrusion of the hernia not at all
prevented. The compress of muslin
may be removed when soiled with perspiration
and a clean one reapplied.
The patient complains, sometimes, of excoriation
at first, and ought to keep quiet
& perhaps in a horizontal position. I have
observed that brandy is useful as a wash
to prevent it.
If the protrusion be on both sides,
two pads must be connected together.


Bubonocele. 310
To tell the size of the truss you want to
employ, pass a tape round from the place
of rupture till it comes back again. In
those who labor the truss must be tighter,
and of course they will be apt to suffer greater
inconvenience from it than those
who are sedentary.
The simple common trusses are better
than the ivory, potent, wire &c. and less
expensive.
After applying the truss, the person
should always walk about the room
to see that it keeps the bowels up.
You are to tell him at the same time
that whenever they do protrude while the
truss is on, he is to take it off immediately,
lest the pressure of it prove injurious.
In Young subjects, the truss sometimes effects
a radical cure; but very seldom
in adults.


311 Radical Cure
The ancients persuaded of the importance and
practicability of effecting a radical cure
of inguinal hernia, applied caustic over
the neck of the hernial sac, so as to produce 
adhesion. This often produced peritoneal
inflammation and death. And
when successful, the patient was exactly
as liable to hernia as before.
Next the cautery was applied to the
same part after removing the integuments.
This gave way to the Royal stitch
which consisted in cutting off the hernial.
sac & then with a needle and thread to
sew it up. This was also not effectual.
The Puncta Aurea, or golden wire
was then employed but without effect.
Regular practitioners failing in their attempts
to effect a radical cure of hernia


Of Bubonocele. 312
itinerant quacks took up the practice, and
in their attempts actually castrated male
subjects who came under their operations.
Though they seemed successful for some time
after the operation, the cure was not
permanent.
Dionis says some of these itinerants
had the faculty of removing the testicles
without the spectators knowing at all
what was done. "One of these fed his dog
with nothing else. He always lay on the
bed, or under the table of his master ready
to devour the luxurious morsel
the moment it was extirpated;
while the spectators would have sworn that
the man was in possession of all his
parts."
Upon the whole we should not expect
a radical cure if wearing the truss
2 years does not produce it.


313 Hernia
2. When from being long down, the increased
quantity of its contents, or from
tumefaction, the hernial protrusion
cannot be reduced with the same case
as usual; it is necessary to resort to the
taxis, to keep the patient at rest, to bleed
him and open the bowels. If the taxis
should fail at first when we have employed
the other remedies, in a few days
it will generally prove successful.
3. Irreducible Hernia. By this
term is designated that kind of rupture
attended with adhesions to the sac & the
latter to the parts in contact with it.
The bowel confined and pressed open
for a long time by a truss which does
not completely keep it up, or by a suspensory
bandage adheres to the contiguous
parts. For this there is no remedy.


4. Strangulated Hernia. 314
Symptoms. Obstruction of the bowels; at least
no passage from above the stricture; tumor
tension & pain; nausea; vomiting of the
contents of the stomach, and even of foeces
sometimes succeed; &c. Sometimes the stricture
is so great that the blood is obstructed
through the veins, which become of a
very dark color; and it is possible
for the stricture to be so great as to
obstruct the passage of the blood altogether,
when mortification takes place
Pott says he has known a patient
die in a few hours; while others with
the same symptoms have continued
for some days.
When death is approaching the
pain ceases & the patient thinks that
he is getting better.


315 Strangulated Hernia.
Hiccough; cold & clammy sweats; cold
extremeties; ghastliness & a sunken
pulse denote the rapid approach of
death.
All of these symptoms occur from
a stricture either at the upper or
lower aperture of the abdominal canal,
according to Mr. Cooper. The
former he believes arises from
spasm in some cases. For when
the intestine presses against the internal
oblique & transversalis muscles,
they become irritated and excited
into action & press forcibly upon
the hernial sac.
I have generally found the stricture
at the abdominal ring, and have never
(known) seen it arise from spasm
at the inner opening.


Treatment Of. 316
The great object is to replace the protruded
parts, except when in a state of mortification.
For as long as the stricture remains
the patient must be considered in danger.
In attempting to replace the protruded
bowels we must place the patient in a horizontal
posture with the buttocks raised higher
than the head, and the legs drawn up with a
view of relaxing as much as possible the
abdominal muscles. Then apply the hands
pressing upwards & outwards.
If the taxis should not succeed at first
it may often be successfully repeated after
the use of the warm bath, or bleeding.
Vs. should be employed very freely, even ad
deliquum animi in some cases. During
this state it may be reduced of its own
accord, or it is frequently easy to do it on
applying the hands. Sometimes by emptying
the contents of the tumor we can readily succeed.


317 Treatment Of
If this fail the warm bath at 98° must
be employed. Keep the patient in till he
is fainty, and at the same time use the
taxis.
I have been in the habit of giving
a moderate purge and I think with advantage
Crem. Tart. & Jalap and a little
ol. mint answer very well.
Purging glysters if they produce sickness
and vomiting ought to be omitted.
In old hernias where there is reason to
believe the strangulation arises from the
foecal contents of the protruded bowel, &
in omental ruptures you will find benefit,
but not, in recent cases.
An infusion of tobacco in clyster is
sometimes employed. If sickness do not occur
in half an hour it may be repeated.
Mr. Cooper relates the case of a girl in
which it proved fatal in 35 minutes.


Strangulated Hernia. 318
Death was preceded by a foecal discharge
by vomiting smelling strong of the tobacco.
Upon the whole I think it far more
safe even in adults to use a suppository
of tobacco which in most cases will
produce all the debilitating effects you
can desire. A string should be attached
to it by which it may be retracted
the moment your ends are accomplished.
In one case I saw alarming effects
produced from the infusion. The sphincters
were relaxed and the greatest prostration
brought on and I was glad to
wash out the tobacco with warm water.
The tobacco clyster is the most efficient
of all the remedies in hernia; though it
is not always successful. Mr. Hey says
it discovers to us sooner than any other
whether the operation will be necessary.


319 Treatment Of
Cold is the next powerful remedy. Ice is
sometimes used: as is also sal ammoniac
and nitre in cold water.
Opiates are almost always useful in
allaying the vomiting and sickness.
I once succeeded in an old gentleman
by giving 3grs of opium at night and
by raising the lower posts of the bedsted. 
He slept soundly and the next morning
he found to his great joy that it
was reduced.
Before operating make strong pressure
with both hands. If all these fail
then an operation becomes necessary;
which consists in dividing the strictured
parts.
The exact time it should be performed
is not quite certain. I believe it a


Strangulated Hernia. 320
good rule to do it as soon as the above
remedies have failed, and always before
soreness of the abdomen has taken
place. If deferred too long mortification
will have taken place and the operation
will fail.
Surgeons frequently put off the operation
because they do not know the
structure of the parts. These parts you
must understand, and you are to proceed
to the operation with as much deliberation
and as little perturbation as carving
a chicken.
The signs of mortification are delusive.
After vomiting, hiccough and
cold extremeties I have known the operation
successful.


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C. Redfield.
Abstracts
From Lectures
On
Surgery
By
Philip Syng Physick M.D.
Delivered in
The University of Pennsylvania
AD. 1818 - 1819.


Surgery.
The word Surgery or Chirurgia
has its derivation from the Greek
Χεερ, the hand, and εργον, work.
It is not to be concluded from this
etymology, that the surgeon has merely
the treatment of those diseases which
require manuel dexterity. To his prooence 
also belong the management
of numerous diseases as well as
accidental injuries: though the treatment
of the last more peculiarly
interest him in a professional
point of view.
The most simple accident that
can possibly occur, is that degree
of concussion in which the only effect
produced, is a debility of the actions
or functions of a part, similar to
that occasioned by a bruise, in


Surgery. 2
which the continuity of the substance
is not interrupted; in such a state the
parts have little to do, but to expand &
reinstate themselves in their natural
position, actions & feelings; and this is
what happens in the concussion of the
brain.
The rupture of a small blood vessel
is perhaps the next in order of simplicity:
though if the vessel be large, or essential
to life, or if the extravasation take
place in a vital part, as the brain, the 
injury may kill from the effusion
alone, however inconsiderable may be
the original mischief.
Another species of injury is where
the ruptured parts have an external
opening constituting a wound. In this
case the coagulation of the effused blood
between the ruptured parts constitutes the
natural bond of union, the ruptured


3 Surgery.
vessels closing up, their inosculation
being promoted, and an absorption
of the superfluous coagulum takes
place. This mode of restoration is
denominated union by the first
intention, and is not attended with
any pain on inflammation.
Whether in these cases a new portion
of the vessel is formed, or whether
the original vessel unites again
without the intervention of a new
cylinder, is not easily determined.


Inflammation. 4
Inflammation generally commences 
with an increased sensibility of the part;
to which succeed pain, heat, redness &
tumefaction: to which may be added impaired
functions of the part affected.
When the inflammation is very severe,
the functions of the part are totally destroyed.
Inflammation is divided into healthy
and diseased. By healthy is understood,
that which has for its object the
restoration of injured parts; by diseased,
that in which some morbid peculiarity
is superadded to the simple
act of inflammation, as in erysipelas,
carauncle &c.
The Remote Causes of inflammation
are various irritations of a mechanical,
or chemical nature, such as wounds,
bruises, acrid substances &c.


5 Inflammation.
The effects which these remote causes
have are different in different constitutions,
and even in the same constitution
at different times. What will produce
the slightest imaginable inflammation
in one, will produce a
most malignant & even fatal inflammation
in another; and even
in the same person at another time.
It is necessary to keep in mind this 
difference of effect in the different constitutions. 
When I am asked by a patient
who is about to submit to an operation,
whether there is danger to be apprehended
from its effects, I answer
yes, there is danger in every thing;
from the scratch of a pin, or the
prick of a needle. I however assure
them that the probability is much
in their favor. For I have seen a
person not complain of pain in


Inflammation. 6
the operation for lithotomy, nor did the
parts assume any bad aspect after the
operation, but healed without any
difficulty. But I have also seen it terminate
in violent inflammation gangrene
& death in a few days in another
person apparently similarly situated,
and where the operation had been performed
with the same skill & dexterity.
In such cases it is not the surgeon 
who is to blame, but the constitution.
In inflammation the motion of the
blood in the vessels of the affected part is
increased. The heat of the part is also
increased when the inflammation is
external, but never transcends that
of the centre of the arterial system.
Inflammation is divided into adhesive,
suppurative, & ulcerative.


7 Inflammation
Inflammation terminates
1. In Resolution: where all the symptoms
gradually subside, and the parts
are restored to their natural color &
appearance.
2. In Suppuration, or Abscess; which
is a circumscribed cavity containing
pus.
3. In a secretion of Serum; as in the
inflammation produced by cantharides.
A termination of inflammation
in the secretion of serum in the brain
produces hydrocephalus, in the chest
hydrothorax, in the abdomen ascitis &c.
4. Hemorage, This is not a very frequent
termination of inflam. But I
have seen the inflam. of an eye terminate by
spontaneous hemorage, & I have seen
the same termination in the throat &
back of the nose (posterior naries])
5. Scirrhus. When the coagulating
lymph remains unabsorbed in the interstices


Inflammation 8
interstices of the part it becomes hard &
the inflammation ends in hand tumors.
Cautions to be observed in the
treatment of inflammations,
1. Some inflammations should be attempted
to be resolved without large
evacuations; as where there is danger
of tetanus supervening.
2. When fever has preceded we are to
be cautious. But I have seen an opacity
of the eye from ophthalmia, &
a fistula in ano, because the patients
were judged too weak to admit the necessary
degree of depletion, for the resolution
of the inflammation.


9 Inflammation.
Treatment.
The first object is to remove the remote
causes if possible, provided they continue
to act. The next, to lessen or entirely subdue
the inflammatory action.
The latter object is accomplished by
§1. General; and §2. by Local
remedies. Of the former are
1. Venaesection. 2. Low-Diet: that is total
abstinence from fish, flesh & fowl,
broth, butter & eggs.
Vs. is useful in 2 ways. 1. by erupting
the distended vessels, & 2nd. by causing them 
to contract. 3. Purging. This probably
acts by reducing the contents of the
blood vessels. When nausea is produced
it acts sympathetically: for when the
stomach is sickened, the circulation is
rendered slower. This effect is produced
by neutral salts combined with antimony


Inflammation. 10
4. Rest: quiet & undisturbed.
5. Proper Position. Such as that
the flow of blood in the arteries to the
inflamed parts shall be retarded, and
that from it by the veins facilitated,
Or oppose the gravity of the blood to the
arteries, & add it to the veins; which is
done by elevating the limb. This is sometimes
of great use when we fear the accession
of tetanus.
6. Opium may sometimes be given to relieve
pain.
Local Remedies.
1. Bleading from the inflamed parts 
by cupping, leeches & scarifications.
But bleeding from the general system
should precede local depletion.
Without attending to this, & to the proper
position, all your local remedies will be
unavailing.


11 Inflammation.
2nd. Cold Applications. I believe
cold acts by diminishing the temperature
of the parts, thereby diminishing the
irritation produced by the temperature.
They should never be employed if they
prove disagreeable to the feelings of the
patient. Lead water, alcohol, laudanum,
poultices &c. are sometimes beneficial.
3rd. Blisters. These should generally
be used after the other methods have been
tried, or where depletion is contra-indicated.
All these remedies tend, by diminishing
the violence of inflammation in its adhesive
stage to prevent suppuration:
though sometimes that event is deniable, &
at others, inevitable. In such cases the
best application is a soft bread & milks,
or linseed poultice.


Inflammation 12
The good effects of Adhesive
Inflammation.
1. When the exposed surface of wounds
cannot be brought into contact, an effusion
of coagulating lymph takes place &
adhesive inflammation follows. In this
way the injury is repaired.
2nd. Adhesive inflam. prevents suppuration
as in the adhesion of the pleura (lining
the thorax) to the lungs.
3. Adhesive inflammation unites the
cells of the cellular substance surrounding
an abscess when suppuration commences
& thus prevents the escape of the
matter into the surrounding parts,
4. Cysts are formed by adhesive inflam.
around bodies, which have proved irritating
to the parts in which they
have been lodged, but not sufficiently
so to cause suppuration.


13 Inflammation.
Suppurative Stage. When suppuration
is about to commence the pain is
increased, and becomes of a shooting, or
throbbing nature, till an abscess forms.
Suppuration is sometimes attended by rigors.
These are often relieve by a discharge of
pus. But sometimes Hectic fever occurs
which is attended with debility, a frequent
small pulse, sharp to the feel; loss of appetite;
a copious flow of pale urine; night sweats;
watchfulness, & frequently a diarrhaea.
Hectic fever constantly attends the suppuration
of vital parts, and of bones,
ligaments & tendons. But it sometimes takes
place before suppuration, as in white
swelling. From the formation of issues
hectic is often relieved & sometimes cured;
though the quantity of pus discharged is
thereby increased. The presence of hectic is
not occasioned by the absorption of pus.
Abscesses should be opened early when
situated near the large cavities


Inflammation. 14
as the throax, abdomen; over a large joint,
or on the cranium. Abscesses are sometimes
attended with very great pain;
as in paronychia. This is instantly relieved
by an early opening.
I saw a case where a tumour seated
upon the external oblique muscle was so
painful that nothing would relieve, and
the patient died. This tumor was found
by Dr. Rush & myself to be an abscess.
A second occurred to me since, which
I opened and the patient got well.
Abscesses are opened by the lancet or by
caustic. Sometimes a puncture is sufficient;
at others a free incision should
be made. Sometimes the pus is absorbed
and the part is reduced to its natural
state. It would be a desideratum
to find some substance capable of doing
this at all times. Nausea & vomiting
sometimes produces that effect; & so does
venaesect. & purging.


15 Inflammation.
Pus. This is of a light straw color, of
the consistence of cream, composed of
globules swimming in a fluid; coagulable
by muriate of ammonia.
Pure pus is not corrosive; if so the
granulations in contact with it would
be destroyed. But like the tears, urine &c.
in an unnatural position it may be
made to excoriate.
Mr. Hunter excited suppuration by a
bogie in the urethra in 6 hours time:
which shows its greater facility in
forming in mucus canals.
Ulceration generally succeeds suppuration:
though it sometimes precedes
it. The process of ulceration is
always attended with a degree of inflammation
which is probably of the adhesive
kind.


Inflammation. 16
Erysipelatous Inflam..
This is often preceded by shivering, succeeded
by fever and a redness & burning
heat at a particular spot. It is generally
situate on the cutis vena & often spreads 
extensively on the skin. The pain is not
acute but burning. I have known it attended
with a distressing itching. It
differs very essentially from adhesive inflammation,
in that it never secretes
coagulating lymph, but serum. As adhesion
of the cellular substance does not
take place when the disease is situated
below the skin, the matter travels from
place to place through the cellular membrane,
the latter becoming gangrenous
and sloughing out like wads of wet toes.
This more generally happens about the
margin of the anus.
A deposition of serum on the cutis vena
causes a vesication.
The disease seldom, seldom terminates before
the 8th or 12th day.


17 Erysipelatous
Treatment. The constitutional remedies
are the same as in phlegmonous
inflammation. Locally, different applications
have been made. Poultices &
oily applications generally do no good;
though I have seen the inside bark of
the elder stewed in cream useful in
relieving pain & quieting irritation.
The best application for the most part
are meal, flour, powdered chalk &c.
I learnt some years ago from a physician
in this city that the application
of a blister had the happiest effect in
erysipelas. I thought this practice had
originated with him, but I find that
Ambrose Paré recommended it in
the same instances & he relates a very
obstinate case thus cured, by himself.
When matter forms under the skin,
large openings should be made to
facilitate its escape, & to prevent it from
spreading the disease from cell to cell.


Inflammation. 18
In the treatment of erysipelas we are
to bleed, purge & confine the patient to
a low diet. Sometimes when the patient
is very low and the pulse such as indicates
languor & depression, yet paying
attention to the appearance of inflammation
vs. though the patient should
faint under the evacuation of blood,
should be employed. The appearance of
the inflammation must regulate our
remedies. Twenty years ago, in London
they were in the habit of giving bark in
erysipelatous inflammation: but I have
seen mortification frequently the effect
of this mode of treatment.


19 Of Gangrene and
Mortification is the entire death of
a part. Gangrene: that state immediately
preceding it, while it yet retains a
degree of sensibility motion & warmth.
Mortification is of two kinds. The
first is preceded by inflammation; the
second is not. Interrupted circulation,
disorganization by external violence, intense
heat or cold, produce mortification
without inflammation.
When mortification commences in a
part the color changes to a livid, purple,
or dark purple; from the coagulation
of the blood in the dead vessels. The
part also becomes cold, is covered with
vesication and emits a foetid smell. 
The best application is a soft bread &
mild poultice. A moderate inflammation
in the surrounding part is
salutary. The use of tonics, opium, bark
and wine becomes necessary.
When a limb has been exposed to intense
cold, numbness or a sensation
of pain is produced; the color alters;


Mortification. 20
and should heat be suddenly applied the
part will invaribly mortify. I have seen
mortification occur in a man recovering
from yellow fever, without inflammation
and without any obvious cause.
2. Mortification preceded
by Inflammation. Violent inflammation
may end in the death of
the part. Sometimes a cause which
produces healthy inflammation in one, 
produces mortification in another.
I knew a woman aged 40, who had a
mortification from the application of
a mustard poultice in a fever. And
Boerhave relates a case of mortification
from the use of volatile liniment to a
paralytic limb. I once saw it happen
from a blundering operator injecting
wine into the cellular texture of the scrotum,
instead of injecting it into the tunica
vaginalis testes, in the operation for hydrocele.


21 Mortification.
A mortification of the toe in old people
sometimes occurs & as I think
is preceded by inflammation, Mr.
Pott recommends opium in this affection
& a soft poultice, Cheselden says
he has known it do well where the
person was left to the salutary operations
of nature.
Pressure long continued will cause inflammation
& mortification. This we
often see in patients confined to bed in
fever, paralysis &c.
When violent inflammation arises and
we have reason to apprehend mortification,
it used to be thought advisable to
employ cordial stimulants, bark, elixer
vitriol &c. But where the constitution is
not impaired, the antiphlogistic treatment
is not to be neglected.


Mortification. 22
Peculiarity of Inflammation
terminating in mortification.
Mr. Hunter thought mortification
originated from some peculiar action
of the constitution independent of the simple
act of inflammation as in small pox,
carbuncle &c. I agree with him here. I
have even gone so far as to believe that
in all cases of mort. preced by inflam.
this peculiar action exists. I have great
doubts whether simple inflammation has
a tendency to produce mortification.
If there was nothing peculiar in inflammations
terminating in the death of the
part, but simple increased action,
then the application of a blister would
spread the disease. But it is only from
reflecting on the subject in the above
light that I was induced many years ago
to employ blisters; nor can they be of benefit
any farther than they have a tendency
to change the nature of that action


23 Mortification.
to one that has a tendency to terminate
in health. But genl. it is only in that
species of mort. preceded by inflam. that
blisters can be beneficial. In that of the
toes of old people & that from obstructed circulation
they would even do harm. I am
exceedingly anxious that you should attend
to this for so many mistakes have already
taken place that I would not wish to add
to them by recommending to you an improper
remedy. From what has been
said you will discern those cases in which
they should be applied & act accordingly.
A mortified leg or arm, should be placed
upon a pillow of carded wool & changed
twice a day. A box, or some contrivance
should be used to prevent the pressure
of the bed cloths.
In order to judge of the state of the parts
in the vicinity of the mortification, press
on them with the fingers for a time which
will force out the blood & the color will
be lighter on raising them. If the circulation


Mortification. 24
circulation be very languid the color will not
be restored for sometime; perheps for a minute.
If at some distance from the mortified
part the blood returns very slow you
will have reason to suppose that, too,
in a condition nearly approaching to
mortification & v.u.


25 Mammary
We seldom see this in its first stage because
nurses think themselves altogether adequate
to its treatment. The inflammation commences
with pain, hardness & tumefaction.
The secretion of milk is often diminished & 
sometimes totally suspended. On examination
a hardness like scirrhus is observed &
extreme pain is caused at the time of suckling
the child, or whenever pressure is applied.
Suppuration generally takes place in 3
or 4 days time. Sometimes are aedematous 
swelling forms, & the nipple is buried below
the level of the skin, In other cases the
inflammation occasions an extravasation
of coagulating lymph and produces distinct
hard tumors.
The remote causes of mammary abscess
are 1. Tight dresses. 2. Exposures to
cold. 3. Accumulations of milk. Sometimes
it takes place without any obvious
cause.


Abscess. 26
Treatment. vs. purging, a soft poultice,
low diet, confinement to bed, suspension of
the breast & proper position. The patient
should rest on the sound side so that the
affected breast may be uppermost.
mercurial ointment is sometimes used
with the poultice, as also lead water,
I have often known a blister do much
good. Stimulating applications are not
to be used. Justamond recommends sal
ammoniac & vinegar. I have tried it &
sometimes with benefit.
When matter is formed it should be discharged
by an opening with the lancet,
In one woman whose breast was oedematous
I tried vs. purging, cold application, &c.
without any benefit. It struck me that
a blister might be proper. I applied it &
the tumefaction went completely away.
In another case where there was a hard tumour
like a scirrhus as big as my fist, a
blister resolved it.


27 Mammary
When the suppuration is deeply seated as
perhaps between the glands of the breast
and the pectoral muscle, or in the cellular
substance between the two, several
sciruses appear communicating with the
same abscess. Mr. Hey says it is the duty
of the surgeon to lay open all these sciruses.
But it cannot be done without cutting
the parts very extensively & dividing one or
more arteries. There is no doubt of its success
however when it can be done. But I
have sometimes effected a cure by introducing
a bogie into the cavity which has
allowed the discharge to take place. And
when that has failed I have introduced
a seton which has never failed. This
reduces all the suppurating cavities to a
mere channel. The way this operates is by
keeping it constantly open, so that no lodgment
being left for the matter the cavities are
all filled up with granulations to the
seton from which the pus is constantly


Abscess 28
oozing out. When thus filled up your seton
may be withdrawn and soon the cure
is affected. This however generally occupies
about 8 weeks.


29 Paronychia.
Paronychia is a very painful & distressing
inflammation, usually seated at the end
of the finger, and generally ending in suppuration;
from παρα, about, & ονυξ, the nail,
It is usually divided into 4 species.
1. That seated near the root or side of the nail.
2. That in the adipose membrane under the 
skin.
3. That, where the inflammation is seated
within the theca covering the flexor tendons.
In this the matter extends sometimes, up to
the wrist, or even to the elbow along the
tendons.
4. In this species, the periosteum, & sometimes
the bone inflame.
The causes of whitlow are not always
obvious. Punctures, irritants applied to the
finger, & vicissitudes of temperature are
among the number.
In the first species which is often
called a run-round, little is necessary
but to open it & if the inflammation
still continues to progress, cut off the cuticle
with the scissors and dress it with


Paronychia. 30
basilicon or lead ointments
In the other species the early application
of a blister frequently puts a stop to all
the mischief. Dr. Perkins employs the
caustic potash. It acts like the blister &
I think a good deal of it. When matter
points in the hand, or above the annular
ligaments of the wrist, make a free incision
& let it out. A free & an early
opening into the primary affects part
when the inflammation is not arrested will
prevent the matter from passing up the arm.
When neglectd I have sometimes seen the
finger become stiff. This may arise from
anchylosis, or from a sloughing of the tendons,
by which motion is prevented.
When anchylosis is expected, bend the
finger if possible; for it is less troublesome
& more useful than if it were suffered
to remain strait. This is of great
consequence to the patient, & should never
be neglected by the surgeon.


