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THE

LECTURES

SIR ASTLEY COOPER, BART. F. R. S,

SVRGEON TO THB KINO, &c. Sec.

ON THE

PRINCIPLES AND PRACTICE

* Wflergi ;

WITH

ADDITIONAL NOTES AND CASES,

FREDERICK TYRRELL, ESQ.

SURGEON TO ST. THOMA»'s HOSPITAL, AND TO THE LONDON

OPHTHALMIC INFIRMARY.

VOL. III.

LONDON:

PRINTEJ) FOR W. SIMPKIN AND R. MARSHALL,

stationers' hall court.
1827.

PRIMTBD BY 8. H0LD8W0RTH,
60, PatCroofter Row, fiOndoo.

CONTENTS.

LECTURE.

XXXI.

XXXII.

XXXIII.

XXXIV.

XXXV.

XXXVI.

XXXVII.

XXXVIII.

XXXIX.

XL.

XLI.

XLII.

XLIII.

XLIV.

XLV.

PAGE.

On Hernia 1

On Irreducible Hernice . . 17

Account of the Operation
continued ..... 48

On Femoral Hernia ... 84

On Umbilical Hernia . . 107

On Wounds 149

0;^ Contused Wounds . .162

On Wounds of Arteries .181

On Wounds of Veins . . 205

On Wounds of Joints . . 250

On Dislocations .... 270

On Dislocations of the Elbow 326

On Dislocations of the Hip 363

On Dislocations of the Kiiee 43 1

On Dislocations of the Ankle 47e3

ERRATA.

Page S, line 28, /or lamina, read lamina.

Page 64y line 24 au<l 25, for the seat of strictare, read the stricture.

Page 80| line 15, for pioas, iliacas interaas, remi pectineiu,

adductor longus.
Pago 118, line 16, for round, r«a<f wound.
Page lt4| line 22, for mniclet, read muscle.
Page 101, line 8, for head, read hand.
Page lOS, line 0, for ulcerated, read ulcerative.
Page 802f line SO, for can, read cannot.
Page 817, line SO, for scapaln, read scapula.
Page 820| line IS, for crepitas, read crepitus.
Page 80P| line 20, for faeture, read fracture.
Page 470, line 1, for Bayer, read Boyer.
Page 4749 line It and 90, for maledns, reitd malleolus.
Pagi 478, line 8, ditto ditto.

LECTURES,

SfC.

LECTURE XXXI.

ON HEKNIA.

This, of all the diseases to which the human import-
body is liable, demands, upon the part of subject,
the surgeon, a large share of anatomical
knowledge, great promptitude and decision,
and the utmost s|e91 and dexterity in ^tfae
performance of ?in jB^ieration, when it is ren*
dered necessary,' by a defeat of the means
employed {0 its deduction. In other impor-
tant cases; ^coilsultations may be held, or the
patient he sient to a distance to obtain the
advantage of the test opinions ; but in hernia
the fate of the patient is decided almost upon
the instant, and an hour's delay may turn the
scale of success against the surgeon, and
% destroy the prospect of safety on the part of
the patient.

VOL. iir. B

DtfiniUoB. A hernia is a protrusion of any viscus from
its proper cavity ; but the term is pryicipally
applied to the protrusions of the abdominal
viscera, to which it is at present my intention
to confine my description.
Abdomen The abdomen is particularly liable to such
lyiuweto protrusions, on account of the moveable state
traiiont?' of its viscera, of the natural openings from it
to give passage to blood vessels, and unna-
tural apertures from deficiency of structure,
and from the great changes in bulk to which
the omentum and mesentery are subject; so
that instead of being surprised at the fre-
quency of its occurrence, it might be expect-
ed , from a knowledge of anatomy, that it would
occur in many more instances than it does.
iMiril* ^^ There are several genera of abdominal
hernite; four of which, however, are more
frequent than the others ; viz. the inguinal,
the femoral, the umbilical, and the ventral ;
but bcfiide these, there is a hernia through
the iMchiatic notch, one through the fora-
men ovale, a pudendal, a perineal, a vagi-
nal, occraNionally a protrusion takes place
thrr)Uf(h tho diaphragm, die kidneys have
heon (bund in a swelling in the loins,
mul thc) NniiiU intestines have been seen
lietwtidu tho laminit' of the mesentery and
ninNocutlon ; but, to tho two latter, the term
\umm IN NiJurooly Ntriclly applicable.

Of Inguinal Hernia.

Of this hernia, there are four different onngamai

hernia.

species : —

1. The oblique taking the course of the Spedcs.
spermatic cord.

2. The direct descending from the abdo-
men immediately through the external abdo-
minal ring.

3.. The congenital, or a protrusion into the
tunica vaginalis.

4. The encysted hernia, composed of a*
bag and protrusion suspended in the tunica
vaginalis.

Before any hernia is formed, unless in contained
wounds, laceration, or deficiency of structure,
a bag of peritoneum precedes the protruded
viscera, and forms a sac in which they are
contained, and which is usually called the
hernial sac. This protrusion is somewhat
thicker than the natural peritoneal lining of
the abdomen, the pressure of the viscera
leading to an interstitial deposition into the
membrane ; it is not placed loosely in the
parts into which it is protruded, but it ad-
heres by cellular tissue to all the surrounding
structures.

B 2

in a sac.

/ t

Of the Oblique Inguinal Hernia.

This is also called bubonocele when seated
in the inguinal canal ; and, when it further
descends, is named scrotal ; as it takes the
course of the spermatic cord, it might well
be denominated spermatocele.

Before I describe the course and dissec-
tion of this hernia, it is necessary that I
should say something on the structure of the
inguinal canal, and of the course of the sper-^
matic cord«
e The spermatic cord first quits the abdo*
h men mid- way between the anterior superior
spinous process of the ilium and the sym-
phisis pubis; it here passes between two
layers of the fescia transversalis, the anterior
layer of which is fixed in Poupart's ligament,
whilst the posterior layer descends behind
Poupart s ligament, and assists in covering
the femoral artery and vein, and in forming
the crural sheath ; above the passage of the
spermatic cord, the tvro planes of this fascia
unite, and form a lining to the transversalis
muscle, extending as far as the diaphragm.
As the cord penetrates between these two
planes, which form the internal ring, a thin
layer of fascia unites it to the edge of each.
No part of importance is situated between

the anterior superior spinous process of the
ilium, and the point at which the spermatic
cord passes through the fascia transversalis ;
but between the latter place and the pubes,
the epigastric artery takes its course. This Epigastric
artery is situated from one-fourth to one- ^^'
half an inch upon the inner side of the inter-
nal abdominal ring, or passage of the sper-
matic cord, from the abdomen> and it passes
to the inner part of the rectus muscle. The
external iliac artery and vein are directly
behind this internal abdominal aperture, and
this opening is the beginning of the inguinal
canal, in which the spermatic cord is next
continued. j

The inguinal canal is bounded anteriorly Bounda-

rics of the

by a superficial fascia from the abdominal ingainai

canal

muscles, and by the tendon of the external
oblique ; posteriorly, by the fascia transver-
salis, and by the tendon of the transversalis
muscle ; above, by the edges of the internal
oblique and transversalis muscles, and be-
low by Poupart's ligament; the canal is
about two inches in length, and terminates
at the external abdominal ring.

The external abdominal ring is formed External
by two columns of the tendon of the external °^'
oblique muscle united by fibres from Pou-
part's ligament; the upper column is in-
serted into the symphisis pubis, the lower

B 3

column into tiie tuberosity of the pubes, the
pubes bounds the opening below; between
these columns the spermatic cord passes;
and from the edge of the ring, as well as
from the surface of the tendon of the exter-
nal oblique muscle, a thin fascia descends,
uniting the cord to the edges of the opening,
and passing down upon it to the tunica vagi-
nalis; this fascia is then situated between
the skin and the cremaster muscle ; which
muscle arises within the inguinal canal from
the internal oblique muscle; it descends
with the spermatic cord, and passes through
the external abdominal ring ; spreading over
the fore and lateral parts of the cord as far
as the tunica vaginalis into which it is in-
' serted.
sperniaUc Behind the fascia and cremaster muscle

coro.

the spermatic cord is found passing to the
testis ; it is covered by the tunica vaginalis, and
is composed of the spermatic artery and vein,
absorbents, and nerves, with the vas deferens
and an artery accompanying it.
Origin and The obliquc inguinal hernia first enters

coarse or ,

the hernia, the Upper Opening of the inguinal canal, or
internal abdominal ring, so that at its com-
mencement it is placed just mid-way be-
tween the anterior superior spinous process
of the ilium and the symphisis pubis, and
close above Poupart's ligament; it has the

spe^au^ord behind it, and the epigastric
artery to its inner side : when in the inguinal
canal it is about two inches in length, and
is covered anteriorly by the superficial fascia
of the external oblique muscle and by the
tendon of that muscle, the inferior edges of
the internal oblique and transversalis muscles
form an arch over it ; the cremaster muscle
covers it partially; it has a thin slender
covering ft'om the edge of the internal ring ;
the fascia transversalis, strengthened by the
tendon of the transversalis, is situated behind
it, and to its inner side \ and Poupart's liga-
ment is placed below it.

Having descended through the inguinal AppeBmi
canal, it next emerges at the external abdo- nai ring.
minal ring, and it is then usually denomi-
nated scrotal hernia.

Its increase being then much less re- i
strained than before, it descends on the fore r
part of the spermatic cord to the testicle,
at the upper part of which it usually termi-
nates.

Upon dissecting this hernia below the ex- '
ternal ring, there is found covering it ;— '
first, the fascia of the spermatic cord, de-
rived from the external oblique tendon and
the edge of the abdominal ring; this substance
is dense, and forms a strong covering, which
often been mistaken for the hernial sac ;
II 4

L has ofte:

when this has been divided, the cremaster
muscle becomes exposed, covering the fore
and lateral parts of the hernial sac. The cre-
miaster muscle is thicker than the fascia of
the cord, and its muscular texture is easily
distinguished in the living body. On cutting
through this muscle, and a dense cellular
tissue, the hernial sac is laid bare, united on
the fore part to the cremaster muscle, and on
the posterior part to the spermatic cord, rest-
ing below upon the tunica vaginalis of the
testicle.
Usual con- The usual contents of the hernia are either

tents of the . , -i* , i. . .

•«c. mtestme or omentum; if the former, it is

called enterocele ; if the latter, it is denomi-
nated omental, or epiplocele. In the young,
omental hernia is rarely met with, it being
generally intestinal, for this obvious reason,
that the omentum in the young subject
covers only the superior iabdominal viscera.

Varieties of Obtiqtie iHguiiml Hernia.

UkiP^Uk Prom the description which I have given
of thiiA hornia» it is clear that it may vary in
longtht tVom the upper ring to the testicle,
luul couHoquoutly that it is sometimes seen
(UHMipyinp: only the inguinal canal.

*m^Mmi»« ill Ht>uic cases the hernia is so large as

reach the knee, but in ge
does not exceed two fingers' breadth, and
barely reaches to the upper part of the
testicle ; its bulk depends considerably
upon the time which it has existed, upon the
degree of relaxation of the patient, and upon
his inattention to the disease.

tl have seen the pylorus descend to the Umuuii
tnouthof the hernial sac. The urinary bladder sions.
is also occasionally situated within it;* and
we have an excellent specimen in the col-
lection at Guy's Hospital, of an inguinal
hernia in the female, where the ovarium and
falopian tube are protruded into the hernial
sac.f

The spermatic cord is usually situated usuai

Biliiation ■

behmd the hernial sac ; but m one of the oftiie«per. i

• nr . r^. rr« • n<aticCOrd,J

preparations m the Museum at St. Ihomass "

Hospital, the cord is divided, the vas deferens
passing upon one side, and the spermatic
artery and vein upon the opposite side. I
have seen also the spermatic artery and vein

■ passing over the fore part of the sac, while

I the vas deferens passed behind it.

When the cacum or urinary bladder are protruded,
re is not a complete peritoneal sac ; but it is deficient
!jlt that part of cither viscus not naturally covered fl

t See hernia in the female.

Symjrioms of Inguinal Hernia.

DistiitcUon It is discriminated from other diseases by
diseases, the following marks : — it gradually descends
from the abdomen in the course of the sper-
matic cord : it usually protrudes in the erect,
and retires when the patient is in the re-
cumbent posture : it dilates upon coughing,
and upon all exertions of the abdominal
muscles : flatus may be often felt in it when
it is intestinal, and it retires with a gurgling
noise : when omental it has a doughy feel, is
much less elastic than the intestinal hernia,
and retires into the abdomen more slowly ;
the intestinal is accompanied with costiveness,
and with pain across the abdomen; the
omental rarely produces any disturbance of
the abdominal functions, when in the re-
ducible state ; the hernia of the bladder is
distinguished by the diminution of the
swelling during the evacuation of the urine.
The following are the principal marks of
distinction from the diseases with which it is
most likely to be confounded.
From hy- From hydrocele, by that disease beginning

urocele* ^

below, and gradually ascendmg, by its trans-
parency, by its fluctuation, its pyriform shape,
its involving the testicle, and by the want
of dilitation from coughing ; however, there

is an exception to this, if the hydrocele
enters the upper part of the scrotum,
when it sometimes dilates upon coughing,
and the only means of distinction are in its
history, its transparency, and its fluctuation.
From hydrocele of the spermatic cord, it From hy-

drocclc o^

is with great difficulty distinguished, unless the cord,
the hydrocele emerges from the external ring,
when its transparency indicates its true
nature.
Hydrocele and hernia are sometimes com- Hemia &

. . . hydrocele

bined in the same individual, of which there sometimc|i

combined.

is a beautiful specimen in the collection at St.
Thomas'sHospital ; a caseof this kind occurred
to Mr. Thomas Blizard, on which he operated,
and a similar one to Mr. Henry Cline ; in each
case the water was in the first instance dis-
charged, and then the hernial sac became
exposed behind the tunica vaginalis.

Hydrocele is also connected with hemia,
when there is water in the abdomen ; and I
have tapped a hernial sac in ascites for the
discharge of the accumulated water, and it
is the best mode of operating in such a case,
when it is quite certain that neither the
omentum or intestine are descended, and
that you can decide by the transparency.

Hemia is known from haematocle, by the From hie.

•^ matocele.

latter being usually the result of a bloy, and
by the ecchy mosis which at first accompanies

it, by its not extending to the inguinal canal,
by its not dilating upon coughing, by the
bowels being undisturbed, and by its not
returning into the abdomen.
Fromdis- Hemia is little liable to be confounded

eased tes-
ticle, with disease of the testicle, the history of the

swelling, its form, the distinctness of the
spermatic cord, the want of intestinal obstruc-
tion, the absence of dilitation on coughing,
and its not returning into the abdomen, are
sufficient marks of the latter disease.
Hernial I havc sccu, howevcr, diseased testicle

sac con- ^ '

nected to complicated with hernia, and have twice been

the sper- *

maticcord. imdcr the necessity of dissecting the hernial
sac from the spermatic cord, during the
extirpation of the diseased testicles. In one
case I opened the sac unintentionally in the
operation, but it did not prevent the patient
from doing well.

Acute in- The acutc inflammation of the testicle is the

flammation i • i t t

of the tea- only State which I have known confounded

tide, mis- .11.1 1 r ^

taken for With hcmia ; the tenderness of the part, the

hemia

swelling extending up the cord, and the
vomiting accompanying the disease, led to
a doubt which could only be removed by a
knowledge of the history and progress of the
complaint.
Fronivari- The discasc with which hernia is most
frequently confounded is varicocele, or en-
largement of the spermatic veins ; this is a

very common complaint, it occurs most fre-
quently upon the left side, and is supposed
to be founded in the termination of the left
spermatic vein, at right angles with the
emulgent. It sometimes dilates upon cough-
ing; it appears in the erect, and retires in the
recumbent position. It is distinguished from
hernia by its feel, (which resembles that of
a bag of large worms,) by its being unattended
with intestinal obstructions, by placing the
patient in the recumbent posture, and empty-
ing the swelling into the abdomen; then
pressing the finger upon the external ring to
prevent any visceral descent, by which the
free return of blood by the spermatic vein is,
obstructed, and the swelling re-appears when
no hernia could escape.

I have more than once known a truss ap-. Tnis« ap-
plied for this disease, and in one instance to varicocele,
the «on of a medical man, by his father.

Inguinal hernia occurs more frequently This hernia
upon the right side than the left, probably qnent on
because the greatest exertions are made of sWe.
the right side, from the preference we give to
the use of the right arm, two-thirds of inguinal
hernia are upon the right side.

Causes of Heimia.
The loose connections of the jejunum, \III^q^^^{

viscera.

ilium, colon, and omentum, giva a proneness
to the disease. The other viscera are rarely
found in hernia.

^enures. '^^^ natural apertures for the passage of
the blood vessels also lead to the ready
production of hernia.

Maiforma. Malformatious also give rise to hernia, as
when the abdominal ring is unnaturally large.
Some species of hernia are originating en-
tirely from malformation, as the phrenic and
ventral.

Increase of Great incrcasc of the omentum or mesentery

omentum ^ ^

ormesen- Jn obcsity Icads to hernia. Pregnancy pro-
duces it. Violent exercise frequently occa-
sions it, by forcing the viscera through the
apertures. Great exertions of the abdominal
muscles in lifting weights, more especially in
the stooping posture, is a common cause of
this disease, as also coughing or straining
violently. Flatulent food, and food difficult
of digestion, tends to produce hernia. Great
wasting of the body, by leaving the abdominal
apertures relaxed, is also a cause.

Thus, then, the parietes give rise to hernia,
by their formation, malformation, and con-
traction ; and the viscera by their pressure,
and from the changes they undergo, espe-
cially in old age.

cumate. The lax state of fibre, induced by a long
residence in warm climates, may also be

mentioned as pre-disposing to the formatioa
of hernia.

Of the Reducible Hernia.

A hernia is said to be reducible when it
can be returned into the cavity of the abdo-
men.

In order to put the patient into a state of Treatment,
safety, and to prevent a future descent, a
truss is to be applied. A truss is required for
the smallest hernia, as the danger from this
disease, is in an inverse ratio to the size of the
tumor.

Salmon and Ody's truss is most easily Salmon 4c

^ , ^ Ody's

worn, and most appropriate for recent and truss,
small hernia; but the objection to it is, that
it cannot be worn during the night, and there-
fore the patient requires one of a different
kind in bed. They are, however, excellent
trusses.
Egg's truss, and those of the common kind. Egg's

, truss.

are worn day and night, and make a steady
pressure on the part.
Hernia, very difficult to support, are best P»ndin's

iriiss*

prevented protruding by Pindin's truss, which
has no springs ; I have seen it succeed when
no other answered the purpose.

To obtain a truss, it is only necessary to
send the measure of the pelvis to the instru-

Effect of a
truss.

ment maker. The principle upon which the
pad of the truss is to press, is the whole length
of the inguinal canal ; that is, to reach from
the upper to the lower ring.

Will this cure me ? the patient inquires :
Yes, if he be young, assuredly ; if old, I have
known it do so in a few instances. How long
must I wear it ? to which the answer is, A
year after the hernia does not appear when
the truss is removed for a few hours, the
patient at the time taking his usual exercise.
Am I to wear it at night as well as by day ?
Yes, or you have little chance of being cured ;
and there is otherwise danger of strangula-
tion.

In consequence of wearing a truss, the sac
falls into folds, and gradually contracts ; but
more particularly at its orifice. If hernia be
complicated with hydrocele from the abdo-
men, both diseases are cured by wearing a
truss. 1

Danger of Giving up the use of a truss before the

leaving off . i ^ • j p

the truss, cure IS Complete, is very dangerous ; as from
the contraction and thickening of the mouth
of the sac, there is more liability to strangula-
tion. The shut sac of a hernia will sometimes
produce hydrocele by the secretion from its
inner surface.

LECTURE XXXII.

IRREDUCIBLE HERNIA.

It is SO called when it is uninflamed, but
does not return into the cavity of the abdo-
men; and it acquires this state from the
following causes : —

1st. Growth of the protruded omentum or Cansc*.
mesentery, rendering it too large to return
through the orifice of the hernial sac.

2nd. Adhesion of the omentum, mesentery,
or intestine, to the inner surface of the sac.

3rd. Membranous bands formed across
the sac by adhesion.

4th. Omentum intangling the intestine.

6th. . A protruded ccecum, in which the in-
testine adheres by cellular membrane behind,
and the sac exists only on the fore part.

6th. A portion of omentum suddenly pro-
truded, of too large a size to be immediately
returned.

Danger of Irreducible Hernia.

If intestine be protruded, it is sometimes Rupture of

-if 1-1 1 X intestine.

ruptured from a blow upon the tumor.

VOL. III. c

UabiUty There is a constant liability of strangula-

ution. tion from any slight additional protrusion.

Formatioii I havo known an abscess form in the pro-
of abuceu. , *■

traded omentum, and prove destractive.

Treatment of Irreducible Hernia.

Nothing can be done in some of these
To give cases, but to give support to the part by the
application of a laced bag truss. When itarises
from obesity, attention to diet, and to the
means of reducing the patient, may sometimes
succeed, for I saw a gentleman v^ho be-
came reduced from dropsy in his chest, and
had a hernia return, which had been for a
long period irreducible.

Apparently in irreducible omental hernia of
recent formation, I have known the application
of ice succeed when there was not any inflam-
mation proceeding, as far as could be ascer-
tained by the pain.

A physician who had an omental hernia irre-
ducible for a fortnight, had ice applied to it
tfarough the medium of a bladder, for four
days, during which period it gradually re-
turned. In another case the same treatment
was successful ; and it appeared to me that
the ice was serviceable, by occasioning a con-
stant contraction of the skin, and supporting
moderate pressure on the part.

Use of Ice.

OftkeStranvtiiated Oblique Inguinal Hernia.

When the parts protruded into the hernial ■?'
sac cannot be returned into the abdomen, and
the pressure is so great as to prevent the free
circulation of blood through the vessels of the
protruded viscera, the hernia is said to be
strangulated, and the following symptoms
are usually present.

The patient directly feels violent pain in s;
the region of the stomach, as if a cord were
bound tightly round his body ; and this is
followed by frequent eructations wlilch con-
tinue until the strangulation be removed ; —
there is a great desire for a fcecal discharge ;
but the person only passes a small quantity
of foeces from the large intestines. The
tumor feels hard, and if it be intestine which
has descended, it is often extremely tender
to the touch. Vomiting soon occurs; first
the patient throws up the contents of the
stomach, afterwards bile, which is regurgitated
from the duodenum ; and if it be a portion of
the large intestine which is strangulated,
fiscal matter is sometimes discharged from
the stomach, as the symptoms become more
urgent. The pulse is at first hard, and rather
quicker than natural.

On the next visit to the patient, the vomit- p
jog is more urgent, the coRtivcness remains, t

the abdomen is tense from flatulence, the
tumor is harder and more tender, the
pulse is more frequent, smaller, but still
hard.
Peritoneal Strangulation still continuing, the abdomen
tion. becomes extremely tender to the touch, on
account of the peritoneum becoming inflamed,
at the same time the pulse is very small,
thready, and frequent: in addition to the
other symptoms, hiccough occurs, the vomit-
ing and costiveness continue, the tumor be-
comes more tense, often is inflamed upon its
surface, and now and then the marks of the
fingers, when pressed upon it, remain.
Laststage. In the last stage, the pulse frequently
intermits, the patient is covered with a cold
perspiration, but his mind appears less de*
pressed, and as his pain is less, he has more
^expectation of recovery.
Expiaiia- With rcspcct to thcsc symptoms, the pain
symptoms, in the abdomcn, and the vomiting, are at first
sympathetic ; and the discharge of bile and
foeculent matter afterwards is kept up by the
anti-peristatic motion, which takes place
above that portion of intestine contained in
the hernia ; perhaps the valve of the colon
may in some instances be imperfect, by which
the vomiting of foeculent matter may be
accounted for ; the obstruction to the passage
of the foeces by the usual course, is prevented

21:

by the strangulation of the intestine; ^e
tension of the abdomen arises at first from
accumulation of flatus, and subsequently
from peritoneal inflammation, which also occa-
sioDs the tenderness of the abdomen ; the
hiccough has been considered as an indication
of gangrene ; but I have known operations
performed in many cases, after its appearance,
and the patients have done well, the contents
of the hernial sac not being found in a gan-
grenous state ; the tension of the tumor is
caused at first by accumulation of blood from
obstructed circulation in the part ; afterwards
it increases from effusion into the hernial sac,
in part of serum, and part of fibrin.

It sometimes happens just previous to the Evacuaiioni
patient's death, that he has evacuation from •'^»'''-
his bowels, and this probably takes place
from the tension of the aflTected parts being
lessened by the approach of dissolution.*

* I have iotroduced the following oase as presentiDg;
some unusual peculiarity respecting the evacuation from
llie bowels, during the continuance of the symptomH of
3trtnguiation.

Thomas Davis, a porter, aged tifty-nine, (who had
for two years been subject to hernia,) on Saturday, the
ISth of March, 1825, after making some unusual exer-
liODs, found that the swelling formed b^^the hernia had
much increased in dize, and resisted his repeated at-
tempts to reduce it. On Sunday morning, the 13th,
he experienced pain in (he tumor, unA in the abdomen,

va»^ The symptoms of strangulation do not
al¥fays continue equally severe; but for

which was soon followed by vomiting. In the erening, as
he did not get better* he apjdied to a sargeon in hia
neighboorhoody who for some time tried the taxis, but
ineffectoally ; in consequence of which he was taken to
St. Thomases Hospital. On examination, a femoral her-
nia was discovered on the right side, about the size of
aa egg, hard, and tender to touch. He was bled,
and placed in the warm bath, and when he appeared
hkat, the taxis was again employed, under which the
hernia became a^arently lessened, but not completely
di^ersed. As he was not perfectly certain of its being
quite rednoble before the existing symptoms, I was in-
dueed to nder an enema; and directed, in case of a
free disdiarge from the bowels after its use, that some
purgative medicine should be given by the month. He
had a copious motion from the enema, and in conse-
quence some |m11s of cathartic extract and calomd, were
given, after which, during the night, he had three more
abuidant motions. On the following morning, (tiie 14th,)
however, I found that the tumor had regained its former
magnitude and tension ; that it was very tender, as also
the abdomoi, and that he had hiooough, with occa-

lal vonuting. Under these curcumstances, after »
lurtlMr short trial of the taxis, and which made no im-
presaion upon tiie swelling, I performed the <yeratkMi>
The hernial sac was surrounded witii enlarged glands ;
it contained a little fluid, and a portioa of mtestine,
which was highly inflamed and peifectly incarceralBd.
This was bbe^iled and leplaeed in the cavity of the
abdoHMn without much dittculty, and the wound was
dressed as Qsuai.

In consequence of much tenderness of the abdomen.

short intervals the patient is often nearly free
from suffering, and then again the symptoms
become violent.

Dissection of the Hernia.

If gangrene has not taken place, a small Before the
quantity of serum is found under the skin, ment of

gangrene*

and in the hernial sac a coffee coloured effu-
sion of the same nature ; this is usually more

on preasure, in the evening, I ordered, Hirud, xxiv.
abdom* 7ot. Papavei is, et Tinct. Opii guU. xxr.

16th. Less pain and tenderness of the abdomen. He
had slept comfortably, (pulse 80, and feeble,) but he
was troubled with occasional sickness; the hiccough
had sabsidedr ordered. Mist: Efferr: pro re nata. c
Tinct : Opii gutt v« Sin. dos, tf the sickness continued.
At two o'clock he was seized with dyspmea and more
frequent vomiting, but had no increase of tenderness.
Ordered enema commun. c Oleo Ricini, and to continue
the mixture. The enema was repeated in the afternoon,
but did not produce any evacuation, and late in the
erening he died.

On examining the body after death, I found the pe-
ntoneum much inflamed^ and exhibiting marks of pre-
vious disease, there being old and firm adhesions. The
portion of intestine which had been strangulated con-
sisted of a complete fold of the ilium, including the
idiole diameter of the gut; it had still the mark from
the stricture upon it, and was ranch more discoloured
than any other part.— T.

c 4

abundant when intestine has descended, than
when omentum alone is protruded. The intes-
tine is of a dark chocolate brown, and has its
surface covered by a coat of adhesive matter,
by which it is in part glued to the hernial
sac, but not very firmly. Directly under the
seat of stricture, the intestine has suffered
particularly, and often gives way to very
slight pressure of the fingers. If omentum has
protruded, it is found red, and somewhat
harder than natural,
^irin^f*!!" W^^^ gangrene has taken place, the skin
iuH'Mrro«j. Qvcr the tumor is emphysematous, and retains
any marks made by the pressure of the fingers.
When the sac is opened, a highly offensive
wmoll is omitted, and if intestine be protruded,
it In of a deep port wine colour, and has on
itn Nurfuce numerous greenish spots, and its
tdxturo ifi so altered, that its surface looses
\tn brllliuncy, and it gives way to very slight
prc^NNUre. Omentum, when gangrenous, is
of li (Ittrk colouri easily breaks, and feels some-
whftt liko a portion of lung, crackling under
I hit prcsuNurc of the fingers.
AiMiKNf <J" opening the cavity of the abdomen, the
fftlli* p^irltorieum i« found inflamed, red lines can
"*•"** hit trWJCcl on the intestines, where they are
lyhiK In (sontact^ and here adhesions are
forifiiid fVoni cfiusion of fibrin. The intes-
Uui'f* u\v lmnu»n«ely distended with flatus.

If omentum alone has descended^ the Symptoms
symptoms are usually much less severe, and from
the patients live longer than when the hernia heraia.
is intestinal.

Seat of Stricture.

In old and large hernia, the seat of stricture External
is at the external abdominal ring, but in by
far the greater number of cases, the stricture
is seated at the orifice of the hernia from the
abdomen, at the internal ring, and here it is Most fre-
occasioned by the semi-circular edge of the thelnter-
tendon of the transversalis becoming thicken- °* "*^'
ed, as well as that portion of the hernial sac
pressed on by this tendon.

I have also seen the stricture mid- way ^". ^f *"■

•^ gmnal ca-

between the two rings, and it appeared in n**-
these cases to be occasioned by a thickening
of the sac, which, by the exertions of the
patient, had been frequently forced down to
the external ring, and had again retired into
the inguinal canal.
There is also a beautiful specimen in the stricture

*■ from mem-

collection at St. Thomas's Hospital, showing bnmons

a stricture formed by a strong membranous

band within a hernial sac ; the patient, from

whom it was taken, had been operated on by

one of the surgeons of that Hospital ; and

although the inguinal canal had been freely
opened, yet the surgeon could not return the
intestine without doubling it back, which he
did, and brought the integument together
over it by sutures* On the day following the
operation, the intestine peeped^ out between
the sutures, and was in a gangrenous state,
and the case terniinated fatally*
Omentom Another occasion of stricture is from omen*

entanpuiig

intestme. tum entangling the intestines, an excellent
example of which I operated upon in the case
of a patient of Mr. Richard Pugh, of Grace-
church Street.

s^tSSgiSl. The cause of strangulation is generally a

^on* sudden protrusion of an additional pcMrtion of
intestine or omentum. The eating of vege-
table food so as to produce flatulence, or
very indigestible animal matter, is a frequent
cause.

Danger in A Small hernia is much more easily stran-

hernia, gulatcd than a larger one.

Of the Treatment of Strangulated^ Oblique, ^

Inguinal Hernia.

Danger ef As the danger is entirely consequent on the

tion. ^ pressure of the stricture upon the protruded

viscus, the great object of. the surgeon is to

return the protruded part into the abdomen,

as quickly as he can with safety.

27
The operation for effecting this reductioil TaiLU,and

_ . mode of

is called the taxis, and it is performed m the employing
following manner : — ^The patient is placed in
a recumbent posture, with his head and
shoulders a little elevated, and his thighs
at right angles with his body. His bladder
should be previously emptied. The surgeon^
standing on the right side of the patient^
passes his right hand down between the
thighs, to grasp the swelling, and with his
left thumb and fingers he kneads the hernia
at the upper part of the inguinal canal. Slight
pressure and elevation of the scrotum, with
a kneading of the upper part of the hernia,
are used for the purpose of returning a small
portion of the protruded parts, when the
whole usually follows without difficulty. The
pressure should T)e continued a quarter of
an hour, at least, for I have known it succeed
after a trial of twenty minutes. The object
is to use a continued steady pressure, and not
violent means ; which, in several instances
which have come under my obseryatioji, have
caused a rupture of the intestine, so that, in
the operation, as soon as the sac has been
opened, fceculent matter has escaped. If the
strangulation has been long continued,the em-
ployment of force becomes doubly dangerous.
The intestinal hernia is more easily reduced [ntestinai

*^ hernia

than the omental, it returns more suddenly, mostcMUy

aad with a gurgling noise^ but sometimes the
f tenderness of the part is such as to forbid
the immediate employment of the taxis.
Case. I attended a young man, with Mr, Croft,

in the city, who, from tenderness, could not
bear the swelling to be touched. I ordered
ice to be applied, and in seven hours the
hernia returned without the aid of the
taxis.*
Bleeding, If the taxis does not succeed, bleeding
of. from the arm should directly be had recourse

to. In all cases it is best to employ it, on two
accounts. First. — By the faintness which it
produces, it frequently becomes the means
of assisting the return of the hernia. Second.
— If the hernia be not reduced, it saves the pa-
tient from the danger of peritoneal inflamma-
tion, which an operation is tikely to produce.
I never saw it do harm ; and have in many
cases witnessed its extreme efficacy. In

* In the month of May last, I was requested to see
a publican in the Borough, who was suffering from the
strangulation of a ventral hernia, about the size of an
orange, seated in the linea alba, between the ensiform
cartilage and umbilicus. The tumor was so extremely
tender, that he could not bear me to make the slightest
pressure upon it. I directed ice to be applied, which
was kept on for three hours; after this period I succeeded
easily in reducing the hernia, which had been strangu-
lated nearly two days. — T.

strong athletic persons it should be carried
to a very great extent ; in the old and infirm^
little need be taken away.

From neglect in bleeding, the patient very conae-
often dies, four or five days after the opera- not bleed-
tion,from peritoneal inflammation. The object *"**
is to produce a fainting state, otherwise the
bleeding does very little good.

Persons are very often deceived in peri- PuUe de-

. ceptive.

toneal mflammation, on account of the small
thready pulse with which it is accompanied ;
but this, instead of being a bar to the abstrac*
tion of blood, only indicates a greater ne-
cessity for it. I shall have occasion to mention
the great benefit derived from it, in a case in
which hiccough was extremely violent.

The next object which the surgeon has in ^^
view, when bleeding and the taxis fail, is to
put the patient in the warm bath, which is of
no use unless it occasion faintness ; and since
I wrote my work on hernia, I have had
several opportunities of witnessing its effi-
cacy in assisting the reduction. If there is
not immediate convenience for its use, no
time should be lost in procuring it, as there
are other and more powerful remedies.

The most powerful agent in the treatment Tobacco

. . glyster.

of Strangulated hernia, is the tobacco glyster ;
for if when the patient is under the influence
of this remedy, the hernia cannot be returned

by the taxis, there is but little chance of any
mode short of an operation succeeding. The
manner of making it is to infuse one drachm
of tobacco in one pint of water, and of this
one half should be first thrown up, and ac->
cording to the efiect produced in twenty
minutes, or half an hour, the other half may
be injected, or not. This is the safest plan of
administering the tobacco, it produces ex-
treme languor and relaxation of all the fibrous
structures, and is certainly the most potent
remedy which is employed, but at the same
time requires the utmost caution in its use.
Fatal ef. I havc sccu a paticut with strangulated
ueco. hernia expire under the effects of tobacco,
which had been used in the quantity of two
drachms, without reduction of the hernia ;
he was placed upon the operating table, but
as his pulse could scarcely be felt, his coun-
tenance showed extreme depression, and as
he was covered with a cold sweat, the opera-
tkm was not performed, and the patient died,
as the assistants were removing him.

A girl who was sent to Guy's Hospital, by
Mr* Tumbull, surgeon, had a single drachm
of the tobacco in infusion injected, to assist
the reduction of a strangulated hernia. She
M>on after its being administered complained
of violent pain in the abdomen, and vomited.
Thft berDia was reduced, but she died in

Case.

thirty-five minutes after the use of the tobacco^
and evidently from its effects.

Mr. Wheeler, senior, of St. Bartholomew's
Hospital, told me he had known it destroy
life, but prudently employed it in the way
that I have recommended ; it is the most
efficacious of the remedies proposed for the
reduction of hernia.

The effect to be wished for from the use of Beneficial

etfecU of

tobacco, is a universal relaxation, so that the tobacco.
patient has not power to exert any of the
voluntary muscles ; when this is produced, a
hernia may be sometimes reduced with very
liUle force, after having previously resist-
ed a firm and continued pressure. Under
the influence of tobacco, hernia, which has
before its employment felt tense, will be-
come soft, and this is not occasioned by any
partial reduction of the hernia, but only by
the force of circulation being for a time
greatly diminished.

I have several times known the application coid.
of cold succeed in reducing a hernia, and it
has this great advantage ; — ^that it arrests the
progress of the symptoms, even when it does
not ultimately succeed; therefore, when an
operation cannot be immediately performed,
it should always be employed. Ice broken
into small pieces and put into a bladder;
or water cooled by adding equal parts of

muriate of ammonia, and nitrate of potash
to it, are the most convenient modes of pro-
ducing the desired effect. I have known the
cold produced by the evaporation of spirits
of wine and water, succeed in reducing a
hernia.

Caution iu It is very improper to apply ice in such a

ice. manner that the patient or his bed clothes

become wet as the ice melts ; it is also wrong
to continue it upon the part for a long time
together, as it may occasion sloughing, as
occurs from the eflfects of frost bite. A case
in which sloughing was produced in this way,
was attended by Mr. Sharp, and Mr. Cline,
who had directed the application of ice over
a strangulated hernia, and continued it for
thirty-six hours. The part, to the extent of
four inches, froze, became hard and white ;
the hernia was reduced, but soon after the
removal of the ice, the part thawed, becoming
red and inflamed ; in about ten days it assumed
a livid hue, and sloughed to the extent that
it had been frozen.

Purga- Purgatives used formerly to be very much

given, but are now little employed. Calomel
given by the mouth, and a strong enema of
the compound extract of colocynth, sometimes
are useful.

Fonienta- If the parts be exquisitely tender, fomen-
tations may be employed, which if long

tives.

tioiis

continued, may by their relaxing effects an-
swer the same purpose as the cold.

Of Direct Inguinal Hernia.

Sometimes a hernia protrudes nearer to the
pubes than that I have just described, des-
cending from the abdomen immediately
behind the external abdominal ring, and
having the epigastric artery situated on its
outer side.

Mr. Cline first observed this species of First ©b-
hernia, in opening the body of a Chelsea MrCWn/
pensioner, with Mr. Adair Hawkins, on the
6th of May, 1777. The hernia was on the
right side, and the mouth of the hernial sac
was situated an inch and a half on the inner
side of the epigastric artery. I have myself
witnessed several cases of this description.

I have carefully dissected this herriia, and course of.
found that it passed on the inner side of the
epigastric artery, and protruded through the
external abdominal ring, under the fascia of
the cord, pushing the spermatic cord to the
outer and upper part of the tumor. I traced a
covering upon it, formed in part by the tendon
of the transversalis muscle, and in part by
the fascia transversalis; beneath which is
situated the hernial sac. The coverings of
this hernia are, therefore, the integument,

VOL. Ill, D

the fascia of the cord, a part of the cremaster
crossing obliquely the outer part of the
swellings then the fascia and tendon of the
transversalis.

r^^the '' ^^^^^® ^^^^ *^® oblique inguinal hernia
obUque in not taking the course of the inguinal canal,

hernia. ^ ^ ^

but m protruding directly through the
external ring^ and having the epigastric artery
to its outer side, and in having but an im-
perfect covering from the cremaster, and d,
perfect one from the fascia transversalis and
tendon of the transversalis united.

^ufhin "^^^ distinguishing marks between the

markf. direct and oblique inguinal hernia, are the
situation of the spermatic cord, and the direc*'
tion of the tumor ; in the first, the spermatic
cord is on the outer and upper part of the
swelling, and the swelling may be traced in
a direction towards the umbilicus : — ^in the
latter, the spermatic cord is situated behind
the hernia, and the inclination of the tumor
is towards the spine of the ilium.

Causes. The direct inguinal hernia may be produced
suddenly from a laceration of the tendon
of the transversalis, in which case the
covering from this tendon will be found
wanting.

Case. A gentleman applied to me, having a direct

inguinal hernia, which had appeared imme-
diately after he had been thrown firom his

liorse, and had fallen with the lower part of
the abdomen upon a post, by which accident
I imagine the tendon of the transversalis
might have been ruptured.

I have never seen this hernia acquire the
size of the common inguinal hernia, and in
most of the cases 1 have witnessed, the
patients have had some disease of the
urethra.

In a patient of Mr. Weston's, of Shoreditch,
who had for a long time laboured under
difficulty in passing his urine, 1 found six
hernia of this description, of which I have
given a plate. I also found several strictures
in his urethra, and a stone lodged behind
one of them.

Splclom

Treatment of Dii'ect Inguinal Hernia.

When reducible, the truss employed should i
be longer than that applied for common in-
guinal hernia, as the part at which the hernia
quits the abdomen, is an inch and a half
nearer to the pubes. The pad of the truss
should not rest on the pubes, but press prin-
cipally a little above the abdominal ring,
otherwise the general form of the truss may
be t^ same.

L hernia be irreducible, the means \
:

recommended for the oblique irreducible
hernia will be proper.

stran^uia- When Strangulated, the reduction must be

ted, taxis, attempted in a different direction to that re-
quired for the oblique. The tumor is to be
grasped as in the oblique hernia, with one
hand, while the fingers and thumb of the
other hand are to be placed over the abdominal
ring, to knead the neck of the swelling, and
the pressure must be directed upwards and
inwards, instead of upwards and outwards.

Case. In this manner I quickly succeeded in

reducing a direct hernia which had become
strangulated, in a patient who was admitted
into Guy's Hospital, for some other complaints.
The hernia was small, it had the cord to its
outer side, and could not be traced higher than
the abdominal ring.

Hernia This hemia may apparently be reduced by

apparently , ./ i x .^ w

reduced, the employment of the taxis, and strangulation
still exist; a case of this kind occurred a
short time ago at Guy's Hospital. A man
applied at the surgery, having a direct hernia
strangulated, and the taxis was had recourse
to, by which the gentleman in attendance
thought he had succeeded in reducing the
hemia, as he had pushed it through the
abdominal ring. The symptoms of strangula-
tion, however, still continued, and in two or
three days the man died. On examination of

hi^ body, the hernia was found placed im-
mediately behind the external ring, with a
stricture still existing at the mouth of the
8ac.

Operation for Strangulated Inguinal Hernia.

When the means I have recommended when ne-
cessary.

have been tried, without enabling the surgeon
to reduce the hernia, or relieve the strangu-
lation, it becomes necessary that an operation
should be performed, to liberate the strangu-
lated viscus.

There is but little danger attending this Butiituc
operation, if the person upon whom it is to
be performed be free from other disease. The
cause of persons who have undergone this
operation, so frequently dying, is not to be
attributed to the operation, but to the degree
of mischief which has taken place previously
to its being performed.

When strangulation has existed for a long Gangrene,
time, the contents of the hernia either become
gangrenous, or in a state so nearly approach-
ing to it, that they do not recover their
proper 'functions, otherwise inflammation
extends from the strictured portion to the
viscera, within the cavity of the abdomen,
and thus the surgeon has to combat with a

D 3

severe di&ease after the removal
strangulation. The danger is therefore in the
delay, and not in the operation.
Danger of Very frequently much time is unnecessarily
lost, before an operation is proposed ; and
too much cannot be said in condemnation of
such practice. Apatient is submitted againand
again to the taxis, and the swelling is rendered
extremely tender, by being so often com-
pressed, in the hope of avoiding an operation,
until at length the rapid increase and urgency
of the symptoms point out the impropriety
of such delay ; and an operation is performed
when but little prospect of success remains.

It is extremely important that the opera-
tion should, if possible, be performed before
the abdomen becomes tender under pressure.
Distension of the intestines from flatus, often
produces tension of the abdomen, soon after
strangulation has occurred; but still the
patient can bear pressure without experienc-
ing pain ; but when he does complain of pain
under pressure, it indicates the extension of
inflammation to the cavity of the abdomen,
which is likely to be much increased by the
operation.

The progress of inflammation, and extent
of mischief, are not always in proportion to
the time that strangulation has existed, for
the period between the commencements

tlOI

tlie symptoms, and the fatal termination,
varies exceedingly.

A large hernia when completely strangu-
lated, is more quickly fatal than a smaller
one ; but the latter more frequently requires
the performance of an operation, on account
of the greater firmness of the stricture.

A hernia containing a portion of strangu-
lated intestine alone, is more rapidly fatal
than one containing omentum only ; and that
containing both intestine and omentum, takes
a middle course between the two above
mentioned.

When a hernia has existed for a long time,
and becomes strangulated, the attempts at
reduction will be more likely to succeed than
if it were of recent formation ; in the first
instance, the parts are more easily relaxed,
having been accustomed to repeated dilita-
tion ; while in the latter case, the powers of

listance are much greater.

Also in very young, or very old persons,
strangulated herniEe are more frequently re-
duced, than when they occur at the middle
period of life, during which the fibrous struc-
ture is firmer, and the muscular strength
greater than at any other period. In very
old persons, also, the strangulation is not so
rapidly fatal ; as long a period as twenty

lys have been known to elapse between

very old
or young

^vdays have

the commencement of the symptoms, and the
death of the patient.

Of the Operation for Inguinal Hernia.

Bladder to Prcvious to the Operation, the patient should

ed^and be directed to empty his bladder, and the

doused, integument upon the tumor and surrounding

parts, must be cleansed from the hair usually

covering it.

Position The patient is then to be placed upon a

tient. ^* table, about three feet six inches in height,

on his back, the shoulders should be raised,

and the thighs a little flexed towards the

body, so as to relax the abdominal muscles ;

the hams are to be brought to the edge of

the table, so that the legs may be allowed to

hang over it.

Operation. The surgcou should now place himself

between the patient's thighs, and grasp the

tumor with his left hand, so as to put the

integument covering it upon the stretch, and

then having a scalpel in his right hand, he

should commence the operation by making

an incision through the skin, on the anterior

part of the swelling, which incision should

be begun opposite the upper part of the

external abdominal ring, and carried down

to the inferior part of the tumor, unless the

swelling be of a large size. Besides the skin and

cellular substance,the external pudendal artery
may be divided by this incision, as it alwayd
crosses the sac near the abdominal ring. The
hsemorrhage from this vessel may usually be
stopped by pressure ; but if very troublesome,
it will be necessary to put a ligature upon it.
By this incision the fascia of the cord be- Fa»cia of

the cord

comes exposed, which generally forms the exposed,
thickest covering of the hernia. This must be
carefully cut through in the centre, so as to
admit the entry of a director which is to be
passed under the fascia, upwards to the ring,
aod downwards to the extent of the external
incision, that the fascia may be safely divided
upon it.

Thus the cremaster muscle is brought into Crcma«tcf
view, forming the next covering, which must"^
be opened and divided in the same manner
as the fascia, and with equal care, and the
cellular tissue beneath must be cautiously cut
through.

When this has been completed, the hernial Hernial
sac itself is laid bare, and the surgeon must ed.
proceed with the utmost caution to open it
in the following manner. He first nips up a
small portion of the membrane on the anterior
and inferior part of the tumor, between his
fore-finger and thumb of the left hand, and
slightly rolling the membrane between them,
he easily distinguishes if any intestine or

omentum be included ; and if so, he r
fresh portion. Being satisfied that he has
only a part of the sac raised, he is to place
the edge of the knife horizontally against it,
and make an opening of sufficient size to
admit the end of a director, which is then to
be introduced, that the sac may be opened
upon it.
" In dividing the different coverings, a very
- cautious operator will make more layers
than I have described, being fearful of doing
mischief which might be irreparable.

When the hernial sac is exposed, it has
usually a bluish tint, and is semitransparent.
If the contents be not adherent to the sac,
it generally contains a quantity of fluid, and
a sense of fluctuation may be usually per-
ceived at the inferior and anterior part of it,
for which reason this part should be first
opened, as the intestine is there in the least

Immediately the sac is opened, this fluid
escapes. If the strangulation have not ex-
isted long, it is occasionally of a serous
colour, but more frequently of a darker, or
coffee colour, and sometimes it has an oflFen-
sive smell.

This fluid is most abundant in intestinal
hernia, and is in quantity in proportion to
the bulk of intestine strangulated. If, how-

erer, the hernia be omental, or if the intestine
adhere to the interior of the sac, little or no
8uid is found, so that it must not always be
looked for as an indication of the sac being
opened.

The sac being opened, the surgeon is en-
abled to see its contents, which he must
attentively examine. If both intestine and
omentum have been strangulated, the latter
is found above and anterior to the former ;
in some instances covering the gut partially,
in others completely.

If the hernia has not been long strangu-
lated, the omentum has much of its usual
charactef, being only a little darker than
natural, and having its veins distended; but
the intestine is found covered with a thin coat
of adhesive matter, and is of a red colour.
When the strangulation has existed for a
long time previous to the operation, or when
the stricture has been unusually tight, the
intestine presents a dark brown chocolate
colour.

The surgeon should now pass his finger
into the hernial sac, and examine accurately
the seat of the stricture, which he will find
in one of the three following situations ; —

First.— At the internal abdominal ring, in
the mouth of the sac.
^^ Second. — In the inguinal canal, an inch,

How eX'
posed.

or an inch and a half within the external
ring.

Third. — At the external ring.

ternSring] '^^^ ^^^^ frequent Seat of stricture is at
the internal abdominal ring, from an inch
and a half to two inches above, and outwards
from the external ring, and it is occasioned
by the pressure of the internal, oblique and
transversalis muscles upon the mouth of the
hernial sac, which becomes thickened, more
especially on its pubic side.

Should the stricture be situated at this part,
it has been thought necessary to divide the ex-
ternal ring, and to slit up in part the inguinal
canal, by dividing a portion of the tendon of the
external oblique muscle, in order to give the
operator a distinct view of the protruded
parts, and to enable him to divide the stric-
ture without danger to his patient. This may
be done by passing the finger into the sac,
through the external ring, as far as the seat
of stricture, and then introducing a curved
bistoury with a probed extremity between
the upper part of the finger and the sac, and
cutting through the tendon, superficial fascia,
and integument, forming the anterior bound-
ary of the inguinal canal.

Having thus exposed the contents of the
hernial sac as far as the seat of stricture, the
operator should insinuate the point of his

finger, or a director, under the stricture,
between the sac and its contents at the upper
part, carefully keeping the latter from turning
over the finger or director. He should then nivWonof
pass the knife for dividing the stricture upon tare,
the finger or director, und^r the stricture, and
by a gentle motion divide the stricture in a
direction parallel with that of the linea alba,
and to an extent sufficient to allow the finger
to be easily passed into the cavity of the
abdomen. The knife thould then be with-
drawn in a careful manner. In this case I
have adopted with advantage the following
plan : — The sac being opened to the external
ring, I have put my finger into it, and hooked
down the sac ; I have then directed an assistant ^
to draw up the tendon of the external oblique
at the ring, and hare thus been able to bring
the stricture into view without cutting the ten-
don of the external oblique to the upper ring.

The knife best adapted for dividing the Knife for
stricture is blunt at its extremity for about a the stric-
quarter of an inch, sharp for half an inch,
and then again blunt, only cutting so far as
is necessary to divide the stricture, without
endangering the neighbouring parts.

The second seat of stricture is in the in- stricture

• • • •

guinal canal, and is formed by the sac itself guinaV"a.

nnl

in the following way:— a person becomes
the subject of oblique inguinal hernia, and

the pressure on the neck of the hernial sac
at the internal ring, creates a thickening of
the sac at this part. From any sudden exer-
tion or straining, which occasions a further
protrusion, this part of the sac is forced into
the inguinal canal, and when the patient
is in the recumbent position, part or the
whole of the contents of the sac being re-
turned into the cavity of the abdomen, the
portion of the sac which had been previously
situated at the interna! ring, and had been
thickened, again takes its former position.
This occurs again and again ; but at length
the sac becoming elongated, the thickened
portion which had been originally placed at
the internal ring, no longer returns to this
situation when the contents of the sac are
reduced ; but it remains in the inguinal
canal, and may here at any future time be
the cause of strjtngulation.
How ex- When the stricture is thus formed, the

poied and ,

divided, surgeon should freely expose the contents of
the hernial sac as far as the stricture, and
then divide it in the same manner, and in the
same direction as before described.

girictiirp Sometimes, but rarely, the seat of stricture

of the rx- II-

ciwii ring, is at the external abdommal ring, in which
case the same plan of dividing the stricture
should be adopted ; but it is not necessary
to make so large an opening.

If the hernia be direct, it is to be re*
membered that the spermatic cord is placed
on its outer side. It is covered by the fascia
of the cord, by the cremaster partially, and
is contained in a sac formed by the tendon
of the transversalis muscle, assisted by the
&scia transversalis, beside a peritoneal sac,
as in other hernia.

The division of the stricture directly up- Bcstdirec-

^ ^ tion for di-

wards is then applicable to every common vidingthe

stricture.

case of strangulated inguinal hernia whether
oblique or direct ; it is equally safe with any
other division that has been proposed, and
the operation is by it more simplified than
by adopting a different mode of dividing
the stricture for each variety.

LECTURE XXXIII.

tiiJ^^*' After having sufficiently divided the stric-
viscera. tare, the surgeon should carefully examine
the protruded intestine, particularly that part
which has been immediately under the
stricture, and ascertain whether the circula-
tion becomes restored, which he may do by
employing pressure to empty the vessels,
and then observe if they be again immediately
filled.

Should the circulation be free, he should
then gradually and very carefully return the
intestine by small portions at a time, until
the whole is reduced. At this time the patient
should be placed much in the same position
as when the taxis is employed.
Adhewons. When adhcsions have taken place between
the intestine and sac, great care is required
in opening the latter, as little or no fluid
exists in it, to separate it from the intestine,
which may be in consequence easily wounded.
The sac being opened, if the adhesions be
found long, and not very numerous, they
may be divided to allow of the return of
the protruded part. Sometimes these adhe-
sions are only found at the mouth of the

, or are otherwise ]

irtial ;

1 either case-

they should be carefully separated, that the
hernia may be completely reduced ; but the
division of such adhesions, particularly at
the mouth of the sac, is attended with con-
siderable danger. Sometimes the sides of
the fold of intestine which has been strangu-
lated are found glued together : in this case
it is best to separate such adhesion, if it can
he easily done, as the free passage of the
faeces is afterwards interrupted, if the intes-
tine be returned doubled back into the abdo-
men with such adhesion remaining.

Should the intestine be in a state of gan- Jnteitioe
grene, it will have a foetid smell, the peritoneal «"»>■
surface will have lost its brilliancy, and be of
a dark port wine colour, with greenish spots
on it ; it will not possess any sensibility, and
will easily give way under slight pressure.

Under these circumstances, the stricture Trcaiment

ofgaiigre-

should be divided in the manner I have de- nomime..
scribed, after which a free incision should be
made into the gangrenous intestine, to allow
of the escape of its contents, and then it
should be returned to the upper part of the
£ac, the wound should be left open, and a
poultice applied ; but if the portion of intes-
tine which has descended be not large, it
should not be disturbed from its adhesions to
the sac.

VOL. HI. E

Case. I was requested, during the absence of

Mr. Chandler, to operate upon a woman who
had been admitted into St. Thomas's Hos-
pital, under his care, with strangulated hernia.
From the examination of the part, and from
the history of the case previous to my seeing
the patient, I imagined that gangrene had
commenced, and I soon found this opinion
to be correct; for before I had opened the
hernial sac, there was a highly offensive and
putrid smell. On opening the sac, I found the
intestine in the state I have before described ;
I therefore divided the stricture, and then
made an incision of about an inch and a half
in extent, on the anterior part of the gangre*
nous intestine, through which the faeces
readily escaped. I afterwards directed that
a poultice should be applied. Feeculent matter
continued to be discharged through the
wound; but nine days subsequent to the
operation she had a stool, per anum, after
which the patient passed her stools by the
natural passage, occasionally at first, then
more frequently, as the artificial anus and
wound closed, and she completely recovered.
This patient was confined five months after
the operation, and delivered of a full grown
but dead child, by Mr. Brown, a respectable
surgeon at Rotherhithe. It is extraordinary;
that being considerably advanced in her

Hppgnancy at the time of tlie operation, she

^B^ not miscarry.

EiiWtea a patient with strangulated hernia Terminii-
■will not submit to the operation necessary oiitnnope-
for his relief, or if the proper assistance can-
not be procured, and gangrene takes place,
the hernia sometimes suddenly returns into
the cavity of the abdomen, and the patient
survives only a few hours. Sometimes the y-r^
skin and other coverings inflame and .slough, /^^^^
when the fseces are discharged through the ^^^
opening thus produced, and the symptoms ^^^^-^
of strangulation subside, after which an arti-
ficial anus is formed, rendering the remainder
of the patient's life miserable.

Occasionally, however, it happens that the Artificial
external wound and artificial anus are gradu-
ally closed, and the patient entirely recovers.

A case of this kind occurred under the ca5e.
care of my friend, Mr. John Cooper, surgeon,
of Wotton Underedge, Gloucestershire. He
was requested to attend a poor woman, aged
sixty, who was the subject of strangulated ^^H
crural hernia. When he first saw her, she had ^^|
been labouring under symptoms of strangula- ^^|
tion for a fortnight, and the hernia was ^^|
evidently in a state of mortification. Thinking, ^^H
therefore, that there would not be any chance I

of saving her life by an operation, he only

^ directed that her strength should be sup-

ported, and the part poulticed. In a few
days the mortified parts began to separate,
and the fjeces were discharged through the
wound. This continued for three months,
during which period several inches of one of
the small intestines sloughed. After this, a
small quantity of faeces began to pass by the
natural channel, and in six months the woman
had perfectly recovered.
'f- The formation of an artificial anus is dan-
gerous, according to its situation in the intes-
tinal canal. If the opening be near to the
stomach in the jejunum, the patient will die
in consequence of the small surface for the
absorption of chyle being inadequate to pro-
duce sufficient nourishment. If the opening
be in the lower part of the iUum, or in the
colon, then the patient may recover, as there
is but little interruption to nutrition.

A man about fifty years of age was admitted
into Guy's Hospital, with a strangulated
umbilical hernia, which sloughed, and oc-
casioned an artificial anus. As he was re-
covering from the effects of the strangulation
and sloughing, and was allowed to take food
in any considerable quantity, it was observed
that part of what solids he ate passed out at
the artificial anus, within half an hour after
he had swallowed thetn, and that fluids passed
out in ton minutes after they had been taken

3 the stomach. Although he took sufficient

I to support a healthy person, he wasted

pidly, and died in three weeks. On ex-

(nining his body after death, and tracing the

jfejunum, the lower part of that intestine was

found entering the hernial sac, and in it the

opening was situated. The other viscera were

healthy.

When an artificial anus has been formed, From in- ,

, veiiiou of

care must be taken to guard against any in- the inte*.
version of the intestine at the artificial open-
ing, as such an occurrence will most likely
prevent the perfect recovery of the patient,
by rendering the false opening permanent.

A patient of Mr. Cowells, in St. Thomas's c«se.
Hospital, underwent the operation for a
strangulated hernia ; the intestine was found
to be gangrenous, and the consequence was
the formation of an artificial anus. For three
weeks after the operation, the fgeces passed
in part by the artificial opening, and in part
by the natural aperture, but most by the
latter; at this period the intestine became
inverted, and protruded at the artificial open-
ing; after which the faeces were entirely
discharged by the false passage. The man
lived eleven years after this, but always dis-
charged his stools by the artificial anus.
I If a portion of the colon has been stran- Appendicai I
^gulated, and the patient be fat, the appen- remM"

dices epiploicse are sometimes found much
more diseased than the intestine, so much
so that it becomes necessary to remove
them, which I have had occasion to do. ' '
SJiTo? *' Having returned the intestine, the surgeon
omentum, should Carefully examine the omentum; and
if it be not in a large quantity, or of an un-
healthy appearance, it should be returned
into the abdomen, with as gentle a preissure
as possible. If a very large portion of omen-
tum be protruded, a part should be removed,
which may be done without any danger to
the patient by means of the knife ; and; if
any arteries sufficiently large to afford a
troublesome haemorrhage, are divided, they
muHt be secured by fine ligatures; th^" di-
vided surface should then be returned to
the mouth of the sac, so as to form a plug,
and tho ligatures should remain hanging
from the external wound.
•u^ #rr Mm 'f|i(3 old mode of applying a ligature
AtntniuM^il around the protruded portion of the oinen-
turit to occasion it to slough off, is now, I
liolicv(% entirely abandoned; and it appears
i^xtniordiuary, that it should ever have been
ndoptod, ttH it is the object of the operation
to romovu the stricture, which would be
lliuN innnediately restored with increased

Ncwority.
ihiiiiihim ll'ilu* omentum be in a state of mortifica-

IIHilllHliff.

may generally be known By'ife
crispy feel, and tlie distension of its veins
by coagulated blood ; or even if any suspi-
cion arise of its being in an unsound state,
it should be removed by excision at the
Bund part. In doing this, the strangulated
jortion should be drawn down a little, so as
I expose some of the sound part, which
diould be held by an assistant to prevent
sudden retraction into the abdomen,
while tlie surgeon cuts off the diseased
and when this has been completed,
any bleeding vessels should be secured as
before directed. Should the omentum, in an
nnsound state, approaching to gangrene, be
^umed into the cavity of the abdomen,
be danger of the patient will be much in-

lased.
kl have, however, known a patient recover, siougiiiog

whom sloughing of the omentum took tum.
lace after it had been returned into the
^vity of the abdomen. This occurred in a
man who had undergone the operation for
a strangulated hernia in Guy's Hospital,
jhe sac contained both intestine and omen-
a ; and the latter, although much changed
( appearance, was returned into the abdo-
men. Some days after the operation, the
lan appeared to be dying ; the ligatures,
ijOlding the edges of the wound together,

L 4

were removed, and poultices and fomenta-
tions employed, when, on the following day,
a portion of gangrenous omentum was found
protruding from the wound, and for several
days more continued to present itself, mitit
the whole of the portion which had been
previously strangulated was exposed, and
gradually sloughed off; after which the
patient recovered.
OMMtmii When the omentum atone adheres to the
*'*" * sac, it may be freely separated and returned,
any vessels likely to afford a troublesome
httmorrhage being previously secured,
omniiittttt Should the protruded omentum be much
Mirrkui. hardened, or have a scirrhus feel, it should
sImo be removed in the same manner as t
have already described.

Ti'tatmcnt after the Operation.

» . ^ When the contents of the hernial sac have
•"••*• "•* liftrn ruturnod into the cavity of the abdomen,
thn wound should be well cleansed, and its
(idKrM sliould be afterwards brought into
roll tacit by means of sutures, in order to
itrotiioto ndhodion, two or three sutures
ImliiK uciccmsary, according to the extent of
Ihft wouiidi Cure »hould be taken in passing

!ae sutures only to include the mtegumei
otberwise, by penetrating the sac, much
subsequent mischief may arise.

The approximation of these parts should
he assisted by the application of slips of
soap plaister, and a compress should be
placed over the wound, and retained there
by means of a T bandage, to close the orifice
of the sac, and prevent any further protru-
sion into it, and at the same time the scro-
tum should be well supported.

The patient should then be carried to bed
in a horizontal position, and placed with his
shoulders a little elevated, and the thigh, on
the same side as the wound, moderately
flexed towards the abdomen.

As it is perfectly necessary that the patient
should keep the recumbent position during
the cure, a folded sheet must be placed under
him, into which he should discharge his
stools, otherwise should he rise to use the
night-chair, much mischief may arise from
the effort. Mr. Cline had operated upon a
patient for strangulated hernia; and some
hours after the operation the patient got
out of bed to use the night-chair, and
from the exertions he made in getting up
and in passing his motion, the intestine,
which had been reduced, again descended
the sac : Mr. Clinc again reduced the

of the re-
cambent

Bkto the s;

intestine, and gave strict orders for the man to
keep the recumbent position, and the patient
ultimately did well.

Usually, if the patient be left to himself,
he will have some natural stools in a few
hours after the operation; but, if several
hours elapse without an evacuation, either
castor oil or sulphate of magnesia should
be given, or a purgative enema, containing
colocynth, or castor oil, should be thrown
up, and the abdomen should be fomented
with spirituous fomentation, which will assist
the action of the bowels, and jEifford much
comfort to the patient.

Medicines. As the Safety of the patient depends much
upon procuring evacuations from the bowels,
the exhibition of opium soon after the ope*
ration should, if possible, be avoided; but
if the irritability of the stomach continue,
or if the patient have a troublesome cough,
it should be administered in conjunction with
calomel.

Purgatives. It is uot Only hcccssary to procure eva-
cuations from the bowels soon after the
operation, but it is extremely desirable to
keep up a free action upon them for several
days following ; as I have frequently known
patients die in a few days after the operation
with constipation and peritoneal inflamma-
tion, although they had passed several stools

within twenty- four hours after the strangu-
lation had been relieved.

Should the patient go on well, die wound sotores
shoiild be' dressed on the third day, and "^**^® *
afterwards daily. The sutures may be re-
moved on the fourth and fifth day ; but the
patient must be kept in bed until the wOutid
is entirely closed. '

When the operation has been perfofmed operation
at any early period after the strangulation
has taken place, the patient generally does
well ; but when much time has elapsed fVoni
the strangulation of the herniai before the
performance of the operation, dangerous
symptoms frequentiy arise.

Sometimes the intestine does notrecoveif sometimes
its furiiction, Vh^en the vomiting and consti->
patron continue, and the patient dies.

Sometimes peritoneal inflamniation con-^ Peritoneal

, * •■ inflamma-

tinues, in which case the abaomen is ex- tion.
tremely tender and t^nse, although thib
bowels are open, and the life of the patient
is soon destroyed. The best means of re-
lieving this inflammation are by local and
general bleeding, fomentations, purgatives,
and extremely low diet.

Occasionally the patient is attacked with Diarrhaea.
a violent diarrhaea, which continues for
many days, producing so great a ^ state of
debility as to prevent recovery: In such

cases, the treatment I have found most
ous, consists in exhibiting small doses of opium
frequently, and the employment of injections
of starch and opium, with a light but nutritious
diet, as gruel, or milk, with isinglass, &c.

Hiccough. In a few instances I have known a trouble-
some hiccough continue for several days after
the operation, but entirely unconnected with
gangrene, being the result of peritoneal inflam-
mation.

vm. The most remarkable example of this kind

I ever met with, was in a gentleman at Maid-
stone, for whom I performed an operation
upon a large strangulated intestinal hernia.
1'ho symptoms had been unusually severe,^
find inflammation had taken place in the
poritonoum. The abdomen continued tender
to pressure for several days after the opera-
tion t and the hiccough continued until the
Mixth day. The patient was bled and purged
IVi^dly, And he eventually recovered* As this
symptom depends upon inflammation of the
prritonoum when gangrene has not taken
pltuii^i the proper means of relieving it are the
sMirifi IIS <lirocted for the inflammation of this
mi»fnhriinr, ns local and general bleeding,

IMirtrntlvMi &c.
HiH«i*fM 'I'lift pcirformance of the operation for stran-

!«'•»* I*"*-* iiHltttpH luirnlu docs not prevent the future

Ml III M III

\m m (litMUUtl uC tho intestine or omentum, but pef-

Iltips renders the patient more liable to its
recurrence, as the mouth of the sac is by the
operation considerably enlarged. It is, there-
fore, perfectly necessary before the patient
be allowed to get up, or use any exertion,
that he should be fitted with a truss, which
will effectually prevent any protrusion, by
keeping the mouth of the sac closed, other-
wise he may in a short time again become
the subject of strangulated hernia.

When the truss is first applied, a dosil of Trrwxiab* I
lint should be placed under the pad, to pro- pfitti.
tect the recently healed wound.

In consequence of a radical cure not being Removal
produced by the operation I have described,
some persons have recommended the removal
of the hernial sac by excision or ligature, or
that it should be returned into the abdomen.

In a patient of Mr. Holt's, at Tottenham, (
I had an excellent opportunity of seeing the
efiects of removing the sac by excision. A
woman, who, for several years, had been sub-
ject to a femoral hernia, applied to Mr. Holt,
on account of the swelling having become so
painful and tender as to prevent her from
following her ordinary occupations, although
the bowels appeared to act very regularly.
Mr. Holt requested me to visit the patient
with bim, and I made many ineffectual at-
tempts to reduce the hernia, and in a few

days afterwards I recommended Mr. Holt to
operate^ as the symptoms had not in the least
subsided. On opening the hernial sac, . ft
small portion of intestine was found at the
mouth of the sac, inflamed^ and adherent to
it« Mr.HoIt carefully separated the adhesions,
and returned the intestine into the abdomen/
The sac itself being but little attached to the
surrounding parts, I requested Mr. Holt to
allow me to remove it, which I did, close to
the mouth of the sac. I then closed the orifice
by sutures, and the external wound was
treated in the usual way. On the sixth day,
the ligatures came away, and the wound was
closed on the tenth. I saw this woman a
niontli after the operation, when she had a
hernia nearly as large as the one for which
tlie operation had been performed, and at the
same s{)0t ; she was subsequently obliged to
wear a truss constantly, to prevent the pro-
trusion of this hernia.
\^^mi\%\ From this it appears that the removal of
Hl.il!mHMv»t the sac will not prevent the re-formation of a
*^** horuitt, nor do I think, upon reflection, that it

scarcely could be expected to do so, as the
nporturo from the abdomen remains equally
largo, and the peritoneum alone oflFers resist-
unco to the formation of another hernia, and
this had been insufficient to prevent the pro-
trusion of the fii^st*

The removal of the sac by ligature is equally ^^^^^
objectionable, even • if it could be done with- J^ ^\^^,
out risk, which it hardly could, more especi- ^""^c-
ally in oblique inguinal hernia, as the ligature
ought, in such cases, to be supplied close to
the internal ring, which could not be done
without a very tedious and hazardous dissec-
tbn; besides, the spermatic cord is some*
times divided by the sac, which would in-
crease the difficulty and danger of such an
operation.

The great danger of this operation is in the Danger of.
inflammation, which is likely to be induced
by the action of the ligature upon the peri-
toneum, and in this inflammation extending
to the cavity of the abdomen.

Of Large Hernia.
In very large inguinal herniae a very difierent Different

operation

mode of operating i^ required, to that which required.
I have already described, for the following
reasons : —

When a large hernia has existed for some Difficulty
time, the cavity of the abdomen becomes ing.
diminished, from the habitual loss of a large
portion of its natural contents', and such a
resistance is offered when any attempt is
made to return the contents of the hernial

sac, that the intestine sometimes gives way,
or is lacerated from the violence employed
in attempting to reduce it, and even if it can
be returned, the slightest exertion will occa-
sion a further protrusion.