31 Onychia
There is another affection of the finger
which has deservedly received the appellation
of onychia maligna. It is a most
dreadful & painful complaint, exceedingly
malignant in appearance, & very obstinate
and difficult to cure.
Till within a few years I considered
amputation as the only remedy. About
two years ago, I observed in looking into
the 3rd Vol. of the medica Chirurgical
Transactions of London that mercury
so as to excite a salivation was recommended
by Mr. Ward as very efficacious.
Rejoiced to find a remedy for so
distressing a complaint, I resolved to try
it the first opportunity. I did so, but
without any benefit whatever.
Not long since Dr. Perkins told me of a
German physician in this city by the
name of Williams who is peculiarly successful
in treating onychia maligna. He
used equal parts of corosive sublumate &
sulph. zinc in powder applied on lint
to the end of the finger, keeping it covered


Maligna. 32
covered with a rag & wet with ꝶ. Myrrh.
So irritating and corrosive an application
I did not choose to hazard till I had
seen it used. Having a case of this nature,
I told Dr. Perkins that as he was
acquainted with Williams' method of
using the remedy, he should make the
application himself. He did so, and
to my utter astonishment it had the
desired effect. I have used it since in a
number of cases, in all of which it has
proved successful.
In a case which occurred to me
in the Pennsylvania Hospital which I
treated for 4 months by the soothing
plan without any benefit, was cured
by applying red precipitate. It
had the effect of allaying the pain &
inflammation & of effecting a speedy
cure.
There is another; similar affection
of the toe to this to which the above treatment
is adapted.


33 Psoas
The matter constituting psoas as lumbar abscess
is seated in the cellular texture exterior
to the peritoneum, surrounding the
psoae muscles. The disease may originate,
from bruises, strains, lifting heavy weights.
Often no cause can be assigned.
The symptoms often commence with difficulty
in walking & weakness about the loins,
but without acute pain. The patient generally
is unable to walk strait & upright &
therefore bends the body. Though generally
attended with a mere sensation of weight &
weakness, yet sometimes there is symptoms
of inflammation & pain.
The matter not being circumscribed by
adhesive inflam. is liable to point at various
places as it travels along the cellular
membrane. It frequently shows itself
by a tumor just under Poupart's ligament,
or even at the middle of the thigh. It
occasionally points about the anus. In
the case of a gentleman who supposed
himself affected with fistula in ano, I passed
a probe 13 inches long up a passage to


Abscess. 34
the lumbar region to the seat of the abscess.
I have almost always found this affection
complicated with caries of the vertebrae.
If the tumor appears in the groin it
has some of the characteristics of hernia
& has actually been mistaken for it the
surgeon applying a tress &c. The discrimination
is very important, & happily
not very difficult. If you place the patient
on the back and press on the tumor
it immediately recedes and the abdomen
rises up. Press on the latter & the tumor
appears again. This together with the fluctuation
renders the case obvious.
In the treatment of lumbar abscess, the
patient should be kept at rest and put
upon a low diet. If fever attend it is
necessary to bleed & purge. Where there is
no pain nor inflammation I believe vs.
is not proper, but purging may be.
Hitherto it has been considered very dangerous
to evacuate the matter in psoas
abscess on account of the violent inflammation


35 Psoas
inflammation & fever which generally supervene.
Mr. Hunter considers this as a
scrofulous affection as well as all abscesses
without inflam. to circumscribe
them. Those collections confined to the
original seat of the disease he calls
abscesses of a part; & those where the pus
passes along the cellular membrane and
points in another place abscesses in a
part. He contends that the inflammation subsequent 
to the opening of the abscess is from
the extent & imperfection of the cavity no
adhesion having taken place to circumscribe 
the matter.
Mr. Abernethy profiting no doubt from
Mr. Hunter's remarks, proposed to open the
abscess by a small puncture, & by a valvular
orifice to let out the matter & close
it again in such a way as that union by
the first intention shall take place in the
orifice & thus preserve the integrity of
the cavity. He directs the opening to be made
by first pushing the lancet longitudinally
upwards with respect to the thigh, & then


Abscess. 36
inwards to the cavity. When a part, or the whole
of the matter is evacuated, the opening is
to be closed with adhesive plaster.
I have used Mr. Hey's method with a good
deal of benefit, but unfortunatily I have
not been able to effect a cure, it having
been in every instance complicated with
caries of the vertebrae.
Sometimes the valvular opening does not close
by the first intention, in which case inflammation
of the cavity will succeed.
Whenever this occurs, however weak the patient
may be vs. purging, & the antiphlogistic
treatment is equally necessary as in
other cases of inflammation.
I opened a lumber abscess in a genl. 27 years
of age & evacuated several pints of matter. But
the opening did not close & inflam. & fever
were the consequence. Vs. & purging produced
an abatement of the symptoms & he was
much relieved. He however languished along
for 8 months & then died. Having
obtained leave to open the body I found


37 Psoas Abscess.
that there had been an extensive caries of
the vertebrae; that the first lumbar vertebra
was so completely destroyed at its anterior part
and the second so disposed as to form an
angle of about 85° degrees, as you see here
exhibited. The inter-articular cartilages were
removed & the bodies of the bone left naked.
As the natural line of support to the trunk
was thus lost, nature formed another line
of support by absorbing the cartilages of all
the oblique processes of the lumbar verterbrae
and by uniting them by anchylosis.
It might be said that inflammation
produced this anchylosis; but these processes
were 3/4 of an inch from the original
seat of the abscess & besides there was
no inflammation attending it when the
curviture took place. I consider this as 
one of the most happy cases to show the
wonderful skill & admirable contrivance
of nature that can possibly be contemplated.


Burns and Scalds. 38
When heat is applied to a living part
various effects are produced according
to its intensity and extent.
When the degree of heat is not very
great it produces pain, redness & slight
inflammation, which subside spontaneously
when the heat is removed. A greater
degree occasions more severe pain;
vessications appear filled with serum
& the true skin under the vesicles, is
much inflamed. Where the burn is
extensive fever attends, & suppuration
ensues. If the heat be still more intense,
the life of the part is destroyed.
A burn small in extent, though it completely
destroy the vitality of the part
will be unattended with any constitutional
derangement; while a very extensive 
one very slight in degree,
is often productive of much mischief.


39 Burns and
When the heat is very intense so as to
destroy the life of the part, or is very
extensive so as to produce much constitutional
derangement, less pain
is experienced than in slight burns.
This is strikingly exemplified in the
case of a boy who fell into a caldron
of boiling water. He appeared not to be
in pain, said he felt none, neither when
he fell in nor afterwards. But death
soon followed. This has reconciled
me to the practice of putting animals
to death by immersing them in boiling
water.


Scalds. 40
Treatment. In the treatment of burns
it may be laid down as a general rule,
that where no inflammatory symptoms
appear, but on the contrary, those of
weakness & want of reaction, stimulants
must be employed. When inflammation
& fever succeed we bleed, purge & confine
the patient to the antiphlogistic
regimen.
Locally there have been a great variety
of applications, both stimulant &
sedative, such as alcohol; lead water, ice,
oil, lime water, &c. and when the skin is
denuded some have recommended vinegar,
cold water, carded cotton &c. Of late the
stimulating applications are most used.
Nature of Burns. Eccessive heat
appears to me to produce a peculiar kind of
inflammation. 1. The pain differs from
that of common inflammation. 2. It has
no disposition to heal like c. inf. but runs


41 Burns and
into ulceration. The ulcer also has a tendency
to form a fungus. 3. It cicatrizes
different from common soars.
Hence we see the necessity of having an
application which has a tendency to counteract
this peculiar species of inflammation.
And such are those which have the effect
of inducing common inflam. in sound
parts. Of this class none seem better
adapted to the purpose than the Sp. Tar.
It certainly is very curious that such a
heating & acrid substance, which produces
inflam. should cure that produced
by fire. The liniment of Mr. Keutish
made by diluting the basilicon ointment
with the Sp. of turpentine I think the best.
But it should not be applied to the
contiguous parts, for in that case the 
same substance that would be best adapted
to cure the burn, would produce inflammation
of the sound parts. I have
often known gentlemen not aware of this


Scalds. 42
apply Sp. turp. on cloths to a burnt leg.
But I have generally found at my next
visit that the patient had suffered severely
from the improper method of applying
the remedy. The best way is to cut
strips of linen just large enough to
cover the parts affected, spread them
with the above mentioned liniment &
be careful that they do not touch the
sound skin. Upon the whole this is
the very best application that I am
acquainted with when the accident is recent.
But if not called in at first, or
till the accession of inflammation, the
basilicon alone, or some milder ointment
must be subsituted. The stimulant applications
can seldom be continud more
than two or three days. If ulceration
succeed & fungus spring up, it must be
destroyed with burnt alum, or some other
escharotic. When the cutis vena is destroyed
the parts beneath become


43 Burns and
diseased & are bound down by an
eschar. To relieve the tension consequent
to this, you are to cut through
this hard eschar, but not through the
living flesh.
When the whole hand has been scalded
care must be taken to interpose dressings
between all the fingers otherwise
they will unite; which is a very deplorable
event, & cannot be separated
so completely as to restore to
the fingers their use. When thus dressed
the hand should be found on a splint.
When the chin & neck are scalded
by suffering them to remain in contact,
a most dreadful deformity
takes place.
In one case where the chin & lip, were
united to the neck, the head bowed forwards,
the mouth kept constantly opened,
& the saliva running down, with a great


Scalds 44
deal of difficulty, I dissected up a flap
of skin from the breast, raised the head
and placed it under the chin. Unfortunately
a part of the skin being
diseased sloughed off: but the deformity
was in a great measure removed
& he was enabled to keep the head erect
& the mouth closed.
When the parts of generation are scalded
it is particularly necessary to prevent such
bad effects: because in the female the labia
may unite by adhesion, and in the male
the penis & scrotum become one confused
mass. When I was in London, such a
case was presented to Mr. Hunter. A
little boy happened unfortunately to
overturn a vessel of hot water on his belly
which scalded the private parts very
much. His mother dressed it - I dont'
know with what - something that she
supposed would draw out the fire, as she
termed it, paying no attention to penis,
scrotum or anything else.


45 Burns and
The boy got well & could make his water
as usual, and was satisfied enough.
But when he arrived at the age of 18, he
was not so well pleased with the manner
in which this accident had been
treated, and applied to Mr. Hunter to
know if something could not be done
for him. Mr. Hunter examined the case
and found that the penis had grown to
the scrotum the whole length. He thought
it hard to do any thing, but was willing
to undertake it. With a great deal
of trouble & difficulty, he succeeded in
liberating a little piece of the penis,
(about 2 inches) and the young man went
away apparently very well satisfied.
When a burn happens in the vicinity of
a joint & the fire has communicated with
the cavity of the joint, it produces a
kind of sub-luxation, & is attended with
a subsultus tendinum. This is not like


Scalds. 46
tetanus: there is not the same spastic rigidity,
but if not relieved the patient may
die: how an opiate will not remove this.
But it is prevented by binding on a
splint so as to prevent the motion of the joints,
& the system from being drawn into
sympathy with the local irritation.
One circumstance is particularly to be
attended to in the treatment of burns or
scalds of the hand, When the back of the
hand only is burnt, if you allow it to be
extended the cicatrization so contracts the
skin of the hand, that it cannot be shut.
On the contrary, if the palm of the hand
be burned & the fingers are not extended
the hand cannot after cicatrization be
opened. Thus then, when the back of the
hand is burned, the finger, should be
flexed, or the hand shut. When it is the
palm of the hand, the fingers should be extended,
or the hand opened; and when the
whole hand is affected, a semi-flexed posion 
should be preserved.


47 Wounds.
A wound may be defined, a solution
of the continuity of a part communicating
externally, produced by mechanical
violence.
Wounds may be comprehended under
two divisions: Incised and Contused.
The latter includes punctured,
lacerated, & gun-shot wounds.
Incised wounds are made with a sharp 
cutting instruments, which divides the part
that comes in contact with the edge, but
the neighboring parts sustain no injury.
Contused wounds are those in which
the surrounding parts are much
bruised at the same time that
the injury is inflicted.
A wound with a sharp instrument is
always attended with profuse hemorhage.
But a lacerated or contused


Wounds. 48
contused wound is not. This is frequently
the case even where large blood vessels
are torn asunder. Cheselden relates
the case of a miller who got caught
in some machinery & had his
arm & scapula completely torn off
from the body without scarcely
any effusion of blood; & he very
happily recovered. And I have, myself,
seen a boy whose arm was ground off
where the hemorrhage was so trifling
as not to stain the dressings.
I have learned from butchers that a
knife immediately off from the stone
does not occasion so great an effusion
of blood as one used for sometime,
an account of its roughness, &
perhaps also from some particles of the
stone adhering to the edge.


49 Wounds.
Hemorrhage. It is now nearly a
century since M. Petit commenced
the investication of the natural process
by which the bleeding from a
wound is arrested; and since his time
a variety of theories have been advanced
on the subject. Mr. Morand, in
1733 thought that the suppression of
hemorrhage was occasioned by the contraction
or corrugation of the divided
artery.
Dr. Jones has lately published a very
excellent treatise on hemorrhage; to
which I shall have very little to add.
The effusion of blood into the cellular
sheath of an artery when divided making
compression on its parieties is
one way in which hemorrhage is 
stopped. But I believe that the muscular
power of the artery is often sufficient
to contract the divided extremity


Wounds. 50
extremity and prevent any further effusion
of blood. That by this contraction
a small vessel can be closed independent
of external or lateral pressure is very
certain. But when the artery is large, we
see that the idea of Petit, that it is stopped
by the formation of a clot in its
divided extremity is correct.
But the permanent closure of divided
vessels depends on the natural process
of inflammation & adhesion.
Incised Wounds.
In the treatments of these the first object
is to command the hemorrhage. To effect
this the tourniquet, if possible, is
to be applied. The wound is next to be
washed out with a sponge & warm water,
and the ends of the divided vessel
drawn out with the tenaculum, a ligature
passed round it & tied.
It becomes a question what kind of


51 Incised.
ligatures is best. Thread or silk ligatures
have generally been employed to take
up arteries but they often remain in
a very long time & produce great irritation.
I saw a case of popliteal aneurism
operated on by Mr. Hunter where
the ligature remained on the aretry 6
weeks; and the patient nearly lost his
life in consequence of the hectic fever
which followed. And a silk ligature applyed
by Dr. Hartshorn remained on 6
months. This disagreeable attendant on
the use of the common lig. led me to
the consideration of some other substances.
It occurred to me that if ligatures
of animal substances which would dissolve
in the suppurative fluid were used,
all the mischief above noticed would
be prevented. Catgut, common fiddle
strings or French kid answer for these
ligatures. I first requested one of my friends
to try it on the spermatic artery of
a horse & it completely succeeded.


Wounds. 52
It was then tryed with equal success in
the human subject. I have now used the
animal ligatures for some time on
arteries of different magnitudes & have
known others to use them and in no
case has a secondary hemorrhage
occurred so far as I have seen or
heard of.
Mr. Lawrence proposed to use a fine
silk thread and to cut it close to the knot,
Now this will not answer as I have ascertained
by experience. Neither should
we expect it when we consider that the
least shred of lint among granulations
keeps up a continual irritation. I
was surprized to find from Mr. Astly
Coopers Surgical Essays that he used animal
ligatures in operations for aneurisms
and claimed it as his own discovery.
It is more than two years before
the appearance of his work that
I employed them. So you see I can
fairly claim the discovery as mine.


53 Incised
The wounded poplitcal artery has been
known to heal without an operation.
I have known the divided brachial artery
close up in this way. Dr. Mease
of this city in the operation of venesect.
had this artery opened and a varicose 
aneurism was the consequence. But
it afterwards spontaneously disappeared.
After a hemorrhage is stopped, never leave
a patient a single moment without
a tourniquet loosely bound on the limb,
and a watch always on the guard ready
to tighten if should the effusion
recur.
When these steps have been taken
the lips of the wound are to be brought
together & retained in situ by adhesive
straps; and to secure these still more
a compress bandage is to be applied.
The reason why hemorrhage in contused
wounds is less profuse than in incised
ones, is, that in the former there


Wounds. 54
is considerable effusion which makes 
lateral pressure on the vessels while
the death of the mouths of the ruptured
vessels is exceedingly favorable to the
formation of a firm coagulum.
I think it is not necessary to tye the artery
very tight in cases of incised wounds,
for by this means the artery might
be cut entirely through. It strikes
me that Dr. Jones has committed an
error by directing arteries to be tied so
tight as to cut through their interior
coats. This I am confident he speaks of,
mearly from theory. I have been in the
habit of applying ligatures in the way
I recommend for this 30 years, and
have never seen secondary hemorrhage
the consequence. If a ligature be applied 
tight enough to bring the sides
of the artery completely in contact &
keep them so for 24 hours, no hemorrhage
will occur unless, some unusual


Incised Wounds.
55.
unusual circumstance attends.
When a wound is deep it is always
necessary to leave a small space unapproximated,
for the escape of blood,
serum, extraneous matter &c.
Wounds produced by glass constitute
an exception to the common mode
of dressing. We should not attempt to heal
them by the first intention, but by suppuration.
Here we apply a poultice as
in contused wounds.
Adhesive plaster in general will answer
to retain the lips of wounds in apposition,
with proper bandages & position.
The soft parts suffer no injury from
adhesive straps, but stitches excite dreadful
inflammation from the irritation
of the punctures & the presence of
a foreign substance in the wound.
But stitches are necessary in some pendulous
parts, as the nose, ears, lips, scrotum
&c. also in wounds of the peritoneum


Contused Wounds
56
are those made by blunt instruments
which besides the simple solution of
continuity, produce an injury of
the adjacent flesh, greater or less,
according to the nature & violence
of the force applied.
In the treatment of these we apply a
soft poultice obviate excessive inflammation
& wait for the separation
of the bruised & dead flesh, and
when suppuration is established and
granulations form, we approximate
& retain in contact the sides of the wound
by means of adhesive plaster.


Punctured
57
Punctured wounds are made
by pointed instruments & the injury
is more obscure than in the other
species
A moderate diet, an emolient poultice
is to be prescribed. If inflammation
succeed vs. & purging together with
sudorific medicine become necessary.
The constitution sometimes suffers
from a punctured wound and convulsions
arise. In the case of a lady
which came under my notice, dilatation
of the wound put an immediate
stop to the convulsions. Also in
a boy who fell from the fence and
struck upon a nail. He was affected
with a variety of disagreeable symptoms,
such as pain in the back & head,
sickness at the stomach &c. Dilation of the
wound immediately relieved them all.
When such accidents occur in warm
weather, it is important to prevent


Wounds.
58
them from healing too quickly, as
tetanus is apt to supervene. In such
cases I order something stimulating
to be applied to the
wound to excite suppuration, and
a generous diet. I have known
tetanus occur from the puncture
of a pin in the great toe. I think tetanus
is less apt to occur from wounds
of the head & upper extremeties,
than from the lower extremeties,
But I knew it happen not long
since in a boy from a wound of
the uvula. I touch the parts with
something irritating when tetanus
is apprehended, which in most instances
has prevented it. I have often
seen it occur where this had
not been done, & therefore I have
great confidence in the remedy.


Wounds of the Eye
59
When the eye lids are wounded, adhesive
plaster is generally sufficient to keep
the parts in contact. But it occasionally
happens that this cannot be used
and we have to resort to stitches. One
caution is necessary never to pass
them through the tunica conjunctiva,
which always excites inflammation.
Sometimes the eye ball & interior parts
of the eye are wounded. The humours
also are sometimes effused; and occasionally
the iris suffers much.
In all such accidents extraneous
bodies must be removed, the eye shut,
vs, cupping, leeches, blisters &c, employed
together with rest in a dark room to
diminish inflammation. Caution the
patient not to rub the eye. The best
collyrium if any is necessary is made
of the pith of the young twigs of the
sassafras.
A child of Dr. Coxe, aged 6 years,
playing with a whip having a


and its Appendages. 60
tinseled hat band for a lash, had
the misfortune to cut himself across
the eye. A piece of the tinsel was observed
the next day and removed by making
a small nich of the cornea with
the cornea-knife and raising it up.
But inflammation had become violent
and a slight opacity succeeded. This
however was nearly removed by the
use of mercury.
I knew a woman who in pulling
a large darning needle thro'
a quill, stuck it into the eye, passing
through the cornea & crystaline
lens. An opacity succeeded, but a
mercurial course & the antiphlogistic
regimen removed the opacity.
I have never known any other
remedy successful.


61 Wounds of the Face.
In uniting these it was formerly the custom
to employ stitches; and I have seen
a lady's beauty spoiled by this means.
They never forgive you for it; and besides
there is not occasion for them in
contused wounds: and in incised wounds
they may mostly be dispersed with. 
Even where the lip is cut through the
adhesive plaster is sufficient. But if
a part of its substance be lost the utmost
caution must be used to bring the lips
together. Here the hare lip suture will
be necessary,
The Tongue is sometimes cut. Here
we have to use the interrupted suture,
In cases of children it is necessary to
interpose some thing between the teeth
to prevent them from biting the surgeon,
or from shutting the mouth, you will
find it necessary to watch your opportunity
& when you have the tongue
within your reach to plunge the needle


Wounds of the Throat. 62
needle into it by which you will be able
to secure it and to pass your stitches.
Now this is of a great deal of importance
to the practitioner. For if the child
finds you are a going to hurt him,
he will not open the mouth.
Wounds of the Throat are generally
the effect of attempts made to commit
suicide. When the trachea is not entirely
cut through, adhesive plaster will
answer. When completely divided, or
even partially cut stitches have usually
been recommended; observing
however to pass them only through
The cellular substance on the outside,
But I beg leave to dyssent from this advise.
I believe it will rarely be necessary
if a proper position be observed.
The chin must be brought down to
the breast & there confined by a bandage.


63 Wounds of the Throat.
If cough occur opiates & demulcents
must be employed. It is better not to approximate
the lips of the wound entirely
that space may be left for the discharge
of any blood or mucus which may be
effused or coughed up. By neglecting
this precaution suffocation has occurred.
It is however necessary to tye up all the
divided vessels before closing the wound
for I have known an effusion of blood
into the trachea produce instant death.
Nothing can more strikingly exhibit
the exceeding impropriety of using
stitches than a case related by Mr. Stark
in the Medical Commentaries.
In this man the whole of the larynx, &
the greatest part of the pharynx was
divided. The pharynx & trachea were
attached by stitches & the wound dressed
in the usual manner. On the 6th day
the patient had symtomatic fever &
the antiphlogistic treatment, with warm
dressings were ordered. 


Wounds of the Throat. 64
On the 9th day when the surgeon expected
to find him dead his fever had abated
and he had new hopes. On the next day
the stitches gave way and the whole wound
opened & appeared as if the windpipe &
gullet had been cut out entirely, leaving
one continued gash from the chin to
the sternum. At last the surgeon did
exactly what should been done in the
first instance. He brought down the
head and rested the chin upon the
breast by means of pillows placed under
the head and straps placed under the
axilla & made fast to a night cap.
This man under this treatment very
happily recovered though the wound
in the trachea had not entirely healed
up at the expiration of 2 months; when
unfortunately, getting intoxicated and
vomiting into the larynx, he expired
in a moment.
The pharynx is sometimes wounded
without the carotids, sustaining any injury.
I knew a woman to stick a knife
through the trach. into the phar. She recovered.


65 Penetrating Wounds,
are such as divide the parieties of the
cavities of the body.
Wounds of the Thorax.
When the thorax is opened by as penetrating
instrument, the lungs, or the lobe
injured, instantly collapse. Sometimes
one of the intercostal arteries is divided:
and it has been suggested to take it up.
I have never done it but think it practicable.
When the wound is small as that made
by a wire or small sword, the blood collects
in the thorax, and the respiration
becomes so laborious & difficult that
the patient soon expires.
Under such circumstances I believe life
might be saved by making an incision
between two ribs & letting out the effused
fluid. We should never inject any
thing in to wash out coagula, or introduce


Wounds of the Thorax. 66
introduce scoops, probes &c. If coagula
exist in the cavity of the thorax, suppuration
of the pleura must take
place. In order to exemplify this I will
mention the case of a boy who carelessly
discharged the contents of his fowling
piece through the left side of the
chest. A piece of gauze was first laid
over the external orifice & then an
emolient poultice applied & secured
by a bandage round the breast. On
the next day I visited him & found
his respiration very apprehensive, though
he complained of no pain. I bled him
examined the wound and reapplied the
poultice. In examining wounds of the
great cavities great caution is necessary
for the careless surgeon has sometimes
let his probe drop in; a very serious
accident indeed. In this case the pleura
inflamed and secreted a water which
flowed out of the wound & nearly subdued
the inflammation. In the space of
12 days it was necessary to take considerable


67 Wounds of the Thorax.
considerable blood & to use purgatives low
diet &c. At the end of 30 days he had
entirely recovered. No attempt was
made to draw out air, - none as necessary.
I have proved by experiment
that air is absorbed when admitted into
the chest, & of itself produces no inflammation.
There is in the Medico-Chirurgical
Journal of London an account of a
case, well attested, where the shaft of a
schaise passed through both cavities
of the thorax without proving 
fatal.
This case was not credited at first,
but Sir. Wm. Blizard, the attending surgeon
called in Mr. Home & A. Coper before
the wound had entirely healed &
all agreed that the above is a just account
of the case. The depositions of those which
came to the assistance of the man was also
taken to prove that the shaft had actually
passed completely through from one


Wounds of the Abdomen, 68
side to the other. That one cavity of the
chest may be laid open without proving
fatal we all know: but that both should
be without inducing death is hard to
reconcile with our views of the circulation.
When the abdomen is wounded
we are to bring the parts together & retain
them by stitches. In doing this begin with
the needle from within the abdomen,
pass it through the peritoneum first and
then through the integuments. After
all are passed commence tying.
If any of the viscera are wounded we are
previously to attend to them. The chief cause
of mischief in such cases is the discharge
of their contents into the cavity of the
abdomen: as is demonstrated by the case 
of the man who was stabbed through the
stomach with a bayonet. The third


69 Wounds of the
day he died; but the wound in the stomach
had entirely healed. In this instance
a quantity of porter he had drunk shortly
before the accident was discharged
into the abdomen & caused a fatal inflammation
of the peritoneum, and
not the wound abstractly considered.
That wounds of the stomach are not necessarily
fatal is abundantly proved by
a case related by Dr. Archer of Maryland.
A man in attempting to apprehend
a black man, was stabbed thro'
the stomach. The wound was 3 inches
long & all his dinner, cabbage, bacon, &c.
escaped into the cavity of the abdomen.
On the 3rd day the Dr. saw him. An old
soldier immediately after the accident had
sewed up the wound with a shoe maker's
awl. The Dr. immediately cut the stitches &
applied mild dressings, and in a short
time it healed up. But suppuration in
the groin took place an opening formed
through which some of the leaves of the
cabbage were discharged & he entirely
recovered.


Abdomen. 70
Had I been called to a case like this, I
would have sewed up the wound in the
stomach with the interrupted suture and
cut off the ligatures close to the knot, and
closed the external orifice with the same
suture. Closed in this way there is a deposition
of coagulating lymph over the external
part of the stitches, ulceration takes
place & they are discharged into the cavity
of the stomach & pass off with the foeces.
In this way the injury is repared. That
wounds of the viscera heal in this manner is abundantly
proved by the experiments of Dr. Smith
and A. Cooper, Longitudinal wounds of the
stomach & intestines heal more difficultly
than those that are transverse.
But if the omentum be wounded, the
vessels must be tyed and the ends of the ligatures
brough without the external wound;
because not being a hollow viscus the
ligature would be discharged into the cavity
of the abdomen & produce an abscess.
When the wound of the external parieties of the
abdomen is small, & yet we have reason to
suppose that some of the bowels are wounded,


71 Wounds of the
if we cannot examine the nature of the accident
without, I believe it right to dilate the
wound a little so as to protrude some of
them; but I am averse to opening largely, 
As adhesion soon occurs; what is done in
this way should be performed early. If not
it is better to trust to the soothing treatments;
bleeding, no diet but water, emolient
poultices &c.
In judging of the nature of wounds penetrating
the cavity of the abdomen, we must
pay attention to their direction. When passing
into the right hypochondrium, we
shall have reason to expect a wound of
the liver; and so of the other viscera according
to their respective situation.
A small wound of the liver if none of
the large vessels are opened heals very
readily; if extensive, they generally prove
rapidly fatal.
Wounds of the gall bladder are
fatal in consequence of the inflammation
produced by the effusion of its
contents.


Abdomen. 72
In cases of this kind the patient should
be bled & kept perfectly at rest.
Wounds of the kidneys are not necessarily
fatal unless they communicate with
the sack of the peritoneum so as to admit
of the discharge of the urine into the
cav. of the ab. The same may be said
of the bladder.


73 Wounds Of
When these occur it is important to
place the limb in such a position as to
allow the parts to be brought neatly
together; means being taken to prevent
the accession of inflammation.
Mr. Hey uses sutures. I do not believe
them necessary; but if you choose to employ
them, you must be careful not to pass
the needle through the capsular ligament
of the joint; for should this be done, violent
inflammation will inevitably take
place.
When inflammation however induced
supervenes, the constitution suffers severely:
fever carries on, with nausea, &
violent pain in the joint, an increased secretion
of synovia thinner & more watery
than usual, the ligaments swell & become
thickened by effusions of coagulating lymph.
At length suppuration takes place & pus
is secreted from the whole surface of the
capsular ligament; ulceration comes on,


The Joints. 74 
and openings are formed in various
parts of the skin about the joint. This together
with hectic fever undermine the
constitution & frequently end in death.
A turner in this city divided the capsular
ligament of the knee with a chisel.
By dressing it with adhesive plaster, and
observing a proper position & regimen, it
healed by the first intention.
And Mr. Hey relates cases where the ends
of the cartilage of the knee & elbow joints
which had been divided, united in the
same manner.
By all means prevent the inflammation
& suppuration of the joints. For I was
called sometime a go to a case of wounded knee-
joint where an ignorant physician had
dressed the wound to the bottom as he called
it, with lint dipped in Sp. of turpentine. Violent
inflam. suppuration, & a variety of
distressing symptoms took place. He also
suffered severely from convulsive twitches


75 Wounds Of
during the continuance of the suppuration.
He however recovered: but with a stiff knee
after suffering for the space of 4 months.
In addition to the common means, it is necessary
to apply a splint. It prevents convulsive
twitches & keeps the limb at rest. It
may be applied on the side, or behind.
In all cases of inflamed joints I would
recommend it to you.
In cases of contused wounds the parts cannot
be brought in opposition. When this is
the case apply a splint to prevent motion;
then put on a poultice of bread & milk, employ
vs. (cupping) & leeching, & purging to keep
down inflammation & attend to the symptoms
of the case. When the dead surface is
separated by the ulcerative process, and
granulations form, bring the parts
together with adhesive strips.
When the wound is complicated with
luxation, it has been a question whether
any attempts should be made to


The Joints ~ 76
save the limb.
I once knew a man who had a contusion
of the elbow joint from a cart wheel
passing over it. The limb was extended,
was stitched at the wound, & adhesive
plaster put over, & this confined by a bandage.
He died, - I believe in consequence of
the treatment. For if it had been dressed
by applying a right angled splint so as to
relax the parts & keep the limb at rest, and
a soft poultice put on, I think he would
have recovered.
But the danger from such a wound
is greater in summer than in winter;
in the intemperate then in the contrary


77 How the Injury of 
I believe that stiffness is often the effect
of ligamentous union between the ends
of the bones.
But when anchylosis takes place
the union is by bone: and before
this can be effected the cartilage must
be removed, out of the way, Now I
have told you that this substance neither
inflames, suppurates nor ulcerates.
I have been confirmed in this opinion
by the case of a young man who
received a wound from a load of small
shot passing through the ancle joint.
Inflammation & suppuration supervened
& produced such a violent irritation
& fever that it was thought advisable
to amputate the leg a little below
the knee, which was done accordingly.
On dissecting the joint it was
found that nearly one half of the cartilage
tipping the lower extremity of the
tibia, & the upper surface of the os astragalus


Joints is Repaired. 78
astragalus was completely removed & the two
surfaces were covered with florid granulations,
the commencement of bony
union. In the other portion it was obvious
that the same process was going
on, though a part of the cartilage still
remained: and had the limb remained
on, and could his constitution withstood
the shock of the disease, there can be no
doubt but that the remaining thin
plate of cartilage would have been removed
by the absorbents on the surfaces
of the granulations which were
seen sprouting out between the cartilage
& the bone to which it was attached:
and then anchylosis would
have been effected.
Perhaps the removal of the cartilage with a
knife, by scraping it off might greatly facilitate
the process of anchylosis. I wish
however to inform you that I have no
experience in the matter.


79 Wounds of the Nerves.
When any of the nerves are wounded
there arises pain immediately after
the accident numbness of the part to
which they are distributed, or at least
diminished sensation. It is said to occur
often in the operation of venaesect, 
But scarcely any operation can be
performed without dividing some
of the nerves.
Sometimes when the soft parts below the
tendonous fascia on the arm, the thigh &
the scalp, are wounded, the symptoms
are very violent.
The application of a splint when seated
on a limb will generally relieve, and
when it does not, the fascia is to be
divided.
- These symptoms frequently arise
from motion separating the wounded
extremeties of the nerves. Even tetanus
sometimes happens from this cause,
Now all this may generally be prevented
by applying a splint which
stops the motion of the parts.


Wounds of the Nerves 80
This affection however is not generally
a spastic rigidity of the whole body
as in tetanus, but it is more partial;
and this is the way we distinguish them.
A lady received a wound of the parts below
the tendonous fascia in the operation
of os. The symptoms became very violent
and continued until the 90th day. Blisters
were applied which in some degree relieved
the symptoms. When 60 had been
applied she was so far recovered as to be
about: though at the end of 10 months it
remained stiff. I recommended the splint
which completely cured her.
I have since had frequent opportunities
of witnessing its complete success in many
other cases.


81: Wounds Of
The tendons are sometimes entirely cut through.
They require the same treatment as wounds
of other parts. The limb is to be placed in
such a position as to relax the muscles to
which they are attached, and bring the
extremety of the tendon together, and to
keep them in opposition by a proper apparatus.
When the tendo achilles is divided,
a splint so curved as to cover a good
deal of the side of the foot to prevent any
lateral motion ought to be used. When the
tendo Aclil. is ruptured the same mode
of treatment is requisite.
But there is still another accident much
more severe: and this is the rupture of
some of the fibres of the gastroenemii muscle.
The perception is that of a severe blow
on the leg, and there is considerable difficulty
in walking. Sometimes you can
feel the pit or depression where the fibres
are ruptured. At other times we are led
to it by ecchymosis. The remedy consists


The Tendons. 82
consists in extending the foot & applying the
curved splint, and keeping the limb at
rest.
I knew a gentleman in whom inflammation,
swelling & pain occurred, one day,
after a long walk. He then lay still awhile
when it entirely subsided. Thinking
himself well enough, he went out again,
And he again had a repetition of
the symptoms. He at length, after a
frequent repetition & subsidence of the complaint,
called on me for advise. I immediately
discovered the nature of the
case, applied the splint, & in a few weeks
his leg had recovered its usual strength. 


83 Wounds of the
Wounds of the veins seldom cause any
bad effects. But occasionally they prove
both troublesome & dangerous.
Mr. Hunter says that the inside of veins
are subject to inflammation as well as
other cavities. Likewise to adhesion, suppuration
and ulceration. The cause of inflammation
in the veins has been imputed to
a bad constitution, to the wound of a nerve
&c. But this inflammation occurs frequently
where no nerve nor fascia could
be wounded: and that it does not occur
in consequence of a bad habit of body
is proved by the fact that the same patient
if bled in the other arm has no
such occurrence take place.
Mr. Hunter imagines that the inflammation
of the veins consequent to venaesect.
& other wounds, arises from the wound
not healing by the first intention.
Sometimes when the inflam. has progressed
to the suppuration stage, a small abscess


Veins. 84
only forms immediately within the orifice
of the vein & is confined by adhesion above
and below. But sometimes this does not
happen & the pus passes along the circulation
to the heart & occasions death.
He conceives the inflam. arises from the
imperfection of the cavity of the vein
the consequence of neglect to close accurately
the lips of the orifice, When the orifice
is not longitudinal with respect to 
the vein & the arm is much used inflammation
may occur from the gaping
of the orifice.
To prevent this accident it is recommended
to apply a thick compress of linen
which has received a little of the blood,
which is more in harmony with the
wounds than any other substance, &
which has a tendency to form a scab,
taking care at the same time to bring
the lips of the orifice neatly in apposition.


85 Wounds of the Veins.
Mr. Hunter supposed that applying a compress
above the abscess of the vein would
obliterate the cavity of the trunk and thereby
prevent the pus from passing along
the circulation, But this plan will not
answer for there are other various branches
which would receive it. It is suprizing
that Mr. Hunter did not think of
this. Besides it is found in practice to be
inadequate.
The operation of cutting down to the
bone, as recommended by Bell, in inflamed
veins can do no good. I saw a patient who
actually died from the violent effects of 
dividing the inflamed parts down to the bone:
and though a second escaped with his life
yet he suffered an immense deal.
I am happy in being able to inform you
that the application of a blister has almost
always cured this affection; all the symptoms
speedily ceasing under its impression. I have
not failed in curing any case where I
have tried it.


Gun-Shot Wounds. 86
Gun-shot wounds are made by the forcible
projection of hard obtuse bodies, the
greatest number of which are musket balls.
The livid color of the parts & the tendency
they have to become gangrenous induced
the old surgeons to suppose that they were either
poisoned or burnt. There seems however
to be no mystery at all in the case; the
only essential difference between gun-shot &
other contused wounds, is found to consist,
in the death of the parts through which the
obtuse body passes, and the necessity for the
separation of these before union can be
effected. The separation of the slough seldom
takes place before the tenth or twelvth
day. At this time it should be carefully watched
for fear of hemorrhage.
Gun-shot wounds for the reason mentioned
do not generally bleed much.
Sometimes when a ball has nearly spent
its force, as when it passes out of a part, it
produces a lacerated instead of a contused
wound, which will heal by the first intention.


87 Gun-Shot
When in consequence of the lodgment of
balls there is a compression of the brain,
the trephine may be used. In some cases
I have seen a patient die for the want 
of it.
Extraneous matter which can easily be
come at should be extracted, and sometimes
dilitation for this purpose may be
proper. But where it is lodged deep, this
should not be done.
In the treatment of gun-shot wounds
we must attend to the direction of the ball
in order to tell the precise parts injured
if possible. The position the person was in,
when the accident took place, must also
be taken into consideration.
The best application to the wound itself
is a soft bread & milk poultice.
It has been recommended to bleed in
every case of gun-shot wound. But
it is better to postpone this till fever supervene
for fear of tetanus. I saw it occur
in a man I believe from copious evacuations.


Wounds. 88 
To prevent violent inflammation & gangrene
position; elevation of the limb &c. is safer
than bleeding. As soon as suppuration
is established it will be useful to administer
the Cinchon. & allow an invigorating
diet.
When the wound penetrates into the thorax,
then as the parts cannot be united
by the first intention we are sure of a
violent inflammation. And here vs.
and a low diet must be prescribed.
Tetanus seldom occurs from wounds of
the internal parts. It oftener occurs from
wounds of the extremeties. We must incur
the risk of it in cases of the above description.
Wounds of the spine when below
the phrenic nerves are not immediately
fatal & sometimes life is prolonged many
days. When above their origin, death is the
immediate consequence.


89 Gun-Shots 
If the liver is wounded there will be pain
in the part of a sickly or depressing kind;
and if it is in the right lobe there will
be a delusive pain in the right shoulder,
or in the left shoulder from a wound
in the left lobe. A wound of the
stomach will produce great sickness
& vomiting of blood, & some times a
delirium. In wounds of the stomach
if any of its contents escape, externally,
the nature of the case
will be immediately discovered.
Here little can be done but to keep
the patient quiet, & allow nothing
but the mildest fluids, and in as
small quantity as possible.
If the intestines be wounded there
will be bloody stools, more or less
pure according as the part wounded
is more or less distant from the anus.
If the blood come from a high
portion, it will be mixed with


Wounds. 90
foeces, & of a dark color. The pain
will be more or less acute according
to the intestine wounded; more of
a sickly kind the higher it is up, &
more acute the lower. There will 
be bloody urine from a wound of
the kidneys or bladder. The sensation
will be trifling. A wound of
the spleen will produce no particular
symptoms except probably
nausea, from its connection by
nerves with the stomach.
Balls lodging in the bladder may give
rise to calculus.
After gun-shot wounds of the abdomen if
foeces escape it shows that the intestines
have been shot through, But they may be
injured and this effect not take place
immediately, or till sloughing occurs.
Bullets sometimes pass through joints


91 Gun_Shot Wounds. 
which is a serious accident. The inflammation,
suppuration & hectic sometimes
waste & destroy the patient. But when
it has only lacerated the joint, from its
force being nearly spent, the wound may
be healed by the first intention. When the
ligament of large joints are much contused
& lacerated, it is best to amputate,
& immediately too, before the subsequent &
disagreeable symptoms I have mentioned appear;
for I have seen death occur merely 
from the irritation induced by the
inflam. & suppur. of the joint. I wish however
to caution you against amputating
when inflammation has supervened.
Here it ought to be deferred till
suppuration is established, & the inflammatory
symptoms have subsided.


Ulcers. 92 
Having treated of inflammation and
wounds, I go on to the consideration of
ulcers, their consequences.
Too much attention cannot be paid
to the treatment of ulcers, as they are
so frequent in their occurence, and
sometimes so obstinate in their nature.
An ulcer is the solution of continuity
in a soft part discharging pus.
Treatment.
In the treatment of a simple healthy
ulcer, nothing more seems necessary
than to apply a bit of lint to absorb 
the moisture from its surface,
and over this a pledgit spread with
simple cerate to prevent it from
drying up.
But Mr. Bagnton recommends
the application of adhesive plaster
to facilitate the healing process,
He however applies them over all
the surface of the ulcer which is


93 Simple
wrong. I apply them at the distance of 1/4
of an inch from each other: for I
have seen the ulcer enlarge when this
precaution had been neglected.
The dressings are to be retained by
means of a calico roller neatly applied
commencing at the foot. By this, the
edges of the old skin are brought together
and the contraction of the
sore facilitated.
I do not find as the rationale
for the utility of adhesive straps in
the healing of ulcers has been given,
I consider that they are useful by
bringing the originally formed skin
together, & by assisting the granulations
in adhering to each other.
This is one way. But another way is
by fixing the edges of the ulcer & keeping
them in one situation.
Another circumstance demands attention.
Some surgeons are in the


Ulcers. 94
habit of washing the surface of ulcers 
with a sponge, and of rubbing it round
from centre to circumference, by
which the edges are separated and
the granulations torn apart. Now
this is entirely wrong. It ought always
to be from the circumference
to the centre. Pulling away the adhesive
straps by taking hold of one
end tears the granulations a part
& should carefully be avoided.
It is sometimes necessary to strengthen
the granulation by constitutional
remedies & by certain astringent applications;
and when these fail exposing
them to the air causes them to dry
scab & heal.
I must not overlook to mention
that when the ulcer is situated on a
tendon, as the tendo Achill. or on
that of the tibiales anticus &c. it is
apt to be extremely difficulty to cure.


95 Simple
I was called sometime since to see a
very obstinate ulcer seated on the tendon
of the tibialis antimus. This case
had baffled the practitioner for a long
time. He had used a great variety of applications
but without success. At one
time it appeared to be doing well, but
it soon relapsed into its former condition
and now looked blue & livid.
I immediately saw the cause of failure
and told him that the reason why the
ulcer would not heal was because
it was seated on this tendon: and
that if he would apply a curved splint
so as to relax the parts & keep the muscles
from motion and thereby tearing
asunder the granulations, it would
heal in a few days. He did so; and
it immediately got well. I have seen
a great many similar cases which
yielded to the same plan of treatment;
and are which resembled the spongoid
ulcer.


Ulcers. 96
My observations apply principally to
ulcers of the legs; for here they are the
most difficult to heal.
The arteries and veins of the leg are
fine in their texture, and the parts are
too weak to carry on a vigorous circulation.
In consequence of this the blood
stagnates and the granulations upon
ulcers are livid, and have a disposition
to bleed when touched.
Place the patient in a horizontal position.
By this means the circul. of the blood in
the arteries is not augmented, nor obstructed
in the veins.
In cases of this sort bandages should
never be omitted. These are of 3 sorts,
1. The Laced Stocking
2. The Roller
3. The Adhesive Straps.


97 Simple Ulcers.
When water is effused into the cells of the
tela cellulosa, the part becomes oedematous.
Confinement of the patient to bed
will enable the ulcer to heal. When this 
cannot be done a fine bandage must
be employed and neatly applied early
in the morning. Lint, powders and
salves sometimes do harm and we shall
find that their removal alone will
give the ulcer a disposition to heal.
Intemperate drinking & other excesses is
very unfavorable to the restoration of
ulcers. In hot weather ulcers heal less
readily. And I have seen the healing
process quickened in consequence of the
patient becoming attacked with pleurisy.


Unhealthy Ulcers. 98
Those ulcers which have no disposition
to heal are called unhealthy.
These I shall divide into 8 species.
1. The Inflamed Ulcer,
2. The Fungous Ulcer,
3. The Oedematous Ulcer: or ulcers
situated on oedematous limbs.
4. The Sloughing Ulcer,
5. The Indolent Ulcer,
6. The Carious Ulcer,
7. The Varicose Ulcer,
8. Ulcers Attended with Specific
diseased action.
1. The Inflamed Ulcer.
This has the following appearances. The
surrounding parts are red, tumified, &
very tender; the margin of the sore ragged,
the skin terminating in an elevated ridge;
the bottom of the ulcer made up of concavities
& no appearance of granulations; the discharge
is thin & serous; the surface of the sore


Fungous Ulcer.
99
acutely sensible & bleeds when touched.
The pain is sometimes very great, though in
general not constant.
The remedies are rest & confinement in
a horizontal posture, low diet, vs. &c,
The best application is a bread & milk, or
linseed poultice till the inflammatory
symptoms subside; then dress like the simple
healthy ulcer.
2. Fungous Ulcer.
This ulcer is covered with large round
granulations, rising above the level of the
surrounding parts; less compact in texture
than usual, & having no disposition
to cicatrize.
Treatment. Compression, bandaging,
escharotics, as calcined alum, red precipitate,
lunar caustic &c. In cancerous
ulcers where the fungus can almost be
seen to spring up, the old surgeons used
to tye on wooden cups to repress the fungus


Oedamatous Ulcer 100
A limb oedamatous is usually cold, tumefied,
& of a pale color; retaining
the mark or pit made by the pressure 
of the finger for sometime.
An ulcer seated in such a limb is generally
somewhat inflamed & tender to the
touch if not painful. The granulations
appear purple & in spots appear
gangrenous or sloughy.
When fever attend bleed, & purge
repeatedly. Where the patients strength
will not admit of it, subsitute the elevation
of the feet of the bed-stead; bandage
the limb, previously approximating
the edges of the ulcer with adhesive
straps.


101 The Sloughing Ulcer.
In consequence of deficiency of strength
in the constitution, or the part affected,
or change of diet, air &c. the granulations
of an ulcer very frequently mortify, &
sloughs fall off from various parts of
the sore, & sometimes from its whole
surface. In some cases this takes place
after the process of skinning, the new
skin becoming, purple, livid & black.
In the treatment of the sloughing ulcer
we must direct our remedies to
the constitution. Bark, wine, porter
and a generous diet are generally indicated:
as opium to relieve pain.
Locally applications of a moderately
stimulating kind. A soft carrot poultice
is sometimes employed with advantage.
Washing the ulcer with diluted laudanum
or an infusion of galls is beneficial
The two last remedies, I have known successful
for some time. It was so in the


The Indolent Ulcer. 102
case of the door-keeper at the Hospital
some years since, after the ulcer had
covered almost all the the leg from
the ham to the ancle.
5. The Indolent Ulcer has its
edges hard, round & tumefied; the granulations
being smooth and glossy on the
surface. It is sometimes inflamed.
If we happen to be called to see the ulcer
while in a state of inflammation; this is
to be subdued by the antiphlogistic treatments.
We are next to destroy the whole
surface of the sore either with the knife
or the caustic potash, and thereby to
change it into the nature of a sore
from accident. Pressure answers exceedingly
well after the inflammation is
brought under, & may sometimes be
had recourse to. Mercury is very useful
even when there is no venereal contamination


103


104


105 Carious
contamination. A slight salivation often
cures. Gastric juice, alcohol, green & blue
& white vitriol, diluted acids, powdered
rhubarb, galls &c. may often be applied
with advantage to stimulate the granulations
6. Carious Ulcers. In the carious
ulcer a portion of dead bone gives the
stimulus of dead matter, keeps up a constant
irritation, & prevents the sore from
healing.
Here we must wait for the dead bone
to loosen; as soon as that takes place it is
to be extracted.
It is impossible for the healing process
to be completed as long as this remains
in the sore. There is sometimes considerable
difficulty in ascertaining whether
the bone be loose or not. When moveable we 
may dilate the orifice if necessary.
To ascertain whether the portion of bone
be loose or not, I have been in the habit


Ulcers. 106
of attending to two circumstances. 1.
Pass down a probe upon the carious bone,
and 2nly press hard upon it. If this causes
pain, and if the granulations bleed in
consequence of the bone being pushed
against them, you will infer that it is
loose. When you have ascertained this
pass down a director & dilate the orifice.
I have sometimes dilated the orifice with
a sponge tent where the blood vessels of
the limb were too contiguous to admit
of dilatation by means of the knife.
Sometimes the bone is easily extracted. But
if large the difficulty will be greater.
I have employed a pair of gold forceps for
the purpose of extracting a long piece of
bone when it has been deeply situated.