Also, in large hernia, a considerable extent
of protruded intestine being submitted to
much violence in the attempt to reduce it,
often gives rise to inflammation, which may
produce fatal consequences.

Sometimes extensive adhesions have been
formed between the sac and protruded in-
testine, or the portion of peritoneum which
has descended, and is forming part of the sac,
may have brought with it a portion of the
intestine, to which it is naturally closely con-
nected, as the ccecum, and which thus be-
comes irreducible: in either case the reduc-
tion of the hernia is of course prevented.

Instead of performing the same operation, as
in other cases, I should, under these circum-
stances, merely expose the upper part of the
hernial sac, and divide the stricture without
opening the peritoneum, unless the irtil iif
stricture happened to be seated in the mouth
of the sac itself.

The first time that I had an opportunity of
performing the operation in this manner,
was upon a patient of Mr. Birch's, in St.
Thomas's Hospital. The man was between

■ and sixty years of age, and had been
X from Ills infancy, which,
jecoming strangulated, and not yielding to
the usual measures, rendered an operation
necessary. From the size of the hernia, which

tsached halfway to the knees, and its dura-
on, I conceived that such adhesions might
ave occurred as would render its reduction
impossible, and that the ordinary mode of
operating would be extremely hazardous, on
account of exposing so large a surface of
intestine; I therefore determined upon trying
^bhat could be effected by a division of the
^Hricture, without opening the hernial sac.

I commenced by making an incision, be- <

ginning about one inch and a half above the

^external abdominal ring, and terminating

^Ebout the same distance below it ; this ex-

Hnsed the tendon of the external oblique,

and the fascia of the cord. I then carefully

made an opening into the latter, large enough

to admit a director, which I introduced, and

upon it divided the fascia so as to expose the

cremaster muscle as far as the external ring ;

after this I passed the director between the

cremaster and edge of the external ring, and

introducing a probed bistoury, I cut through

a part of the tendon of the external oblique,

so as to enlarge the external ring. On passing

I my finger into the inguinal canal, to the edge

L VOL. III. t

of the transversalts muscle ; I felt some
further resistance, and again introducing the
director, I carefully separated some fibres of
this muscle. The contents of the hernial sac
were then reduced, and the edges of the
wound being approximated, the patient was
put to bed.

The wound healed kindly in about three
weeks, although the hernia was protruded
upon the slightest exertion, which would
have occasioned much irritation, had the sac
"been opened. The patient was subsequently
obliged to wear a laced bag truss.
Division of Should the stricture be seated in the neck

the stric'

inr«. of the hernial sac itself, of course the division
of the parts exterior to it, will not relieve the
strangulation ; in this case the sac must be
opened carefiiUy at the upper part only, k)
as to allow of a division of the stricture.
Care in Haviug divided the stricture, the surgieon
tbeTi^^ qiust avoid ^dolence in attempting to return
the protruded parts, for the reasons I have
before mentioned. I have known the: intes-
tine ruptured in forcibly endeavouring to
effect the reduction after the liberation of the
stricture. The case occiurred in St. Thoma&'s
Hospital, and terminated fatally. The ruptured
intestine is preserve^ \n the collection at that
Hospital.

Some surgeons object to the division of

cera«

ft stricture without opening the hernial sa6> \
iirging that the intestine or omentum may bf)
1 a gangrenous state, and that this cannot be
^certained unless the sac be opened ; but I
ihould imagine that a very limited experience
would enable the surgeon to form an accurate
ppinion in this respect.

0/ Hernia in the Inguinal Canal.

The oblique hernia is sometimes confined Appesr-
entirely to the inguinal canal, and does not
emerge through the external ring. It is often
difficult to detect in the living subject, as
there is no distinct tumor perceptible, but
merely a fulness above Poupart's ligament.
When strangulated, the usual symptoms are 1
present, and the part is very tender on pres^
sure, or during coughing.

This hernia is covered by the superficial Cohering*. \
fascia, the tendon of the external oblique
muscle, by a thin fascia from the edge of the
internal ring, and in part by the cremaster
muscle, the spermatic cord and the epigastric
artery lie posterior to it.

These herniae, when strangulated, are often MisukM!.!

mistaken for cases of peritoneal inflammation,

as the patient is not conscious of having a

swelling ; and thus he may fall a victim to

F 2

Blizard, for the following curious anil mtercrt-
ing case of hernia, descending behind the
spermatic cord, which had been accompanied
with hydrocele, in the tunica vaginalis of the
same side.

The patient had been the subject of hernia
on the right side, for six years, for which be
had worn a truss ; and from his own account
a hydrocele had formed on each side, two
years previous to his coming under the care
of Mr. Blizard ; but that on the right side
had gradually disappeared, leaving the testis
wasted and drawn up to the groin.

The hernia becoming strangulated, and not
yielding to the usual means employed for
reducing it, Mr. Blizard performed the ope-
ration about twenty-four hours after the com-
mencement of the symptoms. Having laid
bare what he thought was the hernial sac, he
punctured it, and then freely opened it upon
the director. It extended through the ex-
ternal ring, into the inguinal canal, which
Mr. Blizard in part cut open, in order to
make the necessary examination of what he
conceived to be the hernial sac ; this, how-
ever, proved to be the tunica vaginalis, which
had formerly been distended by the hydrocele,
having the hernia seated behind it. The pos-
terior part of this tunic was then cut through,
exposing the hernial sac, which was found to

contain a portion of intestine nearly of a black
colour, from strangulation. The stricture
which was seated at the mouth of the sac
was divided in the usual manner, and the
intestine returned. The patient did well. Mr.
Henry Cline had occasion to operate upon a
similar case.

Of Inguinal Hernia in the Female.

^L^ The structure of the inguinal canal in the stracture 1
^Hemale is very much the same as that which
\1 have described in the maJe, only that the
round lijjament in the former takes the place of
i^the spermatic cord existing in the latter.
^L. The round ligament, which commences Round
^■jlft the fundus uteri, passes from the abdo- """"^ '
^ftaen midway between the anterior superior
^H^inous process of the ilium to the outer
^*«de of the epigastric artery, above Poupart's
ligament, and below the transversalis and
internal oblique muscles, as the spermatic
cord in the male; it takes a course obliquely
downwards, and inwards to the external
labdominal ring through which it passes, and
s lost upon the pubes.
This round ligament, however, being much
Ismaller than the spermatic cord of the male,
Ipasses through openings corresponding to
\its size, which are consequently much less

than those for the spermatic cord, and' 3n
this account the formation of inguinal hernia
in the female is of comparatively rare oc-
currence.
Course of When this hernia does occur in the female,

the beruiB,

it takes the course of the round ligament,
is at first confined to tlie inguinal canal,
where it is covered by the tendon of the
external oblique, and subsequently it pro-
trudes through the external ring, and forms
a swelling at the upper part of the labium,
which seldom acquires a large size ; here it
is covered by a superficial fascia given off
from the tendon of the external oblique.
Cansci. It is pioduced by the same causes in the

female as in the male, and presents the same
symptoms. The sac usually contains either
intestine or omentum, or both, but some-
times the appendages of the uterus are found
in it.
Less liable As the round ligament in the female is
than in tiie not liable to the same affections as the sper-
matic cord of the male, the hernia in the
former case is not likely to be confounded
as it frequently is in the latter case with
such diseases. I have, however, known this
form of hernia in the female mistaken for a
femoral hernia, which may readily be ima-
gined when we recollect the proximity of
the parts concerned.

A careful examination will readily enable "o* <ii«-

tinguished

the surgeon to distinguish between the two, iromfcmo-
as in the inguinal, the neck of the tumor is
above Poupart's ligament and in the femoral
below ; in the former, also, the spinous pro-
-cess of the pubes can be readily felt outside
l&e swelling, which it cannot be in the
latter.*

When this hernia can be reduced, a truss, Rcdocibie.
similar to that necessary for a mate, is to be
employed.

When irreducible, the same treatment as >
recommended for the male will be proper.
If intestinal and small, a truss with a hollow
pad; if omental, a common pad; and when
the hernia is very large, a T bandage, to give
support, and prevent increase.

Should this hernia become strangulated, strsngn-
.fiie taxis should be first employed in the
same way as in the other sex ; and should
this not succeed, bleeding, the warm bath,
ice, the tobacco enema, or other means to
assist reduction, should be had recourse to.

The usual means having failed to relieve
the strangulation, an operation becomes ne-

* Another good diagnostic mark is in the direction
o^he impetus giveu to the swelling, when the patient
<^otighs or sneezes; in inguinal heniia bein^ downwards,
Md ill femoral, upwards from the thigh, — T.

ceasarjr, which should be performed in the
following manner.

The hair having been removed from the
surface of the tumor, and the patient being
placed in the same position that I directed
the male should be under similar circum-
stances, the surgeon should make an inci-
sion through the integument, commencing
a little above the external abdominal ring,
and terminating at the lower part of the
swelling. This exposes the fascia covering
the hernial sac, which should next be care-
fully divided to the extent of the first in-
cision. The sac, being thus laid bare, should
first be cautiously punctured as before men-
tioned, and then should be further opened
upon the director.

The portion of the hernial sac below the
external abdominal ring may perhaps con-
tain only a quantity of the dark serum usually
found ; in which case the operator must
introduce his finger into that part of the
sac which is in the inguinal canal, and there
he will feel the portion of intestine or omen-
tum which is strangulated. He should then
slit up the canal and sac towards the ante-
rior superior spinous process of the ilium,
so as to expose the strangulated parts ; and,
ascertaining the seat of stricture, he should
pass a small director under it, ami carrying

berdia knife upon the director", the stnc-'
ture should be divided upwards, or upwards
and outwards, after which the protruded
|»8rts are to be returned, if they be not in a
state of gan^ene.

The last case of inguinal hernia in the
female, in which I had an opportunity of
witnessing the operation was under the care
of Mr. Forster, in Guy's Hospital.

Upon opening the sac below- the external Cai.
ring, a quantity of fluid escaped, but there
was not any appearance of intestine or omen-
tum. However, upon passing the finger into
the sac, through the external ring, a portion
of intestine could be distinctly felt, which
Mr. Forster subsequently exposed, by slit-
ting up the inguinal canal. The stricture,
iwhich was seated at the internal ring, was
■divided upon a director in the usual manner,
and the patient did extremely well.

The after treatment does not differ from After
,that I have directed for the other sex. ■ "

When the inguinal hernia in the female i" u>e

iDgnlna)

not descended through the external ring, canal,
it may become strangulated, and occasion
fatal consequences, as in the male, without
its existence having been recognised during
the life of the patient.

A patient was admitted into St. Thomas's case.
Hospital, under the care of Sir Gilbert Blane,

with symptoms of strangulated hernia ; but,
upon being closely questioned by Sir Gilbert,
she denied the existence of any tumor at the
groin, navel, or elsewhere, and the case was
consequently treated as one of inflammation.
The woman died; and Sir Gilbert, supposing
that some concealed hernia might have been
the cause of her death, inspected the body,
and found a small strangulated inguinal
hernia on the right side, which did not
protrude an inch from the internal ring.

When necessary, the operation in this case
is similar to that required for the same
disease in the male.

I have never seen direct inguinal hernia ia
the female.

Of Congtnital Hernia.

r In this hernia the protruded parts have
not any proper peritoneal sac, as the common
inguinal hernia, but are contained in the
tunica vaginalis of the testicle. All herniae
seated in this cavity are not, however, con-
genital, as such protrusion may occur at the
adult period for the first time.

This hernia is originating from the descent
of the testicle in the foetus. Usually about
the seventh month, the testicles, which are up

to that period seated upon the loins, begin
to descend into the scrotum. At this time,
a strong ligament is found connected with
the inferior part of the testis and epididimis,
and passing to the scrotum in the same direc-
tion as the spermatic cord is afterwards
placed ; it is called the gubernaculum, and
appears to guide the testicle into the situation
provided for it.

The testicle and its vessels are covered by
peritoneum, except just where the latter
enter at the posterior part of the former.

In its descent, the testicle takes with it a De*
portion of peritoneum, which afterwards be-
comes the tunica vaginalis ; and it is usually
found in the scrotum at the ninth month ;
but there is considerable variety as to the
period when the descent is complete, some-
times being earlier or later than the ninth
month, sometimes one testicle comes down
first, and the other does not descend until
some time afterwards. In some cases, the
testicles never quit the abdomen, and in
others they only descend to the groin.

When the testicle has reached the scrotum,
the opening through which it quitted the
I abdomen generally closes, but at what period
I is not precisely ascertained. If, however, it
^L should remain open at the time of birth, the
^■efforts of the child in breathing or crying

cause the protrusion of a small portion of

intestine into the cavity, and thus the tsoo-*

genital hernia is formed. , ;; ,:

Called the From its appearance and feel, more paf ^

rupture, ticulaxly when the child cries, the uursei^ oaU

it the lYindy rupture, in opposition, to .th^

term watery rupture, which they apply .to

an hydrocele, when it occurs in the infaAfe^

and this is not very unfrequent. . - j

Sometimes I hstvc fouud the tuuica vaginalis sufficiently

occurs &t

the adult opcu at the adult period to admit the introf
^^"^ ■ duction of a female catheter; and I have
known hernia, similar to the true congenital
form, occur in persons between twenty ian4
thirty years of age. In these cases I imagine
the opening at first to have been so small <w
not to admit the descent of a hernia undst
ordinary circumstances, but that when the
patients have been under the necessity of
doing very laborious work, or during ^: state
of great relaxation, the protrusion has taken

place. jiiin.:

Course. The Congenital hernia must necessarily
take the course of the spermatic cord, passing
in the same direction as an oblique ingumal
hernia, from which it is to be distinguished
by the following marks. In common oblique
inguinal bemia, the testicle is perfectly disf*
tinct from the hernial sac ; whereas, m the
congenital disease, the testicle is confounded

with the sac. In the latter case, also, the
appearance of the part very much resembles
that of a hydrocele ; more especially if, as
sometimes happens, a quantity of fluid de-
scends into the sac with the intestine or
omentum which, upon a close inspection,
gives a irsuisparent appearance to the swell-
ing. To distinguish these joint diseases, the
contents of the hernia should be returned
into the cavity of the abdomen whilst the
patient is in a recumbent posture ; after this,
a moderate pressure is to be made against
the abdominal ring, with the finger, so as to
prevent the descent of the intestine or omen-
tum ; if the patient then assume the erect
position, the water will escape into the
tanica vaginalis, but the intestine or omen-
tum will be felt pressing against the finger
above.

Sometimes the testicle does not descend
to the bottom of the scrotum, and then, if a
congenital hernia form, the tunica vaginalis
becomes elongated, and reaches considerably
below the situation of the testicle.

In the congenital form of hernia, also, the Division oi
Cord is occasionally divided, the artery and
win being on one side, and the vas deferens
taking its course on the other side.

When the congenital hernia is reducible, Redin:ible.J
it requires the use of a truss, as the common

inguinal hernia; provided tiiat the testicle^
completely descended into the scrotum, or
does not rest at the groin. For the first three
months, perhaps a pad and bandage may be
sufficient to prevent the descent of the hernia;
but after this period a truss with a spring
may be employed with safety, or- even at a
younger period if necessary.

> If the testicle be seated in the groin, a
truss canuot be worn without risk of injuring
the gland, and it is better to allow of such a
protrusion as will assist the complete descent
of the testicle, before any truss or other means
of suppressing the hernia be resorted to.

A young man who now holds a situation
of importance, and who is the father of several
children, was brought to me formerly by his
father, on account of his having a congenital
hernia; but because the descent of the
testicle on the same side was incomplete,
I directed that the protrusion should not be
retarded. The testicle afterwards descended
into the scrotum, a truss was then applied
for the hernia, and the disease was ultimately
subdued .

;■ After the truss has been worn for some
time, the tunica vaginalis becomes closed at
the upper part, and near the testicle, but
sometimes remains open between, allowing
a space for the deposit of fluid which occa-

ly takes place, forming hydrocele of the
cord, and for the cure of which 1 have had
to perform an operation on several oceasiona.

With regard to the treatment of this hernia irredncibwll
in the irreducible state, the same as directed
for common inguinal hernia, is here applica-
ble; and when strangulated, the same means
as recommended in the latter case, should be
employed for the relief of the patient.

When an operation is required, it should Operfltioa. j
differ from that described as necessary for
common oblique inguinal hernia, in the follow-
ing particular. Having laid bare the tunica
vaginalis, it should not be opened low down
on account of exposing the testicle, but a
sufficient quantity of the tunic should be left
whole to cover this gland.

On opening the tunica vaginalis, a much i-»fpe

t^ O D miaiUlIJ 01

larger quantity of fluid generally escapes ""id-
than is found in the sac of a common inguinal
Jiernia.

The seat of stricture will be generally seat or
found under the edge of the transversalis
muscle, or at the internal ring, when it
should be divided in the same manner as in
other cases of hernia ; after which, the pro-
truded parts, if not adherent, should be
returned. If extensively adherent, the stric-
ture should be divided in the same way,
but the surgeon should not attempt to separate

VOL. iir. i:

the adhesions, unless very few and slight,
in order to allow of the return of the parts ;
but they should be left ; and after the wound
has healed, a bag truss will be required, as
for other irreducible scrotal hemiae.

In operating for this form of hernia, the
testicle is sometimes found in the inguinal
canal in contact with the intestine; in i^diich
case the intestine only should be returned
into the abdomen, the testicle being left in
the canal. The stricture in this case is at the
orifice of the tunica vaginalis.

Of Encysted Hernia of the Tunica Vaginalis.

How formed. This is a particular species of hernia, which
occurs in the following manner. The tunica
vaginalis becomes closed, by adhesion, op-
posite the abdominal ring, but remains open
above and below it ; and when a protrusion
of intestine occurs, this adherent portion of
the tunic becomes elongated^ forming a dis-
tinct hernial sac within the proper tunica
vaginalis.
Case. I had an opportunity of witnessing the fol-

lowing case, under the care of Mr. Forster,
in Guy's Hospital. A man was admitted into
the house with symptoms of strangulated
hernia, which the usual means failed to re^
lieve, and the operation was proposed and

urged; but the patient would not submit,
choosing rather to die. On examining his
body after death, a sac was found within
the tunica vaginalis, descending from the
abdominal ring towards the testicle. This
sac contained a portion of one of the small
intestines which had become gangrenous^
The stricture was at the mouth of the sac.

In operating upon a case of this kind, the Operation,
tanica vaginalis should be opened freely, to
espose the sac, otherwise some difficulty
may arise.

Mr* Hey, in his surgical observations, has
related 9. casie swilv tp that of Mr^ Forster,

G 2

LECTURE XXXIV.

On Femoral Hernia.

Anatomy BEFORE I proceed to describe the symptoms

parta. of femorial hernia, I shall give an account
of the anatomy of the parts directly or indi-
rectly concerned.

saperfidai The superficial fascia, which covers the
external oblique muscle, is continued down
over Poupart's ligament upon the thigh,
where it is found of considerable density,
and serves to keep the superficial veins and
absorbent vessels in their proper situations.

cnirai Under Poupart's ligament, which stretches

from the anterior superior spinous process
of the ilium, to the spinous process of
the pubes, is a space called the crural
arch, which gives passage to the femoral
artery and vein, the anterior crural nerve,
and psoas and iliacus intemus muscles, with
absorbents, &c.
o^ernafa From that portion of Poupart's ligament
which is inserted into the spine of the pubes,
a process is given ofi*, extending downwards
and outwards, and attached to the ligamept
of the pubes over the linea-ileo-pectinea ; it
presents a concave edge towards the femoral

vein, and is known under the name of
Gimbernat's ligament.

Two fasciae are given off above from Pou-
part's ligament, one passing upwards between I
the peritoneum and transversalis muscle,
which is called the fascia transversalis; a
second fascia extends between the perito-
neum and iliacus, and psoas muscles, called
the fascia iliaca. From another part of the
fascia transversalis, a process passes down
under Poupart's ligament, through the crural .
arch, to the sheath of the femora! vessels, form-
ing its anterior part, and the fascia iliaca forms
the commencement of the posterior portion.

In this sheath are situated the femora! i
artery and vein, the anterior crural nerve >
not being included. The vein is placed most
internal, and about five-eighths of an inch to
the outer side of Gimbernat's ligament ; the
artery lies outside of the vein, and the nerve
still more exterior. The artery and vein are
separated by a septum.

Under the superficial fascia of the groin, i
and extending from the inferior part of Pou-
part's ligament, is a strong fascia, called
fascia lata, which has two attachments
above, but becomes united below. One
portion is joined to Poupart's ligament from
the spinous process of the pubes to the an-
terior superior spinous process of the ilium ;
G 3

and, paMwng downwardi^ coren the femoial
artery and reiiiy the anterior cmal nerwey
aad the nraidcs on the outer and fare part
of the thig^

From its origin at the q>ine of the pubea^
a defined edge passes a little oatwards and
downwards, in a ciescentic fiimij over the
sheath of the fenKHral yessels, then eunres
inwards, and a little upwards, under the
saphena majw vein, and is united to the
second portion. This seocmd portion is caor
nected above with the ligament oi the pubee^
close to the inserticm ci the external oblique
muscle; it then passes inwards ai^ down-
wards upon the psoas, ifiwui iiitiinus,yanQ
other muscles, to join that part which I
described as passing undet the saphena
major vein. From the union of these two
portions, the fascia lata of the thigh results
anteriorly.

Between the free internal edge of the firsts
and the origin of the second portions^ as low
down as their junction under the saphena
major vein, an opening is left, exposing a
part of the femoral sheath. This space is
filled above by absorbent glands; the ab-
sorbent vessels from which, here perforate
the sheath of the femoral vessels, to pass Xi&
the glands in the abdomen. At the lower
part of the space, the saphena major vein

penetrates ttte sheath to enter the femoral
vein about an inch below the crural arch.

If the fascia lata be entirely removed from
the upper part of the thigh, the muscles and
anterior crural nerve are exposed, but the
femoral artery and vein remain enclosed in
their proper sheath.

On opening the femoral sheath, the artery siieaoi

[d vein are exposed ; the former situated shaped.
clo the outer side of the latter, and about
three inches from the symphisis pubes. The
sheath, about two inches downwards, be-
comes intimately connected with a portion
of the fascia lata. It has somewhat a funnel
^ape, heiag larger above, and contracted
lelow, where it joins the fascia lata.
t The epigastric artery, in its course up- EpigMitU
wards and inwards from the external iliac,

isses from one-half to three-fourths of an
inch from the opening where the absorbents
enter the abdomen. There is, however,
considerable variety in the origin of this

from above, the peritoneum, which covers
it, must be taken off, when the relative
situations of the vessels, entering the sheath,
will be distinctly seen, as also the descent
of the two portions of fascia to form the
sheath, that from tlie fascia transversalis

above the vessels, and that fAm the fascia
iliaca beneath them.
Difference Ffom the difference in the formation of the

in the male . _ i c t i.

»nd female pelvis HI the male and female, the space form-
ing the opening to the femoral sheath is largest
in the latter, on which account they are more
hable to the formation of femoral hernia.

ConHDence- When a femoral hernia commences, the

ment of the . , ■ i

herwi. patient's attention is first directed to the part
on account of experiencing pain on suddenly
straightening the limb, as in rising from a
sitting posture. This is occasioned by the
extension of the fascia lata, and its pressing
on the protruded parts.
Appear. On examining the seat of pain, a fulness
hernia. is discovered at the upper and inner part of
the femoral sheath, which disappears on
pressure, or when the patient is recumbent.
This fulness soon increases, so as to foiiB a
tumor about the size of a small walnut, which
is situated immediately below Poupart's
ligament, to the inner side of the femoral
vessels, and to the outside of the spine of
the pubes. As the swelling enlarges, it pro-
jects more forwards and upwards, turning
up over Poupart's ligament; as it meets
with the least resistance in this direction.
^j^aiged When the tumor is small, from its situa-
gland. ^[qu ajj^ circumscribed feel, it has much the
character of an enlarged inguinal gland.

The direction of this hernia is at first a
little downwards in the femoral sheath, then
obliquely inwards and forwards, and lastly
upwards ; sometimes, however, instead of
turning up over Pouparfs ligament, it takes
a course downwards, in the direction of the
saphena major vein; but this very rarely
happens.

On dissecting a femoral hernia, the fol-
lowing appearances present themselves. On
cutting through the integument, the fascia
superficialis is exposed ; this, in its natural
state, is thin and delicate ; but frequently,
when hernia exists, the fascia becomes dense
and tough from pressure. Under this fascia
a portion of the sheath of the femoral vessels
13 found, which closely envelopes the hernial
sac itself; it is that portion which is per-
forated for the entrance of absorbent vessels.

This covering I first became acquainted
with in examining a patient in St. Thomas's
Hospital, in the year 1800, and have since
invariably found it, when operating for this
form of hernia. It may be termed the fascia
propria of the hernia.

Beneath this covering, and between it and
ihe sac itself, there is generally some adipose
matter situated, on separating which the sac

is laid bare. This layer of adipose matter I

liavc known to be mistaken for omentum.

DirecUoD
of the

90
Miitake» The femoral hernia i8 much less likely to

for other "^

diseases, be confounded with other diseases than the
inguinal^ on account of the much m,ore fire**
quent formation of various tumors in the
fiitua,tian of the latter; but still there are
some diseases which I have known to be
mistaken for femoral hernia, apd in the
discrimination of which much care is re<-
quisite.

Enlarged In Several instances, an enlarged gland in

^'"•'- the groin has been mistaken for a femoral
hernia ; and, on the contrary, the hernia has
been treated as an enlarged and suppurating
gland ; but such mistakes must arise from
inattention to the previous history of the
case.

Case. Some years ago, a man was admitted into

Guy's Hospital with a strangulated henm,
over which a poultice had been applied fw
three days before his admission, under the
supposition that it was a bubo. The opera-^
tion was performed, and the intestine found
gangrenous.

Case. Mr. Bethune, surgeon, at Westerham,

in Kent, assured me, that he saw a patient
who had been the subject of a strangulated
femoral hernia, which had been poulticed
for some days, and at length opened, when
air and feculent matter escaped, and the
patient died ten days after.

I When a femoral hernia and enlarged HemiB
iaud exist at the same time, an attentive 'arged
I minute examination is sometimes requi-
site to ascertain the existence of the former.

I once saw a lady with Mr. Owen, sur- caae
geon to the Universal Dispensary, who had
Buifered from symptoms of strangulated
hernia for nine days, and had been treated
for inflammation of the intestines, as she
had not mentioned the existence of a swelling
in her groin. Mr. Owen discovered this
swelling, and in consequence requested me
to visit the patient, at the same time in-
forming me, that the tumor had not the feel
of a hernia, but that he supposed it must be
one from the symptoms. Upon examining
the part, I found an enlarged gland, about
the size of a walnut, very hard, and moveable ;
but beneath this gland, and separate from
it, was an elastic tumor, which I succeeded
in reducing by the employment of the taxis;
and this relieved the patient from all the
symptoms of strangulation.

Some of the symptoms attending psoas P'"*"
abscess resemble those of a femoral hernia,
and might lead to mistake. Psoas abscess
makes its appearance in the groin in the
same situation as a femoral hernia; it dilates
when the patient coughs, and is less apparent
when the person is in a recumbent posture.

than when he is erect. It may, howerer, be
readily distinguished from hernia hy the
pain in the loins, which precedes the ap^
pearances of the swelling, by the general
constitutional derangement attending it, by
its more rapid increase, and by the absence
of intestinal derangement. •

he^** The error of most consequence respecting
femoral hernia, is, that of mistaking it for in-
guinal hernia. Danger arises under such cir-^
cumstances, from the operation of the taxis,
the direction to make pressure in the femoral
being quite different from that proper in the
inguinal ; but the most serious mischief is
likely to arise, if an operation be necessary,
in the division of the stricture. *

caac. I was ouce sent for to operate on a patient

for a strangulated inguinal hernia, which, on
examination, I found to be femoral, and
succeeded in reducing it, by making tiie
pressure in the proper direction ; and I have
known operations performed as for inguinaT
hernia, when the disease has been femoral.
These mistakes arise from the femoral pro-
trusion turning up over the crural arch or
Poupart's ligament ; and much attention is
often requisite in making an examination,
before the surgeon can confidently decide
on the true nature of the disease. The best
marks of distinction which I have observed.

are, that the neck of the femoral hernia is
below and to the outer side of the spine of
the pubes, while that of the inguinal hernia
is above the spine; also, by drawing down
a femoral hernia, Poupart's ligament may
be traced above it, which it cannot be, if
the disease be inguinal.

I have seen a case of enlargement of the varico«
femoral vein, which had somewhat the ap-
pearance of a femoral hernia, but it was rea-
dily detected, by pressing on the iliac vein
above, while the patient was recumbent, when
the tumor immediately appeared.

Femoral hernia is most frequent upon the *"''* ^^"''"■
right side, probably on account of the most iient on
persons employing that side in the greatest side.
degree.

Women who have borne many children Mother
are more liable to this disease than others, i
which arises from the extension of the ab-
dominal parities during gestation, causing a
move relaxed state of the parts ; also, old
persons are more frequently troubled with
this disease than the young.

Most frequently the protruded part in Mo.t fre-

ooral hernia is small intestine, very rarely tcstuial'"'
Twily omentum, but occasionally both intestine
and omentum. I have seen the coecum in a
femoral hernia on the right side, and the ovaria
have also been found in the hernial sac.

The femoral hernia is produced by ■
same causes as occasion the formation of
inguinal hernia, except that I do not recol-
lect a single instance in which this disease
lias been originated by a blow.

Treatment of the Reducible Femoral Hernia.

From the small size of the opening through
which femoral hernia passes, the patient is
in great danger from strangulation, unless
proper means be adopted to prevent the
descent of the viscera.

The employment of a truss is the only
method by which the safety of a patient can
be secured ; but the truss required for fe-
moral hernia must be of somewhat different
construction to that which is required in
inguinal hernia.

The pad, instead of being continued nearly
in a straight direction with respect to the
spring, as when required for inguinal hernia,
should project downwards, nearly at right
angles, to the spring, that it may effectually
press upon the opening through which the
hernia protrudes under Pouparfs ligament,
and also upon the upper part of the thigh.

The truss should be constantly worn, as
for inguinal hernia, to prevent the protrusion

of the hernia, and also with the view of
obliterating the mouth of the sac, and curing
the disease.

It is very rare, however, that a cure is domhi
effected in femoral hernia by means of the
truss, but still it is right that it should be
constantly kept on. I have known many
instances in which the constant application
of the truss has not produced the smallest
apparent alteration in this hernia ; the reason
is, because Poupart's ligament, and tlie
fascia lata, support the pressure of the truss,
and the constant variation in the tension of
these parts on every movement of the body,
prevents the steady pressure necessary to
produce a gradual closure of the opening.

In some cases, when the opening of the
femoral sheath is large, it will be necessary
to have a larger pad, and a stronger spring
to the truss, and the pad may be more effec-
tually kept in place, by means of a strap
passed from it round the upper part of the
thigh.

If a hernia exist on both sides, a double soubif
truss will he required, made upon the same
principles as the single one.

The truss made by Salmon and Odv's, Salmon a
I have generally found best adapted to these trms.

Of the Irreducible Femoral Hernia.

caiiies. Femoral hernia may become irreducible

from adhesions of the protruded parts to the
interior of the hernial sac ; from a growth of
the protruded parts within the sac, so that
they cannot repass the opening into the
abdomen, or by a contraction at the neck
of the sac itself, producing the same con-
sequences.

Treatment. In either case, a truss should be applied
with a hollow pad, which is to receive the
tumour, and prevent its increase.

Case. A gentleman consulted me, in consequence

of his having an irreducible femoral hernia,
which, upon examination, I thought only to
contain omentum ; I directed him to wear a
truss, with a depression in the pad, just
large enough to receive the tumor. Two- oi^
three years afterwards, I saw this gentleman
again, when I was gratified in learning^,
that his hernia had nearly disappeared.
This was in consequence of absorption of the
omentum having been produced by the pres-
sure of the pad.

Truss can- If the hcmia be entirely intestinal, this

not always • i i n ••

be worn, form of truss^ With a hollow pad, cannot
always be borne, as I have known it to
create very severe suffering.

Of Stritngulated Femoral Hernia.

The symptoms of strangulation being the Sympio:

same as those I have already detailed in the

lecture on inguinal hemia, I shall not again

repeat them, but merely observe, that in

femoral hernia, they are usually more urgent

^Hi account of the smallness of the opening,

^brough which the protrusion occurs, causing

^Bteater pressure.

^ft The patients generally complain of more seTw. ■*1
Hpda from strangulated femoral than inguinal
hernia in the same state, and they die sooner
from the former than the latter disease.
The medical treatment required for strangu- Medical
b^ed femoral hernia, does not differ materially
Hpom that necessary for the inguinal disease.

In the first place, the taxis should be Taxis,
employed, but in a different mode to that
^J have described as proper for the reduction
^h|f mguinal hernia. The patient should be
^Waced on a bed, with the shoulders ele-
i rated, and the thighs bent at right angles
with the body, leaving only sufficient space
between them to admit the arm of the
operator. The tumor is first to be pressed
downwards, until it be below the level of
Poupart's ligament, when it is to be kneaded
upwards towards the abdomen.
The difficulty usually experienced iu at- uifficuiiy.

tempting to reduce this form of hernia, arises
from the pressure being made at first in an
improper direction, viz. upwards, so that the
hernia is forced over Poupart's Hgament,
instead of beneath it, and in this way the
hernia never can be reduced.

As in the reduction of inguinal hernia, the
pressure should be gentle and continued,
avoiding violence, which may be productive
of the most serious consequences.

Should the taxis fail, the same general
treatment as that directed for inguinal hernia,
should be pursued, as bleeding, the warm
bath, opium, the application of cold, and the
injection of the tobacco glyster. These reme-
dies, however, have much less beneficial
influence in femoral, than in the other forms
of hernia ; which I imagine is owing to the
nature of the parts through which the pro-
trusion occurs, and the smallness of the
aperture through which it descends.

As the symptoms are usually very urgent
in femoral hernia, and as the disease more
rapidly destroys life, there is the greater
necessity for the early performance of an
operation, when the usual means to effect
reduction have been tried and have failed.
I have known a patient die in seventeen
hours after the symptoms of strangulation
had commenced ; and on the contrary,^

»T^^

nve performed an operation with sucoess,
fter the symptoms had existed seven days.;
'but in general, the patients lahouring under
this disease do not survive the strangulation
more than four days, if the stricture remain ;
whereas, in inguinal hernia, under similar
circumstances, they often live a week or
more.

Of the Operation for Femoral Herni

The hair is to be removed from the sur- Prcpara.
Yace of the tumor, and the bladder should
be emptied. The patient should then be
placed upon a table of convenient height,
in a horizontal position, but his shoulders
should be a little raised, and the thigh bent
towards the abdomen, in order to relax the
abdominal muscles, &c.

The first incision should commence a little OperaUon. ]
above the superior part of the tumor, towards
the umbilicus, and be extended downwards,
somewhat to the inner side of the prominent
part of the swelling, as far as its middle ; a
second incision should then be made from
the inner to the outer side of the tumor, at
right angles with the first incision, and join-r
ing it at the lower part, so that the two
togetiier form a figure resembling an in-
terted ± .

H 2.

The angular flaps should then be dissected
up, to allow of sufficient space for the other
steps of the operation.
ii The superficial fascia which is thus ex-
posed, should next be divided to the same
extent as the integument, by which the
covering formed of the sheath of the femoral
vessels will come into view ;■ this should be
carefully cut into, so as to admit of the intro-
duction of a director under it, upon which it
should be further opened, so as to freely
expose the hernial sac.

If the patient is fat, a layer of adipose
matter may be found between this covering,
formed of the sheath of the femoral vessels,
and the sac itself.

I have known this covering, which I call
the fascia propria, to be mistaken for the
hernial sac, so that the surgeon who ope-
rated, supposed he had opened the peri-
toneal covering when he cut into the sheath,
and after considerable difficulty, he suc-
ceeded in pushing up the protruded parts,
but on the following day, the patient died ;
and when examiniog his body, it was dis-
covered, that the hernial sac had not been
opened, but had been thrust up into the

• There is usually a considerable vein between the
auperficial fascia, and the fascia propria, as well as sb^
Hoibent gtand)^.

ell aBM*|

idomen with its contents, which still re-
i|nained in a strangulated state.

The surgeon having exposed the hernial i

should pinch up a small portion of its
terior and lower part, between his finger
and thumb, carefully excluding any portion
of the contents of the sac, and then placing
the blade of his knife horizontally, he should
cautiously make a small cut into the elevated
part, making an aperture of sufHcient size to
*llow of the passage of a director, upon which
he should further divide the anterior part of
sac upwards and downwards,

A quantity of fluid usually escapes, when f
the sac is first opened, which varies greatly
quantity, and somewhat in colour, accord-
ig to the period that the strangulation has
ejdsted. It is not uncommon, however, for
the fluid to be entirely wanting, even when
Lthere are no adhesions.
^B If inflammation runs high, the peritoneal
^Piwrfaee of the intestine is covered by adhesive
~ matter.

The next and most important step in the i
operation, consists in dividing the stricture, t
the situation of which should first be dis-
tinctly ascertained by passing the point of
the little finger into the hernial sac, on the
tore and inner part of its contents.
li" the hernia be large, the scat of stricture s
H 3

the

may be at or under the opening in the folscm
lata, through which the covering formed by
the sheath of the femoral vessels is pro-
truded ; but generally, the stricture will be
found immediately beneath Poupart's liga-
ment, in the mouth of the sac itself, where
the hernia quits the abdomen.

In either case, a director should be very
carefully introduced into the sac, anterior to
its contents, and gradually insinuated under
the stricture, and upon its grove the hernia
knife (before described) should be passed,
with its cutting edge turned upwards, and
a little inwards, towards the umbilicus, in
which direction the stricture should be
divided.

In some cases when the hernia is large,
strictures may be found both at the cres-
centic margin of the fascia lata, and under
the crural arch of Poupart's ligament, and
each will require division, that at the
fascia lata must of course be first libe-
rated.

When a stricture, therefore, exists at the
crescentic margin, the surgeon, after dividing
it, should make a careful examination, to
ascertain if the passage to the abdomen be
free, before he attempts to return the pro-
truded parts, for should a second stricture
exist, he may rupture the protruded intes-

103

tiiie ki the* vidence he must employ in en-*
dewQwingitQ return iti.

In drn^^fif^ihe ^iner stricture^, it has been Direetioii
recprnmendjod t9 cut in the direction of Gimr
bemtit's ^gam$nt^ inwards towai^ds the
jHibea,; but as the stricture is not occasioned
by this ligament, there cannot be any ueees-
sity fcMT dijiriding . it ; I have known Gim-
b^mat'$ ligaraesit divided, from an idea that
it iormed thQ stricture, but the strieiiure still
remained at the orifice of the &scia fMX>pri9,,
or in. &e mouth of the ssic itself, and the
patient died.*

Great caution is requisite in dividing the Great
sti^turie, if the protrusion be entirely in- Mry.
testinal, and the operator should not intro-
duce the knife, until the int^tine hu been
carefully placed out of danger by an as-
sistant

. Sometime ago, a case occurred in one of Cue.
the Bqrough hospitals, in which the intestine
was wounded, when the operator was dividing

* It is curious, that Gimbernat's ligament should
e^r have been supposed to be the seat of stricture, as
it exipli only upon the inner side of the mouth of the
WnialsaiB, and therefore could not influence the outer
portion. If strangulated femoral hernia be examined in
the dead body, and Gimbernat's ligament be cut through,
the hernia is not liberated by such a division, for the
orifice oE-tiie fascia propria, or the neck of the sac itself,
still girt the viscera as much as ever.

H 4

104

the stricture^ which he did inwards^ tc^ardiEr
Gimbernat's ligament ; feculent matter
was extravasated into the catity of -the
abdomen^ and the patient died. On exa^
mining the parts after deaths two openihgs
were found in the intestine^ close to fhe
mouth of the sac*

Adhesions, fhe treatment I have directed as proper in'
inguinal hernia, when the protruded parts
adhere to the sac, or when the intestine
or omentum are gangrenous/ is also proper
under similar circumstances in femoral^
hernia.

After After the operation, the same mode of

treatineoi' . , ir i '

closing the wound, and indeed the after treat-
ment generally, should be the same as in the
inguinal disease.
But little Very little variety is met with in femoral'

variety. , '' "^

hernia, - the most important one is that • in
which the obturator artery arises from the
epigastric, and surrounds the neck of the
sac.
51* ? *V . ^^* Barclay, a celebrated teacher of
paraUon. auatomy at Edinburgh, was kind enough to
send me a specimen of this variety, which
was taken from a patient, whose previous
history could not be ascertained.

* Cutting directly inwards is a most dangerous
operation in femoral hernia, as the intestine is very likely
to be wounded.

. Wardrop has also met with this
variety.

Although the obturator artery frequently
arises from the epigastric, it is Tery rarely
found passing before the sac in femoral
hernia, but usually takes a course to the
outer side, and beneath the sac, as I have
often witnessed when dissecting the parts
of femoral hemiae. My mode of avoiding
iDJury to the epigastric or obturator arteries,
is to make a very slight division of the stric-
ture with the knife ; and then, by pressure of
the finger or of a director, to enlarge the
opening.

In one instance I have met with a large
quantity of fluid situated between the fascia
propria and the hernial sac. The following
is a short account of the case : —

Miss , Bet. 20, had been the subject

of a femoral hernia on the right side for three
or four years, which had acquired about the
size of a pullet's egg. In June, 1825, the
hernia became strangulated, and increased
to a very large size. As she did not mention
the existence of the hernia to her medical
attendants, it was not discovered until the
third day from the commencement of the
symptoms, the continuance and severity of
which led to an examination. Mr. Wakefield,
of Hatton Garden, who had attended her.

Fluid be-
neUh the
fascia pro-

106

immediately requested me to visit her; wken,
after trying, without effect, the CNndinary
means to reduce the hernia, I cq^arated. On
opening the fiisda {HPf^na, I was astonished
at the escape of nearly a {ant of tianspar^it
fluid, resemUing that nsoally drawn off in
hydrocele. The hernial sac, which then be-
came exposed, was smaQ ; and, chl opauqgt
it, a little of the usual dark-coloured flaiA
was discharged. A small portion of omes-f
turn, with a fold oi small intestine, were pro-
truded. After dividing the stricture^ and
returning the viscera into the cavity of the
abdomen, I removed a large part of loose
bag exterior to the sac. The patient, reeo-
vered rabidly. f. ?. r.

.■ ':0-

' r - .' .

■ • at

LECTURE XXXV.

On Umbilical Hernia.

This form of heniia, which is also termed syoo^
exompbalos, is next in frequency to the
inguinal.

The protrusion takes place through the Nitiirai
opening in the linea alba, wliich is formed
in the foetal state for the passage of the ves-
sels of the umbilical cord.

After the funis has been tied, this opening How dosed

'^ " usually.

usually becomes closed by dense cellular
tissue, and the remains of the umbilical .
vans and arteries, but not by a tendinous
Btracture. The integument over it is adhe-
rent, and generally drawn in, forming the
navel.

Behind the navel, when these parts are DSe'ecUon
dissected, the peritoneum is found, which parn.
adheres more firmly at this part than any
other of the linea alba ; it is connected above
to the remains of the umbilical vein, and
below to the ligament of the bladder and
feniEdna of the umbilical arteries. There is
lot any perforation in the peritoneum behind
'^^ navel, as the vessels do not penetrate

108

it, but pass between it and the abdomimd
parietes.
Commence. Umbilical hernia commences in a small

ment of the

disease. protrusion about the size of a nut, which
can be easily reduced, but which again
appears immediately the patient coughs <Nr
exerts himself. If neglected, it soon increases
in bulk ; and, as it augments, it grantateii ^
so I that the. larger part of the . swelling .^ia
below the orifice of the sac, and in some
instances it acquires so great a size as., to
reach to the upper part of the thighs. }.; .

Creates This discasc, if intestinal, and hot imp-

moch sat- ^ . » r

fering. ported, is attended with much danger, aadt
creates a considerable degree of sufferings
The patient frequently feels so.much.weid&t
ness and sensation of sinking, as to be ine|4
pable of making an exertion. The^-boweif:
are very irregular in their actions, and'tl)y» >
patient is much troubled with flatulenoe, and
nausea. ■ '/»*'- .

symptons Besides the frequent occurrence of- these

when in- - ,

testinai. . symptoms, the intestinal protrusion may be
distinguished by its elasticity, its unifcmn
feel, and by the passage of the air, &€*'
through the canal, producing, a gurgling
noise.

When When the protrusion is entirely omental,^

omental. *^ . ^ f i

the patient experiences but little uneafianesa
or irregularity of the bowels. The feel of the

and doughy, ana is but

sweUing IS nneven

little tender under considerable pressure-
Sometimes, if both intestine and omentum wiicnboth.
are contained in the hernial sac, they can
be distinguished from each other by the
above-mentioned marks. The omentum is
in these cases usually above, and the intes-
tine below. But, most frequently, the quan-
tity of omentum protruded is much larger
than that of the intestine, and the latter is
covered by the former, so that it cannot be
at Brst distinguished.

The umbilical hernia is very common in ^
infants soon after birth. Intestine is then
generally protruded, and the shape of the
swelling somewhat resembles the distended
finger of a glove in shape ; the hernia is
easily reduced, unless the opening in the
tinea alba is very small.

Children, subject to this disease, suffer
from griping and a very irregular state of
bowels, sometimes being constipated, at
others being violently purged.

When this hernia occurs in the adult, if Appe»r-
the patient be thin, the shape of the tumor adoit.
18 pyriform and defined ; but in fat persons,
the hernia is sometimes scarcely perceptible
on a superficial inspection, as it extends
upwards and downwards, is flattened ante-
riorly, and has its circumference blended

Sac in part
deficient.

Two sacs.

Case.

Most fre-
quent in
women.

Causes.

with the adipose matter, so as not to present
any defined edge. The tumor may be flat-
tened in thin persons, but when so, its eldtent
is always evident. j :

Although, generally, the hernia has a peri-
toneal coveripg, or proper sac, yet^ in a 'few
instances, when the disease has been of l6n||(
standing, and , has acquired a very large sttMi
I have seen the sac in part wanting.

I have also known two sacs to exist at the
same time ; one protruded by the side of the
other, and only separated at their origin by
a thin septum.

Mr. Cline operated twice upon a womati
in St. Thomas's Hospital, for strangulated
umbilical hernia, in whom two hemies ex<«
isted, having their commencement about haff
an inch apart, but the sacs lying in contact. • •
Women are much more liable to this
disease than men, and the most frequent
cause of it is pregnancy, the bowels being
pushed up by the gravid uterus as it rises
from the pelvis.

Another cause is the deposition of adipose
matter within the omentum and mesentery,
whereby their size is so much increased that
the abdomen is hardly capable of containing
them. Women who become corpulent after
having had many children, are often subject
to this disease, on account of the lax state

Ill

aomioal parictes, not affordit^ suffi-
cient resistance to prevent such protrusions.

The distension of the abdominal parietes,
and protrusion of the navel, which is some-
times met with in ascites, is said to be a
cause of umbilical hernia; hut I am inclined
lo think that it is more frequently the conse-
quence than the cause of this disease.

Treatment of Reducible Umbilical Hernia.

Id infants subject to this disease, the plan in inraDU.
I usually adopt, is, after having reduced the
hernia, to apply half of an ivory ball sufficient
to cover the opening, and to confine it in that
situation by means of adhesive plaistcr. A
linen belt should be applied, and secured
round the body, but as soon as the child
begins to walk, two straps must be fixed
to the lower part of the belt, which should
pass under the pelvis, between the thighs,
to prevent the belt from slipping.

For the adult, or even for children, when in aJuii>.
the hernia is of small size, a spring truss may
he employed, made on the same principle
as that directed for inguinal or femoral
protrusions. The pad of the truss should
cover the opening through which the viscera
escape ; and the spring should pass from the
pad to the back of the patient, a little beyond

112

the spine ; and a strap should be continued

from the spring to the pad, to complete the

circle.

In very fat ' Whcu the patient is very corpulent, so

persons, ^j^^j ^^ navel is deep, the portion of ivoary

may be advantageously placed under the
pad of the truss, the more effectuidly; Ob
close the opening of the sac; and this is
much better than having a conical pad,
which is liable to shift its position when the
patient is in motion; but the half globe of
ivory does not follow the motion ,of the
pad.*
When very Very large herniae, accompanied witU &
^"^^' lax state of the abdominal parietes, require
a different form of truss, as it. is necessary
to make a more extended pressure. The pad
of the truss, therefore, instead of being CMO^y
of sufficient size to cover little more than the
orifice of the sac, must be of considerable
extent, so as to press upon a large space round
the hernial opening, and thus support the
parietes as well as the hernia, which will
render the patient comfortable, although
there is not any prospect of thus effecting a
cure.

^ The ivory ball with the adhesive plaister, wrll, in
the adult, prevent the increase of a small hernia, m> as
to render a truss unnecessary.

Of the Irredticibk Uinbilical Hernia.

riy large.

Umbilical hernia becomes irreducible from c
the same causes as the inguinal does; viz.
adhesions of the intestines or omentum to
the inner surface of the sac, or a growth of
omentum, rendering it too bulky to repass
the opening by which it escaped.

Under these circumstances, the hernia Bec-o
sometimes acquires an enormous size, more
particularly in women, whose abdominal
parietes have been weakened by frequent
pregnaQcy ; and I have in such persons seen
the pudendum entirely covered by the hernial
swelling. The umbilicus in these cases is
brought nearer to the pubes than natural, by
the constant weight and drag of the hernia.

With such a large hernia the patient is D.111
exposed to constant danger from blows or
falls ; besides the weight of the tumor, and
an ulcerated state of integument, which often
occurs, renders the patient incapable of fol-
lowing any employment requiring bodily
exertion.

When the hernia is irreducible, and not of Tieaiment.
very large size, a truss should be worn with
a hollow pad, as recommended for irreducible
inguinal hernise. The hollow should be just
sufficient to contain the swelling, and the

114

edges should be rounded off so as to prevent
any injury from pressure to the surrounding
parts. The substance of the cup should be
pewter, which should be covered with soft
leather. The spring should be of the same
kind as that of the common truss.
When very Jq y^jy large hcmias of this description;
a truss cannot be worn ; and all that can be
done to relieve the patient is to support tfan
swelling by bandages, passed over the shoul-
ders so as to prevent the constant dragging
of the tumor.

. ■ J

Of Strangulated Vmbilicai HemuB.

Symptoms. fhc symptoms, indicating strangulation in
this form of hernia, are the same as those I
have described as existing when inguinal
or femoral hemiae are in the same state;
but in the umbilical disease they^ are gene^
rally less urgent.

Caoses. Strangulation is frequently produced in

these cases by the 'patient taking food not
easy of digestion, or such as occasions flatu-
lency ; persons having this complaint should
there^Dre eat sparingly, and be careful to
avoid all food difficult of digestion, or likely
to create flatulence.

lid

The seat of stricture is usually at the seat of
tendinous opening through which the hernia
fHTOtTudei, but sometimes the neck of the
sac itself is thickened, and prevents the re*
duction^of -the viscera.

When strangulation exists, the surgeon Treaiment.

" " Taxis.

should first endeavour to relieve the patient
by emplojring the taxis in the follovring
manner. The patient being placed on the
baeky the shoulders should be elevated by
pillows, also the pelvis a little raised, and
the thighs bent at right angles with the
body. The surgeon should then grasp the
swelling with hil^ hand, and direct the
pressure a little upwards as well as in-
wards, because the opening to the abdo-
men is not usually in the centre of the
swelling, unless the hernia is small, or pro-
jecting, when the pressure should be made
dirediy inwards. If the neck of the sac
can be distinctly felt, the surgeon should
knead it with the finger and thumb of one
hand, while he presses the hernia with the
other.

In very large, flat, and spreading hernia, tn very
when the tumor cannot be grasped hy the ifer'nl..
hands, the surgeon should make pressure by
means of some broad surface, as the bottom *
of a wooden platter, which he should place
on the surfoce of the swelling, and keep up

1 2

116

a steady pressure upon it for twenty minutes
or half an hour.
General Should the employment of the taxis fitil
' in relieving the patient, the other nieans
recommended for the femoral and inguinal
hemise, under similar circumstances, should
be tried ; but the remedy which I have found
most successful in this disease, and on which
I place the greatest reliance, is the tobacco
glyster, as it appears to produce much more
beneficial effects in this form of hernia, than
in the others I have described. It should be
used of the same strength, and with the
same precautions I have before mentioned*
In many instances I have known this re-
medy successful, after repeated trials of other
means had failed to relieve the patient.

Bleeding, and the application of cold, I
have known to produce the desired effect
aflter the taxis had failed ; but the surgeon
must be careful how he takes away blood,
as women of delicate constitution, and lax
fibre, are often the subjects of this disease,
in whom the loss of blood, in large quantity,
might prove destructive.

Should the strangulation continue in spite
of these trials to relieve it, the surgeon should
proceed to liberate the hernia by an opera-
tion, the performance of which is extremely
simple, but requires a little caution.

The patient being placed upon a table of opemtion.
convenient height, in an easy position, with
the abdominal muscles relaxed, the surgeon
should commence the operation by making
an incision across the swelling, and then a
second cut at right angles with the first, in
the direction of the linea alba ; the transverse
incision should be below, and should be
joined at its centre by the lower part of the
perpendicular cut, so that the two represent
an inverted x ■

The two angles should be dissected up to
expose the superficial fascia, which the sur-
geon must next divide, but very carefully,
as the hernial sac itself is sometimes wanting
in part; and in such a case the protruded
viscera would be immediately exposed.
This covering should therefore be opened,
as if it were the sac, by nipping up a small
portion between the finger and thumb, in the
manner I have already described.

If the peritoneal covering be complete be- \
neath the superficial fascia, it should be cut
into, and divided further, upon a director,
in the same way as when operating for other
hemiEe. The escape of a small quantity of
fluid usually indicates that the sac has been
opened.

The protruded viscera being exposed, the DiviiioDof
operator should carefully pass his finger over ture.

I 3 I

118

their upper part to the opening of the umbi-
licus, and then introducing the hernia knife
upon his finger, and insmuating it iiader ihe
stricture, he should cut upwards towards
the ensiform cartilage to such an extent as
will make the opening suflSciently large to
allow of an easy reduction of the protruded
parts.
Return of Haviug divided the stricture, the intes-

viscera. . .« . ^ i i •» i /•

tme, if m a fit state, should be first cau-
tiously returned; and the omentum, if in
large quantity, or if in a doubtful state, may
be cut away, but if in a small quantity, and
sound, it may be returned into the abdom^ok.
Alter- The edges of the externaUiound should

'"''*'""'• be brought together by sutures, and the
approximation completed by strips of adhe-
sive plaister ; a compress of linen should be
placed over this, and confined by means of
a broad bandage passed round the body.

It is of much importance, after this ope-
ration, to procure a closure of the wound by
adhesion, as the direct communication with
the abdomen increases the risk of peritoneal
inflammation.
Operation For vcry large umbilical herniae, when
hwnia?^ strangulated, I should recommend a different
mode of operating, which should be per-
formed in the following manner. A small
opening should be made over the neck of

119

ite swelling, ttirough the integument and
superticial fascia, so as to expose the hernial
sac at that part ; then the operator should
pass his finger between the sac and edge
of the umbilical opening, so as to guide the
hernial knife, by which the umbilical opening
should be dilated upwards without dividing
the sac.

1 performed this operation upon a Mrs. Ca«.
Aaron, who had long been afflicted with a
large irreducible umbilical hernia, which
became strangulated. When I had divided
the tendon, I was able, by very slight pres-
sure, to return a portion of the protruded
intestine, anA«he rapidly recovered.

In some cases the intestine adheres so Adiiesious.
firmly to the moutU of the sac, that great
care is requisite to avoid wounding it. The
sepai'ation of these adhesions in part must
be effected with as little violence as [Xissible,
by means of the finger, to allow of the safe
division of the stricture.

In some instances, where there has been stranguii
an opening formed by absorption, or lacera- opening™
tion of the hernial sac, tlie intestine, or ''"^"
omentum escape from the sac through the
aperture, and become strangulated by the
pressure from its edge. lu these cases there
is considerable danger, unless the operation
be very carefully performed, as the viscera

120

are exposed immediately the superficial fascia
is divided.

Should the adhesions be extensive asul

firm^ the surgeon must be content witii

liberating the stricture, and not attempt tO'

return the protruded viscera. >.

Pvtorthe The intestine generally protruded inumr-

colon pro- . . *

truded. bilical hernia, is a portion of the colon ;. the
appendices epiploica^. of which become more
quickly altered than the intestine itself; and
if much changed, they should be cut off
rather than any risk incurred by leaving,
them to slough after the operation.
S*"r'ra^ The danger in this operation is of wound-
tion. ing the intestine, as there is not any vessel
of importance that can be injured.

Of Ventral Hernia.

Like the This hernia only differs from the umbilical
uni ihcai. ^^ j^ g^^^ which is usually at the linea alba,

or linea semilunaris; but any visceral pro-
trusion at the anterior, or lateral parts of the
abdomen, except those already described,
may be called ventral hemise.
symptoms. The symptoms of this form of hernia are
usually the same as those of the umbilical,
excepting when the hernia is formed be-
tween the umbilicus and ensiform cartilage

121

in the linea alba, and contains a portion of
the stomach, when peculiar symptoms will
arise.

I once saw a gentleman with a hernia in cme.
this situation, who suffered constantly from
indigestion, flatulency, and a distressing
sensation of sinking at the scrobiculus
cordis. His hernia was, however, reducible,
and the application of a truss relieved al!
his unpleasant symptoms.

The following causes may give rise to this Came..
hernia : —

1. A natural deficiency of tendinous struc-
ture, which I have known to a very consi-
derable extent, in the linea alba or linea
semilunaris.

2. The apertures for the passage of blood-
vessels being unusually large.

3. Injuries by which the continuity of the
parietes is destroyed.

The coverings of ventral hernia are gene- covetingji.
rally the same as those of the umbilical
disease; viz. the integument, superficial
fascia, and peritoneal sac ; but in some in-
stances I have found another covering con-
nected with the edge of the opening in the
tendon through which the hernia escapes.

When this hernia occurs in consequence
of wound, the coverings must, of course,

122

Of the Reducible Ventral Hernia.

Triui. When seated in the linea alba» a tnisi^

similar to that employed for umbilical hernia^
should be worn ; but, when low down in the
linea semilunaris, the truss applied shoiiUi
resemble that recommended for ingninal
hernia, only that the pad must be turned
somewhat upwards.

When irreducible, the same form of tmss^
with a hollow pad, will be required.

/»,

Of Strangulated Ventral Hernia.

Symptoms. The symptoms indicating strangulatioB of
this hernia are, in every respect; similari to
those already described, as occurring when
umbilical hernia is in the same state; and
the means which should be tried, with a
view of relieving the patient, should be of a
like nature.

Treatment. As in the umbiUcal disease, the tobacco
enema has here a more powerful effect than
in the inguinal cur femoral herniee.

Taxis. In employing the taxis, the pressure

should be made a little upwards as well
as inwards, for the swelling, like the umbi-

J23

lical, has the greater part situated below
the opening from the abdomen.

If an operation becomes necessary for the operation,
relief of the patient, it should be performed
ia the ^same mode as that described for um-
bilical hernia ; but when the disease is seated
low down in the tinea semilunaris, the sur-
geon must bear in mind the course of the
epigastric alrtery, and divide the stricture so
as to ayoid it.

In very large ventral hemiae, the operation For large
I have mentioned before, of merely exposing
the neck of the sac, and dividing the stric-
ture, without opening the sac itself, may be
adopted with advantage.

In the after-treatment of these cases, After-
nothing of importance is necessary beyond ^®**"®"*-
what I hav« already recommended for the
other forms of h^mise.

Cf the Thyrmdeal Hernia, or Hernia
' Faramims Ovalis.

The 'first example of this disease which I
saw, was accidentally discovered in a male
subject, in whom an inguinal hernia also
existed on the same side. The parts are
preserved in the Collection at St. Thomas's
Hospital.

124

courte. The hernia was protruded through the
opening in the ligament of the foramen ovale,
by which the obturator artery and nerve
pass to the thigh; the pubes was imme-
diately before the neck of the sac^ and the
ligament of the foramen embraced the other
portion about three-fourths. The obturstor
vessels were situated behind, and somewhat
to the inner side of the neck of the sac. The
sac itself, not larger than a nutmeg, was
placed under ^the heads of the pectineus and
adductor brevis muscles.
Two her- ^ lately had an opportunity of seeing two
sme^^r- sp^cimeus of this hernia in the same subject,
•^"- one existing on each side, which were .not

discovered during life.

Several cases of this form of hernia arc^
related in the first volume of the Memoirs
of the Royal Academy of Surgeons at Paris. -
Operation The depth at which this hernia is situated,
^" ** would render an operation, in case of stran-
gulation, extremely difficult ; but, should
such a step be necessary, I should recom-
mend the division of the stricture inwards
on account of the obturator artery, &c.
Treatment. If rcduciblc, a truss, similar to that used
for crural hernia, but with a thicker pad,
would prevent its further descent.

Of the Pudendal Hern

This hernia appears in the external labium lu ««t.
pudendi, about its middle.

It commences at the side of the vagina, count,
and passes into the labium between the
vagina and ischium ; it has usually a pyra-
midal figure/ and presents the characters of
other herniae, as elasticity, dilitation on
coughing ; also appearing in the erect, and ,
disappearing when the patient is recumbent.

The situation of the swelling, and its want
of connection with the abdominal ring, suffi-
ciently distinguish it from inguinal hernia,
which also appears in the labium, but at the i

upper part.

The increase of this disease may be pre- Treatmpnt.
vented by the patient's constantly wearing a
bandage to support the part ; but a partial
protrusion cannot readily be checked, as
from its situation, a pessary, unless of very
large size, would not be of any service.

When strangulated, the usual remedies When
before mentioned should be tried; and, if
an operation becomes necessary, the sac
should be carefully opened, and the stric-
ture divided inwards towards the vagina,
the bladder being previously emptied.

126

Of the Vaginal Hernia.

lu teat. This hernia protrudes between the utenii
and rectum, where the peritoneum is re^
fleeted from one viscus to the otiset, at die
posterior part of the vagina; 8om;etimas;
however, it appears at one side instead jrf
the posterior part. It is only cciv^red by th€
lining membrane of the vagina.

Treatment. The uso of a pessaiy will prevent the
protrusion of this disease. :)

Of the Perineal Hernia.

it4 teat. In the male, this hernia protrudes betweetl
the bladder and rectum ; and, in the female,
between the rectum and vagina.

Gate. I have only seen one instance of this

disease, which was in the body* of a male
brought into the dissecting room.
Dissection. The reflected portion of peritoneum be-*
tween the bladder and rectum, was pro-
truded as far as the perineum, but no elrter-^
nal tumor was perceptible; Mr. Ctitli£fej
surgeon, at Barnstaple, has the parts pre^
served.

Anterior to the sac were seated part of
the bladder, the prostrate gland and termi-

nations of the vesiculte seminales ; behind
was the rectum, and the mouth of the sac
was about two inches and a half from the

IDUS.

The following curious case is taken from
Mr. Bromfield's Chirurgical Observations : —

"A lad, between six and seven years of Chbc
age, was put under my care to be cut for
the stone. The staff, in the attempt to in-
troduce it into the bladder, met with resist-
ance from a stone, which seemed to be
lodged in the membranous part of the urethra,
Or a little lower down in the neck of the
bladder. I made my incision, as usual,
through the integument and muscles, to get
at the grove of the staff; and then pressed
the blade of my knife into the sulcus, at the
extremity of the staff, being able to divide
only the membranous part of the urethra;
Mid a very small portion, if any, of the pros-
trate gland ; by the examination of the parts,
with my fingers, I then found that this hard
body was a process continued from the body
of the stone contained in the bladder ; I
therefore took the double gorgeret, without
the cutting blade affixed, intending only to
push back the stone, and dilate the neck of
the bladder, which I did by getting the beak
of the gorgeret into the sulcus of the staff,
and pressing it against the point of the stone,

128

following its course with the instrument as
the stone retired : but the direction that the
gorgeret took alarmed me, as it passed under
the ossa pubis with great obliquity. I then
concluded that the instrument had taken a
wrong route, as I could not, in this case,
have the advantage of the grove of the staff
farther than the extremity of the membra-
nous part of the urethra ; but, on withdraw-
ing the upper part of the gorgeret, I intro-
duced the fore-finger of my right hand into
the bladder, by the under part of the instru-
ment, which remained in the bladder, and
was now no more than the common gorgeret ;
by which I was soon convinced that it was in
the bladder, the situation of which was raised
much higher in the pelvis than usual. I then
introduced my forceps, and, while I was
searching for the stone, a thin diaphanous
vesicle, like an hydatid, appeared rather
below my forceps, which, in the child's
screaming, soon burst, discharged a cleetr
water, as if forced from a syringe ; the next
scream brought down a large quantity of
small intestines. I need not say, that this
was sufficient to embarrass a much better
operator than myself; however, I proceeded
in the operation with the greatest tranquillity,
being convinced, that this very extraordinary
event was not owing to any error in the

eratian::' but tlie difficulty was to keep the
Intestine out of the cheeks of the Ibrceps,
should again attempt to lay hold of
the stone; the extraction of whicli would be
very difficult to effect, from the unusual
situation of the bladder in this subject. The
lower part of the gorgeret remaining in the
bladder, the forceps were again easily intro-
duced, which being done with the fingers of
ray right hand, I pressed back the intestines,
while I laid hold of the stone ; but during
the extraction the intestines were again
pushed out by tlie child's screaming : never-
theless, as I had the stone secure in my
forceps, I proceeded to extract it, which I
did very easily. Before I introduced the
common gorgeret for the introduction of the
forceps the next time, I got up the intestines
again, and desired my assistant to keep them
up till 1 got hold of a second stone, which,
from its shape, appeared to be that which
had got into the neck of the bladder. As
soon as I was convinced by the examination,
with my finger, that the bladder was freed
totally from any pieces of stone, I again
returned the intestines into the pelvis, and
brought the child's thighs close together; a
piece of dry lint was applied on the wound,
and a pledget of digestive over it ; he was
then sent to bed, witli no hopL- of his siir-

V o I, . 1 1 1 . Iv

130

viving till the next day; but, contrary to
expectation, the child had a very good night,
and was perfectly well in little more than a
fortnight, without one alarming symptom
during the process of cure ; neither did the
intestines once descend through the rup^
tured peritoneum after they had been re-
turned when the operation was finished/'

The following are Mr. Bromfield's ideas
of the nature of this case : —

'* After the incision of the integument and
muscles was made, as usual, there soon ap«
peared in the wound something like an hy^
datid, which proved afterwards to be that
part of the peritoneum which is extended
from the left side of the bladder and intes^
tinum rectum to its attachment on the inside
of the left OS innominatum ; preventing th^
intestines from falling down too low into the
pelvis ; therefore, in this case, this expansioii
of the peritoneum must have been forced out
of its usual situation.

^* Suffering daily more and more extension,
it will at length permit the intestines to fall
down to the very bottom of the pelvis, be-
tween the bladder and the rectum; there-
fore, when in the case above related, the
resistance of the integument and muscles
was taken off ^by the operation, the perito-
neum was forced out, and at first was fiUed

\3l

Oily with lymph, which gave it tbo apjiear-
ance of an hydatid ; but its thinness not
being able to resist any longer the force of
the abdominal muscles, pressing the viscera
downwards, it burst, and the intestines soon
followed through the aperture. If this is
allowed, we can easily account for the ob-
lique course that the gorgeret took when first
introduced, as the intestines had raised up
the fundus of the bladder against the back
part of the ossa pubis, so that my forceps
could not be conveyed into the bladder, but
almost in a perpendicular direction ; and I
was obliged to press with my hand on the
lower part of the abdomen, just above the
pubes, to bring the bladder and its contents
sufficiently low for the laying hold of the
last stone with my forceps."

Scarpa met with a case in which this
hernia formed a tumor in the perineum.

This form of hernia, and the vaginal, may
become dangerous during gestation, and
some cases illustrating this are related in
Dr. Sraellie's cases on midwifery.

Of the Ischiatk Ha

This is an extremely rare form of hernia ; very n
indeed, I have only seen one specimen of it,

K 2

132

for which I am indebted to my friend Dr.
Jones, whose name is well known by his
excellent work on haemorrhage.
Case. Dr^ Jones having told me that he had
inspected the body of a patient who had
died in consequence of the strangulation of
a portion of intestine in the ischiatic notch,
I became very anxious to obtain the parts ;
and, after considerable difficulty, we obtained
permission to open the body a second time,
when I removed the hernia and surrounding
parts.

Dr. Jones had been requested to visit the.
patient, a young man, about twenty-seven*
years of age, in consequence of his suffering
from symptoms which resembled those pro-
duced by strangulated hernia. The patient
stated that he had experienced a simitar!
attack before, which had been relieved by
opium, followed by a dose of castor oil. Dr.
Jones, therefore, gave him some opium, and
directed that he should take some pilla
composed of calomel and scammony, as
soon as the stomach appeared tranquil.

On the day following, Dr. Jones found
that the patient had experienced relief for
a short period after taking the opium, but
that the pills had been thrown up, and no
evacuation had taken place from the bowels.
The patient was also much troubled by eruc-

133

■

tations and flatulence, for which he took
some spir: ammoniae comp: and spirit:
lavendulee, with good effect.

Dr. Jones, feeling confident that the
symptoms were produced in consequence
of the strangulation of some portion of the
intestines, now examined the man carefully ;
but could not detect any protrusion; nor
did the patient complain of any local pain,
which could induce Dr. Jones to inspect
the ischiatic notch.

As no stools had been procured, some
purgative glysters were thrown up, but with-
out producing the desired effect. Other
purgatives were subsequently given, and
glysters were again thrown up, but without
affording relief; also leeches and blisters
were employed, but they produced only
temporary benefit. On the sixth day from
the commencement of these symptoms, they
suddenly subsided, excepting that no eva-
cuation from the bowels took place ; and the
patient felt himself so well, that he was de-
sirous of going to business; but Dr. Jones
advised him to remain quiet for some days.
Early on the morning of the seventh day
^ the patient got up, and went down from his
bed-room, which was in the fourth story,
to the ground floor, but he soon returned,
complaining of being very unwell; after

K 3

134

which he gradually sunk, and expired on
the same evening.
DLuection. Qn examining the body after death, %
portion of the ilium was discovered pasBing
by the right side of the rectum to the is*
chiatic notch, through which a fold of the
intestine was protruded into a small h^nial
sac, to the inner surface of which the intes-
tine was adherent. The strangulated part
of the gut, and about three inches of it on
each side of the stricture, was very much
discoloured. The intestines between the
stomach and protruded portion were dis-
tended with air, and had a few livid spots
upon them. The intestines from the stric-
ture to the rectum were very much con-
tracted, particularly the arch of the colon.