107 7. Varicose Ulcers
These are a species of indolent ulcer attended
with a varicose state of the venae
saphenae & its branches. The ulcer is usually
oval in shape, of a purple color, more or less
painful & has a sanious or bloody discharge,
The veins are enlarged their valves do not
support the gravity of the blood because
their edges do not meet. Thus the great
weight of the whole column of blood ruptures
the small vessels & the ulcers frequently
bleeds & sometimes very freely too. This
then is the reason why they do not heal.
In the treatment of the varicose ulcer
it is best to cause cicatrization by common
dressings; horizontal posture; & then
to apply a bandage or laced stocking to
support the parts and prevent it from
opening again. The effect caused by
tying up the vena saphena has not
been so flattering as to induce me
to repeat the operation very often.


Specific Ulcers. 108
In the first case that I tried the operation
I took up not only the large
trunk of the ven. seph. but all the cutaneous
branches which were enlarged.
The patient recovered very happily,
But still I cannot recommend the
operation very strongly to you; because
it is dangerous. The veins may inflame
and produce death, The safest way of treating
this ulcer has been mentioned.
8. Ulcers Continued by some
specific diseased Action.
This division will include venereal, Scrofulous,
cancerous, and all ulcers from
a local or constitutional action of a
morbid nature.
Treatment. As a general rule it may
be laid down that when the constitution
is affected we are to apply those remedies
which may be indicated by the nature
of the disease: and when the morbid action
is local, we must destroy the diseased parts


1.09. Ulcers Continued by
if possible. Sometimes the disease is seated in
a part where it may be removed with the
knife.
There is a kind of ulcer left after the
ravages of the venereal disease which is
cured by removing its edges or the whole
surface. The disease is very often situated
merely on the surface & is kept up by the
irritation produced on the edges of the ulcer.
The bottom of such an ulcer frequently
appears to be healing very kindly, while the
edges look livid & wormeaten; & all at once
slough off.
Very often the patient & practitioner
are harrassed with an idea that the venereal
virus is not entirely exterminated &
mercury is again resorted to under the supposition
that it has not been continued long
enough.
Some years ago on being called to such
a case I gave it as my opinion that it
was only continued by the local irritation


Specific Diseased Action 110 
on the surface of the ulcer. Much against the 
will of the consulting physician & the patient
I applied the caustic potash. It produced
an eschar which soon separated &
the parts underneath healed up very kindly.
But as the caustic is very painful when extensively
applied, I have generally taken off
the ragged edges of the ulcer, & then applied
powdered chatechu. By this means I have
cured very many completely.
But in men, & women too, where there is
no venereal contamination, there is an
internal ulcer of the leg & arm which goes
on separating the muscles from the bone.
This you must lay open & apply caustic to
its parieties. All the applications in the
world without this will do no good.
A woman lately came to me with such
an ulcer of the cheek of 18 months standing
which she supposed cancerous. I assured
her I would cure it in a few weeks
which tended greatly to quiet her fears.
I applied the caustic & it got well in a little
time.


111 Fracture of the Bones.
I had another case which had continued
fifteen years. The practitioner had applied
the caustic freely to the middle of the ulcer,
but it did no good because the ulceration
was continued by specific diseased action
situated in the edges of the sore.
But when these were destroyed it all healed
up.
Fracture of the Bones.
A fracture is the solution of continuity
in a bone produced by external violence,
by muscular action, or by the
conjoint operation of both.
That muscular action has considerable
agency in the fracture of bones
is evident: and some are fractured by
the action of the muscles alone, as the
patella.
It is a notorious fact that drunken
men seldom break their bones by
falling; probably because they use


Fracture of Bones. 112 
no exertion to recover themselves when falling.
The reason why fractures are more
common in slippery wether than at other
times is that the muscular exertion used
to prevent falling superadded to the fall
occasions the fracture.
When a bone is fractured, there is a
sudden & severe pain; the limb is more or
less distorted or bent from its natural
position; and there is an inability to move
it without considerable pain. There is also
crepitus when the ends of the broken fragments
are grated together.
Fractures are either simple or compound.
Simple, when the integuments
are not punctured: Compound
when there is an external opening
communicating with the cavity of
the fracture; and Compound-Simple,
when the external opening of a compound
fracture is of such a nature as to
heal by the first intention.


113 Fracture Of
Treatment. In the treatment of fractures
there are 2 indications.
1. To Place the fragments in contact,
or as nearly so as possible, and
retain there in situ: and
2. To obviate those circumstances which
interfere with the healing process
in the fractured extremities.
The principal resistance to the replacements
of the broken extremeties is,
the action of the muscles.
A fractured bone should always be
set immediately after the occurrence
of the accident. By this means
we avoid the difficulty in overcoming
the force of the muscles where
they have contracted in consequence
of the irritation produced by the
fractured ends. We also avoid the
effusion of blood which takes place, and


Bones. 114
which so distends the limb as to make the
nature of the accident obscure, and
its immediate reduction difficult or
totally impracticable.
There are some conditions in which
the bones do not unite, and a kind of
artificial joint is formed. This has
been imagined to depend on the constitution.
But I do not believe this; for
I have seen a case where the thigh &
tibia were broken at the same time;
the former united, while the latter
never did.
It has been advised in such cases to
cut down & saw off the extreme fragments
under an expectation that ossification
would take place between the
ends & form the bony union which
was wanted. I have actually seen it
done with a fatal termination; &


115 Fracture Of
Mr. Bayer related a case where it was
performed on the arm. The ends of
the bone were sawed off & the vacuity
was 2 1/2 inches. Inflammation & gangrene
put a period to the patients life
the 7th day. Mr. B. says it is one of the
most difficult & dangerous operation
that is performed, and yet, he says it
ought to be done if the patient desires
it.
A great number of years ago it
was performed by a surgeon in the
country but without any advantage,
The patient after finding that his arm
was entirely useless came to the Penn.
hospital & had it amputated.
In several cases of artificial joint
I have caused the bone to unite by
making the patient move the limb about,
or walk on crutches bearing
as much weight on the affected
leg as possible. After several weeks


Bones. 116 
have elapsed & still the ends of the bone
are loose, we must resort to some other
mode of treatment.
I find it has been recommended to
pass the electric shocks through the
parts, and it is said to have succeeded
in some cases. In one case I tried it,
but it did no good.
But when we have made all these
trials without success, it becomes a
serious question, what shall be done.
For if it be the thigh or leg, the person
cannot walk; if the arm, it cannot
be used.
In 1802 a patient applied at the
Hospital with this state of the os humeri.
I proposed to the consulting surgeons
in preference to any other operation
to pass a seton between the ends of
the bones.


117 Fracture Of
As I had seen a case where the other operation
had proved fatal it had made
a strong impression on my mind
against cutting down. This case had
been 20 weeks standing. After passing the
seton inflammation & suppuration
succeeded; but at the end of 12 weeks
no perceptible alteration was obvious
in the artificial joint. But soon after
this it began to stiffen, & pain was
induced whenever it was bended. From
this time bony union went on gradually
& his arm became as strong as
before the accident. This operation
has since been often performed
in the U.S. & in Europe with success


Bones 118
Union of Fractured Bones.
When a bone is broken an effusion of
blood takes place between the fragments
which coagulates. This coagulum soon
became vascular & forms a uniting
medium called callus. This is soft &
vascular at first, but it shortly becomes
cartilaginous & is finally changed into
complete bone.
But there is another way for bones
to unite & that is by granulations.
In compound fractures they always
unite in this way. The ends of the bone
inflame, suppurate, granulate & fill
up the cavity; & the granulations are
gradually changed to bone by the deposition
of the earthy particles to which
bone owes its solidity.
Sometimes the ends of the fragments are
prevented from uniting in either of these
ways in consequence of becoming
dead.


119 Fracture Of
Now under such circumstances the
union is completely in this way:
[image]
At the place where the line of distinction
commences between the living
and dead bone, adhesion of the soft
parts takes place & a bony bridge is
formed round the vacuity on each
side, forming a cylinder of bone over
the gap but with space sufficient for
the dead bone to be discharged through
the same. I here show you a clavicle
where the bony bridge I speak of
is actually to be seen, & a hollow
space left for the discharge of the bone
within by the process of exfoliation.


Bones. 120
Compound fractures are sometimes accompanied
with profuse hemorrhage,
In these cases where practicable we are
to apply the torniquet & secure the bleeding
vessels, if the parts are not so much
contused & comminuted as to render
amputation necessary. If such should
be the case, it ought to be performed
immediately.
Sometimes the medullary artery
causes the hemorrhage in which
case Mr. Gooch recommends amputation.
I have never had such a
case but were it to occur to me, I
would attempt to plug up the orifice
with a wooden plug. I used
this pan with success in a case of amputation
of the leg.
But if the bleeding be in such a place
that the hemorrhage cannot be commanded
the principal artery may


121 Fracture Of
be taken up; as for instance the popliteal.
The posterior tibial artery is sometimes
divided in compound fractures. In this
case it has been recommended to amputate:
& Dr. Wistar actually saw it done
at Paris. But I have taken up this artery
where it is very deeply seated.
In this case it occurred to me that
an artery might be taken up merely
by feeling its [illegible] with a small pair of forceps
which answer the purpose of
slim fingers & a crooked needle I passed
a ligature under the artery.
Sometimes a splinter of bone projects 
through the wound and it is often
difficult to replace it. Sawing
off these fragments may be done when
we cannot reduce them without, I have
never seen a case where dilalation of the
wound was necessary for this purpose,
Having reduced the bony fragments,


Bones. 122
we attempt to close the wound so that
union by the first intention shall take
place, where the state of the parts induce
as to believe it practicable.
To prevent inflammation repeated vs
& a low diet is necessary. The best application
where suppuration must happen
is a bread & milk poultice,
Bark & wine are improperly given
while the inflammatory symptoms
continue. But after they subside &
suppuration is established they are
of use.
Position in cases of compound
fracture is a very important in preventing
inflammation. Elevate the limb.


123 Particular Fractures.
Of the Ossa Nasi. These bones are
occasionally fractured by blows on the nose &c.
The lower part of them is most exposed to
this accident. The broken fragments are
depressed or beaten in. If you see the patient
immediately after the accident, you
can see & feel the depression.
The depressed fragments are to be elevated
by a blunt instrument introduced
into the nostril & at the same time apply
the thumb & finger to the nose on the
outside to assist in adjusting the fragments. 
Then apply adhesive straps to keep
them in situ. There is at first considerable
ecchymosis which however soon
subsides. I have never seen a case where
the broken bones were so loose as
to need any support from within:
nor do I think it likely to happen for
there is no muscles to draw them
out of the place they are put,


Fracture of the Ossa Nasi. 124
When the fracture is very comminuted,
suppuration from loose spicula of
bone comes on . . . . . . . . & an abscess is
the consequence. In this case I would advise
an opening to be made & the spicula to
be extracted. You must however, be certain
that you are cutting into an abscess used
not into an ecchymosis.
I have never seen a case where this violence
was such as to drive the nasal
process of the ethmoid bone upwards,
& push the cresta galli into the brain
producing compression.


125 Fracture Of the Maxil. Inf.
The Lower Jaw is not often broken at
the chin; more frequently between that
and the angles.
But I have seen a jaw broken into
several pieces: at the chin perpendicular,
& just before the angle in the same direction;
& then transversely across those. The
person in whom this happened fell down
several stories where goods are drawn up.
When a fracture of the jaw takes place,
anterior to the angles the symptoms are,
severe pain in the part at the time of
the accident, inequality, perceptible by
passing the fingers along the base of the
jaw, & unevenness of the teeth.
Sometimes the bone is broken without
producing any displacement;
and to examine this you should take
hold of the sides of the jaw & attempt
to move them in opposite directions.
By this means the nature of the accident
will be determined & you will


Continued 126
be sensible of crepitation.
When the condyles are broken, the
fracture is not very obvious, but may
be ascertained by pain in the vicinity
of the ear on moving the jaw, and by
the crepitus which attends it.
If considerable swelling occur before
the surgeon is called great difficulty
is experienced in determining the nature
of the case & it becomes necessary to
wait for the inflammation to subside,
Teeth when loosened by the fracture
ought not to be extracted in any case,
For by so doing you convert a simple,
into a compound fracture, I have
twice seen this produce death. In the
one, there was an extensive fungus, &
in the other, caries.
Splint. The upper jaw is the one prepared
by nature & we need no better.,
The bandage must be so applied as to prevent
all motion of the jaw & the patient


127 patient is not to attempt to open the
mouth nor to talk. His nourishment
must all be fluid.
The bandage used by Dr. R. Basten
is a very good one.
When the condyle is fractured it is
drawn forwards by the pterygoid, ext,
muscle. It here becomes necessary to
push the inferior fragment forwards,
apply a compress behind the angle
of the jaw & a bandage to confine
all in situ.
It is necessary to examine the bandage
every day to see that it does not become
loose. Inflammation must be
guarded against by confining the patient
to the antiphlogistic regimen.
In some cases of fracture near the
condyles, I have been totally unable
to apply any bandage which would
prevent the lower fragment from
being drawn back.


Fracture Of the Vertebrae. 128
The vertebral column is sometimes fractured
though not often. The connical vertebrae
I have seen fractured from the person
falling head long.
The only circumstance which renders
this accident more dangerous than
other fractures is the concussion of the
spinal marrow by the force producing
the fracture, & the compression
produced by the separation of the fragments
constituting the bony bridge
over the spinal marrow.
The consequence of this pressure is a
paralysis in every part deriving its
nerves from the medulla spinalis below
the part fractured.
If the injury is seated above the origin
of the phrenic & intercostal nerves, the patient
dies instantly.
I have never known a patient recover
where a palsy has occurred in consequence
of the fracture of the cere. vert,. They always died
the 3rd, 5th, 6,or 7th day.


129 Fracture Of
A patient in the Hospital survived a
fracture of one of the dorsal vertebrae
nearly 6 months. The body of the vertebrae
was fractured & pressed inwards,
forming an angular point which
pressed on the spinal marrow. He died
in consequence of the extensive ulceration
of the back from lying.
But paralysis from contusion of the
spinal marrow in consequence of
external violence is not always fatal.
I knew a gentleman, in whom it occurred
in consequence of a wound received
by a bullet, who recovered. These
cases however are very tedious, and the
cure sometimes does not take place
for several years.
Sometimes we are called to children in
which a loss of suction occurs in the
lower extremities after a fever. This I
believe is the consequence of the inflammation
attending the fever, terminating in
an effusion of water in the vertebral


The Vertebræ 130
canal so as to compress the spinal marrow.
Low diet, purging every 2nd day, cups
applied to the place of compression appears
to me best at the first; afterwards dry-cupping 
is useful. After evacuating the
child completely (& waiting a reasonable
time) I apply a blister over the part
& keep it running for a great while.
By these means I am happy to say I
have relieved every case I have had,
If this treatment did fail I should
give mercury notwithstanding the
danger attending its administration to
children.
A patient who has received such an injury 
as gives us reason to suppose there is
a fracture of the spine,
is to be placed on the side; but not on
the belly which position might prevent
the action of the diaphragm, and the


131 Fract. Of the Vertebræ.
patient might die before you have
done examining the nature of the
accident.
I have never found any advantage
from machinery; no adjustment
of the fragments can be made. The
bladder must be emptied 2ce or 3times
a day; for the patient has no feeling &
cannot tell whether the bladder is
full or not.
Mortification is apt to occur from
the pressure incident to lying and
is only to be preventing by turning
the patient first on one side, then a
little towards the back, & finaly on
the other side.


Fract. Of the Pelvis. 132
I have seen two cases where the ilium was
broken off transversely. By taking hold of
the anterior superior spinous process & making
an attempt to move it, the crepitus was
perceived.
I have never seen a fracture of the os
ischium: but I have seen the pubis fractured
transversely near its symphysis.
This Patient experienced a great deal of
Pain in raising the leg. By taking hold
of the thigh & moving it, I could discover
a grating noise.
There is no better way of treating
these cases than to pass a broad bandage
round the pelvis & keep the leg &
thigh perfectly at rest. The patient in
general will not attempt to move much
because it occasions pain. He must
be moved very little; just enough to prevent
gangrene from pressure,
Fever must be subdued by vs. & strict diet;
no meat nor spirits.


133. Fracture Of the Pelvis.
I never have seen a fracture of the os
sacrum.
The os coccygis is said to be fractured
when ossified, by falls on the buttocks.
This accident ought to be attended to especially
in females lest it produce a
deformity & be inconvenient in parturition.
Introduce the finger in ano & replace
the fragments, no bandage is
necessary. Diet: laxative,- rye-mush,


Fract. Of the Sternum. 134
I have never seen but one case of fracture
of the sternum & this occurred to me in
St. Bartholomew's Hospital. I could not
at first distinguish it. But I placed the
patients hands on my shoulders & then
told him to press on them; at the same
time I had my hands on the sternum,
In this way I could discover the accident.
I took this hint from seeing the
pectoralis major muscle demonstrated.


135 Fracture Of
The ribs are not often fractured; but
when the accident occurs it is generally
near the angles. I have seen a case where
5 ribs were broken at the same time.
There is no deformity or displacement;
for the connexion of the ribs, liking to the
vertebrae, the sternum before, and the intercostal
muscles prevent it.
The only derangement which can happen
is an angular projection internally
at the place of fracture.
When the ribs are broken the patient 
always experiences considerable
pain in the part & if several are broken
respiration is very painful. By causing
the patients to cough, you will be
sensible of the jar & decide on the crepitus.
Sometimes the patient immediately
after the accident is fainty, & the pulse
is very low. There is however no danger if
respiration goes on.
Fracture of the ribs is often attended


The Ribs. 136
with cough & sometimes the mucus that
is thrown up is tinged with blood from
a wound in the lung produced by the
broken fragments.
Sometimes you discover a degree of
tumefaction which on pressing produce
a crackling noise; which is an
indication of emphysema. When not
extensive, it requires no attention. But
when it is general there is but one
way of relieving the symptoms; that
of making a puncture between two
of the ribs.
In fractures of the ribs, the indication
of cure is to keep the ribs still by applying
a broad bandage tight round the
thorax. Respiration under such circumstance
will be carried on by
the diaphragm alone.
The bandage should be broad enough


137 Fracture Of
to extend all the way from the axilla
to the lower true ribs & scapulary
applied to prevent it from slipping
down.
The cough is generally considerable;
& sometimes distressing. Now I
have succeeded completely in allaying
this, by demulcent remedies.
The Spermaciti mixture is the article.
Why this should be so efficacious
I cannot imagine; but such is the
fact.


The Scapula. 138
The scapula I have seen broken off transversely
& in a perpendicular direction
with respect to the body: i.e. the lower
or inferior angle fractured, & the spine
broken off.
When the inferior fragment is broken
off the lower fragment is pulled
forwards by the serratus major
anticus.
The inequality attendant on the
fracture is perceived by passing the
fingers along the basis of the scapula.
In the treatment of this accident,
you must place the arm in such a
position as to bring the upper part
down to the lower & retain it in
situ by a proper bandage.
In the cases I have seen, there was
a vast deal of pain and inflammation
which required bleeding & purging.


139 T. Of the Scapula.
Sometimes the Acromion scapula
is fractured; in which case it is
drawn downwards by the deltoid
muscle.
Apply one hand to the shoulder
& then push up the os humeri. In
this way you reduce the fracture &
are sensible of the crepitus.
To keep it in its situation is very difficult.
It is to be attempted by applying
the same bandage as for the broken
clavicula. I have never seen a
fracture of the Coronois process
of the scapula. If it should happen
the plan would be to apply a bandage
to keep the arm still.


Fract. Of the Clavicula. 140
This bone is very frequently broken; generally
about the middle; or rather nearer
the shoulder.
When it is fractured near the middle
the accident is very obvious. The 
patient always holds up the arm with
the other hand, & the fragment next the
scapula is depressed. By passing the finger
along the clavicle an unevenness will
be discovered; and by lifting the arm &
leaning it backwards crepitation will
be distinguished,
But when the fracture happens
near the scapular extremety & within the
ligament which joins the clavicula to
the coronoid process of the scapula, no
displacement takes place. If the pain
be great at that place, & if on raising
the arm crepitation occurs, the nature
of the accident will be obvious.
To reduce the fracture you have only


141 Fract. Of the Clavicula.
to raise the arm & bring the scapula backwards.
But to retain it in its place is more
difficult. The English Surgeons attempt it
by employing the figure 8 bandage;
but it does not answer well. That of Desseault
is more scientific & useful, though
it is far from being perfect.
The wedge-shaped pad used in this
instance encounters the action of the
Pectoral muscles which bring the scapular
fragment downwards & inwards.
A piece of soft linen should be interposed
between the hand, arm & belly to prevent
the disagreeable consequence of contact,
before applying the bandage.
When the fracture is oblique, I have
never seen it heal without some deformity.
When fractured between the ligaments
of the clavicula, why then of cours no displacement
happen; & no deformity
succeeds.


Fract. Of The Os Humeri. 142
The os humeri is most generally fractured
near the middle, though sometimes quite at
the end of the bone, or the neck. Besides the
bone is sometimes fractured near the condyles.
Occasionally the condyles are separated
from each other by a longitudinal fracture.
To reduce & dress the fracture when
near the middle of the bone, flex the fore
arm so as to form a right angle with
the humerus. An assistant then fixes the
scapula, while another places one hand
round the fore-arm just below the elbow,
& with the other he takes hold of the condyles
to make extension.
Sometimes an assistant takes hold above
the elbow with both hands & pulls with
all his might, but it does no good: he
stretches the skin a good deal, but does
not move the bone. This therefore


143 Fracture Of
should be avoided. Having adjusted the
fragments, the surgeon applies a roller
beginning just below the elbow, and continues
it up as far as the scapula. He then
applies a pasteboard splint on the posterior
or outer, another on the anterior or inner,
and a third on the external or upper
part of the arm; and then continues
the roller down over the whole of them
moderately tight. It has been usual to
swing the arm in a sling; but this permits
too much motion, and I have seen
the motion thus produced cause an immense
deal of irritation to the patient.
It is best to swing the arm, interpose
soft linen between the arm & the body
& then apply a bandage round the thorax,
from just below the place where
the arm lies up to the axilla,
About the 8th or 10th day remove the


The Os Humeri. 144
dressings & examine the state of the fragments;
and if any deformity is likely to
happen, remedy it while the uniting medicine
is soft; & there reapply the dressings.
When the Neck of the bone is
fractured, it is sometimes a little difficult
to distinguish it from a luxation.
But the head of the bone always remains
in situ; and when you come to examine you
will find the space under the acromion scapulae
will be less considerable than what occurs
in the dislocation of the head of the
bone; and you will feel the sharp or rough
fragments of the os humeri in the axilla,
Now this is of a good deal of importance,
for year before last a case of this nature
occurred in the country where the surgeon
actually mistook the fracture for
a dislocation. The consequence was that
they made numerous attempts to reduce
the dislocation, put the patient to a great


145. Fracture Of
deal of pain, & not only did no good, but
neglected what ought to have been done
by mistaking the nature of the accident.
About 3 weeks after he came to the Pennsylvania
Hospital & put himself under
the care of Dr. Wistan & myself. On examining
we readily discovered that it was a
fracture; for not only was the shoulder rounder
than in a dislocation, but we could
actually feel the fractured ends of the
bone under the pectoral muscles. The union
however was now such that nothing
could be done & he remained lame.
The fractured bone will always be
beat in, in the direction of the force
applied. If externally, as where a man is
thrown out of a carriage on frozen
ground on the arm near the joint, the
lower fragment will be beat in towards
the side of the thorax; or further forwards
when the force is more posterior, & further
backwards when it is more anterior.


The Os Humeri. 146
This fracture must be dressed nearly in the
same manner as the fracture of the clavicula,
after it is reduced; only the pad need
not be so large.
Sometimes the fracture is so completely in
contact with the head of the bone, & so transverse,
that no displacement can be discovered.
By moving the arm backwards
while the scapula is fixed, the bones will
generally grate against each other. Even
this I have known to fail. In one such
case I discovered it in this manner. I
directed an assistant to pull the forearm
downwards, while I pressed the arm
backwards. By this means I was sensible
of the crepitus.
Where there is a severe contusion
in the parts, and the patient complains
of a good deal of pain, you will have reason
to expect a fracture, & will examine
very thoroughly.
After having reduced the fracture it is
necessary to apply the bandage.


147 Fracture Of
you would suppose that fixing the thorax and
pulling the arm would separate the fragments
enough to admit of their reduction. But
the case mentioned above shows that pulling
alone will not do. In order to make
proper counter-extension, we must fix
the scapula, For you may pull the fore
arm ever so much without this, and
not reduce it.
Splints are necessary in this case. One
on the anterior, one on the posterior part,
& one between these.
Begin the application of the roller just
above the elbow & carry it up to the
shoulder, & as the lower fragment will
have a great tendency to be displaced
into the axilla a compress must be fixed
there by a bandage round the thorax.
The splints are to extend one inch or more
above the shoulder. Bring the bandage
above the shoulder, under the opposite
axilla 2 or 3 times, & then bring it round
the body & arm as far as the elbow &


The Os Humeri. 148
suspend it by a sling. A good deal of inflammation
is apt to occur & is to be combatted
by the usual remedies.
When the os humeri is fractured at the
lower end the forearm must be fixed in
order to prevent the separation of the fragments 
& the irritation attending it. And to
do this the angular splint must be used.
Commence the bandage at the wrist, carry
it up to the shoulder. Having applied
the bandage, place the broken ends carefully
in apposition. An assistant supports
the arm while the surgeon applies a splint
on each side, & it is well enough to have
one of the inside. Then bring down
the roller as far as the hand to fix the
splints completely. Next place the arm
in a sling.
Besides these there occur cases sometimes
where the condyles are broken off
longitudinally, or one is broken off.