On carefully dissecting the parts after
I had removed them from the body, I
found a small orifice in the pelvis, anterior
to, but a little above the sciatic narve, and
on the fore part of the pyriformis musclef •
This opening led to the hernial sac, which
was situated under the gluteus masimus
muscle, and in which the intestine had been
strangulated.

The orifice of this hernial sac was placed
anterior to the internal iliac artery and vein,
below the obturator artery, and above the
obturator vein; its neck was seated before

135

the sciatic nerve, aiid its fundus was covered
by the gluteus maximus muscle. Below the
fundus was the sciatic nerve, and behind it
the gluteal artery ; above, it was placed near
the bone.

Should the existence of such a hernia be Treatment.^
ascertained, it might, if reducible, be pre-
vented from protruding by the application
of a spring truss ; but, should it become
strangulated, and an operation be deemed
advisable, I should recommend the division
of the stricture to be made directly forwards.

Of Ike Phrenic Hern

^ Protrusions of the abdominal viscera in
through the diaphragm, may take place
either at the natural apertures framed for
the passage of the (Esophagus, vena cava,
aorta, &c., or through unnatural openings,
t|ie consequence of malformation or injury.

When this hernia exists, the patient suf- .sy.
fers much from interrupted respiration and
cough, besides experiencing the symptoms
of hernia already enumerated.

This hernia has, or has not a proper sac. He
according to the circumstances of its for-
mation; when protruded through one of the

^■Mttural apertures, it has a proper sae ; when

136

occurring from malformation, it someliiiies
has a peritoneal covering, and aometimei
this covering is wanting; when the conae-
quence of laceration or injury, the hemid
sac is always deficient.
Csie. I have never seen an hernia protruding
through any of the natural openings of. the
diaphragm; but several cases are related
by Mortgagni, in which this form of hernia
existed. He mentions the case of a young
man who was attacked with symptoms of
acute cardialgia and constant vomitinjg, v.
under which he expired. On examining his
body after death, the omentum, with part
of the colon, the duodeum, some portion
of the jejunum and ilium were found in
the cavity of the thorax, having passed
through the same opening by which the
oesophagus descends; the lungs and the
heart were compressed into a very small
space.
Fioiiimai. The occurrence of phrenic hernia frmn

formHtion. , , *

malformation is not very uncommon. There
are two preparations in the Museum at St.
Thomas's Hospital exhibiting this disease.
In one instance the opening is of sufficient
size to admit nearly the whole of the small
intestines through it ; in the other specimen
the large portion of the stomach was pro-
truded through a much smaller aperture.

137

In both cases the unnatural openings al-e m
the left muscular portion of the diaphragm.

Some cases of this form of the disease are
also related in the first volume of Medical
Observations and Inquiries, by Dr. G.
Macauley.

When the unnatural aperture is small, the Daiigar
patient suffers frequently from the usual
symptoms of hernia, and is in danger of
being destroyed by a strangulation of the
protruded parts as in other hernia.

In the year 1798, I published the history
of an interesting case of this description,
which I shall take the liberty of relating
here.

Sarah Homan, set. twenty-eight, had, from c«e.
ber childhood, been afflicted with oppression
in breathing. As she advanced in years, the
least hurry in exercise, or exertion of strength,
produced pain In her left side, a frequent
cough, and very laborious respiration.

These symptoms were unaccompanied
with any other marks of disease ; and, as
her appetite was good, she grew fat, and,
to common observation, appeared healthy.
The family with whom she lived suspected
her of indolence, and her complaints being
considered as a pretext for the non-perfor-
mance of her duty, she was forced to under-
take employments of the most laborious kind.

138

This treatment she supported with pa-
tience, though often ready to sink under its
consequences. After any great exertion,
she was frequently attacked with pain ia
the upper part of the abdomen^ with yomif*-
ing, and a sensation, as she expressed it,,
of something dragging to the right side;
which sensation she always referred to the
region of the stomach.

The cessation of these sj^ptoms used to :
be sudden, as their accession. After suffer-
ing severely, for a short time, all the pain
and sickness ceased, and allowed her to
resume her usual employments.

As her age increased, she became mem
liable to a repetition of these attacks ; and,
as they were also of longer continuance tbaa
in the early part of life, she was at length
rendered incapable of labouring for her sup-
port.

Some days previous to her death, she was
seized with the usual symptoms of strangu-
lated hernia; viz. frequent vomitings, coft^
tiveness, and pain ; the pain was confined to
the upper part of the abdomen, which was
tense and sore when pressed.

As these symptoms were unaccompanied
with any local swelling which indicated the
existence of hernia, they were supposed ^to
be produced by an inflammation of the ia^-

139

testines; tut there were other symptoms
that could not be attributed to this cause,
which occasioned much obscurity with re-
spect to the true nature of the complaint,
and seemed to iadicate a disease in the
thorax. She was unable to lie on her right
side, had a constant pain in the left, a cough,
difficulty of breathing, attended with the
same dragging sensation of which she had
formerly complained.

The signs of inflammation of the intes-
tiues, with the addition of a troublesome
cough, continued without abatement for
three days, when she expressed herself
better in these respects ; but the morbid
symptom in the thorax remained as violent
aeat first; and in the fourth day from their
commencement she expired.

On examining the body after death, when Dissection,
the abdomen was opened, there appeared a
rery unusual disposition of the viscera. The
stomach, and left lobe of the liver, were
tliriKt from their natural situation towards
the right side. On tracing the convolutions
(rf the small intestines, they were found to
retain their usual situation ; but lines of
inflammation extended along such of their
surfaces as lay in contact. This appearance
tile adhesive inflammation assumes in its
early stage ; and it is highly probable, that,

140

if the approach of death had been less twpk
these surfaces of the intestines would- ban
been glued together by the effusion of coagti-
lated lymph. ♦;

When the large intestines were examined^
the great arch of the colon, instead of beiog
stretched from one kidney to the other, wai
discovered to have escaped into the left caxntf
of the chest, through an aperture in the
diaphragm. The coacum and beginning'^,
the colon were much distended with aiv^ and
appeared therefore larger than natural ;. bit
the colon, on the left side, as it descend
toward the rectum, was smaller thap it is
commonly found.

A small part only of the omentum i could
be discovered in the cavity of the abdolnen, .
a considerable portion of it having^ be^n fBO^
traded into the chest, through the same
opening by which the arch of the colon had
passed* The displacement of the stomach,
and left lobe of the liver, had arisen/ from
the altered .position of the colon and omen-
tum; which, in their preternatural course
towards the diaphragm, occupied the situa-
tion of each of these parts.

When the chest was examined, the left
lung did not appear of more than one third
of its natural size ; it was placed at the upp^
part of the thorax, and was united to the

141

pleura costalis by recent adhesions. The
protruded omentum and colon were found
at the lower part of the left cavity of the
chest, between the lung and the diaphragm,
floating in a pint of bloody-coloured serum.
The colon, in colour, was darker than usual ;
} in texture, softer, and distended with fecu-
lent matter mixed with a brownish mucus.
The portion of the intestine contained within
the chest measured eleven inches. The
omentum was also slightly altered in colour,
being rather darker than natural; but, in
other respects, this viscus was not changed ;
it adhered firmly to the edge of the aperture,
and more than half of its substance was con-
tained within the chest.

The opening thix)ugh which these viscera
had protruded, was placed in the muscular
part of the diaphragm, three inches from the
oesophagus ; it was of a circular figure, and
two inches in diameter ; its edge was smooth,
Imt thicker than the other parts of the
muscle.

The peritoneum terminated abruptly at the
edge of this aperture, so that the protruding
pairts were not contained in a sac, as in cases
(rf* common hernia, but floated loosely, and
without a covering in the cavity of the chest,
of which' they occupied so large a space, as
to occasion considerable pressure on the left

142

lung, and to produce the diminution I have
before remarked.

The right side of the chest, also the right
lung and the heart, were free from disease.

Gould the precise nature of this disease be
ascertained during the life of the patient, but
little could be done for his relief; no more,
than, perhaps, his own feelings would dic-
tate, the refraining from all kinds of bodily
exertion.
From lace- The third cause of this form of hernia \i I

ration.

woimd, or laceration of the diaphragm, and
the former inflicted with the small 6Wotd,
has been the most frequent. The opening is
at first prevented from closing, by the pressure
of the abdominal viscera, which frequently
protrude through it, in small quantity at first;
but at length, should the patient survive,
very large portions escape.

The only instance in which I have known
this disease produced by accident, has been
from laceration of the diaphragm, in conse-
quence of the fracture of several of the ribs.
Case. William Rattley, aged thirty, was admitted

into Guy's Hospital. About one o^clock on
February 6, 1804, having fallen from the
height of about thirty-six feet, by which six
of the lower ribs on the right side were
fractured. When admitted, he breathed with
great difficulty, and complained of excessive

' pain; the crepitus from the fractured ribs
could be distinctly felt, and there was slight
emphysema. Soon after his admission, he
Tomited violently, had frequent hiccough,
and expired about eight o'clock on the follow-
ing morning.

The following appearances presented them- D'sseeiioi
selves on inspecting the body after death.
A small wound at the inferior and posterior
part of the right lung, with some slight but
recent adhesions between the two portions
of pleura. On pressing down the diaphragm,
i portion of intestine was discovered, in the
cavity of the chest on the right side, of a livid
colour. On examining the cavity of the abdo-
men, this fold of intestine proved to be a part
1 the ilium, which passed upwards behind
l&e liver, through the lacerated opening in
ffte diaphragm, into the chest. The aperture
in the diaphragm was situated about two
iaches from the cordiform tendon on the right
I side, in the muscular structure ; it was filled
Ihy the intestine, which was confined by a
ffinn stricture. The laceration had been oc-
casioned by the fractured end of the tenth
rib. The other viscera of the abdomen were
otherwise but little altered ; but near a quart
of bloody serum was extravasated into the
cavities of the chest and abdomen.

144

Of the Mesenteric Hernia.

\\\

Cause. This hernia occurs in consequence of 4

natural deficiency of one of the layers com-
posing the mesentery, or from an accidentd
aperture being made.

Formation. fhc intcstincs forcc themselves into such
an opening, and, quitting the proper cavity
of the peritoneum, form a hernia, which may
become of very large size, as the cellular
union of the two layers is not sufficiently
firm to ofier much resistance to the pressure i
of the protruding viscera.

Case. Mr. Pugh, of Gracechurch Street, afforded

me an opportunity of examining a hernia of
this kind. The subject in which it was found,
had been brought for dissection to St.
Thomas's Hospital ; and the man had been
a patient under Mr. Forster, in Gruy's Hos-
pital, just previous to his death.

Appear- ^^ Opening the abdomen, and raising the
omentum and colon, the small intestines
were not to be seen, but a large swelling was
discovered, situated over the lumbar vertebrs,
and reaching to the basis of the sacrum;
which, on further examination, proved to be
a sac of peritoneum, containing the small
intestines, and surrounding them completely,
excepting at the posterior part, where the

anccs.

aperture by which the intestines had escaped,

was situated.

From what I could collect of the previous
iistory of the patient, he did not appear to
Aave been much inconvenienced by this
Unnatural position of the viscera.

Of the Mesocolic Hernia.

The formation of this hernia is similar to
that last described ; and the first example I
had an opportunity of examining, was, as the
former, in a subject brought to the Hospital
lor dissection.

The abdomen having been opened, and the Appp«r
omentum and large intestines turned up, a
tumor was discovered on the left side of the
cavity, extending from over the left kidney,
to the edge of the pelvic cavity, the lower
portion being situated in the fold of the sig-
moid flexure of the colon. The large intes-
tines took their usual course, only that the
ccecum was nearer to the centre than in com-
mon. On the left side, the colon was raised
by the tumor. The duodenum, a small part
of the jejunum, and teimination of the ilium,
were the only parts of the small intestines to
a, on first opening the abdomen, all
^ being situated in the sac, having

I VOL. III. L

^-*ic on its right side,
_^i 10 admit two folds
MCiAxed state.
cau9P. ^^^ J y the peritoneal layers

j^iriuloes, sent me a drawing,

^ iipir part of the moveable

*"*''"= '•'■ . ^ w J iie layers of the peritoneum,

^K,a examining the body of a
&u ictonded.

:^^i»^muCMi of t/ie Intestine withm the

Abdomefi.

SIB. w bave known to occur in several
j^tfUw ways.

;n>i. From the intestine protruding^
uwn^^ jin aperture in the omentum^ mesen—
^,%. ^i mesocolon.

>«W«h1. — From the same circumstances*^
vvuittnjt when small openings are left in the -
.vtlKv^^H^ formed in consequence of inflam-

I'hml.- From a membranous band formed
,t; iho mouth of a hernial sac, becoming elon-
>;;iUHl, and entangling the intestine when it
!k^s Ihhmi returned from the hernial sac.

Fourth. — From the appendix vermiformi&
^ uian^liu^ the intestine.

!n;ikes, surgeon, of Barnstey, in casc.
. sent me the accoHiit of a case in
I portion of intestine had been pro-
■ through an opening in the omentum,
iiatl become strangulated. The patient
as eighty years of age, and had been
l^reviously very healthy and active. The Ciase
terminated fatally, two days after the com-
mencement of the symptoms ; and on ex-
amination after death, the intestine was found
in a gangrenous state.

A case in which a portion of small intes- Case.

tine had protruded through an opening in the

meitentery, and become strangulated, occurred

QHder the care of Mr. Palmer, of Hereford.

The symptoms were severe, but the patient

3tirviv6d until the ninth day from their com-

^Hencement.

Dr. Monro has related a case of this nature
*tt his wofk on Crural hernia.

IMfe. Rodsoh, of Lewes, attended a young Case.
^3aan who died in consequence of the strangu-
lation of a fold of small intestine, which had
Protruded through an aperture left in an
^hesion of the omentum to the peritoneum.

I have a very excellent specimen, showing case.
the strangulation of intestine by elongated
membranous bands. It was taken from the
lx)dy of a patient of Mr. Weston's, of Shore-
ditch. The patient was eighty-five years of

L 2

148

n Hozton Wcatiune.

He was seized with symptooiB
hernia, in consequence of ipiiiidi llr.Wii
was sent for, who, on examining At mHi
found a hernia on the ri^t side, wiatk k
soon reduced by the taxis. The synfttni^
however, continued, and the patient died.
On examining his body after deatii, I find
that the intestine had been retained into dn
cavity of the abdomen, but that two CoUiaf
it were entangled and strangulated by a kiy
membranous band,
spedmen la the Museum at Guy's Hospital i» t
Mosemn. beautiful preparation, showing a constdeiaUfi
portion of the small intestine, surrounded and
strangulated by the appendix vennifimniii
but I am not acquainted with the history of
the patient from whom it was taken.

As the precise nature of any of the above
cases could not be ascertained during the
lives of the patients, no ben^t could te
derived from surgical aid.

Ilk

tia

149

.s.v>

LECTURE XXXVI.
On Wounds.

Solutions of continuity on the surface of 2^/!?'*'
the body are of four kinds, according to the
manner in which they are produced; viz.
Incised, Lacerated, Contused, and Punc*
tared.

Incised, when produced by a cutting in*
strument; lacerated, when the parts are
forcibly rent asunder; contused, when oc-
casioned by some heavy body, or one pass-
ing with great velocity ; and, punctured, if
made by a pointed substance.

This division of wounds is attended with
advantage in the description of their treat*
ment, as it must in some degree vary from
the mode of their production.

Of the Incised Wounds

The lips of the divided parts^ are more character,
or less separated according to the extent of
the injury ; and, the division of the mus-
cles, which, by their contraction, lead to

L 3

150

u gaping state of the wound, as in tiie
cheek, the lips, or in transverse incisions in
the limbs.

The wound is covered with blood, which
is florid or purple, as an artery or vein hu
been injured. If an artery, the blood flows
by jets rapidly, and is of a florid colour ; H
a vein, the bleeding is slow, gradoaUy filling
the wound, and the blood is of a pinrpl^
colour. Fainting is produced if an artery
[)0 cut, but rarely, if the bleeding be venotti.
Fainting also results if the wound extends
to parts of vital importance, even although
the haemorrhage be very slight.
i.< tiMuiii. When you are called to a case of incised
wound, you are to make pressure upcm its
Hurface with a sponge to arrest the hsBmorr*>
hage, and if the divided vessels be small,
you will soon find it subside under a steady
and continued pressure.' But if an arteiy
of any magnitude has been injuied, it should
be drawn from the surrounding parts by a
pair of forceps, or raised by a tenaculum,
and then tied with a very fine ligature ; one
end of which should afterwards be cut off,
that no more space than is absolutely neces-
Hary may be occupied by the thread or silk.

So soon as the bleeding ceases, the coagu-
hited blood is to be completely sponged away
hfftn the surface and edges of the wound.

151

the edges are to be brought together, and
a strip of lint or Unen moistened with the
blood, is to be placed on the part in the
direction of the wound, when the blood, by
coagulating, glues the edges together in the
most efficient and natural manner ; adhe-
sive plaister is to be applied over the lint
with spaces between to allow of the escape
of blood or serum.

In a few hours, inflammation arises, and How
fibrin becomes effused upon the surfaces
and edges of the wound, by which they
become cemented.

In a few days, vessels shoot into the fibrin, organwed.
effused by the inflammation ; and it becomes
organized with arteries and veins, and after
a time, with absorbents and nerves ; thus
the structure of the part is restored.

If the wound be in a muscular part, more wound of

■ 11 ■ IP muicle.

especially m transverse wounds of muscles,
it is required that the position of the *
iitnb be carefully attended to, that the
wounded muscle may be relaxed as much
as possible, and its separated portions ap-
proximated. Thus, if the biceps muscle
Were divided in the arm, the limb must be
bent at right angles; and if the triceps be
injured, extension will be necessary.

But if the wound has happened in a mus- t
cillar part, which is not supported, as in the

.^k.

150

ji gaping state of the
check, the lips, or in U.
the limbs.

The wound is co\ .
is florid or purple,
been injured. If ..
by jets rapidly, .
a vein, the blcc
the wound, r
colour. Fai

r\ e ap

■-' >liould b'

iis many a

«> produce thi

iserted.

.:kI of considerabl

t .^le is desirable, o

re returned in thei

be cut, bill
Faintinjr : *
to parts
the hiv

T.rjihiicnt. \VI
WO I

A. X suppose that suturej

. zjLt they should be nevei

. . jtt -iiien heals better witl:

.^ua^ lotion, than with ad-

i^mieed, adhesive plaistei

= .i,riit*c to the edges of wounds.

j^u X produce erysipelas, and

St. ^ry^sipelas followed by the

wieat. After the removal of

jvia the breast, I often em-

^ajfu :^ keep the parts in exact

4Hi ji; pne'%"ent the edges from be-

g^,. :ic wound is healed, the parts
ux ^Mierally reproduced. The

^••«

, oiv. .uccvc, easily ; the rete mucosum,
^^t- \. Vhe cellular membrane is for

.mt*»%.

itKij^TXicd. and requires the use

, » — —

.^^:vu .*t'" the [>arts, to be completely

..»;ll ,V'

%•

branches of arteries and

153

^! instead of the original

s are reproduced. Tendons

■ i formed. Bones are united by

lie parts are not reproduced. There Muscle
vcimen in the Collection at St. Tho- dSced?'"^
^ tiospital, in which a wound of a muscle
f'cn united by a tendinous structure.
i iicre is also a specimen of a cartilage of a
rib united by bone, but in young persons
eartilage is reproduced.

Parts which are nearly separated readily Parts
x^inite, as the finger or the nose when it has parated^
l)een cut, or torn, and a suture is required readuy.
tx) aid its union. >

Parts entirely separated in other animals Parts .
-Mmetimes unite. Mr. Hunter removed the separated
Spur of a cock, and placed it in the comb by ^ ""' **
incision, where it not only adhered, but grew.
He also removed the testis of a cock, and
]daced it in the belly of a hen, where it
^ered. A tooth extracted from the human
subject, and placed in the comb of a cock,
^eres there.

The only instance in which I have seen
^ part removed entirely, and afterwards ad-
here, was in the following case : —

I amputated a thumb for a patient in Guy's
Hospital; and, finding that I had not pre-
served a sufficient quantity of skin to cover

154

the stump, I cut out a piece from the thum
which I had removed, and applied it upoi
the stump, confining it by stripes of adhesive
plaister. On taking off the dressings a fe¥V
days after the operation, I found, that the
portion which had been completely sepa-
rated, and afterwards placed upon the stomp,
was fimly united and organized.

The most extraordinary instance of the
union of a separated part has been related
by Dr. Balfour, in the Edinburgh Medical
and Sui^cal Journal, for October, 1814,
from which the following account is taken: — -
Case. " On the 10th of June last, two men came
to my shop about eleven o*clocfc in the fore-
noon; one of whom, George Pedie, a house
carpenter, had a handkerchief wrapped round
his left hand, from which the blood wa$
slowly dropping. Upon uncovering the hmd^
I found one half of the index finger wanting*
I asked him what had become of the ampu-^
tated part. He told me that he had never
looked after it, but believed that it would be
found where the accident happened. I im^
mediately dispatched his companion «to look
for it, and to bring it to me directly he found
it. During his absence I examined the wound,
which began near the upper end of the se-
cond phalanx on the thumb side, and termi-
nated about the third phalanx on the other

Uillbe^ inflicted

pieew.itf the

cold, BvA

oandle.

^o a

. off

.idhere

with as

:c wounded

sing a confi-

ould take place.

■ 1 re the patient with

V did not appear con-

)ility of sueh an odcw*

. Iiim, that, unless pain or

should occuF> I would not

dressings for a week at least.

him to keep his arm in a sling,

. to attempt any kind of work ; to

a he promised pbedienc^. He called on

0 the next day, when be was quite easy,

but the wound had bled a little. Although

he prqn^sed to call on me daily, I did not

see him^again till the fourth of July. I had

concluded that he hnd applied to some other

jHactitioner ; but, on the second of July, a

gentleman called on me, and gave me the

^wing account of the patient : —

"Two days after the accident, the patient.

154

Case.

the stump, I cut out a piece from
which I had removed, and applif
the stump, confining it by stripes
plaister. On taking ofi* the dre.'
days after the operation, I fbi
portion which had been con
rated, and afterwards placed u
was firmly united and organi?

The most extraordinary
union of a separated part
by Dr. Balfour, in the F
and Surgical Journal, f
from which the following

"On the lOthof Jun^
to my shop about elevo
noon ; one of whom, <
carpenter, had a hand ^
his left hand, from
slowly dropping. U'
I found one half of
I asked him what
tated part. He t
looked after it, b
found where th(

mediately dispr
for it, and to b^
it. During hisi
which began
cond phalan^
nated about

ritf

ly, how->
>v even
iier pnrpMNIJl'

• ■

informatiMf-I^
..und out 'dift pcitidlV
. mion of tte'peltB yhU
7 was in fitBt tiicf ' hadtf
:. and bid tteoVered bctf
7 In As- 'j^0{gf6M of tb
«:tf ^MVedf^fd ><>on aA
fiBoir.

of persons prew
^flieted, I am satisfi
[re elapsed bef

-ni4W

iie

iS can Adhesion
prevents
ceases, danscr.

iiien, ex-

L followed

\e to unite.

iplicated with

be dangerous

. Wounds of the

jii, and the patient

is prevented by the Adhesion

, J preYented.

s in incised wounds : —

uction of many, and of Bysutnrei.

is therefore necessary to

threads, and to cut off one

lat they may occupy as little

ijle ; and in, from four to six

juld be removed; thus they are

om producing suppuration and

he inflsunmation being suffered to By too much

inilammation.

158

run too high from want of bleeding generally,
Of, locally, by leeches ; or, front not eittploy-
ing cooling evaporating lotions. Spirits ctf
wine and water, or acetate of lead and wtttet*,
should be applied upon the wound, and arotind
it. Purging is also often required.

The adhesive inflammation is but a slow
degree of action, and if it be not kept itf
bounds, suppuration will occur.

By poisons. If poisous be inti^oduccd into wounds, it
will be wrong to attempt to produce adhesionfi'
thus the bite of a rabid animal should be eir-
cised, as well as c&uterized afterwards, to
prevent the terribly dangerous consequ^mc^
of such an injury.

Bycaus- The usc of caustic applications, wheth^

tics

by potash, nitric acid, the actual ' cautery,
&c. will necessarily prevent adhesions.
When an When mauv absorbent vessels are divided,

absorbent •' '

is divided, the lymph poured out by them prevents
adhesion^ as I have seen in a transverse
w6und in the groin.

oiasecre- When the secretory glands are wounded,

orygan . ^^^^^ secrctiou prevents union.

Case. I was Called to a gentleman who fell ufjon

his face on an earthen plate, which he broke ;
his face was dreadfully wounded ; I brt)ught
the parts together, and in ten days they ap-
peared to be united, when I allowed him to
' eat ; but the result was a profuse discharge

159

of saliva from the wound, which was a very
long time in healing, on account of the paroted
dHct having been cut across.
Union by adhesion, is often frustrated by By the

, ... , . . surgeon'*

the surgeon s impatience ; he is anxious to impiudence.
see if union be effected or not, and most
absurdly and mischievously raises the dress-
ings, disturbing, and often breaking, the
adhesions, and thus rendering the process of
granulation necessary, when it might have
been avoided.

The adhesive inflammation is often pre- bv sute
vented by the state of the constitution ; if tation.
the patient be much out of health, or if he be
extremely irritable, the inflammation . will
proceed beyond the bounds of adhesion, and
suppuration will take place. In such persons,
evaporating lotions to the wound, and opium
internally, are the means of arresting the
nuschief which will otherwise ensue.

It is not always an object to endeavour to Adhesion
produce adhesion ; when there is much loss desirable."
of substance, and the parts must be forcibly
drawn together, much additional pain and
irntation are occasioned by the attempt at
^hesive union, and this is more especially
the case in children^ when the skin cannot
^ell bear the application of the adhesive
plaister. I therefore, when I remove those
^arks which are called nevi matemi, I do

158

run too high from want of bleeding
or, locally, by leeches ; or, from ■
ing cooling evaporating lotion^
wine and water, or acetate of If
should be applied upon the woi
it. Purging is also often re(
The adhesive inflammat'
degree of action, and if '
bounds, suppuration will
By poisons. If poisons bc intfodv
will be wrong to attemp
thus the bite of a rab'
cised, as well as c
prevent the terribly
of such an injury
The use of ca'

By cans
tics.

by potash, nitr"
&c. will necess
When man^

iiL'OUgh

uccurring.
■o differ from incii
iiung eictraneous boidilto^
lip are frequently filled w^{^
head ploughing the gvouiii^)
their seer. .::;ost care is required to cleaiuiiii ^
I was 1 ^\ Ann water, and to remove yriAm ^
his fiaec j^ extraneous matter, as I have seea
his fkc^' «g«od adhere, and afterwards sup*
the j^ ^ Mrious places, for the discharge of
pear | bodies which the adhesive matter m

^^^^ Hi confined.

When an
absorbent

is divided, the lymph ]
adhedion, a
w6und in '

<) r a secre- W^hcn 1 ■
tory gland. , ,

tneir seer.

Case. I Was .» «

_ disposed to Moredls-

suNKthey require inflame,
uisli^f evapo-
ippreas it.

^ suff'ers Affect the

nervons
ms of •y»tein.

Oil

.an at ^^'
tge and
; he died
.Gin lacerated
jy machines for
i al times known te-
aons and fascia in these
i exposed and injured.
I an unusual effect of lace- Prodnce

erysipelas.

more especially if they are
die scalp, and they therefore
.at attention, although they at first
1 trifling importance.
c treatment of these wounds is the same Treatment,
that which has been described for incised
wounds ; but more care is required in the use
of cooling lotions,and the application ofleeches,
in quiet, and in. the exhibition of opium under
tiie first appearance of spasmodic symptoms.
Patients with lacerated wounds^ should not
be much reduced by-depletion^ as it disposes
to. tetanic symptoms.

VOL. III. M

162

^ s.%;

LECTURE XXXVII.

Of Contused Wounds.

Character. These injuries differ from the incised ancf
lacerated wounds, in being accompanied ^tfa
disorganization: blood is extravasated, the
cellular tissue is broken down, muscles are
bruised, and many parts disorganized.

Procew of The process of restoration is therefore quite
' different to that which takes place after incised
or lacerated wounds.

Sloughing. Inflammation to a considerable extent
must be produced; the dead parts must be
separated by a process of ulceration, and
granulations will arise to fill up the cavities
occasioned by these separations; The surgeon,
therefore, who treats these wounds as he
would the incised or lacerated, has still to
learn the fundamental principles of his pro-
fession.

Contused wounds bleed but little, from the
organization of the parts being destroyed,
and from the extravasation making pressure
upon the vessels which are divided.

Treatment. The treatment of the contused wound in
principle, consists in facilitating the separation

163

"Stead of approximation,

i lacerated wounds. To

Liul to expedite the process,

I poultices are to be used,

-tii iaHammation when too violent,

i the suppurative and ulcera^eS^ro-

1 1 the inflammation be still consider-

ii leeches should be applied ; but bleeding

:^^ht not to be had recourse to from the

arm, for all the powers of the constitution

are required to assist in the process of separa*

tion, and of granulation.

The bowels should be kept regular; but Medidnw,
opium should be combined with the medicines
given, to eflect that object. If the constitu-
lioii become much debilitated, the sulphate
of quinine may be given ; or ammonia, com-
plied with opium.

'. When the sloughing, or separating process AppUca-
ip completed, the fomentations and poultices
He to be abandoned, and the parts may be
^roximated by adhesive plaister, or simple
dressing be applied to the wound, treating it
^ a simple ulcer.

tions.

Of Punctured Wounds.

These wounds are produced by pointed Danger of.
Wies, as needles, scissors, hooks, points of

M 2

i<;j

LECTTl...

- '.%

Of '

> ts which follow
, us, by occasion-
. . i^ rbents ; or when
rres are injured.

'./I the Absorbents.

Clianuster. ThESE injlP

lacerated v
disorgani?'^'
cellular •
brui."

Process of
reparation.

ri'

•%:

k* ■>-

,^ onmsrh the skin iirto the
^ je sometimes followed
. ,x uort, a blush around it,
ayfMat vessels forming red
..uiid CO the absorbent glands,

i'i

Sloughinir.

^^i i have seen very many ex-

^ BLve been a sufferer from it

jgkrtfs^ scmetimes form upon the

.1 :netr course to the axilla, or to

j^ ^cmetimes in the glands in

B» trtmnate ; and in very irritable

^^1 sometimes ensues; and the

. .xampi^' ^* ^t ' ^^^ ^^ opportunity

Imiian- studying at Guy's Hospital,

%.< MiTt'r, the absorbents of his arm

iirfa:tte\l. and he laboured undet

^'^"'^ ^ . r.rji:ivo tever ; the veins seemed to

^^"^ ,, /^,t»* inflammation communicated

.*- •'^•^ limbs became almost incapa^

..- wm the violent pain produced

, , • «nv ot" the joints, and the super^

>66

were very tender when
six days after the attack,
<i.s arm. The absorbents of
iiighly inflamed; and in the
was effused, not in a separate
I ill a sheet of suppuration in the
. issue, between and around the ab-
i vessels. I was not permitted to in-
I the body further.
After an inflammation of this kind in myself, ^*^'
produced by wounding my finger when open-
ing the body of a man executed on the same
morning; my throat became sore as the
inflammation in the absorbents of my arm
subsided, and one of my knees became stiff
firom rheumatism; when this was subdued
by a blister, the other knee became similarly
affected^
It would seem that under certain circum- ^^^ _,

absorbed.

stances a poison is produced sufficiently
strong to excite inflammaticHi, even when
there is no wound.

Mr. Cook, surgeon, at Marsh-gate, West- cue.
fliinster Bridge, sent to me whilst he was la-
bouring under the highest irritative fever, in
consequence of having opened the body of a
person who had died of puerperal fever. When
I examined him, I foimd the extremities of
bos finger, of both hands inflamed, as if they
hd been dipped in scalding water, and the

M 3

8 of his arms red, bard, and knotted
W the axilla ; yet he had not any wound
or abrasion of any kind upon his hands;
itud it would therefore seem, that the fluid
produced in the ahdomen of this woman, in
which his fingers had been frequently im-
mersed, was of a highly stimulating nature.

The effect of punctured wounds depends,
however, very much upon the form of the
wound, and the state of the constitution.
When punctures have been made, by a clean
needle, the tongue of a knee buckle, a frag-
ment of bone, &c., nothing can be introduced
of a poisonous nature, and the effect must
depend upon the form of the wound, and the
structure injured. But the effect also depends
upon the state of the constitution, as is
evinced in our young students suffering in the
Spring, after confinement in London, in the
air of our dissecting room, and in the wards
of our hospitals, and by their escaping these
violent sjnuptoms in the Autumn, when they
have just quitted the country.

I believe, therefore, that these effects arias
(com the form of the wound, and the state of
the constitution ; also occasionally, but rarely,
from the introduction of an irritating fluids
the result of pecuiia' inflammation, ot the
production of the first stage of putrefaction.

1 have known the bites of cats, dogs, and

rats, followed by high inflammation, and '
congtitutional irritation, many days after
the injury has been inflicted ; and these
cases unite the symptoms of punctured
and contused wounds ; the first effects upon
the constitution arise from the punctures
of their pointed teeth ; but when the symp-
toms produced from this cause subside, from
fifteen to twenty days after, 1 have known the
injured parts inflame and slough ; the con-
stitution, as well as the part, undergoes great
changes, and the patient becomes excessively
reduced.

The treatment of punctured wounds con- i
sists in adopting the following plan ;—

First. — A lancet should be used to extend
the puncture to an incision.
Second. — The surrounding parts should be
. pressed to remove, by the blood which issues,
11 any extraneous matter which may have been
il introduced. If the finger is wounded, a piece
^ of string or tape should be bound tightly
H lound the injured finger, from its junction
W- with the hand, as far as the wound, so as to
■ force out blood from the opening.

Third. — The nitric acid, nitrate of silver,
Of caustic of potash, should be applied to the
I Wound.

Fourth.— A lotion composed of the subace-
tale of lead ; spirits of wine and water should

168

be applied over the part, to prevent to6 mubh
action when inflammation begins. . i .' = '•{!(> i

Fifth. — Leeches should be applied^ and
fomentations with poultices employed, if die
pain and inflammation become considerable.

Sixth. — Give calomel and opium at night;
and a brisk purgative in the morning.

7th. — Let the limb be supported on an iiH
clined plane, so that the blood shall gravitate
towards the body; all stimulating food and
drink should be avoided; a measure so absurd
that a caution against it appears unnecessary $
but an anatomist . killed himself by taking
wine to oppose the putrefactive influence of
the matter he supposed to be absorbed;
inflamma. '^'he inflammation from punctures of the
uTrasr ^^^^ i^ dissecting, will continue a long time^
and be resumed when it seems to be at an
end ; attention to the general health, and to
the part, must be therefore regarded closely,
for a considerable period after the injury.

Of Punctured Wounds of Tendinous Structure.

Danger of. If fascia be punctured, alarming symptoms
will sometimes arise, in part from the form
of the wound, from the feeble power of the
structure, and partly from the confinement of
matter beneath the fascia.

169

The formiof the wound produces these Pormoftue
symptoms^ because the parts txe rather for«
cibly separated than actually divided, and
consequently the adhesive process does not
readily succeed. • The structure of tendons
and iascise, from their little vascular organic
zation, and difficult restoration, leads to much
constitutional effort ; and the form of fascia
tends to confine the pus when it is secreted.

A gentleman sat upon a rail, from which case,
alnail projected, and it entered the middle
and back part of his thigh ; great irritative
fever followed, with redness and swelling
of the thigh; and, as fomentations and
poultices, and calomel with opium, did not
relieve him, I made an incision in the situa-
tion of the puncture, and found that the nail
had penetrated the fSeuscia lata; I divided it
iBreely, when some pus, which had formed
under it, was discharged. He quickly re-
coveted.

When a puncture is made into a theca, Eariv

• . induons.

suppuration is apt to ensue, when an early
incision, by allowing the discharge of the
matter, prevents the greatest mischiefs.

If matter forms under the aponeurosis of
the palm of the hand, an early incision ^ is
the only mode of relief, if the puncture which
occasioned the suppuration is too small to
admit of the escape of the pus.

i7a

Treatment. The treatment, therefore, of these wounds,
consists in endeavouring to prevent suppura-
tion by leeches, and evaporating lotions, in
the first instance ; but, if matter does form,
to open the abscess early, both with a view of
making the punctured an incised wound,
and to give a free outlet for the escape of
the pus«

On the Effects of Ptmctured Wounds on' the

Nervous System.

lymptoras '"^^^ spasmodic and tetanic symptontf,
which follow punctured wounds, are the
effects of injury to tendinous, rather than
nervous parts. Most of the cases of tetanus
which I have seen occur from punctured
wounds, have been when the hand or £30t
has been the seat of injury ; the aponeurosis
of the palm, or sole, or the tendons being
hurt. I will not deny that an injury to a
nerve will produce the same effect; but I
cannot help doubting its being the usual
cause.

Case. I divided the posterior tibial nerve in a

Mrs. Sabine, the wife of a surgeon at Dun-
church, for a painful tumor on it ; and Httle
constitutional irritation was produced by tibe
operation.

171

I removed a tumor from the median nerve case,
of a gentleman, and cut away two-thirds of
the thickness of the nerve, leaving one-third ;
tingling of the fingers, with some partial numb-
ness, followed, but no constitutional irrita-
tion; and he did very well.

I cut out five-eighths of an inch of the ci»e.
radial nerve, for aura epileptica; and no
unpleasant symptom followed, but the pa-
tient got well.

Mr. Key removed a portion of the cubital cue.
nerve^ for aura epileptica; and, although it
did not cure the woman, it produced no un-
fiiToiiiable symptoms.

These instances, to which many more
might be added, as well as the usual seat
of the wound, which produces tetanus, lead
me to believe that it is rather the result of
injury to tendinous than to nervous structures.

Extensive injuries, by their sympathetic
io^uence, and by their severe shock to the
nervous system, produce the destruction of
life, even without vascular reaction or in-
flammation.

The symptoms which arise are sometimes
only generi spasm, sometimes trismus, and
sometimes tetanus.

I once saw a boy die, in a few hours, of cue.
the most violent spasms of most of the
muscles of his body, from the pointed extre-

172

mity of a broken thi^*- ''y pub-

trated the under sidt» '>y the

Cane. I saw a person d

by a punctured v -. \o(l by

ligament of the i> =^^^d shower

of wood; and 1 ^f^^- tincture of

of such cases ^^'^^'^ ^so known

foot. -^^ scarcely taken any

Degree of SoHietimi -"-^S ^ do^bt upoD the

2Sr "^ the influci. -^ had, in other cases,

felt in t;. -^ beneficial,

trismus, -"'*"* ^^^^^ ^ ^^^^ witnessed

the mi, ^ trismus, the patient hns

of re . .avflxel and opium are the best

tinv ., jua a blister to the head the

tr! .usvAiifc^ local remedy.*

^ a«i»t«^ interesting case occurred in St
^^ •iMMiai. Milder the care of Dr. EUiotaon

VI ««

*r»<u«r. ««. thirty-nine, of florid complexion,

, ^.•^•«ni;;isco. employed in the London Docks

t. ^dtf admitted December 10. There were

^,,.,^ ^^ *»*n lacerated wounds on the inside of

*^ * -'^' ^^'^ ?^^^ ^^' ^® crepitus indicative

^vti*» .vttvvl be discovered. There was a slight

. x^^cii'.Mjj:. attended with violent pain.

tc ^>*t^ «^*^ ^>=* ^^® ^^^ ^^^^ dislocated, and

,. ...4 .«.^j:v:*. across the other toes, by the fall of

.vvv H !^itt^«'r. ^^ l^ad been, however, forcibly

.i |K*r»o« present, while he was in a fainting

>.. >>

175

condition. He was brought to this Hospital immediately
after.

The edges of the wounds were brought togetlier,
a dossil of lint was placed over them, and afterwards
covered by a light poultice: the foot elevated on a
pillow.

Cap: haust: purg: statim.

December 11. Evening. He was restless, with a
pain in his head, back, and loins. Skin hot and dry ;
pdse full and hard, about eighty ; tongue furred in the
eeatre, and red at the sides ; bowels costive.
rVenesectio ad ^ xij.*— — Repet : haust : purg :
;The dressings were removed from the foot, which
ordered to be fomented all night.

About. an hour after the bleeding, the violence of
the symptonis abated, and the man said he felt relieved.

December 12. Slept comfortably last night. Skin
laoist ; pulse full and soft ; tongue white ; bowels have
been opened.

The foot is very, painful ; the wounds are beginning
to suppurate ; the dorsum of the foot is red, tense, and
swollen.

Applic: Hirudin: xij.

Capt: cal: gr ij opii gr ) o. n. inf: rosee c mag:
sdph : t. d.

The blood abstracted yesterday neither cupped ^or
iNUBed.

December 14. Was very restless. Skin dry; pulse
■nailer and quicker ; boweb costive.

Foot very painftd ; still red, tense, and swollen ;
wonnd suppurating.

Bepet. hirudin, xij. Repet. haust purg.

December 19. Face flushed; skin moist; pulse
amaU and quick ; tongue white and furred ; bowels
relaxed.

176

Foot yery painful^ so much so as to disturb his test,
the wounds suppurating, and the degree of inflammatidii
less.

Omit : calomel and opium.

Capt. Tinct : opii gtt. xxx. Si opus sit.

Foot to be fomented and poulticed as before.

December 22. Diarrhaea subsiding ; but he laboured
under great irritation both of body and mind.

December 24. Imperfect trismus came on yesterday
afternoon, and increased towards this morning. Be
could not open nis mouth more than three-quarters of tti
inch, nor protrude his tongue farther than the teedi.
Deglutition painful, and articulation difficult ; pain in
the back of the neck, and a want of freedom id the
motions of the head ; no rigidity of the muscles ; coun-
tenance aniLious, and spirits very much dejected ; skia
bedewed with moisture ; pulse quick, small, and com-
pressible, 132 ; diarrhsea had ceased.

The wounds were suppurating healthily; granu-
lations at the bottom ruddy ; but perhaps the discharge
was somewhat thinner; tension and swelling on the
dorsum of the foot remained, but the redness was less.

Capt. ol : terebinth : ^ij statim.

Ferri: subcarb : ^ ss. 2nd qque bora (in treacle.)

Applications to the foot as before.

December 25. Took the same quantity of ol. tere-
binth, at 10^ last night, which was followed by five or m
copious dejections, but he was not able to swallow more
than one dose of the ferri subcarb. on account of its
thickness. He therefore took five grains of musk every
four hours ; this he commenced at twelve o'clock last
night, and took four doses of it.

Mouth more closed; a perfect inability to swallow
anything but liquids; complains of pain in Hie back;
the other symptoms of trismus the same.

177

Did not rest last night; face flushed; skin very
moist ; pulse the same.

The foot remained the same.

To omit the musk, and to take the iron mixed up
with his beef tea every two hours, as befo|« ordered.

Capt. vin, rub. J iv. Strong beef tea, Ifeiv. daily.

December 26. Mouth more closed ; other symp(om«
of trismus the same ; belly rigid in a slight degree.

Was restless last night; countenance anxious, and
spirits much depressed ; face flushed and hot ; pulse the
same ; boweb opened twice during the night ; troubled
to-day with tenesmus and prolapsus ani.

Foot very painful, and appeared the same as
yesterday.

December 27. The symptoms of trismus the same as
fssterday ; the belly more rigid, and he complained of
astiffiiess in the back, and a shooting pain through the
lerobic : cordis. ; his face not so hot or flushed ; had no
liool for the last twenty-four hours ; tenesmus and pro-
lapsus ani continued; perspires a good deal at night,
ttd doses a little.

Foot very painful. While removing the poultice
tills morning, an abscess over the metatarsal bone of the
great toe burst, and discharged an ounce or more of
iKItter, of a greenish colour, streaked with blood.
Enema commune statim.

This produced one or two small evacuations. Hi-
tiitrtQ (according to the nurse's account,) the foeces
We been of a natural colour, but to-day they presented
Ike appearance of the ferri. subcarb.
- December 28. Morning. Mouth more closed ; deg-
lutition more difficult; articulation less distinct; the
Mly rigid, and there has been during the night con-
nlnve movements in the muscles of the neck.
" Had no rest last night, and perspired a little ; his

VOL. HI. N

178

skin now cool ; pulse 112, very weak aod smaU ; tenes-
mils has subsided.

About half-an-ounce of pus was eTacuated ffoan the
dorsum pedis, (near the metatarsal bone of the little: toe,)
there was a foetor arising from the wounds on the dcHWum
of the foot, while the original wounds wece looking
healthy.

Afternoon of the same day, all the alarming symp-
toms abated; his skin became moist; hia pulse Adler
and softer, and his mouth more open, with an unpiered
countenance.

December 29. Mouth more open; awallawiig
easier ; no pain in the back of the neck, noi: any ^aoie
conTubiye movements about the muscles oi that part;
belly soft.

Slept last night, and perspired a little, and had Awe
motions from an enema; countenance improTeds fMse
not so flushed ; skin, cool and dry ; pulse fiiUer and
softer, but still weak; appetite beginning to mnnjftnl
itself.

Tension on the dorsum pedis quite subsided. The
surface is still inflamed, but the redness is of a daifcer
colour. The two wounds on this part loddng very uur
healthy, and the discharge foetid and rather thin. The
original wounds on the side of the great toe are begin-
ning to cicatriie.

December 90. Mouth more open ; less difficulty in
deglutition, and a more distinct articulation ; no pain in
the neck or back ; the belly however is rigid.

Was very restless all last night, his foot being very
painful ; skin cod ; pulse contracted and more diatittct,
about 120 ; during yesterday passed some small lumpy
fceces*

Hie foot tense, red, and swdlen; the discharge
has ceased,and there was a fioetor arising from the wounds.

179

whicb were looking unhealthy , accompanied -with severe
laaeinatiag pains. The original wounds, however, were
heafii^. Foot to be fomented.

Ci^ ol.'rieini fss. '

Enema cathart: siopvssit.

Beef tea, Ibvj, instead of ftiv.

December 31. The castor oil operated fire or six
times, bringing away small lumpy fceces. The enema
was not administered.

Opened his mouth readier, but not wider ; complained
of pain running through the scrob. cordis, and of a di^
eeiig^, ^Huch arose, he said, from his not being able to
bieirthe freely; deglutition and articulation better;

'Slept better last night, and did fiot perspire ; coun*
teniUioe and spirits improved ; skin cool ; pulse 180,
BoAer, land itot SO' eontnusted.

~***Foo€ less tense and' inflamed; discharge from the
wMnrib returned, bet it is still too thin ; leg placed in «

frMStur^box; ' ■ •■

■ ■' January 1. Symptoms of tetanus quite subsided, those
of trismus less violent.

Mudi the same as yesterday; pulse 108, soft and
BM>re full; bowels relaxed, with tenesmus; motions
come away of a dark colour, and in very small quan-
tities.

Foot better ; discharge more copious and healthy.

Capt. ferr. subearb. ^ss. 4tu. q : q : hor^, (in powder.)

January 2. The same as yesterday; opened his
mouth wider, but was still obliged to be very careful in
swallowing.

Foot looking better; the excess of inflammation
quite subsided; the suppuration free and healthy. It
was painful last night, and this prevented his sleeping.

January 8. Much improved ; pulse ninety-nine,
softer and fuller.

N 2

186

Suffers very much from a collection of ^
1m8 reptum, a quantity of which was remor^
tially dry state ; this prevented his sleeping J
Capt. ferr. subearb. 6ta. q : q: hora,(in.f
Enema commune — pro re nata. (

Foot improving ; discharge healthy <^n4V^
The fracture box removed. . ^'X

January 4. Same as yesterday. .

January 6. Much improved; pube fi
great deal softer and fuller; has reman ^k
quantity of iron from his rectum. . '

From this period he gradually
any further relapse; he continued,
time, to piassi portions of the subcarhor'
his stools. The sudden improvements ;€
the evening of the 28th, after the :em# ,
torn the donsum of the foot, camioMi^
one, who may carefully p^use
and I think it will require further
before its efficacy in this formidab «.
relied on. — ^T. ■'';^

181

ladled.

LECTURE XXXVIIL

Of Wounds of Arteries.

These wounds we shall divide, as wounds
in general, into the Incised, Lacerated, Con-
tused, and Punctured.

When an artery is cut into, or divided,
ike immediate effect of such injury is to
occasion an impetuous hsemorrhage of florid
blood, which, if the artery be large, whizzes
through the wound. It flows in pulsation in
obedience to the action of the heart.

If the wounded orifice, nearest to the
heart, be compressed, the blood from the
opening, most remote from the heart, flows
in an uninterrupted stream, and is of a dark
venous colour, owing to its having passed
through capillary vessels.

The brain soon ceases to be supplied with Fainting
blood, and fainting is produced: sensation p'<^"««**-
^d volition become suspended; and the
action of the heart is in a great degree sup-
pressed ; the flow of blood from the wound
becomes much diminished, and sometimes
^^tirely ceases.

N 3

182
Recovwy In a few minutes the patient opens his

from funt- 11 /• 1

ing. eyes, and the power of the nervous system

is restored.
Modes of The mode by which bleeding is arrested
thTbie!^- may be either constitutional or local. Faint-
*°^' ing is the constitutional mode, by suspend-

ing the voluntary and involuntary functions,
more especially in the diminution of the action
of the heart, so that the blood scarcely
reaches the wound, but it undulates in the
heart, and large vessels under the fluttering
of the heart.*
i^oeai T^^^ loc^l means consist in, first, the

"**"*• coagulation of the blood, which is effected
in the cellular tissue around the artery, and
.!»> in «.e extremity of the wo„«ied^,
forming a plug ; so that there is a continua-
tion of coagulum from the outer surface to
the orifice, and this sufficiently opposes the
issue of blood under the enfeebled action
of the heart,
contrac- ^^t this proccss IS also aided by the con-
▼cMch.*^^ traction of the artery, not particularly at the
divided part, but also to a considerable ex-
tent from the orifice.

If the carotid artery, on one side, be cut

* The brain and nervous system are, however, some-
times so depressed, that without stimuli to the stomach
and nose, the person will not recover.

183

across, and examined after the death of the
animal, the artery is found much smaller on
the wounded side than on the other which
has not been injured. This state of the vessel
lessens the influence of the blood upon the
wound.

A. retraction of the artery also follows RctrMtion
when the division of the vessel is complete ; sei.
and, by withdrawing itself into the cellular
membrane, the blood becomes effused around
it, so as to compress its orifice. Thus, then,
it . appears that coagulation with contraction
and retraction of the vessel, all concur to put
a check to the bleeding.

These, then, are the immediate means ; process of
but it is required that a further process uoo.
should take place, to render their effects
permanent. Inflammation follows; and the
clot of blood becomes glued to the inner
surface of the vessel, whilst effusion into the
surrounding parts creates pressure upon
the artery so as to diminish its calibre ; this
inflammation also usually produces a union
of the edges of the wound, or otherwise
granulations arise, fill it, and thus it becomes
closed.

The treatment, when an artery of not a pressure,
very large size, is divided in an extremity,
is to apply a tourniquet to compress the
trunk from which it is supplied ; this, with

N 4

184

gentle pressure on the wounds for a short
time, will generally command the haemorr*
hage, when the edges of the wound may be
approximated, and union promoted, leaving
on the tourniquet, so as to continue a mode-
rate pressure on the trunk.

tioo dri ^^'» ^^ *^^ vessel be large, it is necessary
ligatnre. jq make an incision in the direction it takes,
so as to expose the wounded portions, when
a ligature must be placed above and below on
each portion of the vessel. The ligatures
should be small, and one of the ends removed
after their application. Dr. Vetch first recom-^
mended the removal of one of the threads.

When an artery is not completely divided,
its retraction is prevented, and a coag^lum^
with diflSculty, forms in it, and, when formed,
is easily forced off by the action of the heart.
Hence, in a week or ten days after the in-
jury, bleeding will sometimes occur; and
repeated haemorrhage will destroy the patient
if a ligature be not applied. I have known
the temporal artery bleed eleven days after
its partial division, and when the wound in
the integument was almost closed.

The treatment of this injury consists in
completely dividing the vessel, when its
retraction enables a coagulum to form in,
and around it ; but, if the artery be large,
a ligature must be applied.

185

Lacerated Arteriet.

These bleed comparatively little.

A sailor, on board a Margate Packet, was caie.
bringing up his vessel in the river, and hav-
ing his leg in a coil of the cable, the anchor
was unexpectedly let go, when the cable
caught his thigh, and tore off his leg six
inches above the knee, excepting thai a small
podTtion of skin on the outer part still con-
nected the parts; the bone was broken;
the artery, vein, sciatic nerve, and muscles,
were all completely separated. A handker-
chief was bound around the wound, and he
was brought to Guy's Hospital. The artery
had ceased to bleed, but he had lost a con-
siderable quantity of blood. I amputated his
limb, and he proceeded favourably for ten
days, when he was seized with tetanus, and
died.

I have also seen the foot torn off above case,
the ankle, and the bleeding stop without the
aid of tourniquet or ligature.

The case, related by Cheselden, of the cheseiden's
arm being torn off at the shoulder without *^***'
much haemorrhage, is known to every sur-
geon.

There are two causes which operate to ^^*
prevent bleeding : — EteeSn

186

1. The cellular tissue is sometimes drawn
over the mouth of the vessel, ^^d makes a
ligature upon it, which stops the blood.

2. Another state of the artery produces
the same result, and in which the mouth of
the vessel remains open, the coats of the
artery are excessively elongated, and its
sides fall together so as to render its canals
unpermeable.

Treatment The hidst treatment is to apply ligatures
upon lacerated arteries, if they be large;
otherwise, when the powers of circulation
are restored, there is a danger of hsemorr*
hage.

Of Punctured Arteries.
conse. . They produce different symptoms from

qaences. J r ...

the other wounds of arteries in this respect,
that the external opening being small, the
blood does not readily escape; and there-
fore coagulates in the cellular tissue, and
forms a s^^elling there, which gradually in-
creases in size as the blood issues from the
wound in the artery; the impetus of the
blood causes a pulsation; and the cellular
membrane, around the extravasated blood,
being condensed, form a sac, which impedes
the evolution of the swelling. The external

187

wound heals, and* thus an aneurism is
iormedi

It may be said that it differs from an aneu-
rismal swelling in the mode of its production ;
and this is true, but it still has the other
characten^ of the disease, and requires the
same treatment. . . P"??^

in bleed<*

I have several times known it happen from tqg.
bleeding in the arm; in one case the radial
arteiy was wounded, but in all the other
caaes, the brachial artery. CMe.

The first case was in a patient at Guy's
Hospital, a dresser of Mr. Lucas, senior, bled
the man, and he came to me excessively
alarmed, telling me what had happened, and
that he had great difficulty in stopping the
haemorrhage, but had at last succeeded, by
applying a very tight bandage. A short time
afterwards the man came to Guy's, and
showed his arm to Mr. Lucas, who, seeing
the aneurism, and hearing the cause, told
the man that he must submit to an operation,
which the patient refused. In walking home^
he met an old acquaintance, to whom he told
the circumstances ; this friend, who occasion*
ally bled and drew teeth, said he would cure
him, and inviting him into his shop, he put
9, lancet into the swelling, and finding blood
impetuously escape, he as quickly escaped *
from his shop. The patient finding himself

188

ble^ng, fortunately put his hand upon
wound, and called for assistance. A bandage
was bound tightly round his arm, and he
went to St. Thomas's Hospital, where Mr.
Cline operated upon him, when the radial
artery, in consequence of a high division, was
found to be the wounded vessel.

One of the apprentices at Guy's Hospital had
the misfortune to wound the brachial artery in
bleeding, he immediately perceived the nature
of the mischief, but before he could arrest the
bleeding, thirty-seven ounces of blood were
lost. He bound up the arm extremely tight,
and when the bandage was removed a few
days after, an aneurismal swelling appeared
at the fore part of the elbow, for which an ope-
ration was performed, of tying the artery at
the part, an operation which was attended
with great difficulty, and the patient died.

I once assisted Mr. Chandler in performing
the operation for brachial aneurism, produced
by bleeding ; the sac was opened, and the
orifices above and below were secured by
ligatures, but still there was a free hEemorr-
hage, from an anastomasing vessel, which it
ii. was necessary to secure.

The treatment of this injury consists in the
immediate binding up of the wound, and
applying a tourniquet to the middle of the
arm, which should press upon the artery, and

189

upon the opposite side of the arm only, leav-
ing the circulation by amastomasis as free as

possible. If aneiirlim

If an aneurism still follows this accident,
the tourniquet is to be continued, as des-
cribed in the lecture on aneurism. Oiieration.

Should the tumor still continue to increase
after this has been fully tried, it will be
proper to make an incision upon the brachial
artery, about midway between the elbow
and shoulder joints, and place a ligature upon
it, but upon no account cut down upon the
wounded vessel at the elbow.

In one instance, after I had applied a liga-
ture to the brachial artery, I was surprised to
find the thread completely separated on the
fifth day; but the ulcerative process was
probably accelerated by the inflammation
which existed previous to the application of
the ligature. The patient recovered.

Of Contused Wounds of Arteries.

Gun shot wounds and severe bruises some- D»ng«r of.
times destroy the vitality of a portion of
artery. As it will afterwards slough, there
is a remote danger in such a wound, which
must be carefully guarded against. The
slough ^will not separate until from eight to

Case.

Caie.

188

bleeding, fortunately put ^
wound, and called for ass
was bound tightly row
went to St. Thomas's
Cline operated upon
artery, in consequenr
found to be the w(
One of the appr
the misfortune t<
bleeding, he in
of the mischi

bleeding, tl
lost. He I^
and whc
days af*
at the ^
ratio*

the

t until the

ijluted; and he

the tightening of a

aist be applied, and left

0 limb, until all the slough-

the

.ji received a shot through the

. <v ^^^ was proceeding so well as

^^Qitu w sit up, and to put his limb

a#* • ^^^ *^® seventeenth day, he was

,^ »*ui a severe bleeding, from the

a ^aich he sunk.

.W.«5

ui rRKATMENT OF WOUNDS OF
V'VUriCULAR ARTERIES.

Arteries of the Scalp.

v| vHiiiUs of these arteries require in their
v^%iMViil. first, a complete division of the

191

^ond, the application of

t, retraction is per-

* is prievented ; by

nrhage is sup-

.>ee the son of Ctae,

.;eding freely from

. ich had been opened

i like to make an incision,

j)|)lication of a small tourni-

Hiipletely succeeded, and this

1 should advise in all wounds of

of the scalp, as the means of pros-

in aneurism, from wounds of the arteries of
of the scalp, I have, in each case that I have "*™
operated upon, been obliged to open the
aneurismal sac, and to tie each communi-
WtiBgErtery.

, The aneurisms which I have seen on the
8calpfrominjury,havebeenin the temporal and
posterior aural arteries, and have arisen from
wounds and contusions.

Carotid Artery.

The wounds of this artery are usually so speediiy
speedily fatal, that surgery is rarely able to
preserve life.

190

ten days^ or more, al'tei : ars vaga must be
inflicted ; and then tlic ^ . . and although the
caution, may lose uii •-: ne artery cannot be
blood, and someliiu.. securing the ligature,
haemorrhage. *:.i^ is stopped, a fresh

The slough oji- .^ru upon the artery alone,
and, no retra' ..ii^ upon that which has
is unrestraiUv .mployed at first,
blood.

Treatment In til'

patient m^uman Artery.

slough

^"^ ^ -a*»' ^«*tt this artery wounded, but

tou ^ _.^.. »m through.

( ,^ vitf' brought into Guy's Hospital

1 * . ^Lttc« cf the clavicle, in which acci-

^"*- ^ ^^ Hfc/oider was very forcibly drawn

^^ ^. ^j*i jfrtne. The dresser had to bleed

^ .s** a 21^ injured arm, but little blood

^^ ^ imwn ; and, thinking that he had

die lancet suflSciently deep, he

X so for as to wound the brachial

r!ic blood which issued from the

w;fe$ of a venous character, but it

^liittu A ver>' tight bandage to stop the

i,tfad(^'. Great tumefaction succeeded

i 'Jxc sJioulder, gangrene began in the

^t^t constitutional irritation followed,

jK* man died. Upon examination of the

vv> Atkr death, it was found that after the

193

■uire of the clavicle, the scapula was
cibly drawn back, so that the subclavian
nrtery was torn through, but a cord of cellular
membrane united its ends, so that the extra-
vasation of blood had been very slight.

Axillary.

Mr. Key operated, and tied the subclavian Mn Key's
artery, on account of an aneurism of the ax-
illary artery which had been produced by a
forcible extension of a dislocated os humeri.

case.

Brachial Artery.
This artery I have often known wounded Wounded

. -, ,. in bleeding.

fii bleedmg«

A slight bandage, and a thick dossil of Treatment,
lint as a compress, have succeeded in healing
flie artery.
■ If aneurism forms, the tourniquet should ^^^S »"

' A aneurism

lie employed, as I have described ; and if this ^<>"^™»-
^ifoes not succeed, apply a ligature upon the
%rachial artery. Make an incision in the
ittdddle of the arm, on the inner side of the
Inceps, dud take care to exclude the vein and
median nerve from the ligature.

VOL. III. o

192

sccaring In tying the artery the pn

the artery, ^^^j^^j^^ f^^^ ^^^ ^j^^j^j^

dissection of parts from tli
made at the moment of so
yet when the hsemorrhap
ligature may be placed
instead of dependinp
been of necessity eir

Tonu

Cut.

Su/

I have nevei
I have seen i

A man v
with a frac
dent the :^*
back to
this m:
could
not )
plui
art

'.V

ubital

iie artery,

excluded from

of the free anas*

atery and the radial;

vo ligatures, one abovei

the opening into the

necessary to effectually

Artery,

ts much more frequently

^ ulna, being in every res-

The application of two

^ Mindly necessary, as in the

Mf thtf same reason. This vessel is

i^^ni oo the outer side of the flexor

i^iirf*^! •"^^ ^' ^ ^^' accompanied by
magnitude.

]9S

rssels are very ^>«qneiitiy

"^ wounded.

bleeding may be
(continued pressure,
CSS and bandage, and
the brachial artery; the
t, and attention to position,
assist. Should these means
the bleeding, and if the openings
lied vessel cannot be easily found,
::»e necessary to secure the ulna, or
L arteries, or both ; as from the very free
mmunication of these vessels, the securing
of one only, will not, in many instances, pre-
vent further bleeding. It will be best, liow-
ever, in wounds of the superficial palmar
arch, under such circumstances, first to put
a ligature upon the ulna artery, and then try
pressure again, before the radial is taken up ;
iriiich should not be done unless a trouble-
soine haemorrhage continues. On the con-
trary, should the deep palmar arch be the
.leat of injury, and It become necessary to •
secure an artery, the radial should be first
• fed, and afterwards, provided the bleeding
does not stop, the ulna should be likewise
secured.

o 2

196

Of the Femoral Ay^tery.

™^J*P If this artery be wounded high up in the
K^n- groin, the finger must be thrust into the
wound to stop the bleeding, until a com-
press can be applied upon the pubes, and
the vessel be secured.

d"e^f Ae " ^^ ^* ^ wounded in the middle of the thigh,
^^^' in the mode which I have described in the
case of a relation of Mr. Saumarez, a large
swelling will immediately form, and the
artery will be deeply situated, under a large
Treatment coagulum. A free iucisiou must be made to
give the surgeon ample room to proceed in
securing the wounded vessel, a tourniquet
being first applied. The direction of the in-
cision will be that required in the i;>.peration
for popliteal aneurism, only it must be more
extensive. The coagulum, which is then
exposed, must be scooped out from the wound
by the fingers, and the parts be cleanly
sponged. The tourniquet is then to be loosen-
ed, and the aperture in the vessel will be
directly seen, when the tourniquet is to be
again tightened, and two ligatures are to be
placed in the artery, one above, and the
other below the wound, an end of each
thread being cut ofiF; the edges of the wound
are to be approximated, so as to favour the
union by adhesion.

197

It is always right in these cases to divide
the artery, between the ligatures •

Of the Popliteal Artery.

This vessel is so protected by the condyles ««"•«'? ^
of the OS femoris, and so concealed behind
the bone, that it is rarely lacerated, and when
it is so, the wound must be highly dangerous,
as it will be probably complicated with a
division (^ the sciatic nerve.

It was a case of this accident which first
attracted my attention to surgery, and which
taught me its value:

A foster brother of mine, named John Love,. Cue.
aged about thirteen years, was playing and
fell, as a waggon was passing, and one of the
wheels of tlie waggon went over the back of
his knee, as he laid with his face to the
ground. The waggon was stopped, and when'
he was drawn from under it, a stream of Mood
directly burst from his ham ; a handkerchief
was tied tightly over the wound, and he was
put upon the waggon, and was carried hcmie
in a fainting state. Different surgeons in the
neighbourhood were sent for ; but when they
heard the nature of the case they all made
excuses ; one had a most dangerous case of
fever, another was at a labour; a third with a

t) 3

196

Of the Femoral

Hi^jip If this artery be wounc
groin. groin, the finger must
wound to stop the b'
press can be applied
the vessel be secured
Kt'" If it be wounded
^'«^- in the mode whicl
case of a relation
swelling will \\
artery will be d

Treatment COagulum. A

give the sur^
securing thi
being first l
cision will
for poplit.: .
extensive .

iio was
.,l; was ap-
iiLc messenger,
. would be stopped
iv.d; and so it was« for
rod.*
..:c a strong^impression upon
: was the first death I had
1 was directly convinced how
exposed, , jfeember of society a well informed
jKu^n be» wsd how great a cuxsie an
was. If the artery coidd not
the limb might have beea

by th(
spong
ed, V
diro'^

^1-

lie artery in the ham, there is
of including the sciatic nerv^

^ f^i^ %«» forty-three years ago, when a man who
-.^ag^^MU from the operation, for popliteal aneurism,
^ a sufBcient cnrionty to be annually shown
at our Hospitak.

^ artery in cutting into

-carefully avoided ;

^^om the vein

^ upon it.

included in

[)opliteal aneu-

ii a few hours.

/• Tibial Artery.
at the upper part of the leg Rare at the

• opperpart*

i I lent, but they do sometimes

was brought into Guy's Hospital, Case.

I t alien from a considerable height,

a cart, and an iron peg in the cart had

.sed through the calf of his leg, between

ilie tibia and fibula ; a profuse haemorrhage

ensued, but by the application of a tourniquet

it was stopped. In six days the bleeding

recurred, when the tourniquet was tightened,

and the flow of blood was again suppressed ;

hat in two days haemorrhage again took

place. I tied the femoral artery at the usual

{dace, and for a week the man went on well,

but then the bleeding was renewed, and I

was obliged to amputate the limb. On ex-^

amining it after removal, it was found that

Ihe iron had passed through the posterior

tibial artery, at the origin of the anterior

o 4

198

Danger in
tying the
artery.

pressing case of inflammation of the
they were all engaged, and could ^
or, like the hare and many friends

" The first, the stately bull imploi
" And thus replied the mighty lo'
*' Since erery beast alive can tel
" That I sincerely wish you we'
** I may without oflfence pretei
'< To take the freedom of a fr'
** Xooe trails me hence,^ &c.

Tired of waiting, an old
deemed a sorceress in th<
plied to, and she sent ba
saying, that the bleedin
by the time they retume
John Love had expired.

This scene made a s^
my mind, as it was
witnessed, and I was
valuable a member c
surgeon must be, 9
ignorant surgeon v
have been tied,
amputated.

In tying the
some danger o

•{J

..)S1

• This was fo
had recovered fr<
was deemed a s;
to the students

uundei^
Travipiti

pital^^xjyg

oy theteiij^fe9»|

ailed t0Mr^QHMWf:|

by Mi^WhgBMfij

uclMiftiit^viMstiMf
. :axee WMb befcKre I iBv
^^ MIbqd very frequent,;
^^ Imt m time by pressure
«f m tfNimiquet.

\
t

re^

.'t Treatment
iCt,

lich I

le tibia,

ompapy-

oful to ex*

s upon the

should care-

e byadhesiop.

.mb the artery is At the

•^ lower

oehind the.malle^ part.
j[)anied by the pos-
lies on its fibular side

iterossial artery I have interoswai
die case of such a wound
the vessel from the outer
and seek it between the
close to the fibula.

the Anterior Tibial.
1 is rarely wounded at the upper Protected

ftDOve*

200

tibial, and had penetrated between t!
and fibula.
Immediate An immediate amputation woulr^

ampata-

Uoo. best course to pursue.

In com. I have several times known the

pound

fractnre. tibial artery wounded by the bor

pound fracture; once, in a pat^

Chandler, and a piece of lint wa

the wound, which stopped the 1

it was followed by gangreen,

patient died.
Case. In a case of Mr. Lucas's, in (

Mr. Pollard, his dresser, seer

and the patient did well.
Case. A patient of Mr. Key's, a

a tourniquet was applied, 1

restrained, and it did not re
Case. In ^ patient of Mr.Travei

by a scythe, and was tie

in the theatre at St. Tho'

patient did well.
It is sometimes wour
Case. nient of the adzoi- I v

Hunton Bridge, Hert

surgeon, at Market S

small, and the artery r

injury had happened ^

the man, the bleedinp

and were restraine

on the wound, by n

Operatioii.

On the
donnm of
the foot.

e
cd

inugt

rhage

anasto-

ese arteries, I TreatmenU

iplioation of a
^)on the wound,
jgh would effect,
tibial artery, after
ssful trial of these
the artery placed,
st tendinous parts
IS should not be made

•r.
o

poand
tnctnr

part of the limb, but frequently at the lower.

Lyiug between the two bones above, it is
much protected.

When wounded at the upper part of tlie
limb, an incision must be made on the onto
side of the tibialis anticus to find it: a
tenaculum, or a pair of forceps, must be em-
ployed to raise the wounded artery, to remove
it from the interosseous ligament; and then
two ligatures are to be applied upon it.

I have seen it wounded in compound frac-
ture. First, in a brewer's servant, a patient of
Mr. Birch's, in St. Thomas's Hospital ; the
artery being tied, the compound fracture pro-
ceeded quite favourably.

In a second case the result was singular.
A man was brought into Guy's Hospital*
with a compound fracture of the leg. A few
days after his admission, he had a free
haemorrhage from the wound, which was
stopped by the application of the tourniquet ;
but at different intervals the bleeding was
frequently renewed, and I was at length
compelled to amputate his limb. Upon ex-
amining it afterwards, a spicula of bone was
found penetrating the anterior tibial artery,
and the opening into the vessel thus pro-
duced, had been enlarged by a process of
ulceration, so as to give rise to the hEemtMr-
hage.