149 Fracture Of
Here a great deal of attention is
necessary: for the natural angle of
the elbow is very apt to be reversed
& its apex to project upwards. I was in
hopes of preventing this deformity by
the use of the obtuse angular splints.
But in two cases I was disappointed
notwithstanding every attempt. I expected
that by applying the angular
splints at first & then while the uniting
medium was soft I should be able
to bend it as I was minded to. Then
putting on the obtuse angular splint
that is to say about the 14th, or 15th day
I imagined in every case the deformity
mentioned would be prevented.
This sometimes answered very well,
but it likewise sometimes failed.
It struck me afterwards, that
I should succeed by placing the patient
on his back in bed, bending
the arm & laying it supinely on a


The Os Humeri. 150
pillow. The weight of the hand in
this position has the effect of forcing
the head of the radius against the os humeri
pushing up the broken condyle &
thereby preventing the angular derangements
& preserving the angle.
But in the other way the position is
such that in every attempt to move the
os humeri, the radius is separated from
the humerus & a cavity is left between
them, which allows the condyles to descend
& deform the joint.
Two cases have succeeded in my hands
by the new method and I have lately
recommended it in a third which is
healing without deformity.
I would therefore recommend it to
you by all means to apply the rectangular
splint, put the patient to bed,
and incline the arm backwards and
place it upon a pillow. It is necessary


151 Fracture Of
to retain the dressings thus applied for
3 or 4 weeks till union be firm.
The accidents that occur about the
elbow joint are very complex, and
I know of no part of the skeleton
which requires more study & attention.
For the mistakes here have, I think, been
ten to one in any other place, the hip
not excepted.
The Fore-Arm is generally
broken at the middle or a little below.
There are two ways in which
the deformity may occur. One
where there is an angular projection;
and the other where the
broken ends are depressed into
the interosseous space.
In dressing the fracture, the
patient is to be seated; one assistant


The Fore _ Arm. 152 
takes hold, as if to shake hands &
a second one takes hold of the arm
just above the elbow with one
hand & with the other, hold of the
condyles. In this way extension and
counter-extension is made with
the arm at right angles. The fragments
being reduced commence with
the bandage at the wrists and carry
it up to the elbow, (taking care not
to apply the bandage too tight so as
to press the fragments into the interosseous
space & produce deformity)
or a little above. Then apply a pasteboard
splint on each side, the thumb
projecting upward, between. These
should be so broad as not to permit
the roller which passes down
over them to press the bones inwards
towards each other, Then
bring down the roller to the very end
of the splints, which must reach below


153 Fracture Of 
below the ends of the fingers, so as to
prevent all motion of the hand & 
fingers. For if the hand were allowed
to move, the derangement, &
irritation would be great. And,
added to this if ossification were to
take place with the hand prone,
the power of supination would be
entirely lost. The arm is then to
be suspended in a sling & to prevent
deformity in consequence of the perspiration
softening the splints, a thin
splint of wood ought to be interposed
between the arm and the body against
which it rests.
In people subject to rheumastism 
by keeping on the splint, and the
fingers extended for a long time, the
ability to bend the fingers, or use
the joint is much impared or totally
lost for many months. The person
thus situated applies a great variety



The Fore _ Arm. 154
washes, & liniments, but to us manner
of advantage. Time alone can remove
this affection & rigidity.
But being aware of this, we shall
be able to avoid the affection altogether,
my practice is to remove the splints
at the end of the first week & every
day, or every 2nd day after, and flex
the wrists and fingers; & then reapply
them again.
But there is one case in which
nothing of this kind will do any
good. That is where the sharp end
of the bone sticks in a muscle making
nearly a compound fracture.


155 Fracture Of 
I think this bone is oftenest broken
at about 1/3 of its length from the
lower end. But it is frequently fractured
at a place where we should little
expect it, i.e. just above its articulation
with the hand. When it is broken in
the former place no great deal of difficulty
occurs in distinguishing it.
But when it happens at the lower end of 
the bone it is is exceedingly difficult & obscure,
& is often mistaken for a luxation. A
case lately happened in the country of this
description. A boy has the radius fractured,
and mistaken for a luxation,
Of course nothing was done & it healed
with a great projection, a good deal of
deformity, & interruption to the motion
of the wrist. Now this accident occurs
often but the luxation is very rare indeed.
I have never seen but one case
in my life. It therefore requires a good
deal of attention, more especially as it


The Radius. 156 
involves so deeply the character of the
surgeon.
In all the cases of fracture of the radius
that I have seen, it has been in consequence
of falling on the palm of the
hand or the ball of the thumb. The
fragments are frequently so interlaced
with each other, that even by rotating
the hand we cannot render the accident
obvious.
I have distinguished, & reduced it
too, in the following manner. Bend
the arm, let one assistant take hold of
the hand & make extension, & a 2nd,,
take hold of the arm & make counter-extension;
by pulling & placing your 
(fingers) hand against the angular projection
at the lower end of the external
part of the radius, you will bring
out the depressed portion & reduce
it. At the same time crepitation
will be perceived.
It requires the same dressings as
for the fracture of the fore arm.


157 Fract. Of the Ulna.
The ulna alone is not often broken,
and when it is, it generally happens
in consequence of a severe
blow on that bone; or from some
projectile force acting exclusively
on it. Deformity is obvious
at the place of fracture. And
by passing the hand along its
external edge, you will discover
the exact place of the fracture;
or if this be obscure, it will be
evident on rotating the arm.
It is to be managed in the way already
mentioned.


The Metacarpal bones 158
are not often broken. But to ascertain
the accident when suspected, take hold
of the lower end of the metacarpal bone
with one hand & with the other grasp
the upper part of the hand. In this way
motion and crepitus will be made evident.
A compress & carved splints adapted
to the hand must be applied,
The Fingers are sometimes broken
by heavy bodies falling on them. I knew
a boy to break them by boxing at school.
And a lady fractured the index finger
in attempting to raise a window.
The treatment consists in applying a
narrow roller & a splint adapted to the
finger, & then to put on a large one
fitted to the whole hand so as to prevent
any motion in the fingers. This is very
necessary; for by undertaking to treat


159 The lady merely by adapting the splint 
to the finger, expecting no difficulty as
she did not want to use the hand, I
found after some time that the motion
of the other finger caused a corresponding
one in the fractured finger,
producing swelling & inflammation
& I believe suppuration would have
happened if I had not put on the
hand splint.
Compound Fracture of
These occasionally happen in consequence
of bruises or comminution by a great
force; or when the flesh is so much injured
that it gives away leaving a
communication with the cavity of
the fracture. Sometimes the finger is so
nearly dissevered that it adheres only
by a thin slip of flesh which you would
almost be tempted to cut off.


160
But I would dissuade you from this
by all means. Replace the fragments
of bone & the soft parts, and apply
adhesive straps lengthways to keep
them in their situation; & then a
broad splint to the whole hand.
It is surprizing to see how small a
quantity of blood is sufficient to preserve
the vitality of a part, I have
seen a finger cut off, all excepting
a quarter of an inch of skin, grow together
very well.
We are even told by authors
(which we cannot very well disbelieve)
that parts even after being removed
if replaced immediately, have united.
This is analogous to what happens when
a tooth is extracted from the jaw and
engrafted into a cocks-comb, and almost
gives us reason to believe the story of
a man's nose having been bitten off, &


161 Fract. Of the Olecranon. 
even stampted upon, uniting again.
At least there can be no harm in trying
the experiment.
When lecturing of fractures of the fore
arm I forgot to mention that of the
Olecranon Process of the Ulna.
This process is sometimes broken off, in
which case the patient will be unable
to extend the arm; and you will
generally [illegible] see the chink between
the fragments. If you take hold of the
olecranon under such circumstances you
can readily move it.
Extend the arm & the fracture is
reduced. Then apply a roller from the
wrist up to the axilla. Then apply a
graduated splint made by pasting on
muslin narrow bits of shindle, on
the inside of the arm, & bring down


162 
the bandage over it to the wrist.
You will find in reading authors, that
they say a good deal about a fold of
skin which is apt to get between the
fragments. I have had a great many
of these cases but I never saw one where
there was danger of this happening.
To prevent anchylosis it is supposed
necessary to remove the dressings
after a week & flex the elbow gently.
I have never had a case myself
where this did happen; but I have
seen a case in a lady. I suspect however,
that the motion incident to flexing
the joint augments the swelling and
inflammation. In one case where
it was attended with these symptoms
by flexing the arm at right angles &
putting on a bandage and splint
to keep it so (thinking that anchylosis
might happen) the motion of the


163. Fract. Of the
joint was happily preserved.
The Coracoid Process of
the Ulna is not often broken; & it
is actually attended with luxation
backwards.
I had one case which I supposed
was a luxation. On extending the arm
I reduced it very readily. But before
I could apply the bandage I found
it out again. I then examined the
inside of the arm at the bend of the
elbow and I could feel the loose
fragment. By this I was convinced
at once, that in the attempt of luxation
the coracoid process had been
broken off. I then bent the arm &
put on the angular splints which
preserved its position. But on examining
it after sometime I found that
the deformity of the apex was likely
to take place.


Coracoid Process. 164
By applying the other splints I mentioned
I succeeded in preventing it to acertain
degree.
Important.
When in consequence of any of these accidents,
inflammation & tumefaction
arise, elevate the arm & hand. This obviates
or reduces inflammation, prevents suppuration,
& it may even prevent caries
& gangrene, This practice is successful
where very copious depletion
would otherwise be necessary.


"165. Fracture Of 
Fractures of the thigh bone happen
most frequently near the middle, or
a little below. But the fracture sometimes
happens very high up, the head
itself being broken off, or it occurs at
the neck of the bone: and the trochanter 
major is occasionally broken off.
I have never seen such a case, but I
have seen a fracture extend obliquely
through it. It sometimes happens
very low down,
The fracture is most generally
very oblique.
The person experiences a severe
pain at the time of the accident, and
is sometimes sensible of a cracking
(noise.) in the part, There is generally
some displacement, & the limb is 2
inches shorter than the other,
There is another deformity which
is occasioned by the lower fragment
rotating outward, or inward.


The Os Femoris 166 
I have never seen the foot turn inwards
when the fracture was in the middle of
the bone. But to one it happened higher
up, I have known it to fall inward.
It is in general, very easy by extension
& counter-extension to bring
the fragments in contact. But to
keep them so is much more difficult
and can only be done by counteracting
the muscles of the thigh which
are inserted into the lower fragment. 
Most of the Brittish Surgeons believe
a shortening of the limb in oblique
fracture of the thigh bone, a necessary
consequence of the accident,
Mr. Pott attributes this to the improper
manner of treating them, which was
by placing the patient on the back &
extenting the legs. He recommends the
flexed position of the thigh & leg, and
that the patient should be placed on


167 Fracture Of 
the affected side. In reading Mr. Pott's
remarks you would be inclined to believe
that the best position, But the
moment you put it to the test you
will find it full of inconvenience;
and the angular deformity is always
geneater than when treated by the
old way, And besides the position is
a very uneasy one, requiring great
muscular exertion to preserve it &
the patient always gets out of it
during sleep.
I have tried Charles Bell's
apparatus and I found that the patient
twisted the pelvis so that the
fragments overlapped. It is not
effectual.
The best plan which experience
supports is that of Desault. I shall
apply his, & then show you how I
would have it modified.


The Os Femoris. 168
Before we dress the fracture, we must
provide a hair mattress with a circular
hole in the middle in which a cushion
can be placed.
Support the head with only
one, or at the most with two pillows,
The patient often calls for pillows
to raise the head & the consequence
is, he slides down so that the foot projects
over the foot of the bed and
produces displacement.
Having provided the bed, next put
down 4 tapes, then the splint cloth
turning in the corner next the inside
of the thigh. Then 1 splint of pasteboard,
and on this the bandage of strips.
Common silk handkerchiefs answer exceedingly
well for the extending & counter-extending
bandages
Two long lays of chaff, or 2 flannel compresses;
the outer longer than the inner


169 Fracture Of 
one must be provided. This being
done place the patient on the mat.
& let one assistant take hold of the
counter-extending bandage, while
another takes hold of the ancle just
above the foot & extend till you
perceive that the leg is of the same
length as the sound one, - taking care
at the same time that the pelvis
be strait. Next apply the strip bandage,
roll up the splints & fix all 
the long splint. Finally interpose the
bags of chaff and secure all with the
tapes. It is customary to place a
pillow under the foot to give some
support, and also to pass a bandage
round the upper part of the splint
& round the pelvis; and as it is apt
to slip, I always tack it to the splint.
Some contrivance is also necessary
to prevent the pressure of the clothes on the foot,


The Os Femoris 170 
This is the apparatus of Default, the only
modification which I would suggest is to
make the splint long enough to reach
up to the axilla instead of the pelvis, &
to fix a small block to the lower end of
it as you see, over which to pass
the extending bandage.
So great has been the success
of the long splints modified as above,
that not a case of shortened by has
gone from the Pennsylvania Hospital
(except one who would not submit to
the treatment) since it has been adopted
so far as I know,


171 Fracture Of The Neck
Where the Neck of the thigh bone
is fractured, the soft parts are so
thick that you cannot feel the part
but the patient will have been sensible
of a crack, the limb will incline
outwards, and it will generally be
shortened,
Sometimes the accident resembles
a luxation, But in luxation
the foot is turned inwards, and
it is impossible to turn it outwards
without reducing the luxations
when the symptoms ceases,
The bone is sometimes broken
within the capsular ligament;
and in this case there is no displacement,
the part being so firmly
embraced, but there is a great
deal of pain.
Sometime ago I was called to see
an old lady who had received a


Of Th Os Femoris 172 
a violent contusion on the trochanter 
major. As I could feel
no fracture I desired her to stand
up and make an attempt to walk,
This produced pain but did not
disclose the nature of the accident,
I told them I could not tell, but
I really believed the the head of
the bone was fractured & I applied
the apparatus accordingly.
And at my second or third visit
I found the limb 2 or 3 inches shorter
than the other, Thus the action
of the muscles had at length drawn
up the lower fragment.
There is no dressing so good as
the long splint to keep up the permanent
extension,
When the fracture is within
the capsular ligament, I cannot
promise that the union will


17.3 Fracture Of The 
be by bone: but it will unite by
ligament: This is long of becoming
firm so as to afford sufficient support.
I show you an example where
nature, in the course of ten years
removed the neck of the bone, brought
the body under the pelvis, and the
trochanter major in contact with
the tuber ischii, and formed a smoth 
surface, or a kind of ginglimus joint
affording such support that the
patient contemplated laying
aside his crutches when he died
with fever. This specimen shows
in a most striking & admirable
manner the wonderful
resources of nature.
I show you another specimen
where the head of the bone was


Os Femoris 174 
broken off; and a vast knob of
of bone you see is formed on the
neck, making a complete bed for
the head of the bone.
Thus it appears that by a law
of nature no union by bone can
take place in joints where the bone
is broken within. the capsular ligament.
Let us suppose for instance
that this mass of bone had been
thrown into the acetabulum;
the use of the joint would have
been entirely lost.
I exhibit a specimen where
the fracture was from a gun-shot
wound. In this instance the fragments
passed each other, so that
no union could have taken
place. Nature in this case made
an attempt to throw out a kind


175 Fracture Of 
of fennall to inclose the lower fragment,
& had not the suppuration
& hectic rendered amputation necessary,
would have effected the
purpose and the leg would have
been strong.
The Patella is often fractured by
the violent action of the muscles inserted
into it. When this is the case
it is broken transversely. But it is
also broken occasionally by external
violence in which case the fracture
may be longitudinal, or diagonal.
In transverse fracture of the patella,
something is necessary to keep the fragments
in contact. It unites by ligament
When the accident happens there
is an inability of extending the
leg; sometimes it breaks with an


The Patella. 176
audible noise & the person falls down:
& the cleft can readily be felt. The
upper fragment is the one which is drawn
up; the lower one is only connected by
ligament, and is incapable of being drawn
down excepting a very little when the
knee is bent. By drawing up the
lower fragment & pressing down the
upper one, the leg being extended there
will be crepitus. But sometimes the
ecchymosis is such that this cannot be
perceived. Here we must not give an
opinion till it subsides, when the nature
of the accident will be obvious,
To dress it commence a bandage at
the ancle & continue it up to the upper
part of the thigh, to prevent the swelling
of the limbs & to diminish the tendency
to contraction in the muscles
of the thigh. Next apply a splint to
the inside of the leg, bring the bandage


177 Fracture Of
down & pass it in the form of a figure
8, & then carry it down to the ancle.
Or employ the apparatus recommended
in Dr. Dorsey's Surgery.
Sometimes owing to the retraction of
the muscles the upper fragment is kept
at some distance from the lower, no
attention being paid to prevent it, the
ligament between the two fragments is
so long that the leg cannot be extended.
In the case of a lady thus situated
which had baffled all the practitioners
in her neighborhood (near Lander)
who had applied a great many
articles in order to stimulate the muscles
into action without effect, Mr.
Hunter knowing the power of the
muscles is increased by motion, recommended
to the lady to set on the
bed beside a wall & them endeavor


The Patella. 178 
to extend the leg & kick against the
wall. This was done with difficulty
at first & the extent of motion was
very trifling. After a while however it
became more manifest by the adaptation
of the muscles to the new purchase;
and the practitioner was surprized
to find how much higher she
could kick on the wall from day
to day. Simple as this may appear,
by continuing the practice for a
long time, the lady acquired the motion
of the extensors completely,


179 Fracture Of 
When the tibia is broken transversely,
little deformity occurs & the accident is
easily treated
To dress it 1. Put down a pillow,
2. A bandage of strips. 3. Then over this
2 pasteboard splints soaked in water.
4. Then another bandage of strips. The
principal part of the feathers in the
pillow must be pressed to the lower 
part of it so as to be adapted to the
shape of the leg. 5. This done put on
the leg, make extension & counter-extension,
adjust the fragments; and
6. Then apply the bandage of strips,
beginning at the ancle. 7. Then the
pasteboard splints. 8. Then the second
bandage of strips over the splints.
9. Then bring up the sides of the pillow;
and to support them more readily
apply to piece of shingle on
each side & til all layethed with two


The Tibia 180
pieces of tape. To give a little support
to the foot pass a bandage round the
instep & pin the ends to the pillow.
But cases now and then occur in
which the fracture is oblique and
the muscles of the back part of the
leg pull up the lower fragment sometimes
one or 2 inches. You would suppose 
that there would be a great angular
deformity anteriorly. But
this is not the case, & you will be deceived
unless you measure, or compare
the length of the leg with the other,
In general all we have to avoid is angular
(deformity) projection forwards
making what is called a bow-shin.
I have seen the tibia broken low 
down, while the fibula was fractured
high up near its head.


181. Fracture Of
Now it is absolutely necessary to recollect
this, for I have seen the permanent
extension by bandages applied.
to the upper part of the leg do a
great deal of injury by depressing
the fibula & bringing it too near
the tibia.
In the oblique fracture of the leg
permanent extension is necessary
& for this purpose we use Dr,
Hutchinsons splint. However you
see that when the counter-extending
bandage is passed tight it
causes swelling of the parts below;
and when the fibula is broken
high up, it presses in the fragments,
produces inflammation, suppuration,
ulceration & a simple fracture
is converted into a compound
one. Such cases I have seen.


The Tibia 182
One patient did not get over it for
near a year. Now to prevent all this,
I have for a long time used the long
splint of Desault, making the counter
extension on the pelvis.
When both bones are broken no
difficulty occurs in distinguishing
the accident. But when only one of
them is broken, the extension is so kept
up by the other, that no displacement
happens. We can generally discover
it if we are aware of the deception.
We however must examine very
carefully: there is no angular deformity
or derangement.
I was once called to a youngster
with this fracture in which there was
no derangement whatever. I applied
the bandages &c, & left him. But
seeing the length of time I employed


183 Fracture Of
in examining the case, supposed I had
mistaken its nature altogether. He
accordingly, as seen as my back was
turned, in spite of the persuasions of
his relations took off the whole of the
apparatus, got out of bed, sprung
about the room, exclaiming, with exaltation
that his leg was not broken
that the Dr. was mistaken, and he
would laugh at him when he returned.
Making however, an oblique step, it
bent under him, and I was immediately
sent for. He was now well
enough convinced of the nature of
his case and I applied the bandages
again & forgave him; as you will
have to do in similar cases.
But I shall mention another
fracture which is that of the tibia


The Tibia. 184
near its top. Now if you do not put
a boulster between the knee and the
splint, you will produce a disagreeable
deformity; the thigh and leg
being in the same line. The consequence
of this is, that the person
in walking always describes a considerable
part of a circle.


185 Fracture Of
The fibula may be broken in almost
any part of it by external violence.
It is sometimes fractured near the
lower part. It is true this cannot happen
immediately at the ancle, it being
so strongly connected by ligaments.
When it happens it is a little above,
& is attended with luxation of the astragalus.
Now this is not an unfrequent
accident. I was this day called
to see a lady which had sprained
her ancle (as she supposed, by
slipping off from a step obliquely,
producing a violent abduction
of the foot. This was several days ago,
Upon examination I found it was
a fracture of the lower part of the
fibula & dislocation of the astragalus:
which has been mistaken for
a sprain.


The Fibula. 186
By passing the fingers along the fibula
you will easily discover the place of
fracture. To reduce it an assistant
grasps the leg just below the knee another
takes hold of the instep with the
left hand, & the heel with the right.
By making extension in this way, &
pressing the foot inwards, we reduce
both the fracture & luxation at the
same time. It is necessary to apply
splints to the leg sufficiently broad
to extend up more than half the foot
so as to prevent any motion or displacement


187 Dislocations.
When the articulating extremity of one
bone is separated from the other, it is
said to be luxated, or dislocated.
In luxation the motion of the limb is
much impaired, or entirely lost, there is
a shortening or elongation; pain & more
or less visible derangement.
The difficulty we have to encounter
in reducing a dislocation arises from
the violent action of the muscles#.
To relax them moderate vs. & hanging
have been recommended.
The best way of overcoming muscular resistance
is by bleeding ad deliquium animi.
This remedy was first employed by me
in the Pennsylvania Hospital. The idea was
first suggested by Dr. Monroe in his 
lectures.
# This offers the chief resistance. It has been
thought that the rupture of the capsular ligament
produces considerable resistance.
It sometimes does, though in general I believe
it does not.


Dislocations 188
Emetics, opium &c. have been recommended
when bleeding cannot be resorted to
in consequence of weakness. I have been in
the habit of recommending & using
them too, for this 20 years. Yet Mr,
Cooper in a work published last year
recommeds as his own, the same remedies
namely emetics & the warm bath.
After sometime, if unreduced, the involuntary
contraction of the muscles cease,
and the parts are accommodated to the
preternatural state of the luxation.
When the bone remains long in the new
situation, adhesion takes place & reduction
is impracticable unless this
adhesion is broken up. The surgeon will
feel the tearing of the adhesion when sufficient
force is applied. I have always
been sensible of it in reducing such luxations.
In these cases, where the luxation
cannot be reduced, nature forms a new


189 Luxation Of
joint which I have repeatedly seen in
the arm & thigh.
The Jaw can only be dislocated in
one way i.e. forward.
Both of the condyles are generally
dislocated, though sometimes only
one. The accident generally occurs
in consequence of opening the mouth
very wide: sometimes in yawning.
It is sometimes luxated in consequence
of moving very fast & opening
the mouth very wide to vociferate.
A woman in the market
thus circumstanced found she
could not shut her mouth any
more. In this state she was brought
to me in the Hospital with the


The Lower Jaw. 190
saliva dribbling down.
Last year a lady becoming sleepy
yawned so that so that her jaw fell down &
she could not raise it again, and
in this condition she was brought
to my house at 11 or 12 o'clock at
night.
When the dislocation is recent
there is no difficulty in reducing
it. But when it has been out for
some time the adhesion & muscular
force is so great that it is reduced
with great difficulty.
Some years ago a lady was brought
to me from the country whose jaw
had been dislocated in consequence
of a violent salivation in a dropsy.
The accident was not discovered till
it had been out a long time.


191 Dislocation Of
The practitioner who attended this attempted
to reduce it, but without effect.
I made an attempt but found
I could not move it. As Dr. Dorsey
an a Gent. Dentist who were at hand
had more strength than myself,
I proposed that they should try
what they could do. Each of them
made several attempts but they
could no more move it than myself.
As she was in such a state of debility,
I did not think it prudent
to employ vs. and therefore proposed
that she should drink till intoxication
was induced. This I was led to
believe would have the same effect
as blood-letting - I frequently having
had occasion to see that drunkards
in a state of intoxication have
their muscles completely relaxed.


The Lower Jaw 192
The project meeting has approbation,
she chose gin. When she was pretty completely
under its effect Dr. Dorsey proposed
that she should smoke a cigar.
This she did with a good deal of difficulty,
making only a few whiffs.
The two, however, accomplished every
thing I wanted. She now began to reel
every way & could no longer sustain
the head. In this condition I reduced
the jaw as easily as I could put
the one I have before me into its
place


193 Dislocation Of
The clavical is prevented from being luxated 
downwards at its sternal extremety, by
the sternum and the cartilage of the first
rib. But forwards, backwards & upwards
it is liable to be luxated. In general the 
displacement is forwards. This is produced
by violent motions of the clavicle backward.
In consequence of this motion the sternal
extremety is carried forwards, the ligaments
broken, & the end of the bone forced before
the upper end of the sternum, making a
hard projecting tumor, which moves whenever
the arm & shoulder are moved
The bandage & dressing used for fractured
clavicle are proper here. They reduce the
dislocation, & maintain the proper situation
of the bone.


The Clavicula. 194
The scapulary extremety is sometimes luxated
upwards from falls on the shoulder.
The reduction is effected by raising the arm.
I believe the dressing, foe fractured clavicle 
are best. Take care to examine frequently
that the bandage does not slip.
It is impossible to cure it without deformity;
and it is a long time before the
lacerated ligaments are healed. The bandages
ought to be kept on ten or twelve weeks.


195 Luxation Of
The Dislocation of the shoulder joint happens
most frequently of any in the body. It
can take place in every direction excepting
directly upwards. Forwards, backwards,
& downwards, I have seen it luxated. The
most common is that where the head
of the bone passes into the axilla. The
pain is considerable, the arm forms an
angle with the body standing out from
it & the patient cannot bring the forearm
to the body. You will perceive a
hollow under the acromion scapula, & the
round head is readily felt in the axilla.
By this you will distinguish it from
a fracture of the neck of the bone.
When it is luxated forwards, there is a
large tumor on the coracoid process 
which prevents you from feeling
that process. when the head is backwards
it will be perceived, unless there is considerable


The Os Humeri. 196
considerable ecchymosis on the dorsum scapulae. 
In reducing dislocation a great deal of art
consists in taking the patient unawares.
We should not let him know that we are
going to reduce the luxation. For if you let
him know it he will imagine he is a going to
be put to pain & this idea will produce
such contraction of the muscles that it will
be reduced with difficulty.
The idea of taking by surprize, or tripping
the muscles, first occurred to me when I
was house-surgeon in St. George's Hospital in
London in 1789. A person was brought in
who had a luxation of the humerus. I told
him I only wanted to examine it taking hold
of the arm just above the condyles with the
left hand & placing the right hand against
the acromion scapulae. Some of the young
gentlemen in the hospital began to laugh &
sneer; & asked me if I intended to reduce the


197 Luxation Of
bone in this way. But before the words
were cleverly out, by one twitching effort,
the bone was instantly reduced.
I have ever since employed this method.
Mr. Cooper, you will perceive has also
recommended this plan in the reduction
of luxated joints in his surgical essays.
But I certainly was before him in this.
When it is necessary to use much force,
place a soft piece of buck-skin round the
arm just above the condyles. On this apply
the extending bandage, and flex the arm.
The number of assistants employed in extension
and counter-extension should be
equal. Having adjusted every thing, give
the extending bandage to the assistants.
Then one places his hand against the acromion
scap. another places his hand
on that of the first &c. till a sufficient
number are employed.


The Os Humeri. 198
The assistants having pulled so as to bring
the head of the bone out even with the glenoid
cavity. (the edge of it.) At this moment desire
them to let go the bandage & then instantly,
using one fist in the axilla as a purchase,
& the arm as a lever bring it down
to the side of the patient. In this way the
reduction will be immediately accomplished.
By purging this plan I have never failed
in a recent case.
But in chronic luxations we must
have a soft pad adapted to the acromion
and attached to a strap. Pullies may be used if
necessary. Sometimes the patient attempts to
elude the extending & counter extending
force (as he is generally seated) by bending
the body & inclining different ways. When
this has been the case, I have found it best to
place him on his back on the table; in
which posture the bandages can be applied
exceedingly well, without any possibility of


199 Luxation Of
his avoiding the force. Vs. ad. deliq.
may be used in all obstinate cases as I shall
have occasion to mention.
I have to mention another method
of managing a luxated humerus when
others have failed. This is to place the patient
on his back on the floor; and then
to take off your shoe, & lying along the
patient place your heel in the axilla, taking
hold of the wrist & making pretty powerful
extension, & bringing the arm to the
side using it as a lever. In this way we can
sometimes dislodge the head of the bone from
the edge of the glenoid cavity & unhitch it
so that the muscles will bring it into the
cavity.
I have never succeeded in reducing
a luxation of the os humeri after the expiration
of 12 weeks. But Dr. McKenzie
of Baltimore has succeeded in one case


The Os Humeri. 200
of 6 months standing.
I do not recommend it to you to
open and cut through the adhesions in
chronic cases; but at the same time, when
we see the joint is sometimes exposed in
consequence of balls passing through their
cavities without serious detriment, that
practice would surely afford some prospect
of success.
It is necessary to unhook the head
of the bone from the coracoid process
of the scapula. In this case the force of
counter-extension must be partly lateral.
Contusions of the Deltoid
Muscle. A person is sometimes thrown
out of a carriage on the shoulder & arm, by
which the deltoid muscle is so contused that
when he recovers, he is unable to throw out
the arm.


201 Luxation Of
After some time has elapsed, by making 
exertions as I mentioned before, the
use of it will be restored.
The common opinion is, & some practitioners
think so, too, that there is a luxation.
(& unless attempts are sometimes made
to reduce it). But you must explain the
nature of the case to the patient & encourage
him to persist in the attempts to
use the arm. A great number of oils and
liniments are used to restore the motion in
the muscles; but they are of no manner of
use. Motion & time alone are the remedies.
The Luxations of the Fore-Arm
may take place laterally (though not complete)
and backwards. The latter is the
most frequent.
In recent cases there occurs no
difficulty in discovering the accident:
and yet you will find it bears a striking
resemblance to the fracture of the


The Fore _ Arm. 202
os humeri near the condyles In the luxation
backwards the radius & ulna may ascend more
or less behind the humerus, but the coracoid
process of the ulna is always carried above
the articular pulley, & is found lodged in the
cavity destined to receive the olecranon.
The head of the radius is placed behind
and above the external condyle of the humerus.
Having ascertained the luxation upwards
& backwards, the reduction can easily be
accomplished by proper extension and
counter-extension. But by simple extension
it is impossible to reduce it for the
coracoid process of the ulna is actually
hitched in the pit destined for the olecranon.
Let one assistant take hold of the arm
just below the axilla, & another hold of the
fore-arm just above the wrist.
The surgeon then places his left hand on
the posterior & lower part of the arm, and


203 Luxation Of
his right hand on the inner part of the
fore-arm just below the elbow. You then
tell your assistants to extend; at the same time
you pull (downwards) towards you with
the left hand and pushing with the right,
Having thus unhooked the process you tell
your assistant to bend the arm suddenly,
when it immediately slips into its place.
I have never failed in this way. But
I have reduced it at the end of 4 weeks,
notwithstanding Boyer says it cannot
be done after the 16th day.
When the Ulna is partially luxated
it is easily reduced. But when the
olecranon hooks on the internal or external
condyle of the humerus, it is embraced
very tenaciously by the ligaments and
muscles.
Here also we must use extension, &


The Fore _ Arm. 204
taking hold as before we give a lateral
direction with the hand, so as to dislodge
the olecranon, when it is easily
reduced
The Luxation of the wrist
is very rare. I have only seen one case,
you should be careful to distinguish
a luxation from the fracture of the fore-(arm)
radius near the wrist, as I told you.


205 Luxation of the Fingers.
The Fingers are sometimes luxated
the hilt passing backwards. In
this case the finger is bent and immovable.
They are easily reduced.
But when the metacarpal bone of the
thumb is dislocated inwards it is with
great difficulty that it is reduced. I
once had a case of this kind. I tried every
method, used a great deal of force, & continued
it so long that I was entirely out
of patience. At length by a fortunate
motion or direction in the extending force,
it was immediately reduced, I know not
how. Before I would continue my efforts
so long, in another case, I would
divide the lateral ligament with the old
couching-needle, as proposed by Mr.
C. Bell.


Luxation Of the Femur 206
This was formerly supposed to be a very rare
occurrence: and the idea was taught in this
school that it hardly ever happened. But
it is notwithstanding, not unfrequently not
with. Mr. Astley Cooper says he has seen more
fractures of the neck, than luxations, of
the bone, in thirty years practice. The reverse
is the case with me.
The luxation upwards & backwards. I
have seen most frequently. It is sometimes
luxated downwards & forwards. I
have never seen a luxation directly
downwards; it was always carried into
the ischiatic notch, the head of the bone
lying on the pyriform muscles.
When the dislocation is upwards &
backwards, the thigh is shorter than
the other, a little bent & carried inwards,
the toes are turned inwards & you cannot
turn them outwards without reducing
the dislocation.


207 Dislocation Of
In the Luxation Downwards, &
Inwards, the affected thigh is longer
than the other; a hard tumor is felt at
the inner & superior part of the thigh; the
leg is slightly bent; the knee & foot turned
outwards
In the Luxation upwards and
forward the head is forced out of
the acetabulum and lodged on the os
pubis. The leg is sometimes lengthened a
little 1/4 or 1/2 an inch. The toes are turned
a little outwards & the head of the
bone can be felt forming a tumor
in the groin. And bends the trochanter
major projects further from the
spine of the ilium than natural.
This species of luxation is very rare; I have
seen but one case: and Desault & Cooper
only once each.


The Os Femoris. 208
The most difficult luxation to discover, is
where the head passes into the ischiatic notch.
In lean subjects the head of the bone may
be felt. But I have never seen but one 
case. The limb is not shortened as in other
luxations.
To examine whether one leg is shorter
than the other, the patient must be laid
on his back; and a line drawn from one
spinous process of the ilium to the other,
should cut the body as right angles. For
if the pelvis be crooked you will be deceived.
You remember in fracture of the neck
of the bone, the lower fragment is drawn
up, but the foot is turned outwards,
which is not the case here. In the fracture 
it can be pulled down to its place,
but in this case it cannot be done without
reducing the luxation.
A power must always be applied to


209 Dislocation Of
the upper part of the bone to lift up the
head from its lodgment let it be luxated
in what way it may; and this force is
to be applied laterally.
In our attempt to reduce the dislocation
of the thigh bone, we must proceed
as follows.
1. Apply a strong girth between the
thigh & pudendum, on the side affected
so as to pass across the ischium & tye it fast
to a post.
2. Put on a strip of soft buck-skin
just above the knee.
3. Then 2 bandages (extending bands) lengthwise
of the thigh, & secure by a roller passed
over the buck-skin.
4. Next, place a second girth in the perineum
for lateral use.
Then fix the counter extending
bandage to the wall, & adapt the extending
bandage to pullies, or give it into


The Os Femoris. 210
the hands of assistants. I like the notion
suggested in Mr. Cooper's book, of wetting the
bandage above the knee; for in fat persons
it will be very apt to slip without.
Mr. Cooper mentions a case in his
Surgical Essays for 1818, reduced at the expiration
of 5 weeks. I reduced a case of 4 weeks, in
the Infirmary, while the extension was performed
only by assistants. And Dr. Wistar
and myself reduced a case at the end of
12 weeks. It was very surprizing that the
leg after reduction was about 2 inches
longer than the other. This circumstance
gave us reason to fear that the acetabulum
was filled up. But in a few days
this appearance subsided & the patient recovered
the use of his leg very happily.


211
A Dislocation directly backwards occurred
to me in the Pennsylvania Hospital
in 1812. After various attempts to
reduce it in the manner I have related
had proved unsuccessful, it occurred to
me that the dent in the capsular ligament
might be in the form of a buttonhole
& that the neck of the bone was embraced
as a button is by a button-hole;
& that contrary to what happens for
common, the capsular ligament might
impede the reduction. Under this view
I bent the thigh to a right angle with
the pelvis, then abducted it so as to remove 
the strictened parts and relax the
ligaments. I then gave the patient a pretty
smart knock with my fist on the trochanter
major, when it instantly snapped
into the acetabulum. It is of great importance
to recollect this.


Dislocation Of the Patella 212
The Patella is so situated that it is impossible
for it to be luxated either upwards
or downwards. But it may be forced
from its situation laterally. The internal
condyle of the os femoris does not
project sufficiently for the patella to be
lodged, but it immediately flies back when
force in an opposite direction is applied.
This is not the case when it is forced
outwards. It is however a very rare occurrence.
I have never seen but two cases:
one occurred in my practice; the other
in that of Dr. Dorsey.
Mine happened to a young lady in dancing.
She felt pain, heard the snap, & was
incapacitated from bending the knee.
By placing her on a sofa & extending
the leg fully it was easily reduced.
The case which occurred to Dr. D. was reduced 
in the same manner.


213 Dislocation of the Tibia.
After the reduction, rest, horizontal position,
& a low diet are necessary for 10 or
12 days to prevent inflammation.
The Tibia is sometimes, though rarely
dislocated. I have never seen it take
place either forwards or backwards.
It did occur I am told by a gentleman
who attended lectures a year or two
a go, in consequence of very great force
applied so as to lacerate the ligaments of
the leg. In this case the displacement was
backwards.
I have never known the luxation
to happen but in one direction, and
that was when it was turned so that
the head of the tibia rested on the outside
of the internal condyle of the
os femoris.
It was produced in both legs in one
case, & in one leg, in another case, by
the person falling from a ladder with


214
the legs & feet projecting outwards.
In luxations of this nature there is
such a tearing of the ligaments, that
there is no difficulty in reducing the
dislocation. But it is not maintained
without the application of the long
splint of Desault carrying up a bandage
above the knee, & interposing a
flannel compress between the splint
& the outside of the leg.


215 Lux. Of the Ancle.
The dislocation of the Ancle# is also a
very rare accident; except when there
is a fracture of the fibula. But it is
sometimes luxated forwards, or backwards.
When forced forwards it projects very
much, the foot is stiff & cannot be
moved.
When forced backwards the heel projects
very much. I have never seen
but one such a case. A lady cometing
down stairs very rapidly at the
cry of fire, hitched the heel of her shoe
by which the ancle joint was violently
forced backwards & dislocated.
But within a few day, I have seen
a case something like it; but it is accompanied
with the fracture of the tibia,
the internal malleolus being broken
off obliquely. In this case, the only one
I have ever had, or seen, I find great
difficulty in keeping the foot in situ.
#laterally,


Sprains. 216
I have contrived a splint which I am
in hopes will succeed.
When in consequence of force applied,
one of the bones is pushed against the capsular
ligament of the joint there is produced
a strain, a rupture, and sometimes
an effusion of blood. Violent pain takes
place at the moment of the accident &
continues for a long time. Between a
sprain & fracture you can always distinguish
by the absence of crepitus; and
from a luxation by the mobility of the
joint.
Treatment. I believe the affusion of
cold water over the part immediately
after the accident is the best remedy.
Afterwards apply flannel dipped in cold
vinegar & water. If it be the ancle joint


217 Sprains.
the patient must be put in a recumbent
position; if the wrists it is to be swung
in a horizontal sling by the side of the
body. This confinement is so disagreeable
that your patient is exceedingly apt to
rebel. I tell them that if it be a simple
sprain (inflammation) the symptoms will subside
in a few days. But if violent inflammation
& fever come on from carelessness, it
requires more of the same treatment to subdue
them: and therefore it will be best for
them to remain quiet till I think proper
for them to walk about.
I knew a lady which sprained her ancle.
She lay still a few days, & then supposing
that nothing but weekness remained
which would be relieved by exercise, got
up & began to walk about. This produced
an immediate swelling. She then lay by
a while under which treatment it grew
better. But getting a pair of crutches she
repeatedly tried this method.


Sprains. 218
After some time I was consulted, when
on examination I found an abscess of the
joint, & a caries of the os astragalus succeeded.
A hectic came on, and in spite of every
thing that Dr. Rush & I could do, so wasted
the lady that she died in about 9 months.
The Wrist is often sprained, especially
in washer-women, by wringing their
clothes.
Cold applications, bleeding with leeches,
rest &c. must be had recover to.
You must be cautious, however, about
applying cold water while a woman
is menstruating, which might suppress
the discharge producing many distressing
affections. Also in pulmonary affections
we should not apply cold water
For instance: if I should sprain my ancle,
I should not like to submit to this treatment
in my state. We must here employ warm vinegar
enveloping the limb in flannel clothes.


219 Morbus
The Hip Disease occurs to
persons of every age, but more especially
to children.
Lameness with loss of appetite, and
averseness to motion are generally the
first symptoms; though sometimes
pain & violent screaming attend,
which are periodical. I have known this
to happen with a child at the tea-table
without any apparent cause, or
when in bed.
A pain in the knee, in general
attends this disease; which is altogether
delusive, the disease being 
seated in the hip joint. Physicians
are sometimes led to believe from this
symptom, that the complaint is confined
to the knee, & have misapplied
their remedies.
Some pain however, is felt in
the hip-joint, and the affected limb
appears longer than the sound one
because the patient supports himself


Coscarius. 220
himself on the other, bending the pelvis.
The pain becomes more & more severe,
the nates lose their convexity, & we
now observe redness & tumefaction.
Fever comes on, suppuration succeeds,
& a projection of matter.
In some instances a dislocation
of the thigh bone takes place in consequence
of the formation of matter
in the acetabulum & accumulating
to such an extent as to push
out the head of the bone from its sockets.#
Now & then openings are discoverable
about the joint out of which is
constantly oozing a kind of matter.
Sometimes there is only one opening.
The bone is sometimes carious & can
be felt when a probe is passed into the
orifices. Hectic fever comes on at the
period & the patient suffers much before
he expires.
# The swelling of the parts within the acetabulum
is supposed to produce it sometimes.


221 Morbus
Sometimes a more favorable termination
happens; the bone being dislocated,
anchylosis takes place & the patient gets
well.
Treatment.
In purging, emetics, sea-bathing & the
various remedies for scrofula have
been used in this disease without effect.
Issues & blisters have been highly recommended
but they do but little good.
The best practice I have ever pursued,
was to purge actively with jalop and
cremor tartar every other day, & to
enjoin rest & a vegetable diet, and to
put on the long splint. Under this
treatment the health & strength of
the patient improve. After suppuration
has come on, little can
be done but to keep the sinuses open
till the dead bone comes out.


Coxarius. 222
I think I have derived some advantage
from issues or blisters applied behind
the trochanter. But upon the whole I
believe the purging & rest, either with the
long splint, or the patient kept on a
sofa constantly; the best remedy.
In the first stage I do not know that
it has ever failed. But when it has
advanced far, it will do less good of
course: But even here the application
of the splint, & the purging will allay
the pain & case the patient very
considerably.


223 Caries Of
Analogous to the preceeding affection
is the caries of the vertebrae.
In this disease Mr. Pott recommends
very strongly issues made with caustic
on each side of the projecting vertebrae.
I have seen them useful in a great
many cases, though not universally
so. For in some it has grown worse
& worse, and suppuration has come
on. I formerly used the steel splint &
issues in this complaint, but I have
found that the purgative plan is
equally successful when used in this
disease as in the morbus coxarius.
I have this day seen a case where
a stop has been put to the progress
of the disease by observing
the same treatment. It cannot
cure the curviture of the back,
for that depends on the absorption
of the bodies of the vertebrae.


The Vertebra. 224
I believe if we could be consulted
in the beginning of the disease, this
treatment would be as successful as
in the hip disease.
These remarks apply equally well
to the disease of the knee called the
White Swelling.


225 Injuries Of
1. Of the Scull. The head is liable
to all the different wounds that
other parts are subject to.
Incised wounds of the scalp require
no peculiar treatment from such elsewhere.
It is however particularly necessary
to remove the hair & extraneous
matter before approximating the sides of
the wound. The old surgeons were in the 
habit of using sutures. I believe that in
simple wounds it is never necessary,
adhesive plaster being far better.
Dr. Washington of the U.S. Navy
says he has avoided shaving off the hair
& has made use of its tufts tied together
to retain the lips of the wound together.
I however should generally prefer
shaving it away.
In Contused wounds you will
find much advantage in applying an
emolient poultice, and when the


The Head. 226
inflammation subsides, or the sloughs separate
& the wound becomes clean and
in a healing condition approximate the
edges of it with adhesive plaster.
In punctured wounds vs. & other evacuations
are necessary. Generally you
can relieve the inflammation from
a puncture by the application of a
blister. But I have known inflammation
take place on the whole surface of the cranium
in consequence of punctured
wounds. Sometimes this is accompanied
with fever, and occasionally with
violent delirium.
I knew a consultation called in
such a case, in a large hospital to
consider whether the inflammation
had not extended to the brain or its
membranes, and had caused all these
symptoms.


227 Injuries Of
They all came to the conclusion that
this was the case, and that the perforation
of the cranium was necessary.
They however deferred it for a little while,
which completely undeceived them.
This gave me reason to believe that
no such thing had happened as they supposed.
For where the integuments of the
head one very much inflamed, you
never have inflammation of the duramater.
When that membrane is inflamed,
the integuments of the head
are never in a similar condition.
On this principle we derive the good
effects of blisters which by causing inflammation
of the integuments, diminish
the inflammation of the brain.
When the intestines are inflamed the
abdomen never is; and when the pleura
is inflamed the external parieties


The Head. 228
are uninflamed. And when you see
such inflammation on the head, you
may be pretty certain that the brain
is not inflamed. By applying a blister,
and by evacuating remedies, I have
always succeeded in removing the
inflammation of the head.
In some cases of punctured wounds, when
in the beginning there was much tension,
I have introduced a director in the track
of the puncture, and enlarged it; thus
converting a punctured into an incised
wound.
Sometimes the whole scalp is torn
off adhering only be the edges. Always
clean the scalp, remove all extraneous
substances, & replace it neatly. If carefully
done in most cases it will adhere. If
an abscess form, open it & granulations
will fill up the cavity.


229 Injuries Of
But I would recommend it to you
not to place the scalp in a state of tension
in applying adhesive plaster. Allow
an inch in every case for the swelling
from inflammation.
The Scalp when subjected to external
violence, is sometimes affected with
a severe pain which continues a
long time. The pain I speak of does
not take place till the inflammation
attending the accident has entirely
subsided, and the patient supposes himself
entirely well. On examining there
is no swelling nor soreness to the touch.
The pain at first is of a dull obtuse,
or stupefying nature. After continuing
a few weeks it renders the patient 
very miserable, & he experiences
a sensation of fullness in the head as
though it was ready to burst.
I have known it to continue for 5
years before it terminated. The appetite
and digestion are bad, & there is sometimes


The Head. 230
sometimes palpitation & fainty fits: and I
have known a case to terminate in
complete fatuity.
The first case I saw was in consultation
with Dr. Rush. A lady had
received a blow on the head from
which had originated all the mischief.
She was put on a low diet, was
bled, purged, had the hair shaved off
and a blister applied, but without any
benefit. This was all done before I
saw her. I was now desired to examine
if there was any thing wrong about
the head, but I could discover nothing.
I suggested to the Dr. the propriet of
making a crucial incision through
the part that had received the accident,
which was done accordingly.
After the smarting produced by
the incision had ceased, the pain was
put a stop to and never after returned.
I was very much encouraged by the


231 Injuries Of
success of this practice and I employed
it again & again. In several it succeeded,
but it failed in a number of cases.
In one case where the operation relieved,
the pain returned again in a
month. The evacuating plan was then
tried very faithfully but without effect,
Then opium, henbane, bark, arsenic,
mercury &c.
Mercury relieved the affection
for a little while, but was of no
permanent benefit. In a great number
of cases salivation could not be
excited.
Till within a few years I was so 
much discouraged, that I was obliged
to tell my patients that if the
incision did not relieve, I knew no
remedy.
The pain I found sometimes ceased
spontaneously, & always ultimately, though
it sometimes continued very long.


The Head. 232
I now begin to consider whether it was
not of the same nature as the tic
doloreaux. Under this idea I began
a course of experiments with emetics.
I gave them to a lady thus affected &
continued them for some time under
the operation of which she was completely
cured. I have since employed
them with great success in other
similar cases.
I will now mention that in
the tic dolor. The emetic plan is
by far the best. 
You will probably have patients 
consult you in this disease. I
have even cut down & divided the
nerves without benefit.
Within the last year I have had
three cases & have had the pleasure
of curing them all by emetics. I
have given the antimonial medicine
as the best calculated to produce nausea,
& have continued it for some days.


233 Injuries Affecting the
Compression. Symptoms: Stupidity,
loss of sense & voluntary motion, nausea
& vomiting have been enumerated.
The pupils when you open the eyes and
expose them to the light remain in the
state they were at the time of the accident,
- totally immovable. It loses the
power of varying its shape with the variations
of light. There are in addition to
these, slow pulse, slow stertorous respiration,
cold extremeties &c. These symptoms
may take place in two ways: either from
a fracture & depression of the bone, or
from compression produced by extravasation
of blood between the scull and
the dura mater, or in the substance
of the brain. In most cases you will
find that the depression & extravasation
conjointly produce these symptoms.
When it occurs from depression
the symptoms are immediate. But
sometime must elapse before it can


Brain & its Membranes. 234
take place from extravasation. I will
state a case. A boy received a blow on
the head with a brick bat while at
play. He went into the house, told
what had happened & said he was
not hurt much. I was called in to
see him and while he was relating
the circumstances of the case, he became
insensible & stupid, and exhibited
the symptoms of compressed brain.
I immediately applied the trephine &
removed the extravasated blood which
restored his sensibility at once.
I am next to mention to you
that cases do occur where the scull
is fractured and even depressed, so
as to press upon the dura mater
without the symptoms of compression
of the brain. But these are
somewhat uncommon.