203

Wkcm Ae aoieriOT tibial aiteiy is woonded
hm dofvm in the leg, it mart, wfaoi it is tied,
be ci—|Ji5tdy raised from the tendons of the

wlndk it is placed ; bodi ends most

Wsartoy is sometimes woonded on the Om
part of the foot, where it is placed
Ae nafienlar bone;, and the middfe
by a knife or drisd bcay dropped

Sash caUiemilj of the divided Tessd mnst
be canfidty tied, otherwise the hoemofihage
wit I'lmlinne^ on accuuut of the free anasto-
of tins artery widi tiie ]daatar»

Qf the Fhatar Arterks.

fSor awmmd of eiAer of these arteries, I

try what the s^plication of a
wilh a compress upon the wound,
atonnnqnetiqNmthe tUgh would effect,
sad ihonld tie the posterior tibial artery, after

and iDisiiccessfiil trial of these
; fer so deeply is the artery placed,
so situated ammigst tendinous parts
SHlncsfes, dbat incisions dioold not be made
St Ae woonded part.

204

Styptics*

Wool.

Turpca-
tine.

An old
prescrip-
tion.

In bleeding from small vessek on womided
surfaces, very fine wool laid down and con-
fined by bandage upon the part is (me of the
best styptics. The wool may be dipped iin
flour to add to its efficacy.

Turpentine is said to have power as t
styptic, and I have seen bleedings stopped
by it when it has been applied by lint, and
with pressure ; but merely poured upon liie
wounded surface it appears to me to be quit^
powerless.

There is an old prescription for a styptic^
in St. Thomas's Hospital which I have seen
useful.

R. Pulv: Catechu

Pulv: Bol: Armen: aaSij.

Alum: ust: 5j.

Tinct : opii. q. s. iat fiat pasta.-

This will stop the troublesome bleeding:
from leech bites.

205

LECTURE XXXIX.

Of Wounds of Veins.

Mr. Travers has published a very good Traverses
paper tipon the mode in which they heal. p^p®"^-

In a healthy constitution they are little in healthy
dangerous, as the cellular tissue adheres over Sall^erons!
the apertures which have been made in them,
and inflammation speedily closes them.

I €fnce saw the axillary vein wounded in case.
rel&oving a scirrhous gland from the axilla,
a dosil of lint was placed in the wound, and
the arm was confined to the side, when no
bleeding of consequence ensued.

In unhealthy constitutions they inflame in unheal-
and suppurate ; they also ulcerate, and some- "^^^IZ:
times life is destroyed, by bleeding or by the
inflammation extending to the large vein, and
to the heart.

Several cases of this kind I have witnessed;
and in the greater number the wound of the
vein had been made to abstract blood for
inflammation of the lungs ; and I have thought
that the inflammation of the vein was the
result of the impediment to the pulmonary
(^culation.

The patient in a few hours after the bleed- symptoms
mg, complains of tenderness in the arm, and mation?™"

206

requests to have the bandage loosened ; he
next finds great p^n in extending the limb ;
the wound looks red, and its lips are sepa-
rated. Then the plexus of veins on the fore
arm become swollen, hard, and very painful;
afterwards the basilic vein of the upper arm
feels as a solid body, and is much enlarged.
High constitutional fever ensues. If the
patient has sufficient power of constituti<m,
abscesses form in the veins of the fore ami;
and by opening these early, great relief is
afforded; but if the habit be particalarly
feeble, the matter which is produced by Ae
suppurative inflammation, does not point, but
it remains in the veins, producing excessive
constitutional irritation, which destroys life*
Appear. Upou inspecting the vein after death, it is
'^' found partly filled by adhesive matter, and in
part by pus. There is in the collection at St.
Thomas's Hospital, a beautiful specimen of
abscess in the longitudinal sinus of the dura
mater. I have seen the jugular vein inflamed
and adherent throughout the greater part of
its course.
Specimen. We havc, in the collection atGuy's Hospital,
the femoral and iliac veins obliterated, taken
from a patient who had phlegmatia dolens ;
which disease has been extremely well des-
cribed by Dr. Davis, in the " Medico Chirur-
gical Transactions."

207

But the worst cases of inflammation of veins Dwuion or
which I have seen, have arisen from the appU- m^ "* ""
cation of ligatures to the vena saphena.

First, I have seen a disease like phlegmatia Consefiueo-
dolens follow the division of this vein.

Secondly, numerous abscesses form and
break, sometimes destroying life, at others
producing excessive irritative fever, from
which the patient has been with difficulty
recovered. One patient became insane during
the irritation, and did not afterwards recover
her mental faculties.

Thirdly, they have died from suppurative
inflammation, without any abscess appearing,
and this is the cause of death after the opera-
tion of amputation, when it is performed
during a very unhealthy state of the consti-
tution. I have seen, under these circum-
stances, both artery and vein, in a stump, in
a state of partial adhesion and suppuration.

I saw, in Paris, in 1792, a case in which
life was destroyed by suppuration of the
femoral vein, after a gun-shot wound.

Of the Treatment of Wounds of Veins.

The first and greatest object is to empty PMidon.
the veins as much as possible, by the position
of the Umb, which should be such as to allow
of the gravitation of the blood to the heart.

208

In the arm, an inclined plane ; in the leg, the
position for a fractured tibia. This prevents
accumulation of blood, and distention of the
vessels.
GenUe Sccondlv, a roller, from the extreme part

pressure. ^ ^

of the limb, to the wound, wetted with the
liquor plumbi subacetatis, and spirit should
be applied to approximate the sides of the
vein, and to make gentle pressure.

Thirdly. — Leeches should be freely applied,
and if suppuration be produced, fomentaticNos.

Wounds of the Abdomen.

Two kinds. Thesc injurfcs are of two kinds : 1. Those
in which the cavity is opened, but the vis-
cera are not wounded. 2. Those in which
some of the viscera suffer.
First kind, With rcspect to the first of these it is
covered^ sfcarccly ucccssary to say, in the present
state of surgical knowledge, that very exten-
sive wounds of this description are often re-
covered from, as is proved by the operations
for umbilical or ventral herniae, by the Cesa-
rian section ; and, recently, by the removal
of enlarged ovaria.* But the most curious
circumstance in these wounds, is the manner
in which the intestines glide away from the

* See cases by Mr. Listoq.

from.

209

sharpest instruments, and escape injury. I
shall relate two cases: —

In the year 1786, my second year of being ctse,
at the Hospital, a gentleman came almost
breathless to the Hospital; and finding me
the only person there, requested that I would
immediately accompany him. He took me
to a house in the Borough ; and, leading me
up stairs, showed me into a room, where I
found a female in her shift only, lying upon
the floor, weltering in her blood. I with diffi-
culty raised her, and placed her upon the
bed she had just quitted. On examining her,
I found four wounds in her throat ; one of
which was deep and extensive. These I
closed by sutures ; after which she was able
to speak; and I then asked her what had
induced her to commit the act ; she made an
incoherent reply; but repeated the word
stomach two or three times, which induced
me to raise her linen, when I was surprised
to find her bowels exposed by a wound reach-
kg nearly from the pubes to the ensiform
cartilage of the sternum ; for, after cutting
her throat with a razor, she had ripped up
ker beUy with it, and let out her bowels, but
the intestines were still distended with air;
aad I had a difficulty in returning them into
the abdomen. They had not received the
smallest wound. Dr. Key now came intp

VOL. III. P

210

the room^ and I proceeded to sew up this
extensive opening; but she died in niue
hours.

Case. Mr. Tolman and myself were sent for to

see a gentleman who had stabbed himself
in several parts of his abdomen^ with an old
rusty dirk, and had for ^sorne time afterwards
concealed himself from his family. When
found, it was discovered, that a portion of
omentum protruded through one of the open-
ings ; this was carefully returned ; but, not-
withstanding, the dirk still possessed its
point, the intestines were not injured, and
he recovered without a bad symptom.

The free motions of the intestines upon
each other, independent of the. peristaltic
motion, is a great preservative in wounds
of, and blows upon the abdomen.

Peculiar There is another curious circumstance in
wounds into the abdomen; which is, that
they immediately produce universal cold-
ness and paleness, with nausea and faintness,
excepting in the operation for strangulated
hernia ; in which case the intestine has been
accustomed to violence.

Treatment In the treatment of these wounds, it is
best to make interrupted sutures ; the needle
should penetrate the skin and muscles, but
not the peritoneum. If the muscle be not
included in the ligature, a hernia is sure

211

afterwards to form ; and, if the thread is
introduced through the peritoneum, it adds
much to the danger of abdominal inflam-
mation.

Between the sutures, strips of plaister, or
of lint dipped in blood, should be applied,
and the patient should be freely bled from
the arm. If the local inflammation be great,
leeches should be employed; purgatives
must be avoided, and food must not be given
finr several days.

Of the Second Kind of Wound of the Abdomen.

Wounds of the abdomen, extending to the Rare,
stomach, or intestines, are extremely rare.

There, danger is much lessened, if the Dangerous,
wounded portion of the viscus protrudes
through the opening in the parietes ; for, if
not, they are generally fatal.

Wounds of the Stomach.

The best case which I have heard of, is
related by Mr. Scott, in^the medical commu-
nications, from which the following account
is taken : —
"During the election for Weymouth, in Mr.scotfs

case.

p 2

•r

. •• ^

^^ \ii»w Thomas, a seaman,

^-ir. ii a strong and healthy

MM. !ie misfortune to receive

w-.alL sword on the left side

T^» sword passed in between

^ *«. :mv\ of the lower false ribs,

. •^cu :uto the cavity of the abdo-

, «/i!^ontaI direction, to the extent

jLi: dve inches, as appeared after-

Lt*: mark upon the blade.

tiiii about half an hour after the

His whole appearance was then

.*:ci ^\l ; his countenance being quite

A^^vw AUil covered with a cold sweat,

., !K' pulse at his wrist was scarcely

,.. ^'*ii>ic; he had also a constant hie-

.^tu .i frequent retching and vomiting of

v^>vv. ,iud u considerable discharge of blood,

X.V ^i>cr tluids, from the external wound.

b%\>m the i)lace and manner in which the
v**vsv? hud entered, and the symptoms that
<\K^^uhK I was led to conjecture that the
x^oauu^h was wounded ; and that this was
v;<sU\dv the case, I was soon convinced, on
^ \,iu\ming the fluid discharged by the exter-
mI Nxound, and finding in it several small
•MvVi*>^ t)f moat in a soft digested state, toge-
»hvM with some particles of barley.

" llr had complained of thirst, and some
{k\\U\ water had been given him to drink;

213

but this had been immediately thrown up
after passing the oesophagus. Other mild
fluids were now tried, as were likewise a
common saline draught, in an effervescent
state, and some thebaic tincture, but with
no better effect ; and they were all instantly
rejected, tinged with blood.

" The retching and action of the stomach
continuing to be very violent, and the patient
complaining, at the same time, of a lump, or
dead weight, as he termed it, in his inside,
he was desired to drink some warm water ;
this was soon thrown up, accompanied with
a good deal of barley in solid grains, with
the surface slightly broken, and some pieces
of meat in a half-digested state. More water
being given him, it was quickly returned,
tinged with blood, but, otherwise, nearly as
pure as when swallowed.

"I now proposed that we should avoid
giving any thing farther by the mouth ; but,
as the spasms and hiccough were still very
frequent, an emollient clyster was adminis-
tered, by which a considerable quantity of
fceces was discharged. Soon after this,
another clyster, containing twelve ounces of
barley-water, and sij of thebaic tincture,
was thrown up, and the greater part of it
retained. Warm fomentations were like-
wise applied externally ; the surface of the

p 3

214

wound was loosely dressed; and he was
desired to lie as mach as possible upon the
injured side, with a view to &vour the duir
charge.

'' On the first of April, the day after the
accident, the symptoms were still rery im-
favourable. His pulse continued low and
languid, with a great prostration oi strength,
and a coldness of the extremities. He had
had several rigours towards morning, and the
spasms were sometimes very violent. He
complained of extreme coldness over his
whole body, and of a constant gnawing pain
about the pit of his stomach, to which part
warm fomentations were frequently applied.

''A laxative clyster was again administered,
which was followed by a copious discharge ;
soon after this, another clyster, consistiiig
of fourteen ounces of veal broth, and two
drachms of thebaic tincture, was thrown up
and retained. A similar clyster was repeated
in about four hours, with the same effect
Flannels, dipped in warm milk and water,
were occasionally applied to his arms and
legs, and hot bricks to the soles of his feet*
He made a little water twice in the course
of twenty-four hours; this was highly co*
loured, and deposited no sediment, though
kept for a considerable time.

'* April 2. He had passed a restless night,

215

plained of intense i
hiccough and spasms were less frequent, but
he sufiered much from a constant burning
pain in the lower part of his stomach. His
pnlse was small, and beat about 120 in a
minute. The fomentations were applied as
usual; and 3vj of the sal: cathart : amar :
were dissolved iu some broth, and thrown up
into the bowels as a laxative. This produced
a considerable discharge of soft slimy foeces,
in which were several small pieces of clotted
blood enveloped in mucus. After this, in
the course of the day, three clysters of broth
and thebaic tincture were thrown up and
retained. He was desired to use the pulp of
an orange occasionally, to allay his thirst,
and to wash his mouth frequently with barley
water acidulated witii lemon juice.

" April 3. I was called to him early in the
morning, and told he was at the point of
A clergyman had been sent for at
the same time to perform tlie last offices.
The nurse informed me, that, whilst sup-
ported in bed to wash his mouth, he had
ien seized with a violent retching, accom-
inied with convulsions of the chest, but
lat nothing had been discharged from his
stomach, except a small quantity of bloody
fluid. When 1 saw him, the spasms still
continued , his forehead and breast were
p 4

216

covered with a cold sweat; his ptilse was
low, and intermitted; so that it could only
be felt at intervals ; and his strength seemed
to be quite exhausted. Warm fomentations
were immediately applied to the region of
the stomach ; and^ as there was always some
of the veal broth kept in readiness, I threw
up about fourteen ounces of it, with sij of
the thebaic tincture. The violence of the
symptoms was soon moderated, and he ap-
peared very languid, and showed a disposi-
tion to sleep.

" When I saw him about four hours after-
wards, I was told that he had enjoyed some
rest. His pulse wras now regular, but small
and quick; he was very weak, and just
able to inform me, that, in washing his
mouth, he had accidentally swallowed some
of the liquor, and that this had thrown his
stomach into violent action. About one pint
of the broth was now injected without any
addition. This was likewise retained, and
repeated at intervals of five or six hours.
He now made water frequently, which,
upon standing, deposited a considerable
quantity of sediment, of a light brick, or
straw colour.

*'April 4. The hiccough, retching, and other
unfavourable symptoms, were now entirely
gone ; but he still complained of a fixed pain

217

in his stomach, accompanied with a sensation
of heat, and of a soreness of the injured side,
extending from the wound toward the middle
of the ahdonien. He was likewise troubled
with thirst; his pulse was small, and about
110. The external wound had now began to
yield a discharge of good matter.

"The same mode of treatment was conti-
nued, and the symptoms became daily more
favourable. The broth was administered in
clysters, to the amount of two quarts, or five
pints a day. The fomentations were conti-
nued externally, and his feet and hands were
frequently bathed in warm milk and water.
He voided his urine regularly, and in about
the proportion of three pints in the twenty-
four hours, though it sometimes considerably
exceeded this quantity, and continued to i
deposit a great deal of sediment. A little of I
the sal : cathart : amar : was occasionally i
added to the clysters in order to stimulate and
cleanse the intestines ; after the fourth day,
however, there was scarcely any foeculent
matter discharged, but only a small quantity
of viscid bile.

" On the 10th day from the time of his being
wounded, he appeared to be very sensibly
relieved ; his thirst and febrile symptoms
Were much abated, and his pulse was regular,
and about ninety. As he was in good spirits.

covered with ji c<»i . ^ lac he might be
low, and intcrniiLiLu -icching, I procured
be felt at iiitcr\ii.. . aade luke-warm, of
to be quite c.\'. . uit. without feeling any
were immediic.. -.Tie only remarkable

the stomnc h , « blended the first time of
of the vopI ^ jB^ diat it occasioned fre-
up abniit 1,-ni ^od a great discharge of

the thol ^ .^tijkfrauig to his own account,
synip^ ^.^Bk X ^teful sensation than

!)(*•« •' , ijA lay he was allowed some
til- ^ .^ ynnikiatst, and some chicken

rhe nutritious clysters were

#w«%er. till the 16th day, though

.fltttu before. From that period,

.'.itttti^ac, he lived wholly on bread

uM tigbt broth. He was then

tficifieu,. veal, and other meats easy

rhe external wound had been

« ^oitie time, and he recovered his

*«ir% jcradually. The only incon-

jij ^tUK^red was from costiveness,

s)t soreness and stricture which

i iivm the external wound towards

«i^o(c oi' the abdomen. This was par-

,\ cit Arter a violent expiration, or any

^^^u V \tctt^ton of the body, when, to use

*a c \tuv**ion, his side was drawn in-

^^^^ .uKi upwanls. The costiveness was

vH^^i^vM^ o> uuld Uixutives, and gently stimu-

.v' g'

219

■:\(l went off entirely as the
v'crcd their true and natural
;i lier complaint which I appre-
i originated from an adhesion of
■ icd stomach, to the peritoneum,
to go off gradually as he recovered
.reiigth; though it was still felt in a
till degree in stooping, walking quick, or
:reat exertion of the body. When I last
iicard of him, two months ago, he enjoyed
good health,"*

'' This case affords a striking instance of the
resources and peculiar powers with which
nature has endowed the animal machine, for
its preservation, and for remedying any injury
it may sustain. The treatment was sijch as
was necessarily suggested by the symptoms.
The wounded stomach was so extremely irri-
table, that even the mildest fluids increased
the violence of its action, and were rejected ;
for had any substance, whether of medicine
or aliment been admitted, it would probably
have interrupted the union of the divided
parts in the first instance, or afterwards,
by the action necessary for its expulsion
through the pylorus.
'' The liquid contents of the stomach had

* This was in the September twelve months following,
^ the paper is dated November 15, 1786.

220

been chiefly discharged by the exteraal
wound, though part of them must, no doubt,
have passed into the cavity of the abdomen,
and have been afterwards absorbed ; but the
wound of the stomach collapsing, the barley
and indigested meat were left, which increased
the irritation, and occasioned the uneasiness
and sense of weight he complained of, and
which was, in a great measure, remored by
the vomiting that took place upon his drink-
ing the warm water.

" He felt some relief after the retention of
the first clyster, but at that time his strength
WBS so reduced, and the symptoms were
altogether so unfavourable, that neither
himself, nor those who saw him, entertained
any hopes of his recovery. It is indeed sur-
prising what an extreme debility took place
immediately after the accident, which could ,
only arise from the nervous influence and
general sympathy with a part so essential
to life,

" The accident that happened on the fourth
day, induced me to persevere in the mode
of treatment we had adopted. Indeed there
was great encouragement to continue it, as
the broth clysters, were not only retained,
but there was a proof of an absorption having
taken place, by the secretion and evacuation
of urine, which then began to be consi-

221

derable. It is a generally received opinion,
that clysters seldom pass beyond the valve
of the colon: the contrary has indeed been
observed in the volvulus or iliac passion,
but in that case the natural action of the in-
testines is inverted, and a violent degree of
auti-peristaltic motion prevails ; in this case,
however, the broth was thrown up in a very
gradual manner; and though, perhaps, it
did not pass the valve of the colon, in the
first instance, I am inclined to believe, from
the sudden manner in which the absorption
was afterwards carried on, that a gentle de-
gree of anti-peristaltic motion took place,
whereby it (the broth) was impelled to the
smaller intestines ; this will appear less sur-
prising, when we consider, that, in the natu-
ral action, the first impulse is communicated
by the stomach, in discharging the digested
aliment at the pylorus, and continued through
the intestines in determining the foeculent
matter downwards: but here the natural
action was suspended, the stomach was at
rest, and there was no foreign matter to be
discharged.

" The advantages to be derived firom throw-
ing up a supply of fluid, and supporting nature
in this manner, in particular cases of morbid
affections of the digestive organs, will readily
occur to the attentive practitioner."

222

Wounds of the Intestines.

In operat- In a Small wound of the intestine, whidi
hcrnis. I witnessed in strangulated hernia, under
the operation, I pinched up the opening with
a pair of forceps, and tyed a thread around
it; I then passed up the intestine to the
mouth of the hernial sac, leaving the ligature
to hang from the wound, and the patient
recovered, but he had severe symptoms for
several dajrs.
Large In a morc considerable wound of tiie

intestine, I should make an uninterrupted
suture, and return the intestine into the
abdomen, letting the end of the ligature hang
from the external wound, which I should
otherwise close with great care. I well
know, that in experiments on animals, the
ligature has been cut off close to the in*
testine, which has been returned into the
cavity of the abdomen, and the external
wound has been afterwards closed, so as to
leave the ligature to separate into the in-
testine. Now I do not clearly understand
that this plan, in any way, adds to the
patient's security; but, on the contrary, it
increases his danger in my opinion, if the
)>rocess of adhesion be deficient.

223

In the treatment of these wounds, it is Treatment,
right, if the wound be in the small intestines,
to keep the patient without food, and sup-
port him by clysters of broth, &c. If it
be in the large intestines, after a few days,
a little jelly may be allowed. Perfect quiet
is to be observed; and, if there be much
tenderness of the abdomen, leeches should
be applied.

Ruptures of the intestines from blows are Rapture of

/. ^ •J X • • /• 1*1 intestine.

more frequent accidents, arismg from kicks
of horses, falling upon projecting bodies, &c.
The symptoms are, great depression, cold-
ness, and paleness; the pulse is scarcely
to be felt if the laceration be large, and the
patient dies in from twelve to twenty-four
hours after the accident, quite sensible to the
last moment of his existence.

But if the laceration be small, the symp-
toms are less violent ; there is coldness, ten-
sion of the abdomen, vomiting, costiveness,
and not the least disposition for food ; there
is subsequently great abdominal tenderness
and great enervation.

A patient was brought into Guy's Hos- case.
pital, under the care of Mr. Forster ; the
man had been working in a gravel-pit, when
the gravel fell in upon him. He vomited,
Ui& abdomen became tense, and as he made
scarcely any urine, the case had been thought

224

to be retention of urine. The man died six
days after the accident, and, on examin-
ation after death, a rupture was found in the
intestines.
Treatment. The treatment in these cases, is perfect
rest, to prevent any disturbance of the
adhesive process, to apply leeches and
fomentations to the abdomen, to avoid giving
any medicine, and to check the desire of
friends in giving food for several days after
the accident.
Sometime! The intcstincs thus remaining for a length
from^ of time at rest,* and inflammation being kept
within the adhesive bounds, I have seen
(what I believe to have been) cases of this
injury recovered from.

Wounds of the Liver.

ca9c. I have seen deep stabs, with a pen-knife,

in the situation of this org^, recovered from,
after great inflammation in the abdomen.
The patient was bled generally, and by
leeches, and fomentations were employed.
Adhesive plaister had been applied to the
stabs, and on its being removed, a bloody
serum Mras discharged from the wounds.

* The perislaltic motiQii is •greater or less as flie iales-
tiues are full or empty.

226

Wound of the Gall Bladder.

Mr. Edlin, of Uxbridge, informed me of Cate.
the following case : — Two soldiers quarrelled,
and one struck the other with his bayonet
in the tight side, just below the margin of
the ribs. The wounded man directly fainted
and fell; when he recovered from his faint-
ing state, he complained of agonizing pain
in his abdomen, which became extremely
tense and tender to the touch. In thirteen
hours the man died; and, on examination
of the body, the gall bladder was found
to have been penetrated by the bayonet, and
bile was extravasated into the abdomen. Mr«
Edlin said, that wherever the bile rested,
the peritoneum was highly iuflamedt

Wounds of the Spleen.

Although this organ may be removed from
the body, without the destruction of life,
as is known from the case of the soldier,
mentioned by Dr. Gooch, and by numerous
experiments on animals, yet a very small
wound of it is sometimes destructive of life;
the best example of which I shall give in
the following case: —

VOL. III. Q

226

ca«e. A lieutenant of a press-gang was attempt-

ing to press a man, who resisted with much
violence; a scuffle ensued, and the lieu-
tenant struck the man with his dirk, which
entered near the ensiform. cartilage, and its
blade was nearly buried in the body. The
man was brought to St. Thomas's Hospital^
pale and extremely depressed, his abdomen
became tense, and he died. Upoa examine
ing his body, it was discovered that the
dirk had passed from the ensiform cartilage,
under the margin of the chest into die
abdomen, on the left side, and that its
point had penetrated the concave surface of
the spleen ; the cavity of the abdomen was
filled with fluid blood,
wonnded It is Said, that the spleen has been ( often
in tapping, ^quj^^j^ j^j n^^ trochar, when tapping was

performed on the left side, which, under
enlargement of this organ, might happen.

Ruptared. I havc Several times known the spleen
ruptured by carriages going over the abdo-
men, and once by the horn of an ox. Bach
of these cases proved fatal.

Case. Twice have I known the spleen torn from

its natural attachment to the diaphragm.
The first instance, was in a patient of Drs.
Babington and Letsom, a Miss Harris, who,
having vomited violently, discovered soon
after a swelling at the groin, and at th^

' lover part of the abdomen. I waS asked
if it was hernia, and ! declared it was not.
She died after a week, vomiting; constantly
the liquids which she swallowed. When the
abdomen was opened after her death, the
swelling was found to arise from the spleen,
which had been detached from the dia-
phragm, and was enlarged by the inter-
ruption to the return of blood from the
veins, although the artery still contained
blood. The spleen was turned half round
<Hi the axis of its vessels.

The other case was that of a gentleman Case.

who was hunting in Surrey; he fell from

his horse when going at full speed. He

died the following day, or the day after.

I Dr. Pitt, who attended him, examined the

I body after death, and found the spleen torn

1 from the diaphragm.

I In wounds or ruptures of the spleen, Trean
'I I believe nothing can be done. If the case
^L cOold be accurately ascertained, pressure by
^WMoller on the abdomen would be the best
Vtreatmeot.

Wounds of the Kidney.

A wound of this organ is not fatal.
A Boy called at ray house, and showed (:«•■.
iiie some chalky concretions which he had
Q 2

228

coughed up from his lungs or bronchial
glands, I said, " How long have you been
subject to this complaint?" He answered,
" Ever since I have passed blood with my
urine," I asked him to explain himself fur-
ther, when he told me, that when quarrelling
with another boy, he had been struck with a
penknife in his back; that almost imme*
diately he wished to make water, when he
passed a large quantity of blood. This con-
tinued for several days, but subsided by his
remaining quiet in bed. The recumbent
posture is in such a case the very best
secjority.

Wounds of the Bladder.
Danger Thcsc are dangerous, or not, as the

from state , ^

ofbiadder. bladder is full or empty, when the injury
is inflicted. If full, urine is extravasated
into the abdomen, or extensively into the
cellular tissue, and death ensues. If empty,
or nearly so, the danger is greatly lessened.

The bladder is sometimes ruptured when
the above observations are applicable. The
cause of its laceration is generally a fracture
of the pubes.

Treatment. The treatment of these cases, consists
in leaving a catheter in the bladder, and en-
joining perfect rest.

229

Wounds of the Chest.

These are also of two kinds: — First, or two
Wounds of the parietes. Second, Wounds
of the viscera.

Wounds of the parietes are not * attended of parfetes.
with much danger.

'A boy fell from a tree upon some pales, case.
which entered his chest between the seventh
and eighth ribs, tearing his intercostal mus-
cles freely. The air rushed violently into
his chest at each respiration, and was again
expelled, when the anterior surface of the
lungs appeared at the wound. The edges
of the wound were brought together by ad-
hesive plaister, a roller was applied tightly
round the chest to confine the motion of the
ribs, and he was bled very freely. He did
extremely well.

A jnan was brought into St. Thomas's case.
Hospital who had been stabbed between
the . cartilages of his ribs, he bled very pro-
fusely, and I thought the internal mammary
artery was wounded, but the bleeding soon
subsided, and he recovered.

Treatment in wounds of the parietes of
the chest, is to promote as much as possible
the adhesive inflammation to close the wound
externally.

Q 3

230

Hsemorr- If there be bleeding from the intercostal
^^' artery, the finger should be pressed upon tiie
orifice of the vessel, until the disposition to
haemorrhage ceases.
Case, A man died in Guy's Hospital, who had

been wounded through the intercostal mu^
cles with 'an iron spindle, the wound healed,
but tetanus supervened, of which he died*
Upon inspecting the chest after death, the
lung was found to have assisted in closmg
the wound, by adhering to the injured
pleura.

Of Wounds of the Lung.

symptomsi When this happens, the circumstance is
known by the patient's coughing up florid
and frothy blood ; by free bleeding from the
wound, if sufficiently large to permit its
escape ; by considerable irritation and tick-
ling in the larynx, and by dyspnea.

Danger of. Danger in three ways results from wounds
of the lung. First, From haemorrhage, if
any large branch of the pulmonary artery
is wounded. If the vessel be wounded by a
. sword or knife, it bleeds very freely; but,
if by a broken rib, very little, as it has the
nature of a lacerated wound.

Tip.atnieiit. In either case, the patient must be freely

'^e of the
1 the

lion

ilimation Danger
from in-
Cavity of flaramation.

irded against

-;s, determined

CSS of the pulse ;

^ r bleeding too much

as it is an object not

iorce of the circulation,

jf the blood in the pul-

ioUows, it is the result of neg-

j ination, or of having closed the

ound.too early. In the one case,

^)urulent secretion; in the other, a

. serum, which produces the dyspnea

0 days after the accident.

For effusion into the chest, it is right to Operation

. .for effasion.

perform the operation for paracentesis of the
thorax, to draw off the pus or bloody serum
which has collected in the pleura. The mode
of doing this has been already described.

In old persons, there is great danger in Effusion in
fractured ribs with wounded lung, and I ^ p^"**"**

Q 4

230

Haemorr-
hage.

Case.

If there be bleeding from the inten
artery, the finger should be pressed up
orifice of the vessel, until the dispos*
haemorrhage ceases.

A man died in Guy's Hospital,
been wounded through the interc
cles with 'an iron spindle, the wor
but tetanus supervened, of whi
Upon inspecting the chest aftc
lung was found to have assise
the wound, by adhering t
pleura.

Of Wounds of i

Symptoms. Whcu this happcus, '■
known by the patient's
and frothy blood ; by i'
wound, if sufficiently
escape; byconsider?
ling in the larynx, a^

Danger of. Danger in three ^
of the lung. Fir
any large brand
is wounded. If i
. sword or knife
if by a brokei
nature of a la* : j

Tieatmeut. In either c

*Ci

;olkMAig«ttiit^
lira! with Mr^
called-
had been

I in their

y fatal, as

>rding relief.

jh interest, I

IS a preparation

omas's Hospital.

19^

ited in the second
0 Chirurgical Trans-
ient to me by Mr.
ended the patient.
o^e, a private in the North- Case,
while on duty on the 29th

234

of March^ 1810, with an unfixed bayonet in
hiS' hand, sUpped down, and his bayonet
entered his left side, between the sixth and
seventh ribs, upon the superior edge of the
latter. He was some yards distant from the
gate at which he was posted, and being
challenged, he returned to open it^ with the
bayonet still remaining in the wound; he
was incapable of withdrawing it himself,
but the person coming in extracted it iof
him. I was called to him within five minutes
of the accident ; he was then in a state of
syncope, the extremities cold, and his pulse
scarcely perceptible. In about the space of
a quarter of an hour, he gradually revived,
did not complain of any severe pain, and
expressed, *that he believed he was more
frightened than hurt.' I examined the^vound
with much diligence, but could not trace its
extent further than one inch and a quarter,
though it was evident that the bayonet had
penetrated two inches : the haemorrhage was
very inconsiderable. His wound was dressed;
he was conveyed to the military hospital,
and put to bed ; he was incapable of lying
on his right side, but slept tolerably well.
On visiting him the following morning, he
complained of lancinating pains extending
from the wounded part across the chest, and
of severe fugitive pains in different parts

235

of the abdomen; his pulse was quick and
thready, and tongue white and dry. These
symptoms led to a suspicion, that the pleura
costaHs at least was wounded, though no
opening could be ascertained extending into
the cavity of the chest, ^xvj . of blood were
taken trom his arm, a solution of sulphate
of magnesia administered, and fomentations
applied to the abdomen. He was obliged
to be supported in bed nearly in a sitting
posture, as respiration became much impeded
when perfectly horizontal: in this position
he appeared to breathe with freedom. In
the evening, he expressed himself in every
respect much relieved; his pulse was less
quick, and had lost its thready sensation ;
Lgue more moist; hU medicine h<ul ope-
rated moderately. On the following morning,
I found he had passed a good night, his
pulse was calm and steady, scarcely quicker
than natural, and the tongue quite moist;
the lancinating pains had subsided, and he
merely complained of a trifling pain in the
wounded part ; this was increased by a slight
cough, with which he became affected only
this morning, and which was unattended by
any expectoration. His aperient draught
was repeated, an emulsion ordered for his
cough, and the antiphlogistic regimen strictly
adhered to. Throughout the day he wa3

236

walking about the ward, in very good spirits,
quite jocular in his conversation with his
fellow patients, and expressed himself to
them, that ' low diet would not do for him
any longer.' He retired to rest about nine
o'clock, and fell asleep; at eleven, he got
out of bed to the commode, had an eva*
cuation, by no means costive ; said, ' he felt
himself chilly, and a sensation that he
should die;' returned to bed, and expired
immediately; forty-nine hours from his re-
ceiving the wound.

I examined the body on the following
morning, in the presence of two other sur*
geons. On opening the chesty the pleura
was found slightly inflamed for some dis*
tance round the puncture, and an effusion
of adhesive matter, emitting a small portion of
the lung to the wounded part ; the lung was
not injured. At least two quarts of blood
were effused into the cavity of the chest;
the pericardium was nearly filled with blood,
and had a puncture through it, extending
three quarters of an inch into the muscular
substance of the left ventricle, about two
inches from its apex. A small coagulum was
formed at the edge of the wound through the
pericardium.

Upon opening the left ventricle of the
heart, it was discovered that the bayonet had

237

penetrated the substance of the ventricle,
and had cut one of the fleshy columns of the
mitral valve.

On a review of the case, I conceive it very
curious, that an organ like the heart, pos*
sessing such excessive irritability, a point
to which the most interesting of our sym^
pathies are referred, and which is in some
degree influenced by the most trifling, should
be so materially wounded, and yet the sys^
tern take so little cognizance of the injury.
Death, in this case, it was perfectly evident,
was not produced from any alarm excited in
the system by the wound, but occurred as a
secondary consequence, from the haemorr^
hage increasing to such an extent, as to
interrupt the actions of the heart and lungs.
That the haemorrhage proceeded chiefly from
the heart, must be admitted : there was no
symptom whatever that indicated a wound
of the lung; none could be found on the
most deliberate examination; and the in^
tercostal artery was entirely free from
injury."

The second case has been published in the
^'Medical Records and Researches," from
which the following particulars have been
taken. It occurred during the time that
Dr. Babington was employed as assistant
surgeon at the Royal Hospital at Haslar,

238

and by him the particulars were communi*
cated: —
ca«e, «< Henry Thomas, a marine, was received

' into the hospital, from his Majesty's ship
Foudroyant, having a wound in his side.
He had slipped from the gangway, where h6
had been placed as sentinal, to the deck
below ; and had fallen upon the point of his
bayonet, which had penetrated his side a
little below the false ribs, nearly in a perpen-
dicular direction, as far as the hilt of the
instrument. Immediately after the accident
he drew out the bayonet without assistance,
arose, took up his musket, walked cfight
or ten steps, and then dropped down in a
fainting state; from this state he soon
recovered, and was taken to the hospital
about two hours after the receipt of the
injury; he then complained of but little

•

pain, was inclined to sleep, and when roused
appeared in great distress. The wound wai^
on the left side, about two inches above the
ilium, and communicated with the cavity of
the abdomen ; but neither its direction nor
depth could be ascertained. His body was
cold, his pulse scarcely perceptible, but he
had not apparently lost much blood. A por-
tion of omentum, about sij in weight, pro-
truded through the opening, this was cut off.
A purgative enema was thrown up, which

239

procorecni motion, without any appearance
of blood. He drank freely of coltsfoot tea,
and took his medicines ; the fluids produced
nausea, and attempts to vomit, but he did
not eject any thing from the stomach. The
breathing was at first slow, but free, by
degrees it became more oppressed, and at
length grew extremely quick and laborious,
attended with a sense of weight on the right
side of the thorax, which threatened suffoca-
tion. The expectoration was not bloody.
Soon after the injury he began to complain
of a pain in the chest, and at the pit of the
stomach, which gradually increased, and
towards mid-night became almost insuffer-
able. The upper part of the thorax had
swelled a little, and the motion of the right
arm much increased his sufferings. This
tumefaction gradually augmented, and at
eleven o'clock had reached the head and
face ; it subsequently extended all over the
body before his death, which took place a
little after two o'clock in the morning, ap-
parently from strangulation. He retained his
Raises to the last minute.

" On examining the body twelve hours

after death, the following appearances were

discovered : —
"The triangular wound from the bayonet,
I was seated on the left side, midway between

240

the spine and the linea alba, having the last
rib and the crista of the ilium at equal
distances above and below it, it readily ai*
mitted the point of the finger. A portion of
omentum still protruded, and appeared gan-
grenous. The direction of the wound was
obliquely upwards and inwards, and had
penetrated the following parts : — ^the intega*
ment, abdominal muscles, peritoneum, Hie
colon near its termination in the rectum, again
at its arch ; the stomach inferiorly, two inches
from the pylorus, and superiorly, under the
left lobe of the liver, which was also wounded ;
the diaphragm in the centre of the tendon ;
after this the pericardium ; the right ventricle
of the heart in two places, first the inferior
part, and again near the tricurped valve;
next the lungs were pierced; and last the
anterior parietes of the right side of the thorax,
between the cartilages of the second and third
ribs, terminating in the substance of the pec*
toral muscle. The abdomen contained a little
bloody serum ; the pericardium a small
quantity of blood ; but the right cavity of
the pleura had about two quarts of blood
within it.

*^ Although so many parts of importance
were injured, but little was indicated of the
extent of mischief from the symptoms which
occurred during life. Thus the colon was

twice perforated, but the stools were not
tinged with blood, nor was there any feculent
matter in the cavity of the peritoneum. The
stomach was also twice wounded, and yet
vomiting did not take place, excepting once
slightly, as he wjts brought to the hospital .
The liver was opened to the extent of one
inch, but yielded scarcely any hsemorrhage.
The heart had been pierced in two places,
but yet its action continued regular, and
supported circulation for above nine hours.
The middle and upper lobes of the right
lung were both wounded ; yet he did not
cough up any blood. The emphysema had
originated under the pectoral muscle, and
had gradually extended over the whole
body."

Wou7tds of the Throat.

Attempts to commit the act of suicide are f?"* .
the usual causes of these injuries, and
usually one of the following parts suffer : —
The pharynx, the larynx, the trachea, or the

If the chin be a little elevated, its dis- Vbkt
tance from the sternum is about nine inches.
First. Three inches below is the thyroid
cartilage, and the space has the muscles of

VOL. III. R

242

the OS hyoides and tongue on t]»e fore (Mtrt.
Second. In the middle division is the larynx,
with the pharynx behind it. Thirds In the
lower part is the trachea before^ and the
oesophagus behind. On the sides of tb^e
parts are situated the carotid arteries, wUdi
are divided near the bs hyoides. The int^nal
jugular veins are also placed laterally. The
pars vaga accompany the carotid arteries,
and the grand sympathetic nerves are found
somewhat nearer the vertebrae.

Of the Wound above the Larynx.

This is the most frequent seat of injury,
which is inflicted whilst the chin is ele-
vated.
Symptoms. Through the wound, air and blood issue
with frightful impetuosity, more especially
when the patient coughs. A lighted candle
brought near the aperture is immediatdy
blown out, and liquids, when attempted to
be swallowed, are violently ejected from tie
wound. Hence, those ignorant of the struc-
ture of the parts, suppose that the air tube is
injured, but the anatomist is aware that the
wound has "passed through the muscles of
the jaw and tongue into the pharynx, being

generally inflicted between the chin and os
hyoides.

The arteries which bleed freely, are tlie '
sublingual, that pass just above the os hyoides
on each side to the tongue ; but sometimes
the external carotid arteries are divided,
when, from the rapid haemorrhage, death is
^most immediate.

Treatment.

The wound is generally in itself but little
dangerous; and when persons die shortly
after its infliction, it is frequently from the
fever which has led to the commission of the
act, if it be not from haemorrhage.

Position in this wound is to be carefully PosUion.
attended to. If the chin be elevated, the
■^ouod gapes widely ; but when the chin is
depressed, the frightful aperture becomes
closed ; the head should therefore be brought
down towards the chest, and confined in that
position, in order to prevent a separation of
the edges of the wound.

I have generally put three sutures in the Suiore.
integument only, the more effectually to
guard against any disturbance of the aproxi-
mated edges, which may otherwise, from

Lit motion of the patient during

244

Enema.

irritability or delirium, be pro

sutures, through the integuir

ill this respeet very useful, n

disadvantagous.

The patient's mouth anc'

kept cool and moist, by '

portion of lemon dippet

should be chiefly sup«

.1 wa.^

broth and gruel, to v

vned.anc*

added if they quickb

fever has subsided.

>H:

:ifpital, the^

should be made.

remained

I knew a lady *

•
• *

skin fron'^

oesophagus, wh

•: H;

: openinor^

days by clystc

Lilli.

ihe edge^-

she could n " '

•— "

:: unitec*

water.

When fo«

quantity o^

than fluid . « . •

iJir.

best.

The - ..:..

>:. ^

.i:.::: three

and J ^ -

7.*:rz

iinrcfous

them ;

m m •

r-i:hea is

W .^ .-. ilS.

:.> behind,

OS 1' - - -/ '

:-i close to

••% •

•:.^i:. The

ca -^- :. ."

•;«:' r

.jj: of the

\5 "• Iff

m: rushes

245

the firoenum, on the dorsum of the epiglottis,
and fixed it again to the thyroid cartilage.
The man recovered; but whether it was a
post hoc, or a prc^ter hoc, God knows! In
general, these cases are fatal, in which the
epiglottis is separated from the thyroid car-
tilage, from a want of defence to the air
tube.

Of the Wound into the Larynx.

This wound is either into the thyroid or symptoms,
^^icoid cartilages, or into the ligament which
^^ites them.

The air rushes out through the wound in
^^piration, and violently in coughing, and is
^Xso inspired through it. The person is not
^Vile to speak, unless the aperture be closed
^^ pressure ; but the food does not pass out
^t)m it.

A wound confined to the cartilages of the

l^irynx, or to the ligament uniting them, is

^ot dangerous, and by far the greater number

of these cases/which I have seen, have done

"Well. The treatment of them consists in

sipproximation of the parts by position, and

in the application. of adhesive plaister to

retain; the edges in contact.

a 3

246

When the wound is inflicted with excessive
violence^ or by a stab, the pharynx may be
wonnded, as it is situated behmd the larynx,
and then the treatment of the wound is to be
similar to that of the wound above the larynx.

Case. In a case of this nature, which was under

the care of Dr. Ludlow, of Galne, he informed
me that the thyroid cartilage/ which wa&
many weeks in healing, became ossified^ and
that portions of it exfoliated «

Cafe. In a patient of mine in Guy's Hospital, the

wound upon the thyroid cartilage remained
fistulous, and I raised a piece of skin from
the surface of the neck, above the opening,
and turned it over the opening, the edges
of which I had previously pared : it united
extremely welL

Of the Wound below the Larynx^

When the wound is inflicted within three
inches of the sternum, it is more dangerous
than in any other situation. The trachea is
^ here on the fore part, the oesophagus behind^
and the carotid arteries are situated close to
the trachea, more especially the right. The
thyroid gland crosses the upper part of the
trachea, and its veins cov«r the fore part.
Symptoms. If the trachea be cut, the air rushes

247

through the wousd both in expiration and
ins^uration. The blood gets into the trachea,
and excites a violent coughing^ by which a
bloody froth is forcibly ejected, but the food
or liquids do not pass out through the
aperture^

The external opening, in these cases, is
generally small, a9 the wqund often arises
from a stab, and the consequence is, that the
blood does not freely escape, but lodging in
the bronchia, adds excessively to the
dyspnea.

In the treatment, the first object is to stop Treatment,
the bleeding ; and if the wound be not suf-
ficiently large to lead to the easy discovery of
the source of the hsBmorrhage, an incision
should be made, in a longitudinal direction,
to expose the mouths of the vessels. If the
trachea be widely opened, pass a needle and
ligature through the cellular tissue, upon its
surface, which, from its firmness, will support
the ligature, and thus bring the edges of the
aperture into contact; but do not penetrate
the trachea itself with the needle. Thus
securing the trachea, bring the edges of the
external wound together by bending the
head forwards; but do not apply adhesive
plaister, as it prevents the escape of air and
blood in coughing, produces additional diffi-
culty of breathing, and occasions emphysema.

R 4

248

The ligature upon the cellular covering «f
the trachea, is to be separated by the ulcer-
ative process, which will generally be effected
in a week.

A transverse wound in the trachea, will be
followed sometimes by a loss of voice, on ac-
count of the division of the recurrent nerves.

If one of the carotid arteries be opened,
death is usually so instantaneous, that the
patient cannot be saved. If a surgeon were
present, or the wound was very small, and
he could reach the patient before he expired,
he should thrust his hnger into the wound,
to stop the flow of blood, and then cut down
upon the vessel, to expose it sufficiently, to
place a ligature upon it, which he can after-
wards better adjust.*

When the trachea is deeply cut, the ceso-
phagus is sometimes wounded ; and, if the
injury be extensive, death will generally
ensue ; but a stab into the cesophagus, or a
small wound, may be recovered from.

After an injury of this kind, the wound
into the trachea is to be treated as in the
former instance, but whi-h that in the
CESophagus will be best approximated ; all
food, liquid or solid, must be avoided, and
the patient is to be supported, as long as

indcd carotid.

249

nature can bear it^ by clysters. I object
entirely to the introduction of tubes into the
pharynx and cesophagus, as worse than un-
necessary ; for they are highly injurious by
the cough which they occasion^ by their
irritating the wound ; and, if adhesion or
granulation have taken place to close the
wound, such tubes tear it open again and
destroy the process of restoration.

260

LECTURE XL.

Of Wounds of Joinii.

■

These accidents are but trivial, or very dan*?
gerous, as the surgeon is directed by proper
principles, or is ignorant of the treatment
which they require.

Jj^Pj^®' If the patient has a poultice applied, or if
the utmost attention be not paid to the im-
mediate closure of the wound, inflammation
of the ' synovial membrane arises, and sup-
puration ensues. The most violent consti-
tutional irritation succeeds, — shivering, heat,
flushing, and profuse perspiration ; generally,
great swelling and excessive pain in the joint.
Abscesses form in diflerent parts of the joint,
one succeeding another, until the strength
becomes exhausted.

In young In youug and healthy constitutions, these

sons. wounds in the largest joints are recovered .
from ; but, in aged and weak persons, they^
destroy life.

Dissection Upou disscctiou in the first stage, suppu —
rative inflammation of the synovial membrane
is found ; in the second stage, the ligaments of

251

joint are thickened, and the synovial
membrane in part ulcerated, in part granu-
lating. The cartilages are absorbed ; granu-
lations arising from some parts of the bones,
and exfoliation taken place from other
portions.

Recovery from these injuries, when infiam- Anchjiotu.
mation has followed, is by adhesion, so as to
destroy the synovial surface; or else by gra-
nulation, when a partial or general ossific
aachylosis is the result.

AU these effects may be prevented by an Treaimeni.
intelligent surgeon. "When called to treat a
Wound of from one to two inches extent into
the knee joint, he will, with a fine needle and
thread, passed through the skin only, (avoid-
ing the ligaments,) bring the edges of the
external wounds together ; for a wound in
the joint is different to most others, as the
synovia has a constant tendency to force a
passage outwards, and it is more abundantly
secreted than usual, so that adhesive plaister
is apt to be separated, and union prevented ;
he will apply, therefore, lint dipped in blood
over the surface of the wound, and place the
plaister over it; then cover the surface of
ilie knee with soft linen, dipped into a
lotion of the liquor ; plumbi subacet : and
spirit. Afterwards he will place a splint
I behind the limb to prevent all motion

252

of the injured joint, and enjoin positire
rest.

Purgatives should be as much as possible
avoided, and a rigid abstinence enforced*
In eight days, the threads may be cut and
drawn away, but the adhesive plaister and
lotion should be continued. Three weeks
should elapse before the patient be allowed
to quit the bed.

If inflammation follow a wound into a
joint, leeches and an evaporating lotion must
be employed ; and if it run high, the patient
should be bled freely from the arm.

If suppuration be produced, fomentations
and poultices are required locally; liquor:
amoniee acet : and opium internally.

A fungus granulation forms at the wound,
which must not be disturbed, as it is formed
by nature to close the aperture; fresh irri^
tation is produced by disturbing it.

When a limb is stiff firom inflammation
and adhosion» early motion of the joint is re-
quin^t and its use may generally be restored.
A joint thus circumstanced is not injured,
but liH^AC^Atod by motioii» whilst in a chronic
w ntHU'tViUHia mflimmatioii of a joint, rest is
»uwtt «^»»«^utial to its cure. In this case, there-
II^HV% ^ )Mjitiout si^tLmM not only use the limb
«^ \H^uuu>l^ t^^t^wW* but he $iioiild set upon
A U^h tt^M^". Am) c^m|4oy the muscles, for

'8ome length of time at once, in fiesing and

extending the limb.

Partial anchylosis, when the joint is not
altered in form, may, in young persons, be
considerably relieved.

Where ossific granulations have arisen from
every part of the surface, permanent and
complete anchylosis must be the result.

In removing loose cartilages from joints, it Removal of
is proper first to draw down the skin to render lages.
the aperture afterwards valvular. The carti-
lage is fixed by an assistant, an incision is
made over it, after the skin has been drawn
an inch to one side, then as soon as the sur-
face of the cartilage is well exposed it jumps
from its situation, the skin is let go, and
then no direct opening remains communicat-
ing with the joint.

The after treatment is the same as in simple
incised wounds, only a suture is not required.

Wounds of Tendons.

The division of the teudo achillis is most ■
frequently occasioned by a wound from an
adze, and sometimes the injury arises from
accident with a scythe.

In whatever way it is produced, the im-
hediate effect of the division of the tendon is

■iediate efi

254

a great d^aration of its divided portions, tk
upper one being drawn up by the action of
tke gastrocnemei, and a fiiUing of the heel,
the foot being influenced foy oppon^t
muscles. Sometimes the posterior. iikkA
artery and nwve are also divided with the
tendon; where the surgeon shouid secure
the former by a ligature as soon as possiblei
or else apply a tourniquet.

Mischtefor. The mischief arising from this accident de-
pends in a great measure upon the treatmeit
which may be adopted. If the edges of tlie
wound be not approximated, and if l&e e»di
of the divided t^idon are allowed to remiM
at a distance from each cfQier, inflammaliM
arises, granulations are produced, and a unim
of the ends of the tendon takes place t& iSkt
surrounding parts, destroying permanently
the action of the muscles, and the motions of
the tendon. But if the wound be united by
adhesion, and the ends of the divided tendon
brought into contact, or nearly so, the mo-
tions of the foot are generdly restored.

Treatment. The principle in the treatment is to ap-
proximate the ends of the tendon by raising
the heel, extending the foot, and bendtffig the
loaee ; the external wound is then to be care-
fully closed, in order that it may be healed
by the adhesive inflammation. To effect this,
a shoe with a heel one inch and a half in

255

height is to be placed on the foot of the injured
limb, and a strap is to be carried from the
heel of the shoe, to the calf of the leg, then
d roller is to be Ughtly applied upon the
upper part of the leg, to confine the strap and
to keep the foot extended. The edges of the
external wound are to be brought together by
a small suture, and all pressure at the part
should be avoided, only an evaporating lotion
being placed upon it. The patient is to be
confined to his bed until the wound be healed,
and then he may be allowed to walk a little
with a high heeled shoe. This shoe is to have
the heel gradually lowered until it becomes
of the same thickness as the heel of the shoe
irorn on the sound side. By this means, the
muscle which had contracted, and the tendon
which had been injured are gently brought
to their proper action.

If the divided extremities of the tendon are
allowed to remain separate during the union,
an addition is made to the tendon in its length,
and the power of the muscle acting upon it is
thus reduced.

Should much inflammation arise during
the cure, the limb must be elevated to prevent
all gravitation of blood, and leeches should
be applied near the wound.

If the extensor tendons of the fingers be i

256

during the cure, by a splint placed under the
hand and fingers. Indeed it is only necessary
to consider whether the divided tendon, in
any case, belongs to a flexor or extensor
muscle, to know what is to be done to assist
its union.

Punctured Wounds of Tendons.

Dangerous. Thesc are dangerous accidents, being often
productive of tetanus. Several times within
my knowledge, this has occurred from persons
treading upon a nail, which has penetrated
the shoe, and wounded the tendinous apon-
eurosis of the sole of the foot; also an
accident of a somewhat similar nature to the
palm of the hand, I have seen productive of
a similar eflect.

Teunus. Tetauus seems to be the result of a wound
of a structure difiicult to heal, and requiring
great constitutional eflbrts to produce the
effect ; and these efforts in a very irritable
constitution produce the highest nervous ex-
citement.

Treatment. I^ thcsc injuries, I havc observed that it is
best to foment and poultice the parts, so as
to sooth and tranquillize them ; also to care-
fully avoid depletion, even from the first to any
great extent, either locally or constitutionally.

257

The patient should be allowed his common
diet, and if he be restless or complain of
much pain in the wound, opium should be
given. Lowermg the patient only adds to his
irritability.

Of Laceration of Tendons.
The tendo achillis, and sometimes, but not of tcfcdo

achillit.

80 frequently, other tendons are torn through.
This accident to the tendo achillis is pro-
duced either by a violent effort of the muscles
as in jumping or dancing, or by an unexpected
extension of the tendon ; — as for instance, by
treading unawares with the toe only upon an
elevated substance. Dr. Curry, late physician
to 6uy*s Hospital, informed me that he tore
Ms tendo achillis by catching his toes upon
a. scraper, when walking in a dark street;
being at the time unprepared for such an
occurrence.

In whatever way the accident may be pro- Treatment,
duced, the treatment required will be to ex-
tend the* foot, and bend the knee to allow the
ends of the lacerated tendon to approximate.
In this way the tendon soon unites by the
adhesive process, and the use of the limb is
afterwards gradually restored. Some degree
of thickening of the tendon for a long time
VOL. jii. ^ s

^5B

remains^ and th^ patient halts a little in rapi^
motioa.

The position of the foot and leg is to bi^
maintained in the same way as when the
tendon is divided by incision, and an evapo-
rating lotion should be employed. After the
union, the same precautions are to be ob-
served with respect to the employment of the
high heeled shoe.

Of Partial Laceration of the Tendo AchilUs
and Gastrocmmeus Muscle.

Cause of. A porson in running or walking fast, or if
his foot slips backwards when it has beea
advanced, sometimes feels as if he had re-
ceived a severe blow upon the back of his
leg, and is immediately unable to walk, but
with the greatest difficulty, and with the foot

extended-

The cause of this feeling is a laceration, of
some fibres of the tendo achillis, or of the
gastrocnemeus muscle, where it joins the
tendon. There is great tenderness upon pres-
sure on the following day, with some ecehy-
mosis, which daily increases, until the limh
becomes considerably discoloured. The least
sitttempt to bend the foot is accompanied with
great pain, and followed by swelling of the
leg and ancle.

259

From a belief that the injury is slight, and
from negligence in treating it, the lameness
which results from this accident is often of
rery long continuance; but, if properly
attended to from the first, it is in general
soon recovered from.

A similar treatment to that recommended
for division or lacei^tion of the tendon, is
requisite for the cure of this injury, and when
the patient can bend the foot without pro-
ducing pain, then the high heeled shoe must
be worn, and the heel be gradually lowered,
^in the previous cases.

Prom three to six weeks are required to
^fect a cure in.

Of Wounds of the Nerves.

The immediate effect of the division of Effect of.

^ nerve of a limb, is the loss of volition in

*l^se muscles to which the nerve is dis-

Mbuted, and the antagonist muscles being

^KQopposed, gradually contract. If the nerve

supplying the flexors is divided, the limb

Incomes extended; if that distributed to

fte extensors is separated, the opponent

muscles keep the extremity flexed. This

arises from the tendency a muscle possesses

to occupy the smallest space possible, and

s 2

260

which 'diflfers from voluntary or involuntary
contraction, as the latter can only continu*
for a time; but the former is permanent, or
as long as the antagonist muscles are para-
lysed.

The second effect of the division of a nerve
is the diminution of sensibility; I <^all it
diminished, because I do not find that the.
division of the branch of a nerve, although it
benumbs the parts, entirely depriv6s them
of sensation.

In the division of the infra orbitar nerve,
or of one of the nerves of the fingers, some
sensation remains, but numbness is pro-
duced ; when, however, all the nerves pass-
ing to an extremity are divided, sensation is
entirely destroyed.
Case. I once saw a case, in which one of the

branches of the median nerve was divided
in the palm of the hand ; and if pressure was
made on the radio spiral nerve at the elbow,
. it produced a tingling sensation in the be-
numbed finger.*

The temperature of the part to which the
nerve is distributed, if it be covered so as to
prevent the access of a colder medium, is
greater than that of parts similarly covered ;

* It appears, therefore, as if nervous influence is
supported in a degree by anastomosis.

261

but if it be left altogether bare, it then has
less power of resisting diminished tempe-
rature than the surrounding parts. I have
seen severe chilblains, and during the winter,
incurable ulceration follow the division of the
median nerve.

.When a nerve has been divided, if its ^^Jj,^,**
extremities are brought together, it unites, ""**«•
and the function of the nerve becomes gra-
dually restored.

Dr. Haighton divided the pars vaga on one !>"'• Haigh-
siae of the neck of a dog, and, after some nments.
time, he cut through the nerve on the other
side : . the dog lived, which he would not
haye done,. had both the nerves been divided
at the sapae time. When he had allowed time
for the union of the second, he divided both
^t once, and the animal died under the same
circumstances as would have occurred, had
J^o previous experiment been made.

The time required for the union and re-
storation of function, appears to depend upon
the size of the nerve.

A young gentleman who had injured the ^"«-
external condyle of the os humeri, had numb-
ness in the direction of the radial nerve, and
he recovered the sensibility of the parts in
four months.

The numbness sometimes produced by
Weeding is recovered from in three months.

s 3

262

In a fracture of the thigh bone, by which
the sciatic nerve was injured, so as to pro-"
duce numbness in the limb below, the person
recovered in nine months.
<^as«* Koschiusko, the Polish General, had his
sciatic nerve inj ured by a pike, and when in
this country, many months after receiving
the wound, he had not got rid of the effects ;
and I have heard since, that he remained
lame.

At the place of union, after the division of
a nerve, there is the appearance of a gan-
glion, as may be seen in a preparation I
made from the finger of a person brought
into the dissecting room at St. Thomas's
Hospital, a cicatrix covered the ganglion.

Independent of the size of a nerve, the
time in which union will be complete, must
also depend much on the positicm and ap-
proximation of the ends.
Tr«auiieiit In the treatment of a wounded nerve^ the
only objects are the approximation of its
ends and union by adhesion.

Many bad symptoms have been attributed
to the partial division of a nerve ; but I have,
in part, cut through the sciatic nerve of a
dog, without producing any other symptom
than partial paralysis.
Cwe. I removed from the median nerve, a tu-

mor for a gentleman, and took away two

263

thirds of the nerve witb it, and numbness
with tingling were the only unpleasant symp-
toms following.
J^ A Mr. H. called at my house, who had a Caie.
P^wuliat division of the median nerve, ati'ecting
the fore, middle, and ring fingers, but not
the thumb ; he had tingling with the numb-
ness, but no other bad symptom.

A nerve divided in part, therefore, occa-
sions tingling and numbness ; one completely
separated, only numbness ; the treatment of
the former is as that of the latter.

If a ligature be applied upon a nerve of i-igat'"'
magnitude, the consequences are sometimes
fatal, and sometimes productive of lingering

Mr. Cline informed me, that in a case of (;»»'■
popUteal aneurism, operated upon in the
old way, by opening the tumor in the ham,
lie popliteal nerve was included in the

iture with the artery, and that the man
lied in a few hours.

In a case of amputation at Guy's Hospital, casc
i saw the whole sciatic nerve included
in a ligature, which was applied to sup-
press hsemorrhage from the artery which
iccompanies the nerve. In four days,
man was seized with violent spasm in

stump. On the fifth day, spasms afl'ected
le limb, and from thence extended to the

264

other muscles of th6 body. On the seventh
day, he died.

If a nerve be included in a ligature, when
tying an artery, the process of ulceration
is extremely slow, and the slightest drawing
of the ligature produces agonizing pain.
Case. Lord Nelson suffered excessively from

this cause after his limb had been am-
putated ; and with all his heroism, he could
' not bear the least touch of the ligature,

without uttering the most violent expres*.
sions. , "

After amputation, then it is right to avoid,
with the greatest circumspection, any nerve,
or portion of a nerve, in placing the ligatures
on the vessels.

The division of a nerve, or even pressure
upon the spinal marrow, so as to destroy
volition and sensation, does not prevent the
involuntary action of the limb or limbs from
proceeding. The circulation still proceeds,
and the irritability of the part remains as is
shown in the application of a blister, which
produces the usual vesication ; also, a wound
heals by the adhesive process.

Friction and electricity seem to have some
influence in restoring action in a divided
nerve, or of one which has partially lost its
power from any other cause.

Pressure upon b. nerve, occasions the

•266

sensation of a part being asleep; striking
the cubital nerve at the elbow, occasions
violent tingling in the little finger, and half
the rmg finger.

Of Sprains.

A sprain is an injury occurring to the Definition,
ligaments or tendons surrounding a joint,
which are either forcibly stretched or lace-
rated.

It usually happens from the sudden exten- How pro-
sion of the joint in a direction which the
muscles are unprepared for; in the iSame
manner as when a dislocation is produced,
only that the violence is not sufficient to
occasion a displacement of the bones.

The most common situations of these acci- Common
dents are either at the wrist or ancle, arising
from sudden falls, by which joints are unex-
pectedly and forcibly bent.

These injuries are attended with consider- symptoms,
^ble pain at the time of the accident, and the
part soon becomes swollen and tender ; the
fonner symptom arises from the effusion of
Uood in the first instance, out of the lacerated
Wood vessels, and becomes subsequently
much increased from inflammation; the

tenderness and pain are generally in propor-'
tion to the tumefaction.

At first the surface of the skin pnesents it»
natural appearance, but after a short time, aa
the effused blood coagluates it becomes
much discoloured.

Sensation When inflammation has been set up, and
given rise to effusion of fibrin, a sensation of
crepitus is experienced on examining the
injured part, which might, by an ignorant
surgeon, be mistaken for the crepitus of
fractured bone ; but it never ' give& that dis-
tinct grating feel which occurs from the
rubbing of one portion of broken bone upon
another.

^n*t dV^ Immediately after the receipt of the injury,

Btroyed. the Ordinary motions of the joints can be
readily performed ; but as the swelling takes
place, these motions become much impeded^
and ultimately cannot be performed \/ithout
producing acute pain, and increasing the
mischief.

Treatment. In the treatment of these cases, the fiwt
object is to arrest the haemorrhage firom tbe
lacerated vessels, and then to prevent the
occurrence of severe inflammation; after-
wards to promote the absorption of the effused
matter, and subsequently to restore the
motions of the injured parts.

poiitiS!' ^^ *^^ ^^^^ instance, the application of cold

267

by means of evaporating lotions, and attention
to the position of the limb, will efiect much
HI arresting the effusion, and preventing acute
inflammation. The position should be such
as to relax those muscles which act on the
injured tendons, and at the same time such
as. will favour the return of blood to the
heart.

Should the pain and tumefaction increase Bleeding,
in spite of these means, leeches should be
freely employed over the seat of mischief,
and the bleeding encouraged by tepid appli-*
cations ; purgatives should also be adminis-
tered ; and in very robust persons, when the
injury is extensive, general blood letting, and
other constitutional remedies must be had
bourse to.

When the inflammation is subdued, and Aftereffecu.
the patient is free from pain, still the surgeon
hie much to do in effecting the absorption of
the effused matter, and this he should be
careful to remove, as it is from neglecting this
stage of the injury that other and more im-
portant disease originates, thi§ more particu-
larly in persons suffering from any constitu-
tional disease, as in those affected with
serofula.

In persons free from constitutional disease, in healthy
these injuries, if not very extensive, are ^"**"'*
fafndly recovered from ; the effusion quickly

subsides^ and the motions of the joint ai^
restored; but in no : case should the patienl:
be allowed to exercise the part as usdal^ until
all pain has ceased^ and the part has nearly
regained its original form.
Too early By a two early use of the part, the effects
of the injury are kept up, so that weeksi
months, or even years may elapse ; and the
patient still suffer from them ; whereas a
little more attention to the disease in the first
instance, would have completely removed jdl
the suffering and danger.
In an- In persous suffering from constitutional

persons, disease, a chronic form of inflammation is
often set up, which terminates in suppuratioBr
and often affects the bones, which become
carious, and make it necessary for the surgeon
to remove the diseased part by amputatioD^
in order to save the patient's life.

Therefore, after the acute symptoms hare
been removed, be careful to get rid of all the
effects of the injury before the patient be
allowed to employ the limb, as previous to
the accident.
Treatment Rest, position, and the use of mild stimu-
stage. lants, with friction and moderate pressure,
are the best means of producing the desired
effect. The liniment : ammonise ; liniment :
hydrargyri ; liniment : saponis, may either of
them be rubbed over the affected part, night

assure by

. part may

i the following

Empl: ammon:

iii, over which the

J have also known

A from, the pouring a

i cold water on the part

j'ge pitcher.

:sease prove obstinate, and be

.11 occasional pain, the aid of

itation may with great advantage

ced, either in the form of blister, or

ig: Antimon: Tartarizat: I have known

y casj3S quickly cured by these means.

^Vhen the marks of disease have been re- Exercise.

moved, the motions of the parts should be

pFomoted by moderate, but regular exercise.

Too early
motion.

(■■

In nn-

healthy

persons.

Tres.

ofci

StU!

subsides, and th
restored; but in
be allowed to < ^
all pain has c(
regained its oi
By a two

of the inju)

months, or

patient sti

little mor.

instance, -

the sutr»^'"
In ^

':1£ XLI.

_ 4.ujr^n^.

disea>

oftei

am!

caij

.« « :2ie displacement of the
-Y X Jooe. from the surface
.aczrxibr received.

some general obser-

Kcssoents, and afterwards

dislocations.

Kiadents to which the

,w^r » iiiiiie. diat are more likely

as :if?<iacon of the surgeon,

^aytfK,^.tTvinN IS die restoration of the

55 ii:ytac> very much upon his

:C5x:c assistance ; for, if

2nt ,^-:ii?t: b^rbre the parts are

r aex mrjraLl positions, the re-

> t: rc-sit-^'c rr^rortionably diflScult,

•a* XV- mc vtrrrictly impracticable;

:r^ xtct^^c ?«:v.vc:e6 a Hiring memorial

b T c:v^vi st^i^rai instances in which
•i>'it^5^ccji: knowledge or inat-
^^i.vu. : :tv yart ,:' ihe surgeon, to these

%»u

•A^ occasion of irre-
iiis patient, and of the
)nal character.
viedjfe of the anatomy Anatomical

^ *^ knowledge

rcssary, to enable the requuite.

:o detect the nature of

s, as also to adopt the best

ig them. Let me, therefore,

examine and study well the

rhe different joints, the forms

;on, the bones and cartilages com-

jm, the ligaments connecting them,

action of the muscles moving them ;

ithout this knowledge, you cannot

ice your profession with credit to your-

es, or to the advantage of those who may

ome under your care.

I have known a case of fracture of the
neck of the thigh bone treated as a dislo-
cationi, and the puUies applied to the limb,
hy a hospital surgeon, who was deficient in
soatomical knowledge.
In some cases, however, so much tume- sometin)e»

A . . . « ^ ^. /» 1 -I 1 difficult to

mtion arises from extravasation of blood, detect,
or the parts become so tense from the effu-
sion, in consequence of inflammation, that
the best surgeon will not be able exactly
to ascertain the precise nature of the injury
daring the first few days after its receipt;
it would be, therefore, extremely illiberal

272

and unjust to attribute ignorance to a sur-
geon who might have given an incorrect
opinion under such circumstances.

Immediate The immediate effects of a dislocation are,
to produce an alteration in the form of the
joint, in the length and ordinary position of
the limb ; also, after a short time, when the
muscles have contracted, to destroy the
motions of the joint.

At first, In the first few minutes, however, after

mnch mo-
tion, the injury, the degree of motion is consider-

able, which I had an excellent opportuniiy

of seeing in a patient brought to Guy's

Hospital, with a dislocation of the tiiigh bone

into the foramen ovale, which had occurred

only a few minutes before his admissicHi.

The nature of the injury was extremely well

marked, only there was great mobility of

the limb at first, but in less than three hours

it became firmly fixed by the contraction of

the muscles.

Lim^ In dislocation of the extremities, the limb

lengthened

or short- is usuallv shortened ; but when the femur
is displaced into the foramen ovale, or the
humerus into the axilla, the limbs are
lengthened.

Pain. A dull pain is felt from the pressure of

the dislocated bone upon the muscles, but
the pain is sometimes severe when the' bone
rests upon a large nerve or nerves, as vrheli

273

.slocated into the ischiatic
iuimerus into the axilla; and,
/ cause, numbness and a partial
I he limb are also produced.
40 blood vessels also, occasionally, y?"«**

, iDjared.

... auch injury from these accidents.
^ known the subclavian artery so much
essed by a dislocation of the sternal
Linity of the clavicle backwards, as to
p completely the pulsation at the wrist.
Ill another case, the axillary artery was so
much injured by a dislocation of the hu-
merus into the axilla, as to give rise to
aneurism, for the cure of which the subcla-
vian artery was tied.

If there be not much extravasation or Head of
effusion, the head of the displaced bone may
be easily discovered in its new situation, and
may be distinctly felt to roll, if the limb be
stated. In some instances, the usual pro-
minence of the joint is lost, as when the
humerus is dislocated into the axilla, or an
unnatural projection occurs, as in the dis-
locations of the elbow.