235 Compression
Treatment. With respect to the
mode of treatment in accidents of this
kind, I would recommend it to you
when the bone is broken & depressed, &
there are symptoms of compressed brain,
to elevate the depressed portion immediately.
Mr. Pott says that in every instance 
where the scull is broken the
trephine ought to be applied. But
surgeons at this day disagree with
him and I, among the rest. It is
only the symptoms of compression
which can justify the perforation of
the cranium.
That kind of compression where
there is no mark to guide you in the
application of the trephine is the most
difficult.


Of the Brain. 236
In these cases you must be governed
by your knowledge of anatomy. Where
the symptoms are very urgent, but
no marks or bruises to indicate the
seat of the injury. I should recommend
to lay bear the scull & make a perforation
near the anterior inferior angle
of the parietal bone in the direction
of the middle artery of the dura
mater. If the accident be not
now discovered, do the same on the
opposite side, in the same direction.
I know that this may not be successful
for the effusion may be in some
other place, or in the brain. When the
latter is the case, the operation can do
no good. The effusion is however, more
apt to be in the direction above mentioned
than in any other, and the rule is
worth attending to.


237 Compression
To assist us in these cases, Mr Abernethy
has proposed a very ingenious
method of discovering the exact place
of the extravasation. It is to denude the
pericranium & scrape the bone with
the projecting end of the scalpel. If
the bone does not now bleed, it affords
great reason to believe the
extravasation exists under that part
I do not think this conclusive
though it is worth attending
to. If however the bone bleeds, you
then are pretty sure, that the
extravasation does not exist under
that part.
This ingenious idea of Mr. A.
was suggested to him, in reflecting on
the vascular connection subsisting between
the dura mater & the scull; a
great part of the blood, being derived


Of the Brain. 238
derived from the dura mater, so that if
the connection between the scull &
that membrane be destroyed, it is
naturally expected that there will be
a deficiency in the quantity of blood
which the bone receives.
Operation. 1. Cause all the hair
to be removed: first cut it off with scissors
& then shave close; to give an opportunity
of examining it. Sometimes
the nature of the accident is such that
the injured bone is rendered obvious
being fractured & the fragments
beat in. But at other times there is
nothing more than a contusion to be
seen: even this is sometimes wanting.
It is necessary that you should be
able to discriminate between a simple


239 Compression
contusion & a fracture of the bone,
when injuries of the head occur.
When you examine a contusion of
the scalp, you will find it soft & pappy,
& it will be surrounded by a hard ridge
which is liable to be mistaken for the
raggid margin of the broken scull
bone.
Now it is easy under some circumstances
to distinguish the cases, for
if there is no symptoms of compression
you will infer that the bone is not depressed,
that it is a simple contusion
of the scalp, & you will not by any
means cut down to the cranium.
You might think perhaps that cutting
down to the bone could do no hurt
even if no fracture or compression
did exist. But here you will be mistaken;
for you hazzard an exfoliation


Of the Brain. 240
of the bone & a tedious ulceration.
The rule is never to operate even if you
know the bone to be fractured, and
depressed; if there is no symptoms of
compressed brain.
If I were called to such a
case I would not operate. It is the compression
alone, which demands the
operation.
You would suppose from what is
said in books, that the incision down to
the cranium is very simple; for they tell
you to make a free incision. Now this is
never to be done. It is not so simple as
represented. By such boldness the knife
has entered the fissure of the fractured
bone, pierced the dura mater, and has
been attended with fatal consequences.
I always cut down to the cranium


241 Compression
very carefully, and then oppose the back
of the scalpel to the bone & run it along
so as to avoid all danger of entering
the track of the fracture.
The head of the patient must be
placed on something hard & resisting.
The operation cannot be performed
with the head on a pillow, where it
is generally found when the surgeon
is called, but a block must be procured.
You will next find it necissary
to make preparation for the operation
by providing yourselves
with sponges, warm water, needles &
ligatures. Next a good scalpel, with
a projecting end; a rugie to scrape
the bone if necessary. Next a cylindrical
trephine. It is right to have
spaces or interruptions in the saw


Of the Brain. 242
to let out the saw-dust. Also the sliding
centre-pin of Dr. Physick. The old method
was to have a centre pin which was to be
removed by a key. It always projected 1/4 of
an inch, and as it is necessary to continue
it till the teeth of the saw are
steadied in the bone, there was danger of
perforating the scull in some cases before
you could remove it.
Next Mr. Hey's saw with a flat
and circular edge
There is another little instrument
which you must not forget; - a tooth
pick of quill to examine the depth of
the saw track.
Next a lever or elevator. The Lenticulare
of the old instrument case to cut
of the projecting spiculae from the
tabular vitrea, & to receive them in the
cup attached to it is an useful instrument


243 Compression
instrument; as is also a pair of forceps used
to lift up fragments of bone.
2. Make a simple incision four or five
inches long used with the end of the
scalpel scrap away the pericaranum.
3. Apply the centre pin of the trephine
& by a semi-rotatory motion make
a groove large enough to steady the
instrument: then remove the centre-pin.
4. As soon as you have arrived at the
diploë, use the tooth-pick, to examine
whether the bone is perforated; & this examination
should be frequently made.
5. Never be in hurry. It is not
the coursest operation in surgery
by any means; but on the contrary
where a good share of nicety
is requisite. It is one where a puncture


Of the Brain. 244
puncture of the dura mater will prove
fatal.
6. Never think of cutting through
the inner table of the bone. I never
want to do it; but as soon as I come
to the diploë, I try the elevator to
see if the portion enclosed be not
loose, and examine frequently with
the quill if the bone is not perforated
in some places. So far from
sawing the bone out, I only use
the saw to enable me to break a
piece out.
You would think if the bone
were not cute through, there
would be a great many spiculae.
But the projections of the bone
are on the part removed. And if
there should remain any spiculaes you
can easily break them off with the
elevator, & you will be certain


245 Compression
that the dura mater is not injured.
If the blood be fluid it easily escapes
if the perforation be in the right place,
on lifting up the bone, & the symptoms
of compression immediately cease.
If the blood be coagulated the clots
may be removed with a spatula.
In cases where the extravasation is
under the pia mater your operation
will do no good. But sometimes
it is under the dua mater which rises
up in a tumor which you would
be tempted to puncture. Now this ought
not to be done unless the symptoms
are so violent that the patient cannot
survive without.
This tumor will rise during
expiration & fall during inspiration, in
the same manner as the brain.


Of the Brain. 246
I have never seen puncturing the
dura mater to let out either blood
or successful. It has always
proved fatal ultimately, though it
might give temporary relief.
That cases have proved successful we
have the testimony of authors; but
I have never performed the operation.
Cautions.
Never proceed to perforate the
cranium till you have unequivocal
symptoms of compression. Merely
stunning is to be distinguished from
compression.
I once saw a man who fell
& experienced some stunning, and exhibited
considerable stupor. He was
carried into a hospital where the surgeons
seeing an indentation on the


247 Compression
back part of the head which had
previously existed, supposed that the
bone had been fractured & driven in
at the time of the accident. They therefore
applied the trephine; in doing
which they punctured the dura mater,
& he died the 4th day in consequence
of this needness operation. Dr. Dorsey
saw a similar case when he was in
Europe.
Thus we are to keep in mind this
irregularity of the scull in certain cases,
& act accordingly.
I said that puncturing the dura
mater to let out blood had in every
case which came under my
notice proved fatal. But the dura
mater & the brain have both been
wounded without fatal results.


Of the Brain. 248
And Dr. Washington says he has seen
a ball which continued in the substance
of the brain, seven months.
I saw a child which had been
crushed by a beam, the head broken,
the dura mater ruptured; and I distinctly
saw a portion of the brain
which had been squeezed out and
lodged among the hair. Yet remarkable
as it may appear, the
child recovered.
Extraneous matter exists for
some time in the brain before
the fatal result takes place.


249 Inflammation
The brain & its investing membranes
may become inflamed in consequence
of a fracture of the scull, and almost
any injury done to the head.
When it comes on in consequence
of injuries of the head, the symptoms
are not immediate. It generally
does not make its appearance
till 6 or 7 days have elapsed.
I have known a case in which the
inflammation did not occur till
7 or 8 weeks; and in another not till
12 months had supervened the injury.
The symptoms are of a febrile
kind. It comes on with great restlessness;
the patient gets scarcely any
sleep; he experiences nausea, vertigo,
or giddiness; has a quick hard pulse,
much fever & sometimes convulsions.


Of the Brain. 250
When contusion exist, the part is
soft & pappy. If you divide the scalp,
the bone appears a dull white as in the
dead subject.
If there have previously been a
wound of the scalp, it may have been
suppurating, granulating & doing very
well, when all at once the granulations
become flabby, give way &
a sanious discharge takes place.
Upon examining you find that
a separation both between the pericranium
& the scull, & between the later
& the dura mater internally, and
matter is sometimes found under the
scull. These [illegible] idea of Mr. Pott,
That inflammation exists on the scalp
& dura mater & bone at the same
time, is certainly incorrect.


251 Inflammation
For as soon as inflammation of the
brain happens, where there is a
wound of the scalp, I have already
said that the suppuration & granulation
cease.
Inflammation is produced by,
and frequently depends upon the force
of percussion. When this has happened
& the above symptoms occur, we have
no doubt but that inflammation
has actually taken place.
In every injury of the head the patient
should be put on a low diet,
be bled & purged; but in inflammation
of the brain these must be carried
to a great extent. The patient
should be allowed nothing but
bread and water.
You will find that patients


Of the Brain. 252
reluctantly submit to this treatment
in common cases: and it is a fact
that they generally recover from injuries
of the head, though they take
no care to avoid inflammation.
This is more particularly the case
with children, which every now &
then receive knocks & blows on the
head. But even here it often becomes
the foundation of hydrocephalus.
Children after these accidents frequently
have intervals of screaming, and put
their hands to the head. I had myself
a case of this kind a few days since.
I prescribed vs. purging, low diet &c,
& I have had the pleasure of seeing the
symptoms subside. I have no doubt
if this practice had not been pursued,
that the child would have
had hydrocephalus.


253 Injuries Of the
But sometimes in spite of all that we can do
inflammation will take place & matter form
producing the symptoms of compression.
Here we are to apply the trephine immediately
to the injured part.
But sometimes the pus is seated
under the dura mater; and you would be
tempted to open & let it out.
I believe fungus cerebri is a part of the substance
of the brain squeezed out in consequence
of pus deposited in the brain: for
the cranium cannot contain both pus &
brain & hence it protrudes the latter out.
Surgeons do not agree in the treatment
of this disease. Some recommend the cautery,
& others to cut it off.
Now I believe that we ought to evacuate
the pus; and I should not hesitate
to introduce a lancet 3/4 of an inch into the
substance of the brain to open an abscess
& let out the matter. Nothing else


Brain & its Appendges. 254
will do; and if this fails the patient will
die. This is not a new thing, - some of
the French surgeons recommend it.
Of the cases of chronic affections of
the head I will relate one.
A sea captain came to this city in
June 1809 who had received an injury
of the head nearly a year before.
He had convulsive fits & severe headache.
Bleeding & purging was employed: and as
he had fell I cut down & observing a
roughness in the bone, I expected that the
inner table might be in the same condition
as the bone externally. Applying
the trephine & removing a piece of bone
relieved for a while the symptoms, though
in consequence of the induration of the dura
mater it was difficult to separate the
fragment from it. He however died
in a few days; when on examination


255
the dura mater was found nearly 1/2
an inch thick, and the brain in a state
which indicated the speedy formation
of pus
Hemorrhage.
Some times in opening the cranium some
blood vessels are opened and it becomes
necessary to stop the effusion. When the
bleeding is from the sinuses, it is stopped
by lint held on the wounded sinus which
allows the blood to coagulate. The artery
of the dura mater is stopped in general
in the same way. I would never recommend
to take it up with a ligature. I
think a dossil of lint placed in the sulous
in the bone would be successful, & I
would employ a number of assistants to
keep this in for 24 hours before I would
take up the artery.


Of Concussions. 256
Concussion. This is supposed to be a violent
jar communicated to the brain by
external violence, independent of any lesions
of that organ whatever. If the force be so
great as to produce instant death, we,
no doubt shall find little or no injury.
But if the patient survive the accident
a week & then die you will find the case
quite different. Contusion & rupture
of vessels will now be obvious.
The cause of death, then is not seen when
the patient dies immediately from the
instant cessation in the action of the heart
and arteries before an effusion can take
place from the ruptured vessels and
before the symptoms of contusion can
have time to supervene.
The same occurs when a violent blow
on the stomach puts a stop to life in
an instant.


257 Concussion
The symptoms of concussion are so well
described by Mr. Abernethy, that I
would recommend his work to your
notice. Ibid. also Dorsey's Surgery p.284
Vol. 1.
Treatment. The treatment in the first
stage consists in elevating the head and
letting the patient be undisturbed. When
you see the patient pale & ghastly, his
extremeties cold, & his pulse scarcely perceptible,
you would be very apt to
administer stimulants. But this should
not on any account be done. This is
the most favorable state to prevent
effusion.
In the second stage, or when reaction
takes place it becomes necessary to keep
the patient quiet and or a very spare
diet to open the bowels &c. But as soon
as there are any symptoms of inflammation


Of the Brain 258
inflammation, then you are to bleed very copiously.
When I first went to Europe I had
imbibed the opinion of B. Bell in
these cases I thought we ought to
give wine, volatile alkali &c. But seeing
Mr. Hunter's practice put me
out of the notion.
A man was brought into St. George's
Hospital who had received an injury on
the head; Mr. Hunter said it was a case
of concussion and prescribed bleeding.
What: bleed said I, for concussion of the
brain? Yes bleed him, and bleed him again;
bleed him to death if you can.
This copious depletion had a very happy
effect and the man recovered.
But fatuity and paralysis sometimes
came on in consequence of this affection.


259 Diseases of
I had a case of this kind in the Pennsylvania
Hospital. I could hardly get an answer
from him. I mentioned the circumstances
to Dr. Rush who prescribed mercury
supposing it to depend on effusion. I
salivated him & the affection subsided.
Some years after Mr. Abernethy mentioned
mercury in these cases. I think it no
more than just to mention that Dr.
Rush prescribed this remedy long
before Mr. Abernethy wrote
In hydrocephalus, improperly called hydrocephalus
externus, there is an accumulation
of water in the substance of the brain.
In this affection it occurred to me that
if I introduced a trochar obliquely between
the scull & dura mater for some
distance & then carried it into the brain
the seat of the water, so as to make a


The Brain. 260
valvular orifice, inflammation might be
prevented. I performed the operation in
this way several times in one child; drew
off a great deal of water without any
inflammation or any bad consequences
supervening. The water however again
accumulated successively till I became
tired of performing the operation &
the child at length died. A case of this
kind is mentioned by some gentleman
in the class as having been performed
lately. Now I performed it many
years ago. I failed it is true, but
others may be more successful; and
even I, might be so in other cases.
Hydrocele, as I shall tell you had
been cured by letting out the water
and I do not see why dropsy of the
brain may not be cured in some


261 Diseases Of
cases by letting out the water in the
same manner.
It is still necessary for me to mention
that the effects of intoxication and the
symptoms of compression of the brain
are so nearly alike that the perforator
has actually been applied if a slight
scratch or bruise be received by the
person fulling.
Now to distinguish these cases
you must pay particular attention
to the history of the case for some
hours before. The smell of the breath
can generally give you some light on
the subject.
I have even known a physician


The Brain. 262
make the same mistake supposing the
patient to be in a state of apoplexy:
And on recovering from his debauch
the poor unfortunate man has found
his head shaved & blistered, his feet sore
from the application of sinapisms,
& that he has been bled pretty largely.


263 Diseases Of
Inflammation. This may be seated
either in the eye-lids, the tunica conjunctiva,
or in the globe of the eye.
When the eye-lids are inflamed there is
slight pain, tumefaction, redness and a burning
sensation. The disease comes on frequently
in the night and is attributed to the bite
of some insect.
For this complaint, vs. is sometimes
necessary, though generally purging will
answer. Brandy applied as a lotion has
been recommended
When this disease is seated in the edges
of the eye-lids, it is attended with a viscid
purulent discharge which glues the eye-lids
together during the night. This disease
consists of an ulceration around the
roots of the eye-winkers, resembling tinea
capitis.
I judged this to be the case from those


The Eye 264
remedies proving most successful which
are used in that disease, and from this
circumstance that pulling out the hair
cures both cases.
Under this idea I have employed the
same remedies as in tinea.
St. Ives says it is easily cured by applying
to the ulcerated edges the lapis infernalis,
and then washing it with water
taking care to keep it from entering
the eye. I have used this remedy in some
cases with success. But the following
are also applied.
1. Unguent. Citrinum diluted with [illegible]
of lard. 2. Mer. Ointment. They should
be applied to the eye-lids night & morning.
But I have found most advantage
from washing the eye-lids with tar-water,
& applying the tar ointment M. & N.


265 Ophthalmia.
The next part of the eye we find inflamed
is the tunica conjunctiva. It is characterized
by severe pain, redness, & a copious secretion
of tears. The eye waters exceedingly,
the light is offensive; and the pain is of a hot,
burning kind. In some cases the pain is not
entirely confined to the eye, but extends to
the temples. The inflammation is occasionally
confined to one spot.
So great is the intolerance of light in
this disease, that the moment you go to
examine the eye the child (if such you have
for a patient) will close it forcibly & put
his hands over the eye-lids.
Inflammation sometimes extends over the cornea
and an extravasation of lymph takes
place between its lamina, & opacity is
the consequence.
The causes producing ophthalmia
are numerous mechanical & chemical irritants
applied to the eye, the vicissitudes of
heat & cold &c.


Ophthalmia. 266
The causes of ophthalmia may be arranged as
follows:
1. Irritating substances, inversion of the eye-winks
(trich.)
2. Acrid substances introduced into the eye or in
vapor.
3. Cold acting on a predisposition to the
complaint.
4. Strong light.
5. Frequent intoxication.
6. Scrofula, measles, variola &c.
I have seen two cases which were produced
by washing the eyes with urine while
the person labored under gonorrhoea.
Till these obstinate cases occurred, I did not
know that urine was ever used for inflamed
eyes, - a substance exceedingly acrid. What
is most remarkable one of these was a medical
gentleman.
The next seat of inflammation is the 
globe of the eye. The pain here is shooting


267 Ophthalmia.
and very severe.
When it is confined to the anterior chamber
of the eye, or in the anterior part of the
iris, ending in a secretion of pus, it is
termed hypopium. The pupil remains of
the same size in every stage. In general if
not arrested the sight is destroyed.
Treatment. 1. Remove exciting
causes if produced by irritation. Fix
the eye with a speculum & with a lancet
& a pair of forceps remove whatever sticks
in the eye. (such as filings, partials of sand &c.)
A linen rag wet & introduced on the end
of a probe will sometimes be successful.
Trichiasis arises, 1. From hairs turned
inwards & 2. from the ciliary cartilages
turned inwards upon the eye.
Several remedies have been successful
in this last case. The most successful


Ophthalmia. 268
is the one suggested by Dr. Dorsey, and put
to practice for the first time in 1810.
I have performed the operation several times,
and last summer in a gentleman from Virginia,
on both eyes, and where it had nearly
produced blindness, with complete success.
In operating never carry the scissors so as to
remove the puncta lacrymalia.
The best way of doing it is to take hold of
the external canthus of the eye lid with a hook
& then, with a pair of scissors cut off a suitable
portion of the tarsus.
For the treatment of ophthalmia the following
remedies must be employed;
1. Blood-letting. 2. Cups & leeches applied around
the eye-lids & temples, and if the inflammation
is still unarrested divide the vessels of the adnata
with the shoulder of a lancet.
But always subdue the febrile symptoms


269 Treatment Of
before you employ local bleeding.
3. Purging Mercurial cathartics are preferable;
together with nitrous powder & antimony.
External applications should be of the mildest
kind. The best is an infusion of the pith
of the young twigs of the sassafras, in cold
water, and dropped into the eye. It is mucilaginous
& sooths the pain very much.
Blisters applied to the temples or back of the
neck is useful in subduing the inflammation,
but eminently so when applied over
the eye itself.
The general & constitutional symptoms
having subsided but some inflammation
still left in the eye we may employ with
advantage the following Collyrium.
Rx. Acet. Plumb. gr. 5 Sulph Zinci gr. 3 Rx.
Opii Ʒij liquor pur. ℥4 m.


Opthalmia. 270
Mr. Ware recommends a watery solution
of opium to be dropped into the eye.
In some cases I think Ʒij of vinegar
a useful addition.
When matter forms in the eye the
evacuation produced by purging will generally
cause an absorption of it.
If it does not and ulceration must
take place make an opening through the
cornea with a cornea knife. But I
have always been able to cause absorption
by the above means. Should they
not, mercury is next to be resorted to.
Rules to be observed in the management 
of ophthalmia
1. Place the patient in a dark room
2. Restrict his diet to vegetables. All spirits
& fermented liquors are inadmissible.
It is customary to form an issue in the arm.


271 Ophthalmia.
Some cases of ophthalmia are of a peculiar
nature, as is evinced by their not yielding
to the common remedies, but to such as
would augment the inflammation in common
cases.
To illustrate this I will mention
the case of a gentleman who had been
bleed to the extent of 200 ounces, purged
frequently, blistered, scarrified &c. without
effect, the inflammation still remaining
obstinate. In this condition I gave him
for a collyrium the common tar-water.
On my next visit I found him much
better. I only applied it to one eye, but this
being attended with such good effects it was
used on the other, and it cured both in
a few days. Now this application in
a common case would have inflamed it
still more.
I believe these remedies cure by the strong
impression their counter irritation makes.


Unguis. 272
Unguis or ptergium is an enlargement
of the vessels of the adnata proceeding,
from the inner canthus of the eye.
The only remedy is to dissect it off; which
may be done by transfixing it with
a hook before using the knife
Opacity. 
In this complaint it has been usual
to prescribe acrid & stimulating applications.
Some have even blowed into
the eye pounded glass with a view of
grinding off the film as they term it
Now I consider all such applications
dangerous; for as the opacity
is the iffect of inflammation, it
follows that the opacity would be
increased by exciting it again by the
irritants intended to relieve the disease.


273 Opacity Of
It is a common idea that the matter is
on the outside, & can be cut, or scoured
off. But I have already told you that in
opacity there is always an effusion
of coagulating lymph between the lamina
of the cornea.
When there is considerable inflammation
remaining, I have seen
great advantage from puncturing &
unloading the enlarged vessels of the
adnata. You are then to give mercury
till a salivation is produced. Then
remit it, & when the action on the mouth
stops, administer it again so as to keep
up a gentle ptyalism for three months.
In one such case where the opacity
was so complete that no object could
be distinguished, this remedy was entirely
successful.
This was a lady whom I attended


The Cornea. 274
with Dr. Wistar. Thus you see that by
keeping the mouth tender for three months,
the cornea became as pellucid as ever.
I have always known it beneficial,
though I never saw it so completely
successful before the above case.


275 Fistula
The ductus ad nasum is liable to obstruction,
in consequence of which the tears
accumulate in the lacrymal sac.
By pressing with the fingers the tears
will regurgitate together with some mucus.
This is the beginning of the disease
and the patient suffers rather from inconvenience
than from pain. - the
eye being constantly watery especially
when much exposed to cold air.
In some instances however inflammation
is excited either from distention or from
exposures to cold; the obstruction then
becomes more complete & the tears are
prevented from passing per vius naturales.
Most generally vs. & purging will
subdue the symptoms: but sometimes
suppuration takes place & an abscess is
formed in the sack. It is here necessary
to make an opening into the abscess
with a lancet: and to examine


Lacrymalis. 276
the state of the ductus ad nasum with a
probe. If it can pass we remove the obstruction
as much as convenient & introduce
a stile to dilate the stricture.
In some cases the duct becomes
impervious and it is necessary to make
an artificial opening into the nose.
Mr. Pott recommended for this purpose
a curved trochar. But this breaks
the bone so much that it is not to be
employed.
Mr. Hunter used an instrument by
which he could cut out a piece of the
bone & make an opening which would
be permanent: - that of Mr. Pott frequently
closing up again.
Mr. Anel's probes I have used without
effect.
If carious bone exist after the operation


277 Fistula
operation it ought to be extracted.
Its the disease consists in a stricture
of the duct it must some way be
overcome.
For this purpose Mr. Weare's stile
must be introduced. You would be
apt to think that the stem of the stile
would prevent the flow of tears into
the nose; - and some physicians afraid
of this have ordered a groove to be
made to admit the tears to flow
freely.
Now this is a mistaken notion, &
I know by experience that they pass
along the stile perfectly well.
But Mr. Weare has omitted one very
important direction, and that is to
increase the size of the stile so as to
dilate the canal ultimately to its


Lachrymalis. 278
natural size which cannot be done
by employing the one first introduced.
To obtain the exact shape of the passage
I introduce a bagie of waxen materials
and drawing it out suffer it to cool &
carry it to the instrument makers to
get one of the same pattern. When this
has been worn a while a larger sized
one must be substituted in its place.
Never introduce the lancet so as to
cut the tendon of the orbicularis palpebrarum 
in your operation; but
carry it outwards & downwards.
If the sac is distended with pus it
is very easy & can hardly be mistaken.
But every now & then the patient
comes to you with a sore in the angle of


279 Fistula
the eye; and some operators attempt to
cut upon the side of the ulcer in this
instance they miss the sac altogether.
But you should carry the lancet just
within the lower edge of the orbit of the
eye & below the junction of the eye-lids.
Having opened the sac, and introduced
the probe put in the stile; - and as it is
apt to excite the curiosity of people to see
the head of the stile, & give occasion for
them to ask questions, it is best to cover
it with a small piece of court plaster;
or what is better dip it in black
sealing wax.
So long as the patient can empty the sac
with his fingers, it is best not to operate.
But when this cannot be done it ought
not to be long delayed.
But when the duct is completely obliterated,
the operation as performed by
Mr. Hunter must be had recourse to,


Lachrymalis. 280
the object of which is to make an opening
into the nose with a punch.
Operation. 1. Lay open the lachrymal sac,
2. Introduce a wooden spatula into the nose.
Then introduce the punch in a proper direction
and with a boring motion cut out
a piece of the os unguis. The punch then
comes upon the wooden spatula, which
defends the tender structure of the nose.
A saddler's punch if sharp will do as well
as any. Next bring the sides of the wound
together with adhesive plaster. It is an
operation however not frequently necessary.