■ The remote eflFects of these injuries are, — Remate
First. The sensation of crepitus, which oc-
curs a day or two after the accident, from
the effusion of fibrin into the joint or burso&,
although it does not give that grating feel
which arises from the motion of the frac-

VOL. HI. T

274

tured ends of a bone upon each other ; yetj
I have known medical men, not aware of
this circumstance, suspect a fracture when
none existed.
JjJ^- In general, the degree of inflammation

arising from these injuries is very 3light<
Sometimes, however, it is considerahlei
causing, together with the extr^yasatioo,
great tumefaction of the surrounding parted
and rendering it difficult to ascertain the
nature of the injury. I have known, in a
few instances, so high a degree of inflajoi-
mation to follow tl^e receipt of these injurieai
as to destroy the patient.
Case. A master of a ship who had dislocated his

thigh upwards, a few days after its reduc-
tion, had extensive suppurative inflammation
take place in the thigh, under which he sunk.
Mr. Howden, a surgeon in the army, hjas
given the history of a somewhat similar
case to the Physical Society of Guy's
Hospital.
Dissection ^^ disscctiug the injured parts in those
ot parts. ^j^Q ^j^ shortly after a dislocation from vio-
lence, the capsular ligament is found torn
transversely to a great extent, and the per
culiar ligaments of the joint are also rupr
tured, the head of the bone being rempved
from its socket.

In dislocations of the hip, I believe th^

275

ligamenttim teres is always torn through, or
separated from its attachment, sometimes ^
with a piece of cartilage, or even of
bone.

When the humerus is dislocated, however,
the tendon of the biceps, which answers the
purpose of a ligament, is, as far as I have had
as opportunity of witnessing, uninjured, —
although I do not mean to deny the possi-
bility of its being ruptured.

The muscles and tendons surrounding the Tendons

^ and muscles

jmnt are frequently much injured, as for »nj"f«d.
instance, the tendon of the subscapularis
muscle, when the head of the humerus is
displaced into the axilla, or the pectineus
aad adductor brevis muscles, in dislocation
of the femur into the foramen ovale.

When a dislocation has remained unre- when un-
duced for a length of time, some degree of "'""'
motion is gradually restored, but the power
and mobility of the limb are never com^
pletely regained ; and, in the dislocations of
the thigh, the patient is ever after lame.

In dissecting cases of this kind, the head i>i«section
of the bone is- found much altered in figure;
this alteration, however, does not depend
very much upon the length of time that the
bone has been displaced, but more upon the
structure which the head of the bone presses
on, whether bone or muscle.

T 2

276
If the bone If it rest .upou muscle. the bone under-

resti on ' *"

mascie.<> gocs but little change, its articular carti-
lage remains, and a new capsular ligamrat
forms around it, from the thickening and
condensation of the surrounding cellular
tissue.

If on bone. If, ou the contrary, it presses upon bone,
an extraordinary change is produced^ both
in the head of the disloclBLted bone, and in
the ossious surface on which it rests. Th&
articular cartilage becomes absorbed from,
the dislocated extremity, and the peiiosteum.
of the bone on which it presses is removed
in the same manner, so that a smooth .hollow
surface is formed, to which the head of the
displaced bone becomes adapted. At the
same time that the hollow is formed at tibiat
part on which the head of the didocated
bone immediately presses, a deposit takes
place from the surrounding periosteum, be-
tween it and the surface it naturally co-
vers, by which a ridge or lip is produced,
forming with the depression a deep cup to^
receive the head of the bone ; also, the ten-
dons or muscles which were lacerated, are
united, and the latter accommodate them-
selves to their altered positions, so that,
by a beautiful and gradual change in the
injured parts, a new articulation is estal)^
lished.

1277

A- great change which thus
> location has remained un-
it ngth of time, it becomes
rt^store the bone to its original
after the expiration of many
: an attempt would not only be
I attended with much risk to the

attempt to reduce a dislocation of case,
iinerus, which had existed only six
s, so much injury was done to the mus-
- by the violence employed, that the
i'^tient died in consequence.

But although dislocations are generally Dislocation
occasioned by violence, and are accompanied sioni
^Y laceration of the ligaments, yet they oc-
casionally arise from relaxation of the liga-
nients only, the result usually of a morbid
accumulation of synovia in the joint.

I have seen the patella frequently dis- ofpateiu.

placed from this cause; and, in the year

1810, 1 admitted a girl into Guy's Hospital,

who was the subject of such dislocation. The

patella- was suddenly and frequently thrown

outwards in walking, which occasioned her

to fall, and it required considerable force to

reduce it. By the application of some strips

of plaister, and a bandage, the bone was

readily kept in its proper situation.

I once saw a girl who had the power of case.

'r 3

278

throwing the patellee outwards at wiU,-^she
had been brought up as a dancer or tumbkr.

From pa- The loss of power in muscles surrouniiiig
^*"* a joint, either from paralysis, or from l^iiig
kept a long time upon the stretch, allow of
the joint being easily dislocated ; but, und^
such circumstances, the reduction is effected
without difficulty.

Case. A young gentleman who had becdme

paralytic on one side during dentition, would
readily dislocate the head of the humems,
throwing it over the posterior edge of the
glenoid cavity, from whence it could be
replaced with facility.

The loss of muscular power, Arising from
continued extension, is well illustrated by
the following case : —

Case. A junior officer, on board of one of the

Company's ships in India, was punished by
one of the mates, during the absence bf the
captain, in the following manner :— His foot
was placed upon a small projection on the
deck, and his arm was' tied and forcibly
drawn toward the yard of the ship ; in this
position he was kept for one hour. After
this, the muscles of the arm gradually
wasted, and the bon|^could be dislocated
merely by his raisitfg the extremity to
his head, but was easily replaced by slight
extension.

at the muscles Muscles

prevent

Ave considerable dislocation,
lisplacement from
>ting the reduction
curred.

Ilient cause of dislo- Fromulcer-
^ ation.

M, by which the attach*
ionts are destroyed, when
I he joint takes place, either
-11 of the muscles, or from
Jig sufficient support to coun-
v.iglit of the bone. Thus, in long
ulcerative disease of the hip joint,
the head of the femur drawn up on
i sum of the ilium ; and, in the same
.ion of the knee, I have seen the tibia
^ off the condyles of the femur.
There is in the Museum at St. Thomas's case,
ilospital, a preparation, showing an anchy-
losis of the tibia, at right angles with the
femur, after a dislocation from ulceration.
It frequently happens that a fracture occurs Dislocation

, , , with frac-

at the same time with a dislocation ; this is tnre.
more especially the case in the displacements
of the ankle joint, which seldom take place
without fracture. The acetabulum is some-
times broken in dislocations of the hip, and
the coronoid proceli^ of the ulna is occa-
sionally separated when that bone is dis-
located, which renders it scarcely possible

T 4

280

for the surgeon to preserve the partd in their
natural position during the treatment.

Case. A preparation in St. Thome's Museitei

shows a fracture of the head of the husienis^
occurring with displacement.

TreatiiMBt. When dislocation and fracture of a bone
occur at the same time, the dislocatbn
should, if possible, be reduced immediatdly,
taking care to prevent further injury to the
fractured part, by the application of ban*
dages and splints. For, if the fractured bone-
be allowed to unite before attempting to
replace the dislocation, such union would
most probably be destroyed by the addi-
tional violence necessary to reduce the bone,
after having remained so long out of its niBi-
tural situation.

So also, if a bone in one limb is dislocated,

and in another fractured^ the dislocation should

be reduced as soon as the fractured bone has

been supported and secured from injury.

Dislocations Dislocations are not always complete ; but

not com- . . ^ • 1 T 1 ^ t>

piete. in some mstances a partial displacement of

an articulating surface occurs. A preparation
in St. Thomas's Museum, dissected by Mr.
Tyrrell, shows an imperfect dislocation of the
ankle ; the end of the tibia rests still in part
upon the astragalus, but the greatest portion
is seated on the os naviculare.

kifee^^ The knee joint, on account of the extensive

281

articular surfaces^ is seldom completely dis*
placed*

The humerus is sometimes thrown upon oftheha-
the anterior edge of the glenoid cavity, but
is easily replaced.

The elbow joint is liable to partial displace- or the
ment^ both of the ulna and radius.

The injuries to the spine, which are some- Soppoied

_, , , diuocfttioii

times called dislocations, and are producing of vertebrae.

paralysis of the part of the body below the

seat of mischief, are really fractures with dis^

placement of the broken bone. Simple dislo-

csition of the vertebrae, I believe to be an

exceedingly rare accident, if we except that

^v^hich is said to occur sometimes between the

^irst and second cervical vertebrae.

Violence is usually the cause of dislocations, Caasc*,
'^^d is generally applied unexpectedly, when

le muscles are not prepared for resistance,
^nd when the bone is in an oblique posi-
"*^ion with respect to its socket. Under these
^circumstances, very slight force will produce
^^e displacement which could not otherwise
^^ occasioned, but by great violence.

The power of the muscles in resisting ex- Execntion
^essrve lorce, when prepared for its applica-
tion, is well illustrated by what occurred in
the execution of Damien, for an attempt to
murder Louis the XVth. Four young horses
^ere fixed, one to each limb, and were then

for the giugeoii to preserve the par' '

natural position during the treatmt : . .r. Csi
Cm*. a preparation in St. Thomas hii. aia^

shows a fracture of the head of I ,tc',iiioaerr.^<

occurring with displacement.
Trcatmwt. Wheti dislocation and frac

occur at the same time.

should, if possible, be redin

taking care to prevent fur

fractured part, by the

dages and splints. F-i

be allowed to unili'

replace the dislocatioi _^

most probably be d'

tiouat violence nece*»

after having remami

tural situation.
So also, if a ii

andinanothc-rr

be reduced ii

been suppoi:
I Dislocaii:

in some ini

an articuliii

in St. Th-

Tyrrell, / '

ankle ;

upon '

is sc;i'
Th.

^iW

integument,
il. the synovia

i ended with con- Danger of.

>unt of the inflam-

the synovial mem-

■aments ; the former

X indy quickly takes on

(inmation, and thus a

iipidly ensues. The arti-

.vering the extremities of

t adually destroyed by an

•as, and the bone inflames,

re thrown out from the extre-

<.'d of cartilage, so as to fill up

Generally these granulations

i )ecome ossified, producing anchy-

occasionally some degree of motion

lly regained.

effect all this, great constitutional often re-
quire ampa-

s are necessary, and persons naturally taUon.
; are often, under these circumstances,
:i:ed to submit to the removal of the limb

preserve life.

Compound dislocation occurs but very Rare in

_, ••* xi_i' vij 8omc joints.

rarely m some joints, as the hip, shoulder,
and knee ; but is often met with in the ankle,
elbow, and wrist.

Much may be done in these cases by Judicious

treatment*

judicious treatment in the first instance, when

-.1

284

the object should be to promote adhesions of
the external wound, and thus render the dis*
location simple. . Instead of applpng emol'-
lients, therefore, to encourage suppuration,
which is productive of so much mischief, tiie
edges of the wound should be carefully
fipproximated by strips of plaister, and
evaporating lotions should be applied over
the limb, which should be ^ left undisturbed
for several days. ?

I shall, however, enter more fully into the
treatment of these injuries, when describing
the particular dislocations. '■

Treatment of Simple Dislocations. •

RedncHon. The first and principal object is the reduc*

tion of the dislocated bone, which I have

mentioned, becomes difficult in proportion to

the time allowed to escape after the receipt

of the injury.

Difficoity If the muscular power be great, great foroe

Mtimr* will be required to overcome the contractioa

elapses. ^£ ^^ musclcs, and this difficulty will increase

in proportion to the length of time allowed

to pass by between the injury and the attempt

to reduce the dislocation. In very muscular

persons, therefore, no endeavour should be

made to reduce a dislocation of the arm, after

285

a lapse of three montlis from the receipt of
the injury; but in persons with little mus-
cular power, reduction may be effected before
the expiration of four months after the acci-
dent. In displacement of the thigh, two
QiODths in stout persons, and a few days
more in those of relaxed fibre may be allowed
as the period after which it would be wrong
to employ violent means to endeavour to re-
duce the dislocation.

The difficulty in reducing dislocations is From con-
chiefly owing to the contraction of the muscles, muKicj.
which is involuntary, and which becomes
greater in proportion to the length of time
which has elapsed after the injury. The
muscles have a power of contraction inde-
pendent of the voluntary or involuntary
3etion, which are common to them, and the
former of which cannot be maintained but for
^ very limited period.

When the power of a muscle is destroyed, Effeci on

the antagonist muscle immediately contracts,

^d this contraction is permanent, or as long

^ the power of the other muscle is wanting.

T'iiis may be seen in those persons who have

Suffered from paralysis of the muscles on one

aide of the face, the opposite side being drawn

up and disfigured by the contraction of the

apposing muscles. In the same way when a

dislocation has taken place, the muscles soon

286

contract and fix the bone in its new position,
and this contraction becomes firmer Bxd
more difficult to overcome, the longer the
time allowed to elapse before any attempt be
made to replace the bone. The reductioii
should therefore be made as soon as possible
after the receipt of the injury.
Other But independent of the muscular contrac-

creating tiou. Other circumstanccs give rise to difficulty
in attempting to reduce a dislocation of long
standing, and often render the reduction nn-
practicable. The head of the bone becomes
adherent to the surrounding parts, so that
when the muscles have been divided in dis*
secting the injured joint, the bone ca^nnot be
replaced ; this I have observed in the dislo-
cation of the humerus, and also of the raditii^.
After a time the original cavity becomes filled
with new matter, and sometimes a new
articular socket is formed for th^ head of the
dislocated bone ; under these circumstances
the possibility of the reduction is destroyed.
Form of In rcccnt dislocations, the form of the joint

joiots. "^

may in some instances afford an obstaicle
to the reduction ; as, when the articular cavity
is surrounded by a projecting edge as in the
hip, in which case the head of the bone re-
quires to be lifted over the edge when re-
ducing the displacement. If the head of the
bone be much larger than its cervix, as in the

287

radius, it affords an impedioient to the
Feductiou.

Some persons have supposed that the Capmur
return of a dislocated bone to its natural
position, might be impeded by the smallness
oC the aperture in the capsular ligament ; but
this cannot happen, a9 the ligament is in-
elastic, and an aperture admitting the dislo-
ciatitQ^ would as readily admit of the reduction.
The capsular ligaments possess, in fact, but
little power of preventing dislocations, and
the protection is principally afforded by the
peculiar ligaments and tendons covering
each Joint.
Constitutional, as well as mechanical constitu^

A ... tional

rneani^, are often necessary to assist m the means,
reduction of dislocations ; and in many cases,
the eniployment' of force only, is very im-
proper; as, unassisted by constitutional
nieang, roinch greater violence must be exer-
cised, and consequently the immediate suffer-
ing, jxj^d subsequent inflammation, will be
IH:c|)ortioned to this violence.

bleeding, the warm bath, and such medi- Bleeding,
cia^s as create nausea, are the best means of
assisting constitutionally in the reduction of
dislocation, as. they most readily produce a
state of faintness, during which the muscular,
power is greatly diminished. Bleeding is the
most powerful, and at the same time the

288

Warm
bath.

Creating
nans^a.

Opium.

Mode of
^reduction.

most speedy method of the three, if the blood
be drawn from a large orifice, and the pi^i^t
be kept in the erect positicm ; it caimo^ how-
ever, be resorted to in all <^ases, and might
be highly injurious in very old or debiUtated
persons ; but in the young and robost it may
be employed with safety and adyimtage in
the mode I have proposed.

In using the warm bath, the temperature
should be from 100^ to 110''; and the heat
should be kept up until the patient feels ftint,
when he should be taken out, and die
mechanical means should be immedii^Iy
resorted to. The desired effect is much sooner
produced by abstraction of blood, during the
time that the patient is in the bath, than by
bleeding, or the bath singly.

The third mode, viz. that of exciting
nausea by the exhibition of tartarised anti-
mony in small doses, h not so certain as the
former modes, but it is exceedingly useful in
keeping up the state of faintness produced by
bleeding or the warm bath, when the disk)'
cation has been of long standing and likely
to require a continued application of me-
chanical means for its reduction.

Opium might, perhaps, be serviceable in
large doses, as it greatly diminishes muscular
power. I have not yet tried it.

When the power of the muscles has been

289

lessened^ the reduction of the dislobation
should be attempted^ by fixing one bone^
whilst the extremity of the other is drawn
towards the socket by extending the limb.
Inattention to this point is one of the great
causes of failure in attempting to reduce dis-
locations ; for if the bone in which the socket
is situated be not fixed, the reduction cannot
be accomplished* If, for instance, in attempt-
mg to reduce a dislocation of the humerus
llie scapula be not fixed, it is necessarily
drawn down with the os humeri, and the ex-
tension is unavailing. If one person holds the
scapula, whilst two extend the humerus, the .
extension will still be very imperfect: the
one bone must be firmly fixed, at the time
that the other is extended, to render the force
effectual. Tlie extension should be gradu-
ally and carefully made, and continued rather
to fatigue than extend the muscles by violence.
Violence is as likely to lacerate sound parts
as to reduce the dislocation, and this I have
known to occur.

The force required may be applied by the u»e of pui-
aid of assistants, or by compound puUies, and
in cases of difficulty the latter is much the
more preferable mode, as the extension can
be thus made gradually and continued ;
whereas that made by assistants, is usually
irr^ular, and often ill timed, being more

VOL. III. u

288

Warm
bath.

Creating
naatea.

Opi

Mode of
•"^■otioii

most speedy method of the three*
be drawn from a large orificet an
be kept in the erect positkm ; i'
ever, be resorted to in all cr
be highly injurious in very o^
persons ; but in the young
be employed with safety
the mode I have propose

In using the warm 1
should be from lOO"*
should be kept up ui
when he should
mechanical mean
resorted to. The

iucation,

L such as to

.arger muscles,

be greatly iacili-

produced by ab'
time that the p
bleeding, or th

The third ^
nausea by
mony in
former

.ILuil

whether the

ttedidocated

M. Boyer,

in surgery,

<^Hnionitia

bone wUch is

dislocations of

Badenoion from

m liBe with the

placing

at the

Ae reduction

from the

adbidingmuch

will, as long

; but this

^rcumstance
T have

nt.

cted

■ ug the

iiiey had

diminished

s, a wetted roller Mode of
lib, and the leather tiS^pt^ifes.
lixed to receive the
should be buckled on
iiis will prevent it from
the extension. The cord
be drawn very gently, until
je of the muscles is felt, when
)ii should rest for two or three
, and then gradually and carefully
i again, and so on until he perceives the
Aes quiver; after which a very little
>re extension will accomplish the desired
purpose.

The surgeon may know when dislocation when re-
is reduced, by the restoration of the natural
figure of the articulation.
Fot some time after the reduction of the ^eatmont.

u 2

292

dislocation of the shoulder of long standing,
bandages are required to retain the bone in
its proper situation ; and the same treatment
must be adopted after similar accidents to
those joints in which the articular cavity is
shallow.

In all cases after reduction, rest is neces-
sary, to allow of the union of the ruptured
ligaments; evaporating lotions should be
employed to prevent excess of inflammatory
action, and leeches should be applied if the
inflammation run high. Subsequently firiction
will be found of great service in restoring the
natural functions of the joint.

The injuries to the spine, commonly des-
cribed as dislocations, have been already
treated of in a former lecture. I shall now,
therefore, proceed with the description of
these injuries to the other articulations'/ a^
commence with those taking place at the
junction of the ribs.

Of Dislocation of the Bibs.

Three Three forms of dislocation are mentioned

as occurring to the ribs and their cartilages ;
viz. — First, a displacement of the posterior
or vertebral extremity forwards on to the
body of the vertebrae. Second, a separation

293

of the anterior extremity of the riD fronTTta
cartilage. Third, a similar injury between
the cartilage and the sternum.

PThe dislocation of the vertebral extremity J
might occur from a person falling backward
on some pointed substance, so as to drive the
head of the rib from its natural situation ;
such accidents are, however, very rare.

This injury would produce symptoms nearly ;
similar to those from fracture of the rib, as
pain on motion, and difficulty of respiration.

The same mode of treatment would be also Treaiiucnt.
proper in either case ; as bleeding to prevent
inflammation, and the application of a roller
to confine the motions of the ribs.

When a cartilage has been separated and Bii|>iace.
displaced either from the rib or from the ster- cartii&ge.
Cum it may usually be replaced with ease, if
the patient will take a deep inspiration, so as
to enlarge as much as possible, the diameter
ef the chest ; for under these circumstances
very slight pressure will return the parts to
Aieir original position.

After the reduction, a small compress con- Tr«
"" fined over the seat of injury by a bandage, as
applied for fractured rib, will be requisite to
prevent any future displacement.

In sickly and weak children, an alteration Deformity
sometimes takes place in the form and direc-

E cartilages of the ribs, which might

■ven

294

be mistaken for a dislocatton. It most fre-
quently occurs at the cartilages of the sixth,
seventh, or eighth ribs, and is accompanied
with some alteration in the course of the ribs
themselves.

Dislocation of the Clavicle.

Articular The articulatious of the clavicle with the

strong. sternum, and with the scapula, are so firm as

to render displacement of either extremely

rare, when compared with the dislocation of

some other joints.

Dislocations of the Sternal Extremity:

Two kinds. The stcmal end of the clavicle may be dis-
placed in two ways; — ^first, when thrown
anterior to the sternum, or forwards ; — second,
backwards, or behind the sternum.

Anteriorly. In the autcrior dislocation, a swelling is
readily perceived on the anterior and upper
part of the sternum ; and if the finger be
carried on the surface of the sternum upwards,
this projection stops it. On placing the knee
between the scapulae and drawing the
shoulders backwards, the swelling disap-
pears; but it reappears when the shoulders^

are again allowed to advance. If the shoulder
be elevated, the swelling descends, and if the
shoulder be depressed, the projection ascends
towards the neck.

The patient experiences much difficulty Painfi
in moving the shoulder, and the attempt
creates pain ; but when at rest, he suffers
but little pain or inconvenience. In very thin
persons, the nature of the accident is at first
view easily detected, but some difficulty may
occur in ascertaining its nature in very fat
people.

This injury is generally occasioned by a CaiiBc.
fell, either on the pointof the shoulder, which
drives the clavicle inwards and forwards, or
Upon the elbow, at the time that it is separated
from the side, which produces the same
effect.

Sometimes this dislocation is only partial,
the anterior part of the capsular hgament ais^i
alone being lacerated ; in this case the pro-
jection is but slight, but most frequently all
the ligaments are torn through, and the bone
with the interarticular cartilage is completely
displaced.

This dislocation is easily reduced by draw- Tipa
ing the shoulders backwards, by which the
clavicle is drawn off the sternum, when it
falls into its natural situation ; but the
shoulders must be kept in this position to

pffcvcBt a recsrrcBce cf the

and the arm flmst be snpportoi, or ks wci^

wiD afect the poshioB of the faoBC

The a^iplkatioB of die dwride favidage wd
pads IB the aziDK wiD effect the fini iibfect,
and the second win be gpiaed hj plaoBg the
arm in a short sliiig.

I hare nerer seen, or kaowiiof aniBBlaBee,
in which the didoratinn badmaids has been
produced by rioknce ; jti I coMcife that it
might happen from a blow ob the finte part of
the bone.

The ooly ease oi this fiMrm of didocatioii
that I hare known, was occanoned by great
d^nrmity of the qpine, from which the aayofai
was thrown so mnch fiawaids^ as not to
leare sufficient space for tile davide between
it and the sternum : in consequence i)i this
the chnricle was gradually forced bdiind tiie
sternum, whaeit jMresseduponthecesc^diagus,
and gave rise to so much inconTUuence, as to
occasion a necessity for the remoral of the
extremi^; the trachea from its elasticity
escaped pressure, being pushed to one
side.

This case was under the care of Mr. Darie,
surgeon, at Bungay, in Suffolk, from whom
I had many of the particulars. He deserved
great praise for suggesting the mode of relief;
and the skill with which he performed the

297

operation was a proof of the soundness oims
professional knowledge.

Miss Loffty, of Met6eld, in SutFolk, had c««-
very great distortion of her spine, by which
the scapula was gradually thrown so much
forwards, as to displace the sternal extremity
of the clavicle, forcing it inwards behind the
sternum, so as to press upon the cesophagus,
and occasion great difficulty in swallowing.

She had become very much emaciated.

Mr. Davie thinking that he could relieve
the sufferings of the patient, and prevent the
threatened destruction of life, by removing
the sternal extremity of the clavicle, per-
formed the following operation : —

He first made an incision of between two
and three inches in extent, over the seat
of the dislocation, in a line with the direc-
tion of the clavicle. After dividing the soft
parts surrounding the bone, he placed a
portion of stiff sole leather behind it, whilst
he carefully sawed through it, about one inch
from its end, with Hey's saw ; he then
elevated it, and separated it from the inter-
clavicular ligament.

The wound afterwards healed quickly, and
the patient was again able to swallow without
difficulty. She lived six years after the per-
formance of the operation.

VCIV

Extremity.

s HIT other dislocation
incauEv of the clavicle,
\ end of the clavicle
,^ .- wMc 2t: Bsomion process ; and
disit.r ^^ t^ci'^e c reiy unlikely for any

^^^ u^Dziic lut I do not mean to deny
L L i:2$placement beneath the
i£ se scapula.
^lEP- :s more frequently dis-
jm: :» iTcmal end, and may be
% at x'lj: wing signs : —
tiofs^isr K. the injured side appears
. aM iriwn nearer to the sternum,
4^ ifc ^uizc :ce. This arises from the
«* IK .'-"St the support of the cla-
2rt ixiiitiaation, the nature of the
^^Y > >t^aiily Ascertained, by passing the
^^ ^wtK ^<^ :^f^^ of the scapula, so as
9 •mn ^a«r ^vauacaiion of the acromion with
-j: ^^ik ^^ ibe finger is stopped by
4^ ^oit.-'iKOf :i'the clavicle, which projects
^>j^c :^te iccciion. and pain is experi-
— ^^«: w'ltfa ti:5 elevation is pressed. The
•'iiv- jLsarc^TA:^ when the shoulders are
^.;^v,i rocrv'^xr.is, but rises again if they
• ui^^xv, :'^ *-'v^ni« forward. Pressure

299

upon the end of the dislocated bone causes
pain ; but when at rest, the patient suffers
but little.

This injury is most frequently occasioned causes.
by a fall upon the shoulder, by which the
scapula is forced inwards towards the chest.*

The reduction of the displaced bone in TreatmcDt.
these cases, may be, in most instances, rea-
dily accomplished, by placing the knee be-
tween the scapula of the patient, and then
drawing his shoulders backwards and up*
wards. After the reduction, a pad or cushion
should be placed in each axilla, for the
purpose of elevating the scapulae, keeping
them from the side of the thorax, and to
defend the soft parts from the bandage,
which should next be applied, as in the for-
mer case, only it should be broad, and made
to press over the seat of injury. The em-
ployment of a short sling is likewise of
essential importance.

It rarely happens that these accidents to Not per-

fectly re-

the clavicle are perfectly recovered from; csovered
some degree of deformity usually remains,
and of this the patient should be informed
at the commencement of the treatment,

* I have known this dislocation arise from a blow,
^ die falling of a heavy piece of timber upon the extre-^
"Mty of the shoulder. — ^T.

-rrrr^^t .: lo iho neg-

-is^ . ac j^rgeon; but

ip„, - — ^^i^tre with the

r tic ih Humeri.

^ - =te X'lzienis may be dis-
m r: o=:=2uiii w-iniy of the scapula,
•--^tffi^ — dreie of the dislocations
itoi 3« perfectly so.

and inwards into

't --«*Nii£ ^ vr»ari>, under the pectoral

cr*;"* lie •lanc^.
^ itrr. ^ :)A:kv:mi$, on the dorsum of
.^,^:9itti» j«:iu'v ±e spine.
^ iecta > :aly partial, when the head
tss j^nisst the external side
II Tr:ces5 of the scapula.

^f I9L rtsiuxuxxm in the Axilla.

'T^ zisicctccc niay be known by the

j;*c ^ .^: s:ris — The rotundity of the

s;^.«.-v > ::os:r:yt\:. and a hollow may be

. ; X c * -ic ic-viiuon process of the sca-

.: ,\c;Si\:uci:cc of the head of the

«. «••

301

Iiumerus being displaced from the glenoid
cavity, by which the deltoid muscles looses
its support, and is dragged down with the
depressed bone. The arm is lengthened, as
the superior extremity of the humerus is
placed beneath its natural articular surface.
The elbow is separated from the side, and
cannot be made to touch it, but with diffi-
culty, as the effort presses the head of the
bone upon the axillary nerves, occasioning
severe pain, and the patient generally sup-
ports the arm with the hand of the sound
limb, to prevent the weight from pressing
on these nerves. If the elbow be fer re-
moved from the side, the head of the os
humeri can be easily felt in the axilla, but
not so if the arm be allowed to remain nearly
close to the side ; raising of the limb throws
the heaid of the bone downwards, and to
the lower part of the axilla, so that it can
be more readily felt.

The motions of the joint are in a great
degree destroyed, especially upwards and
outwards, and the patient cannot raise his
arm by muscular effort ; for this reason, it
is. usual, when wishing to detect a dislo-
cation, to ask the patient if he can raise his
hand to his head. The answer invariably
% that he cannot, if a dislocation exists .
The arm cannot be rotated, but a slight

302

degree of motion backwards and forwards
still remains.

Motion In very old persons, and in those having

coniTider!^ a relaxed state of muscles, the degree of
motion is occasionally but little inferior to
that which exists when the bone is in iti
natural state.

Crepitus. Somo time after the accident, a crepitus
may be often felt, occasioned by inflammatory
effusion, and from the escape of synovia ; but
it is never so distinct as that produced fit)m
fracture.

There is frequently a numbness of the
fingers, from the pressure of the head of tiie
bone upon the axillary nerves.

Thus it will be found, that the prindpal
marks of the accident are, the loss of tbe
rotundity of the shoulder, the presence of
the head of the bone in the axilla, and
the destruction of the natural motions of the

Signs in- joiut. But oftcu thesc marks are but little
apparent in a few hours after the receipt of
the injury, from the extent of swelling
which occurs, on account of extravasation;
they, however, became again distinct when
the tumefaction and inflammation have sub*
sided. Under these latter circumstances it
is, that the London Surgeons are generally
consulted, when the nature of the injury
can^be mistaken; whereas, the general

303

practitioner is called upon during the state
of tumefaction and inflammation, to form his
opinion, and should he then overlook a dis-
location, it is our duty, in justice to the
jeneral practitioner, to inform the patient

that the difficulty of ascertaining the true
oature of the accident is very greatly di-
minished by the cessation of swelling and
inflammation.

The readiness with which the injury may
be detected, will also differ much in very
dun and emaciated persons, or in those
kaded with fat, and possessing large and
powerful muscles.

The most common causes of this accident, causes.
Ae falls upon the hand, when the arm is
time the horizontal line, or upon the elbow,
when the arm is raised from the side; but
aifire especially by a fall upon the shoulder
iMf^ when the muscles are unprepared to
mist the violence.

When the arm has been once displaced, liabmtyto
it'fe much more liable, after the reduction,
to be again dislocated, unless great attention
bn^pidd to the injured joint; and very slight
caises will often produce a recurrence of the
'Wjfi^y which I have known take place
OHrely from the action of lifting up the sash
ijpft window.
•When an apprentice at St, Thomas's Hos- case.

304

>uau i» I was one morning going through
ne wds^ I was called to visit a man who
md indocated his shoulder in the ordinary
iAft of stretching himself, and rubbing his
jTesy when he first awoke.

To prevent as much as possible this dis-
poRCain to fotore dislocation, the limb should
be kepc perfectly at rest for three weeb
jAst t&e reduction, during which time, a
pai£ s&oafai be fixed on the axilla, and the
SSL bound to the side, thus the lacerated
parts w2I have time and opportunity to unitei
wiuc& diey cannot well do if the usual mo-
tioos are permitted.

I hsve had opportunities of dissecting two
recent cases of the dislocation downward^^
in which I found the following appear-

In the first case, the axillary vessels anci
nerves were forced backwards upon the sub-
^capularis muscle, by the head of the dis-
located humerus. The deltoid muscle was
drawn down, and the supra and infra spinati
muscles were stretched over the glenoid
cavity, and inferior edge of the scapula.
The head of the bone was seated be-
tw\^M\ the coraco brachialis and axillary
I^Wxus. The capsular ligament was exten-
mvclv lacerated on the inner side of the
^Iciuud cavity, as was also the tendon of the

Inbscapularis muscle, where it covers the

kament.

I In the second case, violent attempts had case.

made to reduce the dislocation five
peeks after its occurrence, but without suc-
jsSf and the patient died from the effects
&the violenceused in ihe extension. The pec-
major was slightly lacerated, the
tapra spinatus very much so ; the infra spi-
ns and teres minor were also torn, but
to any jp-eat extent; the deltoid and
[oraco bracUialis had also suffered a little.
The capsular ligament had given way be-
tween the teres minor and subscapularis ten-
i 4ons, the latter being separated from the
|,fcBser tubercle of the humerus,
r In these dissections, I found that the
supra spinatus and deltoid muscles were
those which afforded the chief resistance to
the reduction of this dislocation ; therefore,
io order to effect the reduction, the best di-
rection in which the arm can be extended, is
at a right angle with the body. The biceps
should be at the same time relaxed by bend'

J the elbow.
\ In examining a dislocation which has
pstedfor several years unreduced, the head
i the bone is found much altered in form,
jping flattened on that side next the sca-
but it is perfectly covered by a

I VOL. III. X.

Propr 1-
mode <-
previ'ijf

*^^

r!ie glenoid cavity is

.^ \ L substance of a liga-

^^ ma some small portions of

..^. -.ttfefMaded in it, and a new

^..M« :^ tunned for the head of the

^^ jam, m the inferior costa of the

turn of the Dislocation in the
Axilla.

s employed for the reduction of

^^^ 01 the humerus when dislocated

^.mmus^ into the axilla, must differ ac-

.«^ u the circumstances attending the

^isMi. but in all recent cases, I gene-

^ i»cciupt the reduction by the heel in

^ o^ila» which may be done in the foUow-

tH; patient should be placed on a so&,

. .«a>4c. near the edge, in a recumbent pos-

^si^ luid a wetted roller should be bound

^^aU the arm, just above the elbow, over

^^lish a handkerchief or towel should be

^i^vueil; the elbow being then separated

4Viik the side, the surgeon places the heel

■i v»uo foot in the axilla, and rests the other

'i(H»n tlio ground, as he sits by the patient's

k\kW riu* hoel should be placed far enough

307

back to receive the inferior edge of the sca-
pula, and prevent its descent at the time
that the arm is extended. The extension is
to be made from the handkerchief or towel,
and continued steadily for four or five mi-
nirtes, in which time usually the head of the
bone slips into its proper cavity. The force
of two or more persons may be employed in
extending;, by means of the towel, if required.

If, however, the accident is of several ifof«"'n«
days standing, and if the muscles have been
fixed and rigid, more force than can be ap-
plied as above will be required to effect the
reduction, and the following means must be
resorted to : —

The patient must be placed in a chair, and ^^?"^
the scapula fixed by a bandage with a slit in
it, which admits the arm through it; this
niust be tied over the acromion, so as to keep
it well in the axilla. Next, place a wetted
wUer round the arm immediately above the
dbow, to protect the skin, and upon it fix a
Pery strong worsted tape, by what is termed
the clove-hitch. Then raise the arm at right
angles with the body, or a little above the ^_
I horizontal line, to relax the deltoid and supra ^H
I Epibatus muscles. Two persons then holding ^|
1 the scapula bandage, should keep it fixed,
i whilst two others draw from the bandage
^■ifixed to the arm with a steady, equal, and

L M

*'•• .. 2.Z extension ha

* " z--::c5, the surgeo

— :: ~f axilla, restin
-^^ - iiHT ; he shoul
ending his fool

cliH.

— r :=!:. v-± his right hand

- : - '^'^irds and inwards.

- —iv-iic will be generally

^ii^^rii -5 kept up, a gentle

. - ■• .; -r- '.:>h the counteract-

.^i . :l^ ULscles, and materially

^**"'' _. .: >-:v::i:ii: rut should the force

-^ ^." i«:c r^e sufficiently steady

... .^-^ Hull vr niust apply the pul-

^ . . -. . c»v :i: exerting greater force,

z^ :c at ?;ir-xre:'2 to employ it more

^: :i^u:-j^i^ A.'.. "ritJic applied, as in the

w ,>^ .-. :2c iiizfizz is to be seated be-

^ -. -iUi'iii^ ▼iich are to be fixed in

^ ^, - :^^ Lra:T::::ent. so that the force

•^ XL "/- *:':c .* :ie same direction as

, ^.-r-^-.r.Micc Tie surgeon should first

• . ^- ^.:' i^J«" jCidiily until the patient

> . :u. • -vii" he should stop, but

•\ . .:i:::vZ. Much advantage

X : *»: -• *ry conversing with the

-.•^ V ..c iis attention to indif-

V. '. • r**.- or three minutes he

309

may carefully extend a little more> and then
cease again, and so on, until he has made as
much extension as he thinks correct, but
he should at intervals slightly rotate the
Umb. Then giving the string of the pulley io
an assistant, desiring him not to relax, he
skould place the knee in the axilla, and press
the acromion as before described, when the
bone glides into its proper situation, not
however with a snap> as when the other
means are employed.

In the hospital practice, I usually order Hospital
the patient to be bled, and put into a warm
bath at the "temperature of 100° to 110**,
giving him a solution of tartar emetic until
he becomes nauseated and faint, when he is.
immediately taken from the bath, and ex-
tension applied before he regains muscular
power. This plan obviates the necessity of
losing any great force.

In very old relaxed persons, or in very Py^^^?««
dehcate females, another mode of reducing
thb dislocation may be resorted to, by plac-
ing the knee in the axilla in the following
manner: — The patient should be seated
npon a low chair, when the surgeon should
separate the injured arm from the side, and
then resting his foot upon the chair, should
ptaiee his kneie in the axilla, and holding the
arm with one hand over the condyles of the

316

humerus, and pressing the acromibn ^ the
scapula with the other^ he should then de-
press the elbow, by which the dd6lpcfttiq&
will be reduced.
Znmt ^ft^^ frequent displacements of the shwil-

tv^re^^' ^^^* ^^* ^^^y ®^^8r^* (oTce is necessvy to
duced. reduce any future dislocations. A gentlefiaan

in the country, of my acquaintance^ who has
frequently dislocated his shoulder^ has often
reduced it himself in the following way,—
by leaning over one of the common field
gates, and laying hold of one of the lower
bars, then allowing his body to weigh down
on the other side ; — this is on the same prin-
ciple as placing the heel in the axilla, which
will effect the reduction of three-fourths of
the recent dislocations «

Of Dislocation forwards under the Pectoral

• Muscle.

Easily de- This dislocatiou is much more readily de-*

tcclcd

tected than the former. The depression be-
neath the acromion process of the scapula is
greater, and the process itself appears more
prominent. The head of the os humeri can
be distinctly felt, and, in thin persons, may
be seen forming a swelling beneath the cla-
vicle, which moves when the elbow is rotated.

The head of the bone is situated internal signs of
to the coracoid process, between it and the
sternum, and is covered by the large pec-
toral muscle. The arm is shortened, and the
elbow is separated from the side, being
forced outwards and backwards ; the mo-
tions of the arm are more affected than in '
the former dislocation, the head of the bone
being fixed, by the coracoid process and
neck of the scapula on the outer side, by the
olavicle above, and by the muscle on the
fore part, as well as by the action of the
^eres minor with tlie supra and infra spinati
amuscles, which are rendered very tense.

The pain occasioned by this injury is uot
:so severe as in the dislocation into tlie
^axilla, because the axillary vessels and nerves
3 less compressed.

aition of the limb, the elbow being carried
from the side and backwards ; the head of
bone being readily felt below the cla-
(cle, and its moving when the arm is
petated.
There is in the Museum at St. Thomas's Dissection ]
[ospital, a beautiful preparation, showing a
liBlocation of this kind of long standing,
■hich presents the followiag appearances : —
[The head of the humerus rests upon the
■peck and part of the venter of the scapula,
X 4

312

just below the supra-scapular notcii; ^e
subscapularifr muscle has id part been raised .
so that the head of the bone reirts on the
scapula ; the subscapukfis and serratu^ mag^
nus muscles being between the extremity of
the humerus and the surface iof the ribs. The
'tendons of all the muscles attached to the
tubercles^ as also that of the long head vi
the biceps muscle remain perfect* The gle*'
noid cavity is filled with a ligsmientous sub^i
stance, but its general figure is not much
altered; and to this ligamentous stmctare
the tendons of the supra and infra spinati,
and of the teres minor muscles are adherent,^
having however a sesamoid bone formed in
them : a new socket has been formed, M^iich
extends from the glenoid cavity, to the resL^
ter of the scapula, occupying about one*third
of its width, it has a complete lip, and is
irregularly covered with cartilage ; the head:
of the humerus is a good deal altered in
form, and its cartilage has been in maay
places removed by absorption: a perfect
capsular ligament has bejen formed.
Caases. Violent blows upon the shoulder, or falls
upon the elbow, when it is thrown behind
the line of the body, are the usual causes
of this dislocation.

313

^ €^the Reduction of the Dislocation fortoards.

1^ In recent dislocations of the kind, the re- when
b duction may be accompUshed by placing the ^""^^
^ bed in the axilla, and making extension
\ &om the arm as before described ; the foot
should, however, be placed rather more for-
wards, to press on the head of the bone, and
the arm should be drawn a little backwards
as well as downwards.
When the dislocation has existed for some J^h«nof

long stand-
days, it will be best to use the puUies, as *"«•

continued and steady extension will be re-
paired to reduce it.

The scapula must be fixed by the 'same Mode of
bandage as formerly described, and the
Netted roller, with a strap for the puUies,
^^d on in the same manner above the elbow.
'^he fore-arm should be bent to relax the
biceps muscle.

The most important circumstance, is the Du-ecUonof

!• . . \ extension.

^^ection m which the extension is to be
^^ixade, which must be outwards, a little
downwards and backwards ; for if it be made
l^wizontally, as in the former case, the cora-
^id process of the scapula prevents the head
^f the humerus from' passing outwards in its
pioper situation.

When the head of the bone has been

314

brought below the coracoid process, by the
extenskm, the surgeoa should, with Ids kiiee^
press it backwards and upwards to the gle-
noid cavity, at the same time puUiogthe am
forwards from the elbow, fa^ which m^eaos he
will expedite the reduction. As the i^esist*
ance is greater, the extenskm must gene*
rally be continued longer than that required
to reduce the dislocation into the axilla.

Of the Dislocation backwards an the Dorsum

of the Scapula.

sitofttion In this dislocation, the head of the. ha*
°^' merus is thrown upon the dorsum . of the
scapula, below the spine, where it forms a
projection at once perceptible to the eyes of
the surgeon, and this enlargement, may be
seen and felt to move when the elbow is
rotated. The motions of the arm are less
confined than in either of the former dis-
locations.

Very rare. Only two cascs of this kind has occurred
in Guy's Hospital during thirty-eight years.
One was during my apprenticeship, and was
under the care of Mr. Forster. The nature of
the injury was scarcely to be mistaken, on
account of the projection formed by the head
of the bone upon the posterior part of the

315

bandages were applied, and

made in the same way as for

uii into the axilla, and the re-

s quickly accomplished.

)nd case was reduced in the same

hy the dresser, it occurred some

Ver the former.

. >

occurrence.

Partial Dislocation of the Os Humeri.

This is an accident of frequent occurrence, of common
^ he head of the humerus is displaced for-
^^ards, and rests against the coracoid process
of the scapula ; there is a depression under
^e back part of the acromion, the axis of
the arm is directed inwards and forwards,
^d the under motions of the arm can still
1^^ made, but it cannot be elevated as the
*^^ad of the bone strikes against the coracoid
Pi^ocess, over which it forms an evident pro-
jection, moving when the arm is rotated.

Mr. Brown, aged fifty, was thrown from case*
^is chaise and injured his shoulder, which
^pon examination was found to have lost its
Soundness, and a depression was perceptible
^nder the acromion process; the arm could
^e moved readily, except directly upwards.

The only opportunity which I have had of
Seeing the dissection of this accident, was

through the kindness of Mr. Paty, surgeotf,
Bouverie Street, he had the subject brought
to him for dissection at St. Thomas's Hos^
pital.
The following is Mr. Paty's account:-^
Mr. Paty's Partial dislocation of the head of the os hu-

dUsection

•T meri, found in a subject brought for dis-

section to St. Thomas's Hospital, during the
latter part of the year 1819.

The appearances were as follows: — ^The
head of the os humeri, on the left side, was
placed more forwards than is natural, and
the arm could be drawn no further from the
side, than the half-way to the horizontd
position.

Dissection. The tendons of those mus-
cles which are connected with the joint were
not torn, and ' the capsular ligament was
found attached to the coracoid process of the
scapula. When this ligament was opened, it
was found that the head of the os humeri was
' situated under the coracoid process, which

formed the upper part of the new glenoid
cavity; the head of the bone appeared to
be thrown upon the anterior part of the neck
of the scapula, which was hollowed, and
formed the lower portion of the new glenoid
cavity. The natural rounded form of the
head of the bone was much altered, it hav?
ing become irregularly oviform, with its long

sin

axis from above downwards ; a small por-
tion of the original glenoid cavity remained,
but this was rendered irregular on its sur-
face, by the deposition of cartilage ; there
were also many particles of cartilaginous
matter upon the head of the os humeri, and
upon the hollow of the new cavity in the
cervix scapulse, which received the head of
the bone. At the upper and back part of the
joint, there was a large piece of the car-
tilage, which hung loosely into the cavity,
being connected with the synovial membrane
at the upper part only by two or three small
membranous bands. The long head of the
biceps muscle seemed to have been rup-
tured near to its origin, at the upper part of
the glenoid cavity ; for at this part the tendon
was very small, and had the appearance of
being a new formation.

The same causes which produce the dis- Cau>e»or.
location under the clavicle, only with less
violence, will occasion this displacement.

The reduction in these cases may be ac- Reduction
complished by the same means as those di-
rected to be employed for the dislocation
forwards; but in addition, it is necessary to
' the shoulders backwards, and after the

duction, a bandage must be applied to keep

5 head of the bone in its proper situation,
to prevent the motions of the scapuke a-

318

forwards, or otherwise the bone will ftgf^n
slip out of the glenoid caTity.

Of Cmipimnd Disiocation of the Os Humeri.

Forwards. In the dislocation of the os humeri f(Hr''
wards, the head of th6 bone may, by exces-
sive violence, be forced through the extemr
soft parts.

Treatment In such a casc, the reduction of the dis-

of • ■

placed bone should be immediately efieeieft
by the means I bare already recommended
for the simple dislocation ; and when re-^
placed, the edges of the externieil wcMCttd
should be approximated by a suture, ^Bind
then Hnt dipped in. blood should be applied '
over 1^ wound, which is to be further sup-
ported by strips of adhesive plaister. The
limb must be fixed to the side, by a roller
passed round it and the body, this will pre-
vent any motion of the limb, and thus tbei^
will be less risk of the suppurative inflam-
mation occurring, which would gready efi^
danger the patient's life.
Mn Dixon's Mr, Dixou, of Ncwingtou, kindly fur-
nished me with the following particulars erf
a case which was under his care : —

Robert Price, aged fifty-five, fell, wfeen in*
state of intoxication, upon his shoulder,

case.

319

which produced a dislocation of the humerus,
and forced the head of the bone forwards,
through the integuments of the axilla ; and
I found it situated on the anterior part of the
thorax, over the large pectoral muscle. The
reduction was accomplished with great
ease, after which he was placed in bed,
and an evaporating lotion was applied. The
following morning he complained of great
pain, and considerable swelling had taken
place, for this he was bled and purged freely,
the injured part was poulticed, and anodynes
were given to relieve pain and procure rest.
For several days afterwards, leeches were
repeatedly and freely applied over the joint,
until after about two weeks from the receipt
of the injury, when the wound began to dis-
charge very freely a healthy pus. This con-
^nued for ten or twelve weeks, during which
time his constitution suffered much, he was
restless, irritable, and became emaciated.
Afterwards, a number of small abscesses
formed in the surrounding cellular tissue,
Occasioning sinuses, some of which were
exceedingly troublesome, requiring dilitation.
This was kept up for twelve months, when
all discharge ceased, but the joint was com-
pletely anchylosed. He retained, however,
terfect use of the fore arm and hand.

320

Ofltfjurks near the ShouUer Joint. Habk to k
mistaken for Dislocations.

Fracture of the Acromion.

Signs of. When this process of' bone is broken . off^
it is drawn down by the weight of the arm,
the deltoid muscle having in part lost its
support, allows the head of the os humeri to
sink as far as the capsular ligament will
admit of its doing so, and the roundness 4£
the shoulder is consequently destroyed* On
tracing the finger along the spine of the
scapula, towards the acromion, a depcessioa
is felt at the point of natural junction between
these two parts. If the arm be raised fyom
the elbow, so as to carry the head of the
humerus upwards, the shape of the should^
is immediately restored, as the acromion pror
cess is returned to its original position, but
as soon as the arm is allowed again to hang
down, the deformity recurs ; when the arm
has been elevated, a crepitus may be dis-r
tinctly felt, by pressing one hand over the
seat of injury, and at the same time rotating
the elbow.

Treatment . In the treatment of this accident, the os
humeri is to be made the splint, to keep the
fractured bone in its proper position ; and to

321

effect this^ the elbow is to be raised^ and the

itrm fixed, but a thick pad or cushion must

be placed between the elbow and side, to

Tfieparate the former from the latter, and thus

{elax the deltoid muscle, otherwise the

%loken extremities of the bone will not be

contact. The pad having been placed be^

IQ the side and elbow, the arm should be

4 firmly to the chest by a roller, and a

bandage, or a $hort sling should be

ijied to support the elbow, and this

should be maintained for thre^

li^euy little inflammation usually follows ^^J^l

i; ittjury, and the disposition to ossific

16 very feeble ; thus, Unless the firac-

ends of the bone be placed in close

rt; and if they be not kept perfectly

idlest during the time required for such

Mi9lii the junction will be by a ligamentous

lllrbeture, instead of by bone,

■ , ft y - ^

.*' fracture of the Neck of the Scapula.

\ '''This accident is much more likely to be lakeduio-
^(mfounded with dislocation than any other ^*
W the injuries to the shoulder joint. The
ticture takes place through the narrow part
of the neck of the scapula, opposite the notch

VOL. III. Y

:jl^

^f Injuries near ihv S
mistakai /*

Fractuf'

Signs of. When this >

It is drawn iUr
the deltoid
support, ih '
sink as
admit
the s
trac

■
IS

.:oid cavitv

.:.*.:s into the

..ier is there-

:>:> below the

- - lead of the os

—.1, as when the

•- -">.

-1 i^~

'^-

"^^'' j\ the shoulder
.<-,: the arm ; but
: L.-i':vn. the appear-
Trfsent themselves;
::oier so that the
.rizi'.i process, a
r.: -B^iien the arm is
:- which the form

"i::-? re-appearance
.rcr: is withdrawn;
.r.s in the situation
the principal
•icrure of the neck

— ^-i i -1=

n-: ^ra-cfl I have given for

-:•; * ucii I thought fully to

r ^'.ujcjms attending this

• :t:t:a coatirmed by any

••a.-cs

:\ >• : ::2*:ni^lves, in which I

' t*x.vr.\iminingthe shoulder
-I ir»:<, which, at the time,
»%'iipconis, and which had
-^ if -a»? cervix scapulse.

^-rU

323

i eatment of this injury, two principal Treatment,
ust be attended to. First, to elevate

first case was that of a Mr. B. a West India Mer-
. who, at my request, bequeathed to me the joint in
I this accident was supposed to have occurred ; his
;iitors resisted my claim, but after some little difficulty
otained my legacy. On exposing the cavity of the
villa, I there found the head of the os humeri separated
irom the shaft of the bone ; it was seated just below the
ceryix of the scapula, and was united by a ligamentous
matter to the venter of the scapula, close to the anterior
costa. The fracture had taken place between the articular
surface of the humerus,and its tubercles ; the capsular
%ament had been lacerated, so as to permit the sepa^
t Tited portion to escape into the axilla ; and the upper
jnrt of the shaft of the bone with the tubercles, had
&IIml in upon the glenoid cavity, by which the round*
^89 of ihe shoulder had been destroyed ; the glenoid
c&yity was but little altered, and the patient had before
^ death, acquired a free motion of the joint in every
^bection, excepting as a sword arm, for he could not
liae his elbow above the horizontal line. The parts are
K^served in the museum at St. Thomas's Hospital.
• In the second, that of a gentleman in Gainsford
S^tbet, a patient of Mr. Greenwood's, in whom a frac-
tipe-of the cervix scapulas was supposed to have occurred,
«it Wbo ^tied in consequence of retention of urine, I
' 4ipi»v€red| en inspecting the injured joint, nearly the
MiM appearances as in the former dissection^
* i^Haraig> thus ascertained the true nature of this injury,
hff Ike <mly aecurate mode, viz. that of dissection, I
^ha^m since been able readily to trace it in the living

Mr. Bi the medical attendant of Lord Y. whilst

Y 2

324

•

the head of the humerus ; and, Secondlyi to
carry it outwards ; the latter object will be
effected by putting a thick compress on the
axilla ; and the former, by elevating the arm
and confining it in a short sling.

Of Fracture below the Tubercles of the

Humerus.

Sddic" '^^^^ injury sometimes occurs in the young
wnt^ ^^' and old, but rarely in the middle aged. In
the young the separation takes place between
the epiphysis and shalf of the bone, and iu
the old, near the same spot, from the weak-
ness of the bone at that part. In these cases

travelling with his lordship in the Isle of Wight, had
his shoulder injured in consequence of the carriage being
overturned. Sometime after I saw him in London, in
consultation with several medical gentlemen, and on
examining the shoulder I found a depression beneath
the acromion process ; and could distinctly feel the head
of the humerus in the axilla. The rotundity of Hie
shoulder could be easily restored by elevating the arm
so as to carry the upper portion of the bone upwards
and outwards ; but whilst the humerus was supported
in this position, I could still plainly feel the head of the
humerus in the axilla, separated from the shaft of the
bone.

I must confess, that I now doubt the very frequent
occurrence of the fracture of the cervix scapulte.

.„'J

14.*.^

aierus remains in the

liic body of the bone sinks

ilrawing down the deltoid

'"» lessen the roundness of the

.<: following notes respecting the Case

*iild about ten years of age, brought

; s Hospital with this injury. The

>uld not be moved without creating

pain : if the upper part of the bone was

a, the lower portion could be tilted out so

to be felt, and to form a visible projection,

Hud in doing this a crepitV^ was distinctly

perceived, which could not be felt whilst the

lH)ne remained depressed into the axilla. The

bead of the humerus did not obey the ro-^

tatory motions of the elbow.

In treating this accident, a roller should Treatment,
be applied from the elbow to the shoulder ;
and then a splint must be placed on the
inner, and another on the outer side of the
ann, with proper pads, and these must be
fixed on with tapes, or a roller. A cushion
should be put in the axilla, to throw out the
^per part of the bone, and the limb should
be gently stipported in a sUng, but not at all
forced up, or the bones will overlap.

326

LECTURE XLII.

' Dislocations of the Elbow Joint.

^HE elbow may be dislocated in five differeirt
ways.

1st. The ulna and radius backwards.

2nd. The ulna and radius laterally.

3rd. The ulna separately from the radius.

4th. The radius alone forwards.

5th. The radius alone backwards.

Of Dislocation of the Ulna and Radius bach

wards.

Signs of. This injury is strongly marked by the
great change in the figure of the joint, and
by the destruction of its principal motions.
The ulna and radius form a considerable pro-
jection above the natural position of the
olecranon posteriorly, with a depression on
each side ; on the fore part, the extremity of
the humerus occasions a swelling, behind
the tendon of the biceps muscle- The flexion

327

of the joint is almost destroyed, and the for&
hand are fixed in a supine positian.
the museum at St. Thomas's Hospital
preparation showing the effects of a com-
dislocatiou of this kind, which I had
aa opportunity of dissecting.

The olceranon projected one inch and a DiasecUon
ialf above its usual position, posteriorly, and
the coronoid process of the ulna rested in the
posterior fossa of the humerus ; the radius
Was thrown upon the back part of the exter--
nal condyle of the humerus ; the condyles
themselves formed a large swelling anteriorly.
The capsular ligament was lacerated exten-
sively on its forepart, but the coronary liga-
nient remained entire. The brachialis anticus
^Tiscle was greatly stretched, and the biceps
Qloderately so, by the altered position of the
''^ius and ulna.

The mode in which this accident is pro- Canw.
Sliced is by a severe fall, when the person
puts out the hand to save himself; but the
^hole weight of the body being received
Upon the limb before it is perfectly extended,
. the radius and ulna are forced backwards and
upwards behind the humerus.
^■^The reduction of this dislocation maybe Modeof
readily accomplished by the following means.
The patient being seated on a chair, the
surgeon should lay hold of his wrist and place
Y 4

328

his knee on the inner side of the elbow joints
then pressing down the ulna and radius with
his knee, so as to separate them from the
humerus ; he should at the same time bend
the arm gradually and firmly ; the coronoid
process is thus removed from the posterior
fossa of the humerus, and the action of the
muscles draws the bones into their proper
situations. Bending the arm aroimd a bed
post, or over the back of a chair, will also
effect the reduction.
After After the reduction the arm should be

treatment.

bandaged in the bentrposition, at rather less
than a right angle with the upper arm ; the
bandage should be kept wet with an evapo-
rating lotion, and the limb supported by a
sling.

Of Dislocation of the Ulna and Radius laterally.

iJixtertiai This dislocation may take place either
or mter* externally or internally ; in one case the ulna
is thrown upon the external condyle of the
humerus, and in the other instance, upon the
internal condyle*
Signs of In the external displacement, the olecranon
forms a greater projection than in the dislo-
cation backwards, as its coronoid process is
seated upon the external condyle of the

329

humerus, instead of being placed in its pos-
terior fossa ; the head of the radius is thrown
to the outer side, and behind, where it forms a
swelling, which moves when the hand is ro-
tated.

When dislocated internally, the olecranon of internal,
projects equally as in the former case, but
the head of the radius falls into the posterior
fossa of the humerus ; the external condyle
fonns a large protuberance on the outer
side.

This accident is produced in the same way Cawc.
as the former, only that the direction of the
limb' at the time varies.

The reduction in these cases may be Redaction,
effected by the method described as proper
for the dislocation backwards ; it is not ne*
cessary to move the fore- arm outwards or in-
wards, as the actions of the biceps and
brachialis anticus muscles draw the bones
into their natural positions, immediately that
they are separated from the extremity of the
humerus.

, . In a recent case of this dislocation in a Case,
lady, I speedily reduced it by forcibly ex-
tending the arm ; when the tendons of the
biceps and the brachialis anticus muscles
4tQted as strings from a pulley, and forced the
condyles of the humerus, backwards.

33a

Of Dislocation of the Ulna backwards^

Bigm ofr When the ulna is thrown backwards upon
the OS humeri, and the radius remains in its
natural situation, the olecranon forms a pro-
jection behind, and the fore-arm and hand
are twisted inwards. The fore-arm cannot
be brought to more than a right angle with
the upper-arm, without considerable force.

It is not so readily detected as the former
injuries ; but its chief diagnostic marks are
the projection of the ulna, and the turning of
the fore-arm inwards.

Dissection A preparation in the museum at St,
Thomas's hospital affords an excellent oppor^
tunity of viewing the nature of this dislocation^
The displacement had existed for a long time
unreduced. The coronoid process of the ulna
rests in the posterior fossa of the humerus ;
the olecranon projects behind ; the head of
the radius has made a considerable depres-
sion in the external condyle. The coronary,
oblique, and a small portion of the inter-
osseous ligaments have been torn through.

Cause. '^^^^ dislocation is produced by the appli-

cation of violence in the direction of the lower
extremity of the ulna, which forces it sud-
denly upwards and backwards.

33 r

The reduction is in this case much more Reductioa

1 readily made than when both bones are dis-
placed, and by the same means. The radius
assists the return of the ulna to its proper
position, by pushing the condyles back, when
the fore-arm is bent, and the brachialis anti-
cus acts at the same time in drawing the
ulna forwards.

Of Dislocation of the Radius forwards.
The radius is sometimes separated from situation

4 of b<m€.

its attachment to the coronoid process of the
ulna, and is displaced into the depression
above the anterior part of the external condyle
of the humerus, and also above the coronoid
process.

I have seen several cases of this injfury, signs of.
^hich exhibits the following marks. The
fore-arm is a little bent, but cannot be either
completely flexed or extended. When an
attempt is made to bend the fore-arm, the
inotion is suddenly stopped by the striking
of the radius against the humerus, and the
surgeon is immediately convinced that this
check to the flexion is by the striking of one
hone upon another. The hand is nearly in a
state of complete pronation, but cannot be
I'endered entirely so, nor can it be placed

332

in a supine position. The head of the radias
may be felt on the fore and upper part of tlie
elbow joint, and its moyements are percepttUe
when the hand is rotated.

The sudden stop to the flexion of the fore-
arm, and the situation of the head of the
radius are the most distinguishing marks of
this injury.*

DisftectiGB On dissecting this injury, the head of the
radius is found resting in the depression
above the external condyle of the humerus.
The coronary, the oblique, with part of the
interosseous, and the anterior portion of the
capsular ligaments are lacerated. The biceps^
muscle is shortened.

CwMt^ The dislocation is occasioned by a fall upon

* A sailor about thirty years of age, applied at St.
Thomas's Hospital with a dislocation of the radius for-
wards, which had existed above six months. I could
readily feel the head of the radius- above the external
■^- condyle, particularly when I bent the arm .as much as

possible, and flexed the hand towards the fore- arm. The
hand was half supine, and could not be placed entirely
in the supine or prone positions, if the .humerus was
fixed, A sudden stop was experienced when balding
the arm, by the head of the radius striking upon the
humerus. The man had regained a great degree of mo-
tion, yet was extremely anxious for me to attempt the
reduction, which I declined, and urged him not to allow
any one to make the trial, as I was confident it woald
have been useless. — T.

333

i when the limb is fully extended, i
weight of the body being received upon the
inferior extremity of the radius.

The first case I had an opportunity of see- ca»e.
ing of this accident, occurred under the care
of Mr. Cline, during my apprenticeship to
him, at St. Thomas's Hospital. The most
varied attempts, which his strong judgment
could suggest, were made to reduce the dis-
placement, but without success ; and the
woman was discharged with the bone still
displaced.

The second case which I witnessed was in Cwe.
a lad, whom I was asked to visit by Mr.
Balmanno, in Bishopsgate Street ; hut I
could not succeed in reducing the dislocation

B although I persevered, with varied modes of

^uxtension, for more than an hour and a

^buarter.

j^ In the third case, I succeeded in replacing Cue.
the bone during the time that the patient wels
in a state of syncope ; by resting his olecranon
upon my foot, (as he lay upon the fleor,) to
prevent the ulna from receding, and then ex-
tending the fore-arm.

Another case which I attended with Mr. case.
Gordon, was reduced by placing the arm
over the back of a sofa, thus fixing the hu-
merus, whilst we made extension from the
hand so as to act alone on the radius.

Hjliand

I hjMl lectured upon this
espfauned the difficulties of
]Hh WiDiamSy one of my pupils,
he had known this dislocation
i br estaaufing the hand only. This I
myself was correct, by experi-
r the detd body. The connection of
with the radius, allows of the appli-
of force to extend this bone without
3ttudxiK the ohia. In making the extension
iM iKmenis should be fixed, and the hand
^efuefed js much as possible supine, to re-

of the radius from the upper
it thtt cwoid process of the ulna.

^* Jt&fitinffiwi iff ike Radius backwards.

f!^ sittiy tfistance in which I have seen this

««» in a subject brought to St.

ifissecting room, in the year 1821 ;

^|^$|ilK«aeiit had existed some time.

ni^ Itead of the radius was thrown behind,
1^ Qi^ th^ outside of the external condyle of
'»K? lwitteru?Ss where it formed a projection
v^ilK^h wuW be readily seen as well as felt,
wiKit tht." *^^ ^'^'^^ extended. The oblique,

i c\>rvHi*r\- ligaments were torn through,
^Hi tiK^ vni{X3talar ligament was partially

335

Of the cause of this accident I am ignorant,
as I have never seen the accident in the living
subject.

The reduction, I should imagine, would be Red"cUon.
easily effected by bending the arm, after
which it would be proper to support the bone
in its proper position, by means of bandages,
and keep the arm bent at right angles, for
three or four weeks, until the ligaments have
I had time to unite.

ccidents at the Elbow Joint likely to be con-
founded with Dislocations.

fracture above the Condyles of the Humerus.

When the condyles of the os humeri are iJi^e the

, dislocation

Obliquely fractured a little above the elbow backwardi.
I joint, the appearances presented are so like
lo those occurring from the dislocation of the
llna and radius backwards, that the two
injuries might be readily confounded ; in the
fracture, however, all marks of dislocation are
easily removed by extension, but return again
as soon as the extension is withheld, and by
rotating the fore-arm upon the humerus, a
distinct crepitus can be usually felt.

In July, 1822, a boy about nine years of ^"^
age was admitted into Guy's Hospital, having

336

fallen from a cart upon his elbow. The arm
was a little bent, and the ulna and radius
appeared to form a large projecting behind
the elbow joint : when the fore-arm was ex-
tended, the appearances of dislocation sub-
sided, but they returned immediately that the
extension was discontinued. The arm was
secured in splints, which were removed in
ten days, when passive motion was carefully
employed ; the lad recovered.

Fmuent This injury is much more frequently met
* with in children than adults ; but I have
known it to occur at nearly all aj^es.

Tr«itnMiit In treating this accident, the arm should
be bent, and the fore-arm drawn forwards to
replace the fractured portions, and should be
then secured by a bandage.

A splint having two portions joined at right
angles, is best adapted to this case; the
upper portion is to be placed behind the upper
arm, and the lower part under the fore-arm ;
a splint will be also required on the fore
part of the upper arm ; these should be weU
secured by straps, the arm should be sup-
)>orted by a sling, and evaporating lotions
ke)>t applied.

i««H(v^ AlVer the lapse of a fortnight in the young

IH^licuU and of three weeks with the adult,
|MMMU\f moiiou should be carefully employed
\%\ \\kv\t\\\ anchykisis, which may otherwise

m«til^

337

I
'take place. In some of these cases, the ^ loss

t>f motion in the joint is considerable^ even

after the greatest care and attention on the

part of the surgeon.

Of Fracture of the Internal Condyle of ihe

Humerus.

When this accident occurs the ulna pro- signs of.
jects backwards, from having lost its support.
The injury may be distinguished from others
by the crepitus, which can be felt upon bend-
ing and straightening ^the arm, and from the
hand being turned towards the side during
tbe extension.

The same mode of treatment as that di- Treatment.
reeled for the fracture above the condyles,
will be proper in this case; passive motion
wi»t be employed early, when the recovery
will be complete.

Of Fracture of the External Condyle of the

Humerus.

This injury produces swelling over the ex- signs of:
iemal condyle, and pain is experienced at
the part on pressure, or during the flexion
and extension of the arm ; but it is best

VOL. III. z

338

distinguished by the crepitus, which, can be
readily felt during the rotatory motimis of the
hand. If the portion of bone detadied be
large, it is displaced backwards, and the head
of the radius accompanies it.

Dissection Two preparations in the museum at St.
Thomas's Hospital, exhibit specimens of this
fracture ; one is oblique, and the other trans-
verse at the extremity of the condyle. There
is not any ossific union in either, but the
fractured portions are joined by a ligamentous
substance, and this appears to be the case in
all instances of fracture with a capsular liga-
ment.

i^'hTd*"* Children are generally the subjects of this
accident; it is seldom met with in adults,
and very rarely in advanced age; and it is
occasioned usually by a fall upon the elbow.

Treatment. The bcst modc of treatment in this injury,
is to place a roller around the joints which
should pass also above and below it, then to
support the limb in the splint, having two
portions at right angles, as in fracture above
the condyles ; and to this, the upper and
lower arm are to be well secured. In
young children, a portion of stiff paste board,
applied wet, and bent to the shape of the
elbow, will answer best, as when dry it adapts
itself to the form of the limb, and affords an
excellent support.

339

-I After three weeks, the surgeon should rery Pwii'e
^utiously commence the passive motion.

If the fracture in these cases extends with- Bony
out the capsular ligament, a bony union may
with care be effected ; but when entirely
within the capsule, the union, as far as I have
seen, is always ligamentous.

Of Fracture nf the Cnronoid process of the Ulna.

The following case which I have for many

years related in my lecture, was considered

as a fracture of the coronoid process, and will

show the symptoms produced by such an

I injury.

A gentleman in the act of rimning, fell case.
upon his hand, which he extended to break
his fall, and immediately afterwards he dis-
covered that the motions of his elbow joint
Were greatly diminished, as he could bend
the arm but little, nor could he entirely ■
straighten it. His medical attendant in the
country, to whom he applied, found the ulna
projecting backwards, but that on forcibly
bending the arm, the figure of the joint be-
L ^ime immediately restored. A splint and

ndages were applied, and the arm sup-
wrted by a sling. Several months afterwards
fee gentleman came to town, when I saw
z 2

340

him; his ukia still projected behind the
condyles of the humerus; but could with
little violence be restored to its situation by
bending the arm.

mentowT' Somc time after I had seen this gentleman,

^^*^* I had an opportunity of dissecting a case
this injury, in a subject brought to St.
Thomas's anatomical theatre. The coronoicL
process of the ulna had been broken off with-
in the joint, and had only united by ligament^
so as to move freely on the ulna, and to allow^
the ulna to be carried back between the con-
dyles, when the arm was extended. .

Reasoo of. J ^^jj^ doubtful if the most careful treatment:
would effect a perfect cure, as the coronoidi
process loses its ossific nourishment, and has
only a ligamentous support. The vitality of
the fractured process oi bone 1$ only sup-
ported by the vessels of the reflected pwtions
of the capsular ligament, which do not appear
sufficient to create a bony union.

TreatMM. In the treatment oi this accident, the arm
should be kqpt steadily in the bent position
for three weeks, to allow time for the liga-
mentous union, and to make it as short as
possible.

Of Fract9it>e of the Olecranon.

niitiu M. Tho iu;!irk$ of the injury are generally so

341

evident, that it can scarcely be mistaken.
jA swelling takes place at the back of the
elbow, which, when pressed, feels soft, and
allows the finger to sink in towards the joint;
■this is between the two extremities of the
fractured bone ; the detached portion is drawn
upwards from the head of the ulna, to the
extent of from half an inch, to two inches;
it can be readily moved from side to side
teneath the integument, and becomes further
Hftfeparated from its former connection when
Wfce arm. is bent. The patient can bend the
T7 ann with ease, but he cannot extend it with-
out great difficulty, and the attempt gives
him much pain ; without exertion it remains
semiflexed. No crepitus can be felt; and the
rotatory motion of the radius upon the ulna
are perfect. Considerable tumefaction from
effusion of blood usually follows this accident,
atid in a few days the surrounding parts are
fQuch discoloured from ecchymosis. The
fracture generally occurs about the centre of
the process, transversely ; but I have seen
the bone obliquely fractured,
^L In dissecting the injured parts, sometime DinMtion.
^pfter the occurrence of the accident, the por-
"tion of the olecranon, still connected to the
ulna, exhibits some evidence of ossific de-
posit, and sometimes the detached part has
Lit marks of a similar character;
z 3

342

the cancellated stracture is filled with new
ottific matter. The capsular ligament is lace^
rated posteriorly on each side of the olecra-
non. It appears, therefore, that as soon as
the fracture takes place, the action of the
triceps muscle draws up the extremity of the
process, from half an inch to two inches, ac-
cording to the extent of laceration ci the
capsular ligament, and the ligamentous band
naturally connecting the olecranon to the
coronoid process.

Kxpf rt* To satisfy myself whether this process when
broken would again unite by bone, I tried
several experiments upon dogs and rabits,
when I found that if the fracture was trans-
yerse, and such as to allow of separation be-
tween the fractured ends, by the action c^tiie
muaclee, the union was atwmys ligamentous ;
but if the fimcture was oblique, and not ad-*
mittinir <^ sepantikm, the parts woe readily^
unittil by ossific deposit The want of bon]^
unnm^ appMTSi^ tber^ure, to depend upcm a
wtnut t4' ada|>tiQii of die brokea sufrces, and
m4 u|>^M\ ;9^uy ddkwKy of support, as in tilie
<HM^ witK iW feKfiire$ of processes within
iW \M^>$ular t^wmnis of toinis.

^>Miii^ l^l^i^ tjimci^f^^ VMT be Mrasnaed by fiilling
^|VM\ I W <^K>>w^wWft tbe ana b bent, or it may
M^y4iii\*i^l^>w^ lli^ ^ncwai <if tlie trieqps muscle

The principle of treatment in these cases t
is to render the separation of the fractured
extremities of the bone as slight as possible,
as the limb is weakened in proportion to the
length of the ligamentous union, from the
(Uminished power of the triceps muscle. The
arm, if possible, should be placed and fixed
in a straight position, and if much swelling
and pain exist, leeches and evaporating
lotions must be employed for two or three
days ; and immediately the tumefaction has
subsided, a bandage must be applied above
the elbow, and another below, having a por-
tion of linen or broad tape placed beneath
them longitudinally on each side of the joint ;
the ends of these pieces of linen or tapes are
then to be tightly tied over the rollers, so as
to approximate them, and thus bring the
hroken surfaces together. A splint well
padded must be placed on the fore part of
the arm and joint, and confined by rollers,
so as completely to prevent any flexion of the
limb. The bandages about the seat of injury
should be kept wetted with the evaporating
lotion.

This is the only injury to the elbow joint,
in which the straight position is proper.

Passive motion should be very carefully i
employed about a month after the accident,
hut not sooner.

z 4

344
When When this fracture is compound, uniofi by

compoond*

adhesion should be effected if possible, by
approximating the edges of the external
wound with adhesive plaister, and placing
over this, lint dipped in blood ; the treatment
in other respects, will be the same as in the
simple injury.

Fracture of the Neck of the Radius.

Very rire. This injury, which is said by some surgeons
to be of frequent occurrence, I have never
seen; but I do not mean to deny that it
sometimes happens.

When it exists, I should imagine that it
would be readily detected by the crepitus,
which the rotating of the radius would oc-
casion.

Treatment. The samc mode of treatment as that already
recommended for fracture of the external
condyle, would in such cases be most
proper

Of Compound Fractures, and Dislocations of

the Elbow Joint.

Not dan- I havc kuowu scvcral cases of this nature

gerous.

recover, with a partial anchylosis of the joint;

345

if properly treated, the constitutional derange-
ment in consequence of the injury, is not
productive of any serious mischief,

A brewer's servant was admitted into Case.
Guy's Hospital, on account of a compound
fracture of his elbow joint, attended with
considerable comminution of bone. The ex-
tent of injury was so great as to induce me to
recommend immediate amputation, but I
could not by any means persuade the patient
to submit to the operation. The limb was
therefore placed upon a splint, in a bent
T*osition, the bones being easily reduced ; the
^^Iges of the exterior wound were carefully <
Approximated. He recovered without any :
Vintoward symptoms, and retained sufficient j
**iotioa of the joint, to enable him to resume |
liis former employment.

I have known several other cases in whichf
^he patient have recovered, without any ^^^*
■Bevere constitutional sufferings.
P In the treatment of this injury, the limb Treatment,
should be kept in a flexed position, as anchy-
losis to some extent is sure to be the conse-
quence of it, when the position will lessen
the inconvenience attending it. If attended
with much comminution of bone, the loose
portions should be removed before the ex-
ternal wound is closed. In elderly persons,
or in those not possessing sufficient power of

^mpor — -^- — "^ -^ iuppurative pro

:e amputated in th<
. che edges of the
cogether by adhe-
Ljwred with lint dipped in
aopported by a band-
«iiii ia evaporating lotion.

:uw *f tkt Wrist Joint.

ji "iuA articulation may occur

»aw- Jxuc3tiiia Of the ulna and radius

jTSiuoicoa of the radius alone.
Jbax:i£:oa of the ulna alone.

••.?*-

"t^MOListsm tr VIA Ulna atid Radius.

H^M 3%nie$ nay be displaced from the

ja v^ci ^ carpal bones^ either for-

^^,^ I .ntvs.'^'ird^- If a person in falling

^^1^ %t'C^c ,'£ tie body received upon the

It t :tv i^i^. ^'* 2^s to occasion a dis-

^^•1 I '••i. c^^ forwards; the radius

. *^ ^^<:ft;r uron the anterior annu-

c^uv'tv .i •iv'' carpus ; should the fall.

347

however, be upon the back of the hand, the
contrary displacement may be {nroduced.

In each of these cases, two projections are sigm of.
perceptible, anteriorly and posteriorly, one
from the extremities of the radius and ulna,
the other from the bones of the carpus, which
render the detection of either injury easy.

The effusion which so frequently follows injanrre-

sembliDg

sprains of the tendons, frequently produces disioci&ik
an appearance somewhat similar to that re*
suiting from dislocation ; it may, however, be
distinguished from that occasioned by the
dislocations, as it takes place gradually, and
is rarely found on both sides, — ^whereas, in
the displacement, the projections immediately
follow the accident, and appears both ante-
riorly and posteriorly.

These dislocations may be easily reduced, RedmstiMi.
by fixing the fore and ijipper ?trm, whilst ex-
tension is made from the hand ; immediately
that the ends of the bones are separated from
each other, the actions of the muscles restore
them to their proper situations. When re-
placed^ they must be supported by ban-
di^es, and two splints, one placed before
and another behind the articulation, reaching
frt>m the elbow to the ends of the metacarpal
bcmes, to prevent motion, as weU as to pro-
tect the injured parts. The fore arm and hand
should be placed in a sling.

348

Dislocation of the Radius alone.

Forwards. The radius is sometimes thrown from its
articular surface anteriorly, so as to rest upon
the scaphoid and trapezium, where it forms a
projection ; the hand is twisted, the inner
side of the palm being placed forwards.

canie of. . A fall upou the hand, when it is bent back,
is the common cause of this injury.

Reduction. It may be reduced by the same me^s as
the former dislocation, and will require the
same after treatment.

Dislocation of the Ulna alone.

Backmrds. The displacement of the ulna alone, occurs
much more frequently than that of the radius
. alone ; the mode in which the former bone is
articulated by means of an inter-articular car^
tilage, and its not forming a part of the wrist
joint, allows of its being more readily thrown
from its natural position. It usually projects
backwards, and is attended with laceration
of the sacciform ligament. It may be easily
pressed into its proper situation, but imme-
diately the pressure is discontinued, it again
protrudes, as the support of the ligament is
destroyed. *

349

In the treatment of the injury, it is, there- Treatiicnt.
(ore, necessary to employ a compress over
the extremity of the ulna, aind then to sup-
port the bone in its natural position, , by
bandages and splints, as in the former dis-
location.

Of Dislocations of the Uina, with Fracture of

the Radius.

The ulna is often dislocated forwards, the
Jadius being at the same time fractured
obliquely about an inch above the ar-
ticulation.

The hand is, in these cases, thrown back- signs of.
wards, as in the dislocation of both bones
forwards j the extremity of the ulna can be
felt just above the pisiform bone, beneath the
teiuion of the flexor carpi ulnaris, and the
fir?tct]ired extremity of the superior portion of
^ie radius is situated under the flexor ten-
ddiisof the hand,

.The reduction in these cases is usually ReducUoo.
very difficult, requiring powerful extension ;
Wtd there exists a further difficulty in pre-
serving the proper position, when the reduc-
tion has been effected, as the bones are again
displaced from the slightest cause, unless
confined by bandages, &c. The extension

xV nV "^

Vbx*\»»*^

350

-,^ r .:aue as in the former cases, an<

_^ _c .ones have been drawn into thei

_^ ..uiauons, two cushions must h

_^ a» Jeibre and the other behind th<

^--u'^i and there firmly bound down b]

.^, . ver these, splints, lined with pads

^^ je Jiaced, to reach from the elbow tc

. ...uiu, and secured by a long roller- The

^ :iu$c be placed in a sling for three

.v^* i' "he patient be young ; or from four

• V. veeks if aged, before passive motion

V tsorted to for the purpose of restoring

i«: ULOcions of the joint, which will not be

viitfcdv effected under four or five months.

Jr Cofnpound Dislocation of the Ulna, with
Fracture of the Radius.

The consequences of this injury are serious
sH tK^t, according to the degree of surround-
ing mischief, and the extent of the firacture ;
ii ^vmminuted, the subsequent inflammation
iM sovere, but otherwise of trifling extent,
when judicious treatment is adopted.

Iho reduction is to be accomplished as
\vhi*u the simple dislocation and fracture
\HH*ur ; the edges of the wound must be care-
hill v approximated, and every means taken
lo iironiote adhesive inflammation, and to

351

Tteep it within bounds by evaporating lotions,
and tbe employment of leecbes if necessary.
The arm must be laid on a spHnt, and sup-
ported by a sling. The dressings should not
be disturbed so long as the patient remains
free from suffering, or until the wound has
united ; should symptoms of suppuration
t'OCcur, the removal of part of the dressings
I «iay be sufficient to allow the escape of the
JUS, without taking off the whole.

Dislocation of the Carpal Bones.

This injury is of very rare occurrence. ^"y ■■'

An elderly woman was admitted into Guy's Case.
Hospital, in consequence of an accident to
''er wrist, produced by a fall upon the back
of her hand ; the radius was found to be frac-
tured obliquely through its inferior extremity,
3Qd the part thus separated from the shaft of
tile bone, was thrown backwards upon the
''^rpus with the scaphoid bone. The fingers
•^Ould be extended, but not entirely flexed,
■''he reduction was readily accomplished by
^^ctension and steady pressure, and the part
^^ipported by splints. Leeches and evaporat-
'**g lotions were employed at first, to subdue
'■he inflammation and tumefaction which
followed the injury, and afterwards, further
l^pport was given by strips of soap plaistcr.

352

GangUa. I have knowH ganglia, which so frequently
form about this part, several times mistaken
for displaced bones, but a little attention to
the history of the case will readily explain
the difference.

Partial Relaxation of the carpal ligaments will

18 oca on gQjjjgjijj^^g admit of a partial ^location of

some of the bones, when the joint is forcibly
flexed; and this state is generally accom-
panied with great debility of the part, pre-
venting the patient from any continued exer-
cise of it.
Treatment. Moderate pressure and support are the
best means of relieving such complaints, the
use of friction and of cold water poured from
a height upon the part, I have known of
service.

Of Compound Dislocation of the Carpal Bones.

Causes. ' This frequently happens from the bursting
of guns, or from the hand and wrist being
caught in machinery, and in such cases, one
or two of the carpal bones may be removed,
and a considerable degree of motion be
afterwards preserved in the articulation;
but, if attended with extensive surround-
ing mischief, amputation should be per-
formed.

353

The following case occurred under tlie care '^*-
of Mr. Forster, in Guy's Hospital. Richard
Mitchell, aged 22, was admitted iuto the
Hospital in consequence of an extensive
Wound into the wrist joint, inflicted by a wool
combing machine. Two-thirds of the joint
Were opened, and the surrounding soft parts
'lad suffered considerably. The scaphoid
t>one was dislocated backwards, and nearly

Separated from its usual connexions ; the

extensor tendons of the thumb, of the fore

^nd middle fingers were torn through, as was

^'so the radial artery, which, however, did

**ot bleed much. The scaphoid bone was re-

i^oved, and the edges of the wound were

approximated by sutures, and adhesive plais-

*^^r applied in strips; the whole was covered

"J lint dipped in blood, and supported upon

^ splint to prevent any motion of the joint; .

^ small quantity of blood was taken from the

^TiQ, and the seat of injury kept moistened

^Vith an evaporating lotion. In two or three

*lays it became necessary to remove these

•Itessings ill consequence of suppuration,

^heii a poultice was applied. A small slough

■^liich had formed, separated kindly, and the

Process of granulation went on without a

^^teck, so as to fill up the wound in the course

'^f three weeks. His recovery was somewhat

•"etarded by the occurrence of a pulmonary

VOL. III. 2 A

354

affection, requirmg the use of leeches^ dia-
phoreticsy kc. to which it yielded. He Idt
tiie Hospital^ with but little motion of the
fingers, but this appeared to be gradually
increasing.

Dislocation of the Metacarpal Bones,

Aiticaution The articulation of these bones with (he
carpal is so strong, that great violeace is re-
quisite to separate them. I have seen them
displaced from the bursting of guns, or the
passage of a heavy laden carrit^e over the
hand.

Removal of In thesc cascs, one or more of the m^-

'^' carpal bones may be removed without am-
putating the whole hand.

caso. I amputated the middle and ring fingers,

with their metacarpal bones, from the hand
of a Mr. Waddle, of Cheapside, in con-
sequence of their being extensively injured
by the bursting of a gun. I brought the
edges of the wound together by sutures, and
approximated the fore and little fingers by .a
roller ; the wound united readUy, aiid he had
afterwards a very useful extremity^

Case. A boy was admitted into Guy's Hoi^[ntaI

with a very severe injury to the hand, fiom
the bursting of a gun, by which all the

365

iftetacarpat bones, excepting that of the fere
fing^er, were so sliattered, as to render it im-
possible to save them. The thumb had been
entirely separated, with its metacarpal bone,
and the trapezium was so much injured, that
1 thought it proper to remove it ; I therefore
toolt it away, as well as the metacarpal bones
of the middle, ring, and little fingers, with
the fingers themselves ; thus only leaving the
fore finger with its metacarpal bone. He
iovered quickly, and could use this finger
a hook with the greatest facility and
ailvantage.*

fracture of the Head of the Metacarpal Bone.

The digital extremity of a metacarpal Sf«iof.
^ne, which is called the head, ia sometimes
'"'oken off, and gives rise to an appearance of
I dislocation, but the crepitus, on exami-

^^^ A case somewhat similar to the above, occurred
I *nder my care in Si. Thomas's Hospital, in whicli I was
obliged to amputata tlie little and ring fingers from the
'Bjured hand, with their metacarpal bones. I also re-
■Xored the unciform bone, and the middle finger, with
Iwo-thirds of its metacarpal bone. The recovery was
D^dual, but complete, and ttie patient can ni)w use bis
tbumb and fore finger very expertly.~T. - '"- ■■' — i

360

iiation, makes the nature, of the accideiit mrj
evident. j ;. : ' .
Treatment. I^ the tfeabptent Df Hm^. accident, the pa-
tient should be made to grasp a large .ball of
firm materials, and over this his hand should
be confined by a roller ; this is the best me-
thod of restoring the firactured bone to its
natural position.

Dislocations of the Fingers.

commwi The most frequent seat of this displace-
ment is between the first and second pha-
langes ; but it is not an accident of common
occurrence.

Nature of. The dislocation may occur either back-
wards or forwards, when the projections
formed by the ends of die bones plainly in-
dicate the nature of tie injury.

Reduction. If reccut, the reduction may be easily ac-
complished, by making extension with a
slight inclination forwards, to relax the flexor
muscles ; if of some days standing, a long
continued, and steady extension^ is necessary
to replace the bones. It has been recom-
mended, in cases of difficulty, to divide the
ligaments or tendons, btit I have seejoi too
much mischief result from injuries to these
parts, ever to advise such a practice.

367

The same observations are applicable to Remarks
the dislocations of the toes, but rather more ^a^es
diflSculty is experienced in t^ reduction, on ^
account of the shortness of the phalanges.

of ^^n\ d

Of Dislocation from Contraction of the Tendon. ^IVJ^^^

The phalanges are sometimes drawn out Cause.
of their proper positions, by the cbnitraction of
a flexor tendon and its theca; in consequence
of a chronic inflammation, induced by exces-
sive employment of the hand in rowing,
ploughing, hammering, &c. ; nothing can be
'done to relieve these cases, but when merely
a single band of fascia is thickened, and pro-
duces this deformity, it may be divided with
much advantage by a narrow bistory, intro-
duced by a small opening through the skin.
A splint must afterwards be applied, to keep
ilie finger straight during the healing of the
wdund.

A similar contraction also occurs in the inthetoea.
tendons of the toes from the wearing of tight
'sitoes ; the projection of the first and second
; phalanges, in these cases, often gives rise to
so much suffering and inconvenience, as to
^akeit necessary to amputate the toe, other-
wise the patient cannot take necessary e^lcer-
cise, and is deprived of many enjoytnents.

2 A 3

368

riH^ omm in which I have performed the
•>|MttttiiNi» have generally done extremely
w%^U, and restored the patients to comfort:

Dislocations of the Thumb.

viiucuiHi jjig number of strong muscles connected

^uiHig. ^itd Uie bones of the thumb, render the

reductions of their dislocations very difficulty

especially when much time has been allowed

to elapse from the receipt of the injury.

^tke Mttacarpal from the Carpal

JSotK*

VoTM oc In the majority of cases in which I have
MTitnessed a displacement of the metacarpal
bone of the thumb firom Ae trapeamn, (he
former has been throwii inwards towards the
metacarpal bone of the fore finger. The
thumb has heca, beat backwards, and the
extr»nity oi the bcme has formed a pm-
jection in the palm oi the hand ; it has been
attended with ccmsideraMe pain and tome- -
faction*

H«iiihiNm. In midcing the extension for reduction, it:==
is )>articularly necessary to attend to the re —
Uxatit^n^ as for as possiUe, of the most^

powerful muscles^ which are the flexors, thu$
the thumb iQ,ust^ during the process^ be ixk-
dmed towards the palm of the hand. The
force applied must be continued and steady^
as violence will not eifect the desired object.

If simple e2(tension does not succeed in
reducing the dislocation^ the part must be
left to the degree of recoyery which nature
will effect, as it would be improper to attempt
relief by any division c^ muscles or tendons.

A compound dislocation may be pr^i^duced ^J*^^^
at this articulation by the bursting of a gun>
and in such a case, if the tendons are not
lacerated, the dislocation should be reduced,
which it can be easily, and the edges of the
external wound should be brought together
by suture, when, with careful treatment^ a
good emre may be effected.

A $ai3e of this kind occurred at Brentford, ciue.
under the care of Mr. George Cooper, in a
young ge^tlen^an, aged thirteen; the injury
W|LS CK^casioned by the bursting of a powder
v^asli; ifi his hand. The mass of muscle con-
iKtcting the thumb to the hand was torn
^through, but the tendons of the long flexor,
and of the extensors were pot injured. The
dfelocation was redaeed^ and the wound
doMd^ by sutures a^d adhesive plaister, over
which an waporating lotion was applied.
The wound unU;ed in part rapidly, and the

2 A 4

360

remaining portion healed kindly by grann-
lation. Two weeks after the receipt of the
injury, Mr. Cooper began the use of passive
motion, and the patient ultimately gained
perfect motion in the joint.
AmputatioB Should, howevcr, the tendons be Jace-

required.

rated, or much surrounding mischief didst,
amputation will be required ; and I have
found it necessary, in such a case, to remove
the articular surface of the trapezium, which
I think may be done with advantage, espe-
cially when there is a scarcity of superficial
soft parts.

Dislocation of the First Phalanjr.

Simple. Ii^ the simple dislocation at this articu-

lation, the first phalanx is thrown back upon
the metacarpal bone, • forming a projection
there, whilst the end of the metacarpal Ixme
protrudes towards the palm of the hand ; the
motions of the joint are destroyed, although
the thumb can be made to approximate the
fingers by the movements of the carpo-
metacarpal articulation. .

Rednction. The modc of applying the extension finr
the reduction of this dislocation, should be
as follows, and the direction should be to-
wards the palm of the hand, to relax the

361

r muscles. The hand should be
id warm water for a considerable time, to
relax the soft parts as much as possible, then
a piece of soft leather wetted, should be
placed closely around the first phalanx, and

I over this a portion of tape, two or three yards
m length should be fixed by the clove hitch,
(a knot, so called by sailors.) An assistant
should next firmly hold the metacarpal por-
tion of the thumb, by passing his fore and
middle finger between the patient's fore-fin-
ger and thumb, whilst the surgeon draws the
first phalanx from the metacarpal bone, in a
direction somewhat inwards to the palm of
tLe hand.

if the above plan does not succeed, the Another
! fi)liowing should be adopted ; — The leather
and tape being applied as before, a strong
Worsted tape should be passed between the
patient's fore-finger and thumb, and this
should be tyed to a bed post, around which
the arm should be bent ; a pulley being then
fised to the tape connected to the first phalanx,
a gradual and steady extension should be
"nade.whichwill generally effect the reduction.

When the above described means have Sometimes
i^eeu fairly tried, without success, it will be
''est to leave the case to nature, when the
patient will, after some time, acquire a great

362

When In cases of compound dislocation^ should

*^^**®"" the redaction be difficulty a part of the extre-
mity of the bone may be removed by ampu-
tation ; and the patient may afterwards ob-
tain a useful joints by the early employment
<tf pasttve motion.

Of Disiocatian of the Second PhtUanj^.

Easily de- In a simplc dislocation of this kind, the
nature of the injuiry can scarcely be mistaken,
and the reduction may be accomplished in
the following way:---The surgeoa ahooM
grasp the back of the first phalanx with im
fingers, and apply his thumb upon the ftre-
part of the dislocated phalanx, and then Sei
it upon the first as much as possible.

Treatment The treatment of tiie compound dislocation

of com- ^ *

pound, of this articulation, is the same as that reerai-
mended for a similar accident in the fint
phalanx ; but the ends of the tendon should
be made smooth by the knife, wh^i,. by care-
ful approxijnation they will unites Passive
motion may be used in two or three weeks.

363

I I

LECTURE Xtlll.

11 : J^locatioiu of the Hip

.J ;i 1 1. • « .' ■ »■

•at

"'Hit head df the femur may be throwH
Mm tbe acetabulum in four directioiis.

' Flr8t«-^-^Upwards» upon the dorsum of the
mini*'

Second.r-Downwardft, into the fbramen
Wte;- • '.. .

11iifd;--^Backwarda and upwards, m the
iiehialic notch.

«'ti Ainrth« — FcNrwards and upiwards/upon the
body ef the pnbea.

A digplacement downwards and backwards AfifthfonB.
W been described by some surgeons, but
t haire neveir had an opportunity of witness-
^ it, and I am inclined to beliere that some
^stake exists about this injury, although
1 do not mean to deny the possibility of its
^Hicurrence.

364

Dislocation Upwards and Backwards an the

Dorsum Jliii.

The Mott This is the most common of the displace*
ments of the hip joint, and is marked by tiie
foUowmg signs :—

Signs of. The limb on the injured side is firom one
inch and a half, to two inches and a half
shorter than the sound limb. The knee and
foot are turned inwards ; the knee being
a little advanced upon the other, and the
great toe rests upon the tarsus of the other
foot. The motion outwards is destroyed, so
that the leg cannot be separated finom the
other, but the thigh may be a little bent
across the sound limb. The head of the boiie
may be felt, and seen to move, upon the
dorsum of the ilium, if the knee is rotated
inwards ; excepting when the injury gives
rise to extensive extravasation' of Mood ; the
trochanter major is thrown much nearer fhan
usual to the anterior supierior spinous pro-
cess of the ilium, so as to render the rotun-
dity of the injured hip much less than that of
the sound side. The chief marks will there^
fore be, difference in length, change of posi-
tion, diminuticai of motion, and loss of pro-
jeckion or rotundity Irom the altered position
of th^ trochanter major.

366

The accident with which this dislocation Fracture of
is most liable to be confounded, is the frac-
ture of the neck of the thigh bone within the
capsular ligament. The distinguishing marks
are, however, sufficient to prevent any mis-
take, if common attention be paid to the
e^e. In the fracture of the neck of the
thigh bone, the knee and foot are usually
turned outwards, and the trochanter is drawn
upwards and backwards upon the dorsum of
the ilium ; the limb which is shortened cue
or two inches by the contraction of the mus-
cles, can be restored to the same length as
Ihe other by slight extension ; but the
shortening immediately recurs when the
extension is abandoned ; and the limb
j may be readily flexed, although it creates
much pain. On rotating the limb, when
extended, a crepitus can be felt, which

^is not perceptible whilst the limb is drawn
^ This fracture rarely happens, but
ifiold persons, and is generally the effect of
a very trifling injury ; it occurs, hovrever,
much more frequently than the dislocation.

Thus the greater mobility of the joint, the

ease with which the length of the limb is

i^atored ; and the perception of crepitus

I Airing rotation, when the limb is extended,

^nish ample marks of distinction between

i the two injuries. ,.:aj:|ui ■.!:_;

366

The alterations in the figure of the jdnt

produced from inflammation and nlceratioBj

can hardly be mistaken finr dislocations from

▼ioleiice, excepting by persons ignorant at

anatomy, and but little attentife to thiifa'

{Mofessional duties. The gradnid progress >tf

the symptoms, the pain in the knee, ^

increased length of the limb at first, and AH

marked shortening afterwards; the extent oT

moticm, but the sufferings created by- any

extreme movement, are differences ^whkh

wookl Inrdly escape the notice <rf tfie most

careleas observer. The coasequeiieea of Hm

disease, when of long standii^, are uksr^

ation of tiie heiNl of tiie bone, l^aments^ and

acetabohim, accompanied with aiidi> a

diange of situaticm of the parts, as acMBetimei

to present the appearances of ^Hriocatioa,

but the history of the ease wiH readily infimi

the surgeon of its tme natore.

SI1I9 tr In the dislocatiQa upoii die dofsom of Ikt

ilram, tiie pyiiiMnais and gintei mnadea^ thi

trieqis, tiie pectineiK, the psoas magnoB, and

iUacus intemus, die rectos, die semitendi-

mosus, and membranosos, the obturator ez-

leraus, and one head d die bicqia are aH

sAKMTtened. The obturator intemus, the ge-

rnini^ and quadratus lemoris are all stretched.

The triceps and glutei chiefly oppose the

r^uction.

This dislocation is occasioned by a fall or Camc.
blow when the limb is turned inwards.

following manner ; bleed the patient to the
extent of from twelve to twenty ounces, or
even more if he be very robust, then place
him in a warm bath, at the temperature of
100°, and gradually increase the heat to
110°, until he faints : eind to accelerate the
fiantness, give him in solution a grain of
tartarized antimony every ten minutes, until
nausea is excited. When faint, remove him
from the bath, envelope him in blankets, and
place him between two strong posts, about
ten feet asunder, and in which two staples
Me fixed ; or rings may be fixed in the floor,
and the patient laid between them. He
tuld be placed upon his back, and covered
Ji with blankets. A strong girt should then
passed between the tliighs, close to the
upper and inner part of the injured limb, and
the ends of this should be fastened to one of
tte staples. A wetted roller should next be
placed tightly on the lower part of the thigh,
just above the knee of the injured limb, and
upon this a leatlier belt, with straps and
rings affixed for the attachment of the pul-
lies, should be closely buckled. The knee
should be slightly bent, and the thigh di-
rected across the sound one just above the

• and

368

knee 4 The pulUes must be attached to the
straps of the belt, and ta the other staple.
The.surgeon now should gradually and care-
fully commence the extension^ and continue
it until the patient begins ito complain of pain,
when he should rest a little, without relaxing,
so as to fatigue the muscles ; haying waited
a short time, he should again draw the ccurd,
and when the patient again: complains, he
should again suspend the extension, and so
on, until the muscles yield, and he finds tiie
head of the bone is brought near to the ace-
tabulum, when he should give the string of
the puUies in charge to an assistant, with
directions to keep up the extension, whilst
he himself rotates the knee and foot gently,
under which motion the reduction will be
usually accomplished. When the pullies are
used, the head of the bone. does not generally
return into the acetabulum with a snap, as
the muscles, from continued extension^ have
not sufficient power remaining to allow of
any powerful contraction ; thus the surgeon
can only be assured of the accomplishment
of the reduction, by the restoration of the
figure of the part, and by loosening the pul-
lies and examining the joint.

It sometimes happens, that the bandages
get loose before the extension is sufficient,
when they should be carefully re-applied, but

369

io as short time as possible, to prevent the
muscles from recovering tbeir original tone.

When the head of the femnr has been Head of
l^ught by the extension to the edge of the
acetabulum, the rotatory motion above-men-
tioned, is not always sufficient to promote
the reduction, but the head requires to be
l^ted over the lip of this cavity ; this may
be performed by passing a towel or napkin
as near to the joint as possible^ at the upper
part of the thigh, and by it an assistant
may raise the upper part of the bone from
the surface of the ilium.

When the reduction has been accom-
pliriied, the patient must be very carefully
removed to bed, in consequence of the risk
of fmrther displacement, frpm the very re-
laxed state of the muscles.

. ' The reduction of this dislocation may be in recent
completed, in a very recent case, before the
muscles have had time to contract, by exten-
sion made in a direction, not under other
circumstances, well adapted for this purpose ;
and I have seen it thus effected : — ^The mode
described by Mr. Hey, if I understand it
correctly, appears to me but little calculated
to succeed, unless in a very recent case ;
but I state this with great deference, as no
one can have a higher opinion of the talents
and professional acquirements of Mr. Hey,

VOL. III. 2 B

i30

i«

ittT tNi aa cJiceptSMn to a
rul occQT but verr sekiom.

-viuii I haare advaBcecL

ot' txfsaBBBt deiaiied i^

dir

beoents to be oin lii li bv^tfae
Qi* dK piiUia, and the aHHOBce of
tHBad tnestmcnl*

I ami iodefalefL 10 Jfic* 1^ ^^j ■■■iigwn^ M

Chester, isrtlieiiulDry^af liiefiiDaipm|rewe.
Jofan Fonter, aged tw^Hr-two jrem^ had
iuft dufi^ dislocatied in conaeqiiemre irf* acafft
paaan^ owtt his pelm^ and was aiAnitted
into the ClK^er Infinnary Jiiiy 10, lgl8,
scMMi after the receipt of die injmj. Hie
nature of die injury was well marked. The
patient being ptaced upon a table, extension
was made by poHies for fifty minutes without

He was then placed in the warm
loath for twenty minutes, after which the ex-
tension was repeated for a quarter of an hour,
but stiil without the desired efteet. He
was then bled to the amount of twenty-four
tmnces, and he took forty drops of tincture of
Opium, but as this did not create faintness,
the solution of tartar emetic was exhibited in
small and frequent doses ; this soon produced
nausea and faintness, during which a steady
extension for ten minutes accomplished the
reduction.

Mr. Nott, of CoUumpton, Devon, sent me
the following particulars ; —

John Lee, aged thirty-three, a very stout caie.
^laan, dislocated his left hip by a fall, Octo-
.(ber9, 1819, but was not seen by Mr. Nott
iintil the 4th of December following, just
«ght weeks after the accident, the effects of
which still remained, exhibiting distinctly
the usual appearances. The bandages and
pullies being applied, extension was gra-
dually made, and at the time of its com-
mencement, the solution of tartar emetic was
fcpven him, and repeated every ten minutes,
^teut without creating much nausea. The ex-
tension still being continued, he was bled
to the extent of sixty ounces, but without
producing syncope. The extension was kept
pup for two hours, when an evident alteration
2 a 2

372

•js •^.'T.vL'Cible in the injured limb; the
...a; •! :iie bone was elevated by means of a
>. iwr* titiier the upper part of the thighs and
•IV iinb was rotated ; soon after this period
. ^Ttiau^ ^"us heard from the situation of the
x^HiK ot' the bone, and the man immediately
, \c* aimed that the limb was reduced ; and
tiiss on relaxing the pullies, we found to be
^»rtvcC : before removing him to bed his legs
>»tMX' bound firmly together to prevent any
tviirrence of the displacement, and a large
>iisterwas applied over the trochanter. When
io wus first allowed to rise from his bed, a
Xiitduiro was applied upon the thigh and
|K*lvis ; passive motion was previously em-
ployed. In five weeks after the reduction he
walked noarlv twenty miles without incon-
^euionoo.

Tho above case shews that the reduction
nuw Ih^ ofiected bv skilful mana^fement a
0\M\siderable time after the receipt of the
uyiury. And this is fiirther confirmed by
OAsos rolaicni by >Ir. Mayo, and Mr. Tripe,
of Plymouth, in each of which the disloca-
tions hftii oxisiod seven weeks before the
\xsluotiov.s were accomplished,

Tho t>"\^M i-.ic eases prove that this dislo-
%';Uior, r..;\> ■>;' ;v:^'.Avv\i w.thout the use o
\\\x' ]K,\.w<, >\\\ a: :he s:"u:\e ume shew how
il% vua^;^^ ;lv:: r.ss,sr<v.:oe would have been.

Holt of Tottenham requested me to c
visit, with him, Mr. Piper, aged twenty-five
years, who was the subject of dislocation of
the thigh upon the dorsum of the ilium, but
which had existed a month previous to his
coming under the care of Mr. Holt. Mr.
Holt and myself, assisted by five powerful
men, used our utmost exertions to replace
the bone, and we were several times obliged,
from fatigue, to relax, and renew our at-
Htempts. After repeated trials, for fifty-two
Hiiinutes, we succeeded in effecting the re-
duction, when we had determined to make
but one more effort.

Another case, which I attended with Mr. case.
Dyson of Fore-street, was reduced without
be use of pullies, but with so much violence,
nd such unequal extension, that I am sure
i surgeon, who had seen the puUies em-
ibloyed in reducing this form of dislocation,
ould have recourse to any other method.
Mr. Oldnow, of Nottingham, sent me the Cnsc.
irticulars of a case in which the reduction
iras effected without the assistance of pullies,
"but in which an extension was made from
the ankle, the pelvis being secured by tow-
els. The dislocation was recent, and the
t reduction easy.
L. '

374

Dislocation doumwards, or into the Foramen

Ovale.

Signs of The displacement of the head of thermos
femoris into the obturator foramen, ooca^
sions an immediate lengthening of the lioib,
to the extent generally of two inches.
The projection of the trochanter major is
lessened, and the body is bent forwards from
the stretching of the iliacus internus and
psoas muscles. When the patient is erect
the knee of the injured limb projeete fiN^
wards, and the thigh is widely separated
from the sound one from the action of the
glutei and pyriformis muscles, and it cannot
be made to touch the knee of the perfect
extremity without great violence. The foot
is also widely separated from the other, but
the toes are not either everted or inverted,
but are usually directed forwards. In very
thin subjects, the head of the bone may be
felt, by firmly pressing the fingers upon the
inner and upper part of the thigh, towards
the perineum.

The chief diagnostic marks are, therefore,
the increased length of the limb, the separa-
tion of the legs, and the bent position of the
bodv.

375

The head of the bone is thrown below, and situation of
Hither anterior to the axis of the acetabulum ;
9mA a depression exists below Poupart's liga-
ment.

,erThe dislocation is produced by a fall or Cause.
Jbiw when the legs are much parted from
other,
mischief occasioned by this injury is Dissection
ely well shewn by a preparation in ^'

Museum of St. Thomas's Hospital which
cted many years ago* The head of the
is rested in the foramen ovale,^ which
tirely filled by bone, the external obtu-
muscle and the ligament, naturally oc-
lying this space, being absorbed ; bony
er had been also extensively deposited
iftbund the edge of the foramen, so as to form
iMleep socket, which enclosed the head of
At bone, so that it could not be removed
mithout breaking the cup, but still allowing
inconsiderable motion ; the interior of this
locket was perfectly smooth. The acetabu-
lum waB half filled with ossific matter* and
Sefinuch altered as not to be capable of con-^
kttming the head of the thigh bone, which wa&
but little changed, its articular cartilage still
r^xiaining perfect. The ligamentum teres was
eMupletely torn through, and the capsular
li^ment partially lacerated. The pectinalis
and adductor brevis muscles had been torn,

2 B 4

'»

.'it i3C iJLXcri by tendon, the psoas,
^ -i» czsTJos, and py riformis muscles,

1: rfc :»=^n «;ipposed that the ligamenturo
-.r^e? "»Ti z*:z lacerated in this dislocation,
I :h.e dead subject, the head of the
':•: ir:iwn over the lower edge of
cin. if the capsular ligament be
^T-cei -^i^*: the round ligament remains
jurtLTSC. but as the dislocation occurs
wit I nc tiiirhs are wide apart, and the
:^;;^n:e-^: j? uroa the stretch, when the head
■: .He bcct' :5 thrown from the acetabulum
.>: ii^ace'c: is torn through before the dislo-
rXLXii :> sXiaplete.

1 1 t^lc^^c; cases the reduction of this dislo-

,-icoiz :v.dy be easily accomplished by the

i»uc«-.n^ uieans. The patient being placed

ipt^a ijs back, and his thighs being sepa-

twvc 1^ widely as possible, pass a girt be-

-%cci :i< upi^er part of the injured limb and

V .^««icc^twtti ^ and let the ends be fixed to

i >.;3i,s.^c iti the wall of the room ; then grasp

■V .i *.i''C of the dislocated extremity, and

j:iw ;.w luub over the sound one, and thus

.'K' N\tvl of ihe bone will slip into its proper

^ o ;\ ri.uinsr the patient upon a bed, so

.>.i, .'its oi :':*.c beii-iM>sts is received between

v \;: : v^i" the thighs, and then forcing

vo *.:tib across the sound one, will

» ». •»

also effect the same purpose. Homeiunes,
liowever, it will be found necessary to place
a second girt or bandage round the pelvis
beneath that which I have already described,
and the ends of this second girt should be
fixed to a hook or staple on the sound side of
the patient, to prevent any lateral motion of
the pelvis at the time that the injured extre-
mity is drawn across the sound limb, other-
wise the motion of the pelvis following that
of the limb may prevent the reduction.

Should the dislocation have existed for ofiong

three or four weeks before any attempt is "^•'■"b-

tDade to reduce it, the patient should be

placed upon the sound side, and his pelvis

fixed by one bandage, whilst another is

placed under the upper part of the dislocated

thigh, and connected to the pullies above so

as to act perpendicularly ; the surgeon should

then press upon the knee and leg to prevent

I their being drawn up with the superior por-

! tion of the thigh bone, at the same time that

an assistant elevates this latter part, by draw-

, ing the cord attached to the pullies. Great

J care must be taken not to press the leg and

( knee too much, or the head of the femur will

I be forced backwards into the ischiatic notch,
p the power of the lever which is employed
iP'TCry great.

Ligaroentiiiu
teres torn.

Rcdiictioii
if recent.

but lia< '

iliacus
were a
It])
teres
becar
boiK

.* .=r •» .".aiinunicated to

tlu*
i\h
111
\\

c itty, received an
_• I ynsequence of a fall
. . jBeavnunng to stop the
.jm. -m tsnj with him. Be-
^is after the acci-
X -Wfir, in Essex, was
lacencand Mr. DanieU
r Jlr. Potter at the time,
Tj *t; rie case.
HI! oiiizjed limb, it was
^^ . T rnsf jnriits longer than the

separated, and

itru; ccrward; when the

csflBrsyvan!^ 11 scuid. his body was

Hti 3i:?iry being thus ex-
1115 i:ujwing means were
I .rtcct iiif »iuction of the dislo-
Itfe *auKSC JtfTTu: n?bust, some blood
3Af£ met iifi inn. but as this did
.,utt:^ TMU« lis powers, a solution
-ir -attic "%:» iCtTen to him. He
^dL-»A M US a4ce, near to the edge
i2» . tM. ^^ - -^ >triii^ passed round his
•ssa- .u'T'--'"* m^'-iiii the frame of the
^,^ rr.cc. s: IS to prevent any
:^ ^ii'- . 1 >econd girt was

.f<el%«

379

Miised between the thighs^ and §xed to
be pullies above the upper part of theinr
pred limb. Whilst the ext^sion was making
Mkv Potter rotated the limb^ and drew the
lltoe towards that on the sound side. When
iuf$e means had been continued for ibmit
Ml minutes, the effects of the tartar emetic
became excessive, and in five mmutes after-'
rtifds the head of the bone returned to its
original socket with a snap ; the patient Mraa
Hw placed in bed, and the injured parts
l^pported by a roller. He speedily recovered
tihtuse<tf his limb.

-i: ■ ■ . .: .

^riOfthe Dislocation backwards, or into the :•

Ischiatic Notch.

'fdn?. describing this dislocation, some'sur- common

. . . description

pmm have considered the head of the os wrong.
Anoris as being thrown backwards and downr
Urnds ; ' which must have arisen from their
Ubiscollecting the natural position of the os
itiKiminatam in the skeleton. This notch
^ikkik gives passage ^to the pyriformis muscle,
liA^o to the gluteal, ischiatic and internal
pudental arteries, with the sciatic nerve, is
Manrally situated a little above, as well as
Itttiiiid the acetabulum, so that the head of
^ thigh bone when displaced into this

380

SitoatioB
of bone.

Difficult to
detect.

space, is placed upwards as well as back-
wards, with respect to the acetabulum ; and
this you must carefully bear in mind.

The head of the os femoris in this disloca-
tion is situated on the pyriformis musch^
between the edge of the bone which fionns
the upper part of the ischiatic notch, and did
sacro sciatic ligaments. i

Of all the dislocations of the thigh, this k
the most difficult to detect, because the length
of the limb is but little altered, and the chan^
in the position of the knee and foot is not no
marked as in the dislocation upwards. It is
also more difficult of reduction because the
head of the bone is placed deeply behind the
acetabulum, and requures to be lifted OYtf
the edge, as well as drawn towards it.
signi of. The dislocation is marked by the following
signs : — ^The limb is from half an inch 4x> one
inch shorter than the sound one^ but rarety
more than half an inch. The natural piO|6e^
tion formed by the trochanter major is di-
minished, and is inclined towards the ace-
tabulum, but still remains at right an^
with the ilium. The head of the bone' csi
only be felt in very thin persons^ and then
not very distinctly. The knee and foot are
turned inwards, and the great toe rests against
the ball of the great toe of the sound limb.
When the patient is erect the toe touches the

]

381

ground^ but the heel does not quite reach it,
and the knee is bent and projects a little for-
wards. The motions of the joint are in a
great degree prevented, admitting but of
flight flexion and rotation.

f There is in the collection at St. Thomas's DisMcUooof
Hosfutal, an excellent specimen of this injury,
which I met with accidentally in the dissect-
kig room. The original acetabulum is en-
tirely filled by a ligamentous substance, so
that it could not have ^gSLin received the head
of the femur ; the capsular ligament is torn
anteriorly and posteriorly ; the round ligament
ia torn through ; the head of the bone rests in
tiie situation I have before described; but
there is not any appearance of an endeavour
to form a new socket for its reception. A
oew capsular ligament surrounded the head
<^- the bone, but it has been opened and
tamed down to exhibit the head, with the
lacerated portion of the ligamentum teres
connected to it.

, This displacement occurs from the applica- Canse.
tiou of violence when the thigh is bent at
f^t angles with the body, so that the knee
18 forced inwards.

r The reduction, which is extremely difficult. Reduction.
ia best effected in the following manner : —
Place the patient on a table upon his sound
side, and fix the pelvis by passing a girt

382

between the pudendum and inner part of the
thigh, and making it fast to some firm point;
then apply a wetted roller round the limb
above the knee, and over it buckle the leather
strap, and place a towel under the upper part
of llie injured thigh. The extension should
then be commenced with the aid of the puttie*^
so as to draw the dislocated thigh forwards iH
a direction over the middle of the sound oiakO/
measuring from the pubes to the knee ; wheal
this has been continued for a short time^ ad
assistant should elevate the upper part <^ the
bone, by drawing the towel with one httiMl>
whilst he presses on the pelvis^ wiA flwi
other ; and by this means he will lift the boti6
over the brim of the acetabulum. A round
towel passed under the upper part of the thigh,
and over the shoulders of the assista&t, wil
allow him to employ more force for this puf-^
pose, by raising his body at the same time
that he rests both hands upon the pelvis ^
the patient. - ^

Another I havc kuowu another method succeed in

" *' effecting a reduction of this dislocatiem,
although the one I have described is the
best.
Case. A man, aged twenty-five, was admitted

into Guy's Hospital, under the care of Mr.
Lucas, on account of a dislocation of his thigh
backwards. An extension was made by

383

means of the puUies, drawing the limb in a
line with the body, and at the same lime
thrusting the trochanter major for^vards with
the hand ; the redaction Svas accomplished
in about two minutes.

The reduction is generally indicated by a s
snap which takes place when the head of the
hone returns into the acetabulum ; but when
the muscles have been some time contracted,
and when an extreme state of nausea has been
produced by bleeding, and the tartar emetic,
the reduction is not accompanied by any
noise, as in the following case, the particulars
of which were given to me by Mr. Worts, a
dresser to Mr. Chandler, at St. Thomas's
Hospital.

James Hodgson, aged thirty-eight, a strong
muscular man, was admitted into St.Thomas's
Hospital, on Tuesday, February 8, 1820;
his left thigh being dislocated backwards.
On account of the great swelling which ex-
isted at the time of his admission, the nature
of the injury was not considered sufficiently
evident, and merely evaporating lotions were
applied. On the i2th the patient was seen
by Mr. Chandler and Mr. Cline, and the
latter thought it a case of dislocation. On
14th Mr. Chandler requested me (Sir

sdey) to see the case, when I immediately
ilared it to be a dislocation into the ischi-

384

atic notch, and directed that the man should
be bled, as he suffered considerable pain,
and the tension about the injured part was
still very great. On Saturday the 19th, the
pain and swelUng havmg subsided, means
were employed to effect the reduction. After
bleeding the patient largely, and giving him
the tartar emetic, the bandages and puUies
were applied as I have already directed, »id
the extension conducted in. the same mannor.
The extension was continued for about t^
minutes before any attempt was made to raise
the head of the bone, but it was then tried^ and
at the same time the limb was rotated by
turning the knee outwards. After the expi-
ration of a quarter of an hour, the appeannce
of the hip became much altered, and of its
natural shape; but as no snap had been
heard, the same means were continued for
twenty-five minutes longer, when, in conse-
quence of the strap above the knee beccHning
loose, the puUies were removed, and it was
then discovered that the reduction was ac-
complished; but' it had occurred widiout
either the bye-standers or the patient being
aware of it.

Of the Dislocation on the Pabes.

This is more readily detected than any i
other of the dislocations of the thigh.

It generally happens by the foot slipping (
unexpectedly into some hollow, whilst a per-
son is walking, the body being at the time
bent backwards, so that the head of the os
femoris escapes forwards.

The following signs usually indicate this s
displacement ; the injured limb is an inch
shorter than the sound one ; the knee and
foot are turned outwards ; but what renders
it so evident, is the readiness with which the
head of the bone can be felt a little above the
level of Poiipart's ligament, upon the pubes,
on the outer side of the femoral artery and
vein, it there forms a round hard swelling,
which moves when the thigh is bent.

Although so easy to distinguish, yet 1 have p
known three cases in which the injury has
been overlooked, until too late to afford re-
lief; this could only have arisen from great
carelessness, or excessive ignorance.

A preparation from one of these neglected i

I cases, which I had an opportunity of dissect-
ing, is preserved in the museum at St.
Thomas's Hospital. It presents the following
appearances: — The acetabulum is in jrart
VOL. iir. 2 c

386

filled by a new deposit of bone» and is in part
occupied by. the trochanter major, but both
are very much altered. The capsular liga-
ment is very extensively torn, and the liga-
mentum t^res entirely divided. The head of
the bone is placed on the pubea under
Poupart's ligament, which has been thrust up
by it ; the iliacus intemus and psoas magnl]^
muscles, are stretched over the neck of the
bone, and upon them is the anterior crural
nerve. Both the head and neck of the bone
are flattened, and the latter rests in a new
articular cavity formed for it upbn the pubes,
above the level of which the head of the femur
is situated. The edges of the new acetabulum
project upon each side of the jieck of the
bone, so as to confine it laterally, whilst
Pouparfs ligament confines it upon the fore
part. The femoral artery and vein pass close
to the inner side of this cavity, for the cervix
of the femur.

This injury might be mistaken for ^
fracture of the neck of the bone, but only
through great carelessness and inattentipo.
Redaction ijij^^ reduction of the dislocation may be

accomplished in the following way : — ^Place
the patient upon a table on his sound side;
then pass a girt between the pudendum and
the upper and inner part of the injured limb,
and fix this to a staple rather before the line

387

of the patient's body. The wetted roller,
strap, buckles and puUies, should then be
placed above the knee, as before described
for other displacements. The extension is to
be made backwards and downwards. The

I application of the towel at the upper part of
he thigh, and lifting the head of the bone
}ty it, over the edge of the acetabulum, is

pttlso necessary in reducing this form of dis-
■placement.

The following case, which will illustrate
te mode of reduction, occurred under the
u-e of Mr. Tyrrell, at St. Thomas's Hospital.
Charles Pugh, aged fifty-five, was admitted c»se.
hto St. Thomas's Hospital on the 23rd of
January, 1823, with a dislocation of the right
high, which had been produced by a blow
tapon the back part of the thigh, from a cart
Srheel, at the time he was making water at
be corner of a street, and unprepared to
lesist the violence. The head of the bone
lould be distinctly felt below Poupart's liga-

Rlient, immediately to the outer side of the
femoral vessels. The foot and knee were
kimed outwards, with very little alteration
the length of the limb. The thigh was
tot flexed towards the abdomen, and was
iearly immoveable, admitting only of slight
ptiduction and adduction, also a little rotation
utwards, but not at all inwards. It was

388

speedily reduced by the following means :—
The patient was placed on his left side, a
broad band was placed between his thighs,
and being tied over the crista of the ilium on
the right side, was made fast to a ring in the
vrall. A wet roller having been put on above
the right knee, a bandage was buckled over
it, and its straps attached to the hooks of the
puUies, by which a gradual extension was
made, drawing the thi^h a little backwards
and*dowhwards. When this extension had
been kept up a short time, another bandage
was applied round the upper part of the
thigh, close to the perineum, by means of
which the head of the bone was raised, and
in the course of a few minutes the reduction
was easily accomplished. The patient had
not been bled nor taken any medicine; he
suffered but little after reduction, and was
able to walk without pain or inconvenience
five or six days afterwards.
ofA^S Pr^ni what I have observed respecting the
Scation**" comparative frequency of the dislocation of
the thigh, I should think the proportion in
twenty cases -about as follows : — twelve on
the dorsum ilii; five in the ischiatic notch ;
two in the foramen ovale ; and one on the "
pubes.
Formerly Considering the frequent occurrence o^

over-look- , ^^ ^ ^ ^

^d. these dislocations, it is extraordinary tha.^

389

they should have escaped the obseirrations
of former surgeons ; it can only be accounted
for by the difficulties which existed in the
pursuit of morbid anatomy. I was informed
by Mr. Cline, that Mr. Sharpe, a surgeon of
Ouy's Hospital^ possessing considerable emi-
nence, and author of a " Treatise on Surgery,"
did not believe that these displacements ever
took place.

There is great pleasure in contrasting the NowreadUy
present state of professional information with '^**^"* •
that which existed fifty years, ago. Our
provincial surgeons now readily detect these
injuries, and generally succeed in reducing
them. Let us never, however, forget that
it is to the knowledge of anatomy, and more
especially, of morbid anatomy, that we are
indebted for this superiority ; and therefore
we should never neglect or lose an opportunity
of pursuing our investigation on these points,
if we wish to increase our reputations as
surgeons, and practise our profession with
credit. ?

Injuries liable to be mistaken for Dislocations

of the Hip.

Of Fractures of the Os Innominatum.

In these cases the application of the force

2 c 3

.^. itMQct: a dislocation, increases
liM patients sufferings, and des-
_«. .'iwiMibility of recovery, if any
»^ cxfiited.

d iracture occurs of the os innomi-

.««itca extends through the acetabulum,

Of' the OS femoris is drawn upwards,

.^ lie sochanter major is turned a little

t%»iM\is; thus the leg is somewhat shortened,

^ :tM knee and foot are a little inverted,

-MAUOim^ the appearances produced by a

;d4iJv:;iCion into the ischiatic notch.

'kttea the sacro iliac junction is broken

tf^Mi(ca» and the pubes and ischium are

Kitur^» the limb is in a great degree

^;iiMieued ; but the position of the knee and

^Jwi is^ not altered.

Phc^c injuries do not affect the motions of
'.^^ utp JK>iut so much as dislocations, and a
vi^^(»itu$ can be felt if the limb be moved
^lUa the hand rests upon the crista of the
tUum.

I haw* soon three cases of fracture of the
o«L iuiK^minatum, somewhat resembling dis-
IwsUK^ns, two in which the injury extended
thunt);:h the acetabulum, and one in which
ihsi oa\ ity remained uninjured ; the following^
.uv |M*nwi|\\l features of these cases.

lu the vear 1791. a man was admitted into
^1 ritxMuas s Hospital, on whom a hogsheac^

391

of sugar had fallen. When examined, his
right leg and foot were found inverted, and
the limb appeared shorter than the left, by
itwo inches. Whilst making a gentle exten-
sion to endeavour to bring the injured limb
to an equallength with the perfect extremity,
1 crepitus was discovered in the os innomi-
Batum. The patient was exceedingly pallid,
kds muscular power extremely feeble, and he
appeared rapidly sinking. He expired the
same evening. The following appearances
presented themselves when the body was
examined : — The deep part of the acetabulum
was broken off, so as to allow of the escape
■of the head of the thigh bone from the cavity ;
iie neck of the bone was firmly embraced by
the tendon of the obturator internus, and by
tdie gemini; the junction of the piibes at the
[symphysis had been separated, and the bones
Were nearly an inch apart ; the ilium, ischium
ind pubes were fractured, and the fracture
extended through the acetabulum ; the left ,
kidney was much injured, and about a pint
•ef blood was found extravasated into the cavity
jof the abdomen.

In the second case, which also was in St. ^
^Thomas's Hospital, the appearances of a dis-
location backwards existed. The patient
"died upon the fourth day after the receipt of
tthe injury; and on examination after death,
2 c 4

3J>2

xicture of the innominatum was
through the acetabulum

anmae it into three parts ; the head of

deeply sunk into the cavity

in which the acetabulum
into Guy's Hospital in
If 17, August the 8th. Mary
rT!'ffc:is. £»£ ciirty, had her pelvis caught
ncTT'S'si L :an wheel and a post; — when
ioziiiei. jijsz lie hospital, she was pale,
t=*ii«s. ant iiff aeces passed off involuntarily.
Jn rreciinr 3:^2 right os innominatum a dis-
liR^r: inicau'a izc crepitus could be perceived,
jia 51*5 TOsCserjor superior spinous process
miiiic:^^ 3ivDci above its natural situation.
■?*:^ i%u>K iff^^eared driven in towards the

UV^w^ ^

£ upon the right side below the
j;as. -^iJ. rfce pelvis was fixed by a broad
.\u4UUi^. jasi ^"^^ opium was administered.
SK: i«w: 3acl ihe evening of the 24th, and
^^>•v^wx•^ *-<* *5ttk ttom the effects of a large
>ivv^«i, >»-ju.ca rbrmed over the seat of extra-
.-.^iUJWii j^vu che right side.

!V >vcy ^-as inspected the next day,

t ivi -la ^.v:vu^ve fracture was found extend-

., .:t»ci*$;a :bo body of the pubes and the

,..x»v*x A VIC :5?v.'hium on the left side; the

^.\ .liiiu ^ j;.?^ ^^^'t^rated from the sacrum at

393

the sacro iliac symphysis, witli a portion of
the transverse processes of the sacrum which
were torn from the sacrum with the ligaments ;
the left sacro iliac junction had also given
way, but only to a sufficient extent to admit
the narrow extremity of the handle of the
scalpel between the bones.

I have known several cases of simple
fracture of the innominatum recover.

Of Fractures at the upper part of the Thigh

Bane.

^ •

. These injuries have been frequently mis- Mistaken

. . . ♦ ^ "^ , for dtsloca-

taken for dislocations of the hip, and the dis- tion.
tinguishing marks are sometimes with diffi-
culty detected.

Three species of fracture differing in their Three
nature and result^and requiring distinct modes *p®*^®*
of treatment, are met with at the upper part
of the femur, and have been generally classed
uider the indiscriminate appellation of frac*-
tare of the cervix femoris. Want of proper
anatomical investigation by dissection, has
given rise to this confused classification, and
ias led to the disputes respecting the pro-
cesses which nature employs to effect a cure.
, Thus one surgeon declares that they cannot
^ united, whilst another asserts that the

394

eure is as easily performed as in fractures of
other bones;

The opinions I am about to offer to you,
are the result of extensive observation on fki
living, who have suffered from tiiese injuries;
of numerous examinations of the <]bad body ;
and of many experiments which I have i^er**
formed upon inferior animals.
^ent*ac. Thcsc accidents are of such frequent oc-
corrence. curreuce^ that the wards of our hospitals arc
seldom without an example of them ; whilst
scarcely two cases of dislocation happen th^«
in* the course of the year, although the build*
ings contain about nine hundred patients.

The different species of injury are as
follow: —

First. — ^That which takes place through
the neck of the bone entirely within the cap-
sular ligament.

Secondly. — ^A fracture through the neck of
the thigh bone at its junction with the tro-
chanter major, external to the capsular liga-
ment.

Thirdly. — Fracture through the trochanter
major, beyond the cervix femoris.

Of Fracture of the Neck of the Thigh Bone
within the Capsular ligament.

Ymb^sklv' "^^^ following appearances are usually pro-

t«<icd.

39$

duced by this fracture : — ^the limb becomes
shortened one or two inches ; this arises from
the connection between the head of the bone
Itnd the trochanter major being destroyed^ so
that the latter loses its support and is drawn
lip by the action of the glutei muscles, as far
as the capsular ligament will admit of; and
it therefore rests upon the edge of the aceta-
bulum, and a little upon the ilium above it.
This difference in length is readily detected
by placing the patient in a recumbent posture
<uid comparing the situation of the malleoli ;
the heel of the injured extremity is usually
found resting in the hollow between the in-
ternal malleolus and the tendo achillis of the
sound limb ; but this is not always the case.
For a short period after the receipt of the
injury, this shortening may be made to dis-
appear by a very slight extension of the limb,
but it again reappears immediately that the
extension is discontinued. This may be
again and again effected, until the muscles
acquire a fixed contraction, which cannot be
subdued but by very great force.

Another indication of this accident is the limb
eversion of the knee and foot, from the action
of the powerful and numerous rotators out-
wards, which have but very feeble opponents ;
the obturatores, the gemini, the pyriformis,
the quadratus,. the gluteus maximus, the

W«4 ,*%<^^

■I •! 1

».s »

and the triceps, all assist in the
01 the limb outwards ; whilst only a
lie glmeos mediuSy with the minimus
ma. ciie tensor Tagins femoris act as antago-
nnscies^ or rotators inwards. The ever-
ts ;iQme considered as depending on
Qi the limb, and not upon the
coatraction; but the resistance
ay the rotators outwards, when an
tux » made to turn the limb inwards,
>ux&ciea4aT proTe the true cause of the ever-
Ufae inrersion is also in some degree
by that portion of the neck which
:«»mim^ ^mached to the trochanter major,
tfiL wojadbi nests against the ilium.

(^ jOMtming of the limb, and the ever-
^Qiit v/£ tfte knee and foot, are the two princi-
4^ TnsiriK^ which attract the attention of the

WliBea the femur is dislocated upwards,
si^vr^^^M ol"^ the knee and foot is prevented by
tilicr iifMii sum! neck of the bone ; but the sepa«
t<iC«w v^^ these from the trochanter in the case
v^i if^KCucw allows of a ready eversion. I
i%t^v itt\>wa the limb inverted in a case of
ii ;jfcvHUjrv ot the cervix femoris, but this must
sV :VK^^ ^^ ^^ extremely rare circum-

tUv uAiur^* of this injury is not well marked
'/., u\H\\ >v*iuc few hours after the receipt of the

injury, as the muscles do not acquire a fixed
contraction for some time ; it is firom this cir-
cumstance that the injury has been mistaken
for dislocation, and that the patients, even in
the large hospitals, have been submitted to
useless and painful attempts to reduce the
displacement.

After the receipt of this injury, the patient ^"^^.^ ^^
suffers little or no pain whilst at rest in the
recumbent posture, but rotation of the limb,
more particularly inwards, creates much
suffering from the fractured end of the bone
rubbing upon the synovial membrane, which
lines the capsular ligament. The pain is
most acutely felt at the upper and inner part
of the thigh, near the insertion of the psoas
and iliacus internus muscles, into the tro-
chanter minor.

The limb can be moved in all directions,
but the flexion creates pain, and is accom-
plished with difficulty, particularly if the
thigh be directed towards the pubes ; if the
knee be carried outwards when the thigh is
flexed it is accomplished with more ease, and
without producing much pain.

The trochanter major of the injured side Trachanter

major pro-

projects less than that of the sound side, as jectsiess.
it has lost the support of the neck ; it is also
drawn up towards the ilium, and is therefore
higher than that of the perfect limb.

398

Patient

examined

erect.

Pain on
standing.

Crepitnt.

Most fre-
(juent in
females.

In old age.

To be perfectly satisfied of the nature of
the injury, the patient should be examined in
the erect as well as in the recumbent posture;
he should be made to stand, which he can
do with assistance, and endeavour to bear
his weight upon the sound extremity when
the shortening of the injured limb is distinctly
seen, the knee and foot are everted, and &t
prominence of the hip is lessened.

In attempting to rest upon the nni^nmd
limb, the patient experiences great painincon-
sequence of the stretching of the psoas, iliacus
intemus and obturator externus muscles, as
well as by the pressure of the fractured portion
of the cervix upon the capsulur ligament.

The fracture is not indicated by a crepitus
on motion whilst the patient is recumbdnt,
as in other fractures, but it can generally be
felt, when the limb is extended to the original
length and then rotated; the crepitus may
sometimes be discovered on the mere elonga-
tion of the extremity, but it is most distinct
if it be turned inwards.

Females are more liable to this accident than
males, which may be accounted for by the
powers of the constitution being generally
weaker, and the natural position of the neck
of the thigh bone more horizontal.

The period of life at which this injury oc-
curs, is another circumstance worthy of con-

sideration, as it seldom takes place but ai'fia
advanced period of life. We find it described
as happening in young persons, but in these
cases tlie injury has not been really confined
to the cervix within the capsular ligament,
and thus so much confusion has arisen with
respect to the true character of the accident.
During a period of forty years, for which I
have attended St. Thomas's and Guy's Hos-
pitals, and in my private practice, which has
been more than my share, I have seen be-
tween two and three hundred cases of fracture
of the cervix femoris, within the capsular
ligament ; yet in very few instances have I
known it take place in persons under the age of
fifty years. It is most frequently met with
between the ages of fifty and eighty, at a
time of life when dislocation very rarely takes
place. I have, however, seen a case of the
iScture at the age of thirty-eight, and a case
of dislocation at sixty-two.

The liability to the different forms of injury Rpa
at the different periods of life, is owing to
the changes which are taking place in the
bones as well as in the other structures of the
body, according to the balance of the arterial

Eibsorbent systems ; during youth the
I of the former preponderates, and hence
lurce of growth ; in middle age the two
rve an equilibrium of action, and thus

400

but little alteration occurs ; in old age the
absorbents exceed in activity the arteries,
from which a diminution arises, but tins is
rather from a disease of power in the arteries
than an increase in the absorbents.

Change in Thus the iucreasc of the bones takes place
in youth, until they acquire that bulk, weight,
and compactness which characterises them
at the adult period, and which they for some
time retain, until they become gradually light
and soft in the advanced period of life : even
the neck of the thigh bone undergoes a con-
siderable change from an interstitial absorp-
tion, by which it becomes shortened, and
dtoed m iu angle with the .haft .f the b<»e,
the head often sinking beneath the level: of
the trochanter major, instead of being above
it. This alteration gives the idea, upon a
superficial inspection, of there having been
formerly a fracture which had united.

Period of The pcrfod at which these alterations take

change *

varies. placc. Vary in different individuals, as we
find the general appearances do, which in-
dicate old age, and which are as strongly
marked in some at sixty, as in others at eighty
years of age.

It is from these changes, however, that the
nature of injury varies generally at the differ-
ent periods of life, as from the different states
of the bones, that violence which would

401

n-oduce dislocation in the adult, occasions
fracture in the old person ; and when dislo-
cation does occur at an advanced period of
life,it is in those persons who have particularly
strong constitutions, and in whom the bones
have not undergone the changes I have
described.

The very slight causes which often occasion Caaiet vnj
fracture of the bones in old persons, is a
proof how much this altered state predisposes I

to such injury. The most frequent cause of
the fracture of the neck of the thigh-bone, in
London, is a sudden slip from the foot to the
carriage pavement; which, although only a
fall of a few inches, yet it is suihcient to
produce this serious accident. It is also
often occasioned by a slight fall upon the
tchanter major; and I have known it pro-
ced by the toe catching in the carpet, or
linst some projection in the floor, at the
lie that the body was suddenly turned to
side. It is particularly necessary to
loUect the very slight causes which give rise
s injury, and to be on your guard respect-
' it, otherwise it could hardly be supposed
bt an accident of so serious a nature could
kso easily produced.
Vith respect to the mode in which these opii
«tures of the neck of the thigh bone vnthin oi
[ capsular ligament unite, much difference
I vol-. III. 2 i>

402

of opinion exists; it is asserted by some
surgeons, that these fractures imite like those
occurring in the other bones of the body ;
but from the numerous dissections which I
have had an opportunity of performing in
these cases, I firmly believe that, as a ge-
neral rule, the transverse fracture of the cer-
vix within the capsule does not unite by bcme;
such is the opinion I have delivered in my
lectures for these thurty years, and which has
been from year to year strengthened by fur-
ther observations and fresh dissections.
Win! of In all the examinations which I have made
nyMnon. ^^ these cases, I have seen but one in which
a bony union had followed a transverse frac-
ture of the neck of the bone within the cap-
sular ligament. I do not, however, mean
to deny the possibility of a bony union,
or to maintain that it cannot take place, but
it is an exceedingly rare circumstance. Con-
sidering the various modes in which a frac-
ture may take place, the degree of violence
which may occasion it, and die extent of mis^
chief to the surrounding parts, which may
accompany it, it would be presumptuous in
any one to maintain the impossibility of a
bony junction; the bone may be broken
without the fractured ends being separated
frt^m each other, or without any laceration
or it» )>erio$t^um» or the reflected ligament

403

Blch covers its neck ; and again, the frac-
f be in part within, and in part
without the capsular ligament; under this
latter circumstance, I well know that an
ossific union might be produced; and I have
had the opportunity of seeing more than
one.

I shall now point out several circumstances c
irfiich in my opinion tend to prevent an b
ossific union afler a transverse fracture of the
neck of the thigh bone within the capsular
ligament.

In the first place, a want of proper apposi- y
tion of the fractured extremities of the bone "
may in many cases have considerable effect
in preventing the union by ossific matter, as
we find that a proper junction does not take,
place between the broken portions of bone,
in any part of the body, when the extremities
are much separated from each other.

In the case of a boy, from whom a portion c
of the tibia was removed in consequence of
its protruding from compound fracture, but
in whom the fibula remained uninjured, so
that the ends of the divided tibia could not
he brought into contact, no bony union took

A case somewhat similar occurred in the c
kistol Infirmary, under the care of Mr.
inith'J A portion of diseased tibia, between
2 o 2

404

two and three inches in length was rembved,
leaving a space to that extent between the
ends of the bone ; and six weeks after tiie
operation the boy was able to walk about
without much difficulty, and it was supposed
the ossific union had taken place; but in
consequence of his death 'from small pox, sm
opportunity occurred of examining the limb,
when the larger part of the former space was
found to be occupied by a thin ligamentous
substance, without any bony deposit.

Experi- This is also confirmed by experiments
which I have made on other animals. I took
out a portion of the radius of a rabbit measur-
ing seven-eights of an inch in length, after
which the ends of the bone did not unite to
each other, but formed connections to 'the
ylna; in a second experiment, I removed a
portion of the radius from another rabbit,
measuriDg only one-ninth part of in inch,
: but with the same result. Also a portion' of
the OS calcis being separated and dr&M^
above its natural situation by the action €i
the gastrocnemius muscle, only united by
ligament.

Motion of In the fracture of the cervix femoris it is

^^'^' extremely difficult to keep the limb in a

. . proper and steady position, as the most

trifling change in position produces ' some

motion of the part from the contraction of

406

the powerful muscles which pass from the
pelvis to the thigh. Were this, however,
the only difficulty, it might possibly with
much care and attention, be in a great mea-
sure obviated.

Even in those cases in which the length of want of
the limb is properly preserved, another cir- presBure.
cumstance I conceive may operate to prevent
the bony union, which is the want of pressure
of one portion of bone upon the other, when
the capsular ligament remains entire. This
arises from the secretion of a large quantity
of synovial fluid into the capsule, which dis-
tends the ligament, and prevents the proper
contact of the broken bones. After the
inflammatory process has subsided, and the
eEFusion of ligamentous matter has taken
place from the synovial membrane, then this
fluid becomes absorbed.

In other fractures where the bones are HoiT,
surrounded by muscles, the broken extremi-
ties are kept pressed together by the action
of these muscles ; but in the fracture taking
place through the neck of the thigh bone,
the muscles can only act upon one portion,
and that in such a way as tends to separate
one from the other.

That pressure is essential to the bony Preisnre

. , eueDtiaL

union, IS proved by the exammation oi those

t:ase5 in which the fractured ends of the bone

2 D 3

tion.