281 Cataract.
This disease consists in an opacity of the crystaline
lens or its capsule obstructing the rays
of light in their passage to the retina.
A great many medicines have been introduced
in the treatment of cataract: at
the head of which is mercury.
Venesection, cupping & blisters have often
been employed. I wish I could say they
were effectual. 
In some recent cases originating from
injuries of the eye, mercury has proved
successful.
This remedy must be given till the
mouth becomes sore then suspend it till
it begins to get well, & then give it again &c.
for a long time.
But though we cannot often cure cataract,
there are several operations for removing
the opaque lens.
The oldest of these operations is couching.


Cataract. 282
In some cases however, the old operation produced
inflammation of the eye, gutta serena &c.
I believe the depression of the cataract the
very worst operation which can be performed.
It certainly causes gutta serena,
& almost always fails, notwithstanding what
Mr. Pott, Hey, Scarpa, &c. say in its favor.
The operation I have most generally performed
and which I prefer to every other, is
extraction.
To this I have now to except the operation
of Mr. Saunders as improved by Sir. 
Wm.. Adams.
The idea however was suggested by Mr.
Pott who observed that the lens was often
absorbed when broken down in the old
operation.
As soon as this mode of operation came
to be known Dr. Dorsey commenced with
it which at first was not so successful &


283 Cataract.
I began to think the operation inferior
to mine. But after a while he was much
more successful.
Sir Wm.. Adams has materially
improved the operation of Mr. Saunders
& I would advice you all to study
his work.
Operation. Before either the operation
of Saunders' or Adam's be performed
it is necessary to dilate the pupil to
prevent the iris from being injured
by the needle. The belladonna is used
in Europe, but the juice of the fresh
leaves of stramonium is employed here
with equal advantage. A solution of
the extract is also efficient. Neither of them
in some cases produces dilatation
of the pupil: and it sometimes takes
place in five minutes.


Cataract. 284
Adams introduces his needle posterior to the
cornea about two lines, and carries
it between the uvea & the lens, with the 
flat side before & behind. Then turning
the needle round so as to oppose its edge
to the lens, he moves it gently so as to
cut it in half. This requires a good deal
of nice management; for if you use
much force, you will depress the lens
without dividing it. If you find it
sufficiently soft you cut it up in shreds &
with the flat side of the needle push
the fragments into the aqueous humor in
the anterior chamber of the eye where it
will be speedily absorbed.
I have performed the operation several
times, and am very well pleased with it.
Where the lens is so hard that it cannot
be divided, push the whole of it into
the anterior chamber through the pupil,
and when you have got it there


285 Cataract
make an incision through the cornea &
extract it.
This he conceives is far better than the usual
method of extraction as performed
by Wenzel. In this instance the lens
being anterior to the iris, there is no
danger of its floating before the knife.
Sir Wm Adams makes the incision of
the cornea with a knife of peculiar
construction, and if not large enough
he uses another still broader at the
shoulders. And if this fails he employs
the scissors. I object to the use of the
latter instrument, because I have observed
the inflammation is always
greater than when a keen knife is used.
After making the incision through the
cornea, he has a delicate hook to draw
out the lens.


Closure Of the Pupil. 286
By this operation there is no danger of
wounding the iris & none of the vitreous
humor escaping. He places
the patient on the back when he operates 
and uses the bent wringed speculum
to keep up the upper eye-lid, &
to fix the eye, whilst the lower is held
down by an assistant.
Cheselden was the first who performed
the operation for an artificial pupil
The one now performed is an improvement
on his. Adams advises to make
the section larger than Cheselden. He
uses a very small, delicate scalpel.
It is to be introduced with the flat side
next to the lens: then bring it towards
you so as to divide 3/4 of the width of the
iris. If you fail in this divide it fibre after


287 Of Artificial
fibre, till of the proper size. He then
recommends to push the lens whether opaque
or not into the anterior chamber through
the artificial pupil. By this means it
is prevented from uniting.
I have never done this, but I have
used a circular punch-shaped forceps
which I have introduced after making
the incision through the cornea, with
complete success.
But when the cornea is opaque except
in some one part, as the side, or
above, or below, I have employed
an operation which I claim as my
own invention. It consists in introducing
the cornea knife in the
transparent part then, retracting it
a little to let the aqueous humor
escape, and then carrying it through
so as to complete the section of the cornea.
But this means a fold of the


Pupil. 288
iris which floats before the knife will
be divided & the artificial pupil formed.


289 Hydrocele.
This term is used to designate a collection of
water within the scrotum.
Of this disease there are several species
1. Hydrocele of the tunica vaginals testis
2. " Of the tunica communis, or cellular
membrane, envelloping & connecting the
spermatic vessels.
3. Encysted Hydrocele of the tunica communis.
4. Encystes Hydrocele of the spermatic
cord.
The hydrocele of the tunica vaginalis
testis generally increases very gradually.
When it appears suddenly it has been
imputed to the rupture of a lymphatic.
The encysted Hydrocele of the spermatic
cord might be mistaken for hernia.
But in the latter case the cord cannot


Hydrocele. 290
be felt all all; & besides if the tumor were
to be pressed above the abdominal ring, it
would instantly return on removing the
pressure. The water in some cases in this
species, extends as high as the abdominal ring,
& in one case I had reason to believe that
it extended within the ring along the cord.
I tapped & discharged the water without
injury. He was afterwards cured by a
mercurial course.
When anasarcous, small punctures may
be made if medical means are not successful.
The tunica vaginalis is sometimes ruptured
in hydrocel of that kind, & a rapid distention
of the whole cellular structure takes
place. And as blood is also effused from
some ruptured vessels, it gives to the scrotum
a purple appearance as if mortification


291 Hydrocele.
were coming on.
Dr. Shippen used to tell us, when I was
a pupil that he had cured a hydrocele
with a purge of calomel. I have never
seen calomel of any use when given as a
purge.
The usual & most successful method
of treating this disease, is to draw off the
water; and if it again accumulates, to
inject it some stimulating fluid to excite
inflammation, & thereby cause an obliteration
of the cavity.
Slight as this operation is, I have seen
mortification occur from it. This was
propably in consequence of the constitution
not being able to bear the least
irritation; as where this effect follows


Hydrocele. 292
the prick of a pin, or the scratch of an oystershell.
The patient should always keep
quiet & at rest for a day or two after
the operation of tapping to prevent the
inflammation from rising too high.
This though not absolutely necessary in
every case, is still the safest.
The testicle I have told you is generally
found in the inferior and posterior part
of the scrotum. But it may be in the
anterior & inferior part or in the lateral
part. In some recent cases I have
succeeded in bringing about an absorption
of the fluid by pouring cold water
several times a day, over the scrotum,
for the space of several weeks.
The old surgeons used caustic in hydrocele,
so as to cause a slough of the srotum
and the tunica vaginalis testis.


293 Hydrocele.
It was recommended by others to cut
into the tunic, & if thickened as it frequently
is in some old hydroceles, to cut
out a piece. In either of these cases the
operation was exceedingly severe.
Old Dr. Monroe recommended to tap
with a trochar and to leave the canula
in for a time, so that the introduction
of the air might excite the necessary
inflammation as he supposed.
Mr. Else about fifty years ago proposed
to apply the caustic in one spot so as to
penetrate through the srotum & into the
tunica vaginalis.
I never saw but one case treated in
this way, & that was in the Pennsylvania
hospital, by Dr. Rush. It produced the
usual burning pain of caustic at the time;
but it brought on such inflammation
& swelling of the scrotum as to render


Hydrocele. 294
his life very miserable. It likewise produced
a discharge of coagulating lymph, which
Mr. Else mistook for the tunica vaginalis
which he supposed to be eaten out. This
plan was not found to answered.
Pott's plan was to pass a seton through
the tunica vag. In a great many cases
this proved successful. But I once
saw it produce gangrene and death.
Sir Wm Earle about 30 years ago employed
injections into the cavity of the
tun. vag. test. by which it was obliterated.
Fluids were injected long ago by
a French surgeon; but they were so corrosive
as to produce too violent inflammation


295 Operation For
Provide yourselves with a good trochar,
a syringe adapted to its canula, Portwine
undiluted, sponges, adhesive plaster
and lint.
The patient is then to be seated with his
hands under the nates to prevent him
from dabbling them in your way.
Then with the left hand hold of the
upper part of the scrotum so as to render
it steady & tense, introduce the trochar
into the tunica vaginalis testis, carrying
it in so far as to be sure that it will
not slip out. Then withdraw the stilette
and suffer the water to run off.
which it will readily do by the Protraction
of the parts. When about one
half has run out, with the left hand
grasp the scrotum & pinch up a fold
of it, & of the tun. vag. and hold them
firmly so as to prevent the canula from
slipping out. After the water is evacuated


Hydrocele. 296
evacuated, the assistants holding the scrotum
as above directed, you proceed to inject 
into the tunica vaginalis, a sufficient
quantity of wine to distend it moderately.
The wine generally causes some pain in the
loins, sometimes nausea, and I have seen it
produce fainting; but no pain is felt in the
part itself. I leave the explanation of this
to your ingenuity. When it has been in
sufficiently long, suffer the wine to run
out through the canula, put a piece of
lint on the puncture, and an adhesive
strap over this, and put the patient to bed
directing him to lie on his back, with
the scrotum raised & kept up by a cloth or
cushion to prevent it from being stretched.
In a few days it will generally swell, become
red & painful: this is a very sure sign that
the operation will be successful. It rarely
ever fails indeed, so that I generally tell


297 Extirpation Of
my patients that it is the easiest & safest remedy
that can be. I have cured a case by
affusions of cold water over the parts
when the operation has failed. If both
of these remedies should fail, then employ
the operation of Mr. Hunter, which I never
knew to fail.
In speaking of inflammation of the mamma,
and mammary abscess, I mentioned
that schirrous tumors frequently continued
after the inflammation had subsided.
I stated that vs. purging, blisters,
mercury & mercurial frictions generally
succeeded in curing it. But when
we cannot get rid of the tumor by these
discutient remedies, as no one can tell
its latent tendency, the best & safest
practice is to extirpate it.
I have known a tumor of this kind


Schirious Breast. 298
continue harmless for twenty years, and
then all at once inflammation took place
and a fatal termination succeeded in six
weeks.
Sometimes young ladies have tumors
of the breast which cause no inconvenience,
therefore they pay no attention
to them. But about the time of the cessation
of the menses they become cancerous.
I always recommend their extirpation
and I have never known a cancer
follow when the tumor was confined to
the breast alone. But when the glands
in the arm-pit become affected we are
not so sure that the extirpation of the
tumor of the breast and axilla will be
successful: because contamination may
have taken place further than we can
feel or cut.
I always tell them that I cannot
promise certainty of success.


299 Extirpation Of
This to be sure is terrible to the mind
of a lady; but you cannot retain your
reputation without.
On the propriety of operating I would
observe, that if you cannot pass your fingers
above the indurated parts in the axilla,
decline the operation altogether. Never touch
it. They will ask you why cannot it be
extirpated? You had better tell them the whole
truth than to persuade them with false hopes
and gain the discredit of performing what
would be called a very cruel operation
without removing the seeds of the disease.
A lady once said to me, why will
you not operate? I will suffer you to
cut off one side, but only extirpate the
disease.
The answer is contained in the above
sentence.


Schirrous Breast. 300
Rules to be observed in performing
the operation.
If the external skin be hard, or adhere
at all to the tumor, cut it entirely
away.
We generally are to save skin enough
to cover the part after the operation.
But if discolored, purple, or adherent,
never let the saving of skin influence
you to leave it. Carry the
knife at least one half an inch beyond
the diseased part of the skin, so as to remove
all tincture, or disposition of the
disease to return.
The same is to be the rule in dissecting
out the breast also. After extirpation
in this way I do not, know that
I have ever seen cancer follow. But


301 Extirpation Of
I have seen a surgeon pride himself in
dissecting it out neatly, in saving the
skin &c. but this very neatness of dissection
has again given rise to the disease
which has proved fatal.
Operation. The patient is to be seated, the
arm raised, and the hair shaved from the
axilla. Then commence in the axilla and
carry the knife down the lower part of
the breast. Then make a second incision
to meet the first, so as to include an oval
space between. Next dissect off the adipose
matter from the tumor, and carry down
the incision anterior so as to expose some
fibres of the pectoral muscles. Then dissect
off the tumor from the pectoral muscles.
You would now be very much tempted
to cut off the tumor and dissect from
the axilla afterwards. But by doing


Schirrous Breast. 302
so you would commit a very gross mistake.
Instead of doing this, you will dissect
the skin open in the axilla so as to expose
the glands there, and reach the upper parts
of them. Be extremely careful in cutting
all away in the axilla.
By leaving the tumor adherent by
its vessels to the axilla, you have a handle
to take hold of, by which you can draw
down, the smaller ones situated in the armpit.
Never remove the breast till you have
tyed up the large artery which runs up
into the axilla, till you have tyed a very
strong silk or thread ligature above all
the indurated axillary glanys; (not an animal
ligature) then cut it off below leaving
the ligatures hanging out of the axilla. Then
bring the lower part together.


303 Hernia.
By the term hernia, in the limited
sense I want to apply it, is meant a
protrusion of some of the viscera which
ought to be included within the cavity
of the abdomen. 
The term rupture was improper because
there is always a sac of the peritoneum
inclosing the protruded viscus.
Hernia has been divided into several
species. Inguinal hernia, or Bubanocele, denote
a protrusion at the abdominal ring.
In the male it is called oscheocele or
Scrotal hernia, when the tumor descends
into the scrotum. Femoral hernia, Merocele,
or Crural hernia is used to designate
a protrusion under the crural arch or
Pouparts' ligament. When the protrusion
happens at the naval it is called exomphalos,
or Umbilical hernia: at any other part
of the abdomen Ventral hernia.
Hernia Cangenita is that where the


Anatomy of Bubonocele. 304
tunica vaginalis testis forms the hernial sac,
the testicle & intestine being in contact.
After removing the integuments, make a semilunar
incision through the tendon of the external
oblique muscle, extending exterior to,
and in the direction of the spermatic cord.
By dissecting, and turning the tendinous
flap inwards & downwards, you expose the
fleshy part of the internal oblique, which
goes down to be inserted into the lower part
of the linea alba. Dissecting this up, you expose
a triangular part of the transversalis:
which last being very cautiously dissected
and raised, we then have a view of the fascia
transversalis. Through this passes the spermatic
vessels, and constitutes the upper aperture of
the abdominal canal. From this aperture to
the opening of the abdominal ring is about
1 1/4 inch.


305 Anat. Of the Femoral Hernia.
As you see, the fascia of the thigh, where the
vena saphena enters, has a semilunar
appearance, and in the internal part there
is a space occupied by a lymphatic gland.
Internally between the iliac vein & the posterior
edge of the Pouparts' ligament there is
a weakened spot, through which the intestine
protrudes; over the neck of the sac,
from without, in a direction inwards
runs the epigastric artery; and from
within outwards, the spermatic cord.


Of Bubonocele. 306
A Tumor is observed to protrude for the most part
at the abdominal ring. Mr. Cooper has taught
us that it commences an inch and a quarter
above. The swelling is variable in size, being
smaller in a recumbent, than in an erect position.
Coughing & sneezing vary its size, and generally
except when strangulated it returns of
itself or with a slight effort when the patient
lies down.
The diseases likely to be confounded with
Bubonocele are, hydrocele, varicocel, swelled
testicle, venereal bubo, abscess, & Cysts upon the
spermatic cord.
The varicocele has the strongest resemblance
but you can feel the nervous tubes and with
your finger can cause the blood to pass up,
and when the finger is removed it will return
& distend them as before which is not
the case in hernia. Besides in varicocele
the convoluted appearance is evident.
If you grasp the tumor & desire the patient
to lie down, the hernia will not return into
the abdomen; but the tumor of varicocele will.


307 Causes of Bubonocele.
These are such as weaken the abdominal parieties,
or such as by violence force down
the contents of the abdomen. The abdominal
canal being larger in some than in others
gives them a greater predisposition to the
complaint.
The most frequent exciting cause is violent straining,
by which the diaphragm and abdominal 
muscles are brought into increased action,
as in lifting heavy weights, coughing, vomiting
straining at stool &c.
Treatment. 1. The first indication is
fulfilled by reducing the hernia, & the
2. by preventing its occurrence by wearing
a truss.
Bubonocele, as well as other species of
hernia may be divided into four different
kinds.
1. Such as is of easy reduction.


Treatment of Bubonocele. 308
2. Such as requires manual efforts.
3. Irreducible. 4. Strangulated.
So long as the intestine is allowed to remain
down strangulation will be endangered.
But great neglect takes place in this disease
and so long as it can be returned, especially if
the patient be a woman, the complaint
is not revealed.
In every case we ought to return the protruded
parts & apply a truss, if the case will
admit of it. This can only be done where
the hernia is reducible.
Retaining Bandages are of two
kinds Elastic & Non-Elastic. The elastic
are made of leather, the non-elastic of linen.
The best of the elastic bandages is a steel spring
covered with leather, to which is attached a
leathern strap by which it can be attached


309 Treatment Of
to the body. Thus constructed it is called a
truss.
After reducing the bubonocele, feel
first for the aperture at the abdominal
ring, and then place the pad of the truss
directly over it. If the truss is apt to rise
up, confine it by a bandage passed round
the thigh: and if it slip down confine
it with a scapulary. Never put the pad
of the truss below the abdominal ring.
For if it be applied to the os pubis, the
spermatic cord will be compressed, and
the protrusion of the hernia not at all
prevented. The compress of muslin
may be removed when soiled with perspiration
and a clean one reapplied.
The patient complains, sometimes, of excoriation
at first, and ought to keep quiet
& perhaps in a horizontal position. I have
observed that brandy is useful as a wash
to prevent it.
If the protrusion be on both sides,
two pads must be connected together.


Bubonocele. 310
To tell the size of the truss you want to
employ, pass a tape round from the place
of rupture till it comes back again. In
those who labor the truss must be tighter,
and of course they will be apt to suffer greater
inconvenience from it than those
who are sedentary.
The simple common trusses are better
than the ivory, potent, wire &c. and less
expensive.
After applying the truss, the person
should always walk about the room
to see that it keeps the bowels up.
You are to tell him at the same time
that whenever they do protrude while the
truss is on, he is to take it off immediately,
lest the pressure of it prove injurious.
In Young subjects, the truss sometimes effects
a radical cure; but very seldom
in adults.


311 Radical Cure
The ancients persuaded of the importance and
practicability of effecting a radical cure
of inguinal hernia, applied caustic over
the neck of the hernial sac, so as to produce 
adhesion. This often produced peritoneal
inflammation and death. And
when successful, the patient was exactly
as liable to hernia as before.
Next the cautery was applied to the
same part after removing the integuments.
This gave way to the Royal stitch
which consisted in cutting off the hernial.
sac & then with a needle and thread to
sew it up. This was also not effectual.
The Puncta Aurea, or golden wire
was then employed but without effect.
Regular practitioners failing in their attempts
to effect a radical cure of hernia


Of Bubonocele. 312
itinerant quacks took up the practice, and
in their attempts actually castrated male
subjects who came under their operations.
Though they seemed successful for some time
after the operation, the cure was not
permanent.
Dionis says some of these itinerants
had the faculty of removing the testicles
without the spectators knowing at all
what was done. "One of these fed his dog
with nothing else. He always lay on the
bed, or under the table of his master ready
to devour the luxurious morsel
the moment it was extirpated;
while the spectators would have sworn that
the man was in possession of all his
parts."
Upon the whole we should not expect
a radical cure if wearing the truss
2 years does not produce it.


313 Hernia
2. When from being long down, the increased
quantity of its contents, or from
tumefaction, the hernial protrusion
cannot be reduced with the same case
as usual; it is necessary to resort to the
taxis, to keep the patient at rest, to bleed
him and open the bowels. If the taxis
should fail at first when we have employed
the other remedies, in a few days
it will generally prove successful.
3. Irreducible Hernia. By this
term is designated that kind of rupture
attended with adhesions to the sac & the
latter to the parts in contact with it.
The bowel confined and pressed open
for a long time by a truss which does
not completely keep it up, or by a suspensory
bandage adheres to the contiguous
parts. For this there is no remedy.


4. Strangulated Hernia. 314
Symptoms. Obstruction of the bowels; at least
no passage from above the stricture; tumor
tension & pain; nausea; vomiting of the
contents of the stomach, and even of foeces
sometimes succeed; &c. Sometimes the stricture
is so great that the blood is obstructed
through the veins, which become of a
very dark color; and it is possible
for the stricture to be so great as to
obstruct the passage of the blood altogether,
when mortification takes place
Pott says he has known a patient
die in a few hours; while others with
the same symptoms have continued
for some days.
When death is approaching the
pain ceases & the patient thinks that
he is getting better.


315 Strangulated Hernia.
Hiccough; cold & clammy sweats; cold
extremeties; ghastliness & a sunken
pulse denote the rapid approach of
death.
All of these symptoms occur from
a stricture either at the upper or
lower aperture of the abdominal canal,
according to Mr. Cooper. The
former he believes arises from
spasm in some cases. For when
the intestine presses against the internal
oblique & transversalis muscles,
they become irritated and excited
into action & press forcibly upon
the hernial sac.
I have generally found the stricture
at the abdominal ring, and have never
(known) seen it arise from spasm
at the inner opening.


Treatment Of. 316
The great object is to replace the protruded
parts, except when in a state of mortification.
For as long as the stricture remains
the patient must be considered in danger.
In attempting to replace the protruded
bowels we must place the patient in a horizontal
posture with the buttocks raised higher
than the head, and the legs drawn up with a
view of relaxing as much as possible the
abdominal muscles. Then apply the hands
pressing upwards & outwards.
If the taxis should not succeed at first
it may often be successfully repeated after
the use of the warm bath, or bleeding.
Vs. should be employed very freely, even ad
deliquum animi in some cases. During
this state it may be reduced of its own
accord, or it is frequently easy to do it on
applying the hands. Sometimes by emptying
the contents of the tumor we can readily succeed.


317 Treatment Of
If this fail the warm bath at 98° must
be employed. Keep the patient in till he
is fainty, and at the same time use the
taxis.
I have been in the habit of giving
a moderate purge and I think with advantage
Crem. Tart. & Jalap and a little
ol. mint answer very well.
Purging glysters if they produce sickness
and vomiting ought to be omitted.
In old hernias where there is reason to
believe the strangulation arises from the
foecal contents of the protruded bowel, &
in omental ruptures you will find benefit,
but not, in recent cases.
An infusion of tobacco in clyster is
sometimes employed. If sickness do not occur
in half an hour it may be repeated.
Mr. Cooper relates the case of a girl in
which it proved fatal in 35 minutes.


Strangulated Hernia. 318
Death was preceded by a foecal discharge
by vomiting smelling strong of the tobacco.
Upon the whole I think it far more
safe even in adults to use a suppository
of tobacco which in most cases will
produce all the debilitating effects you
can desire. A string should be attached
to it by which it may be retracted
the moment your ends are accomplished.
In one case I saw alarming effects
produced from the infusion. The sphincters
were relaxed and the greatest prostration
brought on and I was glad to
wash out the tobacco with warm water.
The tobacco clyster is the most efficient
of all the remedies in hernia; though it
is not always successful. Mr. Hey says
it discovers to us sooner than any other
whether the operation will be necessary.


319 Treatment Of
Cold is the next powerful remedy. Ice is
sometimes used: as is also sal ammoniac
and nitre in cold water.
Opiates are almost always useful in
allaying the vomiting and sickness.
I once succeeded in an old gentleman
by giving 3grs of opium at night and
by raising the lower posts of the bedsted. 
He slept soundly and the next morning
he found to his great joy that it
was reduced.
Before operating make strong pressure
with both hands. If all these fail
then an operation becomes necessary;
which consists in dividing the strictured
parts.
The exact time it should be performed
is not quite certain. I believe it a


Strangulated Hernia. 320
good rule to do it as soon as the above
remedies have failed, and always before
soreness of the abdomen has taken
place. If deferred too long mortification
will have taken place and the operation
will fail.
Surgeons frequently put off the operation
because they do not know the
structure of the parts. These parts you
must understand, and you are to proceed
to the operation with as much deliberation
and as little perturbation as carving
a chicken.
The signs of mortification are delusive.
After vomiting, hiccough and
cold extremeties I have known the operation
successful.


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