406

overlap each other, when a proper osi^fle
deposit is found on that side where they press
upon each other; whilst on the o^osite
sides, where no pressure exists, scarcely any
alteration can be perceived. Again, in those
cases where the actions of the nmsdes sepa-
rate the fractured ends of a bone, as we
frequently find, union does not take place
until the surgeon plrodUdes the necessary
pressure by artificial means ; as by the appli-
cation of a belt, which buckles tightly round
the limb.
Deficiency A third circumstauce, however, tends prift-
cipally to explain the want of bony union;
in these cases, it is the deficiency of ossific
inflammation in the head of the bone» wiiieii
separated from the cervix; it iiS then only
supported by the vessels passing, firom the
ligamentum teres, which are minute add few
in number. In the perfect state^ the head
and neck of the femur are chiefly sopptkd
with blood by the vessels of the cmioelli
of the cervix, and by those of the reflected
membrane which covers it. If, therefore, in
cases of fracture the reflected membrane be
torn through, which it generally will be,
the chief source of supply to the head of
the bone, and that portion of the neck con-
nected with it, is cut off*, and there is not
sufficient organic power remaining to pro-

407

uce ossitic matter ; thus we 6nd that '
icarcely any change takes place in the head
the bone, similar to that occurring in
[iDther bones when fractured ; there is merely
jlayer of ligamentous substance thrown out,
I covering the surface of the cancellated
tcture.

On examining these injuries by dissection,
we usually find the following appearances : —
The head of the bone remains in the aceta-
ulum connected by the ligamentum teres,
fhere are upon the head of the bone, very
. white spots, covered by the articular
itilage. The cervix is sometimes broken
irectly transversely, at others with obliquity.
he cancellated structure of the broken sur-
ce of the head of the bone, and of the
ervix, is hollowed by the occasional pressure
F the neck, attached to the trochanter, and
cnsequent absorption ; and this surface is
pmetimes coated partially with a ligamentous
leposit. The cancelli are rendered firm and
smooth by friction, as we see in other bones
which rub upon each other when their
articular cartilages are absorbed, giving the
surface the appearance of ivory. Portions of
. the head of the bone are broken off, and these
|(are found either attached by means of liga-
ment, or floating loosely in the joint, covered
hy a ligamentous matter ; but these pieces
2 P 4

408

do not act as extraneous bodies, so as to
excite inflammation, and thus produce their
discharge ; not more than those loose portions
of bone covered by cartilage, which are found
so frequently in the knee, and sometimes in
the hip and elbow joints. With respect to
the neck of the bone which remains attached
. to the trochanter major, the most remarkable
cii'cumstance is, that it is in a great degree
absorbed, but a small portion of it remain-
ing; its surface is yellow, and bearing t&e
character of ivory, if the bones have rubbed
against each other. Some bssific depost-
tion I have seen manifested around this
small remaining part of the neck of the bone;
and upon the trochanter major, and thigh-
bone below it, in some examples of this
fracture. ..-..rj

li^mllt '^^^ capsular ligament, enclosing the head
thickened, and ncck of the bone, becomes much thicker
than natural; but the synovial membrane
undergoes the greatest change from inflam*
mation, being very much thickened, not only
upon the capsular ligament, but also upon
the reflected portion of that ligament upoii
the neck of the bone, as far as the edge of the
fracture.
Increase Within the articulation, a large quantity of

of synovia. , . . •

serous synovia is found; by which term I
mean to express, that the synovia is less

40fe' -

fntilaginous, and contains mofe serum th&h
usual ; this fluid by distending the ligament,
separates for a time one portion of bone from
the other ; it is produced by the inflammatory
process, and becomes absorbed when the
irritation in the part subsides. I do not
know the exact period at which this change
takes place, but I have seen it in the recent
state of the injury. Into this fluid is poured
a quantity of ligamentous matter, by the
adhesive inflammation excited in the synovial
membrane, and flakes of it are found pro-
ceeding from its internal surface, uniting it to
the edge of the head of the bone. Thus the
cavity of the joint becomes distended, in part
by an increased secretion of synovia, and in
part by the solid eff'usion which the adhesive
inflammation produces ; the membrane re-
flected on the cervix femoris is sometimes
separated from the fractured portions, so as
to form a band from the fractured edge of
the cervix to that of the head of the bone;
bands also of ligamentous matter pass from
the cancellated structure of the cervix to that
of the head of the bone, serving to unite, by
this flexible material, the one broken portion
of bone with the other.

The trochanter is drawn up more or less in Ossificde-
different accidents; and in those cases in !'i"rh(>"y
which it has been very much elevated, 1 have boue.

410

knOwa a considerable osstfie deposit take
place upon the body of the thigh bo]ie» be-
tween the trochanter major and the trochan-
ter minor. When the bone has been mace-
rated, its head is much lighter and more
spongy than in the healthy state, ej^ceptiiig
on those parts most exposed to friction^ where
it is rendered smooth by the attrition^ wiueh
gives it a polished surface.
In most It may therefore, be considered as. a g^Mral

cases no J' » o

oMific principle^ that ossific union is not prodiKsed
in these cases; nature makes sonve cffiorto
to effect it on that portion of the fracture
attached to the body of the bone^ ■, but
scarcely any upon the head and portion of
the cervix separated with it. .

Notonw This want of ossific union does not appear

in the hip *^*

joint. to be merely confined to the firacture of the
cervix femoris, but also occurs in the fractures
of the condyles, of the os humeri and cwonoid
process of the ulna, and other articular pro-
cesses, when broken off entirely within the
capsular ligament.

These opinions, which I have for many
years delivered in my lectures, have been
confirmed by many cases in which I have had
an opportunity of dissecting the injured joint,
and also by the result of the experiments
which I have performed on other animals,
and in which I found only a ligamentous

union occur when the fracture was confined
to within the capsular ligament.

The cases of fracture of the cervix femoris
may be confounded with those dislocations
of the hip in which the limb is shortened ;
viz. those occurring on the dorsum ilii, the
iftchiatic notch, and on the pubes ; the ever-
sion of the knee and foot, with the greater
mobility of the limb will distinguish them
from the two former ; and in the latter in-
stance, the readiness with which the head
of the bone can be felt in the groin, renders
the case sufficiently obvious.

They may be also confounded with the
cases of fracture external to the capsular
ligament; but if the surgeon be sufficiently
attentive to the following points, he will
readily distinguish the difference : — the age
of the patient, the length of the limb, the
cause of the injury, the feeling of crepitus,
the great extravasation of blood, and the
degree of suffering; for the fracture of
the cervix, generally occurs at an advanced
age ; the limb is shortened, the cause of the
injury very slight, there is not any percep-
tion of crepitus until the limb be elongated,
and the degree of suffering is very trivial.

In the treatment of the fractures of the
jw^^he thigh bone, within th^apsujar

Confound- ^^^^
cd with dis-

IdcationB.

With othcB^^H

{

412

ligament, I have tried numerous and variow
means, to endeavour to effect a bony unkHH
and I have known other sui^eons adopt many
ingenious plans with the same view, but all
without success. v. >

The double inclined plane has been em-
ployed with numerous contrivances to. ke^
the injured limb extended, and to suj^rt
the fracturied portions in contact^ also to fxre^
vent as much as possible, the motions of the
pelvis. The straight position, wi& various
modifications, has likewise been emiploy^;
indeed, I scarcely know any form of mechat
nical treatment which could be adopted,
which has not been tried, for the purpose of
aiding the bony union in these cases* I Imve
not, however, yet witnessed one sin^e ex-
ample of such a imion, which was not
doubtful, as to its being entirely within the
ligament.
Case. In a convict at Sheemess, who could be

completely controlled, the limb was^pt
steadily extended for six months, yet^ it
united only by ligament.

I am aware that instances of success have
been published ; but I cannot give credence
to such cases, until I see that the authors are
aware of the distinction between fractures
within, and those without the capsular liga-

413

ment; and that they are likewise acquainted
with those changes in the head and neck of
the bone, which occur in advanced age.

Not having found or known any mode of
treatment succeed in effecting an ossific union
in these cases, and having repeatedly seen
the patient's health much injured by the trials
which have been made, all that I now direct
to be done, is, that a pillow should be placed
under the limb for its whole length, and a
second rolled up, put under the knee, and
that the limb should be allowed to remain
upon these for ten days or a fortnight, until
pain and inflammation have subsided ; the
patient should then be allowed to rise and
sit in a high chair, to prevent much flexion of
the limb, which would be painful. In a few
days more he should begin to walk with
crutches, and after a time a stick should be
substituted for the crutches, and in a few
months he will be able to use the limb with-
out any adventitious support ; when he com-
mences to bear the weight of the body on
the limb, he should be provided with a high
heeled shoe, which will much assist him.

The period and degree of recovery in these

cases, depend much upon the bulk of the

patient ; as the very corpulent patient will,

for a long time, require the aid of crutches,

^D others less bulky, a stick only will be re-

Treatment

meDded,

414

quired; and in very spare persons such
assistance is only necessary for a very short
period ; but unless a shoe be worn having i
sole sufficiently thick to remedy the diminish-
ed length of the limb, the patient has a con-
siderable degree of lameness.
In doabt. Should any doubt exist as to the fractilre
being situated external or internal to the cap*
sular ligament, the case should be treated as
for the former injury, which I shall presently
describe, and in which ossific union majrbe^
procured.
Aowtiaiu The surgeon should be very cautious in
necMMry. the Opinion he gives respecting the result of
these injuries, as when the fracture is tfaais-'
verse, lameness is certain to follow * but in
various degrees, which cannot at first be
estimated.

In very aged and infirm persons, this acci-
dent sometimes produces fatal consequences,
from the exhausted state of the constitutioii,
and from the coi^em^it in the attempts at
unidi.

ikM.

JFWKsterer pf the Cervix
to the Capsular L

wtijMijj H The symptoms produced by this injury,
' are» in many points, so similar to those

415

accompanying the former injury, that great
attention is necessary to distinguish them.
Such a distinction, is, however, highly im-
portant, as the result differs so materially,
an ossific union being readily produced when
the injury is external to the capsular liga-
ment ; whereas, in that which I have already
described, such a union rarely, if ever, takes
place.

When the fracture occurs external to the signsof.
ligament, the injured limb is but little shorter
than the other ; the foot and knee are everted,
the rotundity of the hip is lost, and the patient
experiences much pain at the hip, and about
the upper and inner part of the thigh.

These marks are also found when the
fracture takes place internal to the capsular
ligament.

The following are the principle signs by puiingsirfi-
which the nature of these injuries may be
detected:— 1st. The fracture external to the
capsule occurs frequently at an earlier period
of life than that which takes place internal to
the joint ; although I have known it produced
after fifty years of age, yet it is usually found
under that age. 2nd. The injury is generally
occasioned by much greater violence, as by
severe blows or falls, or the passage of laden
Carriages over the pelvis, whereas the internal
f^racture is tlie consequence usually of very

416

slight cause. 3rd. The crepitus in the frac-
ture external to the ligament^ is readily felt
when the limb is slightly movedf and gene-
rally without drawing it down. 4th* The
degree of suffering is much greater, especi-
ally on moving the limb, if the injury be ex-
ternal to the capsule, as the rough eztranily
of the bone penetrates the suitonndi^
muscles ; the limb also is much more swoUeD,
and the constitutional irritation is considerable.
5th. There is great extravasation of Uoed,.
generally, in these cases.

DiMection Jq dissecting these cases, the fradxure is
generally found at the root of the neck of the
bone, external to the capsular ligament ; but
its seat and extent varies very much in diffid-
ent examples, and the degree of shortening
of the limb, depends upon the form of the
fracture, and upon the extent of laceration
of the surrounding soft parts, so as to admit
of retraction.

compu. Sometimes the fracture external to the
capsular ligament, is complicated with injury
of the trochanters.

Case. Mr. Travers has an excellent specimen of

this form of injury taken from a patient who
was under his care in St. Thomas's Hospital.
Richard Norton, aged sixty, was admitted
into the Hospital on the 24th of January^
1818, in consequence of severe injury of his

417

, occasioned by a fall upor
fltone of the foot pavement. The limb of the
injured side was shortened, and the knee and
foot everted; the swelling about the hip was
very great; the limb could be moved freely
in all directions, but not without creating
much suffering ; and when moved a crepitus
could be distinctly felt in the situation of the
trochanter major. When the swelling had
iu great measure subsided, the limb was con-
fined by the application of the long outer
splint, and two thigh splints well bedded.
In March the splints were removed, when
the limb was found to be a little shortened,
but the hip had regained its natural appear-
ance. About a month after this, he began
to use his limb, walking with the aid of
crutches. He was afterwards placed under
the care of the physician, on account of Iiis
general healtli being defective, and he died
suddenly, "being seized with spasms in his
chest.

On examining the hip after his death, the DiMnciion.
fracture was found to have extended through
the trochanter, some way down the bone,
and it had apparently united with very
slight deformity, but on macerating the
bone, the head and neck became loose on
the body of the femur, they could not, how-

ter, be perfectly separated, as a shell of
Z__

418

bone had formed, confining the head and
cervix.

The preparation which Mr. Traverse was
so kind as to send me, presents the folloW'^
ing appearances^ the head and cenrix of
the bone had been separated from the tr(H
chanter major and body of the femur. The
upper part of the bone had been obliquely
split, so as to receive the cervix into its
cancelli. This fracture had divided the pos^
terior portion of the trochanter majw from
the body of the thigh bone, and the tro^
chanter minor had been removed with it
Union had taken place between* the Jfrac^
tured portions of the trochanter, at a slight
' distance from each other, and thus a holbw
was left into which the cendx femoris was
received, but it had not been united hf
ossific deposit, as it became loose from the
maceration. <

Mnoid- Mr^ Oldnow of Nottingham sent me two
cases. specimens of this fracture, in which the
necks of the bones were fractured at their
junctions with the trochanter major. The
trochanter major itself had been brok^i oC
and the trochanter minor formed a distikict
fracture. The bones had become re-united,
the cervix femoris to the shaft of the bonCr
and the trochanter minor a little higher than
its natural attachment. The trochanter major

419

was in one specimen re-united to the body
of the bone, but not in the other. Thus the
thigh bone was at its upper part divided into
four parts ; the head and neck of the bone
formed one part ; the trochanter major a
second ; the trochanter minor a third, and
the body of the bone the fourth.

Thus this fracture unites by bone in a
similar manner to the friicture of other bones
external to the capsular ligaments, because
the bones can be brought into apposition,
and are confined together by the surround-
ing muscles, and the nutrition of each ex-
tremity of the bone is well supported by
tile vessels which proceed to it from the
surrounding parts.

This in some measure explains the dif- D'fferepce
ference of opinion respecting the union of acooanted
the fracture of the neck of the thigh bone.
In the internal fracture, the bones are not
applied to each other, and the nutrition of
the head of the bone being imperfect, no
•ssific deposit is produced ; but in the ex-
ternal injury, the bones are held together
by the pressure of the surrounding soft parts,
and are easily kept in apposition by external
bandages and splints. Generally a long period cateicu-
is required to produce a perfect union in these
cas^, and many months elapse before the
patient acquires a free use of the limb.
2 E 2

420

Fracture through the Trochanter Miffor.

Nttiire«f. ' An oblique fracture sometimes oc<^r8
tiirough the trochanter major, without anjf:
injury to the cervix of the thigh bone.. Thift
accident takes place at all periods of life,
and its symptoms are as follow. <;

Signs of. The limb is but little shortened, and some^
times its length is not altered ; the .£dot i(i
generally benumbed; the patient cannot
turn himself in bed without , ass^tancei and
any attempt to do so creates excessive pa^i.^
The portion of the trochanter coimected to:
the shaft of the bone, is either drawn foir^^
wards towards the ilium, or it folia towards
the tuberosity of the ischiuitn, being, in
general, widely separated from the superior
portion, or that which remains connected tio
the neck of the bone. The foot is gr^tly
everted, and the patient is unable to sit .oil
account of the violent pain produced by^tiie
position. From the separation of the frac^
tared extremities of the bone, crepitus* /can-
not often be detected, unless the : limb be
very freely moved.

^^' The eversion of the foot, and the altered

•igiM. position of the trochanter major, are the chief
distinguishing marks of the injury.

Ossific union readily takes place in these "aite by
cases, more quickly than in the fracture
through the cervix feraoris, and the patient
recovers a very good use of the limb.

The first case which I recollect seeing of Cwe.
this injury, was about the year 1786, in
St. Thomas's Hospital, under the care of
Mr. Cline. The limb was extended over a
pillow, rolled under the knee, and splints
were applied on each side of the limb ; a
firm union took place, and the man was able
to walk extremely well. After being dis-
missed from the hospital, he was attacked
with fever, of which he died. On examin-
uig the seat of injury after death, the frac-
ture which had extended through the tro-
dianter major, was found firmly united with
^tery little deformity.

^PThe following are the particulars of a
^iise which I attended with Mr. Harris, of
Reading.

July 20th, 1821, Mr. B., aged 51, a gen- Ca.c.
tleman residing about six miles from p.eading,
fell from his horse, and injured his left hip;
he got up immediately, and walked a few
steps, but soon found that he was incapable
of bringing his left leg forward, and he felt
a severe pain in the hip. He was conveyed
home in a cart, a distance of about four
miles, and Mr. Harris visited him about
2 f. 3

J-J

422

two hours after the accident, when/ the fol«
lowing circumstances were noticed. He
could not discover any crepitus on rotating
the limb ; it was of equal length with the
sound one ; the foot was not turned inwards
or outwards, and the patient could retain
it in any position in which it was placed.
A good deal of swelling existed about the
hip, and Mr. B. complained of some pain;
he could bear the limb to be moved without
much increase of suffering, excepting whm
the injured limb Was drawn across the sound
one, when the pain was greatly augmented.
Under these circumstances, Mr* Harris gave
it as his opinion, that there was not either a
fracture or a dislocation.

On the 22nd, Mr. Ring, of Readiiig, saw
Mr. B. and on examining the limb, con-*'
firmed the opinion of Mr. Harris.

The patient was kept at rest, knd leeches,
with evaporating lotions, were employed to
reduce the swelling of the hip.

On the 26th, an acute attack c^ hepa-
titis, rendered active treatment necessary;
and during this time, the limb remained
much in the same state.

August 14. Mr. Ring again examined the
limb, and whilst moving it, thought he felt a
crepitus. On the following day, Mr. Harris
also felt and heard the crepitus.

423

The case being, however, still obscure, Mr.
Brodie was sent for; on his arrival, the
particulars of the case were communicated
to him, and he minutely examined the in-
jured limb, but for some time was doubtful
as to there being a fracture, until, upon ro-
tating the limb very extensively, he distinctly
felt the crepitus ; he was, however, much
surprised to see, that the patient could, when
standing, bear very considerably upon the
injured limb, and he considered the case as
very obscure, the usual symptoms of frac-
ture, except the inability to move the lirab>
being but little marked or entirely wanting.

Mr. Brodie applied a long splint, with a
bandage from the toes to the hip, which he
directed to be worn for a month ; and at the
same time, ordered the limb to be kept per-
fectly at rest.

But little alteration having taken place
in the case at the end of the month, Sir
Astley Cooper was requested to visit Mr. B.
After hearing the history of the case, he
proceeded to examine the limb. First,
looking to the relative position of the ex-
tremities, as the patient lay upon his back,
he placed his hand under the trochanter
major, which he found had dropped from
its natural situation, and raising it toward
the cervix, he readily detected the crepitus,
2 K 4

424

and agreed with Mr. Brodie, and Mr. Harris,
as to the nature of thei injury, viz. a fracture
of the cervix femoris, where it unites with
the trochanter major.

The following plan of treatment was
adopted by Sir Astley, with- a view of re-^
taining the trochanter in its proper position^
whilst the patient could remain perfectly at
rest in the horizontal posture.

A mattress was made of horse hair, about
five inches thick, very smooth, and this
Was covered with a sheet. A part of the
mattress was made to draw out on the oppo*
site side to the fracture, so that when the
natural evacuations took place, there still
should be no motion of the body; before
drawing out the piece of mattress, a board
of two feet long, and six iaches wide, shaped
like a wedge, was insinuated under the
buttock of the right side, the twa ends of
the board resting on the mattress, thereby
preventing the nates from sinking, at all,
into the opening, when the piece of mattress
was removed> the board was of course taken
away, when the portion of the mattress was
replaced. Upon the bedstead, was first
placed a thick smooth board, sufficiently
large to cover the bottom of the bed, and
on that was placed the mattress, thereby
preventing any sinking by the weight of the
body.

4M.

A bandage, made in the following manner,
was applied to support the trochanter : — a
broad web, sufficient to go round the body,
over the hip, was furnished with two straps
and buckles to fix it with, and the belt was
made of a greater width at that part, which
was to be placed under the injured trochan-
ter ; the whole was lined with chamois lea-
ther, and stiitfed ; a pad of the same leather
was made, about six inches long, three
broad, and three thick, gradually tapering
to a point; this pad was placed immediately
under the injured trochanter, so that when
the bandage was buckled on, it passed into
the hollow beneath that process, forcing it
upwards and forwards into its natural posi-
tion. Another thick pad, about eight inches
square, of a wedged shape, was provided,
and this was placed under the upper part
of the thigh of the injured side, after the
application of the bandage.

The patient was placed on his back, the

limb resting on the heel ; and to prevent

the possibihly of any motion of the foot,

and of the body, a wide board was fixed

to the bed posts, at the foot of the bed,

jffith two pieces of wood padded and fas-

kdtcoied to it, between these the foot was

^uecetved, and the least lateral motion pre-

^■nented. A cushion was placed between the

426

foot board, and the sole of the sound foot,
so that by gentle pressure, the patient could
prevent his body from slipping down in the
bed«

This mode of treatment was steadily pur-
sued for a month, without much inconYe«r
nience or suffering to the patient ; the band*'
age being from time to time tig^tened«
Until the expiration of three weeks,, tlie
patient said he could occasionally still fed
the crepitus, but after that period, this sen^i
sation entirely disappeared ; he complained
of some pain in the direction of the ircH
chanter, and the limb became somewhat
aedematous.

Sir Astley Cooper again visited Mtm B*
a little more than a month frmn his .first
seeing him, when he was of opinion tibat
union had begun, and directed a continuance
of the same treatment, which was therefore
persevered with for a further period of about
ten weeks ; Sir Astley seeing the patient
once in this time.

It was not until fourteen or fifteen weeks
from the commencement of this treatmrat,
that the bandage was removed for m(M
than a few minutes, or that any material
alteration was made in the plan. It was
then taken ofi* for about two hours ; when
the trochanter was found to retain its posi-

427

Bbj

lion, and from examinatioa of the ps
considerable thickcoing could be discovered
about the trochanter.

After this, Sir Astley desired that the
bandage should be re-applied every day for
an hour, and directed friction to the limb
from the foot upwards. Mr. B. from this
time, rose every day, and was soon ab!e»
when supported by his crutches, to move
his hip joint freely ; but the limb continued
much swollen, and the motions of the knee
joint were extremely limited. By steadily
persevering with friction, and passive mo-i
tion, Mr. B. has since obtained a free use
of the extremity.

A peculiar form of fracture of the trochanter Fracture at 1
major, in which this process was separated
at the part at which it is naturally united by
cartilage as an epiphysis, occurred under the
care of Mr. Key.

The patient, a girl about sixteen years of ca>e.
age, fell in crossing the street, and struck her
hip against the curb-stone. She rose directly,
and walked home without much suffering or
difficulty, but experiencing afterwards con-
siderablepaiujShewas taken to Guy's Hospital
on the sixth day after the accident. On ac-
count of her constitutional symptoms being
muchmore severe than those usually attending
tjury to the hip, she was placed under the

42d

« Dn Bci^t, at whose request Mr.
the limb, which he found
ereited, and in s^pearance
iaif aa inch longer than the sound
: EC could be moved in all direc-
cntt dbiisctkxi caused great pain; not
jTcpitus Of displacement could be dis-
tuid her having walked both before
admission into the hospital,
rxse CO a supposition that fracture did
esse Her constitutional suffering ra-
ittnm;sed, accompanied with general
about the abdomen, and she died
4iK oiie ojttth day from the receipt of the
jtiurv.

JLiKT indu Mr. Key first examined the
^t:tt oc mtanr externally, with attention, but
sMuifti QiiH liiscover any deviation from the
wGural state.

Ott ^jjipoeiug the capsule of the joint after-
>iiiii:^a cavity vras discovered by the side
vH cfate pectineus muscle, passing backwards
4jiiii downwards towards the trochanter
utiii!i<;r» and containing some pus : it extended
iKhiiui the bone to the large trochanter.
v.hi cutting through the ligaments, and dis-
LWiifcting the head of the bone, a fracture
vkdi^ Ar^t perceived at the root of the tro-
V a^AuMT major- This fracture had separated
i;>c uwhauter from the neck and body of

429

the bone, without tli^ tendons attached to
die outer side of the process having been
mjured, so that a separation of the fractured
pKNTtions could not take place^ on vrhich
account. the nature, of the accident had hot
been detected during the life of the patient. .

»•

: Of Fractures below the Trochanter.

>
f -When tiie thigh bone is broken iust below Difficult to

^ *' manage.

ike .trochanter major and minor, much diffi-
enlty exists in effecting a good union, and if
the treatment be ill*managed, great defor^
mity is the consequence. The fractured
extr^Qoity of the superior portion oi the
boae. is drawn upwards and forwards by
the action of the psoas, iliacus internus,
and pectineus muscles, and any attempts by
pressure to obviate this position of the bone,
only increases the suffering of the patient,
without effecting the desired purpose.

In the treatment of such a case, two prin- Treatment.
dpal circumstances require attention: first,
to elevate the knee, by placing the limb over
a double inclined plane, and secondly, to
raise the body so as to place the patient in
nearly a sitting position ; the degree of ele-
vation of the limb or of the body must de-
pend on the approximation of the fractured

430

ends of the bone, and the surgeon must
carefully ascertain that the proper relative
position of each portion of the femur is
restored, before he proceeds to apply the
splints and bandages to retain them in this
state. A strong leather belt lined with some

« soft material, and made to buckle round the

limb, answers better in these cases, than the
common splints.

s^dmen ^ preparation in the museum at St.Thomas's
Hospital exhibits the mode of union in db
ill-treated case of this kind, and illustrate
the necessity of careful attention to the
points I haye mentioned, viz. : the relatxatioii
of the psoas, iliacus intemus, &c. by elmt^
ing the body, and the raising of the inferior
portion of bone to a line with the superior.

431

LECTURE XLIV.

Of Dislocations of the Knee.

The frequent and great violence to which stroctnre
;. this joint is exposed, also the form of the ^ ''***"
articulation, the cavities on the head of the
tibia being very shallow, would render it
extremely liable to displacement, were it not
ifor the extent of articulating surface, and the
exisitenoe of numerous strong ligaments,
which connect the os femoris, the tibia, and
the patella.

Dislocations do, however, sometimes occur
from excessive violence, or from great relax-
ation of the connecting ligaments.

Of Dishcation of the Patella.
The patella may be dislocated in three Three

'I*.* • xj* 1 1 forms of*

directions ; — ^viz. outwards, inwards, and up-
wards.

The external displacement is the most External,
common ; in which case the patella is thrown
upon the outer condyle of the os femoris,
where it occasions a great projection, which

432

circumstance, and the incapacity of bendiag^
the knee joint, sufficiently mark the naturae/
the injury.

caim of. Persons who have naturally an injj^ation
of the knee inwards, are most liable to this
injury, and it is usually produced by a M
at the time that the knee is turned inwards
and the foot outwards, so that the action of
the muscles, in endeavouring to prevent the
fall, draw the patella over the external con-
dyle of the thigh bone.

internau The displacement of the patella upon the
internal condyle, is much less frequent, and
generally happens from a fall upon a pro*
jetting body, by which the patella is struck
upon the outer side, and, forced inwards
at the time that the foot is turned in the
same direction.
Ligament • Uuless the ligament has been relaxed
from previous disease, it will be torn in either
of these dislocations.

The reduction, in either case, may be
accomplished in the following manner : —
TmtMAt. Place the patient in the recumbent pos-
ture, and let the leg be raised, by lifting it
ut the heel, so that the extensor muscles of
the thigh maybe relaxed as much as pos-
sible ; then press down firmly the edge of
the patella, furthest from the articulation,
by which the opjx>site edge will be raised

433

over the condyle, when the • action of the
miiscres will quickly restore the bone to its
natural situation.

Th^oUowing plan was adopted by Mr. cwe.
Geoi^ Young, in a case of the external dis-
location:; which he could not succeed in re-
ducing by other means. He placed the
inkle of the limb upon his shoulder, which
^ve him considerable power in^ extending
the knee joint, when grasping the patella
with the fingers of his right hand, he pressed
iJbe outer edge of the bone with the ball
ei his lefit thumb, and thua forced it into its
place.

After the reduction^ the limb must be kept Aftertroat
at rest, and the part kept moist with an eva-
porating lotion ; after three or four days,
bandages may be employed. The motions
of the joint are soon restored, but a degree
of weakness remains for some time.

Very slight causes produce the lateral dis- From re-
location, when much relaxation exists, but
the reduction is very easily accomplished,
and it is necessary to employ a laced knee
cap^ with a strap and buckle above and
below the patella, to prevent a recurrence of
the accident.

VOL. III. 2 F

434

OfHk Didocatim of the Patella upwards.

b tkk displacement, the ligameiitum pa-
is torn through, and the patella is
dimwn vpiwBids upon the fore part of the
thigh bone.

The nature of this injury is extremely
wefl narked, by the elevation of the patella,
the fireedom of its motion laterally, and the
depressioQ above the tubercle of the tibia
from laceration of the ligament : the patirat
cannot support himself upon the limb, as the
knee immediately bends when he attempts
to do so. The accident gives rise to a con-

siderable degree of inflammation.

The treatment required for this injury, in
the first place, will be to reduce the inflam-
mation, by the application of leeches and
evaporating lotions, at the same time that the
limb is kept extended, and the body ele-
vated, to relax the muscles, and prevent as
much as possible the elevation of the patella;
after from four to seven days, a roller should
be placed upon the limb, from the toes to
the knee, to prevent swelling, and a splint
should be fixed behind the knee, to prevent
any motion of the joint ; a leather strap
should then be buckled around the lower
|vttrt of the thigh, just above the patella, and

to this should be attached another strap,
which should pass on each side of the leg,
under the foot, by which the circular strap
may be drawn down so as to restore the
patella as near as possible to its natural
position, and thus approximate the lacerated
ends of the ligament, to allow of union.

With great attention, the union will be ^'* '"«•»■

^ Hon, unian

perfect; passive motion may be carefully perfect,
iployed at the expiration of a month.

■The degree of recovery depends upon the Degree of
„ J 1 I recovery,

igth or the ligamentous union, bemg per-
fect when the lacerated extremities are kept
in contact during the union, and the powers
of the limb being diminished in proportion
to their separation.
A dislocation of the patella downwards has Dislocation

, -11 II downwardly

been mentioned by some surgeons, but I
have not seen any injury deserving such a
title. Sometimes the tendon of the rectus
muscle is torn through, in which case a de-
pression can be felt above the patella, but
the bone itself retains its natural situation.
The same position of limb and body is ne-
cessary^in the treatment of this injury, as in
the dislocation upwards, and a pad should

applied over the ligamentum patella, and

ifined there by a roller.*

* In 3 cuse of this nature which (
2 F 2

' under my

436

Of Dislocation of the Tibia at the Knee Joint.

Four
formft of.

InwArdt.

Gate.

The superior extremity of the tibia may
be displaced in four directions, viz. : out-
wards, inwards, backwards, and forwards,
but only the two latter are complete dislo-
cations, as in the two former instances the
articular surfaces of the tibia, and of the
condyles of the os femoris are still pardy in
contact.

These lateral dislocations occur but set«
dom.

When dislocated inwards, the head of the
tibia forms a large projection on the inner
side of the joint, the internal condyle of the
femur rests upon the external semilunar
cartilage, and the external condyle projects
to the outer side.

The first case of this injury which I re-
collect seeing, was brought into St. Thomas's
Hospital, during my apprenticeship th^^,
when I remember being struck with three

care in St. Thomas's Hospital, I found considerable
advantage from the application of a pad over the upper
portion of the rectus muscle, it was confined by a
roller, and assisted materially in approximating tbe
lacerated ends of the tendon ; the patient recovered
with perfect use of the limb. — T.

Circumstances respecting it ; first, the great
deformity of the joint — second, the little
force necessary to reduce the displace-
ment— third, the slight degree of local or
constitutional suffering which followed, the
recovery being complete in a few weeks.

When displaced outwards, the tibia pro- o
jects upon the outer part of the joint, the
internal condyle upon the inner side, and the
external condyle rests upon the internal
semilunar cartilage, the deformity produced
being as great as in the former case.

The reduction in either instance may be r
readily effected by direct extension, and
but little diminution of power in the joint
follows. I believe that, in both these dis-
locations, the tibia is rather twisted upon
the femur, than forced merely inwards or
outwards, so that the condyle of the os
femoris is thrown somewhat backwards with
respect to the head of the tibia, as well as
laterally.

■ When the patient is first allowed to use '
the limb after an accident of this kind, the
joint should be supported by a bandage
or a knee cap, as from the injury to the
ligaments, it remains feeble for some time,
although the recovery ultimately is nearly
■perfect.

2 F 3

438

Dislocation of the Tibia forvmrds.

^ When this accident occurs, the following
mppearances will be presented^ when the
patient is in the recumbent position. The
head of the tibia projects forwards, and the
inferior part of the thigh bone is depressed,
being thrown a little to one side as well as
backwards : the patella is drawn up by the
action of the rectus muscle. The circu-
lation through the popliteal vessels is ob-
structed by the pressure of femur posteriorly,
so that arteries below cease to pulsate, and
the foot feels numbed from pressure upon the
ner>'es.
CMb A man named Briggs was admitted into

Guy's Hospital, in the year 1802, under the
care of Mr. Lucas. He had a dislocation
of the tibia forwards, in one extremity, which
presented the marks I have described, and
a compound fracture of the tibia, with a
dislocation of the head of the fibula existed
in the opposite limb. The extent of mis-
chief attending the compound fracture, ren-
dered it necessary to amputate that extre-
mity. The dislocation in the other extre-
mity was easily reduced, by extending the
tluf»h from above the knee, and by draw-
ing tho leg from the thigh, inclining the

tibia a little downwards. The patient re-
covered.

Dislocation oftlit Tibia bachvards.

This injury occasions the following marks, signiof.

A projection of the condyles of the os fe-

moris anteriorly, a depression of the liga-

I mentum patellte, the head of the tibia is

I seated behind the condyles, and the limb is

' shortened, the leg being bent forwards. My

friend, Dr. Walsham, sent me the following

particulars of a case which was under his

care.

Mr. Luland, a very robust and muscular Cwe.
man, had his shoulder and knee dislocated
in consequence of being thrown from hia
cart, in January, 1794. The head of the
tibia was completely dislocated backwards,
reaching behind the condyles of the femur
into the ham ; the tendinous connexion of
the patella to the rectus muscle was rup-
tured ; the external condyle of the os femoris
was very protuberant; the leg was bent
forward and shortened, and there was a
depression just above the patella. The pa-
tient felt most excruciating pain when the
limb was moved, but there was not any
^considerable suffering when it was at rest.
W 2 F 4

440

It was icduced by the following mjeans:-^
Tjvq men extended upwards, one from the
zroin. ;innther from the axilla, whilst two
ottiers extended the leg from a little above
:iie ankie» in the opposite direction ; and
ihey ijprtidually increased the force of their
exteiifiiuiw till the bone was reduced. At
chfi ame of extension. Dr. Walsham di-
rtH:ted the head of the bone to its natural
s^tundon. A loUer was afterwards placed
aver the knee, the limb was laid upon a
{idlow> and an eTS^Kurating lotion was coa^.
scaatLy applied. In this state, the patient
reinaiiwi for a fortnight free from pain, when
the Doctor gently moved the joint every
other daLy> as far as he could, without creating
paitt. In about a month, Mn Luland began to
walk on crutches, in ten weeks he was able
u^ $it at the dinner table, and in .five
uiouths> had perfectly recovered the use of
limb.

0/ Furtidl Lusntion of the Thigh Bane frm
the Semilunar Cartilages.

The ligaments of the knee joint some-'
umcti^ become so much lengthened from
^^\Uvmo relaxation, or from an increased
\vvtvUv>u into the joint, as to permit the

441-

■semilunar cartilages to glide upon the sur-
fece of the tibia, when pressure is made by
the femur on the edge of the cartilage.
The nature of the 'accident was first accu- F'"' »>£-

scribed by

rately described by Mr. Hey, of Leeds, who Mr. Hbj.
was so justly celebrated from his high pro-
fessional attainments ; he also suggested
an ingenious and scientific mode of treat-
ment, which is generally successful.

The displacement is most frequently oc- cmiiMof,
easioned by a person when walking, catch-
ing the toe against some projecting body,
whilst the foot is everted, pain is imme-
diately felt in the joint, and the limb can-
not be straightened. I have known it also
produced by the bed clothes, obstructing the
motion of the foot, when a person has
been turning in bed. The explanation of
the accident is as follows : —

The semilunar cartilages, which receive Expiann-
the condyles of the femur, are united to the '""' " '
tibia by ligaments ; and when these liga-
ments become extremely relaxed or elon-
gated, the cartilages are easily pushed from
their situation by the condyles, which are
thus placed in contact with the head of the
tibia, and when an attempt is made to extend
the limb, the edges of the semilunar carti-
lages prevent it.
L> The mode of reduction is, to bend the ReJucHoi..

442

limb as much as possible^ so as to ^oiable
the cartilage to slip into its aatund position
firom the pressure of the femur : the cartilage
being thus replaced^ the Umb can be again
properly extended, and the condyles are
tigdixx received upon the cartilage.

I have, however, known this plan to &il
in effecting the desired object, as Hie fcdlow-*
ing case ^U show.

caie. A lieutenant in the army, who had been

repeatedly . the subject of this injury, and
who had been as often relieved by the means
above recommended, had a recurrence oi the
accident whilst turning in his bed ; he came
to town, but the former mode of treatmekit,
although repeatedly tried, did not succeed
in reducing the dislocation ; he afterwards
went to Mr. Hey, of Leeds, but without
obtaining relief.

After A knee cap, made to lace closely upon the

joint, will generally prevent any further dis-
placement; but, in some cases, this is not
sufficient.

Case. Mr. Henry Dobley consulted me, in con-

sequence of his suffering frequently from
this accident, which could only be prevented
by the addition of straps to the knee cap,
one of which, of considerable strength, passed
just below the patella.

Case. In another case, that of a young Iady>

443

also frequently the subject of this dislo-
cation, the accident could only be prevented
by a linen bandage, having four rollers at-
tached to it, which were tightly bound above
and below the patella.

I have seen some cases of this kind, in Effects or.
which a very great alteration has taken
place in the form and size of the joint, in
consequence of a chronic inflammation at-
tending them. The following is an account
of one: —

Lady D. in falling, twisted her thigh in- Case.
wards, so as to occasion great pain in the
knee-joint. On attempting to extend the
limb, she could not move the knee-joint ;
but, after pressing the thigh outwards, and
leg inwards, with some force, she found her-
self capable of straightening the extremity.
For a fortnight after the accident, the joint
was extremely weak, and she could hardly
bear it to be moved. She then began to
stand upon the limb, supporting herself by
crutches ; but when she bore much upon the
injured limb, it suddenly bent back, and
this produced considerable pain and swell-
ing, at the time she felt the condyles slip
from the semilunar cartilages upon the head
of the tibia. This occurred repeatedly dur-
ing a period of fifteen months after the acci-
dent, and each time greatly retarded her

444

recovery. Three months after this^ she had
so far improved^ as to be able to walk with
the aid of a stick only, when, in elideaTt)!!^^
ing to raise herself from a soia> her left knee
gave way, as if the bone had slipped from
its place ; the thigh bone being at the same
time twisted outwards ; this produced great
pain and swelling, and she was again un-
able to stand upright. Her joints were all
remarkably flexible, and when a girl, she
often experienced a sensation of having dis-
located her knees, but from this she soon
recovered. When I saw her, both knees
were much enlarged from effusion of synovia
into the cavities of the joints, she could
not stand without support, and was unable
to straighten the limbs. To relieve her,
blisters were applied, and for some time
kept discharging ; after they were allowed
to heal, pressure was employed by means
of bandages, which were occasionally re-
moved, to allow of friction. She derived
most benefit from the internal use of the
pilul: hydrarg: submuriat: comp: and the
decoct: sarsaparillsB comp: and externally
firom the friction.
Dissection In the disscctiou of these cases, the liga-
joints. ment is found extremely thickened; small
ligamentous and cartilagenous bodies are
hanging from it; part of the articular car-

445

tilage is absorbed, and part presents
thick projecting edge. After maceration,
the edges of the condyles are found to be*
much increased by deposit of bony matter.

Of Compound Dislocations of (he Knee.

This accident is of very rare occurrence; veryn
I have only once seen such a case, which
required immediate amputation ; aad I
scarcely know any form of injury which
would so urgently call for operation.

On the 26th of August, 1819, I was sent Case.
for by Mr. Oliver, of Brentford, to see a Mr.
Pritt, in consequence of severe injury to the
knee, occasioned by a fall from the coach
box of one of the mails. On examining the
limb, I found a large aperture in the inte-
guments, on the outer side of the knee joint,
through which the external condyle of the
femur projected, so as to be on a level with
the edges of the skin. The inferior part of
the OS femoris was thrown behind, and to
the outer side of the head of the tibia, the bone
was twisted outwards, so that the internal
condyle was situated upon the head of the
tibia, whilst the external condyle was turned
backwards and outwards. We succeeded in
replacing the bones with much difficulty.

446

but as soon as the extension ceased^ they
retamed to the same position as I have
^bove described.

In consequence of the great severity of
the injury, the difficulty of the retaining the
bones in their natural situation, and the
patient being of a very irritable disposition,
I immediately proposed, and with his coa*
sent, performed the operation of amputation.
Great constitutional suffering followed the
operation, but under the judicious treatment
of Mr. Oline, who visited him during my
absence from town, he gradually recovered.

DiBiection, On dissecting the limb after the opera-
tion, I found great extravasation of blood
into the cellular tissue surrounding the
joint; the vastus intemus was extensively
lacerated, just above its connexion with the
patella; the tibia projected forwards, and
the patella was situated to the outer side of
the knee. On the posterior part, both the
heads of the gastrocnemius extemus muscle
were torn through, and the capsular ligament
so completely divided, as to admit both the
condyles of the femur through it.

Attempt Should a case of compound dislocation of

to save the

umb. the knee occur, in which a very small wound
only existed, admitting of ready closure, it
would be right to attempt the preservation
of the limb.

447

Of Dulecatiom of the Knee from Ukeratun,

FrcMU the chronic diseases of joints^ not c*w« »^*
only the synovial membrane and articular
cartilages suffer from ulceration^ but in some
cases the capsular, and also the peculiar
ligaments become ulcerated, so that the con-
nexion between the bones is in a great mea-
sure destroyed, when the muscles which par-
ticipate in the irritation, contract and gra-
dually displace the bones producing gr^t
distortion of the limb.

This is most frequently seen in the hip
joint; but it is not uncommon to find at
the knee the tibia drawn out of its proper
Uiie, with respect to the femur from the same
(sause.
/ Occasionally, the distortions thus pro^ Extraordi-

nary distor-

4ucQd are very remarkable. Mr, Cline am** tion.
putated a limb in St. Thomas's Hospital, in
which the following alteration had taken place
from chronic disease in the knee joint. The
leg was placed forwards, at right angles vnth
the thigh, so that, prior to the operation, it
projected before the patient when he was
standing. On examining the joint, the pa-
tella was found anchylosed to the femur, as
also the tibia to the fore part of the condyles
of the thigh bone.

f'lcn :2aT je ione i:i the early stage of
am lisease. "d Trevent deformity, by the
rn-.f-^' 1 f ?ciiiii3. izd the use of internal

:iie puiv : Ipecacuanhas corap :
a MTTwm^sa f^aaoL imtzbiiitY.

■ - *a'

'.V Pnczurss •}/ the Knee Joint.

L ^auil luw cp?ceed to describe the frac*
ixre* -v^ca vHtcut ia the bones formmg the

V. *-

F^ictuTts of the Patella.

The 3ic« ccmmon fracture of this bone,
* TiiT:?^^rsety : sometimes, however, it is
wrntea "cc^lcndinally ; these fractures may
ie itdier siaiple or compound, but the latter

>*"i^!i tricmred transversely, the superior
^i%nt:ca ,*i' b<*ne is separated from the inferior
i^'iK vfnwn up by the action of the rectus
»:i8?c xic or^neus muscles, which are inserted
itce :c. The lower portion of the bone re-
Tt.i. !> •:: *r> natural situation, connected to
.:tv: ;ci:.v.:i:':iv.ni patellae.

l"V .vv^crw of separation will be found io
; <^ -. v^.v, half an inch to five inches, and

.449

depends upou the extent of laceration of
the capsular ligamcDt, and tendinous aponeu-
rosis covering it.

The nature of the injury is readily recog-
nised, on examination, by the fingers, when
pressed between the two portions of bone,
sinking nearly to the condyles of the femur;
by the situation of the upper portion of bone,
and by its free lateral motion upon the fore
and lower part of the thigh bone ; the patient
cannot extend the limb, nor can he support
the weight of the body upon it when stand-
ing, as the knee immediately bends forwards
from the loss of the support of the extensor
muscles. The injury, if simple, is attended
with but little pain, and is not productive of
much constitutional suiFering.

A few hours after the receipt of the accident,
the part becomes tumid from extravasation
of blood, and the surface presents a dis-
coloured appearance from ecchymosis, thisj
however, subsides in a few days, but the
joint enlarges from an increased secretion
of synovia, and from effusion in consequence
of inflammation. As the portions of the bone
are separated, no crepitus can be felt, as is
usual in other fractures.

Two causes are found to produce this
injury: — First, Falls upon the knee, or
blows upon the patella, when the patient is

VOL. III. 2 (i

'it: ictioa of the extensor
:• ae. _=. any sudden effort

a r-r-: - srenii i gentleman, who

•r. .IT-- — ? r^ifLa by an effort he

:v ■ ir >ji>ir : -rid falling, after hav-

>. vv _ iii^ v^o met with the same

. .r:.. : i^-r-r'^nin:^ to save herself

— ^ ::- Ticrj lesiiending some stairs,

=• '.-^ T.II.-:-. rtr leii :x> near to the edge

:- ^••Jt-'T iAtnordinary, that the

. - . iir niiscitrs alone is sufficient

:— v-.i ra-Torf. bm a little attention to

■^ ^r-'-'*..:"^ lui: 2rcde of action easily ex-

^_;a. i.z ui:t. Wien the knee is bent,

•r titt ,i > in-vn down on the end of the

•.::ik'^ .-^i^ i ^tf Srciur, and the upper edge

:t xur irj^^^z forwards, so the muscles

>,,:. A.1 11 1 ^^^ ^th the patella, but at

v-^'. jJi^^iT^^ '^"^ ^^- ^^d more particularly

..tifi i^ ::nnfr rcrt:on.

•^ i:!:i;ii .1 these cases is generally
.,.. .^..,LU5< wriedier the portions of the
^•v.rji xiw Sf nearly approximated, or
..- • ^ ,Mri:iC. Soon after the accident,
. -.•• > -Vii*^ out, and fills the space be-
,.,v-t :K iiv.'^nred ligament and broken
, - ^ I ,vi:v:\ but this soon becomes ab-

451

sorbed, and its place is occupied by adhesive
matter thrown out in consequence of inflam-
mation ; this soon becomes organised by
vessels from the edges of the injured liga-
ment, and a structure, similar in its character
to ligament, is thus produced, by which the
parts divided by the injury are again united.
Sometimes this new structure does not com-
pletely fill up the space formed by the sepa-
ration of the portions of bone and ligament,
but it has apertures in it; but this most
frequently occurs when the separation is
feery great, or when the limb has been moved
■too soon after the accident.

K, On examining the seat of injury, some DUiecUon.
Btne after the accident, I find that the pa-

■tlla itself undergoes but little change, the •

H^erior portion has its broken surface very ^^H

Hktle altered, being only rather smoothed ; ^^H

Plhe upper portion has its fractured surface ^^^H

covered with some ossific deposit, so that ]^^H

there is more ossific action in the superior ^^H

than in the inferior portion of the bone. ^^^|

The articular surface maintains its natural ^^^|

appearance. ^^H

By experiments on the rabbit, I have Enperuneai^^^l

been able to trace the mode in which this ^^H

injury is repaired ; in each experiment I ^^^|

divided the patella, by placing a knife on ^^^|

the bone, and striking it gently with a mallet, ^^^|

452

having first cut throv^ the int^^umeiitSi
which I drew as much as possible to one
side, so that when allowed to resume thw
natural situation after the division of the
patella, the wound was not opposite the
fracture.
^|w^^j^^ Examining the parts forty-eight hours after
g^j^j^J^ the division, I found the portions of bone
separated to the esctent of three quarters^ of
an inch, and the intervening space filled with
coagulated blood.
Eight days In a sccoud experiment, examined eight
•«''• days after, most of the blood was absorbed,

and adhesive matter deposited in its place.
Fifteen A third, examined on the fifteenth day,

dayt after*

the adhesive matter had become smooth and
somewhat ligamentous.

Twenty- A fourth, examined on the twenty-second

after. ^ day, the new lig^ament was perfect.

Five weeks A fifth examined at the expiration of five
weeks,'and injected, showed the organisation
of the new ligament, which was chiefly sup-
plied by vessels from the original ligament,
and by a very few vessels from the bone.

Union by In repeating these experiments upon the
^*^^°^* rabbit and dog, I could not succeed in pro-
ducing a bony union, although I could keep
the fractured pieces in perfect contact.

Bony I believe, however, that ossific union may

union. *

now and then be produced ; in a case which

453

' with Mr. Chopart at Paris, there was
every appearance of such a junction, and
Mr. Fielding of Hull has published another

ol i

Although in a large majority of these
cases, I believe the union to be ligamentous,
yet it is extremely desirable to make the iM ^^J
ligament as short as possible, as the degree
of recovery of the power of the limb is in
proportion to the approximation of the frac-
tured portions of the patella, or according
to the shortness of the new ligament, for as
the superior portion of the bone is separated
from the inferior, by the action of the rectus
muscle, so the muscle becomes shortened,
and its power consequently diminished.
"When, therefore, the intervening ligament
is very long, the person cannot walk fast
without a halt, and is in constant danger of
falling.

In the treatment of the transverse fracture '
of the patella, the patient should first be

iced in bed upon a mattress, with the
ijured limb extended, behind which a hol-
low splint, well padded, should be applied ;
the heel should be elevated a little, and the
body raised, in order to relax, as much as
possible, the rectus muscle, and thereby
prevent it from drawing up the superior
the fractured bone. The limb
2 G 3

■ee ^^zS^
in

■
" I

re Treatment. ^^^H

454

should be fixed to the splint to prevent its
slipping, and the surface of the joint should
be kept constantly moist, with an evapofatiiq;
lotion. If there be much tension or paia
succeeding the injury^ the application of
leeches will be necessary, with a coirt]nuan(^
of the evaporating lotion. In a few days,
the swelling and pain will subside, under
this plan of treatment, after which the ban-
ds^es may be applied to approximate the
portions of bone« The surgeon should be
very careful not to apply the bandages before
the tension has been reduced ; I have known
severe suffering and inflammation produced
by their too early application, so much so ia
some easels as to threaten a sloughing of the
integuments.
conunoD The most common mode of using the

bandage. ^

bands^es is as follows : a roller is first applied
from the toes to the knee, to prevent swelling
of the leg; two pieces of broad tape are
then placed on each side of the patella, in
the direction of the limb, and two rollers
are next bound round the extremity, one
above, and the other below the knee joint,
confining the pieces of tape, and having the
two portions of bone between them; the
ends of ttape on each side are afterwards
turned over the rollers, and tied so as to
bring the rollers nearer to each other, and

:iired bone

Uic splint is

limb, to pre-

^ iiit, the heel is

supported nearly

iiode rather different. Another

mode.

ulc, and which consists

-lur strap around the lower

igh, immediately above the

)ii of the patella, and having

attached to the former on each

•iiough to pass under the sole of

by which the circular strap can

a down, and with it that part of the

II bone connected to the tendon of the

is muscle; the splint and the position

attended to as above-mentioned.

It is necessary in the adult to continue Penodof

^ confinement,

this treatment for five weeks, and in elderly
persons for six we^ks, before any motion is
allowed ; it may then be employed passively^
but very cautiously, until it be ascertained
that t}ie union is sufficiently firm to bear it
without risk, when it may be continued from
day to day until the joint can be completely
flexed.

Passive motion is very essential to pro- Passive mo-
mote the return of power in the muscles and *®"®"®" ** •
joint, as without it many months will elapse,

2 g4

md the pttsnt stfll be ixicapaUe of flezng
±6 'imb. Wlfli pMsnre modoa is to be
empioyed, die polieiit shoold be aeated upon
I iigb stDoi or table, in sucb a manner that
die edge of tbe seat reaches as fin* as the
lam* so that the \tg can be depressed with-
JVC the thigh ; this is to be dime with coor
lidex^l^ care at first, nntil a slight degree
It Tnotxon has been ac(|mred, when the pa-
::enc axay^ by swinging the kg, and directing
his mrnrf to the contraction <tf die rectos and
exterior nxnscies, gradually restore the fimc-
tions of the j<xnt. If the onion has takai
place with a diortened state ci the rectos
muscle, and die porticMis €ji bone are joined
by a kmg intenrening ligament, the mosde
does not recoTer its volantary power nntfl it
h;i$ been again elongated, which is d<me by
bendinsr the knee.

A VDone woman who had suffered finom
transrerse fiactore dt both patellae, was
brought to my house, in consequence d
w>l baring recoTered any power of flexing
the limbs. Passire motion was employed
and she was directed to extend the limbs,
when they had been flexed by the suigeon ;
m this Rianner, after persevering for some
tinu\ ?he craduallv recovered the use of
tho loini^. The pain created by the passive
o*v*thvv .uui the very gradual benefit de-

rived from it, make patients averse to ita
continuance, but it is perfectly essential to
recovery.

Of the Perpendicular Fracture of the
Patella.

This injury, as the former is attended with
considerable effusion and swelling of the
soft parts.

Having seen several cases in which the ^
union had only been effected by ligament,
and not being aware of any circumstance
that should prevent ossific junction, I made
several experiments upon dogs and rabbits,
the result of which was as follows :—

Having produced fractures in a manner i
somewhat similar to that already described,
for occasioning the transverse division of
the bone, sufficient time was allowed for
the process of cure to be completed, when
the bones were examined, and found to be
joined only by ligament, and the two por-
tions considerably separated from each other, .
from the pressure of the condyles of the
femur upon the inner surface of the patella
when the knee was bent.

1 therefore made another experiment, and
)-tbe -patella -in a dog, but in such a-

458

manner, that the tendon above, and the ligi*
meat below, remained uninjured, so that
there could be no separation of the firactaied
portions ; in this case, I found that a perfect
ossific union took place.
i|i»k«iby It appears then, that in either, the lon-
gitudinal or transverse fractures, when the
portions of bone are separated, that a liga-
mentous union takes place ; but if these pcff*
tions remain in contact, diat th^ stay be
united by b<»ie.

Mr* Manyat had kis patella bndcea into
thrw pQftioii8» by m ftll from kia gig, the
booft was divided by m tnnsnrene ftactoie,
and the kiwer piece again divided fay m per*
peodicular fracure; tte tnnsvcne fiactnie
umMd by ligaf t odhf , vrkibt the peqien-
dMilar fracMre jomed fay bime.

i6aMwtd tkepalsBaof aidog;aqpanitiiig
il iiij|# liMr iNnms byacracial dmaQii,iio
^MapM iMik plMit K^^Mi^,^ &e fwoaaDerior
|W«^iV miinligt «9^ eMk olker, mar «d the

M^ <^idh #^i«t ^
IW MMMMK tit lki» MiiiiMn coHBsts in

If^riii^ ik^ Mi^ m as ii ■ai.ndiil positkiii,
xntftk 41 ihM^K^ c$fidE0£ MSKTMiT^ la pievoit
4^ :tt!k^<>^it ve ciie istfe juaat; in apptying
4^ ^tiijNMftaiji: ^MWL lotCL laie sveDing and

padded on each side of the patella should be
buckled around the joint, the straps passing
above and below the patella.

Of Compoimd Fracture of the Patella.

When this accident is attended with ex- Extencrf I

mischief.

tensive laceration, and much contusion of
the surrounding soft parts, it will be right
immediately to amputate the limb ; but
should the wound be small, so that its ed;
can be readily approximated, and not accom- ,
panied with such mischief as is likely tO'
occasion sloughing ; an attempt should be
made to preserve the extremity.

The principal object in the treatment, i
to produce adhesion of the edges of the
wound ; to eft'ect which, all our efforts should
be directed. The application of sutures is
necessary, not only to assist in the imme*'
diate approximation of the edges of thftjl
wound, but to prevent their after separatioQi i
which is otherwise liable to take place j
from the escape of synovia, and the lax ]
state of the integument, besides the sutures)! 1
strips of adhesive plaister should be placed;
and the part kept cool, by the evaporating

L lotion. Poultices or fomentations must not be
Used, as they prevent the adhesive process.

460

in St. Thomas's Hospital, under
1 Mr. Birch, had fomentatjons and
pmutices onployed, after an injury ci tiiis
3anire^ in which bat a small wound comma-
3icaied the joint, — ^he died in consequence
vjt euesaiTe aHistituti(mal irritation, pro-
duced by suppuratiTe inflammation, which
took friace in the joint.

The following case, which was under the
eve of Mr. Dixon, of Newington Butts, wiD
fuDy explain the mode of treatment I woold
recommend.

Mr. Redhead, aged 39, of a spare habit,
was thrown from his gig, June 18, ISIO^
uriien his knee, striking against the wheel
of a cart, produced a compound fractuie
oi his patella. At Mr. Dixon's request, I
Tisited the patient in the afternoon of the
day on which the accident had occurred,
and on examining the joint, I found a wound

00 the fore part, which readily admitted my
finger into the joint ; the patella was broken
into several pieces, one of which being de-
tached, I removed. From the habit of the
patient, and his not having an irritable con^
stitution, we determined on attempting to
j>rvser\'e the limb. I accordingly brought

1 ho edges of the wound together by the
apiUication of a suture, taking care not to
iu\ Uule the ligament; I then further secured

461

i closure of the wound b]
sive plaister, and over the whole, i placed
a roller very lightly, which was to be kept
constantly moistened with spirit of wine and
water. The leg was placed in an extended
position, and he was ordered to live on fruit.
The suture was not removed until the 30th
of June, as he did not at all complain. At
the expiration of a month, Mr. R. was
allowed to leave his bed ; and in five weeks
from the accident, passive motion was com-
menced. He gradually recovered the perfect
use of his limb.

In the year 1816, a case happened io
Guy's Hospital, in which the knee joint was
opened by ulceration, some time after the
occurrence of a transverse fracture of the
patella, which had united by a ligament
about three inches in extent; the patient,
a woman, was admitted into the hospital, in
consequence of having numerous ulcers on
various parts of her body, one of which was
seated in the integument, immediately over
the new formed ligament, uniting the broken
patella ; this ulcer became sloughy, and ex-
tended through this ligament into the joint,
in which excessive inflammation and suppu-
ration occurred, which destroyed the patient.

462

Of Oblique FrMtures €f the Comfyks of the
Os Femorii mto the Knee Joint.

sifMof. Either the external or the mtarnal con-
dyle of the femur may be separated by fiac^
ture from the rest of the bone, producing
much deformity of the knee jcmit, and giving
rise to great swelling, which circumstances,
together with the feeling of crepitus wh^
the joint is moved, indicate the nature of the
injury. In either case, the same mode of
treatment is required.

Treatment ^^'^ injured limb is to be placed upon a
pillow in the extended position ; leeches and
evaporating lotion are to be employed, until
the infianmiation is subdued ; after whiek,
a piece of stiff pasteboard, about a foot and
a half in length, and of sufficient width to
evelope the posterior and lateral parts of the
knee joint, as far as the sides of the patella,
is to be applied wet, and secured by a
roller ; this, when dry, adapts itself to the
form of the joint, and best confines the frac-
tured portion of bone. In five weeks, pas-
sive motion should be employed to &dli-
tate the recovery of the motions of the arti-
culation.

Compound Compound fracture of the condyles of the
OS femoris is a rare accident ; and in the old,

fracture.

or irritable, is most likely to be attended

with fatal consequences, unless the limb be

removed. In young persons, or in those

not of an irritable constitution, a cure may be

effected, unless the opening be very exten-

3, or attended with much surrounding

ichief.

I A boy was admitted into St. Thomas's c«se,

bspital, in September, 1816, under the

ire of Mr. Travers, having a transverse frac-

e of the femur, just above the condyles,

1 an oblique fracture of the external con-

yle, with which a small wound commu-

icated ; the limb was placed in a fracture

'px in the semi-flexed position. The patient

offered but little from constitutional dis-

^rbance, although the integuments over the

loured condyle ulcerated, so as to expose

^e bone, which was removed in November,

consequence of its losing its vitality.

lifter this, the limb was placed in the

aight position, as anchylosis was deemed

bavoidable, but the lad recovered with a

Iferfectly useful joint.

y Obliqite Fracture of the Femur, just above ^
the Condyles.

The consequences of this injury are often couequence,

sry lamentable, producing great deformity

464

of the limb, and destroying, in a great mea-
sure, the motions of the knee joint.

The injury is generally produced by a
fall from a height upon the feet, or upon the
knee when the joint is very much flexed.
SMoiMtt Mr. Paty, surgeon of Bouverie Street,
■iMd. Fleet Street, has a preparation, showing the
great deformity consequent on this injury,
it was taken from a subject brought into the
dissecting room at St. Thomas's Hospital
Before dissecting the parts, it appeared that
the femur had been fractured just above
the condyles, and that the inferior part of
the superior portion of the Ixme projected
as far as the upper part of the patella, being
only covered by the ddn; the size of the
bone was much increased. On examining
the seat of injury, the end of the saperior
portioa of Ixme was found to have pierced
the rectus muscle» through which it coor
tiaued to protect* The pateDa could not be
drawn vfiwards, as it was sti^iped by the
extrtttiity of the bone* The condyles of the
fitmur and the infanw portioQ ai bone had
been drawn upwards and backwards by the
4ICIMI of the oiwdes^ behind the inferior
IvuTt of the $upenor poitioQ, and had united

liHkf^eftdetti 01 the defonnity in this case,
iW ^^"4x^41$ ivT the knee-joint must have

465

been very limited, as the rectus muscle was ^m
hooked upon the projectingf extremity of bone ^H
anteriorly, which also prevented the ascent ^H
of the patella.

The best mode of treatment to obviate Beitm
these great evils, is first to flex the joint as meat.
much as possible, to liberate the rectus muscle
at the same time supportingthe condyles over
some fixed body, to prevent their receding,
and afterwards the limb must be firmly ex-
tended, to prevent retraction. ^H

The following cases will explain the diffi- ^1
culty of effecting these objects ; the first was
under the care of Mr. Welbank, junior.

A gentleman of middle age, a tall and caie,
powerful man, was thrown from his gig in
June, 1821. The medical attendant, who
was called to see hira, found him lying on
a bed, to which he had been carried, with
his right leg bent across the left at an angle. ^_
At first view, it appeared that there was a ^H
lateral dislocation of the knee, a deep hollow ^H
was seen on the outer side, in the situation ^H
of the condyles, and above it a sharp pro- ^H
jection. On examining more attentively the ^H
seat of injury, an oblique fracture of the ^H
femur was found just above the condyles ; ^H
considerable effusion existed in front of the ^M
joint, around the patella, which could not be ^M
distinctly felt. After the fracture had been

VOL. nr. 2 h

466

reduced, which was readily effected by slight
extension, a ridge could be felt just above
the patella, which, upon a superficial exa-
mination, might have been mistaken for a
transverse fracture of that bone. If the
limb was flexed, a great deformity resulted
from the projection of the upper portion of
the fractured bone, which disappeared again
on extending the limb. The sensation of
crepitus was very indistinct.

The extremity was placed in an extended
position, and secured by the application of
short splints, for the space of a week, during
which time means were employed to reduce
the inflammation of the capsule, consequent
on the injury. After this, a long splint was
applied on the outer side of the limb^.ficoiii
the trochanter major to the foot, and a shorts
one on the inner side, from the middle of
the thigh to the middle of the leg; these
were firmly confined by bandages, and the
limb was supported upon an inclined plane.
In consequence of frequent variation in the
projection of the upper portion of bone,
weights were subsequently appended to the
foot, to keep up a constant extension^ which
appeared to be advantageous.

In September following, the union was
thought to be sufiiciently firm, and the pa-
tient was carefully removed to Eastbury,

Herts, in a litter-carriage, with his limb still
in the same position. It being found, how.-
ever, that alteration of posture, or any at-
tempt to flex the limb, produced a greater
projection at the seat of fracture, the former
plan of treatment was continued for another
fortnight. Upon a further examination after
this period, a degree of lateral motion
could yet be felt, and the projection of the
fractured bone was still increased by bend-
ing the knee, indicating that the union was
not yet firm, in consequence of which the
limb was again placed at rest, and a circular
belt was tightly bucltled around it at the
seat of injury, to press the fractured parts
together, and to maintain them in firm appo-
sition. In the middle of October, the pa-
tient was first allowed to get up, the union
being then complete, and he has since gra-
dually recovered the use of the limb, so as
to be able to walk without assistance, but
he has little power of bending his knee,
the upper part of the patella being caught
gainst the projecting portion of the femur,
which is still evident. The limb is somewhat
shortened, and the thigh inclined outwards.

Mr. Kidd, who was tall, muscular, and Caie.

in weight fifteen stone, fell from a height of

twenty-one feet, and by the severity of the

concussion, fractured his thigh bone ob-

2 H 2

408

liquely, just above the condyles, and the
lower part of the superior portion of the bone
penetrated through the rectus muscle and
integuments, appearing just above the pa-
tella. He was immediately carried home,
and I was requested to see him by Mr.
Phillips, Surgeon to the King's Household,
who had been called to him. The project-
ing extremity of the superior portion of bone
was sawn off, and the fracture reduced, when
the edges of the wound were carefully,
bmught together, and the limb was placed
over a double inclined plane. The wound
healed without difficulty, which was ex-
tremely favourable. The accident occurred
ou the 9th of November, 1819, and on the
30th, splints w^ere supplied to press the bones
together. December 23, the limb was
pkccd iu an extended position, which was
continued until the beginning of February.
Th<^ pulient >Kms then allowed to sit tip i but
\>u n cawM exmminatioa of the limb, the
uuk>u of ilie tincture was ascGrtaiined not to
b<^ <v>m|itiHi^> and a katker bandage was
lh<^ixM^^«v (4;jioed aromid tdie injured part,
aih) l^iil)y Imckkd^ to secure the bones in
;i^ |M\^}vr jx^iiiMi. t>a the 3id oi May, the
x^u^N^x xxA^ x-^^Tjd IK> be ocwnfiete, and a few
x^\>. AiVo^^ ;V itiCfidw^ >«tsi remored, the
U^^^^ KNi^^ ^ji^^j'^vctioi 3>y a pillow. He was

still tmable to leave his bed in consequence
of the great swelling of the leg, and some '
degree of superficial ulceration from the ap-
plication of the leather bandage. On the
19th of July, he was removed from London
to Kensington upon a litter. A considerable
period elapsed before the swelling of the
:fimb subsided, or before he was able to be
inoved to a sofa. At the end of January, he
*ras on crutches for the first time, and took
iliis first walk out of doors, near the close of
4he following month.

After union was complete, the inferior part
^the upper portion of the bone, which had
leen broken, continued to project, its size
ras very much increased, and the patella
ras fixed to its extremity, to which also the
iskin adhered.

I have had an apparatus constructed, Apparatns
hich, I think better calculated to preserve "un.
the limb in a constant state of extension,
lUian that employed in either of the above
It consists of a straight splint, long
(enough to reach firom the upper and inner
part of the thigh, as far as several inches
below the sole of the foot ; the upper ex-
tremity is hollowed and padded,, so as to
in between the scrotum and thigh, against
side of the pnbes ; and the lower part
resembles that described and employed by
2 II 3

■ M in

■ the si
Hresem

470

Bayer; having a boot which fixes by the
sole, to a bolt projecting at right angles from
the splint; the bolt is connected with a
screw, let into the lower part of the splint,
and on turning this screw, the bolt is carried
upwards or downwards, according as the
screw is moved to right or left. After hav-
ing liberated the rectus muscles from the
broken extremity of bone, by bending the
knee as before directed ; — the limb is to be
extended, and the apparatus applied on the
inner-side of the limb, in the following man-
ner : — ^The upper padded end being placed
between the scrotum and thigh, against the
side of the pubes ; the foot is to be received
into the boot, and confined there by closing
the firont with a lace in the usual manner,
or with straps and buckles ; then by turning
the screw, the bolt connected with the sole
of the boot, and consequently the boot and foot
are made to descend, thus a powerful mode
of extension is afforded, the upper part of
the splint being fixed against the pelvis, the
whole force of the instrument is exerted upon
tbeUmb*

O/Fructwrt oftkt Head of the Tibia.

KaiHf^vf. A frsWture sometimes occurs obliquely
through the head of the tibia into the knee

471

joinf, in which a mode of treatment vej;y
siaiilar to that recommended for the oblique
fracture of the condyle of the femur is neces-
sary ; viz. an extended position of the lirnb^
in which the extremity of thigh bone tends
to keep the fractured bone in its proper situr
ation ; the application of a piece of wetted
paste board, and a bandage. Passive motion
should be employed early.

Should the fracture not extend so high as if not con-
the joint, the semi-flexed position of the the joint,
limb over a double inclined plane will be
best, as the weight of the leg then counteracts
the efforts of the muscles, which would
otherwise draw up the inferior portion of the
broken bone.

Of Dislocation of the Head of the Fibula.

This accident may occur from violence or Causes,
relaxation of ligament. I have only seen one
case from the former cause, which was ac-
companied with a compound fracture of the
tibia, requiring the removal of the limb.

The displacement in consequence of relax- From re.
artion is more frequent ; the head of the bone
slips backwards, it can be easily replaced ;
but unless confined in its proper situation, it
is directly dislocated again.

2 H 4

*it^ •■

•i ^.A

i-Li.C3=sr* '

1^ '.^x. 'resEonsst is to pn
ji la^^masm it sviiot
line: "lus maT I

, ; .'•■'TTcn z -inni^ in h

T* - y^ Mil

478

LECTURE XLV.

On Dislocations of the Ankle Joint.

This articulation, which is formed by the strength of

the joint.

tibia, fibula, and astragalus, with their carti-
lages, and synovial membrane, is so strongly
protected by the form of the joint, and the
numerous ligaments connecting these bones,
that great violence is necessary to produce
a dislocation, and when this does occur, it is
generally accompanied with fracture, the
ligaments often affording more resistance
than the bones.

The tibia may be dislocated in three dif- Three
ferent directions, viz. inwards, forwards, and
outwards ; a displacement backwards is also
said sometimes to take place. Cases have
likewise occurred in which the foot has been
thrown upwards, the astragalus being re-
ceived between the tibia and fibula, in con-
sequence of the ligament, which unites these
bones, giving way ; but this is only a severe
form of the internal dislocation.

474

OfShmpk Dislocatian of the lUia, mmanb.

This is the most commoii erf the dinloratioiig
<rf the ankle. The malleohis intennis fanx
a projectioii under the skin, on the inner side
of the foot, and the integument is ao much
distended as to a{^>ear in a hoisting state; —
the foot is turned outwards, so tiiat its inner
edge rests npoa the ground, when tiie patient
is er>eci, — adqfMressicm exists aboTe the outer
ankle, but there is otherwise mndi swelling;
a crepitus can be usuaDj kit about three
inches aboTe the external mafcofais cm moTii^
the foot, which can be dooe laterally without
difttcutlT, but the motioa creates violeiit

^<ttM<^ TW ap(>iew^AD» upim examining die seat
fnf iiaiwT bv d^§siectua» aire die foflown^:—
the ettd ^mT t&e ubci tecs iqwrn the ianer skle
^l"^ thp( asscn^a^B^ ; imsiead <rf oo its upper
WticdbiKXT stance : aaai if die arridenthas
iKViMtt^ oraft a pinsiia jnnpiag from a con-
$iii!ca^«^ ^:!Kfiif^ ^ jtfwisr €ad of the tibia
>ii)b^tx^ xc :;^ vVHiisi^ni^L :iL> c^ mbdta by liga-
)ii!i>it^ :c^ ^^&:;^it >^ ioii cefnam^ attached to
tW ivM^u,. ^niici ^ iTijc r-iccir^ Jorom two
V ".V\v .ov^K^ jjX"^^ iii^ I2iiij!ci3&. and the
sStskA H*i ;ac >^ixr?cr Tvcccir >:£ ^e fibula is
;^i^*^v\i^ iv^*«^/j: 4^iVit :;K arroe^ <acnte of the

476

astragalus, occupying the natural situatioa
of the tibia ; the inferior portion of the fibula
with its maleblus remains in its natural posi-
tion, and the ligaments connecting it to the
tarsal bones are uninjured.

The most frequent cause of this accident Caniii.
is jumping from a great height, or it is some-
times produced by the foot being caught
whilst a person is in the act of running, with
the foot turned out, so that the foot is fixed
whilst the body is carried forwards.

The reduction of this dislocation, which Reduciion.
should be effected as soon as possible, may
be accomplished in the following manner: —
place the patient upon a mattress, properly
prepared, on the side which corresponds to
the injured limb, and bend the leg at right
angles with the thigh, so as to relax the
gastrocnemii muscles ; then fix the thigh
whilst an assistant draws the foot gradually
in a line with the leg, and at the same time
press the lower extremity of the tibia out-
wards towards the fibula, to force it upon
the articulatory surface of the astragalus.

Great violence will often fail in reducing Reason of
this dislocation, if the limb be kept extended ;
when, in the same case, the replacement
may be very readily effected after the leg has
been bent in the mode I have described,

I he difficulty in the former instance is from

476

the powerftil resistance of the gastonemir
muscles.

Treatn^at After the reduction, the limb is still to be
kept upon its outer side, being surrounded
by a many tailed bandage, and supported
upon a well padded splint which has a fdot
piece ; a second splint also furnished with a
foot piece is to be placed on the opposite
side of the limb, or that which is uppermost ;
and these splints are to be so secured as to
prevent eversion of the foot, and to preserve
it at right angles with the leg. The bandage
is to be moistened with an evaporating lotion.
The subsequent inflammation must be kept
within bounds by local or general bleeding
as necessary, and the secretions must be
attended to.

i^Hrt*Ji tiT About five or six weeks after the accident,
the patient may be allowed to leave his bed,
liavii^ the jmnt well su{^ported by the appli-
C4itioii ct straps of plaister around it. After
r^t weeks^ pssave moti<m and firiction
9i)Kmikl be emplovied to restwe the moticms
of the jioint.

f V .^StiwMr f>ati[^t^i;'#?; f*f the TTAmt, forwards.

Kr^»«4« ll^i^ ^-vioeDi pr^dxjoe? the following ap-

IHNf^r^ixx^ :^ — ihc ix« ^seems much shortened,

«^v*

toes are poiiited downwards, and the
heel projects. The inferior extremity of the
tibia forms a large projection upon the middle
and upper part of the tarsus, under the ex-
tensor tendons, and a depression exists be-
fore the tendon achillis.

When examined by dissection, the tibia is *?" ^'*'*'!-
found to rest upon the upper surface of the
navicular and internal cunicform bones, but
a small part of its articular surface still is in
contact with the articular surface of the
astragalus. The fibula is broken, and the
superior portion of the bone is carried for-
wards with the tibia; whilst the malleolus
externus, with two or three inches of the
lower part of the fibula remains in its proper
situation ; the capsular ligament is lacerated
extensively on its fore part, and the deltoid
ligament is partially torn through.

The most frequent causes of this injury Causes,
are, a fall backwards at the time that the foot
is confined, or jumping from a carriage in
rapid motion, whilst the toes are pointed
forwards.

To accomplish the reduction, the patient Reduction,
should be placed on his back upon a mattress,
and the thigh being elevated towards the
abdomen, the leg is to be bent at right angles
with the thigh ; the foot is then to be ex-,
tended iu a line a little before the axis of the

478

leg, the thigh being fixed, and the tibia
pressed backwards to its natural position.
Treatment When the reduction has been effected, the
many tailed bandage, and padded splints are
to be applied as in the former case, and the
same means adopted to prevent excess of
inflammation. The position of the limb
should be upon the heel, with the knee bent,
and the foot well supported. After five weeks
the patient may be allowed to get up, as the
fibula will then be united ; and passive mo-
tion may be carefully used.

Of the partial Dislocation of the Tibia,

forvmrds.

Niitiireaf. In this accident, the tibia does but half
quit the articular surface of the astragalus,
resting in part upon the navicular bone, and
in part on the astragalus.

Signs of. The signs of the injury are, the pointing
of the toes, the elevation of the heel, a great
diflSculty in placing the foot flat upon the
ground, and ' a considerable loss of power
in the movements of the joint. The short-
ness of the foot, or the projection of the
heel, are not very remarkable ; the fibula is
broken.
Case. The first case of this injury which I saw,

479

stoat lady at Stoke Newington^
that she had sprained her
anUebjaftD. The toes were pomted» and
the MfltkwR of the ankle joint entirely
destroyed. I attempted to draw the foot
fivwaids, and to bend the ankle joint, but
I could not succeed. Some years after, 1
gaw diis lady walking upon crutclios, tlie
toes weie still pointed, and she could not
place the foot flat upon the ground «

I was not, however, perfectly acquainted niMMi(«ii«
with the precise nature of the injury she
suffered from, until my friend, Mr* Tyrrolli
showed me a foot which ho had dissoctotl
at Goy^s Hospital, and which he wtu^ 90
kind as to give me. It presents the follow-
ing appearances : the articular surface of tho
lower part of the tibia is divided into two,
the anterior part is seated on the navicular
bone, the posterior upon the astragalus;
these two articular surfaces formed at tho
lower extremity of the bone have been rou-
dered smooth by friction; tho fibula had
^been fractured.

The mode of reducing this partial dis- U0du«iioN.
placement should be in every respect similar
to that reconmiended for the complete dis-
location, the same directions for the after-
treatment should also be adopted. As the
signs of the injury are not very well marked,

ances.

480

great attention will be required in the ex-
amination^ and the surgeon should not rest
satisfied until the motions of the joint are
in a great measure restored.

Of simple Dislocation of the Tibia, outwards.

This injury is usually attended with much
more surrounding mischief than either of
the former, as it is produced by greater
violence; there is more laceration of liga-
ments, and more contusion of the integu*
ment.

^J^^!*^ The sole of the foot is turned inwards,
and its outer edge rests upon the ground,
when the patient is standing ; the foot and
toes are pointed somewhat downwards, and
the external malleolus forms so decided a
prominence upon the outer side, by pro-
• truding the skin, that the nature of the
accident can scarcely be mistaken.

On dissec- Upou disscctiou, the malleolus intemus
of the tibia is found obliquely broken from
the shaft of the bone ; the inferior portion
of the shaft of the tibia is thrown forwards
and outwards upon the astragalus before
the malleolus : the deltoid ligament re-
mains entire. If the fibula is perfect, the
three ligaments naturally connecting it to

tion.

481

uptured ; but when the fibula

the tarsus e

is fractured, which often happens, these
ligaments are not injured. The astragalus
is sometimes brolcen, and the capsular liga-
ment is lacerated.

The injury may be occasioned either by
a fall or jump from a height, the foot being
twisted inwards, or by the passage of a
carriage wheel over the articulation.

To etfect the reduction, place the patient Redaction. J
upon his back, elevate the thigh towards the
abdomen, and bend the leg at right angles
with the thigh ; then fix the upper part of
the leg and thigh, whilst an assistant ex-
tends the foot in a line with the leg, and at
the same time press the tibia inwards towards
the astragalus.

When reduced, apply the many-tailed TreBtmem. 1
bandage and padded splints with foot pieces,
as in the former cases ; but in addition,
place a pad over the fibula, just above the
outer malleolus, so that when the limb is
laid upon the outer side, which is the best
position, the portion of bone above the pad
may be raised, and the pressure of the outer
malleolus upon the injured integument may
he prevented.

A similar mode of after treatment to that
described for the other dislocations, will he
proper, but more depletion will usually be

VOL. ill. 2 I

482

required after this injury, aa the inflammar
tiou is generally more violent. Passive mo-
tion should be employed after six weeks
from the accident.

Of Compound Dislocations of the Ankk Joint.

Natan of. The Only difference between these injuries
and those already described is, that in these
cases the integuments and ligaments ai^e
divided, either by the bone, or by the pres*
sure of some uneven and hard body, on
which the limb may have been thrown, so
as to expose the joint from which the synovia
escapes through the wound.

The consequences of these injuries 9se,
however, very different from those occasioned
by the simple dislocations ; usually the M-
lowing effects are produced. The synovia
at first escapes through the wound, and in %
short time after the accident, inflammatioa
commences; this inflammation esteiids to
the ligaments as well as to the extremities
of the bones forming the joint, and the
secretion from the joint becomes much in-
creased. In about five or six days, suppura*
tion commences; at first the discharge of
matter is small, but it soon becomes very
profuse. Under this process of suppuratioDi

the articular cartilages become partially
or wholly absorbed, but in general only
partially ,- the ulceration of the cartilage is
a very slow process, usually attended with
much constitutional suffering, and is often
followed by exfoliation of bone. When the
cartilages have been removed, granulations
arise from the extremities of the bones, and
from the ligaments, which inosculate and
fill the cavity of the joint. In some cases,
I adhesive inflammation occurs in the com-
mencement, and the articular surfaces be-
come united without any absorption of the
cartilages ; this often occurs in part, but I
have seen it extend to the whole surfaces.

But neither the adhesive union, nor the t
inosculation of the granulations entirely de- »
stroy the motions of the joint, if passive
motion be employed sufiiciently early and
carefully; and I have seen, in some cases,
the mobility of the articulation restored to
nearly its original extent; otherwise, the
other joints of the tarsus acquire such an
increase of motion, as to render the deficiency
in that of the ankle hardly perceptible.
When the powers of the joint are completely
destroyed, it is by a deposit of cartilage,
and a subsequent formation of phosphate of
lime, as is usual in the reparation of fracture
of bones.

2 I 2

484
coMtitii- The various local effects which I have

tional

symptoms, described are accompanied usually with much
constitutional suffering. About twenty*foiir
hours^ or in two or three days after the re-
ceipt of the injury, the patient begins to
complain of pain in the head and back, skewing
the influence of the accident upon the bram
and spinal marrow. Loss of appetite, iduisea,
and often vomiting, indica,te disorder of the
stomach ; the tongue is white, yellowish, or
brown, according to the degree of irritation';
the bowels generally become inactive, from
a paucity of the secretions, not only from
their mucous surface, but from the glands
connected with them, as the liver, pancreas,
&c. ; the secretion of the kidneys is much
diminished, and of a deep colour; the skin
becomes hot and dry, ceasing to pour out the
perspirable matter. The action of the heart
and arteries is accelerated, the pulse becom-
ing hard, and in severe cases it is often
irregular or intermittent. The resphradon is
hurried in sympathy with the quickened
circulation. When the irritation is great,
the nervous system becomes further affected,
the patient is restless and watchful, and ta
the severity of the case increases, delirium
subsultus tendinum, or tetanus occur.

Such are the usual effects of local irrita-
tion upon the constitution, but the degree in

485

which they are developed depends upon tlie
irritability of the system, the powers of
reparation, and the extent and violence of
the injury.

The cause of the severity of the local and "^^"^^ "'"
constitutional symptoms in these cases ap-
pears to be the exposure of the joint, and
the great efforts necessary for the reparation
of the injury under such circumstances, as
the simple dislocations very rarely occasion
these distressing effects, but the adhesive
process repairs the mischief, without givingf
rise to either much local or constitutional
disturbance. Thus the first principle in
the treatment of the compound dislocation
is clearly pointed out, viz. : the closure of
the wound, and the aiding, by all means in
our power, its union, by adhesive inflamma-
tion ; so as to prevent suppuration in the
cavity of the joint.

Formerly, and within my recollection, it Amputation

T f- i_ . formerly

was thought expedient lor the preservation pertanned.
of life, by many of our best surgeons, to
amputate the limb in these cases; but from
our experience of late years, such advice
would in a great majority of instances be
now deemed highly injudicious.

The mode of treatment to be adopted in
these cases is as follows, and will apply
generally to either form of dislocation.
2 I 3

*;««:

vii. ~K to suppress has-
ii~ II ^'icsequence exists,
ae -wr .keziks. :2se anterior and poste-
^-i iTr IJtely to be wounded.

ic jiTarf T-^ 3«£ ibund most frequently
i:'ir?ti. z^r acif zeaendiy escaping; but
1 :i=* i aeeoing arom either, it will be
%s:rzMmr^ -^ urcty rwo ligatures, one above
Au iiiicrrrr »±uw cae iperture from which
3fc jitt^uiaic jc::ur5. The projecting ex-
a^ .4 Hi- Mces are often covered with

smfist against the ground;
vsifea Jte i&x:: xsp will be to cleanse them
Tfjoi e«wr particle of extraneous
ic will afterwards excite
nrfti-marion in the joint. Should
:tx. viK :« ^^mnvuaied or shattered, all the
^- ■;» 'tfc-f >;ctic<25 must be carefully removed,
«:u I :xte "vrToai is not sii^ciently large to
^... Ml ;i rtt -T b^ing taken out without much
^acvicv. :c saooki be enlarged with a seal-
^•« MC 2»f :acisioii should be made in, such
4 ^iitKS«/a. J5 will avoid further exposure of
litf \MKC Y!^ woimd will sometimes require
.dUCtficfL^ =1 ihe int^^ments are nipped
na 2K vci; by the projecting bone, as they
, v:.v t >» :: 3any instances liberated with-

-u.

'"^ic ^uccxsa of the dislocation is to be
.v-''i:i^^utfi^<^ bv the same means as already

487

descnbed in tKe simple displacements, aim

when reduced, the edges of the wound are

to be very carefully approximated by sutures

and strips of plaister, over which a piece of

lint, dipped in the patient's blood, is to be

placed ; this, when the blood coagulates,

forms, as far as I have seen, the best covering

for the wound. The part is to be further

supported by the application of separate

pieces of linen, in the same way as the

many-tailed bandage, but each portion being

unconnected with the others, so that any

^-■one piece can be removed, and another sub-

itituted for it, by tacking the ends of the old

nd new strips together, before the former

I drawn from its situation ; in this way the

limb is not disturbed by the change. This

ndage is to be moistened by an evaporating

fation. The padded splints are lastly to be

uployed with foot pieces, as recommended

the simple dislocation, but a portion of

pilhat one situated on the wounded side of

the limb should be cut out, in order to enable

the surgeon to dress the wound without

I' removing the splint. The position in which

■the extremity should be placed is the same

in the simple injury, but must be occa-

ksionally varied a little according to the seat

and extent of the wound. con»atu-

The next object will be to prevent or j?.""''"

■2 I 4

488

diminish the constitutional suffering likety
to ensue ; in some cases it will be necessary
to take away blood generally, but this should
be done with the utmost caution, as great
power is required to support the after pro-
cess of restoration, which will fail altogether
if the patient be rendered feeble by the loss
of blood or other means. Purgatives should
also be administered with great care, as the
frequent change of position which the action
on the bowels necessarily occasions, tends
very much to interrupt or destroy the adhe-
sive process, which it is our chief object to
promote. I am confident that I have seen
many cases of compound fracture prove
destructive under such circumstances. The
bowels should be emptied as soon as possi-
ble after the accident, before the adhesive
inflammation is set up, after which a mild
aperient may be given at intervals.
After Should the patient remain free from pain,

treatmeiit. r '

this mode of treatment should be persevered
in until the adhesive process is complete;
but should he complain of suffering in thfe
injured joint, the dressings must be cau-
tiously raised, so as to expose a very small
part of the wound, to allow of the escape of
any matter which may have formed, but not
to disturb any adhesions which have taken
place. If the suppurative inflammation has

48i>

commenced, the first dressings may be re"'
moved, and the surface of the wound be
merely covered with some simple dressing.
Should much surrounding inflammation arise,
it will be necessary to apply poultices on
the wound, and leeches upon the limb, at a
little distance from it, and afterwards to con-
tinue the use of the evaporating lotion over
the inflamed surface not covered by the
poultice. When the inflammation has sub-
sided, the use of the poultices should be
discontinued, as they relax the vessels too
much, and retard the progress of cure.

In favourable cases, the wound heals in a Period of
few weeks with but little suppuration. In
those less favourable, the discharge is very
copious, and portions of the extremities of
the bones exfoliate, rendering the recovery
very tedious. Even in the most favourable
instances, the patient cannot venture to use
crutches before the expiration of three
months, and often not until a much more
distant period.

I shall now relate a few cases, which will
further explain the best mode of treatment,
and also show the impropriety of recom-
mending amputation indiscriminately in these
cases.

In the year 1797, I attended a gentleman cue.
with Mr. Battley, who then practised as a

490

surgeon. This gentleman had, in a fit of
insanity^ jumped from a two pair of stanrs
window into the street, by which he caused
a compound fracture €i the ankle joint ; he,
nevertheless, got up without assistance, and
having obtained admission into the housci
he ascended the stairs to his bed-room, and
having £sustened the door, got into bed. The
door was forced open, as he would not un-
fasten it. When I examined the injured
Umb, I found that the tibia was dislocated
inwards, and that the astragalus was brokea
into many pieces, many of which h&ng
detached I removed. We then reduced the
displaced bone, and having approximated tiie
edges of the wound, covered the whole
with lint wetted vrith the patient's blood.
The limb was placed on the outer side, with
the knee flexed, and an evaporating lotimi
was freely applied. In three or fyav days
after, considerable inflammation took place,
but this was subdued by general and local
bleeding, with emolient applications to the
wound ; extensive suppuration followed, and
continued very profuse for nearly two months,
when the surface was covered by granula*
tions ; at the same time an improvement took
place in his mental affection, which became
less and less as the wound closed ; between
lour and five months from the accident, the

491

; process was complete, and the state
of his mind natural. At the expiration of
nine months he returned to his employment,
but could not walk without the aid of a
stick for many months.

In October, 1817, I was called by Mr. cwe.
Clarke, a surgeon, residing in Great Turn-
stile, Lincoln's Inn Fields, to visit Mr. Ca-
ruthers, a young gentleman who had a com-
pound dislocation of the ankle joint inwards,
occasioned by the overturning of a stage-
coach at Kilburn, from which place he had
been removed to Lambeth where he resided.
The extremity of the tibia projected to the
extent of between two and three inches from
a wound through the integuments on the
inner side. The tibia was broken, a small
portion of it remaining attached to the joint
by the ligaments ; the fibula was also frac-
tured badly. I found it necessary to en-
large the aperture in the integuments, before
I could replace the dislocated bone. After
the reduction, simple dressings were spread
over the wound, these were confined by a
many-tailed bandage, moistened with an
evaporating lotion, and the limb was sup-
ported by the padded spHnts, and placed in
a semiflexed position upon a quilted pillow.
The patient was bled, and took mild purga-
tives, with saline medicines. Considerable

492

constitutioDal suffering followed,
gmthr exhausted the patient; ab-
fixmed in the leg, and some exfolia-
piace, much retarding the pro-
of cicatrization. These abscesses were
frechr opened, and the parts supported by
pbister ; the limb was kept cool by
weof eTi|MHrating lotion, and the strengl^
igppotted by giving bark and wine. In
dke JvMiaiT, 1819, the last exfoliation oc-
cmcd» after which the wound healed
npidhr, and the patient recovered his health.
Mr. Carathtfs has since obtained very con-
use of the limb, being able, he
[> walk six or eierht miles if neces-

Abbott, of Needham Market, Suffolk,
be particulars of the following inte-
case, which occurred under his care.
)lr. Robert Cutting, aged seventy, cor-
pnknU intoaperate, and of a gouty habit,
lud lub ankle dislocated in consequence of
l^iay durown down in a quarrel ; the end
^' tkie tibia was forced through the integu-
Meni$» and protruded about four inches ; the
^tJb^ was firactured a few inches above the
K^ia(. and the foot was turned outwards.
Ittuiu^iiately he got up, and in struggling to
,4;jaKK he covered the end of the bone with
^at *wi «*>^> ^* which also a considerable

493

quantity got into the joint. He was eon-^
veyed home about four miles in a cart, and
Mr. Abbott saw him about five hours after
the accident, and recommended amputation
in consequence of the extent of injury, and
the disordered state of the patient's consti-
tution ; but this the patient could not be
induced to submit to, therefore the injured
parts were carefully and thoroughly cleansed
with warm water, the dislocation was re-
duced, and the edges of the wound were
nearly brought into apposition by strips of
linen dipped in the tinctura Benzoini com-
posita, without sutures or adhesive plaister ;
a thin board, hollowed to receive the leg,
and with an opening in the situation of the
outer ankle, being well padded, was placed
under the outer side of the limb, which was
enveloped in a folded flannel bandage, from
the foot to the knee ; the leg was laid in a
flexed position, with the foot a little raised.
The patient was bled to Jxij, and ordered a
mild saline purgative every two hours, until
the bowels were relieved, with milk broth
for his food.

The accident happened on the 25th of
April, 1802 ; and he proceeded very favour-
ably until the 27th, when he complained of
darting pains in the injured limb, and he
L*9ra& restless, yet his skin and bowels were

acbag property. Upon unfolding the flannd;
some swelling appeared about the joint, and
some gleety discharge escaped from beneath
the dressing ; the inflammation did not ap-
pear much more than necessary, but six
leeches were applied at a little distance
from the seat of inflammation, which relieved
the pain, and the wound was dressed as
before. This plan of treatment was conti-
nued, and tlie case proceeded most favour-
ably ; on the 2d of May, a small quantity
of matter was discharged, but without aug-
menting the symptoms. After ten weeks,
he was moved daily from the bed to a sopha,
and about this time the whole of the dress-
ings were taken off" for the first time, when
the wound was found to be completely cica-
trized; previously, only small portions had
been elevated at a time, and fresh pieces
put on to keep the covering perfect. When
exposed, the exterior of the joint presented
its usual appearance, excepting a slight en-
largement in the situation of the cicatrix ;
but this was not more than could be ex-
pected. At the end of five months, he was
allowed to go on crutches, and bear as much
weight on the limb as his own feelings sug-
gested to be proper. Being a butcher by
business, he afterwajds rubbed the limb with
the fluid obtained from the joints of animals,

495

and also frequently placed his foot and ankle
in the warm paunch of an ox. Before the
expiration of twelve mouths, he could walk
without the assistance of a stick, and for
many years before his death could walk with
perfect ease and freedom. He lived to th^
age of eighty-three.

The following are the particulars of a case
sent to me by Mr. Scarr, Surgeon, at Bishop's
Storford ; he also sent the patient for my in-
spection, after his recovery, so that I had
an opportunity of witnessing the happy
result of Mr. Scarr's skill.

John Plumb, aged 38, liad ascended on a Cmp.
ladder, about ten feet from the ground, with
a sack of oats upon his shoulders, when
the ladder slipped from under him, and he
fell to the ground upon his feet, still retain-
ing the load of oats. Mr. Scarr was passing
at the time, and immediately attended to
tile man. When his stocking had been
removed, the tibia and fibula were found
projecting through the skin at the outer side
of the ankle, and the astragalus was exposed
through an opening on the inner side ; both
the wounds were clean, and without much
surrounding mischief. Mr. Scarr therefore
immediately reduced the displacement, and
closed the wounds by the application of
adhesive straps, and placed the patient in

496

bed, with the limb flexed, and laid upon the
outer side. The limb was moistened vdth a
lotion of acetate of lead. About jxyj of
blood were taken from the arms; some
saline medicines administered ; and the anti-
phlogistic treatment persevered in, with due
regard to his constitutional powers; some
abscesses formed, which were opened in the
most favourable points, and the patient be-
came gradually convalescent in about - six
months, without any very urgent symptoms.
At the end of twelve months, he was able
to resume his laborious occupation a» before
the accident.
?!II?^J!!? It has been recommended in the tteatment
of bone. q( thcsc cascs, to rcmove with a. saw the
projecting extremity of the tibia, before die
reduction of the dislocation is attempted;
there are some instances in which such a
proceeding is absolutely necessary, and many
reasons are given for adopting this practice
in general.
When ne- jhc cascs in which it must be necessarily

cessary. *'

adopted are the following :

First, when the dislocation cannot be other-
wise reduced without great violence.

Secondly, when the extremity of the
bone is fractured obliquely, so that if reduced
it immediately glips from its proper situation,
when the extension is discontinued; but

497

*■ after the removal of the point by the saw, it
rests readily upon the astragalus.

The reasons assiened for adopting this Beasonsfti
plan m all instances are.

First, That the shortening of the bone
relaxes the muscles, and diminishes the ten-
dency to spasmodic contractions, which so
frequently occur when much force has been
used to replace the bones.

Secondly, That the adhesive process goes
on much more readily from the sawn ex-
tremity of the bone than from the natural
articular surface, consequently the local
irritation is less.

Thirdly, That when the suppurative in-
flammation does occur, it is rendered much
less, as there is not the same extent, by
nearly one half, of cartilaginous surface to
be removed by ulceration, and thus by the
diminution of the ulcerative and suppurative
process, the constitutional irritation is much
lessened.

Fourthly, It has been remarked, that
those cases have usually recovered quickly,
in which the extremities of the bones have
been broken into many small pieces, and
separated so as to render their removal
necessary.

Fifthly, I do not recollect any instance of
unfavourable termination, when this practice

VOL. III. 2 K

Notim-
portaot.

498

had been pursued ; but I have known loaBy
unsuccessful in which^ it had not been
adopted,
objectioiit rjij^^ objections made to this treatment are,

first, that the limb must be shortened by
the removal of the portion of bone, nxA^
secondly, that the joint must afterwards
become anohylosed.

Provided we admit that the danger of the
case is lessened, which I believe, by the
sawing off the extremity of the tibia, the
first objection cannot be considered of much
weight, more especially as the defec;t isae
easily remedied afterwards, by increasing
the thickness of the sole oi the boot or shoe.
With regard to the seoond objection, I do
not imagine that anchylosis is at all a neces-
sary consequence, having seen cases in
which considerable motion remained aft^r
the removal of bone, and recovery of the
patient. I know that anchylosis is liable to
take place in either mode of treatment, but
even then the patient, after a time, walks
with very little halt, as the other tarsal
joints acquire so much increase of motion.
Treaimcnt It appears to me, however, that either
th^caie. plan may be adopted, according to the fea-
tures of the case, and I should not wish it
to be supposed that I recommend the one to
the entire exclusion of the other.

their

Pmd

When the dislocation can be reduced t
without much force, and the bones retain
their proper situation readily, without the

currence of spasmodic muscular action;
Bd if the pa'ient be not very irritable, an
attempt should certainly be made to effect
a cure, without removing the ends of the
bones; but if the bones be shattered, or
fractured obliquely, so that it will not retain
its proper position when reduced, the saw
should be employed, in the first instance, to
smooth the ends of the bones, when the
small separate pieces have been taken away,
and in the second place, to make a surface
to rest upon the astragalus. I would also
rather use the sa-w, than employ great
violence to reduce the dislocation otherwise;
likewise in those cases where the spasmodic
contraction of the muscles renders it ex-
tremely difficult to keep the injured joint
in its natural position.

I shall now relate some cases, which will
afford an opportunity of judging better of
the propriety of what I have stated.

Nathaniel Taylor, aged thirteen, was Ci«e.
admitted into Guy's Hospital, in consequence
of his having a compound fracture of his
ankle joint. The injury had been occasioned
by a boat falling upon his leg. The end of

E, and the fractured extremity of the
__

500

fibula projected through an extensive open-
ing ai the outer ankle; the malleolus ex-
temus retained its natural situaticm and
ligamentous connections. The foot was
turned inwards, and hung so loosely, that
the 8<de could be placed against the side of
the leg. I tried to reduce the bones to their
proper situations, but could not effect it,
but by ?ery great force, and as socm as the
extension was disccmtinued, they again
slif^ped firom their places. Under these
circumstances, those around me urged me
to amputate the limb ; but considmng my
young patient to be otherwise in good health,
and not of an irritable habit, I determined
to presenre the limb if possible. On a
further examination, I discovered that the
malleolus externus and inferior part of the
fibula connected to it, although in its natural
position, was very loose, and I therefore
removed it, by dividing the ligaments ¥dth a
scalpel, and I afterwards sawed off about
half an inch of the end of the tibia. I then
found that I could easUy replace the bones,
and that they retained their positions without
difficulty. Having approximated the edges
of the wound, I covered it with lint dipped
in the patients blood, and by strips of
adhesive plaister ; the limb was placed upon
(ho heel, and supported by padded splints.

501

Scarcely any constitutional suffering oc-
curred, but little suppuration took place,
and the wound gradually healed. One
abscess formed over the tibia, but did not
give rise to any severe symptoms. He was
allowed to get up, and to use his crutches
after about two months, and at the expira-
tion of four months he could walk very
well. There appeared to be some motion
at the ankle, but the tarsal joints had evi-
dently acquired much increase of motion.

In December, 1818, I was called upon case,
to attend, with Mr. Jones, of Mount Street,
a Mr. West, aged forty, who had severely
injured his left ankle, by jumping from a
one horse chair, alarmed at the horse's
kicking.

When 1 first saw him, the extremity of
the tibia projected through a wound in the
integuments, at the inner side of the ankle,
and a portion of skin was nipped into the
joint by the bone, the foot was turned out-
wards, but hung loosely. Finding that our
patient was of a most irritable constitution,
and seeing that great violence must be em-
ployed to reduce the bone, and that to
effect the reduction it would be necessary
to enlarge the wound considerably, I con-
sidered it much better to remove the ex-
Cty of the tibia, in order to avoid these
2k 3

602

I therefore sawed off a portion of
tfctt bone, and then effected the reduction
wiftkoot diflSculty, nor was there any dis«
pMtioii to further displacement from mus-
clar contraction. The edges of the wound
were next secured in contact, by the inser-
tMNH of a fine suture, and the paut was
Oiywed with lint wetted with blood, and a
wuiy-tailed bandage. The limb was secured
bx the padded splints, and placed upon the
outer side, in a semi-flexed position. The
ptlient was bled to the extent of Jx, some
<^um was given him, and the spirit lotion
was freely applied to the extremity. Oa
the third day, the foot exhibited slight
vesications, and he complained of tensicm,
and some pain, but this soon subsided.
About the sixth day, the wound began to
discharge a serous fluid, mixed with red
particles; poultices were employed; the
secretion soon became purulent,^ and con^
tinued to increase until the end of a month,
when it gradually subsided. At the end of
two months, the patient was allowed to get
on to his sopha, as the joint appeared firm ;
u small wound still, however, existed, from
which it was evident some small exfoliation
would take place; this did not happen for
Nevcral months. During the progress of the
t?u«i!. Dr. Pembertbn was consulted in con-

503

sequence of the patient's having an ex-
tremely disordered state of stomach ; but,
notwithstanding, the symptoms produced
by the accident were not more severe than
those usually occurring in a common case of
compound fracture.

Dr. Rumsey, of Amersham, was so kind
as to send me the account of an excellent
case of compound dislocation of the ankle,
complicated with simple fracture of the
thigh bone of the same limb ; the following
are the particulars :

Mr. Toison, aged forty, was thrown from cwe.
a curricle, on the 21st of June, 1792, and
in falling, dislocated his left ankle joint.
Dr. Rumsey saw him about two hours after
the accident, when he found a large wound
at the outer ankle, through which the ex-
tremities of the tibia and fibula, with a
portion of the astragalus, protruded; for
the astragalus had been fractured, and one
portion of the bone still remained attached
to the tibia and fibula, the foot was turned
inwards and upwards, and the skin of the

*pQter side, beneath the wound, was very
|»uch confined by the dislocated bones. Dr.
Rumsey, deeming further advice necessary,
sent for Mr. Pearson, of London, and Mr.
Henry Rumsey, his brother, a surgeon at
LChesham ; and during the absence of

504

the messengers^ the patient directed Dr^
Rumsey's attention to his thigh, which was
then, ascertained to be fractured at the
superior part. This circumstance being con-
sidered by Dr. Rumsey and his brother as
a decided obstacle to amputation, they de-
termined on endeavouring to preserve the
limb. Finding that they could not replace
the bones without excessive force. Dr. Rum-
sey determined upon removing that part of
the astragalus which was attached to the
dislocated bones. Upon separating this por-
tion of bone, it was found to be as near as
possible the superior half, the fracture
having been horizontal through its centre.
After this had been taken away. Dr. Rum-
sey still found it necessary to divide a por-
tion of the integuments, which had been
confined by the dislocated bones, before he
could readily effect the reduction. The
bones being replaced, some lint, dipped in
tincture of opium was laid over the wound ;
the whole was covered with a poultice made
of oatmeal and stale beer, and the leg was
secured with padded splints. On Mr.
Pearson's arrival, he perfectly approved of
the course which had been adopted.

In the night following, the patient became
delirious, vomited, and his pulse was full
and frequent; he was bled to 3x, and

ordered to take a common saline draught
with antimonial wine and tincture of opium
every four hours ; the tartrate of potash and
manna were given in sufficient quantity to
relieve the bowels. He also experienced
considerable pain in the ankle and thigh.
On the 24th, these unpleasant syraptoras
had in a great measure subsided, and a dis-
charge commenced from the wound ; he
continued the same plan of treatment, with the
omission of the antimony, as his stomach was
irritable. He continued doing well until the
28th, when the discharge became thin, and he
was much troubled with pain and flatulence
, in the bowels ; it was therefore considered

P)«eccssary to alter his diet, and on the 29th,
he was allowed a small quantity of animal
food, some table beer, and port wine ; the
bark was also freely taken in substance and
in decoction ; lie was much benefited by
this change. The discharge soon became
very copious, in consequence of which the
wound was obliged to be cleansed frequently;
the limb was therefore placed upon the
heel, as the dressing could not be effectnally
accomplished without considerable disturb-
ance, whilst it continued on the outer side.
After the alteration of position, much more
attention was required to prevent further
displacement, as the foot had a tendency to
incline inwards, causing the end of the fibula

606

to project at the wound ; this waft however
obviated, by placing some small wedges
between the foot and the fracture box, on
the inner side, and others between the calf
of the leg and the box on the outer side^
About the 30tb, the use of the poultice was
discontinued, and the wound was dressed
with dry lint, over which a pledget, spread
with the cerat: plumbi 8uperacetati(&^ wag
placed, and confined by a bandage to keep
up moderate pressure. The bark and opium
were continued until the beginning of August^
and the wound gradually healed with only
one check from the confinement of matter,
the cicatrization being completed about the
middle of September. The union ef the
thigh bone also went on well, but as the
state of the leg prevented the possibility of
keeping up sufficient extension, a degree (tf
curvature was produced by the junction.
The patient was soon able to walk about
with the aid of a stick only, and acquired
a power of motion in the injured joint nearly
equal to that of the sound limb.

Another excellent case occurred, under
the care of Mr. Cooper, of Brentford^ for*
merly my dresser, who obliged me by send-
ing the particulars from which the following
account is taken.
Case. Thomas Smith, aged thirty- six, a psunter,

dislocated his ankle outwards, by a fell

with a ladder, his foot being caught be-
tween two of the steps. Mr. Cooper
was fortunately passing at the time, and
immediately attended to the patient. On
examining the limb, he found that the
fibula was broken about five inches above
the outer malleolus, and the tibia fractured
longitudinally three inches from the joint;
the small inferior portion remained attached
with the inner malleolus. About an inch
and a half of the inferior part of the shaft
of the tibia, and tlie broken end of the
(ibula projected through a wound in the
skin, rather anterior to the malleolus ex-
ternus. Mr. Cooper finding that moderate
force was not sufficient to replace the bones,
he divided a portion of integument, which
was pressed in by the protruding bones, and
he also removed, with a metacarpal saw, an
inch of the tibia, and a small piece of the
fibula, after which the reduction was easily
accomplished. The edges of the wound
were brought together by two sutures, and
iurther secured by strips of adhesive plaister ;
Over this the many-tailed bandage, and the
padded splints were placed to support the
limb, which was placed on the heel, and
kept cool by an evaporating lotion. In the
evening, an opiate was given, and he was
ordered some aperient lor the next morning.

508

Some slight bleeding occurred during the
following night, but not sufficient to require
a removal of the dressings, which were not,
therefore, disturbed until the fourth day,
when they were taken off, and the appear-
ance of the wound was then favourable.
On the eighth day, a slough had formed,
about five or six inches in circumference ; a
poultice was therefore applied to the foot,
and the evaporating lotion continued to the
limb above; he also took port wine and
bark, to support him under the profuse sup-
puration which followed. The slough sepa-
rated on the thirteenth day, exposing a
healthy granulatory surface, after which
merely simple dressing was applied. In
five weeks from the accident, the wound was
perfectly healed ; and in a little more than
two months, the fractured bones had become
so firmly united, that the patient was able
to sit up. In three months he began the
use of crutches, and eventually obtained
almost a perfect limb.

This man had suffered frequently from
colica pictonum, and had an extremely
irritable stomach, he was also naturally of a
nervous temperament, therefore but ill cal-
culated to support the consequences of so
severe an injury. He derived considerable
benefit from the occasional use of the saline

509

effervescent mixture, and from the free
exhibition of opium at night.*

* Although it is perfectly unnecessary to state more
cases in coofirmatiou ol' the correctness of 8ir Astley'a
opinions respecting the treatment uf these injuries; yet
I think the following account of sufficient interest to
warrant its relation : —

Timothy Holland, a very stout muscular man, aged about
thirty-iive years, employed as a labourer at the London
Docks, was standing on the quay, close to one of the
swing bridges, when the bridge was forcibly and un-
expectedly swung round, and struck his right leg on the
outer side, a little above the ankle, occasioning a severe
compound dislocation inwards, tor which he was brougltfc
to St. Thomas's Hospital, soon after the accident, on tha
23rd of August, 1820.

I was immediately sent for, and on my arrival at the
Hospital, found the patient placed upon a bed, with the
iiyured limb in the following state.: — About two incheii
of the inferior extremity of the tibia projected througb
an extensive wound on the inner side of the joint ; thfl
internal malleolus was broken off, and remained loosely;
littached by the deltoid ligament. The wound extended
in two directions, one reaching from about three inches
above the joint, a little to the outer side of tlie course
of the anterior tibial artery, to the centre of the meta^
tarsal bone of the great toe ; the artery was completely
exposed for more than three inches, but had not been,
wounded ; the second portion of the wound extended
from the former, immediately over the articulation,
round the anterior and inner parts of the joint, as far aa
the back of the tendo achillis ; the posterior tibial {
artery and nerve were also exposed to the extent of aih
I ^li, but otherwise uninjured- A portion of the inte-

510

These cases I think quite sufficient to
show, that in very many instances, not only

gumenty about four inches in circumference, near the
inner mde of the joint, appeared to baye suffered con-
siderably, but retained its sensibility. The fibula was
fractured about three inches above its malleolus. — Not-
withstanding the formidable appearance of the case, I
found my patient cool, and willing to submit to any
thing I proposed. His composure and tim^ of life,
wiien the constitutional powers are great, determined
me to attempt the preservation of the limb. On endea-
vouring to replace the boi^s, I found it couM be effected
without much yiolence, but that they became again
dislocated immediately the extension was discontinued,
I therefore removed, with a saw, nearly an kick of the
end of the tibia, and likewise took away the malleoliis
intemua, which was but slightly comiected by ligament
The reduction was then easily accomplished, an^ tiie
dispositioQ to further displacement no longer existed,
excepting that the end of the tibia advanced a little
forwards. This I easily remedied, by placing a long
narrow splint on the posterior part of the limb, from
the upper projecting part of the calf of the leg to the
heel, and then fastening a broad piece of tape around
the splint and leg, a little above the seat of injury, so as
to press the heel forwards, and the eud of the tilHa back-
wards. The edges of the wound were brought together
and secured by sutures and strips of soap plaister, over
which, the many-tailed bandage and splints were applied ;
the limb was placed upon the outer side, in a semi-flexed
position ; the bandages were kept wet with a splint
lotion ; the patient passed a sleepless • night, but was
free from pain, his tongue was slightly furred, and bis
pulse quickened. These' symptoms became alleviated

Ihe life

611

life of the patient may be preserved
without the removal of the injured limb,
but that the extremity is, afterwards, infi-

by the action of some aperieDt medicine, and he pro-
ceeded very favourably uatil the 30th, wheu he com'
plained of considerable pain iu the ankle, and exhibited
a good deal of constitutional derangement. The dress-
tugs being removed, that portion of the skin which hud
been so much injured at the time of the accident was
found to be sloughing; otherwise the appearance of
the wound was favourable. Some fresh strips of plaister
were lightly applied, and covered by a poultice, and he
was ordered some saline effervescing medicine. On the
dth of September, the suppuration had become profuse ;
the poultice was discontinued, and the wound was
dressed with the nitric acid lotion over the slough, and
simple cerate to cover the whole; the same position
was observed, and he was allowed some meat and porter
for the tirst time. From this period, only a slight
obeck occurred in the cure, by the burrowing of some
niatter up the leg, which was relieved, by altering the
position a little, and applying a small compress in the
direction of the sinus, The wound was completel<f
closed by the end of October ; he was then allowed
to sit up, but did not venture to bear at all upon the
limb until some weeks after. He was discharged froni
the Hospital on the -28th of February, 1827, having
regained a perfect use of his limb, wearing a shoe with
the sole thick, in proportion to the shortening of the leg,
with which he walked quite free from any lameness, I
repeatedly examined the joint which had been injured,
and could discover but a very trifling difference between '
its motions and that of the sorind ankle. — T.

512

nitely more useful than any artificial one

could be, and that it may become nearly as

perfect as previous to the accident.

Ampota- There, are some circumstances, however,

^tne^ which render the operation of amputation

^^^^^' absolutely necessary, and these I shall now

briefly point out.
In old per- First, the advanced s^e of the patient,
when the powers of the constitution are
not sufficient to support the extensive sup-
purative inflammation likely to follow the
injury, but which the operation of amputa-
tion does not expose the patient to.
For very Secondly, A very extensive lacerated
wound.^* wound, with much haemorrhage, will render
it imprudent to attempt to preserve the
limb.
Svcfhic" Thirdly, Extensive comminution of the
tare. tibia or of the tarsal bones, as the astragalus
and calcis, will give rise to a necessity for
amputation. When only some small por-
tions of bone are broken off, they should be
carefully removed, and the end of the bon^
be smoothed by a saw.

Fourthly, The dislocation of the tibia

outwards, as it is generally accompanied

with extensive injury to the soft parts, as

well as to the bones, will often require the

Wound of performance of amputation.

artery! Fifthly, The division of a large artery

613

with an extensive wound, might render the
operation necessary ; but 1 should not, in
all cases, recommend amputation on this
account, more especially if the injured vessel
was the anterior tibia, as I have known more
than one instance of recovery, in which this
vessel has been secured, and the limb saved.
Division of the posterior tibial artery could
hardly take place without injury to the large
accompanying nerve, which would increase
•ibG necessity for removing the limb.

Sixthly ; extensive contusion of the sur- j
rounding soft parts, likely to occasion the for- '
raation of large sloughs, would be a reason
for amputating ; this will generally happen
when the injury has been occasioned by the
passage of the wheels of a heavy laden wag-
gon over the joint ; or from the falling of a
very heavy weight upon the limb.

These arc the principal circumstances
which render an immediate performance of
amputation necessary ; but there are others
which may make it equally proper at a more
distant period from the accident.

If mortification ensues, the operation will MorBfio-
be required ; it is, however, best in such a
case, to wait until the extent of the morti-
fication is clearly defined, before the ampu-
tation be performed, although I conceive,
that when the mortification results from the

VOL. III. 2 L

514

division of a blood vessel, or from other loc^
injury in a healthy constitution, a d>fier^|i);
practice may be adopted to that which would
be proper if the disease arose from consti-
tutional causes. I have known the arm am*
putated in consequence of mortification pror
duced by a division of the brachial artery at
the elbow ; the mortification was extending
at the time, but the patient did well, the
limb being removed above the elbow^ I»
another instance, where death of the foot had
occurred in a case of large popliteal aneurism^
the limb was amputated above the swelling,
whilst the mortification was still proceeding
up the leg, and the man recovered.

Should the suppuration from the joint be
greater than the constitution can support, as
J have seen it, amputatipn v^U be required
to save the life of the patient.

Large ex- Again, wheu Considerable portions oi hone
are exfoliating, and keeping up a continued
state of irritation, if, they Qmnot be removed
without inflicting great injury, the operatiaci
of amputation should be performed, .

Deformity Exccssive deformity may result from joeg-
ligence on the part of the surgepn, during the
union of the wound, so as to make the limb
worse than useless to the patient, when it
will be necessary to remove it..

Case. Mr. Norman, of Bath, amputjated the leg

Excessive

snppur-

atioD.

of a man in consequence of such deformity.
The patient had suffered from a compound
dislocation of his ankle inwards, accom-
panied with displacement of the astragalus,
which was removed. After the union of the
wound, it was discovered that the os calcis
had been drawn up against the posterior part
of the tibia, and had there become firmly
united to it, the toes being pointed down-
wards, rendering the limb useless.

It has been recommended to amputate '^j'^"
when tetanus occurs after this injury, but as o":"",
far as my own experience goes, I believe
that the operation only hastens a fatal termi-
nation. I have only seen one case of tetanus
following compound dislocation of the ankle
joint, which, in spite of every attention on
the part of Dr. Relph, who attended the
patient with me, destroyed life.

Although I have not witnessed the per- Notoiiy
formance of the operation after the appear-
ance of tetanic symptoms, when the injury
has occurred in the ankle, yet I have known
it tried in several instances, when this formi-
dable affection has been produced from
other injuries, and it appeared rather to
hasten the progress of the disease than to
relieve it.

In a case of compound fracture just above case,
the ankle joint, producing tetanus, the
2 L 2

516

limb was amputated ; the tetanic symptoms
increased, and speedily destroyed the
patient.
Case. In another instance, when tetanus had

followed injury to the finger, amputation was
performed, but without alleyiating the symp-
toms, and the man died. I could relate other
cases, all showing how unavailing the ope-
ration is under these circumstances.
Chronic I h^Yt kuowu a fonu of tetanus succeeding
tetums. injuries, in which the symptoms have never
been very severe, and which has been termed
chronic tetanus ; this is sometimes gradually
recovered from, although but little be done
by medicine, and nothing at all by surgery.
The medicine which I have seen most ad-
vantage from, has been calomel and opium ;
and opium should be applied to the wouhd.
^xceuiye There are some persons who jure naturally
irritabuity. g^ exccssivcly irritable, that the slightest in-
juries produce fatal consequences; and in
others again, possessing originally good con-
stitutions, this extremely irritable state may
be induced by excess of mental exertion, by
intemperance, by great indolence, or other
causes, so that very trifling accidents will
destroy them . Those persons also, who are
much loaded with fat, and especially those
who, under such circumstances, are extremely
indolent, generally bear important accidents

517

or operations very ill, and frequently perish
in spite of the most cautious and attentive
treatment.

Of Fractarta of the Tibia and Fibula near.

the Ankle Joint. .

Fracture of the fibula frequently occurs or fibula.
about three inches above the outer malleolus.

The patien^t immediately experiences pain svmptoms
at thp seat of the injury, which is much in- ^'
cir^ased by any attempt to bear the weight
of the body upon the limb; and in endea-
ypuring to stand, he does not place his foot

•

flat upon the ground, but rests it upon the
juQ^ner side, to receive the weight chiefly on
the tibia ; the flexion or extension of the foot
also augments his suflering. An inequality
of the surface of the limb over the seat of
frax^ture often exists, and a crepitus is rea-
dily distinguished, by placing one ^ hand
over. the injured part, and by the rotating
the foot at the same time with the other

» • •

hand.

This fracture is produced by a blow upon Causes of.

the inner side of the foot, which forces it
outwards against the lower part of the fibu-
la : also, by a sudden and violent twist of the
foot inwards. It is, perhaps, most frequently

2 L 3

518

occasioned by a lateral fall, when the foot u
confined. I broke niy right fibula by falling
on my right side, whilst my foot was confined
between two pieces of ice : I felt a snap in
the bone at the time of the accident,
and experienced pain from every yAt of tte
carriage in which I was conveyed home.

The treatment necessary for this injury,
consists in applying the ^mmy-^ tailed baftd-
age^ and to keep it wet for a few diry9 with
the spirit lotion; over this bQDidage» the
padded splints with foot jneces are to he
placed and secored, so as to snjqpwt die
great toe in a line with the patella, "^e limb
sJiould be laid upon a jmUow on its side in a
suu-flexed po^on.

AHhoUgh no great deformity can ju^ise fifMd
this accident, <m account ai the sappcnft af-
forded by the tiUa, yet a conAderable d^ree
of lameness may result, if the case be n^-
lected. Dr. Blair, a naval ^ysician, who
bad fitactured his fibola, and Ind not pflud
propw attenticm to the case, became in con-
sequt^Me nnable to walk on flat ground
without a lameness ; as the foot ¥ras twisted
bv the irre^rular union of the broken bone.
iViui^ Fractxire of the tibia often occurs at its
iutorior part, either e3rtending into the joint,
or $catovi iaimedrateiv above it. If the frac-
Uirv enters the joint, but little deformity is

619

produced ; but if above the articulation, the
lowei' part of the upper portion of the bone
usually projects a little. The foot is gene-
jfally inclined somewhat outwards, but the
injury is easily detected by the crepitus,
l^hich can be felt when the foot is freely
moved.

This injury should be treated in every Treatment
lespect as the fbrttier, but great <^are must be
taken to prevent the inclination of' the foot
outwards, and to keep the great toe in a line
with file patella. When the fracture takes
place obliquely from within* to without into
the joint, the foot will be turned slightly in-
wards, and the malleolus externus will pro-
ject mSwe than usual; it will be necessary
therefore, in the treatment) to attend to tbid
point, otherwise it will be the same. By
placing the limb upon the heel, the proper
position of it is more readily observed,
but the case will do equally well, with
attention, if the extremity be laid upon the
outer side.

The observations respecting the compound compound

, , . . -It 1 /* 1 fracture,

dislocations of the ankle jomt, will be found
generally applicable to the cases of com-
pound fracture communicating with the
articulation.

2 L 4

520

Of Dislocations of the Tarsal Bones.

or attm. From the situation of the astragalus, and
its very firm ligamentous connexion to the
tibia, fibula, calcis, and navicular bone, we
could scarcely suppose its displacement pos-
sible, and although it is occasionally dislo-
cated, yet the injury very rarely, if ever,
occurs, without a fracture of one or more of
the surrounding bones.

5^^2St" When dislocated, it is extremely difficult
to reduce, and if this be not eff^ted, lame-
ness to a considerable extent must be the
consequence.

I had an opportunity of seeing a patient
vtrho was under the care of Mr. James, of
Croydon, in consequence of an injury ^o the
tarsal joint.

Case. . I found that the tibia was fractured ob-
liquely at the inner malleolus, and that the
astragalus was dislocated outwards. Every
means which Mr. James could suggest had
been tried to replace the bone, but it still
continued to project upon the upper and
outer part of the foot ; so much force had
been employed in making extension, that
the integument sloughed in part. Conside-
rable deformity resulted ; the toes were
pointed inwards and downwards, and the

K4i

■ <m1

motions of the joint were in a great measure
destroyed,

I attended the following interesting case,
with Mr. West, of IlammcTsmith, and Mr.
Ireland, of Hart Street, Bloonisbury.

Mr. Downes fell from his horse on the
84th of July, 1820, and dislocated his astra-
' gains. Mr. West, who first saw him, endea-
voured to replace the bone, bnt could not
succeed; he therefore placed the limb in
splints, and kept the part moistened with
goulard lotion. The patient was bled largely,
and took some anodyne medicine. On the
25th, I visited Mr. Downes, with Mr. Ire-
land and Mr. West, when I found the astra-
galus displaced forwards and inwards, ac-
companied with a fracture of the fibula a little
above its malleolus. All my attempts to re- '
duce it proved ineffectual. The skin over it i
appeared in a bursting state, so much so, that
I felt inclined to divide it and remove the
astragalus ; but knowing the resources of
nature in accommodating parts under inju-
ries, and of restoring the usefulness of the
limb, I declined interfering, and the previous
treatment was therefore continued. On the
28th, the skin over the bone began to inflame,
and notwithstanding the employment of
leeches and evaporating lotions, it sloughed
^^n the 16th of August, exposing the astra-

622

galus^ which gradually became loosened and
dislodged. A profuse discharge attended
this process^ but bark and wine freely given
kept up the constitutional powers ; the wound
was poulticed. On October the 5th, I re-
moved the astragalus, having only to divide
some few ligamentous fibred. After this, the
wound was dressed with soap plaister, and
the patient gradually recovered, being able
to walk without the aid of a stick. <

compoand lu compound dislocation of the astragalus,
the plan of treatment to be puri^ued has been
already pointed out in the history of the com^
pound dislocations of thd ankle joint, from
which it is evident, that the whole or a part
of the astragalus may be removed, and yet
the patient recover a very useful limb. If,
however, the astragalus should still remain
firmly attached, and can be replaced ; such
treatment should be adopted in preference to
taking it away.

Case. Mr. H^nry Cline had the following case

under his care in St. Thomas's Hospital.

On the 21st of June, 1816, Martin Bent-
ley, aged 30, was admitted into the Hospital,
having been severely injured by the falling of
some heavy stones upon his legs. An ex-
tensive compound fracture of the tibia and
fibula existed in the left leg, near the middle,
attended with so much mischief to the sur-

Fioundtng soft parts, that Mr. Cline ampu-
tatcd the limb below the knee. On the right
side, a dislocation of the astragalus had been
produced, occasioning the following appear- i
ances ; — the os calcis, instead of projecting
at its usual place, formed a protuberance on
the outer side of the foot, beyond the external
malleoius ; and beneath the malleolus was
a considerable hollow ; on the inner side, and
below the internal malleolus was a remark-'
able projection, the toes were turned out;
and the foot was inclined in the same direc- )
tion : the astragalus must have been dislo-' \
•cated inwards, both from the calcis and oh j
naviculare, so that its inferior surface, instead
of resting upon the upper part of the os
calcis, was placed against its inner side. The
reduction was accomplished by bending the
leg at right angles with the thigh, and ex-
tending the foot in a line with the leg, the
knee being fixed ; at the same time, Mr.
Cline placed his knee upon the outer part of
the joint, and pressed the foot firmly against
it, forcing the bones into their natural posi-
tions. The limb was enveloped in a band-
age, and placed as much as could be on the
outer side, upon a well padded splint, to
which it was secured by tapes. The spirit
lotion was applied. On the 1st of July, the

thad some sickness and pain, which was

524

relieved by bleeding, otherwise he recovered
without any urgent symptoms, and was dis-
missed from the Hospital on the 26th of Au-
gust, being able to use his limb tolerably weU.
Cue. Another case of compound dislocation of

the astralagus also occurred under the care of
Mr. Henry Cline, for the particulars of which
I am indebted to Mr. Green. The accident,
as the former had been produced by the fall
of a heavy stone. The foot was turned in-
wards; the anterior or navicular surface of
the astragalus was exposed by an extensive
opening ; a wound on the inner side exhibited
the articular surface of the os calcis for the
fistragalus. The reduction was made by
placing the limb in the same position as for
the reduction in the former case; then by
extending the foot, and at the same time
rotating it outwards.

The patient was a stout,middle-aged labour-
ing man, ef not very sober habits, and subject
to gout. Extensive erysipelatous inflamma-
tion, which terminated in sloughing, and
which gave rise to a great deal of constitu-
tional irritation, retarded his recovery, which
was, however, ultimately complete.

Mr. Green was likewise kind enough to
furnish me with the following particulars of
a case which was under his own care in St.
Thomas's Hospital.

525

Thomas Toms, a bricklayer, aged twenty- <
three, was brought to the Hospital on the
I4th of July, 1820; he had fallen from a
scaffold at the height of three stories, and in
his fall the foot had been caught between
two of the spikes of an iron railing, and in
this way he became suspended, with his
head downwards. When admitted a large
wound existed beneath the inner malleolus
of the left leg, through which protruded the
anterior articular surface of the astragalas,
which had been separated from the navicular
,1ione. The foot was inclined upwards and
feutwards ; the tendons of the flexor muscles
Were tightly stretched ; the posterior tibial
artery had been torn through, and the accom-
panying nerve partially lacerated. Several
attempts were made to re-place the dislocated
bone, but without success, although the
wound was enlarged with a scalpel. As I
■was at the Hospital, Mr. Green requested to
see the case, and after a careful examination
of the injured limb, I proposed the removal
of the astragalus, as much preferable to
'amputating the limb. Mr. Green therefore
carefully separated the ligamentous connec-
tion of the astragalus, and took it away; a
ligature was put upon the posterior tibial
artery. The natural position of the foot, Sec.

526

edges of the wound were brought together
and supported by straps of adhesive plaister ;
the limb was placed upon its outer side, on
a well padded splint, having a foot piece;
the evaporating lotion was applied on the
limb. For several days after the injury the
patient suffered a good deal from febrile
symptoms, and some occasioned pain in the
ankle; but when the suppurative process
was well established, about the seventh day,
all these unpleasant symptoms subsided, and
he proceeded very favourably until the end
of July, when the formation of an abscess
again gave rise to some constitutional de-
rangement, which was relieved as soon as th^
matter was discharged. A second collection
c^ matter which occurred about the end of
August, again retarded his recovery, and he
continued in an indifferent /state until the
7th of September, with loss of appetite, and
flight hectic; the leg becoming slightly
iQ^ematous, but the discharge from the wound
(Continuing copious. From that period b^
]:]»ended rapidly, but little occurring to retard
)m recovery, which wa3 complete on the
25th of October. He left the Hospital on
the 2nd of November, and has since resumed
his business, without any inconvenience,
between^" Another form of dislocation of the tarsal

bones"** boucs somctimcs occurs from the falling of

527

heavy weights upon the foot ; by which the
five lanterior tarsal bones, together with
metatarsus and toes are displaced, the con-
nections between the astragalus and navicular,
and between the calcis and cuboid, being in
a great measure destroyed.

A man was brought into Guy's Hospital, ^*''^*
in consequence of an injury to his foot, upon
which a very heavy stone had slipped. The
fore part of the foot was turned up, whilst
the posterior part formed of the astragalus
and OS calcis remained in the natural state ;
it presented very much the appearance of a
club foot. The reduction was effected by
fixing the heel and leg, and extending the
anterior part of the foot. In five weeks the
man had regained perfect use of the limb.

For the particulars of the following interest-
ing case of compound dislocation, I am in-
debted to Mr^ South. The case was under
the care of Mr. Henry Cline, in St. Thomas s
Hospital.

Thomas Gilmore^ aged forty-five, a stout case.
man, and in the habit of drinking freely, was
admitted into the Hospital on the 28th of
March, 1815, in consequence of an injury to
his ankle, which had been occasioned by the
falling of a very heavy stone upon his heel.
On the fore and external part of the joint was
a large wound, reaching from the middle of

528

the inferior extremity of the tibia to the ex-
ternal malieoluSy and exposing the anterior
articular surface of the astragalus, for the
navicular bone, and also that for the os calcis
on the outside ; the tuberosity of the os calcis
projected outwards, and the toes were direct-
ed inwards, towards the other foot. The
natural position' of the parts was restored by
extending the foot and rotating it outwards.
The edges of the wound were approximated,
and retained in contact by the application of
straps of adhesive plaister; the limb was
placed in a fracture box upon the heel, and
linen dipped in cold water was placed over
the seat of injury, in consequence of some
slight bleeding. During the following night
he suffered much from spasms in the limb,
and slept but little ; but no urgent symptoms
presented themselves. On the 30th, severe
constitutional irritation had been set up ; he
was delirious, his pulse was very quick ; his
skin hot and dry, his mouth parched, and he
had rigor. Some inflammation appeared
about the wound. He continued in this
state until the 2nd of April, ¥rith some exten-
sion of tlie inflammation up the leg ; taking
every six hours the fever mixture, with some
imtiiuonial wine. On the 2nd the severity of
Iho constitutional spnptoms had subsided,
lull ho coiupiiuned of pain in the wound, and

thelimb exhibited an erysipelatous blush.with
some oedema ; a small spot on the leg, which
had been bruised, was ulcerated. He pro-
ceeded favourably until the 5th, when th© (
constitution became seriously affected, but
the symptoms indicated a state of debiUty,
and the ulcer on the leg was in a sloughy
state, although the original wound secreted a
healthy pus. He was ordered the bark in (
decoction. Until the 10th, these unpleasi
symptoms were present with little alteration,
and the superficial inflammation of the limb
extended nearly to the groin, and mattei;
appeared to be forming in different parts; |
he was allowed a pint of porter, and a grain

if opium twice in the day. After this pe-

id, the inflammation gradually subsided,

■und the constitutional suffering became much

!ssened ; the quantity of porter was in-
creased to two pints daily, and subsequently
to three pints, on account of his weakness.
Several superficial sloughs formed on the
lieg, which separated very slowly, not being
got rid of until the 15th of May. His appe-
tite and spirits varied considerably, but with-
out any further serious drawback, he gra-
dually recovered, and quitted the Hospital
:0n the 12th of September, being then able
walk easily with the assistance of a

ack.

,. III. 2 M

530

2f 2!n^.^" I have seen two cases of dislocation of the
ncSfoi^"' internal cuneiform bone; the first was in a
bone. gentleman, who came to consult me a few
weeks after the injury ; and the second was
in a patient at Guy's Hospital. Both pre-
sented the same characters ; the bone pro-
jected inwards, and also a little upwards,
being drawn up by the action of the tibialis
anticus muscle.

In the first case, the dislocation was pro-
duced by a fall from a height ; and in the se-
cond, by the fall of a horse, the foot being
caught between the horse and the curb stone.
In neither instance was the bone re*-
placed, but the displacement did not occasion
any important lameness.
Treatment. I should rccommeud in the U*ea(ment of
these accidents, — first, to confine the bone
as much as possible in its natural position,
by binding a roller around the foot, and to
keep the bandage wet with an evaporating
lotion, until the inflammation has subsided,
and then to employ a leather strap, which can
be buckled around the foot, so as firmly to
confine the bone until the ligaments are
reunited.

Of Dislocations of tke Toes.

These dislocations are common either be- Seat of
tweeu the metacarpal bones and phalanges, or
between the phalanges themselves. The same
treatment should, in such cases, be adopted,
as directed for similar injuries to the fingers.

I had a man under my care in Guy's Case.
Hospital, who, in faUing from a height,
pitched upon the extremities of the toes, and
had forced the first phalanges of the smaller
toes, above the ends of the metatarsal bones,
where they projected very much. Several
months had elapsed after the receipt of the
injury, which rendered all attempts to reduce
the bones useless. The patient was after-
wards obliged to wear a piece of cork hol-
lowed at the bottom of the inner pait of the
foot, to prevent the pressure of the metatarsal
bones upon the vessels and nerves.

Of Dislocalions of the Zoiver Jaw.

The dislocation of the lower jaw may be Twofonii»|
either complete or partial; when complete,
both of the condyles are thrown into the
space between the zygomatic arch, and the
surface of the temporal bonej but when
2 M 2

532

partial, one condyle only escapes, whilst the
other remains in the articular cavity.

Of the Complete Dislocation.

Signs of. When this accident occurs, the patient
appears as if in a continued yawn, the mouth
being widely open, without any power on
the part of the patient to close it. < Some
trifling degree of motion often exists, so that
the chin can be either elevated or depressed
a very little. The chin is advanced, the
cheeks are protruded by the coronoid pro-
cesses, and a hollow is perceived immediately
before the meatus auditorius, on account of
the absence of the condyloid process from the
glenoid cavity. The secretion of the parotid
glands is increased, and dribbled over the
chin, and the pain is at first severe.

Causes of. The displacement may be occasioned by
excessive yawning, by a blow upon the chin
when the mouth is open, or by endeavouring
to force any solid substance into the mouth,
too large for the ordinary aperture. Mr.
Fox, the dentist, informed me that he had
known a dislocation of the jaw take place
from spasmodic action of the muscles, when
the mouth was widely opened to allow, of the
extraction of a tooth.

533

The reduction of the dislocation should,
as in other cases, be effected as speedily as
possible, in the mode which the following
lase will best explain.

1 was called by Mr. Weston, of Shoreditch, <
to visit with him a madman at Hoxtou, who
iiad had his jaw dislocated in an attempt to
force some food into his mouth. Knowing
that there would be great risk in employing 1
the means usually recommended, I adopted ,
itiie following plan ; — I had the patient placed
iupon his back, with a pillow to receive his
head, and in that situation he was firmly
held ; then having procured two forks, I
^wrapped a handkerchief round their points,
and passed the handles into the patient's
mouth, one on each side, behind the molares
teeth, and whilst they were held in that situ-
ation, I forcibly drew the lower jaw towards
the upper, by placing my hand under the
chin ; in this way, the reduction was easily
accomplished.

■ I prefer, however, the use of corks, instead i
^ofany more solid substance, which is likely
to injure the gums ; those employed for
stopping the common quart bottles are of
about the proper size, and should be placed
one on each side of the mouth, behind the
.imolares teeth, after which, the chin is to be
raised in the manner already described.

fi34

^s«p>oy- A long piece of wood is sometimes em-

^"f^- ployed in these cases as a lever^ introducing
it between the molares, first on one side, and
then upon the other, and each time raising
the extremity of the wood furthest from the
mouth, so as to depress that part of the lower
jaw beyond the molar teeth, and ¥rith it the
condyloid process, when the . action of the
muscle will draw it into its articular cavity.

^JjJ^ Another mode which will generally suc-
ceed if the dislocation be recent, consists in
placing the thumbs, which should be well
covered, at the roots of the coronoid pro-
cesses, and with them forcing that part of the
jaw downwards and backwards, and at the
time pressing the chin upwards.

Liabiuty When once this dislocation has happened,

to recnr. * *

the patient is very liable to a further displace-
ment. Aider the reduction, a bandage should
be applied> having four tails, two at each
end, and a hole in the centre to receive the
chin ; of the tails, two are to be tyed over
the head, and two behind the occiput ; and
the patient should not be allowed to mas-
ticate any solid food, until suflScient time has
been allowed for the union of the lacerated
parts.

Of the Partial Dislocation.

In this case, the condyloid process on only signs
one side is displaced ; the mouth opened, but
not so much as in the complete dislocations ;
the chin is directed to the side opposite the
injury, and thrown out of the axis of the face.

This dislocation is usually produced by a *^='"
blow on one side of the jaw when the mouth
is open.

The reduction may be accomplished either Rpfiiidion- J
fay the cork or the lever of wood.

Of Subluxation of the Jaw.

The condyloid process of the lower jaw, Signs of.
is, as I have already described to condyles
of the femur to be in the knee joint, some-
times displaced from the inter-articular car-
tilage of the joint, slipping before its edge;
fixing the jaw with the mouth slightly open.

The efforts of the patient alone are usually Redacedu
sufficient to remedy the evil, but I have tif^p^tion
known it exist a length of time, and after-
wards the motion of the jaw and power of

L closing the mouth return.

M The displacement rarely happens but from cause of. J

H extreme relaxation of the ligaments.

536

iv«ttnieiit. jf called upon to relieve a patient under
these circumstances^ the force employed
should be applied directly downwards, to
separate the condyloid process from the tem-
poral bone, and thus allow the cartilage to
resume its proper situation.

Frequent J have most frequently seen this accident

in yooBg * •'

women, in youug womeu, and have found such reme-
dies as will invigorate the constitutional
powers, as ammonia and steel, with the
shower bath, most serviceable in subduing
the tendency to its recurrence.

537

EXPLANATION OF THE PLATES.

PLATE I.

Shewing the Positions of the Limb in the different

Dislocations of the Hip*

Fig. 1. The dislocation upwards upon the dorsum ilii*
The limb shortened — the hip projecting — the
knee and foot turned inwards^ with the toes
resting oyer the metatarsus of the sound limb.

Fig. 2. The dislocation downwards into the foramen
ovale. The limb lengthened — the knee ad-
vanced and -separated from the other — the toes
pointed — the heel does not touch the ground —
the body bent forward.

Fig. 3. The dislocation into the ischiatic notch. The
limb shortened — the knee and foot a little turned
inwards, with the great toe resting against the
ball of the great toe of the sound limb.

Fig. 4. The dislocation on the pubes. Projection at
Poupart's ligament from the head of the bone,
the limb widely separated from the other^ and
the knee and foot turned outwards — the limb a
little shortened.

VOL. III. 2 N

538

PLATE II.

Skews ihe Mode of reducing the Dielooaiione of the

Hip.

Fig. 5. The bandages and puUies applied to reduce the
dislocation on the dorsum ilii.

Fig. G. The bandages and puUies applied to reduce the
dislocation into the foramen ovale.

Fig. 7. llie bandages and puUies applied to reduce the
dislocation into the ischiatic notch*

Fig. 8. The bandages and puUies applied to reduce the
dislocation on the pubes.

END OP VOL. 111.

S. MOLDJ»WOUTH, PRINTER^ Cfi, PATEKKUSTKK ROW, LUKUOM.

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Full text of "The lectures of Sir Astley Cooper on the principles and practice of surgery"

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